The Association Between Early Antenatal Care and Intermittent Preventive Treatment of Malaria in Pregnancy in Sub-Saharan Africa: Effect Modification by Planned Pregnancy Status

Abstract Background Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for preventing malaria in pregnancy in areas of moderate-to-high transmission in sub-Saharan Africa. However, due to increasing parasite resistance to SP, research on alternative strategies is a priority. The study assessed the implementation feasibility of intermittent screening and treatment (ISTp) in the second and third trimester at antenatal care (ANC) with malaria rapid diagnostic tests (RDTs) and treatment of positive cases with dihydroartemisinin-piperaquine (DP) compared to IPTp-SP in western Kenya. Methods A 10-month implementation study was conducted in 12 government health facilities in four sub-counties. Six health facilities were assigned to either ISTp-DP or IPTp-SP. Evaluation comprised of facility audits, ANC observations, and exit interviews. Intermediate and cumulative effectiveness analyses were performed on all processes involved in delivery of ISTp-DP including RDT proficiency and IPTp-SP ± directly observed therapy (DOT, standard of care). Logistic regression was used to identify predictors of receiving each intervention. Results A total of 388 and 389 women were recruited in the ISTp-DP and IPTp-SP arms, respectively. For ISTp-DP, 90% (289/320) of eligible women received an RDT. Of 11% (32/289) who tested positive, 71% received the correct dose of DP and 31% the first dose by DOT, and only 6% were counselled on subsequent doses. Women making a sick visit and being tested in a facility with a resident microscopist were more likely to receive ISTp-DP (AOR 1.78, 95% CI 1.31, 2.41; and AOR 3.75, 95% CI 1.31, 2.40, respectively). For IPTp-SP, only 57% received a dose of SP by DOT. Payment for a laboratory test was independently associated with receipt of SP by DOT (AOR 6.43, 95% CI 2.07, 19.98). Conclusions The findings indicate that the systems effectiveness of ANC clinics to deliver ISTp-DP under routine conditions was poor in comparison to IPTp-SP. Several challenges to integration of ISTp with ANC were identified that may need to be considered by countries that have introduced screening at first ANC visit and, potentially, for future adoption of ISTp with more sensitive RDTs. Understanding the effectiveness of ISTp-DP will require additional research on pregnant women’s adherence to ACT.

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Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions

Malaria Journal ◽

10.1186/s12936-020-03422-2 ◽

2020 ◽

Vol 19 (1) ◽

Author(s):

Matilda Aberese-Ako ◽

Pascal Magnussen ◽

Margaret Gyapong ◽

Gifty D. Ampofo ◽

Harry Tagbor

Keyword(s):

Intermittent Preventive Treatment ◽

Preventive Treatment ◽

Ethnographic Study ◽

Health Facilities ◽

Malaria In Pregnancy ◽

Sub Saharan Africa ◽

Bed Nets ◽

Maternal Healthcare ◽

Sub Saharan ◽

In Pregnancy

Abstract Background Malaria in pregnancy (MiP) is an important public health problem across sub-Saharan Africa. The package of measures for its control in Ghana in the last 20 years include regular use of long-lasting insecticide-treated bed nets (LLINs), directly-observed administration (DOT) of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and prompt and effective case management of MiP. Unfortunately, Ghana like other sub-Saharan African countries did not achieve the reset Abuja targets of 100% of pregnant women having access to IPTp and 100% using LLINs by 2015. Methods This ethnographic study explored how healthcare managers dealt with existing MiP policy implementation challenges and the consequences on IPTp-SP uptake and access to maternal healthcare. The study collected date using non-participant observations, conversations, in-depth interviews and case studies in eight health facilities and 12 communities for 12 months in two Administrative regions in Ghana. Results Healthcare managers addressed frequent stock-outs of malaria programme drugs and supplies from the National Malaria Control Programme and delayed reimbursement from the NHIS, by instituting co-payment, rationing and prescribing drugs for women to buy from private pharmacies. This ensured that facilities had funds to pay creditors, purchase drugs and supplies for health service delivery. However, it affected their ability to enforce DOT and to monitor adherence to treatment. Women who could afford maternal healthcare and MiP services and those who had previously benefitted from such services were happy to access uninterrupted services. Women who could not maternal healthcare services resorted to visiting other sources of health care, delaying ANC and skipping scheduled ANC visits. Consequently, some clients did not receive the recommended 5 + doses of SP, others did not obtain LLINs early and some did not obtain treatment for MiP. Healthcare providers felt frustrated whenever they could not provide comprehensive care to women who could not afford comprehensive maternal and MiP care. Conclusion For Ghana to achieve her goal of controlling MiP, the Ministry of Health and other supporting institutions need to ensure prompt reimbursement of funds, regular supply of programme drugs and medical supplies to public, faith-based and private health facilities.

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Sub-optimal Intermittent Preventive Treatment in pregnancy (IPTp) is associated with an increased risk of submicroscopic P. falciparum infection in pregnant women: a prospective cohort study in Benin

Clinical Infectious Diseases ◽

10.1093/cid/ciaa1355 ◽

2020 ◽

Author(s):

Cornélia P A Hounkonnou ◽

Nicaise Tuikue Ndam ◽

Nadine Fievet ◽

Manfred Accrombessi ◽

Emmanuel Yovo ◽

...

Keyword(s):

Gestational Age ◽

Negative Binomial ◽

Intermittent Preventive Treatment ◽

Preventive Treatment ◽

Malaria In Pregnancy ◽

Sub Saharan Africa ◽

Increased Risk ◽

Sub Saharan ◽

The Impact ◽

In Pregnancy

Abstract Background Harmful maternal and neonatal health outcomes result from malaria in pregnancy, the prevention of which primarily relies on intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP). WHO recommends IPTp-SP in sub-Saharan Africa, but implementation is highly heterogeneous and often sub-optimal in terms of the number of doses and their timing. In this study, we assessed the impact of this heterogeneity on malaria in pregnancy, mainly with respect to submicroscopic Plasmodium falciparum infections. Methods We used data from 273 Beninese women followed throughout pregnancy. Screening for P. falciparum infections, using both microscopy- and polymerase chain reaction (PCR) -based methods, was performed monthly, and information on IPTp-SP dose was collected. Gestational age was estimated by repeated ultrasound scans. Using a negative binomial model, we investigated the effect of IPTp-SP doses and timing, after 17 weeks of gestation, on the number of P. falciparum infections, focusing on submicroscopic infections detectable only by PCR. Results At least two IPTp-SP doses were taken by 77.3% of the women. The median gestational age at first IPTp-SP dose was 22 weeks. A late first IPTp-SP dose (>21.2 weeks) was marginally associated with an increased number of P. falciparum infections (adjusted incidence rate ratio [aIRR] =1.3; p=0.098). The number of IPTp-SP doses was not associated with the number of submicroscopic infections (aIRR=1.2, p=0.543). Conclusion A late first IPTp-SP dose fail to provide optimal protection against P. falciparum, especially submicroscopic infections. This highlights the need for a new antimalarial drug for IPTp that could be taken early in pregnancy.

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Assessment of Malaria Intermittent Preventive Treatment (Ipt) Uptake among Pregnant Women attending Antenatal Care at Kasanje Health Center III, Wakiso District

10.51168/sjhrafrica.v2i6.46 ◽

2021 ◽

Author(s):

◽

Doreen Kabatongole

Keyword(s):

Antenatal Care ◽

Pregnant Women ◽

Health Center ◽

Intermittent Preventive Treatment ◽

Preventive Treatment ◽

Malaria In Pregnancy ◽

Reproductive Age ◽

Sub Saharan Africa ◽

Major Public Health Problem ◽

In Pregnancy

Background: Malaria in pregnancy is a major public health problem with substantial risks for both the mother and unborn child. Malaria is responsible for 10,000 maternal deaths globally, 20% of stillbirths, and 11% of newborn deaths in sub-Saharan Africa. The study intends to explore the extent of intermittent preventive treatment IPTp uptake among pregnant women attending ANC. Methodology A Cross-sectional survey was carried out among pregnant women attending antenatal care at Kasanje Health Center III to explore the extent of intermittent preventive treatment (IPTp) uptake among pregnant women attending ANC. Data on their socio-demographic characteristics and antenatal service utilization were collected using a questionnaire and review of antenatal care (ANC) cards. In-depth interviews were conducted and data on ANC service delivery collected and analyzed. Univariate, Bivariate and multiple logistic regression analyses were done to determine factors associated with uptake of IPTp. Results: A total of 75 pregnant women were interviewed, all in reproductive age 15-48 years, with an average age of 25.6years. All the respondents (100%) had attended antenatal care at least once. 58% of the participants wherein their third trimester. Many, 31% were on their second visit, 24% on their 3rd visit while only 10% were on their first visit. The majority of the participants (88%) had their ANC started in the first trimester. It was also noted that the number of IPTp varied significantly with the number of ANC visits (chi2=33.8, p<0.001). The majority (62.67) of the participants knew IPTp and the majority of the respondents (99%) knew how malaria is transmitted. Abortion was mentioned as the major outcome of malaria in pregnancy (95%) followed by Stillbirths (72%). Conclusion and recommendations: An increased number of ANC visits, providing IPTp information to pregnant women, and the gestational age of pregnancy resulted in increased uptake of IPTp.

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Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions

10.21203/rs.3.rs-37848/v2 ◽

2020 ◽

Author(s):

Matilda Aberese-Ako ◽

Pascal Magnussen ◽

Margaret Gyapong ◽

Gifty Dufie Ampofo ◽

Harry Tagbor

Keyword(s):

Intermittent Preventive Treatment ◽

Preventive Treatment ◽

Ethnographic Study ◽

Health Facilities ◽

Malaria In Pregnancy ◽

Sub Saharan Africa ◽

Bed Nets ◽

Maternal Healthcare ◽

Sub Saharan ◽

In Pregnancy

Abstract Background: Malaria in pregnancy (MiP) is an important public health problem across sub-Saharan Africa. The package of measures for its control in Ghana in the last 20 years include regular use of long-lasting insecticide-treated bed nets (LLINs), directly observed administration (DOT) of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and prompt and effective case management of MiP. Unfortunately, Ghana like other sub-Saharan African countries did not achieve the reset Abuja targets of 100% of pregnant women having access to IPTp and 100% using LLINs by 2015.Methods: This ethnographic study explored how healthcare managers dealt with existing MiP policy implementation challenges and the consequences on IPTp-SP uptake and access to maternal healthcare. The study collected date using non-participant observations, conversations, in-depth interviews and case studies in eight health facilities and twelve communities for twelve months in two Administrative regions in Ghana. Results: Healthcare managers addressed frequent stock-outs of malaria programme drugs and supplies from the National Malaria Control Programme and delayed reimbursement from the NHIS, by instituting co-payment, rationing and prescribing drugs for women to buy from private pharmacies. This ensured that facilities had funds to pay creditors, purchase drugs and supplies for health service delivery. However, it affected their ability to enforce DOT and to monitor adherence to treatment. Women who could afford maternal healthcare and MiP services and those who had previously benefitted from such services were happy to access uninterrupted services. Women who could not maternal healthcare services resorted to visiting other sources of health care, delaying ANC and skipping scheduled ANC visits. Consequently, some clients did not receive the recommended 5+ doses of SP, others did not obtain LLINs early and some did not obtain treatment for MiP. Healthcare providers felt frustrated whenever they could not provide comprehensive care to women who could not afford comprehensive maternal and MiP care.Conclusion: For Ghana to achieve her goal of controlling MiP, the Ministry of Health and other supporting institutions need to ensure prompt reimbursement of funds, regular supply of programme drugs and medical supplies to public, faith-based and private health facilities.

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Coverage of intermittent preventive treatment of malaria in pregnancy in four sub-Saharan countries: findings from household surveys

International Journal of Epidemiology ◽

10.1093/ije/dyaa233 ◽

2020 ◽

Author(s):

Clara Pons-Duran ◽

Mireia Llach ◽

Charfudin Sacoor ◽

Sergi Sanz ◽

Eusebio Macete ◽

...

Keyword(s):

Antenatal Care ◽

Intermittent Preventive Treatment ◽

Preventive Treatment ◽

Malaria Prevention ◽

Reproductive Age ◽

Cluster Sampling ◽

Household Surveys ◽

Cross Sectional ◽

Sub Saharan ◽

In Pregnancy

Abstract Background Intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) is a key malaria prevention strategy in areas with moderate to high transmission. As part of the TIPTOP (Transforming IPT for Optimal Pregnancy) project, baseline information about IPTp coverage was collected in eight districts from four sub-Saharan countries: Democratic Republic of Congo (DRC), Madagascar, Mozambique and Nigeria. Methods Cross-sectional household surveys were conducted using a multistage cluster sampling design to estimate the coverage of IPTp and antenatal care attendance. Eligible participants were women of reproductive age who had ended a pregnancy in the 12 months preceding the interview and who had resided in the selected household during at least the past 4 months of pregnancy. Coverage was calculated using percentages and 95% confidence intervals. Results A total of 3911 women were interviewed from March to October 2018. Coverage of at least three doses of IPTp (IPTp3+) was 22% and 24% in DRC project districts; 23% and 12% in Madagascar districts; 11% and 16% in Nigeria local government areas; and 63% and 34% in Mozambique districts. In DRC, Madagascar and Nigeria, more than two-thirds of women attending at least four antenatal care visits during pregnancy received less than three doses of IPTp. Conclusions The IPTp3+ uptake in the survey districts was far from the universal coverage. However, one of the study districts in Mozambique showed a much higher coverage of IPTp3+ than the other areas, which was also higher than the 2018 average national coverage of 41%. The reasons for the high IPTp3+ coverage in this Mozambican district are unclear and require further study.

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Factors Associated with Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy: A Cross-Sectional Study in Private Health Facilities in Tema Metropolis, Ghana

Journal of Tropical Medicine ◽

10.1155/2019/9278432 ◽

2019 ◽

Vol 2019 ◽

pp. 1-11 ◽

Cited By ~ 5

Author(s):

Selina Amankwah ◽

Francis Anto

Keyword(s):

Antenatal Care ◽

Intermittent Preventive Treatment ◽

Preventive Treatment ◽

Health Facilities ◽

Malaria In Pregnancy ◽

Second Trimester ◽

Cross Sectional ◽

Factors Associated ◽

Postnatal Women ◽

In Pregnancy

Introduction. Intermittent preventive treatment of malaria in pregnancy with sulfadoxine pyrimethamine (IPTp-SP) is effective in preventing the adverse consequences of malaria on birth outcomes. Methods. A cross-sectional survey was carried out among antenatal and postnatal women and midwives at private health facilities in Tema using the mixed method to investigate factors associated with uptake of IPTp-SP. Antenatal and postnatal women were consecutively enrolled and data on their sociodemographic characteristics and antenatal service utilization collected using a questionnaire and review of antenatal care (ANC) records. In-depth interviews involving attending midwives were conducted and data on ANC service delivery collected. The interviews were manually analyzed. Bivariate and multiple logistic regression analyses were done to determine factors associated with uptake of SP. Results. Of the 382 respondents, 178 (46.6%) took ≥ 3 doses of SP. Uptake was similar for those who had delivered and those yet to deliver (χ2 =2.94, p > 0.05). Ninety-seven of the 176 (55.1%) women who initiated antenatal visit during the first trimester received ≥ 3 doses of SP whilst 42.0% (76/181) of those who started during the second trimester received ≥ 3 doses (χ2 = 5.64, p = 0.02). Those who initiated ANC during the second trimester received more doses compared to those who started during the third trimester (χ2 = 4.43, p = 0.04). Respondents who attended ANC > 5 times increased their uptake by 83% compared to those who attended < 5 times (OR 0.2, 95% C.I 0.12-0.31). There was poor adherence to directly observed treatment and low knowledge of midwives on IPTp-SP protocol. Conclusion. Early initiation and regular visit to antenatal care centres promoted uptake of optimal doses of SP.

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Impact of Health Systems on the Implementation of Intermittent Preventive Treatment for Malaria in Pregnancy in Sub-Saharan Africa: A Narrative Synthesis

Tropical Medicine and Infectious Disease ◽

10.3390/tropicalmed5030134 ◽

2020 ◽

Vol 5 (3) ◽

pp. 134

Author(s):

Atinuke O. Olaleye ◽

Oladapo Walker

Keyword(s):

Health System ◽

Data Extraction ◽

Supply And Demand ◽

Intermittent Preventive Treatment ◽

Preventive Treatment ◽

Malaria In Pregnancy ◽

Sub Saharan Africa ◽

Cochrane Library ◽

Narrative Synthesis ◽

In Pregnancy

Malaria in pregnancy is a public health challenge with serious negative maternal and newborn consequences. Intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine is recommended for the control of malaria during pregnancy within endemic areas, but coverage for the recommended ≥3 doses IPTp regimen has remained suboptimal. We searched PubMed, Cochrane library, and HINARI database from 1 January 2010 to 23 May 2020, for studies investigating the effect of the health system on IPTp implementation. Data extraction was independently performed by two investigators and evaluated for quality and content. Health system barriers and facilitators were explored using thematic analysis and narrative synthesis. Thirty-four out of 1032 screened articles were included. Key health system issues affecting the provision and uptake of IPTp were the ambiguity of policy and guidelines for IPTp administration, human resource shortages, drug stock-outs, conflicting policy implementation on free IPTp provision, hidden costs, unclear data recording and reporting guidelines, and poor quality of care. Factors affecting the supply and demand for IPTp services involve all pillars of the health system across different countries. The success of health programs such as IPTp will thus depend on how well the different pillars of the health system are articulated towards the success of each program.

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Epidemiology of Malaria in Pregnancy and Associated Risk Factors in Nigeria: a Review

International Journal of Pathogen Research ◽

10.9734/ijpr/2021/v8i230202 ◽

2021 ◽

pp. 59-72

Author(s):

Chibuzo Christian Uba ◽

Moses Nkechukwu Ikegbunam ◽

Emmanuel Chigozie Udegbunam ◽

Chioma Abana ◽

Stephen Nnaemeka Ezekwueche ◽

...

Keyword(s):

Risk Factors ◽

Pregnant Women ◽

Preventive Treatment ◽

Malaria In Pregnancy ◽

Sub Saharan Africa ◽

Drug Misuse ◽

Care Services ◽

Sub Saharan ◽

Associated Risk Factors ◽

In Pregnancy

Each year, an estimated number of 300–500 million people are infected with malaria parasite, with an undesirable effect of over one million deaths. Pregnant women as well as young children, non-immune travellers visiting malaria-endemic zones are at the highest risk of suffering or experiencing life - threatening malaria infection. Maternal immunity, parasite density, parity, inadequate antenatal care services, drug misuse and abuse as well intermitted preventive treatment drug failure cum resistance are the most associated risk factors of malaria in pregnancy obtainable in endemic regions of sub-Saharan Africa. Identification and understanding of these factors will play a major role in reducing the burden as well as eliminating malaria disease among pregnant women living in endemic regions.

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