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Prevention of malaria in pregnancy in sub-Saharan
Africa: a synthesis and ecological analysis of
national survey data
Anna Maria van Eijk1, Jenny Hill1, Jayne Webster2, Rick Steketee3, Feiko O ter Kuile1
1 Liverpool School of Tropical Medicine, Liverpool, UK
2 London School of Tropical Medicine and Hygiene, London, UK
3 PATH, Seattle, USA
Malaria in pregnancy prevention coverage July 9, 2012 1
Background
• The use of insecticide treated nets (ITNs) and
intermittent treatment with at least two doses of
sulfadoxine-pyrimethamine (IPTp) have been shown to
reduce the burden of malaria in pregnancy and improve
maternal health and birth outcomes
Objective • To assess recent progress in coverage of these
interventions in sub-Saharan Africa
• To explore factors associated with observed coverage
• Evaluation of equity
Methods
• Evaluation of correlates associated with coverage • Time between policy and survey
• National malaria exposed births for 2010
• Population density
• Use of ANC (at least 1 or 2 visits, median month of start ANC,
start ANC before 6 months)
• Tetanus
• Country with assistance from the President’s Malaria Initiative for
>1 year before survey
• Disbursement from external funds
• Evaluation of distribution by:
– socio-economic status
– education status
– location of residence
Malaria in pregnancy prevention coverage July 9, 2012 2
Malaria in pregnancy prevention coverage July 9, 2012 3
National surveys sub-Saharan
Africa
United Nations Population
Division 2010 revised
database*
Gething 2010*: % of population
malaria exposed
Dellicour 2010*: Live and still
births
Information about ITN, IPTp
and ANC use at national level
Estimated number of
live births/country for
2010
Coverage (% and number)
for ITN and IPTp per country
and overall
Estimated number of
malaria exposed
births (live and
stillbirths) per country
*References: Gething et al 2010, PLoS Computational Biology
6(4): e1000724
Dellicour et al 2010, PLoS Medicine 7(1): e1000221.
UNDP: http://www.un.org/esa/population/
Malaria in pregnancy prevention coverage July 9, 2012 4
United Nations Population
Division 2010 revised
database*
Gething 2010*: % of population
malaria exposed
Population density
Population size
Disbursement per capita
malaria exposed persons per
year per country
Estimated number of
malaria exposed
population per country
Organisation for Economic Co-
operation and Development*
Disbursement of money for
malaria control by external
organizations per year
*References: Gething et al 2010, PLoS
Computational Biology 6(4): e1000724 UNDP: http://www.un.org/esa/population/
OECD: http://www.oecd.org
Information available in malaria in
pregnancy country profiles
Title of presentation July 9, 2012 5
By 2005:
60% of pregnant
women at risk of
malaria
-benefit from ITNs
-have access to
chemoprophylaxis
or IPTp
Source: Abuja
Declaration 2000
By 2010:
80% of people at
risk preventive
measures
Pregnant women:
-80% ITNs
-80% IPTp in areas
of stable malaria
Source: Roll Back
Malaria 2008
Global Malaria
Action Plan
By 2015:
100% of people at
risk preventive
measures
Pregnant women:
-100% ITNs
-100% IPTp
Source: Roll Back
Malaria 2011
Updated Global
Malaria Action
Plan
Targets for malaria control among pregnant women
over the last decennium in sub-Saharan Africa
Policies
• 45 countries
evaluated
– 45 ITN policy
– 38 IPT policy
Malaria in pregnancy prevention coverage July 9, 2012 7
Spread of IPTp policy across Africa
TANZANIA
BURUDI
EQUATORIAL GUINEA
ANGOLA
REP OF THE
CONGO
Zanzibar
MALAWI
ZAMBIA
MOZAMBIQUE MADAGASCAR
ZIMBABWE
BOTSWANA
SWAZILAND
LESOTHO
SOUTH
AFRICA
NAMIBIA
ANGOLA
NIGER
CHAD
SUDAN
ETHIOPIA
DJIBOUTI
ERITREA
UGANDA SOMALIA
KENYA DEMOCRATIC
REPUBLIC
OF THE CONGO
(ZAIRE)
CENTRAL AFRICAN REPUBLIC
RWANDA GABON
NIGERIA
CAMEROON
Berbera
Africa TUNISIA
WESTERN
SAHARA
ALGERIA
MALI
LIBYA EGYPT
BENIN
TOGO COTE DTVOIRE
BURKINA
GUINEA
SENEGAL
GHANA
LIBERIA
MAURITANIA
SIERRA LEONE
GAMBIA
GUINEA BISSAU
THE
MOROCCO
IPTp coverage
(%) in surveys
2009-11
0-9%
10-19%
20-29%
30-39%
40-49%
50-59%
60-69%
No data
No IPTp
No malaria
Countries with data
from surveys in 2005-
8 but not in 2009-11
Benin ’06 3%
Central African
Republic ‘06
9%
Cote d’Ivoire ‘06 12%
Gambia ‘08 49%
Ghana ‘08 44%
Guinea ’05 3%
Mali ‘06 4%
IPTp current situation 2009-2011, 23 countries
Median
coverage: 24.5%
(IQR 17.5-38.6)
Coverage of IPTp and tetanus by ANC
use (at least one visit)
Title of presentation July 9, 2012 9
0
20
40
60
80
100
0 20 40 60 80 100
Co
ve
rag
e (
%)
ANC coverage (at least one visit, %)
Coverage tetanus Use of IPTp
Spearman test ANC and IPTp: rho = 0.638, p=0.001;
Tetanus and IPTp: rho = 0.596, p=0.004
Tetanus
median coverage:
73.3%
(IQR 63.3-83.6%)
(21 countries)
Cameroon Chad
Equatorial Guinea
Liberia
Madagascar
Malawi
Sao Tome & P
Senegal Sierra Leona
Zambia
Zimbabwe
0
20
40
60
80
0 1 2 3 4 5 6 7
IPT
p
co
ve
rag
e (
%)
Average amount of disbursement for malaria control by external organizations per year per capita malaria exposed in the 2 years
before the survey in US$
Disbursements for malaria control by external
organizations vs. IPTp coverage in 21 sub-
Saharan countries, 2009-2011
Spearman test: rho = 0.412, p=0.062
Median
disbursement
US$ 1.44
Range 0.02-6.21
21 countries
Socio-economic status
Risk ratio 2 highest vs.
3 lowest wealth
quintiles, 95% CI
Education status
Risk ratio any education
vs. none, 95% CI
Place of residence
Risk ratio urban vs. rural
location, 95% CI
Zimbabwe '10 Madagascar '08-9 Malawi '10 DRC '10
Liberia '08-9
Sao Tome '08-9 Tanzania '10 Zambia '10 Sierra Leone '10 Uganda '09
Kenya '10
Senegal '10-11 South Sudan '09 Angola '11 Nigeria '10
0.3 3
Zimbabwe '10-11 Liberia '08-9 DRC '10 Uganda '09
Malawi '10
Sierra Leone '10 Zambia '10 Madagascar '08-9 Tanzania '10 Senegal '10-11
South Sudan '09
Sao Tome '08-9 Kenya '10 Angola '11 Nigeria '10
Zimbabwe '10-11 Malawi '10 DRC '10 Congo B '11-12
Liberia '08-9
Kenya '10 Zambia '10 Tanzania '09 Sierra Leone '10 Sao Tome '08-9
Senegal '10-11
Uganda '09 Cameroon '11 Madagascar '11 Mozambique '11 Nigeria '10
South Sudan '09
Burkina Faso '10 Angola '11
0.4 4
0.3 3
IPTp coverage by socio-economic status, educational status and
place of residence in sub-Saharan countries, 2009-2011
1 1
1
Socio-economic status
Risk ratio 2 highest vs. 3
lowest wealth quintiles,
95% CI
Education status
Risk ratio any education
vs. none, 95% CI
Place of residence
Risk ratio urban vs. rural
location, 95% CI
Uganda '09-10 Sao Tome '08-9 Rwanda '10-11
Sierra Leone '10
Malawi '10
Tanzania '09-10 Zimbabwe '10-11 Liberia '08-9 Kenya '10
Senegal '10-11
DRC '10
Madagascar '08-9 Namibia '09 Nigeria '10 South Sudan '09
Zimbabwe '10-11 Rwanda '10-11 Sierra Leone '10
Uganda '11
Tanzania '09-10
Malawi '10 Sao Tome '08-9 Liberia '08-9 Senegal '10-11
Mozambique '11
DRC '10
Madagascar '08-9 Kenya '10 South Sudan '09 Nigeria '10
Djibouti '08-9 Swaziland '10 Zimbabwe '10-11 Burundi '10-11 Rwanda '10-11 Sao Tome '08-9 Malawi '10 Sierra Leone Uganda '11 Kenya '10 Tanzania '09-10 Burkina Faso '10 Liberia '08-9 DRC '10 Zambia '07 Mozambique '11 Senegal '10-11 Congo B '11-12 Madagascar '08-9 Cameroon '11 Angola '06 Nigeria '10 South Sudan '09 Ethiopia '10-11
0.3 3 0.3 3.0
0.3 3
ANC coverage (at least one visit) by socio-economic status, educational
status and place of residence in sub-Saharan countries, 2009-2011
1 1
1
0
20
40
60
80
100
1999 2001 2003 2005 2007 2009 2011
Zambia
Malawi
Zanzibar
Ghana
Senegal
Sierra Leone
Tanzania M
Kenya
Uganda
Mozambique
Angola
Nigeria
Zimbabwe
13 Countries with information on IPTp
coverage from three or more surveys
TANZANIA
BURUDI
EQUATORIAL GUINEA
ANGOLA
REP OF THE
CONGO
Zanzibar
MALAWI
ZAMBIA
MOZAMBIQUE MADAGASCAR
ZIMBABWE
BOTSWANA
SWAZILAND
LESOTHO
SOUTH
AFRICA
NAMIBIA
ANGOLA
NIGER
CHAD
SUDAN
ETHIOPIA
DJIBOUTI
ERITREA
UGANDA SOMALIA
KENYA DEMOCRATIC
REPUBLIC
OF THE CONGO
(ZAIRE)
CENTRAL AFRICAN REPUBLIC
RWANDA GABON
NIGERIA
CAMEROON
Berbera
Africa TUNISIA
WESTERN
SAHARA
ALGERIA
MALI
LIBYA EGYPT
BENIN
TOGO COTE DTVOIRE
BURKINA
GUINEA
SENEGAL
GHANA
LIBERIA
MAURITANIA
SIERRA LEONE
GAMBIA
GUINEA BISSAU
THE
MOROCCO
ITN coverage (%) in
pregnancy
surveys 2009-11
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70-79
No data
No risk
Countries with data
from surveys in 2005-
8 but not in 2009-11
Benin ’06 20%
Ethiopia ‘07 35%
Gabon ‘08 36%
Gambia ‘08 45%
Ghana ‘08 20%
Guinea ‘07 3%
ITN coverage in pregnancy 2009-11
Median
coverage:
35.2%
(range 5.2-72.3)
Burundi
Equatorial Guinea
Madagascar Mali
Niger Rwanda
Sao Tome & P
Swaziland
Tanzania
0
20
40
60
80
0 2 4 6 8 10
Us
e o
f IT
Ns
in
pre
gn
an
cy (%
)
Average amount of disbursement for malaria control by external organizations per year per capita malaria exposed in the 2 years
before the survey in US$
Disbursements for malaria control by external
organizations vs. ITN coverage in 31 sub-
Saharan countries, 2009-2011
Spearman test: rho = 0.345, p=0.062
Median
disbursement
US$ 1.52
Range 0.05-8.65
30 countries
Socio-economic status
Risk ratio 2 highest vs. 3
lowest wealth quintiles,
95% CI
Education status
Risk ratio any education
vs. none, 95% CI
Place of residence
Risk ratio urban vs. rural
location, 95% CI
Nigeria '10 Djibouti '08-9 Senegal '10-11
Liberia '08-9
Namibia '09 Zambia '10 Sierra Leone '10 Kenya '10 Zimbabwe '10-11
Madagascar '08-9
Tanzania '10 DRC '10 Rwanda '10-11 Uganda '09-10 Sao Tome '08-9
Malawi '10
Angola '11 South Sudan '09
Nigeria '10 Liberia '08-9 Madagascar '08-9
Senegal '10-11
Uganda '09-10 Tanzania '09-10 Kenya '10 Malawi '10 Sierra Leone '10
Angola '11
Rwanda '10-11 DRC '10
Nigeria '10 Congo B '11-12 Zambia '10 Djibouti '08-9 Tanzania '09-10 Namibia '09 Liberia '08-9 Burkina Faso '10 Madagascar '11 Zimbabwe '10-11 Kenya '10 Sierra Leone '10 Senegal '10-11 DRC '10 Rwanda '10-11 Cameroon '11 Angola '11 Uganda '11 Malawi '10 Burundi '10-11 Sao Tome '08-9 South Sudan '09 Mozambique '11
0.3 3
0.3 3
0.3 3
ITN use by socio-economic status, educational status and place of
residence in sub-Saharan countries, 2009-2011
1
1
1
12 Countries with three or more surveys with
information on ITN use in pregnancy
Title of presentation July 9, 2012 17
0
20
40
60
80
100
1999 2001 2003 2005 2007 2009 2011
Rwanda
Tanzania M
Zanzibar
Zambia
Uganda
Kenya
Senegal
Malawi
Nigeria
Angola
Zimbabwe
Swaziland
Correlates with coverage
IPTp rho*, p ITN rho*, p
Time between policy adoption and survey 0.257, p=0.2 0.024, p=0.9
National number of malaria exposed births -0.308, p=0.2 0.206, p=0.3
Population density 0.270, p=0.2 0.343, p=0.05
ANC coverage (at least 1 visit) 0.638, p<0.01† 0.364, p=0.04
Support Presidential Malaria Initiative† p=0.1‡ P=0.02‡
Disbursement for malaria control§ 0.412, p=0.06 0.345, p=0.06
Title of presentation July 9, 2012 18
*: Spearman’s rho for correlation (non-parametric test)
† Also significant for at least two ANC visits, and ANC started before 6 months of
gestation
‡ Mann-Whitney U test (non-parametric test)
§Average amount of disbursement for malaria control by external organizations per
year per capita malaria exposed in the 2 years before the survey in US$
Extrapolation of survey data to absolute
numbers of births
2007
Surveys 2004-2009
IPTp 2 doses
• Data from 19 countries
• 13.6% covered
– 2.7 million births
ITN
• Data from 32 countries
• 17% covered
– 4.7 million births
2010
Surveys 2009-2011
IPTp 2 doses
• Data from 23 countries
• 21.6% covered
– 4.4 million births
ITN
• Data from 33 countries
• 38.5% covered
– 9.3 million births
Malaria in pregnancy prevention coverage July 9, 2012 19
Some limitations
• Reliance on public availability of national reports
– MICS IV reports 2010-11 not available : West African countries
more affected
– All countries received Global Fund money, no guarantee for
public reports
• no (recent) public reports on coverage for ITNs: Eritrea, Cote
d’Ivoire, Central African Republic, Mauritania
• No reports on IPTp for Mauritania, Gabon
• Tetanus not ideal for comparison at ANC level
• Estimates risk ratios for equity not adjusted for survey
design
• Analysis not by first administrative units
– National coverage misleading in countries which are only
partly malaria endemic
Title of presentation July 9, 2012 20
For the meeting participants Take away headlines &
surprising findings
• Slow increase overall, but large
discrepancies between
countries
• External funding and assistance
important, but not the most
important factor
• Number of births or population
density not an important factor
• ANC correlated with ITN use
• Discrepancies in equity by
country for IPTp & ITN – E.g. Nigeria: ITNs among poor,
uneducated, rural women; IPTp
among richer, educated, urban
women
Of importance for malaria
programs
• Determination important
• For countries with inequity:
malaria mainly rural, so
rural women priority!
• An ITN against malaria for
everybody, but pregnant
women and children
FIRST!
Malaria in pregnancy prevention coverage July 9, 2012 21
Conclusion
Considerable
success in
some
countries
More work
needs to be
done in
others
IPTp may be
harder to
deliver than
ITN
Malaria in pregnancy prevention coverage July 9, 2012 22
Thank you
Margaret Nagasa, Family-tenderly together, 2003
July 9, 2012 Malaria in pregnancy library 23
0 20 40 60 80
Mauritania '03Chad '10Benin '06
Somalia '08Djibouti '08
Sierra Leone '08South Sudan '09
Guinea B '10Liberia '08Gabon '08
Burkina Faso '10Gambia '08
Togo '10Burundi '10
Sao Tome & P '08
Guinea '05, '07Sudan '05, '09
Mozambique '07, '11Cameroon '04, '11
Ghana '03, '08Congo B '05, '11Namibia '06, '09
Sierra Leone '08, '10Ethiopia '05, '07
Equatorial Guinea '08,…DRC '07, '10
Eritrea '02, '04Mali '06, '10
Madagascar '08, '11Niger '06, '10
ITN coverage pregnancy (%)
Second and last availablesurvey
First or only survey
30 countries with information on ITN use
limited to one or two surveys
0 20 40 60 80
Sudan '05Guinea '05
Benin '06Mali '06
Cote d'Ivoire '06CAR '06
Namibia '06South Sudan '09
Togo '06Chad '10
Congo B '11-12Liberia '08
Sao Tome & P '08
Burkina Faso '06, '10Guinea B '06, '10
DRC '07, '10Madagascar '08, '11
Cameroon '06, '11Equatorial Guinea '08, '09
Ghana '06, '08Gambia '05, '08
IPTp coverage (%)
Second and last availablesurvey
First or only survey
21 countries with information on IPTp coverage
limited to one or two surveys
0
20
40
60
80
100
0 20 40 60 80
Use
of
ITN
th
e p
revi
ou
s n
igh
t am
on
g p
regn
ant
wo
me
n in
ho
use
ho
lds
wit
h
ITN
(%
)
Use of ITN the previous night among pregnant women (%)
Scatter plot of the use of ITNs the previous night among
pregnant women vs. the use of ITNs the previous night
among pregnant women in a household with an ITN, 21
sub-Saharan countries, 2009-2011
Comparison use of SP and use of any antimalarial for
prevention of MiP in 17 countries with information
0 20 40 60 80 100
Angola MIS 2011
DRC MICS 2010
EG MIS 2009 combined
Kenya MIS 2010
Liberia MIS 2008-9
Madagascar MIS 2011
Malawi DHS 2010
Nigeria MIS 2010
Sao Tome & Principe DHS 2008-9
Senegal DHS 2010
Sierra Leone MICS 2010
South Sudan MIS 2009
Tanzania Mainl DHS 2009
Uganda MIS 2009-10
Zambia MIS 2010
Zanzibar DHS 2009
Zimbabwe DHS 2010
Use (%)
SP at least one dose, any source Any antimalarial for prevention of MiP
*Countries with a difference > 9% indicative of use of considerable use of
antimalarials other than SP for MiP prevention. These include: DRC, Equatorial
Guinea, Kenya, Nigeria, Senegal, Sierra Leone, South Sudan and Zimbabwe . Type of other antimarial used not reported in these national surveys.
*
* *
*
*
*
*
*
TANZANIA
BURUDI
EQUATORIAL GUINEA
ANGOLA
REP OF THE
CONGO
Zanzibar
SOUTH AFRICA
MALAWI
ZAMBIA
MOZAMBIQUE MADAGASCAR
ZIMBABWE
BOTSWANA
SWAZILAND
LESOTHO
SOUTH
AFRICA
NAMIBIA
ANGOLA
NIGER
CHAD
SUDAN
ETHIOPIA
DJIBOUTI
ERITREA
UGANDA SOMALIA
KENYA DEMOCRATIC
REPUBLIC
OF THE CONGO
(ZAIRE)
CENTRAL AFRICAN REPUBLIC
RWANDA GABON
NIGERIA
CAMEROON
Berbera
Africa TUNISIA
WESTERN
SAHARA
ALGERIA
MALI
LIBYA EGYPT
BENIN
TOGO COTE DTVOIRE
BURKINA
GUINEA
SENEGAL
GHANA
LIBERIA
MAURITANIA
SIERRA LEONE
GAMBIA
GUINEA BISSAU
THE
MOROCCO
2+ ANC visits (%) DHS
surveys 2000-11
20-29%
30-39%
40-49%
50-59%
60-69%
70-79%
80-89%
90-100%
No data
Not of interest
2+ ANC visits in
pregnancy DHS surveys 2000-11
TANZANIA
BURUDI
EQUATORIAL GUINEA
ANGOLA
REP OF THE
CONGO
Zanzibar
MALAWI
ZAMBIA
MOZAMBIQUE MADAGASCAR
ZIMBABWE
BOTSWANA
SWAZILAND
LESOTHO
SOUTH
AFRICA
NAMIBIA
ANGOLA
NIGER
CHAD
SUDAN
ETHIOPIA
DJIBOUTI
ERITREA
UGANDA SOMALIA
KENYA DEMOCRATIC
REPUBLIC
OF THE CONGO
(ZAIRE)
CENTRAL AFRICAN REPUBLIC
RWANDA GABON
NIGERIA
CAMEROON
Berbera
Africa TUNISIA
WESTERN
SAHARA
ALGERIA
MALI
LIBYA EGYPT
BENIN
TOGO COTE DTVOIRE
BURKINA
GUINEA
SENEGAL
GHANA
LIBERIA
MAURITANIA
SIERRA LEONE
GAMBIA
GUINEA BISSAU
THE
MOROCCO
Start ANC visits < 6 m (%) DHS
surveys 2000-11
20-29%
30-39%
40-49%
50-59%
60-69%
70-79%
80-89%
No data
Not of interest
Start of ANC visit
before 6 months of
gestational age DHS surveys 2000-11
Median month of gestational age at first ANC visit among ANC attendees in 25 countries with IPTp policy
and DHS between 2004-2011
0 1 2 3 4 5 6
Liberia DHS 2006-7Senegal DHS 2005
Ghana DHS 2008Congo DHS 2005
Sao Tome Principe DHS 2008Benin DHS 2006
Mali DHS 2006Cameroon DHS 2004
Chad DHS 2004Guinea ONS 2007-8
Sierra Leone DHS 2008Burkina Faso DHS 2003
Namibia DHS 2006-7Madagascar 2008-9
Niger DHS 2006Nigeria DHS 2008
Mozambique DHS 2003Zambia DHS 2007
DR Congo DHS 2007Zanzibar DHS 2009-10
Zimbabwe DHS 2010-11Tanzania M DHS 2009-10
Uganda DHS 2006Malawi DHS 2010
Kenya DHS 2008-9
Median month of gestational age at first ANC visit among ANC attendees
Gestational age at first ANC visit (%) among survey participants with last live birth in previous 5 years in 25 countries with IPTp
policy and DHS between 2004-2011
0 10 20 30 40 50 60 70 80 90 100
Sierra Leone DHS 2008Malawi DHS 2010
Niger DHS 2006Kenya DHS 2008-9
Tanzania M DHS 2009-10Uganda DHS 2006
Chad DHS 2004Zanzibar DHS 2009-10
Mozambique DHS 2003DR Congo DHS 2007
Zambia DHS 2007Zimbabwe DHS 2010-11Burkina Faso DHS 2003
Madagascar 2008-9Mali DHS 2006
Namibia DHS 2006-7Cameroon DHS 2004
Guinea ONS 2007-8Nigeria DHS 2008
Benin DHS 2006Congo DHS 2005
Sao Tome Principe DHS…Ghana DHS 2008
Senegal DHS 2005Liberia DHS 2006-7
Start ANC visits < 6months gestationalage
Start ANC visits < 4months gestationalage
Four or more ANC visits among survey participants with last live birth in previous 5 years in 26 countries with IPTp policy and
national survey between 2004-2011
0 20 40 60 80 100
Somalia MICS 2006Niger DHS 2006Chad DHS 2004Mali DHS 2006
Rwanda DHS 2010-11Senegal DHS 2005
Tanzania M DHS 2009-10DR Congo MICS 2010
Nigeria DHS 2008Malawi DHS 2010
Kenya DHS 2008-9Uganda DHS 2006
Zanzibar DHS 2009-10Madagascar 2008-9Guinea ONS 2007-8
Mozambique MIS 2007Sierra Leone DHS 2008
Zambia DHS 2007Cameroon DHS 2004
Benin DHS 2006Zimbabwe DHS 2010-11
Liberia DHS 2006-7Namibia DHS 2006-7
Sao Tome Principe DHS 2008Congo DHS 2005Ghana DHS 2008