Prevalence of malaria during pregnancy and coverage of intermittent preventive treatment with sulfadoxine-pyrimethamine in urban Amboasary-Sud, Southern Madagascar

BACKGROUND: Malaria in pregnancy remains a major public health concern in Madagascar, particularly in southern regions with unstable transmission. Intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is a key prevention strategy, yet its coverage remains poorly documented at the district level. This study aimed to assess IPTp-SP coverage, malaria prevalence, and associated complications among pregnant women in Amboasary-Sud, southern Madagascar. METHODS: A retrospective descriptive study was conducted using routine antenatal care (ANC) data from two public health facilities in 2021. A total of 1262 pregnant women attending at least one ANC visit were included. Data on sociodemographics, ANC attendance, IPTp-SP uptake, malaria rapid diagnostic test (RDT) results, and maternal-fetal outcomes were extracted and analysed. Logistic regression was used to identify factors associated with adequate IPTp-SP coverage (≥ 3 doses). RESULTS: Among ANC attendees, 64.9% (819/1262) received at least one dose of IPTp-SP, but only 49.9% (409/819) completed the recommended three or more doses. Malaria RDTs were performed among symptomatic women (n = 289), with a positivity rate of 21.1% (61/289). The observed proportion of confirmed symptomatic malaria cases among all ANC attendees was 4.8% (61/1262). Maternal (n = 7) and fetal (n = 3) complications were observed exclusively among women who had not received IPTp-SP; however, the small number of events precluded causal interpretation. In multivariable analysis, living within 5 km of a health facility (aOR = 1.54, 95% CI 1.14-2.08) and attending four or more ANC visits (aOR = 2.38, 95% CI 1.76-3.21) were independently associated with adequate IPTp-SP coverage. CONCLUSIONS: IPTp-SP coverage in Amboasary-Sud remains suboptimal despite continuous drug availability. Strengthening ANC attendance and addressing geographical barriers may improve uptake of malaria prevention during pregnancy. Community-based delivery strategies could complement facility-based services in settings with limited access.