Quality and Integrated Service Delivery: A Cross-Sectional Study of the Effects of Malaria and Antenatal Service Quality on Malaria Intervention Use in Sub-Saharan Africa

Abstract

Using regionally linked facility and household surveys, we measured the quality of integrated antenatal care and malaria in pregnancy services in Kenya, Namibia, Senegal, and Tanzania. We examined country heterogeneities for the association of integrated antenatal and malaria service quality scores with insecticide-treated bed net (ITN) use in pregnant women and children under-five and intermittent preventive treatment in pregnancy (IPTp-2) uptake. Malaria in pregnancy service quality was low overall. Our findings suggest modest, positive associations between malaria in pregnancy quality and ITN use and IPTp-2 uptake across pooled models and for most studied countries, with evidence of heterogeneity in the strength of associations and relevant confounding factors. Antenatal care quality generally was not associated with the study outcomes, although a positive interaction with malaria in pregnancy quality was present for pooled ITN use models. The improved quality of malaria services delivered during formal antenatal care can help address low coverage and usage rates of preventive malaria interventions in pregnancy and childhood. Study findings may be used to target quality improvement efforts at the sub-national level. Study methods may be adapted to identify low-performing facilities for intervention and adaption to other areas of care, such as HIV/AIDS, child immunizations, and postnatal care.

Keywords: Sub-Saharan Africa; antenatal care; malaria; pregnancy; quality; service integration.

Figure 1

Unadjusted risk estimates for intermittent preventive treatment in pregnancy. Note: Unadjusted risk estimates of mother’s educational level not shown.

Figure 2

Unadjusted risk estimates for insecticide-treated bed net use in pregnancy. Note: Unadjusted risk estimates of mother’s educational level not shown.

Figure 3

Unadjusted risk estimates for insecticide-treated bed net use in children under five. Note: Unadjusted risk estimates of mother’s educational level not shown.

Figure 4

Forest plots of adjusted associations of malaria in pregnancy and antenatal care quality with each of three study outcomes. Abbreviations: IPTp-2—intermittent preventive treatment in pregnancy—2 doses; ITN—insecticide-treated bed net; ANC—antenatal care; MiP—malaria in pregnancy.

Figure 4

Forest plots of adjusted associations of malaria in pregnancy and antenatal care quality with each of three study outcomes. Abbreviations: IPTp-2—intermittent preventive treatment in pregnancy—2 doses; ITN—insecticide-treated bed net; ANC—antenatal care; MiP—malaria in pregnancy.