Healthcare provider and drug dispenser knowledge and adherence to guidelines for the case management of malaria in pregnancy in the context of multiple first-line artemisinin-based combination therapies in Western Kenya

Abstract

Abstract Background Concerns about emerging resistance to artemether-lumefantrine (AL) in Africa prompted the pilot introduction of multiple first-line therapies (MFT) in Western Kenya, potentially exposing women-of-childbearing-age (WOCBA) to antimalarials with unknown safety profiles in the first trimester. We assessed healthcare provider knowledge and adherence to national guidelines for managing malaria in pregnancy in the context of the MFT pilot. Methods From March to April 2022, we conducted a cross-sectional study in 50 health facilities (HF) and 40 drug outlets (DO) using structured questionnaires to assess pregnancy detection, malaria diagnosis, and treatment choices by trimester. Differences between HF and DO providers and between MFT and non-MFT HFs were assessed using Chi-square tests. Results Of 174 providers (77% HF, 23% DO), 56% were from MFT pilot facilities. Most providers had tertiary education; 5% HF and 20% DO had only primary or secondary education. More HF than DO providers had knowledge of malaria treatment guidelines (62% vs 40%, p=0.023), received training in malaria in pregnancy (49% vs 20%, p=0.002), and reported assessing for pregnancy in WOCBA (98% vs 78%, p<0.001). Most providers insisted on parasitological diagnosis, with 59% HF using microscopy and 85% DO using rapid diagnostic tests. More HF than DO providers could correctly name the drugs for treating uncomplicated malaria in the first trimester (oral quinine, or AL if quinine is unavailable) (90% vs 58%, p<0.001), second and third trimesters (artemisinin-based combination therapies) (84% vs 70%, p=0.07), and for severe malaria (parenteral artesunate/artemether) (94% vs 60%, p<0.001). Among HF providers, those in the MFT pilot had more knowledge of malaria treatment guidelines (67% vs 49%, p=0.08) and had received training on treatment of malaria in pregnancy (56% vs 32%, p=0.03). Few providers (10% HF and 12% DO) had adequate knowledge of malaria treatment in pregnancy, defined as the correct drug and dose for uncomplicated and severe malaria in all trimesters. Conclusions Knowledge of national malaria in pregnancy treatment guidelines among providers in western Kenya is suboptimal. Robust training on appropriate antimalarial and dosage is needed. Supervision of DO and HF practices is essential for correct treatment of malaria in pregnancy in the context of MFT programmes.