This study was conducted in the Ebiriogu community, which is located in the Okuzzu-Ukawu political ward in Ukawu Development Centre in Onicha local government area (LGA) of Ebonyi State, Southeast Nigeria. Ukawu Development Centre has 3 political wards: Okuzzu-Ukawu, Isinkwo and Abomege. Each political ward has a variable number of primary health centres (PHCs). Okuzzu-Ukawu political ward has 6 PHCs (one of which is located in Ebiriogu) and a dispensary. Ebiriogu community has 3 settlements and one PHC, which is the major source of orthodox health care services in the community. People of the community also access health services in the PHCs located in the other political wards, as well as from traditional healers. The people of Ukawu are mostly Ibos, the dominant tribe of South-East geopolitical zone of Nigeria and their major occupations include farming and trading. Ebonyi State is located in South-East Nigeria with Abakaliki as the state capital. There are 3 senatorial zones and 13 LGAs in the state. According to the 2006 population and housing census, the population of Ebonyi State is approximately 2,176,947 with a landmass of 5,935 sq km. Infants (children <1 year old) make up 4% of the population, children under 5 years 20%, and women of childbearing age 22% of the population . Malaria transmission in Nigeria is perennial, with seasonal peaks in March to September in the south and August to November in north. Temperature and rainfall variations could affect the distribution of mosquitoes and in turn influence the seasonality of malarial episodes and symptoms [2, 7]. This study was conducted during the rainy season (June-October), which represents the seasonal peak period for malaria transmission in southern Nigeria.
In Ebonyi State, some PHCs are selected and supported by development partners while others are not. This support is usually in line with development partner’s organizational objectives and could range from capacity building on different aspects of health, monitoring and evaluation, supportive supervision, and community-level activities, among others. Ebiriogu community was selected because the PHC is not supported by any development partner. This is because, for supported facilities, development partners may have maternal health-related activities (inclusive of prevention and care for malaria in pregnancy) in the facility and community, which may confound findings from this study. Additionally, it is hoped that using a community with non-supported facilities will discourage dependence on external partners and promote sustainability, given recent donor fatigue in Nigeria and other developing countries.
Eligible women were in the second trimester of pregnancy or who experienced quickening and not had a dose of SP in the previous one month. Pregnant women with a history of allergy to sulfur drugs, unexplained recurrent jaundice, or who were already on cotrimoxazole prophylaxis were excluded from receiving IPTp-SP.
The study was an intervention study without control or randomization conducted in three phases: baseline, implementation and post-implementation evaluation.
Data collection methods
At baseline, uptake of IPTp was assessed using interviewer-administered questionnaires among 242 pregnant women and women who had given birth within 6 months before the survey. The questionnaires were administered by trained graduate research assistants. The respondents were recruited from the PHC in Ebiriogu community as well as 4 other PHCs in Ukawu Development Centre offering immunization and antenatal care services. These other PHCs were selected based on high levels of patronage by mothers. Baseline data collection was conducted over a 3-week period. At the PHC facility, registers were used to collect data on IPTp uptake.
Community-directed distributor training
The intervention included advocacy visits and stakeholder engagements with stakeholders in the community such as Ward Development Committee (WDC) chairmen and members, community and opinion leaders (traditional heads, women group leaders, market leaders, religious leaders, PHC officer-in-charge (OIC), town union leaders, youth leaders, opinion leaders). The community leaders were encouraged to select two trusted and acceptable female volunteer Community Directed Distributors (CDD) of IPTp-SP per settlement in the community. The CDDs were selected based on being trustworthy and well-motivated individuals with at least junior secondary school education who lived and worked in the community. They should also live and/or work in easily accessible sites where pregnant women can access them for IPTp-SP and other concerns. Priority in the selection of CDDs was given to women with prior childbearing experience in order to ensure the selection of CDDs acceptable to the women.
The CDDs were trained on basic information about pregnancy, malaria, malaria in pregnancy, estimation of gestational age, eligibility for IPTp-SP administration and side effects, proper use of insecticide-treated nets (ITN), counselling of pregnant women, referral to the PHC, interviewing technique, and documentation using summary forms. The training module was adapted from the National Guidelines and Strategies for Malaria Prevention and Control during Pregnancy . The training was held for 3 days in the community after which the CDDs were given tool-kit bags containing client visitation forms, registers, ANC referral forms, and IPTp drugs. The training was conducted by the principal investigator and the OIC of the PHC. Before the training, the OIC received refresher training on current WHO recommendations for ANC attendance and frequency of IPTp administration. Weekly and two-weekly supportive supervision of the CDDs was conducted by the OIC and research team, respectively.
The CDDs identified the pregnant women in the community, provided general counselling on pregnancy care, including use of ITN and health-seeking for malaria symptoms to pregnant women and their family members available during the visits, administered IPTp-SP to eligible women, and referred them for ANC for prenatal care and receipt of ITNs over a 5-month period. They also followed up the pregnant women using home visits in order to encourage ANC attendance and ITN use. The CDDs carried out community distribution dressed in branded T-shirts, caps, and bags with educative pictures and write-ups on prevention of malaria in pregnancy. The CDDs received monthly financial token stipends for their transportation and meals. The drug supply to CDDs was linked to the PHC in the community and was only obtained from the facility. For the period of the intervention, the CDDs issued referral forms to pregnant women who received IPTp but were either not enrolled or poorly adherent to ANC. On accessing services in the health facility, the pregnant women were instructed to present the referral forms in addition to verbally communicating that they had been referred by CDDs in the community. With or without the referral forms, the facility health workers also directly enquired from the pregnant women who utilized the health facility whether they had been encouraged to do so through the intervention and if the response was in the affirmative, they indicated this by a tick beside the details of the women in the ANC register. Verbal confirmation was strongly emphasized because the feedback from the CDDs was that some of the women forgot to go along with their referral forms to the health facility.
Review meetings were held on a two-weekly basis with the CDDs. During the review meetings, drug stock and data collection documents were reviewed, field experiences and challenges shared and addressed. Every woman who received IPT from the CDDs was given a card on which doses and the dates the IPT were given was marked and this was presented whenever she visited a health facility for ANC or was due for another dose, in order to avoid inappropriate multiple dosing. The CDDs also visited with their records of IPT administration and verified that pregnant women had not received IPTp in the 4 weeks preceding the current administration.
A community awareness campaign was used to sensitize community members on general malaria prevention and specifically the prevention of malaria in pregnancy. The sensitization was held in the community hall and involved brief health talks, question and answer sessions, and distribution of information and education fliers on prevention of malaria. The leaflets contained pictures and short write-ups in English and Ibo languages conveying information on the prevention of malaria in pregnancy and other preventive practices. The health talks were given in the local dialect by the principal investigator and OIC of the PHC. Additionally, platforms and meetings of social groups in the community and church-based women’s groups and community political groups (cabinet, consultation meetings) were utilized to educate community members. The community town criers were also engaged to disseminate specific messages on the prevention of malaria in pregnancy.
Post-implementation of the intervention
Over the 5 months of the intervention, a monthly implementation evaluation was conducted starting from the first month of the intervention to assess the proportion of women who received various doses of IPTp-SP using records from CDDs and ANC registers. Change in ANC attendance following the intervention was also computed from the PHC. Satisfaction with the community-directed distribution of IPTp and the CDD services was also assessed.
Sample size determination
The estimated annual population of pregnant women in the Ebiriogu community calculated as 5% of the total population in the community was 303, as obtained from the Ebonyi State Primary Health Care Development Agency. Since the study was conducted over 5 months, about half of this number (152 pregnant women) was used as the minimum target population for the IPTp-SP distribution
Data management and analysis
Measurement of variables and statistical analysis
The independent variables include the socio-demographic and clinical characteristics of the participants (age, marital status, gestational age of pregnancy, presence of quickening, parity, history of SP administration within the previous four weeks, antenatal attendance). The dependent variables were the proportion of women who received different doses of IPTp-SP, ITN use, and satisfaction with CDD services. The client visitation forms were used to collect information on the socio-demographic and clinical characteristics, ITN use and the IPT dose provided to each pregnant woman. These were then summarized every month using the monthly summary forms. Post-intervention, a short questionnaire was used to assess satisfaction with the CDD services among women who had received the IPTp.
Frequencies and proportions were calculated for categorical variables while means and standard deviations were calculated for quantitative variables. Pre-intervention and post-initiation of the intervention proportions were compared using Chi-square. The level of significance was set at p <0.05 and the confidence interval at 95%. The fourth month following the initiation of the intervention was used to compare with baseline ANC use, ITN ownership and use, and fever during pregnancy. The fourth month was chosen to allow the pregnant women to receive a minimum of 3 doses (in months 1-3 in line with the WHO recommendation) and also to allow time for the uptake of the intervention. The fourth month was also the month in which the highest number of women received IPTp-SP.
The IBM Statistical Package for Social Sciences (SPSS) version 20 was used for data entry and analysis. Frequency tables and figures were used to present the study findings.