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

Malaria-Related Psychosocial Factors, Past Antenatal Care-Seeking Behaviors, and Future Antenatal Care-Seeking Intentions by Maternal Age in Malawi and Democratic Republic of the Congo

Young women in sub-Saharan Africa are a group at increased risk for malaria in pregnancy. Early antenatal care (ANC) seeking makes it more likely that women will receive the recommended doses of intermittent preventive treatment of malaria in pregnancy. This study used data from national Malaria Behavior Surveys conducted in Malawi and the Democratic Republic of the Congo (DRC) in 2021 to explore the association between intention to attend ANC in the first trimester for a future pregnancy (early ANC intention) and psychosocial factors among women aged 15-49 years. Eight psychosocial factors related to ANC and based on the ideation model were included, including knowledge, attitudes, and self-efficacy. The study used multivariable logistic regression models controlling for demographic characteristics to evaluate associations between early ANC intention and the individual ideational factors and the composite measure. Analysis included 2,148 women aged 15-49 years (Malawi: 827, DRC: 1,321). Antenatal care ideation was lower among young (aged 15-20 years) than among older (aged 21-49 years) women in Malawi. Young mothers with higher ANC ideation were more likely to intend to attend ANC early in their next pregnancy in both countries. Specific ideational factors associated with intention to attend ANC early varied by country and included positive attitudes, knowledge of ANC, and positive self-efficacy. In Malawi and the DRC, youth-friendly social and behavior change interventions to increase ANC-related ideation could increase future early ANC attendance among young women to improve malaria and birth outcomes.

Pregnancy and malaria: the perfect storm

PURPOSE OF REVIEW

Malaria in pregnancy continues to exert a toll on pregnant women and their offspring.

RECENT FINDINGS

The burden of Plasmodium falciparum infection is especially large in Africa, and new data show lasting effects of maternal infection on the infant's neurocognitive development. Elsewhere, P. vivax infection causes relapsing infections that are challenging to prevent. Infection in first trimester of pregnancy is an area of increasing focus, and its adverse effects on pregnancy outcome are increasingly recognised. First-trimester infection is common and frequently acquired prior to conception. Although newer rapid diagnostic tests still have limited sensitivity, they may be useful in detection of early pregnancy malaria for treatment. Artemisinin-based combination therapies are efficacious in later pregnancy but have yet to be recommended in first trimester because of limited safety data. In Africa, intermittent preventive treatment in pregnancy (IPTp) with monthly sulfadoxine-pyrimethamine improves pregnancy outcomes, but sulfadoxine-pyrimethamine resistance is worsening. The alternative, IPTp with dihydroartemisinin-piperaquine, has greater antimalarial efficacy, but does not appear to improve pregnancy outcomes, because sulfadoxine-pyrimethamine has poorly understood nonmalarial benefits on birthweight.

SUMMARY

Novel IPTp regimens must be combined with interventions to strengthen protection from malaria infection acquired before and in early pregnancy.

The moderating role of partners' education on early antenatal care in northern Ghana

BACKGROUND

Early antenatal care (ANC) is essential for improving maternal and child health outcomes. The primary aims of this study were to 1) estimate the association between partners' education attainment and early ANC, and 2) determine whether partners' level of education modified the relationship between mothers' education, mothers' age, planned pregnancy, employment status and early ANC.

METHODS

Data were obtained from a cross-sectional study conducted from April to May 2021 among 519 mothers with a live birth in the past year in the Nabdam district in the Upper East Region in northern Ghana. Generalized estimating equations were used to assess whether partners' level of education modified the relationship between mothers' education, mothers' age, planned pregnancy, employment status and early ANC. Effect modification was assessed on the additive and multiplicative scales using adjusted prevalence ratios (aPR) and corresponding 95% confidence intervals.

RESULTS

Mothers whose partners had secondary or higher education had a 26% higher prevalence of early ANC compared to mothers whose partners had less than a secondary level of education (aPR: 1.26, 95% CI: 1.05,1.51). There was evidence of effect modification by partners' education on the relationship between planned pregnancy and early ANC on both the additive (Relative excess risk due to interaction [RERI]: 0.61, 95% CI: 0.07,0.99), and multiplicative (ratio of PRs: 1.64, 95% CI: 1.01,2.70) scales. Among mothers whose partners had less than secondary education, mothers who had teenage pregnancy (i.e., aged 18-19 years old during pregnancy) were less likely to have early ANC compared to those who did not have teenage pregnancy (aPR: 0.71, 95% CI: 0.53,0.97). Among mothers whose partners had a secondary or higher education, early ANC was more prevalent among employed mothers compared to those who were unemployed (aPR: 1.27, 95% CI: 1.02,1.57).

CONCLUSIONS

Our findings suggest that whilst mothers whose partners had a secondary or higher education were more likely to initiate early ANC, supporting such women to plan their pregnancies can further increase the coverage of early ANC.