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Adapting community interventions thatsupport 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!

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Basic Malaria in Pregnancy Interventionsand Indicators!

Malaria in pregnancy (MIP)causes anemia, miscarriage,still birth and low birth weight!

To control MIP we mustincrease ! Number of antenatal care

(ANC) visits (where MIPcontrol services provided)!

Use of insecticide-treated nets(ITNs) during pregnancy !

Taking the recommendeddoses of sulphadoxinepyrimethamine (SP) asintermittent preventivetreatment (IPTp)!

2!

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High Risk, Low Coverage!

3!

3

Study area has year-round

malaria transmission!

In Akwa Ibom atbaseline:!

Only 11.7% ofpregnant women hadslept under an ITN!

Only 5.8% of pregnantwomen had received

two doses IPTp!

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Basic Concepts!Malaria in Pregnancy! Coverage of interventions

remains low, despite massiveanti-malaria campaigns.!

Low uptake reflects! lack of knowledge,! poor access, and! limited support of programs by

local communities andauthorities!

To reduce MIP lessons wereadapted from communityservice delivery programs!

Community DirectedIntervention (CDI)! CDI happens when

communities plan andimplement health intervention

with minimal guidance fromthe health system!The Question we addressedwas ! Will CDI increase uptake of

the following malaria inpregnancy services:! ITN use during pregnancy?! number of ANC visits?! taking the recommended two

doses of SP for IPTp?!4!

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CDI works; so why not for MIP?!

5!

For the past 16 years, the African Program forOnchocerciasis Control has used CDI to provide ivermectinsuccessfully in over 100,000 African villages

WHO-supported research showed CDI could beadapted to deliver ITNs and malaria treatment!

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6!

Nigeria MIP Community-Clinic PartnershipIntervention!

CLINIC!MIP

performancestandards

developed and

implemented!

COMMUNITY!MIP skills and

responsibilitiesimplemented

through

community-

directedintervention!

Training,Supervision,

Mobilization,Commodities!

Referrals,

Records,Feedback!

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6 LGAs Selected for Intervention

A: Control Arm!Ikot Abasi, Mbo, MkpatEnin!

Train healthworkers on basic

malaria serviceprovision!

B: Treatment Arm!Eket, Esit-Eket,Onna!

Health workers train &equip CDDs with tools

and intervention drugs!

Supply ITN, SPand malaria casetracking forms tohealth facilities!

C C C C C C C

Two ClusterParallel Group

Design!Train healthworkers on basic

malaria serviceprovision!

Supply ITN, SPand malaria casetracking forms tohealth facilities!

C !Reduce Malaria in

pregnancy

Communi'esservedbyhealth

workersinhealthclinicorCDDs

athome

+

7!

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

8!

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Performance Standards Scores (%) for ANCServices!

0!10!20!30!40!50!60!70!80!90!

Percentof16

Standards

Achie

ved

9!

Massivestafftransfer

Based on 16 Performance Standards!

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Key Findings! ANC visits rose in treatment and control groups

(estimated coefficient on group differences -0.016, 95%CI [-0.107, 0.074], p= 0.646).!

CDI led to substantial, additional increases in ITN useand 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

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Program Impact:!Improved IPTp Uptake! There was general

increase in uptake ofIPTp from baseline toendline assessment!

However, the interventionarm with CDI had greaterincrease of women takingany IPTp (p

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Improved Use of ITN and ANC Attendanceover Time!

28 3

1.

1

68.

9

52

20

49.8

50.

2

44.

2

40

10.

5

89.

5

76.

9

30

28.

1

71.

9

58.

3

0

10

20

30

40

50

60

70

80

90

100

SleptunderITNregularly NoANC AnyANC ANCinGovernmentClinic

ITNUse ANCAendance

BaselineInterven'on Basel ineControl EndlineInterven'on EndlineControl

12!

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Conclusions: CDDs Are on Hand to EncourageITN Use, IPTp Adherence and ANC Attendance!

The results suggest thatcommunity-basedprograms can substantiallyincrease effective accessto malaria prevention inhigh endemic, high burdenareas!

The participatory approachunderlying CDI programs

also promises tostrengthen ties betweenthe formal health sectorand local communities andimprove utilization of

services including ANC!

13!