The social dimensions of community delivery of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria and the Democratic Republic of the Congo

Abstract

IntroductionIntermittent preventive treatment in pregnancy with sulphadoxine pyrimethamine (IPTp) is a key malaria prevention strategy in sub-Saharan African countries. We conducted an anthropological study as part of a project aiming to evaluate a community-based approach to the delivery of IPTp (C-IPTp) through community health workers (CHWs) in four countries (the Democratic Republic of Congo, Madagascar, Mozambique and Nigeria), to understand the social context in order to identify key factors that could influence C-IPTp acceptability.MethodsA total of 796 in-depth interviews and 265 focus group discussions were undertaken between 2018 and 2021 in the four countries with pregnant women, women of reproductive age, traditional and facility-based healthcare providers, community leaders, and relatives of pregnant women. These were combined with direct observations (388) including both community-based and facility-based IPTp delivery. Grounded theory guided the overall study design and data collection, and data were analysed following a combination of content and thematic analysis.ResultsA series of key factors were found to influence acceptability, delivery and uptake of C-IPTp in project countries. Cross-cutting findings include the alignment of the strategy with existing social norms surrounding pregnancy and maternal health-seeking practices, the active involvement of influential and trusted actors in implementation activities, existing and sustained trust in CHWs, the influence of husbands and other relatives in pregnant women’s care-seeking decision-making, the working conditions of CHWs, pregnant women’s perceptions of SP for IPTp and persistent barriers to facility-based antenatal care access.ConclusionsThe findings provide evidence on the reported acceptability of C-IPTp among a wide range of actors, as well as the barriers and facilitators for delivery and uptake of the intervention. Overall, C-IPTp was accepted by the targeted communities, supporting the public health value of community-based interventions, although the barriers identified should be examined if large-scale implementation of the intervention is considered.

Cost-effectiveness of community-based distribution of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria, and the Democratic Republic of Congo

“…To ensure efficient distribution of C-IPTp by the government, and therefore, maximise effectiveness, C-IPTp should be integrated with other community programmes already operative within the MoH. Active engagement and acceptability of community key stakeholders would be additional conditions for C-IPTp sustainability, scalability and optimal effectiveness 49…”

“…Active engagement and acceptability of community key stakeholders would be additional conditions for C-IPTp sustainability, scalability and optimal effectiveness. 49 …”

“…Active engagement and acceptability of community key stakeholders would be additional conditions for C-IPTp sustainability, scalability and optimal effectiveness. 49 Finally, to take into consideration uncertainty around model parameters and evaluate the robustness of the While the government's willingness to pay is unknown and will depend on country-specific preferences and resource availability, the CE acceptability curves (figure 2) show that the probability for C-IPTp to be cost-effective at a theoretical willingness to pay equal to the GDP per capita (online supplemental table S10) would be close to 100% in DRC, MDG and NGA. Furthermore, we undertook a threshold analysis on the effectiveness of the intervention and ascertained that the intervention would remain cost-effective if at least 10% (NGA), 11% (MDG), 24% (DRC) and 40% (MOZ) of the effectiveness was achieved.…”

PeRinatal, neOnatal, and Maternal OuTcomEs with azithromycin prophylaxis in pregnancy and labour (PROMOTE-PROPHYLAXIS): systematic review and meta-analysis

“…Hence, it has been used in antenatal and intrapartum periods to prevent malaria, reproductive tract infections, preterm labour, and caesarean section-associated wound infections. 5 , 6 , 7 , 8 It is effective against Group B Streptococcus, one of the most common aetiologies of neonatal sepsis. 9 There have been varying dosing schedules ranging from 500 mg single dose intravenous 10 to 9 g oral administration (one gram on three consecutive days at three different instances each) across the second and third trimesters.…”