title: Effectiveness of antenatal clinics to deliver intermittent preventive treatment and insecticide treated nets for the control of malaria in pregnancy in Mali: a household survey.
abstract: BACKGROUND
  WHO recommends intermittent-preventive-treatment (IPTp) with sulphadoxine-pyrimethamine (SP) and insecticide-treated-nets (ITNs) to prevent malaria in pregnancy in sub-Saharan Africa, however uptake remains unacceptably low. We evaluated the effectiveness of antenatal clinics (ANC) to deliver two doses of IPTp and ITNs to pregnant women in Segou district, Mali.
  
  
  METHODS
  We used household data to assess the systems effectiveness of ANC to deliver IPTp and ITNs to pregnant women and used logistic regression to identify predictors of ANC attendance, receipt of IPTp and ITN use during pregnancy, and the impact on community effectiveness.
  
  
  RESULTS
  Of 81% of recently pregnant women who made at least one ANC visit, 59% of these attended during the eligible gestational age for IPTp. Of these, 82% reported receiving one dose of SP and 91% attended ANC again, of whom 66% received a second dose, resulting in a cumulative effectiveness for 2-dose IPTp of 29%, most of whom used an ITN (90%). Cumulative effectiveness of 2-dose SP by directly observed therapy (DOT) was very low (6%). ITN use was 92%, and ANC was the main source (81%). Reported and ANC-card data showed some doses of SP are given to women in their first trimester. Women were less likely to receive two doses by DOT if they were married (OR 0.10; CI 0.03, 0.40), or lived <5 km from the health facility (OR 0.34; CI 0.14, 0.83). A high household person-LLIN ratio predicted low ITN use in pregnant women (OR 0.16; CI 0.04, 0.55).
  
  
  CONCLUSIONS
  Our findings suggest poor adherence by health workers to provision of IPTp by eligible gestational age and DOT, contributing to low effectiveness of this strategy in this setting. ITN delivery and use among women was substantially higher. Efforts to improve health worker adherence to IPTp guidelines are needed to improve service delivery of IPTp.
authors.affiliation: Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Jenny
authors.initials: J
authors.lastname: Hill
authors.affiliation: Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom; Malaria Research and Training Centre, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali.
authors.forename: Kassoum
authors.initials: K
authors.lastname: Kayentao
authors.affiliation: Malaria Research and Training Centre, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali.
authors.forename: Mahamoudou
authors.initials: M
authors.lastname: Touré
authors.affiliation: Malaria Research and Training Centre, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali.
authors.forename: Sory
authors.initials: S
authors.lastname: Diarwara
authors.affiliation: Disease Control Department, London School of Tropical Medicine and Hygiene, London, United Kingdom.
authors.forename: Jane
authors.initials: J
authors.lastname: Bruce
authors.affiliation: Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: James
authors.initials: J
authors.lastname: Smedley
authors.affiliation: Malaria Research and Training Centre, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali.
authors.forename: Ogobara K
authors.initials: OK
authors.lastname: Doumbo
authors.affiliation: Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Feiko O
authors.initials: FO
authors.lastname: ter Kuile
authors.affiliation: Disease Control Department, London School of Tropical Medicine and Hygiene, London, United Kingdom.
authors.forename: Jayne
authors.initials: J
authors.lastname: Webster
mesh_terms: D000328:Adult; D003710:Demography; D004338:Drug Combinations; D005191:Family Characteristics; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007230:Infant, Low Birth Weight; D057148:Insecticide-Treated Bednets; D008288:Malaria / Q000188:drug therapy / Q000517:prevention & control* / Q000628:therapy*; D008302:Mali; D015999:Multivariate Analysis; D011247:Pregnancy; D015597:Pregnancy Complications, Parasitic / Q000517:prevention & control* / Q000628:therapy; D011261:Pregnancy Trimester, First / Q000187:drug effects; D011295:Prenatal Care; D011739:Pyrimethamine / Q000494:pharmacology / Q000627:therapeutic use; D013413:Sulfadoxine / Q000494:pharmacology / Q000627:therapeutic use; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D004338:Drug Combinations; C001205:fanasil, pyrimethamine drug combination; D013413:Sulfadoxine; D011739:Pyrimethamine