Scaling-up the use of sulfadoxine-pyrimethamine for the preventive treatment of malaria in pregnancy: results and lessons on scalability, costs and programme impact from three local government areas in Sokoto State, Nigeria

Abstract

Background: Intermittent preventive treatment of malaria in pregnancy with 3+ doses of sulfadoxine-pyrimethamine (IPTp-SP) reduces maternal mortality and stillbirths in malaria endemic areas. Between December 2014 and December 2015, a project to scale up IPTp-SP to all pregnant women was implemented in three local government areas (LGA) of Sokoto State, Nigeria. The intervention included community education and mobilization, household distribution of SP, and community health information systems that reminded mothers of upcoming SP doses. Health facility IPTp-SP distribution continued in three intervention (population 661,606) and one counterfactual (population 167,971) LGAs. During the project lifespan, 31,493 pregnant women were eligible for at least one dose of IPTp-SP.

Methods: Community and facility data on IPTp-SP distribution were collected in all four LGAs. Data from a subset of 9427 pregnant women, who were followed through 42 days postpartum, were analysed to assess associations between SP dosages and newborn status. Nominal cost and expense data in 2015 Nigerian Naira were obtained from expenditure records on the distribution of SP.

Results: Eighty-two percent (n = 25,841) of eligible women received one or more doses of IPTp-SP. The SP1 coverage was 95% in the intervention LGAs; 26% in the counterfactual. Measurable SP3+ coverage was 45% in the intervention and 0% in the counterfactual LGAs. The mean number of SP doses in the intervention LGAs was 2.1; 0.4 in the counterfactual. Increased doses of IPTp-SP were associated with linear increases in newborn head circumference and lower odds of stillbirth. Any antenatal care utilization predicted larger newborn head circumference and lower odds of stillbirth. The cost of delivering three doses of SP, inclusive of the cost of medicines, was US$0.93-$1.20.

Conclusions: It is feasible, safe, and affordable to scale up the delivery of high impact IPTp-SP interventions in low resource malaria endemic settings, where few women access facility-based maternal health services. ClinicalTrials.gov Identifier NCT02758353. Registered 29 April 2016, retrospectively registered.

Keywords: Community engagement; Community-based health workers; Human-centered design; IPTp-SP; Integrated MNH; Malaria in pregnancy; Nigeria; Primary health care; Scale up; Sokoto State.

Fig. 1

Map of intervention and counterfactual LGAs

Fig. 2

Sokoto State chlorhexidine–misoprostol distribution system

Fig. 3

Decision tree for SP dosage and referral

Fig. 4

Planning schema for MiPP project review meetings

Fig. 5

Percentage coverage of pregnant women who took SP1 in three intervention LGAs and one counterfactual LGA, Sokoto State, Apr–Nov 2014 and Apr–Nov 2015

Fig. 6

Percentage coverage of pregnant women who took SP1 in three intervention LGAs and one counterfactual LGA by source April–November 2015

Fig. 7

Monthly number of pregnant women who took SP1, SP2, SP3 in three intervention LGAs and one counterfactual LGA, Sokoto State, April–November 2015

Fig. 8

Mean doses of SP between April and November 2015 in the MiPP intervention and counterfactual LGAs

Fig. 9

Mean head circumference in the intervention and counterfactual LGAs by birth month (April–November 2015)

Fig. 10

Mean newborn head circumference in mm by number of SP doses during pregnancy, for births between April and November 2015

Fig. 11

Stillbirth rate by 1, 2 and 3+ doses of SP, for births between April and November 2015