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.


Dr. O.O. Olukoya
Dept. of Community Medicine,
University College Hospital,
E-mail: ebemio1@gmail.com


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 (IPTp- SP) 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 IPTp- SP 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

Evidences have shown that among pregnant women in Sub- Saharan African countries in 2010, the average coverage of at least two doses of IPTp was 14% with a marginal increase in uptake to 24% in 2013. This was found to be well below global and national target of 80% coverage for IPTp-SP. In Africa, only six countries reached the Roll Back Malaria (RBM) coverage target of 60% in 2006 while none has met the 2010 target of 80%.6 A 2014 WHO report revealed that in 2013, of the 35 million pregnant women at risk for MiP approximately half of them did not receive a single dose of IPTp-SP. In the same year, IPTp adoption was implemented in 35 countries in malaria endemic African countries, but only 57% of pregnant women in those countries received at least one dose of IPTp. Following the updated WHO recommendation on IPTp-SP use for the prevention of malaria in pregnancy, only nine of the 35 countries have reported to the WHO on the recommended number of three or more doses of IPTp, while 17% of pregnant women received three or more doses within those countries.9 This represents a huge gap for missed opportunities for the prophylaxis of malaria in pregnancy.

In Nigeria, studies have shown large disparities in prevalence rates for malaria in pregnancy across different parts of Nigeria, ranging from 19.7% to 72.0%.10 Documented evidences of uptake of IPTp- SP in Nigeria typify the African picture. Reports from the Nigeria Demographic Health Survey 2013 showed that of all pregnant women interviewed, only 15% received IPTp-SP during ANC and less than 10% received 3 or more doses of IPTp-SP.11 Findings also show that uptake of IPTp-SP in Nigeria is low, while its level of missed opportunity remains high.12,13 This observation in addition to evidence of Nigeria’s huge contribution to the global burden of malaria emphasizes the need to assess how well the nation has performed in terms uptake of IPTp among pregnant women nationally. The aim of this study was to determine the prevalence and predictors of missed opportunity for IPTp among a nationally representative sample of women who had at least one delivery within two years of the study. Findings from this study will provide information which could assist national working groups on malaria prevention in pregnancy to prioritize and implement appropriate strategies which address the challenges facing the uptake of IPTp- SP in Nigeria.