Inequalities in coverage of three doses of Intermittent Preventive Treatment of malaria among women who attended at least four antenatal care visits in 22 sub-Saharan African countries: a secondary data analysis

Intermittent Preventive Treatment of malaria during pregnancy with at least three doses of Sulfadoxine-Pyrimethamine (IPTp-SP3 +) spaced one month apart is a simple and cost-effective intervention. It is delivered during antenatal care (ANC) visits. Therefore, all pregnant women who book at least four ANC visits (ANC4 +) are expected to get at least the recommended three doses. This analysis aimed to estimate the coverage of at least three doses of Intermittent Preventive Treatment of malaria among pregnant women who attended at least four antenatal care visits (ANC4 +) and to measure rural–urban and wealth-related inequalities in sub-Saharan Africa. We conducted a secondary analysis of the most recent Demographic and Health Survey (DHS), Multiple Indicator Cluster Survey (MICS), or Malaria Indicator Survey (MIS) conducted in sub-Saharan African malaria-endemic countries between 2019 and 2023. The study population was women who had a live birth within two years preceding each survey and reported attending ANC4+. We described wealth-related inequalities using the concentration index (CCI) and Lorenz curves. In the 22 countries, the sample totaled 45,278 women. Country coverage ranged from 13.0% in Mauritania to 70.1% in Liberia, with a median of 46.3%. Urban–rural inequalities were significant in six out of the 22 countries. Liberia was the only country with higher coverage in rural settings (64.3% in urban versus 77.2% in rural, p<0.05). Coverage was higher in urban areas across the five other countries (Burkina Faso, Central African Republic, Mozambique, The Gambia, and Tanzania). There were inequalities favoring women in the richest households in seven countries: Benin, Burkina Faso, Côte d'Ivoire, The Gambia, Ghana, Mozambique, and Tanzania. Inequalities favoring the poorest households were found in Mauritania and Madagascar. However, in all these countries, these wealth-related inequalities were negligible. The coverage of IPTp-SP3+ was equally suboptimal in urban and rural areas and slightly skewed toward wealthier households in some countries. Improving the quality of ANC services and effectively implementing evidence-based strategies, such as directly observed treatment and community-based distribution of SP, can improve the coverage of this life-saving intervention.