title: The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania.
abstract: BACKGROUND
  Intermittent preventive treatment during pregnancy (IPTp) at routine antenatal care (ANC) clinics is an important and efficacious intervention to reduce adverse health outcomes of malaria infections during pregnancy. However, coverage for the recommended two IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage.
  
  
  METHODS
  Data on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Women's timing of ANC visits and health worker's timing of IPTp delivery were analyzed in relation to the different national IPTp schedules and the outcome on IPTp coverage was modelled.
  
  
  RESULTS
  Among all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. Less than 1% of women started ANC attendance after 32 weeks of gestation. During the second IPTp delivery period health workers delivered IPTp to significantly less women than during the first one (55% vs. 73%) contributing to low second dose coverage. Simplified IPTp guidelines for front-line health workers as recommended by WHO could lead to a 20 percentage point increase in IPTp coverage.
  
  
  CONCLUSIONS
  This study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. To maximize the benefit of the IPTp intervention, revision of existing guidelines is needed. Training on simplified IPTp messages should be consolidated as part of the extended antenatal care training to change health workers' delivery practices and increase IPTp coverage. Pregnant women's knowledge about IPTp and the risks of malaria during pregnancy should be enhanced as well as their ability and power to demand IPTp and other ANC services.
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland. karin.gross@unibas.ch
authors: Karin
authors: K
authors: Gross
authors: Sandra
authors: S
authors: Alba
authors: Joanna
authors: J
authors: Schellenberg
authors: Flora
authors: F
authors: Kessy
authors: Iddy
authors: I
authors: Mayumana
authors: Brigit
authors: B
authors: Obrist
references: Malar J. 2007 Jun 29;6:83
references: 17603898
references: J Midwifery Womens Health. 2008 May-Jun;53(3):209-215
references: 18455095
references: Acta Obstet Gynecol Scand. 2002 Dec;81(12):1101-9
references: 12519105
references: Malar J. 2010 Jun 15;9:164
references: 20550654
references: BMC Public Health. 2008 Jun 10;8:205
references: 18544162
references: Trans R Soc Trop Med Hyg. 2007 Oct;101(10):980-9
references: 17658564
references: BMC Infect Dis. 2007 Oct 25;7:121
references: 17961211
references: Trop Med Int Health. 2008 Feb;13(2):208-17
references: 18304267
references: Trop Med Int Health. 2007 Aug;12(8):953-61
references: 17697090
references: J Infect Dis. 2000 May;181(5):1740-5
references: 10823776
references: BMC Pregnancy Childbirth. 2009 Jul 09;9:28
references: 19589164
references: Lancet. 1999 Feb 20;353(9153):632-6
references: 10030329
references: Malar J. 2010 Jun 28;9:187
references: 20579399
references: Am J Trop Med Hyg. 1998 Nov;59(5):813-22
references: 9840604
references: J Infect Dis. 2007 Dec 1;196(11):1585-94
references: 18008241
references: Trop Med Int Health. 2006 Apr;11(4):409-18
references: 16553924
references: J Infect Dis. 2007 Dec 1;196(11):1574-6
references: 18008239
references: Malar J. 2005 Jul 20;4:31
references: 16033639
references: Acta Trop. 1993 Jun;54(1):55-72
references: 8103627
references: Malar J. 2009 Feb 12;8:25
references: 19216759
references: Trop Med Int Health. 2004 Feb;9(2):255-61
references: 15040563
references: Malar J. 2010 Jan 14;9:18
references: 20074372
references: Lancet. 2004 Oct 30-Nov 5;364(9445):1583-94
references: 15519628
references: Lancet Infect Dis. 2007 Feb;7(2):93-104
references: 17251080
references: Malar J. 2008 Dec 18;7:260
references: 19094198
references: Malar J. 2007 Feb 16;6:16
references: 17306014
references: Trop Med Int Health. 2004 May;9(5):630-7
references: 15117309
references: Malar J. 2008 Sep 18;7:180
references: 18801158
references: Br J Obstet Gynaecol. 1985 Oct;92(10):1037-9
references: 3902075
references: Malar J. 2008 May 09;7:79
references: 18471279
references: Trop Med Int Health. 2004 Jan;9(1):77-82
references: 14728610
references: J Infect Dis. 2006 Aug 1;194(3):286-93
references: 16826475
references: Malar J. 2004 Nov 12;3:42
references: 15541178
references: Trans R Soc Trop Med Hyg. 2010 Aug;104(8):536-40
references: 20227739
references: Trans R Soc Trop Med Hyg. 1999 May-Jun;93(3):225-31
references: 10492745
references: Malar J. 2010 Feb 17;9:54
references: 20163707
references: Cochrane Database Syst Rev. 2006 Oct 18;(4):CD000169
references: 17054128
references: Trop Med Int Health. 2005 Nov;10(11):1134-40
references: 16262738
references: J Infect Dis. 2007 Dec 1;196(11):1577-84
references: 18008240
references: Am J Trop Med Hyg. 2001 Jan-Feb;64(1-2 Suppl):28-35
references: 11425175
references: Lancet Infect Dis. 2007 Feb;7(2):145-55
references: 17251085
references: Malar J. 2008 Mar 01;7:44
references: 18312682