Vodouhe MV1, Obossou AAA1*, Sidi IR1, Hounkponoun FM1, Salifou K1, Dah-Bolinon SY1, Tonato-bagnan JA2, Ouendo EM2 and Perrin RX3
1Department of Mother and Child, Faculty of Medicine, University of Parakou, Benin
2Regional Institute of Public Health, University of Abomey-Calavi, Benin
3Department of Mother and Child, Faculty of Health Sciences, University of Abomey-Calavi, Benin
Received date: August 24, 2016; Accepted date: October 05, 2016; Published date: October 10, 2016
Citation: Vodouhe MV, Obossou AAA, Sidi IR, Hounkponoun FM, Salifou K, et al. (2016) Determinants of Adherence to Intermittent Preventive Treatment for Malaria with Sulfadoxine Pyrimethamine (IPTp-SP) in Pregnant Women in Parakou (BENIN). J Preg Child Health 3:282. doi: 10.4172/2376-127X.1000282
Copyright: © 2016 Vodouhe MV, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
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Objective: This study aimed to identify the determinants of adherence to intermittent preventive treatment of malaria with sulfadoxine pyrimethamine (IPTp-SP) in pregnant in Parakou. Method: We conducted a descriptive analytic study in 2015 from July to September. We conducted an exhaustive recruitment of all women from giving birth in major health facilities in the city of Parakou in the period. Results: A total of 387 delivered women aged 14 to 51 years participated in this study. 78.04% of them had benefitted from chemoprophylaxis with SP during pregnancy. But 50% of those who received this chemoprophylaxis were unaware of its purpose. In addition, 63.93% of patients attending ANC had to buy SP outside their counselling centre because of stock-out. The compliance rate was 44.70%. Good adherence significantly increased with the number of CPN (20.83% for one CPN versus 58.44 for 4 CPN p<0.05). Increase in age and gender also positively influenced compliance respectively (8.11% for the U19 vs. 53.49% for more than 20 years, p<0.05) and (23.53% for primiparous vs. 63.47% for multiparous, p<0.05). Conclusion: This study points out a low rate of good adherence to Intermittent Preventive Treatment of malaria with Sulfadoxine Pyrimethamine in pregnant women from Parakou. This result is due to their low level of information and frequent shortages of SP in health facilities.
Observance; Sulfadoxine pyrimethamine; Intermittent preventive treatment of malaria
Malaria is a major public health issue. According to the last estimates from WHO published in December 2014, about 198 million of malaria cases were registered globally in 2013. Sub-Saharan Africa registered a total of more than 90% of global load of morbidity and mortality associated with malaria . Wherever there is malaria, pregnant women run a major risk; they pay a high cost for it . In fact, all the pregnant women living in an endemic area have an increased susceptibility to malarial evidenced by increased frequency and density of parasitemia because of declined immunity associated with their pregnancy-related condition. Every year, according to the World Health Organization, about 25 million pregnant women are exposed to malaria consequences in Sub-Saharan Africa  A high maternal mortality rate is noted, i.e., about 10,000 deaths/year and neonatal morbidity and mortality due to low birth weight, caused either by a intrauterine growth restriction (IUGR) or preterm birth . Malaria is responsible for 8 to 14% of low birth rates and 3 to 8% of deaths before one year of age, according to the World Health Organization .
Due to the significant number of malaria cases among pregnant women and its adverse effects on mother and child health, the WHO proposed a prevention plan involving use of Long-Lasting Insecticidal Nets (LLINs) and IPTp-SP . The use of SP chemoprophylaxis proved to be efficient, thus allowing decline in prevalence of parasitemia in mother, increase in mean birth weight and reduction of the number of children with low birth weight (<2500 g) .
Some recent studies demonstrated that two doses or more of IPTp- SP were more efficient than one dose . Good compliance with IPTp- SP is thus important to make this chemoprophylaxis more efficient.
In Benin, only 35% of the pregnant women comply with ANC schedule. As far as IPTp-SP is concerned, 46% of women receive the two doses of SP or more during their pregnancy. There are significant gaps between the different regions of Benin; for example in the North- Benin in 2013 a low compliance rate for IPTp-SP (27.04%) was noted .
The purpose of this research work was to study the determinants of adherence to IPTp-SP among pregnant women in the city of Parakou and identify IPTp-SP non-compliance effects observed on their health and on the one of the new-born.
It was a descriptive and analytical cross-sectional study carried out from July 1 to September 30, 2015 in the Borgou Regional University Teaching Hospital (CHUD/B), in the 5 peripheral public health centers and in the 2 main private health centers of the city of Parakou. As regional capital city of the North-Benin, Parakou is located in the center of the Republic of Benin.
Study target population
The study involved pregnant women who gave birth in the selected health facilities. The new mothers who did not give their consent to participate to the study were excluded.
We calculated the minimum size of our sample according to Schwartz formula
With n=Size of expected sample; p=Rate of good adherence to IPTp- SP in a previous study (54%) ; q=(1-p)=(46%); α=5 % of Margin of error, hence Zα=1.96; i=2% precision desired for results n=381 female patients. The minimum size of our sample was thus 381 patients. We conducted an exhaustive census of all the pregnant women who gave birth in the different health facilities concerned during the collection period.
The data were collected by means of a survey technique using questionnaire and documents: cards and/or records of the women who gave birth. The study variables were socio-demographic factors, obstetrical history, number of ANC attended, number of SP dose taken during pregnancy, side effects, monitoring entity (public or private), knowledge of reason for chemoprophylaxis, method of SP acquisition, reason related to non-performance of chemoprophylaxis, mother's haemoglobin level in the 3rd quarter and new-borns’ birth weight.
Criteria for assessing compliance
For the purpose of our survey, a compliant subject was considered to be any pregnant woman who received at least two SP doses during pregnancy, as from the 16th week of amenorrhea, with spaced intakes of at least one month.
Data processing and analysis
The input data were analyzed by means of Epi Info 184.108.40.206 software. Word processing, design of tables and graphics were done with application softwares such as Microsoft Word and Excel version 2007. Student's t test was used to compare averages. Chi-square statistical tests (Fischer's exact test, Pearson and Yates tests) served to identify the determinants of adherence to IPTp-SP at 5% significance level.
Ethical considerations and professional rules
The women's written and oral informed consent was obtained before administering the questionnaire and professional secrecy was respected. The anonymity of patients involved in the study as well as confidentiality of information collected was respected.
A total of 387 women aged 14 to 51 years participated to the study. The sociodemographic characteristics are indicated in (Table 1).
|Variables||Numbers||Percentages in %|
|Age groups (Years)|
|14 – 19||37||9.56|
|20 – 29||212||54.78|
|30 – 39||125||32.3|
|40 and more||13||3.36|
|Pupil / Univ. Student||41||10.59|
|Fon and related groups||95||24.55|
|Bariba and related groups||159||41.09|
|Secondary school / higher education||151||39.02|
Table 1: Socio-demographic characteristics of women investigated in Parakou in 2015.
More than three quarters of the participants 88.63% (n=343) had benefitted from at least one ANC (Antenatal Care). 42.38% of the participants had received at least 4 ANC. In general, those pregnancies were followed up in a public health facility (71.14%).
Characteristics of anti-malarial chemoprophylaxis
Anti-malarial chemoprophylaxis with SP was performed by 78.04% (302/387) of the participants. Among the 387 women involved in the study, 173 took at least two SP doses between which there was an interval of at least one month, i.e., a compliance rate of 44.70%; 20.41% (79) of the women investigated took at least three SP doses between which there was an interval of at least one month.
Side effects were reported in 11.26% (34/302) of respondents who used SP prophylaxis (nausea 66%, dizziness 21% and vomiting 13%).
Half of the women (50.00%) said that they took SP during ANC without knowing the reasons why, 31.67% said they took it for malaria prevention and 18.33% for treatment of malaria.
How did the subjects get medicines?
Women got medicines free of charge during ANC (36.07%) or bought them (63.93%) in pharmacies, in health Centers other than they used to attend or in markets or shops.
Reasons related to non-performance of SP chemoprophylaxis
Sixty women (17.33%) said they did not perform chemoprophylaxis during pregnancy. The reasons given by the women for not performing it may be divided into 3 groups: lack of information 82.28% (65), neglect 8.86% (7) or choice of African traditional medicine 8.86% (7).
Factors associated with non-adherence to IPTp-SP
The factors associated with non-adherence to SP were age (below 19 years), occupation (secondary school student) and religion (no belief or animism), with significant statistical differences. Table 2 shows the sociodemographic factors associated with poor adherence to IPTp-SP in the survey.
|Variables||Total(n=387)||Adherence to SP||p-value|
|Age groups (Years)||0|
|14 – 19||37||34||91.89||3
|20 and more||350||180||17048.57|
|Pupil / Univ. Student||41||28||68.29||1331.71|
|Fon and related groups||95||47||49.47||4850.53|
|Bariba and related groups||159||113||71.07||4628.93|
|Secondary/ Higher education||151||81||53.64||7046.36|
Table 2: Socio-demographic factors associated with non-adherence to iptp-sp in pregnant women, parakou 2015.
The obstetrical factors associated with SP non-compliance were parity (primiparous) and number of ANC (low frequency of ANC), with a statistically significant difference. Table 3 shows the obstetrical factors associated with non-compliance in respondents.
|Variables||Total (n=387)||Adhérence to SP||p-value|
|Number of ANC*||0.0007|
Table 3: Obstetrical factors associated with non-adherence to IPTp-SP in pregnant women, Parakou, 2015.
Relation between compliance and malaria complications
In our study non adherence to IPTp-SP had a significant impact on maternal anaemia (21.50% of non-compliant women developed anaemia versus 9.25% of compliant women p<0.05) (Table 4).
|Variables||Total||Adhérence to SP||p-value|
Table 4: Distribution of women according to compliance with IPTp-SP and anemia during pregnancy, Parakou, 2015.
We noted a significant relationship between low birth weight (LBW) and non-compliance with IPTp-SP; with respective rates of 21.77% and 7.51% in non-compliant women and compliant women (Table 5).
|Variables||Total(N=387)||Adherence to SP||p-value|
Table 5: Distribution of birth weights according to adherence to IPTp-SP, Parakou, 2015.
Characteristics of chemoprophylaxis
In our study, the rate of good adherence to SP was 44.70%. A rate similar to the our was observed in Côte d’Ivoire 43.28%  whereas higher rates were observed in Mali  and Burkina Faso , i.e. 71.2% and 55% respectively. As well, some efforts still have to be made to achieve WHO initial recommendations: at least 2 SP doses for at least 80% of the pregnant women .
During our study, 63.93% of the patients said they bought SP. In Burkina Faso  and Mali  where the rate of free-of-charge intake of at least one SP dose was significantly above the i.e. 78.33%; better compliance rates are noted i.e. 55% and 82%. The public authorities of Benin must make an effort to make SP available for free in their health facilities; as pointed out by some authors  SP stock-out may result in a low rate of adherence to IPTp-SP.
Patients' knowledge of the reasons for IPTp-SP use in pregnant woman
In this research work only 31.67% of the respondents took SP for preventive purposes whereas 18.33% took it for curative purposes. Sangaré et al.  made the same remark in Uganda but with much higher values (39.4% for curative treatment of malaria). This situation reflects a lack of explanation on the part of care providers about the reason for SP administration. 17.33% (60/387) of the respondents said they did not perform SP chemoprophylaxis during pregnancy; the reasons given were lack of information (82.28%) or neglect (8.86%). Women sensitization to the issue of malaria in pregnancy and its prevention through information, education and communication (IEC) campaigns, may certainly improve pregnant women’s support for IPTp- SP as it happened in Burkina Faso .
Three hundred two respondents (78.04%) had taken at least one prophylactic dose of SP during pregnancy. 50.00% of them took SP during ANC without knowing the reasons why. Eventually, we had only 44.70% of good adherence.
The determinants of adherence to IPTp-SP
According to our results, age was a major determinant of compliance. Other authors made the same conclusions [5,10]. As suggested by Arnold  , the improvement of adherence based on age of patients may be associated with development of a life experience.
Occupation was also identified as a determinant of compliance or adherence; non-compliance rate in civil servants was estimated at 28.85%; this is relatively low compared to the other professional sectors. This may be due to the fact that civil servants have more access to information with better common sense. Seck et al.  had come to the same conclusion in a research work conducted in Senegal as regards adherence to IPTp-SP.
In our research work, religion was also a determinant of compliance, with a very high non-adherence rate in women who practise a religion other than Islam or Christianity 72.97% unlike Christian and fellows 46.53% or Muslims 58.25%. This may be due to the attachment of some communities to tradition, with low attendance of health facilities. However, Sanata Bamba et al.  had not noted any relationship between adherence and religious belief.
Non-compliance declined significantly with increase of parity (76.47% of primiparous and 36.53% of multiparous). This may be associated with greater awareness of malaria complications during pregnancy.
In our study, non-adherence to IPTp-SP had a significant impact on maternal anaemia. This result agrees with literature data on IPTp-SP efficiency in preventing malaria and its complication of maternal anaemia in the endemic areas [12-14].
We noted a significant relationship between low birth weight (LBW) and non-adherence to IPTp-SP. Several authors reported the same conclusions [13,15].
IPTp-SP compliance rate was low during our study. Age and parity of pregnant women and their lack of information were major factors which influenced adherence to IPTp-SP. Our study also confirms the efficiency of the strategy which consists in preventing low birth weight in new-born and anaemia in mother.
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