Findings from this study showed that the mode of malaria prevention methods being reported to be effective and adopted for use were IPT-sp, Insecticide sprays and ITNs. This finding is similar to many other studies where IPT-sp was the leading malaria prevention method [14, 15]. This could be explained as probably being due to the adoption of these methods by the National Policy for the control of malaria in Nigeria in line with WHO guidelines . Although, Insecticide Spray is not a National Policy, its use has become increasingly popular in some countries in sub-Saharan Africa especially in rural settings .
The study revealed that ITNs was the least utilized malaria prevention method as only 40.9% used ITNs. This rate is rather poor considering that this approach has been discovered to play a major role in malaria prevention methods [2, 5]. This is because the figure fall short of the Global Malaria Action Plan that targeted 100% ITNs utilization coverage for pregnant women . The low utilization of ITNs in this study could be due to several factors. High cost of the net and its unavailability, in addition to poor knowledge of its effectiveness by the end users have been linked to factors contributing to the poor utilization of this method especially in rural areas[7, 8]. However, this finding is similar to the 39.1% obtained from a study in Enugu and 41.1% from Owerri, Southeastern Nigeria [10, 11]. This may be due to the similarities in the study design and setting. However, the result was higher than the reported utilization rate in Ibadan [7, 8], Calabar  and the National estimate rate of 33.7%  but less than 75,0% obtained from a study in Sokoto, Northwestern Nigeria . This was because, the national utilization rate was only calculated for participants who slept under an ITNs the night before survey was conducted. The resultant implication of the low ITNs utilization in the study area is that sadly, the possibility of achieving the 100% utilization coverage as recommended by the Global Action Plan is very low. The finding further revealed that participants who used ITNs as prevention measure against malaria had a lower prevalence (8.3%) of malaria infection while those who shunned the use of ITNs in the index pregnancy had a higher prevalence (32.1%) of malaria infection. This finding is consistent with previous studies in Nigeria which found ITNs to be protective against malaria in pregnancy [8, 11, 20].
In contrast to the poor usage of ITNs, a large proportion (72.0%) of the participants in this study received prophylactic drugs (IPT-sp) for malaria. However, the researchers in the present study did not ascertain whether participants had experience quickening prior to receiving IPT-sp, and so, may have underestimated the proportion of participants who received IPT-sp. The high uptake of this method as compared to ITNs could be due to the fact that it is given to the pregnant mother at presentation during the booking clinic in line with WHO guidelines [3, 5]. Nevertheless, this proportion (72.0%) of IPT-sp use still fall short of 100% targeted by the global action plan [3, 5]. The implications of the low uptake of IPT-sp in this study raises concerns such as how much lower uptake might be in pregnant women who do not access antenatal care. This study revealed that participants who shunned the use of IPT-sp as preventive measure had the highest prevalence (59.5%) of malaria while participants who indicated the use of IPT-sp had the lowest prevalence (7.9%) of malaria. This result further proved the effectiveness of IPT-sp. IPT-sp in pregnancy has been established to lower the incidence of maternal anaemia and low birth weight baby through prevention of maternal parasitaemia [8,9,]. The overall result of this study is similar to that documented by Inyang-Etoh et al . It was also consistent with previous studies in Nigeria which found IPT-sp to be protective against malaria in pregnancy [11,16,]. However, a study by Umeh et al showed no difference in parasitaemia levels between treatment and control groups but suggested other con-founding factors like participant education and socio-economic status as reasons for the low parasitaemia .
Similarly, this study revealed that 62.9% of participants used insecticide sprays as malaria prevention measure. This finding was similar to finding by Tongo et al , but higher than the reported finding by Michael et al . This study revealed that women who used insecticide spray had a lower parasitaemia (10.8%) than those who did not (41.8%). This finding was consistent with the findings of other studies that insecticide spray is an effective control measure against malaria [11, 16]. Although, the use of insecticide spray is not a National Policy, the result from this study suggested that it is becoming popular among the study population as an effective malaria control measure and if properly implemented, will contribute positively to the control of malaria in endemic areas. However, some studies have shown that insecticide sprays are no longer as effective to combat the new species of mosquitoes that are now rampant in some parts of this country . A study by Joseph et al, showed that women who used insecticide spray have a higher prevalence of malaria infection than those who did not .
Finally, this study has demonstrated low prevalence of maternal parasitaemia among the participants who used malaria prevention methods. However, majority of the participants in this study use one or both forms of malaria preventive measures, but its use does not offer 100% panacea against malaria infection. This is because the women cannot remain indoors for almost 24 hours as ITNs and Insecticide sprays offer protection only during the period of use .
The study focused on the protective effectiveness of the three malaria prevention methods that were most commonly employed by the study population. Thus, it is possible that there were other prevention methods that were occasionally practiced by the participants but not included in the questionnaire. Therefore, there may be other con-founding factors that are associated with the level of maternal parasitaemia in this study. Secondly, the study was facility and not community based, therefore, findings from this study may not be a true reflection of the utilization rate of these malaria prevention methods in the community. Also, the questionnaires were interviewer administered, therefore, it is possible that the participants might have introduced some biases in the way they responded to the use of these malaria prevention methods.
Benefit of the study:
Interventions were put in place for the participants identified with poor utilization of malaria preventive methods and those with malaria parasitaemia. These interventions included:
Detailed health education about the benefits of the usage of the preventive methods was given to the participants in order to improve its use.
Those participants with malaria parasitaemia were treated with safe antimalaria drug to prevent the complications associated with the burden of malaria.
Implications for the policy makers:
The study revealed that several years after Nigeria has adopted the use of ITNs and IPT-sp for malaria control, the desire goals are yet to be achieved. Therefore, stakeholders in the health sector should strengthen health education in the rural areas to improve utilization of these preventive measures. There is also need for the policy makers to canvass for more funding at the primary health care so as to make ITNs and IPT-sp free and accessible to the end users especially at the rural areas.
In view of the consequences associated with malaria in pregnancy, there is need for concerted efforts to ensure proper implementation of the national policy as adopted by other countries.
Information, education and communication based strategies should be employed to drive home the anti-malaria campaign especially among the pregnant women in the rural areas who are more vulnerable.
Large community- based studies are required to clarify fully the utilization and effectiveness of these malaria preventive methods.
Further research is needed to identify factors negating the poor utilization of these malaria preventive methods among the study population.