Perceptions of Malaria in Pregnancy and Acceptability of Preventive Interventions among Mozambican Pregnant Women: Implications for Effectiveness of Malaria Control in Pregnancy

et al. (2014) Perceptions of Malaria in Pregnancy and Acceptability of Preventive Interventions among Mozambican Pregnant Women: Implications for Effectiveness of Malaria Control in Pregnancy. PLoS ONE 9(2): e86038. doi:10.1371/journal.pone.0086038 Perceptions of Malaria in Pregnancy and Acceptability of Preventive Interventions among Mozambican Pregnant Women: Implications for Effectiveness of Malaria Control in Pregnancy Helena Boene 0 Raquel Gonza lez 0 Anifa Vala 0 Maria Rupe rez 0 Ce sar Velasco 0 So nia Machevo 0 Charfudin Sacoor 0 Esperan ca Sevene 0 Euse bio Macete 0 Clara Mene ndez 0 Kha tia Munguambe 0 Thomas Eisele, Tulane University School of Public Health and Tropical Medicine, United States of America 0 1 Centro de Investigac a o em Sau de da Manhic a, Manhic a, Mozambique, 2 Barcelona Centre for International Health Research, Hospital Clinic - Universitat de Barcelona , Barcelona , Spain , 3 Direcc a o Nacional de Sau de Pu blica, Ministe rio da Sau de , Maputo , Mozambique , 4 Universidade Eduardo Mondlane, Faculdade de Medicina , Maputo , Mozambique Background: Intermittent Preventive Treatment (IPTp) and insecticide treated nets (ITNs) are recommended malaria in pregnancy preventive interventions in sub-Saharan Africa. Despite their cost-effectiveness and seemingly straight-forward delivery mechanism, their uptake remains low. We aimed at describing perceptions of pregnant women regarding malaria and the recommended prevention interventions to understand barriers to uptake and help to improve their effectiveness. Methods and findings: We used mixed methods to collect data among 85 pregnant women from a rural area of Southern Mozambique. Information was obtained through observations, in-depth interviews, and focused ethnographic exercises (Free-listing and Pairwise comparisons). Thematic analysis was performed on qualitative data. Data from focused ethnographic exercises were summarized into frequency distribution tables and matrices. Malaria was not viewed as a threat to pregnancy. Participants were not fully aware of malaria- associated adverse maternal and birth outcomes. ITNs were the most preferred and used malaria preventive intervention, while IPTp fell between second and third. Indoor Residual Spraying (IRS) was the least preferred intervention. Conclusions: Low awareness of the risks and adverse consequences of malaria in pregnancy did not seem to affect acceptability or uptake to the different malaria preventive interventions in the same manner. Perceived convenience, the delivery approach, and type of provider were the key factors. Pregnant women, through antenatal care (ANC) services, can be the vehicles of ITN distribution in the communities to maximise overall ITN coverage. There is a need to improve knowledge about neonatal health and malaria to improve uptake of interventions delivered through channels other than the health facility. - Funding: This work was supported by a grant from the European and Developing Countries Clinical Trials Partnership (EDCTPIP.07.31080.002). Helena Boene is supported by a grant by EDCTP (EDCTPCT.2006.33111.001). Maria Ruperez is supported by a grant by Rio Hortega (CM11/00278). The Manhica Health Research Center receives core funding from the Spanish Agency for International Cooperation and Development. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. . These authors contributed equally to this work. Pregnant women are the main adult group at risk of malaria in sub-Saharan Africa, where approximately 25 million pregnancies are exposed to the infection and an estimated 10,000 maternal deaths attributable to malaria occur every year [1]. To control malaria in pregnancy the World Health Organisation (WHO) recommends IPTP with sulfadoxine-pyrimetamine (SP), use of insecticide treated nets (ITNs), and effective treatment of malaria episodes [2]. Despite the fact that both IPTp with SP and ITNs are highly cost-effective in improving maternal and infant health [3], and have been rolled out for many years in several malaria endemic countries, their coverage is still unacceptably low in subSaharan Africa [4]. Several factors may explain the low uptake, and hence low effectiveness of preventive interventions for malaria in pregnancy, such as, limited access to ANC services, health system factors which include drugs and ITN stock outs, health professionals attitudes and practices, low patient adherence, or community attitudes towards one intervention among others [5,6]. Anthropological studies have suggested variations in individual and communitys malaria-related beliefs according to their sociocultural, educational, economic, and environmental contexts and backgrounds, which in turn affect malaria prevention outcomes [7,8]. For example, in Malawi it has been reported that local taboos prohibiting the ingestion of bitter substances during pregnancy posed limitations on the acceptability of potential anti-malarial drugs for IPTp [7]. In addition, the belief that drugs lead to miscarriage or to difficult labour due to large-sized babies have also been suggested to be related to the low uptake of preventive drugs for malaria in pregnancy [5]. It is recognized that there has been more focus on quantitative data collection approaches on perceptions of malaria in pregnancy and acceptability of preventive interventions compared to qualitative or mixed methods [8]. Moreover, studies on acceptability of malaria preventive interventions often examine them in isolation from other interventions. Therefore there is a need to better understand womens perceptions, acceptability and adherence to these interventions when they are integrated with other health services offered to them, such as ANC services [5,9]. In Mozambique, since 2006 IPTp is administered under directly observed therapy, and ITNs are delivered to pregnant women free of charge through ANC [10]. However, the average country uptake of at least two IPTp doses is still only 23% and the proportion of households with pregnant women who have at least one ITN is about 19% [11]. There is a lack of information about the acceptability of specific malaria preventive interventions among Mozambican pregnant women. A context-specific analysis might provide insights as to what extent factors such as perceptions and beliefs, may be related to the low uptake of malaria preventive interventions. This study aimed at describing the perceptions and behaviours of pregnant women in relation to malaria and the acceptability of currently recommended malaria preventive interventions. This information may serve to understand the barriers that affect the uptake of malaria preventive interventions in pregnancy and help to improve their effectiveness. Materials and Methods Study site and population The study was conducted (...truncated)