A cross-sectional descriptive study was carried out among mothers who had just delivered live babies at selected health facilities in the Secondi-Takoradi Metropolis of Ghana. The study identified individual level factors associated with uptake of three and five doses of IPTp-SP as recommended by WHO and Ghana respectively. The study established that early initiation of ANC and making more visits were the main factors associated with uptake of higher doses of SP.
The current study reports a high proportion (74.60%) of pregnant women initiating ANC during the first trimester (early). This level of early initiation of ANC is much higher than was found in our earlier studies (ranging from 30–46%), which found most of the women starting ANC during the second trimester [10, 11, 16]. A recent report by Vandy and colleagues also from Ghana, found less than 50% of the women initiating ANC during the first trimester [12]. Even much lower levels of early initiation of ANC have been reported from some other malaria endemic areas in Eastern (39.4%) [17, 18] and Central (2.2%) Africa [19].
Early initiation of ANC in the current study, was associated with being aged 20–39 years, married and working in the government sector. Other studies have also reported association between early initiation of ANC and individual and service delivery factors, including the educational level of the woman and the number of living children [20, 21]. Also, household wealth [22], charging of fees during booking for ANC and whether the particular pregnancy was planned or not [18], have been associated with early initiation of ANC.
The high level of early initiation of ANC found in the current study may be due to the fact that a high proportion of the women have secondary to tertiary level education (60%) [23] and possibly having adequate knowledge on IPTp-SP [24]. Most of these women (85.28%) were also gainfully employed [25]; thus, empowering them to make decisions on issues affecting their health. This high level of early initiation of ANC enabled the women to make more visits with over 90% of them making more than the minimum recommended number of four visits by WHO, and 47% being able to make the required eight or more visits [26]. Consequently, a high proportion of the women (over 80%) were able to receive ≥ 3 doses of SP as recommended by the WHO. Though, the study by Vandy and colleagues in the Volta Region of Ghana reported a lower level of early initiation of ANC, a high proportion (82.1%) of the women were able to meet the WHO recommendation of ≥ 3 doses of SP. Also, many more women (17.1%), relative to our current 6.65%, received Ghana’s five dose coverage recommendation. Obviously, there should be other factors, possibly the number of ANC visits made, that should be playing a more critical role in the uptake of five or more doses of SP besides early initiation if ANC.
Thus, the early initiation of ANC recorded in the current study, did not translate into meeting Ghana’s target of five 5 doses of SP. Uptake of five doses of SP was very low with only 6.65% of the women being able to meet the target. This level of uptake, was much lower than earlier reports of 14.5% [10] and 16.0% [11] from other parts of the country. For the few women who were able to meet the five-dose target, more than half (56.58%) of them had to make ≥ 8 ANC visits.
The multinomial logistic regression analysis revealed that the number of ANC visits during pregnancy was a critical factor that determined the uptake of 5 or more doses of SP [12] as against 1–2 doses. Thus, if a pregnant woman initiates ANC during the second trimester and receives the first dose of SP at week 16 gestational age and continuous regularly on monthly and then weekly basis till delivery, she should be able to make the minimum number of visits (five) to enable her take five doses of SP before delivery.
Generally, women who initiate ANC early are much more likely to receive the WHO recommended services than those who start late [8, 27]. According to Agha and Tappis, however, uptake of these services is independent of a range of socio-economic and demographic factors and independent of the number of ANC visits made during pregnancy [22]. Thus, some other factors possibly service-related factors, (which were not investigated in the current study), might have contributed to the inability of most of the women to take five doses of SP. Earlier studies have implicated some service related factors including, unavailability of SP at the time of ANC [28] and insufficient time for proper antenatal care counselling by health workers as driving factors for inadequate IPTp delivery [7, 16]. By this, if the service-related factors (e.g. availability of SP) are adequately addressed, and midwives spend adequate time to educate mothers on the importance of high doses of SP, increased ANC attendance could enable the pregnant woman meet the required 5-dose target. Community involvement, especially opinion leaders and men in general may also help improve uptake of SP. In the current study, six women did not take any dose of SP, as they were G6PD deficient.
The study had some limitations as it was focused on identifying individual level factors that could be addressed to help achieve the IPTp-SP target of three and five doses set by WHO and the Ghana malaria control programme respectively. Service and community factors such as stock-out, staff strength, time for education/counselling, travel distance, and financial cost to the women, that could explain some of the findings of this study were not considered. These limitations notwithstanding, valuable information has been provided to inform programme implementers that, the women are initiating ANC early and some are making eight and more visits and yet are not getting the required number of SP doses.