Antenatal care visit attendance, intermittent preventive treatment and bed net use during pregnancy in Gabon

In 2007, about 32 million women were pregnant in malaria endemic areas in Sub-Saharan Africa [1]. The World Health Organization (WHO) guidelines for malaria prevention during pregnancy include use of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP), sleeping under an insecticide treated bed net (ITN) and prompt management of malaria cases and anaemia [2]. These strategies have been adopted by 35 of the 45 African endemic countries including Gabon, and should be delivered through collaboration between reproductive health systems and malaria control programs, during the four target antenatal care (ANC) visits throughout the pregnancy as recommended by WHO [2‐5]. Although a high proportion of pregnant women had an ANC visit at least once during pregnancy, coverage level of IPTp-SP and ITNs remains low in Sub-Saharan Africa [6‐8]. In 2010, it was estimated that 55% of pregnant women received a full IPTp-SP dose (at least two curative doses) during ANC visits [3]. Few studies have analyzed the relationship between the number of ANC visit, IPTp-SP and bed net coverage, the reported data are controversial [8, 9]. In Gabon, during the last ten years, more than 70% of women have attended ANC at least twice during their pregnancy, correct IPTP-SP and bed net coverage were estimated at around 56% and 50% in 2006, respectively [10]. Awareness campaigns in recent years for both health workers and pregnant women were organized by the Gabonese Malaria National Control Program (MNCP) supported by the Global Fund. An evaluation of the implemented programs is needed, including the key indicators of intervention coverage, ANC visit planning and attendance, health workers adherence to the recommendations and local socio-demographic and economic factors [11‐13]. We present in this study the quality of care for pregnant women through ANC attendance and its relationship with access to adequate malaria preventive measures in Libreville.

Malaria transmission is perennial in Gabon with slight seasonal fluctuations. The annual entomological inoculation rate is estimated at 33.9 infected bites per person per year, Anopheles gambiae s.s is the predominant vector [14]. Plasmodium (P.)falciparum infection prevalence is respectively of 24%, 31% and 11% at Libreville, Melen and Owendo.

The WHO recommends at least four ANC visits, with three of them occurring after quickening, for pregnant women in order to receive and appropriate health care and timely intervention for malaria prevention strategies [2, 5]. Our study confirms the high coverage of ANC attendance in Gabon, which ranged from one to eight visits. The WHO goal of four ANC visits was met by more than 70% of the interviewed women. This is considerable when compared to West and East Africa [9, 15‐17]. Improvement of strategies for pregnant woman care can explain this high attendance. Several community health centers and public hospitals, where health care services have been made affordable for the middle and low-income population, were built in the country these last five years. IPTp-SP is freely provided to the mothers and is always available in all the public health centers, even in the remote areas; and the cost of an ANC consultation is officially free of charge. Furthermore, each delivering woman must show an ANC card when arriving at the delivery unit they are distributed only during ANC. The timing of ANC was also found to be correct, with the majority of women having their first visit during the second trimester. Education sessions and oral communication from older women and mothers who encourage young pregnant women to go to ANC at three months of gestation may contribute to this. Moreover, after the first ANC, the midwife schedules the visit, reports the schedule in the ANC card and highlights each time the next appointment.

Regular attendance leads to the prevention, identification and treatment of maternal illnesses and obstetric complications. The Gabonese Ministry of Health recommends at least one dose of SP in the second trimester and one dose in the third trimester for malaria prevention, administered through ANC visits. Data from sentinel sites show acceptable adherence of midwives to these guidelines. IPTp-SP coverage is over 80%, it is considered high when compared to some countries where strategies have been adopted for more than 10 years [16‐18]. Nevertheless, the goal of 80% coverage of two full course doses of SP has not yet been reached (57.4%), although the observed coverage is in range with reports from other settings [9, 16‐19]. In 2007, 56% of delivering women in the CHL received a correct chemoprophylaxis; it is noteworthy that this frequency has not increased over the last four years. The fact that almost 40% of delivering women with more than three ANC visits had no or partial SP uptake is a proof that several ANC visits are not sufficient to ensure complete IPTp coverage; barriers to complete IPTp coverage need to be explored. Indeed, comparison between on-site practices showed that when SP administration is supervised, coverage increases and ANC attendance is substantial.

Adolescent mothers from Sub-Saharan Africa are known to initiate ANC attendance late with a higher risk of low birth weight [20, 21]. The present data suggest a better attendance for this population. The number of teenagers below the age of 17 years is too few to draw a conclusion and this study was not designed for this analysis. However, it would be interesting to investigate the behaviors of this subgroup several years after the previous study performed in Libreville and Lambaréné, and also after the implementation of new maternal and child health policy in the country [21].

This was not a survey evaluating knowledge and practices. An assessment of individual factors that may influence uptake of malaria prevention strategies revealed that high education level and higher gravidity did not predict complete attendance and good prevention. As previously stated, incomplete IPTp-SP may not be a problem deriving from pregnant women but a health center strengthening issue [9, 21].

Bed net coverage is still low, below 60%. Although its utilization has been found to be associated with a reduced risk of malaria, it is difficult to assess its real coverage and impact. They are not always available in health centers where they are supposed to be distributed. ITNs distribution campaigns are organized from time to time in our country by the MNCP, there is no daily distribution to all pregnant women presenting at their first prenatal visit in all the health centers. Only one third (34%) of all the bed net used by the women are ITNs confirming the coverage model proposed by WHO [3].

Our study has some limitations. It was conducted in the capital city and surrounding areas, and may overestimate actual ANC visits and use of SP as attitudes and practices may differ from those in rural areas in terms of access to health care, health worker motivation and training, and availability of health service. Knowledge of malaria symptoms and prevention among pregnant women and health workers, as well as a correct evaluation of attitude and practice of midwives including lack of adherence to guidelines for offering IPTp-SP to all eligible women, were not performed in this survey. All these factors may influence the use of malaria preventive measures [18, 22‐25].

Six years after the implementation of malaria control strategies according to the WHO in Gabon, this baseline survey performed at sentinel sites highlights that despite high complete ANC attendance, the use of full courses of IPTp-SP is still sub-optimal and insufficient. Evaluation and training of health workers, as well as surveys from other areas of the country are needed to further measure the impact of these strategies.