Malaria is a life-threatening disease caused by
Pregnant women and children under five years bear the brunt of the disease with over 70% of all malaria deaths being reported among children under five years. Malaria infection during pregnancy is of public health concern as it poses significant risk in terms of morbidity and mortality to both the pregnant woman and the developing foetus. Malaria-associated maternal morbidity and poor birth outcomes including preterm delivery and low birth weight are due primarily to
Intermittent preventive treatment of malaria in pregnancy (IPTp) using sulfadoxine-pyrimethamine (SP) remains an effective strategy for preventing malaria in pregnancy. This strategy entails the administration of a full treatment dose of SP to pregnant women when they visit antenatal care (ANC) facilities for health services, regardless of whether the pregnant woman has malaria infection or not [
The World Health Organization (WHO) revised the recommendations for IPTp-SP in 2012 and now calls for all pregnant women to take SP at each ANC visit until delivery. The administration of SP should start early in the second trimester, with doses taken at least one month apart [
The Malaria Control Programme of Ghana also revised the national policy and now requires every pregnant woman to take a minimum of five doses of SP during each pregnancy [
The purpose of the current study was to assess the level of uptake of more than three doses of SP and its relationship with birth outcomes at the Navrongo War Memorial Hospital, a rural district hospital in northern Ghana.
The study was carried out at the War Memorial Hospital (WMH) at Navrongo, the capital of the Kassena-Nankana East Municipality (KNEM) of northern Ghana. The KNEM lies in the Sahelian savannah between latitude 10°30’ and 11°00’ north and longitude 1°00’ and 1°30’ west and covers an area of about 1,674 square kilometres of land with a population of about 110,000 [
The WMH has a total bed capacity of 169 and is the only hospital in the municipality and serves as a referral centre for all other health facilities in the municipality and adjoining districts including Bulsa and Sissala West.
A cross-sectional study was carried out at the postnatal and child welfare clinics of the Navrongo War Memorial Hospital in northern Ghana. Nursing mothers who had delivered within the past 10 weeks were enrolled into the study. These mothers were recruited on a daily basis in a sequential manner as they reported at the units for care. Data on demographic characteristics, number of ANC visits, and uptake of IPTp-SP were collected from the mothers onto a case record form. The antenatal care cards of the mothers were also reviewed and data on obstetric history and care extracted. Data collection lasted for 13 weeks during the months of June to September 2017.
The sample size was estimated using the Cochran formula, n= (Z2pq)/d2, where n is sample size, Z is the z-score that corresponds with the 95% confidence interval (1.96), P is proportion of antenatal attendants who received IPT 3 in 2016 (20.3%, = 0.203), q is proportion of antenatal attendants who received less than three doses of SP (1-0.203, = 0.797), and d is margin of error set at 5% (0.05) [
All nursing mothers who visited the postnatal or child welfare clinics of the WMH for healthcare during the study period and gave written informed consent to participate in the study were eligible to participate. Nursing mothers who had delivered beyond ten weeks at the time of data collection were excluded to minimize recall bias.
One-on-one interviews were held with the mothers and data on background characteristics including age, education, number of children, occupation, and marital status collected from them onto a case record form designed specifically for this study. The ANC cards of the mothers were also reviewed and information on gestational age at first ANC visit, number of visits, number of doses of SP taken before delivery, and the gestational age at which the first and subsequent doses of SP were taken was extracted. Other data extracted from the ANC card included malaria infection during the most recent pregnancy and the method of confirmation (RDT or microscopy), gestational age of delivery, birth weight, and length of baby. Whenever there was discrepancy between the information given by the mother and what was documented, the information on the ANC card was used. The interviews were conducted in the local languages (Kassem, Nankam, and Buli) and English by trained research assistants (midwives), who are fluent in these languages. The questionnaire was in English and so the information was recorded in English.
The questionnaire was pretested using 20 ANC attendants over a period of two days (10 per day). The pretest data collected were analysed to inform the content and formatting of the final questionnaire that was used for the data collection. The pretest was conducted one week before commencement of the actual data collection at the same facility, as this is the only hospital in the municipality. The data were however not included in the study. The midwives who did the data collection were trained for three days on how to obtain informed consent, explain the objectives of the study to participants, and complete the questionnaire.
Data were entered into Excel version 2013, cleaned, and imported to Stata version 13 for analysis. The uptake of IPTp-SP was categorised into < 3 and ≥ 3 doses. The sociodemographic and ANC characteristics were also grouped into categories. The birth weight of the babies was categorised into low birth weight (< 2.5 kg) and normal birth weight (≥ 2.5 kg). Time of delivery was categorised into preterm (< 37 weeks’ gestation) and term (37-42 weeks). The length of the babies was categorised into < 45.7 cm and ≥ 45.7 cm. Bivariate analysis was done using Pearson chi-square tests to assess significant association between IPTp-SP uptake and each independent categorical variable. Factors with
Two hundred and fifty-four nursing mothers took part in the study. Their ages ranged from 15 to 47 years (median: 26 years; IQR: 21-28), 56.3% (143/254) were aged 20-29 years, and 85.8% were married. One hundred and nine (42.9%) of the mothers had formal education up to the secondary level, with 11.0% without formal education. The majority of the participants (57.5%, 146/254) were engaged in some form of self-employment including farming, with 27.0% of them practicing a trade, including dressmaking and hairdressing. Most of the mothers (64.6%, 164/254) had one or two children with an average number of two children (range: 1-6) (Table
Background characteristics of study mothers.
Characteristics | No. | % |
---|---|---|
| ||
15-19 | 35 | 13.8 |
20-29 | 143 | 56.3 |
30-39 | 67 | 26.4 |
40-47 | 9 | 3.5 |
| ||
Married | 235 | 85.8 |
Single | 37 | 13.4 |
Divorced | 2 | 0.8 |
| ||
No formal education | 28 | 11.0 |
Basic education | 61 | 24.0 |
Secondary education | 109 | 42.9 |
Tertiary education | 56 | 22.1 |
| ||
Trading | 54 | 21.2 |
Housewife | 56 | 21.5 |
Farming | 24 | 9.5 |
Civil service | 52 | 20.8 |
Practicing a trade | 68 | 27.0 |
| ||
1-2 | 164 | 64.6 |
3-4 | 75 | 29.5 |
5-6 | 15 | 5.9 |
Only 75 (29.5%) out of the two hundred and fifty-four mothers made their first ANC visit during the first trimester of their pregnancy, with 59.1% making the first visit during the second trimester. The mean gestational age at the time of the first ANC visit was 16.7 weeks (SD: 6.43; range: 4-33 weeks). The number of ANC visits made ranged from 0 to 14 (mean: 7.5; SD: 8.57), with two of the mothers (0.8%) not making any ANC visits during their most recent pregnancy. A total of 109 (42.9%) of the mothers made five to seven visits, and 93 (36.6%) made eight or more visits before delivery (Table
ANC attendance, ITN use, IPTp-SP uptake, and malaria infection during current pregnancy by mothers.
Characteristics | No. | % |
---|---|---|
| ||
First trimester | 75 | 29.5 |
Second trimester | 150 | 59.1 |
Third trimester | 29 | 11.4 |
| ||
No ANC visit | 2 | 0.8 |
1-4 | 50 | 19.7 |
5-7 | 109 | 42.9 |
≥ 8 | 93 | 36.6 |
| ||
One | 29 | 11.4 |
Two | 31 | 12.2 |
Three | 99 | 39.0 |
Four | 54 | 21.3 |
Five | 37 | 14.6 |
Six | 4 | 1.6 |
| ||
16 | 43 | 16.9 |
17-24 | 144 | 56.7 |
25-36 | 67 | 26.4 |
| ||
All the time | 247 | 97.2 |
Most of the time | 7 | 2.8 |
| ||
Used ITN | 242 | 95.3 |
Did not use ITN | 12 | 4.7 |
| ||
Had infection | 20 | 7.9 |
Did not have infection | 234 | 92.1 |
ANC= antenatal centre, ITN = insecticide treated net, SP = sulfadoxine pyrimethamine, and IPTp = intermittent preventive treatment in pregnancy.
Gestational age at first ANC visit among women that had recently delivered at the Navrongo War Memorial Hospital in rural northern Ghana.
Twenty-nine (11.4%) of the mothers received only one dose of SP during their most recent pregnancy. Ninety-nine (39.0%) received three doses; IPTp-SP coverage of at least three doses was 76.4% (194/254). Forty-one of the mothers received five or more doses of SP giving coverage of ≥ 5 doses of 16.1% (Table
Gestational age at first dose of IPTp-SP uptake among women that had recently delivered at the Navrongo War Memorial Hospital in rural northern Ghana. The points plotted (-) indicate the percentage of mothers who took the first dose at the particular gestational age, while the vertical lines show the corresponding 95% confidence intervals.
The gestational age at which the first ANC visit was made, the total number of ANC visits that were made, and the gestational age at which the first dose of SP was received were found to be significantly associated with the total number of doses of SP received before delivery (
Relationship between ANC visits, sociodemographic characteristics, IPTp-SP uptake, and malaria infection among women that had recently delivered.
Variables | No. | % uptake of IPTp-SP | | ||
---|---|---|---|---|---|
< 3 doses | ≥ 3 doses | ||||
| |||||
First trimester | 75 | 12.0 | 88.0 | 51.0 | <0.001 |
Second trimester | 150 | 19.3 | 80.7 | ||
Third trimester | 29 | 75.9 | 24.1 | ||
| |||||
< 4 | 29 | 93.1 | 6.9 | 87.6 | <0.001 |
≥ 4 | 225 | 57.8 | 42.2 | ||
| |||||
16 weeks | 43 | 9.3 | 90.7 | 60.5 | <0.001 |
17-24 weeks | 144 | 11.8 | 88.2 | ||
25-36 weeks | 67 | 58.2 | 41.8 | ||
| |||||
1-2 | 164 | 24.4 | 75.6 | 1.4 | |
3-4 | 75 | 20.0 | 80.0 | 0.501 | |
5-6 | 15 | 33.3 | 66.7 | ||
| |||||
Married | 218 | 21.6 | 78.4 | 3.6 | 0.146 |
Single | 34 | 35.3 | 64.7 | ||
Divorced | 2 | 50 | 50 | ||
| |||||
No formal education | 28 | 42.9 | 57.1 | 8.8 | 0.032 |
Basic education | 61 | 26.2 | 73.8 | ||
Secondary education | 109 | 22.0 | 78.0 | ||
Tertiary education | 56 | 14.3 | 85.7 | ||
| |||||
15-19 | 35 | 37.1 | 62.9 | 5.0 | 0.175 |
20-29 | 143 | 20.3 | 79.7 | ||
30-39 | 67 | 22.4 | 77.6 | ||
40-47 | 9 | 33.3 | 66.7 | ||
| |||||
Had infection | 20 | 20.0 | 80.0 | 0.16 | 0.691 |
Did not have infection | 234 | 23.9 | 76.1 |
IPTp-SP= intermittent preventive treatment in pregnancy with sulfadoxine pyrimethamine, n= number of respondents.
The difference between mothers making their first ANC visit during the first trimester and those making the first visit during the second trimester in terms of receiving ≥ 3 doses of SP was not statistically significant (
Mothers who also took their first dose of SP during week 16 of pregnancy were able to receive ≥ 3 doses compared to those who took the first dose during weeks 25-36 (
A total of 247 (97.2%) live babies were delivered, with most of them (77.6%, 197/254) delivered at term (37-42 weeks). Two hundred and nine (82.3%) of the babies weighed ≥ 2.5 kg with mean birth weight of 2.9 kg (SD: 0.54; range: 2.0-4.3 kg). Most of the babies (83.1%) were ≥ 45.7 cm in length at birth (mean: 49.0 cm; SD: 4.0; range: 33-61 cm). The majority of the babies (83.7%, 210/254) had head circumference < 35 cm (mean: 32.0 cm; SD: 6.32; range: 21-39 cm) (Table
IPTp-SP uptake, gestation at delivery, outcome of delivery, and anthropometric indices of babies.
Characteristics | No. | % | % uptake of IPTp-SP | | ||
---|---|---|---|---|---|---|
| < 3 doses | ≥ 3 doses | ||||
< 37 | 57 | 22.4 | 40.4 | 59.6 | 11.4 | 0.001 |
37-42 | 197 | 77.6 | 18.8 | 81.2 | ||
| ||||||
Alive | 247 | 97.2 | 23.1 | 76.9 | 1.4 | 0.224 |
Dead | 7 | 2.8 | 42.9 | 57.1 | ||
| ||||||
< 2.5 | 45 | 17.7 | 48.9 | 51.1 | 19.4 | <0.001 |
≥ 2.5 | 209 | 82.3 | 18.2 | 81.8 | ||
| ||||||
< 45.7 | 43 | 16.9 | 33.3 | 66.7 | 2.6 | 0.105 |
≥ 45.7 | 211 | 83.1 | 21.7 | 78.3 | ||
| ||||||
< 35.0 | 210 | 83.7 | 23.8 | 76.2 | 0.02 | 0.878 |
≥ 35.0 | 44 | 17.3 | 23.6 | 76.4 |
IPTp-SP= intermittent preventive treatment in pregnancy with sulfadoxine pyrimethamine.
Statistically significant association was found between doses of SP taken by mothers, gestational age at delivery, and birth weight of babies (
Crude and adjusted associations between gestation at delivery (weeks) and uptake of ≥3 doses of SP
Characteristics | Crude OR | 95% CI | | Adjusted OR | 95% CI | |
---|---|---|---|---|---|---|
| ||||||
< 3 doses of SP | 1.00 | 1.00 | ||||
≥3 doses of SP | 2.93 | 1.54-5.54 | 0.001 | 3.16 | 1.63-6.11 | 0.001 |
| ||||||
Used ITN | 1.00 | 1.00 | ||||
Did not use | 0.87 | 0.23-3.31 | 0.834 | 1.25 | 0.27-5.82 | 0.773 |
| ||||||
No formal education | 1.00 | 1.00 | ||||
Primary education | 1.66 | 0.80-3.41 | 0.171 | 1.83 | 0.84- 4.00 | 0.128 |
JHS and above | 1.65 | 0.77-3.55 | 0.200 | 1.71 | 0.76-3.81 | 0.193 |
| ||||||
<3 | 1.00 | 1.00 | ||||
≥3 | 1.25 | 0.66-2.34 | 0.490 | 1.33 | 0. 68-2.62 | 0.401 |
| ||||||
Had malaria | 1.00 | 1.00 | ||||
Did not | 3.12 | 1.22-7.96 | 0.017 | 3.78 | 1.36-10.47 | 0.011 |
Crude and adjusted associations between birth weight (kg) and uptake of ≥3 doses of SP
Characteristics | Crude OR | 95% CI | | Adjusted OR | 95% CI | |
---|---|---|---|---|---|---|
| ||||||
< 3 doses of SP | 1.00 | 1.00 | ||||
≥3 doses of SP | 4.30 | 2.18-8.51 | <0.001 | 3.92 | 1.94-9.92 | <0.001 |
| ||||||
Used ITN | 1.00 | 1.00 | ||||
Did not use | 1.09 | 0.23-5.13 | 0.919 | 1.05 | 0.19-5.89 | 0.955 |
| ||||||
No formal education | 1.00 | 1.00 | ||||
Primary education | 1.21 | 0.55- 2.63 | 0.640 | 1.31 | 0.56-3.05 | 0.535 |
JHS and above | 1.63 | 0.68-3.86 | 0.272 | 1.63 | 0.66-4.01 | 0.291 |
| ||||||
<3 | 1.00 | 1.00 | ||||
≥3 | 1.12 | 0. 57-2.21 | 0.746 | 1.04 | 0.50 -2.16 | 0.924 |
| ||||||
Had malaria | 1.00 | 1.00 | ||||
Did not | 1.67 | 0.58-4.94 | 0.353 | 1.88 | 0.59-6.04 | 0.288 |
Intermittent preventive treatment of malaria in pregnancy using SP (IPTp-SP) is known to reduce maternal malaria episodes and improve pregnancy outcomes [
Antenatal care is very important in the prevention, early detection, and treatment of general medical and pregnancy-related conditions. All pregnant women are therefore expected to go for their first ANC visit in the first trimester [
There are reports that initiation of ANC visits in Africa is generally late with most women making their first visit during the second trimester, with significant variations across subregions and settings [
In our current study, no significant association was observed between marital status and number of doses of SP taken even though a higher proportion of married women took the drug compared to the single or divorced women. The level of formal education was found to be important in the uptake of more doses of SP. Higher education is likely to improve on one’s understanding of the benefits of the policy and therefore willingness to take full advantage of it. This supports the earlier report by Nsibu and colleagues from the Democratic Republic of Congo that pregnant women living alone or without much education are likely to initiate ANC late [
Since normally ANC services are sought on a monthly basis, starting late will not allow for achieving the recommended eight visits [
The prevalence of low birth weight as found in the current study seems not to have changed since an earlier report from the same health facility by Oduro and colleagues eight years ago [
The study has some limitations. First, information was collected from mothers receiving postnatal care in a rural community on their ANC attendance and services provided to them by the healthcare staff during their most recent pregnancy. There is a possibility of recall bias; however, recall was limited to only three months which might not affect the reliability of responses given. Also, the ANC cards were reviewed and information collected from the mothers was validated. Second, it is important to note that even as receiving ≥ 3 doses of IPTp-SP significantly influenced delivery at term, delivery at preterm could affect the number of doses received before delivery. The mean and median number of times of ANC visits by mothers who delivered preterm was five, which was more than the recommended minimum of four visits.
The uptake of ≥ 3 doses of IPTp-SP was quite high in this rural community but much lower than in an earlier study in Accra. The proportion of mothers who received five doses of SP as recommended by the new Ghana policy was very low but similar to the earlier report from Accra. Uptake of higher doses of SP was significantly associated with delivery at term and normal birth weight babies. Equal attention would be needed in both rural and urban communities in Ghana to increase uptake of SP and improve pregnancy outcomes in order to achieve sustainable development goal three. It is therefore recommended that healthcare providers especially midwives should encourage women in their fertility age to seek early ANC service when they are pregnant and have regular monthly visits to increase uptake of SP and therefore better pregnancy outcome. In the long term, formal education for the girl child should be encouraged to improve knowledge and birth outcome.
Antenatal care
Child welfare clinic
Directly observed therapy
Intermittent preventive treatment
Intermittent preventive treatment of malaria in pregnancy with sulfadoxine pyrimethamine
Kassena-Nankana East Municipality
National Malaria Control Programme
President’s Malaria Initiative
Sulfadoxine pyrimethamine
War Memorial Hospital.
All data generated during the current study are included in this published article and its supplementary information file (Additional files 1 and 2).
The study protocol was reviewed and approved by the Ghana Health Service Ethical Review Committee before the study was carried out (Ethical Approval ID No.: GHS-ERC: 60/12/2016). Permission was also sought from the management of the Navrongo War Memorial Hospital before data collection.
The purpose of the study was explained to each study participant in their local language (Kasem, Nankam, or Buli) before the data collection. Written informed consent was obtained from each participant. For participants < 18 years, they were followed to their homes after ANC to obtain parental consent (from their mothers) before data collection. Such participants also gave assent to be part of the study. Also, participants were interviewed individually in an office provided by the hospital administration. Data access was limited to the principal investigator, research assistants, and supervisor of the study only. All data collected were stored under lock and key.
The authors declare that they have no conflicts of interest.
Francis Anto, Ibrahim Haruna Agongo, Victor Asoala, Elizabeth Awini, and Abraham Rexford Oduro designed and conducted the study and analysed the data. Francis Anto, Ibrahim Haruna Agongo, Victor Asoala, Elizabeth Awini, and Abraham Rexford Oduro were responsible for interpretation of the data and writing of the manuscript. Francis Anto drafted the manuscript and all authors reviewed and accepted the final manuscript.
We are very grateful to all our study participants who willingly volunteered to participate in this study and sincerely provided these valuable data. Our special thanks go to the medical superintendent and staff of the Navrongo War Memorial Hospital for their support in diverse ways. We are also grateful to all the research assistants for their help in the data collection.
Additional File 1: dataset. Additional File 2: Table 6: List of variables measured. Additional File 3: Table 7: Logistic regression analysis II.