Intermittent preventive treatment during pregnancy and antenatal care in practice : a study from the Kilombero valley, Tanzania

Each year an estimated 125 million pregnant women are at risk of getting infected with malaria in areas with P. falciparum and P. vivax transmission. In Tanzania, approximately 1.7 million pregnant women contract malaria each year leading to a high prevalence of maternal morbidity, maternal mortality and adverse birth outcomes.
The World Health Organization (WHO) recommends for sub-Saharan Africa a package of prompt and effective case-management combined with the delivery of insecticide-treated nets (ITN) and intermittent preventive treatment during pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) through the national antenatal care (ANC) programs. Implemented in Tanzania around 2001, uptake of IPTp has been poor up to date with less then 30% of pregnant women receiving a full course of two SP doses.
The aim of this thesis was to contribute to a better understanding of women’s access to and use of IPTp and other ANC services in the Kilombero Valley, Tanzania. In order to explain low IPTp coverage levels, factors influencing ANC utilization on the demand side and the quality of ANC on the supply side were investigated. Drawing on conceptualizations of scholars from the “New Institutionalism” this thesis sought to provide a more in-depth understanding of 1) how rules, regulations and guidelines at the health system level influence health providers’ implementation of health policies and guidelines concerning IPTp and ANC and 2) how old and new norms and values at the household level and beyond influence women’s access to and use of ANC and IPTp services.
The study was conducted in close collaboration with the ACCESS Programme and was carried out in the Demographic and Surveillance System (DSS) area of the Kilombero and Ulanga district in south-eastern Tanzania. Research was conducted in three phases between April 2007 and June 2009 and combined a set of qualitative and quantitative methods for data collection.
Our findings revealed a high coverage level of the first IPTp dose (79%) but confirmed a low uptake of the second one with only 27% of pregnant women having received two SP doses. Although 71% of all women started ANC after the four gestational months recommended by guidelines, their late attendance was not found to be the main constraint for IPTp delivery since 81% of the women had attended the ANC clinic at the time of the first IPTp delivery and 60% had attended both during the first and the second IPTp delivery period. The observation that among these women only 73% actually received one dose and only 29% received two doses of IPTp, pointed to the high number of missed opportunities. Low coverage levels for the second IPTp dose could be explained by health workers delivering IPTp to significantly less women during the second IPTp delivery period than the first one (55% vs. 73%) despite their high knowledge about the IPTp policy.
Apart from women’s late ANC initiation, it appeared that the majority of pregnant women respected the ANC schedule. However, it seemed that women’s attendance was rather based on norms than on their awareness of the benefits of ANC services for their own and their child’s health. Late ANC initiation was associated with belonging to the Sukuma ethnic group, multiparity, and late recognition of pregnancy. Early ANC attendance, on the other hand, was triggered by primiparity, experience of a previous reproductive loss and feeling supported by the partner or husband. Male’s support during pregnancy appeared to be facilitated and constrained by a broad range of institutions working along the lines of gender, family and kinship. On the other hand new norms and values imposed by the legal system or the ‘modern’ health system were identified as being influential on men’s support during the prenatal period.
Case studies in four health facilities revealed that the quality of ANC care was generally poor. Among a sample of 36 observed ANC consultations, 12 of the services recommended by the FANC guidelines were not given to any women, a further 18 services were given to 3%-58% and eight services were given to over 80% of women. Instead of FANC guidelines, health workers rather complied to ANC cards; analysis showed that health services for which information was required on the ANC card were delivered far better than services not listed on the ANC card but recommended by the FANC guidelines. Moreover, dichotomous IPTp schedules in the guidelines for ANC and malaria resulted in health workers’ continued delivery of IPTp according to restrictive IPTp schedules despite the existence of a more simplified IPTp schedule recommended by WHO. Calculations showed that the effective implementation of the latter guidelines could potentially increase IPTp coverage by up to 20 percentage points, which urgently calls for a revision of the national IPTp guidelines. Besides health policy factors, health care practices were found to be clearly shaped by health providers’ difficult working conditions. In order to cope with constraints caused by lack of trained staff, resource shortages and a high demand for their services, health workers appeared to adopt informal rules and routines such as attendance and diagnostics schedules and routines that allowed for mass treatment such as health education and counselling in groups.
In order to better understand how the availability of material and human resources and health workers’ access to them influence health service delivery and its quality, this thesis proposed and applied the concept of “workhood” as a new analytical device. By introducing an actors-perspective to the health system, the concept allowed light to be shed on the limitations and potentials of health workers’ capabilities.