A socio-ecological approach to understanding the factors influencing the uptake of intermittent preventive treatment of malaria in pregnancy (IPTp) in South-Western Nigeria.

Malaria in pregnancy (MiP) remains a key cause of poor maternal and neonatal health outcomes, particularly in the African region. Two strategies globally promoted to address MiP require pregnant women in malaria-endemic regions to sleep under insecticide-treated bed nets (ITNs) and take at least three doses of intermittent preventive treatment (IPTp) during pregnancy. Yet, several multilevel factors influence the effective uptake of these strategies. This study explored the factors for the poor uptake of IPTp and use of ITNs in lower socio-economic communities in Nigeria. We conducted semi-structured interviews (SSI) and focus group discussions (FGD) with a total of 201 key stakeholders in six communities in Ogun State, South-Western Nigeria. Twelve SSIs were conducted with traditional birth attendants (TBAs), faith-based birth attendants and healthcare providers operating in public health facilities. Community leaders (7), pregnant women (30) and 20 caregivers were individually interviewed. Sixteen FGDs were conducted with multi- and first-time pregnant women grouped by location and pregnancy experiences. A thematic approach was used for data analysis. At the individual and social levels, there is a high general awareness of MiP, its consequences and ITNs but low awareness of IPTp, with type of antenatal care (ANC) provider being a key factor influencing access to IPTp. The choice of ANC provider, which facilitates access to IPTp and ITNs, is influenced by the experiences of women, relatives and friends, as well as the attitudes of ANC providers and community perceptions of the type of ANC providers. Concurrent use of multiple ANC providers and ANC providers' relationships further influence acceptability and coverage for IPTp and ITN use. At the health sector level, there is low awareness about preventive malarial strategies including IPTp among TBAs and faith-based birth attendants, in contrast to high IPTp awareness among public healthcare providers. The findings highlight several factors that influence the utilisation of IPTp services and call for greater synergy and collaboration between the three groups of healthcare providers towards enhancing access to and acceptability of IPTp for improving maternal and child outcomes