In this study, which was conducted in six antenatal care facilities in Côte d'Ivoire, the coverage of IPT-SP was evaluated among 2,044 women giving birth and their newborns. Overall, only half (49.8%) of the pregnant women received a complete dose of IPT-SP (≥2 doses). The prevalence of placental malaria in mothers was estimated at 4.8% and the prevalence of congenital parasitaemia was 4.7% among infants born to mothers with placental malaria parasitaemia. Factors that protected the mothers from placental malaria parasitaemia were the use of IPT-SP or ITNs during pregnancy and multigravidity. The proportion of babies with LBW was 10.6%, with a larger proportion among babies born to women with placental malaria parasitaemia (22.2%) than among those born to women without placental malaria parasitaemia (10.1%).
Five years after Côte d'Ivoire adopted and implemented the 2004 WHO recommendations for the control of malaria in pregnancies throughout sub-Saharan Africa, the prevalence of placental malaria parasitaemia was lower in this study (4.8%) than those reported in recent African studies in which this prevalence ranged from 10.6% to 20.5% [3, 6, 15]. Comparison between these studies was difficult. However, several explanations may explain this difference. First, the study site locations were different in the two studies. The previous studies were generally conducted in rural areas [3, 6, 15] while this study was conducted in six urban and semi-urban areas. Second, the characteristics of study population were different. For example, the proportion of primigravidae was higher in the African studies (ranging from 32.7% to 56.2%) [3, 6, 15] while it was 26.1% in this study. Third, the proportion of ITNs use was different; it ranged between 8% and 30% in the previous study, but it was 48% in this study.
This study clearly showed a dose-effect relation between IPT-SP use and placental malaria, although the possible influence of selection biases cannot be excluded because this study is an observational study. Indeed, a 82% reduction in placental malaria was found among women who took ≧2 doses of IPT-SP, and a 68% reduction were found among women who took one dose, compared to women who did not receive any IPT-SP. Only a few studies have also demonstrated this dose-effect relation [16–18]; most of them having focused on the effectiveness of IPT-SP in preventing placental malaria parasitaemia in comparison with placebo  or weekly chloroquine chemoprophylaxis [20, 21]. However, IPT-SP coverage in Africa is generally much lower than the 80% target coverage by 2010, as proposed in 2000 in Abuja [1, 22]. In 2007-2008, the percentage of women who received at least two doses of IPT-SP during pregnancy ranged from 3% to 66% . In this study, only 49.8% of pregnant women took complete dose (≥two doses). In recent African studies, the coverage of IPT-SP ranged from 12.5% to 58.8% [15, 17, 18]. The operational challenges to delivering ≥2 doses of IPT-SP during pregnancy include staff shortages, poor drug supplies, poor access to antenatal care, and improper health worker practices [23–25]. In this study, only half of the women (53.0%) attended antenatal care visits at least three times. A similar observation was found in other African studies in which this proportion ranged from 45.8% to 58.7% [3, 4, 15]. Therefore, strategies, such as free antenatal care, training health care workers, or providing IPT-SP free of charge and directly observed treatment (DOT), must be implemented or must be encouraged in most African countries to increase the access to antenatal care and IPT-SP use as well as other prophylactic methods such as ITNs. Additional qualitative studies consisting of in-depth interviews of women as well as health care workers should be conducted to determine the existing obstacles to complete IPT-SP coverage.
In this study, the prevalence of congenital malaria was 4.7% among children born to mothers with placental malaria parasitaemia, and all the cases of congenital malaria occurred among adolescent and primigravidae women. A possible explanation for these results is that the immunity women acquire from a first pregnancy affected with malaria helps control the subsequent parasitization of the placenta [26, 27]. Generally, the prevalence of congenital malaria in a holoendemic area is globally below 2% and is estimated among all children without regard to their mother's status [28–30]. In this study, infants with congenital malaria were not further followed to observe if they developed symptoms of malaria. In one study conducted in Nigeria, among the 95 neonates with congenital malaria, spontaneous clearance of parasitaemia occurred in 62.1% of neonates before the second day of life and 33.7% were symptomatic within three days of birth .
The overall prevalence of LBW was 10.6%, with almost twice as many low-weight babies born to women with placental malaria parasitaemia (22.2%) compared to malaria-uninfected women (10.1%). These findings are consistent with previous studies that report LBW prevalence rates range from 12.4% to 17.3% [6, 15, 20] and define placental malaria parasitaemia as a predictor of LBW [5, 7, 31]. In this study, IPT-SP was not associated with a reduction in LBW; however, some studies had highlighted an association [17, 18, 32]. A comparison between this study and others is difficult to make because the gestational age of women when first dosed of IPT-SP was given was not collected in this study as well as other factors that could explain the occurrence of LBW.
The main strengths of this study were the enrollment of women in six different districts of Côte d'Ivoire, the large sample size, and the assessment of malaria parasitaemia in both mothers and neonates. This study also had several limitations. First, the selected health facilities are only representative of all PMTCT facilities, but may not be representative of all delivery facilities across Côte d'Ivoire. The impact of this limitation was reduced by selecting centers in different regions in Côte d'Ivoire. In addition, the coverage estimates must be interpreted as the best-case scenario because only urban and semi-urban centers were included. Second, because malaria transmission is endemic throughout the entire region in Côte d'Ivoire and because the transmission season lasts 7 to 12 months in all of the regions, based on this study, there is no clear evidence that explains the high prevalence of placental malaria in the coastal sites in comparison to other sites (except for their geographical location). Finally, measurements of the CD4 counts were not performed for the HIV-infected women. The impact of the immune status on the LBW was, therefore, not evaluated.
Additional studies are needed to evaluate the impact of increasing resistance to SP  and should also focus on the pharmacokinetics of IPT-SP to determine the optimal dosing interval for pregnant women .
In conclusion, international and national advocacy and investments in malaria control have increased substantially in recent years, and there is convincing evidence that, with currently available methods, malaria could shift from a major public health priority to a fairly minor burden for already over-stretched health systems. National health programmes should continue to educate women on the benefits of receiving antenatal care early in their pregnancies and of taking a complete course of IPT-SP. Despite relatively successful IPT-SP coverage in Côte d'Ivoire, substantial commitments on the part of national authorities are urgently required for such public health campaigns. Strategies such as providing IPT-SP free of charge and DOT should be immediately established.