title: Individual, facility and policy level influences on national coverage estimates for intermittent preventive treatment of malaria in pregnancy in Tanzania.
abstract: BACKGROUND
  Delivery of two doses of intermittent preventive treatment of malaria during pregnancy (IPTp) is a key strategy to reduce the burden of malaria in pregnancy in sub-Saharan Africa. However, different settings have reported coverage levels well below the target 80%. Antenatal implementation guidelines in Tanzania recommend IPTp first dose to be given at the second antenatal visit, and second dose at the third visit. This investigation measured coverage of IPTp at national level in Tanzania and examined the role of individual, facility, and policy level influences on achieved coverage.
  
  
  METHODS
  Three national household and linked reproductive and child health (RCH) facility surveys were conducted July-August 2005, 2006, and 2007 in 210 clusters sampled using two-stage cluster sampling from 21 randomly selected districts. Female residents who reported a livebirth in the previous year were asked questions about malaria prevention during that pregnancy and individual characteristics including education, pregnancy history, and marital status. The RCH facility serving each cluster was also surveyed, and information collected about drug stocks, health education delivery, and the timing of antenatal care delivery by clinic users.
  
  
  RESULTS
  The national IPTp coverage had declined over the survey period being 71% for first dose in 2005 falling to 65% in 2007 (chi2 2.9, p = 0.05), and 38% for second dose in 2005 but 30% in 2007 (chi2 4.4, p = 0.01). There was no evidence of any individual factors being associated with second dose coverage beyond living in an urban area. Availability of sulphadoxine-pyrimethamine at RCH had decreased year on year from 85% of clinics in stock in 2005 to 60% in 2007 (chi2 20.6, p < 0.001). This reduction was evident in rural but not urban clinics. If safety recommendations and national antenatal care guidelines for IPTp delivery were followed, in 2007 only 76% of pregnant women could have received IPTp first dose and only 46% could have received second dose.
  
  
  CONCLUSIONS
  There is scope to improve IPTp first and second dose coverage at national scale within existing systems by improving stock at RCH, and by revising the existing guidelines to recommend delivery of IPTp after quickening, rather than at a pre-defined antenatal visit.
authors.affiliation: Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK. tanya.marchant@lshtm.ac.uk
authors.forename: Tanya
authors.initials: T
authors.lastname: Marchant
authors.forename: Rose
authors.initials: R
authors.lastname: Nathan
authors.forename: Caroline
authors.initials: C
authors.lastname: Jones
authors.forename: Hadji
authors.initials: H
authors.lastname: Mponda
authors.forename: Jane
authors.initials: J
authors.lastname: Bruce
authors.forename: Yovitha
authors.initials: Y
authors.lastname: Sedekia
authors.forename: Joanna
authors.initials: J
authors.lastname: Schellenberg
authors.forename: Hassan
authors.initials: H
authors.lastname: Mshinda
authors.forename: Kara
authors.initials: K
authors.lastname: Hanson
mesh_terms: D000818:Animals; D000962:Antimalarials / Q000008:administration & dosage* / Q000627:therapeutic use; D004334:Drug Administration Schedule; D004338:Drug Combinations; D005260:Female; D019983:Guideline Adherence; D019538:Health Care Surveys; D006268:Health Facilities / Q000600:supply & distribution; D007722:Health Knowledge, Attitudes, Practice; D006291:Health Policy; D006801:Humans; D008288:Malaria / Q000188:drug therapy* / Q000517:prevention & control; D010342:Patient Acceptance of Health Care; D010961:Plasmodium / Q000187:drug effects*; D011247:Pregnancy; D015597:Pregnancy Complications, Parasitic / Q000188:drug therapy* / Q000517:prevention & control; D011295:Prenatal Care; D011739:Pyrimethamine / Q000008:administration & dosage* / Q000627:therapeutic use; D013413:Sulfadoxine / Q000008:administration & dosage* / Q000627:therapeutic use; D011795:Surveys and Questionnaires; D013636:Tanzania / Q000453:epidemiology; D013997:Time Factors
chemical_list: D000962:Antimalarials; D004338:Drug Combinations; C001205:fanasil, pyrimethamine drug combination; D013413:Sulfadoxine; D011739:Pyrimethamine