Malaria is a life-threatening disease caused by parasites that are transmitted to people through bites of infected female Anopheles mosquitoes.¹ Malaria is a preventable and curable disease.² Africa is the home to over 90% of malaria burden when compared to other regions of the world.² The region is estimated to have a dominance of 94% of maternal deaths occurring in the World.⁴

Malaria is one of the indirect causes of maternal deaths, accounting for about 15% of all reported maternal deaths in the world. In 2015, malaria was considered the third cause of deaths among women of child bearing age in the world. About 24 million pregnant women in the sub-Saharan Africa are affected with malaria every year. In endemic areas, events of maternal deaths due to malaria accounts for about 25%.⁶ A study that used District Health Information System (DHIS) data of 2014 and 2017 in Tanzania, reported malaria prevalence of 8.1% and 6.7% respectively, indicating an absolute difference of 1.4.%⁷

Primigravidae, adolescents, and pregnant women coinfected with Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) are usually accompanied with adverse complication.⁶ Commonly reported compactions of malaria in pregnancy include; placental malaria, maternal anaemia, abortions, premature labour, intrauterine growth retardation and low birth weight.⁸ Asymptomatic malaria is also common among primigravidae especially among those from malaria-endemic areas.⁹ Maternal decline of immunity pronounced during the first and second pregnancies predispose them to high vulnerability to malaria¹⁰.

The World Health Organization (WHO) and the Global Malaria Community targets a malaria free world by 2030.² Nurses should routinely administer Intermittent Preventive Treatment of Malaria in Pregnancy Sulfadoxine-Pyrimethamine (IPTp-SP) to all pregnant women attending antenatal care services as one of the strategies to preventing malaria in pregnancy. Administration of IPTp-SP is based on the assumption that every pregnant woman living in malaria-endemic areas has malaria parasites in her blood or placenta, regardless of whether she is symptomatic or asymptomatic.¹⁰ The appropriate time to administer the first IPTp-SP dose is during the early second trimester. Subsequent doses are scheduled at 4 weeks apart while the last dose can be administered during late pregnancy, i.e. after 36 weeks of gestation, up to the time of delivery. Frontline antenatal care providers should ensure that pregnant women receive not less than 3 doses of IPTp-SP before delivery.¹¹

According to Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) (2015/2016), 71% of pregnant women who attended antenatal care services in Tanzania received IPTp-SP.¹² The 2019 World Malaria Report indicated that Tanzania and Burkina Faso had over two-third of their pregnant women receive 3 doses of Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp3) in 2018. The report also showed low coverage (31%) of IPTp-SP across sub-Saharan Africa.¹³

Several factors have been raised as enablers and/or barriers to IPTp-SP uptake. A study conducted in Korogwe District, Tanzania showed that nurses do not provide IPTp-SP as Direct Observed Therapy (DOT) due to reasons such as shortage of clean drinking water; therefore, it is not clear whether the provided anti-malaria drugs are taken as intended¹⁴. Having knowledge on when to start and stop IPTp-SP can also be a challenge to IPTp-SP uptake.^15,16 Studies have also revealed that factors such as education level of up to college level, early booking and having atleast 4 ANC visits contribute to adequate uptake.^16,17 Moreover, having parity of at least 4, being single and self-employment have been reported to impede the uptake.¹⁸ The nurse's limited knowledge on IPTp-SP protocol was a barrier to adequate uptake of the service as it was reported in Ghana.¹⁹ Similarly, IPTp-SP uptake can be determined by the age of the woman. Several studies from elsewhere showed that as the woman's age increases, the likelihood to IPTp-SP uptake also increases.^17,20,21.

The Tanzanian government has invested in ensuring that all pregnant women access IPTp-SP services during their visit for Antenatal Care Services. The government not only expanded health facilities to each village but also deployed adequate number of nurse/midwives to ensure pregnant women receive skilled services. However, according to TDHS-MIS (2015/2016), 24% and 49% of pregnant women book ANC services late and had inadequate ANC visits respectively.¹² This can impede the pregnant women to receive IPTp-SP timely. Therefore, this study aimed at analysing factors associated with uptake of intermittent preventive treatment for malaria dose at least once during pregnancy using data from TDHS-MIS.

A national-based cross-sectional study utilising the 2015-16 TDHS-MIS dataset was carried out among women of reproductive age (aged 15 to 49 years) to investigate factors associated with uptake of IPTp-SP in Tanzania. The outcome of the survey revealed that early ANC booking increased the odds of IPTp-SP uptake to more than one-fold compared to reference category. This finding mirrors the findings of a study conducted in Ghana, which also revealed early ANC booking being among the factor which influenced IPTp-SP uptake.¹⁹ Significance similarity was also reported in a study conducted in Arusha, Tanzania which revealed that early booking increased the odds of IPTp-SP uptake to almost two-folds.¹⁶ Early booking provides the pregnant women with ample chance to have adequate ANC visits and hence increasing the chance of IPTp-SP uptake. The research evidence support the premise that increased ANC visits increased the probability to IPTp-SP uptake.^17–20

This study revealed that maternal age had a positive influence to IPTp-SP uptake. The uptake of IPTp-SP increases with increasing maternal age. This results echoed the DHS of 2013 which indicated that women with greater than or equal to 30 years had increased odds to IPTp-SP uptake.²¹ Contrary to this, a demographic health survey (UDHS-2015/2016) conducted in Uganda indicated that maternal age did not contribute to IPTp-SP uptake among pregnant women.¹⁷ Similarly, the results of a systematic and meta-analysis study conducted in sub-Saharan Africa demonstrated insignificant association between maternal age and IPTp-SP uptake.²⁰ Differing socio-demographic characteristics of the respondents could be the reason for the demonstrated conflicting results.

The analysis also reported wealth index of the respondents to be a significant determinant of IPTp-SP uptake. The likelihood for IPTp-SP use increased based on the woman's wealth index. Middle class and richer women were more than one-fold likely to have adequate IPTp-SP associated with uptake of IPTp-SP were; early ANC uptake compared to the poor group. This observation is in line with what was revealed from a data analysis study conducted in Nigeria.²⁰ Being wealthy implies that the pregnant woman has the ability to cater for costs relating to access and utilisation of ANC services, and hence, promoting IPTp-SP uptake. There is a positive relationship between increasing wealth quintile and receiving ANC services which increases the chance of pregnant women to received IPTp-SP services.

The uptake of IPTp-SP was also found to increase with increasing education level of the woman. Pregnant women with primary education were one-fold versus those with secondary education or above whose odds were almost two-folds likely to have adequate IPTp-SP uptake compared to the reference category. This observation is supported by several other studies conducted in sub-Saharan Africa.^17,20 Educated women tend to have greater awareness and knowledge of the existence of IPTp-SP services and the benefits of using such services.²²

This study showed that multi-parity and grand-multi-parity increased the likelihood of uptake of IPTp-SP compared to primiparity. However, this observation is contradicted by a cross-sectional study conducted in Ghana at Winneba, Trauma and Orthopedic Hospital, which revealed that women with 4 and above parities had the least likelihood to use IPTp-SP during pregnancy.¹⁸ The difference in the findings can be attributed to the different sample sizes used, 6,885 and 391. A similar study conducted in Ethiopia reported the significant association maternal parity and health services utilisation including IPTp-SP uptake.²³

It was further revealed that being a resident of Mainland rural, Unguja and Pemba was negatively associated with IPTp-SP uptake compared to urban Mainland residency. The observed results could be due to socio-cultural differences especially with reference to residents of Unguja and Pemba Islands. Research evidence have linked rural residency with illiteracy, inadequate access to health services, inaccessible to health information updates, poverty etc., and all these attribute to inadequate IPTp-SP uptake.^24,25

Although IPTp-SP is a recommended routine measure against malaria infection during pregnancy, a considerable percentage of pregnant women do not receive the service. Based on this study, women who are most likely not to receive IPTp-SP are; those who book late for their ANC, below 20 years of age, with no formal education, low parity and reside in Mainland rural, Island Unguja and Pemba. Innovative strategies are recommended to address the challenge of low uptake of IPTp-SP during pregnancy.