Guest Posting by Bright Orji, Jhpiego, Nigeria
Malaria control in pregnancy in endemic nations is an integral component of Ante-natal Clinic and made up of three essential components. These include the 1) use of long lasting insecticide treated nets (LLINs), 2) intermittent preventive treatment of malaria (IPTp) using sulfadoxine-pyrimethamine, and 3) effective case management.
In recent times, National Malaria Control Programs (NMCP), State Governments and the Development partners embarked on campaigns for nets distribution and use through various methods that include routine, stand alone and through integration with other interventions such as measles campaign most times with under-five children and pregnant women as key entry points. However, these efforts have improved net ownership and use. Ownership of at least one ITN among households in Nigeria increased from 2% in 2003 to 8% in 2008 and more recently to 42% in 2010; similarlyÂ net use increased from 1.3% to 5% and 33.7% during the same period (NDHS 2003, 2008; MIS 2010).
Other components of malaria in pregnancy control have not enjoyed similar large scale campaign as nets. In 2003 National survey, IPT with sulfadoxine-pyrimethamine use among pregnant women was found to be 1%, and then increased to 5% in 2008 and further to 13.2%Â in 2010 (NDHS 2003, 2008; MIS 2010) compared to the global RBM target of 80% and PMI 85%. IPTp and insecticide treated bed nets (ITNs) is a recommendation of World Health Organization. IPTp was first piloted as a project in 2002/2003 in three Local Government Areas (Akinyele, Ibadan South East and Ibadan North) of Oyo State, Nigeria. The outcome of this project among others informed policy direction for Nigeria.
It is important to note that IPTp implementation in Nigeria and elsewhere is faced with multiple challenges. These include lack of trained personnel, SP stock-outs – even though the medicine is available in-country and cheap but due to logistical distribution problem they are not where and when needed;Â whileÂ poor ANC attendance however has been identified as one of the major key factor for the low uptake of IPTp.
In the last two decade, there has been effort to improve the health system through the active involvement of communities in the distribution of health commodities. The notable concept in this regard was the Community Directed Distribution (CDI) that was first introduced in 1985 by African Program on Onchocerciasis Control (APOC).Â Recently there has been growing effort that keyed into the lessons learned from APOC projects to apply the concept of CDI to malaria control using nets and IPTp as key entry points.
These efforts were piloted in Uganda and Nigeria respectively. The Ugandan projectÂ findings showed that more women accessed IPTp and adhered to 2 doses of SP in the intervention arm compared to the control. Furthermore, ANC attendance increased as well as access and benefits from essential care at health facilities. Similarly, another studyÂ concluded that the involvement of community distributors offered an alternative option in the administration of IPTp given that the strategy does not reinvent the while rather it keys into the existing health system and community structures.
Whilst it may be said that the Ugandan project was under control measures, the Nigerian projectÂ was more of field implementation program. In the Nigerian program in Akwa Ibom State, over 45,000 pregnant women received IPTp in five years with the effect of CDI more on pregnant women access to IPTp, adherence to at least two doses of SP, and ITNs use, relatively very cheap and without distraction to ANC attendance. In both projects, there was no record of adverse event since SP has a very high safety profile if administered properly and appropriately too.
As many African countries struggle with meeting the Millennium Development Goals as well as the global targets for IPTp, the call to explore community IPTp as another option to strengthen the health system to improve the uptake of IPTp is increasing given the growing research evidence. Change does not just come; it comes with conscientious planning, discipline and deliberate effort. Countries might not meet the MDG targets if they choose to continue to do things the same way it is being done over the years.