Parasite Epidemiology and Control 15 (2021) e00222 Available online 18 August 2021 2405-6731/© 2021 The Authors. Published by Elsevier Ltd on behalf of World Federation of Parasitologists. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Uptake challenges of intermittent preventive malaria therapy among pregnant women and their health care providers in the Upper West Region of Ghana: A mixed-methods study Frederick Dun-Dery a, 1, * , Peter Meissner b , Claudia Beiersmann a , Naasegnibe Kuunibe a, c , Volker Winkler a , Jahn Albrecht a , Olaf Müller a a Heidelberg Institute of Global Health, Ruprecht-Karls-University, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany b University Hospital Ulm, Dep. of Pediatrics and Adolescent Medicine, Ulm University, Eythstraße 24, 89075 Ulm, Germany c Simon Diedong Dombo University of Business and Integrated Development Studies, Wa, Ghana A R T I C L E INFO Keywords: Malaria Pregnancy Intermittent-preventive therapy Sulfadoxine-pyrimethamine Mixed-methods Folic acid ABSTRACT Background: Malaria in pregnancy remains a major public health problem in endemic countries, especially in sub-Saharan Africa (SSA). Existing interventions such as intermittent preventive therapy in pregnancy (IPTp) using sulfadoxine-pyrimethamine (SP) are effective against placental malaria. However, low uptake of this intervention is a challenge in SSA. This study assessed factors affecting IPTp-SP uptake among pregnant women as well as their health care providers, including health system-related factors. Methods: From November 2018 until May 2019 a mixed-methods study was conducted in one urban and one rural district of the Upper West Region of Ghana. A multi-stage sampling technique was used to recruit 740 3rd trimester pregnant women and 74 health service providers from 37 antenatal care (ANC) facilities. Quantitative data was collected through a standard questionnaire from pregnant women and ANC service providers. Three focus group discussions (FGDs) were conducted in each district with pregnant women who had defaulted on their IPTp doses to collect information about the challenges in accessing IPTp-SP. The primary outcome was the uptake of IPTp-SP during antenatal care visits. In addition, the health care provider and health system- related factors on the administration of SP were assessed, as well as details of folic acid (FA) supplementation. Data were analysed using descriptive statistics and Poisson regression. Results: Responses from 697 pregnant women were analysed. Of these, 184 (26.4%) had taken the third dose of SP (SP3) in line with international guidelines. IPTp-SP uptake was low and signif- icantly associated with the number of maternal ANC contacts and their gestational age at 1st ANC contact. Most pregnant women were regularly co-administered SP together with 5 mg of FA, in contrast to the international recommendations of 0.4 mg FA. The main challenges to IPTp-SP uptake were missed ANC contacts, knowledge defciencies among pregnant women of the importance of IPTp, and frequent drug stock outs, which was confrmed both from the ANC providers as well as from the pregnant women. Further challenges reported were provider negligence/absenteeism, adverse drug reactions, and mobile residency of pregnant women. * Corresponding author. E-mail addresses: kuanufred@gmail.com, frederick.dundery@uni-heidelberg.de (F. Dun-Dery), meissnerulm@gmail.com (P. Meissner), beiersmann@uni-heidelberg.de (C. Beiersmann), nkuunibe@uds.edu.gh (N. Kuunibe), volker.winkler@uni-heidelberg.de (V. Winkler), albrecht. jahn@uni-heidelberg.de (J. Albrecht), olaf.mueller@urz.uni-heidelberg.de (O. Müller). 1 Both authors contributed equally to the paper. Contents lists available at ScienceDirect Parasite Epidemiology and Control journal homepage: www.elsevier.com/locate/parepi https://doi.org/10.1016/j.parepi.2021.e00222 Received 16 November 2020; Received in revised form 4 May 2021; Accepted 15 August 2021