Assessing and addressing barriers to IPTp uptake in Uganda

The project examines demand and supply side barriers to uptake of intermittent preventive treatment in pregnancy (IPTp). Based on formative research, we will develop, pilot and evaluate an intervention to address these barriers and contribute towards meeting IPTp coverage targets in Uganda.
Project outline
Malaria in pregnancy is a significant public health problem which affects more than 30 million pregnant women each year in malaria-endemic areas. It poses substantial risks to mother and unborn child, including maternal anaemia, stillbirth, miscarriage and low birth weight, a leading cause of child mortality.
To prevent malaria infections among pregnant women living in areas of moderate or high transmission, the World Health Organization recommends intermittent preventive treatment in pregnancy (IPTp), a full therapeutic course of antimalarial medicine given to pregnant women regardless of whether or not they are infected with malaria.
Uganda’s Malaria Control Strategic Plan identifies IPTp as one of three elements of malaria in pregnancy prevention and control. It is delivered as part of the focused antenatal care package and has been implemented country-wide since 2002. Yet, despite having made significant progress, Uganda is far from meeting the government’s target of 80 percent of pregnant women receiving two doses of IPTp by the end of 2015. In 2011, only 24.5 percent of pregnant women in Uganda received two or more doses of IPTp, despite generally high antenatal care attendance.
As the lead technical partner on the Stop Malaria Project – which is funded by the President’s Malaria Initiative to assist the Government of Uganda to reduce malaria-related mortality – Malaria Consortium has been implementing interventions for malaria prevention, diagnosis and treatment across 34 districts in Uganda since 2009. A number of measures have been designed to increase IPTp coverage, such as training health workers, producing job aids, tracking stock of antimalarial drugs and providing clean water at antenatal care clinics. Despite these, uptake figures in Stop Malaria Project districts have plateaued at around 55 percent of pregnant women receiving two or more doses of IPTp.
To explore the factors that continue to impede IPTp uptake, this project will undertake formative qualitative research which includes an analysis of: operational challenges at the district and facility level, the accessibility, affordability and acceptability of IPTp and antenatal care services, and the accuracy, reliability and quality of available IPTp coverage data.
The study comprises two elements:
» 40in-depth interviews with key informants (pregnant women and mothers, health workers, district-level officials). The interview guides were informed by a literature review on barriers to IPTp uptake
» a document and record review comparing antenatal care registers at four facilities with monthly antenatal care reports filed by those facilities
The study will sample facilities and communities in two regions – Eastern and West Nile – which represent a wide range of Uganda’s geographical and ethnic diversity.
According to household survey data, IPTp uptake figures in these regions vary from low (20.5 percent in West Nile) to high (32.5 percent in Eastern) compared with the national average. The sample also allows for a comparison between a region where Stop Malaria Project operates (Eastern) and might have impacted on provision of malaria in pregnancy interventions, and a region where it does not operate (West Nile) and could not have impacted on IPTp uptake.
Facilities and communities in the sample have been selected purposely to include respondents from both rural and urban backgrounds, different levels of antenatal care providers (health centres II, III, IV and hospitals), public and private-not-for-profit providers, as well as communities with easy access to health facilities and those where access is likely to be a major barrier.
The results of the formative research will determine the nature and scale of a pilot intervention, agreed in consultation with stakeholders in Uganda and designed to address the major barriers identified by the study. Following a pilot, the intervention will be evaluated, and the findings shared at a national dissemination workshop. We aim to develop a set of policy recommendations, including for implementing the pilot intervention at scale if appropriate.
Project objectives
The main objectives of the study are to:
» provide evidence and enhance understanding of the supply and demand side barriers to IPTp uptake in Uganda
» explore issues with regard to accuracy, reliability and quality of available IPTp coverage data
» inform the development of a pilot intervention which addresses the barriers to IPTp uptake identified through the formative research
» evaluate the pilot intervention and develop a set of recommendations with the aim of increasing the number of pregnant women receiving at least two doses of IPTp as part of the focused antenatal care package
» engage with malaria in pregnancy stakeholders to improve services and interventions that will help Uganda to meet the goal of 80 percent coverage of two doses of IPTp

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