Use of insecticide-treated nets (ITN) and intermittent preventive treatment (IPTp) for malaria prevention and its associated factors among pregnant women in Sub-Sahara Africa

Abstract

Background

Malaria is a significant public health issue in sub-Saharan Africa, accounting for 96% of global malaria-related deaths. Malaria during pregnancy can lead to maternal morbidity and death, stillbirths, and newborn deaths. Prevention and control policies in areas of stable transmission emphasize a combination of intermittent preventive treatment during pregnancy (IPTp) and use of insecticide-treated nets (ITNs), along with effective case management. Neither ITNs nor IPTp provide complete protection alone, and since IPTp and ITNs work synergistically, combining these interventions could be highly effective. The World Health Organization (WHO) recommends that pregnant women receive IPTp, starting early in the second trimester, with at least three doses, regardless of ITN use. Therefore, this study aims to assess the utilization of ITNs and IPTp and the factors influencing their use among pregnant women in sub-Saharan Africa.

Methods

We used the most recent Malaria Indicator Survey (MIS) or Demographic and Health Survey (DHS) data from 18 sub-Saharan African (SSA) countries, conducted between 2018 and 2024. A weighted sample of 63,561 women who had given birth in the 3 years preceding the survey was included in this analysis. Pooled estimates for the utilization of both insecticide-treated nets (ITN) and IPTp were reported with 95% confidence intervals (CI). To determine factors associated with utilization, we performed a multilevel multinomial regression analysis. Variables with a p-value < 0.05 or whose ARRR confidence interval did not include one were considered significant factors associated with malaria preventive measures utilization among pregnant women.

Results

Among our weighted sample of 63,561 pregnant women, the following utilization rates of malaria preventive measures were observed: 28.9% (95% CI 28.4, 29.3%) used both an ITN (slept under one the previous night) and IPTp (3 or more doses), and 17.6% (95% CI 17.2, 18.0%) used neither ITN nor IPTp. Multilevel multinomial regression analysis revealed that age, educational status, sex of household head, wealth index, mass media exposure, residence and sub-region of SSA were significant factors associated with ITN and IPTp utilization.

Conclusion

Fewer than one-third of expectant mothers took advantage of combined ITN and IPTp malaria prevention strategies. Both community-level and individual-level predictors should be considered when developing strategies and implementing programs run by both governmental and non-governmental organizations in order to achieve the global goal of reducing malaria by 90% by 2030.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-026-05970-5.

Background

Malaria remains a major public health problem in sub-Saharan Africa (SSA). According to the World Malaria Report 2024, the WHO African Region accounted for about 94% of global malaria cases and 95% of malaria deaths [1]. Household survey data from 19 SSA countries further show a malaria prevalence of 22.5% [2]. In high-transmission African countries, an estimated 12.4 million pregnancies (34%) were exposed to malaria infection. By sub-region, West Africa had the highest number of malaria-exposed pregnancies, followed by Central Africa [1]. Placental malaria affected 28% of malaria cases among pregnant women in the SSA region [3].

The African region accounts for the highest share of malaria deaths worldwide [4]. About 95% of global malaria deaths occur in this region [1]. Malaria in pregnancy contributes to 10,000 maternal deaths each year [5]. It is responsible for an estimated 100,000 newborn deaths globally, including 11% of newborn deaths and 20% of stillbirths in sub-Saharan Africa [6–8].

The current WHO recommendation for malaria prevention and control during pregnancy in areas of stable transmission emphasizes a package of intermittent preventive treatment during pregnancy (IPTp), use of insecticide-treated net (ITN), and ensuring effective case management of malaria illness and anemia [9]. According to WHO recommendations, IPTp should be administered to pregnant women starting early in the second trimester, with at least three doses in areas of moderate to high malaria transmission. Since ITNs alone cannot provide complete protection against malaria, IPTp-SP is not a replacement but rather a complementary intervention. Both ITNs and IPTp-SP offer important benefits and work synergistically to reduce malaria risk [10].

The utilization of ITNs and IPTp reduces malaria-related maternal and fetal complications. IPTp with sulfadoxine-pyrimethamine is associated with a reduced incidence of preterm delivery, spontaneous abortion, intrauterine fetal death, neonatal mortality, and low birth weight [11–13]. Insecticide-treated nets (ITNs) are also effective in reducing child mortality, parasite prevalence, and both uncomplicated and severe malaria episodes [14].Malaria prevention strategies in sub-Saharan African countries recommend that pregnant women use both ITNs and IPTp during pregnancy to reduce the risk of malaria infection [15–19].

Previous studies on malaria prevention measures, such as ITNs and IPTp, have revealed that factors including age, educational status, wealth index, marital status, sex of the household head, place of residence, and number of children are associated with the use of these malaria prevention measures [20–24].

Although numerous studies have examined the associated factors of malaria preventive measure utilization at the national level in African countries, most have focused on the use of either ITNs or IPT. However, few studies have considered the combined utilization of both ITNs and IPTp among pregnant women, despite the greater effectiveness of malaria prevention when both measures are used together [25, 26].

The combined use of insecticide-treated nets (ITNs) and intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) offers enhanced protection against malaria infection and anemia during pregnancy. Women who used both IPTp-SP and ITNs had a lower risk of malaria infection than those who used either intervention alone. Notably, malaria prevalence was higher in the IPTp-SP plus ITN group at the time of the first SP dose compared to the second and third doses, likely due to SP’s increasing effectiveness with repeated dosing and the added protection from continued ITN use [25–27].

Therefore, our study will fill this gap and be useful in strengthening malaria prevention implementation efforts in sub-Saharan African countries. This study aimed to identify and highlight factors that need improvement in the sub-Saharan African region to achieve the Global Technical Strategy for Malaria targets, including at least a 90% reduction in case incidence and mortality rates, and the elimination of malaria in 35 countries by 2030 [28].

Methods

Study area, design and population

We used recent data from the Malaria Indicator Survey (MIS) or Demographic and Health Survey (DHS) for eighteen sub-Saharan African (SSA) countries, selecting those with available outcome variables in surveys conducted after 2017 (Supplementary File 1). For countries with both DHS and MIS data, we generally used the most recent survey based on the year of data collection. However, for Kenya, we used the MIS data despite a more recent DHS being available, because the DHS lacked the outcome variable. The surveys included in this analysis were conducted between 2018 and 2024.The DHS and MIS employed a two-stage sampling method: stratified cluster sampling to select clusters from urban and rural areas, followed by systematic sampling to select households from the chosen clusters. This study included women who gave birth within three years preceding the survey. Since ITN utilization was only asked among women who had access to ITNs as per the DHS questionnaire our analysis focused on those with ITN access. Details of the inclusion and exclusion criteria are presented in the flowchart (Fig. 1). Individual countries contributed between 12% (Mali) and 2% (Liberia) of the weighted study sample. (Table 1).

Fig. 1.

Flow chart of study sample selection for the study on malaria prevention measures among pregnant women Sub-Sahara Africa (SSA), 2025

Table 1.

Frequency of study samples from 18 Sub-Sahara Africa countries for the study on malaria prevention measures utilization among pregnant women, 2025

Country	Data	Survey year	Frequency unweighted (N = 64, 899)	Percentage (%)	Frequency weighted (N = 63, 561)	Percentage (%)
Burkina Faso	DHS	2021	5613	8.7	5535	8.7
Cameroon	MIS	2022	1983	3.1	1987	3.1
Gabon	DHS	2019/21	1660	2.6	1440	2.3
Ghana	DHS	2022	4155	6.4	3676	5.8
Gambia	DHS	2019/20	4.214	6.5	3770	5.9
Guinea	MIS	2021	1475	2.3	1474	2.3
Kenya	MIS	2020	1559	2.4	1395	2.2
LIBERIA	MIS	2022	1,334	2.1	1264	2.0
Madagascar	DHS	2021	5515	8.5	5374	8.4
Mali	DHS	2023/24	7113	10.9	7604	12.0
Mauritania	DHS	2019/21	3166	4.9	3146	5.0
Mozambique	DHS	2022/23	3277	5.1	3,344	5.3
Nigeria	MIS	2021	3567	5.5	3,831	6.0
Niger	MIS	2021	2613	4.0	2,770	4.4
Sieraleone	DHS	2019	4198	6.5	4,080	6.4
SENEGAL	DHS	2023	4010	6.2	3,478	5.5
Tanzania	DHS	2022	4828	7.4	4,848	7.6
Zambia	DHS	2018	4619	7.1	4,544	7.2

DHS- Demographic and Health Survey; MIS- Malaria Indicator Survey

Study variables

Outcome variable

The outcome variable, utilization of malaria preventive measures, was constructed as a composite measure derived from two survey items. The first item assessed ITN use, based on whether the respondent slept under a mosquito bed net the night before the survey. Responses were recoded into a binary variable: “Yes” if the respondent used only treated nets, and “No” if they used no net or only untreated nets. The second item assessed IPTp use, measured by the number of sulfadoxine-pyrimethamine (SP/Fansidar) doses received during pregnancy. A response was coded as “Yes” if the woman received three or more doses, indicating adequate IPTp coverage, and “No” if she received two or fewer doses.

Using these two binary indicators, a four-category outcome variable was created for multinomial regression. Women who used neither treated nets nor received at least three IPTp doses were classified as using no preventive methods (0); those who used treated nets but received fewer than three IPTp doses were categorized as using only ITNs (1); those who received three or more IPTp doses but did not use treated nets were categorized as using only IPTp (2); and women who both used treated nets and received three or more IPTp doses were classified as using both ITNs and IPTp (3).

Individual-level variables- age, educational status, marital status, wealth index, parity, sex of the household head, mass media exposure and Antenatal care visit.

Community level factors- residence and sub-region of SSA.

Operational definition

Mass media exposure was determined by combining three variables from the survey. Women were considered to have mass media exposure if they were exposed to magazines, radio, or television at least once per week. Otherwise, they were classified as having no mass media exposure.

Data management and statistical analysis

R 4.3 software was used for data extraction, cleaning, and management. All descriptive and analytical analyses were conducted using R and Stata 17. We weighted our sample before any analysis to account for the unequal selection probability of samples, following DHS guidelines.

DHS data has a clustered structure, with women nested within clusters. Women in the same cluster are more likely to share similar characteristics, violating the classical multinomial logistic regression assumption of independence of observations. To address this, we used a multilevel multinomial logistic regression model incorporating both fixed and random effects to account for the clustering of observations. We ran the multilevel multinomial regression model to identify both individual- and community-level determinants of malaria preventive measure utilization among pregnant women. The outcome category 'No preventive methods used' was used as the reference category for the multinomial regression analysis.

In the fixed-effects analysis, we first selected potential factors from the bi variable multinomial multilevel analysis based on a p-value <0.20 for the multivariable multinomial multilevel analysis. During the multilevel multinomial regression analysis, we assessed multi-collinearity among independent variables using the Variance Inflation Factor (VIF), considering variables with VIF >10 as having high multi-collinearity [29]. We fitted four multilevel multinomial models to identify determinants of malaria preventive measures utilization: the null model, which included only the outcome variable; Model 1, which included individual-level factors; Model 2, which incorporated community-level factors; and Model 3, which combined both individual- and community-level factors. After conducting the multivariable multilevel multinomial analysis, we reported the adjusted relative risk ratio (ARRR) with a 95% confidence interval. Variables with a p-value <0.05 or whose ARRR confidence interval did not include one were considered significantly associated with malaria preventive measures utilization among pregnant women.

To account for variability due to differences between clusters in our models, we reported the intra-class correlation coefficient (ICC) to indicate the proportion of total variability attributable to clustering. The ICC was calculated using the formula: ICC = σ²/ (σ² + π²/3); σ² is the variance between clusters. An ICC value greater than 0.10 indicated the presence of clustering, prompting us to use a mixed-effects model rather than a classical model for the analysis [30]. The Proportional Change in Variance (PCV) was used to assess the variation in model variance when different factors were included to explain the outcome. It was calculated using the formula: PCV = [(V_a–V_b)/V_a]*100; V_a is the variance of the null model, and V_b is the variance of other consecutive models [30]. For model comparison, we reported the log-likelihood and deviance for each model. The best-fitting model was selected based on the highest log-likelihood and the lowest deviance.

Result

Background characteristics study participants

Our study included 63,561 weighted study participants who gave birth in the five years preceding the survey. The mean age of the participants was 28.2 years (SD ± 7.07). Among the participants, two-thirds (66.9%) lived in rural areas, more than one-third (39.1%) had not attended formal education, and more than 80% of household heads were male (Table 2).

Table 2.

Background characteristics of study participants for the study on malaria prevention measures utilization among pregnant women in Sub-Sahara Africa (SSA), 2025

Variables	Frequency (N = 63,561)	Percentage %
Age group (in years)
15–19	6094	9.6
20–24	15,722	24.7
25–29	15,828	24.9
30–34	12,447	19.6
35–39	8825	13.9
40–44	3699	5.9
45–49	946	1.5
Residence
Urban	21,058	33.1
Rural	42,502	66.9
Educational level
No education	24,818	39.1
Primary	18,161	28.5
Secondary	18,066	28.4
Higher	2515	4.0
Sex of household head
Male	52,134	82.0
Female	11,427	18.0
Wealth index
Poorest	13,996	22.0
Poorer	13,924	21.9
Middle	13,067	20.6
Richer	12,109	19.1
Richest	10,465	16.5
Parity
One	14,134	22.2
Two	12,339	19.4
Three or more	37,088	58.4
Mass media exposure
No	43,717	68.8
Yes	19,844	31.2
Antenatal care visit
No visits	4210	6.6
1–3 visits	18,696	29.4
4 or more visits	40,654	64.0

Malaria preventive measures utilization of pregnant women in SSA countries

Among our weighted sample of 63,561 pregnant women, the utilization of malaria preventive measures was as follows: 28.9% (95% CI 28.4, 29.3%) used both insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp); 10.4% (95% CI 10.1, 10.7%) used only IPTp; and 43.2% (95% CI 42.7, 43.6%) used only ITNs (Fig. 2).

Fig. 2.

Malaria prevention measures utilization among pregnant women in Sub-Sahara Africa (SSA), 2025

Country-specific analysis revealed that Burkina Faso had the highest proportion and Mauritania had the lowest proportion of pregnant women utilizing both ITN and IPTp among sub-Saharan African (SSA) countries. In contrast, Mauritania had the highest proportion of pregnant women who utilized neither ITN nor IPTp (Fig. 3).

Fig. 3.

Malaria preventive measures utilization among pregnant women across Sub-Sahara Africa (SSA) countries, 2025

Factors associated with malaria prevention measures utilization

In the multilevel multivariable analysis, we modeled malaria prevention measures, including only ITN utilization, only IPTp utilization, and the combined use of ITN and IPTp, along with their factors among pregnant women. Model three, which includes both individual- and community-level factors, was identified as the best-fit model, as it had a higher log-likelihood and lower deviance; therefore, it was used as the final model (Table 3). Therefore, our findings are presented based on this model. A detailed comparison of all four models, including their log-likelihoods, deviances, other fit statistics, and aRRR estimates for the associated factors, is attached (see Supplementary Files 3 and 4).

Table 3.

Parameters of the final model for malaria preventive measures utilization among pregnant women in Sub-Sahara Africa (SSA), 2025

Parameter	Final Model
Variance (95% CI)	0.30 (0.24,0.37)
ICC	0.09
PCV	0.37
LL	− 76,467
Deviance	152934

ICC Intra-class correlation coefficient, PCV Proportional Change in Variance, LL Log-likelihood

ITN utilization was found to be significantly and positively associated with age, parity, mass media exposure, antenatal care visits, and rural residence, while it was negatively associated with educational status, female household head and wealth quantile. Significant differences were observed by sub-region of sub-Saharan Africa (SSA).

IPTp utilization showed a statistically significant positive association with a woman's age, educational status, wealth index, mass media exposure, and antenatal care visits, but was negatively associated with female household head and sub-region of SSA.

The utilization of both ITNs and IPTp was significantly and positively associated with a woman's age, mass media exposure, antenatal care visits, and rural residence, while it was negatively associated with educational status, female household head, wealth index, and sub-region of sub-Saharan Africa (SSA) (Table 4). This study primarily focused on the factors of combined malaria prevention method utilization, as the use of both ITNs and IPTp is highly effective in preventing malaria.

Table 4.

Multilevel multinomial regression of factors associated with malaria preventive measure utilization among pregnant women in Sub-Sahara Africa (SSA), 2025

Variables	Final Model
	Both community and individual level factors
	ITN IPTp Both ITN and IPTp aRRR (95% CI) aRRR (95% CI) aRRR (95% CI)
Age group(in years)
15–19	1	1	1
20–24	1.11 (1.01, 1.21)*	1.05 (0.93, 1.19)	1.25 (1.13, 1.38)**
25–29	1.05 (0.95, 1.16)	1.18 (1.04, 1.35)*	1.36 (1.22, 1.52)**
30–34	1.04 (0.93, 1.16)	1.15 (0.99, 1.34)	1.44 (1.28, 1.62)**
35–39	0.98 (0.87, 1.09)	1.14 (0.98, 1.34)	1.34 (1.18, 1.52)**
40–44	1.08 (0.94, 1.24)	1.25 (1.03, 1.51)*	1.45 (1.25, 1.68) **
45–49	0.87 (0.71, 1.08)	0.93 (0.68, 1.27)	1.31 (1.05, 1.64)*
Educational level
No education	1	1	1
Primary	0.72 (0.68, 0.77)**	0.95 (0.87, 1.04)	0.78 (0.73, 0.84)**
Secondary	0.79 (0.75, 0.85)**	1.31 (1.20, 1.43)**	0.97 (0.90, 1.04)
Higher	0.68 (0.59, 0.78)**	1.38 (1.17, 1.61)**	0.81 (0.70, 0.93)**
Sex of household head
Male	1	1	1
Female	0.70 (0.66, 0.74)**	0.86 (0.79, 0.92)**	0.69 (0.65, 0.74)**
Wealth index
Poorest	1	1	1
Poorer	0.94 (0.87, 1.01)	1.13 (1.02, 1.25)*	0.99 (0.92, 1.07)
Middle	0.96 (0.89, 1.04)	1.10 (0.99, 1.23)	1.01 (0.94, 1.09)
Richer	0.95 (0.88, 1.03)	1.01 (0.91, 1.14)	0.91 (0.84, 0.99)*
Richest	0.85 (0.77, 0.93)**	1.05 (0.92, 1.19)	0.82 (0.74, 0.90)**
Number of children
One	1	1	1
Two	1.13 (1.05, 1.22)**	1.01 (0.91, 1.11)	1.06 (0.97, 1.15)
Three or more	1.27 (1.17, 1.37)**	0.93 (0.83, 1.03)	1.04 (0.96, 1.14)
Mass media exposure
No	1	1	1
Yes	1.15 (1.09, 1.21)**	1.19 (1.11, 1.28)**	1.28 (1.21, 1.35)**
Antenatal care visit
Less than four	1	1	1
Four and above	1.16 (1.10, 1.22)**	2.82 (2.63, 3.03)**	3.49 (3.31, 3.69)**
Residence
Urban	1	1	1
Rural	1.41 (1.32, 1.50)**	0.92 (0.84, 1.01)	1.39 (1.30, 1.49)**
Sub-region of SSA
Western	1	1	1
Eastern	1.84 (1.71, 1.96)**	0.74 (0.67, 0.82)**	1.23 (1.14, 1.33)**
Central	0.83 (0.75, 0.92)**	0.99 (0.88, 1.13)	0.83 (0.74, 0.92)**
South	1.36 (1.25, 1.47)**	1.74 (1.58, 1.92)**	1.85 (1.70, 2.01)**

^*-P value < 0.05, ** -P value < 0.01, 1-reference category

CI Confidence interval, ITN Insecticide treated net, IPTp Intermittent preventive treatment for pregnant women, SSA Sub-Saharan Africa

Women aged 20 years and above were more likely to use both ITN and IPTp compared to those aged 15–19 years, with adjusted odds ratios across the 20 years and above age categories ranging from approximately 1.25–1.45.

Regarding educational level, pregnant women with primary education were 0.78 times (95% CI 0.73–0.84) less likely to utilize both ITN and IPTp compared to those with no formal education. Similarly, women with higher education had a 0.81 times (95% CI 0.70–0.93) lower likelihood of utilizing both ITN and IPTp than those with no formal education.

Women from female-headed households were 30% less likely (aRR = 0.69; 95% CI 0.65–0.74) to utilize both ITN and IPTp preventive measures compared to those in male-headed households.

Mass media exposure, antenatal care (ANC) visits, rural residence, and being from the Eastern and Southern sub-regions of SSA were all associated with a higher likelihood of utilizing both ITN and IPTp measures (Table 4).

In addition, we conducted a country-stratified analysis to examine significant factors across countries. Among these, antenatal care (ANC) visits were consistently and positively associated with the utilization of both ITN and IPTp. Details on other associated factors for each country are presented in the figure (Fig. 4).

Fig. 4.

Country stratified analysis for associated factors of Both ITN and IPTp utilization among pregnant women in Sub-Sahara Africa (SSA), 2025

Discussion

This study aimed to assess the utilization of both ITN and IPTp measures, as well as their associated factors, among pregnant women in sub-Saharan Africa. The findings showed that 82% of women used at least one preventive measure (either ITNs or IPTp), while 29% used both ITNs and IPTp. In contrast, 18% of pregnant women did not use any malaria prevention methods (neither ITN nor IPTp). In the multilevel multinomial regression analysis, factors such as women's age, educational status, ANC visit, sex of the household head, wealth index, mass media exposure, place of residence, and sub-region within sub-Saharan Africa were identified as significant factors of ITN and IPTp utilization.

Only one-third of pregnant women utilized both ITN and IPTp, and those who did not use both measures missed out on the synergistic benefits of ITN and IPTp. The utilization of both ITN and IPTp in this study is higher than in previous studies [31–33]. One possible explanation for this difference could be the variation in study periods and differences in the operational definitions of IPTp uptake. In this study, IPTp utilization was defined as receiving at least three dose of sulfadoxine-pyrimethamine during pregnancy.

Women aged 20–49 years were more likely to use both ITN and IPTp compared to those aged 15–19 years, as supported by another study [34]. This may be because older women often have more experience with antenatal care (ANC) visits and more frequent interactions with healthcare providers, such as during family planning services. These encounters increase their exposure to health education on malaria prevention. Furthermore, older women may feel more confident in making informed health decisions, which can lead to greater adoption of malaria prevention measures.

Women with primary education were less likely to use both insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp) compared to those who did not attend formal education. This finding may be due to that women with no formal education are often more reliant on public health services, where ITNs and IPTp are provided free of charge during antenatal care. They may also be more likely to follow health professionals’ advice strictly, without questioning or seeking alternative sources of information. In contrast, women with primary education might feel a degree of autonomy in health-related decision-making but may not yet have sufficient health literacy to fully understand the importance of malaria prevention interventions during pregnancy.

Women from female-headed households were less likely to use both ITN and IPTp compared to those from male-headed households. One possible explanation is that male-headed households are often associated with more authoritative decision-making, where rules and health-related choices, including the use of ITN and IPTp, may be more strictly enforced. In contrast, female-headed households might experience more flexibility in these decisions, potentially leading to lower utilization of these preventive measures [35–37]. Another reason could be the gender-related inequality in the SSA region, where women and girls have unequal access to education and economic opportunities [38].

Women in the poorer, middle, or richer wealth categories were less likely to use both ITNs and IPTp compared to those in the poorest category. One possible explanation is that women from the poorest households are more likely to rely on public health services-where ITNs and IPTp are routinely provided free of charge during antenatal care visits-due to higher perceived risk. In contrast, wealthier women may seek care in private facilities, where malaria prevention may not be consistently integrated into routine maternal services. Additionally, public health campaigns often target low-income and rural communities where malaria transmission is highest more intensively, thereby increasing awareness and uptake of government-provided preventive interventions among the poorest groups [39].

Antenatal care (ANC) attendance plays a crucial role in increasing the uptake of insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp) among pregnant women. Women who attend ANC visits regularly are more likely to receive health education from trained professionals, which raises their awareness of malaria risks and the benefits of preventive measures [40, 41]. In many countries, ITNs are also distributed during ANC visits, and IPTp is provided as well, further facilitating access and utilization. Additionally, the trust established between pregnant women and healthcare providers during ANC visits can encourage consistent adherence to recommended malaria prevention practices.

Women who had mass media exposure were more likely to use both ITN and IPTp compared to those who did not, which is consistent with findings from other studies [42, 43]. This may be because mass media serves as a primary channel for disseminating health education initiatives, including malaria prevention campaigns, to a broad audience. Therefore, exposure to mass media platforms such as television and radio plays a crucial role in influencing the adoption of ITN and IPTp.

Women from rural areas were more likely to use both insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp) compared to their urban counterparts. This may be partly explained by rural women’s greater reliance on public health services and their adherence to the advice and guidance provided by health professionals during antenatal care visits. Additionally, targeted distribution campaigns for malaria prevention tools, such as mass ITN distributions, are often prioritized in rural and high-transmission areas, further increasing access and utilization in these settings [44].

From a programmatic perspective, increasing the proportion of pregnant women who utilized both IPTp and ITNs was highly relevant for malaria prevention programs. In our pooled analysis, 71.1% of women did not utilize both interventions, and these women fell into distinct subgroups (only ITN, only IPTp, or none), underscoring the need for tailored strategies. Our country-level findings also revealed substantial heterogeneity in the factors associated with both ITN and IPTp: while ANC uptake consistently showed a positive association across all settings, other factors varied considerably between countries. To enhance coverage of both interventions, national programs might therefore have benefited from more in-depth exploration of their own data to identify context-specific barriers. Such insights could have guided the design and implementation of targeted approaches to move women from utilizing one or no intervention to utilizing both ITN and IPTp.

This analysis used nationally representative Malaria Indicator Survey (MIS) data from multiple countries. The large sample size, combined with the use of standardized and validated data collection instruments and methodologies, enhances the generalizability of the findings. To account for the clustering effect inherent in the data, a multilevel modeling technique was employed. IPTp utilization was assessed based on the World Health Organization's (WHO) recommendation of at least three doses. Nevertheless, the study has some limitations. First, the cross-sectional design precludes the establishment of causal relationships between the outcome and explanatory variables. Second, reliance on self-reported data introduces the potential for recall bias. Third, the analysis was conducted using national-level data for each country. However, in some countries, such as Kenya, malaria prevention policies targeting IPTp interventions are implemented only in specific geographic areas, which may have affected the national-level indicators.

Conclusion

Pregnant women in the Sub-Saharan African region utilize both ITN (Insecticide-Treated Nets) and IPTp (Intermittent Preventive Treatment in pregnancy) at a rate of 29%. The study identified several significant factors influencing ITN and IPTp utilization, including women's age, educational status, number of ANC (Antenatal Care) visits, sex of the household head, wealth index, mass media exposure, place of residence, and sub-region within Sub-Saharan Africa.

Therefore, special attention should be given to those with fewer than four ANC visits and to younger women, especially first-time pregnant women whose utero-placental interface has not previously been exposed to malaria parasites, making them more susceptible, as well as to those with no mass media exposure, residents of urban areas, and households headed by females during malaria prevention interventions. However, our country-level analysis demonstrated substantial variation in the influence of these factors across countries, underscoring the need for national programs to interpret and adapt these findings to their specific contexts. Both individual and community level factors must be considered when developing strategies and implementing programs led by governmental and non-governmental organizations. This comprehensive and context-sensitive approach is essential for achieving the global goal of reducing malaria by 90% by 2030.

Abbreviations

ANC

Antenatal care

ARR

Adjusted relative risk

DHS

Demographic and health survey

ITN

Insecticide treated net

IPTp

Intermittent preventive treatment for pregnant women

ICC

Intra class correlation

PCV

Proportional change in variance

LL

Log likelihood

MIS

Malaria indicator survey

SDG

Sustainable development goal

SSA

Sub-Saharan africa and

WHO

World Health Organization

Author contributions

EAA-developed the concept, reviewed literature, carried out the statistical analysis, interpret and discuss the results, and write the final manuscript. MAT, TYB, SGD, GY, LD and AAT -reviewed literature, involved in the analysis, interpreting and discussing results, and revised the drafted manuscript. All authors read and approved the final manuscript.

Funding

No funding.

Data availability

The data that the authors used to produce this manuscript are available upon reasonable request from demographic and health survey (DHS) cite). (www.dhsprogram.com) The DHS Program is authorized to distribute, at no cost, unrestricted survey data files for legitimate academic research. Registration is required for access to data.

Declarations

Ethics approval and consent to participate

Not applicable—consent from participants is not required since a publicly available dataset was used. Permission to access the data was obtained from the Measure DHS Program (www.dhsprogram.com) via an online request after explaining the purpose of the study. The website and the data used are publicly available and contain no personal identifiers. All methods were carried out in accordance with relevant guidelines and regulations. The DHS also confirmed that informed consent was obtained from all subjects and/or their legal guardians during the primary data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.