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Intermittent Preventive Treatment of Malaria in Pregnancy Coverage Estimates from Population-based Surveys: Reliability of Women's Recall Among Women with ANC Cards

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  • 1 President’s Malaria Initiative, U.S. Agency for International Development, Washington, District of Columbia;
  • | 2 The Demographic and Health Surveys Program, ICF, Rockville, Maryland

ABSTRACT.

Large household surveys performed to estimate coverage rates for various health interventions, including intermittent preventive treatment, depend on recall. Many studies question the validity of recalled data. Regarding vaccine coverage rates, it is standard practice to validate responses using medical history cards. To validate the coverage rates of intermittent preventive treatment during pregnancy reported by large household surveys, recalled coverage rates were compared with antenatal care card data in Benin, Ghana, Malawi, and Tanzania. The results indicated that recall was comparable to the coverage rates provided indicated by the antenatal care cards. These findings suggest that intermittent preventive treatment coverage rates reported by large household surveys performed using recalled data are valid.

Demographic and Health Surveys (DHS) and Malaria Indicator Surveys (MIS) are large, nationally representative household surveys conducted every 3 to 5 years.1 These surveys rely on the participants’ ability to accurately recall receiving health services, including insecticide-treated net (ITN) use, intermittent preventive treatment during pregnancy (IPTp), and the vaccination history of children. The World Health Organization (WHO) recommends IPTp with sulphadoxine-pyrimethamine for pregnant women residing in most sub-Saharan African countries to protect them from malaria during pregnancy.2 IPTp is administered monthly during the second and third trimesters of pregnancy during routine antenatal care (ANC) visits; at least three doses of IPTp are recommended during pregnancy.2 Key indicators for assessing optimal IPTp coverage are the percentage of women receiving at least one dose (IPTp1+) and the percentage of women receiving at least three doses (IPTp3+).

IPTp coverage is a self-reported indicator in national household surveys; therefore, many of the studies of IPTp uptake cite recall bias as a potential limitation.35 The risk of recall bias may lead to inaccurate estimates of coverage. To eliminate recall bias for vaccination coverage rates, it is standard practice in DHS surveys to verify a parent’s recall of their children’s vaccination history using the children’s medical card.6 However, this practice is not standardly used to assess interventions that protect pregnant women from malaria. Recall bias is a real concern for IPTp estimates because the data used to calculate IPTp coverage come from questions asked of women who experienced a live birth within the 2 years before completing the survey. This means it could have been as long as 2.5 years since some women received IPTp during the second trimester. Respondents’ health records, such as an antenatal care (ANC) card kept by women during their pregnancies, may be used as a second verification source to increase confidence in self-reported statistics; this practice is similar to the process used for self-reported immunization data in household surveys.7

This analysis assessed the validity of self-reported IPTp coverage in nationally representative household surveys by comparing interviewee responses based on recall with the interviewee’s written ANC card record. Several questions and a process of cross-referencing ANC cards were added to the 2017 Malawi MIS, the 2017–2018 Benin DHS, the 2011–2012 Tanzania HIV and Malaria Indicator Survey (THMIS), and the 2014 Ghana DHS.1 Surveyors recorded the results of each woman’s recall and what was recorded on her ANC card using the survey questionnaire tool.

We compared the self-reported results to the ANC card data by testing specificity, sensitivity, kappa statistics, and area under the curve (AUC) of the receiver-operating characteristic (ROC) curve for each of these surveys assuming the IPTp frequency reported on the ANC card was the gold standard. The sensitivity represents the likelihood of a woman correctly reporting that she received IPTp during her most recent pregnancy. The specificity represents the likelihood of a woman correctly reporting that she did not receive IPTp. The kappa test was used to assess the overall agreement between the recall and the ANC card data. These statistics were calculated separately for each incidence of IPTp (one dose, IPTp1; two doses, IPTp2; and three or more doses, IPTp3+). For the purpose of this analysis, only women who had experienced live birth within the past 2 years before the survey, attended an ANC appointment at least once, received at least one dose of IPTp, and had an ANC card that was observed by the surveyor were included. Of the eligible women participating in the Benin survey, 69.2% presented an ANC card (N = 1,847); 46.8% (N = 873) participating in the Ghana DHS, 69.9% (N = 658) participating in the Malawi survey, and 47.3% (N = 997) participating in the Tanzania survey presented an ANC card. Table 1 shows the IPTp coverage according to background and sociodemographic characteristics of the women.

Table 1

Self-reported IPTp coverage by background characteristics and by survey

1 dose of SP2 doses of SP3+ doses of SP
% (CI)P value% (CI)P value% (CI)P valuen
Benin DHS 2017–2018
Residence0.0710.7270.114
 Urban28.6 (25.3–32.2)41.9 (38.7–45.1)29.5 (26.4–32.9)1,108
 Rural32.9 (30.0–35.9)41.1 (38.2–44.1)26 (23.3–28.9)1,562
Mother’s education0.0010.003< 0.0001
 No education34.3 (31.5–37.2)43.3 (40.4–46.3)22.3 (20.0–24.9)15,33
 Primary28.2 (24.1–32.7)43.0 (38.8–47.7)28.7 (25.1–32.7)561
 Secondary or more25.3 (21.6–29.5)34.7 (30.7–39.0)39.9 (35.7–44.3)576
Wealth quintiles< 0.00010.124< 0.0001
 Lowest37.7 (32.2–43.4)45.7 (40.4–51.0)16.6 (13.0–21.0)387
 Second35.8 (31.6–40.4)44.8 (40.2–49.5)19.3 (15.9–23.3)524
 Middle32.5 (27.9–37.4)39.4 (35.0–43.9)28.1 (24.1–32.5)580
 Fourth30.6 (26.5–35)38.9 (34.5–43.4)30.6 (26.5–35.0)602
 Highest21.5 (18.0–25.5)40.2 (36.1–44.4)38.3 (33.9–42.8)577
Age, years0.5450.8380.301
 15–1933.7 (26.6–41.5)40.5 (33.0–48.5)25.8 (19.6–33.2)192
 20–2930.2 (27.6–33)41.0 (38.3–43.8)28.7 (26.1–31.5)1,486
 30–4931.9 (28.7–35.3)42.2 (38.9–45.6)25.9 (23.1–29.0)991
Time since delivery0.0540.940.066
 0–12 months postpartum29.6 (27.0–32.4)41.5 (38.8–44.2)28.9 (26.3–31.6)1,586
 13–24 months postpartum33.3 (30.2–36.4)41.3 (38.2–44.6)25.4 (22.6–28.5)1,085
ANC card presented0.3210.9250.367
 No29.6 (26.3–33.1)41.6 (37.7–45.5)28.8 (25.4–32.5)823
 Yes131.8 (29.1–34.6)41.3 (38.8–43.9)26.9 (24.5–29.5)1,847
Total31.1 (28.9–33.4)41.4 (39.3–43.6)27.5 (25.4–29.6)2,670
Ghana DHS 2014
Residence0.650.0410.049
 Urban17.6 (14.0–21.8)31.8 (27.9–35.9)50.7 (45.4–56.0)836
 Rural18.7 (15.9–21.9)37.8 (33.8–42.0)43.4 (38.7–48.3)1,033
Mother’s education0.7730.0860.043
 No education19.2 (15.5–23.5)36.5 (32.2–41.1)44.2 (38.8–49.8)472
 Primary18.7 (14.7–23.4)39.9 (33.7–46.4)41.5 (35.3–47.9)352
 Secondary or more17.6 (14.4–21.3)32.9 (29.1–36.9)49.5 (44.9–54.2)1,043
Wealth quintiles0.0070.0710.016
 Lowest17.3 (13.1–22.5)36.0 (31.0–41.2)46.8 (39.9–53.8)406
 Second15.1 (11.3–19.8)41.7 (34.0–49.8)43.2 (35.6–51.2)396
 Middle24.6 (19.2–31.1)35.1 (28.9–41.7)42.5 (34.5–50.8)369
 Fourth21.6 (16.4–27.9)35.1 (28.9–41.7)43.4 (26.5–50.4)258
 Highest12.3 (8.3–17.9)28.9 (23.4–35.1)58.7 (52.2–65.0)339
Age, years0.1470.1150.709
 15–1920.4 (12.8–30.9)29.2 (18.4–43.0)50.4 (35.4–65.3)120
 20–2920.3 (16.6–24.6)32.6 (28.9–36.4)47.1 (42.9–51.4)877
 30–4915.7 (13.0–19.0)38.5 (34.0–43.2)45.7 (41.7–49.8)871
Time since delivery0.0490.4370.014
 0–12 months postpartum20.3 (17.4–23.5)36.1 (32.0–40.3)43.7 (39.4–48.1)1,007
 13–24 months postpartum15.8 (12.6–19.6)34.0 (30.4–37.8)50.2 (45.5–54.9)860
ANC card presented0.5520.4740.782
 No17.5 (14.4–21.1)36.2 (32.5–40.1)46.3 (41.9–50.7)994
 Yes119.0 (15.7–22.8)33.9 (29.3–38.9)47.1 (42.1–52.2)873
Total18.2 (15.9–20.7)35.1 (32.2–38.2)46.7 (43.0–50.4)1,867
Malawi MIS 2017
Residence0.9470.2320.262
 Urban16.9 (13.1–21.7)42.3 (36.0–48.8)40.8 (34.1–47.8)144
 Rural16.8 (13.3–20.9)37.7 (33.7–41.8)45.6 (40.9–50.3)797
Mother’s education0.5410.7110.913
 No education20.5 (12.5–31.9)36.5 (28.6–45.2)43.0 (31.2–55.5)141
 Primary16.5 (12.7–21.1)38.1 (33.8–42.7)45.4 (40.5–50.4)630
 Secondary or more14.8 (10.4–20.5)40.8 (34.3–47.7)44.4 (35.4–52.8)170
Wealth quintiles0.5820.4530.199
 Lowest19.4 (12.0–29.7)39.4 (30.1–49.6)41.2 (32.3–50.6)242
 Second18 (11.3–27.6)32.7 (24.5–42.1)49.2 (39.4–59.2)198
 Middle12.4 (7.6–19.5)35.2 (26.8–44.6)52.5 (43.3–61.4)179
 Fourth18.3 (12.1–26.8)43.2 (34.2–52.7)38.4 (29.3–48.4)165
 Highest14.6 (10.5–19.8)42.4 (35.4–49.7)43.1 (36.2–50.2)158
Age, years0.050.1430.186
 15–1924.7 (17.0–34.4)31.1 (24.4–41)43.2 (34.1–52.7)160
 20–2914.3 (10.8–18.6)37.8 (33.0–42.8)48.0 (42.7–53.5)515
 30–4916.9 (11.9–23.5)43.3 (36.2–50.6)39.8 (32.8–47.3)265
Time since delivery0.4280.5120.971
 0–12 months postpartum18.0 (13.9–23.0)37.2 (32.4–2.3)44.8 (39.7–50.0)509
 13–24 months postpartum15.4 (11.3–20.6)39.7 (34.4–45.3)44.9 (39.5–50.4)432
ANC card presented0.0430.1820.002
 No22.1 (16.5–28.8)42.3 (36.0–48.8)35.7 (29.5–42.4)283
 Yes114.5 (10.9–19.0)36.7 (32.3–41.4)48.8 (43.8–53.8)658
Total16.8 (13.8–20.3)38.4 (34.8–42.0)44.8 (40.7–49.0)941
Tanzania THMIS 2011–2012
Residence0.8420.810.291
 Urban46.9 (41.0–52.9)47.8 (41.5–54.1)5.3 (3.5–8.1)469
 Rural46.2 (42.6–49.7)46.9 (43.6–50.3)6.9 (5.5–8.7)1,637
Mother’s education0.2060.4960.325
 No education45.5 (39.0–52.0)49.1 (42.9–55.3)5.5 (3.1–9.7)385
 Primary47.7 (44.2–51.1)46.0 (42.5–49.6)6.3 (5.0–7.9)1,450
 Secondary or more40.5 (33.4–48.1)49.9 (42.8–57.1)9.5 (5.2–16.8)272
Wealth quintiles0.5410.8160.835
 Lowest48.3 (41.5–55.1)45.7 (40.0–51.5)6.1 (3.5–10.2)398
 Second48.5 (42.6–54.5)45.2 (38.8–51.8)6.2 (4.0–9.7)452
 Middle44.6 (38.7–50.6)48.0 (42.1–54.1)7.4 (4.8–11.3)379
 Fourth47.8 (42.1–53.4)46.7 (41.0–52.5)5.5 (2.5–8.7)451
 Highest42.2 (35.3–49.5)50.0 (42.7–57.3)7.8 (4.8–12.5)426
Age, years0.5770.7810.538
 15–1949.8 (40.6–59.1)46.0 (36.8–55.5)4.2 (2.0–8.6)200
 20–2946.8 (43.1–50.7)46.3 (42.8–49.9)6.8 (5.1–9.1)1,073
 30–4944.8 (40.1–49.7)48.4 (43.4–53.4)6.8 (4.7–9.8)833
Time since delivery0.0370.010.531
 0–12 months postpartum49.4 (45.2–53.7)43.6 (39.8–47.4)7.0 (5.3–9.2)1,098
 13–24 months postpartum42.9 (38.6–47.4)50.9 (46.7–55.2)6.1 (4.6–8.2)1,009
ANC card presented0.9040.1630.001
 No46.1 (41.9–50.4)44.9 (40.7–49.2)9.0 (7.0–11.4)1,110
 Yes146.5 (42.1–51.0)49.6 (45.1–54)3.9 (2.6–5.9)997
Total46.3 (43.3–49.4)47.1 (44.2–50.0)6.6 (5.4–8.0)2,106

ANC = antenatal care; CI = confidence interval; DHS = Demographic and Health Survey; IPTp = intermittent preventive treatment during pregnancy; MIS = Malaria Indicator Survey; SP = sulphadoxine-pyrimethamine; THMIS = Tanzania HIV and Malaria Indicator Survey.

In the Benin 2017–2018 MIS and the Ghana 2014 DHS, the proportion of women with IPTp3+ was higher among the more educated and wealthier women. The proportion of women with IPTp3+ was also higher among women in urban settings than among those in rural settings who participated in the Ghana 2014 DHS. The proportions of women with IPTp3+ appeared to be more equitable among women who participated in the Malawi 2017 MIS and the Tanzania 2011–2012 MIS.

For the women who participated in the Malawi 2017 MIS, IPTp3+ coverage was higher among women who presented an ANC card compared with women who did not present an ANC card (49% versus 36%); however, IPTp1 coverage was lower among women who presented an ANC card (15% versus 22%). For the women who participated in the Tanzania 2011–2012 THMIS, IPTp3+ coverage was lower among women who presented an ANC card (4% versus 9%). For the women who participated in the Ghana and Benin surveys, no significant difference was apparent in IPTp coverage based on the ANC card availability.

The proportions of women who received IPTp1, IPTp2, and IPTp3+ according to self-report, ANC card data, both self-report and ANC card data, and the survey are shown in Table 2; however, these data are restricted to the subpopulation who presented ANC cards at the time of the interview. The IPTp3+ coverage was highest for women who participated in the Ghana and Malawi surveys and ranged from 47% to 55% and from 45% to 49%, respectively, depending on method of reporting information. The proportion of women with IPTp3+ in Benin ranged from 23% to 28%. However, the IPTp3+ coverage was lowest in Tanzania (range, 2–5%).

Table 2

IPTp rates reported by women who presented ANC cards1

% (CI)Total
Benin DHS 2017–2018
Percentage who received IPTp1 during ANCSelf-report31.8 (29.1–34.6)1,847
ANC card31.2 (28.5–34.1)
Either source35.6 (32.8–38.5)
Percentage who received IPTp2 during ANCSelf-report41.3 (38.8–43.9)
ANC card39.9 (37.4–42.4)
Either source44.6 (42.1–47.2)
Percentage who received IPTp3+ during ANCSelf-report26.9 (24.5–29.5)
ANC card23.2 (20.9–25.7)
Either source27.6 (25.2–30.2)
Ghana DHS 2014
Percentage who received IPTp1 during ANCSelf-report19 (15.7–22.8)873
ANC card15.5 (12.6–18.9)
Either source21.1 (17.7–25)
Percentage who received IPTp2 during ANCSelf-report33.9 (29.2–38.9)
ANC card30.8 (27–34.8)
Either source39.9 (35.2–44.8)
Percentage who received IPTp3+ during ANCSelf-report47.1 (42.1–52.2)
ANC card47.5 (43.1–51.9)
Either source54.7 (49.9–59.4)
Malawi MIS 2017
Percentage who received IPTp1 during ANCSelf-report14.5 (10.9–19)658
ANC card19.1 (15.6–23.3)
Either source19.6 (16–23.7)
Percentage who received IPTp2 during ANCSelf-report36.7 (32.3–41.4)
ANC card35.6 (31–40.5)
Either source38.7 (34.1–43.5)
Percentage who received IPTp3+ during ANCSelf-report48.8 (43.8–53.8)
ANC card44.5 (39.8–49.2)
Either source48.8 (43.8–53.8)
Tanzania THMIS 2011–2012
Percentage who received IPTp1 during ANCSelf-report46.5 (42.1–51)997
ANC card43.7 (39.6–47.8)
Either source50.6 (46.2–55)
Percentage who received IPTp2 during ANCSelf-report49.6 (45.1–54)
ANC card47.4 (43.3–51.5)
Either source54.1 (49.7–58.4)
Percentage who received IPTp3+ during ANCSelf-report3.9 (2.6–5.9)
ANC card2.1 (1.2–3.4)
Either source4.8 (3.2–7.1)

ANC = antenatal care; CI = confidence interval; DHS = Demographic and Health Survey; IPTp = intermittent preventive treatment during pregnancy; MIS = Malaria Indicator Survey; THMIS = Tanzania HIV and Malaria Indicator Survey.

To test the validity of women’s recall of IPTp doses received, we calculated the sensitivity and specificity of IPTp1, IPTp2, and IPTp3+ by comparing self-report with ANC card data. Additionally, we calculated a kappa statistic to test the agreement between the two measures and the AUC of the ROC curve to test the individual validity of the self-report measure compared with that of the ANC card data (Table 3).

Table 3

Sensitivity, specificity, and agreement of IPTp coverage comparing self-report with ANC card records among women who presented an ANC card

SensitivitySpecificityROC curve area
% (CI)% (CI)% (CI)Kappa statistic
Benin DHS 2017–2018
Recall of IPTp188.4 (85.4–91)94 (92.6–95.3)0.912 (0.9–0.93)0.8162
Recall of IPTp291.7 (89.4–93.6)92.3 (90.5–93.8)0.92 (0.91–0.93)0.8377
Recall of IPTp397.2 (95.1–98.5)94.4 (93–95.5)0.958 (0.95–0.97)0.8655
Ghana DHS 2014
Recall of IPTp182.5 (75.3–88.4)92.4 (90.2–94.2)0.874 (0.84–0.91)0.6887
Recall of IPTp279.3 (74–84)86.6 (83.6–89.2)0.83 (0.8–0.86)0.6431
Recall of IPTp384 (80.1–87.5)86.4 (82.9–89.3)0.852 (0.83–0.88)0.7039
Malawi MIS 2017
Recall of IPTp179.1 (70–86.6)99.6 (98.6–100)0.894 (0.85–0.93)0.8526
Recall of IPTp295.6 (92–97.9)96.4 (94–98)0.96 (0.94–0.98)0.9164
Recall of IPTp3100 (98.7–100)94.3 (91.2–96.5)0.971 (0.96–0.98)0.938
Tanzania THMIS 2011–2012
Recall of IPTp191.6 (88.8–94)87.5 (84.5–90.1)0.896 (0.88–0.91)0.7871
Recall of IPTp291.2 (88.3–93.6)88.4 (85.4–90.9)0.898 (0.88–0,92)0.7928
Recall of IPTp372.7 (49.8–89.3)97.8 (96.7–98.6)0.853 (0.76–0.95)0.5203

ANC = antenatal care; CI = confidence interval; DHS = Demographic and Health Survey; IPTp = intermittent preventive treatment during pregnancy; MIS = Malaria Indicator Survey; ROC = receiver-operating characteristic; THMIS = Tanzania HIV and Malaria Indicator Survey.

Across surveys, the sensitivity of women's ability to correctly report IPTp coverage ranged from 79% to 92% for IPTp1, from 79% to 96% for IPTp2, and from 73% to 100% for IPTp3+. The proportion of women who correctly reported that they did not receive IPTp (specificity) ranged from 88% to 99.6% for IPTp1, from 87% to 96% for IPTp2, and from 83% to 98% for IPTp3+. The agreement between self-reported IPTp coverage and coverage indicated on ANC cards, as measured by kappa scores, ranged from 0.69 to 0.85 for IPTp1, from 0.64 to 0.92 for IPTp2, and from 0.52 to 0.94 for IPTp3+. Although interpreting kappa scores can be somewhat problematic, the scores found during this analysis represent a moderate to high level of agreement on most scales.8,9 The AUC of the ROC curve values were > 0.8 for all reported IPTp measurements from all surveys and > 0.9 for the majority, indicating an excellent to outstanding level of individual validity for the self-reported coverage estimates.10,11

This analysis demonstrates that self-reported recall of IPTp is an adequate method of reporting IPTp with sulphadoxine-pyrimethamine doses received by women who had experienced a live birth within the 2 years before the survey using the standard protocols for household surveys such as the DHS and MIS. The analysis suggests that additional validation through external sources, such as ANC cards and a review of medical records, is not necessary. It has been found that using local context (i.e., a local word for iron folate) or a visual aid (photograph of a drug) can improve recall.12,13 For example, because of the potentially long period of recall (up to 2.5 years), the accuracy of IPTp recall may be improved by providing visuals of sulphadoxine-pyrimethamine tablets during household survey interviews to help women recall the number of IPTp doses they received.

This study only includes data from four countries; therefore, the results presented here may not be representative of all countries implementing IPTp with different rates of coverage. Another limitation of this study was that the dataset was restricted to include only women who were able to present their ANC card to the interviewer; therefore, only 47% of the women in Ghana and Tanzania, 69% in Benin, and 70% in Malawi were eligible for this study. This group of women may be different than the group women who were unable or unwilling to present their ANC card at the time of the survey. Additional studies that use health facility records of IPTp administration to verify self-reported data could be considered to address this bias. Furthermore, the surveys used for this study covered a wide date range and a wide range of IPTp coverage. The Tanzania survey was conducted in 2011 to 2012, but the others were conducted more recently. The IPTp3+ coverage indicated by this early Tanzania survey was low; therefore, these data could have affected the sensitivity and agreement statistics. Finally, the potential for interviewer bias should be considered because it is possible that during the interviews, surveyors reconciled self-reported responses based on the data observed on the ANC card.

Despite these limitations, after validation using the ANC card data as the gold standard, the results of this study demonstrate that the self-reported IPTp coverage estimates indicated by these national household surveys are accurate. The results of this study support the validity of recall of IPTp indicated by large household surveys, thus suggesting that national malaria control programs can reliably assess their IPTp intervention coverage and make programmatic decisions based on survey data. Additionally, this analysis demonstrates that including additional questions and ANC card data verification may not be necessary and is not likely to significantly change IPTp coverage estimates.

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Author Notes

Address correspondence to Susan Youll, President’s Malaria Initiative, U.S. Agency for International Development, 1300 Pennsylvania Avenue, Washington, DC 20004. E-mail: syoull@usaid.gov

Authors’ addresses: Natasha Hansen, Susan Youll, and Lia Florey, President’s Malaria Initiative, U.S. Agency for International Development, Washington, DC, E-mails: natasha.hansen16@gmail.com, syoull@usaid.gov, and lflorey@usaid.gov. Cameron Taylor, The Demographic and Health Surveys Program, ICF, Rockville, MD, E-mail: cameron.taylor@icf.com.

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