Pooled prevalence and factors associated with insecticide-treated net use among pregnant women in malaria high-burden countries in sub-Saharan Africa: a multilevel mixed-effects analysis

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INTRODUCTION: Malaria remains a significant public health challenge among pregnant women in sub-Saharan Africa (SSA). Proper use of insecticide-treated nets (ITNs) is a key intervention for malaria; however, their utilisation remains low and suboptimal in high-burden countries. Investigation of correlates of use of ITNs among pregnant women in only high-burden malaria countries SSA are dearth. This study aimed to identify the pooled prevalence and factors associated with ITNs use among pregnant women in seven malaria high-burden countries in SSA. METHODS: Secondary analysis of recent (2017-2021) Malaria Indicator Survey (MIS) data from seven malaria high-burden countries in SSA was utilised. Women aged 15-49 years, who were pregnant during the survey, were included in this study, resulting in a pooled sample size of 4950 women. Pooled prevalence of ITN use was obtained through the use of proportions, with a 95% confidence interval (CI). A multilevel mixed-effect logistic regression model was run to obtain factors associated with ITNs use among pregnant women at 5% level of significance. Data analysis was done in Stata v17.0 and R 4.5.0. FINDINGS: The pooled prevalence of ITNs use among these countries was 63.8 [95% CI 61.8, 65.9], low in Ghana (49.2%) and high in Niger (90.5%). Having a primary level of education [aOR = 1.36, 95% CI 1.21, 1.53] compared to those with no formal education, having given birth to one to two children [aOR = 1.24, 95% CI 1.06, 1.44] compared to those with no births yet were associated with higher odds of ITN use. 14% of the total variation in ITN use was attributable to differences between countries [intra-cluster correlation (ICC) = 0.14, 95% CI 0.06, 0.20] and 32% of the variation in ITN use within countries is attributed to differences between regions [ICC = 0.32, 95% CI 0.21, 0.46]. CONCLUSIONS: The prevalence of ITN use was suboptimal, and socio-demographic and household factors are associated with ITN use among pregnant women, with substantial in-country variation underscoring the role of regional context in ITN utilization. These findings suggest that beyond individual and household determinants, local and regional contexts play a critical role in shaping ITN usage patterns. Interventions should, therefore, be tailored not only to socio-demographic profiles but also to regional and local disparities in access, awareness, and implementation effectiveness.

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