Barriers to malaria prevention services in pregnancy: a multi-methods study in rural western Uganda

Malaria in pregnancy (MiP) remains a substantial public health problem, accounting for a large proportion of adverse outcomes for both mothers and developing child in endemic areas. Although interventions such as intermittent preventive treatment in pregnancy (IPTp) have been shown to be effective, uptake remains suboptimal. This study aimed to identify factors associated with MiP among pregnant women at their initial antenatal visit and to explore perceptions of MiP among both midwives and pregnant women in the community to identify barriers to the utilization of available prevention services.

Pregnant women attending their first antenatal clinic visit at one of four lower-level health facilities were screened for Plasmodium falciparum malaria using a rapid diagnostic test. Demographic characteristics and clinical measures were documented on case report forms to assess associations with the malaria test result. Quantitative findings informed focus group discussions with pregnant women and individual semi-structured interviews with midwives at each facility.

From February 2021 to September 2022, 1,644 pregnant women underwent testing for malaria. A total of 225 (13.5%) had a positive rapid diagnostic test (RDT) result. Primigravid status and younger maternal age were associated with malaria positivity. In the qualitative arm, stakeholders identified the following risk factors and barriers regarding MiP: (i) delayed testing for pregnancy and MiP, (ii) fear or hesitancy of chemoprevention, (iii) financial constraints, (iv) transportation barriers, (v) antenatal clinic operations, (vi) low bed net use, (vii) knowledge gaps, (viii) and attitudes of spouses.

Young, primigravid women remain at the highest risk of MiP in rural western Uganda. Although consistent with findings from other regions, the impact of geographic barriers that may delay pregnancy testing and initiation of antenatal care merit further study. Approaches to decentralize services further into the community may be particularly beneficial.