Inequities in the use of sulphadoxine-pyrimethamine for malaria prophylaxis during pregnancy in Nigeria

  • Malawi Medical Journal, Volume 32, No. 1, Year 2020

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Study Justification:
– The study aims to address the inequities in accessing and using sulphadoxine-pyrimethamine (SP) for malaria prophylaxis during pregnancy in Nigeria.
– It provides insights into the geographic and socio-economic variations in SP use, as well as client-related and service delivery determinants.
– The study highlights the need for targeted interventions to reduce existing inequities and scale-up malaria prevention strategies.
Study Highlights:
– Women in the upper three wealth quintiles were 1.33-1.80 times more likely to receive SP than the poorest.
– Women who received antenatal care (ANC) from public health facilities were twice as likely to use SP compared to those who used private facilities.
– Women who attended at least 4 ANC visits were 1.46 times more likely to receive SP prophylaxis.
– Rural women were 0.86 times less likely to use SP compared to urban women.
Recommendations for Lay Reader and Policy Maker:
– Implement targeted interventions to improve access to and use of SP for malaria prophylaxis during pregnancy, particularly among the poorest women.
– Strengthen public health facilities to ensure adequate provision of SP and promote its use.
– Encourage women to attend at least 4 ANC visits to increase the likelihood of receiving SP prophylaxis.
– Address the rural-urban disparity in SP use by improving access to healthcare services in rural areas.
Key Role Players:
– Ministry of Health: Responsible for policy development and implementation of interventions to improve access to SP for malaria prophylaxis during pregnancy.
– National Population Commission: Conducts national surveys, such as the Nigeria Demographic and Health Survey (NDHS), to provide data for research and policy-making.
– Health Facilities: Play a crucial role in providing ANC services and ensuring the availability of SP for pregnant women.
– Non-Governmental Organizations (NGOs): Can support the implementation of targeted interventions and provide resources to improve access to SP.
Cost Items for Planning Recommendations:
– Training and Capacity Building: Budget for training healthcare providers on the use of SP and its importance in malaria prevention during pregnancy.
– Procurement and Supply Chain: Allocate funds for the procurement and distribution of SP to health facilities.
– Infrastructure and Equipment: Invest in improving the infrastructure and equipment of public health facilities to ensure adequate provision of ANC services and SP.
– Awareness and Education: Allocate resources for awareness campaigns to educate pregnant women about the importance of SP and ANC visits.
– Monitoring and Evaluation: Set aside funds for monitoring and evaluating the implementation of interventions and measuring their impact.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on a large sample size (38,948 eligible women) and utilizes secondary data from the 2013 Nigeria Demographic and Health Survey (NDHS). The study also includes descriptive and logistic regression analysis to identify factors associated with the use of sulfadoxine-pyrimethamine (SP) for malaria prophylaxis in pregnancy. To improve the evidence, it would be beneficial to provide more information on the methodology used for data collection and analysis, such as the specific variables included in the regression analysis and any potential limitations of the study.

Background Intermittent presumptive treatment in pregnancy (IPTp) of malaria using sulfadoxine-pyrimethamine (SP) was introduced in Nigeria in 2005 to reduce the burden of malaria in pregnancy. By 2013, 23% of reproductive aged women surveyed received SP for malaria prevention in their last pregnancy of the past 5 years. This paper highlights geographic and socio-economic variations and inequities in accessing and using SP for malaria prophylaxis in pregnancy in Nigeria, as well as client-related and service delivery determinants. Methods Secondary data from 2013 Nigeria demographic and health survey (DHS) was used. Sample of 38,948 eligible women were selected for interview using stratified three-stage cluster design. Data obtained from the individual recode dataset was used for descriptive and logistic regression analysis of factors associated with SP use in pregnancy was performed. Independent variables were age, media exposure, region, place of residence, wealth index, place of antenatal care (ANC) attendance and number of visits. Results Women in the upper three wealth quintiles were 1.33-1.80 times more likely to receive SP than the poorest (CI: 1.15-1.56; 1.41-1.97; 1.49-2.17). Women who received ANC from public health facilities were twice as likely (inverse of OR 0.68) to use SP in pregnancy than those who used private facilities (CI: 0.60-0.76). Those who attended at least 4 ANC visits were 1.46 times more likely to get SP prophylaxis (CI: 1.31-1.63). Using the unadjusted odds ratio, women residing in rural areas were 0.86 times less likely to use SP compared to those in urban areas. Conclusions Inequities in access to and use of SP for malaria prophylaxis in pregnancy exist across sub-population groups in Nigeria. Targeted interventions on the least covered are needed to reduce existing inequities and scale-up IPTp of malaria.

This study used secondary data from the 2013 Nigeria Demographic Health Survey (NDHS). The NDHS is a national sample survey which is conducted at five year intervals by the National Population Commission, within the months of June and October of the reporting year, to provide up to date information on demographic characteristics and health status of households in Nigeria. Nigeria has an annual population growth rate of 3.2 percent and ranks seventh among highly populated countries in the world13. The constitution of Nigeria provides for the operation of three tiers of government – the Federal, 36 semi-autonomous States (and the Federal Capital Territory) and 774 local government areas grouped into six geopolitical zones. In the last national census of 2006, each locality in Nigeria was subdivided into census enumeration areas determined by average number of households13. Primary health care is recognized nationally as the framework for achieving universal health care, including provision of maternal and child health (MCH) care at primary health centers12. Utilization of services in the primary health facilities is limited and varies across socioeconomic and geopolitical differences. Ante-natal care attendance ranges from 31% north-east to 87% in the south-west whereas health facility delivery ranges from 8.4% in the north-east to 73% in the south-west17. On the other hand, majority of PHCs in the country do not run 24-hour services, thereby denying a lot of patients the opportunity to patronize such centres when ill or for deliveries. In order to address these and other challenges in MCH service delivery, Nigeria introduced the Midwives Service Scheme (MSS) from 2009–2011, the Subsidy Reinvestment and Empowerment Program (SURE-P MCH) in 2012–2015, and the most recent PHC revitalization in 2017, to strengthen coordination and improve quality of service delivery12. The 2013 NDHS sample was selected using a stratified three-stage cluster design consisting of 904 clusters, 372 in urban areas and 532 in rural areas. The list of census enumeration areas of 2006 population census formed the DHS sampling frame and primary sampling unit. The sample design allowed for specific indicators to be calculated at zonal and state levels. Mapping of households was done between December 2012 and January 2013 by trained enumerators using Global Positioning System (GPS) receivers. An updated list of households in each CEA was produced and this formed the sampling frame for households12. A fixed sample of 45 households was selected per cluster giving a total of 40,680 households. In each selected household, all reproductive aged women who were resident de facto were surveyed12. Two modified NDHS model questionnaires (Households and Women’s) were used to collect information on maternal and child health including antenatal care, malaria preventive strategies as well as other relevant health issues. Relevant data from this study were obtained from the individual recode dataset for women. This dataset is generated using relevant information from the household and women’s questionnaires and contains data on intermittent preventive treatment for malaria during pregnancy, antenatal visits, type of place of residence (urban or rural), geopolitical region, asset ownership and wealth index. The women’s questionnaire was administered to all reproductive aged women in every second household in the 2013 NDHS sample. Questions concerning IPTp access and use were asked, as well as questions on frequency of antenatal visits and antenatal care service provider. Principal component analysis based on household ownership of goods, characteristics of dwelling place, source of drinking water, sanitary/toilet facilities and level of education of head of household, was used to rank households into socioeconomic quintiles namely: Q1 – poorest, Q2 – poorer, Q3 – middle, Q4 – richer, Q5 – richest. DHS dataset is self-weighted by the selection of clusters with probability-proportionate-to-size (PPS)12. To create the individual women recode dataset, data from household questionnaire and women’s questionnaires were merged. Individual responses were matched to household identification numbers. A total of 38,948 women were surveyed. A new SPSS file was created with relevant variables for analysis. Relevant variables were identified and their data extracted from the individual women recode dataset into a new SPSS file. Descriptive statistics were performed to determine the respondent characteristics, place and number of ANC visits, and malaria prophylaxis in pregnancy. Use of SP for malaria prophylaxis in pregnancy was cross-tabulated with respondent characteristics, place and number of ANC visits, to check for statistical significance. Regression analysis was done to identify the determinants of use of SP for malaria prophylaxis in pregnancy. The independent variables included age category, media exposure, geopolitical region, place of residence (urban vs rural), wealth index, place of ANC attendance and number of ANC visits.

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

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services to provide pregnant women with information about antenatal care, malaria prevention, and the importance of taking sulfadoxine-pyrimethamine (SP) for malaria prophylaxis. These tools can also send reminders for ANC visits and SP intake.

2. Community Health Workers: Train and deploy community health workers to remote and underserved areas to provide education on maternal health, distribute SP, and monitor pregnant women’s adherence to malaria prophylaxis.

3. Telemedicine: Establish telemedicine services to connect pregnant women in rural areas with healthcare providers who can provide remote consultations, advice, and guidance on antenatal care and SP use.

4. Public-Private Partnerships: Collaborate with private healthcare providers to increase access to SP and antenatal care services, particularly in areas where public health facilities are limited.

5. Financial Incentives: Implement financial incentives, such as conditional cash transfers or vouchers, to encourage pregnant women to attend ANC visits and adhere to malaria prophylaxis, especially among the poorest populations.

6. Supply Chain Management: Improve the supply chain management system to ensure a consistent and reliable availability of SP in all health facilities, including those in remote areas.

7. Health Education Campaigns: Conduct targeted health education campaigns to raise awareness about the importance of ANC visits and SP use during pregnancy, addressing misconceptions and cultural beliefs that may hinder access to maternal health services.

8. Integration of Services: Integrate maternal health services with other existing healthcare programs, such as immunization or family planning, to reach pregnant women and provide comprehensive care.

9. Quality Improvement Initiatives: Implement quality improvement initiatives in health facilities to enhance the overall experience of pregnant women, ensuring respectful and patient-centered care that encourages continued engagement with antenatal care and malaria prophylaxis.

10. Policy and Advocacy: Advocate for policy changes and increased funding to prioritize maternal health and address the inequities in access to SP and antenatal care services across different population groups in Nigeria.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health and address the inequities in the use of sulphadoxine-pyrimethamine (SP) for malaria prophylaxis during pregnancy in Nigeria is to implement targeted interventions. These interventions should focus on the least covered sub-population groups to reduce existing inequities and scale-up the use of SP for malaria prevention.

Specifically, the following actions can be taken:

1. Targeted interventions: Identify and prioritize the sub-population groups that have the lowest access to and use of SP for malaria prophylaxis during pregnancy. This could include women from lower wealth quintiles, those attending private health facilities, and those residing in rural areas.

2. Improve access to SP: Ensure that SP is readily available and accessible in both public and private health facilities across different regions. This may involve strengthening the supply chain management system to ensure an adequate and consistent supply of SP.

3. Increase awareness and education: Conduct targeted awareness campaigns to educate women, especially those in underserved areas, about the importance of using SP for malaria prevention during pregnancy. This can be done through community health workers, radio programs, and other communication channels.

4. Enhance antenatal care services: Improve the quality and availability of antenatal care services, particularly in rural areas. This may involve increasing the number of ANC visits and ensuring that ANC services include the provision of SP for malaria prophylaxis.

5. Address socio-economic barriers: Implement strategies to address socio-economic barriers that prevent women from accessing and using SP. This could include providing subsidies or financial assistance for SP, especially for women from lower wealth quintiles.

6. Monitoring and evaluation: Establish a robust monitoring and evaluation system to track the implementation and impact of the interventions. This will help identify any gaps or challenges and allow for adjustments to be made as needed.

By implementing these recommendations, it is expected that access to and use of SP for malaria prophylaxis during pregnancy will be improved, leading to better maternal health outcomes and a reduction in the burden of malaria in Nigeria.
AI Innovations Methodology
To improve access to maternal health, here are some potential recommendations:

1. Strengthening primary healthcare facilities: Enhance the capacity and resources of primary healthcare centers to provide comprehensive maternal health services, including antenatal care, skilled birth attendance, and postnatal care.

2. Community-based interventions: Implement community-based programs that focus on educating and empowering women and their families about maternal health, promoting early and regular antenatal care visits, and encouraging facility-based deliveries.

3. Mobile health (mHealth) solutions: Utilize mobile technology to provide information, reminders, and support to pregnant women, such as appointment reminders, educational messages, and access to teleconsultations with healthcare providers.

4. Task-shifting and training: Train and empower community health workers and midwives to provide basic maternal health services, including antenatal care, delivery assistance, and postnatal care, especially in underserved areas.

5. Financial incentives: Introduce financial incentives, such as conditional cash transfers or health insurance schemes, to encourage pregnant women to seek and utilize maternal health services.

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

1. Define the indicators: Identify key indicators to measure access to maternal health, such as antenatal care coverage, facility-based deliveries, postnatal care utilization, and maternal mortality rates.

2. Data collection: Gather baseline data on the selected indicators from reliable sources, such as national surveys, health facility records, and population databases.

3. Model development: Develop a simulation model that incorporates the potential impact of the recommendations on the selected indicators. This could involve using statistical modeling techniques, such as regression analysis or mathematical modeling, to estimate the expected changes in the indicators based on the implementation of the recommendations.

4. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the model and explore different scenarios and assumptions. This could involve varying parameters, such as the coverage of interventions, the effectiveness of implementation, and the population characteristics.

5. Impact assessment: Use the simulation model to estimate the impact of the recommendations on the selected indicators. This could include projecting changes in coverage rates, calculating potential reductions in maternal mortality, or estimating the number of additional women accessing maternal health services.

6. Policy recommendations: Based on the simulation results, provide evidence-based policy recommendations on the most effective interventions and strategies to improve access to maternal health. Consider the feasibility, cost-effectiveness, and scalability of the recommendations in the local context.

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. Additionally, involving relevant stakeholders, such as policymakers, healthcare providers, and community representatives, in the process can help ensure the relevance and acceptability of the recommendations.

Statistics:
Citations: 3
Authors: 4
Identifiers:
DOI: 10.4314/mmj.v32i1.9
ISSN: 19957262
Research Areas:
Community Interventions, Environmental, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Workforce
Study Countries:
Nigeria
Study Design:
Case-Control Study, Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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