Factors affecting providers' delivery of intermittent preventive treatment for malaria in pregnancy: a five-country analysis of national service provision assessment surveys

Background: Intermittent preventive treatment in pregnancy (IPTp) delivered during antenatal care (ANC) visits has been shown to be a highly efficacious and cost-effective intervention. Given the high rates of ANC attendance in sub-Saharan Africa, the current low IPTp coverage represents considerable missed opportunities. The objective of this study was to explore factors affecting provider's delivery of IPTp during ANC consultations. Methods: Data from five nationally representative service provision assessment surveys informed the statistical analyses (Kenya, Namibia, Rwanda, Tanzania, and Uganda; 2006-2010). Poisson regression models with robust/clustered standard errors were used to estimate the effect of different determinants on IPTp delivery from 4,971 observed ANC consultations. Results: The five major modifiable determinants of IPTp delivery were: 1) user-fees for ANC medicines (relative risk (RR) = 0.76; 95% confidence intervals (95% CI): 0.62-0.93); 2) facilities having IPTp guidelines (RR = 1.12; 95% CI: 1.01-1.24); 3) facilities having implemented IPTp as part of their routine ANC services offering (RR = 4.18; 95% CI: 1.75-10.01); 4) stock-outs of sulphadoxine-pyrimethamine (RR = 0.40; 95% CI: 0.27-0.60); and, 5) providers having received IPTp training (RR = 1.21; 95% CI: 1.09-1.35). Using the population-attributable fraction, it was estimated that addressing these barriers jointly could lead to a 31% increase in delivery of this intervention during ANC consultations. Of these four potentially modifiable determinants, training of providers for IPTp had the largest potential impact. Conclusions: If proved to be cost-effective, dispensing IPTp training to ANC providers should be prioritized. Multifaceted approaches targeted in areas of low coverage and/or type of facilities least likely to provide this intervention should be implemented if the Roll Back Malaria target of 100% IPTp coverage by 2015 is to be attained.