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Intermittent screening and treatment versus intermittent preventive treatment of malaria in pregnancy: user acceptability



Malaria in pregnancy is associated with increased risks of maternal and foetal complications. Currently, intermittent preventive treatment (IPT) of malaria during pregnancy with sulphadoxine-pyrimethamine (SP) is recommended by the WHO as part of a package of interventions also including insecticide-treated nets and effective case management. However, with increasing resistance to SP, the effectiveness of SP-IPT has been questioned. A randomized controlled trial (RCT) to investigate the relative efficacy of an alternative strategy of intermittent screening and treatment (IST), which involves a rapid diagnostic test for malaria at scheduled ANC visits and treatment of women only if positive, versus SP-IPT has been conducted in Ashanti region, Ghana. This paper reports on a complementary study investigating the acceptability of the different strategies to women enrolled in the trial.


Data were collected through twelve focus group discussions with women selected at random from the different arms of the RCT, exploring their experiences and perceptions about antenatal care and their involvement in the trial. Content analysis was used to identify relevant themes to structure the results.


Five main themes emerged from participants' experiences of ANC and the RCT that would influence their acceptability of malaria prevention strategies during pregnancy: health benefits; drugs received; tests received; other services received; and health worker attitude. Their own health and that of their baby were strong motivations for attending ANC, and reported favourably as an outcome of being in the RCT. Women were not always clear on the biomedical function of drugs or blood tests but generally accepted them due to strong trust in the health staff. Home visits by staff and free ITNs as part of the trial were appreciated. Politeness and patience of health staff was a very strong positive factor.


Overall, both intermittent screening and treatment and intermittent preventive treatment appeared equally acceptable to pregnant women as strategies for the control of malaria in pregnancy. The women were more concerned about quality of services received, in particular the polite and patient attitude of health staff, and positive health implications for themselves and their babies than about the nature of the intervention.


Plasmodium falciparum infection in pregnancy is associated with an increased risk of maternal and foetal complications including maternal anaemia and low birth weight [1, 2]. The WHO has recommended a package of interventions for preventing and controlling malaria infection in pregnancy (MiP) in endemic areas, which includes the early diagnosis and treatment of malaria, intermittent preventive treatment during pregnancy (IPT) using sulphadoxine-pyrimethamine (SP) and the use of insecticide-treated nets (ITNs) [3].

Currently, SP-IPT has been rated as having the most favourable cost-benefit profile because of its relatively low cost, high compliance and efficacy in reducing maternal anaemia and low birth weight [4, 5]. However, implementation of IPT in pregnancy in most settings is limited by social, cultural, economic and operational challenges despite good coverage of antenatal services [6, 7]. In addition, resistance to SP has been spreading across sub-Saharan Africa and thus the effectiveness of SP-IPT has been questioned [5]. There are few anti-malarial drugs with plasma half-life comparable to that of SP that could be used to replace SP for IPT in areas with high SP resistance. Furthermore, there is very limited data on the efficacy and safety during pregnancy of alternative drugs [8]. Studies have shown that rapid diagnostic tests (RDT) have a reasonable sensitivity to diagnose malaria in pregnancy [9