Factors affecting providers' delivery of intermittent preventive treatment for malaria in pregnancy: a five-country analysis of national service provision assessment surveys.

Mathieu Maheu-Giroux,Marcia C Castro

doi:10.1186/1475-2875-13-440

Abstract

BackgroundIntermittent preventive treatment in pregnancy (IPTp) delivered during antenatal care (ANC) visits has been shown to be a highly efficacious and cost-effective intervention. Given the high rates of ANC attendance in sub-Saharan Africa, the current low IPTp coverage represents considerable missed opportunities. The objective of this study was to explore factors affecting provider’s delivery of IPTp during ANC consultations.MethodsData from five nationally representative service provision assessment surveys informed the statistical analyses (Kenya, Namibia, Rwanda, Tanzania, and Uganda; 2006-2010). Poisson regression models with robust/clustered standard errors were used to estimate the effect of different determinants on IPTp delivery from 4,971 observed ANC consultations.ResultsThe five major modifiable determinants of IPTp delivery were: 1) user-fees for ANC medicines (relative risk (RR) = 0.76; 95% confidence intervals (95% CI): 0.62-0.93); 2) facilities having IPTp guidelines (RR = 1.12; 95% CI: 1.01-1.24); 3) facilities having implemented IPTp as part of their routine ANC services offering (RR = 4.18; 95% CI: 1.75-10.01); 4) stock-outs of sulphadoxine-pyrimethamine (RR = 0.40; 95% CI: 0.27-0.60); and, 5) providers having received IPTp training (RR = 1.21; 95% CI: 1.09-1.35). Using the population-attributable fraction, it was estimated that addressing these barriers jointly could lead to a 31% increase in delivery of this intervention during ANC consultations. Of these four potentially modifiable determinants, training of providers for IPTp had the largest potential impact.ConclusionsIf proved to be cost-effective, dispensing IPTp training to ANC providers should be prioritized. Multifaceted approaches targeted in areas of low coverage and/or type of facilities least likely to provide this intervention should be implemented if the Roll Back Malaria target of 100% IPTp coverage by 2015 is to be attained.Electronic supplementary materialThe online version of this article (doi:10.1186/1475-2875-13-440) contains supplementary material, which is available to authorized users.

Highlights

Intermittent preventive treatment in pregnancy (IPTp) delivered during antenatal care (ANC) visits has been shown to be a highly efficacious and cost-effective intervention
Pregnant women are especially vulnerable to malaria as parasitaemia during pregnancy can lead to serious adverse maternal, foetal, and infant health outcomes [1]
For this reason the service provision assessment (SPA) from Namibia and Rwanda are included in this study even though they abandoned their national in pregnancy administered as directly observed therapy (IPTp) policy in 2010 and 2008, respectively, following important declines in malaria transmission experienced by these two countries

Summary

Introduction

Intermittent preventive treatment in pregnancy (IPTp) delivered during antenatal care (ANC) visits has been shown to be a highly efficacious and cost-effective intervention. IPTp consists of presumptive provision of anti-malarials to pregnant women, shortly after quickening and at intervals of at least four weeks, under the direct observation of health workers. This intervention has been shown to be safe and highly effective to prevent maternal anaemia, low birth weight, and neonatal mortality [4,5,6,7], even in areas of recorded resistance to SP [8]. IPTp delivered through antenatal care clinics (ANC) is considered very cost-effective with an incremental cost-effectiveness ratio of $1.02 (2007 USD) per disability-adjusted life-year averted [9]

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