The effectiveness of an enhanced antenatal care service package for the control of malaria and anaemia in pregnancy in Ghana

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Background Recommended efficacious interventions for malaria prevention and control during pregnancy have been implemented for over two decades yet malaria and anaemia prevalence during pregnancy remain high. This may be due to sub-optimal uptake of these interventions. Patient participation in their own health care improves health outcomes by improving adherence to treatment recommendations. We conceptualised that when pregnant women participated in their antenatal care it would improve their adherence to antenatal care recommendations and treatment and promote better health outcomes. Methods A cluster randomized controlled trial to assess the effectiveness of pregnant women’s participation in their antenatal care on the risk of malaria and anaemia during pregnancy, the risk of low birth weight and the risk of sub-optimal pregnancy outcomes was conducted. The study was conducted in 14 antenatal clinics (7 clinics per arm) in the Ejisu-Juaben Municipality and Sekyere-East District of the Ashanti Region of Ghana. The intervention consisted of staff showing pregnant women their malaria rapid test and haemoglobin colour scale test results to facilitate their participation in their care in addition to standard antenatal care. The feasibility and acceptability of this intervention to antenatal care staff and pregnant women were also assessed. 6 Results The overall mean age, gestational age and Hb concentration at baseline were 26.4yrs, 17.3 weeks and 11.0 g/dl respectively and similar in both groups; 10.7% had asymptomatic parasitaemia; 74.6% owned an ITN, only 48.8 % sleeping under it the night prior to enrolment. The adjusted risk ratio by 8 weeks of follow up in the intervention vs. control group was 0.97 (95% CI: 0.78-1.22) for anaemia and 1.17 (95% CI: 0.68-2.04) for parasitaemia. At 36-40 weeks gestation, the adjusted risk ratio was 0.92 (95% CI: 0.63-1.34) for anaemia and 0.83 (95% CI: 0.27-2.57) for parasitaemia in the intervention vs. control group. The adjusted risk ratio for low birth weight was 0.93 (95% CI: 0.44-1.97) while that for sub-optimal pregnancies was 0.77 (95% CI: 0.17-3.52). Using the haemoglobin colour scale and malaria rapid test to facilitate participation within routine antenatal care was feasible and acceptable to the pregnant women and staff members. The pregnant women saw and believed the test results and felt motivated to take action to improve their health. Antenatal care staff and pregnant women perceived some improvement in pregnant women’s adherence to antenatal recommendations with regards to malaria and anaemia. Conclusion It was feasible and acceptable for pregnant women to participate in their antenatal care using the malaria rapid test and the haemoglobin colour scale. Their participation appeared to have potential benefit during pregnancy although clear evidence of a biologic effect was not found. The effect may have been diluted out by the concurrent introduction of malaria rapid tests into routine ANC during the time of the study and possible methodological and implementation challenges of the intervention. More research is thus recommended.
A thesis submitted to the School of Graduate Studies, Kwame Nkrumah University of Science and Technology in partial fulfillment of the requirements for the award of the Degree of Doctor of Philosophy in Public Health.