Simple Intervention Helps Double the Number of Women Receiving at Least Two Doses of IPTp in Kenya
|Source: Samantha Lobis/Health Right International|
Malaria infection during pregnancy poses a serious health risk to both the mother and her unborn child. In Africa, malaria in pregnancy is estimated to cause up to 200,000 infant deaths annually. A straightforward intervention called intermittent preventive treatment for pregnant women (IPTp) can reduce the adverse effects associated with malaria in pregnancy and increase the chances of a healthier mother and baby. The World Health Organization currently recommends that pregnant women take at least two doses of IPTp with the antimalarial drug sulfadoxine-pyrimethamine after quickening, i.e., when the baby first moves inside the mother. The doses should be taken at least one month apart and are provided during routine antenatal care visits. IPTp is usually administered during routine antenatal care visits under direct observation of health workers.
In sub-Saharan Africa, most women visit an antenatal clinic at least once during pregnancy, and in many countries, women visit an antenatal clinic several times, providing sufficient opportunity to provide IPTp. Despite this fact, in most countries, the percentage of pregnant women who receive at least two treatment doses of IPTp is well below the Roll Back Malaria target of 80 percent. (IPTp coverage targets for the President’s Malaria Initiative [PMI] are 85 percent.)
In Kenya, IPTp was adopted and implemented in 1998. However, the 2003 Kenya Demographic and Health Survey (KDHS) showed only 4 percent of recently pregnant women received two doses of IPTp. This low IPTp coverage was surprising since, in Kenya, the vast majority of women visit an antenatal clinic at least twice during pregnancy, typically beginning in their second trimester of pregnancy. A primary reason identified for the missed opportunities to provide at least two doses of IPTp is health worker confusion over when to give pregnant women IPTp.
The Ministry of Health (MOH) attempted to increase IPTp coverage by simplifying the IPTp policy in 2006 to state that women should be given IPTp at every antenatal clinic visit after quickening, provided there is an interval of four weeks between doses. Despite this effort, a Kenya Malaria Indicator Survey (KMIS) conducted in 2007 showed only 13 percent of recently pregnant women received two doses of IPTp.
Implementation of a New Strategy to Increase IPTp Coverage
The U.S. Centers for Disease Control and Prevention (CDC) has had a long-standing, productive partnership with the Kenya Medical Research Institute (KEMRI). In 2009, KEMRI/CDC and the MOH, with support from PMI, piloted a simple intervention to improve IPTp coverage in the districts of Asembo and Gem. The Chief of the Kenyan Division of Malaria Control sent a memorandum to all government health facilities located in the survey area. The memorandum simply restated the current IPTp guidelines, instructed health workers to follow these guidelines, and informed the health worker that there would be an evaluation in a year. In March 2009, the MOH staff made half-day supervisory visits to all health facilities providing antenatal care services in the survey area. During the visit, MOH staff reviewed the memorandum with the health workers and responded to questions. Approximately six months later, the same memo, signed by the Provincial Director of Medical Services (the supervisor of all MOH clinical staff), was re-sent to the same health facilities.
Approximately one year later, KEMRI/CDC conducted a cross-sectional household survey in a random sample of women who had given birth recently in the survey area. Of the 1,680 women in the study area, 688 were selected for the survey and 549 (80 percent) participated. Nearly 90 percent of participants had made at least two antenatal clinic visits and therefore could have received at least two doses of IPTp.
Of all participants, 69 percent reported having received at least one dose of IPTp, a significant improvement from 41 percent in 2005; in addition, 43 percent received the recommended two or more doses of IPTp, double the 21 percent reported in 2005.
Since IPTp was first introduced in Kenya in 1998, the recorded 43 percent coverage of two doses of IPTp was the highest coverage ever recorded in the country. In the absence of other plausible explanations, the study team concluded that the simple intervention of providing clear directions on when to give IPTp in a memo from the MOH, and the review of this memo during a routine supervisory visit, resulted in a twofold increase in coverage of the recommended two doses of IPTp.
A memo can be incorporated into routine supervisory visits at very little cost over that of the visit itself and delivered directly to health care workers in antenatal care clinics; it appears to be a practical way to improve IPTp coverage and save lives in other districts of Kenya and elsewhere in Africa where IPTp is government policy.