Community-based strategies to increase coverage of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in sub-Saharan Africa: a systematic review, meta-analysis, meta-ethnography, and economic assessment

Background Community-based approaches might increase uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). We assessed the effects of community-based approaches on IPTp-SP and antenatal care coverage, and barriers and facilitators to implementation in sub-Saharan Africa. Methods We did a systematic review, meta-analysis, meta-ethnography, and economic assessment. We searched the WHO International Clinical Trials Registry Platform, PubMed, the Malaria in Pregnancy Library database, Medline, Global Health and Global Health Archives, and the Cochrane Library for trials, mixed-methods, qualitative, and cost-effectiveness studies of community health worker promotion of antenatal care, IPTp-SP delivery, or both, with no language restrictions, published before March 21, 2024. Information on interventions, number of IPTp-SP doses, antenatal care visits, and barriers and facilitators were extracted. We did a meta-analysis (random effects) comparing effects on two or more or three or more IPTp-SP doses and one or more or four or more antenatal care visits. We followed Noblit and Hare's method of meta-ethnography to synthesise qualitative findings, using reciprocal translation and line-of-argument synthesis. We developed a theory for increased community IPTp-SP uptake. We also summarised cost and cost-effectiveness studies. This study is registered with PROSPERO, CRD42022364114. Findings Of 4753 records screened, we included 23 (0<middle dot>5%) reporting on 15 studies. Community health worker involvement was associated with an increase in two or more IPTp-SP doses (pooled risk ratio 1<middle dot>48, [95% CI 1<middle dot>24-1<middle dot>75]; 12 sub-studies; I-2 94<middle dot>7%) and three or more IPTp-SP doses (1<middle dot>73 [1<middle dot>19-2<middle dot>50]; ten sub-studies, I-2 97<middle dot>5%), with no decrease in four or more antenatal care visits (1<middle dot>17 [1<middle dot>00-1<middle dot>36]; 13 sub-studies; I-2 90<middle dot>3%). Cluster-randomised controlled trials showed a lower increase in coverage of three or more IPTp-SP doses (1<middle dot>08 [1<middle dot>00-1<middle dot>16]; I-2 0<middle dot>0%; six studies) compared with before-and-after studies (2<middle dot>86 [1<middle dot>29-6<middle dot>33]; I-2 98<middle dot>9%; four studies; subgroup analysis p=0<middle dot>019). Barriers to community health worker delivery of IPTp-SP included women's fear of side-effects, lack of knowledge, lack of trust in community health workers, and sociocultural factors. Community sensitisation, engagement of husbands, pre-established community health worker networks, and trained and supported community health workers facilitated IPTp-SP delivery by community health workers. Incremental cost-effectiveness ratios ranged from $1<middle dot>1 to $543 per disability-adjusted life-year averted. Interpretation Community-based approaches increased IPTp-SP coverage and might have a positive effect on the number of antenatal care visits in addition to being cost-effective, although we found high heterogeneity among studies. Community sensitisation and engagement in addition to established, trained, and supported community health workers can facilitate acceptability, delivery, and uptake of IPTp-SP delivered by community health workers.