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

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Abstract

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.

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Intermittent preventive therapy for malaria during pregnancy using 2 vs 3 or more doses of sulfadoxine-pyrimethamine and risk of low birth weight in Africa: systematic review and meta-analysis.

Kassoum Kayentao, Paul Garner, Anne Maria van Eijk … (2013)

Intermittent preventive therapy with sulfadoxine-pyrimethamine to control malaria during pregnancy is used in 37 countries in sub-Saharan Africa, and 31 of those countries use the standard 2-dose regimen. However, 2 doses may not provide protection during the last 4 to 10 weeks of pregnancy, a pivotal period for fetal weight gain. To perform a systematic review and meta-analysis of trials to determine whether regimens containing 3 or more doses of sulfadoxine-pyrimethamine for intermittent preventive therapy during pregnancy are associated with a higher birth weight or lower risk of low birth weight (LBW) (<2500 g) than standard 2-dose regimens. ISI Web of Knowledge, EMBASE, SCOPUS, PubMed, LILACS, the Malaria in Pregnancy Library, Cochrane CENTRAL, and trial registries from their inception to December 2012, without language restriction. Eligible studies included randomized and quasi-randomized trials of intermittent preventive therapy during pregnancy with sulfadoxine-pyrimethamine monotherapy. Data were independently abstracted by 2 investigators. Relative risk (RR), mean differences, and 95% CIs were calculated with random-effects models. Of 241 screened studies, 7 trials of 6281 pregnancies were included. The median birth weight in the 2-dose group was 2870 g (range, 2722-3239 g) and on average 56 g higher (95% CI, 29-83 g; I2 = 0%) in the ≥3-dose group. Three or more doses were associated with fewer LBW births (RR, 0.80; 95% CI, 0.69-0.94; I 2 = 0%), with a median LBW risk per 1000 women in the 2-dose group (assumed control group risk) of 167 per 1000 vs 134 per 1000 in the ≥3-dose group (absolute risk reduction, 33 per 1000 [95% CI, 10-52]; number needed to treat = 31). The association was consistent across a wide range of sulfadoxine-pyrimethamine resistance (0% to 96% dihydropteroate-synthase K540E mutations). There was no evidence of small-study bias. The ≥3-dose group had less placental malaria (RR, 0.51; 95% CI, 0.38-0.68; I 2 = 0%, in 6 trials, 63 vs 32 per 1000; absolute risk reduction, 31 per 1000 [95% CI, 20-39]). In primigravid plus secundigravid women, the risk of moderate to severe maternal anemia was lower in the ≥3-dose group (RR, 0.60; 95% CI, 0.36-0.99; I2 = 20%; in 6 trials, 36 vs 22 per 1000; absolute risk reduction, 14 per 1000 [95% CI, 0.4-23]). There were no differences in rates of serious adverse events. Among pregnant women in sub-Saharan Africa, intermittent preventive therapy with 3 or more doses of sulfadoxine-pyrimethamine was associated with a higher birth weight and lower risk of LBW than the standard 2-dose regimens. These data provide support for the new WHO recommendations to provide at least 3 doses of intermittent preventive therapy during pregnancy at each scheduled antenatal care visit in the second and third trimester.

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Effect of sulfadoxine-pyrimethamine resistance on the efficacy of intermittent preventive therapy for malaria control during pregnancy: a systematic review.

Feiko Kuile, Peter van Lent, S A Filler (2007)

In malaria-endemic regions, strategies to control malaria during pregnancy rely on case management of malaria illness and anemia, and preventive measures such as insecticide-treated nets and intermittent preventive therapy (IPT). To determine the effect of increasing resistance to sulfadoxine-pyrimethamine on the efficacy of IPT during pregnancy in Africa. The 6 databases of MEDLINE, EMBASE, SCOPUS, LILACS, Cochrane CENTRAL, and the trial register and bibliographic database of the Malaria in Pregnancy Library were searched for relevant studies regardless of language, published between 1966 and December 2006. The reference lists of all trials identified were searched and researchers were contacted about relevant data. Nine trials of IPT with sulfadoxine-pyrimethamine during pregnancy in Africa were identified and matched by year and location with treatment studies of sulfadoxine-pyrimethamine among symptomatic children. Data on the efficacy of IPT with sulfadoxine-pyrimethamine on placental and peripheral malaria, birth weight, and hemoglobin level/anemia were independently abstracted by 2 investigators. Sulfadoxine-pyrimethamine resistance was defined as the proportion of total treatment failures in symptomatic children by day 14. Four trials compared 2-dose IPT with sulfadoxine-pyrimethamine to case management or placebo in women during their first or second pregnancy. The IPT reduced placental malaria (relative risk [RR], 0.48; 95% CI, 0.35-0.68), low birth weight (RR, 0.71; 95% CI, 0.55-0.92), and anemia (RR, 0.90; 95% CI, 0.81-0.99). The effect did not vary by sulfadoxine-pyrimethamine resistance levels (range, 19%-26%). Efficacy of IPT with sulfadoxine-pyrimethamine was lower among women using insecticide-treated nets. Three trials compared 2-dose with monthly IPT with sulfadoxine-pyrimethamine during pregnancy. Among HIV-positive women in their first or second pregnancy, monthly IPT resulted in less placental malaria (RR, 0.34; 95% CI, 0.18-0.64) and higher birth weight (mean difference, 112 g; 95% CI, 19-205 g) over the range of sulfadoxine-pyrimethamine resistance tested (8%-39%). Among HIV-negative women, there was no conclusive additional effect of monthly dosing (2 trials; 24% and 39% resistance). In areas in which 1 of 4 treatments with sulfadoxine-pyrimethamine fail in children by day 14, the 2-dose IPT with sulfadoxine-pyrimethamine regimen continues to provide substantial benefit to HIV-negative semi-immune pregnant women. However, more frequent dosing is required in HIV-positive women not using cotrimoxazole prophylaxis for opportunistic infections.

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Timing and adequate attendance of antenatal care visits among women in Ethiopia

Sanni Yaya, Ghose Bishwajit, Michael Ekholuenetale … (2017)

Introduction Although ANC services are increasingly available to women in low and middle-income countries, their inadequate use persists. This suggests a misalignment between aims of the services and maternal beliefs and circumstances. Owing to the dearth of studies examining the timing and adequacy of content of care, this current study aims to investigate the timing and frequency of ANC visits in Ethiopia. Methods Data was obtained from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS) which used a two-stage cluster sampling design to provide estimates for the health and demographic variables of interest for the country. Our study focused on a sample of 10,896 women with history of at least one childbirth event. Percentages of timing and adequacy of ANC visits were conducted across the levels of selected factors. Variables which were associated at 5% significance level were examined in the multivariable logistic regression model for association between timing and frequency of ANC visits and the explanatory variables while controlling for covariates. Furthermore, we presented the approach to estimate marginal effects involving covariate-adjusted logistic regression with corresponding 95%CI of delayed initiation of ANC visits and inadequate ANC attendance. The method used involved predicted probabilities added up to a weighted average showing the covariate distribution in the population. Results Results indicate that 66.3% of women did not use ANC at first trimester and 22.3% had ANC less than 4 visits. The results of this study were unique in that the association between delayed ANC visits and adequacy of ANC visits were examined using multivariable logistic model and the marginal effects using predicted probabilities. Results revealed that older age interval has higher odds of inadequate ANC visits. More so, type of place of residence was associated with delayed initiation of ANC visits, with rural women having the higher odds of delayed initiation of ANC visits (OR = 1.65; 95%CI: 1.26–2.18). However, rural women had 44% reduction in the odds of having inadequate ANC visits. In addition, multi-parity showed higher odds of delayed initiation of ANC visit when compared to the primigravida (OR = 2.20; 95%CI: 1.07–2.69). On the contrary, there was 36% reduction in the odds of multigravida having inadequate ANC visits when compared to the women who were primigravida. There were higher odds of inadequacy in ANC visits among women who engaged in sales/business, agriculture, skilled manual and other jobs when compared to women who currently do not work, after adjusting for covariates. From the predictive margins, assuming the distribution of all covariates remained the same among respondents, but everyone was aged 15–19 years, we would expect 71.8% delayed initiation of ANC visit. If everyone was aged 20-24years, 73.4%; 25-29years, 66.5%; 30-34years, 64.8%; 35-39years, 65.6%; 40-44years, 59.6% and 45-49years, we would expect 70.1% delayed initiation of ANC visit. If instead the distribution of age was as observed and for other covariates remained the same among respondents, but no respondent lived in the rural, we would expect about 61.4% delayed initiation of ANC visit; if however, everyone lived in the rural, and we would expect 71.6% delayed initiation in ANC visit. Model III revealed the predictive margins of all factors examined for delayed initiation for ANC visits, while Model IV presented the predictive marginal effects of the determinants of adequacy of ANC visits. Conclusion The precise mechanism by which these factors affect ANC visits remain blurred at best. There may be factors on the demand side like the women’s empowerment, financial support of the husband, knowledge of ANC visits in the context of timing, frequency and the expectations of ANC visits might be mediating the effects through the factors found associated in this study. Supply side factors like the quality of ANC services, skilled staff, and geographic location of the health centers also mediate their effects through the highlighted factors. Irrespective of the knowledge about the precise mechanism of action, policy makers could focus on improving women’s empowerment, improving women’s education, reducing wealth inequity and facilitating improved utilization of ANC through modifications on the supply side factors such as geographic location and focus on hard to reach women.

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Author and article information

Journal

Journal ID (nlm-ta): Trop Med Infect Dis

Journal ID (iso-abbrev): Trop Med Infect Dis

Journal ID (publisher-id): tropicalmed

Title: Tropical Medicine and Infectious Disease

Publisher: MDPI

ISSN (Electronic): 2414-6366

Publication date (Electronic): 11 February 2018

Publication date Collection: March 2018

Volume: 3

Issue: 1

Electronic Location Identifier: 18

Affiliations

[1 ]School of International Development and Global Studies, University of Ottawa, Ottawa, ON K1N 6N5, Canada; sanni.yaya@ 123456uottawa.ca

[2 ]Warwick Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; olalekan.uthman@ 123456warwick.ac.uk

[3 ]Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; aamouzo1@ 123456jhu.edu

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[* ]Correspondence: brammaputram@ 123456gmail.com ; Tel.: +1-613-262-4856

Author information

Sanni Yaya https://orcid.org/0000-0002-4876-6043

Ghose Bishwajit https://orcid.org/0000-0003-4461-3821

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Publisher ID: tropicalmed-03-00018

DOI: 10.3390/tropicalmed3010018

PMC ID: 6136633

PubMed ID: 30274416

SO-VID: 63326706-64dc-493e-bfae-ddeb8e90dfd3

License:

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

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

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Most cited references 46

Intermittent preventive therapy for malaria during pregnancy using 2 vs 3 or more doses of sulfadoxine-pyrimethamine and risk of low birth weight in Africa: systematic review and meta-analysis.

Effect of sulfadoxine-pyrimethamine resistance on the efficacy of intermittent preventive therapy for malaria control during pregnancy: a systematic review.

Timing and adequate attendance of antenatal care visits among women in Ethiopia

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