An analysis of country adoption and implementation of the 2012 WHO recommendations for intermittent preventive treatment for pregnant women in sub-Saharan Africa

Marianne Henry,Lia Florey,Susan Youll,Julie R Gutman

doi:10.1186/s12936-018-2512-1

Abstract

BackgroundAn estimated 30 million women give birth annually in malaria endemic areas of sub-Saharan Africa. Malaria in pregnancy is associated with an increased risk of adverse maternal and infant outcomes. To combat the adverse effects of MiP, the World Health Organization (WHO) recommends the provision of intermittent preventive treatment in pregnancy with sulfadoxine–pyrimethamine (IPTp–SP) in areas of moderate to high malaria transmission. In 2012, the WHO updated its policy with respect to IPTp administration to recommend administration at each antenatal care visit in the second and third trimesters, with a minimum of three, rather than two, doses. While rapid improvements in coverage were expected, gains have occurred more slowly than anticipated.MethodsThe President’s Malaria Initiative (PMI) assessed IPTp uptake before and after countries implemented the new WHO policy, and assessed how long it took for implementation to occur, using a combination of data from household surveys, routine health management information systems, and programmatic data provided to PMI.ResultsIt took an average of 2 years for countries to complete the process of revising their IPTp policies, and it was not until 2015 that all 17 PMI countries had updated their policies. Policy dissemination and training had not been completed in several countries as of early 2018, and only seven countries had fully implemented the new policy including updating their antenatal care registers to collect information on IPTp3+ coverage. The coverage of IPTp1+, 2+, and 3+ has increased by 19, 16, and 13 percentage points since the revised IPTp policy adoption.DiscussionOverall, coverage of both IPTp2+ and IPTp3+ has improved in recent years. The change in policy from a minimum of two to a minimum of three doses has likely contributed to these improvements. Progress has been slow, likely related to the complicated process of policy adoption exacerbated by the lag in measurement through national household surveys. The impact of future policy changes may be more readily seen if the policy change and implementation process were more streamlined and coordinated between key stakeholders (National Malaria Control Programmes and Reproductive Health Programmes), with more real-time data reporting.

Highlights

An estimated 30 million women give birth annually in malaria endemic areas of sub-Saharan Africa
This paper examines the timing of policy adoption and implementation, as well as trends in IPTp uptake following adoption of the updated policy in 17 President’s Malaria Initiative (PMI) countries between 2012 and 2017
A total of ten countries followed World Health Organization (WHO) guidance with regard to recommending initiation of IPTp starting at 13 weeks or as early as possible in the second trimester, while the other seven recommended initiation at 16 weeks or during the second trimester (Table 1)

Summary

Introduction

An estimated 30 million women give birth annually in malaria endemic areas of sub-Saharan Africa. Malaria in pregnancy (MiP) is associated with an increased risk of severe maternal illness, anaemia, and death, as well as adverse birth outcomes, including premature delivery, miscarriage, stillbirth, low birth weight, and increased neonatal mortality [3] To address this problem, the World Health Organization (WHO) recommends: (1) distribution of insecticide-treated bed nets (ITNs) to all pregnant women, (2) administration of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine–pyrimethamine (SP) to HIV negative pregnant women in areas of moderate-to-high endemicity (HIV positive women receive cotrimoxazole for opportunistic infections, which provides protection against malaria), and (3) provision of prompt diagnosis and effective treatment of malaria and anaemia [4]. Prior to 2012, the WHO recommended at least two doses of IPTp, but updated this recommendation in October 2012, based on evidence concluding that provision of three or more doses of SP during pregnancy, rather than two doses, was associated with higher mean birth weight and fewer low birth weight infants [10]

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