Predictors of insecticide-treated bed nets use among pregnant women in Sierra Leone: evidence from the 2019 Sierra Leone Demographic Health Survey | Malaria Journal


Malaria, a vector-borne disease, is a significant worldwide health issue, particularly in sub-Saharan Africa, with pregnant women and children under five being the most severely impacted [1, 2]. In 2019, the World Health Organization (WHO) anticipated that 11 million pregnant women were exposed to malaria infections. West Africa had the highest prevalence of low-birth-weight infants related to malaria in pregnancy, resulting in 872,000 children being delivered by pregnant mothers with low birth weight [1]. Additionally, around 25 million pregnant women are currently vulnerable to contracting malaria. Malaria infection in pregnant women causes more than 10,000 maternal and 200,000 neonatal deaths per year [3, 4].

Sierra Leone is heavily affected by parasitic diseases, such as malaria, schistosomiasis, lymphatic filariasis, onchocerciasis, soil-transmitted helminth infections, and African trypanosomiasis [5, 6]. In 2019, the Global Burden of Disease Study reported that Sierra Leone had a malaria burden of 824,000 (355,000–1,400,000) disability-adjusted life years (DALYs) per 100,000 people and an onchocerciasis burden of 23,000 (9,750–40,000) DALYs per 100,000 inhabitants [7]. Sierra Leone recorded 2,615,850 cases of malaria in 2019, resulting in an incidence rate of 33.5%. Additionally, there were 6824 malaria-related fatalities, leading to a case fatality rate of 0.3%. Approximately 2.24 million outpatient visits annually were attributed to malaria, with around 1 million involving children under five years old [8]. Parasitic diseases, particularly malaria, have presented significant challenges to the health and economic progress of Sierra Leone.

Malaria during pregnancy is linked to severe illness and death for both the mother and the child due to adverse maternal health and birth complications such as miscarriage, stillbirth, and intrauterine growth retardation [9, 10]. The WHO suggests utilizing ITN, Intermittent Preventive Therapy in pregnancy (IPTp), early diagnosis, and efficient treatment to prevent and manage malaria during pregnancy [11]. Using ITNs is advantageous for preventing malaria in regions with high transmission rates and is, therefore, advised together with other preventive measures [12]. Due to the high probability of reduced immunity in pregnant women, it is crucial to use ITN even in regions with low disease transmission rates [9]. The goals for malaria interventions during pregnancy, particularly the timely use of ITN and IPTp, have often not been achieved despite remaining problems that need to be addressed [13, 14].

Current malaria policy and interventions for pregnant women in Sierra Leone include intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and ITN distribution on their first ante-natal care visit [8]. This is the cornerstone of malaria prevention for pregnant women in Sierra Leone. Insecticide-treated bed nets (ITNs) are also universally distributed through campaigns and encouraged for regular use, especially during pregnancy and early childhood [15]. Targeted social and behaviour change communication (SBCC) campaigns emphasize the importance of preventive measures like ITNs and IPTp-SP to increase awareness and understanding. Rapid diagnostic tests (RDTs) are also used to accurately diagnose malaria at all healthcare system levels, ensuring prompt and appropriate treatment. Pregnant women with suspected or confirmed malaria receive a prompt diagnosis, treatment, and counselling on prevention and adherence to IPTp-SP [8, 15]. Despite these improvements in the country, rural communities often face distance and resource limitations, hindering consistent preventive care and treatment. Also, not all pregnant women receive all recommended doses due to various factors, including limited access to care or misconceptions about the medication. Challenges like ITN damage, discomfort, or lack of proper hanging practices reduce their effectiveness [8, 15]. Continued efforts are crucial to address the challenges, improve policy implementation, and increase access to effective preventive and treatment interventions for pregnant women in Sierra Leone.

Several studies have explored the sociodemographic and behavioural factors influencing bed net use, including household size, number of nets available, education level, and awareness of benefits [16,17,18,19,20,21,22,23,24,25]. However, limited research has examined the specific factors influencing the adoption of ITNs among pregnant women in Sierra Leone. Understanding these factors is crucial to improving the country’s maternal and child health outcomes.

Previous studies [26,27,28,29,30,31] on malaria in Sierra Leone have focused on the testing, diagnosis, management, and treatment of malaria and no study has looked at the factors associated with ITN use among pregnant women who are particularly vulnerable. Therefore, this study aims to identify the specific factors that hinder ITN use among pregnant women in Sierra Leone using the 2019 SLDHS. Understanding these factors is crucial to improving the country’s maternal and child health outcomes. By identifying the factors of ITN use in this population, this study can inform targeted interventions and policy improvements to promote ITN use and optimize malaria prevention for pregnant women in Sierra Leone.


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