title: Prevention of malaria in pregnancy with intermittent preventive treatment and insecticide treated nets in Mali: a quantitative health systems effectiveness analysis.
abstract: BACKGROUND
  The objectives of the study were to evaluate the health system effectiveness of ANC for the delivery of a dose of IPTp and an ITN to women attending ANC during eligible gestation, and to identify the predictors of systems effectiveness.
  
  
  METHODS
  A cross sectional study was undertaken in 10 health facilities including structured non-participant observations of the ANC process for 780 pregnant women followed by exit interviews. The proportion of pregnant women receiving a dose of IPTp-SP and an ITN was assessed. Predictors of each ineffective intermediate process were identified using multivariable logistic regression.
  
  
  RESULTS
  Overall, 0% and 24.5% of pregnant women of eligible gestation on the first visit to ANC received a dose of IPTp-SP by DOT at the district and community levels respectively. Ineffective intermediate processes were 'given IPTp-SP at the ANC' 63.9% and 74.0% (95% CI 62.0, 83.3), and 'given IPTp-SP by DOT' 0% and 34.3% (95% CI 10.5, 69.8), at district and community levels, respectively. Delivery of ITNs was effective where they were in stock; however stock-outs were a problem. Predictors of receiving IPTp-SP at the district level were 4 to 6 months gestation, not reporting symptoms of malaria at ANC visit and the amount of money spent during the visit. At the community level, the predictors were 4 to 6 months gestation, maternal education below primary level, routine ANC visit (not for an illness), palpation of the abdomen, and expenditure of money in ANC.
  
  
  CONCLUSIONS
  In Segou District, the delivery of IPTp-SP was ineffective; whilst ITN delivery was effective if ITNs were in stock. Predictors of receiving IPTp-SP at the district and community levels included gestational age, the amount of expenditure during the ANC visit and no illness.
authors.affiliation: Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom. Jayne.webster@lshtm.ac.uk
authors.forename: Jayne
authors.initials: J
authors.lastname: Webster
authors.forename: Kassoum
authors.initials: K
authors.lastname: Kayentao
authors.forename: Jane
authors.initials: J
authors.lastname: Bruce
authors.forename: Sory I
authors.initials: SI
authors.lastname: Diawara
authors.forename: Amadou
authors.initials: A
authors.lastname: Abathina
authors.forename: Alhassane Ag
authors.initials: AA
authors.lastname: Haiballa
authors.forename: Ogobara K
authors.initials: OK
authors.lastname: Doumbo
authors.forename: Jenny
authors.initials: J
authors.lastname: Hill
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000379:methods; D005260:Female; D006801:Humans; D057148:Insecticide-Treated Bednets; D007306:Insecticides / Q000008:administration & dosage*; D008288:Malaria / Q000517:prevention & control*; D008297:Male; D008302:Mali; D008875:Middle Aged; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000517:prevention & control*; D015597:Pregnancy Complications, Parasitic / Q000517:prevention & control*; D011315:Preventive Medicine / Q000379:methods; D011739:Pyrimethamine / Q000008:administration & dosage; D013413:Sulfadoxine / Q000008:administration & dosage; D055815:Young Adult
chemical_list: D007306:Insecticides; D013413:Sulfadoxine; D011739:Pyrimethamine