Socio-Demographic Factors Responsible for Uptake of Intermittent Preventive Treatment and Health Seeking Behaviours for Malaria in Pregnancy among Women of Reproductive Ages in Nigeria

Malaria has been identified as one of the most severe public health problems globally ¹. It is a threat to about 40% of the world’s population and characterised with recurrent and repeatedly large scale epidemics ². The economic burden of malaria remains high with an estimated US$ 12 billion spent annually for prevention and treatment and about 25% of household income spent on treatment ³.

This disease remains one of the main causes of mortality and morbidity especially in Sub –Saharan Africa. Africa accounts for the highest burden of malaria with 95% of all cases and 96% of the deaths occurring globally ³. Additionally, the burden of malaria is greatest in Nigeria and as a result, Nigeria accounted for the largest proportion (25%) of cases which is equivalent to 84 million cases ⁴. Nigeria also accounted for 24% of the global mortality among the 19 countries with 85% of the global burden ⁴.

Although malaria affects all Nigerians, children and pregnant women have been found to be at higher risk of severe malaria infection and mortalities. In 2018, about 39% of the 11 million malaria cases among pregnant women occurred in Nigeria ⁴. While this disease increases the risk of birth complications and mortalities among pregnant women, there are evidence of malaria in pregnancy leading to low birth weight, anaemia and other health impacts on children born to malaria infected mothers ⁵.

In Nigeria, malaria accounts for 60 % of all Out-patient visits to hospitals, 11 % maternal mortality and 30 % child mortality ⁶. As a result, over 200,000 deaths was recorded which resulted in about 31.9% of the 627,000 deaths that occurred due to malaria in 2020 ⁷. Malaria in pregnancy is a serious public health concern that could result in detrimental health outcomes for pregnant women and their foetuses. As a result, strategies have been adopted to prevent the occurrence of malaria in pregnancy. Intermittent Preventive Treatment (IPT) for malaria has been recommended by World Health Organization (WHO) which includes the intake of sulfadoxine-pyrimethamine (SP) at least 3 times during the course of pregnancy ⁸.

Despite the numerous programmes that have been implemented to mitigate the risk of malaria in Nigeria, there is still a significant risk of the disease epidemic and adverse effects especially in pregnancy. Considering that the malaria is epidemic and occurs throughout the year, there are limited population based studies assessing certain socio-demographic factors that influences individual as well as community risks for the disease. With pregnant women being at risk of malaria during pregnancy and poor health outcomes, it is important that studies are conducted to assess these risks and improve access to preventive care for this high risk population. The aim of this study is to assess the socio-demographic factors associated with uptake of IPT among pregnant women in Nigeria. This will be achieved through the following objectives;

To assess the uptake of IPT among pregnant women in Nigeria

To determine socio-demographic factors associated with uptake of IPT for prevention of malaria in pregnancy

To determine socio-demographic factors associated with health seeking behaviours for malaria in pregnancy

Table 1 presents the descriptive statistics of women of reproductive ages (15-49 years) in Nigeria. As indicated in Table 1, majority were between ages 30-39 years (39.5%) and 40-49 years (37.8%) compared to only 0.7% of women that were between ages <18 years. Also, 91.8% of the women were married or cohabiting while only ≤ 5% were either widowed or separated. Islam was the most practiced religion and accounted for 59.5% of the religion practiced by women of reproductive ages while 39.6% were Christians and <1% practicing traditional or other religion. Majority of the study participants were located in the north where 31.3% were from the north-west, 20.6% and 17.0%from the north-east and north-central respectively. The south-east account for 11.0% of the population while <11% were found in the south-south and south-west. About 49.9% of the population were uneducated compared to only 6.1% of the population that had acquired a higher level of education. In addition, there were declining proportions of women from poorest to richest wealth index as majority of the population were either in the poorest (24.4%), poorer (23.1%) and middle (21.3%) while the richest accounted for only 13.0% of the population. Also majority were either grandparous (65.7%) or multiparous (23.2%) compared to only 11.1% that had low parity.

In this population, 63.4% of the women of reproductive ages had taken fansidar for malaria in pregnancy while only 6.1% had received healthcare for malaria from informal sources.

Table 2 represents the chi-squared analysis to assess the association between socio-demographic variables and initiation of IPT for malaria in pregnancy. As indicated in table 2, there was a statistically significant association between region of residence and intake of IPT for malaria in pregnancy among women of reproductive ages (X²=452.31, P:.000). Similarly, educational level (X²=1212.76, P:.000), wealth index (X²=1372.83, P:.000) and age group (X²=43.56, P:.000) of women were significantly associated with intake of IPT intake for malaria in pregnancy among women of reproductive ages. Also, religion (X²=269.76, P;.000) and parity (X²=84.20, P:.000) were significantly associated with IPT intake for malaria in pregnancy among women of reproductive ages. However, marital status was no significantly associated with intake of IPT for malaria in pregnancy (X²=5.72, P:.126).

As represented in (Table 3) below, there was a statistically significant association between region of residence and health seeking behaviour for malaria among women of reproductive ages (X²=63.21, P;.000). Similarly, educational level (X²=144.42, P;.000), wealth index (X²=188.28, P;.000) and age group (X²=17.61, P;.001) of women were significantly associated with health seeking behaviour for malaria in pregnancy among women of reproductive ages. Also, marital status (X²=14.01, P;.003) and religion (X²=501.04, P;.000) were associated with health seeking for malaria in pregnancy among women of reproductive ages. However, parity (X²=3.85, P; .146) was not significantly associated with health seeking for malaria in pregnancy among women of reproductive ages.

Table 4 represent the summary of statistics assessing the relationship between socio-demographic variables and intake of IPT for malaria in pregnancy among women of reproductive ages. The logistic regression model was statistically significant (P<.001). As represented in (Table 4), rural residents had 97% reduced likelihood of taking IPT for malaria in pregnancy compared to urban women ^{AOR = 0.97 (CI: 0.91}. Adjusted odds ratio revealed increased odds of taking IPT for malaria during pregnancy among women of reproductive ages that had primary ^{AOR = 2.43 (CI: 2.07}, secondary ^{AOR = 1.50 (CI: 1.30} and higher education ^{AOR = 1.22 (CI: 1.06}.

All wealth index categories were significant associated with increased likelihood of taking IPT for malaria in pregnancy including poorer [AOR = 2.72 (CI: 2.38-3.11), P<.05], middle [AOR = 2.18 (CI: 1.92-2.49), P<.05], richer [AOR = 1.50 (CI: 1.33-1.69), P<.05] and richest [AOR = 1.19 (CI: 1.06-1.35), P<.05]. On the other hand, the odds of taking fansidar for malaria in pregnancy were insignificant among the different age groups (P>.05). Married/cohabiting [AOR = 1.39 (CI: 1.07-1.81), P<.05] women were more likely than women that were never in a union to take IPT for malaria in pregnancy. Similarly, Muslim women [AOR = 0.45 (CI: 0.30-0.67), P<.05], traditional women [AOR = 0.39 (CI: 0.26-0.58), P<.05] and women that practice other religion [AOR = 0.26 (CI: 0.14-0.48), P<.05] had reduced likelihood of taking IPT for malaria in pregnancy compared to Christian women of reproductive ages. However, parity had no influence over intake of IPT for malaria in pregnancy among women of reproductive ages in Nigeria.

(Table 5) below represents the relationship between socio-demographic variables and health seeking behaviour for malaria in pregnancy. Women living in the rural region were 80% less likely to seek formal healthcare compared to women living in the urban region [AOR = 0.80 (CI: 0.67-0.97), P<.05]. Also, women that had primary [AOR = 2.17 (CI: 1.44-3.27), P<.05] and secondary [AOR = 1.52 (CI: 1.01-2.30), P<.05] education had higher likelihood of seeking formal healthcare for malaria during pregnancy compared to women that had no form of education. However, there was significant relationship between health seeking behaviour for malaria in pregnancy among women with tertiary education compared to women that had not form of education [AOR = 1.34 (CI: 0.92-1.94), P>.05].

Women categorized into the poorer wealth index were 2.22 times more likely than the poorest women to seek formal healthcare for malaria in pregnancy [AOR = 2.22(1.59-3.09), P<.05]. Similarly, the richest women were 1.36 times more likely than the poorest women to seek formal healthcare for malaria in pregnancy [AOR = 1.36 (1.01-1.83), P<.05]. Other socio-demographic variables were insignificantly related with health seeking for malaria in pregnancy among women of reproductive ages in Nigeria.

This study was conducted to assess how socio-demographic factors affect the occurrences and health seeking for malaria in pregnancy among Nigeria women of reproductive ages. The socio-demographic factors assessed in this study includes region of residence, highest educational level, wealth index, age group, marital status, religion and parity. After controlling for other variables, some socio-demographic variables were found to be significantly associated with intake of IPT and health seeking for malaria in pregnancy.

It is also important to note that recommendation has been made by the World Health Organization that countries should adopt intermittent preventive treatment (IPT) for malaria in pregnancy ¹⁴. In this study, region of residence was not associated with intake of IPT for malaria in pregnancy. However, health seeking for malaria in pregnancy was significantly influenced by region as women from rural region were less likely to access conventional source for malaria in pregnancy. Some of the challenges associated with healthcare seeking in rural regions compared to urban include lower socio-economic status as represented in this study and other studies that have been conducted ^{15, 16, 17, 18, 19, 20}. Also, distance to health facility and poor perception of healthcare practitioners have been found to influence health seeking for women seeking healthcare ^{21, 22, 23, 24}.

Despite numerous programs and policies developed and implemented to prevent disease and improve access to healthcare services in African countries, socio-economic status significantly impacts the occurrence and health seeking behaviours for infectious disease ²³. In this study, increasing wealth index was found to increase the likelihood of women utilizing preventive treatment for malaria in pregnancy. Health seeking behaviour for malaria in pregnancy was also significant in the poorer and richest group compared to the poorest. A previous study conducted in Nigeria provides an evidence of the prevailing challenges of socio-economic status of pregnant women and its negative impact on the likelihood to seek conventional source for treatment of malaria in pregnancy ¹⁷. Other findings have revealed increased likelihood of pregnant women with higher socio-economic status to seek IPT ^{24, 25}.

Education plays a critical role on health awareness and literacy especially in populations where there are limitations in the health systems and health care service delivery ²⁶. In turn, health literacy also influences actions and decisions to prevent disease occurrences. In this study increase in the level of education was associated with increased likelihood of taking IPT for malaria in pregnancy among women of reproductive ages while increasing education was significantly associated with increased likelihood to seek healthcare from formal sources.

Although there are limited studies assessing relationship between socio-demographic variables and intake of preventive treatment for malaria in pregnancy, finding from this study is consistent with a previous study that revealed the influence of educational level in increasing the likelihood to utilize preventive method for malaria in pregnancy ^{16, 17, 24, 27, 28, 29, 30, 31}. As a result, less educated women in Nigeria may lack adequate information about the prevention of adverse effects of malaria in pregnancy and this in turn influence their decisions to take preventive measures. Also, women that are less educated may be less likely to seek conventional healthcare for malaria in pregnancy. While socio-economic status influencing health seeking behaviours of women, education also influences wealth index of women and therefore influence health seeking for malaria in pregnancy.

In this study, there was a significant increase in the likelihood of women to take IPT during pregnancy among married/cohabiting women compared to single women. On the other hand, there was a significantly increased likelihood of widowed women to seek formal healthcare for malaria in pregnancy compared to single women. It is expected that married women due to their experiences in pregnancies and increased knowledge of malaria in prevention, should seek formal healthcare for malaria in pregnancy However, another Nigerian study found the divorced/separated were less likely than single women to seek formal healthcare for malaria in pregnancy ²⁴. Additionally, this study showed that Muslim, traditional and women of other religions were less likely to initiate IPT for malaria in pregnancy compared to their Christian counterpart. It could be suggested that as a result of certain religious beliefs among the other religions, choice to initiate IPT may be prevented due to women‘s dependence on their religious beliefs.

This study is however not without limitations. Due to the use of NDHS, there were many missing variables which may have affected the statistical strength of our findings. Also, due to incomplete data, it was impossible to assess the influence of other socio-demography on other key healthcare indices relevant to this study. Also, the use of survey data increases the risk of measurement errors, and information bias as some of the variables assessed were dependent on the participant’s ability to recall previous experiences.

However, this research has provided evidence of the existing limitations in strategies adopted in the prevention of malaria in pregnant women in Nigeria. It also provides adequate data to compare findings from previous studies and track progress in the awareness of IPT and utilization for appropriate healthcare for maternal illnesses. By using NDHS data, this study provides a more representative finding that can be generalized on the Nigerian population. With findings from this study, strategies can be adopted to improve prevention of malaria in pregnancy while improving health seeking behaviour of women of reproductive ages in Nigeria. Also, using NDHS data, the potential of selection bias has been reduced.

This study has revealed that socio-demographic factors predispose women of reproductive ages to the risk of malaria in pregnancy. Also, health seeking for malaria in pregnancy has been shown to be affected by socio-demographic factors.

It is therefore important that strategies are adopted to reduce missing survey data. In order to improve the volume of missing data, the NDHS should adopt a semi-structure survey questionnaire that allows surveyors to provide adequate direction towards completion of the questionnaires without influencing participant’s decisions and choices. Also, knowledge about the prevention of malaria in pregnancy should be improved through awareness and campaigns programs that are targeted at high risk populations for malaria occurrence in pregnancy as indicated in this study. Although this study does not address other limitations to health seeking behaviour among women of reproductive ages, it is recommended that strategies be adopted to eliminate the barriers to access to healthcare service delivery among this population such as cost, distance and quality of healthcare service delivery. While the choices of women to seek healthcare can also influence household health seeking, more resource and public health actions must be targeted at this population in order to achieve universal healthcare coverage especially for high risk populations. This can be achieved to collaborations with both private and public stakeholders and program implementers involved in malaria prevention and care in Nigeria.

The authors received no funding for the conduct, authorship or publication of this research.

TAA designed the study. AA, TAA, IE and JL supervised the conduct of the research. TAA carried out data analysis. JE, BI, ZS performed literature review. TAA drafted the first version of the manuscript. All authors (TAA, AA, JL, BI, JE, ZS, IE) reviewed and approved the final version of the manuscript.

The authors gratefully acknowledge the Nigerian Demographic Health Survey for providing data to conduct this study.

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