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Perception and Practice of Malaria
Prophylaxis in Pregnancy among Health
care Providers in Ibadan
Onyeaso N.C, Fawole A.O
ABSTRACT
The study assessed knowledge and practice of health care providers on current concepts on malaria prophylaxis in
pregnancy. 497 randomly selected respondents at the three levels of care in two local governments in Ibadan, South
western Nigeria were interviewed using a self-administered questionnaire. Respondents were selected from 45 health
facilities: 48 (9.7%) community health extension workers (CHEWS), 139 (28.9%) auxiliary nurses, 220 (44.3%) formally
trained nurses and 90 (18.1%) medical doctors. Only 57 (11.5%) respondents were knowledgeable about current WHO
strategies for malaria prevention in pregnancy. Three hundred and eighty six respondents (77.7%) were aware of intermittent
preventive treatment (IPT). Awareness about IPT was highest among CHEWS (95.8%). Pyrimethamine was prescribed
mainly by healthcare providers in the secondary (60.6%) and primary (60.3%) levels of care (X2 = 11.54, p < 0.01).
Chloroquine was prescribed by 42.5% of respondents. Sulfadoxine-pyrimethamine was significantly more commonly prescribed
by primary health care providers than in other levels of care (X2 = 15.07, p < 0.01). Prescription for insecticide treated nets
was high. Respondents' practice of anti-malarial chemoprophylaxis was influenced by the cadre of the health care provider
and level of practice. There are several knowledge gaps on current malaria prevention strategies in pregnancy among
healthcare providers. Multiple strategies are required to improve health care workers' knowledge and practice of malaria
prevention during pregnancy. (Afr J Reprod Health 2007; 11[2]:60-69).
RÉSUMÉ
Perception et pratique de la prophylaxie du paludisme pendant la grossesse chez les dispensateurs des soins
de santé à Ibadan L'étude a évalué la connaissance et la pratique chez les dispensateurs de soins de santé à l'égard de
concepts courants à l'égard de la prophylaxie du paludisme pendant la grossesse. Nous avons selectionné au hasard 497
répondants à tous les trois niveaux de soin dans deux administrations locales à Ibadan au sud-ouest du Nigéria qui ont été
interviewés à l'aide d'un questionnaire auto-administré. Les répondants ont été selectionnés aupres des 45 établissements de
santé: 48(9,7%) parmi le personnel des services de santé extra-hospitalier (PSSEH) 139(28,9%) infirmières auxillaires,
220(44,3%) infirmières formellement formées et 90(18,1%) médecins. Seuls 57(11,5%) des répondants connaissaient les
stratégies courantes de l'OMS pour la prévention du paludisme pendant la grossesse. Trois cent quatre-vingt-six répondants
(77,7%) étaient au courant du traitement préventif intermittent (TPI). La conscience du TPI était la plus élevée parmi les
PSSEH (95,8%). Les dispensateurs de soins de santé ont surtout prescrit pyriméthamine au niveau secondaire (60, 6%) et au
niveau primaire (60,3%) de soin (X2 = 11, 54, p < 0, 01). Chloroquine a été prescrite par 42,5% des répondants. Sulfadoxine-
pyriméthamine a été, de manière signifactive, la plus communément prescrite par les dispensateurs des services de soins
primaries qu'à d'autres niveaux de soin (X2 = 15, 07, p < 0, 01). La prescription pour les moustiquaires traités à l'insectide
était considérable. La pratique de la chemoprophylaxie antipaludisme a été influencée par le cadre du dispensateur de soin de
la santé et le niveau de la pratique. Il y a beaucoup de vide quant aux stratégies actuelles de la prévention du paludisme pendant
la grossesse parmi les dispensateurs de soin de la santé. Il faut de multiples stratégies pour améliorer la connaissance et la
pratique de la prévention du paludisme pendant la grossesse chez les dispensateurs de soin de la santé. (Rev Afr Santé Reprod
2007; 11[2]:60-69).
KEY WORDS: malaria in pregnancy, intermittent preventive treatment, malaria control, health care providers Department of Obstetrics & Gynaecology, University College Hospital, Ibadan Corresponding Author: Dr. Fawole AO, Department of Obstetrics & Gynaecology, University College Hospital, Ibadan E-
Perception and Practice of Malaria Prophylaxis in Pregnancy among Health care Providers in Ibadan 61 One of the major challenges facing the Malaria is a major public health problem, with implementation of malaria prevention strategiesthe largest population at risk in sub-Saharan Africa. in pregnancy is creating awareness amongAt least 300 million people become acutely ill healthcare providers8. A recent evaluation of thewith malaria each year, and more than a million malaria prevention strategies using drugs amongdie from the infection1. Over 80% of malaria Nigerian obstetricians revealed that the majoritydeaths occur in Africa2. Malaria costs Africa an were deficient in current evidence-basedestimated 12 billion US dollars in lost production recommendations9. A policy document has beenyearly2.
produced by the Nigerian health authority to guide Pregnant women and their unborn babies health care workers on strategies for the prevention are especially vulnerable to malaria. Each year, and control of malaria during pregnancy10.
more than 25 million African women in malaria- Therapeutic regimes used by healthcare workersendemic areas become pregnant and are at risk are usually not in compliance with such guidelinesof infection with Plasmodium falciparum2,3. as shown in the Republic of Benin whereInfection with Plasmodium falciparum during physicians and health care workers were unawarepregnancy increases the risk of maternal anaemia, of their national policies for the control ofspontaneous abortion, stillbirth, low birth weight malaria11.
and neonatal death, and is thought to be Thus there appears to be a poor knowledge responsible for the death of approximately base regarding current evidence-based guidelines10,000 African women and 200,000 infants each on malaria control during pregnancy amongyear4.
health care workers. Yet healthcare workers are The World Health Organization (WHO) crucial to effective malaria control. Therefore it recommends a package of interventions for the is necessary to investigate their knowledge base
prevention and control of malaria during on this crucial issue. Thus this study was designed
pregnancy. This comprises of intermittent to assess the knowledge of health care providers
preventive treatment (IPT), use of insecticide in Ibadan, south-western Nigeria on current
treated nets (ITNs), and access to effective case concepts on malaria prophylaxis in pregnancy, to
management for malaria illness and anaemia3. ascertain their preferred drugs and to identify
Routine prophylaxis for malaria during pregnancy strategies that would enhance programmes for
is associated with reduced incidence of severe preventing malaria during pregnancy.
antenatal anaemia, higher birth-weight and fewer
perinatal deaths5. ITNs have been shown to have Methods
beneficial impact on pregnancy outcome in This cross sectional descriptive study was
malaria-endemic regions of Africa when used conducted in Ibadan, Oyo state of south-western
by communities or individual women6.
Nigeria between June and August 2006. Two of Presently, sulfadoxine-pyrimethamine (SP) is the five local government areas (LGAs) within the only antimalarial medicine for which data on Ibadan municipality were selected by randomefficacy and safety for IPT is available from sampling. The selected LGAs were Ibadan Northcontrolled clinical trials, and WHO recommends and Ibadan North East respectively. In each localthat at least 2 doses of SP are given after government area, two public primary healthquickening during the second and third trimesters, facilities and a secondary health facility and at leastat least one month apart. However even a single 25% of all registered private health facilities weredose has been shown to be beneficial7.
randomly selected from a list of all registered African Journal of Reproductive Health Vol. 11 No.2 August, 2007 62 African Journal of Reproductive Health health facilities obtained from the Oyo state their current practice regarding prophylaxis forministry of health.
malaria among pregnant women. It was pre- Within Ibadan North LG, there were 10 tested and the questions validated prior to public primary health facilities, one public commencement of the study.
secondary facility and a tertiary health facility. There Ethical approval was obtained from the Joint were 115 registered private hospitals, clinics and University of Ibadan/University College Hospitalmaternity centre within the local government. In institutional review board. Approval for the studyIbadan North East local government, there were was also sought from the authorities of all selected13 public primary health facilities, 2 public health facilities. A trained research assistantsecondary health facilities and 14 registered private distributed the questionnaires and recruitedhospitals, clinics and maternity centres. The only participants for the study. Each participant signedtertiary health care facility in Ibadan located within a written consent form after being given adequateIbadan North local government was selected.
explanation about the purpose of the study.
The main study population consisted of all Completed questionnaires were cleaned and health care personnel who provide antenatal edited prior to data entry.
services in the selected health facilities. These Data entry and analysis were performed using included community health extension workers the EPI-Info 6 statistical package from the US
(CHEWs), auxiliary nurses, formally trained nurses Centers of Disease Control and Prevention. The
and medical doctors. CHEWs are individuals with chi-square test was used to test for associations
minimal education who have received some basic and the level of statistical significance was set at
formal training; they are employed in primary p < 0.05.
health centres and provide maternity care.
Auxiliary nurses are individuals with minimal Results
education who are employed in private health A total of 551 questionnaires were administered; facilities. They are given on-the-job training by of these 501 were retrieved and 497 were individual Physicians; they also provide maternity sufficiently completed to permit detailed analysis.
care. Auxiliary nurses do not have formal training They were administered in 45 randomly selected prior to employment. At the primary level of health facilities in Ibadan North and Ibadan care in public health facilities, the health care North East local government areas of Ibadan.
personnel include CHEWs, trained nurses and The distribution of the un-completed midwives and a few Physicians. Auxiliary nurses, questionnaires cut across the different levels of CHEWs, trained nurses and midwives and care and private and public health facilities. No Physicians are the personnel in private health refusals were reported.
facilities. There are only trained nurses and Of these 45 health facilities, one was a tertiary midwives and Physicians in public secondary and healthcare facility and two were secondary tertiary health facilities.
healthcare facilities; one public and the other a A pre-designed semi-structured self- missionary hospital. Of the remaining forty-two administered questionnaire was given to randomly primary healthcare facilities, five were public selected healthcare workers representing all cadres health facilities and 37 were privately owned.
of healthcare workers who managed pregnant Two hundred and ninety six respondents women in the different levels of healthcare. The (59.6%) were in Ibadan North LGA while the questionnaire explored the respondents' remaining 201 respondents (40.4%) were in knowledge of the hazards posed by malaria to Ibadan North-East LGA. Overall, 287 (57.8%) pregnancy, current strategies for preventing it and respondents were in primary, 109 (21.9%) were African Journal of Reproductive Health Vol. 11 No.2 August 2007 Perception and Practice of Malaria Prophylaxis in Pregnancy among Health care Providers in Ibadan 63 based in secondary and the remaining 101 (20.3%) Knowledge among professional cadres and were found in the only tertiary healthcare facility. levels of healthcare practice of the correct drug, Forty-eight respondents (9.7%) were dose and timing of IPT is depicted in Table 2.
community health extension workers (CHEWS), CHEWs were more likely than other cadres of139 respondents (28.9%) were auxiliary nurses. healthcare workers to correctly indicate the correctFormally trained nurses comprised 220 dose and timing of IPT (X2 = 19.58, p < 0.01);respondents (44.3%) while the remaining 90 respondents at the primary level of care wererespondents (18.1%) were medical doctors.
also more likely to report the correct dose and The majority of respondents (94.6%) felt that timing of IPT (X2=25.40, p < 0.0001).
training on malaria control should be Sulfadoxine-pyrimethamine was the most institutionalized. Most respondents (90.3%) felt widely prescribed antimalarial for prophylaxisthe Federal government should subsidize with 335 respondents (67.4%) prescribing it. Itsantimalarial interventions.
use was highest among CHEWS (77.1%) Knowledge of WHO strategies on malaria followed by auxiliary nurses (73.4%) and medical prevention in pregnancy was poor with 57 doctors (64.4%). It was least prescribed by trainedrespondents (11.5%) having correct knowledge nurses/midwives (62.7%). These differencesof all WHO strategies. Table 1 depicts knowledge however did not reach statistical significanceof all WHO recommended strategies by (X2=6.86, p > 0.05).
professional cadre and levels of healthcare. A Healthcare providers at the primary level of total of 386 respondents (77.7%) were aware of care were significantly more likely to useintermittent preventive treatment. Awareness was sulfadoxine-pyrimethamine for IPT than other highest among CHEWS (95.8%). Though 349 levels of care, followed by tertiary healthcare respondents (70.2%) believed IPT to be effective, providers (65.4%). SP was least used by secondary 93 respondents (18.7%) felt a single dose could healthcare providers (53.2%). These differences be beneficial.
were statistically significant (X2 = 15.07, p < 0.01).
Table 1: Correct knowledge of WHO strategies for prevention of malaria in pregnancy by
professional cadre and level of practice
Trained Nurse/Midwife Levels of Healthcare Practice
Primary
X2=5.60, p=0.06 African Journal of Reproductive Health Vol. 11 No.2 August, 2007 64 African Journal of Reproductive Health Table 2: Knowledge of the Correct Dose and Timing of IPT
Trained Nurse/Midwife X2 = 19.58, p< 0.01
Levels of Healthcare Practice
Primary
X2=25.40, p< 0.0001
The prescription for use of insecticide treated followed by trained nurses/midwives (93 nets was generally high with 75.1% of respondents respondents, 42.3%) and auxiliary nurses (35 prescribing it. It was most prescribed by trained respondents, 25.2%). It was least prescribed by nurses/midwives (80.0%) followed by auxiliary CHEWS (8 respondents, 16.7%). The differences nurses (79.9%) and CHEWs' (72.9%). It was least in these prescription patterns attained statistical prescribed by doctors (56.67%); these differences significance (p < 0.0001). By level of healthcare, were statistically significant (X2=20.95, p < 0.001). tertiary healthcare providers prescribed it most Two hundred and eleven respondents (42.5%) (82 respondents, 81.2%) followed by secondary prescribed Chloroquine (CQ) as antimalarial health care providers (35 respondents, 32.1%) prophylaxis in pregnancy. CQ was most while 74 primary healthcare providers (25.8%) prescribed by CHEWs' (54.2%) followed by prescribed it (p < 0.0001).
auxiliary nurses (48.9%) and trained nurses/ Two hundred and eighty-one respondents midwives (44.6%). CQ was least prescribed by (56.5%) prescribed pyrimethamine for Medical Doctors (21.11%) and the differences antimalarial prophylaxis. It was mostly prescribed were statistically significant (X2 = 22.25, p < by auxiliary nurses (98 respondents, 70.5%), followed by trained nurses/midwives (123 Chloroquine for antimalarial prophylaxis was respondents, 55.9%) and CHEWs' (23 more frequently prescribed by primary healthcare respondents, 47.9%). It was least prescribed by providers (49.8%), followed by secondary medical doctors (37 respondents, 41.1%). The healthcare providers (36.7%); only 27.7% of differences reached statistical significance (X2 = tertiary healthcare providers prescribed it 21.24, p < 0.0001).
(X2=16.83, p < 0.001).
Pyrimethamine was mostly prescribed by Proguanil was prescribed by 191 respondents secondary healthcare providers (66 respondents, (38.43%). Its prescription was highest among 60.6%) and primary healthcare providers (173 medical doctors (55 respondents, 61.1%), respondents, 60.3%). It was least prescribed by African Journal of Reproductive Health Vol. 11 No.2 August 2007 Perception and Practice of Malaria Prophylaxis in Pregnancy among Health care Providers in Ibadan 65 tertiary healthcare providers (42 respondents, quality of care given to pregnant women. Such41.6%). These differences also reached statistical an endeavour is particularly relevant in the controlsignificance (X2 = 11.54, p < 0.01).
of malaria during pregnancy from the public CHEWs were least likely to correctly identify health perspective.
groups of pregnant women that required IPT as Current strategies for malaria control in shown in Table 3. The majority of respondents pregnancy are based on the tripod of IPT, vectorfrom primary and secondary levels of care could control and prompt treatment of acute illness.
not correctly indicate groups of pregnant women The performance of any health system withat higher risk of the effects of malaria (Table 4). regards to control of malaria and thereby reduction of malaria related morbidity and mortality can thus be evaluated by the extent to which it meets Provision of care conforming to standard these best practices.
guidelines is one of the major elements of quality This study revealed a poor knowledge of of care12. Consequently, periodic assessment of WHO strategies against malaria in pregnancypractice will yield valuable insights regarding the among healthcare providers; only one-tenth were Table 3: Knowledge of Antimalarial Prophylaxis under Special Circumstances in Pregnancy
by Professional Cadre
First & Second Pregnancies
CHEW
Trained Nurse/Midwife Trained Nurse/Midwife HIV Positive Patients
CHEW
Trained Nurse/Midwife African Journal of Reproductive Health Vol. 11 No.2 August, 2007 66 African Journal of Reproductive Health Table 4: Knowledge of Indications for Antimalarial Prophylaxis under special Circumstances
in Pregnancy by level of Practice
Level of Healthcare
First & Second Pregnancies
Primary
HIV Positive Patients
Primary
seco nd ary
African Journal of Reproductive Health Vol. 11 No.2 August 2007 Perception and Practice of Malaria Prophylaxis in Pregnancy among Health care Providers in Ibadan 67 aware of the correct WHO strategies. This poor possible reasons for this would include easyknowledge was evident among all cadres and availability, affordability. Another important butlevels of healthcare providers.
often overlooked reason could be the inefficient Approximately three-quarters of respondents dissemination of current information to were aware of intermittent preventive treatment. healthcare providers leading to ignorance andSulfadoxine-pyrimethamine (SP) was the most poor knowledge of drug resistance patterns andwidely prescribed antimalarial for prophylaxis efficacy.
with approximately two-thirds of respondents Assessment among respondents of knowledge prescribing it in pregnancy. This was not surprising of the groups of pregnant women that need as its low cost, wide availability, easy deliverability antimalarial prophylaxis again showed several and acceptability make it the clear choice in knowledge gaps. Only about two-fifths of all countries where efficacy of the drug remains respondents agreed to use of malaria prophylaxis for first and second pregnancies and HIV patients, However, further assessment of the awareness while only half felt use of prophylaxis for sickle revealed surprising knowledge gaps. Only half cell disease patients was appropriate. This is of respondents knew the correct dose and timing disappointing as it is known that the deleterious of IPT. This was dependent on both professional impact of malaria is particularly more in first and cadre and level of healthcare with the CHEWs' second pregnancies18. Additionally women with and primary healthcare providers being most HIV infection are more likely to have knowledgeable. This could be due to the fact symptomatic malaria infections and to have an that WHO efforts are focused on developing increased risk of an adverse birth outcome due primary healthcare practice in the developing to malaria3. Anti-malarial prophylaxis in this world, so these groups are better educated and group is justified given the association of placental informed about current WHO strategies.
parasitaemia with increased risk of vertical Three-quarters of respondents prescribed transmission of HIV 19, 20. The WHO therefore insecticide treated nets (ITNs) for use. As recommends three IPT doses for HIV positive heartwarming as this might be, it is important to women3. IPT is also recommended for patients
note that prescription for use does not necessarily with sickle cell disease as this reduces the
lead to similar coverage results. Attributable possibility of sickle cell crisis due to malaria
reasons for the difference include cost of ITNs' infections21.
which is a barrier to their widespread use and the
erroneous perception in some areas that chemicals Conclusion and Recommendations
for treatment of nets could be harmful14. The This study has highlighted several knowledge gaps
disheartening and alarming news is that on current malaria prevention strategies in approximately half of our doctors do not counsel pregnancy among healthcare providers. Lack of patients on the use of ITNs' which has been awareness is apparently the major obstacle to shown to be effective.
changing practice8; incorporating new strategies Approximately two-fifths and three-fifths of into routine antenatal care programmes will healthcare providers still prescribe chloroquine therefore require active dissemination of this and pyrimethamine respectively despite information among the various cadres of health overwhelming evidence against such practice due workers providing antenatal care.
to increasing resistance to these drugs, and Possible solutions include institutionalizing reducing efficacy of chloroquine (CQ) chemo- malaria prevention strategies in pregnancy22 and prophylaxis15 and weekly pyrimethamine16,17. The continuing professional development programmes African Journal of Reproductive Health Vol. 11 No.2 August, 2007 68 African Journal of Reproductive Health on current concepts by healthcare providers. 8. Fawole B. Drugs for preventing malaria relatedProfessional associations by their strategic illness in pregnant women and death in the positions should indeed take the lead in this area.
newborn: RHL commentary. The WHO Some researchers have advocated the creation Reproductive Health Library, No 7, Update software of an organization to promote consultation and Ltd, Oxford. 2004.
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Hospital, Oluyoro, Ibadan, and Adeoyo Maternity 11. Nahum A, Akogbeto M Malaria and pregnancy: Hospital, Ibadan. The contribution of the attitude of health care personnel during prenatal research assistants and all the participants in this care in Cotonou, Benin Med Trop (Mars). 2000; study is gratefully acknowledged.
12. O'Connor PJ. Adding value to evidence-based clinical guidelines. JAMA 2005; 294 (6): 741 – 743.
WHO. Roll Back Malaria (RBM) 2002; Info-sheet 13. Newman RD, Parise ME, Slutsker L, Nahlen B, Steketee W. Safety, efficacy and determinants ofeffectiveness of antimalarial drugs during WHO. Malaria and HIV interactions and their pregnancy: implications for prevention implications for public health policy. Report of a programmes in Plasmodium falciparum-endemic technical consultation, Geneva, 2004.
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African Journal of Reproductive Health Vol. 11 No.2 August, 2007

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