Intermittent Preventive Treatment: Community and/or Clinic?

This posting looks at some of the issues in the debate of whether Intermittent Preventive Treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) should be based on a platform of Antenatal Care (ANC) or delivered through community volunteers or even a combination of strategies. (References for the information provided herein are found as an attached comment.) Roll Back Malaria has set minimum target 80% coverage of two IPTp doses (IPTp2) by 2010, but even though a high proportion of African women attend ANC during pregnancy, IPTp2 coverage is below target.

Those in favor of a community approach believe this is the best way to reach out to all women and achieve the 2010 high coverage targets. Those against the idea think that community distribution will detract from ANC attendance and deprive women of the services that come with ANC and thus, adversely affect women’s health.

prema-sm.jpgWhat is actually feasible? Eckert, Hyslop and Snow analyzed recent Demographic and Health Survey data from 20 African countries to see what proportion of pregnant women attended ANC in a way that was compatible with receiving two doses of IPTp. This ranged from 17-91% with a median of 70%. Even when ANC attendance seems good, IPTp2 coverage may not meet targets as for example in Malawi a in 2004 where 78% received one dose of SP but only 47% got two doses. Even more discouraging was a study from Kenya which reported that while 91.9% of pregnant women made more than one ANC visit, only 19.1% received IPTp1 and 6.8% received more than one dose.

Different studies have identified factors associated with not receiving IPTp2. These are a combination of system and personal variables as seen below. Some may be addressed through quality improvement of ANC services while others might require a community based strategy.

  • Charges at some types of facilities
  • Health worker confusion about spacing of IPTp doses
  • Less access and utilization in rural compared to urban areas
  • Clinic logistics including overcrowding, lack of resources to provide clean water and inadequate supply/distribution systems
  • Community perceptions about side effects and need to take with food
  • Late first registration
  • Being multigravida

Alternatively a pilot community based distribution in Malawi achieved 95% IPTp2 coverage, and another in Uganda reached 67.5% for IPTp2 among the community distribution group compared to 39.9% in the control group. The former may have detracted from ANC attendance while the latter apparently did not make a difference in ANC utilization.

As resistance to SP grows, health programs are not abandoning the drug, but may start to give it monthly. This may put additional pressure on coverage based solely on ANC attendance. The solution appears to lie first in a thorough situation analysis of the current levels of ANC acceptance and factors influencing IPTp delivery. In cases with existing high levels of ANC attendance strengthening ANC quality may be the best approach, while in those with low attendance, a community approach may be needed. Ultimately a combination may work best, but programs need to be flexible to investigate what is appropriate in each setting.

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