Abstract
Malaria in pregnancy (MiP) is associated with increased risks of maternal and foetal complications. The WHO recommends a package of interventions including intermittent preventive treatment (IPT) with sulphadoxine-pyrimethamine (SP), insecticide-treated nets and effective case management. However, with increasing SP resistance, the effectiveness of SP-IPT has been questioned. Intermittent screening and treatment (IST) has recently been shown in Ghana to be as efficacious as SP-IPT. This study investigates two important requirements for effective delivery of IST and SP-IPT: antenatal care (ANC) provider knowledge, and acceptance of the different strategies. Structured interviews with 134 ANC providers at 67 public health facilities in Ashanti Region, Ghana collected information on knowledge of the risks and preventative and curative interventions against MiP. Composite indicators of knowledge of SP-IPT, and case management of MiP were developed. Log binomial regression of predictors of provider knowledge was explored. Qualitative data were collected through in-depth interviews with fourteen ANC providers with some knowledge of IST to gain an indication of the factors influencing acceptance of the IST approach. 88.1% of providers knew all elements of the SP-IPT policy, compared to 20.1% and 41.8% who knew the treatment policy for malaria in the first or second/third trimesters, respectively. Workshop attendance was a univariate predictor of each knowledge indicator. Qualitative findings suggest preference for prevention over cure, and increased workload may be barriers to IST implementation. However, a change in strategy in the face of SP resistance is likely to be supported; health of pregnant women is a strong motivation for ANC provider practice. If IST was to be introduced as part of routine ANC activities, attention would need to be given to improving the knowledge and practices of ANC staff in relation to appropriate treatment of MiP. Health worker support for any MiP intervention delivered through ANC clinics is critical.
Highlights
Plasmodium falciparum infection in pregnancy is associated with an increased risk of maternal and foetal complications including maternal anaemia and low birth weight [1,2]
A three-arm, open label, individually-randomized trial was conducted in the Ashanti Region of Ghana between February 2007 and November 2008 to investigate the efficacy of an alternative strategy: in two of the arms, pregnant women were screened at scheduled antenatal care (ANC) visits with a rapid diagnostic test (RDT) and those with a positive result were treated with either artesunate-amodiaquine (AS–AQ) or SP; women in the third arm received three doses of SP-intermittent preventive treatment during pregnancy (IPT) at monthly intervals as per current national policy
Knowledge of most of the key components of the IPTp policy is extremely good with over 95% knowing that SP is the recommended drug, that women should receive three doses during their pregnancy, with an interval of a month between doses, and that SP-IPT should be given as directly observed therapy (DOT); 92% knew that the first dose should be given after 16 weeks or quickening
Summary
Plasmodium falciparum infection in pregnancy is associated with an increased risk of maternal and foetal complications including maternal anaemia and low birth weight [1,2]. The WHO has recommended a package of interventions for preventing and controlling malaria infection in pregnancy (MiP) in endemic areas, which includes the early diagnosis and treatment of malaria, the use of insecticide-treated nets (ITNs), and intermittent preventive treatment during pregnancy (IPT) using sulphadoxine-pyrimethamine (SP)[3]. The alternative strategy, termed intermittent screening and treatment (IST) was found to be non-inferior to SP-IPT in preventing maternal anaemia and low birth weight [6]
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