Malaria continues to be a major public health burden in Tanzania, a country with the world's third largest population at risk of stable malaria, after Nigeria and the Democratic Republic of Congo . About 35 million Tanzania's population are at risk, pregnant women and under five children being the most vulnerable groups [1, 2]. The NMCP's Mid-term Strategic Plan for 2002–2007 reports that malaria account for about 1.3% reduction in national economic growth, 30% of the national disease burden. There are about 1.7 million cases per year among of the pregnant women alone. One recent study in northern Tanzania reported malaria to be responsible for about 20% of all deaths among pregnant women , while malaria related anaemia contributes significantly to maternal deaths in Tanzania .
For decades chloroquine (CQ) was the first line drug for the treatment of uncomplicated malaria in Tanzania [5, 6]. Accumulating evidence of increasing parasite resistance to CQ and treatment failure rates prompted the Ministry of Health (MOH) to replace CQ with SP as the first line in 2001 [1, 7–10]. SP has also been recommended for IPTp purposes. According to national policy guidelines its administration at ANC clinics was supposed to start since then, however, appropriate training of service givers and community sensitization were to be effectively done thereafter in most districts (Dr. Pasiens Mapunda, CEEMI Director and Dr. M.W. Marero-NMCP, personal communication). In the light of increasing parasite resistance, the policy recommendation of SP for preventive and curative treatment against malaria was left as an interim strategy while an appropriate combination therapy is being considered .
In an attempt to achieve the targets of the Abuja Declaration of 2000 regarding the reduction of malaria burden, many sub-Sahara African countries (including Tanzania) have targeted to reduce the burden of malaria through IPTp and insecticide-treated nets [2, 11]. Under the IPTp strategy it is recommended that all pregnant women in malaria endemic areas receive a full three tablets single dose of SP at least twice during the second and third trimester of pregnancy. ANC clinics are considered an important entry points to target the pregnant women as records show that about 80% of Tanzanian pregnant women attend such clinic at least once during their pregnancy [12, 28], although the latter figure contradicts the 98% attendance rate reported from another source . Nevertheless, the extent to which public and private facilities will comply with the IPTp guidelines remains to be seen .
While empirical evidence from Kenya [13, 14] and Malawi [15, 16, 18, 19] indicate high efficacy of IPTp in reducing anaemia during pregnancy and increasing birth weight, reports on treatment failures and parasite resistance to SP in malaria endemic countries has stimulated debates about the appropriateness of SP [10, 20, 22] and has prompted some African NMCPs to recommend combination therapy [21, 23]. Depending on further scientific documentation on safety and efficacy in pregnancy, artemisinin-based combination therapy (ACT) may be a useful alternative to SP in the future . However, there are critical debates about the potential limitations of ACT in terms of cost to the poor, its complicated treatment regimen and the limited knowledge about acceptability among users [20, 24–26, 28]. The UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases (TDR) has warned that an intervention deemed efficacious within clinical trials may not be easily transformed into the reality of control operations .
To reduce maternal morbidity and morality and better health for the baby, focused ANC package advocates for the timely and appropriate care during pregnancy and timely attendance at ANC clinics is a key factor for the effective delivery of IPTp services . However, inadequate/irregular attendance has been noted in some sub-Sahara African countries . In Tanzania, only 40% of pregnant women deliver at health facilities although some records show a high antenatal clinic attendance rate . One study in Kenya found the late timing of the first dose of SP corresponding with late registration at ANC clinics among pregnant women . Another study from the same country found that despite high awareness about the IPTp strategy, only 5% of pregnant women had received two or more doses of SP as preventive treatment and only 14% of the women received at least one dose . Similarly findings were reported from Malawi whereby less than 40% of the 391 pregnant women surveyed in Blantyre district received the full dose regimen of SP for IPTp . In two cross-sectional studies funded by the World Health Organization in Muheza district, Tanzania (Massaga et al, personal communication) and Mpwapwa district in Central Tanzania (Magesa et al, personal comunication), low compliance with the use of SP was partly attributed to health care providers' and users' fear of side effects of SP and their inadequate knowledge of the correct dose. NMCP's Mid-Term Strategic Plan for 2002–2007 states that serious side effects of SP are rare and that fear among the users has been aggravated by speculative media reports.
The present study was carried out in Korogwe District, Tanzania in February 2004 and assessed (a) the extent to which staff (clinical officers and nurses) at public health facilities and pregnant women understood and appreciated the IPTp strategy, (b) district-level health managers' opinion of the appropriateness of the IPTp strategy and potential impediments for its effective implementation at the district level and (c) the opinion of each of these study populations regarding programmatic changes that could improve the delivery of ANC services and increase compliance with IPTp at ANC clinics.