Assessing health system factors affecting access and delivery of IPTp-SP and ITN to pregnant women attending ANC clinics in Ghana

Introduction

Malaria interventions including use of Sulfadoxine-Pyrimethamine as Intermittent Preventive Treatment (IPTp-SP) and distribution of Insecticide Treated Nets (ITNs) have been implemented through ante-natal clinic (ANC) services in Ghana. Yet, the high ANC attendance is not commensurate with the uptake of these interventions, with missed opportunities to deliver the interventions. This study sought to assess the health system factors affecting access and delivery of IPTp-SP and ITN as defined by the Ghana Malaria Policy Guideline to eligible pregnant women attending ANC clinic sessions.

Methods

A quantitative cross-sectional study was conducted in the Volta Region of Ghana, with data collected across three levels of health care delivery facilities, including hospitals, health centres and Community-Based Health Planning Service (CHPS) compounds. Data collection included structured observation checklists to document the communication and interaction between the ANC health staff and pregnant women. Additionally, structured questionnaires were used to elicit information on cadre, trainings attended, knowledge and delivery practices of health workers on IPTp-SP and ITN. Stata 16 was used for data analysis, and a defined delivery algorithm was used to compute appropriate and inappropriate delivery practices, using the Ghana policy directive as a guide. Predictors of appropriate delivery were determined using logistic regression analysis.

Results

Approximately 97% of the 680 ANC observations had complete information for analysis. Of these, 78% (511/657) were eligible for IPTp-SP after excluding women who have less than 16 weeks of gestation, G6PD deficient, malaria positive and have taken 5 doses of IPTp-SP prior to day of observation. Appropriate delivery of IPTp-SP was 76% (390/511). Despite the availability of SP, 15% (75/511) of all eligible women were not offered the medication and 37% (44/119) of inappropriate delivery was recorded during periods of stock out. ITNs were appropriately delivered to 59% (139) out of 237 eligible women. Thirty-two percent (77/237) of eligible women, mostly continuing ANC clients, were not given ITN despite stock availability.

Conclusions

IPTp-SP was appropriately delivered to most of the eligible pregnant women compared to ITN. While stock out of both intervention could account for inappropriate delivery, despite stock availability, IPTp-SP and ITN were not delivered to some eligible women.

Comparative analysis of four malaria diagnostic tools and implications for malaria treatment in southwestern Nigeria

OBJECTIVES

One of the problems encountered in malaria control and elimination is inaccurate diagnosis, resulting from the degree of sensitivity of the different malaria diagnostic tools. Even though microscopy remains the gold standard for malaria diagnosis, more sensitive and robust diagnostic tools such as polymerase chain reactions (PCR) are used in research settings to monitor interventions and track sub-microscopic infections due to some of the drawbacks of microscopy. Since diagnosis is a critical determinant for rational malaria treatment, it is imperative that accurate diagnosis must be assured for an effective treatment plan. Therefore, this study compared two routinely used point of care malaria diagnostic tools with two molecular tools and discussed their implication for malaria treatment.

DESIGN

In this study, 436 individuals with suspected malaria were sampled and systematically tested using four methods, namely rapid diagnostic test (henceforth referred to as malaria RDT- mRDT), microscopy, nested PCR (nPCR), and quantitative PCR (qPCR). Test sensitivities and specificities were compared, and their level of concordance was determined.

RESULTS

With nPCR as the gold standard, a false positivity rate of 42.2%, 8.9%, and 57.8% was obtained for mRDT, microscopy, and qPCR. Similarly, false negativity rates of 12.5%, 62.5%, and 0.8% were obtained for each of the methods mentioned above, respectively. Of all the tools assessed, qPCR gave the highest sensitivity (99.2%) and moderate specificity (42.2%), followed by the mRDT kit used (87.5%).

CONCLUSIONS

With the detection of a high false positivity rate based on mRDT and a substantial proportion of sub-microscopic carriers in this study area by nested/quantitative PCR, we recommend that these molecular tools should be in specialized laboratories within the region to (i) track and treat sub-microscopic carriers to prevent their contribution to malaria transmission; (ii) provide reliable epidemiological data using high throughput testing tools for evaluating malaria interventions.

Adverse pregnancy outcomes are associated with Plasmodium vivax malaria in a prospective cohort of women from the Brazilian Amazon

Background

Malaria in Brazil represents one of the highest percentages of Latin America cases, where approximately 84% of infections are attributed to Plasmodium (P.) vivax. Despite the high incidence, many aspects of gestational malaria resulting from P. vivax infections remain poorly studied. As such, we aimed to evaluate the consequences of P. vivax infections during gestation on the health of mothers and their neonates in an endemic area of the Amazon.

Methods and findings

We have conducted an observational cohort study in Brazilian Amazon between January 2013 and April 2015. 600 pregnant women were enrolled and followed until delivery. After applying exclusion criteria, 329 mother-child pairs were included in the analysis. Clinical data regarding maternal infection, newborn’s anthropometric measures, placental histopathological characteristics, and angiogenic and inflammatory factors were evaluated. The presence of plasma IgG against the P. vivax (Pv) MSP1₁₉ protein was used as marker of exposure and possible associations with pregnancy outcomes were analyzed. Multivariate logistic regression analysis revealed that P. vivax infections during the first trimester of pregnancy are associated with adverse gestational outcomes such as premature birth (adjusted odds ratio [aOR] 8.12, 95% confidence interval [95%CI] 2.69–24.54, p < 0.0001) and reduced head circumference (aOR 3.58, 95%CI 1.29–9.97, p = 0.01). Histopathology analysis showed marked differences between placentas from P. vivax-infected and non-infected pregnant women, especially regarding placental monocytes infiltrate. Placental levels of vasomodulatory factors such as angiopoietin-2 (ANG-2) and complement proteins such as C5a were also altered at delivery. Plasma levels of anti-PvMSP1₁₉ IgG in infected pregnant women were shown to be a reliable exposure marker; yet, with no association with improved pregnancy outcomes.

Conclusions

This study indicates that P. vivax malaria during the first trimester of pregnancy represents a higher likelihood of subsequent poor pregnancy outcomes associated with marked placental histologic modification and angiogenic/inflammatory imbalance. Additionally, our findings support the idea that antibodies against PvMSP1₁₉ are not protective against poor pregnancy outcomes induced by P. vivax infections.

Malaria during pregnancy is associated with adverse effects on the fetus and the newborn. As far as we know, no study has previously investigated in a single work, the link between Plasmodium vivax malaria in pregnancy and poor gestational outcomes, alteration of the newborn’s anthropometric profile, placental lesions, angiogenic and inflammatory factors, and humoral immunity against the parasite. For this purpose, we investigated the association between P. vivax malaria during pregnancy and newborn’s anthropometric profile, placental pathology, gestational outcomes, and the presence of IgG against P. vivax MSP1₁₉ that may confer protection against infection during pregnancy. We performed a large cohort study of malaria during pregnancy that analyzed data from mother-child pairs delivered between 2013 and 2015 in the Southwestern Brazilian Amazonian region. By evaluating data from 329 pregnancies, we found that P. vivax malaria during the first pregnancy trimester is significantly associated with the occurrence of preterm birth, low birth weight, and reduced newborn head circumference and body length. We also noted that P. vivax malaria in pregnancy promoted placental lesions and homeostasis imbalance, characterized by increased syncytial nuclear aggregates, fibrin deposition, and monocytes/leukocytes infiltrate, as well as imbalanced angiogenic factors, leptin, and cytokines. We observed that pregnant women with IgG against P. vivax MSP1₁₉ are not protected against poor pregnancy outcomes caused by P. vivax infections during pregnancy. Our observations improve our understanding of the disease and P. vivax burden during pregnancy, changing the current paradigm of the outcome of P. vivax malaria in pregnancy. That may represent a long-term severe consequence for the affected populations living in P. vivax-endemic regions. Our results also indicate that IgG against P. vivax MSP1₁₉ is not associated with protection from poor pregnancy outcomes, excluding this protein as a possible vaccination target that can prevent adverse outcomes caused by P. vivax infections during pregnancy.

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.

Knowledge, motivation, self-efficacy, and their association with insecticidal net use among pregnant women in a secondary health centre in Maiduguri, Nigeria

BACKGROUND

Despite the high prevalence of malaria among pregnant women and its associated complications, the level of compliance with insecticide-treated nets (ITN) remains very low. Motivation and self-efficacy have been reported as important determinants of health behaviour, and may be important factors to consider in developing health intervention programmes. The aim of this study was to determine the knowledge, motivation and self-efficacy of ITN use, and their association with its practice, among pregnant women in a secondary health centre in Maiduguri.

METHODS

The study utilized a cross-sectional study design, using a structured and pre-tested questionnaire to obtain information from 380 respondents. Respondents were classified as ITN users if they slept under an ITN for at least 3 days in a week, while those who did not at all, or slept under it less frequently were classified as ITN non-users. Chi squared test was performed to test the bivariate association between ITN use and each of the items of the questionnaire. A further multivariate logistic regression was performed to determine the predictors of ITN use.

RESULTS

The respondents' ages ranged from 15 to 45 years, with median (interquartile range) age of 25 (8) years. Eighty percent of them were aware of ITN, but 50.5% believed ITNs could be dangerous. Only 5.5% and 0.8% respectively felt that sleeping under and ITN was either just bad or very bad for their health. Thirty-five percent of the respondents were ITN users. Not having a previous miscarriage (OR = 2.38; 95% CI 1.41-4.03, p = 0.001), knowledge that ITNs were not to be washed after every 1 month (OR = 3.60; 95% CI 1.18-11.06), significant others thinking they should sleep under an ITN (OR = 3.06; 95% CI 1.35-6.96), ability to effectively persuade others to sleep under an ITN (OR = 2.37; 95% CI 1.14-4.94) were significantly associated with ITN use.

CONCLUSIONS

A large proportion of pregnant women in this study were not sleeping under ITNs. The development of health promotion interventions aimed at boosting their self-efficacies for ITN use, and improving social support from their spouses are, therefore, recommended. Health education on ITN use should also be incorporated into post-abortal management.