Coverage and efficacy of intermittent preventive treatment with sulphadoxine pyrimethamine against malaria in pregnancy in Côte d Ivoire five years after its implementation

Parasites and Vectors, Volume 7, No. 1, Year 2014

Interpretation

Background: The World Health Organization (WHO) recommends for sub-Saharan Africa a package of prompt and effective case-management combined with the delivery of insecticide-treated nets (ITN) and intermittent preventive treatment during pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) through the national antenatal care (ANC) programs. Implemented in Cote d fIvoire around 2005, few Data on IPTp coverage and efficacy in the country are available. Methods: A multicentre, cross-sectional survey was conducted in Cote d fIvoire from September 2009 to May 2010 at six urban and rural antenatal clinics. IPTp-sp coverage, Socio-economic and obstetrical data of mothers and neonate birth weights were documented. Peripheral blood as well as placental and cord blood were used to prepare thick and thin blood films. In addition, pieces of placental tissues were used to prepare impression smears and maternal haemoglobin concentration was measured. Regression logistics were used to study factors associated with placental malaria and LBW (<2.500 grams). Results: A total of 1317 delivered women were enrolled with a median age of 26 years. A proportion of 43.28% of the women had received at least two doses of IPTsp during the current pregnancy although a high proportion (90.4%) of women received antenatal care and made enough visits (.2). Variability in the results was observed depending on the type of area (rural/urban). Plasmodium falciparum was detected in the peripheral blood of 97 women (7.3%) and in the placenta of 119 women (9%). LBW infants were born to 18.8% (22/107) of women with placental malaria and 8.5% (103/1097) of women without placental malaria. LBW was associated with placental malaria. Conclusions: This study found relative low coverage of IPTp in the study areas which supported findings that high ANC attendance does not guarantee high IPTp coverage. Urgent efforts are required to improve service delivery of this important intervention. The study was carried out in urban (PMI of Yopougon, Fsucom of Anonkoua-kouté, CHU Cococdy, FSUCOM Abobo PK18) and rural areas (Hospital of Bonoua, CSU of Yaou CSU of Samo). In the study sites, perennial malaria transmission with seasonal peaks is mostly attributable to P. falciparum. Pregnant women who gave birth at any of the six study clinics during the study period, gave their written informed consent, and donated placentas for blood collection were enrolled. The sample size calculation was based on the estimate of a proportion of placental malaria. The prevalence of placental malaria after IPT-SP implementation was approximatively 10% [9]. With a margin of error of ±2% using an alpha type-1 error of 5%, at least 1120 delivered pregnant women should be included. During labor, venous blood samples were collected for determination of Hb concentration and malaria diagnosis. Immediately after delivery, babies were weighed using a hanging weighing scale (Model 180; Salter Brecknell, West Midlands, United Kingdom). Data regarding newborn characteristics (vital status at birth, birth weight, sex, and the presence of twins or malformation) were collected. Blood smears were made with blood collected from the maternal side of the delivered placenta and the umbilical vein cord. In addition, pieces of placental tissues were used to prepare impression smears after swabbing it on blotting paper. Thick films and placental impression smears were stained with 10% Giemsa for 15 minutes. To determine the percentage of malaria parasitemia from placental impression smears, malaria parasite-infected red cells were counted against 2000 erythrocytes. Placental infection status was categorized as infected (presence of any asexual parasite stages in the placenta) and noninfected (parasite negative smear). Smears with malaria pigment but with no asexual parasite stages were declared as unknown and were not included in the analysis. Malaria pigment is a sign of malaria infection during pregnancy. We would consider these samples as positive. Microscopic examination of blood smears was done under oil immersion for parasite detection and 200 high-power fields were examined before the smear was considered negative. Parasites were enumerated using thick film, as previously described [11]. The parasite density (per 1 μL of blood) was calculated, assuming a normal leukocyte level of 8000/μL. The thin film was used to speciate the parasites. Each blood film was independently examined by two microscopists. In cases of discrepancy, a third microscopist counted the number of parasites in the films. The average of two counts that agreed was used as the final level of parasitemia. Venous blood (5 mL) was collected using butterfly needles into ethylenediaminetetraacetic acid Vacutainer® tubes (BD Diagnostics, Franklin Lakes, NJ) for measurement of Hb levels using an automated hematology analyzer (Mythic 22; Orphee SA, Geneva, Switzerland). The study was approved by the Comité National d’Ethique et de Recherche (CNER) of Côte d’Ivoire. All study participants were informed in their local language about the study objectives and procedures. For each study participant, written informed consent was obtained and the participant was free to withdraw consent at any time of the study without influencing their access to health services. We classified participants as primigravidae (first pregnancy), secondigravidea (second pregnancy) and multigravidae (third and subsequent pregnancy). Doses of SP IPTp were classified as no SP treatment, 1 dose, 2 doses, or ≥3 doses. Bed net usage was coded as whether or not the woman usually slept under a bed net. We defined anemia as hemoglobin concentration, 11 g/dl and low birth weight (LBW) as infant’s birth weight <2500 g. The exposure variables of interest were SP IPTp (0, 1, 2 or ≥3 doses) and bed net use. Outcome variables were peripheral parasitemia (detection of parasites in peripheral blood), placental parasitemia (detection of parasites in placental blood), maternal hemoglobin concentration at delivery and anemia, infant’s birth weight and LBW. Differences in frequencies were compared by either chi-squared or Fisher’s exact tests as appropriate, and continuous variables by Student’s t-test when the data were normally distributed. Nonparametric tests were used for non normally distributed data. In the multivariable analysis, the factors associated with the dependant variable (LBW or placental malaria) based on univariable analysis were included. Statistical analysis was performed using Stata® version 10.0 (StataCorp LP, College Station, TX).

AI Digest

Study Justification:

– The study aimed to assess the coverage and efficacy of intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) against malaria in pregnancy in Côte d’Ivoire, five years after its implementation.
– The World Health Organization (WHO) recommends IPTp-SP as part of the antenatal care (ANC) programs in sub-Saharan Africa, but there is limited data on its coverage and efficacy in Côte d’Ivoire.
– The study aimed to provide valuable information on the implementation and effectiveness of IPTp-SP in the country.

Study Highlights:

– The study found that there was a relatively low coverage of IPTp-SP in the study areas, despite high ANC attendance.
– Plasmodium falciparum, the malaria parasite, was detected in the peripheral blood of 7.3% of women and in the placenta of 9% of women.
– Low birth weight (LBW) infants were born to 18.8% of women with placental malaria, compared to 8.5% of women without placental malaria.
– The study highlighted the need for urgent efforts to improve the delivery of IPTp-SP and increase its coverage in order to reduce the burden of malaria in pregnancy.

Recommendations for Lay Reader and Policy Maker:

– Increase awareness and education about the importance of IPTp-SP among pregnant women and healthcare providers.
– Strengthen the delivery of ANC services to ensure that all pregnant women have access to IPTp-SP.
– Improve monitoring and evaluation systems to track the coverage and effectiveness of IPTp-SP.
– Conduct further research to identify barriers to IPTp-SP uptake and develop strategies to address them.
– Collaborate with international partners and stakeholders to mobilize resources and support for the implementation of IPTp-SP programs.

Key Role Players:

– Ministry of Health: Responsible for policy development, planning, and coordination of IPTp-SP programs.
– Healthcare providers: Responsible for delivering ANC services and administering IPTp-SP.
– Community health workers: Involved in community education and mobilization efforts.
– International organizations and donors: Provide technical and financial support for IPTp-SP programs.
– Research institutions: Conduct studies to evaluate the effectiveness and impact of IPTp-SP.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers.
– Procurement and distribution of IPTp-SP drugs.
– Monitoring and evaluation systems.
– Community education and awareness campaigns.
– Research and data collection.
– Infrastructure and equipment for ANC clinics.
– Coordination and management of IPTp-SP programs.

Strength of Evidence

The strength of evidence for this abstract is 6 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is cross-sectional, which limits the ability to establish causality. Additionally, the sample size calculation is based on the estimate of a proportion of placental malaria, which may not accurately represent the population. To improve the strength of the evidence, a randomized controlled trial or a longitudinal study design could be considered. Additionally, including a larger sample size and conducting the study in multiple regions could increase the generalizability of the findings. Finally, providing more details on the statistical analysis methods used would enhance the transparency and reproducibility of the study.

Abstract

The study was carried out in urban (PMI of Yopougon, Fsucom of Anonkoua-kouté, CHU Cococdy, FSUCOM Abobo PK18) and rural areas (Hospital of Bonoua, CSU of Yaou CSU of Samo). In the study sites, perennial malaria transmission with seasonal peaks is mostly attributable to P. falciparum. Pregnant women who gave birth at any of the six study clinics during the study period, gave their written informed consent, and donated placentas for blood collection were enrolled. The sample size calculation was based on the estimate of a proportion of placental malaria. The prevalence of placental malaria after IPT-SP implementation was approximatively 10% [9]. With a margin of error of ±2% using an alpha type-1 error of 5%, at least 1120 delivered pregnant women should be included. During labor, venous blood samples were collected for determination of Hb concentration and malaria diagnosis. Immediately after delivery, babies were weighed using a hanging weighing scale (Model 180; Salter Brecknell, West Midlands, United Kingdom). Data regarding newborn characteristics (vital status at birth, birth weight, sex, and the presence of twins or malformation) were collected. Blood smears were made with blood collected from the maternal side of the delivered placenta and the umbilical vein cord. In addition, pieces of placental tissues were used to prepare impression smears after swabbing it on blotting paper. Thick films and placental impression smears were stained with 10% Giemsa for 15 minutes. To determine the percentage of malaria parasitemia from placental impression smears, malaria parasite-infected red cells were counted against 2000 erythrocytes. Placental infection status was categorized as infected (presence of any asexual parasite stages in the placenta) and noninfected (parasite negative smear). Smears with malaria pigment but with no asexual parasite stages were declared as unknown and were not included in the analysis. Malaria pigment is a sign of malaria infection during pregnancy. We would consider these samples as positive. Microscopic examination of blood smears was done under oil immersion for parasite detection and 200 high-power fields were examined before the smear was considered negative. Parasites were enumerated using thick film, as previously described [11]. The parasite density (per 1 μL of blood) was calculated, assuming a normal leukocyte level of 8000/μL. The thin film was used to speciate the parasites. Each blood film was independently examined by two microscopists. In cases of discrepancy, a third microscopist counted the number of parasites in the films. The average of two counts that agreed was used as the final level of parasitemia. Venous blood (5 mL) was collected using butterfly needles into ethylenediaminetetraacetic acid Vacutainer® tubes (BD Diagnostics, Franklin Lakes, NJ) for measurement of Hb levels using an automated hematology analyzer (Mythic 22; Orphee SA, Geneva, Switzerland). The study was approved by the Comité National d’Ethique et de Recherche (CNER) of Côte d’Ivoire. All study participants were informed in their local language about the study objectives and procedures. For each study participant, written informed consent was obtained and the participant was free to withdraw consent at any time of the study without influencing their access to health services. We classified participants as primigravidae (first pregnancy), secondigravidea (second pregnancy) and multigravidae (third and subsequent pregnancy). Doses of SP IPTp were classified as no SP treatment, 1 dose, 2 doses, or ≥3 doses. Bed net usage was coded as whether or not the woman usually slept under a bed net. We defined anemia as hemoglobin concentration, 11 g/dl and low birth weight (LBW) as infant’s birth weight <2500 g. The exposure variables of interest were SP IPTp (0, 1, 2 or ≥3 doses) and bed net use. Outcome variables were peripheral parasitemia (detection of parasites in peripheral blood), placental parasitemia (detection of parasites in placental blood), maternal hemoglobin concentration at delivery and anemia, infant’s birth weight and LBW. Differences in frequencies were compared by either chi-squared or Fisher’s exact tests as appropriate, and continuous variables by Student’s t-test when the data were normally distributed. Nonparametric tests were used for non normally distributed data. In the multivariable analysis, the factors associated with the dependant variable (LBW or placental malaria) based on univariable analysis were included. Statistical analysis was performed using Stata® version 10.0 (StataCorp LP, College Station, TX).

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile health (mHealth) interventions: Develop mobile applications or text messaging services to provide pregnant women with information on antenatal care, IPTp, and malaria prevention. This could include reminders for clinic visits, medication adherence, and bed net usage.

2. Community health workers: Train and deploy community health workers to provide education and support to pregnant women in rural areas. These workers can help increase awareness about the importance of IPTp and provide guidance on accessing antenatal care services.

3. Telemedicine: Implement telemedicine services to connect pregnant women in remote areas with healthcare providers. This would allow for remote consultations, monitoring of maternal health, and timely interventions when necessary.

4. Supply chain management: Improve the supply chain for IPTp medications and bed nets to ensure consistent availability in both urban and rural areas. This could involve implementing electronic inventory management systems and strengthening distribution networks.

5. Quality improvement initiatives: Implement quality improvement initiatives in antenatal care clinics to ensure that pregnant women receive comprehensive and evidence-based care. This could include training healthcare providers, improving infrastructure, and implementing standardized protocols for IPTp administration.

6. Public-private partnerships: Foster collaborations between the government, private sector, and non-profit organizations to leverage resources and expertise in improving access to maternal health services. This could involve joint initiatives to increase IPTp coverage, improve healthcare infrastructure, and enhance community engagement.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and needs of Côte d’Ivoire.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health and develop an innovation could include the following steps:

1. Increase coverage of intermittent preventive treatment during pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP): The study found a relatively low coverage of IPTp in the study areas, indicating a need to improve the delivery of this important intervention. Efforts should be made to ensure that pregnant women have access to and receive the recommended number of doses of IPTp to prevent malaria during pregnancy.

2. Improve service delivery of IPTp: Despite high antenatal care attendance, the study showed that high attendance does not guarantee high IPTp coverage. Urgent efforts should be made to improve the service delivery of IPTp, ensuring that pregnant women have access to and receive the necessary doses of IPTp during their antenatal care visits.

3. Enhance education and awareness: It is important to educate pregnant women and healthcare providers about the benefits of IPTp and the importance of adhering to the recommended treatment regimen. This can be done through targeted health education campaigns, training programs for healthcare providers, and community outreach initiatives.

4. Strengthen monitoring and evaluation: Regular monitoring and evaluation of IPTp coverage and efficacy are crucial to identify gaps and track progress. This can help identify areas where improvements are needed and inform decision-making for resource allocation and program planning.

5. Collaborate with stakeholders: Collaboration with various stakeholders, including government agencies, healthcare providers, community leaders, and non-governmental organizations, is essential to ensure a coordinated and comprehensive approach to improving access to maternal health. This can involve joint advocacy efforts, resource sharing, and knowledge exchange.

By implementing these recommendations, it is possible to develop innovative strategies to improve access to maternal health, specifically in relation to the coverage and efficacy of IPTp for preventing malaria during pregnancy.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening Antenatal Care (ANC) Programs: Focus on improving the quality and availability of ANC services, including regular check-ups, health education, and counseling for pregnant women.

2. Increasing Intermittent Preventive Treatment during Pregnancy (IPTp) Coverage: Implement strategies to ensure that a higher proportion of pregnant women receive the recommended doses of IPTp, such as improving the supply chain management of SP, training healthcare providers on IPTp administration, and raising awareness among pregnant women about the importance of IPTp.

3. Enhancing Malaria Diagnosis and Treatment: Improve the capacity of healthcare facilities to diagnose and treat malaria during pregnancy, including the availability of diagnostic tools and effective antimalarial drugs.

4. Promoting Bed Net Usage: Implement campaigns to increase the use of insecticide-treated bed nets among pregnant women, emphasizing the importance of protection against malaria and other vector-borne diseases.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data Collection: Gather data on the current coverage and efficacy of IPTp, ANC attendance, malaria prevalence, bed net usage, and other relevant indicators in the target population.

2. Baseline Assessment: Analyze the collected data to establish a baseline for maternal health indicators, including maternal mortality rates, prevalence of placental malaria, and low birth weight.

3. Intervention Design: Develop a simulation model that incorporates the recommended interventions, taking into account the specific context and characteristics of the target population.

4. Parameter Estimation: Estimate the parameters of the simulation model based on available data and expert knowledge. This may involve conducting surveys, interviews, or literature reviews to gather relevant information.

5. Simulation Runs: Run the simulation model multiple times, varying the input parameters to reflect different scenarios and assumptions. This will allow for the exploration of different intervention strategies and their potential impact on maternal health outcomes.

6. Impact Evaluation: Analyze the simulation results to assess the impact of the recommended interventions on access to maternal health services, as well as on key indicators such as IPTp coverage, malaria prevalence, and birth outcomes.

7. Sensitivity Analysis: Conduct sensitivity analysis to test the robustness of the simulation results and identify key factors that may influence the effectiveness of the interventions.

8. Policy Recommendations: Based on the simulation findings, provide evidence-based recommendations for policymakers and stakeholders on the most effective strategies to improve access to maternal health in the target population.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and available data in Côte d’Ivoire.

Author

Dima Health

Statistics:

Citations: 12

Identifiers:

DOI: 10.1186/s13071-014-0495-5

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health

Study Countries:

Ivory Coast

Study Design:

Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female