Objective: (i) Highlight field realities on proportions of parturient mothers who use during pregnancy intermittent preventive treatment-sulfadoxine-pyrimethamin (IPT-SP) without insecticide-treated net (ITN), IPT-SP in combination with ITN or ITN without IPT-SP; (ii) investigate associations existing between these preventive approaches with low prevalence of peripheral parasitemia, placental malaria, low birth weight (LBW) and anemia. Materials and Methods: Proportions of parturient mothers who utilize any of these approaches during pregnancy were estimated as well as associated rates of peripheral parasitemia, placental malaria, anemia and LBW; associations were investigated by comparing each group with participants who never utilized IPT-SP or ITN during pregnancy. Results and Conclusions: Of the 705 participants, 121 (17.2%) never used IPT-SP or ITN during pregnancy; 83 (11.8%) utilized ITN without IPT-SP and 501 (71.0%) utilized IPT-SP of those, 97% used IPT-SP1 and 3% used IPT-SP2/SP3. 275 (39%) used IPT-SP without ITN and 226 (32%) used IPT-SP in combination with ITN. While significant associations were found between: (i) Combined utilization of IPT-SP with ITN and low prevalence of peripheral parasitemia, placental malaria and LBW, (ii) utilization of IPT-SP without ITN and low prevalence of LBW and (iii) utilization of ITN without IPT-SP and low prevalence of placental malaria, no associations were seen between any of these approaches and low prevalence of anemia. Neither IPT nor ITN alone reduced as much adverse outcomes as when used together in combination, suggesting that in areas of moderate or high transmission of malaria, combined utilization of IPT-SP1/SP2 with ITN was the most effective approach for malaria prevention in pregnancy.
Keywords: Insecticide-treated net, IPT-SP, prevalence of mother and birth outcomes
Malaria in pregnancy has adverse outcomes on mothers and fetus.  Protection with intermittent preventive treatment using sulfadoxine-pyrimethamine (IPT-SP) and/or insecticide-treated net (ITN) reportedly reduces adverse outcomes. , Despite differences in their protective mechanisms, both approaches, IPT-SP and ITN, are proven effective in reducing the prevalence rate of peripheral parasitemia, placental malaria, low birth weight (LBW) and anemia among parturient mothers. ,,,, Although the protective effect of ITN lies in prevention of infection, IPT-SP effect is built on precluding asymptomatic cases, especially in areas where Plasmodium falciparum transmission is moderate or high. It is for these reasons that World Health Organization advocates the use of both approaches to ensure the best possible protection against malaria in pregnancy, thus recommending all pregnant women to sleep under ITN and to receive one dose of IPT-SP (IPT-SP1) at the first antennal clinic visit after quickening (first noted movement of the fetus) and during each scheduled visit thereafter or, ideally 2 doses or IPT-SP2 for women who are human immunodeficiency virus (HIV) negative. , Unfortunately, in resource poor endemic areas, usage of IPT-SP2 is often a nightmare. Many women cannot revisit antennal clinics in advanced pregnancy because of walking distance to the health center, bad road conditions or simply the erratic availability of SP and gap on appropriate timing for IPT with SP;  thus the majority of them end up in the labor room with a utilization record of: IPT-SP1 without ITN, IPT-SP1 in combination with ITN or ITN utilization without IPT-SP. Whether or not these utilization approaches are effective in reducing adverse mother or birth outcomes is little understood to date. Available data on IPT-SP effectiveness seem to be more from randomized studies ,, in which participants were assigned to predefined SP intervention and placebo groups then followed-up until delivery. ,, These studies can therefore not reflect field realities of endemic areas where parturient mothers hardly utilized IPT-SP2 due to various barriers.  To highlight ITN and IPT-SP utilization patterns in resource poor endemic areas and associated adverse mother or birth outcomes, we collected data from 705 parturient mothers in a poor neighborhood maternity ward of Kinshasa, DRC, with intentions to:
The study was conducted, in a maternity ward, located in the hilly landscape of southwestern Kinshasa, DRC and a part of the city distinguishable by its eroded soil and gullying, which makes walking difficult for people with limited mobility. Characteristics of hospitals or maternity wards of Kinshasa were as described by Tshikuka and collaborators.  In summary, the maternity has 100 beds; 1 doctor and 32 nurses deliver services to an average of 20 parturient mothers admitted daily to these facilities. The maternity lacked a surgery room and women needing cesarean section were referred to other facilities. About 1006 women gave birth in this maternity ward during the study period; of those, 705 consented and were recruited in the study.
A clinical exam was conducted on participants, their age, weight and body temperature were recorded. Finger prick blood samples were taken, as well as placental and umbilical cord blood; blood films were prepared and transferred to the National Institute of Biomedical research, Kinshasa for laboratory tests by thick and thin blood film under light microscopes (×1000). Babies were weighed to the nearest gram using an electronic weighing scale, neonatal birth weight of bellow 2,500 g were classified as LBW. HemoCue photometer was used for hemoglobin testing and women with readings of <11 g/dL were regarded as cases of anemia.
We also examined antenatal clinic records and collected the following from every participant: number of IPT-SP doses utilized during pregnancy; whether or not the woman slept under ITN during pregnancy, number of gravidities, neighborhood of residence and date of delivery. No data on HIV status were collected.
Data handling and processing
Data were processed and analyzed using Epi data 3 (CDC, Atlanta, Georgia, USA) and SPSS 12 (Gorinchem, Netherlands). Proportions of parturient mothers who have utilized IPT-SP in combination with ITN during pregnancy, of those who have utilized IPT-SP or ITN as a single preventive approach and the proportion of parturient mothers who did not use IPT-SP or ITN during pregnancy (control group) were assessed. The prevalence rate of peripheral parasitemia, placental malaria, anemia and LBW were estimated in each group; associations between each preventive approaches and low prevalence of adverse mother or birth outcomes were investigated by comparing the comparison group to:
The study was approved by the Ethical Committee of the School of Public Health of the University of Kinshasa, DRC. The Committee is mandated by the government of DRC to provide general oversight and ethical approval for research studies involving human and/or human substances throughout DRC.
Of 705 parturient mothers recruited in the study (median age: 28 years, interquartile range: 23-32 years), 121 (17.2%) never used IPT-SP or ITN during pregnancy (comparison group); 83 (11.8%) utilized ITN without IPT-SP and 501 (71.0%) utilized IPT-SP, of those, 97% used IPT-SP1, 2.8% utilized IPT-SP2 and only 0.2 utilized IPT-SP3. 275 (39%) used IPT-SP without ITN and 226 (32%) used IPT-SP in combination with ITN. 15 (2.0%) of parturient mothers had a fever or clinical malaria during labor, 190 (27%) had peripheral parasitemia, 106 (15%) had placental malaria, 382 (54.2%) had HemoCue readings of <11 g/dL and were considered as anemic and 53 (7.5%) had babies with LBW; none of the outcomes under study were affected by the number of gravidities. 97.6% of parturient mothers lived in low income neighborhoods of the maternity catchment’s area and only 2.4% of them came from other low income neighborhoods of Kinshasa.
Data presented in [Table 1] shows a significantly (P < 0.05) lower prevalence of peripheral parasitemia among parturient mothers who utilized IPT-SP in combination with ITN during pregnancy compared to the comparison group. No significant (P > 0.05) difference is observed between the comparison group and parturient mothers who utilized IPT-SP without ITN, or parturient mothers who utilized ITN without IPT-SP during pregnancy.
The prevalence of placental malaria in [Table 2] is significantly (P < 0.05) lower among parturient mothers who utilized IPT-SP in combination with ITN and among those who utilized ITN without IPT-SP during pregnancy compared with the comparison group; no significant (P > 0.05) difference is seen between the comparison group and parturient mothers who utilized IPT-SP without ITN.
As shown in [Table 3] results indicate no significant (P > 0.05) difference in the prevalence of anemia between parturient mothers who utilized any of the three preventive approaches and the comparison group.
Data presented in [Table 4] shows mothers who utilized IPT-SP in combination with ITN and those who utilized IPT-SP without ITN during pregnancy with a significant (P < 0.05) low prevalence of LBW babies compared to the comparison group; no significant (P > 0.05) difference is observed between the comparison group and parturient mothers who utilized ITN without IPT-SP during pregnancy.
We analyzed data from 705 parturient mothers and found that 71% of them have used IPT-SP during pregnancy; of them, only 3% utilized IPT-SP2 or IPT-SP3, the majority, or 97%, used IPT-SP1. Nearly 39% utilized IPT-SP without ITN, 32% used IPT-SP combined with ITN, 11.8% utilized ITN without IPT-SP and 17.2 did not used ITN or IPT-SP. Significant associations were revealed between
Outstanding finding in this study was that combined utilization of IPT-SP with ITN was the most effective protective strategy against adverse mother or birth outcomes, given its association with low prevalence of 3 of the 4 outcomes under investigation. Such associations were unexpected since 97% of parturient mothers had utilization records of only IPT-SP1. The required IPT-SP2, , was used by only 3% of participants. Even though reports of a single dose of SP as an effective drug for prevention of malaria in pregnancy are in the literature,  such a protective effect has been shown only in areas where P. falciparum were still sensitive to SP.  In areas where P. falciparum is resistant to SP, as in Kinshasa, only IPT-SP2 is known to provide protection against malaria during pregnancy, when used alone or in combination with ITN. , To the best of our knowledge, this is the first report in the region showing associations between IPT-SP1 combination with ITN and low prevalence rates of peripheral parasitemia, placental malaria and LBW. Neither IPT nor ITN reduced the prevalence of so many adverse mother or birth outcomes under investigation, except when they were used together in combination, which clearly suggest that in areas of moderate or high transmission of P. falciparum, the most effective preventive approach for malaria in pregnancy is the combined utilization of IPT-SP1/SP2 with ITN.
The fact that none of the utilization approaches investigated was associated with low prevalence of anemia among parturient mothers is simply an indication that though malaria is known to cause anemia in endemic areas,  hemoglobin deficiency observed among more than 54% of parturient mothers in this study likely resulted from other causes, such as malnutrition due to low socioeconomic status of populations; , the reason why utilization of IPT-SP and/or ITN during pregnancy failed to reduce the prevalence of anemia. Other studies in endemic areas also failed to associate IPT-SP or NTN use with low prevalence of anemia and thus corroborate our findings. 
However, the pooling of IPT-SP2, IPT-SP3 and IPT-SP1 groups in a single IPT-SP cluster in this study may have led to an overestimation of outcomes and be a limiting factor; but since only 3% of parturient mothers had records of IPT-SP2/SP3, it is with no doubt that associations observed herein are primarily attributable to IPT-SP1 effects even though IPT-SP2/SP3 might have played a role. On the other hand, the non-stratification of participants into cigarette smokers and non-smokers cannot affect the result on LBW prevalence given the abstinence from cigarette smoking among women in this cultural community. 
In short, this study has provided bases for policy and decision making on suitable approaches for controlling malaria during pregnancy in resource poor endemic areas. We hope that more studies of similar design will be conducted to confirm these findings. In the meantime, efforts should be focused on promoting utilization of IPT-SP1/SP2 combined with ITN in a single package as part of routine antenatal clinic health interventions in endemic areas.
We are gratefully acknowledge the technical support received from the National Malaria Control Program (PNLP) and the National Biomedical Research Institute (INRB), Kinshasa. We express our deepest gratitude to Mr. Mulumba Tshikuka Jr., Writer, for excellent editing. Special thanks go to all health professionals of Mbinza Delvaux maternity ward and to parturient mothers for their contribution and collaboration.
Source of Support: DGIS-ITG Raamakkord, Belgian Cooperation., Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]