Malaria prevention in pregnancy, birthweight, and neonatal mortality: a meta-analysis of 32 national cross-sectional datasets in Africa
Malaria prevention in pregnancy, birthweight, and neonatal mortality: a meta-analysis of 32 national cross-sectional datasets in Africa
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DOI：
10.1016/s1473-3099(12)70222-0
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发表时间：
2012-12-01
影响因子：
56.3
通讯作者：
Steketee, Richard W.
中科院分区：
文献类型：
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作者：
Eisele, Thomas P.;Larsen, David A.;Steketee, Richard W.
背景低出生体重儿是新生儿和婴儿死亡的重要危险因素。低出生体重儿的一个主要原因是孕期感染恶性疟原虫。孕期抗疟疾间歇预防疗法(IPTp)和驱虫蚊帐(ITN)大大降低了疟疾稳定传播地区低出生体重的风险。我们旨在评估在非洲疟疾流行国家实施孕期疟疾预防(IPTp或ITNS)在常规规划条件下预防低出生体重和新生儿死亡的有效性。方法我们使用了2000年至2010年非洲25个国家横断面数据的回顾性出生队列。我们使用了截至2011年公开提供的多指标类集调查、人口和健康调查、疟疾指标调查和艾滋病指标调查的所有可用数据集。我们试图通过精确匹配孕期和生育结果中与疟疾预防相关的潜在混杂因素(ITNS或IPTp与磺胺多辛乙胺)，包括当地疟疾传播、新生儿破伤风疫苗接种、母亲年龄和教育程度以及家庭财富，来限制混淆偏见。我们使用Logistic回归模型来检验孕期疟疾预防与低出生体重之间的关联，并使用泊松模型来检验新生儿死亡率的结果。这两个模型都将匹配的地层作为随机效应纳入其中，同时考虑了具有固定效应协变量的额外潜在混杂因素。在完全匹配和控制潜在的混杂因素后，第一次或第二次怀孕的妇女暴露在使用IPTp或ITNS的完全预防疟疾的环境中，与没有保护的母亲的新生儿相比，新生儿死亡的风险显著降低(保护效果[PE]18%，95%可信区间4-30；发病率比[IRR]0.820，95%可信区间0.698-0.962)。与没有保护措施的妇女相比，在完全匹配和控制潜在的混杂因素后，孕妇在头两次怀孕期间通过IPTp或ITNS接受全面的孕期疟疾预防，显著降低了低出生体重的几率(PE21%，14-27；IRR0.792，0.732-0.857)。在常规疟疾控制方案的条件下，妊娠期的解释疟疾预防与新生儿死亡率的大幅降低和低出生体重相关。疟疾控制方案应努力通过IPTp和ITNS实现对孕妇的全面保护，以最大限度地发挥其效益。尽管试图通过将妇女与被认为与在怀孕和生育结果中获得疟疾预防相关的因素相匹配来减轻偏见和潜在的混淆，但可能仍然存在某种程度的混淆偏见。
Background Low birthweight is a significant risk factor for neonatal and infant death. A prominent cause of low birthweight is infection with Plasmodium falciparum during pregnancy. Antimalarial intermittent preventive therapy in pregnancy (IPTp) and insecticide-treated mosquito nets (ITNs) significantly reduce the risk of low birthweight in regions of stable malaria transmission. We aimed to assess the effectiveness of malaria prevention in pregnancy (IPTp or ITNs) at preventing low birthweight and neonatal mortality under routine programme conditions in malaria endemic countries of Africa.Methods We used a retrospective birth cohort from national cross-sectional datasets in 25 African countries from 2000-10. We used all available datasets from multiple indicator cluster surveys, demographic and health surveys, malaria indicator surveys, and AIDS indicator surveys that were publically available as of 2011. We tried to limit confounding bias through exact matching on potential confounding factors associated with both exposure to malaria prevention (ITNs or IPTp with sulfadoxine-pyrimethamine) in pregnancy and birth outcomes, including local malaria transmission, neonatal tetanus vaccination, maternal age and education, and household wealth. We used a logistic regression model to test for associations between malaria prevention in pregnancy and low birthweight, and a Poisson model for the outcome of neonatal mortality. Both models incorporated the matched strata as a random effect, while accounting for additional potential confounding factors with fixed effect covariates.Findings We analysed 32 national cross-sectional datasets. Exposure of women in their first or second pregnancy to full malaria prevention with IPTp or ITNs was significantly associated with decreased risk of neonatal mortality (protective efficacy [PE] 18%, 95% CI 4-30; incidence rate ratio [IRR] 0.820, 95% CI 0.698-0.962), compared with newborn babies of mothers with no protection, after exact matching and controlling for potential confounding factors. Compared with women with no protection, exposure of pregnant women during their first two pregnancies to full malaria prevention in pregnancy through IPTp or ITNs was significantly associated with reduced odds of low birthweight (PE 21%, 14-27; IRR 0.792,0.732-0.857), as measured by a combination of weight and birth size perceived by the mother, after exact matching and controlling for potential confounding factors.Interpretation Malaria prevention in pregnancy is associated with substantial reductions in neonatal mortality and low birthweight under routine malaria control programme conditions. Malaria control programmes should strive to achieve full protection in pregnant women by both IPTp and ITNs to maximise their benefits. Despite an attempt to mitigate bias and potential confounding by matching women on factors thought to be associated with access to malaria prevention in pregnancy and birth outcomes, some level of confounding bias possibly remains.