Malaria in pregnancy control and pregnancy outcomes: a decade’s overview using Ghana’s DHIMS II data

  • Malaria Journal, Volume 21, No. 1, Year 2022

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Study Justification:
– The study aimed to investigate the impact of malaria control interventions on pregnancy outcomes in Ghana over the past decade.
– It is important to understand how improvements in intervention uptake and reduction in malaria infection prevalence have affected maternal anaemia and low birth weight rates.
– The findings of this study can inform policy and practice in addressing the complex factors contributing to maternal anaemia and low birth weight.
Highlights:
– The prevalence of maternal anaemia at booking and at term, as well as low birth weight, showed marginal increases over the last decade.
– Severe anaemia prevalence remained low throughout the study period.
– The uptake of malaria in pregnancy control interventions, such as ANC visits, intermittent preventive treatment of malaria, and insecticide-treated net usage, improved over the years.
– Malaria test positivity rate decreased significantly between 2014 and 2021.
– The percentage of women receiving iron and folate supplementation for 3 and 6 months also increased.
Recommendations:
– Despite improvements in intervention uptake, there is still room for further improvement in implementation levels.
– The study highlights the need for urgent investigation and quantification of the complex factors contributing to maternal anaemia and low birth weight.
– The findings suggest the importance of addressing these factors to improve pregnancy outcomes.
Key Role Players:
– Ghana Health Service (GHS)
– Regional, Metropolitan/Municipal/District, and Sub-metropolitan/Sub-municipal/Sub-district Health Management teams
– Health facility staff (tertiary, secondary, and primary level)
– Private, faith-based, traditional, and alternative service providers
Cost Items for Planning Recommendations:
– Training and capacity building for health facility staff
– Procurement and distribution of insecticide-treated nets
– Provision of intermittent preventive treatment of malaria
– Iron and folate supplementation programs
– Monitoring and evaluation activities
– Research and investigation into the factors contributing to maternal anaemia and low birth weight

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a descriptive study utilizing secondary data from Ghana’s DHIMS II database over a 10-year period. The study provides trends and percentages of maternal anaemia, low birth weight, and uptake of malaria in pregnancy control interventions. However, the abstract does not mention the sample size, methodology, statistical analysis, or any potential limitations of the study. To improve the evidence, the authors could include more details about the study design, sample size, statistical methods used, and potential limitations of the study. Additionally, providing information on the representativeness of the DHIMS II database and the generalizability of the findings would strengthen the evidence.

Background: Malaria in pregnancy control interventions have been implemented through antenatal care services for more than 2 decades in Ghana. The uptake of these interventions has seen steady improvement over the years. This has occurred within the context of decreasing global trends of malaria infection confirmed by decreasing malaria in pregnancy prevalence in Ghana. However, not much is known about how these improvements in interventions uptake and reduction in malaria infection prevalence have impacted pregnancy outcomes in the country. This study aimed at describing trends of maternal anaemia and low birth weight prevalence and uptake of malaria in pregnancy control interventions over the last decade using data from Ghana’s District Health Information Management System (DHIMS II). Methods: Data from Ghana’s DHIMS II on variables of interest covering the period 2012 to 2021 was analysed descriptively using Microsoft Excel 365. Results were computed as averages and percentages and presented in tables and graphs. Results: The prevalence of maternal anaemia at booking and at term and low birth weight increased marginally from 31.0%, 25.5% and 8.5% in 2012 to 36.6%, 31.9% and 9.5% in 2021 respectively. Severe anaemia prevalence at booking and at term remained under 2% over the study period. Women making at least 4 ANC visits, receiving at least 3 doses of intermittent preventive treatment of malaria and an insecticide-treated net increased from 77.0%, 41.4% and 4.1% in 2012 to 82%, 55.0% and 93.3% in 2021, respectively. Malaria test positivity rate reduced from 54.0% to 34.3% between 2014 and 2021 while women receiving iron and folate supplementation for 3 and 6 months rose from 43.0% and 25.5% to 89.7% and 61.8%, respectively between 2017 and 2021. Conclusion: Maternal anaemia and low birth weight prevalence showed marginal upward trends over the last decade despite reduced malaria infection rate and improved uptake of malaria in pregnancy control interventions. There is room for improvement in current intervention implementation levels but the complex and multi-factorial aetiologies of maternal anaemia and low birth weight need urgent investigation and quantification to inform policy and practice.

This was a descriptive study utilizing secondary data from Ghana’s DHIMS II database over a 10-year period from 2012 to 2021. DHIMS II is an integrated internet-based electronic database of aggregated health facility-based data on health services provided nation-wide [35]. Ghana, a sub-Saharan African country located in West Africa, has a total population of 30.8 million; 50.7% females and a total fertility rate of 3.745 births per woman [36]. It is endemic for malaria, being the leading cause of outpatient health facility visits. Malaria accounted for 34% of all cases seen at the Outpatient’s Department (OPD), 19%% of admissions and 2% of total deaths with pregnant women constituting 3.9% of total suspected cases of malaria reported to the OPD in 2017 [37]. The country is divided into three malaria epidemiological zones with varying transmission intensities; the northern Guinea savannah zone covering the northern regions of Ghana with intense and seasonal transmission (and some pockets of perennial transmission in areas of irrigation projects), the transitional forest zone in the middle of the country with perennial and intense transmission and the coastal savannah zone along the coast of the Atlantic Ocean [33, 38]. Malaria infection in pregnancy is highest in the northern Guinea zone, followed by the middle transitional zone and lowest in the coastal savannah zone [33]. There are currently 16 administrative regions, the last 6 being couched from bigger regions in 2018. Each region is divided into metropolitan areas, municipalities or districts depending on population sizes. For health services, metropolitan areas, municipalities and districts are further subdivided into sub-metropolitan areas, sub-municipalities and sub-districts. The regions, metropolis/municipalities/districts and sub-metropolis/sub-municipalities/sub-districts are managed by Regional, Metropolitan/Municipal/District and Sub-metropolitan/Sub-municipal/Sub-district Health Management teams, representatives of the GHS to enhance delivery, supervision and reporting of health services. Health services are delivered through tertiary level (teaching hospitals), secondary level (regional hospitals) and primary level (district/municipal hospitals, health centres and Community-based health planning services (CHPS) compounds) facilities. The health facilities are mostly public but are supported by private, faith-based, traditional and alternative service providers [35]. At all the health facilities (primary to tertiary), primary data of maternal health services is captured manually into paper-based registers, forms and books which are then summarized monthly onto nationally pre-designed forms for further imputing into the DHIMS II data-base either at the district or sub-district level [39]. This enables timely access to health information by health managers and policy makers at the health facility, district, regional and national levels for tracking progress of health service delivery to inform adequate planning, monitoring and evaluation purposes. Formal permission was sought from the GHS to use the DHIMS II data regarding maternal health services. Based on the aim of this study and availability of data, variables of interest for which data was extracted into an excel spreadsheet included yearly total numbers of: The data obtained from the DHIMS II was analysed descriptively and presented as averages and percentages in tables and graphs, first for the whole country and then per zones using Microsoft Excel 365. The regions of Ghana were grouped into three geographical zones to mimic the ecological and malaria epidemiological zones [33, 38] as follows: Northern/savannah zone comprised of the Upper West, Upper East, North East, Northern and Savannah regions; Middle/forest zone comprised of Bono East, Brong Ahafo, Ahafo, Ashanti, Eastern, Western North and Oti regions and the Southern/coastal zone comprised of the Western, Central, Greater Accra and the Volta regions. Per the definitions in Table ​Table22 below, the various indicators for the years under review were computed. The total number of expected pregnancies was computed as 4% of the estimated yearly population size of Ghana [40]. The country-wide trends over the 10-year period for anaemia and severe anaemia at booking and at 36 weeks gestation, total LBW prevalence and by primiparous and multiparous women; uptake of IPTp-SP and HIV and syphilis infection prevalence were depicted graphically (values in Additional file 1: Table S1) while those for number of ANC visits, IFA supplementation, ITN distribution and malaria test positivity rate were presented in a table. The trends in anaemia, LBW and IPTp-SP uptake were further analysed at geographical zone level, compared with the national averages and depicted graphically or in a table (values in Additional file 1: Table S2). Definition of indicators for MiP control and pregnancy outcomes Source: Ghana Health Service Health Information Management System Standard Operating Procedures, 2020; Maternal and Child Survival Programme Malaria in Pregnancy Monitoring and Evaluation brief, 2020 [88, 89]

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

1. Mobile health (mHealth) applications: Develop mobile applications that provide pregnant women with information on antenatal care, malaria prevention, and other maternal health topics. These apps can also send reminders for appointments and medication adherence.

2. Telemedicine: Implement telemedicine services to allow pregnant women in remote areas to consult with healthcare providers and receive prenatal care remotely. This can help overcome geographical barriers and improve access to healthcare.

3. Community health workers: Train and deploy community health workers to provide education, counseling, and basic prenatal care to pregnant women in underserved areas. These workers can also distribute insecticide-treated bed nets and promote malaria prevention strategies.

4. Integration of services: Integrate maternal health services with other existing healthcare programs, such as immunization campaigns or family planning services. This can increase the reach and efficiency of healthcare delivery.

5. Public-private partnerships: Foster collaborations between the government, private sector, and non-profit organizations to improve access to maternal health services. This can involve leveraging private sector resources and expertise to expand healthcare infrastructure and service provision.

6. Health information systems: Strengthen and expand the use of electronic health information systems, like Ghana’s DHIMS II, to improve data collection, analysis, and monitoring of maternal health indicators. This can help identify gaps and target interventions more effectively.

7. Maternal health financing: Explore innovative financing mechanisms, such as health insurance schemes or conditional cash transfers, to reduce financial barriers to accessing maternal health services. This can ensure that cost does not prevent women from seeking necessary care.

8. Quality improvement initiatives: Implement quality improvement programs to enhance the delivery of maternal health services. This can involve training healthcare providers, improving infrastructure and equipment, and ensuring adherence to evidence-based guidelines.

9. Health education campaigns: Conduct targeted health education campaigns to raise awareness about the importance of antenatal care, malaria prevention, and other maternal health practices. This can empower women to make informed decisions and seek appropriate care.

10. Research and innovation: Support research and innovation in the field of maternal health to identify new interventions, technologies, and approaches that can improve access and outcomes. This can involve partnerships with academic institutions and research organizations.

It’s important to note that these recommendations are general and may need to be tailored to the specific context and needs of Ghana’s maternal health system.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health is to focus on the following areas:

1. Strengthening Antenatal Care (ANC) Services: ANC visits play a crucial role in monitoring the health of pregnant women and providing necessary interventions. Efforts should be made to ensure that pregnant women have access to quality ANC services, including regular check-ups, screenings, and counseling.

2. Increasing Uptake of Malaria in Pregnancy Control Interventions: Malaria infection during pregnancy can have serious consequences for both the mother and the baby. It is important to promote and increase the uptake of interventions such as intermittent preventive treatment of malaria (IPTp), insecticide-treated nets (ITNs), and malaria testing and treatment.

3. Addressing Maternal Anaemia: Maternal anaemia can lead to adverse pregnancy outcomes. Strategies should be implemented to improve iron and folate supplementation for pregnant women, as well as identify and address the underlying causes of anaemia.

4. Enhancing Health Information Systems: Accurate and timely data is essential for monitoring and evaluating maternal health interventions. Efforts should be made to strengthen health information systems, such as the District Health Information Management System (DHIMS II), to ensure that reliable data is collected, analyzed, and used for decision-making.

5. Investigating and Addressing Complex Factors: Maternal anaemia and low birth weight have multifactorial causes. Further research and investigation are needed to understand the underlying factors contributing to these issues in Ghana. This information can then be used to inform policy and practice and develop targeted interventions.

By focusing on these recommendations, it is possible to improve access to maternal health and ultimately reduce maternal and neonatal morbidity and mortality rates in Ghana.
AI Innovations Methodology
Based on the provided description and methodology, here are some potential recommendations for improving access to maternal health:

1. Strengthen antenatal care services: Focus on improving the quality and availability of antenatal care services, ensuring that pregnant women have access to comprehensive care, including regular check-ups, screenings, and education on maternal health.

2. Increase coverage of malaria control interventions: Implement strategies to increase the uptake of malaria control interventions during pregnancy, such as intermittent preventive treatment of malaria (IPTp), insecticide-treated bed nets (ITNs), and malaria testing and treatment.

3. Enhance iron and folate supplementation: Promote the importance of iron and folate supplementation during pregnancy to prevent maternal anaemia and improve birth outcomes. Ensure that pregnant women have access to these supplements and are educated on their benefits.

4. Improve data collection and analysis: Enhance the use of electronic health information systems, like Ghana’s District Health Information Management System (DHIMS II), to collect and analyze data on maternal health services. This will enable timely access to health information for monitoring and evaluation purposes.

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

1. Define indicators: Identify key indicators related to access to maternal health, such as the percentage of pregnant women receiving antenatal care, the percentage receiving malaria control interventions, the prevalence of maternal anaemia, and the prevalence of low birth weight.

2. Collect baseline data: Gather baseline data on the identified indicators from the DHIMS II database or other relevant sources. This data should cover a specific time period, such as the last decade, to establish a baseline for comparison.

3. Implement interventions: Implement the recommended interventions, such as strengthening antenatal care services, increasing coverage of malaria control interventions, and enhancing iron and folate supplementation.

4. Monitor and collect data: Continuously monitor the implementation of interventions and collect data on the identified indicators. This can be done through routine data collection systems, such as the DHIMS II database, or through targeted surveys and assessments.

5. Analyze and compare data: Analyze the collected data and compare it to the baseline data to assess the impact of the interventions on improving access to maternal health. This can be done by calculating changes in the indicators over time and comparing them to the baseline values.

6. Evaluate and adjust interventions: Evaluate the effectiveness of the implemented interventions and make any necessary adjustments based on the findings. This may involve refining strategies, addressing implementation challenges, or scaling up successful interventions.

7. Repeat the process: Continuously repeat the data collection, analysis, and evaluation process to monitor progress and make further improvements in access to maternal health.

By following this methodology, policymakers and healthcare providers can simulate the impact of recommended interventions on improving access to maternal health and make informed decisions to enhance maternal health outcomes.

Statistics:
Authors: 8
Identifiers:
DOI: 10.1186/s12936-022-04331-2
Research Areas:
Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations
Study Countries:
Ghana, Guinea, Multi-Countries
Study Design:
Cross Sectional Study, randomised-control-trial
Participants Gender:
Female
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