Use of antenatal care services and intermittent preventive treatment for malaria among pregnant women in Blantyre District, Malawi

Perceptions of sulphadoxine-pyrimethamine use among pregnant women in sub-Saharan Africa: a scoping review

Background

Malaria is a major global public health issue that disproportionately affects pregnant women in sub-Saharan Africa. The World Health Organization recommends intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) for its control. Despite its proven efficacy, drug uptake remains low. Sulphadoxine-pyrimethamine (SP) safety concerns have been cited as one of several reasons for this low uptake.

Methods

We conducted a scoping review using the Arksey and O'Malley framework and the health belief model to investigate perceptions of SP use among pregnant women in sub-Saharan Africa. We looked for peer-reviewed publications in five international databases.

Results

The review included 19 articles out of a total of 246. It showed that pregnant women in sub-Saharan Africa have a good understanding of malaria and its consequences, but this does not necessarily translate into increased IPTp-SP uptake. It is worrisome to know that some pregnant women (from 2 studies) did not believe that SP use is beneficial, and several participants (from 4 studies) were unsure or did not see the drug as an effective intervention. Many pregnant women believe SP harms them, their partners, or their unborn children.

Conclusions

Healthcare professionals should continue prescribing and encouraging pregnant women to use SP for malaria prevention until a better substitute becomes available.

Community-based delivery of intermittent preventive treatment of malaria in pregnancy in Burkina Faso: a qualitative study

Background

Burkina Faso is among ten countries with the highest rates of malaria cases and deaths in the world. Delivery and coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) is insufficient in Burkina Faso; In a 2016 survey, only 22% of eligible women had received their third dose of IPTp. It is also an extremely rural country and one with an established cadre of community healthcare workers (CHWs). To better meet the needs of pregnant women, an enhanced programme was established to facilitate distribution of IPTp at the community level by CHWs.

Methods

In order to assess the perceptions of CHWs and facility healthcare workers (HCWs) involved in this programme rollout, semi-structured interviews were conducted at three high malaria burden health districts in Burkina Faso. Interviews were conducted at baseline with 104 CHWs and 35 HCWs prior to the introduction of community based IPTp (c-IPTp) to assess capacity and any areas of concern. At endline, interviews were conducted with 29 CHWs and 21 HCWs to identify key facilitators and suggestions for further implementation of the c-IPTp programme.

Results

CHWs reported feeling capable of supporting c-IPTp delivery and facilitating linkage to antenatal care (ANC). They noted that the opportunity for enhanced training and close and ongoing connections with facility HCWs and supportive supervision were imperative. Both CHWs and HCWs perceived this approach as acceptable to community members and noted the importance of close community engagement, monthly meetings between CHWs and facility HCWs, and maintaining regular supplies of sulfadoxine–pyrimethamine (SP). Those interviewed noted that it was beneficial to have the involvement of both female and male CHWs.

Conclusions

Community-based delivery of IPTp was feasible and acceptable to both facility HCWs and CHWs. This approach has the potential to strengthen delivery and uptake of IPTp and ANC both in Burkina Faso and across the region.

Determinants of uptake of first dose of intermittent preventive treatment among pregnant women in a secondary health Centre in Maiduguri, Nigeria

Background

Studies on uptake of first dose of intermittent preventive treatment in pregnancy (IPTp) are lacking, despite it being a predictor of subsequent doses. This study aimed at assessing the determinants of uptake of first dose of IPTp among pregnant women at the State Specialist Hospital, Maiduguri.

Methods

A cross-sectional study was conducted, in which respondents were selected using a systematic random sampling method, and structured questionnaires were used to obtain information from them. Chi-squared test was used to determine factors associated with uptake of first IPTp dose, while a further multivariate logistic regression was performed to determine its predictors.

Results

Three hundred and eighty respondents answered the survey, whose ages ranged from 15 to 45 years, and 86.8% were multigravid. Sixty five percent of them were aware of IPTp, and 34.7% believed that IPTp could be harmful to their pregnancies. Over a half of the respondents (52.9%) believed that taking all their IPTp medicines was very good for their pregnancies, while 45.0% felt that taking their IPTp medicines was very pleasant. Only two respondents (0.5%) stated that it was very untrue that their significant others thought that they should take all their IPTp medicines. Half of the respondents said it was very easy for them to take all their IPTp medicines even if they were experiencing mild discomforts while taking them. Less than a half (42.37%) had received their first dose of IPTp. In bivariate as well as multivariate analysis, only higher level of knowledge was significantly associated with uptake of first IPTp dose. Those with better knowledge of IPTp were about twice more likely to have taken their first dose of IPTp, compared to those with lower knowledge of IPTp (AOR = 1.85; 95% CI: 1.17–2.92).

Conclusions

Knowledge of IPTp as well as its uptake, were sub-optimal in this study. Since knowledge of IPTp significantly predicts uptake of the first dose of IPTp, there is the need to implement health education campaigns to raise the awareness of pregnant women and their families on the need to receive and comply with it.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03388-8.

Inequities in the use of sulphadoxine-pyrimethamine for malaria prophylaxis during pregnancy in Nigeria

Background

Intermittent presumptive treatment in pregnancy (IPTp) of malaria using sulfadoxine-pyrimethamine (SP) was introduced in Nigeria in 2005 to reduce the burden of malaria in pregnancy. By 2013, 23% of reproductive aged women surveyed received SP for malaria prevention in their last pregnancy of the past 5 years. This paper highlights geographic and socio-economic variations and inequities in accessing and using SP for malaria prophylaxis in pregnancy in Nigeria, as well as client-related and service delivery determinants.

Methods

Secondary data from 2013 Nigeria demographic and health survey (DHS) was used. Sample of 38,948 eligible women were selected for interview using stratified three-stage cluster design. Data obtained from the individual recode dataset was used for descriptive and logistic regression analysis of factors associated with SP use in pregnancy was performed. Independent variables were age, media exposure, region, place of residence, wealth index, place of antenatal care (ANC) attendance and number of visits.

Results

Women in the upper three wealth quintiles were 1.33 - 1.80 times more likely to receive SP than the poorest (CI: 1.15-1.56; 1.41-1.97; 1.49-2.17). Women who received ANC from public health facilities were twice as likely (inverse of OR 0.68) to use SP in pregnancy than those who used private facilities (CI: 0.60-0.76). Those who attended at least 4 ANC visits were 1.46 times more likely to get SP prophylaxis (CI: 1.31-1.63). Using the unadjusted odds ratio, women residing in rural areas were 0.86 times less likely to use SP compared to those in urban areas.

Conclusions

Inequities in access to and use of SP for malaria prophylaxis in pregnancy exist across sub-population groups in Nigeria. Targeted interventions on the least covered are needed to reduce existing inequities and scale-up IPTp of malaria.

Factors associated with the uptake of intermittent preventive treatment of malaria in pregnancy in the Bamenda health districts, Cameroon

Introduction

The World Health Organization (WHO) recommends that in malaria endemic areas with moderate to high transmission rates, pregnant women presenting for antenatal clinic (ANC) should receive at least three doses of intermittent preventive treatment in pregnancy (IPTp) for malaria between the 16^th and 36^th weeks of pregnancy at intervals of 4 weeks between doses. Several challenges remain in effective implementation of IPTp policy making the targeted coverage (80%) of the third doses of IPTp far from being achieved. The main objective of this study was to assess factors associated with the uptake of IPTp among pregnant women attending ANCs in the Bamenda Health District.

Methods

To reach our objectives, we carried out a cross-sectional study following informed consent with thirty-nine (39) healthcare workers (HCW) and four hundred (400) pregnant women who were either in the third trimester of pregnancy or had recently given birth in any of thirty-six (36) health facilities (HF) within the Bamenda Health District (BHD) from May to August 2014. All sites within the BHD were included. The participants were selected by simple random sampling. The principal research instrument was a structured and pre-tested questionnaire that was designed to capture socio-demographic data and data related to stage of pregnancy and knowledge about IPTp. Data was entered using Ms Excel and analysed using SPSS v20.0. Descriptive statistics (frequencies and percentages) was used to report findings. We used Chi-Square test to compare the categorical variables (Fischer’s exact test was used in cases were conditions for Chi-Square test were not met).

Results

Uptake for at least one dose of IPTp was 95.3% (381/400) and 54.9% (209/400) had received all three doses, 15.5% (59/400) received only one dose and 4.8% (19/400) did not receive any of the doses of IPTp. Knowledge about IPTp was associated with an increase uptake of IPTp (P<0.001). All health care providers were knowledgeable about the importance and use of IPTp. However, 35.9% reported not receiving any training on IPTp. Among the health providers, 28.2% did not know when to start IPTp and 43.59% did not know when to stop IPTp. Out of all the health care providers, 30.77% complained of medication (sulfadoxine-Pyrimethamine) stock out and 84.62% practiced the policy of direct observed therapy.

Conclusion

The uptake of the third dose of IPTp is poor in the Bamenda Health District and this may be attributed to medication stock out and inadequacy of routine trainings for the health providers. The good practice observed was that of direct observed therapy by HCWs. Patient knowledge about IPTp in our study was associated with better uptake of IPTp. Encouraging education of pregnant women on the importance of IPTp, providing routine training to HCWs and promoting direct observation of therapy may improve on IPTp uptake during pregnancy.

Antenatal visits are positively associated with uptake of tetanus toxoid and intermittent preventive treatment in pregnancy in Ivory Coast

Background

Malaria and tetanus infections among pregnant women represent two major public health problems in sub-Saharan Africa. Optimum use of Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (IPTp-SP) and immunization against tetanus among pregnant women during antenatal care (ANC) visits are recommended strategies to prevent these issues. Despite these recommendations, many women in Africa remain deprived of these cost-effective and life-saving interventions. In this study, we aimed to examine the prevalence of women using these two services, and the association between women’s uptake of IPTp-SP and tetanus toxoid (TT) with antenatal care use in Ivory Coast.

Methods

This study was based on the fifth round of Multiple Indicator Cluster Survey (MICS 5) conducted in Ivory Coast in 2016. Participants were 9583 women aged between 15 and 49 years. Outcomes were TT and Intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP). Data analysis was conducted using bivariate and multiple logistic regression.

Results

In this study, the prevalence of taking TT immunization and IPTp-SP drugs was 81.97 and 17.83% respectively. Of the participants who took these drugs at all, the prevalence of taking adequate doses of TT immunization was 78.75% and that of IPTp-SP was 35.46%. In the multivariable analysis model, higher age groups, 25–29 years (OR = 2.028, 95%CI = 1.120–3.669) were found to be positively associated with uptake of adequate doses of IPTp-SP drugs. Women who attended at least four ANC visits had higher odds of taking IPTp-SP drugs (OR = 1.656, 95%CI = 1.194–2.299) and TT immunization (OR = 2.347, 95%CI = 1.384–3.981), and also had higher odds of receiving adequate doses of IPTp-SP drugs (OR = 3.291, 95%CI = 2.157–5.020) and that of TT immunization (OR = 1.968, 95%CI = 1.398–2.771). The odds of taking IPTp-SP drugs were significantly higher among women with primary (OR = 2.504, 95%CI = 1.020–6.146) and secondary/higher education (OR = 3.298, 95%CI = 1.343–8.097) compared to those with no education. Also, women with higher parity had lower odds of taking TT immunization (OR = 0.218, 95%CI = 0.055–0.858) compared to those with lower parity. Findings from this study also revealed that the odds of taking adequate doses of IPTp-SP drugs were significantly lower among participants from Mandé du Nord ethnicity (OR = 0.378,95%CI = 0.145–0.983) compared to those from other ethnicities.

Conclusion

In this study, uptake of IPTp-SP drugs was much lower than TT immunization. High number of ANC visits were found to be significantly associated with taking IPTp-SP drugs and TT immunization and also with that of taking them in adequate doses. Vaccination promotion is necessary to protect pregnant women and reduce adverse health outcomes among the newborn in Ivory Coast.

Mass media exposure and its impact on malaria prevention behaviour among adult women in sub-Saharan Africa: results from malaria indicator surveys

BACKGROUND

Mass media exposure plays a pivotal role in health communication and adoption of a healthy lifestyle. In this study, we aimed to measure the prevalence of malaria prevention behaviour among adult women in eight malaria-endemic countries in sub-Saharan Africa (SSA), and assess the influence of mass media exposure in the adoption of those behaviours.

METHODS

For this study, we collected cross-sectional data on 46,822 women aged between 15 and 49 years from the Malaria Indicator Surveys (MIS) conducted in Burkina Faso, Ghana, Mali, Malawi, Kenya, Nigeria, Sierra Leone and Uganda. As the outcome variable, malaria prevention behaviour was proxied by the use of insecticide treated nets (ITNs) and uptake of antimalarial drugs in last pregnancy.

RESULTS

The overall prevalence of sleeping under ITN and that of taking antimalarial drug during the last pregnancy was respectively 67.9% (95%CI = 66.6-69.2) and 72.8% (95%CI = 71.3-74.2). However, there were disparities in the prevalence of using ITN and antimalarial drug use across the study countries. In the multivariable regression analysis, not receiving malaria related information from radio, poster/billboards, community events, and health workers were found to be significantly associated with reduction in the odds of using ITN the previous night. For the use of antimalarial drugs during last pregnancy, the odds were 23% [OR = 0.773, 95%CI = 0.625-0.956] lower for those who did not receive malaria information on radio compared with those who received.

CONCLUSIONS

These findings indicate a potentially important role of malaria information received through mass media on utilisation of ITN among women in SSA. More research is needed to explore the factors that limit the accessibility to malaria information through mass media.

Use of Intermittent Preventive Treatment among Pregnant Women in Sub-Saharan Africa: Evidence from Malaria Indicator Surveys

Uptake of intermittent preventive therapy in pregnancy (IPTp) with sulfadoxine-pyrimethamine (IPTp-SP) is a clinically-proven method to prevent the adverse outcomes of malaria in pregnancy (MiP) for the mother, her foetus, and the neonates. The majority of countries in sub-Saharan Africa have introduced IPTp policies for pregnant women during the past decade. Nonetheless, progress towards improving IPTp coverage remains dismal, with widespread regional and socioeconomic disparities in the utilisation of this highly cost-effective service. In the present study, our main objective was to measure the prevalence of IPTp uptake in selected malaria-endemic countries in sub-Saharan Africa, and to investigate the patterns of IPTp uptake among different educational and wealth categories adjusted for relevant sociodemographic factors. For this study, cross-sectional data on 18,603 women aged between 15 and 49 years were collected from the Malaria Indicator Surveys (MIS) conducted in Burkina Faso, Ghana, Mali, Malawi, Kenya, Nigeria, Sierra Leone, and Uganda. The outcome variable was taking three doses of IPTp-SP in the last pregnancy, defined as adequate by the WHO. According to the analysis, the overall prevalence of taking three doses of IPTp-SP in the latest pregnancy was 29.5% (95% CI = 28.2–30.5), with the prevalence being highest for Ghana (60%, 95% CI = 57.1–62.8), followed by Kenya (37%, 95% CI = 35.3–39.2) and Sierra Leone (31%, 95% CI = 29.2–33.4). Women from non-poor households (richer—20.7%, middle—21.2%, richest—18.1%) had a slightly higher proportion of taking three doses of IPTp-SP compared with those from poorest (19.0%) and poorer (21.1%) households. Regression analysis revealed an inverse association between uptake of IPTp-SP and educational level. With regard to wealth status, compared with women living in the richest households, those in the poorest, poorer, middle, and richer households had significantly higher odds of not taking at least three doses of IPTp-SP during their last pregnancy. The present study concludes that the prevalence of IPTp-SP is still alarmingly low and is significantly associated with individual education and household wealth gradient. Apart from the key finding of socioeconomic disparities within countries, were the between-country variations that should be regarded as a marker of inadequate policy and healthcare system performance in the respective countries. More in-depth and longitudinal studies are required to understand the barriers to, and preferences of, using IPTp-SP among women from different socioeconomic backgrounds.

How I treat anemia in pregnancy: iron, cobalamin, and folate

Anemia of pregnancy, an important risk factor for fetal and maternal morbidity, is considered a global health problem, affecting almost 50% of pregnant women. In this article, diagnosis and management of iron, cobalamin, and folate deficiencies, the most frequent causes of anemia in pregnancy, are discussed. Three clinical cases are considered. Iron deficiency is the most common cause. Laboratory tests defining iron deficiency, the recognition of developmental delays and cognitive abnormalities in iron-deficient neonates, and literature addressing the efficacy and safety of IV iron in pregnancy are reviewed. An algorithm is proposed to help clinicians diagnose and treat iron deficiency, recommending oral iron in the first trimester and IV iron later. Association of folate deficiency with neural tube defects and impact of fortification programs are discussed. With increased obesity and bariatric surgery rates, prevalence of cobalamin deficiency in pregnancy is rising. Low maternal cobalamin may be associated with fetal growth retardation, fetal insulin resistance, and excess adiposity. The importance of treating cobalamin deficiency in pregnancy is considered. A case of malarial anemia emphasizes the complex relationship between iron deficiency, iron treatment, and malaria infection in endemic areas; the heightened impact of combined etiologies on anemia severity is highlighted.

Factors Influencing Anti-Malarial Prophylaxis and Iron Supplementation Non-Compliance among Pregnant Women in Simiyu Region, Tanzania

Malaria and iron-deficient anemia during pregnancy pose considerable risks for the mother and newborn. Intermittent Preventive Treatment during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) and iron supplement to prevent anemia to all pregnant women receiving antenatal care (ANC) services is highly recommended. However, their compliance remains low. This study aimed at identifying factors influencing non-compliance of medications among pregnant women. A descriptive cross-sectional study was conducted in Simiyu region in northwest Tanzania using a structured questionnaire to collect data from 430 women who were pregnant or gave birth 12 months prior to data collection. Data were analyzed using non-parametric statistical analysis with STATA 10. Overall, 284 (66%) and 195 (45%) of interviewed women received IPTp-SP and iron supplementation during their ANC visits, respectively. The majority (85%) of women whom received medications were aware if they had received IPTp-SP or iron supplementation. Of those received IPTp-SP, only 11% took all the three doses, while the remaining 89% took only two doses or one dose. For women who received iron supplementation, 29% reported that they did not take any dose at all. Reasons given for not complying with regiments included not liking the medications and disapproval from male partners. Our findings suggest that IPTp-SP and iron supplement compliance among pregnant women in Simiyu region is low. Intensification of community education, further qualitative research and administration of medication through directly-observed therapy (DOT) are recommended to address the problem.

Clinical malaria among pregnant women on combined insecticide treated nets (ITNs) and intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine in Yaounde, Cameroon

BACKGROUND

Malaria remains a burden for pregnant women and the under 5. Intermittent preventive treatment of pregnant women (IPTp) for malaria with sulfadoxine - pyrimethamine (SP) has since replaced prophylaxis and legislation has been reinforced in the area of insecticide treated mosquito nets (ITNs) in Cameroon. Clinical malaria despite all these measures remains a problem. We compared the socio-obstetrical characteristics of women who developed clinical malaria and those who did not though in the same regimen.

METHODS

A 5 - year nested cohort study (2007 - 2011 inclusive) at the tertiary level hospitals in Yaounde. Pregnant women who willingly accepted to participate in the study were enrolled at booking and three doses of SP were administered between 18 - 20 weeks of gestation, between 26-28 weeks and between 32 - 34 weeks. Those who developed clinical malaria were considered as cases and were compared for socio - obstetrical characteristics with those who did not. Venous blood was drawn from the women in both arms for parasite density estimation and identification and all the clinical cases were treated conventionally.

RESULTS

Each arm had 166 cases and many women who developed clinical malaria were between 15 and 19 years (OR 5.5, 95% CI 3.9 - 5.3, p < 0.001). They were of low gravidity (OR 6.5, 95% CI 3.8 - 11.3, p < 0.001) as well as low parity (OR 4.6, 95% CI 2.7 - 7.9, p < 0.001). The cases were single women (OR 4.58, 95% CI 2.54 - 8.26, p < 0.001) and had attained only primary level of education (OR 4.6, 95% CI 2.8 - 7.9, p < 0.001). Gestational ages were between 20 to 30 weeks during clinical malaria (OR 6.8, 95% CI 4.1 - 11.7, p < 0.001). The time between the first and second dose of SP was longer than ten weeks in the cases (OR 5.5, 95% CI 3.2 - 9.3, p < 0.001) and parasite density was higher also among the cases (OR 6.9, 95% CI 5.9 - 12.1, p < 0.001).

CONCLUSION

Long spacing between the first and second dose of SP seemed to be responsible for clinical malaria in the cases.

Antenatal care visit attendance, intermittent preventive treatment during pregnancy (IPTp) and malaria parasitaemia at delivery

Background

The determinants and barriers for delivery and uptake of IPTp vary with different regions in sub-Saharan Africa. This study evaluated the determinants of ANC clinic attendance and IPTp-SP uptake among parturient women from Mount Cameroon Area and hypothesized that time of first ANC clinic attendance could influence uptake of IPTp-SP/dosage and consequently malaria parasite infection status at delivery.

Methods

Two cross sectional surveys were carried out at the Government Medical Centre in the Mutengene Health Area, Mt Cameroon Area from March to October 2007 and June 2008 to April 2009. Consented parturient women were consecutively enrolled in both surveys. In 2007, socio-demographic data, ANC clinic attendance, gestational age, fever history and reported use/dosage of IPTp-SP were documented using a structured questionnaire. In the second survey only IPT-SP usage/dosage was recorded. Malaria parasitaemia at delivery was determined by blood smear microscopy and placental histology.

Results and discussion

In 2007, among the 287 women interviewed, 2.2%, 59.7%, and 38.1% enrolled in the first, second and third trimester respectively. About 90% of women received at least one dose SP but only 53% received the two doses in 2007 and by 2009 IPTp-two doses coverage increased to 64%. Early clinic attendance was associated (P = 0.016) with fever history while being unmarried (OR = 2.2; 95% CI: 1.3-3.8) was significantly associated with fewer clinic visits (<4visits). Women who received one SP dose (OR = 3.7; 95% CI: 2.0-6.8) were more likely not to have attended ≥ 4visits. A higher proportion (P < 0.001) of women with first visit during the third trimester received only one dose, meanwhile, those who had an early first ANC attendance were more likely (OR = 0.4; 95% CI = 0.2 - 0.7) to receive two or more doses. Microscopic parasitaemia at delivery was frequent (P = 0.007) among women who enrolled in the third trimester and had received only one SP dose than in those with two doses.

Conclusion

In the study area, late first ANC clinic enrolment and fewer clinic visits may prevent the uptake of two SP doses and education on early and regular ANC clinic visits can increase IPTp coverage.

Health facility-based data on women receiving sulphadoxine-pyrimethamine during pregnancy in Tanzania: lessons to learn from a cross-sectional survey in Mkuranga and Mufindi districts and other national survey reports

BACKGROUND

A study of health facility (HF) data on women receiving sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria during pregnancy (IPTp) was carried out at antenatal care clinics in Mkuranga and Mufindi districts.

METHODS

A review of health management information system (HMIS) registers, interviews with health-care workers (HWs) and district and national level malaria control program managers corroborated by inter-temporal assessment through observations at HF levels. Statistical data were analyzed in Excel and interpreted in triangulation with qualitative data from interviews and observations.

RESULTS

Data indicated that IPTp doses administered to women were inadequate and partly inconsistent. HMIS registers lacked space for IPT records, forcing HWs to manipulate their record-keeping. The proportion/number of IPTp recipients in related to the supply of SP for free delivery, to women's attendance behaviours, showed variation by quarter and year of reporting.

CONCLUSION

It is impossible to achieve rational health service planning when the HMIS is weak. Whilst it is acknowledged that the HMIS is already overloaded, concerted measures are urgently needed to accommodate data on new interventions and other vertical programs if malaria programs are to achieve their goals.

Factors affecting uptake of optimal doses of sulphadoxine-pyrimethamine for intermittent preventive treatment of malaria in pregnancy in six districts of Tanzania

Background

Intermittent preventive treatment during pregnancy (IPTp) with optimal doses (two+) of sulphadoxine-pyrimethamine (SP) protects pregnant women from malaria-related adverse outcomes. This study assesses the extent and predictors of uptake of optimal doses of IPTp-SP in six districts of Tanzania.

Methods

The data come from a cross-sectional survey of random households conducted in six districts in Tanzania in 2012. A total of 1,267 women, with children aged less than two years and who had sought antenatal care (ANC) at least once during pregnancy, were selected for the current analysis. Data analysis involved the use of Chi-Square (χ²) for associations and multivariate analysis was performed using multinomial logistic regression.

Results

Overall, 43.6% and 28.5% of the women received optimal (two+) and partial (one) doses of IPTp-SP respectively during pregnancy. Having had been counseled on the dangers of malaria during pregnancy was the most pervasive determinant of both optimal (RRR = 6.47, 95% CI 4.66-8.97) and partial (RRR = 4.24, 95% CI 3.00-6.00) uptake of IPTp-SP doses. Early ANC initiation was associated with a higher likelihood of uptake of optimal doses of IPTp-SP (RRR = 2.05, 95% CI 1.18-3.57). Also, women with secondary or higher education were almost twice as likely as those who had never been to school to have received optimal SP doses during pregnancy (RRR = 1.93, 95% CI 1.04-3.56). Being married was associated with a 60% decline in the partial uptake of IPTp-SP (RRR = 0.40, 95% CI 0.17-0.96). Inter-district variations in the uptake of both optimal and partial IPTp-SP doses existed (P < 0.05).

Conclusion

Counseling to pregnant women on the dangers of malaria in pregnancy and formal education beyond primary school is important to enhance uptake of optimal doses of SP for malaria control in pregnancy in Tanzania. ANC initiation in the first trimester should be promoted to enhance coverage of optimal doses of IPTp-SP. Programmes should aim to curb geographical barriers due to place of residence to enhance optimal coverage of IPTp-SP in Tanzania.

Treatment and prevention of malaria in pregnancy: opportunities and challenges

Control of malaria in pregnancy through prevention or treatment may save lives of mothers and babies. Selection of drugs for treatment of infected pregnant women, or for prevention in exposed populations is problematic owing to resistance to established drugs and lack of pregnancy-specific safety and pharmacological data for new drugs. Encouragingly, a number of new drugs and combinations of drugs hold promise for effective treatment, but adequate data on their safety in pregnancy is currently lacking. Our principal challenges are to decide which drugs to develop for use in malaria treatment and prevention in pregnancy and to develop mechanisms to rapidly and comprehensively evaluate their safety. Prevention of pregnancy malaria by vaccination may also become possible, but targets must be closely defined, and strategies developed to test candidates against meaningful end points.

Factors associated with utilization of sulphadoxine-pyrimethamine during pregnancy among women in Kenya: a cross-sectional study

The effectiveness of sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment during pregnancy for malaria is well established. However, adherence to recommended guidelines remains poor. This study examines factors related to receipt of SP among pregnant women in Kenya. Descriptive and inferential statistics for complex survey data were utilized using the 2008-2009 Kenya Demographic and Health Survey. With the exception of women residing in Nyanza, women who reside in other provinces were more likely to receive one dose of SP versus none compared to women living in Nairobi. Women receiving antenatal care from a nurse or midwife and women who owned a bed net were almost twice as likely to receive one dose of SP versus none (aOR 1.92, 95% CI 1.28, 2.86 and aOR 1.79; 95% CI 1.12, 2.78; respectively); whereas, women who received other anti-malarial drugs were over 90% less likely to receive one dose of SP versus none (aOR 0.08; 95% CI 0.02, 0.26). Among women who receive any SP, increased numbers of antenatal care visits were associated with receipt of two or more doses of SP (aOR 1.16; 95% CI 1.02, 1.32-per additional visit), while women living in the western province were nearly 75% less likely to receive two or more doses compared to women in Nairobi (aOR 0.27; 95% CI 0.08, 0.94). Receipt of the recommended ≥2 doses of SP is associated with predisposing and enabling characteristics. Further research is needed to identify barriers to receiving SP during pregnancy.

Factors affecting the delivery, access, and use of interventions to prevent malaria in pregnancy in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Malaria in pregnancy has important consequences for mother and baby. Coverage with the World Health Organization-recommended prevention strategy for pregnant women in sub-Saharan Africa of intermittent preventive treatment in pregnancy (IPTp) and insecticide-treated nets (ITNs) is low. We conducted a systematic review to explore factors affecting delivery, access, and use of IPTp and ITNs among healthcare providers and women.

METHODS AND RESULTS

We searched the Malaria in Pregnancy Library and Global Health Database from 1 January 1990 to 23 April 2013, without language restriction. Data extraction was performed by two investigators independently, and data was appraised for quality and content. Data on barriers and facilitators, and the effect of interventions, were explored using content analysis and narrative synthesis. We conducted a meta-analysis of determinants of IPTp and ITN uptake using random effects models, and performed subgroup analysis to evaluate consistency across interventions and study populations, countries, and enrolment sites. We did not perform a meta-ethnography of qualitative data. Ninety-eight articles were included, of which 20 were intervention studies. Key barriers to the provision of IPTp and ITNs were unclear policy and guidance on IPTp; general healthcare system issues, such as stockouts and user fees; health facility issues stemming from poor organisation, leading to poor quality of care; poor healthcare provider performance, including confusion over the timing of each IPTp dose; and women's poor antenatal attendance, affecting IPTp uptake. Key determinants of IPTp coverage were education, knowledge about malaria/IPTp, socio-economic status, parity, and number and timing of antenatal clinic visits. Key determinants of ITN coverage were employment status, education, knowledge about malaria/ITNs, age, and marital status. Predictors showed regional variations.

CONCLUSIONS

Delivery of ITNs through antenatal clinics presents fewer problems than delivery of IPTp. Many obstacles to IPTp delivery are relatively simple barriers that could be resolved in the short term. Other barriers are more entrenched within the overall healthcare system or socio-economic/cultural contexts, and will require medium- to long-term strategies. Please see later in the article for the Editors' Summary.

Antenatal care visit attendance, intermittent preventive treatment and bed net use during pregnancy in Gabon

Background

The World Health Organization (WHO) recommends that intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and insecticide treated bed nets (ITNs) must be provided during antenatal care (ANC) visits for malaria prevention during pregnancy. The aim of this study was to determine the level of ANC attendance and its relationship with IPTp-SP and bed net coverage in Gabonese pregnant women.

Methods

This was a cross-sectional survey performed in 2011 in sentinel sites for malaria: two ANC units (Melen and Owendo) and one delivery unit (CHL). A validated structured questionnaire was used to collect the following data: age, parity, history of the current pregnancy including gestational age at the interview, number of ANC visits already performed, date of first visit, use of malaria preventive measure and details on IPTp-SP administration.

Results

During the study, 1030 women were interviewed, 735 at their ANC visit and 295 at the delivery. Their median age was 24[20–29] years and 21.0% were primigravidae. More than 70.0% attended their first ANC visit during the second trimester. Among the 442 women who were at the end of their pregnancy, 71.5% had a correct attendance, at least four ANC visits, most frequently women with no education and older women; IPTp-SP was offered to 84.1% of them and 57.4% received at least two doses. The number of SP doses was correlated to the number of ANC visits. Bed net coverage was 59.0%, not associated with ANC attendance. Among the women with correct ANC attendance, only 49.5% had a complete IPTp-SP course associated with bed net use during pregnancy. In the site where SP administration was supervised, 80% had four ANC visits and 97.4% received a full 2-dose course of IPTp-SP.

Conclusions

Despite a high level of correct ANC attendance in Gabon, the goal of 80% of women with 2-dose IPTp-SP during pregnancy is not achieved. Evaluations, training of health workers, as well as surveys from other areas of the country are needed to further measure the implementation and the impact of these strategies.

Comparative efficacy of uncontrolled and controlled intermittent preventive treatment during pregnancy (IPTp) with combined use of LLTNs in high resistance area to sulfadoxine-pyrimethamine in Côte d'Ivoire

Introduction

In recent years, intermittent preventive treatment for pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) has become policy in much of sub-Saharan Africa. But resistance to SP has been spreading across sub-Saharan Africa and thus the effectiveness of IPTp-SP has been questioned. The present study therefore sought to assess the incidence of placental malaria, low birth weight, and anemia of two IPTp-SP approaches (directly observed treatment scheme versus no directly observed treatment) in Anonkoua-Kouté and Samo, Côte d’Ivoire where the reported prevalence of dfr single mutant 108 was 62% and 52.2%, respectively.

Methods

The study was a longitudinal design involving pregnant women and was conducted in Anonkoua-Kouté, a suburban area, and Samo, a rural area, from January 2008 through March 2009. Women of a pregnancy less than 28 weeks duration were randomized to receive SP (1.5 g/0.075 g SP) in a single intake twice and were followed up monthly until delivery. Doses were administered under supervision in the controlled IPTp group, while SP was given free to women in the uncontrolled IPTp group with a recommendation to take it at home. The primary end point was the proportion of low birth weight infants (body weight < 2500 g) and the secondary end point was the rate of severe anemia and placental malaria detected at delivery.

Results

A total of 420 pregnant women were enrolled (212 and 208, respectively, in the controlled and uncontrolled groups). Delivery outcome was available for 378 women. In the modified intention-to-treat analysis, low birth weight infants were born from 15.5% of women of the uncontrolled IPTp group and from 11.9% of women in the controlled IPTp group (P = 0.31). The per-protocol population analysis showed consistent results. The proportion of women with placental malaria infection, moderate anemia (hemoglobin < 11 g/dL), and severe anemia (hemoglobin < 8 g/dL) at delivery were similar between the two groups (P > 0.05).

Conclusion

The study showed that the two approaches were equivalent, suggesting that unsupervised IPTp-SP free of charge should be used in areas where implementation of the directly observed treatment scheme suffers from many constraints.

Relatively low prevalence of peripheral and placental Plasmodium infection at delivery in bangui, central african republic

Introduction. The aim of this study was to estimate the prevalence of malaria among women giving birth in Bangui. Association between sociodemographic characteristics of those women and malaria, as well as prevention compliance (use of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTsp) and insecticide-treated bed nets (ITNs)), was analyzed. Methods. During September 2009, a survey was conducted on 328 women who gave birth at two main maternities of Bangui. Information was obtained by standardized questionnaire about sociodemographic criteria, IPTsp, other antimalarial treatment, and use of bet nets. Smears prepared from peripheral and placental blood were analysed for malaria parasites. Findings and Discussion. Positive results were found in 2.8% of thick peripheral blood smears and in 4.0% of placental slides. A proportion of 30.5% of the women had received at least two doses of IPTsp during the current pregnancy. Only a proportion of 42.4% of this study population had ITNs. Multigravid women were less likely to use IPTsp and ITNs. However, use of IPTsp was associated with personal income and secondary or university educational status. Hence, although this relatively prevalence was observed, more efforts are needed to implement IPTsp and ITNs, taking into account sociodemographic criteria.

Social and cultural factors affecting uptake of interventions for malaria in pregnancy in Africa: a systematic review of the qualitative research

Background

Malaria during pregnancy (MiP) results in adverse birth outcomes and poor maternal health. MiP-related morbidity and mortality is most pronounced in sub-Saharan Africa, where recommended MiP interventions include intermittent preventive treatment, insecticide-treated bednets and appropriate case management. Besides their clinical efficacy, the effectiveness of these interventions depends on the attitudes and behaviours of pregnant women and the wider community, which are shaped by social and cultural factors. Although these factors have been studied largely using quantitative methods, qualitative research also offers important insights. This article provides a comprehensive overview of qualitative research on social and cultural factors relevant to uptake of MiP interventions in sub-Saharan Africa.

Methods and Findings

A systematic search strategy was employed: literature searches were undertaken in several databases (OVID SP, IS Web of Knowledge, MiP Consortium library). MiP-related original research, on social/cultural factors relevant to MiP interventions, in Africa, with findings derived from qualitative methods was included. Non-English language articles were excluded. A meta-ethnographic approach was taken to analysing and synthesizing findings. Thirty-seven studies were identified. Fourteen concentrated on MiP. Others focused on malaria treatment and prevention, antenatal care (ANC), anaemia during pregnancy or reproductive loss. Themes identified included concepts of malaria and risk in pregnancy, attitudes towards interventions, structural factors affecting delivery and uptake, and perceptions of ANC.

Conclusions

Although malaria risk is associated with pregnancy, women's vulnerability is often considered less disease-specific and MiP interpreted in locally defined categories. Furthermore, local discourses and health workers' ideas and comments influence concerns about MiP interventions. Understandings of ANC, health worker-client interactions, household decision-making, gender relations, cost and distance to health facilities affect pregnant women's access to MiP interventions and lack of healthcare infrastructure limits provision of interventions. Further qualitative research is however required: many studies were principally descriptive and an in-depth comparative approach is recommended.

Field evaluation of the intermittent preventive treatment of malaria during pregnancy (IPTp) in Benin: evolution of the coverage rate since its implementation

Background

Malaria is an important public health problem in Africa. Pregnant women are a vulnerable population and this disease can underlie an increased risk of low-birth weight newborns (< 2500 g); these women therefore need management during pregnancy. This was previously provided by chloroquine treatment, which, because of compliance problems and drug resistance, was replaced by intermittent preventive treatment with sulfadoxine-pyrimethamine (ITPp-SP) with two single doses taken after 16 weeks of amenorrhea, at least 4 weeks apart. This protocol was recommended by the World Health Organization (WHO) in 1998 and was initiated in Benin in 2006 after its political adoption in 2004.

A retrospective longitudinal study was conducted in eight maternity hospitals in two geographical areas in Benin (in the south and north). The study investigated 2420 women who gave birth from 2005 to 2009. The antenatal cards of those women were randomly selected over 5 years with the aim of analyzing the IPT coverage in the study's maternity hospitals.

Results

The rate of IPT-SP coverage evolved from 3.7% in 2005 to 87.8% in 2009 for women who had received at least one dose and from 2.7% to 68.4% from 2005 to 2009 for those who had received complete ITP (two doses). Variability in the results was observed depending on the geographical area (north/south) and the type of area (rural/urban).

Conclusions

In total, application of IPT-SP 2-doses has rapidly evolved since 2005, but the objective of 80% IPT coverage has not yet been achieved throughout the country. Moreover, problems of drug shortage recurring in the field (reported by health staff) remain to be resolved.

Prenatal care associated with reduction of neonatal mortality in Sub-Saharan Africa: evidence from Demographic and Health Surveys

OBJECTIVE

To determine whether prenatal care by a skilled provider (physician, nurse or midwife) and specific prenatal interventions were associated with decreased neonatal mortality.

DESIGN

Mothers' reports in nationally representative surveys (conducted 2003-2009) about their most recent delivery were analyzed. Setting. Sub-Saharan Africa, 17 least developed countries (UN designation).

POPULATION

89 655 women aged 15-49 years with a singleton birth within 3 years prior to survey. Methods. Logistic regression models were used to measure the associations between having a skilled prenatal provider, as well as specific interventions, and neonatal mortality.

MAIN OUTCOME MEASURES

Neonatal mortality, defined as a live birth ending in death at less than one month of age.

RESULTS

Overall, 70.7% of women saw a skilled prenatal provider during their previous pregnancy. Prenatal care from a skilled provider was associated with a decreased neonatal mortality risk compared with no provider [adjusted odds ratio (AOR) 0.70, 95% confidence interval (CI) 0.62-0.80] and compared with an unskilled provider (AOR 0.81, 95% CI 0.68-0.96). The most effective prenatal interventions were weight (AOR 0.71, 95% CI 0.64-0.80) and blood pressure measurements (AOR 0.77, 95% CI 0.69-0.86), and two or more tetanus immunizations (AOR 0.78, 95% CI 0.70-0.86). Four or more prenatal visits compared with none were associated with decreased neonatal mortality risk (AOR 0.68, 95% CI 0.59-0.79).

CONCLUSIONS

Prenatal care provided by skilled providers, at least four prenatal visits, weight and blood pressure assessment, and two or more tetanus immunizations were associated with decreased neonatal mortality in Sub-Saharan African countries.

The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania

Background

Intermittent preventive treatment during pregnancy (IPTp) at routine antenatal care (ANC) clinics is an important and efficacious intervention to reduce adverse health outcomes of malaria infections during pregnancy. However, coverage for the recommended two IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage.

Methods

Data on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Women's timing of ANC visits and health worker's timing of IPTp delivery were analyzed in relation to the different national IPTp schedules and the outcome on IPTp coverage was modelled.

Results

Among all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. Less than 1% of women started ANC attendance after 32 weeks of gestation. During the second IPTp delivery period health workers delivered IPTp to significantly less women than during the first one (55% vs. 73%) contributing to low second dose coverage. Simplified IPTp guidelines for front-line health workers as recommended by WHO could lead to a 20 percentage point increase in IPTp coverage.

Conclusions

This study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. To maximize the benefit of the IPTp intervention, revision of existing guidelines is needed. Training on simplified IPTp messages should be consolidated as part of the extended antenatal care training to change health workers' delivery practices and increase IPTp coverage. Pregnant women's knowledge about IPTp and the risks of malaria during pregnancy should be enhanced as well as their ability and power to demand IPTp and other ANC services.

Determinants of use of intermittent preventive treatment of malaria in pregnancy: Jinja, Uganda

Background

Maternal malaria is associated with serious adverse pregnancy outcomes. One recommended means of preventing malaria during pregnancy is intermittent preventive therapy (IPTp) with sulfadoxine/pyrimethamine (SP). We sought to identify determinants of preventive use of SP during pregnancy among recently pregnant women in Uganda. Additionally, we characterized the timing of and indications for the administration of SP at antenatal care (ANC) visits and missed opportunities for SP administration.

Methodology/Principal Findings

Utilizing a population-based random sample, we interviewed 500 women living in Jinja, Uganda who had been pregnant in the past year. Thirty-eight percent (192/500) of women received SP for the treatment of malaria and were excluded from the analysis of IPTp-SP. Of the remaining women, 275 (89.3%) reported at least two ANC visits after the first trimester and had an opportunity to receive IPTp-SP according to the Ugandan guidelines, but only 86 (31.3%) of these women received a full two-dose course of IPTp. The remaining 189 (68.7%) women missed one or more doses of IPTp-SP. Among the 168 women that were offered IPTp, 164 (97.6%) of them took the dose of SP.

Conclusions/Significance

Use of IPTp in Uganda was found to be far below target levels. Our results suggest that women will take SP for IPTp if it is offered during an ANC visit. Missed opportunities to administer IPTp-SP during ANC were common in our study, suggesting provider-level improvements are needed.

Determinants of utilisation of maternal care services after the reduction of user fees: a case study from rural Burkina Faso

OBJECTIVE

To identify determinants of utilisation for antenatal care (ANC) and skilled attendance at birth after a substantial reduction in user fees.

METHODS

The study was conducted in the Nouna Health District in north-western Burkina Faso in early 2009. Data was collected by means of a representative survey on a sample of 435 women who reported a pregnancy in the prior 12 months. Two independent logit models were used to assess the determinants of (a) ANC utilisation (defined as having attended at least 3 visits) and (b) skilled assistance at birth (defined as having delivered in a health facility).

RESULTS

76% of women had attended at least 3 ANC visits and 72% had delivered in a facility. Living within 5 km from a facility was positively associated, while animist religion, some ethnicities, and household wealth were negatively associated with ANC utilisation. Some ethnicities, living within 5 km from a health facility, and having attended at least 3 ANC visits were positively associated with delivering in a facility.

CONCLUSIONS

User fee alleviation secured equitable access to care across socio-economic groups, but alone did not ensure that all women benefited from ANC and from skilled attendance at birth. Investments in policies to address barriers beyond financial ones are urgently needed.

Decreasing burden of malaria in pregnancy in Malawian women and its relationship to use of intermittent preventive therapy or bed nets

Background

The World Health Organization recommends insecticidal bednets and intermittent preventive treatment to reduce malaria in pregnancy. Longitudinal data of malaria prevalence and pregnancy outcomes are valuable in gauging the impact of these antimalarial interventions.

Methodology/Principal Findings

We recruited 8,131 women delivering in a single Malawian hospital over 9 years. We recorded demographic data, antenatal prescription of intermittent preventive therapy during pregnancy with sulfadoxine-pyrimethamine and bed net use, and examined finger-prick blood for malaria parasites and hemoglobin concentration. In 4,712 women, we examined placental blood for malaria parasites and recorded the infant's birth weight. Peripheral and placental parasitemia prevalence declined from 23.5% to 5.0% and from 25.2% to 6.8% respectively. Smaller declines in prevalence of low birth weight and anemia were observed. Coverage of intermittent preventive treatment and bednets increased. Number of sulfadoxine-pyrimethamine doses received correlated inversely with placental parasitemia (Odds Ratio (95% CI): 0.79 (0.68, 0.91)), maternal anemia (0.81, (0.73, 0.90)) and low birth weight from 1997–2001 (0.63 (0.53, 0.75)), but not from 2002–2006. Bednet use protected from peripheral parasitemia (0.47, (0.37, 0.60)) and placental parasitemia (0.41, (0.31, 0.54)) and low birth weight (0.75 (0.59, 0.95)) but not anemia throughout the study. Compared to women without nets who did not receive 2-dose sulfadoxine-pyrimethamine, women using nets and receiving 2-dose sulfadoxine-pyrimethamine were less likely to have parasitemia or low birth weight babies. Women receiving 2-dose sulfadoxine-pyrimethamine alone had little evidence of protection whereas bednets alone gave intermediate protection.

Conclusions/Significance

Increased bednet coverage explains changes in parasitemia and birth weight among pregnant women better than sulfadoxine-pyrimethamine use. High bed net coverage, and sulfadoxine-pyrimethamine resistance, may be contributing to its apparent loss of effectiveness.

Intermittent preventive treatment of malaria in pregnancy (IPTp): do frequent antenatal care visits ensure access and compliance to IPTp in Ugandan rural communities?

The relationship between antenatal care (ANC) visits and coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), and barriers to IPTp-SP access were examined. Four hundred and fifty-three women who had given birth during the study period were interviewed using a semi-structured questionnaire. Of these, 425 (93.8%) attended ANC at least once, but only 90 (21.2%) made four or more visits. Primigravidae 25 (29.8%) were more likely than multigravidae 65 (17.6%) to make more than four visits (P=0.012). Only 237 (52.3%) women accessed two or more doses of IPT-SP, which increased with the number of ANC visits (X(2) for linear trends, 117.7, P<0.001). However, 131 (28.9%) women made two or more ANC visits, which were sufficient for them to access two or more doses of IPTp-SP, but they did not. The main reasons were: not given SP by the midwife for unknown reasons 36 (27.5%), SP stock-outs 34 (26%) and irregular ANC attendance 18 (13.7%). Frequent ANC visits do not seem to ensure access to IPTp-SP in the presence of other barriers. The Roll Back Malaria target of 80% of women accessing two or more doses of IPTp-SP by 2010 appears unachievable unless alternative channels of delivery are found.

Intermittent screening and treatment versus intermittent preventive treatment of malaria in pregnancy: user acceptability

BACKGROUND

Malaria in pregnancy is associated with increased risks of maternal and foetal complications. Currently, intermittent preventive treatment (IPT) of malaria during pregnancy with sulphadoxine-pyrimethamine (SP) is recommended by the WHO as part of a package of interventions also including insecticide-treated nets and effective case management. However, with increasing resistance to SP, the effectiveness of SP-IPT has been questioned. A randomized controlled trial (RCT) to investigate the relative efficacy of an alternative strategy of intermittent screening and treatment (IST), which involves a rapid diagnostic test for malaria at scheduled ANC visits and treatment of women only if positive, versus SP-IPT has been conducted in Ashanti region, Ghana. This paper reports on a complementary study investigating the acceptability of the different strategies to women enrolled in the trial.

METHODS

Data were collected through twelve focus group discussions with women selected at random from the different arms of the RCT, exploring their experiences and perceptions about antenatal care and their involvement in the trial. Content analysis was used to identify relevant themes to structure the results.

RESULTS

Five main themes emerged from participants' experiences of ANC and the RCT that would influence their acceptability of malaria prevention strategies during pregnancy: health benefits; drugs received; tests received; other services received; and health worker attitude. Their own health and that of their baby were strong motivations for attending ANC, and reported favourably as an outcome of being in the RCT. Women were not always clear on the biomedical function of drugs or blood tests but generally accepted them due to strong trust in the health staff. Home visits by staff and free ITNs as part of the trial were appreciated. Politeness and patience of health staff was a very strong positive factor.

CONCLUSIONS

Overall, both intermittent screening and treatment and intermittent preventive treatment appeared equally acceptable to pregnant women as strategies for the control of malaria in pregnancy. The women were more concerned about quality of services received, in particular the polite and patient attitude of health staff, and positive health implications for themselves and their babies than about the nature of the intervention.

Use of intermittent preventive treatment for malaria by pregnant women in Buea, Cameroon

We identified individual factors associated with IPT use, by comparing characteristics of pregnant women who use IPT to those who do not. A cross-sectional study was conducted in antenatal clinics in Buea, Cameroon, from December 2006 to December 2007. Information on factors: age, parity, gravidity, gestational age, level of education, use of insecticide treated nets (ITN), socioeconomic status and IPT use was collected through interview and filled in a questionnaire. Data was entered using EPIDATA version 3 and analysis done using STATA version 8.2. A total of 527 pregnant women were interviewed with a mean (+/-SD) age of 26.45+/-5.37 years. 69.71% of the pregnant women used at least two doses of IPT. Logistic regression revealed women with higher educational status were more likely to use IPT compared to those with lower educational status (OR=3.14, 95% CI=1.20-8.25, p=0.02). Meanwhile, multigravid women tend to use IPT less than their primigravid counterparts (OR=0.47, 95% CI=0.26-0.84, p=0.01). There was no evidence that maternal age, parity, marital status, gestational age, use of ITN and socioeconomic status were each associated to IPT use. In antenatal clinics in Buea, South Western Cameroon, educational status and gravidity are the key determinants of IPT use.

Intermittent preventive treatment of malaria in pregnancy (IPTp): participation of community-directed distributors of ivermectin for onchocerciasis improves IPTp access in Ugandan rural communities

Access and compliance to sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria in pregnancy (IPTp) when delivered by community-directed drug distributors (CDDs) of ivermectin for onchocerciasis control (intervention arm) and through delivery of SP-IPTp during antenatal care visit (control arm) was investigated in western Uganda. Every woman in both arms who delivered during the study period was interviewed on access and compliance to SP-IPT during her previous pregnancy. Overall, 926 women participated in the study (473 and 453 in the intervention and control arms, respectively). There were 467 (98.7%) women who accessed SP-IPTp at least once in the intervention arm and 401 (88.5%) in the control arm (P<0.001), and 424 (89.6%) women accessed at least two doses of SP-IPTp in the intervention arm compared with 237 (52.3%) in the control arm (P<0.001). The findings of this study suggest that a strategy using community resource people such as CDDs is an effective and feasible option to deliver SP-IPTp, because it uses existing community structures and volunteers, which creates easy access of the intervention, and should complement SP-IPTp access during antenatal care visit.

The potential role of private pharmacies in maternal iron supplementation in rural Tanzania

BACKGROUND

The reduction of maternal anemia is an agreed public health goal but one that has been very difficult to achieve. On Pemba Island, Tanzania, more than 90% of pregnant women are anemic, despite government efforts to identify and treat anemia during antenatal clinic visits.

OBJECTIVE

To investigate the potential of private pharmacies to be accessed for iron supplements for maternal anemia.

METHODS

We compared and contrasted the care given at private pharmacies and public clinics in terms of six characteristics: accuracy, affordability, availability, geographic accessibility, accommodation, and acceptability. We used data from in-depth interviews, surrogate customer encounters, governmental medicine record reviews, and participant observation.

RESULTS

The accuracy of health care workers' advice about the treatment of anemia at private pharmacies and government clinics was similar. Supplements purchased at pharmacies were sometimes cheaper than the free supplements from the government, when the costs of transportation and time spent at the clinic were considered. Supplements at private pharmacies were always available, whereas the supply at government clinics was erratic. Private pharmacies were physically closer, socially less distant, and more accommodating than government clinics. Both clinics and private pharmacies were socially acceptable to pregnant women, although government clinics were typically not attended until later in pregnancy.

CONCLUSIONS

The private sector probably has untapped potential for the reduction of maternal anemia in settings in which public health services fall short. Private pharmacies can contribute to the reduction of maternal anemia on Pemba Island and beyond.

Community-based distribution of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy improved coverage but reduced antenatal attendance in southern Malawi

OBJECTIVE

To evaluate the impact of a 2-year programme for community-based delivery of sulfadoxine-pyrimethamine (SP) on intermittent preventive treatment during pregnancy coverage, antenatal clinic attendance and pregnancy outcome.

METHODS

Fourteen intervention and 12 control villages in the catchment areas of Chikwawa and Ngabu Government Hospitals, southern Malawi, were selected. Village-based community health workers were trained in information, education and counselling on malaria control in pregnancy and the importance of attending antenatal clinics and promoted these messages to pregnant women. In the intervention group community health workers also distributed SP to pregnant women.

RESULTS

In the control area, coverage of intermittent preventive treatment during pregnancy (>2 doses) was low before (44.1%) and during the intervention (46.1%). In the intervention area, coverage increased from 41.5% to 82.9% (P < 0.01). Antenatal clinic attendance (>2 visits) was maintained in control villages at above 90%, but fell in intervention villages from 87.3% to 51.5% (P < 0.01). Post-natal malaria parasitaemia prevalence fell in women from both study areas during the intervention phase (P < 0.05). Increasing the coverage of intermittent preventive treatment during pregnancy to >40% did not significantly improve maternal haemoglobin or reduce low birthweight prevalence.

CONCLUSIONS

Better coverage of community-based intermittent preventive treatment during pregnancy can lower attendance at antenatal clinics; thus its effect on pregnancy outcome and antenatal attendance need to be monitored.

Prospects, achievements, challenges and opportunities for scaling-up malaria chemoprevention in pregnancy in Tanzania: the perspective of national level officers

OBJECTIVES

To describe the prospects, achievements, challenges and opportunities for implementing intermittent preventive treatment for malaria in pregnancy (IPTp) in Tanzania in light of national antenatal care (ANC) guidelines and ability of service providers to comply with them.

METHODS

In-depth interviews were made with national level malaria control officers in 2006 and 2007. Data was analysed manually using a qualitative content analysis approach.

RESULTS

IPTp has been under implementation countrywide since 2001 and the 2005 evaluation report showed increased coverage of women taking two doses of IPTp from 29% to 65% between 2001 and 2007. This achievement was acknowledged, however, several challenges were noted including (i) the national antenatal care (ANC) guidelines emphasizing two IPTp doses during a woman's pregnancy, while other agencies operating at district level were recommending three doses, this confuses frontline health workers (HWs); (ii) focused ANC guidelines have been revised, but printing and distribution to districts has often been delayed; (iii) reports from district management teams demonstrate constraints related to women's late booking, understaffing, inadequate skills of most HWs and their poor motivation. Other problems were unreliable supply of free SP at private clinics, clean and safe water shortage at many government ANC clinics limiting direct observation treatment and occasionally pregnant women asked to pay for ANC services. Finally, supervision of peripheral health facilities has been inadequate and national guidelines on district budgeting for health services have been inflexible. IPTp coverage is generally low partly because IPTp is not systematically enforced like programmes on immunization, tuberculosis, leprosy and other infectious diseases. Necessary concerted efforts towards fostering uptake and coverage of two IPTp doses were emphasized by the national level officers, who called for further action including operational health systems research to understand challenges and suggest ways forward for effective implementation and high coverage of IPTp.

CONCLUSION

The benefit of IPTp is appreciated by national level officers who are encouraged by trends in the coverage of IPTp doses. However, their appeal for concerted efforts towards IPTp scaling-up through rectifying the systemic constraints and operational research is important and supported by suggestions by other authors.

Treatment and prevention of malaria in pregnancy and newborn

Pregnant women are at increased risk for malaria infection. Although important advances have been made in the last years, the mechanisms that explain the increased susceptibility are not yet fully understood. Malaria infection in pregnancy is associated with maternal and fetal morbidity and mortality. The severity of the disease depends on the level of pre-pregnancy acquired immunity against malaria, and the consequences of infection are more severe in non-immune women. In highly endemic areas, the frequency and severity of the infection is higher in primigravida and decreases with increasing parity. In non-immune women, the risk is similar across the parity and malaria may be an important direct cause of maternal mortality. Malaria infection during pregnancy has important negative effects on infant's health, causing intrauterine growth retardation and prematurity or directly through congenital infection. In this paper, we review the pathology, diagnosis, and current recommendations for treatment and prevention of malaria in the pregnant woman and her infant.

Timing of intermittent preventive treatment for malaria during pregnancy and the implications of current policy on early uptake in north-east Tanzania

Background

Intermittent preventive treatment (IPTp) is efficacious in reducing the adverse outcomes associated with pregnancy-associated malaria, however uptake of the recommended two doses is low in Tanzania, and little is known of the timepoint during pregnancy at which it is delivered. This study investigated the timing of delivery of IPTp to pregnant women attending antenatal clinics (ANC), and the potential determinants of timely uptake.

Methods

Structured interviews were conducted with staff and pregnant women at antenatal clinics in northeast Tanzania, and antenatal consultations were observed. Facility-based and individual factors were analysed for any correlation with timing of IPTp uptake.

Results

Almost half the women interviewed first attended ANC during or before the fourth month of gestation, however 86% of these early attendees did not receive IPTp on their first visit. The timing of IPTp delivery complied closely with the national guidelines which stipulate giving the first dose at 20–24 weeks gestation. Uptake of at least one dose of IPTp among women who had reached this gestation age was 67%, although this varied considerably between clinics. At one facility, IPTp was not delivered because SP was out of stock.

Conclusion

Early uptake of IPTp was found to be hampered by factors external to health worker performance or women's individual preferences. These include insufficient drug stocks and an apparent lack of information to health workers on the reasoning for continued use of SP for IPTp when it has been replaced as a first-line treatment. In addition, an unexpectedly high proportion of women attend antenatal clinics before 20 weeks of pregnancy. While current policy denies the use of IPTp at this time, there is emerging, but incomplete, evidence that malaria in early pregnancy may contribute considerably to the burden of pregnancy-related malaria. Current policy may thus result in a missed opportunity for maximising the benefit of this intervention, and efforts to encourage earlier attendance at ANC alone are unlikely to improve uptake of IPTp. More evidence is needed to weigh the benefits of early IPTp use against theoretical risks of antifolate drugs in early pregnancy.

Use of antenatal care, maternity services, intermittent presumptive treatment and insecticide treated bed nets by pregnant women in Luwero district, Uganda

Background

To reduce the intolerable burden of malaria in pregnancy, the Ministry of Health in Uganda improved the antenatal care package by including a strong commitment to increase distribution of insecticide-treated nets (ITNs) and introduction of intermittent preventive treatment with sulphadoxine-pyrimethamine for pregnant women (IPTp-SP) as a national policy in 2000. This study assessed uptake of both ITNs and IPTp-SP by pregnant women as well as antenatal and maternity care use with the aim of optimizing their delivery.

Methods

769 post-partum women were recruited from a rural area of central Uganda with perennial malaria transmission through a cross-sectional, community-based household survey in May 2005.

Results

Of the 769 women interviewed, antenatal clinic (ANC) attendance was high (94.4%); 417 (57.7%) visiting initially during the 2^nd trimester, 242 (33.5%) during the 3^rd trimester and 266 (37.1%) reporting ≥ 4 ANC visits. About 537 (71%) and 272 (35.8%) received one or ≥ 2 IPTp-SP doses respectively. Only 85 (15.8%) received the first dose of IPTp-SP in the 3^rd trimester. ITNs were used by 239 (31.3%) of women during pregnancy and 314 (40.8%) delivered their most recent pregnancy outside a health facility. Post-partum women who lacked post-primary education were more likely not to have attended four or more ANC visits (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.2–9.3).

Conclusion

These findings illustrate the need to strengthen capacity of the district to further improve antenatal care and maternity services utilization and IPTp-SP uptake. More specific and effective community health strategies to improve effective ANC, maternity services utilization and IPTp-SP uptake in rural communities should be undertaken.

[Comparative impact of three malaria preventive regimens during pregnancy on maternal anemia due to malaria in Burkina Faso]

OBJECTIVES

The main objective of this study was to compare the efficacy of three regimens of malaria prevention during pregnancy for the reduction of anemia between the first and third antenatal consultations. The first treatment arm was the classical weekly chemoprophylaxis with chloroquine; the other two were the intermittent preventive treatment using either three doses of chloroquine or sulfadoxine-pyrimethamine.

DESIGN

We conducted an open, randomized, three-arm study in a rural district of Burkina Faso. A cohort was constituted by 648 pregnant women of any parity.

RESULTS

The hemoglobin gain was more significant with the intermittent preventive treatment using sulfadoxine-pyrimethamine compared to the other treatment arms. The hemoglobin increased from 10.3g/dl (at the first antenatal consultation) to 11.4 g/dl (at the third antenatal consultation). In the three arms of treatment, the chemoprophylaxis reduced the prevalence of moderate anemia and severe anemia. The reduction of moderate anemia was more substantial in the sulfadoxine-pyrimethamine arm (65.6 to 36.7%) at second antenatal consultation (p=0.069) and third antenatal consultation (p=0.014). Conversely, in the two chloroquine arms, there was no significant reduction either at second antenatal consultation (p=0.72) or third antenatal consultation (p=0.55). The prevalence of peripheral parasitemia decreased in all treatment groups. However, it was significantly higher in the sulfadoxine-pyrimethamine group (44.3%).

CONCLUSIONS

Intermittent preventive treatment with three doses of sulfadoxine-pyrimethamine is a more effective strategy to prevent maternal anemia during pregnancy in Burkina Faso.

Implementing Intermittent Preventive Treatment for Malaria in Pregnancy: Review of Prospects, Achievements, Challenges and Agenda for Research

INTRODUCTION: Implementing Intermittent Preventive Treatment for malaria in Pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) through antenatal care (ANC) clinics is recommended for malaria endemic countries. Vast biomedical literature on malaria prevention focuses more on the epidemiological and cost-effectiveness analyses of the randomised controlled trials carried out in selected geographical settings. Such studies fail to elucidate the economic, psychosocial, managerial, organization and other contextual systemic factors influencing the operational effectiveness, compliance and coverage of the recommended interventions. OBJECTIVE: To review literature on policy advances, achievements, constraints and challenges to malaria IPTp implementation, emphasising on its operational feasibility in the context of health-care financing, provision and uptake, resource constraints and psychosocial factors in Africa. RESULTS: The importance of IPTp in preventing unnecessary anaemia, morbidity and mortality in pregnancy and improving childbirth outcomes is highly acknowledged, although the following factors appear to be the main constraints to IPTp service delivery and uptake: cost of accessing ANC; myths and other discriminatory socio-cultural values on pregnancy; target users, perceptions and attitudes towards SP, malaria, and quality of ANC; supply and cost of SP at health facilities; understaffing and demoralised staff; ambiguity and impracticability of user-fee exemption policy guidelines on essential ANC services; implementing IPTp, bednets, HIV and syphilis screening programmes in the same clinic settings; and reports on increasing parasite resistant to SP. However, the noted increase in the coverage of the delivery of IPTp doses in several countries justify that IPTp implementation is possible and better than not. CONCLUSION: IPTp for malaria is implemented in constrained conditions in Africa. This is a challenge for higher coverage of at least two doses and attainment of the Abuja targets. Yet, there are opportunities for addressing the existing challenges, and one of the useful options is the evaluation of the acceptability and viability of the existing intervention guidelines.

A community-based delivery system of intermittent preventive treatment of malaria in pregnancy and its effect on use of essential maternity care at health units in Uganda

Community delivery of intermittent preventive treatment of malaria in pregnancy (IPTp) is one potential option that could mitigate malaria in pregnancy. However, there is concern that this approach may lead to complacency among women with low access to essential care at health units. A non-randomised community trial assessed a new delivery system of IPTp through traditional birth attendants, drug shop vendors, community reproductive health workers and adolescent peer mobilisers (the intervention) compared with IPTp at health units (control). The study enrolled a total of 2081 pregnant women with the new approaches. Data on care-seeking practices before and after the intervention were collected. The majority of women with the new approaches accessed IPTp in the second trimester and adhered to two doses of sulfadoxine/pyrimethamine (SP) (1404/2081; 67.5%). Antenatal care (four recommended visits) increased from 3.4% (27/805) to 56.8% (558/983) (P<0.001). The proportion of women delivering at health units increased from 34.3% (276/805) to 41.5% (434/1045) (P=0.02), whilst the proportion of women seeking care for malaria at health units increased from 16.7% (128/767) to 36.0% (146/405) (P<0.001). Similarly, use of insecticide-treated nets increased from 7.7% (160/2081) to 22.4% (236/1055) (P<0.001). In conclusion, the community-based system was effective in delivering IPTp, whilst women still accessed and benefited from essential care at health units.

The effect of health care worker training on the use of intermittent preventive treatment for malaria in pregnancy in rural western Kenya

BACKGROUND

In 1998, Kenya adopted intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine (SP) for malaria prevention during pregnancy. We conducted a survey in 2002 among women who had recently delivered in the rural neighbouring areas Asembo and Gem and reported coverage of 19% of at least one dose and 7% of two or more doses of SP. Health care workers (HCW) in Asembo were retrained on IPTp in 2003.

OBJECTIVES

To evaluate if IPTp coverage increased and if the training in Asembo led to better coverage than in Gem, and to identify barriers to the effective implementation of IPTp.

METHODS

Community-based cross-sectional survey among a simple random sample of women who had recently delivered in April 2005, interviews with HCW of antenatal clinics (ANC) in Asembo and Gem.

RESULTS

Of the 724 women interviewed, 626 (86.5%) attended the ANC once and 516 (71.3%) attended two or more times. Overall IPTp coverage was 41% for at least one dose, and 21% for at least two doses of SP. In Asembo, coverage increased from 19% in 2002 to 61% in 2005 for at least one dose and from 7% to 17% for two doses of SP. In Gem, coverage increased from 17% to 28% and 7% to 11%, respectively. Interviews of HCW in both Asembo and Gem revealed confusion about appropriate timing, and lack of direct observation of IPTp.

CONCLUSION

Training of HCW and use of simplified IPTp messages may be a key strategy in achieving Roll Back Malaria targets for malaria prevention in pregnancy in Kenya.

Safety and toxicity of sulfadoxine/pyrimethamine: implications for malaria prevention in pregnancy using intermittent preventive treatment

Plasmodium falciparum infection during pregnancy is strongly associated with maternal anaemia and low birth weight, contributing to substantial morbidity and mortality in sub-Saharan Africa. Intermittent preventive treatment in pregnancy with sulfadoxine/pyrimethamine (IPTp-SP) has been one of the most effective approaches to reduce the burden of malaria during pregnancy in Africa. IPTp-SP is based on administering >or=2 treatment doses of sulfadoxine/pyrimethamine to pregnant women at predefined intervals after quickening (around 18-20 weeks). Randomised, controlled trials have demonstrated decreased rates of maternal anaemia and low birth weight with this approach. The WHO currently recommends IPTp-SP in malaria-endemic areas of sub-Saharan Africa. However, implementation has been suboptimal in part because of concerns of potential drug toxicities. This review evaluates the toxicity data of sulfadoxine/pyrimethamine, including severe cutaneous adverse reactions, teratogenicity and alterations in bilirubin metabolism. Weekly sulfadoxine/pyrimethamine prophylaxis is associated with rare but potentially fatal cutaneous reactions. Fortunately, sulfadoxine/pyrimethamine use in IPTp programmes in Africa, with 2-4 treatment doses over 6 months, has been well tolerated in multiple IPTp trials. However, sulfadoxine/pyrimethamine should not be administered concurrently with cotrimoxazole given their redundant mechanisms of action and synergistic worsening of adverse drug reactions. Therefore, HIV-infected pregnant women in malaria endemic areas who are already receiving cotrimoxazole prophylaxis should not also receive IPTp-SP. Although folate antagonist use in the first trimester is associated with neural tube defects, large case-control studies have demonstrated that sulfadoxine/pyrimethamine administered as IPTp (exclusively in the second and third trimesters and after organogenesis) does not result in an increased risk of teratogenesis. Folic acid supplementation is recommended for all pregnant women to reduce the rate of congenital anomalies but high doses of folic acid (5 mg/day) may interfere with the antimalarial efficacy of sulfadoxine/pyrimethamine. However, the recommended standard dose of folic acid supplementation (0.4 mg/day) does not affect antimalarial efficacy and may provide the optimal balance to prevent neural tube defects and maintain the effectiveness of IPTp-SP. No clinical association between sulfadoxine/pyrimethamine use and kernicterus has been reported despite the extensive use of sulfadoxine/pyrimethamine and related compounds to treat maternal malaria and congenital toxoplasmosis in near-term pregnant women and newborns. Although few drugs in pregnancy can be considered completely safe, sulfadoxine/pyrimethamine - when delivered as IPTp - has a favourable safety profile. Improved pharmacovigilance programmes throughout Africa are now needed to confirm its safety as access to IPTp-SP increases. Given the documented benefits of IPTp-SP in malaria endemic areas of Africa, access to this treatment for pregnant women should continue to expand.

Geographical disparities in core population coverage indicators for roll back malaria in Malawi

BACKGROUND

Implementation of known effective interventions would necessitate the reduction of malaria burden by half by the year 2010. Identifying geographical disparities of coverage of these interventions at small area level is useful to inform where greatest scaling-up efforts should be concentrated. They also provide baseline data against which future scaling-up of interventions can be compared. However, population data are not always available at local level. This study applied spatial smoothing methods to generate maps at subdistrict level in Malawi to serve such purposes.

METHODS

Data for the following responses from the 2000 Malawi Demographic and Health Survey (DHS) were aggregated at subdistrict level: (1) households possessing at least one bednet; (2) children under 5 years who slept under a bednet the night before the survey; (3) bednets retreated with insecticide within past 6-12 months preceding the survey; (4) children under 5 who had fever two weeks before the survey and received treatment within 24 hours from the onset of fever; and (5) women who received intermittent preventive treatment of malaria during their last pregnancy. Each response was geographically smoothed at subdistrict level by applying conditional autoregressive models using Markov Chain Monte Carlo simulation techniques.

RESULTS

The underlying geographical patterns of coverage of indicators were more clear in the smoothed maps than in the original unsmoothed maps, with relatively high coverage in urban areas than in rural areas for all indicators. The percentage of households possessing at least one bednet was 19% (95% credible interval (CI): 16-21%), with 9% (95% CI: 7-11%) of children sleeping under a net, while 18% (95% CI: 16-19%) of households had retreated their nets within past 12 months prior to the survey. The northern region and lakeshore areas had high bednet coverage, but low usage and re-treatment rates. Coverage rate of children who received antimalarial treatment within 24 hours after onset of fever was consistently low for most parts of the country, with mean coverage of 4.8% (95% CI: 4.5-5.0%). About 48% (95% CI: 47-50%) of women received antimalarial prophylaxis during their pregnancy, with highest rates in the southern and northern areas.

CONCLUSION

The striking geographical patterns, for example between predominantly urban and rural areas, may reflect spatial differences in provider compliance or coverage, and can partly be explained by socio-economic and cultural differences. The wide gap between high bed net coverage and low retreatment rates may reflect variation in perceptions about malaria, which may be addressed by implementing information, education and communication campaigns or introducing long lasting insecticide nets. Our results demonstrate that DHS data, with appropriate methodology, can provide acceptable estimates at sub-national level for monitoring and evaluation of malaria control goals.

Intermittent preventive treatment of malaria in pregnancy: a community-based delivery system and its effect on parasitemia, anemia and low birth weight in Uganda

OBJECTIVE

The main objective of the study was to assess the impact of a community-based delivery system of intermittent preventive treatment (IPT) for malaria in pregnancy with sulfadoxine-pyrimethamine (SP) on access, parasitemia, anemia and low birth weight as primary outcome measures.

METHODS

A study was designed to test the community-based delivery system of IPT through traditional birth attendants (TBAs), drug-shop vendors (DSVs), community reproductive health workers (CRHWs) and adolescent peer mobilizers (APMs), and to compare these with IPT at health units in an area of high malaria transmission - Mukono District, Uganda.

RESULTS

Two thousand seven hundred and eighty-five pregnant women participated in the study. The majority of the women (92.4%) at the community-based approaches received their first dose of IPT during their second trimester compared to 76.1% at health units (p<0.0001). At both health units and the community-based approaches, IPT increased mean hemoglobin by 6.7% (p<0.0001) for all parities and by 10.2% among primigravidae. IPT reduced the prevalence of severe anemia from 5.7% to 3.1% (p<0.04). The prevalence of parasitemia was reduced from 24.5% to 16.1% (p<0.001), and parasite density reduced significantly (p<0.02) after the first dose and remained stable with the second dose. Overall the proportion of low birth weight was 6.3% (8.3% at health units versus 6.0% at the community-based approaches, p<0.03) highlighting the importance of access and adherence to IPT. This intervention was acceptable to 89.6% of the women at the community-based approaches intending to use IPT in the future, while 48.1% of them had recommended it to other women.

CONCLUSIONS

The community-based approaches increased access and adherence to IPT with an effect on anemia, severe anemia, parasitemia and low birth weight. However the reduced effect of IPT on parasitemia points to drug resistance with SP and this requires further evaluation; research into the identification of other more efficacious drugs for malaria prevention in pregnancy is also required.

Intermittent preventive treatment of malaria in pregnancy: the effect of new delivery approaches on access and compliance rates in Uganda

OBJECTIVE

To assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilizers can administer intermittent preventive treatment (IPT) with sulfadoxine-pyremethamine to pregnant women, and reach those most at risk of malaria and increase access and compliance to it.

METHODS

The study was designed to assess new approaches of delivering IPT through these groups and compare it with IPT at health units. The primary outcome measures were: the proportion of adolescents and primigravidae accessed; gestational age at recruitment and the proportion of women who completed two doses of sulfadoxine-pyremethamine.

RESULTS

Two thousand seven hundred and eighty-five pregnant women (78% of those in the study area) participated. With new approaches, 92.4% of the women received IPT during the second trimester as recommended by the policy, vs. 76.1% at health units, P < 0.0001. Of the women who received two doses of sulfadoxine-pyremethamine, 39.9% were at health units (control) vs. 67.5% through new approaches (P < 0.0001). Women using the new approaches also accessed IPT early: the mean gestational age when receiving the first dose of sulfadoxine-pyremethamine was 21.0 weeks vs. 23.1 weeks at health units (P < 0.0001). However, the health units were used by a higher proportion of primigravidae (23.6% vs. 20.0%, P < 0.04), and this was also the case for adolescents (28.4% vs. 25.0%, P < 0.03). This intervention was acceptable with 89.1% of the women at the new approaches intending to use IPT in future.

CONCLUSIONS

The new approaches increased access to and compliance with IPT. We recommend a review of the policy to allow the provision of IPT through the new approaches.

Malaria in pregnancy: what can the social sciences contribute?

Building on existing knowledge from social science work on malaria, the authors propose two models for studying social science aspects of malaria in pregnancy.

Emergency obstetric care as the priority intervention to reduce maternal mortality in Uganda

PURPOSE

We conducted a survey to determine availability of emergency obstetric care (EmOC) to provide baseline data for monitoring provision of obstetric care services in Uganda.

METHODS

The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions. Following this, performance improvement process was implemented in 20 district hospitals to scale-up EmOC services.

FINDINGS

A maternal mortality ratio (MMR) of 671/100,000 live births was recorded. Hemorrhage, 42.2%, was the leading direct cause of maternal deaths, and malaria accounted for 65.5% of the indirect causes. Among the obstetric complications, abortion accounted for 38.9% of direct and malaria 87.4% of indirect causes. Removal of retained products (OR 3.3, P<0.002), assisted vaginal delivery (OR 3.3, P<0.001) and blood transfusion (OR 13.7, P<0.001) were the missing signal functions contributing to maternal deaths. Most health facilities expected to offer basic EmOC, 349 (97.2%) were not offering them. Using the performance improvement process, availability of EmOC in the 20 hospitals improved significantly.

CONCLUSION

An integrated programming approach aiming at increasing access to EmOC, malaria treatment and prevention services could reduce maternal mortality in Uganda.

Intermittent preventive treatment of malaria in pregnancy: evaluation of a new delivery approach and the policy implications for malaria control in Uganda

The impact of intermittent preventive treatment (IPT) on malaria in pregnancy is well known. In countries where this policy is implemented, poor access and low compliance to this intervention has been widely reported. A study was designed to assess a new approach to deliver IPT to pregnant women through traditional birth attendants (TBAs), drug-shop vendors (DSVs), community reproductive health workers (CRHWs) and adolescent peer mobilisers (APMs); and compared this approach with IPT at health units. We evaluated this approach to assess user perceptions, its acceptability and sustainability. Results show that the new approach increased access and compliance to IPT. Mean gestational age at first dose of IPT was 21.0 weeks with the community approaches versus 23.1 weeks at health units, P>0.0001. Health units accessed a high proportion of adolescents, 28.4%, versus 25.0% at the new approaches, P<0.03; most primigravidae, 23.6%, versus 20.0% at the new approaches, P<0.04. The proportion of women who received two doses of SP was 67.5.2% with the new approaches versus 39.9% at health units, P<0.0001. The new approach was associated with a three-fold increase in use of ITNs from 8.8% at baseline to 23.4%. The factors that most influenced acceptability and use of IPT were trusted and easy accessible resource persons, their ability to make home visits especially with CRHWs and APMs; the support of spouses. Another factor was the high awareness on dangers of malaria in pregnancy and the benefits of IPT created by the resource persons. The women perceived better health using the first dose of sulphadoxine-pyremethamine (SP) and this compelled them to go for the second dose. IPT with this approach was highly acceptable with 89.1% of women at the new approaches intending to use it for the next pregnancy, while 48.0% of them had recommended it to other women. We suggest a review of the current policy on malaria prevention in pregnancy to allow provision of IPT through community structures that are feasible, practical and acceptable.