Factors Affecting Access to and Utilisation of Intravenous Iron to Treat Anaemia in Pregnancy in Zomba, Malawi: A Qualitative Study

Anaemia in pregnancy increases risks for both maternal and neonatal complications, including death, preterm birth, and low birth weight. Iron tablets are the recommended standard treatment but are often poorly tolerated and adhered to. Intravenous (IV) iron offers an effective and practical alternative with faster replenishment of iron stores and fewer side effects. A randomised controlled trial in Malawi evaluated the safety and efficacy of IV iron compared to standard oral iron supplementation for pregnant women with moderate to severe anaemia in the third trimester (REVAMP-TT). Our qualitative study, embedded within the trial, aimed to explore the factors affecting access to and utilisation of IV iron to treat anaemia in pregnancy within the primary healthcare system of Malawi. MethodologyWe conducted in-depth interviews (n=16) and focus group discussions (n=3) with pregnant women who participated in the REVAMP-TT trial, those who withdrew, and their husbands and caregivers. All interviews and discussions were audio-recorded, transcribed, and coded in NVivo 12. We iteratively used reflexive thematic analysis to develop the themes mapped across the supply and demand domains of the Patient-Centered Access to Healthcare framework. ResultsWe identified five key themes under supply-side barriers, including i) lack of transparency in REVAMP-TT trial procedures and processes, ii) lack of continued community sensitisation about IV iron, iii) long distances from home to the health facilities, iv) long waiting times for procedures and IV iron administration, and v) pregnant women non-compliance with appointments. Four demand-side obstacles were highlighted, including i) myths and misconceptions about IV iron, ii) prevailing cultural norms like concealing pregnancy, iii) lack of social and financial support from husbands, and iv) physical discomfort when receiving IV iron. Five facilitators emerged from the supply side, including the i) availability of clear information about anaemia and antenatal care outreach services, ii) pregnant women were not pressured to participate in the REVAMP-TT trial, iii) flexible health facility opening hours and appointment mechanism, iv) perceived effectiveness and benefits of IV iron and v) healthcare providers interpersonal quality and skills. Four demand-side enablers included i) health literacy about anaemia, ii) social value and a sense of autonomy, iii) peer support, iv) available social and financial support from family or husband, and iv) caregiver support. ConclusionIn conclusion, our study underscores the potential of IV iron therapy to address anaemia in pregnancy in LMICs like Malawi. Patient-centred approaches, improved health literacy, and strengthening health systems are vital for optimising intervention uptake and ensuring equitable access to antenatal care interventions, ultimately improving the health outcomes for mother and child. Contributions to literatureOur study demonstrates the practical aspects and challenges of implementing an IV iron intervention in a low-resource setting, including how the Malawian healthcare system could be strengthened to effectively deliver IV iron in local healthcare facilities. It provides a blueprint for implementation in similar contexts to integrate this treatment into existing healthcare delivery structures. Our study offers insights into how cultural norms and beliefs shape health-seeking behaviour and practices, contributing to our understanding of how to tailor health interventions to cultural contexts. Additionally, it highlights facilitators, such as local health facilities, that can improve the uptake of IV iron therapy in rural and underserved areas, showcasing how these approaches can be scaled up to enhance maternal health.