Abstract
BackgroundIn malaria endemic regions in Kenya, pregnant women are offered long-lasting insecticidal nets and intermittent preventive treatment (IPTp) with sulfadoxine–pyrimethamine (SP) at antenatal care (ANC) to prevent the adverse effects of malaria. Fears of growing SP resistance have heightened the search for alternative strategies. The implementation feasibility of intermittent screening and treatment (ISTp) with dihydroartemisinin–piperaquine (DP) in routine ANC settings was evaluated using qualitative and quantitative methods, including the exploration of healthcare provider and pregnant women’s perceptions.MethodsQualitative methods included data from 13 focus group discussions (FGDs) with pregnant women and 43 in-depth interviews with healthcare providers delivering ANC services. FGDs were conducted with women who had received either ISTp-DP or current policy (IPTp-SP). Thematic analysis was used to explore experiences among women and providers and findings were used to provide insights into results of the parallel quantitative study.ResultsWomen were accepting of testing with rapid diagnostic tests (RDTs) and receiving treatment if malaria positive. Providers perceived DP to be an effective drug and well tolerated by women. Some providers indicated a preference for test and treat strategies to reduce unnecessary exposure to medication in pregnancy, others preferred a hybrid strategy combining screening at every ANC visit followed by IPTp-SP for women who tested negative, due to the perception that RDTs missed some infections and concerns about the growing resistance to SP. Testing with RDTs during ANC was appreciated as it was perceived to reduce wait times. The positive attitude of healthcare providers towards ISTp supports findings from the quantitative study that showed a high proportion (90%) of women were tested at ANC. There were concerns about affordability of DP and the availability of sufficient RDT stocks.ConclusionIn ANC settings, healthcare providers and pregnant women found ISTp-DP to be an acceptable strategy for preventing malaria in pregnancy when compared with IPTp-SP. DP was considered an effective anti-malarial and a suitable alternative to IPTp-SP in the context of SP resistance. Despite providers’ lack of confidence in RDT results at current levels of sensitivity and specificity, the quantitative findings show their willingness to test women routinely at ANC.
Highlights
In malaria endemic regions in Kenya, pregnant women are offered long-lasting insecticidal nets and intermittent preventive treatment (IPTp) with sulfadoxine–pyrimethamine (SP) at antenatal care (ANC) to prevent the adverse effects of malaria
Malaria in pregnancy (MiP) guidelines for malaria endemic regions in Kenya include the use of longlasting insecticidal nets (LLINs), prompt diagnosis and case management of active infections, and Intermittent preventive treatment in pregnancy (IPTp) with SP delivered via directly observed therapy (DOT) at every ANC visit starting in the 2nd trimester and given at least 4 weeks apart with a target of at least 3 doses throughout the pregnancy [2, 15]
Healthcare provider perspectives Healthcare provider perceptions are explored across the feasibility constructs, understanding acceptability towards key components of the intervention as well as how Intermittent screening and treatment in pregnancy (ISTp) fits into routine ANC services and potential implementation challenges should the strategy be adopted
Summary
In malaria endemic regions in Kenya, pregnant women are offered long-lasting insecticidal nets and intermittent preventive treatment (IPTp) with sulfadoxine–pyrimethamine (SP) at antenatal care (ANC) to prevent the adverse effects of malaria. Where IPTpSP remains policy, concerns have been raised regarding the possible increased risk of fetal anaemia in areas with high levels of SP resistance [3], more recent studies indicate that SP continues to be effective in reducing low birth weight outcomes in areas of high resistance but is compromised in areas with highly resistant parasites [4]. These concerns have accelerated the search for alternative drugs for IPTp or new strategies that are at least as effective in controlling MiP and can be implemented and delivered through routine ANC services. The ISTp strategy was explored previously in western Kenya under trial conditions and was found to be broadly acceptable to both pregnant women and healthcare providers [12], but this will be the first study to examine perceptions and experiences of implementation in the routine setting in this region
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