Assessment of coverage of preventive treatment and insecticide-treated mosquito nets in pregnant women attending antenatal care services in 11 districts in Mozambique in 2011: the critical role of supply chain

Malaria Journal Salomão et al. Malar J (2017) 16:223 DOI 10.1186/s12936-017-1872-2 Open Access RESEARCH Assessment of coverage of preventive treatment and insecticide‑treated mosquito nets in pregnant women attending antenatal care services in 11 districts in Mozambique in 2011: the critical role of supply chain Cristolde Salomão1*, Jahit Sacarlal2 and Eduardo Samo Gudo1 Abstract Background: Malaria during pregnancy is associated with poor maternal and pregnancy outcome and the World Health Organization recommends the administration of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) and distribution of insecticide-treated mosquito nets (ITNs) to all pregnant women attending antenatal care (ANC) services. This study was conducted with the aim to assess the uptake of IPTp and ITNs in pregnant women attending ANC services and correlate with ANC attendance and frequency of stock-outs in 22 health facilities Mozambique. Methods: A cross-sectional study was conducted between July and December 2011 in 22 health units in 11 districts situated in 11 provinces in Mozambique. Two health facilities were selected per district (one urban and one rural). Data were collected by reviewing logbooks of antenatal consultations as well as from monthly district reports. Results: During the period under investigation, a total of 23,524 pregnant women attended their 1st antenatal care visits, of which 12,775 (54.3%) and 7581 (32.2%) received one and two doses of IPTp, respectively. In regard to ITNs, a total of 16,436 (69.9%) pregnant women received ITNs. Uptake of IPTp and ITNs by pregnant women at ANC services was higher in southern Mozambique and lower in districts situated in the northern part of the country. Stock-outs of SP and ITNs were reported in 50.0% (11/22) and 54.5% (12/22) of the health facilities, respectively. Coverage of IPTp and ITN in health facilities with stock-outs of SP and ITNs was much lower as compared to health facilities with no stock-outs. Conclusions: Altogether, data from this study shows that coverage of the 2nd dose of IPTp, as well as ITNs, was low in pregnant women attending ANC services in Mozambique. In addition, this data also shows that stock-outs of SP and ITNs were frequent and led to lower coverage of IPTp and ITN, representing a serious barrier for the accomplishment of targets. In conclusion, this study recommends that efforts should be made to improve the supply chains of SP and ITNs. Keywords: Malaria, Pregnant woman, IPTp, Insecticide-treated mosquito nets, Mozambique *Correspondence: 1 National Institute of Health, Ministry of Health, Field Epidemiology and Laboratory Training Programme-Mozambique, PO Box 264, Av Eduardo Mondlane 1008, Ministry of Health Main Building, 2nd floor, Maputo, Mozambique Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Salomão et al. Malar J (2017) 16:223 Background Malaria in pregnancy remains a major public health problem in endemic countries, mostly in sub-Saharan Africa, the region that carries the heaviest burden. According to the 2015 Global Malaria Report, 87.9% of all malaria cases and 90.2% of all malaria deaths reported worldwide in 2015 occurred in sub-Saharan Africa [1]. Acquisition of malaria during pregnancy is associated with poor outcomes, which include maternal anemia, low birth weight, and higher risk maternal and child mortalities [2–4]. Worldwide it is estimated that 10,000 of all maternal deaths and 200,000 of all neonatal deaths are attributable to malaria [5]. In countries with moderate to high transmission, the World Health Organization (WHO) recommends intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), together with the distribution of insecticide treated nets (ITNs) for all pregnant women attending for antenatal care (ANC) services [2]. As per the WHO recommendation, pregnant women should receive SP at each ANC visit until delivery, starting in the second trimester of pregnancy, with subsequent doses provided at least 1 month apart [2, 6]. In Mozambique, SP is administered under directly observed therapy (DOT) as per WHO recommendation [2]. Although the majority of countries in sub-Saharan Africa have adopted WHO guidelines for malaria prevention in pregnancy [7], results of studies conducted in several countries in the region demonstrate that the coverage of IPTp and ITNs in pregnant women is still low [8, 9]. Stock-outs of SP and ITNs, a lack of awareness of health care workers at ANC services [10–12], inconsistencies of national policies [7], among other factors were identified as barriers for implementation of these intervention in several countries. In regards to Mozambique, available evidence demonstrates that malaria is a leading cause of maternal mortality, being responsible for up to 26.9% of deaths in southern Mozambique [13–15]. The National Malaria Programme adopted the WHO guideline for malaria prevention in pregnancy in 2006, which since then has been offered free of charge in the public sector in Mozambique [16]. Two studies conducted in the southern region provided convincing evidence of the program’s cost-effectiveness in reducing maternal and neonatal mortality in the country [17, 18]. However, data from repetitive nationwide household surveys demonstrate the coverage of both IPTp and ITNs is still low [19– 22], and a meta-analysis conducted by van Eijk et al. in 2013 showed that the coverage in Mozambique is lower when compared with several countries in the region [9]. Stock-out of SP and ITNs has consistently been considered a major cause for low coverage in pregnant women in other countries [11, 12]; however, no study has yet Page 2 of 8 been conducted to understand the possible role of stockouts on coverage of IPTp and ITNs in pregnant women in Mozambique. Indeed, data on the determinants of low coverage of these interventions are limited in Mozambique, and the few studies conducted in the country focused their research on knowledge and acceptability of this intervention among pregnant women [23]. Moreover, current estimates on coverage in Mozambique are based mostly on data from household surveys alone. In this regard, this is the first facility-level survey to determine the coverage of IPTp and ITNs and investigate the influence of stock-outs of SP and ITNs on the cov (...truncated)