Coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) influences delivery outcomes among women with obstetric referrals at the district level in Ghana

Background: The aim of the study was to determine the coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) and its relationship with delivery outcomes among obstetric referral cases at the district level of healthcare. Methods: An implementation research within three districts of the Greater Accra region was conducted from May 2017 to February 2018, to assess the role of an enhanced inter-facility communication system on processes and outcomes of obstetric referrals. A cross-sectional analysis of the data on IPTp coverage as well as delivery outcomes for the period of study was conducted, for all the referrals ending up in deliveries. Primary outcomes were maternal and neonatal complications at delivery. IPTp coverage was determined as percentages and classified as adequate or inadequate. Associated factors were determined using Chi square. Odds ratios (OR, 95% CI) were estimated for predictors of adequate IPTp dose coverage for associations with delivery outcomes, with statistical significance set at p = 0.05. Results: From a total of 460 obstetric referrals from 16 lower level facilities who delivered at the three district hospitals, only 223 (48.5%) received adequate (at least 3) doses of IPTp. The district, type of facility where ANC is attended, insurance status, marital status and number of antenatal clinic visits significantly affected IPTp doses received. Adjusted ORs show that adequate IPTp coverage was significantly associated with new-born complication [0.80 (0.65-0.98); p = 0.03], low birth weight [0.51 (0.38-0.68); p < 0.01], preterm delivery [0.71 (0.55-0.90); p = 0.01] and malaria as indication for referral [0.70 (0.56-0.87); p < 0.01]. Positive association with maternal complication at delivery was seen but was not significant. Conclusion: IPTp coverage remains low in the study setting and is affected by type of health facility that ANC is received at, access to health insurance and number of times a woman attends ANC during pregnancy. This study also confirmed earlier findings that, as an intervention IPTp prevents bad outcomes of pregnancy, even among women with obstetric referrals. It is important to facilitate IPTp service delivery to pregnant women across the country, improve coverage of required doses and maximize the benefits to both mothers and newborns. At delivery, a cross-sectional analysis of data for obstetric referrals which ended in deliveries in three districts/municipalities in the Greater Accra region of Ghana from May 2017 to January 2018 was conducted. This study was part of an implementation research to evaluate the role of an enhanced inter-facility communication system on the processes and outcomes of obstetric referrals in these districts in the region. The Greater Accra region hosts Ghana’s capital city and has 20 administrative metropolises, municipalities, districts and sub-metropolises. It is mostly urban but has 4 rural districts. The study was conducted in Ga West which is semi-urban and Ada East and Ningo-Prampram which are largely rural. Two of the selected districts (Ada East and Ga West) have district hospitals while one (Ningo-Prampram) has a polyclinic as the highest-level public facility. It however has a private hospital where patients are referred to, which is included in this study. A small number of patients are also referred outside the district, (but were not included in the sample). Participants were pregnant women who had been referred from lower levels of care (health center, polyclinic, community clinic and community health and planning services [CHPS] compounds), within the district to the district hospital, and received care at the district hospital, over the period from May 2017 to January 2018, and delivered before discharge. These women, who were already part of a larger study, were included in this study because It was possible to analyse the pregnancy outcome as well as the IPTp doses and other related factors at one point in time without the need to follow them up. A facility audit was conducted to, among other things, assess the availability of sulfadoxine-pyrimethamine (SP) at pharmacy or dispensary as well as stock-out of SP at the pharmacy or dispensary within 6 months prior to and at the time of the study. The availability of a laboratory that offers malaria testing services was determined. Participants answered a questionnaire while on admission, and their records as well as hospital registers were also reviewed during the period of stay in hospital for additional data using a checklist. Data was collected on participants’ sociodemographic characteristics, previous pregnancy history, current pregnancy details, indication for referral and delivery factors. The primary outcome variables were any maternal complication at delivery and any new-born complications at delivery. Secondary outcomes were gestational age, birth weight and anaemia at delivery, gender of baby and whether malaria was the indication for the referral. Focus was not on complications during the whole pregnancy period because participants had been referred and most of them had one complication or the other before delivery. Independent variables were dose of IPTp received during pregnancy and others shown in Table 1. For analysis of relationship between IPTp coverage and delivery outcomes, IPTp doses received was categorized as adequate or inadequate based on the WHO recommendation of at least 3 doses during pregnancy [16], Definition of variables for the study Gestational age at delivery: preterm (< 37 weeks) Term (37–40 weeks) Post term (> 40 weeks) Haemoglobin level at delivery: Normal (≥ 12 g/dl), mild anaemia (10.0–11.9 g/dl), moderate anaemia (9.9–7.0 g/dl) severe anaemia (< 7.0 g/dl) Birth weight of baby: Low birth weight (< 2.5 kg) Normal weight (2.5–4.0 kg) Big baby (> 4.0 kg) Dose of IPTp received during pregnancy: 0, 1–3, 4–5, > 5; Adequate (NMCP/WHO): (5 +)/(3 +), Inadequate (NMCP/WHO): (< 5)/(< 3) ANC antenatal care, IPTp intermittent presumptive treatment of malaria in pregnancy Total missing data were more than 5% and this level of missing data is rarely random. Thus, multiple imputations of missing data were conducted and analysis was based on the imputed data set. Descriptive analysis using frequencies and proportions was done for all the independent and outcome variables. Bivariate analysis using χ2 test was used to investigate the relationship between the IPTp dose coverage and other independent variables, with detection of significance set at p < 0.05. Using a backward stepwise approach, a model was built with all the significant factors in the χ2 analysis to determine the predictors of IPTp dose coverage. For analysis of association between IPTp coverage and outcomes, IPTp doses received was categorized as adequate or inadequate based on the WHO recommendation of at least 3 doses during pregnancy [16]. Associations between IPTp dose coverage and the outcomes were estimated using odds ratios (OR), with their 95% confidence intervals (CI). Significance tests were based on Wald Chi square tests and p-values < 0.05 were considered significant, with all potential confounders adjusted for. Data analysis was carried out using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. The strength of this paper is in the fact that it focused on women with obstetric referrals and not all pregnant women in general as most studies have looked at. Most of these women have some pregnancy complication and yet the data shows that adequate IPTp coverage is associated with improved delivery outcomes among them. Patient records for data on the IPTp coverage and some of the secondary outcome variables were used, leading to some missing data. This is a limitation of the study which was addressed by doing multiple imputation of data for the analysis. Also, it must be noted that this work was done among referred pregnant women and so results may not reflect what the situation is for the entire pregnant women population.