Assessment of the Use of Malaria Prophylaxis, (Intermittent Preventive Therapy) and Its Related Outcome among Pregnant Women in Imo State, Nigeria

Aims: The aim of this study was to assess the use of malaria prophylaxis and its related outcome among pregnant women in Imo state. Study Design: Descriptive cross-sectional study. Place and of Study: Six health facilities; the most prominent one from the urban and rural areas of each of the three geopolitical zones of the state was selected, between August November 2013. Methodology: Pregnant women in their third trimester attending ante-natal care clinics were involved, and for multiparas only those who used the present facility during their last pregnancy were studied. All eligible parturient who gave consent (432) were studied using a pretested, interviewer administered questionnaire. Data analysis was done with SPSS statistical software; version 20 and significance level was set at p value of less than 0.05. Results: The mean age of the parturient was 27.9±6.1 years. Though majority of the pregnant women (64%) used sulfadoxine-pyrimethamine for malaria prophylaxis, a sizeable proportion (9.8%) used chloroquine. Most of the pregnant women (94.7%) used one form of malaria prophylaxis or the other, the major reason given by the non users was erroneously that they felt healthy (56.5%). Primigravidas were more likely to use malaria prophylaxis compared to multigravidas (OR = 0.44, 95% CI: 0.40 – 0.49). Use of malaria prophylaxis had a protective effect on parturient against malaria episodes (OR = 0.08, 95% CI: 0.03 – 0.23) and low birth weight babies (OR= 0.70, 95% CI: 0.55 – 0.89). Conclusion: Malaria prophylaxis in pregnancy was found to be useful in protecting against malaria episodes and in minimizing incidence of low birth weight babies. A sizeable proportion did not use the recommended regimen, and this calls for persistent health education and public enlightenment campaign especially targeted at the pregnant women.


INTRODUCTION
An estimated 198 million cases of malaria occurred in 2013 globally, most of which were reported in sub-Saharan African children less than five years of age and resulted in 584,000 deaths [1]. Malaria in pregnancy is an immense public health problem that affects approximately 25 million women per year in malaria-endemic areas [2]. Pregnant women, especially primigravidae and secundigravidae are particularly vulnerable to malaria than nonpregnant women from the same area [3]. Previous Nigerian studies reported malaria parasite prevalence of between 60% and 72% among pregnant women [4,5].
Malaria during pregnancy causes up to 10,000 maternal deaths each year in sub-Saharan Africa and contributes to high rates of maternal morbidity including fever and severe anaemia, especially in first time mothers [6,7]. It is also a cause of low birth weight and placental parasitaemia [8,9]. Between 75,000 to 200,000 infant deaths annually are attributable to malaria infection in pregnancy globally [10,11].
In stable malaria transmission areas like Nigeria, the Roll Back Malaria (RBM) partnership recommends a three pronged approach for reducing the burden of malaria among pregnant women, [11,12] which are effective case management of malaria infection, use of insecticide treated nets (ITNs) and intermittent preventive therapy (IPT). Nigeria as such adopted the IPT strategy in year 2005 [12].
IPT entails administration of curative dose of an effective anti-malaria drug at least twice during the second and third trimesters of pregnancy at routinely scheduled antenatal clinic visits regardless of whether the woman is infected or not [9,13,14]. The drug is administered under supervision during antenatal care visits. SP the currently recommended drug for IPT strategy [11][12][15][16] has a good safety profile and remains a good option for IPT in endemic areas in Africa [15,17]. The documented side effects in pregnancy from a Nigerian study was dizziness with no congenital malformations or death [9]. The single dose therapy makes supervised administration in antenatal clinics feasible for compliance [12].
IPT with SP has been shown to reduce the risk of maternal anaemia, placental parasitaemia and low birth weight [8,18,19]. In a study in south west Nigeria, IPT -SP was found to be effective in preventing maternal and placental malaria among parturient as well as in improving pregnancy outcomes such as delivery of bigger babies and lower prevalence of preterm deliveries and maternal anaemia [9].
Antenatal clinics are considered an important entry point to target the pregnant women [12,17] as 60-70% of women attend antenatal clinic at least once during any pregnancy in Nigeria [12,17]. Implementation of IPT strategy has been established in many health facilities in malaria endemic areas including Nigeria. However, it is estimated that less than 5% of pregnant women have access to effective malaria interventions, this is worse in the rural areas [20]. A survey carried out in four African countries showed that less than 20% of women use a prophylactic regimen close to the World Health Organisation (WHO) recommendations [21]. As a result of this poor access, malaria remains one of the most important causes of maternal and childhood morbidity and mortality in sub -Saharan Africa, [22].
To date only few studies have investigated factors affecting adherence to IPT use. [23,24] The identified barriers to IPT use are related to concerns about SP safety and poor understanding of the protocol among health care providers and the community. [10] In a study conducted in Tanzania, majority of respondents linked low compliance with IPT to poor acceptance of SP because of perceived association of SP with adverse effects [17]. Other factors influencing compliance include late enrolment, periodic shortages of drugs and health workers underperformances [23].
Studies related to IPT use during pregnancy in Nigeria are limited, [24] and in the study area there is no available data on IPT use among parturient, thus, this study set out to assess IPT use and its related outcome among pregnant women attending health facilities in Imo state.

Study Area
The study was carried out in the three geo political zones of Imo state namely: Owerri, Orlu and Okigwe zones. It was a hospital based cross-sectional study. Two most prominent health facilities were purposively selected from each of the geopolitical zones, one in an urban setting and the other in a rural community.
In Owerri zone, the study was conducted at Federal Medical Centre (FMC), Owerri (urban) and Holy Rosary Hospital, Emekuku (rural). The urban and rural centres for Orlu zone were Imo State University Teaching Hospital (IMSUTH), Orlu and Primary Health Care Centre, Umuowa. While, for Okigwe zone, General Hospital Okigwe and Comprehensive Health Centre, Anara represented the urban and rural centres respectively. The FMC which is in Owerri Municipal Local Government Area (LGA) is over 30 Kilometres from IMSUTH in Orlu LGA at one axis of the state and over 40 Kilometres from General Hospital in Okigwe LGA at another axis of the state.
The main occupations in Orlu and Okigwe are farming and trading respectively, while Owerri is civil / publc service and trading. The people are mainly of Igbo ethnicity and Christian religion. Owerri is a high malaria endemic area like Orlu and Okigwe zones, with stable malaria transmission. There are two seasons in the state; wet season (April to October) and dry season (November to March). Maximal mosquito breeding is observed between the ending of the wet and beginning of the dry which is a period of high malaria attacks, this was the study period (August to November).

Study Population
The study was conducted using parturient in their third trimester that presented at the antenatal care (ANC) clinics of the above mentioned hospitals and health centres who gave consent.

Inclusion and exclusion criteria
Inclusion criterion for multigravidas was the use of the present health facility during their last pregnancy and delivery, for verification of baby's birth weight. Exclusion criteria for the study were known pregnancy related disease (like diabetes and hypertension) or chronic diseases (like HIV/AIDS).

Study Design
This was a descriptive cross sectional study using interviewer administered questionnaire and a profoma. All eligible parturient who gave consent at the clinics within the three months of data collection were studied and upon analysis were 432.

Data Collection Methods
Information was collected using a pretested, semi-structured, interviewer administered questionnaire developed for the study. Questionnaire administration on parturient was aided by two trained research assistants. The questions were translated into the native language and back translated to English. The questionnaire comprised of sections on sociodemographic characteristics, knowledge of malaria and intermittent preventive therapy (malaria prophylaxis), use of malaria prophylaxis and related outcome of IPT. The profoma collected information on IPT use and birth weight during last delivery from client's file to compliment the questionnaire on this section.

Data Analysis
Data was collated, sorted, and analysed using IBM SPSS (version 20, Armonk. NY: IBM Corp. 2011). Frequency distributions, percentages and means of relevant variables were tabulated. Bivariate analysis was done with Chi-square or Fisher's Exact test to compare proportion for categorical variables and one-way ANOVA to compare means for continuous variables. Results were considered significant when the two-sided P-value was < 0.05. The Odds ratio and confidence intervals were calculated where applicable.

Ethical Consideration
Ethical approval for the study was obtained from Imo state university teaching hospital (IMSUTH) ethics committee. Permission was also obtained from the appropriate authorities involved in the care of the pregnant women at the various health centres used for this study. Written informed consent was obtained from each respondent before participation. Confidentiality of information was ensured and those who refused consent were not victimized.

Scope
The study concentrated on one of the three interventions for malaria prevention in pregnancy (IPT) and did not study use of insecticide treated nets (ITN) or other problems

Limitations
(1) Loss of records and poor documentation; as out of the 204 multigravidas involved in the study, only 84.8% (173) had birth weight of their last babies verified by records. (2) Loss of recall power as a few parturient could not remember exact agent used for prophylaxis, some forgot the exact number of doses of IPT used with no available record, hence were not involved in that particular analysis. (3) Some parturient refused consent

RESULTS
A total of four hundred and thirty two women participated in this study. Majority of the participants (60.2%) were aged between 21 -30 years with a mean age of 27.9 ± 6.1 years. A good proportion of them (97.5%) was married and had tertiary education (69.0%). About twothirds (62.7%) of the parturient were full time housewives and more were primigravidas 228 (52.8%) ( Table 1). All the parturient were aware of malaria, 397 (92%) knew it was transmitted by mosquito bite, 2.7% said it was sexually transmitted, 1;5% each attributed it to oily food and bad water, while 2.8% did not know. Four hundred and ten (95%) knew malaria in pregnancy could cause problems like miscarriage, low birth weight and still birth. Regarding IPT 346 (80%) were aware of it, and 320 (74%) of these got their information from health workers, while 66% agreed Fansidar (SP) was the recommended option.
The commonest drug used by parturient in this study for malaria prophylaxis was Fansidar (63.3%) or generic SP (64%), though a sizeable proportion (11.3%) did not know the name of the drug they took. Majority of the mothers (94.7%) used some form of malaria prophylaxis in this study and more than half of them (63.8%), got their anti-malaria from a healthcare facility. The main reason given for none usage by the other 5.3% of mothers was that they felt healthy (56.5%) ( Table 2).
All the primigravidas used prophylaxis compared to 88.7% of the multigravidas, (X 2 = 27.2, p = 0.00) ( Table 5). IPT was protective against malaria attack, as only 22.7% of the parturient who took at least 2 doses of IPT in the index pregnancy had malaria attack compared to 78.3% of those who did not use IPT, (OR = 0.08, 95% CI: 0.03 -0.23) ( Table 6).
The proportion of multigravidas who had low birth weight babies (<2.5kg) in their last pregnancy despite use of IPT was only 12.8% whereas the nine multigravidas who did not use IPT in their last pregnancy all had low birth weight babies (OR = 0.07, 95% CI: 0.55 -0.89) ( Table 6).
Tables 8a and b show that there was difference in the mean birth weight distribution of the babies from mothers that had three different doses of IPT, with those who completed 3 doses having the highest mean birth weight of 3.27kg while those with 2 doses had the least of 3.18kg (F-test = 77.48, P = 0.00).

DISCUSSION
Uptake of IPT -SP described as generally low in sub-Saharan Africa [25] was relatively commendable in this study. About 60.0% of the enrolled pregnant women received at least a dose of IPT -SP, while 48.8% received the stipulated minimum of two doses of IPT. This is similar to the 62.8% IPT use by ANC attendees in neighboring Rivers state of south-south Nigeria by 2013 [26]. In all, 94.7% of our participants took a preventive malaria medication whether it was SP or other types of anti-malaria drug. These figures were higher than what was reported in the 2013 Nigeria Demographic and Health Survey (NDHS) [27]. According to this survey, 14.6% of pregnant mothers received at least two doses of IPT -SP, while 49% took preventive malaria medication whether it was SP or other types of anti-malaria drugs [27]. Other hospital based study by Falade et al. [9], in 2007 recorded 84.4% and 14.6% for women who took at least a dose of IPT -SP and the stipulated minimum of two doses respectively. The higher rate observed in this study compared to the NDHS could be because it was hospital based.
The study showed that about 35% of the pregnant mothers procured their drugs from patent medicine dealers, though in accordance with the national guidelines SP should be administered free of charge to pregnant women receiving ANC in public health facilities and Non Governmental or Faith Based facilities under direct observation [12,26]. This could be due to ignorance, availability of patent medicine dealers and the observed lack of free SP at the health facilities. About 10% of the respondents used chloroquine for their malaria prophylaxis. This is in keeping with finding by WHO that nearly a third of pregnant women continued to use chloroquine for IPT despite its well documented resistance and the recommendation of SP [8]. This proportion still using chloroquine for IPT could be explained by the fact that a lot of pregnant mothers still patronize patent medicine dealers for their health needs. There is need to intensify awareness on the dangers of buying drugs from less than ideal sources especially during pregnancy.
The stated reasons for non usage of IPT like feeling healthy, no knowledge of it and don't know of its effectiveness are similar observations from elsewhere [26,[28][29]. This calls for intensified public health education to raise awareness on the importance of IPT compliance even when the pregnant woman perceives no health problem.
Primigravidas used prophylaxis more significantly compared to multigravidas, this contrasts with a study in Abuja, Nigeria where parity had no significant association on IPT use [29]. However, an insignificantly higher proportion of the multigravida completed at least two doses of IPT as stipulated when compared with the primigravida, this concurs with the finding by Olorunda et al. [30] Though the reason for this was not sought in this study, it is possible that these women learnt of the benefits of adequate malaria prophylaxis in their previous pregnancies. Also the trimester of IPT initiation did not differ with gravid status.
IPT protected parturient from malaria attack, evidenced by the fact that the proportion of parturient who took IPT and still had malaria attack was about 23% compared to 78% of those who did not take IPT, a significant observation in keeping with other studies in Nigeria [9] and elsewhere [8,31]. Indeed, IPT has been shown to reduce maternal peripheral parasitaemia [32] and placental parasitaemia [33,34].
Among the IPT compliant parturient, a higher incidence of malaria attack was observed in the multigravida (28%) compared to the primigravida (18%) in this study, though not statistically significant. There is increasing evidence however, that prevalence of malaria infection is parity -related and primigravida was the most at risk, [35,36] while other workers have found no association between parity and malaria infection [37].
Mothers who did not take IPT were more likely to have low birth weight babies when compared with mothers who did, a significant observation in keeping with other findings [8][9][10]. On the same vein, a comparison of the birth weight of the babies from mothers who took between one to three doses of IPT revealed that those who had three doses had the highest mean birth weight. This corroborates the finding of a study by Keyautao et al. [38] whose data provided support for the new WHO recommendation that pregnant mothers should be given at least 3 doses of IPT with a dose given at each scheduled antenatal care visits in the 2 nd and 3 rd trimester. Other researchers have also found that giving a third dose of IPT using SP further reduces the risk of low birth weight compared with the standard 2 dose regimen [39]. Upon multiple comparisons to know how the mean birth weights differed from each other using the least significant difference, the asterisked mean differences with accompanying confidence intervals were significant.

CONCLUSION
IPT use was relatively commendable, but a sizeable proportion of the pregnant women took their IPT in the first trimester, used unrecommended drugs or doses for malaria prophylaxis and obtained their drugs from patent medicine stores. The major barriers to IPT use were the erroneous belief of filling healthy and lack of awareness of its effectiveness. The study also revealed beneficial outcome for IPT use in terms of reduced episodes of malaria and reduced risk of low birth weight babies.
Special information and education packages to create awareness in the general public on the use, safety and benefits of IPT in pregnancy with efforts to target women of child bearing age should be provided. In addition, health workers should be provided continuing education and training to improve their knowledge about malaria during pregnancy and in particular IPT strategy and DOT scheme, so they can help fill the knowledge gap among the pregnant women.