i UNIVERSITY OF GHANA COLLEGE OF HEALTH SCIENCES SCHOOL OF PUBLIC HEALTH DEPARTMENT OF EPIDEMIOLOGY AND DISEASE CONTROL FACTORS INFLUENCING INTERMITTENT PREVENTIVE TREATMENT OPTIMAL UPTAKE AMONG POSTNATAL WOMEN IN LA-NKWANTANANG MADINA MUNICIPALITY BY YAA FOSUA KWARTENG (10875596) A DISSERTATION PROTOCOL SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR MASTER OF PHILOSOPHY IN APPLIED EPIDEMIOLOGY AND DISEASE CONTROL FEBRUARY, 2022 University of Ghana http://ugspace.ug.edu.gh ii DECLARATION I, Yaa Fosua Kwarteng, declare that apart from references to other works that I have duly acknowledged, this report is a product of my original work conducted under the supervision of Professor Ernest Kenu and Professor Benedict Calys-Tagoe. I further declare that no part or whole of this dissertation has ever been submitted for the award of any academic credit at this University or elsewhere. Yaa Fosua Kwarteng 06-12-2023 (Student) Signature Date Prof Ernest Kenu ……………… 13-12-2023 (Supervisor) Signature Date Prof Benedict Calys-Tagoe ……………… 13-12-2023 (Co-Supervisor) Signature Date University of Ghana http://ugspace.ug.edu.gh iii ABSTRACT Introduction: In Africa, where malaria is endemic, malaria-causing Low Birth Weight (LBW) kills between 62,000 and 363,000 newborns annually. In Ghana, nearly 5.9 million people were diagnosed with malaria in 2020, a considerable drop from the previous year (2019), which reported 6.7 million such cases. Ghana adopted a new IPTp-SP of MIP policy in 2004, which was updated in 2014, to reflect the updated policy of WHO 2012. In 2017, the uptake of IPTp3 was 43.0%, and IPTp5 was 8.9%, which was below the target of 85%. The study aimed at assessing factors influencing optimal intermittent preventive treatment uptake among postnatal women in the Pentecost hospital and Madina polyclinic in the LaNkwantanang Municipality of Ghana. Methods: This study was a facility-based, analytical cross-sectional study. The study population was made of postnatal mothers, of which a sample size of 366 was adopted. A simple random sampling was deployed in soliciting responses by administering a questionnaire. Data was gathered using an Open Data Kit (ODK) and analysed using STATA 15.1 for the chi-square test, Micro-Soft Excel for frequency distribution, and JAMOVI version 2.3.2 for regression analysis. Also, ethical approval was attained from Ghana Health Service ethical review board. Results: The study recruited 366 participants from Pentecost hospital and Madina Kekele Polyclinic in the LaNkwantanang Municipality in the Greater Accra region of Ghana. The optimal uptake of IPTp-SP was 29% (CI:0.385-1.95). Of the respondents, 261 took IPTp-SP 1 and 2, representing 79%, while those who received the optimum dose of IPTp-SP 3 plus was 29%. Also, about 50% of the midwives received training on IPTp-SP for the last two years. The respondent's income was statistically associated with IPTp-SP uptake (X2=15.7, p-value 0.03). In this study, the odds ratio for patients with optimal IPTp-SP uptake at the Madina Kekele Polyclinic compared to the Pentecost Hospital was 1.02 (95% CI: 0.677-1.56). The University of Ghana http://ugspace.ug.edu.gh iv estimated difference in odds for patients optimal IPTp-SP uptake at the Madina Kekele Polyclinic compared to the reference group (Pentecost Hospital) was 0.08 (95% CI: 0.00-0.82). Age: The odds of optimal IPTp-SP uptake were higher for women aged 20-29 years (OR = 0.77, 95% CI = 0.346-1.73) and 30-39 years (OR = 0.86, 95% CI = 0.385-1.95) compared to women aged 10-19 years. However, the odds were significantly lower for women aged 40-49 years (OR = 1.18, 95% CI = 0.506-2.76) compared to women aged 10-19 years. Conclusion: This study found that optimal IPTp-SP uptake was below the national (85%) targets for IPTp3,4, and 5 among postnatal mothers. Keywords: Intermittent Preventive Treatment, Uptake, Postnatal, Antenatal, Sulfadoxine- Pyrimethamine University of Ghana http://ugspace.ug.edu.gh v DEDICATION I dedicate this work to my entire family for their support and those who supported me in diverse ways. Thank you all for the support University of Ghana http://ugspace.ug.edu.gh vi ACKNOWLEDGEMENT My gratitude first goes to God Almighty for giving me life, strength, and courage to complete this work. I wish to express my heartfelt appreciation to my academic supervisors, Professor Ernest Kenu and Professor Benedict Calys-Tagoe, for their timely feedback, immense support, and invaluable contribution towards this research work. I am grateful to all my lecturers at the School of Public Health and the management of Pentecost and Madina polyclinic for their cooperation towards data collection. Also, to all respondents, I say God bless you all University of Ghana http://ugspace.ug.edu.gh vii TABLE OF CONTENTS DECLARATION ....................................................................................................................... ii ABSTRACT ............................................................................................................................. iii DEDICATION ........................................................................................................................... v ACKNOWLEDGEMENT ........................................................................................................ vi TABLE OF CONTENTS ......................................................................................................... vii LIST OF TABLES ..................................................................................................................... x LIST OF FIGURES .................................................................................................................. xi LIST OF ABBREVIATIONS .................................................................................................. xii OPERATIONAL DEFINITION OF TERMS ......................................................................... xiv CHAPTER ONE ........................................................................................................................ 1 1.0 Background ....................................................................................................................... 1 1.1 Problem Statement ............................................................................................................ 5 1.2 The Conceptual Framework ............................................................................................. 6 1.3 Justification of the study ................................................................................................... 8 1.4. Research questions ........................................................................................................... 9 1.5 General objective ............................................................................................................ 10 1.5.1 Specific objectives .................................................................................................... 10 CHAPTER TWO ..................................................................................................................... 11 2.0 Introduction ..................................................................................................................... 11 2.1 intermittent preventive treatment of malaria in pregnancy using sulfadoxine- pyrimethamine ...................................................................................................................... 12 2.2 The coverage of IPTP Sub-Sharan countries .................................................................. 14 2.3 IPTp-SP Coverage in Ghana ........................................................................................... 14 2.3.1 Socio-demographic factors affecting IPTP-SP uptake ............................................. 15 2.3.2 Age ........................................................................................................................... 15 2.3.3 Marital Status ........................................................................................................... 16 2.3.4 Education .................................................................................................................. 16 2.3.5 Occupation and Religion .......................................................................................... 16 2.3.6 Locality (Residence) ................................................................................................. 17 2.3.7 Parity ........................................................................................................................ 18 2.4 Number of ANC visits ................................................................................................. 18 2.5 Individual-based factors .................................................................................................. 20 2.5.1 Maternal, ANC health-seeking behaviour ................................................................ 21 University of Ghana http://ugspace.ug.edu.gh viii 2.5.2 IPTp-SP and LLIN (Intervention) ............................................................................ 22 2.5.3 IPTp-SP and LLINs. ................................................................................................. 22 CHAPTER THREE .................................................................................................................. 25 3.0 Study Design ................................................................................................................... 25 3.1 Study Areas ..................................................................................................................... 25 3.1.1 Pentecost Hospital .................................................................................................... 25 3.1.2 Madina Polyclinic (Kekele) ...................................................................................... 26 3.2 Study Population ............................................................................................................. 26 3.3. Inclusion criteria ............................................................................................................ 27 3.4 Exclusion Criteria ........................................................................................................... 27 3.5 Sample Size .................................................................................................................... 27 3.5.1 Definition of Variables in the Formula .................................................................... 27 3.5.2 Gaps and yearly coverages of the health facilities under study. .............................. 28 3.5.3 Quota distribution of respondents per facility .......................................................... 28 3.6 Study Variable ................................................................................................................ 29 3.7 Data Collection Technique ............................................................................................. 31 3.8 Sampling approach ......................................................................................................... 32 3.9 Pre-testing of the instrument ........................................................................................... 32 3.9 Data Quality Control ....................................................................................................... 33 3.9.1 Training of Research Assistants ............................................................................... 33 3.9 Data Processing and Analysis ......................................................................................... 33 3.10 Ethical Consideration .................................................................................................... 34 3.10.1 Possible Benefits and Risks .................................................................................... 35 3.10.2 Informed Consent ................................................................................................... 35 3.10.3 Confidentiality ........................................................................................................ 35 3.10.4 Data Storage ........................................................................................................... 35 3.10.5 Proposal and Funding Information ......................................................................... 35 3.10.6 Compensation ......................................................................................................... 35 3.10.7 Voluntary Participation .......................................................................................... 36 3.10.8 Conflict of Interest .................................................................................................. 36 3.10.9 Compensation ......................................................................................................... 36 3.10.10 Risk and benefits .................................................................................................. 36 3.10.11 Safety Considerations ........................................................................................... 36 CHAPTER FOUR .................................................................................................................... 37 University of Ghana http://ugspace.ug.edu.gh ix 4.0 Socio-demographic Characteristics of Respondents ...................................................... 37 4.1 Facility based factor that affects optimal IPTp-SP uptake. ............................................ 39 4.2 Monitoring of Patient Adherence to the IPTp-SP course by Health workers ................. 40 4.3 The uptake of IPTp-SP among pregnant women ............................................................ 40 4.4 Respondent's Knowledge of IPTp-SP up-take ................................................................ 41 4.5 Pay-out-of-pocket services. ............................................................................................ 42 4.6 Maternal health records review data extraction form ..................................................... 43 4.7 Haemoglobin level among respondents .......................................................................... 44 4.8 Assessment of ANC Staff ............................................................................................... 44 4.9 How malaria is transmitted ............................................................................................. 45 4.10 The dangers of malaria to a pregnant woman (Patient factor) ...................................... 46 4.11 Respondents views on when to take IPTp-SP (Patient factor) ..................................... 47 4.12 Respondent's knowledge of IPTp-SP............................................................................ 49 4.13 IPTp-SP Uptake among Postnatal care women ............................................................ 49 4.14 Type of Side Effects Respondents Experience ............................................................. 51 4.15 Association Between Respondent Demography and IPTp-SP Uptake in Pregnancy ... 51 4.16 Bivariate Analysis of the respondent’s knowledge of IPTp-SP and IPTp-SP Uptake . 54 4.17 Bivariate analysis of client characteristics and uptake of IPTp-SP .............................. 57 4.18 Socio-demographic factors influencing IPTp-SP uptake ............................................. 60 4.19 Multivariate analysis with the uptake of IPTp-SP ........................................................ 64 CHAPTER FIVE ...................................................................................................................... 67 5.0 The uptake of IPTp-SP in Postnatal Mothers ................................................................. 67 5.1 IPTp-SP uptake ............................................................................................................... 68 5.2 SOCIAL DEMOGRAPHIC FACTORS AFFECTING IPTP UPTAKE........................ 69 5.3 HEALTH FACILITY FACTORS .................................................................................. 73 CHAPTER SIX ........................................................................................................................ 76 6.1 CONCLUSIONS ............................................................................................................ 76 6.2 Limitations of the Study. ................................................................................................ 77 6.3.1 Health Facility-Based (Both health facilities) .......................................................... 77 6.3.2 District, regional and National Levels ...................................................................... 78 References ................................................................................................................................ 79 APPENDIX A .......................................................................................................................... 91 University of Ghana http://ugspace.ug.edu.gh x LIST OF TABLES Table 3.1: Gaps in IPTp-SP uptake .......................................................................................... 28 Table 3.2:Quota distribution of respondents ............................................................................ 28 Table 3.3:Study Variables and their operational definitions .................................................... 29 Table 4.1: Respondent's Socio-demographic information ....................................................... 37 Table 4.2: Uptake of IPTp-SP among pregnant women……………………………………………………………………………………..…39 Table 4.3: The respondents’ knowledge of IPTp-SP uptake………………………………………………………………………………….…….40 Table 4.4: Pay-out-of-pocket services………………………………………………………………………...……………40 Table 4.5: Sulphadoxine Pyrimethamine assessment .............................................................. 43 Table 4.6:Assessment of health staff ....................................................................................... 45 Table 4.7: What are the dangers of malaria to a pregnant woman. .......................................... 47 Table 4.8:Respondents views on when to take IPTp-SP ......................................................... 48 Table 4.9: IPTp-SP Uptake among Postnatal care women ...................................................... 50 Table 4.10: Test of association between respondent demography and IPTp-SP uptake in pregnancy ................................................................................................................................. 52 Table 4.11: Bivariate Analysis of the respondent’s knowledge of IPTp-SP and IPTp-SP Uptake .................................................................................................................................................. 55 Table 4.12: Bivariate analysis of client characteristics and uptake of IPTp-SP ...................... 58 Table 4.13: Un-adjusted (COR) and Adjusted (AOR) Regression model to determine the statistical association between respondent demography and IPTp-SP uptake. ........................ 61 Table 4.14: Multivariate analysis of some patient factors with the uptake of IPTp-SP .......... 64 University of Ghana http://ugspace.ug.edu.gh xi LIST OF FIGURES Figure 1: Conceptual framework of IPTp-SP uptake. Source: Adapted and modified from Hein and Hoa (2009) .......................................................................................................................... 8 Figure 4.1: How helpful were the health professionals. .......................................................... 39 Figure 4.2: How well did the health workers monitor your adherence to the course? ............ 40 Figure 4.4: How is malaria transmitted. ................................................................................... 46 Figure 4.5: Respondent's knowledge of IPTp-SP .................................................................... 49 University of Ghana http://ugspace.ug.edu.gh xii LIST OF ABBREVIATIONS ACT Artemisinin-based combination therapy ANC Antenatal care CDC Centre for Disease Control CI Confidence Interval DHIMS District Health Information Management System DM Diabetes Mellitus DOT Directly Observed Therapy DRC Democratic Republic of Congo FANC Focused antenatal care G6PD Glucose-6-phosphate dehydrogenase deficiency GHS Ghana Health Service IPT Intermittent Preventive Therapy IPTp-SP Intermittent Preventive Treatment with sulphadoxine-pyrimethamine ITN insecticide-treated bed nets LBW Low Birth Weight LLIN Long-lasting insecticide-treated nets MDGs Millennium development goals MiP Malaria in Pregnancy MIS Malaria indicator survey mTOR Mammalian target of rapamycin NADPH Nicotinamide adenine dinucleotide phosphate NMCP National Malaria Control Programme OR Odds Ratio PCR Polymerase chain reaction University of Ghana http://ugspace.ug.edu.gh xiii RBCs Red blood cells RBM Rollback malaria RDT Rapid Diagnostic Test SCA Sickle Cell Anaemia SDG Sustainable Development Goal SP Sulphadoxine- Pyrimethamine SSA Sub Saharan Africa WHO World Health Organization University of Ghana http://ugspace.ug.edu.gh xiv OPERATIONAL DEFINITION OF TERMS  Optimal IPTp-SP / (IPTp3+): This refers to more than three (3) doses of IPTp-SP received.  Suboptimal IPTp-SP Uptake: This refers to less than three (3) doses of IPTp-SP received.  IPTp-SP1: This refers to only one (1) dose of IPTp-SP received.  IPTp-SP2: This refers to two (2) doses of IPTp-SP received.  IPTp-SP3: This refers to three (3) doses of IPTp-SP received. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.0 Background About 50 million women living in malaria-endemic countries become pregnant yearly (World Health Organization (WHO) 2018). Of this number, more than 50% live in tropical areas of Africa with high transmission of Plasmodium falciparum (WHO 2018). Countries in sub- Saharan Africa (SSA) continue to suffer disproportionally from malaria, with pregnant women and children under age five being the most vulnerable to malaria infection (Badirou et al. 2018; Owusu-Boateng and Anto 2017; WHO 2017). Estimates show that between 3.1 and 3.5 million cases of clinical malaria, including malaria in pregnancy, are reported in public health facilities each year, with considerable seasonal variations (Fullman et al. 2019; Hemingway 2020; Kayentao et al. 2021; Slutsker and Kachur 2021; West et al. 2021). An estimated 10,000 women and 200,000 infants die due to malaria during pregnancy, and severe malarial anaemia contributes to more than half of these deaths (WHO 2018). Malaria is endemic in Ghana, with some 30 million people exposed to malaria infections (United States Agency for International Development (USAID) 2017; WHO 2018). Seasonal variations exist and are more pronounced in the northern part of the country. About 31.4 % of all patients reporting for outpatient services, 31.3% of all hospital admissions, and 31.7% of all deaths in children under age five reported in Ghana are due to malaria infections (Malaria Indicator Survey (MIS),2019). Available evidence shows that malaria among pregnant women accounts for about 14% of outpatient cases, 11% of hospital admissions, and 9% of deaths (Boateng et al. 2018; GHS 2016; Odjidja, Kwanin, and Saha 2017). To reduce the burden of malaria in SSA, the Ghana government and development partners have deployed several strategies to deal with the problem, especially among pregnant women, neonates and infants (Mathonga et al. 2018; Snow et al. 2018; WHO 2016). In the 1990s, University of Ghana http://ugspace.ug.edu.gh 2 malaria prevention during pregnancy in sub-Saharan countries was based on a weekly administration of chloroquine prophylaxis during Antenatal Care (ANC) visits (Steketee et al. 2001). As a result of pregnant mothers' poor adherence to treatment outside of the medical environment and the resistance of the Plasmodium falciparum parasite to chloroquine, this strategy became inefficient (Braun et al., 2015; Sirima et al., 2018; Slutsker and Kachur 2018). In 2000, the WHO recommended intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) in daily or weekly doses as a new strategy for preventing malaria in pregnancy to replace chloroquine chemoprophylaxis for pregnant women attending ANC (Yoder et al. 2015; Hill and Kazembe 2006; WHO 2004, 2005). Malaria among pregnant women is a significant public health concern, particularly in sub- Saharan Africa (SSA), where malaria exerts the highest health and socio-economic burden (Kwenti, 2018). The primary infection parasite, plasmodium falciparum, is responsible for 99% of all malaria cases during pregnancy (Bauserman et al., 2019). In 2018, about 29% (over 11 million) of all malaria cases occurred among pregnant women, with most cases in SSA – West and Central Africa (35%), followed by East and Southern Africa (20%) (Berry et al. 2018). Out of the over 38 million pregnancies in SSA in 2018, over 5.5 million children had low birth rates, and 872,000 were due to malaria infection. About 70% of malaria deaths were recorded among pregnant women and their children under age five. In addition to vector control and prompt diagnosis and effective treatment of malaria, the WHO recommends intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) - the only antimalarial currently recommended for malaria-endemic areas in Africa (WHO, 2019). IPTp-SP use is integral to WHO’s three-pronged approach to preventing and treating malaria during pregnancy. The package includes insecticide-treated mosquito nets (ITNs) and effective case management (WHO 2015; WHO 2014). Until 2012, IPTp-SP consisted of administering three doses to pregnant women after the first trimester of pregnancy (WHO 2018). In 2012, University of Ghana http://ugspace.ug.edu.gh 3 however, after research had shown the safety of IPTp-SP, WHO updated its policy and recommended IPTp3 SP for all pregnant women at each ANC visit from the second trimester till delivery, with doses administered at least one month apart (Kayentao et al. 2013; WHO 2014). According to Clara (2020), about a 48.3% gap existed between IPTp1 and IPTp3 globally, of which 29.3% were from SSA countries. Data from four SSA countries reported that out of a total of 3911 women who were interviewed from March to October 2018, the coverage of at least three doses of optimal IPTp (IPTp3+) was 22% and 24% in DRC project districts; 23% and 12% in Madagascar districts; 11% and 16% in Nigeria local government areas; and 63% and 34% in Mozambique districts. This study reports the baseline estimates of IPTp3+ coverage in four SSA countries where community delivery of optimal IPTp is being evaluated as part of the called TIPTOP project. This assessment was conducted before the implementation of a community IPTp programme. The optimal uptake of IPTp3+ was less than 25% in three of the four study countries, namely DRC, Madagascar and Nigeria. Unexpectedly, in Mozambique, the estimates of optimal IPTp3+ uptake were considerably higher, especially in the Nhamatanda district where it was 63% (before (1st figure) and After (2nd figure). In DRC, Madagascar, and Nigeria, more than two-thirds of women attending at least four antenatal care visits during pregnancy received less than three doses (< 3) of IPTp (suboptimal) (Duran, 2020). As of 2016, 36 African countries had provided IPTp3 to pregnant women (WHO, 2017). However, many countries are still far from achieving their targets for optimal IPTp uptake, generally 80% (PMI, 2018). In 2016, the WHO estimated that IPTp1, 2, and 3 coverage was 56%, 43%, and 19%, respectively (WHO, 2017). The gap between high ANC attendance and the low proportion of eligible pregnant women receiving suboptimal IPTp3 primarily reflects a failure of the health system to provide optimal IPTp-SP at ANC facilities (Andrews, 2016). The decrease in coverage between IPTp-SP1 and subsequent doses are a great concern. University of Ghana http://ugspace.ug.edu.gh 4 Intermittent Preventive Treatment of malaria in pregnancy (IPTp) is an entire therapeutic course of antimalarial Sulfadoxine-Pyrimethamine (SP) medicine given to pregnant women in their second trimester at routine antenatal care visits, regardless of whether the recipient is infected with malaria (WHO, 2016). In addition to the several maternal morbidities, including anaemia, infants born to mothers with untreated malaria have reduced immunity to malaria and are at increased risk of placental malaria, rapid malaria progression, and death (WHO, 2019). IPTp-SP has several benefits for the mother and her unborn child. These include reducing maternal and fetal anaemia, placental parasitaemia, low birth weight, and neonatal mortality (Eisele, 2016). The objectives of reducing and eliminating the malaria burden are intrinsically linked to most of the Sustainable Development Goals (SDGs). They are central to SDG 3, which seeks to ensure healthy lives and promote well-being for all ages. Unlike other parts of Africa, countries in North Africa, such as Morocco in 2010 and Algeria in 2019, have eliminated malaria, and other countries, such as Egypt, have attained three consecutive years of zero non-indigenous cases (WHO, 2019). However, malaria is still highly endemic in SSA (WHO, 2019). For instance, over 50% of all malaria cases occurred in countries such as Nigeria (25%), DR Congo (12%), Uganda (5%), Cote d'Ivoire (4%), Mozambique (4%), and Niger (4%). In Ghana and Nigeria, notable cases of increase in malaria (8% and 6%, respectively) were recorded in 2018 (WHO, 2019). The WHO revised the IPTp- SP policy in 2012 and recommended that all areas with moderate to high malaria transmission in Africa should increase access to three doses of IPTp-SP. Since then, several countries have revised their IPTp-SP policy to reflect the new three-dose recommendation. Ghana was the first country in SSA to revise its policy in 2012. Other countries such as Angola, DR Congo, Guinea, Malawi, and Senegal revised their policy in 2013, and most countries adopted the three doses of IPTp-SP policy in 2014 (Henry, 2018). However, progress toward improving the three University of Ghana http://ugspace.ug.edu.gh 5 doses of IPTp-SP uptake among pregnant women has been inadequate, and country and regional variations have been recorded. Recent studies still show that the uptake of three or more doses of SP is still low in some countries, even after the new WHO policy. There are still stock-out issues and non-adherence to protocols by healthcare providers. Several other service-related and community factors, such as the unavailability of skilled attendants at ANC, staff's poor attitudes, and travel distance to health facilities, still hinder the implementation of IPTp-SP. Sometimes, the women are given the drug, yet they do not swallow it as it is not always given as Directly Observed Therapy. Reports of low IPTp-SP coverage in many endemic countries in Africa raise concerns about achieving the higher targets in the new WHO policy. In 2012, the median coverage of at least one, two and three doses of SP during pregnancy in SSA was 64% (range 25-85%), 38% (range 10-64%), and 23% (range 2-44%), respectively. 1.1 Problem Statement Despite the established efficacy of Intermittent Preventive Treatment (IPT) in preventing malaria-related complications during pregnancy, there exists a significant gap in understanding the multifaceted factors influencing the optimal uptake of IPT among postnatal women in the La-Nkwantanang Madina Municipality. Malaria remains a critical public health concern in the region, particularly for postnatal women who are susceptible to the adverse effects of the disease. Current research indicates that despite the availability and accessibility of IPT, its uptake among postnatal women remains suboptimal (WHO, 2019; Ghana Health Service, 2021). Moreover, while existing literature underscores the importance of antenatal care in promoting IPT, there is a scarcity of research examining the postnatal period's unique dynamics, hindrances, and facilitators associated with IPT adherence (Mbonye et al., 2015; Hill et al., 2020). The transition from antenatal to postnatal care represents a critical juncture, and University of Ghana http://ugspace.ug.edu.gh 6 understanding the contextual factors influencing IPT uptake during this phase is imperative for designing targeted interventions. Socioeconomic determinants, cultural beliefs, healthcare infrastructure, and knowledge gaps have been identified as potential barriers to optimal IPT uptake in various settings (GSS, 2018; Ayub et al., 2017). However, the specific nuances of these factors in the La-Nkwantanang Madina Municipality remain unexplored. Addressing this research gap is crucial for tailoring interventions that are contextually relevant and effectively promote IPT adherence among postnatal women, contributing to the overall reduction of malaria-related morbidity and mortality in this vulnerable population. Therefore, this research aims to comprehensively investigate the factors influencing the optimal uptake of Intermittent Preventive Treatment among postnatal women in the La- Nkwantanang Madina Municipality, providing evidence-based insights for the development of targeted interventions and policy recommendations. 1.2 The Conceptual Framework The conceptual framework is an overview of some of the factors contributing to the utilization of IPT in the district and how the uptake of IPT influences malaria in pregnancy leading to maternal morbidity, perinatal deaths, and poor birth outcomes. It provides a framework within which this study will be conducted. The socio-demographic factors of the respondents provide their general characteristics such as age, income level, marital status, parity, educational background and occupation. The factors influence the healthcare-seeking attitude of the respondents and may likely affect ANC attendance and IPTp utilization. The obstetric factors of the respondents, such as the parity, gravidity and ANC visits, may also influence the level of uptake of IPTp-SP by pregnant women. Multiparous pregnant women are more likely to adhere to the optimal uptake of higher doses of IPTp-SP compared to nulliparous women. Also, the number of times a pregnant woman visits the ANC units throughout her pregnancy will University of Ghana http://ugspace.ug.edu.gh 7 likely influence the number of doses of IPTp-SP the woman will take. The individual-based factors of the respondent, such as knowledge of IPT, distance to health facility and side effects of the drug, influence the level of uptake of IPTp-SP by pregnant women. Pregnant women who are well aware of IPT and its importance are likely to go in for higher doses of IPTp-SP compared to pregnant women with little or no knowledge of IPT. Health system factors such as the availability of SP, the practice of Direct Observation Therapy (DOT) and the cost of ANC services may also influence the uptake of IPTp-SP by pregnant women. The availability of SP at various health facilities that provides ANC services is likely to increase the uptake of IPTp-SP by pregnant women compared to health facilities without SP. Using IPTp-SP will reduce the risk of malaria in pregnancy, invariably influencing maternal morbidity, perinatal deaths and poor birth outcomes due to malaria in pregnancy. (See Fig 1.0 below). University of Ghana http://ugspace.ug.edu.gh 8 Figure 1: Conceptual framework of IPTp-SP uptake. Source: Adapted and modified from Hein and Hoa (2009) 1.3 Justification of the study Among the three package interventions fronted by WHO and adopted by Ghana for fighting MiP (NMCP, 2016), a 2015 report on 20 African countries showed that IPTp-SP intervention had the lowest coverage (WHO, 2016). This is evident in Ghana because, four years after the IPTp- SP5 strategy was rolled out, in 2018, IPTp-SP5 coverage was 10.8% (NMCP, 2019). Furthermore, the World Malaria Report (2016) data indicates that one in every five pregnant women did not receive ANC (20%) in 2015. However, among those that received ANC, 30% did not receive even a single dose of IPTp-SP, and many did not complete the full schedule recommended by the WHO. University of Ghana http://ugspace.ug.edu.gh 9 In 2017 Ghana reported an optimal dose (3+ doses) IPTp uptake of only 38.5%, while ANC visits stood at about 87.3% (Odjidja et al., 2017). Nevertheless, the Ghana antimalarial drug policy requires that IPTp-SP be administered as Directly Observed Therapy (DOT) monthly from pregnancy until delivery (GHS, 2010). According to the NMCP annual report (2018), the Greater Accra region generally had fewer MiP cases than the country on average. However, despite recording fewer MiP cases than any of the regions in Ghana, the Greater Accra region has performed below the national target in optimal IPTp-SP uptake (46.7%, 80%). This is also reflected in the IPTp-SP coverage in La Nkwantanang municipality (DHIMS2, 2019). This influenced the selection of this study area. It seeks to provide evidence-based research regarding the level of optimal IPTp-SP uptake and associated factors among mothers who received ANC services at the different health facility levels in the municipality. Based on the above, the prevalence of the optimal IPTp-SP uptake among Postnatal care mothers in Madina Municipality will be addressed in this study. Also, facility-based factors that could contribute to the optimal IPTp-SP uptake among the respondents as well as patient-related factors that are associated with the uptake between IPTp-SP1 and IPTp-SP3 (suboptimal) will be elaborated on in the study. 1.4. Research questions 1. What is the prevalence of the optimal IPTp-SP uptake among Postnatal care mothers in Madina Municipality? 2. What facility-based factors could associate to the optimal IPTp-SP uptake among the respondents? 3. What could be the patient-related factors that are associated with optimal IPTp-SP uptake? University of Ghana http://ugspace.ug.edu.gh 10 1.5 General objective To determine factors influencing the optimal IPTp-SP uptake among women attending postnatal clinic at Pentecost hospital and Madina Polyclinic (Kekele). 1.5.1 Specific objectives 1. To determine the prevalence of optimal IPTp-SP uptake among women attending postnatal clinic at Pentecost hospital and Madina Polyclinic (Kekele). 2. To determine facility-based factors associated with optimal IPTp-SP uptake among the respondents. 3. To determine patient-related factors associated with optimal IPTp-SP uptake among postnatal care mothers. University of Ghana http://ugspace.ug.edu.gh 11 CHAPTER TWO LITERATURE REVIEW 2.0 Introduction Malaria in pregnancy (MiP) is a significant public health problem. There is a wealth of evidence showing that malaria (both infection and clinical disease) is higher in pregnant than in non- pregnant women. In endemic countries, malaria in pregnancy (MiP) is a significant public health problem (De Beaudrap et al., 2013). MiP may be due to immunological, hormonal changes or other factors occurring during pregnancy (Tobin-West & Kanu, 2016). Most of the available evidence is on Plasmodium falciparum and P. vivax. However, there is much less information for the latter than for P. falciparum, while little is known about the burden of P. ovale and P. malariae, the other two human malaria species. Where transmission is stable and relatively high, mainly in sub-Saharan Africa, adults have acquired immunity against malaria, including pregnant women who can control but not clear malaria infections despite the immune tolerance occurring during pregnancy (Kwenti, 2018). Therefore, asymptomatic infections are common in this high-risk group, while clinical malaria is rare. A recent review of studies carried out in sub-Saharan Africa between 2000 and 2011 reports that malaria prevalence in pregnant women attending antenatal clinics was 29.5% (95%CI: 22.4 -36.5) in East and Southern Africa, and 35.1% (95%CI: 28.2-41.9) in West and Central Africa, while the prevalence of placenta malaria was 26.5% (95%CI: 16.7-36.4) in East and Southern Africa, and 38% (95%CI: 28.4-47.6) in West and Central Africa (Yaya et al., 2018). More recently, the reported malaria prevalence was lower, reflecting the recent decrease in malaria transmission in several African countries (Chico et al., 2012). Most of the prevalence estimates were done by microscopy, and they would probably be higher if more sensitive methods like PCR or placental histology were used (Okell et al., 2012; Walker et al., 2017). In addition, blood samples were collected at different times during pregnancy, increasing the University of Ghana http://ugspace.ug.edu.gh 12 difficulty of comparing different estimates. In areas of low, unstable malaria transmission, mainly the Asia-Pacific region and South America, pregnant women have lower acquired immunity, and malaria infections are more likely to evolve towards clinical disease. In these areas, the number of pregnancies was estimated at 70.5 million in 2007 (Samahidu, 2017). In the Asia-Pacific region, the median proportion of women with peripheral infection has been estimated at 15.3% and that with placenta malaria at 11%. For South and Central America, less data on the burden of malaria in pregnancy is available. In Peru, the cumulative incidence of clinical malaria in pregnant women between January, August 2004 and 2005 was 43.1% compared to 31.6% in non-pregnant women. This study also suggested that subclinical malaria infections may frequently occur among pregnant women in this region, despite the relatively low transmission and that passive surveillance, i.e., data collection at health facilities, may underestimate the actual burden of MiP. In Colombia, malaria prevalence among parturient women attending the local hospital was 13% determined by microscopy and 32% by PCR. In the same study, the prevalence of placenta malaria was 9% by microscopy and 26% by PCR. 2% and 13% of cord blood samples were positive by microscopy and PCR. Maternal factors associated with the risk of malaria in pregnancy include maternal age, parity and gestational age (Alessandro, 2013). (Leke et al., 2010; McClure, 2013; Takem & D'Alessandro, 2013). 2.1 intermittent preventive treatment of malaria in pregnancy using sulfadoxine- pyrimethamine According to WHO, every effort should be made to integrate IPTp-SP with initiatives promoting focused antenatal care (FANC) services. Also, they recommend a schedule of at least four antenatal care visits. IPTp-SP should be delivered at each scheduled ANC visit (except during the first trimester and with doses given at least one month apart), and compliance with antenatal care should be encouraged as much as possible. It was stated that SP can be given every month until delivery, with doses given at least one month apart. This University of Ghana http://ugspace.ug.edu.gh 13 will ensure that many women receive at least three doses of SP during pregnancy (World Health Organization, 2014). Furthermore, it should be made available at antenatal care clinics so that pregnant women have immediate access to IPTp-SP during routine care. Despite the known side effects of sulfonamides, SP for intermittent preventive treatment in pregnancy is generally very well tolerated. Mild and transient side effects, including nausea, vomiting, weakness, and dizziness, have been reported by some women, particularly with the first dose of SP. Studies have demonstrated that side effects tend to decrease with further doses. However, it was stated that side effects should be discussed openly and managed in the ANC. The World Health Organization's position on IPTp-SP uptake in pregnancy was well understood. WHO proposes at least four visits before a pregnant woman delivers, which is a good call to follow. However, some mothers report late in some communities due to customs, traditional beliefs, societal norms, and religious practices. These factors affect the woman to compliance with the WHO directives. The strength literature is that (World Health Organization 2014) the call for SP availability at all health facilities will help reduce missed opportunities, low SP uptake, and malaria burden among pregnant women. It will also solve the problem of shortages of SP. The above policy calls for programme managers along the supply chain to make the product available at all regional stores for easy access. Again, the WHO document made it clear that the side effect of the drug (SP) should be made known to pregnant mothers at ANC. This call will help address the hesitancies and low uptake and increase SP coverage. However, in some health facilities, some midwives believed that this would rather reduce ANC attendance, thereby do not focus or dwell much on the side effects during health talks. However, this directive does not address issues of handling side events following drug administration in the literature. Despite the known side effects of sulfonamides, SP for IPTp is generally very well tolerated. Mild and transient side effects, including nausea, University of Ghana http://ugspace.ug.edu.gh 14 vomiting, weakness, and dizziness, have been reported by some women, particularly with the first dose of SP. Studies have demonstrated that side effects tend to decrease with further doses (Clerk et al. 2008, Tagbor et al. 2006). Side effects should be discussed openly and managed in the ANC. 2.2 The coverage of IPTP Sub-Sharan countries Several African countries adopted the WHO IPTp-SP policy for MIP prevention. A study showed that at least thirty-nine sub-Saharan African countries had policies for MIP prevention (Gomez et al., 2014a; Yaya et al., 2018). The World Malaria Report (2013) showed that only 23% of pregnant women in African countries received at least three doses of IPTp-SP. This was short of the 80% global target for IPTp coverage (Mwandama et al., 2015; Walker et al., 2017) 2.3 IPTp-SP Coverage in Ghana In 2003, the Ghana NMCP started implementing the IPTp-SP strategy in some districts in the country. Later in 2005, the program was scaled up to all districts in the country (Gbenatey, 2018). It was reported that 44% received two or more doses of IPTp during their then-recent pregnancies Ghana Demographic Health [(DHS, 2008). Even if the NMCP 85% target was never achieved, this showed substantial progress. NMCP also updated its policy in 2014 to reflect WHO's new recommendations (2012) that required all pregnant women to receive at least three doses of SP from sixteen weeks of gestational age monthly until delivery (PMI, 2016). Given these recommendations, it was important for the women to initiate ANC visits early enough to accomplish the required doses of SP (Oppong et al., 2019). Ghana's target to achieve a 55% uptake of at least three doses of SP in 2015 was never achieved, as merely 41.3% of the women took three or more doses of SP (GHS, 2015). There were 942,755 pregnant women recorded in 2017, of which 68.3% received IPTp1, compared to 64.0% in 2016. Compared with 43.0 % in 2017, 36.7% took IPTp3 in 2016. Lastly, in 2017, 83,890 (8.9%) University of Ghana http://ugspace.ug.edu.gh 15 took up IPTp5 (NMCP, 2018). That same year, Accra's hospital-based research in the capital reported a low IPTp- SP 5 uptake of 14%. (Owusu-Boateng & Anto, 2017). Ghana's approach to IPTp-SP implementation was laudable during a pilot study like SP. The methods, approach and mechanisms seem to follow how community drug trials should be done. The programme started on a smaller scale. This helps to weigh the impact before a larger implementation takes place. Between 2003 and 2005 (two years), even though it wasn’t enough to study drug efficacy, much effort from stakeholders (GHS, MoH, FDA) drove the programme to success. It is also important to note that the paper (DHS, 2008) fails to mention the district which implemented (piloted) this policy. 2.3.1 Socio-demographic factors affecting IPTP-SP uptake A study by Nkoka et al. (2018) did not observe any strong correlation between socio- demographics and IPTp uptake. Below are other factors and how they were studied. 2.3.2 Age Generally, studies reported age as a significant predictor of IPTp uptake (Choonara et al., 2015). For instance, WHO (2014) stated that 20 years of age or under is significantly associated with pregnant women not receiving optimal IPTp-SP uptake. According to Kibusi et al. (2015), participants between 30 to 34 and 35 to 39 were more likely than those in other age groups to complete the optimal IPTp dose. However, Okethwangu et al. (2019) revealed that women older than 34 years were linked with decreased chances of taking optimal IPTp-SP doses. As for Bajaria et al. (2019), women's age was not significantly correlated with the IPTp uptake. The age factor in SP uptake is very important. WHO. (2014) reported that SP uptake is associated with pregnant women in their 20s. The paper fails to give a background on the economy, education and accessibility to a healthcare facility. In areas where education was poor, most young ladies will either get pregnant as teenagers or early 20s. University of Ghana http://ugspace.ug.edu.gh 16 2.3.3 Marital Status In a study of Tanzanian origin, married women or those cohabiting were substantially linked with optimal IPTp-SP uptake than women who never married or were divorced (Kibusi et al., 2015). Similarly, in a Kenyan-based study, married women were more likely to take recommended doses of optimal IPTp-SP than unmarried women (Choonara et al., 2015). This could be due to the potential support provided during pregnancy to their partners since women primarily depend on their husbands for financial support in seeking healthcare in most rural settings in Ghana (Amratia et al., 2019). Otherwise, Bajaria et al. (2019) reported no association. 2.3.4 Education The World Malaria Report (2014) states that having no formal education was significantly associated with pregnant women not receiving optimal IPTp-SP uptake. The same was also reported in a study in Tanzania that has a significant relationship between the level of education and IPTp uptake (Kibusi et al., 2015). Furthermore (Mpogoro et al., 2014), women with a secondary school education or higher were almost twice as likely to have received higher IPTp- SP doses during pregnancy as those who never went to school. In conclusion, these findings informed us that promoting formal education beyond primary school could improve optimal IPTp-SP uptake (Frederico et al., 2018). 2.3.5 Occupation and Religion IPTp-SP uptake was lower among self-employed participants (30.4%) than in other occupational classes (Choonara et al., 2015). In both studies, Sociocultural practices such as religious beliefs or family support limited ANC attendance; thus, IPTp-SP uptake, too (Bajaria et al., 2019; Yaya, Uthman, Amouzou, & Bishwajit, 2018). University of Ghana http://ugspace.ug.edu.gh 17 2.3.6 Locality (Residence) According to Frody (2019), about 41% who live in rural areas are less likely to have completed the uptake of IPTp-SP (Anchang-Kimbi et al., 2020a; Azizi et al., 2020). Even though rural poverty has declined rapidly in recent decades, poverty remains primarily a rural phenomenon, and the poorest in rural areas are at risk of being left behind. The World Social Report 2021 (Lee & Kind, 2021) finds that successes in poverty reduction have not always led to lower rural inequalities or closing the rural-urban divide. Indeed, disparities in access to essential services and opportunities exist within rural areas and between rural and urban areas and can be persistently high for specific population groups, such as indigenous peoples and women. The COVID-19 pandemic has further exacerbated the precarious situation of the rural poor and disadvantaged groups by reducing incomes, limiting mobility and threatening livelihoods and food security. Several financial, administrative, and programme design barriers hinder people's access to social protection in rural areas, even when schemes are available. Few social protection programmes are tailored to rural populations or their specific vulnerabilities and constraints, particularly in developing countries. Beyond ensuring programme availability, understanding these barriers is vital to achieving increased social protection coverage in rural areas. Financially, a lack of stable and sufficient incomes among rural populations hinders participation in social insurance schemes. Agricultural income is highly seasonal and weather- dependent, especially in low-income countries. This makes a regular contribution to social insurance a challenge. Seasonal workers, for example, may earn their primary incomes in a short period during the year. As a result, making regular monthly contributions will be more difficult, particularly at the end of the off-season. Rather than investing their limited financial resources in pensions or other schemes, many people living in poverty in rural areas must prioritize more immediate needs. For social assistance, the costs associated with travelling to University of Ghana http://ugspace.ug.edu.gh 18 banks or other sites to collect benefits, being away from work or complying with programme conditions may reduce the potential benefit of the programme to participants. 2.3.7 Parity There was no significant relationship between pregnancy history and taking the prescribed three or more IPTp-SP doses (Oppong et al., 2019). Those with three or four children may have had some experience with taking SP, especially the drug's side effects with the first dose, and thus may not want to have these encounters leading to lower SP intake (Owusu-Boateng & Anto, 2017). The same conclusion of no association between parity with IPTp uptake was obtained in research by (Bajaria et al., 2019; Ibrahim et al., 2017). So, did Amoran & Ariba (2012) in a study carried out in western Nigeria. On the contrary Tanzanian studies Detected parity as a critical predictor of IPTp uptake (Mwandama et al., 2015). As for Kisibu et al. (2015) and Stephen et al. (2016), low uptake of IPTp was reported by participants with three or more children. 2.4 Number of ANC visits In a study in South West Cameroon, among 465 study participants, 463 (99.4%) women attended antenatal clinics at least once during pregnancy, but only 61.9% (288) completed the recommended four or more ANC visits. Uptake of adequate SP dosage varied significantly (p < 0.001) according to the timing of ANC initiation and the number of clinic visits (Anchang & Kimbi et al., 2014). More than half (53.1%, 199/375) of the participants in a study in the keta district of Ghana had their first ANC visit during the second trimester (13–26 weeks), 44.0% (165/375) during the first trimester and only 2.9% (11/375) had their first ANC visit in the third trimester. The mean gestational age at the first ANC visit was 14.4 ± 6.5 weeks. In the multivariate logistic regression model, after adjusting for characteristics of participants, having ≥8 ANC visits (AOR=4.51) was significantly associated with adherence to IPTp-SP (Vandy et University of Ghana http://ugspace.ug.edu.gh 19 al., 2019). In a study conducted in Accra by Owusu-Boateng & Anto, (2017), among 255 nursing mothers a Pearson's Chi-square/Fischer's exact test revealed that gestational age at first ANC visit, the total number of visits to the ANC and gestational age at receiving the first dose of SP were significantly associated with uptake of IPTp- SP (p < 0.001). None of the socio- demographic characteristics was associated with IPTp-SP uptake (p > 0.05). A univariate logistic regression analysis revealed that IPTp-SP uptake of ≥3 doses during pregnancy was six times less among respondents registering their first ANC in the third trimester than in the first trimester (COR = 0.06). Uptake of ≥3 doses was 10.76 times higher among women visiting the ANC for ≥ four times during pregnancy than those visiting the ANC for <4 times (COR = 10.7). The odds of receiving ≥3 doses of SP were five times less in women receiving the first dose in the third trimester than in the second trimester (COR = 0.05). IPTp policy in Ghana indicates IPT should be given to pregnant women only after 16 weeks and not after 36 weeks. IPTp timing is associated with the start of ANC visits among pregnant women. Earlier attendance for ANC through the education of clients and staff can increase the proportion of women receiving at least two doses of IPT with SP (suboptimal). Women who are pregnant for the first time may be anxious about sudden physiological changes that they may experience because of the developing foetus and will attend the hospital earlier than those who have had the experience before. This schedule is a suggested adaptation of the WHO ANC schedule for countries implementing IPTp; training should highlight that women attending off-schedule should be attended to appropriately and that it is the interval, rather than the specific weeks, that are most critical. It is recommended that the first dose of IPTp-SP be given as early as possible in the second trimester of pregnancy to ensure optimal protection from malaria for the mother and her baby. However, pregnant women who come later in pregnancy can and should receive their first dose anytime (as long as it is not in the first trimester), with the following doses being given at least University of Ghana http://ugspace.ug.edu.gh 20 1 month apart. When malaria-endemic countries plan their ANC programming, they may wish to add another contact to allow for monthly dosing of IPTp-SP. 2.5 Individual-based factors If pregnant women are educated about IPTp and their level of knowledge increases, it will influence them to attend the ANC and receive SP regularly. Their best and most viable source of this knowledge is at the ANC, where health workers are supposed to educate them. In a study conducted in the Keta district of Ghana, over half of the respondents (52.0%) had a fair knowledge of malaria and Malaria in Pregnancy (MiP), 42.8% had poor knowledge, and only 5.2% had good knowledge about malaria and MiP. The majority (83.5%, 308/375) of respondents knew the optimal IPTp-SP and its benefits. The main source of information on malaria was from ANC/Health facilities, followed by the media. Pregnant women's knowledge of IPTp-SP (AOR=2.74) was significantly associated with adherence to higher doses of IPTp- SP (Vandy et al., 2019). In a study conducted in the Tema metropolis, among 323 respondents, the only service-related factor was found to be significantly associated with the uptake of IPTp- SP. Among those who indicated that they were given prior education/counselling on SP, 31.9% took ≥ 3 doses compared to those who were not given any education/counselling on SP (13.6%) (p=0.001) (Amankwah & Anto, 2019). Maheu-Giroux & Castro (2014) conducted a study exploring the determinants of uptake for both ITNs and IPTp-SP by pregnant women and the role that personal knowledge and socioeconomic status play. A logistic regression model found that attendance at health education sessions was the only factor that predicted IPTp-SP use (OR 1.8). At the same time, high knowledge of malaria predicted the use of ITNs (OR 2.3). It was concluded that individual knowledge of malaria was important for ITN uptake but not for IPTp- SP use. When both interventions were used, severe anaemia postpartum was reduced by 69%. Two hundred ninety-three women were studied in a cross-sectional survey at Kibaha district hospital, Tanzanian, an ethnography study involving two administrative regions in Ghana; the University of Ghana http://ugspace.ug.edu.gh 21 cost of ANC services was found to influence ANC visits and, invariably, the uptake of IPTp- SP. Women who could afford maternal healthcare and MiP services and those who had previously benefitted from such services were happy to access uninterrupted services. Women who could not afford maternal healthcare services resorted to visiting other sources of health care, delaying ANC and skipping scheduled ANC visits. Consequently, some clients did not receive the recommended 5+ doses of SP, others did not obtain LLINs early, and some did not obtain treatment for MiP. Healthcare providers felt frustrated whenever they could not provide comprehensive care to women who could not afford comprehensive maternal and MiP care (Aberese-Ako, Magnussen, Gyapong, Ampofo, & Tagbor, 2020). 2.5.1 Maternal, ANC health-seeking behaviour Maternal health-seeking behaviour is among the few attributes that could influence IPTp-SP uptake. Generally, the number of women utilizing maternal healthcare services has been downward since the turn of the millennium, with many women dying due to maternally related problems. Low utilization of institutional health facilities before delivery (antenatal care), during child delivery (institutional delivery), and after child delivery (postnatal care) is one of the primary reasons that explain the high maternal, infant and child mortality rates in Zimbabwe (Grossman, 2018). Despite increased efforts to reduce maternal-related deaths, such as increasing the number of healthcare centres that provide free maternal health services and removing user fees in most public health institutions, maternal mortality is unacceptably higher than WHO permissible levels of 71 deaths per 100 thousand live births. With such high levels of maternal mortality, some countries could find it challenging to achieve Sustainable Development Goal (SDG) Goal 3 after failing to achieve the Millennium Development Goal 5 target of 185 per 100 thousand live births (World Health Organization, 2015). University of Ghana http://ugspace.ug.edu.gh 22 2.5.2 IPTp-SP and LLIN (Intervention) According to Patricia (2014), about five countries (protocol reviewed) had national documents promoting IPTp-SP, LLINs and MIP case management (Gomez et al., 2014). WHO guidance from 2004 frequently was not reflected: four countries recommended the first dose of IPTp-SP at 20 weeks or later (instead of 16 weeks), and three countries restricted the first and second IPTp-SP doses to specific gestational weeks. Documents from four countries provided conflicting guidance on MIP prevention for HIV-positive women, and none provided complete guidance on managing uncomplicated and severe malaria during pregnancy. Inconsistencies between NMCPs and RH programmes on the timing or dose of IPTp-SP were documented in all countries, as was the mechanism for providing LLINs. Inconsistencies also were found in training documents from NMCPs and RH programmes in a given country. Outdated, inconsistent guidelines can confuse and lead to incorrect practices among health workers who implement MIP programmes, contributing to low coverage of IPTp-SP. 2.5.3 IPTp-SP and LLINs. Placental malaria is thought to occur via Plasmodium avoidance of spleen clearance through the expression of the VAR2CSA protein that binds to the chondroitin sulfate A (CSA) in the placental intervillous space (Rogerson SJ, 2017). Placental malaria accumulates these infected RBCs in the intervillous space and subsequent maternal monocytes/macrophages (McDonald, 2015). Prominent inflammatory infiltration by monocytes/macrophages causing massive chronic intervillositis is related to severe placental malaria. Inflammatory response to placental malaria inhibits critical mTOR signalling. Intervillositis due to placental malaria was associated with increased autophagosome formation but decreased autophagosome/lysosome fusion leading to autophagosome accumulation in syncytiotrophoblasts blocking placental amino acid uptake (Dimasuay, 2017). In mothers with placental malaria, autophagy-related genes were downregulated, leading to autophagy dysregulation and impeding transplacental University of Ghana http://ugspace.ug.edu.gh 23 amino acid transport. Also, blockage of mTOR signalling due to placental malaria leads to decreased placental amino acid uptake. Recently, it was found that placental malaria stimulates placental expression of inflammasomes linked to placental secretion and maturation of IL-1β, a pro-inflammatory cytokine that causes diminished nutrient transporter expression (Reis, 2020). In primigravid women, the proportion of anti-inflammatory maternal vs fetal macrophages showed opposite trends in the setting of placental malaria (Noguchi et al., 2020; Sangho et al., 2021). On the other hand, compared with primigravid women, multigravida women had higher IL-27 and IL-28A, inducing the secretion of protective cytokines against malaria. The influence of the timing of infection changes according to gravidity, as primigravidas with early asymptomatic infection and multigravidas experiencing parasitaemia later in pregnancy, have higher rates of placental malaria (Djontu, 2018). Other than these, a study in Sudan proposed the female fetus's carriage as a novel risk factor for placental malaria (Adam, 2017). Increased pro-inflammatory cytokines, oxidative stress (Megnekou, 2017), and apoptosis lead to pathological changes in the placenta and poor pregnancy outcomes (Sharma, 2017). It has been shown that histopathological changes and placental malaria enhance the risk of preeclampsia in pregnant women, especially in primigravidas. Histopathological changes during placental malaria include hemozoin, perivillous fibrin deposition, syncytial knot formation, and a decrease in villous surface area. These pathologic alterations in the placenta may limit the exchange of nutrients between mother and foetus, increasing the risk of fetal growth restriction and low birth weight babies (Odorizzi, 2018). Placental malaria decreases the abundance of megalin and DAB2 in syncytiotrophoblasts, which may be associated with low birth weight (Ahenkorah, 2019). Increased placental mitochondrial DNA copy number in Papua demonstrated a relationship with reduced birth weight. Malaria infection during early pregnancy leads to alterations in the vascular structure of the placenta, such as a decrease in University of Ghana http://ugspace.ug.edu.gh 24 transport villi volume and an increase in diffusion distance and diffusion vessel surface, which influence birth weight and gestational length. Plasmodium infection mid-pregnancy has been linked to an increased risk of pre-term birth, possibly due to angiogenic, metabolic, and inflammatory changes (Moeller, 2019). Summary and Identification of gaps Since the approval of the introduction of IPTp-SP in 2005 in Ghana, scientists worldwide have tried to study SP at all levels. This is evident in the previous pages of the literature review. Nevertheless, there are some pertinent issues of concern that previous studies on this intervention have not yet addressed. A critical evaluation of the literature review reveals that most studies focusing on factors contributing to or predicting IPTp-SP uptake were quantitatively aimed at evaluating the drug. More than 17 years have elapsed since the SP was introduced in Ghana. Yet little is known about the perceptions of women of reproductive age towards the uptake of SP in a qualitative study, Experiences of the women with SP, and also these social-cultural and economic factors that influence accessibility and acceptability of the drug. This constitutes a knowledge gap. Also, most literature in this study stated that studies were carried out in health facilities settings. I, however, believe that the study's generalisation will be limited by the fact that not all who attend hospitals in a given area are from the same community. University of Ghana http://ugspace.ug.edu.gh 25 CHAPTER THREE METHODS 3.0 Study Design An analytical cross-sectional study was adopted in this study. It was a facility-based study. 3.1 Study Areas 3.1.1 Pentecost Hospital Pentecost Hospital Madina, formerly Alpha Medical Centre, was established in May 1997 by the Church of Pentecost to provide health care to the people in the immediate Madina catchment area and beyond. The hospital was approved by the Government of Ghana and registered with the Christian Health Association of Ghana (CHAG) in 1999. It was also approved as a Budget Management Centre (BMC) by the Ministry of Finance in 2006. The National Health Insurance Scheme Board has duly accredited Pentecost Hospital, Madina. It is designated as La Nkwantanang Madina Municipal Hospital and receives referrals from the clinics and health centres in the municipality and beyond. The facility has a total workforce of 398. The hospital's mission is to be an excellent holistic Christian healthcare institution, providing affordable and quality health care. The hospital's vision is "Healthy Community, Christ's Love and Healing Ministry Fulfilled." The hospital is located at Madina Estate. Pentecost Hospital, Madina, has twenty-three (23) full-time medical officers, including eight (8) specialists. The specialists comprise Obstetricians and Gynaecologists, Paediatricians, Family Physicians, Ophthalmologists, and Radiologists. It has ninety-six (96) nurses. Services provided include; ultrasound scans, MCH clinics, TB, special Diabetics, hypertension, ENT, and eye and dental clinics. The facility has a 58-bed capacity. University of Ghana http://ugspace.ug.edu.gh 26 3.1.2 Madina Polyclinic (Kekele) The clinic started as a child welfare clinic near the old Assembly building. The client numbers increased, and the three nurses who started it saw the need for a bigger space. They, therefore, decided to relocate to kekele Park, as it used to be called in the early 90s. Clinical care became necessary, especially for the babies who attended the welfare clinic. The mothers of Madina carried sand and stones from their various houses and, with assistance from the assembly, constructed a building for child welfare and the treatment of minor illnesses. As the numbers increased, there was a need for more staff, such as medical officers and nurses. The clinic expanded over the years in containers. These containers were used as consulting rooms, offices, antenatal units and other units. All disciplines of nursing care, such as maternal and child health, increased over time. In 2009 the facility was accredited by NHIS. Madina polyclinic kekele shares boundaries with Adenta Municipal to the North, South and East by Tataana Sub-district and to the West by Social Welfare Sub-district. It comprises one static clinic, Madina polyclinic kekele (Atima), and Eight CHPS zones, namely, Redco Dela CHPS, Redco Warehouse CHPS, Aviation CHPS, Doku CHPS, Central Mosque CHPS, Nkwatanang1 and Nkwantanang 2 CHPS zones. All CHPS ZONES are fully operational. (100%) The facility is sited in a strategic location, making assessing the facility less difficult; clients come as far as Dodowa, Oyibi, Aburi, Abokobi Teiman, Ashongman, Agboba, Dome, Kwabenya, Santor, Ashaiman, Botwe, Spintex, East Legon, Okponglo, Bawaleshie Shiashie. 3.2 Study Population The study included all eligible women (postnatal) who delivered in the past three years and consented to the study and all ANC health care workers. Again, all healthcare workers involved in SP administration were interviewed (census) using a semi-structured questionnaire. The average number of postnatal mothers at Pentecost hospital was 2808, while in Madina Polyclinic (Kekele) was 1960 (2019 to 2021 years) University of Ghana http://ugspace.ug.edu.gh 27 3.3. Inclusion criteria 1. All mothers who delivered at the hospital in the past three years and were 18 years and above. 2. Also, the study included postnatal mothers who had registered their children at the CWC six weeks after delivery. 3.4 Exclusion Criteria The following was excluded from the study. 1. Mothers who did not attend ANC at the hospital. 2. Mothers with G6PD deficiencies who were not required to take SP. 3. All postnatal and ANC mothers who were without their ANC records. 4. Mothers receiving Cotrimoxazole prophylaxis throughout pregnancies. 3.5 Sample Size A total sample size of 370 postnatal mothers from all health facilities was used. This was derived from Cochran's sample size formula, as shown below (Cochran, 1972). 3.5.1 Definition of Variables in the Formula n=z2p(1-p) d2 n = minimum sample size required z = confidence level (95% level of confidence = 1.96 P = (uptake of IPTp-SP in the district) =40.5%=0.405 d = the margin of error (5% = 0.05). n =1.962 ∗ 0.405(1 − 0.405) = 370 0.052 University of Ghana http://ugspace.ug.edu.gh 28 3.5.2 Gaps and yearly coverages of the health facilities under study. Table 3.1: Gaps in IPTp-SP uptake Pentecost Hospital IPTp1 IPTp3 Gap Coverages Mean % Coverages 2019 1455 985 470 38% 37% 40.5% 2020 1236 890 346 37% 2021 2326 1560 766 36% Madina Polyclinic (Kekele) IPTp1 IPTp3 gap Coverages Mean 2019 4544 2646 1898 55% 44% 2020 3173 1457 1716 36% 2021 1450 755 695 41% 3.5.3 Quota distribution of respondents per facility Table 3.2:Quota distribution of respondents Pentecost Hospital Registrants Total Participants Respondents 2019 2625 370 2020 2624 2021 3176 222 Average 2808 Madina Polyclinic (Kelele) Registrants Respondents 2019 2264 2020 1869 148 2021 1747 Average 1960 Total 4768 370 University of Ghana http://ugspace.ug.edu.gh 29 3.6 Study Variable Table 3.3: Study Variables and their operational definitions Variables Operational Definitions Type of Variable Measurement Scale Source of Data Dependent Variables Optimal IPTp-SP Uptake Three (3) or more doses of IPTp-SP received during pregnancy Categorical Nominal (Dichotomous) ANC record Book/ Antenatal register Independent Variable Socio-demographic factors Age Age at as last birthday Continuous Ratio ANC record Book/ Antenatal register Marital Status Single, married, divorced, Widow Categorical Nominal ANC record Book/ Antenatal register Educational Background No formal education Primary, JHS, SHS/ vocational, Tertiary Categorical ordinal ANC record Book/ Antenatal register Occupation Formal or informal work or non Categorical ANC record Book/ Antenatal register Income level The income level of the mother (Low, High) Categorical Ordinal Data Collection Instrument Parity Number of children one had ever given birth to Discrete Ratio ANC record Book/ Antenatal register Other independent variables Client-related factors Awareness of SP Low (unaware) or high (aware)-level of awareness Categorical Ordinal Data Collection Instrument ANC attendance Number of ANC visits Discrete Ratio ANC record Book/ Antenatal register University of Ghana http://ugspace.ug.edu.gh 30 Male (Husband) Involvement Number of times client was escorted by their partner for the ANC visits Discrete Ordinal ANC record Book/ Antenatal register Side effects of SP Any adverse drug reaction following SP administration Categorical Nominal ANC record Book/ Antenatal register Knowledge of SP and MIP Good, Poor Categorical Ordinal Data collection instrument Gestational age at first ANC Number of months at which the client first visited the hospital Continuous Ratio ANC record Book/ Antenatal register Gestational age during the first SP dose Number of months at which client received first SP dose Continuous Ratio ANC record Book/ Antenatal register Facility factors a. Health staff factors Level of education Diploma, Undergraduate and Tertiary Categorical Ordinal ANC record Book/ Antenatal register Level of knowledge about MIP/IPTp-SP Low, middle and high (what is the dose, how many doses and when to give them) Categorical Ordinal Survey instrument Perception towards IPTp-SP Do they believe IPTp-SP was effective or not Categorical Nominal Survey instrument DOT policy Do they observe as clients swallow the medication and record it in the client's ANC book? Categorical Nominal MiP Policy SOP Health care worker- patient relationship How do clients perceive attitudes about staff Categorical Nominal Survey instrument b. Health facility factors Categorical Health care worker to patient ratio Average Health Care Provider- Patient Ratio on ANC Clinic Continuous Ratio Survey instrument University of Ghana http://ugspace.ug.edu.gh 31 Drinking water availability availability of a water dispenser or drinking water at the ANC clinic Categorical Nominal Survey instrument Distance to the health facility Accessibility of the health facility Continues Nominal Survey instrument Training status for practitioners IPTp-SP training for ANC Staff Categorical Nominal Availability of SP monitoring Chart Availability of the SP chart and whether it is put into use Categorical Nominal MiP Policy SOP Documentation of SP Doses administered. Is documentation done will in both ANC card and Register Categorical Nominal MiP Policy SOP 3.7 Data Collection Technique Data was collected using a structured questionnaire in a face-to-face interview with participants, coupled with a review of maternal health record booklets of the participants. Research assistants were recruited and trained to assist in the data collection. The questionnaire was interpreted into the appropriate local languages (specifically Twi and Ga) to women who did not understand English language. The questionnaire collected data on socio-demographic and health facility-related factors. The independent variables included educational status, age, antenatal visits, and maternal occupation; whereas the data retrieved from the maternal health records review included; parity, gravida, ANC booking, number of ANC visits, Hemoglobin level at ANC booking, 36 weeks pregnancy and birth, number of IPTp-SP taken and existing conditions. IPTp-SP-related practices such as DOT, water availability, and IPTp-SP posters were observed in the ANC units. The dependent variable was the uptake of SP. Information was also collected on delivery out-comes (still birth, low birth weight and pre-term delivery). University of Ghana http://ugspace.ug.edu.gh 32 3.8 Sampling approach Data collection was conducted at two health facilities: Pentecost Hospital and Madina Kekele Polyclinic. These health facilities were purposively selected due to their high patient inflow and the diversity of pregnant women who visit for antenatal care. Regarding study participants selection, simple random sampling technique was employed. This method involves selecting individuals from the larger population purely by chance, with each individual chosen independently of the others. To begin the selection of participants, a list of postnatal women at both health facilities for the current year 2022 was retrieved from the postnatal register (the sampling frame). Unique identifiers for each postnatal woman in the sampling frame were assigned. This was done consecutively based on the order in which names of the women appeared in the postnatal register. Randomization technique was used to select the first and subsequent participants from the list until the sample size was reached. This method ensured that every postnatal woman in the sampling frame had an equal chance of being included in the sample. After, the researcher reached out to the randomly selected postnatal women via phone calls, explained the purpose of the study, and sought their consent for participation in the study. 3.9 Pre-testing of the instrument Pre-test of the research instrument was conducted at Madina polyclinic (Rawlings circle) and Legon Hospital, among 40 postnatal women (10% of the sample size). This preliminary phase was crucial in identifying and rectifying potential issues with the questionnaire. One significant modification was made concerning the respondents’ age. Initially, the questionnaire had an open-ended question about age, but it was observed that most respondents were hesitant to disclose their actual age. To address this, the age parameter was categorized into different age groups. This enabled respondents to choose an age range that they were comfortable with, University of Ghana http://ugspace.ug.edu.gh 33 thereby increasing the response rate for this particular question. This amendment, along with other minor modifications that addressed ambiguous questions in the questionnaire were made, and further modified to suit the actual survey setting. These changes were aimed at improving the clarity of the questionnaire, increasing the response rate, and ensuring the collection of accurate and reliable data for the study. The revised questionnaire was then used for the main study conducted at the Pentecost Hospital and the Madina Kekele Polyclinic. 3.9 Data Quality Control The questionnaire was pretested at Madina polyclinic (Rawlings circle) and Legon Hospital. These health facilities were chosen because of similarities (geographical settings, language of the people, common practice) between them. 3.9.1 Training of Research Assistants Training of Research Assistant before the pre-testing phase, a crucial step was undertaken to train the research assistants involved in the study. A total of four research assistants were thoroughly trained over a single day, for about 8hours to ensure the integrity and accuracy of the data collection process. The training was comprehensive, covering various aspects such as understanding the objectives of the study, familiarizing themselves with the questionnaire, ethical considerations, and effective communication techniques. This was done to ensure that the research assistants were well-prepared to administer the questionnaire and handle any potential issues that might arise during the data collection process. This rigorous one-day training played a significant role in enhancing the reliability of the study and ensuring that the collected data was both valid and consistent. 3.9 Data Processing and Analysis The forms that were added to the database were approved by the principal investigator (PI). The PI ensured that all items were crossed-checked for completeness and accuracy. The whole University of Ghana http://ugspace.ug.edu.gh 34 database was downloaded in an excel sheet at the end of data collection. The data was cleaned in Microsoft Excel, including variable coding, scoring and other manipulations. Stata version 15, SPSS, and JAMOVI version 2.3.2 were used to analyse the data. To address the first objective, frequencies and percentages described the prevalence of IPTp-SP uptake. The data were summarised in frequency tables, graphs, percentages, mean and standard deviation. Chi- Square Test, Fischer Exact, and logistic regression analysis were used to measure the significance level and the association between all variables and IPTp-SP uptake and pregnancy outcome to address the factors of clients and health facilities. However, Crude odds ratios measured the strength of the association between independent variables, IPTp-SP uptake, and pregnancy uptake. All variables found to be statistically significant in simple logistic regression were again assessed in multiple logistic regression to obtain adjusted odds ratios. A p-value of <0.05 and a 95% confidence interval were the levels of statistical significance to establish the association with the optimal uptake of IPTp-SP. The optimal IPTP-SP uptake was tested using an independent Pearson Chi-square model to test the hypothesis between two variables (dependent and independent). Jamovi (a product of R- Studio), STATA, SPSS, and Excel were used to run the model. The formula; X2 (N= # of participants, df) = Chi-square stat, P= p-value guided the calculation. 3.10 Ethical Consideration Ethical approval for the research was obtained from the Ghana Health Service Ethical Review Committee (GHS-ERC: 045/09/22) before the commencement. Permission was sought from the district health directorate, La Nkwantanang Madina, and each health facility's Medical Director. Verbal informed consent was received from every study participant before data collection. This was done after the purpose of the study. The benefits and rights of the participants were explained to them in a language best understood. Participation in the study University of Ghana http://ugspace.ug.edu.gh 35 was voluntary. All respondents were assured of the confidentiality of every information they provided to the data collectors. 3.10.1 Possible Benefits and Risks There was no risk associated with this study. However, the items in the questionnaire caused the participants to unravel a few of their privacy issues. The participants did not directly benefit from the study. The study findings helped strengthened services rendered at the ANC. There was no monetary gain in this study. 3.10.2 Informed Consent The researchers provided all the needed information, and the participant's consent was also sought. The researcher again informed the participant to ask more questions to understand the procedure before the administration of the instrument began. 3.10.3 Confidentiality Personal data collected was not shared with anyone (third part). The participants were informed that their information was kept secret. Their right was again respected during and after the data collection. 3.10.4 Data Storage The data that was generated was kept under lock (password). The result was made known to the hospital directors and heads of the various units and presented at a DHIM meeting. 3.10.5 Proposal and Funding Information There was no sponsoring agency in this study. The researcher was responsible for financing the research from her resources. 3.10.6 Compensation The participants were not given any money for their time. However, they were gratefully thanked at the end of the data collection. University of Ghana http://ugspace.ug.edu.gh 36 3.10.7 Voluntary Participation Neither the principal investigator nor the assistants forced the participants to respond to the questionnaire. 3.10.8 Conflict of Interest There was no conflict of interest in this study. 3.10.9 Compensation Respondents did not receive any form of compensation, and this was made known to them before they consented to be part of the study. 3.10.10 Risk and benefits No risk, cost, or direct benefit was associated with participating in the study. However, the respondents spent time answering the questions. Again, the study's findings helped contribute to policy decisions that improved the quality of healthcare delivery in the facilities. 3.10.11 Safety Considerations There was no physical or social harm in participating in the study. Research assistants ensured that study participants were stable before engaging them to respond to the questionnaire. University of Ghana http://ugspace.ug.edu.gh 37 CHAPTER FOUR RESULT 4.0 Socio-demographic Characteristics of Respondents Results indicated that, of the total number of respondents, 60% (222/370) were from Pentecost hospital. A greater proportion 37% (136/370) of the respondents were between the ages 20-29 years. Majority of the respondents 96% (355/370) were from Urban communities and most of them 61% (225/370) were married. Again, a greater percentage 65% (242/370) of respondents had primary education with a significant proportion 61% (227/370) being self-employed. More than half of the respondents 54% (201/370) earned between 300 – 1000 cedis as income with majority 68% (250/370) stating that they were Christians. Also, a greater number of the respondents 92% (340/370) had their children born in an institution with just a few 47% (175/370) having NHIS insurance. Details are found in table 4.1 and 4.2 below. Table 4.1: Respondent's Socio-demographic data Demographic Variables Frequency Percentage (n=370) (%) Health Facility Type Madina Kekele Polyclinic 148 40.0 Pentecost Hospital 222 60.0 Age Category 10-19years 29 7.8 20-29years 136 36.8 30-39years 124 33.5 40-49years 81 21.9 Residence Rural 15 4.1 Urban 355 95.9 Marital Status Co-habiting 17 4.6 Divorced 9 2.4 Married 225 60.8 Prefer not to say 20 5.4 Separated 1 0.3 Single 97 26.2 Widowed 1 0.3 University of Ghana http://ugspace.ug.edu.gh 38 Level of education No formal education 34 9.2 Primary Education 242 65.4 Senior High Education 66 17.8 Tertiary Education 28 7.6 Occupation Government Sector Employee 25 6.8 Non- Government sector employee 31 8.4 Self-employed 227 61.4 Unemployed 87 23.5 Income level 300-1000 cedis 201 54.3 Dependent 23 6.2 Less than 300 cedis 12 3.2 More than 1000 cedis 14 3.8 No regular income 120 32.4 Religion African Traditional 25 6.8 Christianity 250 67.6 Islam 60 16.2 Prefer not to say 35 9.5 Ethnicity Akan 73 19.7 Ewe 54 14.6 Ga-Dangme 82 22.2 Northern tribes 161 43.5 NHIS status Insured 175 47.3 No health insurance 195 52.7 Place of delivery Home delivery 30 8.1 Institutional delivery 340 91.9 Gravidity(pregnancy) Four 74 20.0 Five 37 10.0 One 65 17.6 Three 103 27.8 Two 91 24.6 Parity(deliveries) Five 73 19.7 Four 35 9.5 One 71 19.2 Three 93 25.1 Two 98 26.5 Reported malaria pregnancy No 328 88.6 Yes 42 11.4 University of Ghana http://ugspace.ug.edu.gh 39 IPTp-SP doses received One 91 24.6 Two 178 48.1 Three 40 10.8 Four 24 6.5 Five 37 10.0 Ever heard about IPTp-SP? No 7 1.9 Yes 363 98.1 Bed net use No 348 94.1 Yes 22 5.9 ANC visit 1st Trimester 162 43.8 2nd Trimester 200 54.1 3rd Trimester 8 2.2 4.1 Facility based factor that affects optimal IPTp-SP uptake. Majority of the respondents 87% (323/370) stated that the health personnel in charge of IPTp- SP administration were very helpful. Details can be seen in fig.4.1 below. Figure 4.1: How helpful were the health professionals. 3 367 3 10 34 323 0 50 100 150 200 250 300 350 400 No, I took it home Yes, it was taken at the hospital Not at all Fairly helpful Quite helpful Very helpful SP Taken at Home or hospital How helpful were the health professionals University of Ghana http://ugspace.ug.edu.gh 40 4.2 Monitoring of Patient Adherence to the IPTp-SP course by Health workers A significant proportion of respondents 57% (211/370) stated that health workers quite strictly monitored their adherence to IPTp-SP administration. Details can be seen in fig.4.2 below. Figure 4.2: How well did the health workers monitor your adherence to the course? 4.3 The uptake of IPTp-SP among pregnant women About 1.4% (5/370) of the respondents said they paid for the IPTp-SP that was administered with majority 63% (233/370) stating that IPTp-SP had significant effect on their pregnancies. Details are found in table 4.2 below. 54 3 211 102 0 50 100 150 200 250 Faily well Not at all Quiet strickly Strickly University of Ghana http://ugspace.ug.edu.gh 41 Table 4.2: Uptake of IPTp-SP among pregnant women IPTp-SP UPDATE Frequency Percentage (n=370) (%) Did you pay for the IPTp-SP drug at the hospital? No 365 98.6 Yes 5 1.4 Have you had a prior pregnancy without being put on the IPTp-SP drugs? No 362 97.8 Yes 8 2.2 To what extent do you think the IPTp-SP has positively affected your health status throughout pregnancy Average effect 157 42.4 Not at all 43 11.6 Significant effect 170 46.0 To what extent has the IPTp-SP positively affected your health status during prenatal and postnatal stages? Average effect 130 35.1 Not at all 7 1.9 Significant effect 233 63.0 4.4 Respondent's Knowledge of IPTp-SP up-take All the respondents 100% (370/370) indicated that IPTp-SP was available at all scheduled times during their ANC. However, only 1% (3/370) of the respondents stated that IPTp-SP was not administrated under DOT throughout. Details are found in table 4.3 below. University of Ghana http://ugspace.ug.edu.gh 42 Table 4.3: The Respondent's Knowledge of IPTp-SP uptake Parameters Frequency (n=370) Percentage (%) Was SP available at all scheduled times during your ANC? Yes 370 100.0 No 0 0.0 Did you have to pay for the SP at any point? Yes 0 0.0 No 370 100.0 Were you prescribed SP to purchase? Yes 0 0.0 No 370 100.0 Was IPTp-SP administered under DOT throughout? Yes 367 99.2 No 3 0.8 4.5 Pay-out-of-pocket services. Most of the respondents 94% (349/370) paid out of pocket (pop) for services such as laboratory investigations. Details are found in table 4.4 below. Table 4.4: Pay-out-of-pocket services. Services Responses Percentage (%) Laboratory investigations 349 94.3 Ultrasound scan 188 50.8 Other medication 363 98.1 University of Ghana http://ugspace.ug.edu.gh 43 4.6 Maternal health records review data extraction form The maternal health record booklet and other services regarding IPTp-SP uptake were reviewed. All (100%) of the health parameters were available and updated. Details can be seen in table 4.5 below. Table 4.5: Sulphadoxine Pyrimethamine assessment Parameter MPC/ Kekele Pentecost Hospital Remarks Presence of water for sale for DOT Yes (100%) Yes (100%) Free, but some mothers come with their water SP available at ANC over the past 6 months Yes (100%) Yes (100%) No shortages were recorded in both physical observation and inspecting the bin cards. Presence of posters of IPTp/MIP on the wall Yes (100%) Yes (100%) It is available but was not updated at the time of the visit. Presence of ANC Monthly Data returns form Yes (100%) Yes (100%) Monthly returns were available with all portions filled and signed before the 5th of the following month (completeness, timeliness) SP given is recorded in ANC Report Book Yes (100%) Yes (100%) Both ANC record books and Register have used the document the SP Presence/Record of Adverse Event forms for SP Yes (100%) Yes (100%) It was seen at the ANC SECTION. After filling it out, the staff then submit it to the pharmacist. Was recording done in both ANC Record book and Register Yes (100%) Yes (100%) Both ANC record books and Register have used the document the SP. University of Ghana http://ugspace.ug.edu.gh 44 4.7 Haemoglobin level among respondents From the maternal health record booklet for all respondents, it was observed that about 28% of the respondents from Pentecost hospital had normal haemoglobin levels (11g/dl). Details can be seen in fig 4.3 below. Figure 4.3 Haemoglobin level among respondents 4.8 Assessment of ANC Staff The mean age for the health staff in Madina Polyclinic was 38 years, whereas that for Pentecost Hospital was 42 years. 45 was the maximum. Details can be found in table 4.6 below. 28.38 25.68 11.62 0.27 18.11 10.27 5.14 0.54 0.00 5.00 10.00 15.00 20.00 25.00 30.00 Normal (11g/dl and above) Mild (9-10.9 g/dl) Moderate (7-8.9 g/dl) Severe (7 g/dl) p e rc e n ta ge Haemoglobin level Health facility Pentecost Health facility Madina PC University of Ghana http://ugspace.ug.edu.gh 45 Table 4.6: Assessment of health staff Characteristics No. staff assessed Madina Polyclinic Pentecost Hospital No staff assessed Four (4) 2 2 Age (in complete years) (31, 45) =MPC (36, 48) = PH mean= 38 Mean= 42 Category of staff Four (4) M