Coverage of malaria protection in pregnant women in sub-Saharan Africa: a synthesis and analysis of national survey data

Abstract

Background: Insecticide-treated nets and intermittent preventive treatment with sulfadoxine-pyrimethamine are recommended for the control of malaria during pregnancy in endemic areas in Africa, but there has been no analysis of coverage data at a subnational level. We aimed to synthesise data from national surveys about these interventions, accounting for disparities in malaria risk within national borders.

Methods: We extracted data for specific strategies for malaria control in pregnant women from national malaria policies from endemic countries in Africa. We identified the most recent national household cluster-sample surveys recording intermittent preventive treatment with sulfadoxine-pyrimethamine and use of insecticide-treated nets. We reconciled data to subnational administrative units to construct a model to estimate the number of pregnant women covered by a recommended intervention in 2007.

Findings: 45 (96%) of 47 countries surveyed had a policy for distribution of insecticide-treated nets for pregnant women; estimated coverage in 2007 was 4·7 million (17%) of 27·7 million pregnancies at risk of malaria in 32 countries with data. 39 (83%) of 47 countries surveyed had an intermittent preventive treatment policy; in 2007, an estimated 6·4 million (25%) of 25·6 million pregnant women received at least one dose of treatment and 19·8 million (77%) visited an antenatal clinic (31 countries). Estimated coverage was lowest in areas of high-intensity transmission of malaria.

Interpretation: Despite success in a few countries, coverage of insecticide-treated nets and intermittent preventive treatment in pregnant African women is inadequate; increased efforts towards scale-up are needed.

Funding: The Malaria in Pregnancy Consortium and Wellcome Trust.

Figure 1

Malaria risk (A), IPTp policy adoption (B), ITN coverage in women aged 15–49 years (C), IPTp coverage of at least one dose of sulfadoxine–pyrimethamine from any source (D), and ANC coverage (E) in countries in sub-Saharan Africa Ethiopia and Burundi have no IPTp policy (D), but data were collected for sulfadoxine–pyrimethamine use in pregnant women in the last-available survey; Mauritania, Congo, and the Central African Republic had no IPTp policy at the time of the survey; Chad and Guinea adopted IPTp <1 year before the survey. ADMIN1=first-level administrative unit. IPTp=intermittent preventive treatment in pregnancy. ITN=insecticide-treated net. ANC=antenatal clinic.

Figure 2

Flow diagram for calculation of number of pregnancies protected against malaria by ITNs or IPTp in sub-Saharan Africa for a hypothetical pregnant population in 2007 IPTp=intermittent preventive treatment in pregnancy. ITN= insecticide-treated net. ANC=antenatal clinic. PfPR_2–10=predicted annual mean prevalence of Plasmodium falciparum in children aged 2–10 years. ADMIN1=first-level administrative unit.

Figure 3

Coverage of SP intermittent preventive treatment (A) and estimated number of pregnant women who received at least two doses of SP, one from an ANC, projected for 2007 (B) SP=sulfadoxine–pyrimethamine. ANC=antenatal clinic. DR Congo=Democratic Republic of the Congo. *Nigeria: 6 150 000 pregnancies per year.