A Triple Win: A Multi-Pronged Approach to Improving IPTp in Angola

By Anya Fedorova, Country Representative, PSI Angola & Suse Emiliano, Marketing and Communications Director, PSI Angola

To protect herself and her future baby from malaria, a pregnant woman should do two simple things: sleep under an insecticide-treated net (ITN) and take sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp). Both products are available – for free – to women in Angola at public health clinics during antenatal care (ANC) appointments.

Unfortunately, these actions, especially taking SP, are incredibly difficult. For various reasons, women simply are not able to take SP for IPTp.

In Angola, only 64.8% of women in urban areas and 37.3% of women in rural areas take the first doses of SP for IPTp during her first ANC visit, and the percentage of women who take second, third and fourth dosages declines to 45.3%, 23.9%, and 11.3% respectively. For IPTp to protect a pregnant woman and her future baby from malaria, the WHO strongly recommends three or more doses for all pregnant women living in areas of moderate-to-high malaria transmission in Africa. So, ultimately, only a few are protected.

Like a Russian doll, the challenges preventing women from taking SP for IPTp are multi-faceted and multi-layered, each requiring a separate solution.

PSI Angola, through the five-year USAID-funded Health For All project, sought to address these challenges to IPTp faced by pregnant women, ANC providers and the health system. Through a literature review, discussions with stakeholders, focus groups with pregnant women, observation and in-depth interviews with ANC providers, the following challenges were identified:

1. Health Infrastructure
57% of women in Angola have physical access to an ANC facility. Physical access to an ANC facility—or distance to an ANC facility—directly influences a woman’s ability to attend all four ANC appointments. While a pregnant mother might go to her first ANC appointment to receive an ITN, a ‘’baby journal”, and her first dose of SP, her desire to invest more of her limited time and financial resources for the seemingly unimportant second, third and fourth ANC appointments is low.

How can physical access to ANC services be improved? Nongovernmental organizations (NGOs), such as PSI Angola, cannot rapidly build more ANC facilities or other facilities, nor equip them with the necessary supplies and nurses to meet near term demand. However, NGOs can engage in task shifting discussions with the Ministry of Health (MOH) to advocate for the community-based distribution of SP for IPTp to distant locations through the existing cadre of community health workers. This strategy is perhaps daunting —and would require policy change—but it is worth testing. PSI Angola is rising to the challenge.

2. Availability of SP for IPTp in ANC Facilities
If SP is not available at the ANC facility during the time of her visit, regardless of whether a pregnant woman wants to take SP to protect herself and her future baby, there is no opportunity for her to do so!

Working with the MOH and supply chain partners is critical in solving this challenge. Using health facility data from the District Health Information System (DHIS2), PSI Angola is able to understand ANC attendance and SP consumption at each health facility. Close collaboration with the USAID-funded project Global Health Supply Chain Procurement and Supply Management (GHSC-PSM), implemented by Chemonics International, ensures the availability of necessary quantities of SP for IPTp to supported health facilities.

However, there is another often overlooked aspect of availability: the availability of clean drinking water. SP for IPTp is administered as directly observed therapy (DOT). For a pregnant woman to take SP at the health facility as DOT she needs clean water. Clean water is not always available at health facilities. Where clean water is not available for the administration of SP as DOT, nurses will often distribute SP to pregnant women with the hope that the pregnant women will take them once she has access to potable water. Unfortunately, there is no guarantee that pregnant women will follow through, especially given limited understanding or awareness of the importance of IPTp; an issue that PSI will be aiming to elevate through their community and MOH channels.

3. High Workloads, Low Risk Perception
Generally, ANC providers are burdened by high workloads and have poor attitudes towards pregnant women. Furthermore, pregnant women have low knowledge of the importance of IPTp and risk perception of malaria. These three seemingly separate challenges are interrelated.

ANC providers often see approximately 100 women a day. During standard working hours in a clinic, from 8 am to 3 pm, a provider can only dedicate about four minutes to each woman if no breaks are taken. The ANC provider is not only responsible for ANC counseling and malaria in pregnancy; the same nurse often provides family planning services to other clients or must see urgent cases in situations of emergency. Health providers are overworked and overstressed.

One consequence of this situation is that health providers often do not counsel women on the importance of ANC visits, IPTp, ITN use, and prompt care-seeking for the symptoms of malaria. During in-depth interviews, women confirmed that the providers are often short-tempered and judgmental, do not explain why IPTp is important, and say nothing about potential side effects of SP. The result of this treatment by overworked and overstressed health providers is that pregnant women attend their first ANC visit for an ITN and a baby journal and opt to never see the ANC provider again unless absolutely necessary. The pregnant women involved in the in-depth interviews indicated that they were interested in access to non-judgmental services and counseling and additional information on a healthy and safe pregnancy.

To address this triple challenge, PSI Angola shifted tasks to a larger workforce. A cadre of 181 communication workers were trained in empathetic listening and communication skills to provide malaria in pregnancy counseling to pregnant women in ANC facilities supported by the Health For All project. Communication workers engage with pregnant women while they are waiting to see the ANC provider: answering their questions and concerns, providing easy to understand malaria prevention information, and addressing the barriers and facilitators of malaria prevention behaviors. The communication workers provide a listening, non-judgmental ear to pregnant women; address pregnant women’s knowledge gaps and low risk perception and help lessen ANC providers’ workload.

This World Malaria Day, PSI Angola is proud to support the National Malaria Control Program and MOH in Angola to improve IPTp for pregnant women through innovative access, supply, and communication approaches to ensure Health for All!

Banner image: An Angolan woman and child near Tapella Chitado Ruacana-Dam, courtesy of jbdodane/Flickr

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