Malaria in pregnancy (MiP) is a major public health problem associated with undesirable health consequences for both pregnant women and new-borns. It is of considerable importance particularly in the absence of adequate preventive interventions (1). Pregnant women are three times more likely to suffer from severe disease due to malaria infection compared with their non-pregnant counterparts (2). In malaria endemic areas, the risk of malaria infection during pregnancy is 50% higher among pregnant women than non-pregnant women (3). Pregnant women are more vulnerable due to pregnancy induced lowered immunity (4). MiP significantly accounts for maternal and neonatal mortality by causing anaemia, which in turn raises the risk of maternal and neonatal death (3). Apart from malaria-related anaemia and its associated risks, other undesirable health consequences of MiP include haemorrhage, intrauterine growth retardation, still birth, preterm delivery, maternal death, placental malaria, miscarriage, low birth weight and congenital infections (3, 5).
Globally, 125.2 million pregnant women face the risk of malaria infection each year and 30.3 million (24%) of these reside in the stable malaria transmission zones of Sub-Saharan Africa (6). Approximately 40% of all pregnancies in Sub-Saharan Africa would experience P. falciparum placental infection in the absence of interventions for the prevention of malaria during pregnancy resulting in an estimated 900,000 low birth weight deliveries annually (7). In Africa, about 10,000 women and 75,000 to 200,000 infants die yearly due to MiP while low birth weight resulting from P. falciparum parasite infections during pregnancy is estimated to cause 100,000 (11%) of neonatal deaths (3). In Kenya, pregnant women bear the greatest burden of malaria and it has been estimated that about 1.5 million pregnancies occur yearly, with about 44% in moderate to intense malaria endemic areas (4). In 2018, the prevalence of MiP in Kenya was approximately 4,918/100,000 (8). Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulphadoxine pyrimethamine (SP) is one of the three interventions recommended by the World Health Organization (WHO) for controlling malaria and its effects during pregnancy (9).
The WHO recommends the provision of IPTp-SP to all pregnant women in areas of moderate to high malaria transmission starting as early as possible in the second trimester at each scheduled antenatal care (ANC) visit until delivery (9). In line with the WHO guidelines, Kenya’s Ministry of Health currently recommends that pregnant women living in malaria endemic areas should receive at least three doses of SP drug to achieve optimal IPTp-SP dosage (IPTp-SP3+) (10). The drug is given as a single dose of three tablets under directly observed therapy in the ANC. It is safe and can be taken with or without food. However, the WHO does not recommend SP to pregnant women on cotrimoxazole prophylaxis due to an increased risk of adverse events (9). The drug remains cost effective and efficacious for IPTp (11, 12). Previous studies have demonstrated that IPTp-SP is beneficial to both pregnant women and new-borns. The intervention has been linked to reduced malaria cases among pregnant women, lower risk of placental malaria and reduced neonatal deaths (13). In a study in Tanzania, uptake of more than three SP doses was associated with reduced odds of having placental malaria compared to less than three SP doses (14). A study conducted in six countries in Sub-Saharan Africa found that IPTp-SP had an association with higher maternal haemoglobin and birth weight even in areas that experienced SP resistance (15).
In Sub-Sahara African countries, the uptake levels of IPTp-SP are still far below global targets set by Roll Back Malaria Partnership of 80% by 2010, and 100% by 2015 (16). Among 33 African countries that reported on IPTp coverage levels in 2017, an estimated 22% of eligible pregnant women received the recommended optimal IPTp-SP dose (17). In a study involving selected malaria endemic countries in Sub-Saharan Africa, the overall prevalence of taking three doses of IPTp-SP in the latest pregnancy was 29.5% (18). In Malawi and Uganda, the IPTp-SP optimal uptake were 29.8% and 18% respectively (19, 20). Contrastingly, other studies in Ghana and Sierra Leone reported high optimal IPTp-SP uptake levels of 71%, 76.4% and 93.24% (18, 21, 22). In Kenya, only 37.5% of pregnant women residing in malaria endemic zones received the recommended optimal dose of IPTp-SP (23), which is far below the national target of 80% (10). However, the uptake of the recommended IPTp-SP optimal dose in many other areas in Kenya remained unknown. Studies on optimal uptake of IPTp-SP in Kenya after malaria policy revision in 2014 have been limited. The observed differences in various research findings across Africa demonstrates the geographical variations and contextual natures in which the studies were conducted.
Socio demographic and obstetric characteristics such as maternal age, educational level, marital status, socio-economic status, residence, parity, gestational age at initial ANC visit and frequency of ANC attendance have been found to influence the uptake of IPTp-SP by pregnant women (18–20, 24). Knowledge related factors such as maternal knowledge of MiP and IPTp-SP have also been demonstrated to predict IPTp-SP optimal uptake (25, 26). All these are factors attributable to an individual pregnant woman. They are likely to influence IPTp-SP uptake either singularly or in combination with others. Despite this, it was unclear and unknown which of these factors influenced the uptake of optimal IPTp-SP in Sabatia Sub County.
Service delivery is one of the health systems strengthening blocks. In this study health service delivery factors referred to those confined to a health facility and related to the availability, affordability and quality of IPTp-SP service delivery through ANC. Health service delivery dynamics in the facilities is critical to appropriate IPTp-SP uptake (27). In Sub-Saharan Africa, it has been advanced that poor IPTp-SP coverage levels and many missed opportunities for IPTp-SP delivery are attributable to inadequacies in the health care systems (27–29). However, a clear and scientific understanding of the health service delivery factors associated with the uptake of optimal IPTp-SP was missing in Sabatia Sub County.
This study sought to investigate the prevalence of and factors influencing IPTp-SP optimal uptake in Sabatia Sub County of western Kenya. Enhancing knowledge and strengthening the responsiveness of key stakeholders for improved access to and use of IPTp-SP is important. Therefore, understanding the epidemiology of MiP is core for making decisions and setting priorities towards improved uptake of optimal IPTp-SP.