Uptake of intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTp-SP) in pregnancy and associated factors in a malaria endemic setting of Sub-Saharan Africa

doi:10.21203/rs.3.rs-5143172/v1

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Uptake of intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTp-SP) in pregnancy and associated factors in a malaria endemic setting of Sub-Saharan Africa

https://doi.org/10.21203/rs.3.rs-5143172/v1

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Introduction: Malaria in pregnancy (MiP) is a public health issue that poses risks to maternal and fetal health. Although the World Health Organization recommends intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTp-SP) to prevent MiP, its uptake remains low among endemic countries. This study aimed to evaluate IPTp-SP uptake and factors associated with its use at Bonassama District Hospital (BDH) in the Littoral Region of Cameroon.

Methods: A cross-sectional study was conducted at BDH from March to June 2022. Data were collected from antenatal care (ANC) attendees who were more than 30 weeks pregnant. Asymptomatic malaria infections were assessed using PfHRP2/pLDH diagnostic testing. Pearson Chi-square and Fisher’s Exact tests evaluated associations, while binary logistic regression assessed predictors of optimal IPTp-SP uptake, with statistical significance set at p < 0.05.

Results: Of the 393 participants, 273(69.5%, 95%CI: 64.7-74.0) received optimal IPTp-SP dosing. Predictors of IPTp-SP optimization were: level of education, religion, gravida, parity, gestational age at first ANC, number of ANC visits and maternal knowledge of optimal SP dose. Women who had taken at least three doses of IPTp-SP had less P. falciparum infections (aOR =2.6, 95% CI:1.65-4.14, p < 0.001). Primigravida women (aOR = 3.2, 95% CI: 1.69-5.98, p < 0.001), who started ANC during the first trimester of pregnancy (aOR = 28.5, 95% CI: 12.58-64.58, p <0.001), with ≥ 4 ANC visits (aOR = 16.7, 95% CI 7.9–35.3, p < 0.001) and had good knowledge of optimal SP dosing required during pregnancy (aOR =3.2, 95% CI: 2.0-5.22, p < 0.001) were more likely to receive optimal IPTp-SP dosing. IPTp-SP uptake was not associated with utilization of long-lasting insecticidal nets (LLINs) (p>0.05).

Conclusion: This study revealed that the optimal uptake of IPTp-SP was below the nationwide 80% coverage target set for 2030. This reinforces the urgency to promote early and frequent ANC visits. Additionally, there is a continuous need for health education highlighting the importance of IPTp-SP uptake and the use of LLINs as essential strategies to reduce MiP.

Pregnancy

Intermittent preventive treatment

Sulphadoxine pyrimethamine

Optimal uptake

Bonassama District Hospital

Malaria due to plasmodium falciparum remains a significant infectious disease linked to poverty that is of public health concern despite progress made in recent years. According to 2023 World Malaria Report, an estimated 249 million malaria cases and 608 deaths were recorded in 85 malaria endemic countries and territory in 2022, an increase of 5 million cases compared to 2021[1]. The WHO African Region, with an estimated 233 million cases in 2022, accounted for about 94% of cases globally. Pregnant women, especially primigravida mothers, have an increased susceptibility to malaria infection due to their reduced immunity arising from immunological, hormonal and physiological change [2, 3], making them more prone to severe complications, including maternal anemia, low birth weight, and maternal mortality [4, 5]. According to the 2022 World Malaria Report, more than 13 million cases of malaria occur in pregnancy globally [6]

Malaria is endemic across all the ten regions of Cameroon and the first major cause of morbidity and mortality among pregnant women. The country is ranked among 15 highest burden malaria countries worldwide contributing over 3% of all global malaria cases and deaths [7]. The prevalence of MiP recorded in 2021 in Cameroon was 39.8% [8]. A pregnant woman suffering from malaria is estimated to be three times more at risk of dying of the disease compared to a non-pregnant woman suffering from the disease [9]. To mitigate these risks of MiP, the use of Intermittent Preventive Treatment with sulfadoxine-pyrimethamine (IPTp-sp) among other preventive methods, is recommended as a cost-effective and proven intervention to prevent malaria transmission.

The world health organization (WHO) recommends Intermittent Preventive Treatment with sulfadoxine-pyrimethamine (IPTp-SP) in pregnancy. Pregnant women in malaria endemic zones take IPT-SP regardless of whether they are symptomatic of malaria or not. The IPTp-SP policy recommends that each pregnant woman receive at least three doses of sulfadoxine-pyrimethamine (SP) during her pregnancy, starting at 13 weeks of gestation and lasting till delivery with each dose safely administered at least one month apart [10, 11].

In Cameroon, the Ministry of Public Health adopted the use IPTp-SP in 2004 following WHO recommendations consisted of at least three free SP doses between the 16th and the 36th weeks of pregnancy alongside free distribution of long-lasting insecticide treated nets (LLINs), treatment of malaria cases, folic acid supplementation [12]. These interventions are commonly delivered during antenatal care (ANC) through collaboration between malaria control and reproductive health programmes. Existing literature in the country revealed that, over 54% of pregnant women received at least two doses of intermittent preventative treatment of malaria in pregnancy (IPTp2) in 2018. The proportion of pregnant women who received at least three doses (IPTp3) increased from 26% in 2014 to 32% in 2018 [7]. In recent studies, an optimal uptake of 54.9% in 2022 and 65.0% in 2024 were recorded within the North West [13] and West [14] regions, respectively of the country. However, these observations fall short of the country’s target coverage rate of 80% by 2023.

Identifying the barriers that limit access to malaria prevention and treatment in pregnant women in malaria-endemic regions through continuous monitoring and evaluation IPTp-SP is essential to track control efforts. This study therefore is aimed at assessing the uptake of intermittent preventive treatment with Sulphadoxine pyrimethamine during pregnancy (IPTp-SP) and associated factors in Bonassama District Hospital, Littoral Region of Cameroon, a region characterized by high malaria transmission.

Study area

This study was conducted in the Bonassama District Hospital (BDH), Littoral Region of Cameroon. The BDH is one of seven health district hospitals located between latitude 4° 4′ 23.3″ North and longitude 9° 41′ 8.15″ East in the city of Douala and circumscribed within the administrative boundaries of Douala IV Sub-Division[4, 15] (Fig. 1). The hospital is one of the health facilities is the Bonassama Health District, which is one of the thirty health districts in the Littoral Region of Cameroon. The district has a surface area of about 55km² with a population of over 350,000 inhabitants and is situated just before the Bonaberi bridge of the Wouri River. The inhabitants of Bonaberi comprise predominantly of the Sawa indigens of the Bantu ethnic group [16]. However, there are a significant number of other tribes and ethnic groups from all over the country as well as foreigners. Bonaberi is home to many industries, markets, and transport facilities. It is also a cultural hub, with a vibrant music scene and a rich history.

Figure 1 Map showing the location of Bonassama District Hospital

The Littoral Region is characterized by forested equatorial climate, characterized by a succession of vegetation, including deep equatorial evergreen forest, mangroves and humid savannah. The climate comprises four seasons, two rainy seasons and two dry seasons with heavy rainfall (1500–5000 mm3/year). Malaria transmission is perennial and holoendemic with P. falciparum the main malarial species [17].

Study design, population and setting

This was a hospital based cross-sectional quantitative study conducted from March-June, 2022 to examine the uptake of IPTp-SP and associated factors in pregnancy. The study population comprised all consenting pregnant women aged 15–49 years and older than 30 weeks gestational age and attending antenatal care at BDH. Pregnant women who were sick or mentally ill were excluded from the study.

Sample size and sampling

A minimum sample size of 335 was computed with the Cochran (1977) formula, using an IPTp-SP uptake of 32.0% obtained from the 2018 Demographic and Health Survey summary report data in Cameroon [18]; 95% confidence interval; a margin of error of 5%. The sampling technique was purposive, and patients were enrolled consecutively.

Data and sample collection

A semi-structured pretested interviewer administered questionnaire was designed and used to document information related to obstetric and socio-demographic, antenatal care history, malaria during pregnancy, intake of IPT, malaria prevention practices, and knowledge of malaria (Suppl 1). Some of these data including number of ANC visits, gestational age at first ANC visit and number of SP doses taken were extracted from the ANC cards of the mothers and ANC registers of the units. Where there was discrepancy between the verbal information given and that written on the ANC card, what was on the card was used. For those without antenatal cards data collected were based on the interviews and ANC registers. Table 1 shows the list of study variables, indicators, operational definition and scale of measurement. To ensure uniformity and correctness, five research assistants were trained for three days on how to explain the study objectives, obtain informed consent and conduct the interviews.

The presence of asymptomatic malaria infection was determined from consenting pregnant women using Bioline rapid diagnostic test (RDT). Briefly, about 5 µl of capillary blood sample from consenting pregnant women was collected by finger pricking under standard aseptic procedure. The blood sample was placed in the sample window of PfHRP2/pLDH malaria rapid diagnostic kit (SD BiolineTM, Alere, South Korea) cassette and three drops of diluent added. The results were then read after 15 minutes. The presence of two (or three), one or no distinct line is an indication of a positive, negative or invalid result, respectively.

Study variables

The primary outcome measure was the number of IPTp-SP doses received, a dichotomous variable created to have sub-optimal IPTp-SP uptake (≤ 2 doses) and optimal IPTp-SP uptake (≥ 3 doses). A total of 16 independent variables were analyzed in the bivariate analysis. Among them were knowledge of malaria prevention practices, LLINs ownership and utilization and malaria parasite infection status. Other independent variables were sociodemographic and obstetric characteristics of the respondents including gravida, parity, gestational age at first ANC, number of ANC visits, age, level of education, religion, distance to the hospital, etc.

Table 1

Definition of independent variables
variable	Definition
Optimal ITPp-SP uptake	3 or more doses of IPTp-SP
Sociodemographic
Age	Age in years, further grouped < 25, 25–34 and ≥ 35 years
Level of education	Highest level attained, classified as none, primary, secondary and tertiary
Marital status	Marital status of respondent, either single, married or divorced/widowed
Religion	Religion of respondents, grouped as Christian, Muslim or Atheist
Distance to hospital	Distance to the hospital, either near or far
Gravida	Number of pregnancies, classified as primigravida or multigravida
Parity	number of children, grouped as nulliparous (no child), primiparous (1 child) or multiparous (more than 1 child)
ANC and obstetric
Gestational age	Age of pregnancy in weeks, further grouped 31–33 and ≥ 34
Gestational age at first ANC	Pregnancy age at 1st ANC visit, further grouped as first trimester (≤ 12 weeks), second trimester (13–27 weeks) or third trimester (≥ 28 weeks)
Number of ANC visits	Total number of ANC visits, further classified as ≤ 3 and ≥ 4
SP doses received	Total number of SP doses received
Malaria prevention practices, malaria infection and knowledge of malaria
Own mosquito nets	Whether a woman own LLIN or not
Utilization of mosquito nets	Frequency of using LLINs, further classified as “always used” or “not always used”
Malaria infection status	Presence or absence of malaria parasite in blood detected using RDT, classified as “positive” or “negative”
Knowledge of malaria transmission	Selecting only “mosquito” as an agent of malaria transmission
Knowledge of malaria prevention	Mentioning that mosquito nets, and the elimination of stagnant water can prevent malaria indicated good knowledge, otherwise poor knowledge
Knowledge of SP doses required during pregnancy	Mentioning uptake of SP doses of more than 3 doses during the entire pregnancy period indicated good knowledge, otherwise poor knowledge

Data management and analysis

Data were entered into Microsoft Excel 2018, cross-checked for completeness, and imported into SPSS version 28 for analysis. Descriptive statistics using frequencies, percentage, means and standard deviation was used to summarized data related to sociodemographic, ANC and obstetric characteristics as well as knowledge of malaria and prevention practices. The uptake of IPTp-SP was categorized into < three doses versus ≥ three doses. Pearson Chi-square and Fischer Exact tests were conducted to establish association between uptake of IPTp-SP and each independent categorical variable. To identify predictors of IPTp-SP uptake, variables with p value of 0.1 or lower in bivariate analysis were included in the multivariate regression model at 5% level of significance. Adjusted Odd ratios (aOR) with 95% confidence interval (CI) were reported and all predictors with P < 0.05 were considered to be independently associated with IPTp-SP optimal

uptake.

A total of 393 pregnant women attending ANC at the BDH were enrolled in the study. Table 2 summarizes the socio-demographic characteristics of the respondents. The mean age (± SD) of the participants was 28.81 ± 5.60 years, with majority (55.2%) in the 25–34 years age group. Most of the women 165(42.0%) had secondary level of education, of Christian religion (81.9%), and leaving closer to the health facility (72.3%).

Majority of the women reported starting antenatal care during the second trimester (48.3%), with a total of less than 3 ANC visits (60.1%) (Table 3). Three hundred and sixty-two women reportedly owned LLINs (92.1%), with over 222(61.3%) always using the LLINs. Majority of the pregnant women had good knowledge of malaria transmission (75.8%), prevention (70.2%) and the required number of SP doses during pregnancy (75.3%) (Table 4).

Table 2

Socio-demographic characteristics of participants
Variable		n (%)	95% CI
Age group	< 25	107(27.2)	22.9–31.9
	25–34	217(55.2)	50.2–60.2
	> 34	69(17.6)	13.9–21.7
Mean (SD)		28.81(5.6)	28.3–29.4
Level of education	None	31(7.9)	5.4–11.0
	Primary	67(17.0)	13.5–21.1
	Secondary	165(42.0)	37.1–47.0
	Tertiary	130(33.1)	28.4–28.0
Marital status	Single	127(32.3)	27.1–37.2
	Married	251(63.9)	58.9–68.2
	Divorced/Widowed	15(3.8)	2.2–6.2
Religion	Christian	322(81.9)	77.8–85.6
Religion	Muslim	71(18.9)	14.4–22.2
Distance to hospital	Near	284(72.3)	67.6–76.6
Distance to hospital	Far	109(27.7)	23.4–32.4
Number of pregnancies (Gravida)	Primigravida (1)	89(22.6)	18.6–27.1
Number of pregnancies (Gravida)	Multigravida (> 1)	304(77.4)	72.9–81.4
Parity (number of children)	Nulliparous (none)	66(16.8)	13.2–20.9
	Primiparous (1)	126(32.1)	27.5–36.9
	Multiparous (> 1)	201(51.1)	46.1–56.2

CI: Confidence Interval, SD: Standard Deviation

Table 3

ANC and obstetric characteristics (N = 393)
Variable		n (%)	95% CI
Gestational age (weeks)	< 34	132(33.6)	28.9–38.5
Gestational age (weeks)	≥ 34	261(66.4)	61.5–71.1
Mean (SD)		35.4(3.0)	35.1–35.7
Gestational age at first ANC	First trimester	147(37.4)	32.6–42.4
	Second trimester	190(48.3)	43.3–53.4
	Third trimester	56(14.2)	11.0-18.1
Number of ANC visits	≤ 3	236(60.1)	55.0-64.9
Number of ANC visits	≥ 4	157(39.9)	35.1–45.0
SP doses received	< 2 doses	120(30.5)	26.0-35.4
SP doses received	≥ 3 doses	273(69.5)	64.7–74.0

CI: Confidence Interval, SD: Standard Deviation, ANC: Antenatal care, SP: SP: Sulphadoxine pyrimethamine

Table 4

Malaria prevention practices, malaria infection and knowledge of malaria
Variable		n (%)	95% CI
Own mosquito nets	Yes	362(92.1)	88.9–94.6
Own mosquito nets	No	31(7.9)	5.4–11.0
Utilization of mosquito nets (n = 362)	Always use	222(61.3)	51.4–61.4
Utilization of mosquito nets (n = 362)	Not always use	140(38.7)	30.9–40.6
Malaria infection	Positive	125(31.8)	27.2–36.7
Malaria infection	Negative	268(68.2)	63.3–72.8
Knowledge of malaria transmission	Good knowledge	298(75.8)	71.3–80.0
Knowledge of malaria transmission	Poor knowledge	95(24.2)	20.0-28.7
Knowledge of malaria prevention	Good knowledge	276(70.2)	65.4–74.7
Knowledge of malaria prevention	Poor knowledge	117(29.8)	25.3–34.6
Knowledge of number of SP doses	Good knowledge	296(75.3)	70.8–79.5
Knowledge of number of SP doses	Poor knowledge	97(24.7)	20.5–29.3

ANC attendance and IPTp‑SP uptake during pregnancy

Of the 393 women, only 157(39.9%,95%CI: 35.1–45.0) completed the recommended four or more ANC visits (Table 3). Figure 2 shows the IPTp-SP coverage. Six (1.5%) did not take chemoprophylaxis during their pregnancy giving IPTp-SP coverage of at least one dose of 98.5% (386/393). Among the women who took IPTp-SP, 273(69.5%, 95%CI: 64.7–74.0) received optimal IPTp-SP dose (≥ 3 doses), while 120(30.5%, 95%CI:26.0-35.4) took sub-optimal IPTp-SP dose (< 2 doses). The median IPTp-SP dosage received in this study was 3 doses. IPTp-SP optimal uptake was significantly higher (p < 0.001) among women with more four ANC visits (91.1%) than those who recorded three or less ANC visits (51.1%).

Figure 2 Coverage of Intermittent preventive treatment of malaria in pregnancy

with Sulphadoxine pyrimethamine

Asymptomatic malaria infection and IPTp-SP uptake

Of the 393 pregnant women screened for malaria infection, 125(31.8%, 95%CI: 27.2–36.7) were positive while 268(68.2%, 95%CI: 63.3–72.8) were negative (Table 4). It was observed that women who had taken at least three doses of IPTp-SP had less P. falciparum infections (p < 0.001) compared to their counterparts who had taken less than three doses (Fig. 3).

Figure 3 IPTp-SP uptake and malaria infection

Determinants of IPTp-SP uptake during pregnancy

This study compared characteristics of women who received optimal IPTp-SP doses to those who received sub-optimal IPTp-SP. Pearson Chi-square and Fischer exact tests revealed that IPTp-SP uptake was significantly associated with level of education (p < 0.001), religion (p = 0.029), gravida (p < 0.001), parity (p < 0.001), gestation age at first ANC visit (p < 0.001), number of ANC visits (p < 0.001), malaria parasite infection (p < 0.001) and maternal knowledge of optimal SP dose required during pregnancy (p < 0.001) (Table 5). Although no significant association was observed between optimal uptake of IPTp-SP and utilization of LLINs (p = 0.322), women who always used LLINs (71.6%) tended to have received optimal SP doses compared to those who do not always use LLINs (66.4%) (Table 5).

In the multivariate logistic analysis (Table 6), receipt of optimal IPTp-SP dose was significantly higher among women with secondary level of education (aOR = 2.7, 95% CI: 1.20–6.21, p = 0.017) compared to women with no level of education. Conversely, women of primary level of education were 70% less likely to receive optimal IPTp-SP dose (aOR = 0.3, 95% CI: 0.14–0.80, p = 0.014). Women who were Muslims were 2 times more likely to receive optimal IPTp-SP dose (aOR = 2.0, 95% CI: 1.07–3.75, p = 0.031) than their Christian counterparts. It was also observed that primigravida (aOR = 3.2, 95% CI: 1.69–5.98, P < 0.001) and nulliparous women (aOR = 3.8, 95% CI: 1.71–8.39, p = 0.001) were 2 times and 3 times more likely to receive optimal IPTp-SP, respectively. Women who started ANC attendance at first trimester of pregnancy (aOR = 28.5, 95% CI: 12.58–64.58, p < 0.001) and second trimester (aOR = 5.9, 95% CI: 3.01–11.61, p < 0.001) were more likely to receive optimal IPTp-SP when compared to those in the third trimester. Those with ≥ 4 ANC visits were about 8 times more likely to receive optimal IPTp-SP dose (aOR = 8.3, 95% CI: 4.54–15.27, p < 0.001). Women with no malaria parasite infection (aOR = 2.6, 95% CI:1.65–4.14, p < 0.001) had over three-fold increased likelihood to receive optimal doses than those diagnosed of malaria (Table 6). Those with good understanding of optimal SP dose were more likely to receive optimal IPTp-SP dose (aOR = 3.2, 95% CI: 2.0-5.22, p < 0.001).

Table 5

Demographic, obstetric, ANC and knowledge characteristics associated with IPTp-SP uptake during pregnancy
Independent variable		All N = 393 n (%), Mean ± SD	Uptake of IPTp-SP		P-value
			Optimal N = 273 n (%),	Sub-optimal N = 120 n (%),
			Mean ± SD	Mean ± SD
Age group	< 25	107(27.2)	77(72.0)	30(28.0)	0.229
	25–34	217(55.2)	154(71.0)	63(29.0)
	> 34	69(17.6)	42(60.9)	27(39.1)
Level of education	None	31(7.9)	19(61.3)	12(38.7)	< 0.001*
	Primary	67(17.0)	23(34.3)	44(65.7)
	Secondary	165(42.0)	134(81.2)	31(18.8)
	Tertiary	130(33.1)	97(74.6)	33(25.4)
Marital status	Single	127(32.3)	91(71.7)	36(28.3)	0.739
	Married	251(63.9)	171(68.1)	80(31.9)
	Divorced/Widowed	15(3.8)	11(73.3)	4(26.7)
Religion	Christian	322(81.9)	216(67.1)	106(32.9)	0.029*
Religion	Muslim	71(18.9)	57(80.3)	14(19.7)	0.029*
Distance to hospital	Near	284(72.3)	201(70.8)	83(29.2)	0.363
Distance to hospital	Far	109(27.7)	72(66.1)	37(22.9)	0.363
Gravida	Primigravida (1)	89(22.6)	76(85.4)	13(14.6)	< 0.001*
Gravida	Multigravida (> 1)	304(77.4)	197(64.8)	107(35.2)	< 0.001*
Parity	Nulliparous (none)	66(16.8)	58(87.9)	8(12.1)	0.002*
	Primiparous (1)	126(32.1)	83(65.9)	43(34.1)
	Multiparous (> 1)	201(51.1)	132(65.7)	69(34.3)
Gestational age (weeks)	< 34	132(33.6)	79(59.8)	53(40.2)	0.003*
Gestational age (weeks)	≥ 34	261(66.4)	194(74.3)	67(25.7)	0.003*
Gestational age at first ANC	First trimester	147(37.4)	133(90.5)	14(9.5)	< 0.001*
	Second trimester	190(48.3)	126(66.3)	64(33.7)
	Third trimester	56(14.2)	14(25.0)	42(75.0)
Number of ANC visits	≤ 3	236(60.1)	130(55.1)	106(44.9)	< 0.001*
Number of ANC visits	≥ 4	157(39.9)	143(91.1)	14(8.9)	< 0.001*
Own mosquito nets	Yes	362(92.1)	252(69.6)	110(30.4)	0.831
Own mosquito nets	No	31(7.9)	21(67.7)	10(32.3)	0.831
Utilization of mosquito nets	Always use	222(61.3)	159(71.6)	63(28.4)	0.322
Utilization of mosquito nets	Not always use	140(38.7)	93(66.4)	47(33.6)	0.322
Malaria parasite infection	Positive	125(31.8)	69(55.2)	56(44.8)	< 0.001*
Malaria parasite infection	Negative	268(68.2)	204(76.1)	64(23.9)	< 0.001*
Knowledge of malaria transmission	Good knowledge	298(75.8)	213(71.5)	85(28.5)	0.128
Knowledge of malaria transmission	Poor knowledge	95(24.2)	60(63.2)	35(36.8)	0.128
Knowledge of malaria prevention	Good knowledge	276(70.2)	194(70.3)	82(29.7)	0.590
Knowledge of malaria prevention	Poor knowledge	117(29.8)	79(67.5)	38(32.5)	0.590
Knowledge of number of SP doses	Good knowledge	296(75.3)	225(76.0)	71(24.0)	< 0.001*
Knowledge of number of SP doses	Poor knowledge	97(24.7)	48(49.5)	49(50.5)	< 0.001*

*Statistically significant result at 5% significance level, SD: standard deviation, ANC:Antenatal care

Table 6

Predictors of uptake of SP during pregnancy
Predictors		Optimal uptake n(%)	Unadjusted P-value	OR	CI	Adjusted P-value
Level of education	None	19(61.3)	< 0.001	Reference
	Primary	23(34.3)		0.33	0.14–0.80	0.014*
	Secondary	134(81.2)		2.73	1.20–6.21	0.017*
	Tertiary	97(74.6)		1.86	0.82–4.23	0.138
Religion	Christian	216(67.1)	0.029	Reference
Religion	Muslim	57(80.3)	0.029	2.01	1.07–3.75	0.031*
Gravida	Primigravida	76(85.4)	< 0.001	3.18	1.69–5.98	< 0.001*
Gravida	Multigravida	197(64.8)	< 0.001	Reference
Parity	Nulliparous	58(87.9)	0.002	3.79	1.71–8.39	0.001*
	Primiparous	83(65.9)		1.01	0.63–1.61	0.972
	Multiparous	132(65.7)		Reference
Gestational age (weeks)	< 34	79(59.8)	0.003	Reference
Gestational age (weeks)	≥ 34	194(74.3)	0.003	1.92	1.25–3.03		0.003*
Gestational age at first ANC	First trimester	133(90.5)	< 0.001	28.50	12.58–64.58		< 0.001*
	Second trimester	126(66.3)		5.91	3.01–11.61		< 0.001*
	Third trimester	14(25.0)		Reference
Number of ANC visits	≤ 3	130(55.1)	< 0.001	Reference
Number of ANC visits	≥ 4	143(91.1)	< 0.001	8.32	4.54–15.27		< 0.001*
Malaria parasite infection	Positive	69(55.2)	< 0.001	Reference
Malaria parasite infection	Negative	204(76.1)	< 0.001	2.62	1.65–4.06		< 0.001*
Knowledge of number of SP doses	Good knowledge	225(76.0)	< 0.001	3.21	2.0-5.22		< 0.001*
Knowledge of number of SP doses	Poor knowledge	48(49.5)	< 0.001	Reference
*Statistically significant result at 5% significance level, AOR: adjusted odds ratio, 95% CI: 95% confidence interval

Intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) remains a key intervention recommended by the World Health Organization (WHO) to reduce morbidity and mortality associated with malaria during pregnancy. To evaluate the impact of this control measure, there is a need to periodically report the uptake of IPTp-SP in malaria endemic areas. This study sought to assess the uptake of intermittent preventive treatment with Sulphadoxine pyrimethamine during pregnancy (IPTp-SP) and associated factors in Bonassama District Hospital. The most active age group observed in this study was 25–34 years. This is similar to other studies in Cameroon [14], and Kenya [19] where women in the age group 24–34 were the most represented age group.

Our results showed that 98.5% of the pregnant women had taken at least one dose of IPTp-SP. Similar results were observed in studies conducted in various parts of Cameroon; Bamenda (98.35%) by Diengou et al. [20], South west (92.9%) by Anchang-Kimbi et al. [21], Littoral (94.9%) by Moukoko et al. [22]. The World Health Organisation (WHO) recommends optimal uptake of three or more doses of IPTp-SP during pregnancy and a coverage of at least 80% ([11, 20]. However, our study recorded an optimal uptake of IPTp-SP of 69.5%, similar to optimal uptake of IPTp-SP of 64.99% in a recent study conducted in the western part of the country by Kamga et al.[14]. Contrary to our results, lower optimal uptake were obtained in other parts of Cameroon; South West (47.0%) [21] and North West (54.9% )[13] regions. Moreover, 36.8% was obtained among women in Northern Nigeria in 2012, 55.1% of women in private health facilities in Ghana in 2019 [23, 24]. Despite this variation, it’s interesting to note that, though optimal uptake is lower than the WHO recommended target, endemic countries progressively adhere to this recommendation over the years from 2012 to 2024; The differences in optimal uptakes might be due to challenges in implementation, level of compliance and intensity of malaria transmission. The drug combination Sulfadoxine-Pyrimethamine is recommended for malaria prophylaxis because it blocks the malaria parasite’s utilization of folinic acid hence killing the parasite [25].

Our study also revealed a significant association between uptake of IPTp-SP and asymptomatic malaria infection. Women who had taken the optimal doses recommended for IPTp-SP (at least three doses) had less P. falciparum infections compared to their counterparts who had taken less than three doses. Interestingly, other studies carried out in the Southwest of Cameroon, in 2020 and 2022 and in Littoral, Cameroon in 2023 reported similar results[21, 22, 26]. This confirms the fact that optimal doses of IPTp-SP protect against malaria [11, 27]. Although our study did not reveal any significance between good knowledge of transmission and prevention, most of those who had good knowledge received optimal doses of SP. These women might have been counselled against the dangers of malaria infection during pregnancy in health talks given during ANC. A study carried out in six districts of Tanzania reported similar results (Exavery et al., 2014). Moreover, studies conducted in Benin confirmed that women with comprehensive knowledge of malaria were almost 5 times more likely to receive optimal doses of IPTp-SP [28].

Our results revealed a number of determinants of uptake of IPTp-SP including level of education, religion, parity, gestational age at first ANC, number of ANC, malaria infection and knowledge of number of SP doses. Educational level was a great determinant of uptake of optimal doses of IPTp-SP [24, 29–32]. Educated women are more likely to understand the devastating consequences of malaria in pregnancy as revealed by our study where women with secondary level of education were 3 times more likely to receive the optimal dose of IPTp-SP compared to those with no level of education. This is in line with studies conducted in Nigeria by Kalu et al. [33] who reported that apart from household index and media exposure, level of education of a spouse positively influenced uptake of optimal doses of IPTp-SP. This is however contrary to a study conducted in Benin [28] and in Cameroon [34] where level of education was not significantly associated with uptake of IPTp-SP. This can be explained by the fact that, there have been advances in knowledge due to increased awareness in recent years. It was also observed that primigravida women experiencing pregnancy for the first time with excitement were 3 times more likely to receive IPTp-SP compared to multigravida women who were acquainted with the situation. Nulliparous women were 4 times more likely to receive optimal IPTp-SP. This is possibly because since it is their first experience, they fear losing their first child to malaria compared to those who had had multiple births. The period when women started ANC was significantly correlated to IPTp-SP uptake. Women who started ANC attendance at first trimester of pregnancy were 29 times more likely to receive IPTp-SP than those who started during the second and third trimesters. This is comparable to studies carried out in Burundi, Western Kenya, and Ghana [19, 23, 30, 31]. Number of ANC visits were also positively correlated with uptake of IPTp-SP in our study. Those with ≥ 4 ANC visits were about 8 times more likely to receive optimal IPTp-SP dose. This corroborates with other studies that identified ANC visits as a determinant of uptake of IPTp-SP [19–22, 27, 29].This is possibly because during such visits, women are constantly reminded of the consequences of malaria in pregnancy both to the mother and the child that is reflected in the optimal uptake of IPTp-SP.

Although our results did not show any significant association between utilization of LLINs and optimal uptake of IPTp-SP, women who always used LLINs (71.6%) tended to have received optimal SP doses compared to those who do not always use LLINs (66.4%). This is however different from studies that reported LLINs utilization as a significant determinant of SP uptake [24]. When uptake was associated to malaria infection, our results revealed that women who received the optimal IPTp-SP doses were almost 3 times less likely to have malaria parasite infection than those who did not. This is similar to studies carried out in Southwest Cameroon where there was a reduced prevalence of malaria in woman with optimal uptake of IPTp-SP [21]. This shows that optimal uptake of IPTp-SP can actually prevent malaria as confirmed by the fact that 76.1% of the participants with optimal uptake in our study were negative for malaria. Furthermore, other studies reported that there was more likelihood of malaria in Southeastern Nigerian women who failed to take optimal doses of IPTp-SP [35]. An understanding of the reasons why a drug is taken will always encourage the uptake of the drug. This was true in this study in that those with good understanding of optimal IPTp-SP dose were 3 times more likely to receive optimal IPTp-SP dose. This was also reported by Badirou and colleagues [28] who reported that women with adequate knowledge of IPTp-SP doses were 3.3 times more likely to receive optimal IPTp-SP doses. Other studies also supported that maternal knowledge of optimal doses was significantly associated to uptake of IPTp-SP [19].

Study limitations

This study employed a cross-sectional study design whose weakness is the impossibility to infer causation. Only women in the third trimester of pregnancy (> 32 weeks of gestation) were included in the study who could have a possibility of attending another ANC or taking another IPTp-SP dose. A study including women attending postnatal care could give a better picture of the uptake of IPTp-SP doses. Moreover, some answers to questions such as sleeping under LLINs, were self-reported by the participants not observed by the researchers. However, self-reporting was minimized by verification of some responses using ANC clinic attendance booklets. In addition, with all survey data, the findings are limited by recall and social desirability biases. Finally, this study cannot be generalized to the whole population in Cameroon as the sample was selected in only one health facility.

In this study, the optimal uptake of ITPp-SP as recommended by WHO was 69.5%, though below the 80% coverage expected by 2030 in the country. Optimal uptake of IPTp-SP was found to be significantly associated with ANC attendance and malaria infection. Determinants of uptake of IPTp-SP included; level of education, religion, parity, gestational age at first ANC, number of ANC, malaria infection and knowledge of number of SP doses.

ANC Antenatal care

aOR Adjusted odd ratio

BDH Bonassama District Hospital

CI Confidence Interval

IPTp-SP Intermittent preventive treatment in pregnancy with Sulphadoxine pyrimethamine

LLIN long-lasting insecticide-treated nets

MiP Malaria in pregnancy

NMCP National Malaria Control Programme

RDT Rapid diagnostic test

SD Standard deviation

SP Sulphadoxine pyramithamine

SSA Sub-Saharan African

WHO World Health Organization

Ethics approval and consent to participate

The study was approved by the Institutional Review Board of the Faculty of Health Sciences, University of Buea, Cameroon (Approval Number: 2022-243061), while administrative authorization was obtained from the Littoral Regional Delegation for Public Health and the Bonassama District Hospital. A written informed consent was obtained from all participants by way of signing or thumb printing on the informed consent form, after the nature and objectives of this study were explained to them. Participation in this study was voluntary. All data gathered was handled under strict confidentiality and stored in a computer with password protection. The research was conducted in accordance with the Declaration of Helsinki.

Consent for publication

Not Applicable.

Funding

This study received no external funding.

Author Contributions

MUA, IUA and TOA conceived and designed the experiments. CKN, CMN and SF conducted the study. MUA, TOA, KBW and IUA performed the analysis. MUA, IUA, JN and MA drafted the manuscript. All authors contributed to revision of the manuscript prior to submission.

Availability of data and materials

The dataset used in the present study is available from the corresponding author upon reasonable request.

Competing interests

The authors declare no competing interests.

Acknowledgments

Our appreciation to the participants who made this study realistic. We thank the Director of the Bonassama District Hospital for the permission granted to conduct the study in the health facility.

Authors' information

1Graduate School of Health Sciences, St Louis University Institute, Douala, Cameroon,

2Department of Public Health, The University of Bamenda, Bambili, Bamenda, Cameroon,

3School of Health Sciences, Charisma University, 1321 Discovery Drive, Billings, MT, USA,

4Department of Microbiology and Parasitology, The University of Bamenda, Bambili, Bamenda, Cameroon,

5United States Health Resources and Services Administration, 5600 Fishers Lane, Rockville, MD, USA,

6Department of Medical Sciences, Icon Higher Institute of Management and Biomedical Sciences, Douala, Cameroon,

7McGadi Education and Research Initiative, Buea, Cameroon,

8Mercer University College of Pharmacy, 3001 Mercer University Drive Atlanta, GA, USA.

9Department of Biochemistry and Molecular Biology, University of Buea, Buea, Cameroon.

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No competing interests reported.

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Uptake of intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTp-SP) in pregnancy and associated factors in a malaria endemic setting of Sub-Saharan Africa

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Abstract

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Background

Methods

Study area

Study design, population and setting

Sample size and sampling

Data and sample collection

Study variables

Data management and analysis

Results

CI: Confidence Interval, SD: Standard Deviation

CI: Confidence Interval, SD: Standard Deviation, ANC: Antenatal care, SP: SP: Sulphadoxine pyrimethamine

ANC attendance and IPTp‑SP uptake during pregnancy

Asymptomatic malaria infection and IPTp-SP uptake

Determinants of IPTp-SP uptake during pregnancy

*Statistically significant result at 5% significance level, SD: standard deviation, ANC:Antenatal care

Discussion

Study limitations

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Funding

Author Contributions

Availability of data and materials

Competing interests

Acknowledgments

Authors' information

References

Additional Declarations

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