Our study showed that despite the institution of IPTsp and ITN as the national policy on MIP, only 20% uptake of ITN and 18.5% for IPTsp was documented, with significant use of pyrimethamine monotherapy, and this uptake level is well below the expected target of over 50% in the Nigerian national policy on malaria prevention strategies document [14
]. The study also showed that consumption of traditional herbal medications for prevention of MIP is still a common practice among Nigerian pregnant women. These low uptakes and prevailing use of herbal remedies may have contributed to the high preterm and low birthweight deliveries demonstrated in this study. In spite of the Nigerian national policy and the relative availability of methods for preventing malaria in pregnancy, the poor uptake by mothers could be a result of poor government commitment, inadequate dissemination of information by healthcare workers, lack of knowledge by mothers and inadequate monitoring of implementation or competing priorities within tight budgetary constraints. There is a need, therefore, to ensure adequate dissemination of information to bring about attitudinal change as most of those who did not use these measures had no specific reasons for not doing so.
The adverse consequences associated with MIP [1
] underscore the need for concerted efforts to ensure proper implementation of the national policy as adopted by other nations. Studies to evaluate the reasons for the apparent poor implementation need to be conducted. Compared with Falade et al
], and despite a higher level of educational attainment in the present study group, twice as many mothers admitted to have used herbal preparations to prevent MIP. The higher level of education in the study group is largely accounted for by the mothers from UCH which is less patronized by people of lower socioeconomic status because of cost. Insecticide space spray which costs a lot more in terms of money and effort than ITN and SP was utilized by 71.5% of participants and was associated with a protective effect on preterm delivery but was not associated with any significant protective effect on low birthweight risk. It may give mothers a false sense of security. The fact that such a large proportion of pregnant mothers actually make the effort to protect themselves against malaria suggests that if they were better informed about the efficacy of IPTsp and ITN with accessibility and affordability, the uptake level might be much improved.
The LBW and preterm deliveries in this study, as in Dolan et al
], were similar in those who slept under ITN and those who did not. Estimates for protective effectiveness of self-reported use of ITNs gave values for reduction of low birthweight at 22% (95% CI, 17.7-26.4), but lower than for SP use [16
]. The present study showed that the non-utilisation of IPTsp for MIP was associated with about twice increased risk of having low birth weight babies and preterm deliveries after adjusting for the effects of maternal age and parity. Previous studies have shown that the mean birth weights were significantly higher, and incidence of LBW significantly lower, in babies born to mothers who had received two or three doses of sulfadoxine-pyrimethamine treatment than those seen in babies born to women who had had just one dose [16
], and that use of three doses of IPTsp is associated with a reduction in population-attributable risk of LBW in primigravidae from 34.6% to 0% [17
]. This study, as in an earlier report from Ibadan, showed that the mean birthweight and gestational age of babies delivered to mothers who used IPTsp in pregnancy were higher than any other form of prevention.
The mean birth weight was significantly higher and risk of preterm delivery reduced by half among those who did not use herbal preparations. Though the contents of the traditional medication consumed are unknown and these authors are unaware of previous documentation of the impact of traditional medications, this present study therefore highlights the need to discourage the use of traditional herbal medication through improved health education and promotion before and during pregnancy.
The financial burden of managing preterm, low birthweight deliveries in developing countries can be prohibitive compared with the cost of preventing these poor outcomes. Tongo et al
] in Ibadan showed that cost of managing LBW babies can range between 22% and 3000% of combined parental monthly income where the cost of prevention of LBW and prematurity especially those associated with MIP may be as low as 1% of family income. It is therefore imperative that efforts geared towards promotion of utilization of proven effective preventive strategies should be enhanced. The commitment of government and other relevant authorities in promoting safe motherhood and roll back malaria should be enhanced by ensuring implementation of the existing policy and monitoring.
The study relied solely on self reported use of malaria preventive measures as indicator of utilization and this may have some limitations in the interpretation of the actual effects of these measures on pregnancy outcomes. Though the different social classes in the population were represented in this study, care has to be taken in extrapolating data to the whole population. The study excluded mothers who delivered on weekends, but it is not expected that the subjects' characteristics would differ whether they delivered on weekdays or weekends.