title: Missed opportunities to deliver intermittent preventive treatment for malaria to pregnant women 2003-2013: a systematic analysis of 58 household surveys in sub-Saharan Africa.
abstract: BACKGROUND
  Despite the availability of effective preventive measures, including intermittent preventive treatment for malaria during pregnancy (IPTp), malaria continues to cause substantial disease burden among pregnant women in malaria-endemic areas. IPTp coverage remains low, despite high antenatal care (ANC) attendance. To highlight areas of potential improvement, trends in IPTp coverage were assessed over time, missed opportunities to deliver IPTp at ANC were quantified, and delivery of IPTp was compared to that of tetanus toxoid (TT).
  
  
  METHODS
  Data from 58 Demographic and Health Surveys conducted between 2003 and 2013 in 31 sub-Saharan African countries, with relevant questions on IPTp, ANC and TT were used to assess ANC attendance, and IPTp and TT delivery. A missed opportunity for IPTp delivery is an ANC visit at which IPTp could have been delivered according to policy but was not.
  
  
  RESULTS
  The proportion of pregnant women who received ≥2 doses of IPTp increased in surveyed countries from nearly zero before to a median of 29.6% (IQR 20.1-42.5%) seven or more years after IPTp policy adoption. ANC attendance was high (median 76.6% reported ≥3 visits); however, even seven or more years post policy adoption, a median of 72.9% (IQR 58.4-79.5%) ANC visits were missed opportunities to deliver IPTp. Among primigravid women, a median of 61.5% (IQR 50.9-72.9%) received two doses of TT; delivery of recommended TT exceeded IPTp in all but one surveyed country.
  
  
  CONCLUSIONS
  IPTp coverage measured by household surveys is unsatisfactorily low, even many years after policy adoption. The many missed opportunities to deliver IPTp suggest that deficiencies in delivery at ANC are a significant contributing factor to the low coverage levels. High levels of TT delivery indicate capacity to deliver preventive measures at ANC. Further research is required to determine the factors driving the discrepancies between IPTp and TT coverage, and how these may be addressed to improve IPTp coverage.
authors.affiliation: Harvard T. H. Chan School of Public Health, Boston, MA, USA. kathryn.andrews@mail.harvard.edu.
authors.forename: Kathryn G
authors.initials: KG
authors.lastname: Andrews
authors.affiliation: Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA. mlynch@cdc.gov.|Global Malaria Programme, World Health Organization, Geneva, Switzerland. mlynch@cdc.gov.
authors.forename: Michael
authors.initials: M
authors.lastname: Lynch
authors.affiliation: President's Malaria Initiative, USAID, Washington, DC, USA. eeckert@usaid.gov.
authors.forename: Erin
authors.initials: E
authors.lastname: Eckert
authors.affiliation: Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA. fff2@cdc.gov.
authors.forename: Julie
authors.initials: J
authors.lastname: Gutman
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D000962:Antimalarials / Q000008:administration & dosage*; D004363:Drug Utilization; D005191:Family Characteristics; D005260:Female; D006801:Humans; D008288:Malaria / Q000453:epidemiology / Q000517:prevention & control*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000517:prevention & control*; D011795:Surveys and Questionnaires
chemical_list: D000962:Antimalarials