DHS ANALYTICAL 

STUDIES 39

PREVENTING Malaria DURinG 

Pregnancy in Sub-Saharan Africa:

Determinants of effective IPTp Delivery

SEPTEMBER 2013

This publication was produced for review by the United States Agency for International Development. It was prepared by 

Lia Florey of ICF International, Calverton, Maryland, USA.
MEASURE DHS assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. Additional information about the MEASURE DHS project can 

be obtained by contacting MEASURE DHS, ICF International, 11785 Beltsville Drive, Suite 300, 

Calverton, MD 20705 (telephone: 301-572-0200; fax: 301-572-0999; e-mail: reports@measuredhs.com; 

internet: www.measuredhs.com). 

The main objectives of the MEASURE DHS project are: 

• to provide decision-makers in survey countries with information useful for informed policy choices 

• to expand the international population and health database 

• to advance survey methodology and 

• to develop in participating countries the skills and resources necessary to conduct high-quality demographic 

and health surveys 
DHS Analytical Studies No. 39

Preventing Malaria during Pregnancy in Sub-Saharan Africa: 

Determinants of Effective IPTp Delivery 

Lia Florey 

ICF International 

Calverton, Maryland, USA 

September 2013 

Corresponding author: Lia Florey, International Health and Development, ICF International, 11785 Beltsville 

Drive, Calverton, Maryland 20705, USA; Phone: +1 301-572-0922; Fax: +1 301-572-099; 

E-mail: Lia.Florey@icfi.com 
Acknowledgment: The author would like to thank Cameron Taylor for her invaluable assistance in 

producing maps and figures, Jessica Yi for help formatting tables, and Erin Eckert and Julie Gutman for 

expert advice, and guidance on methods and presentation. Rebecca Winter, Cameron Taylor, Erin Eckert 

and Susan Youll also provided invaluable feedback. 

Editor: Ward Rinehart, Jura Editorial Services 

Document Production: Yuan Cheng 

This study was carried out with support provided by the United States Agency for International 

Development (USAID) through the MEASURE DHS project (#GPO-C-00-08-00008-00). The views 

expressed are those of the authors and do not necessarily reflect the views of USAID or the United States 

Government. 

Recommended citation: 

Florey, Lia. 2013. Preventing Malaria during Pregnancy in Sub-Saharan Africa: Determinants of 

Effective IPTp Delivery. DHS Analytical Studies No. 39. Calverton, Maryland, USA: ICF International. 
iii 

Contents 

List of Tables ............................................................................................................................................... v 

List of Figures ............................................................................................................................................. vi 

Preface ........................................................................................................................................................ vii 

Executive Summary ................................................................................................................................... ix 

Introduction ................................................................................................................................................. 1 

Methods ........................................................................................................................................................ 5 

Data ...................................................................................................................................................... 5 

Variables ............................................................................................................................................... 7 

Analyses ................................................................................................................................................ 9 

Results ........................................................................................................................................................ 13 

Descriptive Analyses ........................................................................................................................... 13 

Descriptive Analyses—Antenatal Care ............................................................................................... 15 

Descriptive Analyses—IPTp Coverage ............................................................................................... 20 

Service Effectiveness Analyses ............................................................................................................ 23 

Determinants of IPTp .......................................................................................................................... 25 

Comparative Analyses of Lower and Higher IPTp Coverage Countries ............................................ 31 

Discussion .................................................................................................................................................. 35 

References .................................................................................................................................................. 39 

Appendix .................................................................................................................................................... 43 

v 

List of Tables 

Table 1. Information on populations included in analyses: survey information, national population 

size, sample size of target populations ......................................................................................... 5 

Table 2. Basic information on variables included in analyses .................................................................... 8 

Table 3. Percent distribution of socioeconomic, demographic, and health variables in recently 

pregnant women age 15-49 years from multi-country, pooled survey data ............................... 13 

Table 4. Percent distribution of ANC care seeking and service variables among recently pregnant 

women age 15-49 years who made at least one ANC visit, from multi-country, pooled 

survey data .................................................................................................................................. 15 

Table 5. Mean number of ANC visits among recently pregnant women age 15-49 years who made 

at least one ANC visit, by survey ............................................................................................... 18 

Table 6. Mean months of gestation at first ANC visit among recently pregnant women age 15-49 

years who made at least one ANC visit, by survey .................................................................... 19 

Table 7. Stepwise summary of service effectiveness of malaria in pregnancy interventions (IPTp 

and ITN use by pregnant women), stratified by lower IPTp coverage and higher IPTp 

coverage surveys ......................................................................................................................... 25 

Table 8. Results of pooled, univariate and adjusted, multivariable logistic regression models of 

IPTp1 use among women age 15-49 years with a live birth in the past two years who made 

at least one ANC visit during the most recent pregnancy ........................................................... 27 

Table 9. Results of pooled, univariate and adjusted, multivariable logistic regression models of 

IPTp2 use among women age 15-49 years with a live birth in the past two years who made 

at least one ANC visit during the most recent pregnancy ........................................................... 29 

Table 10. Comparing groups of higher and lower IPTp coverage countries by percent distributions of 

health intervention and ANC service-related determinants of IPTp2 among recently 

pregnant women age 15-49 years who made at least one ANC visit .......................................... 32 

Table A.1. Percentage of recently pregnant women age 15-49 years who made at least one, at least 

two, and at least four ANC visits, by survey .............................................................................. 44 

Table A.2. Percentage of recently pregnant women age 15-49 years who made at least one ANC 

visit, by number of ANC visits and by survey ............................................................................ 45 

Table A.3. Percentage of recently pregnant women age 15-49 years who made at least one ANC 

visit, by timing of first ANC visit and by survey........................................................................ 46 

Table A.4. Percentage of recently pregnant women age 15-49 years who took SP, by dose, by 

survey, and by higher and lower IPTp coverage countries ......................................................... 47 
vi 

List of Figures 

Figure 1. Service effectiveness framework for IPTp, adapted from Tanahashi, 1978 ................................. 3 

Figure 2. Conceptual framework: Factors influencing effective delivery of interventions to prevent 

malaria in pregnancy .................................................................................................................... 4 

Figure 3. Countries with survey data included in analyses .......................................................................... 6 

Figure 4. Standard IPTp questions from nationally representative household surveys (DHS/MIS) .......... 10 

Figure 5. Formula for calculating intermediate and cumulative effectiveness of malaria in pregnancy 

intervention delivery (adapted from Hill et al., 2013a) .............................................................. 11 

Figure 6. Percentage of recently pregnant women age 15-49 years making antenatal care visits by 

country and by number of visits ................................................................................................. 16 

Figure 7. Among recently pregnant women age 15-49 years who made at least one ANC visit, 

distribution of the number of visits, by survey ........................................................................... 17 

Figure 8. Distribution of timing of first ANC visits among recently pregnant women age 15-49 

years who made at least one ANC visit, by survey .................................................................... 19 

Figure 9. Percentage of recently pregnant women age 15-49 years receiving SP by number of doses 

and by survey .............................................................................................................................. 20 

Figure 10. Surveys with lower IPTp coverage (<20%) and with higher IPTp coverage (≥20%) among 

recently pregnant women age 15-49 years ................................................................................. 21 

Figure 11. Percentages of recently pregnant women age 15-49 years receiving SP, by dose and 

gestational age, in multi-country pooled estimates from 16 countries with surveys between 

2007 and 2011 ............................................................................................................................ 22 

Figure 12. Percentages of recently pregnant women age 15-49 years receiving SP, by dose and 

number of ANC visits in multi-country, pooled estimates from 16 countries with surveys 

between 2007 and 2011 .............................................................................................................. 22 

Figure 13. Stepwise summary of cumulative service effectiveness of malaria in pregnancy 

interventions (IPTp and ITN use by pregnant women), stratified by lower IPTp coverage 

and higher IPTp coverage surveys .............................................................................................. 24 

Figure 14. In higher and lower IPTp coverage countries, percent distributions of determinants of 

IPTp2 in recently pregnant women age 15-49 years who made at least one ANC visit ............. 33 

Figure A.1. IPTp intervention districts in Kenya 2008, Madagascar 2008, and Zimbabwe 2010-11 ......... 43 
vii 

Preface 

One of the most significant contributions of the MEASURE DHS program is the creation of an 

internationally comparable body of data on the demographic and health characteristics of populations in 

developing countries. 

The DHS Comparative Reports series examines these data across countries in a comparative framework. 

The DHS Analytical Studies series focuses on analysis of specific topics. The principal objectives of both 

series are to provide information for policy formulation at the international level and to examine 

individual country results in an international context. 

While Comparative Reports are primarily descriptive, Analytical Studies provide in-depth, focused 

studies on a variety of substantive topics. The studies are based on a varying number of data sets, 

depending on the topic being examined. These studies employ a range of methodologies, including 

multivariate statistical techniques. 

MEASURE DHS staff, in conjunction with the U.S. Agency for International Development (USAID), 

selects the topics covered in Analytical Studies. 

It is anticipated that the DHS Analytical Studies will enhance the understanding of analysts and 

policymakers regarding significant issues in the fields of international population and health. 

Sunita Kishor 

Project Director 

ix 

Executive Summary 

Malaria infection during pregnancy leads to adverse health outcomes for both mothers and infants. 

Intermittent preventive treatment during pregnancy (IPTp) of at least two doses of sulphadoxinepyrimethamine (SP), administered at antenatal care (ANC) visits, is an effective prevention intervention 

in malaria-endemic areas. Despite increasing investment in IPTp programs across malaria-endemic subSaharan African countries over the past decade, and despite high rates of attendance at ANC visits, use of 

IPTp remains low. Identifying factors associated with successful delivery of IPTp may help guide 

improvements in intervention programs. To this end, this study compares IPTp delivery processes and 

socio-demographic and behavioral factors related to successful delivery and use of IPTp in countries with 

different levels of IPTp coverage. 

Objectives 

This study has three objectives: 

1) Assess the cumulative and intermediate effectiveness of the IPTp delivery system 

2) Identify determinants of IPTp use 

3) Compare determinants of IPT delivery and use in countries with lower IPTp coverage and those with 

higher coverage 

Methods 

To identify bottlenecks in IPTp delivery, service effectiveness analyses were performed on data from 16 

Demographic and Health Surveys (DHS) and Malaria Indictor Surveys (MIS) conducted between 2007 

and 2011 in sub-Saharan African countries with endemic malaria. Both cumulative and intermediate 

effectiveness were measured. Multi-country, pooled, multivariate logistic regressions were used to 

identify determinants of IPTp1 (that is, at least one dose of SP) and IPTp2 (at least two doses of SP). To 

identify any differential patterns, distributions of key determinants were compared for lower IPTp 

coverage countries (<20% IPTp use) and higher IPTp coverage countries (≥20% IPTp use). 

Results 

IPTp was effectively delivered for only 18% of targeted women. Access to ANC services was not 

identified as a major reason for this low rate, however. In fact, 83% attended ANC at least once and 97% 

of those receiving one dose of SP attended ANC twice. The main problem appears to be that levels of SP 

delivery to those attending ANC was low: 42% of those attending one ANC visit received one SP dose, 

and 57% of those attending two ANC visits received two SP doses. 

Intermediate and cumulative effectiveness of IPTp delivery systems varied substantially between higher 

and lower IPTp coverage countries. Determinants of IPTp1 and IPTp2 use included number of ANC 

visits, receipt of other maternal health interventions, and malaria transmission level. Individual sociodemographic factors such as marital status, mother’s education, and mother’s age were associated with 

IPTp1 but were not significantly associated with IPTp2 in multivariate models. Distribution of key 

determinants varied significantly between women in lower IPTp coverage countries and those in higher 

IPTp coverage countries. Women in higher coverage countries made fewer ANC visits, attended ANC for 

the first time earlier in gestation, and were more likely to use ANC services at public or religious facilities 

than were women in lower coverage countries. Women in higher IPTp coverage countries were less likely 
x 

to live in areas of highest malaria risk and more likely to live in areas of intermediate risk than were 

women from lower IPTp coverage countries. 

Conclusions 

IPTp is not being effectively delivered in malaria-endemic countries of sub-Saharan Africa. Most 

pregnant women are obtaining ANC services at sufficient frequency and appropriate timing to permit 

IPTp delivery, but the intervention is not being effectively delivered in these settings. Number and timing 

of ANC visits as well as type of health facility are important predictors of IPTp delivery, as is malaria 

transmission risk. Surprisingly, women in high malaria transmission areas are less likely to use IPTp than 

those in low transmission areas, suggesting a need for reallocation of resources. Women in lower IPTp 

coverage countries attended more ANC visits than women in higher IPTp coverage countries, providing 

further evidence of the relative importance of behavioral or service-related factors other than ANC 

attendance in determining the effectiveness of IPTp delivery. Further study of interactions between 

women and providers at the health facilities will be necessary to design improvements in the delivery of 

this life-saving intervention. 
1 

Introduction 

Although great progress has been made in the fight to reduce malaria in recent years, malaria still kills 

655,000 people every year and infects as many as 219 million (World Health Organization, 2012b). 

Pregnant women are particularly susceptible to malaria, which elevates the risk of poor health outcomes 

for mothers and children alike (Brabin, 1983; Guyatt and Snow, 2004; Lindsay et al., 2000; Steketee et 

al., 2001). Placental parasitemia can cause maternal anemia (Guyatt and Snow, 2001a) and low birth 

weight (Brabin, 1983; Guyatt and Snow, 2004), both of which are risk factors for neonatal mortality 

(Guyatt and Snow, 2001b; Marchant et al., 2004). As millions of pregnancies occur every year in malariaendemic countries, the scope and severity of the potential adverse health outcomes makes prevention of 

malaria in pregnant women an important priority. In 2007 approximately 32 million pregnancies occurred 

in malaria-endemic regions of sub-Saharan Africa (Dellicour et al., 2010). 

The World Health Organization (WHO) recommends a three-pronged approach to malaria prevention and 

control in areas of stable malaria transmission in Africa, including use of insecticide-treated bednets 

(ITNs) and intermittent preventive treatment (IPTp) for malaria prevention as well as timely and effective 

management of clinical malaria and anemia (World Health Organization, 2012a). These interventions 

commonly are provided through existing antenatal care (ANC) programs. ITNs are also distributed 

through mass house-to-house campaigns. Current IPTp guidelines recommend one dose of sulphadoxinepyrimethamine (SP) at each ANC visit after the first trimester, with at least one month between doses 

(World Health Organization, 2012a). Use of both ITNs and IPTp during pregnancy leads to reduced risk 

of disease and of adverse birth outcomes (Eisele et al., 2012; Gamble et al., 2007; Menéndez et al., 2010), 

and both have been shown to be cost-effective interventions (Sicuri et al., 2010; van Vugt et al., 2011). 

Due to the effectiveness of these interventions and the risk 

associated with inaction, the Roll Back Malaria (RBM) 

Partnership has set goals of 100% coverage of IPTp and of 

ITN use by 2015 (Roll Back Malaria Partnership, 2011). 

Unfortunately, many countries are far from achieving that 

goal. A recent review of nationally representative survey 

data from 2009-2011 from sub-Saharan Africa reported that 

median coverage of interventions for malaria in pregnancy was low (21.5% for IPTp and 38.8% for use of 

ITNs among pregnant women) despite high use of ANC services (75.1% of women attended at least two 

ANC visits) (van Eijk et al., 2013). 

Patterns of access to and delivery of interventions to prevent malaria in pregnancy are not homogenous. 

Some countries have made great progress in reaching RBM goals, while others have struggled. For 

example, Malawi, Zambia, and Senegal have invested in integration of reproductive health and malaria 

control programs to address malaria in pregnancy through focused antenatal care (FANC)1

 (Sethi et al., 

2011; Wallon et al., 2011; Wallon et al., 2010). In 2002 WHO recommended FANC in lieu of the highrisk approach to ANC, with an aim to provide evidence-based interventions for all women at critical times 

in pregnancy (Villar et al., 2002). FANC programs in these countries have contributed to increased uptake 

of IPTp, although coverage still lags behind RBM goals. 

 

1 FANC is defined as the minimum package of evidence-based services to all pregnant women during ANC to 

promote health, detect existing diseases, prevent and detect complications of pregnancy, and encourage birth 

preparedness. Source: World Health Organizations (WHO). Antenatal Care Randomized Trial: Manual for the 

Implementation of the New Model. Geneva, WHO, 2002. http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.30.pdf

The Roll Back Malaria Partnership has 

set goals of 100% coverage of IPTp 

and of ITN use by 2015. 

Unfortunately, many countries are far 

from achieving that goal. 
2 

Identifying factors associated with higher IPTp coverage may help direct needed changes to intervention 

programs and thus lead to increases in coverage. This topic has received increasing attention in the 

literature of late, although most papers have been country-specific. For example, Webster and colleagues 

recently published several papers about IPTp in Segou region, Mali, analyzing health service 

effectiveness as it relates to prevention of malaria in pregnancy with IPTp (Webster et al., 2013a; Webster 

et al., 2013b). The authors identified gestational age, the amount of expenditure during ANC visits, and 

the woman’s current health status to be predictive of effective delivery of the intervention (Webster et al., 

2013b). Health system factors found to discourage effective IPTp intervention included complex policy 

guidelines, lack of guidance on implementation, and institutional practices (Webster et al., 2013b). A 

similar study in Nyando District, Kenya, concluded that IPTp was not being effectively delivered and that 

the lack of effective delivery reduced the potential impact of the intervention by 231 low birth weight 

babies per 10,000 pregnant women (Hill et al., 2013a). As was found in other settings (Anders et al., 

2008; Gross et al., 2011; Marchant et al., 2008; Sangaré et al., 2010), this study concluded that health care 

providers’ practices were more important than women’s ANC attendance in determining the effectiveness 

of the intervention delivery. A very recent systematic review and multi-country meta-analysis identified 

education, knowledge about malaria and IPTp, socioeconomic status, parity, and number and timing of 

ANC visits as key predictors of IPTp coverage (Hill et al., 2013b). Barriers to effective IPTp delivery 

included unclear IPTp policies, stockouts, user fees, poor performance of health care providers, and poor 

ANC attendance. 

As IPTp is an intervention that is typically administered 

through formal health sector channels, it can be evaluated 

through a service effectiveness framework. Service 

effectiveness was described by Tanahashi as the result of 

interaction between a service and a target population over a 

range of processes beginning with resource allocation and 

ending in effective administration of an intervention (Tanahashi, 1978). Tanahashi conceived of this 

process as involving several stages, each with its own coverage measure, such that service effectiveness 

was ultimately a cumulative measure of the coverage of each separate stage. Examination of specific 

coverage for each stage allows identification of bottlenecks and permits further analyses of factors 

contributing to low coverage at any stage. Extensions of this framework have been developed by the 

malERA Consultative Group on Health Systems and Operational Research (2011) and by Webster and 

colleagues (Webster et al., 2010) and have been employed by other researchers to investigate the 

effectiveness of IPTp delivery systems (Hill et al., 2013a; Webster et al., 2013a). A variation of 

Tanahashi’s original framework is employed here to provide a general overview of the service delivery 

processes relevant to IPTp (Figure 1). 

As this study uses household survey data, it is not possible to evaluate some of the steps in Tanahashi’s 

framework. For example, household survey data allow estimation of the target population and of the 

percentage of the target population that accessed ANC services (contact coverage) and the percentage of 

women who received effective IPTp intervention (effectiveness coverage). Survey data do not, however, 

allow estimation of the percentage of the target population with access to services (availability coverage) 

or the percentage that are willing to use services (acceptability coverage). A second, more detailed 

framework was developed based on Hill and colleagues’ design (Hill et al., 2013a) to home in on the 

specific processes that comprise the contact coverage and the effectiveness coverage in delivery of IPTp 

and to specify the factors likely to affect these processes (Figure 2). The framework includes factors 

previously mentioned that have been shown to be associated with uptake of IPTp, focusing on those that 

can be measured using household survey data. Unfortunately, few service-related factors are explicitly 

measured in standard nationally representative household surveys, and thus data used in these analyses 

are limited to individual characteristics of women and their households. These factors, such as maternal 

age, parity, use of other health interventions, household residence, level of endemic malaria risk, etc., are 

Service effectiveness is ultimately a 

cumulative measure of the coverage 

of each separate stage in the service 

delivery process. 
3 

likely to affect both a woman’s use of health services and uptake of interventions administered through 

these services, as indicated in the framework. 

This study aims to use a service effectiveness framework to better understand the determinants and 

processes that predict successful IPTp intervention programs in sub-Saharan Africa. Specifically, 

nationally-representative household survey data were used to: 

1) Assess the cumulative and intermediate effectiveness of the IPTp delivery system 

2) Identify determinants of IPTp use 

3) Compare determinants of IPT delivery and use in countries with lower IPTp coverage and those with 

higher coverage 

Figure 1. Service effectiveness framework for IPTp, adapted from Tanahashi, 1978

Target Population: Women with a live birth in the past two years in 

malaria endemic regions

Availability Coverage: Women with access to ANC services 

Acceptability Coverage: Women who are willing to use ANC 

services

Contact Coverage: Women who actually use ANC 

services

Effectiveness Coverage: Women who 

receive effective IPTp intervention
4 

Figure 2. Conceptual framework: Factors influencing effective delivery of interventions to prevent 

malaria in pregnancy 

The yellow section represents factors related to pregnant woman. The blue section represents health system and 

health care provider factors. The green section represents interaction between pregnant woman factors and health 

system and health provider factors. Adapted from Hill et al., 2013a. 

 

Woman attends ANC Woman attends ANC 

again 

Takes 1st dose SP Takes 2nd dose SP Takes 2 doses SP and 

uses ITN 

Given 1st dose SP Given 2nd dose SP Given ITN via ANC 

Health System: Facility hours; trained staff; available medications; potable water and cups; fee for 

IPTp/ANC services. 

Health Care Provider Factors: Knowledge of guidelines; follows guidelines; attitude toward clients. 

Pregnant Woman Factors: Maternal age; marital status; educational level; parity; gestational age at 

first ANC visit; use of other health interventions; socioeconomic status; malaria knowledge; urban or 

rural residence; malaria transmission risk. 
5 

Methods 

Data 

All nationally representative household surveys—Demographic and Health Surveys (DHS) and Malaria 

Indicator Surveys (MIS)—conducted between 2007 and 2011 for which data on IPTp and health-seeking 

behavior for ANC were available were included in the analyses. In cases of more than one available 

dataset for a country, the most recent survey was used except where the most recent dataset excluded key 

variables. In total, 16 surveys were included (Table 1; Figure 3). Unfortunately, most MIS do not include 

detailed questions on ANC visits for recently pregnant women. 

In Kenya, Madagascar, and Zimbabwe, IPTp implementation programs were not national in scale at the 

time of the most recent survey. Thus, analyses were restricted to the IPTp implementation areas for these 

three countries (see Figure A.1). Kenya implemented IPTp in 63 of the 69 administrative districts from 

the 1999 census. Excluded are: Nairobi Province; Kiambu, Nyandarua, and Nyeri districts in Central 

Province; Meru Central district in Eastern Province; and Laikipia district in Rift Valley Province. In 

Madagascar the IPTp program was implemented in all districts in 17 regions and in some districts in the 

remaining 5 regions (Analmanga, Vakinankaratra, Haute Matsiatra, Amoron’i Mania, and Itasy). In 

Zimbabwe 33 of the 62 rural health districts fall into the moderate to high transmission zones and were 

therefore eligible for IPTp. More information on data collection and survey methods employed by the 

DHS and MIS can be found in individual survey reports and in online MEASURE DHS references 

(Rutstein and Rojas, 2006). 

Table 1. Information on populations included in analyses: survey information, national population 

size, sample size of target populations 

Country Year Survey Total population1 Sample size2 

Burkina Faso 2010 DHS 16,468,714 5,510 

Burundi 2010 DHS 8,382,849 3,016 

Cameroon 2011 DHS 20,030,362 4,593 

DRC 2007 DHS 60,772,175 3,264 

Ghana 2008 DHS 23,264,176 1,174 

Kenya 2008 DHS 30,803,092 2,046 

Madagascar 2008 DHS 13,257,289 3,560 

Malawi 2010 DHS 14,900,841 7,525 

Mozambique 2011 DHS 23,929,708 4,522 

Nigeria 2008 DHS 150,665,730 10,746 

Senegal 2010-11 DHS 12,767,556 4,714 

Sierra Leone 2008 DHS 5,612,129 2,166 

Tanzania 2010 AIS/MIS 44,841,226 3,033 

Uganda 2011 DHS 34,509,205 1,924 

Zambia 2007 DHS 12,055,384 2,590 

Zimbabwe 2010-11 DHS 5,081,306 1,008 

1 Mid-year national population estimates for the survey year (World Bank, 2013) 

2 Number of interviewed women age 15-49 years with a live birth in the two years preceding interview who are 

included in the analyses 

 
6 

Figure 3. Countries with survey data included in analyses 

 
7 

Variables 

The outcome variable of interest is IPTp2, defined as receipt of at least two doses of SP for prevention of 

malaria in recently pregnant women (women with a live birth in the two years immediately preceding 

interview), regardless of the source of the medication. This variable is used as a proxy measure of 

effective delivery of IPTp. A secondary outcome variable is IPTp1, defined as receipt of at least one dose 

of SP for prevention of malaria in recently pregnant women. Other variables included in analyses are 

mother’s age (in five-year categories from 15 to 49), mother’s educational status (primary or greater 

versus less than primary), mother’s marital status (married/living with a partner versus 

single/divorced/widowed), gravidity (primigravidae, secundigravidae, multigravidae), ANC attendance 

for the most recent pregnancy leading to a live birth (at least one ANC visit versus none), iron 

supplementation for the most recent pregnancy leading to a live birth (yes/no), tetanus immunization (at 

least one dose given during most recent pregnancy leading to a live birth), urban/rural residence, 

household wealth quintile, household size (categorized as <4, 4-5, 6-7, 8-9, 10+), and malaria risk 

category based on 2010 data from the Malaria Atlas Project (MAP). MAP provides a spatial data layer of 

age-standardized PfPR2-10 , describing the estimated proportion of 2-10 year olds in the general population 

that are infected with P. falciparum at any one time, averaged over the 12 months of 2010 (Malaria Atlas 

Project, 2013). DHS and MIS data include geospatial data for the location of the centroid of each cluster, 

thereby permitting linkage of MAP data to survey clusters; thus, all residents of a cluster from the DHS or 

MIS survey data were assigned the same malaria risk value based on corresponding MAP data. Standard 

MAP PfPR2-10 cut-offs (<0.1%, 0.1%-5%, 5%-40%, and >40%) were used for the high and medium 

transmission categories, but the lowest two were combined due to small sample sizes (thus, ≤5%, 5%-

40%, and >40%). Any entries with missing values for any of the key variables were excluded from 

analyses. For the subset of respondents who attended at least one ANC visit (the majority), additional 

variables included number of ANC visits attended (two or more, four or more), timing of first ANC visit 

(0-3, 4-6, or 7-9 months’ gestation), and components of ANC visit (blood and urine samples were taken 

and blood pressure was measured; yes or no). Table 2 summarizes specific information on the variables 

analyzed. 

 
8 

Table 2. Basic information on variables included in analyses 

Variable Description 

Socio-demographic variables 

Residence Residence of the woman's household (urban/rural) 

Household wealth Country-specific quintile of household wealth based on household assets (1-5) 

Number of household residents Number of household residents, categorized as <4, 4-5, 6-7, 8-9, 10+ 

Malaria transmission risk Malaria transmission risk based on MAP 2010 PfPR2-10, categorized as <0.5%; 

0.5-40%, 40%+ 

Maternal age Woman’s age, categorized as 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49 

Education level Woman's educational level: primary or greater, less than primary 

Marital status Woman's marital status: married or living with a partner, single/divorced/widowed 

Gravidity Number of births, categorized as primigravidae, secundigravidae, multigravidae 

Maternal health intervention variables 

Tetanus immunization status During last pregnancy in past two years ending in live birth, had at least one 

tetanus injection (Y/N) 

Vitamin A supplementation During last pregnancy in past two years ending in live birth, received vitamin A 

dose in first two months after delivery (Y/N) 

Iron supplementation During last pregnancy in past two years ending in live birth, received iron 

supplementation (Y/N) 

Slept under ITN Used an ITN the night immediately preceding the survey (Y/N) 

ANC variables 

≥1 ANC Attended ANC at least once during most recent pregnancy in past two years 

leading to a live birth (Y/N) 

≥2 ANC Attended ANC at least twice during most recent pregnancy in past two years 

leading to a live birth (Y/N) 

Number of ANC visits Number of ANC visits attended during most recent pregnancy in past two years 

leading to a live birth, categorized as 1, 2, 3, 4, 5+ 

Timing of ANC visit Months’ gestation at which first ANC visit occurred during most recent pregnancy 

in past two years ending in live birth, categorized as 0-3, 4-6, 7-9 months 

Place of ANC visit Home, public facility, private facility, religious facility, other facility 

Level of facility of ANC visit Home; health center, health post, or mobile clinic; hospital; other 

Components of ANC visit During ANC visit for last pregnancy in past two years ending in live birth, had 

blood, urine, and blood pressure tests – all three (Y/N) 

Outcome variables 

Any SP Received at least one dose of SP for prevention of malaria during last pregnancy 

in past two years leading to a live birth (Y/N) 

Any SP – ANC Received at least one dose of SP for prevention of malaria during last pregnancy 

in past two years leading to a live birth, at least one of which was given at ANC 

(Y/N) 

2 doses SP Received at least two doses of SP for prevention of malaria during last 

pregnancy in past two years leading to a live birth (Y/N) 

2 doses SP – ANC Received at least two doses of SP for prevention of malaria during last 

pregnancy in past two years leading to a live birth, at least one of which was 

given at ANC (Y/N) 

MAP = Malaria Atlas Project 

PfPR2-10 = Plasmodium falciparum prevalence rate in children age 2-10 years 

 
9 

Analyses 

All analyses were conducted using STATA 11. Household survey data were adjusted for survey design, 

clustering, and sample weights. Any analyses that pooled data from multiple countries involved a process 

of weighting each survey by countries’ mid-year populations in order to have proportional representation. 

Population weights for Kenya, Madagascar, and Zimbabwe were adjusted for the populations in the IPTp 

districts. 

Descriptive analyses 

Descriptive trends were compiled for the proportion of women with a live birth in the past two years. 

Socio-demographic variables were described and compared. A series of intervention outcomes were also 

calculated and compared for this group of women: the proportion of women attending ANC by numbers 

of visits and by timing of visits; the proportion of women receiving SP for prevention of malaria, by 

numbers of doses; and the proportion of women reporting ITN use the night before interview. According 

to historical definitions of IPTp coverage, women who reporting taking two doses of SP were considered 

to have received IPTp, and this outcome was used to determine levels of IPTp coverage by country and 

overall. 

Service effectiveness analyses 

Service effectiveness analyses was done to identify bottlenecks in the delivery of malaria in pregnancy 

interventions. Household surveys used for these analyses include standard questions about use of 

interventions during pregnancy. Interviewed women with a live birth in the two years immediately 

preceding interview are asked a series of questions regarding IPTp (Figure 4). Women are asked if they 

took drugs during pregnancy to prevent malaria infection, which drugs they took, how many times they 

took the drugs, and whether or not the drugs were obtained during an ANC visit or from another source. 

With the data from these questionnaires, it is not possible to match each dose of SP with when in 

gestation it was given or with its source. 

Throughout this paper, references are made to the service effectiveness of IPTp delivery as well as to 

service effectiveness of malaria in pregnancy intervention. These outcomes represent cumulative 

measures of multiple intermediate processes. From the available household survey data, it was possible to 

measure coverage at several intermediate levels: the percentage of women who 1) attended at least one 

ANC visit; 2) took at least one dose of SP; 3) took at least one dose of SP during an ANC visit; 4) 

attended at least two ANC visits; 5) took at least two doses of SP; 6) took at least two doses of SP, at least 

one during an ANC visit; and 7) slept under an ITN the night preceding interview. Coverage of each 

intermediate step was estimated using the numerator of the previous step as the denominator for the 

current step (Figure 5). Step six represents the service effectiveness of IPTp delivery. The final step 

represents the percentage of the eligible population that was effectively delivered the recommended 

interventions for preventing malaria in pregnancy. (The available proxy measure using DHS data is the 

percentage of women taking at least two doses of SP, at least one of which was obtained during ANC, and 

using an ITN) (MEASURE Evaluation et al., 2013).) Stratified service effectiveness analyses were 

conducted for all women in countries with lower IPTp coverage (IPTp2 ≤20%) and in those with higher 

IPTp coverage (IPTp2 >20%) in order to identify the greatest bottlenecks in lower IPTp coverage 

countries, which might help target areas for improvement in IPTp delivery and uptake. 

 
10 

Figure 4. Standard IPTp questions from nationally representative household surveys (DHS/MIS) 

 
11 

Figure 5. Formula for calculating intermediate and cumulative effectiveness of malaria in 

pregnancy intervention delivery (adapted from Hill et al., 2013a) 

 

IE = intermediate effectiveness 

Identifying determinants of IPTp 

Regression models were run to identify predictors of successful uptake of IPTp interventions. Using 

logistic regression, univariate analyses of IPTp1 and IPTp2 were conducted with potential predictors. 

Potential predictors were chosen based on previous studies; they included environmental and 

socioeconomic variables (PfPR2-10, urban/rural residence, household wealth, women’s age, women’s 

marital status, education; number of household residents); women’s health and service factors (gravidity, 

number and timing of ANC visits, location of ANC visit, testing performed during ANC visit, use of 

other health interventions including tetanus immunizations, iron supplementation, vitamin A 

supplementation, and use of ITNs). Collinearity was assessed by examination of variance inflation 

factors. Also, F-adjusted mean residual tests were used, as these tests are specifically designed to assess 

goodness of fit of design-based logistic regression models. Potential predictors significant at α = 0.1 in the 

univariate analyses were included in multivariable models. Multivariable logistic regression models were 

run to determine variables associated with IPTp1 and IPTp2 in recently pregnant women. Age of mother 

and gravidity were found to be highly correlated, and so only age was included in multivariate models. 

Similarly, number of ANC visits was highly correlated with gestational age at first ANC visit, and so only 

the former was used in multivariate models. Models were run separately for the higher IPTp coverage 

countries and for the lower coverage countries as well as pooled. Stratified trends in variables in lower 

and higher coverage countries were weighted according to mid-year populations. Variables found to be 

significantly associated with the outcome variable at α = 0.1 in multivariate models were included in 

comparative analyses of lower and higher coverage countries. 

Target population (N)

Women attending ≥1 

ANC (Na) • IE = Na/N

Women taking ≥1 SP 

(Nb) • IE = Nb/Na

Women taking ≥1 SP 

during ANC (Nc) • IE = Nc/Nb

Women attending ≥2 

ANC (Nd) • IE = Nd/Nc

Women taking ≥2 SP 

(Ne) • IE = Ne/Nd

Women taking ≥2 SP, 

≥1 during ANC (Nf) • IE = Nf/Ne

Women using ITN 

(Ng) • IE = Ng/Nf

Cumulative effectiveness = Ng/N
 
 13 

Results 

Descriptive Analyses 

The study population was first restricted to women ages 15-49 with a recent live birth for whom no 

variables were missing for any of the key socioeconomic or service-related variables including ANC 

attendance (at least once). The distributions of socioeconomic, demographic, and health intervention 

variables are summarized in Table 3. Among these women almost three-quarters lived in rural locations 

and over half lived in areas with a PfPR2-10 greater than 40% (areas of high malaria transmission). More 

women lived in households in the lower wealth quintiles than in the higher quintiles, and over half of the 

women lived in households with 4-7 residents. Over 50% of women were between the ages of 20-29. 

Over 60% were multigravidae, with the most recent birth the third or greater. Fifty-seven percent of 

women had less than a primary school education, and 90% were married or lived with a partner. As for 

pregnancy-related health interventions, 71% had received at least one tetanus immunization during 

pregnancy, 36% had received vitamin A supplementation, and 67% had received iron supplementation. 

Thirty percent reported having slept under an ITN the night preceding interview. Eighty-three percent had 

made at least one ANC visit. Only a subset of women who had responded to questions concerning ANC 

visit history answered questions about numbers of visits (95.3%). Seventy-nine percent of those who 

indicated number of visits reported having made at least two ANC visits, and 47% made at least four 

visits (the number that WHO currently recommends). 

Table 3. Percent distribution of socioeconomic, demographic, and health variables in recently 

pregnant women age 15-49 years from multi-country, pooled survey data 

Variable % 95% CI N 

Residence 

Urban 26.8 [25.4,28.3] 16,112 

Rural 73.2 [71.7,74.6] 43,979 

Wealth index 

Lowest 23.5 [22.6,24.4] 14,108 

Second 22.4 [21.6,23.2] 13,443 

Middle 19.7 [19.0,20.4] 11,828 

Fourth 18.6 [17.8,19.4] 11,149 

Highest 15.9 [15.1,16.8] 9,564 

Number of household residents 

<4 13.4 [12.9,13.8] 8,027 

4-5 29.5 [28.9,30.1] 17,716 

6-7 25.3 [24.8,25.9] 15,210 

8-9 15.1 [14.7,15.6] 9,099 

10+ 16.7 [16.1,17.4] 10,039 

PfPR2-10

<5% 8.6 [7.8,9.4] 5,142 

5-40% 40.6 [39.2,42.1] 24,417 

>40% 50.8 [49.4,52.3] 30,532 

(Continued...) 
 14 

Table 3. – Continued

Variable % 95% CI N 

Age (5-year groups) 

15-19 10.1 [9.8,10.5] 6,079 

20-24 26.2 [25.7,26.8] 15,756 

25-29 26.6 [26.1,27.1] 15,969 

30-34 18.5 [18.0,18.9] 11,109 

35-39 12.2 [11.8,12.6] 7,308 

40-44 4.9 [4.7,5.2] 2,966 

45-49 1.5 [1.4,1.6] 904 

Education 

Less than primary 57.7 [56.7,58.7] 34,681 

Primary or greater 42.3 [41.3,43.3] 25,410 

Marital status 

Single/divorced/widowed 10.0 [9.6,10.4] 6,025 

Married/living together 90.0 [89.6,90.4] 54,066 

Gravidity 

Primigravidae 20.1 [19.6,20.6] 12,074 

Secundigravidae 18.8 [18.3,19.2] 11,277 

Multigravidae 61.1 [60.5,61.8] 36,741 

Tetanus immunization 

No 29.0 [28.1,29.9] 17,428 

Yes 71.0 [70.1,71.9] 42,663 

Vitamin A supplementation 

No 63.7 [62.9,64.4] 38,255 

Yes 36.3 [35.6,37.1] 21,836 

Iron supplementation 

No 33.2 [32.2,34.1] 19,938 

Yes 66.8 [65.9,67.8] 40,153 

ITN use 

No 69.7 [68.9,70.5] 41,895 

Yes 30.3 [29.5,31.1] 18,196 

At least 1 ANC 

No 16.6 [15.8,17.4] 9,948 

Yes 83.4 [82.6,84.2] 50,143 

Total 60,091 

At least 2 ANC visits 

No 20.9 [20.1,21.8] 11,995 

Yes 79.1 [78.2,79.9] 45,263 

At least 4 ANC visits 

No 52.6 [51.7,53.5] 30,102 

Yes 47.4 [46.5,48.3] 27,156 

Total 57,258 

N= weighted sample size 

 
 15 

Descriptive Analyses—Antenatal Care 

Table 4 summarizes the distributions of variables related to ANC care seeking and service. Among the 

women who made at least one ANC visit who responded to additional questions, over 60% reported 

having attended a public facility for care, 11% sought care at a private facility, 2% at a religious facility, 

and 22% did not recall where they had received care. Forty-three percent of women attended ANC at a 

health center, health post, or mobile clinic, and 31% at a hospital. Half of the women reported that they 

received urine, blood, and blood pressure testing during their ANC visits. Thirty-six percent reported 

attending ANC at least five times, 22% reported four visits, and 27% three visits. Most women reported 

attending ANC for the first time during the second trimester (63%), while 25% reported first attending 

during the first trimester. 

Table 4. Percent distribution of ANC care seeking and service variables among recently pregnant 

women age 15-49 years who made at least one ANC visit, from multi-country, pooled survey data 

Variable % 95% CI Weighted N 

Number of ANC visits 

1 4.3 [4.1,4.6] 2,046 

2 11.4 [10.9,11.9] 5,385 

3 26.9 [26.2,27.2] 12,722 

4 21.6 [21.1,22.2] 10,231 

5+ 35.8 [34.9,36.6] 16,921 

Total 47,307 

Gestational age at 1st ANC 

1-3 months 24.9 [24.2,25.5] 12,352 

4-6 months 63.3 [62.6,64.0] 31,432 

7-9 months 11.8 [11.3,12.3] 5,867 

Total 49,651 

Source of ANC 

Home 2.4 [2.1,2.6] 1,182 

Public 62.1 [60.9,63.3] 31,131 

Private 10.6 [10.0,11.2] 5,318 

Religious 2.3 [2.0,2.6] 1,138 

Other 0.9 [0.7,1.1] 444 

Don't know 21.8 [20.5,23.1] 10,931 

Total 50,143 

Level of ANC facility 

Home 2.4 [2.1,2.6] 1,182 

Health center/post/mobile clinic 43.3 [42.2,44.4] 21,715 

Hospital 31.1 [30.2,32.1] 15,614 

Other 1.4 [1.2,1.6] 702 

Don’t know 21.8 [20.5,23.1] 10,931 

Total 50,143 

Testing done at ANC 

No 50.4 [49.4,51.5] 25,234 

Yes 49.6 [48.5,50.6] 24,790 

Total 50,024 
 16 

Following current WHO recommendations for effective 

delivery of IPTp requires that women access ANC services at 

least four times during pregnancy, at least three after 

quickening, and that they receive one dose of SP at each visit 

that occurs after the first trimester. ANC attendance rates for at 

least one visit and at least two visits are high everywhere except 

in Nigeria in 2008. The percentage of women who attended ANC at least four times is much lower in all 

countries; pooling estimates across countries, 83% of women attended ANC at least once, 79% at least 

twice, and 47% attended four times (Figure 6; Annex Table A.1). 

Figure 6. Percentage of recently pregnant women age 15-49 years making antenatal care visits by 

country and by number of visits 

0

10

20

30

40

50

60

70

80

90

100

Percent

≥1 ANC

≥2 ANC

≥ 4 ANC

* Total represents a multi-country, pooled estimate. 

Among recently pregnant women who attended ANC at least once, the distribution of number of ANC 

visits attended varied across countries. Figure 7 presents the distributions of ANC visits among women 

who attended ANC at least once by country as well as a pooled estimate across countries (see also Annex 

Table A.2). On average, among women attending ANC, only 4% reported attending ANC only once, 11% 

reported two visits, 27% reported three visits, 22% reported four visits, and 36% reported attending ANC 

five or more times. The mean number of ANC visits ranged from 3.2 visits in Burkina Faso in 2010 to 7.0 

visits in Nigeria in 2008, with an average of 4.5 visits in the pooled estimate (Table 5). The denominator 

for these estimates is women who made at least one ANC visit; thus, the estimates are not representative 

of all pregnant women, but rather of only those who obtained ANC services. 

 

ANC attendance rates are high 

everywhere except in Nigeria. Overall, 

83% attended ANC at least once; 79%, 

at least twice. 
 17 

Figure 7. Among recently pregnant women age 15-49 years who made at least one ANC visit, 

distribution of the number of visits, by survey 

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

5 or more

4 visits

3 visits

2 visits

1 visit

* Total represents a multi-country, pooled estimate. 

Sub-national IPTp implementation and ANC Use 

Kenya, Madagascar, and Zimbabwe have implemented targeted IPTp interventions in areas of highest malaria 

risk. IPTp programs do not appear to be driving ANC use in these countries, however. ANC coverage is not 

significantly higher in districts with IPTp programs than in those without. In fact, the percentages of targeted 

women who attended ANC at least once and at least twice were higher in non-IPTp districts than in IPTp districts 

in Madagascar, and in Kenya the percentage who made at least four ANC visits was higher in non-IPTp districts 

than in IPTp districts. 

 

Attended ≥1 ANC visit Attended ≥2 ANC visits Attended ≥4 ANC visits 

Non 

IPTp 

district 

IPTp 

district 

pvalue 

 Non 

IPTp 

district 

IPTp 

district

pvalue 

 Non 

IPTp 

district 

IPTp 

district 

pvalue 

Kenya 2008 94 92.5 0.51 88 88.2 0.95 62.2 42.8 <0.005 

Madagascar 

2008 96.6 87.7 <0.005 93.8 82.5 <0.005 48.5 45.1 0.23 

Zimbabwe 

2010-11 86.1 89.5 0.11 82.9 85.9 0.18 60.3 59.1 0.68 
 18 

Table 5. Mean number of ANC visits among recently pregnant women age 15-49 years who made 

at least one ANC visit, by survey 

Survey Mean number of ANC visits 95% CI N 

Burkina Faso 2010 DHS 3.2 [3.1,3.2] 5,677 

Burundi 2010 DHS 3.2 [3.2,3.3] 3,099 

Cameroon 2011 DHS 4.8 [4.7,4.9] 4,594 

DRC 2007 DHS 4.0 [3.8,4.2] 3,228 

Ghana 2008 DHS 5.8 [5.6,6.1] 1,134 

Kenya 2008 DHS 3.7 [3.6,3.8] 1,973 

Madagascar 2008 DHS 3.7 [3.6,3.8] 3,470 

Malawi 2010 DHS 3.5 [3.5,3.5] 7,493 

Mozambique 2011 DHS 3.8 [3.7,3.8] 4,834 

Nigeria 2008 DHS 7.0 [6.8,7.1] 10,535 

Senegal 2010-11 DHS 3.6 [3.5,3.7] 4,326 

Sierra Leone 2008 DHS 5.4 [5.1,5.6] 2,220 

Tanzania 2010 AIS/MIS 3.4 [3.3,3.4] 3,144 

Uganda 2011 DHS 3.6 [3.5,3.7] 2,031 

Zambia 2007 DHS 3.9 [3.9,4.0] 2,604 

Zimbabwe 2010-11 DHS 4.5 [4.3,4.6] 1,001 

Total* 4.5 [4.5,4.6] 47,307 

N = weighted sample size 

* Total represents a multi-country, pooled estimate. 

Among women who attended ANC at least once, the timing of the first ANC visit also varied across 

surveys (Figure 8; Annex Table A.3). The percentage of women who attended ANC for the first time 

during the first trimester of pregnancy ranged from 62% in Senegal to 13% in Malawi. On average, 

pooled across surveys, 15% of women attended ANC for the first time during the first trimester, 63% first 

attended during the second trimester, and 12% first attended during the third trimester. The mean months 

of gestation at first ANC visit are summarized in Table 6; values range from 3.5 (Senegal 2010-11 and 

Ghana 2008) to 5.2 months (Kenya 2008), with a pooled average of 4.6 months. 

 
 19 

Figure 8. Distribution of timing of first ANC visits among recently pregnant women age 15-49 

years who made at least one ANC visit, by survey 

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3rd trimester

2nd trimester

1st trimester

 

 * Total represents a multi-country, pooled estimate. 

Table 6. Mean months of gestation at first ANC visit among recently pregnant women age 15-49 

years who made at least one ANC visit, by survey 

Survey Mean months of gestation 95% CI N 

Burkina Faso 2010 DHS 4.1 [4.0,4.1] 5,677 

Burundi 2010 DHS 4.9 [4.8,4.9] 3,099 

Cameroon 2011 DHS 4.1 [4.1,4.2] 4,594 

DRC 2007 DHS 4.9 [4.7,5.0] 3,228 

Ghana 2008 DHS 3.5 [3.4,3.6] 1,134 

Kenya 2008 DHS 5.2 [5.1,5.3] 1,973 

Madagascar 2008 DHS 4.5 [4.4,4.6] 3,470 

Malawi 2010 DHS 5.1 [5.0,5.1] 7,493 

Mozambique 2011 DHS 5.0 [4.9,5.0] 4,834 

Nigeria 2008 DHS 4.6 [4.5,4.6] 10,535 

Senegal 2010-11 DHS 3.5 [3.4,3.5] 4,326 

Sierra Leone 2008 DHS 4.3 [4.2,4.4] 2,220 

Tanzania 2010 AIS/MIS 5.0 [5.0,5.1] 3,144 

Uganda 2011 DHS 4.9 [4.8,5.0] 2,031 

Zambia 2007 DHS 4.7 [4.6,4.8] 2,604 

Zimbabwe 2010-11 DHS 5.1 [4.9,5.2] 1,001 

Total 4.6 [4.6,4.7] 49,651 

N = weighted sample size 

* Total represents a multi-country, pooled estimate. 
 20 

Descriptive Analyses—IPTp Coverage 

Outcomes of interest include the percentage of women receiving SP (IPTp1) and the percentage receiving 

the recommended two or more doses of SP (IPTp2). IPTp2 coverage ranged from 0.3% in Burundi in 

2010 to 66% in Zambia in 2007, with a pooled, weighted 

average of 20% (Figure 9; Annex Table A.4). In order to 

focus subsequent analyses on differences between 

women in countries that achieved higher IPTp coverage 

and those in countries with lower IPTp coverage, survey 

data were stratified into two categories, using 20% coverage with two doses of SP as a cut-point (Figures 

9 and 10). The weighted average for IPTp2 in the lower coverage countries was 9%; in the higher 

coverage countries, 36%. 

Figure 9. Percentage of recently pregnant women age 15-49 years receiving SP by number of 

doses and by survey 

* Total represents a multi-country, pooled estimate. 

 

0

10

20

30

40

50

60

70

80

90

100

Percent

1 dose

2 doses

3 doses

LOWER 

HIGHER 

IPTp2 coverage averaged 20%--9% in the eight 

lower coverage countries and 36% in the eight 

higher coverage countries. 
 21 

Figure 10. Surveys with lower IPTp coverage (<20%) and with higher IPTp coverage (≥20%) among 

recently pregnant women age 15-49 years 

In pooled estimates across surveys, IPTp coverage declines as the gestational age at first ANC visit 

increases. This pattern holds for IPTp1, IPTp2, and three or more SP doses (Figure 11). In pooled 

estimates IPTp coverage increases as the number of ANC visits increases from one to four visits. This 

pattern holds for all doses of SP. Women who reported five or more ANC visits were not more likely to 

receive three or more doses of SP than were women attending four ANC visits, and they were 

significantly less likely to receive at least one or at least two doses of SP (Figure 12). 
 22 

Figure 11. Percentages of recently pregnant women age 15-49 years receiving SP, by dose and 

gestational age, in multi-country pooled estimates from 16 countries with surveys between 2007 

and 2011 

0

5

10

15

20

25

30

35

40

45

50

1-3 months 4-6 months 7-9 months

Percentage receiving SP by dose

Gestational age at first ANC visit

≥1 dose SP

≥2 doses SP

≥3 doses SP

Figure 12. Percentages of recently pregnant women age 15-49 years receiving SP, by dose and 

number of ANC visits in multi-country, pooled estimates from 16 countries with surveys between 

2007 and 2011 

0

10

20

30

40

50

60

1 2 3 4 5+

Percent receiving SP by dose

Number of ANC visits

≥1 dose SP

≥2 doses SP

≥3 doses SP
 23 

Service Effectiveness Analyses 

Service effectiveness analyses were done to identify bottlenecks in the delivery of malaria in pregnancy 

interventions. Separate analyses were run for countries with lower IPTp coverage and those with higher 

IPTp coverage to try to identify steps in the IPTp delivery process where effectiveness differed 

significantly. Thess analyses found some expected and some revealing patterns (Figure 13; Table 7). The 

percentage of recently pregnant women who attended at least one ANC visit is quite high for both higher 

and lower IPTp coverage countries (98% and 76%, respectively). Unsurprisingly, the difference in IPTp 

coverage between the two groups is significant; among the women who made at least one ANC visit, 

about two-thirds of those in higher coverage countries received at least one dose of SP; whereas only 22% 

of women in lower coverage countries received at least one dose. Among women who attended ANC at 

least once and who received at least one dose of SP, almost all from both higher and lower IPTp coverage 

countries received at least one dose of SP via ANC (89% and 87%, respectively). These estimates verify 

that ANC is the most common source of SP for prevention of malaria in pregnancy among women in this 

study. Among women who attended ANC at least once and who received a dose of SP through this venue, 

virtually all attended ANC at least twice (97% and 98% for higher and lower coverage countries, 

respectively, a non-significant difference). Of the women who made at least two ANC visits, 60% from 

higher coverage countries and 52% from lower coverage countries reported taking at least two doses of 

SP, a significant difference in intermediate effectiveness. Eighty-nine percent from higher IPTp coverage 

countries and 87% from lower coverage countries who received two doses of SP received at least one of 

these doses during an ANC visit. This difference is not 

statistically significant. Finally, 48% of the women in higher 

IPTp coverage countries who received at least two doses of 

SP, at least one of these during an ANC visit, and 35% of 

these women in lower IPTp coverage countries also used an 

ITN the night before interview, a significant difference in 

intermediate effectiveness. 

Cumulative measures of service effectiveness show that only 8% overall—14% of eligible women in 

higher IPTp coverage countries and only 3% of those in lower IPTp coverage countries—received the 

recommended malaria in pregnancy interventions. Focusing just on the effective delivery of IPTp, only 

18% of eligible women received IPTp following the recommended delivery steps, 30% of women in 

higher IPTp coverage countries and 8% in lower IPTp coverage countries. 

 

Only 8% overall—14% of eligible women in 

higher IPTp coverage countries and only 

3% of those in lower IPTp coverage 

countries—received the recommended 

malaria in pregnancy interventions. 
 24 

Figure 13. Stepwise summary of cumulative service effectiveness of malaria in pregnancy 

interventions (IPTp and ITN use by pregnant women), stratified by lower IPTp coverage and higher 

IPTp coverage surveys 

Note: Lower IPTp coverage surveys are those with IPTp2 coverage less than 20%; higher IPTp coverage surveys are 

those in which IPTp coverage is 20% or more. Intermediate effectiveness estimates are derived from multi-country, 

pooled, weighted calculations. 

 

0

10

20

30

40

50

60

70

80

90

100

≥1 ANC ≥1 SP ≥1 SP via 

ANC

≥2 ANC ≥2 SP ≥2 SP, ≥1 

via ANC

≥2 SP, ≥1 

via ANC & 

ITN use

Percent

High

Total

Low
 25 

Table 7. Stepwise summary of service effectiveness of malaria in pregnancy interventions (IPTp 

and ITN use by pregnant women), stratified by lower IPTp coverage and higher IPTp coverage 

surveys1

N IE (%) 95% CI CE (%) 

Lower IPTp Coverage 

Attended ANC 27,086 75.8 74.5-77.0 100.0 

Received one dose SP 5,957 22.0 21.0-23.0 22.0 

SP via ANC 5,166 86.7 85.2-88.1 19.1 

Attended ANC at least twice 4,968 97.7 97.1-98.2 18.7 

Received two doses SP 2,962 51.6 48.5-54.7 9.6 

SP2 via ANC 2,565 86.6 84.4-88.6 8.3 

SP2 via ANC and ITN use 908 35.4 62.5-38.4 3.0 

Higher IPTp Coverage 

Attended ANC 23,057 94.8 94.1-95.3 100.0 

Received one dose SP 14,938 64.8 63.6-66.0 64.8 

SP via ANC 13,234 88.6 87.8-89.4 57.4 

Attended ANC at least twice 12,658 97.1 96.7-97.6 55.7 

Received two doses SP 8,221 59.7 58.3-61.0 33.3 

SP2 via ANC 7,335 89.2 88.3-90.1 29.7 

SP2 via ANC and ITN use 3,482 47.5 45.7-49.2 14.1 

Total 

Attended ANC 50,142 83.4 82.6-74.2 100.0 

Received one dose SP 20,896 41.7 40.8-42.5 41.7 

SP via ANC 18,400 88.1 87.4-88.7 36.7 

Attended ANC at least twice 17,741 97.3 96.9-97.7 35.7 

Received two doses SP 11,183 57.4 56.0-58..7 20.5 

SP2 via ANC 9,900 88.5 87.7-89.4 18.1 

SP2 via ANC and ITN use 4,390 44.3 42.9-45.8 8.0 

IE = intermediate effectiveness; CE = cumulative effectiveness; N = sample size 1 Lower coverage surveys are those with IPTp2 coverage less than 20%, higher coverage surveys are those in which 

IPTp coverage is 20% or more. Intermediate effectiveness estimates are derived from multi-country, pooled, weighted 

calculations. 

Determinants of IPTp 

Regression models were run to identify potential determinants of successful delivery and uptake of IPTp 

interventions. Outcomes included IPTp1 and IPTp2. Logistic regression models identified sociodemographic, maternal health, and service variables, such as level of malaria transmission (PfPR2-10), 

maternal health interventions (iron supplementation, vitamin A supplementation, tetanus immunization, 

ITN use), specifics of antenatal care visits (testing done, number of visits, timing of first visit, type of 

facility), marital status, education, parity, maternal age, household wealth, and the number of household 

residents, as important predictors of effective delivery of one dose of SP during the most recent 

pregnancy in women who made at least one ANC visit (IPTp1) (Table 8). The only variable that was not 

significantly associated with effective IPTp1 delivery was household residence (urban/rural). Due to 

collinearity between number of ANC visits and timing of first ANC visit, the latter was omitted from 

multivariable models. Similarly, parity and maternal age were found to be collinear, and so parity was left 

out of multivariable models. In adjusted, multivariable models, most of these associations remained 

significant (Table 8). Women in the highest malaria transmission areas were significantly less likely to 
 26 

receive IPTp1 than were those in medium or low malaria transmission areas. Effective delivery of IPTp1 

was more likely for women receiving other maternal health interventions (vitamin A supplementation 

(OR=1.4), iron supplementation (OR=2.0), tetanus immunization (OR=1.2), and ITN use (OR=2.0)) than 

for those who did not. Women who attended ANC at private facilities or at home were less likely than 

those who sought care at a public facilities to receive IPTp1 (OR=0.5, 0.3, respectively). IPTp1 was more 

likely for those who attended ANC at religious facilities than for those who went to public facilities 

(OR=1.7). The level of delivery of IPTp1 was higher for women who made more than one ANC visit than 

for those making only one visit (OR=1.6, 1.8, 1.8, and 1.2 for two, three, four, and five or more ANC 

visits, respectively). Married women were less likely to receive IPTp1 than other women (OR=0.9). 

Women with at least a primary school education were more likely to receive IPTp1 than were those with 

less education (OR=1.1). Household wealth was not associated with IPTp1 in the adjusted model. Women 

age 15-24 years and those age 35-49 years were less likely than women age 30-34 to receive IPTp1, while 

women age 25-29 years had similar odds of IPTp1 to those of women age 30-34. Women living in 

households with 10 or more household members were more likely to receive IPTp1 than those living in 

households with fewer than four residents (OR=1.1). 

Models of effective delivery of at least two doses of SP (IPTp2) to women who made at least one ANC 

visit produced very similar results (Table 9). There were a few notable exceptions: marital status and 

education were not significantly associated with IPTp2, and associations with maternal age and number of 

household residents were only marginally significant. In the multivariable model also, differences were 

found: Women living in areas of moderate malaria transmission (PfPR2-10 between 5% and 40%) were 

more likely than those living in low transmission areas to receive IPTp2 (OR=1.2). Maternal age and 

number of household residents were not significantly associated with IPTp2. 
 27 

Table 8. Results of pooled, univariate and adjusted, multivariable logistic regression models of 

IPTp1 use among women age 15-49 years with a live birth in the past two years who made at least 

one ANC visit during the most recent pregnancy1

Univariate Adjusted 

OR LCI UCI p-value OR LCI UCI p-value 

Residence 

Urban ref 

Rural 1.00 0.90 1.10 0.930 

Household wealth quintile 

Lowest ref ref 

Second 1.03 0.93 1.14 0.553 1.01 0.91 1.12 0.818 

Middle 1.10 0.99 1.22 0.088 1.04 0.93 1.15 0.509 

Fourth 1.21 1.08 1.35 0.001 1.06 0.95 1.19 0.318 

Highest 1.18 1.05 1.32 0.006 0.96 0.85 1.08 0.495 

Number of household residents 

<4 ref 

4-5 1.03 0.93 1.13 0.592 1.02 0.92 1.13 0.720 

6-7 1.01 0.92 1.11 0.887 1.02 0.92 1.14 0.665 

8-9 1.02 0.92 1.13 0.769 1.07 0.95 1.20 0.249 

>9 1.13 1.01 1.27 0.031 1.20 1.06 1.35 0.003 

PfPR2-10

<5% ref 

5-40% 0.83 0.73 0.96 0.010 0.98 0.85 1.13 0.763 

40+% 0.60 0.52 0.68 <0.0005 0.71 0.61 0.81 <0.0005 

Mother's age 

15-19 0.85 0.77 0.95 0.004 0.82 0.72 0.92 0.001 

20-24 0.92 0.85 1.00 0.050 0.91 0.83 0.99 0.03 

25-29 0.94 0.86 1.02 0.142 0.94 0.85 1.02 0.146 

30-34 ref 

35-39 0.86 0.78 0.96 0.006 0.87 0.78 0.97 0.012 

40-44 0.74 0.64 0.85 0.000 0.73 0.63 0.84 <0.0005 

45-49 0.64 0.49 0.82 0.001 0.70 0.53 0.93 0.012 

Educational status 

Less than primary ref 

Primary or greater 1.08 1.01 1.15 0.022 1.13 1.05 1.22 0.001 

Marital status 

Single/divorced/widowed ref 

Married/living with partner 0.87 0.80 0.95 0.003 0.88 0.80 0.97 0.013 

Gravidity 

Primigravidae ref 

Secundigravidae 1.11 1.02 1.21 0.012 

Multigravidae 1.05 0.98 1.13 0.159 

Tetanus immunization during pregnancy 

No tetanus immunization ref ref 

Tetanus immunization 1.49 1.37 1.62 <0.0005 1.19 1.09 1.29 <0.0005 

(Continued...)
 28 

Table 8. – Continued

Univariate Adjusted 

OR LCI UCI p-value OR LCI UCI p-value 

Vitamin A supplementation 

No vitamin A ref ref 

Vitamin A 1.60 1.50 1.70 <0.0005 1.35 1.26 1.44 <0.0005 

Iron supplementation 

No iron ref ref 

Iron supplementation 2.30 2.09 2.53 <0.0005 2.00 1.82 2.20 <0.0005 

ITN use 

No ITN use ref ref 

ITN use 2.20 2.06 2.35 <0.0005 1.96 1.83 2.10 <0.0005 

Number of ANC visits 

1 ANC visit ref ref 

2 ANC visits 1.98 1.69 2.32 <0.0005 1.62 1.37 1.91 

3 ANC visits 2.38 2.04 2.76 <0.0005 1.78 1.52 2.08 

4 ANC visits 2.63 2.26 3.07 <0.0005 1.84 1.57 2.15 

5 or more ANC visits 1.61 1.38 1.87 <0.0005 1.18 1.00 1.39 

Timing of 1st ANC visit 

1st trimester ref 

2nd trimester 0.89 0.83 0.96 0.002 

3rd trimester 0.61 0.55 0.68 <0.0005 

Location of ANC 

Home 0.21 0.16 0.29 <0.0005 0.34 0.25 0.46 <0.0005 

Public ref ref 

Private 0.45 0.40 0.50 <0.0005 0.48 0.42 0.54 <0.0005 

Religious 1.94 1.54 2.43 <0.0005 1.69 1.32 2.16 

Other 0.41 0.18 0.60 <0.0005 0.52 0.34 0.78 

Don't know 0.64 0.58 0.72 <0.0005 0.75 0.68 0.84 

Components of ANC testing 

Fewer than 3 tests done ref ref 

3 ANC tests done (BP, anemia, urine) 1.32 1.23 1.41 <0.0005 1.26 1.17 1.35 <0.0005 

OR = odds ratio; LCI = lower confidence interval; UCI = upper confidence interval; ref = reference value 1 Weighted sample size is 48,084 

 
 29 

Table 9. Results of pooled, univariate and adjusted, multivariable logistic regression models of 

IPTp2 use among women age 15-49 years with a live birth in the past two years who made at least 

one ANC visit during the most recent pregnancy1

 

Univariate Adjusted 

OR LCI UCI p-value OR LCI UCI p-value 

Residence 

Urban ref 

Rural 0.93 0.84 1.03 0.139 

Household wealth quintile 

Lowest ref ref 

Second 1.01 0.91 1.12 0.931 0.97 0.87 1.08 0.574 

Middle 1.08 0.97 1.21 0.174 0.99 0.89 1.11 0.897 

Fourth 1.19 1.06 1.33 0.002 0.99 0.89 1.11 0.912 

Highest 1.22 1.09 1.37 0.001 0.91 0.81 1.03 0.153 

Number of household residents 

<4 ref ref 

4-5 0.97 0.87 1.08 0.549 0.99 0.89 1.10 0.845 

6-7 0.93 0.83 1.03 0.165 0.99 0.88 1.11 0.817 

8-9 0.87 0.78 0.98 0.021 0.97 0.86 1.10 0.655 

>9 0.98 0.86 1.11 0.747 1.08 0.95 1.24 0.230 

PfPR2-10

<5% ref ref 

5-40% 1.10 0.95 1.28 0.190 1.20 1.04 1.39 0.013 

40+% 0.84 0.73 0.97 0.019 0.87 0.75 1.01 0.067 

Mother's age 0.97 0.86 1.09 0.555 0.99 0.86 1.12 0.828 

15-19 

20-24 0.98 0.90 1.08 0.714 1.00 0.91 1.10 0.951 

25-29 1.03 0.94 1.14 0.525 1.03 0.93 1.14 0.569 

30-34 ref ref 

35-39 0.92 0.82 1.03 0.139 0.95 0.84 1.07 0.363 

40-44 0.82 0.70 0.97 0.021 0.83 0.70 0.99 0.039 

45-49 0.76 0.58 1.01 0.057 0.86 0.64 1.15 0.310 

Educational status 

Less than primary ref 

Primary or greater 1.06 0.99 1.14 0.102 

Marital status 

Single/divorced/widowed ref 

Married/living with partner 0.94 0.85 1.04 0.226 

Gravidity 

Primigravidae ref 

Secundigravidae 1.02 0.93 1.12 0.682 

Multigravidae 0.93 0.86 1.01 0.067 

Vitamin A supplementation 

No vitamin A ref ref 

Vitamin A 1.72 1.61 1.85 <0.0005 1.40 1.31 1.50 <0.0005 

(Continued...)
 30 

Table 9. – Continued

Univariate Adjusted 

OR LCI UCI p-value OR LCI UCI p-value 

Tetanus immunization during pregnancy 

No tetanus immunization ref ref 

Tetanus immunization 1.58 1.43 1.75 <0.0005 1.15 1.04 1.27 0.005 

Iron supplementation 

No iron ref ref 

Iron supplementation 2.66 2.39 2.96 <0.0005 1.96 1.76 2.18 <0.0005 

ITN use 

No ITN use ref ref 

ITN use 1.65 1.54 1.77 <0.0005 1.51 1.41 1.62 <0.0005 

Number of ANC visits 

1 ANC visit ref 

2 ANC visits 4.43 3.25 6.04 <0.0005 3.83 2.81 5.22 <0.0005 

3 ANC visits 6.20 4.62 8.33 <0.0005 5.01 3.73 6.73 <0.0005 

4 ANC visits 8.15 6.06 10.97 <0.0005 6.19 4.60 8.34 <0.0005 

5 or more ANC visits 6.09 4.53 8.20 <0.0005 4.67 3.46 6.30 <0.0005 

Timing of 1st ANC visit 

1st trimester ref 

2nd trimester 0.71 0.66 0.77 <0.0005 

3rd trimester 0.36 0.32 0.41 <0.0005 

Location of ANC 

Home 0.33 0.23 0.48 0.000 0.51 0.36 0.73 <0.0005 

Public ref ref 

Private 0.58 0.50 0.66 <0.0005 0.58 0.50 0.66 <0.0005 

Religious 1.60 1.31 1.95 0.000 1.41 1.14 1.76 0.002 

Other 0.58 0.38 0.88 0.010 0.68 0.44 1.06 0.090 

Don't know 0.48 0.43 0.54 <0.0005 0.58 0.52 0.66 <0.0005 

Components of ANC testing 

Fewer than 3 tests done ref ref 

3 ANC tests done (BP, anemia, urine) 1.41 1.31 1.51 <0.0005 1.24 1.15 1.33 <0.0005 

OR = odds ratio; LCI = lower confidence interval; UCI = upper confidence interval; ref = reference value 1 Weighted sample size is 48,084 

 
 31 

Comparative Analyses of Lower and Higher IPTp Coverage Countries 

Using variables that were identified in multivariable regression models to predict IPTp2, a comparison of 

lower IPTp coverage and higher IPTp coverage countries was conducted. None of the household factors 

or socio-demographic characteristics of recently pregnant women were found to be significantly 

associated with IPTp2 coverage. Therefore, the comparative analysis was limited to malaria risk and ANC 

service variables. Significant differences were found between women in lower and higher IPTp coverage 

countries for most health intervention and ANC service-related 

variables except for the percentage attending two or more ANC visits, 

the percentage receiving tetanus immunizations, and the percentage 

that had blood, urine and blood pressure testing done during ANC 

visits (Table 10). Significant differences in the other variables of 

interest between women in lower and higher IPTp coverage countries 

also were found; these are depicted in Figure 14A-F. 

A greater percentage of women in higher IPTp coverage countries live in high malaria transmission 

regions, and fewer live in medium transmission regions than women in lower coverage countries (Figure 

14A). The percentage of recently pregnant women who made at least two ANC visits was similar in lower 

and higher IPTp coverage countries; however, women from higher IPTp coverage countries were much 

less likely to have made four or more ANC visits than women from lower IPTp coverage countries. 

Women from higher IPTp coverage countries were more likely to have benefited from other maternal 

health interventions, such as tetanus immunizations, vitamin A supplementation, iron supplementation, 

and ITN use, than were women from lower IPTp coverage countries. The percentage of women receiving 

blood, urine, and blood pressure testing during ANC visits was similar between lower and higher IPTp 

coverage countries (Figure 14B). Among women who made at least one ANC visit, the mean number of 

total ANC visits was significantly lower among women in high IPTp coverage countries than among 

those in lower coverage countries (3.9 versus 5.0) (Figure 14E), likely due to the significantly smaller 

proportion attending five or more ANC visits (Figure 14C). Women in higher coverage countries were 

more likely to attend ANC for the first time during the first trimester of pregnancy and less likely to 

attend for the first time during the second or third trimester than women in lower coverage countries 

(Figure 14D). The mean months of gestation at first ANC visit was 4.5 for women in higher IPTp 

coverage countries compared with 4.8 months for women in low IPTp coverage countries (Figure 14E). 

Women in higher coverage countries were more likely to seek ANC from public or religious facilities and 

were less likely to seek ANC from private facilities or at home or to not know the source of care than 

women in lower coverage countries (Figure 14F). 

 

Significant differences were 

found between women in lower 

and higher IPTp coverage 

countries for most health 

intervention and ANC servicerelated variables. 
 32 

Table 10. Comparing groups of higher and lower IPTp coverage countries by percent distributions 

of health intervention and ANC service-related determinants of IPTp2 among recently pregnant 

women age 15-49 years who made at least one ANC visit1

Lower IPTp coverage Higher IPTp coverage 

% 95% CI % 95% CI p-value

SES/environment 

PfPR2-10

<5% 10.7 [9.4,12.3] 9.5 [8.4,10.7] <0.0005 

5-40% 38.2 [35.8,40.6] 49.9 [47.6,52.2] 

>40% 51.1 [48.7,53.5] 40.6 [38.5,42.8] 

Maternal health interventions 

Tetanus immunization 82.8 [81.8,83.8] 84.1 [83.2,84.9] 0.056 

Vitamin A supplementation 40.2 [39.0,41.5] 43.3 [42.1,44.5] 0.001 

Iron supplementation 73.5 [72.0,74.9] 81.2 [79.9,82.4] <0.0005 

ITN use 24.2 [23.1,25.4] 48.6 [47.3,50.0] <0.0005 

ANC factors 

ANC testing done 48.7 [47.0,50.4] 47.0 [45.6,48.4] 0.130 

≥2 ANC visits 95.4 [94.9,95.8] 95.8 [95.4,96.2] 0.155 

≥4 ANC visits 62.1 [60.8,63.5] 51.0 [49.9,52.1] <0.0005 

Number of ANC visits 

1 ANC visit 4.6 [4.2,5.1] 4.2 [3.8,4.6] <0.0005 

2 ANC visits 10.1 [9.4,10.8] 13.1 [12.4,13.9] 

3 ANC visits 23.1 [22.1,24.2] 31.8 [30.9,32.7] 

4 ANC visits 19.0 [18.1,19.9] 24.9 [24.1,25.7] 

5 or more ANC visits 43.2 [41.8,44.5] 26.1 [25.1,27.1] 

Mean number of ANC visits 5.0 [4.9,5.1] 3.9 [3.85,3.95] <0.0005 

Source of ANC 

Home 2.9 [2.6,3.3] 0.5 [0.4,0.7] <0.0005 

Public 53.4 [51.3,55.4] 68.6 [67.0,70.2] 

Private 11.5 [10.7,12.4] 6.2 [5.6,6.9] 

Religious 0.8 [0.6,1.1] 3.6 [3.1,4.1] 

Other 0.9 [0.7,1.1] 0.5 [0.4,0.7] 

Don't know 30.5 [28.2,33.0] 20.6 [19.0,22.2] 

Facility of ANC visit 

Home 2.9 [2.6,3.3] 0.5 [0.4,0.7] <0.0005 

Health center/post/mobile clinic 34.1 [32.6,35.7] 52.9 [51.3,54.5] 

Hospital 30.9 [29.4,32.5] 25.3 [24.1,26.6] 

Other 1.5 [1.3,1.8] 0.7 [0.5,0.9] 

Don’t know 30.5 [28.2,33.0] 20.6 [19.0,22.2] 

Gestational age at 1st ANC 

1st trimester 20.3 [19.3,21.3] 28.1 [27.1,29.0] <0.0005 

2nd trimester 66.2 [65.1,67.3] 60.9 [59.9,61.9] 

3rd trimester 13.5 [12.6,14.4] 11.0 [10.3,11.8] 

Mean months’ gestation at 1st ANC 4.84 [4.80,4.88] 4.53 [4.49,4.57] <0.0005 

1 Weighted sample size is 48,084 

 
 33 

Figure 14. In higher and lower IPTp coverage countries, percent distributions of determinants of 

IPTp2 in recently pregnant women age 15-49 years who made at least one ANC visit 

0

10

20

30

40

50

60

70

80

90

100

<5% 5-40% >40%

A) Malaria Risk (PfPR2-10)

Lower

Higher 0

10

20

30

40

50

60

70

80

90

100

B) Maternal health interventions

Lower

Higher

0

10

20

30

40

50

60

70

80

90

100

1 ANC

visit

2 ANC

visits

3 ANC

visits

4 ANC

visits

≥5 

ANC 

visits

C) Among ANC users, the distribution 

of total visits

Lower

Higher

0

10

20

30

40

50

60

70

80

90

100

1st

trimester

2nd

trimester

3rd

trimester

D) Among ANC users, the month 

gestation at first ANC visit

Lower

Higher

0

1

2

3

4

5

6

Mean number of

ANC

Mean month

gestation at 1st

ANC

E) Among ANC users, the average 

number of ANC vistis and average 

gestation at first ANC vist

Lower

Higher

0

10

20

30

40

50

60

70

80

90

100

F) Among ANC users, source of ANC

Lower

Higher

 35 

Discussion 

This study makes use of nationally representative household survey data to take a broad look at coverage 

of malaria in pregnancy interventions across malaria endemic countries in sub-Saharan Africa between 

2007 and 2011. Use of a service effectiveness approach enabled assessment of intermediate steps in the 

process of delivery and uptake of malaria in pregnancy interventions, thereby identifying bottlenecks in 

the delivery process. Use of household survey data allowed many socio-demographic and maternal health 

data to be examined as potential determinants of IPTp uptake. A stratified approach to analyses was taken 

in order to identify bottlenecks to delivery or determinants of IPTp coverage that differed between 

countries with higher and lower levels of IPTp coverage. Better identification of the least effective steps 

in the delivery process and of individual-level factors associated with higher coverage is essential to 

improving targeting and delivery of malaria in pregnancy interventions. 

The service effectiveness approach to assessing malaria in 

pregnancy interventions showed that a small fraction of the 

targeted population received the recommended interventions. 

The cumulative effectiveness of IPTp intervention, defined as 

two doses of SP and two ANC visits, was only 18% across the 

surveys included in this analysis. Cumulative effectiveness was 

30% in higher IPTp coverage countries and only 8% in lower IPTp coverage countries. These findings 

suggest that IPTp is not being effectively delivered to eligible women and that even the most successful 

IPTp programs are likely underperforming. 

Analyses of intermediate steps were performed to identify bottlenecks in the overall process of malaria in 

pregnancy intervention delivery. While this exercise was useful in highlighting problematic steps in the 

delivery process, the available data did not permit in-depth analyses of cause. As was shown in the 

conceptual framework (Figure 2), the steps in the delivery of IPTp are influenced by women’s behaviors, 

by health care providers’ behaviors, and by elements of the health system. Household surveys, however, 

are intended to collect socio-demographic information about women and their health status and behaviors; 

they do not typically ask about health care providers or health systems. Thus, results of the service 

effectiveness analyses revealed broadly that certain steps in the process of IPTp delivery were more 

successful than others and that coverage of some of the intermediate steps varies considerably between 

lower and higher IPTp coverage countries. Identification of specific causes for success or failure was not 

possible, however. 

The first step in attaining effective IPTp coverage in most settings requires that women attend ANC. ANC 

attendance was not found to be a major limiting factor, however. Overall, across the surveys 83% of 

women with recent births attended ANC at least once during the most recent pregnancy; 79% made at 

least two ANC visits; the mean gestation at first ANC visit was about half way through pregnancy, at 4.6 

months; and the mean number of ANC visits overall was 4.5. Thus, the majority of women attended ANC 

at sufficient frequency and timing to receive the recommended two or more doses of SP. Only 20% of 

eligible women actually received at least two doses, however. Similar results have been found in 

subnational studies of the effectiveness of malaria in pregnancy interventions in Nyando District, Kenya 

(Hill et al., 2013a) and in Segou District, Mali (Webster et al., 2013a), but this study substantiates 

findings at a national level, across 16 countries. 

Stratified by IPTp coverage groups, ANC attendance was lower in lower IPTp coverage countries than in 

higher IPTp coverage countries (76% versus 95% for ≥1 ANC visit; 70% versus 91% for ≥2 ANC visits). 

Despite this difference, the relatively high attendance overall suggests that ANC attendance is not the 

driving factor behind lower IPTp coverage. Further, among women who attended ANC at least once and 

IPTp is not being effectively delivered 

to eligible women and even the most 

successful IPTp programs are likely 

underperforming. 
 36 

who received at least one dose of SP via ANC, almost all attended ANC a second time (97%). This 

finding did not differ in lower and higher IPTp coverage surveys, supporting the contention that women’s 

ANC care seeking behaviors are not the key barriers to effective IPTp delivery. 

Despite high levels of ANC attendance, few women received SP 

during ANC visits. Delivery of both first and second doses of SP was 

identified as a clear bottleneck in the process of malaria in pregnancy 

intervention. Coverage of IPTp1 was only 42% among women who 

attended ANC at least once. Delivery of IPTp1 was much higher in 

higher IPTp coverage countries than in lower IPTp coverage countries (65% versus 22%). Delivery of 

IPTp2 among women who attended ANC at least twice was higher (57%) and did not vary as much 

between higher and lower IPTp coverage countries (60% versus 52%). These steps are clearly bottlenecks 

that could be targeted to improve coverage of the intervention. 

Although the data used for these analyses do not include the information necessary to identify the causes 

of lower IPTp coverage, other researchers have identified health systems factors, such as complex policy 

guidelines or lack of implementation guidelines, as important (Webster et al., 2013a). In a study in 

Nigeria, IPTp coverage was 13% for one dose of SP and 7% for two doses. The main barrier to IPTp 

delivery was a failure of providers to offer the medications; almost all women who were offered SP 

during ANC visits took it (98.9% for the first dose and 96.9% for the second dose) (Onoka et al., 2012). A 

very recent systematic review and meta-analysis identified barriers to receiving IPTp from the 

perspectives of both pregnant women eligible for the intervention and of the health care providers (Hill, et 

al., 2013b). Many studies reviewed have reported providers’ lack of knowledge of IPTp policies and of 

potential side effects and potential benefits to be barriers. Other barriers identified in Hill and colleagues’ 

review included health care staff not offering the medication, stockouts, and lack of cups or drinking 

water necessary to provide SP by directly observed therapy (DOT). The review concludes that lack of 

clear policies and guidelines as well as insufficient training, supervision, and quality assurance at the 

health facility level are responsible for many of the barriers to effective delivery of IPTp. A recent 

qualitative review of malaria in pregnancy interventions also identified a lack of resources, including 

trained staff, drugs, cups, and clean water, as a barrier (Pell et al., 2011). Other barriers identified related 

to demand for ANC services such as cost of care and distance to facilities. Follow-up studies focusing on 

predictive factors for delivery of SP in the ANC setting are necessary to better inform intervention efforts. 

Finally, use of ITNs is recommended as part of the standard malaria prevention package for pregnant 

women. Overall, the rate of ITN use was low among women who received IPTp2—44%; it was higher in 

higher IPTp coverage countries than in lower IPTp coverage countries (48% versus 35%). 

While service effectiveness analyses allow identification of 

intermediate steps that may be targeted for improvements in 

uptake of the intervention, they do not identify specific 

determinants of IPTp uptake. Regression models identified 

factors significantly associated with IPTp1 coverage: malaria 

transmission levels; use of other maternal health 

interventions; location, frequency, and timing of antenatal 

care visits; marital status; education; maternal age; and number of household members. Parallel models 

examining the determinants of IPTp2 produced similar results except for the lack of significance of 

maternal age and number of household members and the greater significance of malaria transmission 

levels. These results support findings of Hill and colleagues’ recent meta-analysis (2013b), in which 

frequency and timing of ANC visits, ITN use, education, and parity were found to be important 

determinants of IPTp coverage. Knowledge about malaria was also an important determinant of IPTp in 

this meta-analysis; unfortunately, this parameter is not measured in household surveys as a matter of 

Despite high levels of ANC 

attendance, few women received 

SP during ANC visits. 

The finding that coverage of IPTp is lower 

in high malaria transmission areas than in 

the lowest transmission zones could argue 

for reconsideration of resource allocation 

at both the local and global levels. 
 37 

course and thus could not be analyzed in this study. Also, source of ANC care was associated with IPTp 

use; women attending ANC at religious and public facilities were more likely to use IPTp than women 

who attended other private ANC facilities. Analyses also show that women who use other maternal health 

interventions such as vitamin A, iron supplementation and tetanus immunization and who use ITNs are 

more likely to use IPTp, even after controlling for factors such as women’s education, socioeconomic 

status, household residence and type of health facility. This could be due to unmeasured factors such as 

women’s individual health knowledge (some women may be more likely to request interventions), to 

factors such as provider knowledge or resource availability (some facilities may be more likely to have 

the resources and staff to provide multiple interventions), or to policies and practices at facilities (some 

facilities may provide better overall care including more and better maternal health interventions).While 

these findings are informative in characterizing socio-demographic and maternal health factors linked to 

successful IPTp uptake, they do not provide insight into the reasons that certain steps in the delivery 

process are ineffective. Studies focused on facilitators of or barriers to SP delivery within the ANC clinic 

context will be essential for improving IPTp coverage. 

With an aim of identifying key differences in determinants of IPTp use between countries with lower 

IPTp coverage and those with higher IPTp coverage, distributions of significant determinants of IPTp use 

were compared. Significant differences by IPTp coverage level were seen in the distributions of most 

determinants with the exception of the percentage of women attending two or more ANC visits and the 

percentage of women receiving urine, blood, and blood pressure testing during ANC visits. Some 

interesting patterns emerged from these stratifications. First, although the odds of IPTp coverage 

increased with increasing number of ANC visits, women in lower coverage countries were more likely to 

attend five or more ANC visits than women in high coverage countries, even though women in lower 

IPTp coverage countries were less likely to attend ANC for the first time early in their pregnancies. 

Women from higher IPTp coverage countries were also more likely to obtain ANC at public facilities and 

at religious facilities than were women from lower IPTp coverage countries. As ANC care at public and 

religious facilities is associated with greater likelihood of IPTp use this finding argues for education 

campaigns to encourage use of public and religious facilities for ANC or for expansion of IPTp service 

delivery to more facilities in the private sector. A much greater percentage of women in lower IPTp 

coverage countries than in higher IPTp coverage countries lived in high malaria transmission areas, 

whereas women in higher IPTp coverage countries were more likely to live in medium transmission areas 

than were women in lower IPTp coverage countries. Targeting efforts to improve IPTp delivery and 

uptake to areas of high malaria transmission is likely to be cost–efficient, given the greater potential for 

reductions in total number of infections and in adverse outcomes. 

In summary, effective delivery of IPTp appears to be 

driven by service delivery dynamics within health 

facilities more than by lack of access to ANC 

services. Although the type of health facility was 

shown to be an important factor in determining 

effective delivery of IPTp, identification of other important service delivery factors was not possible in 

these analyses due to the use of household surveys that do not include the necessary data. However, from 

the results of this study, it is clear, first, that focusing on ANC attendance alone is not sufficient to 

improve delivery of IPTp; the services and the overall health infrastructure need to be functional and 

effective, and women need to be informed and willing to use interventions in order for the intervention to 

be successful. Second, among the available household survey data, malaria transmission risk, maternal 

health interventions, and ANC factors were found to be the most important determinants of successful 

delivery of IPTp. Socio-demographic characteristics of the target population were not associated with 

IPTp use. These results suggest that allocating available malaria in pregnancy resources to improvements 

in ANC services, especially in areas of highest malaria risk, are likely to have the greatest effect on IPTp 

coverage. Finally, more targeted research and analyses of facility-based data are needed to identify 

Effective delivery of IPTp appears to be driven by 

service delivery dynamics within health facilities 

more than by lack of access to ANC services. 
 38 

precisely which factors are responsible for the bottlenecks in 

IPTp delivery within the context of ANC visits. This is 

necessary in order to recommend appropriate improvements to 

IPTp delivery, whether they include better communication with 

pregnant women to increase knowledge of and demand for 

IPTp, increased training for health care providers regarding 

IPTp policies and the importance and benefits of IPTp for 

pregnant women, improvements in commodity supply chains to ensure continual availability of SP, or 

any combination thereof. 

Every study has limitations. The analyses presented here make use of nationally representative household 

survey data in which women who have had a live birth in the two years preceding interview were asked 

questions about their use of antenatal care services and use of medications for their most recent 

pregnancies. Asking women to report retrospective events introduces the potential for recall bias. 

Reporting bias may also occur if women feel compelled to under- or overreport intervention use. Also, 

IPTp coverage may be underestimated in countries with high HIV prevalence, as SP is contraindicated for 

HIV-positive women taking cotrimoxazole, and DHS and MIS questionnaires do not ask about use of this 

medication. Not all DHS surveys measure HIV prevalence and MIS rarely do. Thus, it was not possible to 

control for HIV infection in these analyses. 

An additional limitation of these analyses lies in the content of the questionnaires—a typical MIS does 

not ask extensive questions on history of antenatal care (numbers of visits, gestation at first visit, 

components of visits). This limits the analysis pertaining to service effectiveness that could be done with 

these data. Adding several questions to the standard MIS about numbers and timing of ANC visits would 

be beneficial for programmatically useful analyses. Similarly, women are not asked about the source of 

each dose of SP they receive or whether or not the medication was taken under directly observed therapy 

(DOT). This limits the extent to which DHS/MIS can be used to measure precisely adherence to WHO 

recommendations for IPTp administration. Finally, the retrospective nature of data collection about 

behaviors during recent pregnancies, in combination with a range of survey years, means that pooled data 

present a somewhat dated snapshot of the IPTp coverage levels. As much funding and programmatic 

effort has gone into malaria in pregnancy programs in recent years, current coverage levels are likely to 

be higher. Until routine reporting systems can be relied on to produce timely and accurate data, however, 

household surveys, despite their limitations, provide invaluable data for monitoring and evaluation of 

malaria programs. 

More targeted research and analyses of 

facility-based data are needed to 

identify precisely which factors are 

responsible for the bottlenecks in IPTp 

delivery in ANC. 
 39 

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Appendix 

Figure A.1. IPTp intervention districts in Kenya 2008, Madagascar 2008, and Zimbabwe 2010-11 

43 
Table A.1. Percentage of recently pregnant women age 15-49 years who made at least one, at least two, and at least four ANC visits, by 

survey 

≥1 ANC LCI UCI N ≥2 ANC LCI UCI ≥4 ANC LCI UCI N 

Burkina Faso 2010 DHS 96.2 95.2 97.0 5,677 92.2 91.0 93.2 32.3 30.6 34.2 5,674 Burundi 2010 DHS 99.1 98.7 99.4 3,099 95.5 94.6 96.2 33.1 30.7 35.5 3,093 Cameroon 2011 DHS 84.3 81.5 86.7 4,594 81.9 79.1 84.3 59.1 56.5 61.6 4,568 

DRC 2007 DHS 87.5 83.5 90.7 3,228 81.7 77.6 85.2 48.1 43.8 52.4 3,130 

Ghana 2008 DHS 96.2 94.7 97.3 1,134 92.8 90.9 94.4 77.4 74.1 80.5 1,112 

Kenya 2008 DHS 92.4 90.0 94.2 1,973 88.1 85.5 90.3 42.4 39.1 45.8 1,952 

Madagascar 2008 DHS 87.6 85.6 89.4 3,470 82.5 80.1 84.6 45.0 42.3 47.7 3,446 

Malawi 2010 DHS 98.3 97.8 98.7 7,493 95.3 94.6 96.0 43.5 41.8 45.1 7,448 

Mozambique 2011 DHS 90.6 88.6 92.4 4,834 85.6 83.3 87.6 48.6 46.2 51.0 4,791 

Nigeria 2008 DHS 62.9 60.9 64.8 10,535 55.9 53.8 58.0 45.9 44 47.9 9,297 

Senegal 2010-11 DHS 95.5 94.5 96.3 4,326 90.8 89.5 92.0 49.3 46.8 51.8 4,263 

Sierra Leone 2008 DHS 93.2 90.7 95.1 2,220 89.9 86.8 92.3 65.5 61.8 69.0 1,850 

Tanzania 2010 AIS/MIS 98.0 97.1 98.6 3,144 93.4 92.1 94.5 38.7 36.2 41.3 3,138 

Uganda 2011 DHS 94.6 92.6 96.0 2,031 89.5 87.3 91.3 44.4 41.8 47.1 1,996 

Zambia 2007 DHS 97.4 96.5 98.1 2,604 94.5 93.3 95.5 57.0 54.7 59.4 2,586 

Zimbabwe 2010-11 DHS 89.2 86.3 91.6 1,001 85.6 82.7 88.1 59.0 55.2 62.8 980 

Total* 83.4 82.6 84.2 60,091 79.1 78.2 79.9 47.4 46.6 48.3 57,258 

LCI = lower confidence interval; UCI = upper confidence interval; N = weighted sample size. *Total represents the multi-country, pooled, weighted estimates. 

44 
Table A.2. Percentage of recently pregnant women age 15-49 years who made at least one ANC visit, by number of ANC visits and by 

survey 

1 ANC LCI UCI 2 ANC LCI UCI 3 ANC LCI UCI 4 ANC LCI UCI 5+ ANC LCI UCI N 

Burkina Faso 2010 DHS 4.2 3.6 4.9 17.8 16.4 19.2 44.4 42.7 46.1 28.7 27.1 30.4 4.9 4.2 5.7 5,459 Burundi 2010 DHS 3.7 3.0 4.5 15.4 13.9 17.1 47.5 45.3 49.8 24.0 22.1 26.0 9.3 8.1 10.8 3,066 Cameroon 2011 DHS 2.7 2.2 3.4 7.3 6.4 8.4 19.7 18.3 21.3 18.9 17.5 20.5 51.2 49.1 53.4 3,846 

DRC 2007 DHS 6.2 5.0 7.7 11.2 9.2 13.5 27.4 24.4 30.7 22.7 20.0 25.6 32.5 28.6 36.6 2,726 

Ghana 2008 DHS 3.5 2.5 4.8 5.1 3.6 7.1 10.9 9.0 13.2 13.3 11.0 16.0 67.2 63.5 70.7 1,069 

Kenya 2008 DHS 4.6 3.4 6.1 13.1 11.0 15.4 36.4 33.0 40.0 22.0 19.3 24.9 24.0 20.7 27.7 1,801 

Madagascar 2008 DHS 5.8 4.8 7 15.4 13.7 17.2 27.5 25.3 29.7 26.4 24.3 28.6 25.1 22.9 27.3 3,016 

Malawi 2010 DHS 3.0 2.5 3.6 14.1 13.1 15.2 38.7 37.3 40.1 26.9 25.7 28.2 17.3 16.0 18.6 7,319 

Mozambique 2011 DHS 5.5 4.6 6.6 13.2 11.7 14.9 27.6 25.8 29.6 24.8 23.0 26.7 28.8 27.0 30.7 4,338 

Nigeria 2008 DHS 3.5 3.0 4.1 6.3 5.6 7.1 11.0 10.0 12.0 11.9 11.0 12.9 67.3 65.7 69.0 5,385 

Senegal 2010-11 DHS 4.8 4.0 5.7 12.8 11.5 14.2 30.7 28.9 32.6 34.0 32.0 36.1 17.7 15.1 20.5 4,066 

Sierra Leone 2008 DHS 2.2 1.5 3.2 7.9 6.3 9.8 18.7 16.3 21.3 20.3 18.1 22.6 51.0 47.5 54.6 1,699 

Tanzania 2010 AIS/MIS 4.7 3.8 5.8 17.4 15.4 19.5 38.4 36.2 40.7 24.5 22.5 26.6 15.0 13.3 16.8 3,075 

Uganda 2011 DHS 5.3 4.2 6.8 13.8 12.1 15.8 33.8 31.6 36.1 28.3 26.1 30.6 18.7 16.6 21.0 1,886 

Zambia 2007 DHS 2.9 2.3 3.8 9.1 7.9 10.5 29.4 27.3 31.5 29.4 27.6 31.3 29.1 26.9 31.5 2,518 

Zimbabwe 2010-11 DHS 3.9 2.6 5.7 7.4 5.6 9.7 22.5 19.5 25.7 24.0 20.8 27.4 42.4 38.4 46.4 873 

Total* 4.3 4.0 4.6 11.4 10.9 11.9 26.9 26.2 27.6 21.6 21.1 22.2 35.8 34.9 36.6 47,307 

LCI = lower confidence interval; UCI = upper confidence interval; N = weighted sample size. * Total represents the multi-country, pooled, weighted estimates.

45 
Table A.3. Percentage of recently pregnant women age 15-49 years who made at least one ANC visit, by timing of first ANC visit and by 

survey 

1st 

trimester LCI UCI 

2nd 

trimester LCI UCI 

3rd 

trimester LCI UCI N 

Burkina Faso 2010 DHS 41.9 39.8 44.0 52.6 50.6 54.6 5.5 4.8 6.2 5,454 Burundi 2010 DHS 19.6 17.9 21.4 67.4 65.4 69.3 13.0 11.5 14.6 3,063 Cameroon 2011 DHS 37.3 35.3 39.3 55.4 53.5 57.4 7.3 6.2 8.5 3,847 

DRC 2007 DHS 20.3 17.4 23.5 66.7 63.4 69.8 13.0 10.7 15.8 2,781 

Ghana 2008 DHS 55.4 51.9 58.8 41.9 38.6 45.3 2.7 1.9 4.0 1,084 

Kenya 2008 DHS 13.8 11.6 16.3 68.8 65.5 71.9 17.4 14.8 20.3 1,819 

Madagascar 2008 DHS 27.4 25.1 29.8 64.7 62.4 66.9 7.9 6.7 9.3 3,017 

Malawi 2010 DHS 12.6 11.5 13.7 73.9 72.5 75.2 13.5 12.5 14.6 7,353 

Mozambique 2011 DHS 13.3 12.0 14.8 75.5 73.8 77.1 11.2 9.9 12.5 4,361 

Nigeria 2008 DHS 25.8 24.5 27.3 62.1 60.7 63.5 12.1 11.2 13.0 6,480 

Senegal 2010-11 DHS 61.6 59.4 63.7 32.9 31 34.9 5.5 4.6 6.6 4,018 

Sierra Leone 2008 DHS 32.0 29.4 34.6 60.5 57.6 63.3 7.6 6.2 9.2 2,017 

Tanzania 2010 AIS/MIS 13.6 12.0 15.4 71.4 69.3 73.4 15 13.1 17.1 3,079 

Uganda 2011 DHS 19.5 17.5 21.6 64.0 61.5 66.5 16.5 14.5 18.7 1,915 

Zambia 2007 DHS 18.0 16.0 20.1 73.3 71.0 75.4 8.8 7.5 10.3 2,527 

Zimbabwe 2010-11 DHS 17.3 14.6 20.3 63.9 60.5 67.1 18.8 16.2 21.8 892 

Total* 24.9 24.2 25.5 63.3 62.6 64.0 11.8 11.3 12.3 49,651 

LCI = lower confidence interval; UCI = upper confidence interval; N = weighted sample size. * Total represents the multi-country, pooled, weighted estimates. 

46 
47 

Table A.4. Percentage of recently pregnant women age 15-49 years who took SP, by dose, by 

survey, and by higher and lower IPTp coverage countries 

1 dose SP 95% CI 2 doses SP 95% CI 3 doses SP 95% CI N 

Higher IPTp Coverage

Burkina Faso 2010 73.8 [71.4,76.0] 38.5 [36.4,40.7] 5.2 [4.5,6.1] 5677 

Cameroon 2011 16.2 [13.5,19.3] 6.7 [5.4,8.3] 2.4 [1.8,3.3] 3228 

Ghana 2008 58.9 [55.1,62.7] 46.0 [42.1,49.8] 28.4 [25.2,31.8] 1134 

Malawi 2010 87.7 [86.6,88.8] 55.1 [53.4,56.7] 18.1 [16.9,19.4] 7493 

Senegal 2010-11 20.2 [17.7,22.9] 12.1 [10.2,14.4] 5.2 [4.2,6.5] 2220 

Tanzania 2010 63.5 [60.4,66.4] 27.2 [25.0,29.5] 2.8 [2.2,3.5] 3144 

Uganda 2011 48.2 [44.8,51.7] 26.6 [24.2,29.3] 9.9 [8.3,11.7] 2031 

Zambia 2007 86.9 [84.9,88.6] 65.7 [63.1,68.3] 43.0 [40.3,45.8] 2604 

Total* 61.8 [60.5,63.0] 35.8 [34.7,36.8] 13.2 [12.6,13.9] 24,333 

Lower IPTp Coverage 

Burundi 2010 0.3 [0.1,0.7] 0.3 [0.1,0.7] 0.3 [0.1,0.7] 3099 

DRC 2007 44.2 [41.5,47.0] 26.8 [24.9,28.9] 12.1 [10.9,13.3] 4594 

Kenya 2008 36.2 [33.1,39.4] 15.4 [13.2,18.0] 7.5 [6.0,9.4] 1973 

Madagascar 2008 15.3 [13.5,17.3] 8.6 [7.4,10.1] 2.5 [1.9,3.3] 3470 

Mozambique 2011 37.2 [35.2,39.3] 19.6 [18.0,21.4] 9.5 [8.3,10.9] 4834 

Nigeria 2008 11.0 [10.1,12.0] 6.6 [6.0,7.4] 3.3 [2.8,3.8] 10,535 

Sierra Leone 2008 68.4 [65.2,71.4] 40.4 [37.9,42.9] 13.3 [11.5,15.5] 4326 

Zimbabwe 2010-11 24.0 [20.3,28.1] 14.1 [11.1,17.8] 9.1 [6.8,12.3] 1001 

Total* 17.2 [16.4,18.0] 8.9 [8.4,9.5] 4.2 [3.8,4.6] 35,758 

Overall Total** 35.2 [34.5,36.0] 19.8 [19.2,20.4] 7.8 [7.5,8.2] 60,091 

N= weighted sample size. 

* Total represents the multi-country, pooled, weighted estimates for each strata of IPTp coverage, separately. 

**Overall Total represents the multi-country, pooled, weighted estimates.