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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 4  |  Page : 356-361

Malaria in pregnancy: Assessment of doctors’ conformity to monthly intermittent preventive treatment in a Sub-Saharan African Country


1 Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku/Ozalla, Nigeria
2 Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Nsukka, Enugu, Nigeria

Date of Submission12-Feb-2022
Date of Decision04-May-2022
Date of Acceptance17-Jun-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Chidinma I Onwuka
Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria Nsukka/University of Nigeria Teaching Hospital, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.ijmh_36_22

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  Abstract 

Background: Administration of intermittent preventive treatment (IPT) in pregnancy is recommended for all pregnant women living in areas of stable malaria transmission. In order to increase the chances of a parturient receiving adequate number of IPT in pregnancy, World Health Organization (WHO) now recommends that it should be commenced from second trimester and given every month (at least 4 weeks apart) until the time of delivery, however, this recommendation is not being practiced by all doctors attending to pregnant women. Objective: To determine the conformity of Doctors to monthly prescription of IPT till delivery. Materials and Methods: This was a cross-sectional survey of antenatal clinic Doctors’ prescription of IPT during pregnancy in Enugu state. Information obtained included the socio-demographic characteristics of the Doctors, knowledge of IPT in pregnancy for malaria and implementation of the new IPT policy. A P-value of <0.05 was considered statistically significant. Results: A total of 119 doctors participated in the study. The mean age of the doctors was 36.15 +/- 2.42 years. One hundred and seven (89.9%) of the respondents had good knowledge that IPT is for prevention of malaria. One hundred and eighteen (99.2%) used sulphadoxine-pyrimethamine for IPT. One hundred and fourteen (95.8%) respondents knew that IPT should be commenced in second trimester, and 85.7% conformed to the new monthly policy of IPT prescription. Among the 20.2% of doctors who prescribed IPT only for 2 – 3 times during pregnancy, 13 (54.2%) gave the reason that they were comfortable with the old pattern of stopping at 36 weeks. There was significant association between knowledge of IPT in pregnancy and year of attainment of MBBS (P = 0.015). Age (P = 0.006) and level of practice (P = 0.002) were significantly associated with practice of the new IPT in pregnancy policy. Conclusion: There was high conformity to monthly IPT prescription until delivery among doctors in Enugu, Nigeria.

Keywords: Doctors, IPT, malaria, placental malaria, pregnancy


How to cite this article:
Ikpeama EC, Udealor PC, Onwuka CI. Malaria in pregnancy: Assessment of doctors’ conformity to monthly intermittent preventive treatment in a Sub-Saharan African Country. Int J Med Health Dev 2022;27:356-61

How to cite this URL:
Ikpeama EC, Udealor PC, Onwuka CI. Malaria in pregnancy: Assessment of doctors’ conformity to monthly intermittent preventive treatment in a Sub-Saharan African Country. Int J Med Health Dev [serial online] 2022 [cited 2022 Sep 27];27:356-61. Available from: https://www.ijmhdev.com/text.asp?2022/27/4/356/356630




  Introduction Top


Malaria in pregnancy is a major public health problem which causes maternal and infant morbidity and mortality in malaria endemic countries like Nigeria.[1]

Each year, about 50 million women in malaria endemic countries become pregnant and malaria is known to contribute to at least 10,000 maternal deaths and to at least 200,000 newborn deaths annually with greater than 80% occurring in Africa.[2] In Nigeria, many researchers have reported high prevalence rates of malaria in pregnancy, ranging from 19.7% to 72.0%.[3]

Malaria in pregnancy accounts for 63% of all clinic attendances, 70.5% of maternal morbidity and 11% of maternal mortality in Nigeria.[2]

It is caused by protozoan plasmodium falciparum.[4] Other species are P.ovale, P.malariae and P.vivax. Due to the fact that pregnant women have reduced immune response, they clear malaria parasitaemia less effectively, and therefore about three times more likely to develop severe disease than non-pregnant women acquiring infections from the same area.[5] Furthermore, due to the sequestration and replication of malaria parasites in the placenta during pregnancy, malaria can be transmitted to the baby.[5] Malaria in pregnancy can lead to premature delivery, low birth weight, miscarriage as well as perinatal death amongst others.[5]

World Health Organization (WHO) recommends protection against malaria for women during pregnancy. Weekly chemoprophylaxis with Chloroquine or Pyrimethamine alone were previously used for malaria prevention in pregnancy.[6] However, due to increasing resistance of parasite strains to Chloroquine and poor patient compliance, intermittent preventive treatment in pregnancy (IpT) with Sulfadoxine/Pyrimethamine is now recommended for all pregnant women living in areas with stable malaria transmission.[6]

Intermittent preventive treatment of malaria in pregnancy (IpT) involves administration of a single curative dose of an antimalarial at predefined intervals during pregnancy, notwithstanding whether the women are infected.[7]

IpT with Sulfadoxine-Pyrimethamine (SP) is recommended for malaria prevention in both HIV-negative and HIV-positive pregnant women, however, it is contraindicated in HIV-infected women taking daily Cotrimoxazole prophylaxis (CTXp) because of the potential risk of adverse effects associated with taking the two drugs (which are anti-folate) simultaneously.[8]

A recent WHO meta-analysis evaluating Intermittent Preventive treatment of malaria in pregnancy with Sufadoxine-Pyrimethamine (IPTp-SP) showed that higher mean birth weight and fewer low birth weight (LBW) were associated with taking three or more doses of IPTp-SP than two doses of IPTp-SP.[9] There was reduction in low birth weight.[9] It was noted that 3 or more groups had less placental malaria.[9] Based on the evidence review in October 2012, WHO updated the recommendations on IPTp-SP that it should be given at each scheduled antenatal clinic (ANC) visit except during the first trimester, provided each dose is one month apart.[9] Giving IPTp-SP monthly until the time of delivery (with doses given at least one month apart), will ensure that a high proportion of women receive at least three doses of SP during pregnancy.[9]

There is paucity of data on the conformity of doctors to the new monthly IPTp-SP. Information obtained may help in policy making with resultant improvement in maternal and child health. This study aimed to ascertain the knowledge of Doctors on the new policy, their implementation and factors responsible for both.


  Materials and Methods Top


This was a cross-sectional survey of Doctors’ prescription of IPTp-SP during pregnancy in Enugu state. This study was conducted over 3 months and limited to only Doctors who run antenatal clinics in the teaching hospitals (University of Nigeria Teaching Hospital, Enugu State University Teaching Hospital and Mother of Christ), private hospitals and some selected health centers in Enugu State such as Uwani health center, Poly clinic and New haven health center. The hospitals were selected by convenience sampling method. Ethical clearance was obtained from research ethics committee of UNTH and additional approvals obtained from all the hospitals.

Information was obtained using a proforma that was specifically developed for this study. The proforma was used to collect relevant data which included the socio-demographic characteristics of the Doctors, knowledge of IpT in pregnancy for malaria and implementation of the new IpT policy.

The convenience non-probability sampling technique was used to select subjects for the study. Informed consent was obtained. Inclusion criteria included all consenting doctors that run antenatal clinic while those who did not give their consent or do not run antenatal clinics were excluded from the study.

Data obtained was analyzed using statistical package for social sciences (SPSS) IBM version 23.0. Descriptive statistical tools which included frequency and percentage were used to summarize categorical variables. Inferential tools such as chi-square were used to test for association between categorical variables. A P-value of <0.05 was considered statistically significant. Results were presented in tables and charts.

Sample size determination was done using the formula for prevalence by Daniel:[10] using no = Z2 P (1-P)/ d2

Where no = sample size, z = statistic corresponding to level of confidence (95%), p was set at 50% and d = precision (5%). no = 384.

Since the population is small (n = 172), we further reduce the sample size using the correction formula as follows:

n = no

1 + (no – 1)/N

n = 119.

Thus the sample size for the study was 119.


  Results Top


Most of the respondents were between 25 and 35 years of age (60.5%). There were more male respondents (66.4%) than females. Majority of the Doctors were residents (61.3%) and a greater number of the doctors were over 5 years in practice. Details are as seen in [Table 1].
Table 1: Demographic characteristics of the respondents

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One hundred and seven (89.9%) of the Doctors accurately described IPT as prevention of malaria in pregnancy while 99.2% correctly identified Sulphadoxine-pyrimethamine as the approved anti-malarial drug for IPT and second trimester (95.8%) as the recommended time for commencement of IPT. [Table 2].
Table 2: Knowledge of IPT in pregnancy for malaria

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There was a high level of knowledge of the new policy on IPT among doctors (85.7%). [Figure 1].
Figure 1: Summary of knowledge of the new policy on intermittent preventive treatment

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Ninety five (79.8%) of the Doctors correctly prescribed IPT after first trimester monthly and 82.4% gave till delivery. See [Table 3].
Table 3: Practice of the new intermittent prophylactic treatment

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There was a high level of practice of the new policy on IPT among doctors (94%). [Figure 2].
Figure 2: Summary of practice of the new intermittent preventive treatment

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Being comfortable with the old pattern of IPT administration was the reason given by most of the doctors (54.2%) who do not comply with the new policy. Other reasons were as seen in [Table 4].
Table 4: Reasons for non-compliance to new prescription policy

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There was significant association between knowledge of IPT in pregnancy and year of attainment of MBBS (χ2 = 12.405, P = 0.015). Doctors who were 5 to 10 years in practice (100%) had better knowledge of IPT in pregnancy followed by those less than 5 years (80%) and greater than 10 years (77.3%) in that order. Age (χ2 = 6.836, P = 0.336) and level of practice (χ2 = 7.613, P = 0.107) were not significantly associated with knowledge of IPT in pregnancy. Further details in [Table 5].
Table 5: Association between age, level of practice, year of attainment and knowledge of new IPT in pregnancy policy

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Age and level of practice were significantly associated with practice of the new IPT in pregnancy policy (P < 0.05). Doctors aged 36 to 40 years (100%) practiced better followed by those aged 20 to 30 years (97.7%), 31 – 35 years (96.4%) and greater than 40 years (79.2%) in that order. Similarly, resident doctors (98.6%) had better practice when compared to general practitioners (72.7%) and consultants (72.7%). However, year of attainment was not significantly associated with practice of the new policy (P = 0.087). Further details as seen in [Table 6].
Table 6: Association between age, level of practice, year of attainment and practice of new IPT in pregnancy policy

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  Discussion Top


One hundred and nineteen doctors participated in the study. Majority of them had good knowledge of IpT, used sulphadoxine-pyrimethamine for IpT and knew that IpT should be commenced in second trimester. The reason given for non-conformity with the new recommendation was that they (the respondents) were comfortable with the old pattern of stopping at 36 weeks.

In our study, 89.9% correctly stated what IPT is. This was at variance with previous study conducted by Arulogun AS in 2012,[11] where only 32.5% correctly defined IPT as a prophylactic treatment of malaria during pregnancy. This may be due to the difference in the period the two studies were conducted. This therefore, shows that over the years, doctors are becoming more aware of the essence of IPT. However, it is surprising to know that some doctors still think IPTp-SP is for treatment instead of prevention. There may be a need for continuous medical education on malaria in pregnancy and its management in order to improve maternal and child health.

The years of attainment of MBBS had a significant association with knowledge as those between 5 – 10 years had 100% knowledge of IPT. A similar study done by Nigeria Medical Association in Enugu[5] among general practitioners showed that those who obtained MBBS qualification less than or equal to 5 years prior to the survey were more likely to comply with the national policy on malaria control in their prescriptions compared to the older ones. In this study, the doctors who attained MBBS qualification between 5 to 10 years comply most with the new WHO policy 2012, followed by those greater than 10 years. This could be as a result of the cadre of the respondents involved in this age brackets which included resident doctors and consultants. For the general practitioners, their knowledge could be attributed to continuing professional development (CPD) in Nigeria.

In the study done by Nigeria medical association of doctors, 51.7% of general practitioners in Enugu State prescribed IPTp-SP. While in a study done by Akodun BA[12] between private and public practitioners, only 69.0% of public providers and 74.8% of private providers prescribed IPT using Sulphadoxine-Pyrimethamine. In another study done by Arulogun AS in Southwest Nigeria,[11] 75.5% correctly named Sulphadoxine-Pyrimethamine as the approved anti-malarial drug. These were different from the result gotten from our study as 99.2% use IPTp-SP. This could be attributed to the fact that most of the respondents in this study were in tertiary institutions where IPTp-SP is a standard protocol during antenatal period.

To the best of our knowledge, there is paucity of data comparing the findings of IPT prescription on monthly basis after first trimester till delivery. However, this study has shown that many Doctors are aware of the new WHO policy 2012, and are already practicing it because of the immense maternal and child benefits.

The study limitation was that convenient sampling method was used to select the participants, and this may affect the generalizability of the study result to the entire population. Another limitation was that the study was based on self-reported information and may be prone to bias.


  Conclusion Top


There is high compliance to monthly IPTp-SP prescription till delivery among doctors. However, there is need for more continuous medical education for doctors in order to improve maternal and child health.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Isah AY, Nwobodo EI Awareness and utilisation of insecticide treated mosquito nets among pregnant mothers at a tertiary health institution in North-Western Nigeria. Niger J Med 2009;18:175-8.  Back to cited text no. 1
    
2.
Ejikeme NN, Onwe AB. Malaria in pregnancy. In: Umeora OUJ, Egbuji CC, Onyebuchi AK, Ezeonu PO, editors. Our Teacher. 1st ed. Nigeria: St Benedict Printing and Publishing; 2017. p. 67-70.  Back to cited text no. 2
    
3.
Agomo CO, Oyibo WA, Anorlu RI, Agomo PU Prevalence of malaria in pregnant women in Lagos, South-West Nigeria. Korean J Parasitol 2009;47:179-83.  Back to cited text no. 3
    
4.
Kalu MK, Nwogo AO, Nduka FO, Otuchristian G A comparative study of the prevalence of malaria in Aba and Umuahia urban areas of Abia state, Nigeria. J Parasitol 2012;7:17-24.  Back to cited text no. 4
    
5.
Ugwu EO, Iferikigwe ES, Obi SN, Ugwu AO, Agu PU, Okezie OA Anti-malaria prescription in pregnancy among general practitioners in Enugu state, South East Nigeria. Niger Med J 2013;54:96-9.  Back to cited text no. 5
    
6.
Deloron P, Bertin G, Briand V, Massougbodji A, Cot M Sulfadoxine/pyrimethamine intermittent preventive treatment for malaria during pregnancy. Emerg Infect Dis 2010;16: 1666-70.  Back to cited text no. 6
    
7.
Briand V, Bottero J, Noël H, Masse V, Cordel H, Guerra J, et al. Intermittent treatment for the prevention of malaria during pregnancy in Benin: A randomized, open-label equivalence trial comparing sulfadoxine-pyrimethamine with mefloquine. J Infect Dis 2009;200:991-1001.  Back to cited text no. 7
    
8.
González R, Desai M, Macete E, Ouma P, Kakolwa MA, Abdulla S, et al. Intermittent preventive treatment of malaria in pregnancy with mefloquine in HIV-infected women receiving cotrimoxazole prophylaxis: A multicenter randomized placebo-controlled trial. PLoS Med2014;11:e1001735.  Back to cited text no. 8
    
9.
WHO policy brief for the implementation of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP). 2013. Available from: www.who.int/malaria/publications/atoz/iptp-sp-updated-policy- brief-24jan2014.pdf. [Last accessed on Sep 2019].  Back to cited text no. 9
    
10.
Daniel WW, editor. Biostatistics: a foundation for analysis in the health sciences. New York: John Willy and sons; 1999.  Back to cited text no. 10
    
11.
Arulogun OS, Okereke C Knowledge and practices of intermittent preventive treatment of malaria in pregnancy among health workers in a south west Local Government Area of Nigeria. 2012. Available from: https://www.researchgate.net/.../274078747_Knowledge_and_practices_of_intermittent. [Last accessed on Sep 2019].  Back to cited text no. 11
    
12.
Akodu BA, Amaechi BO, Inem V Chemoprophylaxis for malaria - in pregnancy by public and private health providers in Lagos. Available from: https://www.ajol.info/index.php/rejhs/article/download/158764/148383. [Last accessed on Sep 2019].  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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