A cluster randomized trial of delivery of intermittent preventive treatment of malaria in pregnancy at the community level in Burkina Faso

Julie R Gutman,Kristen Vibbert,Daniel K Stephens,Justin Tiendrebeogo,Danielle Burke,John Williamson,Mathurin Dodo,Ousmane Badolo,William R Brieger,Yacouba Savadogo,Susan J Youll

doi:10.1186/s12936-020-03356-9

Abstract

BackgroundMalaria in pregnancy is responsible for 8–14% of low birth weight and 20% of stillbirths in sub-Saharan Africa. To prevent these adverse consequences, the World Health Organization recommends intermittent preventive treatment of pregnant women (IPTp) with sulfadoxine–pyrimethamine be administered at each ANC visit starting as early as possible in the second trimester. Global IPTp coverage in targeted countries remains unacceptably low. Community delivery of IPTp was explored as a means to improve coverage.MethodsA cluster randomized, controlled trial was conducted in 12 health facilities in a 1:1 ratio to either an intervention group (IPTp delivered by CHWs) or a control group (standard practice, with IPTp delivered at HFs) in three districts of Burkina Faso to assess the effect of IPTp administration by community health workers (CHWs) on the coverage of IPTp and antenatal care (ANC). The districts and facilities were purposively selected taking into account malaria epidemiology, IPTp coverage, and the presence of active CHWs. Pre- and post-intervention surveys were carried out in March 2017 and July–August 2018, respectively. A difference in differences (DiD) analysis was conducted to assess the change in coverage of IPTp and ANC over time, accounting for clustering at the health facility level.ResultsAltogether 374 and 360 women were included in the baseline and endline surveys, respectively. At baseline, women received a median of 2.1 doses; by endline, women received a median of 1.8 doses in the control group and 2.8 doses in the intervention group (p-value < 0.0001). There was a non-statistically significant increase in the proportion of women attending four ANC visits in the intervention compared to control group (DiD = 12.6%, p-value = 0.16). By the endline, administration of IPTp was higher in the intervention than control, with a DiD of 17.6% for IPTp3 (95% confidence interval (CI) − 16.3, 51.5; p-value 0.31) and 20.0% for IPTp4 (95% CI − 7.2, 47.3; p-value = 0.15).ConclusionsCommunity delivery of IPTp could potentially lead to a greater number of IPTp doses delivered, with no apparent decrease in ANC coverage.

Highlights

Malaria in pregnancy is responsible for 8–14% of low birth weight and 20% of stillbirths in sub-Saharan Africa
Since 2012, the World Health Organization (WHO) has recommended that pregnant women receive intermittent preventive treatment of pregnant women (IPTp)-sulfadoxine pyrimethamine (SP) as early as possible starting at the beginning of the second trimester (13th week of pregnancy), at every antenatal care (ANC) contact up until delivery, with doses spaced at least 1 month apart, ideally administering a minimum of three doses during pregnancy (IPTp3) [5]
A cluster randomized, controlled trial assessing the effect of IPTp administration by Community health worker (CHW) on the coverage of IPTp and ANC was conducted in three districts of Burkina Faso over 15 months, from May 2017 to August 2018, with baseline and post-intervention surveys carried out in March 2017 and July–August 2018, respectively

Summary

Introduction

Malaria in pregnancy is responsible for 8–14% of low birth weight and 20% of stillbirths in sub-Saharan Africa To prevent these adverse consequences, the World Health Organization recommends intermittent preventive treatment of pregnant women (IPTp) with sulfadoxine–pyrimethamine be administered at each ANC visit starting as early as possible in the second trimester. Since 2012, the WHO has recommended that pregnant women receive IPTp-SP as early as possible starting at the beginning of the second trimester (13th week of pregnancy), at every antenatal care (ANC) contact (which typically occurs in health facilities) up until delivery, with doses spaced at least 1 month apart, ideally administering a minimum of three doses during pregnancy (IPTp3) [5] Despite this recommendation, which was meant to increase IPTp uptake to 3 or more, coverage remains low.

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