Factors influencing uptake of intermittent preventive treatment of malaria in pregnancy using sulphadoxine pyrimethamine in Sunyani Municipality, Ghana

Introduction Malaria continues to pose a public health challenge in Ghana particularly in pregnant women. Ghana adopted intermittent preventive treatment of malaria in pregnancy policy using sulphadoxine pyrimethamine. Despite its implementation, its coverage still remains low. This study sought to investigate factors that influence the uptake of intermittent preventive treatment of malaria in pregnancy in the Sunyani Municipality. Methods This was a cross sectional study which employed a quantitative method. The study was conducted in five selected facilities in the Sunyani Municipality within the period of January to June 2015. Structured questionnaires were administered to 400 pregnant women randomly sampled from antenatal clinics of selected health facilities. Descriptive, bivariate and multivariate analysis of quantitative data was done using Stata12. Results A total of 400 pregnant women at 36 weeks or more gestational age were studied. The study revealed that 98.5% of the pregnant women received at least one (1) dose of sulphadoxine pyrimethamine during the current pregnancy with 71% receiving optimal (at least 3 doses) doses of sulphadoxine pyrimethamine for intermittent preventive treatment of malaria in pregnancy at the time of study. The study revealed that women who attended ANC ≥4 times (Adjusted OR = 4.7, 95% CI 1.31-17.2), knowledge of malaria in pregnancy (Adjusted OR = 2.2, 95% CI 1.03-4.62) and knowledge of intermittent preventive treatment for malaria in pregnancy (Adjusted OR = 1.8, 95% CI 1.15-2.96) were found to be positively associated with the uptake of optimal doses of sulphadoxine pyrimethamine. Conclusion This study has demonstrated that having a good knowledge of malaria in pregnancy and intermittent preventive treatment of malaria in pregnancy can significantly influence the uptake of optimal doses of sulphadoxine pyrimethamine. Encouraging women to attend antenatal care regularly (at least four visits) could also increase the optimal uptake of sulphadoxine pyrimethamine.


Introduction
Malaria is an enormous international health problem affecting mainly young children, pregnant women and adults with little or no immunity. Over 25 million pregnant women are at risk of the infection each year worldwide. Malaria in pregnancy may result in maternal and foetal anaemia, prematurity, stillbirths, rarely congenital malaria as well low birth weight which is the single greatest risk factor for neonatal deaths [1,2]. More than 30 million women in Africa become pregnant in malaria endemic areas and are at risk of Plasmodium falciparum malaria infection compared to nonpregnant women. Yet only a fraction of these women have access to effective anti-malaria interventions [3]. The susceptibility of pregnant women to Plasmodium Falciparum malaria increases the risk of disease and a high incidence of death for both the mother and her foetus [4]. In Ghana, malaria among pregnant women accounts for about 14% of Out Patient Department (OPD) attendance, 11% of admissions and 9% of deaths [5]. Malaria in pregnancy may occur depending on a woman's exposure to mosquitoes, her level of immunity and possible co-infections such as other malaria species, HIV or helminths as well as the efficacy of treatment and preventive interventions available to her [6]. Even though adult women in malaria endemic areas have a high level of immunity, this generally is impaired during pregnancy particularly in the first pregnancy, thereby increasing their risk of infection [7].
This increased risk has been attributed to the immunological, hormonal and physiological changes in pregnancy [8]. The reduced immunity may result in the risk of acute and severe clinical disease as well as more frequent episodes [2]. Although malaria in pregnancy may sometimes be asymptomatic, it can still affect the health of a woman and that of her unborn child. Following the recommendation of the World Health Organization (WHO) in 2000, Ghana adopted a new malaria treatment policy in 2004. The country thus moved from the use of mono-therapy to combination therapy using Artemisinine-Based Combination Therapy [1]. As part of this policy was the change from use of weekly Chloroquine Chemoprophylaxis to Sulphadoxine-Pyrimethamine (SP) as Intermittent Preventive Treatment (IPT) for malaria prevention during pregnancy.
This was based on growing concerns of resistance to Chloroquine and the fact that only 11.6% were adhering to the policy of using Chloroquine as IPT [1]. The new policy of Intermittent Preventive Treatment in pregnancy (IPTp) using SP was piloted in 20 selected districts of Ghana and by 2005 scaled up to a nationwide coverage.
A revision of the policy was done in 2007 and the revised current policy was formulated in 2012 [9]. According to the policy, IPT was to be implemented as part of a multipronged approach as recommended by WHO to reduce the burden of malaria in pregnancy. These approaches consist of three tenets; which include the use of SP as IPTp, Insecticide Treated Nets (ITN) and case management of malaria illness. A clinic-based prevention approach was adopted as over 90% of the target (pregnant women) attend antenatal clinic at least once during pregnancy [1,10]. Intermittent preventive treatment of malaria in pregnancy is based on the assumption that every pregnant woman living in areas of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria. It involves the administration of treatment doses of SP in at least monthly intervals during pregnancy with the first dose administered as early as possible in the second trimester and the last dose administered up to the time of delivery [11]. The potential of IPT to achieve great levels of programme coverage due to high level of acceptability by women and its benefits in reducing malaria in pregnancy which causes maternal anaemia and Low Birth Weight (LBW) makes it a preferred strategy [5]. According to the Ministry of Health, every pregnant woman is expected to receive at least two doses of SP under Directly Observed Therapy (DOT) [1]. Although Ghana has adopted WHO recommendations on the use of SP for IPTp, IPT2 coverage remains generally low [12]. Like many other endemic countries, Ghana's ability to achieve the global target of 80% IPT2 coverage still poses a great challenge [13][14][15]. However, not much has been documented about the knowledge of pregnant women on IPT and malaria in pregnancy as well as factors that influence the uptake of IPT of Malaria in Pregnancy using SP among pregnant women. This study therefore will determine the factors that influence the uptake of IPT of Malaria in Pregnancy using SP among pregnant women.

Methods
Settings, population and study design: this was a cross-sectional study that was conducted in the Sunyani Municipality between annually [16].
Sample size: a sample size of 384 was calculated based on the sample size formula for a single population. This was estimated using an expected IPT3 prevalence of 50% in the Sunyani Municipality [17]. This sample had a margin of error of 5% and confidence interval of 95%. This was calculated using the formula: Where: n = the minimum required sample size. z = standard normal deviation corresponding to 95% confidence interval, which equals to 1.96. P= proportion of pregnant women who received IPT3 taken to be 50% E = the margin of error on P estimated to be at 5%. Therefore: n = 384. Adjusting for 10% of non-response rate, a total 422 participants were required for the study.
Sampling method: a total of 400 participants were recruited for the study. Five health facilities were randomly sampled from health facilities with antennal clinics from the Sunyani Municipality. Health facilities that were selected include; Brong Ahafo Regional Hospital, Sunyani Municipal hospital, SDA hospital, Owusu Memorial Hospital and Monica Maternity home. Study participants were randomly sampled from antenatal clinics of these health facilities. The inclusion criterion for sampling was pregnant women who had 36 weeks gestation and above were selected for study. The first pregnant woman who was met at the antenatal clinic was recruited for the study provided she met the inclusion criterion and consented for the study. Permission was also sought from health facility managers where the study was conducted. Written informed consent was obtained from study participants after they were well informed about the study.
Participants were not pressured to take part in the study and were informed about the purpose of the study. They were also assured of full confidentiality of information they provided and their right to withdraw from the study even after they have participated.
Limitations of the study: some of the pregnant women might not have given accurate responses because they might be aware of the national policy on SP in pregnancy or they might be afraid that their responses might incriminate their healthcare providers. However, we assured them of privacy and confidentiality of the information they provided. Some of the study participants did not understand the English language so we had to make use of the local language to interview them.
Page number not for citation purposes 4 Coverage of SP is summarized in Figure 1 below. The uptake of SP by the pregnant women ranged between 0 and 5 doses. An average of 3 doses received is considered optimal IPT uptake. Majority of the women, 44% (176/400) had received 3 doses while only 1.5% (6/400) received no dose of SP at 36 weeks gestation or above.

Discussion
Findings from this study suggest that 98.5% of pregnant women found that over 95% of received at least one dose of SP, which is consistent with the findings of this study [19]. The educational level of the study participants was significantly associated with the optimal (≥3 doses of SP) uptake of IPTp-SP. This might be due to the fact that education enables people to be well informed and make informed decisions and choices especially on maternal health issues. Women who are educated better appreciate the complications associated with pregnancy and childbirth and are more likely to receive optimal doses of SP [20]. Also, Sunyani Township is both a municipality and a regional capital, thus majority of the pregnant women were probably in the working group,  [19]. This implies that women in the Sunyani Municipality attend antenatal clinics at an early gestational age but this did not make a significant difference on SP uptake. This is similar to findings by a study in Northern Nigeria that found that early gestation at booking was not associated with IPTp uptake among pregnant women [21]. Over 90% of the respondents in this study made four or more ANC visits.
The number of recommended visits by WHO is at least four visits for no risk pregnancy. This study observed that attending antenatal care for four or more times was significantly associated with receiving optimal doses of SP. This finding is in consonance with many other studies that demonstrated that making four or more ANC visits is significantly related to receiving more doses of SP [19,28,29]. The age group and marital status of respondents was not significantly associated with the uptake of optimal doses of SP among pregnant women. This finding was inconsistent with studies conducted in Tanzania that observed that age group and marital status of pregnant women influenced the uptake of optimal doses of SP [30].

Conclusion
This study has demonstrated that education, having a good knowledge of IPTp and malaria in pregnancy as well as four or more ANC visits significantly influenced the uptake of optimal IPTp doses.
Education of women on IPTp and malaria in pregnancy should be intensified. Follow up visits or contacts should also be made on pregnant women who initiate ANC to encourage them to return for

SP.
What is known about this topic  Maternal education influences the uptake of optimal doses of SP;  Having four or more ANC visits is positively associated with optimal uptake of SP;  Knowledge of malaria in pregnancy influences the uptake of optimal doses of SP.

Acknowledgments
We are thankful to the Sunyani Municipal Health Directorate and the Brong Ahafo Regional Health Directorate for granting us permission to conduct this study. We are also grateful to health facilities that provided us with their support and cooperation during the study. We are also indebted to Professor Augustine Ankomah for his professional guidance and support during the study. Table 1: Socio-demographic characteristics of study participants,