This study used data from TDHS-MIS 2015/16 to analyze the predictors for the uptake of optimal doses of SP (three or more doses) among pregnant women. The uptake of three or more doses of SP was reported to be 8% countrywide which is still low than the recommended coverage of 80% from WHO and Roll Back Malaria (RBM) benchmark target (3). This was also observed in several studies conducted in other sub-Saharan countries (20–23). Hence, the urgent need to plan effective strategies to improve IPTp-SP coverage and uptake in sub-Saharan Africa.
The predicators for the uptake of optimal doses of SP were; geographical zones, education level (primary, secondary or higher education), attending ANC in the first trimester of pregnancy, attending ANC visit more than four times and attending government health facility for ANC services. Pregnant women who attained at least primary education were likely to receive optimal doses of SP compared to those with informal education. This is because educated pregnant women could be aware and knowledgeable on the importance and benefits of using SP for malaria prevention during pregnancy. Similarly, the findings from Nigeria (24), Malawi (21, 25), Ghana (22), and Zimbabwe (23) showed that the knowledge on the SP and on the consequences of not taking IPTp-SP as a facilitator toward the uptake hence the association between education level and the likelihood of the uptake of three or more doses of SP for malaria prevention during pregnancy.
Pregnant women who registered and attended ANC clinics in their first trimester received optimal doses of SP compared to those attended ANC clinic in third trimester. The possible explanation could be; attending ANC clinics in first trimester give the room for pregnant women to attend ANC for more than 4 times hence higher chances for start taking SP doses in their second trimester as required. Also, it has been predicted in several studies conducted in Zimbabwe, Sierra Leone, Malawi, Nigeria and Uganda that early booking and attending of first ANC in first or second trimester has an association with receiving optimal doses of SP while late attending to ANC clinic results in lower uptake of SP doses (6, 15, 23, 24, 26).
The significant relationship between number of ANC visit and uptake of optimal doses of SP was observed in our study. The pregnant women who attended at least four ANC visit received optimal doses of SP compared to those with few attendance. The more the pregnant women attend to clinic, the higher the exposure toward health information on IPTp-SP hence the higher likelihood of receiving optimal doses of SP. The findings are consistent with the studies conducted in Malawi, Ghana and Cameroon (21, 27, 28). Also, attending ANC visits only once or at late such as after 36 weeks where SP cannot be administered were observed to be a barrier towards the uptake of optimal doses of SP (25). Therefore, the urge to raise awareness among pregnant women on the importance of early and adequate attendance to ANC clinics so as to receive optimal doses of SP for malaria prevention is important.
Attending government health facilities ANC was found to influence the uptake of optimal SP doses among pregnant women compared to those who attended private clinics. The plausible explanation could be sensitization of the SP uptake under direct observation therapy (DOT) and seriousness on following SP administration protocol. It was noticed that in some private clinics pregnant women were allowed to take the drugs at home hence compromise the optimal uptake of SP doses. The findings are in accordance to a study conducted in Ghana which found poor adherence to DOT in private health facilities as one of the obstacles towards the uptake of optimal doses of SP (29).
Geographical zones were also the predictors for the optimal uptake of SP doses. Being a resident of regions that belong to Central, Eastern, Southern, Lake, Southern highlands, and South west highlands was significantly associated with the optimal uptake of SP doses compared to the residents of Zanzibar and Northern zones. This might be contributed by level of malaria endemicity in different zones. In the zones with a high or moderate level of malaria transmission, possibly the awareness and emphasis on SP uptake could be higher due to higher risk of contracting malaria that’s why pregnant women in those zones had higher odds of taking optimal doses of SP compared to those residing at Zanzibar and Northern zones where there is a low level of malaria transmission. The observed findings are in lines with another study conducted in Tanzania which showed that pregnant women residing in Eastern and Coastal regions had higher odds of optimal uptake of SP (26).
This study had the following limitations; the data analysis was limited only on the variables captured on demographic and health survey questionnaire, some of the important variables that could influence uptake of optimal doses of IPTp-SP were not captured for example socio-cultural factors, knowledge of health care providers and availability of SP in ANC clinics hence hindered full exploration of other important variables. Response (recall) bias was another limitation, the data collection was based on self-reported experiences of the past two years hence due to response bias there was a possibility of over- or- underestimation of the responses.