Prioritizing Pregnant Women for Long-Lasting Insecticide Treated Nets through Antenatal Care Clinics

The use of insecticide treated nets (ITNs), and subsequently the new generation of long-lasting insecticide treated nets (LLINs), has been a core malaria prevention strategy for more than two decades [1], and until 2010, distribution of LLINs targeted biologically vulnerable groups such as pregnant women and children aged less than 5 years [2,3]. In 2008, due largely to increased funding for malaria control leading to impressive gains in LLIN coverage, the Roll Back Malaria (RBM) Partnership set a more ambitious target of universal coverage of LLINs, defined as universal access to, and use of, LLINs [4,5]. The strategy for achieving and maintaining universal coverage outlined by the RBM Partnership involves a combination of strategies based on mass campaigns, either target-specific or population-wide, to rapidly scale up coverage (‘‘catch up’’), complemented by continuous distribution through routine health services, including antenatal clinics, child health clinics, and expanded programme on immunisation (EPI) services (‘‘keep up’’) [6]. The choice of the combination is generally based on existing coverage and status of available distribution mechanisms in a given country. It is well recognised that, individually, each mechanism is suboptimal to maintain universal coverage and will leave some gaps. Use of ITNs among pregnant women is well below national and international targets; a recent meta-analysis of national survey data in 37 countries for the years 2009–2011 estimated the median use of an ITN the previous night among pregnant women was 35.3% (range 5.2%–75.5%) [7]. ITN use was higher in areas with both a high disbursement of funds for malaria control and a lower per-head gross domestic product. Younger or adolescent, unmarried, and less educated women are significantly less likely to use ITNs, which may be related to lower affordability and in-household access among these women [8].