The finding of this study presents an important insight into existing poor implementation practices affecting IPTp delivery. While most providers were aware of the existence of a national policy on IPTp, their overall knowledge of the guidelines for implementation of the policy was poor. This was more obvious with the knowledge of time of administration of second dose of SP and the use of DOT strategy for IPTp delivery. The overall poor knowledge amongst providers found in this study may have negatively contributed to the low IPTp coverage level of 13.7% and 7.3% for first and second doses, respectively, found for the study area in a related study [6
The effectiveness of IPTp intervention, which is compromised by the low coverage levels of IPTp in the Nigeria, is further worsened by poor delivery practices for the few women that receive SP. The poor knowledge of guidelines amongst providers was reflected in the poor delivery practices reported amongst providers, whether they were categorized as public/private or across urban/rural. Inappropriate practices such as asking women to take two tablets on the first day, and the third the next day, adjusting the number of tablets to two for women below 50
kg and providing women with SP monthly, have no clinical basis, can compromise effectiveness of SP, and may enhance the development of parasite resistance to SP. The inappropriate adjustment of the number of tablets also means that such women received sub-optimal levels of SP required for the intended protection against malaria. Additionally, the provision of ANC services in some facilities by unskilled staff further raised the likelihood of poor IPTp delivery practices in such facilities.
The practice of DOT is also very poor amongst various categories of providers, and the reasons for such practices raises critical concerns with respect to the effectiveness of IPTp policy. The requirement for women to attend on empty stomach for the purpose of palpation seems to have been institutionalized within some facilities, even though the practice has no scientific basis. A study in Malawi reported that ANC providers felt women should not take drugs on an empty stomach [12
]. This is similar to the finding that having come with an empty stomach, women were allowed to take drugs home. The underlying faulty perception among these providers needs to be addressed to enhance the practice of DOT.
It is remarkable that the few providers who had overall correct knowledge did not include a private provider. A study in south-west Nigeria also found poorer knowledge of the guidelines amongst private providers compared to their public sector counterparts, although the respondents were not restricted to those providing antenatal care [14
]. Other faulty institutional policies noted among private providers, such as not allowing women to take drugs in the facility, and the assumption that women would take drugs given to them at home, constitute additional impediments to IPTp effectiveness. These findings highlight the importance of observing the knowledge and practices of private providers, and ensuring that they comply with national guidelines.
This study could not verify whether women actually took the drugs that they took home. Nonetheless, observations elsewhere have reported that women may throw such drugs away [19
]. Allowing women to take drugs home overrules the very objective of the recommended DOT strategy. Again, not informing women about the drugs they are being given, for whatever reason, conflicts with existing policies for drug administration and safety [20
]. It also means that a woman would be unable to report if she had received SP from a provider, and may receive multiple doses if registered with more than one provider.
Unlike the case elsewhere [9
], health facility factors such as availability of water and SP in the facility do not seem to be important constraining factors to delivery of IPTp in this setting. Cheap alternative water sources existed, SP stock-outs were uncommon and both providers and the women had insignificant concerns about side effects.
The results of this study therefore support suggestions that provider factors rather than demand-side factors, such as timely attendance to ANC, constrain IPTp delivery in the study area [6
].The findings also suggest that interventions targeting improvement in provider knowledge and behaviour, coupled with supportive supervision, should result in improved IPTp delivery. Further research focusing on measuring the effectiveness of provider training and supervision with respect to IPTp delivery is required. In addition, it would be necessary to understand policy-maker and programme-manager behaviour at both state and LGA levels which create the lapse in monitoring implementation of the policy. There is also the need to conduct empirical research using the interpretive policy analysis approach to better diagnose reasons for gaps in the implementation of national IPTp guidelines.
Finally, this paper shows that it is just not enough to have an IPTp policy in place, and attention needs to be paid to how providers implement policy if intended policy objectives of reduction in impact of malaria on pregnant women and their babies are to be achieved. Low coverage of IPTp and use of DOT strategy for its administration is influenced by inappropriate implementation resulting from poor provider knowledge and practices. Policy makers and programme managers of malaria control interventions need to pay attention to monitoring the IPTp provision system in both urban and rural areas as well as amongst public and private providers. Efforts at improving provider practices for IPTp delivery need to go beyond training them, to setting up effective supervisory activities aimed at observing their practices and correcting deviations from recommended policy guidelines. A monitoring system should also be in place to periodically assess the content of antenatal care services being provided by primary providers.