Determinants of intermittent preventive treatment of malaria among women attending antenatal clinics in primary health care centers in Ogbomoso, Oyo State, Nigeria

Introduction Despite the effectiveness of intermittent preventive treatment in pregnancy using sulphadoxine-pyrimethamine (IPTp-SP), the uptake and coverage in southwest Nigeria are low. We assessed the factors influencing utilisation of IPTp-SP. Methods A multistage sampling technique was used to select 400 pregnant women from six primary healthcare centers in Oyo State. Data on socio-demographic characteristics, knowledge, attitude towards IPTp-SP and its utilisation were obtained using a semi-structured questionnaire. Data were analyzed using SPSS software. Focus group discussions (FGD) and key informant interviews (KII) were held for pregnant women and healthcare workers and analysed thematically. Results Mean age of respondents was 27.2 (SD ± 5.5) years. Mean gestational age was 29.5 weeks (SD ± 5.4). Overall, 320 (80.0%) took SP, of which 152 (47.5%) took 2 doses and 112 (35.0%) took under directly observed therapy (DOT). We found that early booking for ANC, more than two visits to ANC (adjusted odds ratio (aOR) = 5.6; 95% CI: 1.2 - 26.6), good knowledge on IPTp (aOR = 9.3; 95% CI: 5.4 - 16.0), positive attitude towards IPTp (aOR = 2.1; 95% CI: 1.5 - 2.9) and being employed (aOR = 1.4; 95% CI: 1.1 - 1.7) were factors associated with IPTp-SP utilisation. The FGD and KII revealed that IPTp-SP drugs were mostly taken at home due to stock out. Conclusion Late ANC booking with stock out of IPTp-SP drugs was responsible for its low utilisation. There is need to encourage pregnant women to book early for ANC. Adherence to the practice of DOT scheme is recommended to improve IPTp-SP utilisation.


Introduction
Malaria is a major public health problem with the greatest impact of its burden being in sub-Saharan Africa which accounts for 90% of the global deaths [1]. Most of the burden of disease occurs among populations at highest risk namely; pregnant women and infants [2,3]. Malaria in pregnancy causes up to 10,000 maternal deaths each year and contributes to high rates of maternal morbidity especially in first-time mothers [4,5]. Also, 75,000 to 200,000 infant deaths annually are attributable to malaria in pregnancy [3,6].
Malaria in pregnancy increases the risk of miscarriage, stillbirth and low birth weight [2,3]. The World Health Organisation (WHO) and national guideline recommendations on malaria infection during pregnancy include use of intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) at each routine antenatal clinic (ANC) visit at least one month apart after the first trimester till delivery [6]. It should be administered under supervision during ANC visits. In Nigeria, ANC clinics are considered an important entry point to target pregnant women for care as 60-70% of women attend ANC clinic at least once during any pregnancy [7,8]. The 2013 Nigeria Demographic and Health Survey (NDHS) showed that 15% of pregnant women received two doses of SP with at least one dose administered during an ANC visit [9]. The 2015 Malaria Indicator Survey (MIS) however reported an increase from those that received at least one dose (47% of women) and three or more doses (19% of women) [10]. In the south-west zone of Nigeria, there has been an increase of pregnant women that received at least a dose, two or more and three or more doses of IPTp-SP from 23%, 10.5% and 4.3% to 64%, 54% and 20% respectively [9,10]. In Oyo State, 11% of pregnant women received any SP during an ANC visit while 3% took two or more doses of SP and 1.9% three doses or more of SP [9].
To address this inadequacy, identification of determinants of IPTp-SP utilisation is critical to the institution of control efforts. We carried out a study to assess factors influencing the utilisation of intermittent preventive treatment in pregnancy in Ogbomoso, Oyo State, Nigeria.

Study area:
Ogbomoso town is situated about 600m above sea level with a mean annual temperature of about 26.2°C. The vegetation is a derived savannah region. Ogbomoso has the tropical wet and dry climate as it falls in the transition zone of guinea-savannah. The region experiences a fairly high uniform temperature, moderate to heavy seasonal rainfall. The relative humidity is within the range 75-95% [11,12]. Stable malaria transmission occurs in the south-west region with a prevalence of 16.6% [10]   Transcripts were then analysed using the thematic approach. KII reports were also analyzed using the thematic approach.

Results
Overall, 400 respondents were included in the analysis. A total number of 430 questionnaires were administered during the study. ( Table 5).

Discussion
We found that early booking for ANC, more than two visits to ANC,