Perceptions and drivers of healthcare provider and drug dispenser practices for the case management of malaria in pregnancy in the context of multiple first-line therapies in western Kenya: a qualitative study

Abstract

Abstract Background Emergence of Plasmodium falciparum resistance to artemether-lumefantrine in Africa prompted the pilot introduction of multiple first-line therapies (MFT) against malaria in Kenya, potentially exposing women-of-childbearing-age (WOCBAs) to antimalarials with unknown safety profiles in the first trimester. We undertook a qualitative study to explore knowledge and perceptions among healthcare providers providing malaria treatment to WOCBAs and pregnant women.Methods In-depth interviews were conducted with purposively selected public and private health facility (HF) and drug outlet (DO) providers within and outside the pilot-MFT area. County health managers were interviewed about their knowledge of the national treatment guidelines. Transcripts were coded by content analysis using the WHO health system building blocks (leadership/governance, financing, health workforce, health information systems, access to medicines, and service delivery).Results Thirty providers (HF:21, DO:9) and three health managers were interviewed. Eighteen providers were from HFs in the pilot-MFT area; the remaining three and all nine DOs were outside the pilot-MFT area. The analysis revealed that providers had not been trained in malaria case management in the previous twelve months. DO providers were unfamiliar with national treatment guidelines in pregnancy and reported having no pregnancy tests. Health managers were unable to supervise DOs due to resource limitations. Providers from HFs and DOs noted poor sensitivity of malaria rapid diagnostic tests (RDTs) and hesitancy among patients who associated malaria-RDTs with HIV testing. Almost all providers reported antimalarial stock-outs, with quinine most affected. Patient preference was a major factor in prescribing antimalarials. Providers in HFs and DOs reported preferentially using artemether-lumefantrine in the first trimester due to the side effects and unavailability of quinine.Conclusion Knowledge of malaria case management in drug outlets and health facilities remains poor. Improved regulation of DO providers is warranted. Optimising treatment of malaria in pregnancy requires training, availability of malaria commodities, and pregnancy tests.