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Adapting community interventions that support improved outcomes for MIP !

while strengthening ANC services in Akwa Ibom State, Nigeria! Bright C. Orji with! William Brieger, Joseph Okeibunor, Gbenga Ishola, ! Emmanuel Otolorin, Barbara Rawlins, Eno Ndekhedehe! With support from the ExxonMobil Foundation!

Basic Malaria in Pregnancy Interventions and Indicators!


Malaria in pregnancy (MIP) causes anemia, miscarriage, still birth and low birth weight! To control MIP we must increase !
Number of antenatal care

(ANC) visits (where MIP control services provided)! Use of insecticide-treated nets (ITNs) during pregnancy ! Taking the recommended doses of sulphadoxine pyrimethamine (SP) as intermittent preventive treatment (IPTp)!
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High Risk, Low Coverage!


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In Akwa Ibom at baseline:!


Only 11.7% of

pregnant women had slept under an ITN! Only 5.8% of pregnant women had received two doses IPTp!

Study area has year-round malaria transmission!

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Basic Concepts!
Malaria in Pregnancy! Coverage of interventions remains low, despite massive anti-malaria campaigns.! Low uptake reects!
lack of knowledge,! poor access, and! limited support of programs by

local communities and authorities!

To reduce MIP lessons were adapted from community service delivery programs!

Community Directed Intervention (CDI)! CDI happens when communities plan and implement health intervention with minimal guidance from the health system! The Question we addressed was ! Will CDI increase uptake of the following malaria in pregnancy services:!
ITN use during pregnancy?! number of ANC visits?! taking the recommended two

doses of SP for IPTp?!

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CDI works; so why not for MIP?!


For the past 16 years, the African Program for Onchocerciasis Control has used CDI to provide ivermectin successfully in over 100,000 African villages!

WHO-supported research showed CDI could be adapted to deliver ITNs and malaria treatment!
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Nigeria MIP Community-Clinic Partnership Intervention!


Training, Supervision, Mobilization, Commodities! Referrals, Records, Feedback! COMMUNITY! MIP skills and responsibilities implemented through communitydirected intervention!

CLINIC! MIP performance standards developed and implemented!

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6 LGAs Selected for Intervention


A: Control Arm! Ikot Abasi, Mbo, Mkpat Enin! B: Treatment Arm! Eket, Esit-Eket, Onna!

Train health workers on basic malaria service provision!

Train health workers on basic malaria service provision!

Supply ITN, SP and malaria case tracking forms to health facilities!

Supply ITN, SP and malaria case tracking forms to health facilities!


Health workers train & equip CDDs with tools and intervention drugs!

Two Cluster Parallel Group Design !

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! Reduce Malaria in! pregnancy !

Communi'es served by health workers in health clinic or CDDs at home

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Intervention Timeline!
Activity/Month! Baseline Survey! Cascade Training State, LGA Staff! Community Directed Distributor (CDD) Training, Equipping! Intervention Starts, Supervision! Supervision Continues, Supplies! Follow-up Survey! Training in Control Areas!
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0-6! 7-12! 13-18! 19-24!

Performance Standards Scores (%) for ANC Services!


90! 80! 70! 60! 50! 40! 30! 20! 10! 0! Percent of 16 Standards Achieved!
Massive staff transfer!

Based on 16 Performance Standards!

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Key Findings!
ANC visits rose in treatment and control groups (estimated coefcient on group differences -0.016, 95% CI [-0.107, 0.074], p= 0.646).! CDI led to substantial, additional increases in ITN use and in adherence to the prescribed IPTp protocol. !
Relative to women in the control area, an additional 7.4 % of

women slept under a net during pregnancy (95% CI [0.035, 0.115], p<0.01). ! An additional 8.5% of women slept under an ITN after delivery and before the interview (95% CI [0.045, 0.122], p-<0.001) ! The effects of the CDI program were largest for IPTp adherence, increasing the fraction of pregnant women taking at least two SP doses during pregnancy by 35.3 percentage points [95% CI: 0.280, 0.425], p < 0.001) relative to the control group.!
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Program Impact: !Improved IPTp Uptake!


There was general increase in uptake of IPTp from baseline to endline assessment! However, the intervention arm with CDI had greater increase of women taking any IPTp (p<0.0001)! Similarly, more of the women in areas with CDI took IPTp2 than the control between baseline and endline assessment (p<0.0001)!
Uptake of IPTp over ;me among pregnant women
90 80 70 60 Percentage 50 40 30 20 10 0 Interven'on Control Interven'on Control Baseline Any IPTp IPTp2 Endline 19.8 13.2 14.8 9 28.4 66.5 53.7 85.3

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Improved Use of ITN and ANC Attendance over Time!


90 68.9 71.9 80 70 49.8 60 50 31.1 40 30 20 10 0 Slept under ITN regularly ITN Use Baseline Interven'on Baseline Control No ANC Any ANC ANC APendance Endline Interven'on Endline Control ANC in Government Clinic 28 30 40 76.9 52 44.2 58.3 20 10.5 28.1 50.2 89.5 100

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Conclusions: CDDs Are on Hand to Encourage ITN Use, IPTp Adherence and ANC Attendance!
The results suggest that community-based programs can substantially increase effective access to malaria prevention in high endemic, high burden areas! The participatory approach underlying CDI programs also promises to strengthen ties between the formal health sector and local communities and improve utilization of services including ANC!
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