IPTp of at least two doses of sulphadoxine-pyrimethamine (SP), administered at ANC visits, is an effective malaria prevention intervention. Despite increasing investment in IPTp programs over the past decade, and despite high rates of attendance at ANC visits, use of IPTp remains low. To identify bottlenecks in IPTp delivery, service effectiveness analyses were performed on data from 16 DHS and Malaria Indictor Surveys (MIS) conducted between 2007 and 2011 in malaria-endemic countries in SSA. Multi-country, pooled, multivariate logistic regressions were used to identify determinants of IPTp delivery. Distributions of key determinants were compared for lower IPTp coverage countries and higher IPTp coverage countries. IPTp was effectively delivered for only 18% of targeted women. Access to ANC services was not identified as a major reason for this low rate. However, levels of SP delivery to those attending ANC was low: 42% of those attending one ANC visit received one SP dose, and 57% of those attending two ANC visits received two SP doses. Determinants of IPTp use included number of ANC visits, receipt of other maternal health interventions, and malaria transmission level. Effectiveness of IPTp delivery systems varied substantially between higher and lower IPTp coverage countries. Women in higher coverage countries made fewer ANC visits, attended ANC for the first time earlier in gestation, and were more likely to use ANC services at public or religious facilities than were women in lower coverage countries. Results show that most pregnant women are obtaining ANC services at sufficient frequency and appropriate timing to permit IPTp delivery, but the intervention is not being effectively delivered in these settings.