Malaria, a significant health issue in sub-Saharan Africa, disproportionately affects pregnant women and children under five. In 2019, the World Health Organization (WHO) estimated that 11 million pregnant women were exposed to malaria, with West Africa having the highest prevalence of low-birth-weight infants linked to malaria, resulting in 872,000 children born with low birth weight. Additionally, about 25 million pregnant women are at risk of malaria, which causes over 10,000 maternal and 200,000 neonatal deaths annually.
Sierra Leone is heavily burdened by parasitic diseases, especially malaria. In 2019, the country recorded 2,615,850 malaria cases, with an incidence rate of 33.5% and 6,824 malaria-related deaths. Malaria during pregnancy is associated with severe health risks, including miscarriage, stillbirth, and intrauterine growth retardation. The WHO recommends the use of insecticide-treated nets (ITNs), intermittent preventive therapy in pregnancy (IPTp), early diagnosis, and effective treatment to manage malaria in pregnancy.
Sierra Leone’s malaria prevention policy for pregnant women includes IPTp with sulfadoxine-pyrimethamine (IPTp-SP) and ITN distribution during their first antenatal care visit. ITNs are also distributed through campaigns and encouraged for use, especially during pregnancy and early childhood. Social and behavior change communication (SBCC) campaigns emphasize the importance of preventive measures like ITNs and IPTp-SP. Rapid diagnostic tests (RDTs) are used at all healthcare levels to ensure prompt and appropriate treatment. Despite these improvements, rural communities face challenges such as distance and resource limitations, hindering consistent preventive care and treatment.
Several studies have examined factors influencing ITN use, including household size, net availability, education level, and awareness of benefits. However, limited research has focused on the specific factors influencing ITN use among pregnant women in Sierra Leone. This study aims to identify these factors using data from the 2019 Sierra Leone Demographic Health Survey (SLDHS).
Methods
Data for this study were sourced from the 2019 SLDHS, which collected demographic, health, and nutritional data over four months from a sample of 13,872 households. The survey used a multistage sampling method, selecting 578 enumeration areas (EAs) and 24 households from each EA. The study included 900 pregnant women aged 15-49 with complete datasets on the variables of interest. The study followed the Strengthening Reporting of Observational Studies in Epidemiology (STROBE) guidelines.
The outcome variable was a binary measure of ITN use, based on whether the women slept under an ITN the night before the survey. Sixteen explanatory variables were included, such as age, place of residence, education level, wealth index, employment status, region, parity, marital status, sex of household head, media exposure, religion, distance to health facilities, and recent health facility visits.
Data analysis was performed using SPSS version 28, with the complex sampling command for weighting and complex sampling design. The prevalence of ITN use was presented using percentages and confidence intervals (CI). Chi-square tests determined the variables significantly associated with ITN use at p<0.05. Binary logistic regression analysis examined the variables associated with ITN use, with results presented as adjusted odds ratios (AOR) with 95% CI.
Results
The study found that 64.2% of pregnant women in Sierra Leone used ITNs. The predictors of ITN use included marital status, parity, region, religion, and sex of the household head. Married women had higher odds of ITN use compared to unmarried women (aOR = 2.02, 95% CI 1.32-3.07). Women with five or more children had higher odds of ITN use than those with fewer children (aOR = 1.69, 95% CI 1.01-2.84). Women living in the Northern, Northwestern, Southern, and Western regions had lower odds of ITN use compared to those in the Eastern region, with the lowest odds in the Western region (aOR = 0.19, 95% CI 0.09-0.40). Muslim women had lower odds of ITN use compared to Christians (aOR = 0.63, 95% CI 0.41-0.95). Households with female heads had lower odds of ITN use (aOR = 0.65, 95% CI 0.44-0.95).
Discussion
The study revealed a suboptimal ITN use rate of 64% among pregnant women in Sierra Leone. Regional disparities, religious beliefs, and household head gender influenced ITN use. Married women and those with more children were more likely to use ITNs. The findings highlight the need for targeted interventions to address regional, cultural, and socioeconomic barriers to ITN use.
Policy implications include developing culturally sensitive messaging tailored to specific regions and religious beliefs, utilizing diverse communication channels, collaborating with religious leaders, and exploring public-private partnerships to improve ITN distribution and affordability. Continued efforts are crucial to improve ITN use and ultimately reduce the malaria burden among pregnant women in Sierra Leone.
Conclusion
ITN use among pregnant women in Sierra Leone remains suboptimal. Being married and having more children were associated with higher ITN use, while regional disparities and religious beliefs influenced lower usage rates. Targeted interventions are needed to address these barriers and promote ITN use, contributing to improved maternal and child health outcomes in Sierra Leone.
