Improving the utilization of insecticide-treated nets for malaria prevention among pregnant women, lactating mothers and children in Sierra Leone: a commentary

Carshon‑Marsh and Di Ruggiero Malaria Journal (2025) 24:185 https://doi.org/10.1186/s12936-025-05429-z Malaria Journal Open Access COMMENT Improving the utilization of insecticide‑treated nets for malaria prevention among pregnant women, lactating mothers and children in Sierra Leone: a commentary Ronald Carshon‑Marsh1* and Erica Di Ruggiero1 Abstract Malaria in pregnancy poses significant public health challenges with severe consequences for mothers, fetuses, and newborns. Despite the proven efficacy of insecticide-treated nets (ITNs), the coverage rate among pregnant women, lactating mothers and young children in sub-Saharan Africa remains suboptimal. For example, in Sierra Leone, only 52% of pregnant women and 50% of children under five years utilize ITNs. This coverage rate fell short of the national target, in which at least 80% of pregnant women are expected to report sleeping under an ITN. While considerable research has examined ITN access and usage in the general SSA population, focused implementa‑ tion research on these high-risk groups in Sierra Leone is notably lacking. Addressing this gap is vital for enhancing intervention effectiveness and achieving sustained malaria control. The authors of this commentary recommend that further implementation research is needed to investigate the barriers and enabling factors to ITN adoption and utilization in pregnant women, lactating mothers and children under five years of age. Implementation research is crucial for understanding the gap between ITN access and actual use, enabling the design of effective and equi‑ table interventions to boost utilization rates. Implementation research anchored in frameworks like Reach, Effective‑ ness, Adoption, Implementation, and Maintenance (RE-AIM) offers a pathway to decode these complexities, ensuring that global strategies resonate with local realities. By centering the voices of pregnant women, lactating mothers, and caregivers as well as addressing structural, cultural, and logistical barriers, Sierra Leone can transform ITN coverage into tangible reductions in malaria morbidity and mortality, advancing equity in its march toward elimination. Keywords Malaria in pregnancy, ITN utilization, Pregnant women, Sierra Leone Background Malaria remains a significant, preventable threat caused by Plasmodium parasites, primarily transmitted *Correspondence: Ronald Carshon‑Marsh 1 Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5 T 3M7, Canada by infected female Anopheles mosquitoes. According to the World Health Organization (WHO), there were an estimated 263 million cases of malaria worldwide in 2023, with approximately 597,000 malaria deaths [1]. The WHO African region is disproportionately affected, accounting for 94% of malaria cases and 95% of malaria deaths, with children accounting for the majority of these fatalities. [1]. It is a major public health problem with heightened risk to the pregnant © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Carshon‑Marsh and Di Ruggiero Malaria Journal (2025) 24:185 woman and her fetus. Each year, Malaria in Pregnancy (MIP) is responsible for 20% of stillbirths and 11% of all newborn deaths in sub-Saharan Africa (SSA) [2]. To mitigate these risks, the WHO recommends a threepronged approach for controlling malaria and its effects during pregnancy: (1) the administration of Intermittent Preventive Treatment during pregnancy using sulfadoxine–pyrimethamine (IPTp-SP) that is quality assured; (2) the widespread distribution and consistent use of Long-Lasting Insecticidal Nets (LLINs) or Insecticide-Treated Nets (ITNs); and (3) effective management of cases by providing prompt, quality diagnosis and effective treatment of malaria infections [3]. Pregnant women, lactating mothers and under-fiveyear-old children in SSA are particularly vulnerable due to immune system changes, developmental factors, and nutritional challenges that make them more susceptible to malaria. Also, socio-cultural factors (such as low levels of education, cultural beliefs and practices, poverty), poor environmental conditions, limited access to healthcare, and health system challenges further increase their vulnerability. There are many dire consequences of malaria in pregnancy on both the mother and fetus or newborn. Malaria in pregnancy can result in maternal anaemia, placental infection, spontaneous abortion, stillbirth, preterm births, severe malaria, and maternal deaths [4]. For the exposed fetus or newborn, consequences include Intra Uterine Growth Restriction (IUGR), low birth weight, fetal anaemia, prematurity, congenital malaria, and early mortality [4]. In a nationally representative mortality surveillance study conducted in Sierra Leone, stillbirths were high, accounting for 34% of the national mortality total, with a stillbirth rate of 15.6 per 1000 live births [5]. Malaria was the leading cause of death, representing 22% of all deaths in all age groups except neonates [5]. This commentary argues for the need to better understand the implementation barriers and enablers related to a complex public health intervention, which is the adoption and utilization of ITNs in the prevention of malaria in pregnancy, using Sierra Leone as an illustrative case example. ITNs are designed to physically block, repel, or kill vector mosquitoes. This targeted public health intervention aims at preventing and controlling the transmission of malaria. It has wide coverage and, beyond the personal protection it provides, ITNs have a communal effect where community members who do not sleep under ITNs may still be protected if a large proportion of the community uses ITNs [6]. They are cost-effective with a high return on investment in terms of health benefits. They are well integrated into the health system, they are a global Page 2 of 6 health priority and have been proven to reduce malaria morbidity and mortality [3, 4, 6]. While considerable research has examined ITN access and usage in the general SSA population, there is limited research on the factors that influence the adoption and practical implementation of ITNs in pregnant women (...truncated)