With an eye toward the future Nigeria’s National Malaria Control Program also refers to itself as the National Malaria Elimination Program (NMEP). Given that Nigeria has the highest burden of malaria in Africa, along with around one-quarter of sub-Saharan Africa’s population, the elimination goal will take a lot of work.
Recently the 2015 Malaria Information Survey (MIS) for Nigeria was released and gives a perspective on how far we have some and how far we need to go. We will focus on malaria in pregnancy (MIP) interventions today.
Intermittent Preventive Treatment for pregnant women (IPTp) using sulfadoxine-pyrimethamine (SP) remains the key MIP intervention due to the high and stable malaria transmission that still persists. There is always a challenge in delivering health interventions that require multiple contacts, and IPTp is not exception. The difficulty in achieving two doses when that was policy was clear. Now that WHO recommends monthly dosing from the second trimester forward (giving the possibility of 3, 4 or more doses), the service delivery challenge is heightened.
We can see in the attached graph from the MIS report that while there is progress, it remains well below the 2010 Roll back malaria Target of 80%. Part of the problem resides in the fact that the 2013 DHS showed only 61% of pregnant women attended even one antenatal care visit while 51% attended four or more.
The second lesson of the graph is missed opportunities. There is a gap between IPTp1 coverage of 37% and at least one ANC visit of 61%. Granted, 18% of women made their first visit in the first trimester when SP is not given, but not all of those stopped ANC then. The next evidence of missed opportunities is the gap between IPTp1 and IPTp2, almost a quarter of women who started IPTp did not get a second dose. We cannot say that the women’s own attendance gaps account for all the missed opportunities; some are likely due to health systems weaknesses such as stock-outs and health staff attention.
Key demographic factors are linked to receiving two or more IPTp doses. Only 30% or rural women received two or more compared to 50% of urban. There was a steady progression from 21% of the poorest women to 55% of those in the highest wealth quintile. A second chart also shows variation by section of the country. These access gaps are why we have advocated for supplementary distribution of IPTp through trained community health workers.
Use of insecticide treated bed nets by pregnant women shows a similar increase over time. The dip in 2013 probably related to fact that mass campaigns had occurred between 2009 and 2011 and thus by the time of the survey some nets had become damaged and abandoned. A major challenge in achieving net coverage is NOT relying on periodic distribution campaigns only, but ensuring regular and reliable supplies during routine services such as antenatal care. This again is a health systems problem that must be solved.
Net access is not only a health systems issue, bit may be factor of internal household dynamics. Even when the household possesses nets, only 63% of pregnant women therein slept under one the night before the survey. Community education needs strengthening – more than just telling people what to do but involving them is solving the problems of net use.
So as mentioned earlier, progress is being made, but more effort is needed. We are especially concerned because of the precariousness of global financial support for disease control. Nigeria needs to strategize how it can meet its own needs in protecting pregnant women and their unborn children from malaria, disability and death.