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EVALUATION OF INTERMITTENT PREVENTIVE TREATMENT OF MALARIA IN PREGNANCY
(IPT) IMPLEMENTATION IN THE KUMASI
ASHANTI REGION, GHANA.
DEPARTMENT OF COMMUNITY HEALTH
SCHOOL OF MEDICAL SCIENCES
Priscilla Anima Siaw
MPH. Health Services Planning & Management
Malaria is a public health problem
Approximately 40% of the world population is at risk of malaria
whilst about 500 million people become severely ill with malaria
(Korenromp et al., 2005).
Globally, a child dies of malaria every 30 seconds and more than
one million people die of malaria annually and these are mostly
infants, young children and pregnant women in Africa
(Korenromp et al., 2005, Rugemalila et al, 2006).
Globally, approximately 50 million women living in malaria-
endemic countries become pregnant in each year.
Malaria worsens during pregnancy and together with anaemia is
responsible for 10, 000 maternal deaths and 200, 000 infant deaths
per year (Steketee RW et al., 2001: Murphy SC and Breman JG, 2001).
About 90% of these deaths occur in sub Saharan Africa and nearly 25%
of all childhood mortality in Africa (WHO, 2000; Byrne N, 2007).
In Ghana about 44% of out-patient cases is due to malaria and is the
leading cause of cases admitted to hospital.
Malaria among pregnant women in Ghana accounts for 13.8 percent of
outpatient attendance, 10.6 percent of admission and 9.4 percent of
maternal deaths (GHS, 2005).
In Kumasi Metro, malaria is still the number one cause of OPD
The basic elements of malaria control are prevention and prompt treatment.
Prevention- Indoor Residual Spraying of long acting Insecticides (IRS), use of
insecticide treated nets (ITNs), Intermittent Preventive Treatment (IPT) used
in pregnant women and case management of malaria. (WHO media centre,
Chloroquine (CHQ), was the first line drug for the treatment and prophylaxis
of uncomplicated malaria in pregnancy.
Due to the resistance to (CHQ), its bitter taste, its abortive nature and low
compliance, there was the need for a new anti-malaria drug policy (AMDP).
Sulphadoxine-Pyrimethamine (SP) is currently used for prophylaxis in
pregnancy because it is safe in women of reproductive age and pregnancy, no
bitter taste and delivered as a single dose under observation by a health worker.
Without any intervention, malaria would cause 10, 000 of these
women and 200, 000 of their infants death as a result of malaria
infection and severe malarial anaemia.
In 2005, Ghana implemented IPTp malaria control programme .
Though some successes have been chalked in the IPTp
implementation, there is still a lot to be achieved by way of
reduction in the incidence of malaria.
Uptake of IPT by the pregnant women and default in the doses of
those who take the SP drug are the main problem.
PROBLEM STATEMENT contd
In the Kumasi metropolis, malaria accounted for 1.2% - 2005, 1.4% -
2006 and 1.7% - 2007 accounted for malaria in pregnancies out of all
the malaria cases recorded (KMHD Annual Report, 2005, 2006 and
Since IPTp programme was implemented in the Kumasi metro of the
Ashanti Region, no evaluation has been conducted to assess the
processes, outcomes and impacts of the programme.
Although, reports say there has remarkable improvement in the
utilization of IPTI, IPT2 and IPT3 doses from 2005 to 2007, it is still
necessary to evaluate the programme as this is believed to provide a
good insight on current performance so as to guide managers in their
However, if the study yields desirable result, then, this would be
replicated elsewhere to strengthen the health care system in the
The objective of the study is to evaluate the
processes, outcomes and impacts of the IPTp
programme using SP for malaria control in
To assess the implementation of IPTp programme in:
(i) The proportion of health staff that have been trained for the
IPTp programme in the Metro.
(ii) awareness and knowledge level of healthcare providers and
pregnant women towards malaria in pregnancy and the IPTp
(iii) the supply management of SP in the district.
(iv) the proportion of pregnant women and nursing mothers who
received IPT1, IPT2 and IPT3.
(v) ascertain the incidence of adverse drug reactions to SP in
Specific objectives contd;
• To assess whether the pregnant women attend ANC
To assess malaria in pregnancy before and after the
implementation of IPTp programme.
To assess the birth weights of newly born babies of the
nursing mothers and to determine the haemoglobin (Hb)
levels of pregnant women before and after the
implementation of IPT programme.
Study design is cross sectional study
Data collection tools used were key informant interview, questionnaires and
Purposive sampling technique was employed to select the key informants and other
health care providers in the three (3) sub metro to assess the progerss of IPTp
280 pregnant women and 120 nursing mothers were selected and interviewed from
their household by going through EPI cluster survey method (Hoshaw-Woodard, 2001).
At the health facility level, 70 midwives, 22 key informants and 47 checklists were
used to assess the level of training, IPT utilization and supply chain of SP.
The data was entered using Microsoft Access 2007 and EPI- INFO Version 3.2.2.
The data was analyzed using the statistical software, STATA Version 9.0
78.51% of the nursing mothers and pregnant mother were aware and had
knowledge of IPTp programme. An average of (82.36%, N= 262) respondents
said they heard it after attending ANC services.
About (31.66%, N=38) of the nursing mother and (30.35%, N=85) of pregnant
women respondents knew that the SP drug can reduce malaria episodes,
prematurely, maternal anaemia and maternal death caused by malaria
(83.16 %, N=79) of the nursing mothers and (69.26%, N=151) of the pregnant
women said they did not experience any side effects after taking the SP drug.
The level of knowledge of midwives in the IPT programme was high. About
91.42 have been trained in the IPT programme and out of the 91.42 trained 52
(78.78%) of them were trained over a year ago
About 91.42 have been trained in the IPT programme and out of the 91.42
trained 52 (78.78%) of them were trained over a year ago.
Again, (91.42%, N=256) of the pregnant women and (87.37%, N=100) of the
nursing mothers attended ANC and only 16.66% of the nursing mothers do not
utilizes ANC services whilst (8.57%, N=24) did not attend ANC.
The data gathered (49.60%, N=127) of pregnant women and (44.00%, N=40)
of nursing mothers interviewed mentioned that they prefer to seek ANC
services from the fourth month.
Source: Author’s Field Work, 2008.
Although a high proportion of nursing mothers and the pregnant women took the SP
during ANC under DOT, generally, there was a decline of IPT1 uptake to IPT3. as shown
in the table below.
Variable Pregnant women
Freq % Freq %
Yes 218 77.86% 95 75% 76.43%
No 62 22.14% 25 20.8% 21.47%
Dosage regimen of SP
IPT1 156 71.55% 64 67.36% 69.46%
IPT2 102 47.78% 43 45.26% 46.52%
IPT3 81 37.15% 31 32.63% 34.38%
An average of 47.8% and 53.45% of the respondents had their Hb levels equal or
greater than 11g/dl at registration and 36 weeks respectively.
65% of the babies’ weights were equal or greater than 2.5kg at birth whereas only
26.66% weighed less than 2.5kg.
All the 22 key informants recommended for the IPTp programme sustainability.
(72.27%, N=17) and (4.54%, N=1) indicated that the IPTp programme was good and
Again, (68.18%, N=18) mentioned that they provide in-service training for staff on
IPTp progamme once whilst (31%, N=7) said they did it twice in a year.
Of the 47 health facilities surveyed, 87.23% had a copy of the IPTp manual available,
95.74% kept patients records at the facility whilst 68.08% showed that patients’ data
are analyzed for self evaluation and health services improvement.
All the midwives interviewed had been trained for the IPTp programme
but (74.29%, N=52) were trained over a year ago.
Knowledge and awareness of IPT programme in the metropolis by the
nursing mothers and the pregnant women was found to be relatively
Thus, a total of 313 respondents indicated that they were aware of the
IPTp programme and thus out of 313 respondent (79.16%, N=95) and
(77.86, N=218) received the message upon attending ANC. A (78.94%,
N=75) and (85.77%, N=185) nursing mothers and pregnant women
respectively confirmed that they became first made aware at the health
All the 47 facilities visited collected data for monitoring and self
evaluation . Storage conditions of the SP were good.
Generally, Sulphadoxine-Pyrimethamine has a good safety profile in
pregnancy. The active components of SP (Sulfonamides and
pyrimethamine) are generally considered to be safe in the second and
third trimesters of pregnancy.
It was found that IPT coverage in the study area was high. This is due to
the fact that study revealed that 76.43% of the respondents have taken
the SP drug either once, twice thrice.
The introduction of IPT has resulted in the reduction in the prevalence
rate in malaria in pregnancy since in 2004 the prevalence rate was
14.4% but it significantly reduced to 8.35% in 2005.
The study revealed that 26.66% of nursing mothers’ babies was less
than 2.5 kg. However 65% of the babies were greater or equal to 2.5kg.
The 26.66% LBW rate obtained after the survey is not quite different
from LBW rate of Kumasi Metro since 2004 (31%), 2005 (21%), 2006
(23%) and 2007 (25%).
According to the survey conducted (36.67%, N=44) of the nursing
mothers had haemoglobin levels greater 11 g/dl whilst more than half of
the pregnant women had haemoglobin levels of greater that 11g/dl, thus
58.93%, N=165 at registration.
It was also recorded that 32.50% and 28.21% of the nursing mothers
and pregnant women had Hb levels less than 11 g/dl. This is an
indication that those respondents were anaemic at registration.
From that same study, there was significant increase in the HB levels at
36 weeks for both nursing mothers and the pregnant women.
Records on the IPT programme should be accurately kept, SP should be given to
clients under DOT and three doses of SP should be given to clients as recommended
The management of SP must be improved and monitoring of the incidence of
adverse effects of SP in pregnant women on IPT should be intensified.
The Metro Health Directorate should strongly sensitize the communities on
importance of seeking ANC services at the early stages of pregnancy, regularly
attending ANC and also been encouraged to deliver at the health facilities.
The Ministry of Health in conjunction with Ghana Health Services and the
Autonomous Hospitals) should intensify educational campaigns in English language
and selected local dialects on malaria in pregnancy on all the television and the FM
More satellite ANC and health centres with well equipped laboratories should be
established to increase accessibility and bring out of correct HB levels at 36 weeks of
Academic Supervisor - Dr Ellis Owusu-Dabo
(Department of Community Health, KNUST)).
Field supervisor - Dr. Oduro (DDHS, Kumasi
Head of Department and the Staff of Community
Health Department , KNUST