Perspectives of postpartum women on intermittent presumptive treatment in Uganda: implications for malaria prevention: a qualitative study

Abstract

Background

Malaria during pregnancy leads to many deaths in Africa. COVID-19 contributed to more malaria cases due to interruptions in prevention efforts. Intermittent presumptive treatment (IPTP) is an effective malaria prevention strategy for pregnant women, but adoption barriers still exist. The study aim was to explore barriers to the adoption of IPTP at Kawempe National Referral Hospital (KNRH) Uganda.

Methods

In a qualitative study design, data was collected using focus group discussions. A total of 37 postpartum mothers were interviewed in six focus group discussions. The interviews were conducted using a structured guide to explore barriers to IPTP implementation at KNRH. The data was transcribed, coded, and analysed using NVivo 10.

Results

The study found that mothers lacked adequate knowledge about IPTP, faced socioeconomic and cultural constraints, fear of side effects, a high pill burden, and experience of health system challenges as major themes of barriers to optimal IPTP use.

Conclusions and recommendations

Challenges in the service delivery and inadequate information in regard to importance and expected side effects were identified by the users as the major barriers to IPTP delivery in public health care setting. Improving delivery of focused health education talks and health work attitude and delivery chain for IPTP in the health facilities are recommended to increase its uptake.

Background

Pregnant women in regions with stable malaria transmission are at a higher risk of contracting the disease [1]. In 2021, it was estimated that over 13 million women living in moderate to high transmission areas in the African region were exposed to malaria during pregnancy [2]. In 2020, 627,000 deaths were directly attributed to malaria, an increase from 558,000 in 2019 and 562,000 in 2015 [2]. The increase in malaria-related deaths was linked to disruptions in control measures during the COVID-19 pandemic and changes in malaria data collection methods [3]. Uganda is one of the six African countries that account for 55% of global malaria cases.

Pregnant women residing in malaria-prone regions may face various detrimental outcomes resulting from malaria infection. Pregnant women with malaria face a higher risk of complications such as miscarriage, stillbirth, low birth weight, and intrauterine growth restriction (IUGR) [4]. To address the burden and consequences of malaria in pregnancy, the World Health Organization (WHO) recommends a three-pronged approach, including the use of insecticide-treated bed nets, effective clinical management of malaria cases, and intermittent presumptive treatment. Intermittent presumptive treatment in pregnancy (IPTP) faces a challenge of low coverage in malaria endemic areas.

Using a mathematical model, Walker et al. [5], estimated that scaling up IPTP in absence of ITN use would lead to an additional 16.5% reduction in low birth weight. Data from the East Africa Preterm Birth Initiative study revealed a reduction in mortality before discharge, dropping from 336 to 47 per 1000 live births for babies weighing 500–999 g and 3500–3999 g at birth, respectively [6]. The current IPTP guideline is to give all pregnant mothers in endemic areas sulfadoxine-pyrimethamine (SP, Fansidar®) monthly from the second trimester until delivery, with a minimum of three doses [2]. Uganda, despite being one of the countries with the highest burden of malaria globally, has low IPTP coverage. Data from the 2016 Uganda national demographic survey showed that on 18% received three doses of IPTP [7]. At a tertiary referral hospital in eastern Uganda, 23.3% of mothers reported receiving at three doses of Fansidar IPTP [8]. According to the 2018–2019 Uganda National Malaria Indicator survey 45% of pregnant women received three doses of IPTP [9] which was far below the 93% that Uganda targeted to achieve by 2019/20 [10].

The use of effective interventions for malaria prevention is one of the key strategies for the reduction and elimination of malaria. The use of insecticide-treated bed nets is relatively higher, with two-thirds of pregnant women aged 15–49 years reported to have slept under an insecticide-treated net the previous night [11]. Evaluation of the key barriers to the use of effective malaria prevention strategies is very important in the fight against malaria. Data from health surveys have identified factors associated with suboptimal use of IPTP in Uganda and other endemic settings [7, 12].

Recurrent stock-outs of Fansidar in private-sector facilities and insufficient knowledge of IPTP guidelines among health workers were hindering pregnant women from receiving the required IPTP doses in Uganda. On the demand side, it revealed instances where pregnant women attending private facilities were being charged for treatments that should be provided free of charge [13]. Health-seeking behaviour emerged as another concern, with certain interviewees expressing that they only seek medical care during pregnancy when they feel unwell.

Despite various interventions designed to increase coverage, significant improvements in IPTP uptake have been elusive, even with the increased use of insecticide-treated bed nets among pregnant women. A systematic review of qualitative studies in Africa revealed that while mothers are aware of Fansidar IPTP, they express concerns about potential side effects and harm to the baby [14]. Perceived barriers, representing individual feelings and hindrances to adopting recommended interventions, may play a crucial role in shaping pregnant women's decisions regarding IPTP utilization.

This study aimed to explore the barriers to IPTP from the perspective of postpartum women in a public health care facility in Uganda. The findings from this study will contribute to the body of knowledge on IPTP utilization and may aid in the development of evidence-based policies and interventions aimed at reducing the burden of malaria in pregnancy in Uganda and similar endemic settings.

Methods

Study design

This is a qualitative study was conducted at Kawempe National Referral Hospital in Kampala, from 1st to 20th November 2020, focusing on postnatal mothers within 2 weeks after delivery. Reporting of the study methods and results follows the consolidated criteria for reporting qualitative research (COREQ) [15].

Study setting: study site

The study site, Kawempe National Referral Hospital (KNRH), is a tertiary, national referral hospital situated in Kampala, Uganda's capital and largest city. KNRH provides specialized health care services in obstetrics and gynaecology, paediatrics, adolescent health, HIV/AIDS care, research, and training. KNRH, with a 170-bed capacity, offers free specialized health care services. As a teaching hospital for Makerere University College of Health Sciences, KNRH's Department of Obstetrics and Gynaecology adheres to national guidelines, providing SP IPTP monthly from the first trimester to delivery through antenatal care clinics. The facility caters to patients from both urban and rural areas, with the majority (> 90%) residing in Kampala district. Referrals encompass self-referrals, facility referrals from lower-level health units, and those initially booked at KNRH for antenatal care services.

Maternal healthcare services in Kampala are given through the public and private facilities. These are estimated to serve over 1.6 million residents of Kampala. Due to overcrowding in the free public health facilities some mothers seek maternal health care services from the private facilities.

Study population and sample for focus group discussions

The eligible participants for this study were postpartum mothers who had given birth within the past two weeks to a live baby. After obtaining informed consent, participants were selected to join six- to seven-member focus group discussions (FGDs) aimed at exploring barriers to the adoption of intermittent presumptive treatment (IPTP) during pregnancy. Mothers with live births at the time of discharge were purposefully chosen for the FGDs. All the participants were able to listen and speak in both English and Luganda.

Participants were invited and recruited after obtaining informed consent. Participants were grouped into six- to seven-member focus group discussions (FGDs) based on their ability to communicate in either English or Luganda, to explore the barriers to adopting IPTp. Postpartum mothers with live births on the maternity ward were purposefully sampled at the time of discharge. Participants unable to communicate in English or the local language (Luganda) were excluded. Mothers whose babies had passed were excluded because the study was done in the immediate postpartum period when they were still grieving for their loss.

Study procedures

Face-to-face FDGs were conducted within the hospital premises, specifically in designated consultation rooms. Trained female research assistants, proficient in both English and Luganda, facilitated the interviews. The discussions were guided by a semi-structured interview guide and were audio-recorded for subsequent transcription prior to data analysis. Transcription was done with simultaneous translation to English.

Data collection tools

The data collection tools encompassed assessments of participants' knowledge of IPTP, identification of perceived barriers and facilitators influencing IPTP uptake, and exploration of policy bottlenecks in IPTP implementation.

Ethical approval

Ethical approval for this study was obtained from the School of Medicine Ethical Review Board at Makerere University College of Health Sciences. Postpartum mothers below the age of 18 were considered as emancipated minors which aligns with the ethical guidelines of the Uganda National Council of Science and Technology [16]. Additionally, the study received approval from the Uganda National Council for Science and Technology, which serves as the national ethical board overseeing the research.

Data analysis

The qualitative data analysis for this study utilized NVivo 10, a software for qualitative analysis provided by QSR International. Initially, interviews conducted in the local language dialect, Luganda, were transcribed and then translated into English. The transcriptions of the English-language interviews from the focus group discussions (FGDs) were imported into NVivo for subsequent analysis. The research team, led by the primary researcher (FN), identified and coded the data to develop themes and subthemes related to the barriers and facilitators of adopting IPTP. To ensure the validity of the coding and themes, a social scientist with relevant expertise participated in the validation process. Rigor in the study was maintained through a collaborative approach, with regular discussions and peer debriefing sessions held to ensure consensus and the credibility of the findings. Data triangulation was employed to enhance reliability by cross-verifying information from different sources and comparing perspectives among various participants.

Results

Participants sociodemographic characteristics

A total of 37 postnatal mothers who had delivered at Kawempe National Referral Hospital in November 2020 participated in the focus group discussions. The majority of the mothers had one living child and had taken at least one dose of Fansidar IPTP during their most recent pregnancy. Details of the demographics and obstetric history of the mothers who participated in the focus group discussions are shown in Table 1.

Table 1 Demographics characteristics and obstetric history of mothers in the FGDs

Themes and subthemes on barriers for IPTP

Patient centred and supply related barriers were the two major themes identified after analysis. The details of the subthemes generated are shown in Table 2.

Table 2 Themes and subthemes for barriers to IPTP use at KNRH

Patient centred barriers

Inadequate knowledge as a key barrier

Majority of the mothers 35 (94.5%) reported taking at least one dose of IPTP. Of these 22.9% reported taking less than the recommended doses IPTP. It is indicated for asymptomatic pregnant women. The post-partum mothers identified inadequate information on importance and scheduling of IPTP as a barrier.

“Most people's problem is not the tablet itself; when they look around, they keep on wondering why they are swallowing it”. FGDI "Respondent 6 (Para4, 21 years)

“They say, “I am not sick, so why are they giving this drug to me to swallow?”. FGDI Respondent 1(Para 9,30 years)

Pill size

The size and number of pills taken during the intermittent presumptive treatment in pregnancy was identified a key barrier. Postpartum mothers felt that the size of tablets if reduced may improve compliance. This presents a high pill burden to pregnant women which is a barrier, as demonstrated in the quotes from mothers below,

“… they were three tablets and yet they were too huge, eh! I swallowed the three tablets but they were huge. FGDIV: Respondent 7 (Para1, 25years)

Some mothers devised a way of dealing with the pill burden and fear of side effects to improve compliance. The attributed side effects affected the compliance and suggested ways of managing the problem.

“They should reduce the number of tablets because they are many and yet big.” FGDIV: Respondent 1 (Para 3, 25 years)

“It is not easy. To a person like me who breaks them into pieces to be able to swallow them, it is really difficult”. FGDV Respondent 6 (Para 1,17 years)

Fear of side effects

Postpartum mothers felt that some of the pregnant women do not take the Fansidar IPTP as prescribed because of fear of side effects. Lack of information about the potential side effects is a barrier to IPTP.

“The first time I swallowed those drugs, I always felt dizzy. I didn't always like to swallow it; I feared it because the first time I swallowed it, it caused me dizziness’. FGDIV Respondent 3 (Para 1,21 years)

“They don’t tell us about the side effects like; laziness, discomfort or even vomiting. They just give you the drug. Interviewer: They don’t tell you about the side effects? All respondents: No. Interviewer: Would it be good if they told you about them? All respondents: Yes.” FGDIV Respondent 1(Para 3, 25 years)

Some participants had experienced the side effects related to taking Fansidar IPTP on an empty stomach.

“There was a time when I swallowed it before eating. ….. when I swallowed it before eating, I vomited and felt so weak and on the following doses, I decided that I would swallow that tablet at night after supper when I am settled”. FGD IV Respondent 6 (Para 6, 37 years)

Supportive partners/sociocultural influences

Postpartum mothers identified that some family members discouraging them to take IPTP. The propaganda from the community further discourages pregnant women to take the intervention. Some of the mothers felt that Fansidar is given to prevent normal deliveries. The lack of family support and misconception is demonstrated in the quotes below,

“They used to tell us that Fansidar is not good because the government is trying to prevent people from having normal deliveries that’s why people are giving birth to many disabled children. I think that’s why some people don’t like taking the tablets”. FGDII, Respondent 2 (para 1, 21 years)

Sometimes when we stay with our mothers and tell them about Fansidar they will say, “What’s that? how come we only used this and that? It’s up to you.” FGDV, Respondent 5 (Para 6, 43 years)

A supportive partner who follows the mothers to the antenatal clinic and interventions provided promotes compliance with IPTP. The partner may follow by looking at the records to check the medicine given, escorting the pregnant mother to the antenatal clinic, and providing financial support for transport and buying medicine.

“Every time I went for antenatal, my husband would tell me that we'll eat in a hotel. [laughs] I loved this so much so, I had to remember my appointments. We went together on our first pregnancy but for this pregnancy, we only came together once because he also had to be tested for HIV. He later got busy with making craft shoes so, I told him to work and I would go alone” FGDIII Respondent 3 (Para 1, 17 years).

“My husband always asks to look at my antenatal book and if I haven't bought the drugs, he will give me money to buy it. If I don't buy it, he will ask, "Where is the medicine?" he knows that I might use the money to buy other things so, he has to make sure I buy it.” FGDIII Respondent 2 (Para 3, 23 years):

Poverty

Postnatal mothers identified poverty as a barrier to taking IPTP. The pregnant mothers are required to buy Fansidar in cases when its not freely available in the hospital. Some pregnant mothers may be willing to take the Fansidar but cannot afford to buy it from a private pharmacy or transportation to hospital.

‘In some government facilities there are no drugs so, they will tell you to go to the pharmacies. However, in the pharmacy, it is expensive yet they told us that the government hospitals were put in place to treat us!’ FGDIII, Respondent 5 (Para 5, 24 years)

I remember that one time they told me to return on the 4th of the following month but I failed because I couldn't get transportation. FGDII, Respondent 2(Para 1, 21 years)

What I can comment about this is that not all of us had our antenatal care from government facilities. Some of us had it from private facilities and some from government facilities. So, in a government facility, it is easy for someone to get those tablets whenever she goes there but for someone who went to a private facility, sometimes she might get money this month to buy those tablets because they will be for sale but in another month, she might go there without money and therefore have to miss out. Interviewer: About how much were these tablets being sold in private facilities? FGDII, Respondent 6 (Para 1, 20 years)

They would charge you about 5000 Uganda shillings (1.27USD) for three tablets and yet you would have to swallow all of them at once. FGDII, Respondent 6 (Para 1,20 years)

Health systems barriers

Mistrust of health workers

Some mothers felt that there was unfair treatment of health workers. Some patients think that some health workers are corrupt and hold back the Fansidar from the patients.

There are drugs in government hospitals however, why do they tell us it is not available when we go there? FDG 1, Respondent 1 (Para 9, 30years)

It hasn't been easy because there are some times you come here so early that you are the first on the line but you end up being served last simply because some health workers are corrupt. They work on people with money first, so you end up being seen last. FGD II, Respondent 1 (Para 2, 20 years)

I was angry with the facility I was getting my antenatal because I went there to get my medicine with just 500ugshs (0.13USD) in my pocket. What's even worse is that the nurse prescribed to me drugs that were available in the tins. By the time the health care worker tells you to come every month, it means that the government puts drugs in those hospitals. So, where do the drugs go to? Why don't they tell us not to come if the drugs are not available so that we just go to the clinics? It is so annoying that these health care providers know where the drugs are and it's them who tell you where to go to buy them. FGDI, Respondent 4 (Para 2, 33 years)

Health worker attitudes and capacity

The negative attitude of some health workers towards pregnant women during antenatal visits was identified as a barrier. This is done by the way they address the mothers during the antenatal care visits. This is especially evident among the front desk workers who receive the clients in the clinics.

The providers at the front are not easy; they speak badly but the providers that examine the pregnancy and dispense drugs are so good. However, the ones that write down or check your blood pressure, can suffer with them. FGDII, Respondent 5 (Para 2, 23 years)

When we go for antenatal, some nurses are strict; when you arrive, they start saying, "Look at how you look. Look at the cloth you are wearing." but as you know pregnant women wear whatever makes them comfortable. She can wear a tight or free dress because she feels comfortable in it. When you go to the hospital and the health care providers bark at you. You can't tell them about your problems. FGDII, Respondent 1 (Para 2 ,20 years)

You might go to a facility where the provider is yelling at you because they are short-tempered. FGDII, Respondent 2 (Para 1, 21 years)

Inconsistent drug supply

Lack of consistent supply of the Fansidar in the hospitals during the antenatal visit was identified as a barrier. When the medicines are not available in the free public health facilities pregnant mothers are asked to buy from private pharmacies. The inconsistent supply of the Fansidar leads to mistrust of the health workers in how drugs are handled.

The other thing, Fansidar is never available in the hospital, they write them for us and send us to buy them at pharmacies. They used to just write them for me and buy them outside. FGDV, Respondent 1 (Para 1, 22 years)

They would tell us that the supplier hasn’t arrived yet. They would say, “They haven't come. You will swallow another time but if you stay close by, you can wait and get it before it is distributed.” FGD V, Respondent 3 (Para 1, 18 years)

Long queues and facility delays

The long queues in the health facilities and the long waiting time to receive care negatively impact the IPTP programme in health facilities. The waiting time makes the mothers tired and hungry which frustrates the attempts to adhere to the programme.

The health care providers easily take care of us during pregnancy. However, what gets me annoyed is the fact that they tell us to come early to the hospital but when we arrive at 10 am, we leave at 6 pm. FGDI, Respondent 4 (Para 3,22 years)

What mainly made me hate coming alone was that I would spend a very long time waiting. You would even start feeling dizzy while waiting for the drugs simply because the queues were always so long. Sometimes you leave home after eating and sometimes you do not like the eats that are sold at the hospital, so you delay. FGDIV, Respondent 1(Para 3, 25 years)

The line was long but they were working on a “first come first serve” way. FGDI, Respondent 4 (Par3, 22years)

People were many and we had to wait for some time. FGDI Respondent 1 (Para 9, 30 years)

Limited health education talks on IPTP

The limited knowledge of SP IPTP was attributed to limited time allocated to health education on malaria in pregnancy. The health education talks in the antenatal clinic focus mainly on HIV in pregnancy. This is demonstrated in the quotes below after probing by the interviewer.

They have never taught us about Fansidar. Respondent 1: They taught us about HIV. Respondent 6: It was my parents who told me about antenatal and mosquito nets. FGDV, Respondent 5 (Para 6, 43years)

In cases where information was given, it may be inadequate and incomplete. The mothers felt that empowering them with the right information will help to improve coverage.

They just say, "We give you these tablets to prevent you from getting malaria and to protect the child" but they never mention how many times you must swallow or at what time you must start swallowing. It is instead the dispenser who says that at the ward, otherwise the other providers here just write down and tell you to go to the second ward. FGDII Respondent 1 (Para 2, 20 years)

It is important because I would know whether I have swallowed properly or not or if I have finished all the tablets. If I missed some, it would force me to return and tell the provider or not Respondent 1: It is important because it helps you know what time to start swallowing and for how long you have to swallow. FGDII, Respondent 3 (Para 8, 38 years)

I think that it would be better if they tell you the right months in which you must swallow Fansidar. FGDII, Respondent 6 (Para 1, 20 years)

In some cases, the health education talks given in the antenatal clinics are given late when some mothers have left the hospital. Some mothers have a good attitude towards the health education talks but did not get an opportunity to attend them. Mothers believe that giving health education talks effectively can be used in improving the IPTP uptake. Increasing the publicity in the general public other than antenatal clinic was suggested as a way to obtain information on the use of Fansidar in the general public. This is demonstrated in the quotes below.

I was angry with the hospital that I went to, they would attend to us early and even give us the drugs but then the teacher would arrive late. So, we would wait feeling hungry until we gave up and left. But those who could, waited. FGDV, Respondent 3 (Para 1, 18 years)

I could have attended the health education but no one ever told me about it. FGDV, Respondent 6 (Para 1, 17 years)

I wish they can also advertise Fansidar on Television or radio so that women can know about it the same way they know about mosquito nets. With that, she can go to the hospital knowing about Fansidar. FGDV, Respondent 6 (Para 1, 17 years)

Discussion

This study aimed to explore the perspective of post-partum mothers on the barriers IPTP use in the health care system in Uganda. The barriers identified under the themes patient-related barriers and facility-related barriers. The patient-related barriers included the inadequate knowledge on the purpose of IPTP, fear of side effects, pill burden, lack of social support and poverty. Long queues in the antenatal clinics, mistrust of health workers, inconsistent supply of Fansidar were identified as the health facility-related barriers.

Patient related barriers

Inadequate knowledge

Postpartum mothers identified having inadequate knowledge of the importance, and scheduling of using Fansidar for preventing malaria in pregnancy as a barrier to getting optimal doses recommended for prevention. Pregnant women generally have a good attitude towards IPTP in Uganda [13] but adherence is likely affected by inadequate knowledge. Studies are previously shown that mothers who are knowledgeable about the recommended dose and its usefulness are more likely to take optimal doses of IPTP [12, 17, 18]. Poor understanding of the providers on the protocols used for IPTP has been identified as a key barrier to IPTP use [19]. Good knowledge has been associated with practice in neonatal care [20]. A Kenyan study with high IPTP coverage emphasizes how maternal awareness of benefits and dosing requirements improves adherence [18].

Knowledge plays a pivotal role in empowering pregnant women to seek timely antenatal care, promoting IPTP utilization. Addressing this knowledge gap necessitates targeted educational campaigns for pregnant women and healthcare providers, including integration of malaria education into antenatal care and service provider training. Community-based initiatives could also aid widespread information dissemination [21].

Pill burden and fear of side effects

Mothers expressed concerns about the potential side effects of Fansidar as a barrier to IPTP use. Inadequate addressing of safety concerns during antenatal care health education talks has led to fear and hesitation among pregnant women in Uganda [22]. The discomfort of taking three large tablets at once, poses a significant hindrance to the acceptance and adherence to IPTP. Reducing the Pill burden has been associated with increased adherence to medication [23]. Improving patient-provider communication increases the uptake of IPTP [17]. To overcome these barriers, prioritizing effective communication between healthcare providers and pregnant women, addressing concerns, and offering accurate information about IPTP benefits and risks is essential. Exploring alternative dosing strategies to reduce pill burden could also enhance Fansidar's acceptance and use for malaria prevention during pregnancy.

Socio-cultural influences and family support

Inadequate social support and sociocultural influences emerged as barriers that influence Fansidar utilization. This is in keeping with a study in Ghana which showed that having good social support for the pregnant woman was associated with taking optimal doses of IPTP [24]. Having a positive community perception of IPTP promotes taking optimal doses [25]. The community including the partner and relatives offers financial and social support that encourages the pregnant women to adhere to the preventive regimen.

Poverty

Poverty and the high cost of acquiring Fansidar were identified as significant challenges to IPTP uptake. This aligns with prior research, such as the 2016 Uganda Demographic Survey, which demonstrated how financial constraints contribute to suboptimal IPTP dosing among economically vulnerable women [26]. These financial limitations not only affect medication affordability but also hinder transportation and timely healthcare access, further diminishing IPTP coverage. Malaria has been described as a disease of the poor who often experience more severe malaria consequences [27].

The study found that the added costs of seeing a skilled health worker from private health facilities and buying the medicine in a community where poverty is high prevents mothers from getting optimal doses of IPTP. Financial empowerment of women is key to the success of the IPTP programme since malaria is a disease of the poor [27]. Poor adherence to medicine as recommended leads to high costs in management of the conditions [28].

Mistrust of health workers

The study revealed that the negative attitudes of some health workers towards pregnant women during antenatal visits were a barrier to the successful implementation of the IPTP program in the setting. The negative attitude of health workers is shown by a range of verbal and psychological mistreatment by the health workers in public health facilities [29]. The majority of maternal health care managers and providers in different countries in Africa reported poor quality services given at different facilities [29]. Addressing health worker attitudes and fostering a supportive, respectful healthcare environment is vital to build trust and improve IPTP uptake.

Health worker attitudes and capacity

Poor attitude of the health workers towards the pregnant women receiving antenatal care services was identified as a key barrier to IPTP in this study. A previous systematic review of studies on attitudes and behaviours of maternal health care providers showed a range of negative attitudes and behaviours are prevalent in Africa [29]. Effective communication and demonstration of care by health workers were associated with increased trust in the services given among low-income women in USA [30]. Health workers have a key role in the success of the IPTP implementation.

Inconsistent drug supply

The inconsistent supply of Fansidar at the health facility was cited by the mothers as a barrier to using IPTP during pregnancy. This finding is in agreement with previous studies from health workers [31] and mothers in Uganda [32] that demonstrated that availability of supplies for IPTP is a major barrier to the policy. A similar finding has been found in Ghana [24]. Ensuring a consistent Fansidar supply at health facilities is crucial for uptake and adherence to the IPTP regimen. Inadequate supply couple with poverty provides a challenge of taking optimal doses of IPTP.

Long queues and facility delays

The study highlighted that long queues and waiting times at health facilities negatively impact the IPTP programme. Long waiting time in patients receiving antenatal care leads to dissatisfaction of the pregnant women [33]. Extended waiting times and long queues at health facilities can cause physical and emotional strain for pregnant women seeking IPTP, potentially resulting in low follow-up rates and poor medication adherence. Strategies like streamlining scheduling and task shifting with proper training could mitigate these challenges.

Study limitations

Self-Report Bias is a potential limitation of this study, as the data was gathered within the healthcare setting. Participants might have been influenced by social desirability or memory recall issues, leading to underreporting or overreporting of certain factors. However, steps were taken to mitigate this bias. The data collection was carried out by a neutral person not involved in the participants' care, and it occurred after delivery, potentially minimizing underreporting.

The study was specifically conducted at one health facility Kawempe National Referral Hospital in Uganda, and the findings may not be directly transferable to settings with distinct healthcare systems, sociocultural norms, and economic circumstances. Generalizing the results to other regions or countries should be approached cautiously. The study outcomes offer valuable insights into the public healthcare services within Uganda, shedding light on the challenges and opportunities within this context. The study included only mothers who could speak English or Luganda. This could have led to loss of important information in those excluded. However, the majority of people in Kampala speak either of the languages which is likely not affected the outcome of the study. While the study focused on pregnant women's perspectives, understanding health workers' views and experiences regarding IPTP utilization could provide valuable insights into the barriers and enablers from the provider's view standpoint.

Conclusions

The findings from pregnant women's perspectives on the barriers for IPTP utilization indicate inadequate knowledge on IPTP, economic challenges, lack of supply of IPTP medicines in the facility, shortcomings in the health system, and socio-cultural influences were identified as barriers.

Recommendations

The study suggests a range of recommendations to address barriers and enhance the adoption of IPTP for pregnant women. Ensuring a reliable supply of Fansidar at healthcare facilities, health education talks in the facility should emphasize the importance, potential side effects and dosing schedules for IPTP. Further research and collaboration with stakeholders are essential to developing and implementing evidence-based strategies that cater for gaps in the IPTP delivery chains and identify specific needs and contexts of pregnant women in malaria-endemic areas.

Financial empowerment of women will help to overcome economic barriers, and consequently enhance access to affordable anti-malarial medications for pregnant women. Iintegrating partner involvement into antenatal care services, and promoting male engagement during antenatal visits can reinforce adherence to IPTP.

Addressing negative attitudes and mistrust towards pregnant women during antenatal visits requires ongoing training and capacity-building for healthcare providers, fostering a supportive and respectful healthcare environment. Streamlining health facility processes in order to alleviate long queues and facility delays. This can be done through implementing strategies such as appointment scheduling, task shifting, and community-based distribution of IPTP can reduce waiting times and enhance the overall healthcare experience for pregnant women. Further research on how to implement the suggested intervention in the specific health care setting is highly recommended.