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Background: Malaria in pregnant women has been shown to be associated with low birth weight, stillbirth and mortality in newborns. The WHO has adopted the use of sulphadoxine-pyrimethamine (SP) to control malaria, a disease which worsens the plight of pregnant women leading to low birth weight, stillbirths and increased neonatal mortality. The present study assessed the effectiveness of SP and perception of its use in pregnant women in Offinso district (Ashanti Region), Ghana. Method. Pregnant women, gestational age 32 weeks prior to term, were studied from November 2006 to October 2007. Their haemoglobin levels (Hb), parasitaemia and other quantitative determinants were assessed. In-depth interviews (IDIs) and focus group discussions (FGDs) were used to assess the perception of SP usage and its effectiveness. Results: Of the 306 study participants, 92 (30%) took one dose, 100 (33%) two doses and 114 (37%) three doses of SP, respectively. There was significant association between gravidity and SP dosage taken (Pearson 2 = 18.9, p < 0.001). Although adverse effects were produced in 113 (i.e. 37%) of the pregnant women, no significant difference was observed with regard to the dosage of SP taken (Pearson's 2 = 2.3, p 0.32). Peripheral parasitaemia was present in 47 (15%) of the subjects. There was a poor negative relationship of doses of SP with parasitaemia (r = -0.07, p 0.24). Mean Hb was 11.3 1.6 g/dl, with 118 (39%) of the subjects anaemic (Hb < 11.0 g/dl), whilst 187 (61%) were normal (Hb 11.0 g/dl). Significant positive correlation of SP use with Hb level (r = 0.15, p < 0.008) was observed. SP use reduced malaria and anaemia prevalence, contributed to reduced maternal morbidity with mild side effects being reported. Conclusions: This study points to the effectiveness of IPTp using SP as an evidence-based measure for control of malaria and malaria-related anaemia in pregnancy. Therefore, the Ghana Health Service should improve current programme strategies to increase the proportion of pregnant women who take three doses of SP, paying attention to improved face-to-face health education, focussed antenatal care and better social mobilization. © 2011 Tutu et al; licensee BioMed Central Ltd.
The study area has been described elsewhere [9], but briefly, the study was conducted in Offinso District, one of the 27 administrative districts in the Ashanti Region of Ghana (Figure (Figure1).1). The study was carried out in six health facilities that provide antenatal, delivery and postnatal services in the district, and communities where these health centres are situated. The health facilities were St. Patrick's Hospital (Offinso), District Assembly Maternal and Child Health Care Centre (Offinso), Nkenkaasu Hospital, Abofour Health Centre, Akomadan Health Centre and A.M.E. Zion Health Centre (Afrancho). Map of Offinso District showing the study towns (Source: Prepared using ArcGIS software, 2008). The study was an analytical type with a cross-sectional design. Pregnant women attending antenatal clinic in the six health facilities and who were 32 weeks of gestation to term and had taken SP were included in the study. Pregnant women with gestational age < 32 weeks irrespective of their IPTp status were excluded from the study. A sample size of 296 was estimated for the cross sectional study. The prevalence of anaemia in pregnant women was 50% [14] and in reducing maternal anaemia by 5% through the use of SP at the power of 80% and 5% significance, a sample size of 296 was required for the cross sectional study (using Statcalc, Epi info software 2002, version 6). However, a little over the sample size, 306 data was collected. Stratified sampling method was used in selecting the health facilities while convenience (purposeful) sampling method was used to sample the respondents. The total number of pregnant women seen yearly in each health facility was made as a fraction of the total number of pregnant women seen in all these health facilities annually. The proportion for each health facility was used to determine the number of pregnant women to be sampled from that health facility. The finger-prick method was used to collect blood for determination of haemoglobin (Hb) levels and parasitaemia as previously discussed [9]. Focus Group Discussions (FGDs) and in-depth interviews (IDIs) were conducted in the communities. This qualitative study was undertaken to assess the knowledge and understanding of study participants on SP in IPTp programme and possible outcomes of treatment. Three assemblymen, three chiefs, one queen mother, an opinion leader as well as nine chemical sellers in the district were interviewed. Four focus group discussions (FGDs) of "horse shoe" type were conducted with pregnant women. Two were conducted in Offinso Central communities and the other two in Akomadan and Afrancho communities. The pregnant women were assigned to one or the other of two categories namely: pregnant women who were less than twenty years of age and those who were twenty years or older. Information on the study was provided to the District Health Administration, the District Assembly and the opinion leaders in the study communities. Permission to undertake the study was obtained from these stakeholders. Ethical clearance was sought and obtained from the Ghana Health Service and the School of Medical Sciences (SMS) of the KNUST Ethics Committees. Each study participant, after being briefed and offered the opportunity to ask questions about the study, was provided with individual informed written consent form to sign or thumbprint. The written consent forms and participant information forms were kept separately from the data collection tools. IPTp was defined as administration of a curative anti-malarial treatment dose of SP at predefined intervals (between 16-36 weeks) to asymptomatic pregnant women during antenatal clinic (ANC), who are at risk of malaria, regardless of whether or not they are parasitaemic at the time of visit. Haemoglobin levels (Hb < 11 g/dl) and (Hb < 7 g/dl) in pregnant women were considered as moderate anaemia and severe anaemia, respectively. Parasitaemia was defined as the presence of asexual stage parasites in thick smears. Gravidity was categorized into primigravidae (women in their first pregnancies), secundigravidae (women in their second pregnancies) and multigravidae (women in their third, fourth or more pregnancies) as discussed in elsewhere in Tutu et al. [9]. The study participants were given an identification number, identifying village, house number and a randomly computer generated digit. All answers were numerically coded on the questionnaire and laboratory results entered into Microsoft Office Access, 2003 version. Data were analysed using Stata version 10.0 (Stata Corporation 4905, Lakeway Drive College Station, Texas 77845, USA). Averages and 95% confidence interval (CI) were used for summarizing of results. Frequencies and percentages were used to compare number of participants associated with the use of SP, parasitaemia, haemoglobin levels etc. Analyses of differences in proportions were done using Pearson's chi-square test or Fisher's exact test where appropriate. Analysis of variance (ANOVA) with Bonferroni measure of comparison was used to measure the differences in means and Pearson correlation coefficient used to determine the relations between variables. For all statistical tests in this IPTp study, p < 0.05 was considered significant. Responses from the qualitative survey were tape-recorded and transcribed. The data were manually analysed along defined themes including knowledge of SP in IPTp and its effects and benefits in preventive treatment of malaria in pregnancy.
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