A cluster randomized trial of delivery of intermittent preventive treatment of malaria in pregnancy at the community level in Burkina Faso

Abstract

Background: Malaria in pregnancy is responsible for 8-14% of low birth weight and 20% of stillbirths in sub-Saharan Africa. To prevent these adverse consequences, the World Health Organization recommends intermittent preventive treatment of pregnant women (IPTp) with sulfadoxine-pyrimethamine be administered at each ANC visit starting as early as possible in the second trimester. Global IPTp coverage in targeted countries remains unacceptably low. Community delivery of IPTp was explored as a means to improve coverage. Methods: A cluster randomized, controlled trial was conducted in 12 health facilities in a 1:1 ratio to either an intervention group (IPTp delivered by CHWs) or a control group (standard practice, with IPTp delivered at HFs) in three districts of Burkina Faso to assess the effect of IPTp administration by community health workers (CHWs) on the coverage of IPTp and antenatal care (ANC). The districts and facilities were purposively selected taking into account malaria epidemiology, IPTp coverage, and the presence of active CHWs. Pre-and post-intervention surveys were carried out in March 2017 and July-August 2018, respectively. A difference in differences (DiD) analysis was conducted to assess the change in coverage of IPTp and ANC over time, accounting for clustering at the health facility level. Results: Altogether 374 and 360 women were included in the baseline and endline surveys, respectively. At baseline, women received a median of 2.1 doses; by endline, women received a median of 1.8 doses in the control group and 2.8 doses in the intervention group (p-value < 0.0001). There was a non-statistically significant increase in the proportion of women attending four ANC visits in the intervention compared to control group (DiD = 12.6%, p-value = 0.16). By the endline, administration of IPTp was higher in the intervention than control, with a DiD of 17.6% for IPTp3 (95% confidence interval (CI) − 16.3, 51.5; p-value 0.31) and 20.0% for IPTp4 (95% CI − 7.2, 47.3; p-value = 0.15). Conclusions: Community delivery of IPTp could potentially lead to a greater number of IPTp doses delivered, with no apparent decrease in ANC coverage.

Risk factors for Plasmodium falciparum infection in pregnant women in Burkina Faso: a community-based cross-sectional survey

“…One option to increase IPTp-SP coverage is community delivery by community health workers, rather than ANC. This delivery route has been shown in a clinical trial in Burkina Faso to increase IPTp-SP compliance from 2.1 to 2.8 doses in the community delivery study arm with no apparent decrease in ANC attendance [ 46 ]. Seven women reported receiving IPTp-SP despite being in the first trimester.…”

Community-based delivery of intermittent preventive treatment of malaria in pregnancy in Burkina Faso: a qualitative study

“…Despite long-standing recommendations, IPTp coverage has lagged, leading to efforts to explore more efficient delivery models such as community-based delivery [ 14 , 15 ]. This intervention in Burkina Faso, as described in Gutman et al was found to increase IPTp, to not reduce ANC visits [ 20 ] as had occurred in several other studies delivering c-IPTp [ 23 , 24 ], and to be a safe and acceptable delivery model both from the perspectives of CHWs and facility HCWs.…”

“…To address the challenge of low IPTp uptake, the Burkina Faso government, with support from the U.S. President’s Malaria Initiative (PMI), conducted a cluster-randomized trial to determine the effect of community based IPTp (c-IPT) distribution on IPTp uptake and ANC coverage [ 20 ]. The intervention involved training existing CHWs to implement community sensitization activities around antenatal care (ANC) and malaria in pregnancy, and to refer pregnant women to ANC for their first dose of IPTp.…”

A Cluster Randomized Trial of Delivery of Intermittent Preventive Treatment of Malaria in Pregnancy at the Community Level in Malawi

“…Similar trials increased IPTp2+ uptake in Uganda by 37.3 percentage points and IPTp3+ uptake in Burkina Faso by 17.6 percentage points [12,13]. The impact on ANC attendance was variable, with a statistically signi cant increase in number of visits in Uganda, but no effect in Nigeria or Burkina Faso [11][12][13]. Trials in Uganda and Malawi that focused exclusively on training CHWs for IPTp delivery without emphasizing ANC referrals also led to increased IPTp2+ uptake (27.6 and 29.3 percentage points, respectively), but ANC attendance decreased (19.3 and 17.9 percentage points, respectively) [14,15].…”

“…A cluster randomized controlled trial in Nigeria found that training CHWs to deliver IPTp and provide ANC referrals increased the proportion of pregnant women taking IPTp2+ by 35.3 percentage points [11]. Similar trials increased IPTp2+ uptake in Uganda by 37.3 percentage points and IPTp3+ uptake in Burkina Faso by 17.6 percentage points [12,13]. The impact on ANC attendance was variable, with a statistically signi cant increase in number of visits in Uganda, but no effect in Nigeria or Burkina Faso [11][12][13].…”