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Systematic assessment of factors affecting the delivery, access and use of
interventions to control malaria in pregnancy in sub-Saharan Africa
Hill, J.A.
Publication date
2014
Document Version
Final published version
Link to publication
Citation for published version (APA):
Hill, J. A. (2014). Systematic assessment of factors affecting the delivery, access and use of
interventions to control malaria in pregnancy in sub-Saharan Africa. Dutch University Press.
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Chapter 8:
Access and use of interventions to prevent and treat
malaria among pregnant women in Kenya and Mali: A
qualitative study
Access and use of interventions to prevent and treat malaria among
pregnant women in Kenya and Mali: A qualitative study
Jenny Hill1*, Kassoum Kayentao2, Florence Achieng3, Samba Diarra2, Stephanie Dellicour1, Sory I
Diawara2, Mary J Hamel4, Peter Ouma3, Meghna Desai4, Ogobara K Doumbo2, Feiko O ter Kuile1,
Jayne Webster5
1Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom;
2Malaria Research and Training Centre, University of Sciences, Techniques and Technologies of
Bamako, Mali;
3Kenya Medical Research Institute/Center for Global Health Research, Kisumu, Kenya;
4 Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America and Kenya;
5Disease Control Department, London School of Tropical Medicine and Hygiene, London, United
Kingdom
*Corresponding author
Jenny Hill, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
Tel : +44 151 705 3216; Fax: 44 (0)151 705 3329 ; Mobile: 07732 161 353 ; email: j.hill@liv.ac.uk
^ƵďŵŝƚƚĞĚ
114 Community perceptions of malaria control in pregnancy
Abstract Background
Coverage of malaria in pregnancy interventions in sub-Saharan Africa is suboptimal. We undertook a systematic examination of the operational, socio-economic and cultural constraints to pregnant women’s access to intermittent preventive treatment (IPTp), long-lasting insecticide-treated nets (LLINs) and case management in Kenya and Mali to provide empirical evidence for strategies to improve coverage.
Methods
Focus group discussions (FGDs) were held as part of a programme of research to explore the delivery, access and use of interventions to control malaria in pregnancy. FGDs were held with four sub-groups: non-pregnant women of child bearing age (aged 15-49 years), pregnant women or mothers of children aged <1 year, adolescent women, and men. Content analysis was used to develop themes and sub-themes from the data.
Results
Women and men’s perceptions of the benefits of antenatal care were generally positive; motivation among women consisted of maintaining a healthy pregnancy, disease prevention in mother and foetus, checking the position of the baby in preparation for delivery, and ensuring admission to a facility in case of complications. Barriers to accessing care related to the quality of the health provider-client interaction, perceived health provider skills and malpractice, drug availability, and cost of services. Pregnant women perceived themselves and their babies at particular risk from malaria, and valued diagnosis and treatment from a health professional, but cost of treatment at health facilities drove women to use traditional remedies or drugs bought from shops. Women lacked information on the safety, efficacy and side effects of antimalarial use in pregnancy.
Conclusion
Women in these settings appreciated the benefits of antenatal care and yet health services in both countries are losing women to follow-up due to factors that can be improved with greater political will. Antenatal services need to be patient-centred, free-of-charge or highly affordable and accountable to the women they serve.
Keywords
antenatal care; pregnancy; malaria; intermittent preventive treatment; insecticide-treated nets; treatment; focus group discussions; service delivery; health providers; Kenya; Mali; sub-Saharan Africa
Introduction
Pregnant women living in malaria endemic areas of sub-Saharan Africa are at substantial risk of the adverse consequences of malaria in pregnancy [1], and each year an estimated 55 million pregnancies occur in areas with stable P. falciparum malaria [2]. These adverse consequences can be prevented through the use of two highly effective prevention interventions, intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) [3] and long-lasting insecticide-treated nets (LLINs) [4]. In areas of stable malaria transmission in Africa WHO recommends a package of intermittent preventive treatment (IPTp) with sulphadoxine–pyrimethamine (SP) and use of insecticide-treated nets (ITNs), together with effective case management of clinical malaria and anaemia [5,6]. Until 2006, WHO recommended two doses of SP for IPTp, taken one month apart commencing after quickening (approximately 18 weeks gestation) [7,8], and together with ITNs, is routinely delivered through antenatal clinics. Despite relatively high coverage of antenatal clinic (ANC) attendance among pregnant women in sub-Saharan Africa, coverage of both interventions across many countries in the region is low [9], limiting achievement of their full potential effectiveness or impact on maternal and neonatal outcomes [10,11]. Case management practices for malaria illness during pregnancy are less well understood and exclusion from national population and facility-based surveys suggests the need for more systematic evaluation through research.
Kenya in East Africa and Mali in West Africa represent two countries with different malaria epidemiology, health systems and socio-economic and cultural settings, both with low coverage of malaria in pregnancy interventions. Kenya adopted the IPTp policy in 1999 and the ITN policy in 2001, and Mali in 2003 and 2006, respectively. According to national survey data for Kenya and Mali available in 2009 when this study was designed, the proportion of women receiving GRVHVRI IPTp-SP was 4% in both Kenya and Mali, and ITN use the night before the survey was 4% and 49%, respectively [12,13]. Coverage of GRVHV of IPTp was substantially lower than the proportion of women making 2 or more ANC visits (84% and 63% in Kenya and Mali respectively) [12,13], indicating substantial missed opportunities to provide IPTp when the pregnant woman was at the ANC. We undertook a systematic examination of the operational, socio-economic and cultural constraints to pregnant women’s access and use of IPTp, LLINs and case management in the diverse settings of these two countries to provide data from which rational strategies aimed at improving coverage could be developed and implemented. We used a combination of health facility and community assessments using quantitative and qualitative methodologies. The household survey, health facility surveys and in-depth interviews with health staff are described elsewhere [14-17]. Here we report the findings of a qualitative study focussing on the community level in Kenya and Mali.
Methods Ethics statement
The study was approved by the ethical committees of the Kenya Medical Research Institute’s (KEMRI) National Ethics Review Committee, Kenya; the Institutional Ethical Committee of the Faculty of Medicine, Pharmacy and Odonto-stomatology, University of Bamako in Mali; the Liverpool School of Tropical Medicine, UK; and the London School of Hygiene and Tropical Medicine, UK; and for the Kenya study, ethics approval was also obtained from the Centres for Disease Control and Prevention, Atlanta, Georgia, USA. All ethics committees approved verbal informed consent to be obtained from study participants as the study procedures posed minimal risk to participants and to avoid the potentially negative influence of written consent on rapport between participants and researchers. With participants’ prior agreement, verbal consent was obtained and recorded prior to the focus group discussions. Pregnant women aged 15 -17 years are considered emancipated minors in Kenya and Mali and were consented directly; for adolescents who did not fall into this category, verbal assent of the
116 Community perceptions of malaria control in pregnancy
participant and consent from the next of kin was witnessed and recorded. During transcription, any names were replaced with codes to ensure anonymity and digital recordings were deleted once transcription and translation were completed and quality approved.
Study Sites and context
The study was conducted in Kenya and Mali, in 2009 and 2010 respectively, chosen to represent very different African health system, epidemiological, cultural and socioeconomic contexts as part of a larger study to evaluate the barriers to the scale up and use of interventions to control malaria in pregnancy [14-17].
Kenya. This work was conducted under KEMRI and CDC’s collaboration in western Kenya. The Kenya study site was Greater Nyando District, Nyanza Province, now divided into three sub-Counties, Nyando, Muhoroni and Nyakach, each managed by a district commissioner. The district has a population of 355,800 projected from the 1999 census, with more than 90% of this population living in rural areas. The district has a total of 40 health facilities of which 24 are government-owned, five by missions, seven privately owned and four community-operated. The most common ethnic group is Luo, who live on the shores of Lake Victoria and the main economic occupation is subsistence agriculture and cultivating cash crops such as rice, sugar cane, sisal and fishing. Malaria in Nyando District is perennial holo-endemic with a parasite prevalence of 8.3% among women of child bearing age (2008 unpublished data, KEMRI/CDC). HIV prevalence among women aged 15-49 years is higher in Nyanza Province compared to all other provinces, 18% compared to a national average of 9% [18].
In line with WHO recommendations on focussed antenatal care (FANC), the Kenya National Guidelines for the diagnosis, treatment and prevention of malaria state that a package of interventions should be delivered through antenatal care which, in areas of high transmission, includes malaria in pregnancy and prevention of mother to child transmission (PMTCT) alongside other components [19]. These include a free LLIN for all women at first ANC visit and two doses of IPTp-SP given at each ANC visit after quickening, administered under directly observed therapy (DOT), unless SP has been taken in the prior 4 weeks or the woman is HIV-infected and taking daily cotrimoxazole prophylaxis for opportunistic infections. Malaria episodes should be treated with a 7-day course of oral quinine (all
trimesters) or Artemether-Lumefantrine (AL) (2nd& 3rdtrimester and 1sttrimester if quinine is not
available) [20].
Mali. The Mali study site was Segou District, Segou Region. Segou District has a total population of 448,552 projected from the 1998 census, with more than 60% of this population living in rural areas. The most common ethnic groups are Bamanan and Sarakole/Soninke, and the main economic occupation is subsistence agriculture. The district has a total of 26 functioning health structures comprising one hospital and one district level health facility (Centre de santé de reference [CSRef]), both of which are government operated and 24 community-owned health centres of which eight are headed by a physician paid by the government and 16 headed by a nurse paid by the community. Malaria in Segou Region is seasonal ranging from holo-endemic in the southern part of the district to meso-endemic in the north. HIV prevalence among women aged 15-49 years is higher in Segou Region compared to the national average, 1.7% vs 1.4% [13].
The health system in Mali has been described elsewhere [16]. The government funds health facilities down to district level, including one hospital and one CSRef. All health facilities below this level are funded by communities themselves, in some cases with assistance from non-governmental organisations. Malaria in pregnancy services provided through ANC include two doses of IPTp administered by DOT between month 4 and 8 (inclusive) gestation, with each dose given at least one
month apart, and three doses for women who are HIV positive, in addition to a free LLIN to all women at first ANC visit [21].
Data collection and Participants
The study was undertaken during the rainy season, February-March at the start of the long rainy season in Kenya, and September towards the end of the rainy season in Mali, to capture experience and use of malaria in pregnancy interventions as a current or fairly recent event. Focus group discussions (FGDs) were held in a sample of women of child bearing age (aged 15-49 years) living in two villages from within the study areas. There were three sub-groups within this population, to represent both pregnant and non pregnant women, and adolescents as a high risk group: women who were not pregnant, women who were either currently pregnant or a mother of a child under 1 year, and adolescent girls. FGDs were also held with men living in the selected villages aged 18 years or older. Each sub-group contained 8-12 participants and two FGDs were held per sub-group. Sessions ran for approximately one hour, were conducted in the local languages, Dholuo (Kenya) and Bambara (Mali), and were digitally recorded. In Kenya, the FGDs took place in Ochoria and Kamahawa villages in Koru and Kakola locations respectively, selected randomly using a sampling frame. The FGDs were conducted by an experienced female social scientist (FA) assisted by a community health worker (note taker). FGD participants were randomly selected from a list of village members, and field staff visited consecutive names on the list until 12 community members had agreed to participate. In Mali, FGDs were undertaken in Banankoro and Sagni villages, representing urban and rural communities respectively, and the FGDs with women were undertaken by three female researchers and an experienced male social scientist (SD) for men. Participants were recruited with the help of community leaders including village chiefs, assistant chiefs and village elders, and the location of the focus groups chosen by the community based on their convenience and proximity to all participants.
FGD guides were developed covering the same topics for both countries. Exploration of the women’s opinions focussed on: experiences during ANC visits including perceptions of services provided at ANC, perceptions of malaria risk and patterns of care seeking, experiences with ITNs, IPTp-SP, and antimalarial drugs for treatment of malaria, and community influences of health seeking behaviour. Exploration of the men’s opinions focussed on their views on the same topics.
Data analysis
Transcripts were first translated from the local language into English and verified by two of the authors (Kenya: FA; Mali: KK). The translated transcripts were read to get an overview of the themes arising then entered into NVivo10 for data management and analysis. Data from each site were coded separately using a combination of pre-defined themes based on the original research questions and themes that emerged from the data using content analysis. Pre-defined and emerging themes from Kenya and Mali were then compared to explore similarities and differences in the experiences and beliefs concerning access and use of ANC and of malaria in pregnancy interventions, and the views of men in relation to those of women. The findings were also compared with the quantitative data collected during household surveys and quantitative and qualitative data from health facility surveys in each country.
The policy and programme implications of the findings were explored using the WHO health system framework comprising six building blocks: Governance, Human resources, Products and technologies, Service delivery, Information systems and Financing [22].
118 Community perceptions of malaria control in pregnancy
Results
A total of 158 participants were recruited into the FGDs, 79 in Kenya and 79 in Mali. The participant numbers by group, village, country and demographics are provided in Table 1. Pre-defined and emergent themes were coded around the five key topics in the topic guide, which were pregnant women’s: access and use of ANC; access and use of case management of malaria in pregnancy; access and use of IPTp; access and use of ITNs; and sources of information, including social and cultural influences.
Access and use of ANC
Factors affecting pregnant women’s access and use of ANC emerging from the data were coded into five main themes: perceptions of the benefits of ANC; experiences at ANC (both positive and negative); health staff corruption and malpractice; poor attitudes of health staff; long waiting times; shame or fear of pregnancy disclosure; and distance and/or cost (Table 2).
Perceptions of benefits of ANC
The key motivation for women to attend ANC in both Kenya and Mali was to have their pregnancy monitored and managed in the hope this would lead to a healthy pregnancy and, ultimately, reduce the risk of complications at delivery. Knowing the position of the baby was important and having the baby in the correct position for delivery was seen to be critical for avoiding problems at delivery. Women who didn’t attend ANC at least once were said to risk being sent away by midwives if they came with complications at delivery. One man in Kenya described the benefit of his wife attending clinic was that she would have a record of her treatment and care, which would be useful in case there were problems at delivery. Men in Mali were also aware of the dangers of women not obtaining regular antenatal care, and referred to the ‘past’ when many women died during delivery due to the absence of adequate antenatal care services.
Another key element of attending antenatal clinics referred to by women was to have tests for HIV and other diseases, including malaria, so that ‘tablets against malaria’ could be taken to safeguard the health status of both her and the unborn child. Preventing the onset of malaria was said to save money compared to treatment of the illness once it had progressed. Knowing one’s HIV status was more commonly mentioned by women in Kenya, where men were said to sometimes accompany their wives as the clinics encouraged partner testing for HIV. Receiving counselling on disease prevention and professional advice on the use of safe regimens during pregnancy and tetanus immunisation were additional reasons cited for attending ANC. Monitoring and information to control high blood pressure and receiving iron was mentioned by women in Mali but not in Kenya. Testing for blood group was mentioned in Kenya but not in Mali.
Experiences of ANC service quality (positive and negative)
Experiences of ANC were predominantly negative, as remarked by one woman in Mali ‘Nobody goes to health centre for pleasure’, although there were some positive experiences too. There were instances where women didn’t get all the services they would have liked, as observed by a woman in Kenya who complained that although they are supposed to be given a blood group test, sometimes they were only given an HIV test. Some adolescent women were fearful of going to clinics because they would be tested for HIV, whereas others were afraid of taking ‘medicines’ or of being pricked for a blood test. Although health staff at ANC were generally considered to be well trained and experienced, there were examples in Mali where mothers reported that young nurses were unable to do essential procedures
T ab le 1. Focu s g roup d iscu ssio n pa rt ici p an t dem o gr aphics. FG D group Vill age G roup N Average Ag e Average G ravidi ty (range ) Mari ta l s tatus Educati o n Si ngle Marr ie d Wido w ed / divorc ed N o ne P rim ary Secondary or above K eny a 1 K ak ola W OCBA, not p reg nant 10 28 4 (0-12) 0 10 0 1 7 2 1 K or u W OCBA, not p reg nant 10 31 5 (0-9) 1 8 1 W 0 10 0 2K ak o la Preg nant wom an or m o ther of chi ld <1 y 10 26 3 (1-5 ) 1 9 0 1 5 4 2 K or u Preg nant wom an or m other of chi ld <1 y 92 3 3 ( 1 -7 ) 0 9 0 0 6 3 3 K ak ola A doles cen t 15-18y 10 17 1 (0-1) 1 0 0 0 0 5 5 3 K or u A doles cen t 15-18y 10 18 2 (1-4) 0 1 0 0 0 8 2 4 K ak ola M an 10 40 N /A 0 9 1 W 1 8 1 4 K or u M an 10 38 N /A 0 9 1 D 0 5 5 † Mal i K enya Sub to ta l 7 9 1 B anank oro WOCBA, not p reg nant 8 45 5 (1-13) N R N R N R N R N R N R 1 S ag ni WOCBA, not p reg nant 12 35 5 (0-9) N R N R N R N R N R N R 2B an an ko ro Preg nant wom an or m other of chi ld <1 y 10 28 2 (1-6 ) N R N R N R N R N R N R 2S ag n i Preg nant wom an or m other of chi ld <1 y 12 28 4 (1-7 ) N R N R N R N R N R N R 3 B an an ko ro Ad ol es ce nt 1 5-18 y 8 1 7 0 NR NR NR NR NR NR 3 S ag ni Adoles cen t 15-18y 9 1 7 N R N R N R N R N R N R N R 4 B anank o ro Man 8 49 N /A N R N R N R N R N R N R 4 S ag ni M an 12 4 0 N/ A NR NR NR NR NR NR Mali Subt ot al 79 Ke y: W O CBA, women o f childbearin g ag e; y, ye ar ; W , widowed; D, di
vorced; NR, not reported; †
2 men had been to colle ge (R3 and R 4) 120
T ab le 2. Fac to rs a ffe ct ing preg nant w o m en’s acce ss a nd use o f A N C . T h em es K en y a S u b -th em es & Q u otati o n s fro m s tud y p a rti ci p an ts Mal i Sub-th em es & Quo ta tio ns f ro m st u dy pa rt icipa n ts Perceptions of the b en efits of ANC T o m o
nitor pregnancy and red
uce co m p lica tio ns a t deliv ery W e al w a ys go t o t h e cl in ic s o t hat w h en m y del iver y com es i n a b ad w a y, I cann ot be s ent aw ay. (R 1: m arried w o m an ag ed 42 years , m u ltip ar o us, Ka ko la) Som et im es t h e baby i s l yi ng w rongl y s o he/ she m u st be chec ked an d al so our w ei ght i s bei ng m eas ur ed. (R 4, m arri ed w o m an a ge d 30 year s, m ultip ar o u s, Kak o la) I s ee i t good w h en m y w ife go es t o t h e cl in ic becaus e s h e w ill have a recor d t hat can be us ed f o r t he cas e of pr obl em i n del iver y. (R 6: m arri ed m an a ged 66 y ears , K ak o la ). To m o nit o r preg na ncy a n d redu ce co m p lica tio ns a t deliv ery It is good for the child. Dur in g the AN C , y ou w ill know that your child h a s not a goo d pos iti on an d w on’t kn ow i f yo u do not g o t o AN C . (P 7 : w o m an a ged 3 2 y ear s, m u ltip ar o us, Sag ni) L a st t im e wi th our gr andp ar en ts , t h er e w er e m any deat hs of w o m en at del iver y due t o t h e abs ence of AN C . N o w i f t h e w ife does not s ee her m ens es f o r one m ont h an d i n fo rm her hus ban d, her h u sband s ends h er t o t h e heal th ce nt re t o know i f s h e i s pr egnant or i f s h e h as anot her di se as e. If s h e i s pr eg nant , y ou s end her t o AN C an d you as t h e hus band r em ind an d f o rce her t o r es p ect t h e ap poi nt m ent d a ys . M en s houl d al w a ys be i n vol ved i n t h e heal th sta tu s o f h is fa mily. (P 8: m an ag ed 55 y ears , Sa gn i) T o tes t for HI V or o ther dis eas es W e go t o cl in ic t o be t a ught a nd be t es ted of m a la ria ad H IV w h en w e ar e pr egnant . And i f f ound w ith H IV w e ar e gi ven m edi ci ne t hat can p reven t th e u nb o rn fro m g ettin g th e d isea se a nd a lso so me m ed icin e fo r m a la ria you ar e al so gi ven and . .. vi ta m ins . (R 7: s in gl e, a doles cen t ag ed 17 y ears , 1 prev io us pregn an cy , K ak o la ) W e [m en ] go w ith t h em [ our w ives ] beca us e w h en t h e w o m an goes th ey as k ‘w her e i s your hus ba nd?’ m o stl y w h en t h ey w ant t o t es t t h e HIV sta tu s. (R 7: m arri ed m an ag ed 23 y ears , K ak o la ) T o tes t for HI V or o ther dis eas es If yo u sta y a t h o me, y o u will n o t b e in fo rmed o n certa in d ise a
ses like fib
ro ma , d ia b etes, hi gh bl ood pr es su re , H IV, and m any ot her di se as es . (P 3: w o m an a ged 26 y ears , m u ltip ar o us, B an an ko ro ) Other reas o ns for attending ANC T o be gi ven s o m e t eac hi ngs h o w t h ey can hel p t h e u nbor n f rom cont act ing m a la ria an d how t h ey can pr event ot her di se as es not t o af fe ct t h e unb or n. (R 9: s in gle, adoles cen t ag ed 18 years , 1 pr ev ious p re gna nc y, K ako la ) W e al w a ys go t o get t h e advi ce f rom t h e doct o rs and al so t o get al l t h e vacci nat ions [t et anus to xoi d] . (R 2, m arri ed w o m an ag ed 35 y ears , m u ltip ar o us, Ko ru ) Other reas o ns for attending ANC D u ring AN C , i n je ct ions agai ns t t et anus ar e done. Al l t h is i s t h e adva n tage of AN C . (P 2 : adol es cen t ag ed 17, n o prev io us pregn an ci es , Ban ank oro) T h ey t el l you how t o t a ke your dr ug, w h en t o com e f o r yo ur appoi nt m ent . T h e adv ant ag es of AN C ar e enor mous , the doc tor s give couns elling on the r egimens to ado pt, check y our bl ood pr es su re . (P4: w o m an a ged 30 y ears , m ul tip arou s, Ban ank oro) E x periences at ANC (bo th po sitiv e an d n egati v e) W h en you go t o t h e cl in ic , yo ur bl ood s h ou ld be t es ted t o det er m in e like H IV s tat us and bl ood gr oup t h in gs l ike t hat but s o m et im es you go b u t th ey ju st test HI V sta tu s o nly. (R 10: s in g le w o m an ag ed 20, m u ltip ar o us, Ka ko la) Som et im es a doct o r can j u st l eave a p a tie nt even dyi ng i n t h e queue sa yi ng t hat t h ei r t im e f o r l unc h or l eavi ng f o r hom e h a s r eached s o th ey m a y l eave a pat ie nt dyi n g and t h is al w a ys an noys ver y m u ch. (R 10: s ing le w o m an ag ed 20, 1 prev io us preg na nc y, K ak o la ) N obody g o es t o heal th cent re becaus e of pl ea su re ! (P 7 : w o m an a ged 2 8 y ear s, m u ltip ar o us, Ban ank oro) Fr om t h e begi nni ng t o t h e en d of t h e pr egn ancy I di d not get s ick. D u ring m y AN C , t h ey received me ver y w ell and I di d not a n y difficulty d u ring the deliver y. (P5: a dol es cen t ag ed 16 y ears , n o prev ious preg na nci es , Ban ank oro) W hat di sc our ages me i s t h e behavi our of new nur se s .... T h e bi g doct o rs t ry and gi ve h and to the new doctor s that have n o exper ience. You ng n u rs es don’t know the pos ition of the fo et us . I do n’t w ant t h e f a ct t hat t h ey w ant us t o be exam ine d by t h e y oun g d o ct or s, w h ic h is w h y I don’t w a nt t o go t h er e now . (P 9 : w o m an a ged 2 5 , m u ltip ar o us, B an an ko ro ) 121
Health s taff co rrupt io n a nd m a lp ractice If you g o t o pr iv at e hos pi ta ls y ou can be f o rced t o be t es ted b u t t h is shoul d o n ly be yo ur w is h s o as t o know your s tat us . (R 8: m ar ri ed, adoles cen t ag ed 17 years , 3 pr ev ious preg na nc ies al l aliv e, Koru ). Y ou can go a nd m a ke a l in e and s ee t hat yo u ar e a bout t o r each, b u t wh en th eir rela tive o r so me ri ch p erso n h ad co me, t h ey will ta ke th em in the fr ont an d give them tr ea tment ....they ar e alw a ys cor ru p t.( R1 , sing le , adol es cen t a ged 18 y ea rs , 1 prev io us preg na nc y, K akol a) The r eception mus t be ver y att ractive at the health ce ntr e. So metimes the doctor comes to th e heal th ce nt re and do n o t r ecei ve peopl e f o r co ns ul ta tion. T h ey t rans fe r t h ei r dut ie s t o th e nur se or m idw ife, w h ile t h is [per so n] c annot do t h e w o rk . (P7: adoles cen t ag ed 16, n o prev io us pregn an ci es , Ban ankoro) Poor a tti tu d es of hea lt h st a ff Som et im es t h ey can cal l yo ur nam e t w ice and yo u d on’t hea r, s o w h en yo u g o in sid e th ey will sta rt h a ra ssin g yo u sa yin g we d id n ’t sen d yo u ! W e w er e not t h er e! So i f you go f o r t h e f ir st t im e and t h ey ha ndl e you like th a t, th en y o u will n o t g o f o r th e seco n d time like fo r me th ey handl ed m e t hat w a y b u t I l ef t and eve n l ef t f o r t h em t h e bo ok and onl y w a ite d f o r s ix m ont hs t h en w ent t o K is u m u . (R 9: s ing le, adoles cen t ag ed 18 y ears , 1 prev io us pregn an cy , K ak o la ) D o ct or s m u st be ki nd w ith us . T h er e ar e cer tai n doct or s w ho ar e not ver y ki nd and s hout at pr egnant w o m en and w h en yo u go f o r del iver y s o m e i n su lt you. (P 8: w o m an ag ed 25 year s, m u ltip ar o us, B an an ko ro ) W hat di sc our age peopl e i s t h at t h ey ar e negl ect ed, t h e m a nn er t h e heal th r ecei ve pat ie nt i s not go od as it d o es not cr eate confidence. .... Th at is the r eas on w h y peo p le do n’t w ant to go t o t h e heal th ce nt re , t h e do ct or s ar e not acces sib le . (P1: m an a ged 71, Ban an koro) Lo ng w a it ing tim es ... if it rea ch es twelve o ’clo ck, th ey will g o fo r lu n ch a n d tell yo u to wa it u n til two p m .( R 1 , s ing le , adol es cen t ag ed 18 years , 1 pr ev ious p re gna nc y, K ako la ) Som et im es you can s p en d o n e hour or m o re w ithout s eei ng th e doct o rs . T hat i s t h e r eas on w h y peopl e d on’t w ant t o g o t o t h e heal th ce nt re , t h e doct o rs ar e not acces sibl e. B u t, eve n i f th ey ar e not good i n r ecei vi ng pat ie nt , you ar e obl ig ed t o go t h er e and to be ver y pat ie nt . (P 1 : m an a ge d 7 1 , B ana nko ro ) S h a m e or fear of preg na ncy disclo su re It i s f eel ing as ham ed, becaus e so m et im es you ar e goi ng t o t he cl in ic at th e s a m e t im e your m o th er i s al so goi ng now you f eel as ha m ed. (R 9: sing le , adol es cen t a ged 18 y ea rs , 1 prev io us preg na nc y, al iv e, K ak o la ) It i s f eel ing as ham ed bec aus e so m et im es
you have not
t rie d so you ca n as k s o m eone, w hat d o t h ey n or m a lly as k, t h ey as k i f you ar e m a rr ie d and ot her t h ings s o i t i s onl y f eel ing as ham ed. (R 4, s in gle, a d oles cen t ag ed 1 7 y ea rs, no p re vi o us p re gna nc ie s, K ako la ) Som e f ear t hat t h ey w ill be s ee n w h ile pr egnant . (R 4: s in g le, adoles cen t ag ed 17 ye ars , n o prev iou s pregn an cies , Ka ko la) Becaus e dur ing pr egna ncy, w o m en get m any di sc om fo rt. Fo r each di sc om fo rt you ca n’t g o to th e h ea lth cen tre o th erwise yo u r h u sb an d will n o t b e h a pp y o n yo u . Th ey sa y th a t a lwa ys to pos e f inanci a l pr obl em s. (P1 0 : w o ma n a ge d 2 8 y ea rs, 4 pr ev io us p re g na nc ie s, Sa g ni ) T h e hus ban d as ks [yo u] t o hi de t h e pr egna ncy bec aus e pr eg nancy i s al w a ys a ps ychol ogi cal pr obl em . (P 8 : w o m an a ged 2 7 y ear s, m u ltip ar o us, Sag ni) Dista n ce T h e hos pi ta ls ar e f a r and s o m et im es you ar e i n t h e i n te rior s o w h en you go , you can r eac h w h en ti re d and the nur se s w ill not tr ea t w ell becaus e you al so do n’t h a ve m oney. (R 4, s in gl e, adoles cen t ag ed 17 ye ar s, no p re vi o u s p re gna nc ie s, K ako la ) For exam pl e i f t h e b aby i s not in a go od pos iti on, bec aus e he re w e don’t have t h e m eans of quick tr ans por tation and it is ver y fr equent t hat peo p le ar e killed becaus e of th at. (P 2 : w o m an a ged 2 3 y ear s, m u ltip ar o us, Sag ni) Co st I w ent and t h ey as ked m e i f I ha ve ever done i t [AN C ] an d I sa id no it’s w h en I w ant t o s tar t and t h ey neede d m oney and I di dn ’t have m oney s o t h ey s tar te d qu ar re lli ng w h y I di dn’t h a ve m oney a nd i t i s done w ith m oney. ( R 10: sin gl e, adol es cen t ag ed 17 y ears , 1 prev io us p re gna nc y, K a kola) Peopl e al w a ys go t o t h e T BAs ju st becaus e of p o ver ty and l ack of m oney but t h ey ar e not goo d (R 6: m arri ed m an ag ed 66 y ears , Kak o la). M o dera to r: w h at is t h e m a in ba rrier o f at te nding a n te na ta l clinic? T h e l a ck of m oney . ( P 7: w o m an ag ed 28 years , 2 prev io us preg na nc ie s, Ban ank oro) If you d on’t have m oney a nd y our hus ba nd al so , you ar e obl ig ed t o s tay at hom e. (P 6 : w o m an a ged 3 6 y ear s, m u ltip ar o us, B an an ko ro ) 122
such as determining the position of the foetus, and some women stated that they avoided attending particular clinics for that reason.
Health staff corruption or malpractice
Corruption among staff was identified as a problem in Kenya, with staff demanding bribes before agreeing to see patients and showing favouritism toward ‘rich’ clients. Private sector providers in Kenya reportedly refused to see patients unwilling to have HIV tests. In Mali, doctors were reported to sometimes refer their duties to the nurse or midwife, who was unable to do the work of a doctor. Poor attitudes of health staff
Women in both countries complained about the rude and sometimes bullying behaviour of health staff, both doctors and nurses. Women in Mali claimed they were frequently shouted at and insulted, and were often neglected. Neglect was also mentioned in Kenya, where one woman said patients were left in a queue whilst the doctor went for lunch. Another woman in Kenya reported delaying ANC until the
6thmonth of pregnancy due to the rudeness of the nurses. Women in Mali reported lack of staff morality
and ‘poor reception’ at health facilities as reasons for avoiding certain health facilities. Long waiting times
Women and men in both Kenya and Mali complained of long waiting times at clinics. In Kenya, women said they were made to wait for two hours between 12-2pm whilst the nurses ‘went for lunch’. In Mali, long waiting times were said to be a disincentive for patients attending health centres.
Shame or fear of pregnancy disclosure
Shame and fear of pregnancy disclosure was a common theme in both countries, but of very different natures. In Kenya, shame was associated with an adolescent being pregnant out of wedlock, or being pregnant at the same time as their mother so that they had to attend the clinic together. In Mali, women were conscious of not disclosing ailments associated with pregnancy to their husbands; husbands perceived ailments to be too frequent causing them irritation due to the costs associated with seeking care, for which the husband is responsible. One woman said she did not like to disclose her pregnancy because her husband regarded pregnancy as a ‘psychological problem’.
Distance and/or Cost
Distance from a hospital or health facility was cited as a problem mainly because of lack of transportation, especially in Mali where lack of transport was said to result in the death of many women, for example when the baby was not in the correct position at delivery. Lack of money was said to be the main barrier to attending ANC. In Kenya, distance and lack of money went hand in hand, and money was seen as an essential requirement to receiving antenatal services. There were examples in both countries where women were offered a credit system. In Mali, this involved a temporary credit, applied by the health facility, whilst women found the money to reimburse the clinic. In Kenya, a district hospital was said to sponsor patients who could not afford to pay for inpatient care.
Access and use of treatment for malaria
Factors affecting pregnant women’s treatment seeking for malaria emerging from the data were categorised into six main themes: perceptions of illnesses and diagnosis; perceptions of treatment drugs; experience of treatment drugs; pregnancy disclosure; cost (affecting source and type of treatment); and perceptions of different providers and other factors affecting source of treatment (Table 3).
Perceptions of illnesses and diagnosis
Malaria in pregnancy was widely considered to be dangerous and a serious threat to both the pregnant women and their unborn children, causing ‘weakening the blood’, headache, vomiting, hot body and dizziness. It was said to result in small babies, babies born with malaria, abortion, and death. Malaria was described as a hidden illness that can kill fast, and could easily be confused with pregnancy symptoms (Mali) or with other diseases such as pneumonia (Kenya and Mali). Women claimed that malaria symptoms could be confused with pregnancy so that sometimes treatment was sought very late, after the infection was well established.
These factors combined suggest an importance placed by women in both countries on suspected cases requiring diagnoses at a health centre or hospital, before seeking treatment. In Mali, severity of the illness was also a consideration for going to a health centre, for example when pregnant women or infants had severe malaria, known locally as ‘kono’ (used also to mean cerebral malaria).
Perceptions of treatment drugs
Women and men in both countries had many preconceptions about the different antimalarials or traditional medicines available for the treatment of malaria, mostly on their safety or efficacy for use in pregnancy. Women and men in Kenya correctly observed that ‘Fansidar’ (SP) was no longer effective for treatment of malaria, and the men explained that some chemicals had been added or that the doses were incorrect. The newer drugs were widely perceived to be more effective than the older drugs in both countries. Kenyan women were concerned about using drugs correctly (as prescribed) and about safety, and Coartem (AL) and quinine were said to be too powerful to be used in for treatment in pregnancy. Drugs obtained from chemists were said to potentially harm the baby and the preference was to obtain treatment from a trained provider at a health facility following diagnostic confirmation. In Mali, both traditional and modern medicines were reportedly used to treat malaria in pregnancy, and traditional medicines used if women could not afford modern medicines. Modern medicines were seen to be more effective than traditional medicines, with a more rapid mode of action, but there was some confusion over the application of some drugs such as ACTs, which were thought to be used for both treatment and prevention. In Mali, the misuse of traditional plants for treatment was seen to cause problems, and if someone had received only modern medicines from birth, traditional medicines were said to be no longer be effective in adulthood; we labelled this sub-theme the ‘habit’ of modern medicines.
Experience of treatment drugs
Women in both countries complained of side effects from some of the antimalarials they had used; quinine was said to cause deafness and scratching or itchiness (Kenya) or buzzing in the ears and dizziness (Mali). One woman in Mali observed that she could avoid adverse events if she ate enough before taking quinine. There were mixed views among women in both countries as to the effectiveness of quinine, being either very effective at fighting malaria or to no longer work at any dose of quinine injection (300 mg, 400 mg, 600 mg, and 800 mg)(Mali). Similarly, SP was said to cause nausea and to no longer work for treatment in Mali.
Pregnancy disclosure to prescribers
Disclosing one’s pregnancy to the person prescribing treatment was recognised as important by most women in Kenya and Mali, to avoid being given harmful drugs that may cause miscarriage and because, as early pregnancy was not visible, providers would not always think to ask a woman whether or not she is pregnant. However not all women were willing to disclose their pregnancy status, as described above in response to questions about ANC access.
Cost (affecting source and type of treatment)
124 Community perceptions of malaria control in pregnancy
T ab le 3. Fac to rs a ffe ct ing preg nant wom en’s p rac tices for the tr eatm ent o f m alar ia . T h em es K en y a S u b -th em es & Q u otati o n s fro m s tud y p a rti ci p an ts Mal i S u b -th em es & Q u otati o n s fro m s tud y p a rti ci p an ts Perceptions of illnes ses a nd d iagn os is I di dn’t know t hat i t w a s m a la ria s o I us ed di ffer ent m edi ci ne not know ing t hat i t i s m a la ria. I t hought t hat I w a s pr event in g s o m e dis eas es like pneumonia s o w henever I feel any c o ld, Pa nad ol is the onl y opt io n t hat I us e a nd w h en i t di dn’t get over , I w ent t o t h e hos p ita l and w a s t es ted and f oun d o u t t hat i t w a s m a la ria. (R 9 , si ngl e, adoles cen t ag ed 18 years , 1 pr ev ious preg na nc y w ho is ali ve , Kak o la) W h en I am pr egnant and I get at ta cked w ith m a la ria, I m u st go t o t h e h o sp ita l so th a t th e d o cto r ca n test me b eca u se if I g o t o th e ch emist and I can be gi ven dr ug t hat h a rm m y baby t hat I car ry. (R 1, m arri ed w o m en a ged 2 8 y ear s, m u ltip ar o us, Kak o la) But w hat I fear is the s yr inge t houg h I c an s w allow even a p a le of m edi ci ne. But w h en I go t o t h e hos pi ta l an d a t im e f o r l a b t es t com es , I will n o t g o . (R 9: s in gl e, adoles cen t ag ed 18 years , 1 prev iou s p re gna nc y, K ako la ) T h e abus ed us e of t radi tional pl ant ca n caus e ot her di se as es . It i s good t hat y ou get t o t h e heal th cent re f o r di agnos is bef o re you get any t reat m ent . ( P 5: w o m an ag ed 40 y ears , m u ltip ar o us, B an an ko ro ) ‘KONO’ [cerebral m alaria] w h ich means that the body b eco mes hot and s tiffnes s and w e go t o t h e heal th ce nt re . (P 5: w o m an a ged 40 y ears , m ul tip arou s, Ban ank oro) Pr egnant w o m en s u ffe r f rom m a la ria becaus e m a la ria s ym p to m s ar e ver y s im ila r t o pr egnancy s ym p to m s s o t hat y ou do n’t kn ow t hat yo u have m a la ria and t h is gi ve oppor tuni ty t o in fe ct ion t o s ta y l onger i n yo ur body , an d yo u di sc over ver y l a te t hat you have m a la ria. (P 4, w o m an ag ed 20 y ears , n o prev io us pregn an ci es , S agn i) Som e h a ve m a la ria but t h ey t hi n k t hat i t i s t h e be gi nni ng of p regnancy. So if t h ey ex pl ai n t o a health w o rk er , they ca n get m o re clar ificati ons . If it is pr egnancy, they pr ovide co uns el ling and as k y ou t o s leep under be dn et . (P 8: ad oles cen t ag ed 18 ye ars , n o prev iou s pregn an cie s, Sag ni) Perceptions of treat m ent drugs E ffectivenes s D rugs us ed now adays ar e m o re ef fe ct iv e t han t h e p a st ones .(R 3, m arri ed m an ag ed 23 y ears , K ak o la ) In t h e p a st w e w er e us ing dr ugs l ike Al gon a nd F ans idar bu t t h ey w er e very effective b u t th e Fa n sid a r o f n o wa da ys a re n o t effective, it is like th ey have adde d s o m e chem ic al s t hat i s w h y i t i s i n ef fe ct ive. (R 10, m arri ed m an ag ed 20 y ears , K ak o la ) Thes e medicines only w o rk if w e us e them accor d ingly. (R 8 , m arried, adoles cen t ag ed 17 ye ars , m ul tiparou s, Koru ) S a fety Y ou cann ot t a ke C oar te m w h en you ar e pr egna nt beca us e i t i s pow er fu l l l ike Fans idar . (R 2, m arri ed w o m an a ged 31 y ears, m u ltip ar o us, Ka ko la) T h er e ar e s o m e bad ef fe ct s becaus e s o m e have n o t un der g on e a s tudy and w e can not t el l t h e d o sage, s o m e ar e not f o r m a la ria t h ou gh t h ey ar e i ndi cat ed b u t t h ey ar e f o r s o m e com pani es w h ic h w ant t o m a ke p ro fit o u t o f u s a n d th ese med icin es a re n o t tested th a t th ey c a n trea t ma la ria . (R es pon den t 7, m arri ed m an ag ed 36 years , K o ru ) T h e pas t ant i-m a la rial dr ug s l ik e qui ni ne ar e not g ood w ith expect ant mo th ers. (R 1 , m ar ried , ad o lescen t ag ed 1 8 year s, m ultip ar o us, Ko ru ) E ffectivenes s W e ar e t reat ed us ing t radi tional m edi ci ne a nd m oder n m edi cat io ns . But m oder n m edi cat ions ar e r api d ( tr eat ed m o re qui ckl y. (P8: a d oles cen t ag ed 18 y ears , n o prev iou s p re gna nc ie s, Sa gni ) ‘H a bit ’ of m o dern m edicine W e us ed t o gi ve her b t o our w ife , but n o w w e br in g h er t o t h e heal th cent re . …. Si nce t h e day of bir th the child r eceived moder n medi cation and 15 da ys after he r eceives another m oder n m edi cat ion s o t hat t h e bl ood and t h e b ody of t h e chi ld take h abi t of t h e dr ug a nd final ly t h e t radi tional pl ant ca nnot hel p t h e chi ld f o r t reat m ent . So i t i s go od t o get t o t h e heal th cent re. Y ou c an do a w eek t o t reat m a la ria w ith t radi tional pl an ts w ithout any su cces s, but w ith t h re e days of m oder n t reat m ent you get s u cces s. (P10: m an ag ed 41 ye ar s, Sa gni ) Co nf usio n o v er use Bot h pr event io n an d t reat m ent . It ( A C T ) al so cont ai n vi ta m in i n side. (P 6: w o m an ag ed 36 year s, m ultip ar o u s, B an an ko ro ) E x perience of treat m ent drugs Side effects I have hear d a bout i t [qui ni ne ] an d I have us ed i t but af te r t hat , I f el t like I w a s deaf . (R 4, m arried, adoles cen t ag ed 17 years , m ul tiparou s, Koru ). Side effects I take it [ quinine ] w h en I eat e noug h to av oid a d ver se events . (P 1: w o m an ag ed 48 ye ars , 1 prev io us preg na nc y, Ban ankoro) 12 5
