Determinants of uptake of intermittent preventive treatment during pregnancy: a review

Prevalence and correlates of tetanus toxoid uptake among women in sub-Saharan Africa: Multilevel analysis of demographic and health survey data

BACKGROUND

Tetanus toxoid vaccination is one of the most effective and protective measures against tetanus deaths among mothers and their newborns. We examined the prevalence and correlates of tetanus toxoid uptake among women in sub-Saharan African (SSA).

MATERIALS AND METHODS

We analysed pooled data from the Demographic and Health Surveys (DHS) of 32 countries in SSA conducted from 2010 to 2020. We included 223,594 women with a history of childbirth before the survey. Percentages were used to present the prevalence of tetanus toxoid vaccine uptake among the women. We examined the correlates of tetanus toxoid uptake using a multilevel binary logistic regression.

RESULTS

The overall prevalence of tetanus toxoid uptake was 51.5%, which ranged from 27.5% in Zambia to 79.2% in Liberia. Women age, education level, current working status, parity, antenatal care visits, mass media exposure, wealth index, and place of residence were the factors associated with the uptake of tetanus toxoid among the women.

CONCLUSION

Uptake of tetanus toxoid vaccination among the women in SSA was low. Maternal age, education, current working status, parity, antenatal care visits, exposure to mass media, and wealth status influence tetanus toxoid uptake among women. Our findings suggest that health sector stakeholders in SSA must implement interventions that encourage pregnant women to have at least four antenatal care visits. Also, health policymakers in SSA could ensure that the tetanus toxoid vaccine is free or covered under national health insurance to make it easier for women from poorer households to have access to it when necessary.

Status of malaria in pregnancy services in Madagascar 2010-2021: a scoping review

BACKGROUND

Malaria in pregnancy (MIP) increases the risk of poor maternal and infant outcomes. To reduce these risks, WHO recommends insecticide-treated net (ITN) use, intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), and prompt case management. However, uptake of these interventions remains sub-optimal in Madagascar. A scoping review was conducted to determine the breadth and depth of information available during 2010-2021 about Madagascar's MIP activities and to identify barriers and facilitators to MIP interventions uptake.

METHODS

PubMed, Google Scholar, and USAID's files (Development Experience Catalog) were searched using the terms "Madagascar AND pregnancy AND malaria," and reports and materials from stakeholders were collected. Documents in English and French from 2010 to 2021 with data regarding MIP were included. Documents were systematically reviewed and summarized; results were captured in an Excel database.

RESULTS

Of 91 project reports, surveys and published articles, 23 (25%) fell within the stated time period and contained relevant data on MIP activities in Madagascar and were categorized accordingly: eight (35%) quality of care, including health facility readiness, provider knowledge and commodity availability; nine (39%) care-seeking behaviour; and, six (26%) prevention of MIP. Key barriers were identified: nine articles mentioned SP stockouts; seven found limitations of provider knowledge, attitudes, and behaviours (KAB) regarding MIP treatment and prevention; and, one reported limited supervision. MIP care seeking and prevention barriers and facilitators included women's KAB regarding MIP treatment and prevention, distance, wait times, poor service quality, cost, and/or unwelcoming providers. A 2015 survey of 52 health facilities revealed limited client access to antenatal care due to financial and geographic barriers; two 2018 surveys revealed similar findings. Self-treatment and care-seeking delays were reported even when distance was not a barrier.

CONCLUSION

Among the studies and reports on MIP in Madagascar, the scoping review frequently noted barriers that could be mitigated by reducing stockouts, improving provider knowledge and attitudes, refining MIP communication, and improving service access. There is a need for coordinated efforts to address the identified barriers is the key implication of the findings.

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.

Were Women Staying on Track with Intermittent Preventive Treatment for Malaria in Antenatal Care Settings? A Cross-Sectional Study in Senegal

A significant gap exists between high rates of antenatal care attendance and low uptake of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) in Senegal. This study aims to investigate whether IPTp-SP is delivered per Senegal's national guidelines and to identify factors affecting the delivery of IPTp-SP at antenatal care visits. A secondary analysis was conducted using the 2014 and 2016 Senegal's Service Provision Assessment. The study sample consists of 1076 antenatal care across 369 health facilities. Multiple logit regression models were used to estimate the probability of receiving IPTp-SP during the antenatal care visit based on prior receipt of IPTp-SP and gestational age during the current pregnancy. At an antenatal care visit, the probability of receiving IPTp-SP is 84% (95% CI = [83%, 86%]) among women with no IPTp-SP history and 85% (95% CI = [79%, 92%]) among women with one prior dose. Women who visit a facility in the top quintile of the proportion of IPTp trained staff have a nearly 4-fold higher odds of receiving IPTp compared to those who visit a facility in the bottom quintile (95% CI = [1.54, 9.80]). The dose and timing of IPTp-SP provided in antenatal care settings in Senegal did not always conform with the national guideline. More training for providers and patient engagement is warranted to improve the uptake of IPTp-SP in antenatal care visits.

Uptake of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) in Uganda: a national survey

Background

In spite of the missed opportunities of sulfadoxine-pyrimethamine (IPTp-SP) in Uganda, scanty literature exist on malaria in pregnancy. To date, empirical national study utilizing the 2018-19 Uganda Malaria Indicator Survey to explore predictors of attaining three or more doses of IPTp-SP in the country is non-existent. This study investigated the factors affecting uptake of three or more IPTp-SP doses as recommended by the World Health Organization.

Methods

Data from the 2018–2019 Uganda Malaria Indicator Survey (2018-19 UMIS) was analysed. Adequate uptake of intermittent preventive therapy with IPTp-SP was the dependent variable for this study. Weighted frequencies and percentages were used to present the proportion of women who had adequate IPTp-SP uptake or otherwise with respect to the independent variables. A three-level multilevel logistic regression was fitted. The Bayesian Deviance Information Criterion (DIC) was used in determining the goodness of fit of all the models.

Results

Less than half of the surveyed women had three or more IPTp-SP doses during their last pregnancies (45.3%). Women aged 15–19 had less odds of receiving at least three IPTp-SP doses compared to those aged 45–49 [aOR = 0.42, Crl = 0.33–0.98]. Poor women [aOR = 0.80, Crl = 0.78–0.91] were less likely to have three or more doses of IPTp-SP relative to rich women. Most disadvantaged regions were aligned with less likelihood of three or more IPTp-SP uptake [aOR = 0.59, CI = 0.48–0.78] compared to least disadvantaged regions. The variation in uptake of three or more IPTp-SP doses was substantial at the community level [σ² = 1. 86; Crl = 11.12–2.18] than regional level [σ² = 1.13; Crl = 1.06–1.20]. About 18% and 47% disparity in IPTp-SP uptake are linked to region and community level factors respectively.

Conclusion

IPTp-SP interventions need to reflect broader community and region level factors in order to wane the high malaria prevalence in Uganda. Contextually responsive behavioural change communication interventions are required to invoke women’s passion to achieve the recommended dosage.

Barriers and facilitators to access and uptake of intermittent preventive treatment with sulfadoxine-pyrimethamine among pregnant women in Nigeria: a scoping review

Background

Malaria in pregnancy is a significant public health concern in Nigeria. It threatens pregnant women and their unborn babies and undermines the achievement of Sustainable Development Goal 3. The World Health Organization has recommended intermittent preventive treatment with sulfadoxine-pyrimethamine [IPTp-SP] for its control, but there are challenges to its access and uptake.

Methods

Using the Arksey and O'Malley framework and the cascade of care model, we conducted a scoping review to investigate barriers and facilitators of IPTp-SP access and uptake, including their influence on pregnant women's health-seeking behaviour for the control of malaria in pregnancy in Nigeria. We searched seven scientific databases for papers published from 2005 to date.

Results

We included a total of 31 out of 2149 articles in the review. Poor provider knowledge of the IPTp-SP protocol and lack of essential commodities for sulphadoxine-pyrimethamine administration in clinics are significant barriers to IPTp-SP use. Staff shortages and poor remuneration of health care professionals are obstacles to IPTp-SP utilisation.

Conclusions

To improve IPTp-SP access and uptake, the government should ensure a continuous supply to clinics and support the employment of additional health care professionals who should be well paid and trained on using the IPTp-SP protocol.

Differentials in prevalence and correlates on uptake of tetanus toxoid and intermittent preventive treatment with sulfadoxine-pyrimethamine during pregnancy: A community-based cross-sectional study in The Gambia

Objectives:

The study examined the differentials in prevalence and correlates on the uptake of tetanus toxoid and intermittent preventive treatment of malaria among pregnant women in The Gambia.

Methods:

The 2018 data from The Gambia Multiple Indicators Cluster Survey were analyzed. Data from 6143 women of reproductive age who have given birth were extracted for the analysis. Percentages and Chi-square tests were used. In addition, a multivariable logistic regression model was used to calculate the adjusted odds ratios (with a corresponding 95% confidence interval). The level of significance was set at p < 0.05.

Results:

The prevalence of tetanus toxoid uptake among women in The Gambia was 88.2%, while that of the adequate tetanus toxoid doses was 34.8%. The prevalence of intermittent preventive treatment with sulfadoxine-pyrimethamine uptake among maternal women in The Gambia was 98.6%, while that of the adequate intermittent preventive treatment with sulfadoxine-pyrimethamine doses taken was 34.3%. The identified statistically significant covariates of tetanus toxoid immunization and intermittent preventive treatment with sulfadoxine-pyrimethamine uptake includes women’s age, local government areas, parity, use of radio, use of newspaper, and antenatal care visits.

Conclusion:

The current utilization rate for adequate intermittent preventive treatment with sulfadoxine-pyrimethamine and tetanus toxoid immunization during pregnancy in The Gambia is very low and even below universal levels. The country needs to strengthen more and effective mass media advocacy programs that would target both rural and urban populace, and motivate maternal women to ensure adequate vaccination against malaria and tetanus.

Is improvement in indicators of women's empowerment associated with uptake of WHO recommended IPTp-SP levels in sub-Saharan Africa? A multilevel approach

OBJECTIVES

The global burden of malaria has reduced considerably; however, malaria in pregnancy remains a major public health problem in sub-Saharan Africa (SSA), where about 32 million pregnant women are at risk of acquiring malaria. The WHO has recommended that pregnant women in high malaria transmission locations, including SSA, have intermittent preventive treatment of malaria during pregnancy with at least three doses of sulphadoxine-pyrimethamine (IPTp-SP). Therefore, we investigated the prevalence of IPTp-SP uptake and associated individual-level, community-level and country-level predictors in SSA.

DESIGN

A cross-sectional survey was conducted using recent Demographic and Health Surveys datasets of 20 SSA countries. A total of 96 765 women were included. Optimum uptake of IPTp-SP at most recent pregnancy was the outcome variable. We fitted three-level multilevel models: individual, community and country parameters at 95% credible interval.

RESULTS

In all, 29.2% of the women had optimal IPTp-SP uptake ranging from 55.1% (in Zambia) to 6.9% (in Gambia). The study revealed a high likelihood of optimum IPTp-SP uptake among women with high knowledge (aOR=1.298, Crl 1.206 to 1.398) relative to women with low knowledge. Women in upper-middle-income countries were more than three times likely to have at least three IPTp-SP doses compared with those in low-income countries (aOR=3.268, Crl 2.392 to 4.098). We found that community (σ²=1.999, Crl 1.088 to 2.231) and country (σ²=1.853, Crl 1.213 to 2.831) level variations exist in optimal uptake of IPTp-SP. According to the intracluster correlation, 53.9% and 25.9% of the variation in optimum IPTp-SP uptake are correspondingly attributable to community-level and country-level factors.

CONCLUSIONS

The outcome of our study suggests that low-income SSA countries should increase budgetary allocation to maternal health, particularly for IPTp-SP interventions. IPTp-SP advocacy behavioural change communication strategies must focus on women with low knowledge, rural dwellers, married women and those who do not meet the minimum of eight antenatal care visits.

Active case detection of malaria in pregnancy using loop-mediated amplification (LAMP): a pilot outcomes study in South West Ethiopia

BACKGROUND

125 million women are pregnant each year in malaria endemic areas and are, therefore, at risk of Malaria in Pregnancy (MiP). MiP is the direct consequence of Plasmodium infection during pregnancy. The sequestration of Plasmodium falciparum parasites in the placenta adversely affects fetal development and impacts newborn birth weight. Importantly, women presenting with MiP commonly develop anaemia. In Ethiopia, the Ministry of Health recommends screening symptomatic women only at antenatal care visits with no formal intermittent preventive therapy. Since MiP can display low-level parasitaemia, current tests which include microscopy and RDT are challenged to detect these cases. Loop mediated isothermal Amplification (LAMP) technology is a highly sensitive technique for DNA detection and is field compatible. This study aims to evaluate the impact of active malaria case detection during pregnancy using LAMP technology in terms of birth outcomes.

METHODS

A longitudinal study was conducted in two health centres of the Kafa zone, South West Ethiopia. Both symptomatic and asymptomatic pregnant women were enrolled in the first or second trimester and allocated to either Standard of Care (SOC-microscopy and RDT) or LAMP (LAMP, microscopy and RDT). Women completed at least three visits prior to delivery, and the patient was referred for treatment if Plasmodium infection was detected by any of the testing methods. The primary outcome was to measure absolute birth weight, proportion of low birth weight, and maternal/neonatal haemoglobin in each arm. Secondary outcomes were to assess the performance of microscopy and RDT versus LAMP conducted in the field.

RESULTS

One hundred and ninety-nine women were included and assigned to either LAMP or SOC. Six were lost to follow up. In this cohort, 66.8% of women did not display any clinical symptoms and 70.9% were multi-parous. A reduced proportion of low birth weight newborns was observed in the LAMP group (0%) compared to standard of care (14%) (p <0.001). Improved neonatal haemoglobin was observed in the LAMP (13.1 g/dL) versus the SOC (12.8 g/dL) (p = 0.024) arm. RDT and microscopy had an analytical sensitivity of 66.7% and 55.6% compared to LAMP as a reference standard.

CONCLUSIONS

These results support the use of highly sensitive tools for rapid on-site active case detection of MiP which may improve birth outcomes in the absence of IPT. However, further large-scale studies are required to confirm this finding.

Malaria preventive practices and delivery outcomes: A cross-sectional study of parturient women in a tertiary hospital in Eastern Uganda

BACKGROUND

Uganda ranks third in the number of deaths attributable to malaria and has some of the highest recorded malaria transmission rates in the general population. Malaria in Pregnancy is associated with detrimental effects for the mother and unborn baby and these effects seem to have long term effects and consequences on the life of the baby. Despite the preventive measures put in place by the World Health Organization in antenatal care, the burden of malaria in pregnancy is still high. We determined the use of malaria preventive strategies during pregnancy and the presence of plasmodium infection, anemia, and low birth weight babies at delivery among parturient women at Mbale regional referral hospital in eastern Uganda.

METHODS

A cross-sectional study was conducted among 210 women delivering at MRRH between July 2017 and January 2018. Information on demographics, antenatal care, and prevention practices was collected using an interviewer-administered questionnaire. Maternal venous blood and cord blood samples were screened for Plasmodium infection by both microscopy of Giemsa-stained blood films and Plasmodium falciparum rapid diagnostic test (pf. HPR2 mRDT). Polymerase Chain Reaction (PCR) was done on cord blood. The presence of anemia was determined by the use of an automated hemoglobin analyzer. Data were analyzed using descriptive and analytical statistics.

RESULTS

Of the 210 women, 3 (1.4%) and 19(9.1%) tested positive for malaria by using Giemsa stained blood smear microscopy and malaria rapid diagnosticMRDT tests respectively. PCR detected 4(%) of Plasmodium in cord blood. Twenty-nine percent of the women had anaemia and 11 (5.2%) had low birth weight babies. Only 23.3% of the women received at least three doses of IPTp-SP and 57.9% reported sleeping under an Insecticide Treated Net the night before the survey. The women who reported sleeping under a mosquito net the previous night (OR 0.67, 95% CI: 0.24-1.86) and those who reported taking fansidar as a directly observed therapy (OR 0.31, 95% CI: 0.04-2.39) appeared to have few chances of getting plasmodium infection though the findings were not statistically significant.

CONCLUSION

The effective use of malaria preventive strategies (IPT-SP and Insecticide Treated Nets) was generally low. Most of the women took less than three doses of SP and there was no strict adherence to the recommended directly observed therapy. The prevalence of Plasmodium infection during pregnancy was low though maternal anaemia and low birth weight were relatively high.

Safety of Artemisinin Derivatives in the First Trimester of Pregnancy: A Controversial Story

Artemisinin combination therapy (ACT) is recommended by the World Health Organization (WHO) as first line treatment for uncomplicated malaria both in adults and children. During pregnancy, ACT is considered safe only in the second and third trimester, since animal studies have demonstrated that artemisinin derivatives can cause foetal death and congenital malformation within a narrow time window in early embryogenesis. During this period, artemisinin derivatives induce defective embryonic erythropoiesis and vasculogenesis/angiogenesis in experimental models. However, clinical data on the safety profile of ACT in pregnant women have not shown an increased risk of miscarriage, stillbirth, or congenital malformation, nor low birth weight, associated with exposure to artemisinins in the first trimester. Although further studies are needed, the evidence collected up to now is prompting the WHO towards a change in the guidelines for the treatment of uncomplicated malaria, allowing the use of ACT also in the first trimester of pregnancy.

Coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) influences delivery outcomes among women with obstetric referrals at the district level in Ghana

Background

The aim of the study was to determine the coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) and its relationship with delivery outcomes among obstetric referral cases at the district level of healthcare.

Methods

An implementation research within three districts of the Greater Accra region was conducted from May 2017 to February 2018, to assess the role of an enhanced inter-facility communication system on processes and outcomes of obstetric referrals. A cross-sectional analysis of the data on IPTp coverage as well as delivery outcomes for the period of study was conducted, for all the referrals ending up in deliveries. Primary outcomes were maternal and neonatal complications at delivery. IPTp coverage was determined as percentages and classified as adequate or inadequate. Associated factors were determined using Chi square. Odds ratios (OR, 95% CI) were estimated for predictors of adequate IPTp dose coverage for associations with delivery outcomes, with statistical significance set at p = 0.05.

Results

From a total of 460 obstetric referrals from 16 lower level facilities who delivered at the three district hospitals, only 223 (48.5%) received adequate (at least 3) doses of IPTp. The district, type of facility where ANC is attended, insurance status, marital status and number of antenatal clinic visits significantly affected IPTp doses received. Adjusted ORs show that adequate IPTp coverage was significantly associated with new-born complication [0.80 (0.65–0.98); p = 0.03], low birth weight [0.51 (0.38–0.68); p < 0.01], preterm delivery [0.71 (0.55–0.90); p = 0.01] and malaria as indication for referral [0.70 (0.56–0.87); p < 0.01]. Positive association with maternal complication at delivery was seen but was not significant.

Conclusion

IPTp coverage remains low in the study setting and is affected by type of health facility that ANC is received at, access to health insurance and number of times a woman attends ANC during pregnancy. This study also confirmed earlier findings that, as an intervention IPTp prevents bad outcomes of pregnancy, even among women with obstetric referrals. It is important to facilitate IPTp service delivery to pregnant women across the country, improve coverage of required doses and maximize the benefits to both mothers and newborns.

Correlates of uptake of optimal doses of sulfadoxine-pyrimethamine for prevention of malaria during pregnancy in East-Central Uganda

Background

In 2012, the World Health Organization recommended that pregnant women in malaria-endemic countries complete at least three (optimal) doses of intermittent preventive treatment (IPTp) using sulfadoxine-pyrimethamine (SP) to prevent malaria and related adverse events during pregnancy. Uganda adopted this recommendation, but uptake remains low in East-Central and information to explain this low uptake remains scanty. This analysis determined correlates of uptake of optimal doses of IPTp-SP in East-Central Uganda.

Methods

This was a secondary analysis of the 2016 Uganda Demographic Health Survey data on 579 women (15–49 years) who attended at least one antenatal care (ANC) visit and had a live birth within 2 years preceding the survey. Uptake of IPTp-SP was defined as optimal if a woman received at least three doses; partial if they received 1–2 doses or none if they received no dose. Multivariate analysis using multinomial logistic regression was used to determine correlates of IPTp-SP uptake.

Results

Overall, 22.3% of women received optimal doses of IPTp-SP, 48.2% partial and 29.5% none. Attending ANC at a lower-level health centre relative to a hospital was associated with reduced likelihood of receiving optimal doses of IPTp-SP. Belonging to other religious faiths relative to Catholic, belonging to a household in the middle relative to poorest wealth index, and age 30 and above years relative to 25–29 years were associated with higher likelihood of receiving optimal doses of IPTp-SP.

Conclusions

In East-Central Uganda, uptake of optimal doses of IPTp-SP is very low. Improving institutional delivery and household wealth, involving religious leaders in programmes to improve uptake of IPTp-SP, and strengthening IPTp-SP activities at lower level health centers may improve uptake of IPTp-SP in the East-Central Uganda.