Karin Gross: Access to malaria prophylaxis and antenatal care in south-eastern Tanzania The role of institutions and livelihoods

PhD-thesis, Swiss Tropical and Public Health Institute, 2011

Malaria-infection during pregnancy may lead to adverse consequences or even the death of the woman and her child. In Tanzania, where malaria is highly endemic, malaria prevention strategies are integral elements of antenatal care (ANC). Thus, pregnant women should receive two doses of Sulphadoxine-pyrimethamine (SP) as intermittent preventive treatment during pregnancy (IPTp). However, ANC attendance is often irregular and IPTp uptake is still low. Little is known about socio-cultural and legal factors influencing access to IPTp and ANC services among pregnant women.


This PhD project aims at a better understanding of pregnant women’s access to
IPTp and ANC services. It investigates how institutions such as informal norms and
rules and formal regulations at the household, community and health facility level
affect pregnant women’s access to ANC and malaria prevention services.


The study area encompasses the Demographic Surveillance System (DSS) sites of
the Ulanga and Kilombero districts in south-eastern Tanzania. To allow for data
triangulation a mixed-method approach was applied combining different qualitative
(in-depth interviews, FGDs and observation of health worker practices and patient provider interactions) and quantitative (cross-sectional study) methods.


IPTp coverage at the selected ANC clinics improved between 2006 and 2008 due
to better availability of SP at the health facilities. Yet, IPTp uptake is still low, especially for the second dose due to health worker practices and restrictive IPTp
guidelines. Women’s access to services recommended by the national guidelines varied widely. Health-workers’ performance was influenced by health workers’ lack of training and absenteeism, inconsistencies between the guidelines and practical working tools such as the ANC cards, and shortages of work supplies. In order to
cope with difficult work conditions health-workers created informal organizational rules and routines that were not fully compatible with the guidelines. At the household and community level, socio-cultural factors regulate women’s access to ANC services. Men play a significant role in supplying their pregnant women with necessary resources (transport, financial, human and social resources). However, gender roles and changing structures of marriage and family as well as the fact that men’s involvement at the ANC clinics has only recently been encouraged, constrain male involvement during pregnancy.


Identifying and understanding institutions at the household, community and health facility level is of high relevance for informing and improving policy implementation in the field of maternal health care.


Supervision: Prof. Dr. Brigit Obrist

Funding: Commission for research partnerships in developing countries (KFPE), Novartis Foundation for Sustainable Development, Rudolf-Geigy Stiftung, Freiwillige Akademische Gesellschaft

Collaboration: Ifakara Health Institute, Tanzania

Duration: 2007 – 2011

Download Poster: Access to malaria prophylaxis and antenatal care in south-eastern Tanzania (2012)