Abstract
Background
Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is a key intervention for preventing malaria during pregnancy in areas with moderate to high malaria transmission. While IPTp-SP coverage has increased in Sierra Leone, disparities in uptake and completion of the recommended three doses persist. Understanding these trends and inequalities is crucial for improving maternal and child health outcomes. This study examined the trends and inequalities in using three doses of IPTp-SP among pregnant women in Sierra Leone between 2008 and 2019.
Methods
The research utilised data from the Sierra Leone Demographic Health Survey conducted in 2008, 2013 and 2019. The World Health Organisation Health Equity Assessment Toolkit software calculated several inequality measures, including simple difference (D), ratio (R), population-attributable risk (PAR), and population-attributable fraction (PAF). Inequality was assessed for four stratifiers: economic status, education level, place of residence, and sub-national province.
Results
In Sierra Leone, IPTp-SP coverage among pregnant women increased from 5.2% in 2008 to 35.7% in 2019. Economic inequalities among pregnant women in Quintile 5 (richest) and Quintile 1 (poorest) increased from a difference of −1.4 percentage points in 2008 to −5.2 percentage points in 2019. Disparities in education-related outcomes among pregnant women with secondary or higher education compared to those with no education decreased from a difference of 4.4 percentage points in 2008 to −3.8 percentage points in 2019. The disparities in place of residence among pregnant women in urban versus rural areas decreased from a difference of 1.4 percentage points in 2008 to −6.3 percentage points in 2019. Provincial inequalities increased from a difference of 4.1 percentage points in 2008 to 18.4 percentage points in 2019.
Conclusion
Despite the overall improvement in IPTp-SP coverage and the decreasing economic, educational and place of residence-related inequalities, continued provincial-level disparities indicate the necessity of tailoring interventions to address provincial-specific barriers. To achieve universal and equitable coverage of IPTp-SP, the study recommends a multifaceted approach that combines strengthening the health system, targeted behaviour change communication and addressing social determinants of health.
Keywords: Intermittent preventive treatment in pregnancy (IPTp), Malaria prevention, Maternal health, Sulfadoxine-Pyrimethamine (SP), Sierra Leone
Background
Malaria continues to pose a major public health challenge, particularly in sub-Saharan Africa [1–3]. Pregnant women are especially vulnerable to malaria due to decreased immunity during pregnancy, which increases their risk of severe consequences, such as maternal anaemia, miscarriage, low birth weight, stillbirth, and newborn death [3–5]. To reduce these risks, the World Health Organization (WHO) recommends the use of intermittent preventive treatment during pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) in malaria-endemic regions [6, 7]. IPTp-SP involves administering sulfadoxine-pyrimethamine at least 1 month intervals, during antenatal care (ANC) visits, starting in the second trimester [7, 8]. This strategy has been shown to significantly reduce the adverse effects of malaria during pregnancy, including maternal anaemia, low birth weight, premature delivery, and infant mortality [9–11]. Consequently, IPTp-SP is regarded as a cornerstone of malaria prevention and a vital component of strategies to achieve sustainable development goals (SDGs) related to maternal and child health [5, 12].
Globally, while efforts to enhance IPTp coverage have achieved notable progress, uptake remains suboptimal in many areas [8, 13]. According to the WHO’s 2021 World Malaria Report, although 32 countries had adopted the IPTp-SP + policy (which requires at least three doses of SP during pregnancy) by 2019, only 34% of eligible women received the recommended three doses in 2020 [14]. This statistic highlights the significant gap between policy adoption and actual implementation. Sub-Saharan Africa bears the highest global burden of malaria, accounting for over 95% of malaria cases and deaths [4, 15, 16]. Despite the crucial role that IPTp-SP plays in alleviating this burden, coverage across the region remains inconsistent, with disparities driven by socio-economic status, geographic location and access to healthcare [5, 15, 17].
Sierra Leone, like many sub-Saharan African nations, experiences a high malaria burden, which poses significant challenges to maternal and child health [18–20]. Malaria is prevalent throughout the country and is a leading cause of morbidity and mortality among pregnant women and children [21]. The Government of Sierra Leone has implemented WHO-recommended malaria control strategies, including the IPTp-SP + policy [22], free malaria treatment for pregnant women through the Free Health Care Initiative (FHCI), and community-based programmes aimed at raising awareness and increasing ANC attendance [23, 24]. In 2014, IPTp-SP was formally adopted with the policy aiming to provide three doses of SP to pregnant women [22]. While these measures have advanced malaria prevention, substantial obstacles remain. Access to healthcare facilities, stockouts of sulfadoxine-pyrimethamine, irregular ANC attendance, and sociocultural barriers hinder the widespread implementation of IPTp [25]. Consequently, IPTp-SP coverage has historically been limited, with significant variations across different sociodemographic groups.
Interventions to address these challenges include training healthcare personnel to administer IPTp-SP during ANC visits, incorporating malaria prevention messages into community health initiatives, and improving supply chain mechanisms to ensure sulfadoxine-pyrimethamine availability in healthcare facilities. International partners, such as the Global Fund and the Presidential Malaria Initiative, have provided technical and financial support for these efforts [22, 26]. Despite these initiatives, discrepancies in IPTp-SP adoption persist, with rural and poorer populations exhibiting lower coverage rates than their urban and wealthier counterparts [25, 27]. These disparities underscore the need for more targeted and context-specific strategies to enhance access and utilization of IPTp-SP.
While various studies have investigated the coverage and determinants of IPTp-SP during pregnancy in Sierra Leone [25, 28, 29], no research has specifically explored trends and inequalities in IPTp-SP coverage. Understanding these trends and inequalities is essential for developing evidence-based malaria prevention strategies that address the root causes of inequity. It will also provide valuable insights into the effectiveness of government policies and actions, indicating areas that require further attention. This study aims to fill this gap by analysing trends and inequalities using three doses of IPTp-SP during pregnancy in Sierra Leone from 2008 to 2019.
Methods
Study design and source
Data on pregnant women from the 2008, 2013, and 2019 Sierra Leone Demographic Health Survey (SLDHS) were utilised in this study. The SLDHS is a comprehensive national survey designed to identify consistent trends and variations in demographic indicators, health indicators and social issues across gender and age groups. The research employed a cross-sectional design, utilising a stratified multi-stage cluster sampling method for the selection of participants. The SLDHS report provides a detailed explanation of the sampling process [30]. The SLDHS data were accessible through the World Health Organisation (WHO) Health Equity Assessment Toolkit (HEAT) online platform [31]. The study was carefully designed according to the guidelines established by Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [32].
Variables
The outcome variable was the utilisation of IPTp-SP during pregnancy. Pregnant women who received a minimum of three tablets of SP, each comprising 500 mg/25 mg SP, administered at each scheduled antenatal care visit until delivery, with doses spaced at least 1 month apart, were classified as Yes. In contrast, those who received only one or two doses were classified as No. The economic status was categorised into five groups: poorest, poor, middle, rich, and richest. The maternal education status was classified into three categories: no, primary and secondary or higher education. The residence was classified as either urban or rural. The sub-national province comprised five regions: Eastern, Northern, Northwestern, Southern, and Western.
Data analysis
The analysis was conducted using the web-based version of the WHO HEAT programme [31]. This software includes the indicator of interest (IPTp-SP use during pregnancy) categorised by four dimensions of inequality, facilitating a thorough analysis of IPTp-SP utilization in this context. WHO HEAT offers estimates, confidence intervals and summary measures of inequality, enabling the assessment of disparities in IPTp-SP use during pregnancy and supporting informed conclusions derived from the data. The analysis commenced with the selection of data, wherein pertinent datasets regarding IPTp use during pregnancy, socio-economic status, and geographical distribution were collected from the SLDHS. The software's visualisation tools were utilised to analyse the data and identify potential patterns or disparities. Factors considered include socio-economic status, educational attainment, geographic location, and province. The analytical tools of the HEAT software were utilised to evaluate health inequalities. This involves the computation of summary measures related to health inequality. Estimates and confidence intervals (CIs) for IPTp-SP use among pregnant women were calculated using the designated stratifiers within the WHO HEAT software. Four measures were employed to assess inequality: difference (D), population attributable Risk (PAR), population attributable fraction (PAF), and ratio (R). D quantifies the absolute disparity in IPTp-SP utilization during pregnancy between two subgroups by directly comparing their respective rates. A higher Difference value signifies increased inequality. Ratio analyses the use of IPTp-SP during pregnancy across two subgroups by calculating the ratio of coverage in one subgroup to that in the other, providing a relative measure of inequality. A ratio value exceeding 1 signifies reduced IPTp utilization during pregnancy among the disadvantaged group. Difference and ratio are unweighted measures, indicating that they do not consider the population sizes of the subgroups and concentrate exclusively on the two groups under comparison. Conversely, PAR quantifies the proportion of a health outcome attributable to a specific risk factor in the population, whereas PAF represents the percentage of the total health outcome that would be eradicated if the risk factor were eliminated. A positive PAF indicates that mitigating inequalities would result in a reduction of overall IPTp use during pregnancy, while a higher PAR signifies a more substantial effect of inequalities on IPTp use during pregnancy. These measures offer insights into the potential impact of diminishing inequalities on overall health outcomes. R and PAF serve as relative measures of inequality, utilised to assess and compare the disparities among different elements in relation to each other. Difference and PAR serve as absolute measures, offering definitive values that reflect the disparity in vaccination coverage or the percentage of health outcomes linked to a particular risk factor. This distinction is significant, as absolute measures such as Difference and PAR provide clear insights into the extent of inequality, whereas relative measures like Ratio and PAF place these differences within broader population dynamics. The incorporation of summary measures is based on the WHO’s acknowledgement that absolute and relative summary metrics are crucial for generating policy-relevant insights. The literature provides a detailed overview of the summary measures and calculations associated with WHO measures [33–35].
Results
Trends in the use of three doses of intermittent preventive therapy in pregnancy, Sierra Leone, 2008-2019
In 2008, the IPTp-SP coverage among pregnant women was around 5.2% as it reflects the period before the updated guidelines were implemented. By 2013, the coverage had increased to around 20.7%. In 2019, coverage increased to around 35.7% (Fig. 1).
Fig. 1.
Trends in the use of three doses of intermittent preventive therapy in pregnancy, Sierra Leone, 2008–2019
Table 1 shows the trends in using three doses of IPTp-SP in pregnancy in Sierra Leone across different socio-economic and demographic characteristics from 2008 to 2019. In 2008, the coverage was around 5% across all wealth quintiles. By 2019, the coverage had increased, with the highest coverage in Quintile 2 and Quintile 3 at 41%. The coverage was lowest in the richest Quintile 5 at 29% in 2019. In 2008, the coverage was around 5% regardless of education level. By 2019, the coverage was highest among those with primary education at 38%, followed by those without education at 36%. The coverage was lowest among those with higher education at 32% in 2019. In 2008, the coverage was 5% in rural and urban areas. By 2019, the coverage was higher in rural areas at 38% compared to urban areas at 32%. In 2008, the coverage ranged from 4% in the North to 8% in the East. By 2019, the North had the highest coverage at 43%, followed by the Northwestern province at 41%. The West area had the lowest coverage at 24% in 2019.
Table 1.
Trends in the use of 3 doses of intermittent preventive therapy in pregnancy, Sierra Leone, 2008–2019
| Dimension | 2008 | 2013 | 2019 | |||
|---|---|---|---|---|---|---|
| Sample | Estimate | Sample | Estimate | Sample | Estimate | |
| Economic status | ||||||
| Quintile 1 (poorest) | 571 | 5.0 | 1110 | 17.0 | 917 | 34.0 |
| Quintile 2 | 535 | 5.0 | 1012 | 23.0 | 867 | 41.0 |
| Quintile 3 | 517 | 5.0 | 1056 | 24.0 | 792 | 41.0 |
| Quintile 4 | 476 | 7.0 | 923 | 23.0 | 753 | 33.0 |
| Quintile 5 (richest) | 379 | 4.0 | 719 | 15.0 | 622 | 29.0 |
| Education | ||||||
| No education | 1819 | 5.0 | 3118 | 20.0 | 2037 | 36.0 |
| Primary education | 339 | 5.0 | 735 | 24.0 | 610 | 38.0 |
| Secondary education | 295 | 7.0 | 920 | 21.0 | 1199 | 34.0 |
| Higher education | 25 | 9.0 | 47 | 12.0 | 105 | 32.0 |
| Place of residence | ||||||
| Rural | 1797 | 5.0 | 3580 | 22.0 | 2558 | 38.0 |
| Urban | 681 | 5.0 | 1240 | 17.0 | 1393 | 32.0 |
| Province | ||||||
| Eastern | 500 | 8.0 | 1113 | 10.0 | 847 | 35.0 |
| Northern | 1114 | 4.0 | 2830 | 26.0 | 796 | 43.0 |
| Northwestern | NA | NA | NA | NA | 758 | 41.0 |
| Southern | 507 | 6.0 | 877 | 16.0 | 816 | 35.0 |
| Western | 357 | 6.0 | NA | NA | 734 | 24.0 |
NA Not Available
Inequalities in the use of three doses of intermittent preventive therapy in pregnancy, Sierra Leone, 2008-2019
Table 2 displays inequality measures related to factors influencing IPTp-SP utilization during pregnancy among women in Sierra Leone from 2008 to 2019. Economic inequalities among pregnant women in Quintile 5 (richest) and Quintile 1 (poorest) increased from a difference of −1.4 percentage points in 2008 to −5.2 percentage points in 2019. The PAF was zero in 2008 and 2019, indicating improved coverage among pregnant women in Quintile 2 and Quintile 3 over time. Disparities in education-related outcomes among pregnant women with secondary or higher education compared to those with no education decreased from a difference of 4.4 percentage points in 2008 to −3.8 percentage points in 2019. The PAF declined from 79.3 percentage points in 2008 to 0.4 percentage points in 2019, suggesting that the national average of IPTp-SP utilization during pregnancy would have risen by 0.4 percentage points without educational disparities, with pregnant women possessing primary education experiencing improved coverage over time. The disparities in place of residence among pregnant women in urban versus rural areas decreased from a difference of 1.4 percentage points in 2008 to −6.3 percentage points in 2019. The PAF declined from 0.1 percentage points in 2008 to zero in 2019, reflecting improved IPTp-SP coverage among pregnant women in rural areas. Provincial inequalities increased from a difference of 4.1 percentage points in 2008 to 18.4 percentage points in 2019. The PAF declined from 47.1 percentage in 2008 to 19.3 percentage points in 2019, suggesting that the national average of IPTp-SP coverage among pregnant women would have risen by 19.3% without provincial disparities.
Table 2.
Inequalities in the use of three doses of intermittent preventive therapy in pregnancy, Sierra Leone, 2008–2019
| Dimension | Measure | 2008 Estimate (%) | 2008 CI-LB | 2008 CI-UB | 2013 Estimate (%) | 2013 CI-LB | 2013 CI-UB | 2019 Estimate (%) | 2019 CI-LB | 2019 CI-UB |
|---|---|---|---|---|---|---|---|---|---|---|
| Economic status (Wealth Quintile) | D | −1.4 | NA | NA | −1.9 | NA | NA | −5.2 | NA | NA |
| PAF | 0.0 | −0.3 | 0.3 | 0.0 | −0.1 | 0.1 | 0.0 | −0.1 | 0.1 | |
| PAR | 0.0 | −1.8 | 1.8 | 0.0 | −2.5 | 2.5 | 0.0 | −3.3 | 3.3 | |
| R | 0.7 | NA | NA | 0.9 | NA | NA | 0.8 | NA | NA | |
| Education (4 groups) | D | 4.4 | NA | NA | −8.3 | NA | NA | −3.8 | NA | NA |
| PAF | 79.3 | 77.1 | 81.5 | 0.0 | −0.4 | 0.4 | 0.0 | −0.2 | 0.2 | |
| PAR | 4.2 | −7.4 | 15.7 | 0.0 | −9.2 | 9.2 | 0.0 | −8.8 | 8.8 | |
| R | 1.9 | NA | NA | 0.6 | NA | NA | 0.9 | NA | NA | |
| Place of residence | D | 1.4 | 1.1 | 1.7 | −4.4 | NA | NA | −6.3 | NA | NA |
| PAF | 0.1 | −1.4 | 1.5 | 0.0 | −0.1 | 0.1 | 0.0 | −0.1 | 0.1 | |
| PAR | 1.0 | NA | NA | 0.0 | −1.9 | 1.9 | 0.0 | −2.0 | 2.0 | |
| R | 1.4 | 1.1 | 1.7 | 0.8 | NA | NA | 0.8 | NA | NA | |
| Subnational province | D | 4.1 | NA | NA | 16.3 | NA | NA | 18.4 | NA | NA |
| PAF | 47.1 | 46.8 | 47.5 | 26.8 | 26.8 | 26.9 | 19.3 | 19.2 | 19.4 | |
| PAR | 2.5 | 0.5 | 4.4 | 5.6 | 4.7 | 6.5 | 6.9 | 3.8 | 9.9 | |
| R | 2.1 | NA | NA | 2.6 | NA | NA | 1.8 | NA | NA |
Discussion
This research examined the trends and inequalities in the uptake of three doses of IPTp-SP in Sierra Leone from 2008 to 2019. The findings indicate an increase in IPTp-SP coverage over the study period, starting at 5.2% in 2008 and reaching 37.5% by 2019. IPTp-SP coverage improved among pregnant women in Quintile 2 and 3 wealth status, those with primary education, and those living in rural areas. While progress has been made in addressing these inequalities, certain gaps remain, particularly provincial inequalities, necessitating targeted efforts to ensure equitable access to IPTp services.
The national trend in IPTp-SP uptake reveals a notable rise during the 11-year research period. The incidence increased from 2008 to 2019, reflecting the efforts of the Government of Sierra Leone and international partners to enhance malaria prevention measures. Comparisons with previous studies in sub-Saharan Africa indicate that Sierra Leone's improvements align with regional trends, as a review shows an increase in IPTp uptake from 2011 to 2015 across the countries included in the review. However, overall IPTp-SP coverage remains low despite WHO recommendations [16]. However, Sierra Leone’s coverage is still below the regional average, with some countries reporting IPTp-SP coverage exceeding 50% in recent years [8, 16, 36]. Several factors could have contributed to the increased IPTp-SP coverage. Beginning in 2014, IPTp-SP was integrated into routine ANC visits, ensuring that healthcare providers actively promoted its uptake [22]. In 2013, community health workers were mobilized to enhance access in rural areas, bridging the gap between healthcare facilities and underserved communities [38]. Training programmes for healthcare providers and community health workers were established in 2014 to ensure effective communication of IPTp-SP benefits [23]. From 2015 to 2019, awareness campaigns utilising various media, including radio broadcasts and community meetings, educated the public on the importance of IPTp-SP and encouraged ANC attendance [23]. Continuous monitoring and evaluation were implemented from 2016 onwards to assess the effectiveness of these strategies, leading to notable increases in coverage following their introduction [23].
Education and economic status are notable predictors of IPTp adoption. The data indicate that disparities based on these factors have diminished over time, suggesting that efforts to reduce socio-economic barriers have been effective. Between 2008 and 2019, women without formal education and those in the poorest wealth quintiles experienced substantial increases in IPTp-SP coverage. This contrasts with findings from a study which noted that women with secondary or higher education were significantly more likely to comply with IPTp recommendations compared to those without formal education [39]. Educated women tend to be better informed about the importance of IPTp and ANC attendance, and wealthier women also demonstrated higher IPTp-SP uptake due to better access to healthcare and the ability to afford indirect costs such as transportation [39, 40]. The increase in Sierra Leone may be attributed to the FHCI, which alleviated financial barriers to receiving ANC treatments and targeted outreach initiatives for marginalized populations. Despite these advancements, gaps persist, with women of higher education levels and those in wealthier quintiles continuing to have lower IPTp-SP uptake rates, highlighting the need for ongoing efforts to address these disparities. Policies aimed at enhancing educational access and alleviating poverty could influence IPTp-SP adoption. Additionally, improving healthcare staffing and ensuring consistent availability of SP in underprivileged areas will help promote equitable access to malaria prevention treatments.
Inequalities in IPTp-SP uptake based on place of residence decreased, with pregnant women living in rural areas having more IPTp-SP coverage over time whilst provincial inequalities increased. Initially, rural women had much lower coverage than their urban counterparts, but the gap has narrowed due to initiatives to improve healthcare access in remote areas. Peripheral Health Units, community health workers, and targeted ANC programmes in rural regions likely contributed to this success [41, 42]. However, long travel distances to healthcare facilities, poor road infrastructure, and a shortage of healthcare workers in rural areas continue to hinder IPTp-SP utilization [40, 43]. Geographic disparities are particularly pronounced among provinces, with pregnant women in the Western area experiencing the lowest IPTp-SP coverage in 2019. While progress has been made in all provinces, specific interventions in the Western area may be necessary to address the remaining disparities. Provincial healthcare planning, increased investment in healthcare infrastructure, and enhanced community engagement could help close these gaps.
Strengths and limitations of the study
This study offers valuable insights into the trends and inequalities in IPTp-SP coverage in Sierra Leone over 11 years, utilizing nationally representative data to uncover disparities across sociodemographic and geographic dimensions. By analysing data spanning over a decade, the study identifies significant gains in IPTp-SP adoption while revealing persistent gaps, providing essential information to inform policy and intervention strategies. The large, population-based dataset enhances the generalizability of the findings, making them relevant for broader public health planning and decision-making. However, several limitations should be acknowledged. The reliance on self-reported data for IPTp-SP uptake introduces the possibility of recall bias, as individuals may inaccurately report their use of IPTp. This could lead to an underestimation or overestimation of actual coverage. Furthermore, the study does not account for critical factors such as healthcare provider characteristics, facility-level dynamics, or community-level influences, all of which have been shown to affect IPTp adoption. These omissions hinder our ability to understand the underlying causes of inequality fully. Finally, the study's timeline concludes in 2019, precluding an examination of the impact of more recent policies, initiatives or changes in healthcare delivery systems. Future research should address these gaps to provide a more comprehensive understanding of IPTp-SP coverage patterns.
Implications for policy and practice
The findings from the study have important policy and practice implications. The economic-related disparities, with the richest quintile experiencing significantly lower coverage than the poorest, underscores the need for targeted social protection measures and equitable financing mechanisms to ensure affordable access to IPTp services, particularly for marginalized populations. Addressing the persistent provincial-level inequalities will require a decentralized, context-specific approach that empowers local health systems and communities to identify and mitigate barriers to IPTp uptake. Strengthening the capacity of the health workforce to deliver quality, respectful maternal care and engaging with communities to raise awareness and address sociocultural norms that may hinder IPTp utilization will also be crucial. Integrating IPTp services with other ANC touchpoints and leveraging digital health innovations could improve coverage and continuity of care. Ultimately, a comprehensive, equity-focused strategy that tackles the social determinants of health and ensures equitable access to IPTp is necessary to achieve universal coverage and realize the full maternal and child health benefits of this critical intervention in Sierra Leone.
Conclusion
Despite the overall improvement in IPTp-SP coverage and the decreasing economic, educational and place of residence-related inequalities, continued provincial-level disparities indicate the necessity of tailoring interventions to address provincial-specific barriers. To achieve universal and equitable coverage of IPTp-SP, the study recommends a multifaceted approach that combines strengthening the health system, targeted behaviour change communication and addressing social determinants of health. Particular focus should be placed on empowering and supporting pregnant women from all income households, with varying educational levels, and those in underserved provinces to access and utilize IPTp-SP services. Continuous monitoring and evaluation of these efforts will ensure sustained progress towards equitable maternal health outcomes in Sierra Leone.
Acknowledgements
We are grateful to MEASURE DHS and the World Health Organization for making the dataset and the HEAT software accessible.
Author contributions
AO contributed to the study design and conceptualisation. AO performed the analysis. US, AO, AUBS, CB, and BOA developed the initial draft. All the authors critically reviewed the manuscript for its intellectual content. All authors read and amended drafts of the paper and approved the final version. AO had the final responsibility of submitting it for publication.
Funding
This study received no funding.
Data availability
The dataset used can be accessed at https:/whoequity.shinyapps.io/heat.
Declarations
Ethics approval and consent to participate
This study did not seek ethical clearance since the WHO HEAT software and the dataset are freely available in the public domain.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The dataset used can be accessed at https:/whoequity.shinyapps.io/heat.