Although 46% of women interviewed received three or more doses of IPTp, the WHO target of 85% IPTp3 coverage has not yet been achieved in Malawi, highlighting the need for innovative approaches to increase IPTp-SP coverage. Our data highlight a need to better understand why a higher percentage of women are not receiving at least three doses of SP, despite 84% attending three or more ANC visits and half attending four or more visits. There is also a need for increased efforts to improve women’s understanding of the dangers of malaria in pregnancy and the benefits of IPTp3 + and early ANC attendance.
Although most women recognized ITNs as a means to prevent malaria in pregnancy, less than one quarter cited IPTp as a method of malaria prevention. Women who cited both ITNs and IPTp as ways of preventing malaria had increased odds of receiving IPTp which approached statistical significance. There were clear regional differences; women in Nkhata bay were more likely to be assisted by a CHW, had better knowledge on the cause and means of preventing malaria, and were more likely to receive IPTp3+.
Overall, less than half of women surveyed cited malaria as being a serious problem in pregnancy; this has similarly been reported by a number of other studies [15–17]. This lack of awareness may contribute to failure to seek out IPTp. Women’s awareness of the dangers of malaria in pregnancy was lower in Ntcheu than Nkhata Bay, corresponding to lower IPTp3 uptake. Women in Ntcheu reported discussing malaria less often with CHWs than women in Nkhata Bay. The lack of malaria health information shared by CHWs in Ntcheu may be contributing to women’s decreased knowledge about the dangers of malaria in pregnancy, and, consequently, to the lower uptake of IPTp. To improve community-level health education, it is important to provide CHWs with additional education, especially on prevention of malaria in pregnancy.
CHWs are tasked with addressing numerous health issues within communities, and the importance of early and frequent ANC attendance, as well as the dangers of malaria in pregnancy, has not been prioritized. It is anticipated that including discussions on these health topics during every CHW interaction with pregnant women in their communities will increase both early and frequent ANC visits. Including men in health education and messaging related to the importance of early ANC attendance may also increase the number of women attending it the first trimester, as husbands are frequently the first person told about a pregnancy and they can encourage their wives/partners to attend ANC. Male involvement has previously been suggested as a way to encourage earlier attendance at ANC [18–20]. Women who come to ANC without their husbands may face additional barriers, such as being made to wait to be seen until after all the women who came with their husbands or being required to bring a letter from their village chief, which likely contribute to later and less frequent ANC visits (Alinafe Chibwana, personal communication).
Counseling on ANC attendance is a critical component of the planned pilot, so that community distribution of IPTp is not perceived as a replacement for an ANC visit. It is particularly important to address the fact that the primary message on malaria prevention women received was to sleep under a bed net, while only a quarter were told by the CHW to take IPTp-SP. Discussing the dangers of malaria in pregnancy and how malaria can be prevented by sleeping under an ITN and especially by receiving regular doses of IPTp-SP should also help to improve uptake of these interventions.
Increased education and community delivery of IPTp-SP are not replacements for regularly scheduled ANC visits, but may be a valuable supplement to these services. Although Malawi has adopted the WHO eight-contact schedule, this does not include monthly visits in early second trimester. Further, many women face barriers to attending ANC. Given the drop off in attendance from three visits (84%) to four or more visits (50% of women) currently, it seems unlikely that a high proportion of women will attend eight ANC visits only as a result of a policy change, without additional changes to the system.
Distribution of SP in the community will help to address the issue of women traveling long distances to attend ANC visits, and allow for more frequent delivery of IPTp. Even with the currently recommended schedule of eight ANC contacts, early in 2nd trimester the visits are widely spaced, thus availability of SP in the community would allow for dosing in between ANC visits. Further, CHWs will provide education on the importance of ANC and IPTp, which is hypothesized will improve the perceived value of those services. CHWs are an important resource within communities and there is great potential for them to improve the health of pregnant women and their infants, if they are empowered to do so.