Impact Story 09: A dose of prevention. Protecting pregnant women from malaria
Translation & Impact What We Do Impact Unit

A dose of prevention

Protecting women from malaria during pregnancy

The TIPTOP project, in which ISGlobal played a key role, showed that meeting pregnant women where they are, through trained community health workers, can dramatically reduce the burden of malaria in pregnancy. Piloted across four countries in sub-Saharan Africa, the innovative approach led to a significant rise in the number of pregnant women taking preventive malaria treatment, without affecting antenatal care uptake or fuelling drug resistance. Backed by solid evidence of cost-effectiveness, this community-led model is already helping shape health policies in African countries.

What is the problem?

Malaria during pregnancy remains a major public health threat in many parts of sub-Saharan Africa. In 2023 alone, an estimated 12.4 million pregnancies in Africa were infected with malaria, contributing to 11% of neonatal deaths and 20% of stillbirths. To reduce these devastating consequences, the World Health Organization (WHO) recommends that pregnant women in areas with moderate to high malaria transmission receive at least three doses of the preventive antimalarial drug sulfadoxine–pyrimethamine (SP) during antenatal care (ANC) visits —a strategy known as intermittent preventive treatment in pregnancy, or IPTp.

However, in many regions, uptake of IPTp remains unacceptably low. Despite the availability of the treatment, pregnant women often face barriers such as long distances to health facilities, a lack of information, or limited access to ANC.

Key facts

4 countries
18,000 women across 32 household surveys
473% increase in IPTp coverage

What did our researchers do?

To address this gap, researchers from the Maternal, Child and Reproductive Health Initiative at ISGlobal partnered with Jhpiego, other research institutions and ministries of health in four African countries —the Democratic Republic of Congo (DRC), Madagascar, Mozambique, and Nigeria— to implement and evaluate a novel, community-based approach to IPTp delivery. Malaria in pregnancy creates a substantial economic burden for households and health systems in these countries, with societal costs per pregnancy ranging from 31 to 46 USD.

The four countries were selected based on insights gained through the MiPPCOD project, funded by the Gates Foundation, which helped identify the most suitable settings for implementation.

This new initiative, known as TIPTOP (Transforming IPT for Optimal Pregnancy), was supported by Unitaid and ran from 2017 to 2022. It was led by Jhpiego with partners including ISGlobal, the WHO, and Medicines for Malaria Venture (MMV). The implementation of this model included a community distribution pilot phase in three specific Health Zones (HZs) in the Democratic Republic of Congo (DRC): Kenge, Bulungu, and Kunda, to assess the feasibility of scaling up this approach.

The idea was simple but powerful: train community health workers (CHWs) to identify pregnant women in their communities, provide them with IPTp doses if eligible, and refer them to health centres for ANC. These frontline workers, already trusted by local populations, became a critical link between communities and the formal health system.

ISGlobal led the research and evaluation components of this large-scale implementation science project, which included more than 18,000 women across 32 household surveys. The aim was to measure the impact of community IPTp (C-IPTp) on treatment uptake, ANC attendance, drug resistance, and cost-effectiveness. Anticipated acceptability of the intervention was also explored in the four countries, providing insights into how to strengthen trust in community health workers.

The results were highly encouraging: IPTp coverage increased in all intervention areas, with no decline in ANC attendance. Crucially, there was no evidence of increased prevalence of SP-resistant parasites. In addition, a modelling study showed that integrating community delivery of IPTp into national health systems, as a complement to its delivery at ANC clinics, would be a highly cost-effective strategy. Finally, the team also explored the acceptability of C-IPTp among a diverse range of stakeholders, as well as the social factors that enable or hinder its delivery and uptake.

As Clara Menéndez, Director of the Maternal, Child and Reproductive Health Programme, explains:

These results are robust and will help to inform malaria control strategies. Increasing IPTp uptake through community health workers can save thousands of maternal and infant lives in African countries.

What changes has our research contributed to?

More pregnant women protected against malaria

By the end of the project, IPTp coverage increased significantly in all four countries where the community-based intervention was implemented, rising by 133.6% in Madagascar and up to 473% in Nigeria, where coverage jumped from 12.7% to 31.8%.

Before the implementation of the TIPTOP project, data from the United States Department of Health and Human Services (HHS) indicated that in the survey districts of DRC, Madagascar, and Nigeria, fewer than 25% of eligible pregnant women were receiving at least three doses of SP (IPTp3+). By the end of the project, however, all TIPTOP districts had met or surpassed the target of 50% coverage for IPTp3+ among eligible pregnant women.

There's an improvement because before this project came into the community, pregnant women did not come for antenatal care. When you would bring out the register, you will see one person every month, but now, we do have up to twenty pregnant women due to those who go from house to house to administer drugs and also refer those who need referral. (Healthcare worker, In-depth interview, Ohaukwu, Nigeria, 2021)

Although the longer-term impact of this coverage increase has not yet been measured, the intervention in the future could contribute to 2.9 million malaria infections averted,  100,806 deaths averted, and 7.9 million DALYs averted from 2023-2027 across the four project countries and six additional countries in the African continent with the highest likelihood for adoption and scale-up.

Strengthened women's perception of the benefits of ANC

The TIPTOP project supported consistent ANC attendance by referring pregnant women identified through trained CHWs to health facilities. By integrating malaria prevention into broader maternal health services, TIPTOP reinforced the message that comprehensive care during pregnancy is important. The fact that C-IPTp did not compromise ANC attendance countered concerns that community delivery might bypass formal care.

Before, women waited until the last month of pregnancy to go to the antenatal care (ANC) or if she was sick. But since the TIPTOP project arrived, they started their ANC from the first month of pregnancy. (Pregnant woman, in-depth interview, Kunda, DRC, 2021)

Influenced international policy discussions and guidance

The TIPTOP project has already influenced international policy discussions and guidance on malaria prevention in pregnancy. Its findings, including evidence on cost-effectiveness and acceptability, were reviewed during a WHO technical consultation in June 2022, convened to “assess the evidence generated in the context of the TIPTOP project, discuss molecular markers of SP resistance monitored in the project, and share best practices for implementation of c-IPTp with partners involved in this intervention.

This consultation was later referenced by WHO’s malaria policy advisory group (MPAG) in April 2023, whose members were “encouraged by the results of the community-based IPTp pilot studies”. The evidence also informed WHO’s field guide on deployment of IPTp, focused on increasing its coverage through trained community health workers. In addition, TIPTOP’s findings were cited in a Consensus Statement on Community-Based Delivery of IPTp issued by the Partnership to End Malaria, reinforcing its role in guiding best practices and global recommendations.

Strengthening community health workers’ capacities

The project did not just implement the strategy, but also actively strengthened the capacities of CHWs. This was an integral component to ensure the correct execution of the community prevention model (c-IPTp). The WHO highlighted the importance of building community bonds through these workers to successfully implement maternal and child health interventions, citing TIPTOP as an example. The project’s success underscores the crucial role of CHWs as a bridge between communities and the formal health system.

This real-world impact was recognised in November 2025, when ISGlobal researcher Raquel González received the UB-Santander Award for the Social Impact of Research in Health Sciences for the TIPTOP project.

Links and References