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 <.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.

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

“…During the study period, IPTp3+ coverage in the control areas increased from 45.6-59.8% and assuming a similar underlying trend in the intervention areas, this higher level of coverage may have meant diminishing returns for CHW outreach activities. It is possible that CHWs are more impactful in settings with lower and more stable levels of IPTp3+ coverage, such as Burkina Faso [13].…”

“…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].…”