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O.O Olukoya1 and O.A. Adebiyi1,2

1. Department of Community Medicine, University College Hospital, Ibadan, Nigeria

2. Department of Community Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria


Background: Malaria is of global health concern particularly among pregnant women. Nigeria contributes largely to global burden but coverage of Intermittent Preventive Treatment of malaria in pregnancy using Sulphadoxine pyrimethamine remains low. This study was conducted to determine the national situation of missed opportunity for IPTp-SP and attempted to look at correlates and predictors.

Method: The study used secondary data analysis of the Nigeria Demographic Health Survey, 2013. Data on socio-demographics, ANC characteristics and IPTp-SP use during pregnancy among 6,910 women aged 15-49 years who delivered in the last two years with at least 4 ANC visits were analyzed. Missed opportunity for IPTp delivery was defined as an ANC visit where IPTp was not delivered as per the policy. Data was analyzed using SPSS version 21. Associations used Chi-square test and significant variables were fit into multivariate logistic regression model. All analyses were performed at 5% level of significance.

Results: National prevalence for missed opportunity for IPTp-SP was high (73.4%). Predictors of missed opportunity are being of poorer, middle and richer wealth index (OR=0.737, CI 0.566-0.960); (OR=0.659, CI 0.521-0.833); (OR=0.686, CI 0.550-0.857), residence in South East OR=0.549, CI (0.415-0.726) and in the North West (OR=0.176, CI 0.133-0.232). Other predictors are having a primary and secondary education and presenting for the first ANC visit in the second trimester OR=0.739, p=0.024, CI (0.569-0.961).

Conclusion: Missed opportunity for IPTp-SP was high. The need for stronger governmental commitment to upscale uptake of IPTp-SP by incorporating the knowledge of socio-economic, cultural and demographic barriers to accessing IPTp is paramount.

Keywords: Missed opportunity, Malaria in pregnancy, Nigeria.


Malaria is the second commonest infectious disease with a high mortality globally, with the greatest burden of morbidity and mortality in sub-Saharan Africa. This represents over 90% of global deaths.1 Although, there is a general risk for malaria within the population, there is an increased vulnerability of some population groups to this disease. In Sub-Saharan Africa, high risk population groups include pregnant women, infants, children less than five years of age, patients with HIV/AIDS, non-immune migrants, mobile populations as well as travelers.2 Malaria in pregnancy (MiP) has remained a major public health issue with documented adverse effects on both mother and child. Maternal consequences of MiP include high blood parasitaemia and maternal anemia while consequences to the child includes miscarriages and low birth weight (LBW) which is further compounded by attendant sequel of sickness and death in infancy through the mechanism of Intrauterine Growth Restriction (IUGR) and preterm delivery.3,4

Intermittent preventive treatment of malaria in pregnancy using Sulphadoxine- pyrimethamine (IPTpSP) was one of three interventions designed by World Health Organization (WHO) to control MiP especially in malaria endemic regions where pregnant women are required to receive at least two doses of IPTp after quickening till birth. This is based on the assumption that every pregnant woman living in malaria endemic area with or without symptoms of malaria has malaria parasites in her blood or placenta, with increased susceptibility in the second and third trimester of pregnancy.3 In 2012, the WHO updated recommendations for IPTp-SP now stipulated that commencing from the second trimester; all pregnant women take Sulphadoxine-pyrimethamine at each scheduled antenatal care visit (ANC), with doses given at least one month apart under the supervision of a trained health care practitioner. This recommendation was a sequelae to evidences showing low uptake of IPTp-SP, believing that the new recommendation will ensure that a greater proportion of women receive at least three doses of SP during each pregnancy.4 In spite of this modification, IPTp-SP uptake in sub-Saharan Africa still remains largely sub-optimal.5 This suboptimal IPTp-SP uptake within the context of high ANC attendance represents significant missed opportunities for IPTp-SP at ANC facilities.6

Consequently, an ANC visit with non-delivery of IPTpSP as per policy is termed a missed opportunity which is measured in this study as the number of pregnant women with less than two IPTp-SP uptake despite four ANC visits.7 Due to the integration of IPTp-SP to ANC, this programme’s uptake is also subject to overwhelming challenges which are influenced by supply and demand for ANC services, general health systems weakness as well as socio-economic, demographic and cultural barriers to accessing health.9,10,11 Hence, the progress recorded in the battle against the prevention of the occurrence of malaria in pregnancy has been much slower compared to that against malaria in the general population in the last 16 years.8

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Dr. O.O. Olukoya

Dept. of Community Medicine,

University College Hospital,

Ibadan, Nigeria