Introduction According to Uganda s

Introduction According to Uganda's Ministry of Health (MOH 2012a:91), intermittent preventive treatment (IPT) to avoid malaria during pregnancy is a free preventive service available to all pregnant women without clinical signs and symptoms of malaria, attending prenatal clinics. However, pregnant women diagnosed with malaria, are treated with the recommended first or second line treatment, depending on the clinical presentation of the disease. Two doses of IPT should be taken by pregnant women between the 6th and the 8th months of pregnancy (MOH, 2012a:91-92) because IPT drugs, sulfadoxine and pyrimethamine (SP), are contra-indicated during the first trimester. The interval between the two doses should be at least one month because IPT contains long acting anti-malarial drugs, that could accumulate in the body if taken more frequently, potentially causing hepato-toxicity (MOH, 2012a:91-92). In the context of the current study, IPT utilisation was accepted as the gold standard with which other anti-malaria services were compared. This was based on the guidelines that specify IPT as being the major anti-malaria service to be provided by midwives in prenatal clinics (MOH, 2012b:92). Malaria has devastating effects on pregnant women and their unborn babies (MOH 2012b:9) including maternal anaemia, maternal deaths and low birth weights of babies. Although Uganda provides free malaria prevention and control services, including two doses of IPT for pregnant women, malaria continues to cause complications in most pregnancies in this Amprolium HCl country. This might be partly attributable do the fact that during 2011 only 48% of pregnant women in Uganda took the first dose of IPT and merely 27% took the second dose (Uganda Bureau of Statistics, 2012). Malaria prevention during pregnancy was also adversely affected because only 47% of pregnant women used long lasting insecticidal treated nets (LLINs) and 7.2% of houses implemented indoor residual spraying (IRS) to kill mosquitoes resting on indoor walls (UBOS, 2012). These findings were reported despite the provision of free LLINs and IPT. On the basis of the MOH's and WHO's recommendations, IPT should be administered as directly observed treatment (DOT) (Mpogoro et al., 2014). This implies that pregnant women should swallow these pills in the presence of a midwife in the prenatal clinic presuming that both IPT drugs and clean drinking water are available at prenatal clinics. Midwives working in prenatal clinics without regular supplies of IPT drugs and/or without clean drinking water are unable to offer an effective IPT service. Dispensing IPT drugs for pregnant women to take at home might be ineffective as it is unlikely that pregnant women, who do not feel ill and thus do not perceive any need to take medicines, would indeed take IPT pills unsupervised at home. The objectives for this study were to identify factors that might influence midwives’ provision of antimalaria services to pregnant women, namely:
Methods A questionnaire was designed, based on a literature review and on the MOH's guidelines. It comprised three major sections addressing midwives’ personal characteristics (10 items), environmental factors influencing pregnant women's utilisation of antimalaria services (29 items) and pregnant women's health-seeking behaviours (15 items including one open-ended question, namely: ‘What do you think could be done to reduce the incidence of malaria during pregnancy?’). With the exception of one open-ended question, all items were either multi-response items (requiring the selection of the most appropriate answer) or one-word answers to questions such as age or years of midwifery experience. As the accessible population of midwives comprised 40 persons, no pretesting of the questionnaire was done. Four trained research assistants administered the questionnaire during face-to-face encounters with the midwives. No problems were encountered to respond to any questionnaire items. The calculated Cronbach alpha for the questionnaire was 0.749. This implies that the items in the instrument had acceptable levels of internal consistency (Burns and Grove, 2005, Polit and Beck, 2008). Five experts (two doctors from Kawolo Hospital and one from Nyenga Hospital as well as two senior midwives from Kawolo Hospital working in the field of malaria control) were requested to rate each item on a scale ranging from 1 to 5, with 5 indicating perfect validity and 1 no validity. Thereafter the scores of the five experts were calculated and only items scoring a mean content validity of at least 4 (out of 5) were included in the respective instruments. This implied that there was a good content validity of the instrument used in the study (Burns and Grove, 2005, Polit et al., 2007).