In this study, the lake of information about malaria pregnancy risks is the bottleneck that limits SP's DOT. This result is consistent with another study conducted in India, in which 80% of pregnant women did not have information about Malaria at the time of contact with health professionals[19]. The same observation was made in Benin, where half of the pregnant women had not explained how to take the SP[20].
The use of a reminder provider checklist improved; statistically, the SP supervised intake, by encouraging the provider to transmit Malaria structured information to the visiting pregnant woman. This simple one-page checklist reduced women's gap information during their only one contact during ANC. Moreover, due to the high level of doctors' trustfulness by their patients, doctors' story is more appreciative and less unforgettable. In our study, the second group was the most respectful of all SP future visits and preventive measures as theoretically scheduled for 95% of all the pregnant women recruited with a gestational age between four and eight months. The adoption of the SP intake from pregnant women was highly significant compared with the first group.
Thus, the feasibility and the adoption of this intervention were proved in the context of our study. A recent qualitative study from Mozambique highlighted the same need to foster health education and information sources against Malaria risks in pregnancy for both health professionals and pregnant women[21].
The participating women with the checklist, whatever their level of previous knowledge or education, understood that SP is also a preventive and non a curative drug, designed to protect them during pregnancy and protect their newborns like a study from India found out[19]. This checklist usefulness is consistent with Nigeria's finding confirming that women knowledge and education improvement impact the malaria control[22].
Such results, confirm that for health facilities where the ANC recruitment is highly achievable in Mali, fostering information about pregnancy risks and its prevention tools could help reach better coverage of IPTp-SP. For instance, the checklist reminder improved the immediate scope of more than half of the IPTp participants in real-life conditions contextualising this study by moving from 0–59% after its use. Simultaneously, the sustained rate jumped to 38% and 95% for the first and second groups, respectively. Our mean rate (59%) of pregnant women who enrolled in IPT-SP is slightly higher than the results of a study from Burkina Faso (55%)[23]. This coverage rate is much higher than women who received at least three or more doses in a multicentric study done in 36 African countries where the improvement goes slower 31% in 2018, compared with 22% in 2017 versus 2% in 2010[1].
Without supervision, the community agents and health workers could worsen the preventive treatment information targeting pregnant women[24, 25]. For instance, the contradictory message that asks pregnant women to take the SP drug at home after a meal to minimise side effects was also found in another study in Mali[14]. These communities should understand that Malaria has harmful consequences for the mother and her future born child and that administering DOT SP at specific times of pregnancy is one of the most effective ways in addition to other preventive measures to be protected[26]. The need for effective communication and understanding between health workers in one hand, and between health workers and their patients and communities in the other hand are essential for increasing acceptability and adoption of the IPT-SP[27].
Mali adopts WHO standards to define ANC coverage needs. Thus, Mali's 2018–2022 National Malaria Control Strategic Plan targets the achievement of 80% of the use of IPT3 or higher. According to the new WHO recommendations, contact between the woman and the provider must be more than just one ANC visit [28]. This provider checklist as a routine ANC new tool associated to an extension by MHealth innovating technologies (reminder SMS, reminder calls) could systematically create more opportunities for giving complete information about Malaria and pregnancy, helping to achieve the desired ANC coverage quickly. However, the underreporting of SP intake by women who do not visit health facilities and take SP by themselves or take SP from other sources than the ones available at the public health facilities mitigate the accuracy of the coverage rate and need more investigation [15].
This study has some limitations. Firstly, although the physicians confirmed giving the ten information on the checklist, the study investigator did not have access to the full physician-woman speech during the ANC. Thus, it is impossible to verify if all ideas included in the checklist were explained in the same way and with the same time-length. Secondly, the evaluation of the time spent by each physician for each woman was not assessed due to the variety of ANC motivations that included, in the same visits, other discussed health questions than the malaria prevention. Finally, the study investigator was not blinded about the checklist use and was not planned to confirm the SP's source taken previously by some participants, if it was exclusively available in the health facility or had other extra-sources.