Factors affecting access to and utilisation of intravenous iron to treat anaemia in pregnancy in Zomba, Malawi: a qualitative study

Background Anaemia in pregnancy significantly increases the risk of maternal and neonatal complications. Oral iron supplementation, the standard treatment, is often poorly tolerated and associated with low adherence. Intravenous iron presents a rapid alternative, and we examined the factors influencing access to and utilisation of intravenous iron in treating anaemia in pregnancy within Malawi’s primary healthcare system.Methods We conducted a qualitative study embedded with a clinical trial. We collected data through in-depth interviews (n=16) and focus group discussions (n=3) with pregnant women enrolled in the trial, those who withdrew and their husbands and caregivers. Interviews were audio-recorded, transcribed and analysed using a reflexive thematic approach in NVivo 12. Themes were mapped onto the supply and demand domains of the Patient-Centred Access to Healthcare framework.Results Barriers to access and utilisation operated across both supply-side and demand-side domains. On the supply side, limited service awareness, logistical constraints and unclear provider communication reduced engagement with intravenous iron. On the demand side, pregnant women’s knowledge about anaemia, cultural norms, personal beliefs and social support shaped decision-making and ability to access care. Facilitators across both domains included patient-centred service delivery, clear and responsive provider communication and family or peer involvement in decision-making, which enhanced trust, understanding and uptake.Conclusion In conclusion, our study demonstrates that patient-centred approaches are critical for improving health literacy, and strong health systems are essential for the effective delivery of intravenous iron intervention. Addressing supply and demand barriers is vital for optimising uptake of intravenous iron interventions, improving health system performance and ensuring equitable access to antenatal care interventions, ultimately improving the health outcomes for mother and child.