A study of pregnant women and health workers knowledge on malaria prevention and treatment guidelines during pregnancy

Background: The standard treatment guideline for Tanzania mainland which was released in 2007 indicated that Artemether-Lumefantrine (ALu) should be used as the first line for malaria treatment instead of Sulphadoxine-Pyrimethamine (SP). With this change it was still advocated that pregnant women should continue to take SP for Intermittent Preventive Treatment (IPT) of malaria during pregnancy. A number of studies have stated that artemisinin derivatives are not recommended for treatment of malaria in pregnant women in the first trimester which is quite contrary to the use of SP which is safe in all pregnancy stages. The challenge most likely to be faced is the knowledge on when it is safe to use ALu during pregnancy and the compliance to ALu dosage and the time intervals in between doses. Another challenge is the continuation of SP use for IPT in pregnant women, while SP was said to be ineffective in treatment of malaria and hence replaced with ALu. Purpose: To assess the level of knowledge of pregnant women and health care providers regarding the use of SP for IPT and ALu for treatment of malaria during pregnancy. Methods: The study was conducted in Rufiji district, southern Tanzania from March 2010 to February 2012. This was a facility based descriptive cross sectional study which was carried out in 2 hospitals, 4 health centers and 8 dispensaries which were selected based on cluster sampling technique. Both qualitative and quantitative data were collected in this study. Four hundred and seventy (470) pregnant women in their second and third trimesters were interviewed when attending antenatal clinics at the selected health facilities using semi structured questionnaires written in Swahili. Four focus group discussions (FGDs) were also conducted with 46 pregnant women involved in discussions. A focus group discussion guide was prepared based on the objectives of the study. Fourteen health facilities were assessed using a formatted health facility assessment form and 22 health care providers working at the antenatal clinics in these facilities were also xii recruited in this study. Self administered questionnaires written in Swahili were used to collect data from the health care providers. Results: More than half (54.3 %) of pregnant women did not know if SP was used for IPT. Most women (76.6 %) did not know the use of SP for IPT in relationship with gestation age. Overall, the results show that most women had very low knowledge about the use of SP for IPT. Forty three (9.1 %) pregnant women reported to have had malaria during their current pregnancies. The antimalarials reported to be used by pregnant women were quinine 42.9%, SP 23.8%, ALu 21.4% and sulphamethoxyprazine-pyrimethamine 2.4%. Irrespective of the gestation age of pregnancy, almost all (98.3%) pregnant women had low level of knowledge on the use of ALu and perceived it as unsafe drug to be used during pregnancy. Out of 22 interviewed health care providers, 17 had high level of knowledge on IPT policy and the rest (5) had medium level. With regards to the use of ALu during pregnancy, 9 health care providers had medium knowledge and the rest (13) had low level of knowledge. Frequent stock out of SP and ALu, late enrollment of pregnant women to ANC and lack of trained health care providers were among major factors causing poor implementation of the national guidelines at the health facilities. Conclusion: Most pregnant women had minimum knowledge on the use and benefits of SP for IPT and ALu for treatment of malaria during pregnancy. Most health care providers had low level of knowledge on the correct use of ALu in pregnant women. Views on ALu safety for use during pregnancy where also sorted out among pregnant women and health care providers. For effective implementation of IPT policy and treatment of malaria during pregnancy, pregnant women and health care providers should be sensitized and educated on the rational use of antimalarial drugs especially in pregnant women. Since most of the health facilities reported frequent stock outs of antimalarials it is suggested that there should be a mechanism established by both public and private health facilities to ensure uninterrupted supply of antimalarial drugs at the health facilities even when these medications are not supplied by the medical stores department. On behalf of xiii the government the Ministry of Health and Social Welfare should ensure that there is a mechanism that will monitor proper implementation of the guidelines, this will save a lot of cost incurred when changing guidelines simply because there was no proper monitoring mechanism leading to failure of the treatment guideline