Malaria remains highly endemic in sub-Saharan Africa , and about 25 million pregnancies are estimated to occur yearly in malaria-endemic regions of the sub-continent . Several interventions aimed at improving knowledge, attitude, and practice of malaria prevention, have been studied among different groups, only a few of which were among pregnant women. A systematic review of educational interventions in sub-Saharan Africa which included studies which focused on ITN, IPTp, home-based management and environmental management revealed evidence of its effectiveness in improving these practices among the intervention group . Amoran  had demonstrated that directly training caregivers could lead to improvements in knowledge, attitudes and practice of ITN use. Among refugee mothers, health education, facilitated by Vector Control Programme personnel and Voluntary Collaborators, also led to improvements in knowledge of malaria transmission and positive treatment seeking behaviours for fevers with chills . In Iran, a health education intervention based on the Protection Motivation Theory had led to improvements in malaria prevention self-efficacy scores, but not preventive behaviour scores among households in the intervention group . Net impregnation also significantly improved among households, following a health education intervention on malaria with provision of net impregnation services in Piron, Mali . Among Home-Based Care workers in Limpopo, South Africa, enrolled into a three to four-week training under the Malaria Awareness Programme (MAP), those who had completed the full course had thrice the odds of having knowledge of malaria transmission and knowledge of malaria prevention compared to those who were not in the training, or those who had dropped out after just a week .
For pregnant women, sleeping under an insecticide-treated net (ITN) and receiving intermittent preventive treatment in pregnancy (IPTp) would be the ultimate aim of any preventive intervention, as they are the main preventive practices recommended by the World Health Organization . We reviewed published studies on interventions for pregnant women against malaria. The aim was to ascertain the progress made so far, identify current gaps, and provide suggestions for policy makers and future researchers on possible ways forward.
Summaries of few intervention studies conducted among pregnant women are presented in Table 1, Table 2 and Table 3. A recent study in a health centre in north-eastern Nigeria revealed that a four-hour malaria health educational intervention based on the information-motivation-behavioural skills was effective in leading to an overall improvement in knowledge, motivation and behavioural skills by 12.75% (p < 0.001), 8.55% (p < 0.001), and 6.350% (p < 0.001) respectively . Training of Community-Directed Distributors (CDDs) to give basic counselling to antenatal women, was effective in improving both ITN use and IPT uptake among the intervention group . In another study in Bangladesh, Community Health Workers visiting households with at least one pregnant woman or an under-five child, to give health education on malaria, was followed byan increase in insecticidal net use to above 80% . This study however makes it difficult to draw conclusions as it had no control group.
Table 1: Malaria health education intervention for household members. View Table 1
Table 2: Malaria health education intervention for pregnant women. View Table 2
Table 3: Malaria health education intervention for household members. View Table 3
The cost implications as well as small effect sizes of the previous interventions do not seem encouraging enough to make governments adopt them. More effective interventions are thus needed. The intervention module in one of the previous studies  could however complementon-going routine health education given to pregnant women during their ANC. The target pregnant women need to be actively involved in all stages of the development of such interventions. Qualitative studies in the form of focus group discussion and key informant interviews would play a great role in identifying strategies which need to be incorporated into such studies. Furthermore, additional interventions directed at significant others need to be implemented, considering the important role they play in determining pregnant women's use of ITN . Owing to its wide coverage and effectiveness in influencing behaviour , the mass media also provides a promising platform for not only disseminating such intervention programmes, but also actively engaging remotely-located participants.