Sulfadoxine-pyrimethamine-based intermittent preventive treatment, bed net use, and antenatal care during pregnancy: demographic trends and impact on the health of newborns in the Kassena Nankana District, northeastern Ghana

Malaria in pregnancy control and pregnancy outcomes: a decade's overview using Ghana's DHIMS II data

Background

Malaria in pregnancy control interventions have been implemented through antenatal care services for more than 2 decades in Ghana. The uptake of these interventions has seen steady improvement over the years. This has occurred within the context of decreasing global trends of malaria infection confirmed by decreasing malaria in pregnancy prevalence in Ghana. However, not much is known about how these improvements in interventions uptake and reduction in malaria infection prevalence have impacted pregnancy outcomes in the country. This study aimed at describing trends of maternal anaemia and low birth weight prevalence and uptake of malaria in pregnancy control interventions over the last decade using data from Ghana’s District Health Information Management System (DHIMS II).

Methods

Data from Ghana’s DHIMS II on variables of interest covering the period 2012 to 2021 was analysed descriptively using Microsoft Excel 365. Results were computed as averages and percentages and presented in tables and graphs.

Results

The prevalence of maternal anaemia at booking and at term and low birth weight increased marginally from 31.0%, 25.5% and 8.5% in 2012 to 36.6%, 31.9% and 9.5% in 2021 respectively. Severe anaemia prevalence at booking and at term remained under 2% over the study period. Women making at least 4 ANC visits, receiving at least 3 doses of intermittent preventive treatment of malaria and an insecticide-treated net increased from 77.0%, 41.4% and 4.1% in 2012 to 82%, 55.0% and 93.3% in 2021, respectively. Malaria test positivity rate reduced from 54.0% to 34.3% between 2014 and 2021 while women receiving iron and folate supplementation for 3 and 6 months rose from 43.0% and 25.5% to 89.7% and 61.8%, respectively between 2017 and 2021.

Conclusion

Maternal anaemia and low birth weight prevalence showed marginal upward trends over the last decade despite reduced malaria infection rate and improved uptake of malaria in pregnancy control interventions. There is room for improvement in current intervention implementation levels but the complex and multi-factorial aetiologies of maternal anaemia and low birth weight need urgent investigation and quantification to inform policy and practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04331-2.

OUP accepted manuscript

Background

Malaria in pregnancy remains a significant cause of morbidity and mortality, affecting the highly endemic countries of sub-Saharan Africa (SSA). Insecticide-treated nets (ITNs) are effective for malaria prevention. However, poor adherence in SSA remains a challenge.

Methods

We conducted a standard questionnaire survey among 710 pregnant women from 37 primary care clinics in the Upper West Region of Ghana from January through May 2019. Using a sequential explanatory design, we integrated the survey data from six focus group discussions with pregnant women.

Results

While 67% of women had some general knowledge about malaria prevention, only 19% knew the specific risks in pregnancy. Determinants of ITN use included ITN ownership (odds ratio [OR] 2.4 [95% confidence interval {CI} 1.3 to 4.4]), good maternal knowledge of the risks of malaria in pregnancy (OR 2.4 [95% CI 1.3 to 4.3]) and more antenatal care (ANC) contacts (OR 1.3 [95% CI 1.0 to 1.5)]. Focus group discussions showed that non-use of ITNs resulted from inappropriate hanging infrastructure, a preference for other malaria prevention alternatives, allergy and heat.

Conclusions

Specific maternal knowledge of malaria risks in pregnancy was low and influenced the regular use of ITNs. Community and ANC-based malaria interventions should prioritize increasing knowledge of the specific risks of malaria.

Uptake challenges of intermittent preventive malaria therapy among pregnant women and their health care providers in the Upper West Region of Ghana: A mixed-methods study

BACKGROUND

Malaria in pregnancy remains a major public health problem in endemic countries, especially in sub-Saharan Africa (SSA). Existing interventions such as intermittent preventive therapy in pregnancy (IPTp) using sulfadoxine-pyrimethamine (SP) are effective against placental malaria. However, low uptake of this intervention is a challenge in SSA. This study assessed factors affecting IPTp-SP uptake among pregnant women as well as their health care providers, including health system-related factors.

METHODS

From November 2018 until May 2019 a mixed-methods study was conducted in one urban and one rural district of the Upper West Region of Ghana. A multi-stage sampling technique was used to recruit 740 3rd trimester pregnant women and 74 health service providers from 37 antenatal care (ANC) facilities. Quantitative data was collected through a standard questionnaire from pregnant women and ANC service providers. Three focus group discussions (FGDs) were conducted in each district with pregnant women who had defaulted on their IPTp doses to collect information about the challenges in accessing IPTp-SP. The primary outcome was the uptake of IPTp-SP during antenatal care visits. In addition, the health care provider and health system-related factors on the administration of SP were assessed, as well as details of folic acid (FA) supplementation. Data were analysed using descriptive statistics and Poisson regression.

RESULTS

Responses from 697 pregnant women were analysed. Of these, 184 (26.4%) had taken the third dose of SP (SP3) in line with international guidelines. IPTp-SP uptake was low and significantly associated with the number of maternal ANC contacts and their gestational age at 1st ANC contact. Most pregnant women were regularly co-administered SP together with 5 mg of FA, in contrast to the international recommendations of 0.4 mg FA. The main challenges to IPTp-SP uptake were missed ANC contacts, knowledge deficiencies among pregnant women of the importance of IPTp, and frequent drug stock outs, which was confirmed both from the ANC providers as well as from the pregnant women. Further challenges reported were provider negligence/absenteeism, adverse drug reactions, and mobile residency of pregnant women.

CONCLUSIONS

The uptake of IPTp-SP in the study area is still very low, which is partly explained by frequent drug stock outs at health facilities, staff absenteeism, knowledge deficiencies among pregnant women, and missed ANC contacts. The high dosing of co-administered FA is against international recommendations. These observations need to be addressed by the national public health authorities.

Intermittent Preventive Treatment of Malaria in Pregnancy: Assessment of the Sulfadoxine-Pyrimethamine Three-Dose Policy on Birth Outcomes in Rural Northern Ghana

BACKGROUND

Intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) decreases placental parasitaemia and improves birth outcomes. Currently, WHO recommends three or more doses of SP given during antenatal care (ANC), spaced one month apart after 16 weeks of gestation till delivery. This study determined the level of uptake of SP and its association with birth outcomes in rural northern Ghana.

METHODS

A survey was carried out at the War Memorial Hospital in Navrongo, Ghana, among mothers who had delivered within ten weeks and were seeking postnatal care. Data on time of first ANC, number of visits, receipt of IPTp-SP, and birth outcomes were extracted from the antenatal records of 254 mothers. Mothers were interviewed on their background characteristics and obstetric history. Chi-square tests and logistic regression were carried out to determine association between antenatal indicators, uptake of IPTp-SP, and birth outcomes using Stata version 13.

RESULTS

Uptake of three-five doses of SP was IPT3 =76.4%, IPT4 =37.3%, and IPT5 = 16.0%. Receipt of first dose of SP at 16, 17-24, and 25-36 weeks of gestation was 16.9%, 56.7%, and 26.4%, respectively. Taking the first dose of SP during the second trimester allowed for taking ≥3 doses of SP compared to taking the first dose during the third trimester (χ2 = 60.1, p<0.001). Women who made ≥4 visits were more likely to receive ≥3 doses of SP compared to those who made <4 visits (χ2 = 87.6, p<0.001). Women who received ≥ 3 doses of SP were more likely (OR = 3.3; 95% CI: 1.69-6.33) to give birth at term and also have normal weight babies (OR =4.0; 95% CI: 1.98-8.06).

CONCLUSION

Uptake of three or more doses of SP contributed to improved pregnancy outcomes. Increased efforts towards improving early ANC attendance could increase uptake of SP and improve pregnancy outcomes.

A New Look at Care in Pregnancy: Simple, Effective Interventions for Neglected Populations

BACKGROUND

Although this is beginning to change, the content of antenatal care has been relatively neglected in safe-motherhood program efforts. This appears in part to be due to an unwarranted belief that interventions over this period have far less impact than those provided around the time of birth. In this par, we review available evidence for 21 interventions potentially deliverable during pregnancy at high coverage to neglected populations in low income countries, with regard to effectiveness in reducing risk of: maternal mortality, newborn mortality, stillbirth, prematurity and intrauterine growth restriction. Selection was restricted to interventions that can be provided by non-professional health auxiliaries and not requiring laboratory support.

METHODS

In this narrative review, we included relevant Cochrane and other systematic reviews and did comprehensive bibliographic searches. Inclusion criteria varied by intervention; where available randomized controlled trial evidence was insufficient, observational study evidence was considered. For each intervention we focused on overall contribution to our outcomes of interest, across varying epidemiologies.

RESULTS

In the aggregate, achieving high effective coverage for this set of interventions would very substantially reduce risk for our outcomes of interest and reduce outcome inequities. Certain specific interventions, if pushed to high coverage have significant potential impact across many settings. For example, reliable detection of pre-eclampsia followed by timely delivery could prevent up to ¼ of newborn and stillbirth deaths and over 90% of maternal eclampsia/pre-eclampsia deaths. Other interventions have potent effects in specific settings: in areas of high P falciparum burden, systematic use of insecticide-treated nets and/or intermittent presumptive therapy in pregnancy could reduce maternal mortality by up to 10%, newborn mortality by up to 20%, and stillbirths by up to 25-30%. Behavioral interventions targeting practices at birth and in the hours that follow can have substantial impact in settings where many births happen at home: in such circumstances early initiation of breastfeeding can reduce risk of newborn death by up to 20%; good thermal care practices can reduce mortality risk by a similar order of magnitude.

CONCLUSIONS

Simple interventions delivered during pregnancy have considerable potential impact on important mortality outcomes. More programmatic effort is warranted to ensure high effective coverage.

Decrease of microscopic Plasmodium falciparum infection prevalence during pregnancy following IPTp-SP implementation in urban cities of Gabon

BACKGROUND

Six years after the implementation of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) in Gabon, its impact on placental malaria and pregnancy outcomes remains unknown.

METHODS

Age, gestational data, use of IPTp-SP and birth weight were recorded during a hospital-based cross-sectional survey performed in 2011 in 387 women at the end of pregnancy.

RESULTS

Malaria prevalence was 6.7 and 5.3% in peripheral and placental blood respectively. Overall, 59.0% women took at least two IPTp-SP doses which was associated with 50% reduction of Plasmodium; (P.) falciparum infection in primigravidae. Previous malaria treatment was a risk factor for peripheral P. falciparum infection, while uptake of IPTp-SP was associated with reduced parasitaemia. Anaemia prevalence was 38.0%, low birth weight and prematurity rates were 6.0 and 12.0% respectively. Young age was associated with a higher frequency of malaria, anaemia, low birth weight and preterm delivery (p<0.01). Birth weight significantly rose with increasing age (p<0.01), parity (p=0.03) and number of SP doses (p=0.03). A birth weight reduction of 230 g in case of peripheral parasitaemia (p=0.02) and of 210 g with placental parasitaemia (p=0.13) was observed.

CONCLUSIONS

Microscopic P. falciparum prevalence during pregnancy significantly declined between 2005 and 2011, following IPTp-SP implementation in Gabon. Young women and paucigravidae remain the most susceptible to malaria and associated outcomes.

Ownership and use of insecticide-treated nets during pregnancy in sub-Saharan Africa: a review

Over the past decade, significant gains have been made in the implementation of malaria prevention measures in pregnancy in sub-Saharan Africa, including the distribution of insecticide-treated nets (ITNs). These have been shown to cause a reduction in the incidence of malaria and its consequences such as maternal anaemia, stillbirths and intrauterine growth restriction. Currently most nations in Africa have policies for distributing ITNs to pregnant women through various mechanisms, however coverage remains well below the targets. This review summarizes recent evidence regarding the correlation between ownership and use of ITNs and the determinants of both, in pregnancy in sub-Saharan Africa, and reviews interventions directed at improving coverage. A review of the literature using Pubmed, CINAHL and scanning of reference lists was conducted in October 2012 and 59 articles were selected for final review. The research obtained was a mixture of national and district level surveys, and a narrative synthesis of the data was undertaken. Ownership of ITNs varied from as low as 3% to greater than 80%, and the main determinants were found to be education level, knowledge of malaria, community involvement, socio-economic status and parity, although the significance of each varied between the different settings and studies reviewed. In more than half the settings where data were available, the combination of lack of availability and lack of use of an available net meant that less than half of all pregnancies received the recommended intervention. Supply and cost remain major barriers to achieving optimal coverage, but the additional important contributor to reduced efficiency of intervention was the clear discrepancy between ownership and use, with available ITN use below 60% in several settings. Cited reasons for not using an ITN, where one was available, included discomfort, problems with hanging up nets and lack of space, low awareness of need, and seasonal variations in use. These findings highlight the need for context-specific approaches and educational components to be incorporated into ITN distribution programmes to address some of the reasons why some pregnant women do not use the ITNs they own.

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.

The effects of malaria and intermittent preventive treatment during pregnancy on fetal anemia in Malawi

BACKGROUND

Fetal anemia is common in malarious areas and is a risk factor for infant morbidity and mortality. Malaria during pregnancy may cause decreased cord hemoglobin (Hb) and fetal anemia among newborns. Intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is protective against malaria but may also affect hematopoiesis and contribute to fetal anemia.

METHODS

Peripheral, placental, and cord blood were examined for malaria parasitemia and Hb concentration in a cross-section of 3848 mothers and infants delivered at Queen Elizabeth Central Hospital in Blantyre, Malawi between 1997 and 2006. Unconditional linear and logistic regressions were performed with multiple imputation for missing covariates to assess the associations between malaria, IPTp with SP, and fetal anemia.

RESULTS

The overall prevalence of fetal anemia was 7.9% (n = 304). Malaria parasitemia at delivery was associated with an adjusted decrease in cord Hb of -0.24 g/dL (95% confidence interval [CI], -.42 to -.05). The adjusted prevalence odds ratio for the effect of malaria on fetal anemia was 1.41 (95% CI, 1.05-1.90). Primigravidae who did not take IPTp had infants at highest risk for fetal anemia, and density of parasitemia was correlated with the decrease in cord Hb. There was no significant association between SP use and cord Hb or fetal anemia.

CONCLUSIONS

Malaria during pregnancy, but not IPTp, decreases cord Hb and is a risk factor for fetal anemia in Malawi. Intermittent preventive treatment during pregnancy with SP may continue to be safe and effective in preventing malaria during pregnancy and fetal anemia despite development of SP resistance.