Category Archives: Malaria in Pregnancy

Acceptance of the Contribution of Community-Based Health Workers (CBHWs) to Improving Prevention of Malaria in Pregnancy in Burkina Faso by Health Center Staff

Efforts are underway to test the a community-based system for providing IPTp to pregnant women in Burkina Faso as a means of increasing coverage. Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Yacouba Savadogo, Danielle Burke, Susan Youll, and William Brieger share a formative study among health staff concerning their perceptions of the ability of Community Based Health Workers to provide increased doses. This was presented at the 7th Multilateral Initiative for Malaria Conference in Dakar. Below are the findings.

The Burkina Faso Ministry of Health, with support from its partners, initiated a study on the feasibility of increasing provision of intermittent preventive malaria treatment in pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP). Existing community-based health workers (CBHWs) were enlisted to deliver the third and fourth doses recommended by the World Health Organization. Currently, only facility-based health care providers give SP, and women in rural areas have trouble accessing health facilities for the medicine.

Using CBHWs has the potential to reach more women with a greater number of doses of IPTp-SP. Direct training and supervision of CBHWs is the responsibility of frontline health care staff, including antenatal care (ANC) providers. Therefore, to ensure a successful rollout of community delivery of IPTp, it is crucial that these staff accept the new roles of CBHWs. This baseline study was conducted to learn the frontline staff’s views about existing and proposed CBHW activities.

Study’s Geographic Areas. Three districts (Batié, Pô, and Ouargaye) in the southern part of Burkina Faso. Twelve centre de santé et de promotion sociale (health and social promotion centers [CSPS]) were selected in Ouargaye, Pô, and Batié Health Districts. In each district, two CSPS were randomly assigned as intervention catchment areas, for a total of six centers. Then using matching criteria, the remaining six CSPS were designated as control sites.

Health Worker Interviews were conducted among a total of 35 CSPS staff: 23 were men, and 12 were women. Semi-structured interview guides were used in this formative study. Open-ended questions sought the views of ANC providers and CBHW supervisors about the current work of CBHWs and the feasibility of using this health cadre to administer IPTp to pregnant women. The Study sought to understand provider opinions to design an IPTp-SP intervention involving CBHWs.

Qualitative analysis identified common themes in the open-ended responses. Providers like the CBHW program, noting that “CBHWs come from the community” and help with language barriers. However, CBHWs are not always available or move frequently from one community to another. A few male providers noted issues with timely payment of stipends to CBHWs.

Most providers were open to CBHWs providing IPTp-SP to pregnant women: “It will reduce [our] workload.” Unlike female providers, some male providers stressed the need for CBHWs to be “well trained.”

Providers commented that CBHWs were needed and could contribute. For example CBHWs could increase the uptake of IPTp-SP, prevent deaths and malaria, educate women and the community, and prevent stock-outs of SP. While CBHWs do not currently provide IPTp-SP, several providers noted that CBHWs already conduct community education sessions with pregnant women on taking IPTp-SP.

A few noted that CBHWs already monitor adherence to IPTp-SP doses and send women to the health facility when doses are needed. Providers expressed the importance of including information on malaria prevention and treatment, IPTp-SP administration, stock management, and data collection in the CBHW training.

The findings guided discussions and planning with both district and CSPS staff in the design of the CBHW training and IPTp-SP intervention. The results led to development of the training-of-trainers process that started with the district health team, who then trained CSPS staff—the CSPS staff then trained CBHWs.

Gaining the frontline staff’s acceptance of and perceptions about CBHWs—and building on them—will hopefully lead to greater ownership and better management of project implementation at the community level.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID, PMI, or the United States Government.

Community-Based Health Workers in Burkina Faso: Are they ready to take on a larger role to prevent malaria in pregnancy?

Community Based Health Worker (CBHW) opinions were sought prior to establishing community delivery of intermittent preventive treatment of malaria in pr4egnancy in Burkina Faso. Bill Brieger, Danielle Burke, Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Yacouba Savadogo, and Susan Youll report on the findings from the CBHWs at the 7th Multilateral Initiative for Malaria Meeting in Dakar.

In 2012 and 2013, World Health Organization recommended that a minimum of three doses—rather than two doses—of intermittent preventive treatment of malaria in pregnancy (IPTp). This three-dose recommendation has made it more challenging to achieve the 85% national coverage target in Burkina Faso. Existing health services in other endemic countries have also had difficulty achieving the two-dose target. Using a formative approach, this study tested if the 85% target could be achieved by having IPTp delivered to the community through trained community-based health workers (CBHWs) who are supervised by the health system.

Existing training materials for these CBHWs outline a basic role in promoting antenatal care (ANC) and guiding communities to use curative and preventive malaria services. The question was to what extent are the CBHWs practicing what they were taught, and could training in community delivery of IPTp build on their existing roles.

Because of continuous malaria transmission, these three districts in the southern part of Burkina Faso were chosen for the intervention study: Batie, Po, and Ouargaye. Also in these three districts, community health workers have been involved in the implementation of other programs, such as immunization, malaria, nutrition, and family planning.

As part of this formative study to design the community-based IPTp intervention, semi-structured interviews were conducted with CBHWs in three health districts (Batie, Po, and Ouargaye) with a high malaria burden. In general, the Directorate of Health Promotion in the Ministry of Health encourages communities to select one male and one female CBHW, although the actual CBHWs chosen would depend on availability and literacy of the CBHW.

In each district, four centre de santé et de promotion sociale (health and social promotion centers [CSPS] were selected, and their catchment areas were divided among intervention and control groups. Effort was made to reach all CBHWs currently practicing in these 12 catchment areas. Numerical and narrative data were entered in a database and analyzed by gender based on major themes relating to ANC, pregnancy, and malaria services. Interview transcripts were manually reviewed for themes.

Of the CBHWs interviewed, a total of 62 were male and 42 were female.  Both female and male CBHWs provide advice and education to women in their villages, which may include advising women to go to the CSPS for pregnancy or ANC, family planning, immunization, or illness. Some CBHWs stated that they remind women about follow-up ANC appointments. As one female CBHW explained, “on their return [from CSPS for care], I ask [the pregnant woman] what has been said and I shall ensure they practice this.”

A male CBHW noted that he “direct[s] women, in case of amenorrhea, [to] go to CSPS to check for pregnancy, to [receive] follow[-up] care, and be in good health.” Many male CBHWs were likely to mention malaria-related activities, including education about causes and prevention of malaria. A few male CBHWs talked about helping people recognize malaria, seek treatment, and comply with recommended medicine regimens.

A few male and female CBHWs specifically mentioned encouraging women to take sulfadoxine-pyrimethamine for IPTp. Some reported involvement in distributing bed nets. In contrast to the male CBHWs, some female CBHWs may even accompany women to ANC to ensure that the women receive services.

Some challenges were faced by CBHWs. At least a third of the CBHWs noted difficulties in carrying out their work, but they also had encouragements: “Acceptance by the community of my activities facilitates the task.” “Nothing is easy, but with the understanding of people, there are no problems.” While officially, CBHWs were to receive a stipend, one CBHW explained that “nothing is easy, especially that I am not paid for all these activities.” Others also noted that “for the moment, there is nothing that is easy as we lack the tools [for the job].”

CBHWs report being active in promoting the health of pregnant women and encouraging women and the community to prevent and treat malaria. Although their training stresses postnatal care, this area was not mentioned during interviews. Likewise, CBHWs did not address the danger signs of malaria in pregnancy during the interviews, which is in their training. Female CBHWs were more likely to encourage pregnant women to attend ANC at CSPS and follow up with them after the visit, while the male CBHWs were more focused on providing health information. Logistical challenges and payment of stipends need to be addressed before adding more duties for the CBHW to complete. Overall, CBHWs are positioned to deliver IPTp under the supervision of CSPS staff.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID, PMI, or the United States Government.

Improved IPTp Uptake: MCSP Restoration of Health Services Experience in Liberia

Nyapu D.Taylor, Birhanu Getahun,Topian Zikeh, Anne Fiedler, and Allyson Nelson of the USAID supported Maternal and Child Survival Program/Jhpiego in Liberia are presenting their project aimed at strengthening health services in Liberia to improve uptake of Intermittent preventive treatment of malaria in pregnancy at the 7th Multilateral Initiative for Malaria in Dakar this week. Below are a description of their work and their main findings.

Mother and baby in Liberian Government Hospital, Grand Bassa County, Liberia. Photo by Kate Holt, Jhpiego.

In Liberia more than 170,000 pregnancies occur each year. Provision of two or more doses of SP for IPTp (IPTp2+) merely increased from 50% 2016. Provision of the three or more doses of

IPTp (IPTp3+) remains at 22%.Liberia adopted WHO’s IPTp3+ guideline but it is not practiced all over the country. There is a gap in the competency of the health care workforce. There are recurring stock-outs of SP.The Maternal and Child Survival Program (MCSP) Restoration of Health Services (RHS) intended to address these challenges. Project

Objectives included Prevention at facilities by strengthening infection prevention and control (IPC) practices at 77 health facilities through training, intensive supportive supervision, triage, improvement of waste management, and provision of essential IPC commodities and supplies.  Also the project aimed to Increase utilization of and demand for maternal and child health services bu restoring delivery of quality primary health care services through implementation of integrated reproductive, maternal, newborn, child, and adolescent health as part of the Essential Package of Health Services in 77 facilities.

MCSP RHS supported health facilities in three counties:

  • Grand Bassa: 30 (91% of health facilities in county)
  • Lofa: 17 (27% of health facilities in county)
  • Nimba: 30 (46% of health facilities in county)

Population coverage was 900,000 or 20% of population. This included 45,000 pregnancies per year. The Project timeline is September 2015–June 2018. The quality improvement process used in the project is seen in the attached diagram.

Several achievements were documented. Adherence to malaria clinical standards improved from 25% at baseline to 100% at endline in 39 MCSP-supported facilities—sampled at endline (see Figure 1). Adherence to malaria clinical standards improved substantially from baseline to endline in 39 MCSP-supported facilities—sampled at endline (see Figure 2). Increasing uptake of IPT2+ in the 77 RHS facilities has been observed since the inception of the project (see Figure 3).

The project met and dealt with several challenges. Health facilities were sporadically stocked with SP and mosquito nets (another component of malaria in pregnancy services). Bad roads prevented travel to field during rainy seasons. This affected distribution of malaria supplies and provision of mentorship and supervision for quality service. Clients had huge difficulty accessing health facilities.

Among the lessons learned were that close collaboration and involvement of key actors, especially MOH (National Malaria Control Program) and country health team at all levels, is an effective and efficient approach for project implementation. Regular mentorship and coaching during supportive supervision improves the quality of care provided for malaria in pregnancy. Ensuring availability of IPTp drugs and long-lasting insecticidal nets at health facilities are key to preventing malaria in pregnancy.

In conclusion the project met IPC objectives and achieved 80% Safe, Quality, Health Services score. Thus there was improved service delivery utilization.

The poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

Multilateral Initiative for Malaria (MIM) – Jhpiego Presents in Dakar

The 7th Pan African Malaria Conference holds from 15-20 April 2017, Dakar, Senegal. The conference celebrates 20 years since the initial establishment of the Multilateral Initiative on Malaria (MIM) by the Tropical Disease Research Program and partners.

During the conference next week, staff from Jhpiego malaria projects in Burkina Faso, Liberia, Nepal, Madagascar and Cameroon will share oral and poster presentations to highlight their work. Below is a list along with the location numbers.

  • Application d’un Audit de la Qualité des données (DQA) du paludisme dans le District Sanitaire de Kribi, Cameroun, SS-13 Oral
  • Contribution des Agent de Santé Communautaire (ASC) à l’amélioration de la prévention et la prise en charge du paludisme dans le district de Kribi, Cameroun, B-40 Poster
  • MOH’s effort in developing and implementing Quality Assurance plan (QAP) for Global Fund-supported antimalarial drugs: A case study of Nepal in the context of malaria elimination, C-107 Poster
  • Community-Based Health Workers in Burkina Faso: Are they ready to take on a larger role to prevent malaria in pregnancy? D-115 Poster
  • Contribution of Community-Based Health Workers (CBHWs) to Improving Prevention of Malaria in Pregnancy in Burkina Faso: Review of health worker perceptions from the baseline study D-118 Poster
  • Malaria in Pregnancy: The Experience of MCSP in Liberia, D-140 Poster
  • Improved Malaria Case Management of Under-Five Children: The Experience of MCSP-Restoration of Health Liberia project D-141 Poster
  • Experiences and perceptions of care seeking for febrile illness among caregivers, pregnant women and health providers in eight districts of Madagascar D-142 Poster

Abstracts will be shared here on the day of each presentation for those unable to attend MIM. Also check Jhpiego at Exhibit Booth 148.

Prof Lateef A Salako, 1935-2017, Malaria Champion

Professor Lateef Akinola Salako was an accomplished leader in malaria and health research in Nigeria whose contributions to the University of Ibadan and the Nigeria Institute for Medical Research (among others) advanced the health of the nation, the region and the world. His scientific research and his over 140 scientific publications spanned five decades.

His research not only added to knowledge but also served as a mentoring tool to junior colleagues. Some of his vast areas of interest in malaria ranged from malaria epidemiology, to testing the efficacy of malaria drugs to tackling the problem of malaria in pregnancy. He led a team from three research sites in Nigeria that documented care seeking for children with malaria the acceptability of pre-packaged malaria and pneumonia drugs for children that could be used for community case management. Prof Salako was also involved in malaria vaccine trials and urban malaria studies.

As recent as 2013 Prof Lateef Salako, formerly of NIMR said: “It is true there is a reduction in the rate of malaria cases in the country, but to stamp out this epidemic there is the urgent need for a synergy between researchers, the government, ministries, departments and agencies and involved in malaria control. That will enable coordinated activities that will produce quicker results than what obtains at the moment.”

At least one website has been set up where people can express their condolences.  As one person wrote, “Professor Lateef Salako was an exceptional student, graduating with distinction from medical school; an unforgettable teacher, speaking as a beneficiary of his tutelage; an exemplary scholar, mentoring many others; an accomplished scientist, making indelible contributions to knowledge. May his legacy endure.”

Readers are also welcome to add their own comments here about Prof Salako’s contribution to malaria and tropical health.

Improving intermittent preventive treatment for pregnant women (IPTp) coverage in 5 districts in Chad and Cameroon

Kodjo Morgah and Naibei Mbaïbardoum of Jhpiego with support from the ExxonMobil Foundation ave been working to increase interventions that protect pregnant women from malaria. The results below were shared at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria is the leading cause of morbidity and mortality in Cameroon and Chad, where an estimated 500,000 and 1.5 million cases occur every year, respectively. In Cameroon, 55% of hospitalizations and 241 deaths among pregnant women reported in 2010 were due to malaria. In Chad, malaria accounted for 30% of hospital admissions and 41% of deaths among pregnant women in 2013.

To improve uptake of intermittent preventive treatment for pregnant women (IPTp) for malaria in 5 districts in Chad and the Kribi district of Cameroon, Jhpiego adopted strategies targeting the 4 levels of the health system in each country: updating national policies and guidelines, building capacity of providers, building community health workers’ (CHWs) capacity, and engaging in behavior change communication.

Nationally, Jhpiego provided technical guidance to the Ministries of Health to develop tools including: training and malaria in pregnancy (MIP) reference manuals for providers and CHWs, guidelines on IPTp, and key supervision and data collection tools. At the regional/district levels, 38 supervisors were trained, and they conducted 248 supervisory visits in both countries, reaching 137 health facilities.

At the facility level, 234 providers were trained in malaria prevention and management, MIP, data collection and commodity management. At the community level, 146 CHWs in both countries were trained to raise awareness on malaria prevention and control.

In Chad, CHWs referred 6424 pregnant women for antenatal care/IPTp and 11679 pregnant women for malaria treatment in 2014 and 2015. Health facility and CHW data collection tools were revised and monthly validation of district data was implemented to improve data reliability, completeness, and readiness.

As a result of Jhpiego’s activities in Kribi, IPTp rates increased from the start of the project in 2012 to 2015: from 70% to 83% (IPTp1), 61% to 80% (IPTp2), and 12.7% to 28.1% (IPTp3). Similarly, from 2012 to 2015 in Chad, IPTp1 rates increased from 40% to 83% and from 30% to 50% for IPTp2. These gains are a result of training paired with coaching and supervision activities of trained providers and targeted facilities.

 

Results of an evaluation of the Toolkit to Improve Early and Sustained Intermittent Preventive Treatment in Pregnancy (IPTp) Uptake in Mozambique and Madagascar

Lalanirina Ravony, Elana Fiekowsky, Lisa Noguchi, Patricia P. Gomez, Jean Pierre Rakotovao, Eliane Razafimandimby, Armindo Tiago, Kathryn Smock, Arsene Ratsimbarisoa, Kristen Vibbert, and Robert Sellke shared their efforts to apply a toolkit to enable health providers to ensure better uptake of intermittent preventive treatment for malaria during antenatal clinics. As seen below, they presented their findings at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria in pregnancy (MIP) is a leading cause of maternal and newborn morbidity and mortality; however uptake of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP), an effective prevention tool, remains alarmingly low across sub-Saharan Africa, including Mozambique and Madagascar.

The WHO 2012 policy recommendations to prevent MIP include early enrollment into antenatal care (ANC), accurate estimation of gestational age (GA) and administration of IPTp-SP during ANC visits beginning early in the second trimester, spaced at least one month apart. Preventing MIP remains a challenge in settings with inconsistent application of these recommendations and inadequate provider training in estimating GA.

To improve adherence to these recommendations, a toolkit was designed which includes a job aid with an algorithm to guide providers during ANC visits to determine IPTp-SP eligibility. Twenty-four providers from 24 facilities in Madagascar and 29 providers from seven facilities in Mozambique were trained on use of the job aid and interviewed three months later about their experience.

Individual providers were interviewed using a questionnaire to assess the clarity and utility to the job aid, and their opinions of the practicality of the orientation. Interviewers also gathered information on years of experience and clinical certification. All providers reported that the job aid reminded them to estimate GA and measure fundal height, which is particularly helpful since few women remember the date of their last menstrual period (LMP).

Health workers also reported that the job helped them encourage the use of long-lasted insecticide treated nets, and reminded them of the proper timing to start IPTp-SP. We conclude that the toolkit is useful to prompt providers to calculate GA and offer IPTp as early as possible in the second trimester.

Future potential directions include revision of all Toolkit components to reflect input from this evaluation, including development of a wall poster version to enhance readability, and inclusion of a pregnancy wheel to facilitate calculation of GA and estimated date of delivery.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

Results from a Formative Evaluation of the Malaria in Pregnancy Case Management Job Aid in Nigeria

Job Aids can provide valuable assistance to health workers, but it is important to evaluate if they serve the intended purpose.  With support from USAID’s Maternal and Child Survival Program, Bright Orji, Enobong Ndekhedehe, Elana Fiekowsky, Patricia Gomez, Aimee Dickerson, Reena Sethi, Bibian Udeh, Kristin Vibbert, and Robert Sellke reported at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene on their evaluation of a Job Aid for Nigeria on the prevention of malaria in pregnancy as seen below.

Annually, nearly 7 million pregnant women in Nigeria are at risk of malaria in pregnancy (MIP). Although antenatal care is the platform for the prevention and treatment of MIP, malaria is also treated at outpatient departments.

It is known that women of reproductive age (WRA) are often treated for malaria without assessing pregnancy status, although artemisinin combination therapies are contraindicated in the first trimester of pregnancy, and many pregnant women do not receive the recommended low cost interventions.

In order to increase access to these MIP interventions, the President’s Malaria Initiative supported the Maternal and Child Survival Program and partners to develop a two-page job aid for case management of uncomplicated malaria among WRA. In collaboration with the Nigeria Malaria Elimination Program, the job aid was evaluated in Ebonyi State, a high malaria burden area, to determine providers’ perceptions of its clarity, acceptability, and utility.

A half-day workshop on use of the job aid was provided to 35 health workers (nurses – 20%; nurse-midwives – 20%; community health extension workers – 48%; and medical doctors – 12%) already trained on MIP case management, selected from 15 facilities where WRA seek care. After 3 months of use, a one-page questionnaire was administered to 34 health workers.

One-hundred percent stated that the job aid helped them to do the following: identify pregnant women among the WCBA presenting with fever; use rapid diagnostic tests to diagnose malaria; and treat uncomplicated MIP. Sixty-eight percent used the job aid to provide correct treatment for severe malaria and 88% used it while providing services all or most of the time.

The results indicated that after a half-day orientation on use of the job aid, health workers were able to use it to help them identify women who may be pregnant and provide appropriate treatment for uncomplicated MIP. They are also able to explain its use to colleagues.

It is suggested that a poster-size version could be printed and disseminated to appropriate cadres of health workers in clinics where WRA seek care for fever, as it is anticipated that providers could benefit from its use.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

Using the Antenatal Care Quality Improvement Tool and targeted training to strengthen ANC Services including MiP in Tanzania

Malaria prevention in pregnancy (MIP) is a major component of antenatal services in endemic countries. Jasmine Chadewa, Dunstan Bishanga, Elaine Roman, Godlisten Martin, Kristen Vibbert, Lauren Borsa, Agrey Mbilinyi, Jeremie Zoungrana, and Hussein Kidanto describe how they applied a quality improvement tool to strengthen ANC and MIP services at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings follow:

Malaria in Pregnancy (MiP) is a major, preventable cause of maternal morbidity and poor birth outcomes. In collaborations with partners, Tanzania’s National Malaria Control Program (NMCP) and the Reproductive and Child Health Unit has been working to promote the World Health Organization’s three-pronged approach to address the burden of MiP.

A malaria training for 180 supervisors and 360 ANC providers from 221 health facilities was conducted in the Kagera and Mara regions. Updates included an orientation on MiP as well as malaria case management, screening, data management and ITN promotion.
Prior to the training, facility baseline assessments were conducted using the Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) antenatal care quality improvement (ANC QI) tool to identify gaps in knowledge and skills of health providers to better target trainings to improving the quality of ANC services.

A second assessment took place six months post training. Both assessments included hospital, health facility and dispensary levels and included observation, interviews, record reviews and skills assessments.

Results demonstrated that over 90% of the facilities scored below 30% across all categories in the overall baseline assessment with a high score of 35 %, while the 2nd assessment showed a large improvement with 40% of the facilities scoring below 30% and a high score of 70%.

The ANC QI tool is effective in determining the impact of ANC health provider’s knowledge and skills to target training to improve ANC service quality.

The presentation was made possible through support provided to the USAID Boresha Afya Project, under the terms of the Cooperative Agreement AID-621-A-16-00003 by the President’s Malaria Initiative via the United States Agency for International Development (USAID), an inter-agency agreement with Centers for Disease Control and Prevention (CDC). The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the President’s Malaria Initiative via the US Agency for International Development.

Missed Opportunities for Uptake of Intermittent Preventative Treatment for Malaria in Pregnancy in Tanzania

A major reason that coverage targets for intermittent treatment of malaria in pregnancy fall short are missed opportunities at health service sites. Jasmine Chadewa, Yusuph Kulindwa, Dunstan Bishanga, Mary Drake, Jeremie Zoungrana, Elaine Roman, Hussein Kidanto, Naomi Kaspar, Kristen Vibbert, and Lauren Borsa share what they have learned about this issue at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

About 35 million people in Tanzania are at risk of malaria, with pregnant women and under five children being the most vulnerable. The Tanzania National Malaria Control Program’s (NMCP) Strategic Plan for 2007–2012 reports that malaria accounts for 30% of the national disease burden, with about 1.7 million cases per year among pregnant women.

To prevent the effect of malaria in pregnancy, the Tanzania Government adopted IPTp3+ therapy for pregnant women per the WHO recommendations for IPTp-SP. This study explores missed opportunities to deliver IPT by looking at predictors causing the drop between coverage of IPTp2 (34%) and IPTp3+ (7%).

The study examined Tanzania Demographic and Health Survey (TDHS) 2015/2016 data on women aged 15-49 with a live birth in the two years preceding the survey and at least 2 doses or more of IPTp during ANC (n=4219) to identify factors associated with differences in IPTp uptake. Variables of interest were identified, recoded and generated as required. Data was analyzed using STATA v14, whereby frequency distributions were calculated and cross-tabs and logistic regressions were done comparing dependent and independent variables.

The analysis shows the factors contributing to the drop of IPTp uptake include wealth (the richest people are 2.5 times more likely to take at least three doses of IPTp) and education (those with no education are less likely to take more doses of IPTp compared to those who are educated). Residency is the largest contributing factor: 50% of pregnant mothers in rural areas are less likely to take three or more doses of SP.

Clients living within 5 km of health facilities have higher uptake of IPTp3+ compared to their counterparts who live further from the health facilities (33% less likely). However, our analysis shows that there is no correlation between IPTp3+ uptake and number of ANC visits, health insurance or number of children.

Based on these results, it is important to strategize to make health services and education more accessible to the population in order to increase IPTp uptake among pregnant women.