Trends and inequalities in the uptake of at least three doses of intermittent preventive treatment (IPTp3⁺) among pregnant women in Ghana, 2003–2022

Trends and inequalities in the uptake of at least three doses of intermittent preventive treatment (IPTp3⁺) among pregnant women in Ghana, 2003–2022 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Trends and inequalities in the uptake of at least three doses of intermittent preventive treatment (IPTp3⁺) among pregnant women in Ghana, 2003–2022 Julius Kwabena Karikari, Martin Badagda Lugutuah, Kweku Bedu-Addo, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7574280/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Intermittent preventive treatment during pregnancy (IPTp) is a key strategy for malaria control recommended by the World Health Organization (WHO). However, in Ghana, uptake of at least three doses (IPTp3⁺) remains below the WHO target of 80%. This study therefore examined the trends and inequalities in IPTp3⁺ uptake among pregnant women between 2003 and 2022. Methods This study analyzed data from the 2003, 2008, 2014, and 2022 Ghana Demographic and Health Surveys. The WHO Health Equity Assessment Toolkit was used to assess trends and inequalities in IPTp3⁺ uptake across wealth quintiles, educational attainment, place of residence, and subnational regions. Inequalities were quantified using absolute measures [Difference (D) and Population Attributable Risk (PAR)] and relative measures [Ratio (R) and Population Attributable Fraction (PAF)]. Results National IPTp3⁺ uptake increased markedly from 0.8% in 2003 to 60.2% in 2022. Regional inequalities were the largest, widening from D = 2.0; PAF = 138.3; PAR = 1.2 in 2003 to D = 34.4; R = 1.8; PAF = 30.8; PAR = 18.6 in 2022. Economic disparities were minimal in 2003 (D = − 0.7; R = 0.5; PAF = 0.0; PAR = 0.0) but grew substantially in 2008 (D = 18.0; R = 2.0; PAF = 31.3; PAR = 8.8) and persisted in 2022 (D = 14.0; R = 1.3; PAF = 13.4; PAR = 8.1). Educational inequalities were absent in 2003 but peaked in 2008 (D = 29.0; R = 2.4; PAF = 78.2; PAR = 21.9) before narrowing by 2022 (D = 12.5; R = 1.2; PAF = 7.7; PAR = 4.7). Urban–rural differences remained modest across the study period, with disparities of D = − 0.1; R = 0.9; PAF = 0.0; PAR = 0.0 in 2003 and D = 4.8; R = 1.1; PAF = 4.3; PAR = 2.6 in 2022. Conclusion Ghana has made significant progress in scaling up IPTp3⁺ coverage over the past two decades. However, persistent regional, economic, and educational disparities threaten equitable access to malaria prevention. Targeted, equity-focused interventions, particularly in underserved regions and among socioeconomically disadvantaged women, are critical for achieving universal IPTp3⁺ coverage and improving maternal and neonatal health outcomes. Clinical trial number: Not applicable. Ghana Demographic and Health Surveys Health Equity Assessment Toolkit Intermittent Preventive Treatment Malaria in Pregnancy Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Malaria in pregnancy remains a major public health concern in sub-Saharan Africa (SSA), where it contributes significantly to maternal morbidity, adverse birth outcomes, and neonatal mortality. Globally, an estimated 12.4 million pregnancies were exposed to malaria in 2021, with nearly 30% of these occurring in West Africa [ 1 ]. In Ghana, malaria accounts for approximately 20% of outpatient attendance and is a leading cause of maternal anaemia, preterm delivery, and low birth weight [ 2 ]. Pregnant women are particularly vulnerable because of immunological changes during pregnancy, which increase susceptibility to infection and its complications [ 3 ]. To mitigate these risks, the World Health Organization (WHO) recommends intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) as part of a three-pronged approach, alongside insecticide-treated nets (ITNs) and prompt case management of malaria [ 4 ]. In 2012, the WHO updated its guidelines to recommend that all pregnant women in areas of moderate-to-high malaria transmission receive at least three or more doses of SP during antenatal care (ANC) visits, beginning in the second trimester and spaced at least one month apart [ 4 ]. Evidence indicates that receiving three or more doses (IPTp3⁺) is associated with improved birth outcomes compared with fewer doses [ 5 ]. Despite notable improvements in IPTp coverage in Ghana, uptake of the recommended three or more doses remains below the WHO target of 80% [ 6 – 8 ]. More importantly, persistent disparities across socioeconomic, educational, and regional groups threaten equitable progress. While previous studies have explored individual determinants of IPTp uptake, few have comprehensively assessed long-term trends in coverage and inequalities using nationally representative data with standardized equity measures [ 6 , 9 , 10 ]. This gap limits understanding of whether gains in IPTp coverage have been equitably distributed across population subgroups. Addressing this knowledge gap is crucial for informing policy and programmatic interventions aimed at achieving universal IPTp coverage and enhancing maternal and neonatal health outcomes in Ghana. Against this background, the present study examines trends and inequalities in the uptake of IPTp3⁺ in Ghana using nationally representative data from the Ghana Demographic and Health Surveys (GDHS). By employing the WHO’s Health Equity Assessment Toolkit (HEAT), this study quantifies disparities across economic status, education, residence, and subnational regions. Findings from this analysis provides critical insights for policymakers and health program implementers to design equity-focused strategies that enhance IPTp uptake and reduce maternal and neonatal morbidity and mortality. Methods Study design and data source This study utilised cross-sectional data from the GDHS conducted in 2003, 2008, 2014, and 2022. These surveys are nationally representative and are periodically conducted to assess key health indicators across the country, including child growth and development. The GDHS employs a multi-stage cluster sampling design based on population data from national censuses. These data are used to select clusters that ensure the sample reflects the country’s geographic and socio-economic diversity. Data are collected through face-to-face interviews conducted by trained personnel, targeting men and women of reproductive age. The interviews cover a wide range of topics, including demographic characteristics, reproductive and child health, and family planning. A comprehensive description of the survey methodology, including the sampling design and data collection procedures, can be found in the main GDHS report [ 11 ]. This study included women aged 15–49 years who had a live birth within the two years preceding the survey and reported receiving three or more doses of SP/Fansidar during the pregnancy of their most recent live birth, in line with WHO recommendations [ 12 ]. For this study, data were accessed through the WHO’s HEAT platform [ 13 ], an online software tool designed to facilitate the analysis and reporting of health inequalities. HEAT draws from the Health Inequality Data Repository and allows users to disaggregate, visualise, and compare health data across different population subgroups. It is important to note that HEAT includes only selected indicators relevant to health equity assessments and does not cover the entire GDHS dataset. This study utilized disaggregated data on the uptake of at least three doses of IPTp3⁺ from GDHS, as accessed through HEAT, to examine the trends and associated inequalities among pregnant women in Ghana. Variables Outcome variable The outcome variable of this present study was IPTp3⁺, which refers to the uptake of at least three doses of intermittent preventive treatment among pregnant women in Ghana. Following the WHO recommendations [ 12 ], women who reported receiving three or more doses of SP/Fansidar during the pregnancy of their most recent live birth were coded as ‘1’ (indicating optimal IPTp uptake), while those who received less than three doses were coded as ‘0’. It is important to note that the variable was not recategorized; instead, the analysis relied on pre-processed, population-weighted data obtained directly from the WHO’s HEAT software. The utilization of this dataset, covering the survey years 2003, 2008, 2014, and 2022, ensured alignment with WHO-recommended standards and methodological consistency across time points. Explanatory variables The study employed four key dimensions of inequality, as identified in existing literature, to assess disparities in IPTp3⁺ uptake [ 10 , 14 – 16 ]. These dimensions are incorporated into the WHO HEAT and are widely used to examine variations in health and social outcomes [ 13 ]. The economic dimension was assessed using wealth quintiles, which classify the population into five levels of economic status: the poorest, poorer, middle, richer, and richest. This classification is based on a composite wealth index derived from household assets, housing characteristics, and access to essential services, enabling an equity-based comparison of health outcomes across socioeconomic groups [ 11 ]. Educational status was categorized as no education, primary education, secondary education, or higher education. The place of residence was distinguished as either rural or urban. The subnational regional dimension included all sixteen administrative regions of Ghana: Ahafo, Ashanti, Bono, Bono East, Central, Eastern, Greater Accra, North East, Northern, Oti, Savannah, Upper East, Upper West, Volta, Western, and Western North. Data analysis For this study, we utilized the online version of the WHO HEAT, a tool specifically developed to facilitate the analysis of health inequality data. The software includes key health indicators disaggregated by multiple dimensions of inequality, allowing for an in-depth examination of IPTp3⁺ uptake among pregnant women in Ghana. HEAT provides both point estimates and confidence intervals, along with a suite of summary measures of inequality, enabling a comprehensive assessment of disparities and supporting data-driven inferences. The dimensions of inequality explored in this study included economic status, educational attainment, place of residence, and subnational region. Using these dimensions, we calculated estimates and 95% confidence intervals for IPTp3⁺ coverage. Four summary measures were employed to quantify inequality: Difference (D), Ratio (R), Population Attributable Risk (PAR), and Population Attributable Fraction (PAF). These measures allowed for a nuanced understanding of both absolute and relative disparities in IPTp3⁺ uptake across different population subgroups. Difference (D) The Difference is an absolute measure that quantifies the gap in IPTp3⁺ uptake between the most advantaged and the most disadvantaged groups within a given inequality dimension. A higher value of D indicates greater absolute inequality in IPTp3 + uptake. It is calculated as: D = IPTp3⁺ uptake in the advantaged group − IPTp3⁺ uptake in the disadvantaged group Ratio (R) The Ratio is a relative measure used to compare IPTp3⁺ uptake between the most advantaged and most disadvantaged groups. It reflects the proportional difference in coverage. A value greater than 1 indicates higher IPTp3⁺ uptake in the most advantaged group, while a value less than 1 suggests greater uptake among the disadvantaged. It is calculated as: $$\:R=\frac{IPTp3⁺\:uptake\:in\:the\:most\:advantaged\:group}{IPTp3⁺\:uptake\:in\:the\:most\:disadvantaged\:group}$$ Population Attributable Risk (PAR) PAR is an absolute measure that quantifies the difference in IPTp3⁺ uptake between the general population and the most advantaged subgroup. It represents the potential improvement in overall IPTp3⁺ coverage if the entire population achieved the same uptake level as the most advantaged group. A higher PAR value indicates a greater impact of inequality on national IPTp3⁺ coverage. It is calculated as: PAR = IPTp3⁺ uptake in the most advantaged group − µ where µ represents the average IPTp3⁺ uptake in the general population. Population Attributable Fraction (PAF) PAF is a relative measure that estimates the proportion of the overall IPTp3⁺ uptake that is attributable to inequalities. It reflects the potential percentage improvement in population-level IPTp3⁺ coverage if all subgroups achieved the same uptake as the most advantaged group. A positive PAF indicates that inequalities are contributing to lower overall coverage, and reducing these disparities could enhance national IPTp3⁺ uptake. It is calculated as: $$\:PAF=\frac{PAR}{{\mu\:}}*100$$ Results Trends of the uptake of at least three doses of IPTp among pregnant women in Ghana by different inequality dimensions, 2003–2022 Figure 1 shows the trends in the uptake of at least three doses of IPTp among pregnant women in Ghana from 2003 to 2022. The figure illustrates a substantial increase in at least three doses of IPTp coverage over the years, rising from a very low coverage of 0.8% in 2003 to 28.0% in 2008. This upward trend continued moderately, reaching 38.6% in 2014. A more significant improvement was observed between 2014 and 2022, with coverage reaching 60.2%, likely reflecting enhanced malaria prevention efforts and improved antenatal care services nationwide. The uptake of at least three doses of IPTp among pregnant women in Ghana has shown a consistent upward trend from 2003 to 2022 across all inequality dimensions, including economic status, educational level, and place of residence (Fig. 2 and Supplementary Table 1). Economic Status (Wealth Quintiles) Across all five wealth quintiles, there has been a remarkable increase in IPTp uptake over the nearly two-decade period. In 2003, coverage was extremely low across all groups, ranging from 0.5–1.3%. By 2022, uptake had risen substantially, with the poorest quintile reaching 54.3% and the richest 68.3%. This trend reflects a narrowing of the equity gap, though wealthier women continue to have higher uptake rates than their poorer counterparts. Educational Status Similarly, IPTp uptake improved across all educational categories. Women with no formal education experienced a significant increase, rising from 0.3% in 2003 to 52.4% in 2022. Those with primary education improved from 0.5–57.7%, and women with secondary education increased from 1.7–63.2%. The highest uptake in 2022 was recorded among those with higher education, rising from 50.0% in 2008 to 64.9% in 2022. These results suggest a positive association between maternal education and the likelihood of receiving IPTp. Place of Residence (Urban vs. Rural) IPTp uptake rose substantially in both urban and rural settings. The proportion of rural women increased from 0.9% in 2003 to 58.0% in 2022, while the proportion of urban women improved from 0.8–62.8%. Despite the consistent increase, urban women maintained slightly higher coverage across the years, possibly reflecting better access to ANC services. The regional use of at least three doses of IPTp among pregnant women in Ghana across different years (2003, 2008, 2014, and 2022) demonstrated improvements in uptake over time. For instance, the Ashanti region increased from 1.3% in 2003 to 49.9% in 2022. Notably, regions like Eastern (0.0% in 2003 to 73.1% in 2022), Upper East (2.0% in 2003 to 78.8% in 2022), and Upper West (1.5% in 2003 to 77.9% in 2022) showed exceptionally high uptake over the study period, suggesting successful program implementation in those areas. However, the Northern Region, while improving from 0.0% in 2003 to 44.4% in 2022, remained among the regions with lower coverage in 2022. The six newly created regions, Bono, Bono East, North East, Oti, Western North, and Savannah, reported IPTp coverage ranging between 51.7% and 66.6% in 2022, indicating early gains in service expansion (Figs. 3 and 4 ; Supplementary Table 1). Inequality measures of estimates of factors associated with the uptake of at least three doses of IPTp among pregnant women in Ghana, 2003–2022 Table 1 presents inequality measures related to factors associated with the uptake of at least three doses of IPTp among pregnant women in Ghana between 2003 and 2022. Economic-related inequality showed the widest disparities, with the Difference (D) increasing from − 0.7 percentage points in 2003 to 18.0 and 13.8 percentage points in 2008 and 2014, respectively, before slightly reducing to 14.0 percentage points in 2022. The PAR and PAF values reflect this disparity, indicating that the national average of IPTp coverage could have been 8.8% points or 31.3% higher in 2008, 12.2% points or 31.5% higher in 2014, and 8.1% points or 13.4% higher in 2022 if economic-related inequalities were eliminated. Educational inequality was not reported in 2003, but showed significant disparities in later years. The Difference dropped from 29.0 percentage points in 2008 to 12.5 in 2022, showing progress in narrowing education-based disparities. However, the PAR and PAF remained non-trivial, indicating that IPTp uptake could have been 21.9% points or 78.2% higher in 2008, and 4.7% points or 7.7% higher in 2022, without disparities in maternal education levels. Inequality related to place of residence was relatively modest throughout the years, with the Difference ranging from − 0.1 percentage points in 2003 to 6.1 percentage points in 2014 and decreasing to 4.8 percentage points in 2022. The PAR and PAF values suggest that IPTp coverage could have been improved by 2.6% points or 4.3% in 2022 if urban–rural disparities were addressed. Subnational regional disparities were substantial and persistent. The Difference rose from 2.0 percentage points in 2003 to a peak of 34.4 percentage points in 2022. The PAF was notably high throughout the years, suggesting that IPTp coverage could have been 68.7% higher in 2008, 33.3% in 2014, and 30.8% in 2022 if regional inequalities were eliminated. The corresponding PARs suggest improvements of 19.3, 12.9, and 18.6 percentage points, from 2008 to 2022, respectively. These results underscore that region-based disparities contribute significantly to unequal IPTp uptake in Ghana. Table 1 Inequality measures of estimates of factors associated with the use of at least three doses of IPTp among pregnant women in Ghana, 2003–2022 2003 2008 2014 2022 Dimension Est.(%) LB UB Est.(%) LB UB Est.(%) LB UB Est.(%) LB UB Economic status D -0.7 - - 18.0 - - 13.8 - - 14.0 - - PAF 0.0 -1.2 1.2 31.3 31.1 31.5 31.5 31.3 31.6 13.4 13.3 13.5 PAR 0.0 -1.0 1.0 8.8 2.1 15.4 12.2 7.7 16.7 8.1 4.6 11.6 R 0.5 - - 2.0 - - 1.4 - - 1.3 - - Educational status D - - - 29.0 - - 16.3 - - 12.5 - - PAF - - - 78.2 77.6 78.8 31.9 31.7 32.2 7.7 7.6 7.8 PAR - - - 21.9 5.1 38.8 12.3 3.0 21.7 4.7 -0.3 9.6 R - - - 2.4 - - 1.5 - - 1.2 - - Place of residence D -0.1 - - 2.9 - - 6.1 - - 4.8 - - PAF 0.0 -0.8 0.8 6.4 6.2 6.5 8.8 8.7 8.8 4.3 4.2 4.3 PAR 0.0 -0.7 0.7 1.8 -1.5 5.0 3.4 1.1 5.6 2.6 0.8 4.3 R 0.9 - - 1.1 - - 1.2 - - 1.1 - - Subnational region D 2.0 - - 31.5 - - 20.9 - - 34.4 - - PAF 138.3 135.0 141.6 68.7 68.4 69.1 33.3 33.1 33.5 30.8 30.7 30.9 PAR 1.2 -1.6 3.9 19.3 10.3 28.3 12.9 6.5 19.2 18.6 12.8 24.3 R - - - 3.0 - - 1.7 - - 1.8 - - Est: Estimates; UB: Upper-class boundary; LB: Lower-class boundary; D: Difference; PAF: Population attributable fraction; PAR: Population attributable risk; R: Ratio; NA: Not available; -: Not available Discussion This study examined trends and inequalities in the uptake of IPTp3 + among pregnant women in Ghana between 2003 and 2022. The findings highlight a remarkable increase in coverage over the two-decade period, with national uptake rising from less than 1% in 2003 to over 60% in 2022. This coverage is notably higher than the average 35% of sub-Saharan African women receiving IPTp3 + in 2021 [ 17 ], 18.8% in Nigeria [ 18 ], 25% in Uganda [ 19 ], and 37% in Kenya [ 19 ], but lower than the WHO target of 80% [ 20 ]. This progress may reflect the cumulative impact of sustained malaria control interventions, improvements in ANC services, and broader health systems strengthening efforts, including increased availability of SP, policy updates, and community-level awareness campaigns. Our findings are similar to those found in recent studies in Ghana [ 14 , 21 , 22 ] and 2022-based line projections in the Ghana 2024–2028 National Malaria Elimination Strategic Plan [ 23 ]. Studies in Malawi, however, found coverage higher than our findings [ 21 ]. These differences in findings could be due to contextual disparities in policy implementation. Despite this overall progress, the analysis reveals persistent inequalities across key social determinants: economic status, education level, place of residence, and subnational region. While disparities appear to have narrowed in some areas, significant gaps remain, particularly along economic and regional lines. Our study demonstrated economic status as a contributor to IPTp3 + uptake. Women in the richest wealth quintile maintained higher coverage levels throughout the study period, although the gap between the poorest and richest narrowed somewhat over time. In 2022, the difference in IPTp3 + uptake between the richest and poorest women remained considerable (14.0 percentage points), with a PAF of 13.4%, suggesting that eliminating economic disparities could have increased national IPTp3 + coverage by more than 8 percentage points. Our findings are comparable to those found in other developing countries, where uptake of IPTp was documented as pro-rich [ 14 , 21 , 24 – 26 ]. In contrast, Kalu et al. (2023) and Pons-Duran et al. (2021) found no disparity between the poorer and richest wealth quintiles [ 18 , 27 ]. The relatively homogeneous economic status in their study population could explain the difference in findings. In settings such as Ghana, where SP is consistently available and free, the poor may still face indirect costs as transportation and informal charges. We also found education as a contributor to IPTp3 + uptake. Women with higher levels of education consistently showed greater use of IPTp [ 14 , 19 ], with a notable narrowing of disparities between 2008 and 2022. The difference in uptake between women with no formal education and those with higher education declined from 29.0 to 12.5 percentage points. Nonetheless, the 2022 PAF (7.7%) and PAR (4.7%) indicate that education-based disparities still constrain optimal IPTp3 + coverage. Like findings from other studies [ 28 – 30 ], our study demonstrated maternal education as a contributor to IPTp3 + uptake. This could be attributed to the fact that higher education empowers women, enhances their decision-making abilities, and equips them with accurate information, helping to dispel misconceptions and myths related to IPTp-SP use [ 31 , 32 ]. A study in Nigeria [ 18 ] and in some malaria-endemic countries in sub-Saharan Africa [ 19 ] found an inverse relationship between educational level and adequate uptake of IPTp-SP. Their findings appear to contradict expectations based on typical patterns of health service utilization and may require further studies. Our findings underscore the importance of female education not only for improving maternal and child health outcomes broadly but also for enhancing the effectiveness of specific interventions such as IPTp. Results from this study suggest that IPTp3 + uptake increased significantly in both urban and rural settings. However, urban women consistently had slightly higher uptake than their rural counterparts. In 2022, the urban–rural difference stood at 4.8 percentage points, with modest attributable risk and fraction estimates. Although this gap is relatively small, it may reflect lingering challenges in rural service delivery, including SP stockouts, fewer skilled ANC providers, and longer travel distances to health facilities. In several countries [ 14 , 27 , 33 ], both urban and rural IPTp3 + coverage has improved over the past decade, with notable rural gains in places like Mozambique that previously lagged [ 27 ]. The narrowing of this disparity is a positive sign, potentially resulting from Health-system strengthening, especially ensuring SP availability, integrating IPTp into routine ANC, and deployment of midwives to Community-Based Health Planning and Services (CHPS) that appear effective across geographic contexts. These findings underscore that urban–rural disparities can narrow when interventions are designed inclusively The most striking inequalities in our study were observed at the subnational level. Regional disparities in IPTp3 + coverage widened over time, with the difference increasing from 2.0 percentage points in 2003 to 34.4 percentage points in 2022. In 2022, the PAF of 30.8% and PAR of 18.6 percentage points suggest that nearly one-third of the national coverage shortfall could be attributed to regional inequality alone. These findings are consistent with other studies that reported regional IPTp3 + uptake variations within the Ghanaian context [ 22 , 34 – 36 ]. The current study revealed substantial regional variation in optimal SP uptake, with the highest levels observed in the Upper regions of Northern Ghana. Specifically, women residing in the Upper West and Upper East Regions recorded notably high coverage, with over 77% having received the recommended three or more doses of SP. The lowest uptake of less than 50% in the Ashanti and Northern regions highlights a concerning geographic disparity. Other studies in Nigeria [ 18 ] and Guinea [ 37 ] documented regional variations in IPTp3 + uptake. The observed regional differences in IPTp3 + uptake may be partly explained by the more advanced implementation of the CHPS initiative in the Upper Regions, which historically served as the pioneering zones for this national policy. These regions have benefited from sustained investments in CHPS infrastructure and personnel, leading to improved access to ANC and other maternal health services. Several studies have demonstrated the effectiveness of CHPS in enhancing the utilization of maternal and child health interventions, particularly in rural and underserved communities [ 38 – 40 ]. The high uptake may indicate potential best practices and successful models that can inform scale-up in lagging regions, such as Ashanti and Northern. Implications for policy and practice The findings of this study underscore the crucial importance of addressing equity gaps in IPTp delivery to sustain gains and achieve national and global malaria targets. While national strategies have made significant progress, addressing economic, educational, and especially regional inequalities remains crucial. Tailored approaches, such as mobile outreach for rural and remote communities, incentives for ANC attendance among low-income women, leveraging mobile SMS reminders, and region-specific program adaptations, including urban CHPS and a virtual community of practice, may be necessary. Furthermore, strengthening health information systems to monitor subnational performance and social determinants is crucial for responsive, equity-oriented programming. Strengths and limitations of the study A significant strength of this study is its use of nationally representative data spanning two decades and its application of standardized inequality metrics, providing a robust assessment of trends and disparities. However, limitations include potential recall bias in survey responses and the lack of qualitative insights into contextual drivers of inequality. Additionally, while the WHO HEAT provides valuable disaggregation, some measures (e.g., Ratio, Difference) lacked confidence intervals, limiting statistical interpretation. Conclusion Ghana has made commendable progress in increasing IPTp3 + coverage among pregnant women over the past 20 years. However, achieving equitable access remains a challenge. Significant economic, educational, and regional disparities persist, impeding optimal coverage. Future policies must incorporate equity-focused strategies to ensure that all pregnant women, regardless of socioeconomic status, education, or geographic location, receive full protection against malaria in pregnancy. Abbreviations ANC Antenatal Care GDHS Ghana Demographic and Health Survey WHO World Health Organisation HEAT Health Equity Assessment Toolkit IPTp Intermittent Preventive Treatment in Pregnancy D Difference PAF Population Attributable Fraction PAR Population Attributable Risk R Ratio. Declarations Ethics approval and consent to participate Ethical clearance was not required for this study as the WHO HEAT software and its dataset are publicly available in the public domain. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding The authors had no support or funding for this current study. Author Contribution JKK, MBL, KB-A, EK, DAO, YSAH, LAAB-A, and EAB contributed as follows: JKK, EK, DAO and EAB conceptualised the study and developed the methodology; JKK, EK, and DAO performed formal analysis; JKK, MBL, and KB-A drafted the initial manuscript; EK, YSAH, LAAB-A, DAO and EAB critically reviewed and edited the manuscript. All authors have read and approved the final manuscript and agree to be accountable for all aspects of the work. Acknowledgement We sincerely acknowledge MEASURE DHS and the World Health Organisation for providing access to the dataset and the HEAT software. Data Availability The dataset utilised in this study is accessible at: https://whoequity.shinyapps.io/heat/ References Li J, Docile HJ, Fisher D, Pronyuk K, Zhao L. Current Status of Malaria Control and Elimination in Africa: Epidemiology, Diagnosis, Treatment, Progress and Challenges. J Epidemiol Glob Health. 2024;14:561–79. Ampofo GD, Osarfo J, Aberese-Ako M, Asem L, Komey MN, Mohammed W, et al. Malaria in pregnancy control and pregnancy outcomes: a decade’s overview using Ghana’s DHIMS II data. Malar J. 2022;21:303. Mor G, Cardenas I. REVIEW ARTICLE: The Immune System in Pregnancy: A Unique Complexity. Am J Rep Immunol. 2010;63:425–33. WHO. Intermittent preventative treatment to reduce the risk of malaria during pregnancy [Internet]. 2023 [cited 2025 Aug 21]. Available from: https://www.who.int/tools/elena/interventions/iptp-pregnancy Kayentao K, Garner P, Van Maria A, Naidoo I, Roper C, Mulokozi A, et al. Intermittent Preventive Therapy for Malaria During Pregnancy Using 2 vs 3 or More Doses of Sulfadoxine-Pyrimethamine and Risk of Low Birth Weight in Africa: Systematic Review and Meta-analysis. JAMA. 2013;309:594. Agyeman YN, Bassoumah B, Owusu-Marfo J. Predictors of optimal uptake of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine and outcome of pregnancy in selected health facilities: a cross-sectional study in Northern Ghana. Malar J. 2023;22:80. Ansong D, Otoo DM, Mensah V, Knowledge. Uptake and Therapeutic Effectiveness of Sulfadoxine-Pyrimethamine (IPTp-SP) among Pregnant Women Attending the Antenatal Clinic at Ayeduase Health Centre in Oforikrom Municipality in the Ashanti-Region, Ghana [Internet]. 2023 [cited 2025 Sep 9]. Available from: https://www.researchsquare.com/article/rs-3686754/v1 Anto F, Agongo IH, Asoala V, Awini E, Oduro AR. Intermittent Preventive Treatment of Malaria in Pregnancy: Assessment of the Sulfadoxine-Pyrimethamine Three-Dose Policy on Birth Outcomes in Rural Northern Ghana. J Trop Med. 2019;2019:1–10. Ampofo GD, Ahiakpa AK, Osarfo J. Interventions for malaria prevention in pregnancy; factors influencing uptake and their effect on pregnancy outcomes among post-natal women in a tertiary facility in the Volta Region of Ghana. SAGE Open Med. 2023;11:20503121231199653. Darteh EKM, Buabeng I, Akuamoah-Boateng C. Uptake of intermittent preventive treatment in pregnancy for malaria: further analysis of the 2016 Ghana Malaria Indicator Survey. J Public Health (Berl). 2021;29:967–78. Ghana Statistical Service (GSS). and ICF. Ghana Demographic and Health Survey 2022. Accra, Ghana, and Rockville, Maryland, USA: GSS and ICF. [Internet]. 2024 [cited 2025 Apr 26]. Available from: https://www.dhsprogram.com/pubs/pdf/FR387/FR387.pdf World Health Organization. WHO policy brief for the implementation of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) [Internet]. 2013 [cited 2025 Jul 14]. Available from: https://www.who.int/publications/i/item/WHO-HTM-GMP-2014.4 Health Equity Assessment Toolkit (HEAT). Software for exploring and comparing health inequalities in countries. Built-in database edition. Version 6.1. Geneva. World Health Organization; 2024. Darteh EKM, Dickson KS, Ahinkorah BO, Owusu BA, Okyere J, Salihu T, et al. Factors influencing the uptake of intermittent preventive treatment among pregnant women in sub-Saharan Africa: a multilevel analysis. Arch Public Health. 2021;79:182. Klu D, Owusu L. Factors affecting the uptake of optimal doses of intermittent preventive treatment of malaria in pregnancy using sulfadoxine pyrimethamine in Ghana: new evidence from the 2019 malaria indicator survey. J Public Health (Berl). 2025;33:269–79. Tackie V, Seidu A-A, Osei M. Factors influencing the uptake of intermittent preventive treatment of malaria among pregnant women: a cross-sectional study. J Public Health (Berl). 2021;29:1205–13. González R, Manun’Ebo MF, Meremikwu M, Rabeza VR, Sacoor C, Figueroa-Romero A, et al. The impact of community delivery of intermittent preventive treatment of malaria in pregnancy on its coverage in four sub-Saharan African countries (Democratic Republic of the Congo, Madagascar, Mozambique, and Nigeria): a quasi-experimental multicentre evaluation. Lancet Global Health. 2023;11:e566–74. Kalu GO, Francis JM, Ibisomi L, Chirwa T, Kagura J. Factors associated with the uptake of Intermittent Preventive Treatment (IPTp-SP) for malaria in pregnancy: Further analysis of the 2018 Nigeria Demographic and Health Survey. Ahmed SM, editor. PLOS Glob Public Health. 2023;3:e0000771. Yaya S, Uthman O, Amouzou A, Bishwajit G. Use of Intermittent Preventive Treatment among Pregnant Women in Sub-Saharan Africa: Evidence from Malaria Indicator Surveys. TropicalMed. 2018;3:18. World malaria report 2023. Licence: CC BY-NC-SA 3.0 IGO. Geneva: World Health Organization; 2023. Muhammad FM, Majdzadeh R, Nedjat S, Sajadi HS, Parsaeian M. Socioeconomic inequality in intermittent preventive treatment using Sulphadoxine pyrimethamine among pregnant women in Nigeria. BMC Public Health. 2020;20:1860. Sarfo JO, Doe PF, Mireku DO. Individual- and community-level correlates of intermittent preventive treatment of malaria in pregnancy in Ghana: further analysis of the 2019 Malaria Indicator Survey. Res Health Serv Reg. 2024;3:22. Ministry of Health. National Malaria Elimination Strategic Plan (NMESP) 2024–2028. Ministry of Health/ Ghana Health Service. 2023. 1–70 p. [Internet]. [cited 2025 Aug 17]. Available from: https://mesamalaria.org/resource-hub/national-malaria-elimination-strategic-plan-nmesp-of-ghana-2024-2028/ Amankwah S, Anto F. Factors Associated with Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy: A Cross-Sectional Study in Private Health Facilities in Tema Metropolis, Ghana. J Trop Med. 2019;2019:1–11. Buh A, Kota K, Bishwajit G, Yaya S. Prevalence and Associated Factors of Taking Intermittent Preventive Treatment in Pregnancy in Sierra Leone. TropicalMed. 2019;4:32. Were V, Buff AM, Desai M, Kariuki S, Samuels AM, Phillips-Howard P, et al. Trends in malaria prevalence and health related socioeconomic inequality in rural western Kenya: results from repeated household malaria cross-sectional surveys from 2006 to 2013. BMJ Open. 2019;9:e033883. Pons-Duran C, Llach M, Sacoor C, Sanz S, Macete E, Arikpo I, et al. Coverage of intermittent preventive treatment of malaria in pregnancy in four sub-Saharan countries: findings from household surveys. Int J Epidemiol. 2021;50:550–9. Anto F, Ayepah C, Awini E, Bimi L. Determinants of uptake of intermittent preventive treatment for malaria with sulfadoxine pyrimethamine in pregnancy: a cross-sectional analytical study in the Sekondi-Takoradi Metropolis of Ghana. Arch Public Health. 2021;79:177. Ibrahim H, Maya ET, Issah K, Apanga PA, Bachan EG, Noora CL. Factors influencing uptake of intermittent preventive treatment of malaria in pregnancy using sulphadoxine pyrimethamine in Sunyani Municipality, Ghana. Pan Afr Med J [Internet]. 2017 [cited 2025 Aug 17];28. Available from: http://www.panafrican-med-journal.com/content/article/28/122/full/ Nakalega R, Nabisere-Arinaitwe R, Mukiza N, Kuteesa CN, Mawanda D, Natureeba P, et al. Attitudes and perceptions towards developing a health educational video to enhance optimal uptake of malaria preventive therapy among pregnant women in Uganda: a qualitative study involving pregnant women, health workers, and Ministry of health officials. BMC Health Serv Res. 2024;24:484. Kretchy IA, Atobrah D, Adumbire DA, Ankamah S, Adanu T, Badasu DM, et al. Enhancing the uptake of intermittent preventive treatment for malaria in pregnancy: a scoping review of interventions and gender-informed approaches. Malar J. 2025;24:49. Odwe G, Matanda DJ, Zulu T, Kizito S, Okoth O, Kangwana B. Women’s empowerment and uptake of sulfadoxine–pyrimethamine for intermittent preventive treatment of malaria during pregnancy: results from a cross-sectional baseline survey in the Lake endemic region, Kenya. Malar J. 2023;22:241. Xu X, Liang D, Zhao J, Mpembeni R, Olenja J, Yam EL, et al. The readiness of malaria services and uptake of intermittent preventive treatment in pregnancy in six sub-Saharan countries. J Glob Health. 2024;14:04112. Doku DT, Zankawah MM, Adu-Gyamfi AB. Factors influencing dropout rate of intermittent preventive treatment of malaria during pregnancy. BMC Res Notes. 2016;9:460. Gogue C, Wagman J, Tynuv K, Saibu A, Yihdego Y, Malm K, et al. An observational analysis of the impact of indoor residual spraying in Northern, Upper East, and Upper West Regions of Ghana: 2014 through 2017. Malar J. 2020;19:242. Ndayishimiye JC, Teg-Nefaah Tabong P. Spatial distribution and determinants of intermittent preventive treatment for malaria during pregnancy: a secondary data analysis of the 2019 Ghana malaria indicators survey. BMC Pregnancy Childbirth. 2024;24:379. Barry I, Toure AA, Sangho O, Beavogui AH, Cisse D, Diallo A, et al. Variations in the use of malaria preventive measures among pregnant women in Guinea: a secondary analysis of the 2012 and 2018 demographic and health surveys. Malar J. 2022;21:309. Dun-Dery F, Meissner P, Beiersmann C, Kuunibe N, Winkler V, Albrecht J, et al. Uptake challenges of intermittent preventive malaria therapy among pregnant women and their health care providers in the Upper West Region of Ghana: A mixed-methods study. Parasite Epidemiol Control. 2021;15:e00222. Koita K, Kayentao K, Worrall E, Van Eijk AM, Hill J. 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. Lancet Global Health. 2024;12:e1456–69. Matsubara C, Dalaba MA, Danchaka LL, Welaga P. Situation Analysis of a New Effort of Community-Based Health Planning and Services (CHPS) for Maternal Health in Upper West Region in Rural Ghana. IJERPH. 2023;20:6595. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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04:19:12","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":96745,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrends in the uptake of at least three doses of IPTp among pregnant women by economic status, education, and place of residence dimensions in Ghana from 2003 to 2022. Source: World Health Organisation Health Equity Assessment Toolkit, 2024\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7574280/v1/de906b36e232b1e57c9a9334.jpeg"},{"id":94623230,"identity":"85fc13e2-f6b9-4990-b0b2-924cd786f8b9","added_by":"auto","created_at":"2025-10-29 04:19:01","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":81074,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrends in the uptake of at least three doses of IPTp among pregnant women by regional inequality dimension in Ghana from 2003 to 2022. Source: World Health Organisation Health Equity Assessment Toolkit, 2024\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7574280/v1/7e3ee13c1881636704509879.jpeg"},{"id":94623447,"identity":"24914cb0-29f7-411a-954c-2f809d5a7a95","added_by":"auto","created_at":"2025-10-29 04:19:10","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":110886,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrends in the uptake of at least three doses of IPTp among pregnant women by regional inequality dimension in Ghana in 2022. Source: World Health Organisation Health Equity Assessment Toolkit, 2024\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7574280/v1/16f689bfc3fa2eafd44e5a59.jpeg"},{"id":104882314,"identity":"cfc7da8e-baaa-4d81-a7cb-55916127d5ec","added_by":"auto","created_at":"2026-03-18 09:29:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1744014,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7574280/v1/99b0b948-3fd9-4c8f-ac1f-61a786879605.pdf"},{"id":94623450,"identity":"0c34d00b-c63f-4df1-82ad-bf101fca49ab","added_by":"auto","created_at":"2025-10-29 04:19:10","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":22593,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7574280/v1/18eb38e0ded89bdb54a2e208.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Trends and inequalities in the uptake of at least three doses of intermittent preventive treatment (IPTp3⁺) among pregnant women in Ghana, 2003–2022","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMalaria in pregnancy remains a major public health concern in sub-Saharan Africa (SSA), where it contributes significantly to maternal morbidity, adverse birth outcomes, and neonatal mortality. Globally, an estimated 12.4\u0026nbsp;million pregnancies were exposed to malaria in 2021, with nearly 30% of these occurring in West Africa [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Ghana, malaria accounts for approximately 20% of outpatient attendance and is a leading cause of maternal anaemia, preterm delivery, and low birth weight [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Pregnant women are particularly vulnerable because of immunological changes during pregnancy, which increase susceptibility to infection and its complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo mitigate these risks, the World Health Organization (WHO) recommends intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) as part of a three-pronged approach, alongside insecticide-treated nets (ITNs) and prompt case management of malaria [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In 2012, the WHO updated its guidelines to recommend that all pregnant women in areas of moderate-to-high malaria transmission receive at least three or more doses of SP during antenatal care (ANC) visits, beginning in the second trimester and spaced at least one month apart [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Evidence indicates that receiving three or more doses (IPTp3⁺) is associated with improved birth outcomes compared with fewer doses [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite notable improvements in IPTp coverage in Ghana, uptake of the recommended three or more doses remains below the WHO target of 80% [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. More importantly, persistent disparities across socioeconomic, educational, and regional groups threaten equitable progress. While previous studies have explored individual determinants of IPTp uptake, few have comprehensively assessed long-term trends in coverage and inequalities using nationally representative data with standardized equity measures [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This gap limits understanding of whether gains in IPTp coverage have been equitably distributed across population subgroups. Addressing this knowledge gap is crucial for informing policy and programmatic interventions aimed at achieving universal IPTp coverage and enhancing maternal and neonatal health outcomes in Ghana.\u003c/p\u003e\u003cp\u003eAgainst this background, the present study examines trends and inequalities in the uptake of IPTp3⁺ in Ghana using nationally representative data from the Ghana Demographic and Health Surveys (GDHS). By employing the WHO\u0026rsquo;s Health Equity Assessment Toolkit (HEAT), this study quantifies disparities across economic status, education, residence, and subnational regions. Findings from this analysis provides critical insights for policymakers and health program implementers to design equity-focused strategies that enhance IPTp uptake and reduce maternal and neonatal morbidity and mortality.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and data source\u003c/h2\u003e\u003cp\u003eThis study utilised cross-sectional data from the GDHS conducted in 2003, 2008, 2014, and 2022. These surveys are nationally representative and are periodically conducted to assess key health indicators across the country, including child growth and development. The GDHS employs a multi-stage cluster sampling design based on population data from national censuses. These data are used to select clusters that ensure the sample reflects the country\u0026rsquo;s geographic and socio-economic diversity. Data are collected through face-to-face interviews conducted by trained personnel, targeting men and women of reproductive age. The interviews cover a wide range of topics, including demographic characteristics, reproductive and child health, and family planning. A comprehensive description of the survey methodology, including the sampling design and data collection procedures, can be found in the main GDHS report [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This study included women aged 15\u0026ndash;49 years who had a live birth within the two years preceding the survey and reported receiving three or more doses of SP/Fansidar during the pregnancy of their most recent live birth, in line with WHO recommendations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFor this study, data were accessed through the WHO\u0026rsquo;s HEAT platform [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], an online software tool designed to facilitate the analysis and reporting of health inequalities. HEAT draws from the Health Inequality Data Repository and allows users to disaggregate, visualise, and compare health data across different population subgroups. It is important to note that HEAT includes only selected indicators relevant to health equity assessments and does not cover the entire GDHS dataset. This study utilized disaggregated data on the uptake of at least three doses of IPTp3⁺ from GDHS, as accessed through HEAT, to examine the trends and associated inequalities among pregnant women in Ghana.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eVariables\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eOutcome variable\u003c/h2\u003e\u003cp\u003eThe outcome variable of this present study was IPTp3⁺, which refers to the uptake of at least three doses of intermittent preventive treatment among pregnant women in Ghana. Following the WHO recommendations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], women who reported receiving three or more doses of SP/Fansidar during the pregnancy of their most recent live birth were coded as \u0026lsquo;1\u0026rsquo; (indicating optimal IPTp uptake), while those who received less than three doses were coded as \u0026lsquo;0\u0026rsquo;. It is important to note that the variable was not recategorized; instead, the analysis relied on pre-processed, population-weighted data obtained directly from the WHO\u0026rsquo;s HEAT software. The utilization of this dataset, covering the survey years 2003, 2008, 2014, and 2022, ensured alignment with WHO-recommended standards and methodological consistency across time points.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eExplanatory variables\u003c/h3\u003e\n\u003cp\u003eThe study employed four key dimensions of inequality, as identified in existing literature, to assess disparities in IPTp3⁺ uptake [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These dimensions are incorporated into the WHO HEAT and are widely used to examine variations in health and social outcomes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The economic dimension was assessed using wealth quintiles, which classify the population into five levels of economic status: the poorest, poorer, middle, richer, and richest. This classification is based on a composite wealth index derived from household assets, housing characteristics, and access to essential services, enabling an equity-based comparison of health outcomes across socioeconomic groups [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Educational status was categorized as no education, primary education, secondary education, or higher education. The place of residence was distinguished as either rural or urban. The subnational regional dimension included all sixteen administrative regions of Ghana: Ahafo, Ashanti, Bono, Bono East, Central, Eastern, Greater Accra, North East, Northern, Oti, Savannah, Upper East, Upper West, Volta, Western, and Western North.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eFor this study, we utilized the online version of the WHO HEAT, a tool specifically developed to facilitate the analysis of health inequality data. The software includes key health indicators disaggregated by multiple dimensions of inequality, allowing for an in-depth examination of IPTp3⁺ uptake among pregnant women in Ghana. HEAT provides both point estimates and confidence intervals, along with a suite of summary measures of inequality, enabling a comprehensive assessment of disparities and supporting data-driven inferences.\u003c/p\u003e\u003cp\u003eThe dimensions of inequality explored in this study included economic status, educational attainment, place of residence, and subnational region. Using these dimensions, we calculated estimates and 95% confidence intervals for IPTp3⁺ coverage. Four summary measures were employed to quantify inequality: Difference (D), Ratio (R), Population Attributable Risk (PAR), and Population Attributable Fraction (PAF). These measures allowed for a nuanced understanding of both absolute and relative disparities in IPTp3⁺ uptake across different population subgroups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDifference (D)\u003c/h2\u003e\u003cp\u003eThe Difference is an absolute measure that quantifies the gap in IPTp3⁺ uptake between the most advantaged and the most disadvantaged groups within a given inequality dimension. A higher value of D indicates greater absolute inequality in IPTp3\u003csup\u003e+\u003c/sup\u003e uptake. It is calculated as:\u003c/p\u003e\u003c/div\u003e\n\u003cp\u003eD = IPTp3⁺ uptake in the advantaged group − IPTp3⁺ uptake in the disadvantaged group\u003c/p\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eRatio (R)\u003c/h2\u003e\u003cp\u003eThe Ratio is a relative measure used to compare IPTp3⁺ uptake between the most advantaged and most disadvantaged groups. It reflects the proportional difference in coverage. A value greater than 1 indicates higher IPTp3⁺ uptake in the most advantaged group, while a value less than 1 suggests greater uptake among the disadvantaged. It is calculated as:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:R=\\frac{IPTp3⁺\\:uptake\\:in\\:the\\:most\\:advantaged\\:group}{IPTp3⁺\\:uptake\\:in\\:the\\:most\\:disadvantaged\\:group}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePopulation Attributable Risk (PAR)\u003c/h2\u003e\u003cp\u003ePAR is an absolute measure that quantifies the difference in IPTp3⁺ uptake between the general population and the most advantaged subgroup. It represents the potential improvement in overall IPTp3⁺ coverage if the entire population achieved the same uptake level as the most advantaged group. A higher PAR value indicates a greater impact of inequality on national IPTp3⁺ coverage. It is calculated as:\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePAR\u0026thinsp;=\u0026thinsp;IPTp3⁺ uptake in the most advantaged group\u0026thinsp;\u0026minus;\u0026thinsp;\u0026micro;\u003c/h2\u003e\u003cp\u003ewhere \u003cem\u003e\u0026micro;\u003c/em\u003e represents the average IPTp3⁺ uptake in the general population.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePopulation Attributable Fraction (PAF)\u003c/h2\u003e\u003cp\u003ePAF is a relative measure that estimates the proportion of the overall IPTp3⁺ uptake that is attributable to inequalities. It reflects the potential percentage improvement in population-level IPTp3⁺ coverage if all subgroups achieved the same uptake as the most advantaged group. A positive PAF indicates that inequalities are contributing to lower overall coverage, and reducing these disparities could enhance national IPTp3⁺ uptake. It is calculated as:\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:PAF=\\frac{PAR}{{\\mu\\:}}*100$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eTrends of the uptake of at least three doses of IPTp among pregnant women in Ghana by different inequality dimensions, 2003\u0026ndash;2022\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the trends in the uptake of at least three doses of IPTp among pregnant women in Ghana from 2003 to 2022. The figure illustrates a substantial increase in at least three doses of IPTp coverage over the years, rising from a very low coverage of 0.8% in 2003 to 28.0% in 2008. This upward trend continued moderately, reaching 38.6% in 2014. A more significant improvement was observed between 2014 and 2022, with coverage reaching 60.2%, likely reflecting enhanced malaria prevention efforts and improved antenatal care services nationwide.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe uptake of at least three doses of IPTp among pregnant women in Ghana has shown a consistent upward trend from 2003 to 2022 across all inequality dimensions, including economic status, educational level, and place of residence (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Supplementary Table\u0026nbsp;1).\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eEconomic Status (Wealth Quintiles)\u003c/h2\u003e\u003cp\u003eAcross all five wealth quintiles, there has been a remarkable increase in IPTp uptake over the nearly two-decade period. In 2003, coverage was extremely low across all groups, ranging from 0.5\u0026ndash;1.3%. By 2022, uptake had risen substantially, with the poorest quintile reaching 54.3% and the richest 68.3%. This trend reflects a narrowing of the equity gap, though wealthier women continue to have higher uptake rates than their poorer counterparts.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eEducational Status\u003c/h2\u003e\u003cp\u003eSimilarly, IPTp uptake improved across all educational categories. Women with no formal education experienced a significant increase, rising from 0.3% in 2003 to 52.4% in 2022. Those with primary education improved from 0.5\u0026ndash;57.7%, and women with secondary education increased from 1.7\u0026ndash;63.2%. The highest uptake in 2022 was recorded among those with higher education, rising from 50.0% in 2008 to 64.9% in 2022. These results suggest a positive association between maternal education and the likelihood of receiving IPTp.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003ePlace of Residence (Urban vs. Rural)\u003c/h2\u003e\u003cp\u003eIPTp uptake rose substantially in both urban and rural settings. The proportion of rural women increased from 0.9% in 2003 to 58.0% in 2022, while the proportion of urban women improved from 0.8\u0026ndash;62.8%. Despite the consistent increase, urban women maintained slightly higher coverage across the years, possibly reflecting better access to ANC services.\u003c/p\u003e\u003cp\u003eThe regional use of at least three doses of IPTp among pregnant women in Ghana across different years (2003, 2008, 2014, and 2022) demonstrated improvements in uptake over time. For instance, the Ashanti region increased from 1.3% in 2003 to 49.9% in 2022. Notably, regions like Eastern (0.0% in 2003 to 73.1% in 2022), Upper East (2.0% in 2003 to 78.8% in 2022), and Upper West (1.5% in 2003 to 77.9% in 2022) showed exceptionally high uptake over the study period, suggesting successful program implementation in those areas. However, the Northern Region, while improving from 0.0% in 2003 to 44.4% in 2022, remained among the regions with lower coverage in 2022. The six newly created regions, Bono, Bono East, North East, Oti, Western North, and Savannah, reported IPTp coverage ranging between 51.7% and 66.6% in 2022, indicating early gains in service expansion (Figs.\u0026nbsp;3 and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e; Supplementary Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003e\u003cb\u003eInequality measures of estimates of factors associated with the uptake of at least three doses of IPTp among pregnant women in Ghana, 2003\u0026ndash;2022\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents inequality measures related to factors associated with the uptake of at least three doses of IPTp among pregnant women in Ghana between 2003 and 2022. Economic-related inequality showed the widest disparities, with the Difference (D) increasing from \u0026minus;\u0026thinsp;0.7 percentage points in 2003 to 18.0 and 13.8 percentage points in 2008 and 2014, respectively, before slightly reducing to 14.0 percentage points in 2022. The PAR and PAF values reflect this disparity, indicating that the national average of IPTp coverage could have been 8.8% points or 31.3% higher in 2008, 12.2% points or 31.5% higher in 2014, and 8.1% points or 13.4% higher in 2022 if economic-related inequalities were eliminated. Educational inequality was not reported in 2003, but showed significant disparities in later years. The Difference dropped from 29.0 percentage points in 2008 to 12.5 in 2022, showing progress in narrowing education-based disparities. However, the PAR and PAF remained non-trivial, indicating that IPTp uptake could have been 21.9% points or 78.2% higher in 2008, and 4.7% points or 7.7% higher in 2022, without disparities in maternal education levels. Inequality related to place of residence was relatively modest throughout the years, with the Difference ranging from \u0026minus;\u0026thinsp;0.1 percentage points in 2003 to 6.1 percentage points in 2014 and decreasing to 4.8 percentage points in 2022. The PAR and PAF values suggest that IPTp coverage could have been improved by 2.6% points or 4.3% in 2022 if urban\u0026ndash;rural disparities were addressed. Subnational regional disparities were substantial and persistent. The Difference rose from 2.0 percentage points in 2003 to a peak of 34.4 percentage points in 2022. The PAF was notably high throughout the years, suggesting that IPTp coverage could have been 68.7% higher in 2008, 33.3% in 2014, and 30.8% in 2022 if regional inequalities were eliminated. The corresponding PARs suggest improvements of 19.3, 12.9, and 18.6 percentage points, from 2008 to 2022, respectively. These results underscore that region-based disparities contribute significantly to unequal IPTp uptake in Ghana.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInequality measures of estimates of factors associated with the use of at least three doses of IPTp among pregnant women in Ghana, 2003\u0026ndash;2022\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"13\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e2003\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003e2008\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEst.(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEst.(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eEst.(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eLB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eUB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eEst.(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003eLB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c13\"\u003e\u003cp\u003eUB\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEconomic status\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" 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colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e13.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e14.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e31.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e31.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e31.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e31.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e31.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e31.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e13.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e13.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e15.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e7.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e8.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e4.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e11.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducational status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e29.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e16.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e12.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e78.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e77.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e78.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e31.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e31.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e32.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e7.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e7.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e7.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e38.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e21.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e4.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e-0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e9.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePlace of residence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e6.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e4.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e8.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e8.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e8.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e4.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e4.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e5.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e4.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubnational region\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e31.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e20.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e34.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e138.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e135.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e141.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e68.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e68.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e69.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e33.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e33.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e33.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e30.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e30.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e30.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e19.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e28.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e6.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e19.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e18.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e24.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"13\"\u003eEst: Estimates; UB: Upper-class boundary; LB: Lower-class boundary; D: Difference; PAF: Population attributable fraction; PAR: Population attributable risk; R: Ratio; NA: Not available; -: Not available\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined trends and inequalities in the uptake of IPTp3\u003csup\u003e+\u003c/sup\u003e among pregnant women in Ghana between 2003 and 2022. The findings highlight a remarkable increase in coverage over the two-decade period, with national uptake rising from less than 1% in 2003 to over 60% in 2022. This coverage is notably higher than the average 35% of sub-Saharan African women receiving IPTp3\u003csup\u003e+\u003c/sup\u003e in 2021 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], 18.8% in Nigeria [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], 25% in Uganda [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and 37% in Kenya [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], but lower than the WHO target of 80% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This progress may reflect the cumulative impact of sustained malaria control interventions, improvements in ANC services, and broader health systems strengthening efforts, including increased availability of SP, policy updates, and community-level awareness campaigns. Our findings are similar to those found in recent studies in Ghana [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and 2022-based line projections in the Ghana 2024\u0026ndash;2028 National Malaria Elimination Strategic Plan [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Studies in Malawi, however, found coverage higher than our findings [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These differences in findings could be due to contextual disparities in policy implementation. Despite this overall progress, the analysis reveals persistent inequalities across key social determinants: economic status, education level, place of residence, and subnational region. While disparities appear to have narrowed in some areas, significant gaps remain, particularly along economic and regional lines.\u003c/p\u003e\u003cp\u003eOur study demonstrated economic status as a contributor to IPTp3\u003csup\u003e+\u003c/sup\u003e uptake. Women in the richest wealth quintile maintained higher coverage levels throughout the study period, although the gap between the poorest and richest narrowed somewhat over time. In 2022, the difference in IPTp3\u003csup\u003e+\u003c/sup\u003e uptake between the richest and poorest women remained considerable (14.0 percentage points), with a PAF of 13.4%, suggesting that eliminating economic disparities could have increased national IPTp3\u003csup\u003e+\u003c/sup\u003e coverage by more than 8 percentage points. Our findings are comparable to those found in other developing countries, where uptake of IPTp was documented as pro-rich [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In contrast, Kalu et al. (2023) and Pons-Duran et al. (2021) found no disparity between the poorer and richest wealth quintiles [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The relatively homogeneous economic status in their study population could explain the difference in findings. In settings such as Ghana, where SP is consistently available and free, the poor may still face indirect costs as transportation and informal charges.\u003c/p\u003e\u003cp\u003eWe also found education as a contributor to IPTp3\u003csup\u003e+\u003c/sup\u003e uptake. Women with higher levels of education consistently showed greater use of IPTp [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], with a notable narrowing of disparities between 2008 and 2022. The difference in uptake between women with no formal education and those with higher education declined from 29.0 to 12.5 percentage points. Nonetheless, the 2022 PAF (7.7%) and PAR (4.7%) indicate that education-based disparities still constrain optimal IPTp3\u003csup\u003e+\u003c/sup\u003e coverage. Like findings from other studies [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], our study demonstrated maternal education as a contributor to IPTp3\u003csup\u003e+\u003c/sup\u003e uptake. This could be attributed to the fact that higher education empowers women, enhances their decision-making abilities, and equips them with accurate information, helping to dispel misconceptions and myths related to IPTp-SP use [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. A study in Nigeria [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and in some malaria-endemic countries in sub-Saharan Africa [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] found an inverse relationship between educational level and adequate uptake of IPTp-SP. Their findings appear to contradict expectations based on typical patterns of health service utilization and may require further studies. Our findings underscore the importance of female education not only for improving maternal and child health outcomes broadly but also for enhancing the effectiveness of specific interventions such as IPTp.\u003c/p\u003e\u003cp\u003eResults from this study suggest that IPTp3\u003csup\u003e+\u003c/sup\u003e uptake increased significantly in both urban and rural settings. However, urban women consistently had slightly higher uptake than their rural counterparts. In 2022, the urban\u0026ndash;rural difference stood at 4.8 percentage points, with modest attributable risk and fraction estimates. Although this gap is relatively small, it may reflect lingering challenges in rural service delivery, including SP stockouts, fewer skilled ANC providers, and longer travel distances to health facilities. In several countries [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], both urban and rural IPTp3\u003csup\u003e+\u003c/sup\u003e coverage has improved over the past decade, with notable rural gains in places like Mozambique that previously lagged [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The narrowing of this disparity is a positive sign, potentially resulting from Health-system strengthening, especially ensuring SP availability, integrating IPTp into routine ANC, and deployment of midwives to Community-Based Health Planning and Services (CHPS) that appear effective across geographic contexts. These findings underscore that urban\u0026ndash;rural disparities can narrow when interventions are designed inclusively\u003c/p\u003e\u003cp\u003eThe most striking inequalities in our study were observed at the subnational level. Regional disparities in IPTp3\u003csup\u003e+\u003c/sup\u003e coverage widened over time, with the difference increasing from 2.0 percentage points in 2003 to 34.4 percentage points in 2022. In 2022, the PAF of 30.8% and PAR of 18.6 percentage points suggest that nearly one-third of the national coverage shortfall could be attributed to regional inequality alone. These findings are consistent with other studies that reported regional IPTp3\u003csup\u003e+\u003c/sup\u003e uptake variations within the Ghanaian context [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The current study revealed substantial regional variation in optimal SP uptake, with the highest levels observed in the Upper regions of Northern Ghana. Specifically, women residing in the Upper West and Upper East Regions recorded notably high coverage, with over 77% having received the recommended three or more doses of SP. The lowest uptake of less than 50% in the Ashanti and Northern regions highlights a concerning geographic disparity. Other studies in Nigeria [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and Guinea [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] documented regional variations in IPTp3\u003csup\u003e+\u003c/sup\u003e uptake. The observed regional differences in IPTp3\u003csup\u003e+\u003c/sup\u003e uptake may be partly explained by the more advanced implementation of the CHPS initiative in the Upper Regions, which historically served as the pioneering zones for this national policy. These regions have benefited from sustained investments in CHPS infrastructure and personnel, leading to improved access to ANC and other maternal health services. Several studies have demonstrated the effectiveness of CHPS in enhancing the utilization of maternal and child health interventions, particularly in rural and underserved communities [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The high uptake may indicate potential best practices and successful models that can inform scale-up in lagging regions, such as Ashanti and Northern.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eImplications for policy and practice\u003c/h2\u003e\u003cp\u003eThe findings of this study underscore the crucial importance of addressing equity gaps in IPTp delivery to sustain gains and achieve national and global malaria targets. While national strategies have made significant progress, addressing economic, educational, and especially regional inequalities remains crucial. Tailored approaches, such as mobile outreach for rural and remote communities, incentives for ANC attendance among low-income women, leveraging mobile SMS reminders, and region-specific program adaptations, including urban CHPS and a virtual community of practice, may be necessary. Furthermore, strengthening health information systems to monitor subnational performance and social determinants is crucial for responsive, equity-oriented programming.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e\u003cp\u003eA significant strength of this study is its use of nationally representative data spanning two decades and its application of standardized inequality metrics, providing a robust assessment of trends and disparities. However, limitations include potential recall bias in survey responses and the lack of qualitative insights into contextual drivers of inequality. Additionally, while the WHO HEAT provides valuable disaggregation, some measures (e.g., Ratio, Difference) lacked confidence intervals, limiting statistical interpretation.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eGhana has made commendable progress in increasing IPTp3\u003csup\u003e+\u003c/sup\u003e coverage among pregnant women over the past 20 years. However, achieving equitable access remains a challenge. Significant economic, educational, and regional disparities persist, impeding optimal coverage. Future policies must incorporate equity-focused strategies to ensure that all pregnant women, regardless of socioeconomic status, education, or geographic location, receive full protection against malaria in pregnancy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAntenatal Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGDHS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGhana Demographic and Health Survey\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organisation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHEAT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Equity Assessment Toolkit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIPTp\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntermittent Preventive Treatment in Pregnancy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDifference\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePAF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePopulation Attributable Fraction\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePAR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePopulation Attributable Risk\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRatio.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eEthical clearance was not required for this study as the WHO HEAT software and its dataset are publicly available in the public domain.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors had no support or funding for this current study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJKK, MBL, KB-A, EK, DAO, YSAH, LAAB-A, and EAB contributed as follows: JKK, EK, DAO and EAB conceptualised the study and developed the methodology; JKK, EK, and DAO performed formal analysis; JKK, MBL, and KB-A drafted the initial manuscript; EK, YSAH, LAAB-A, DAO and EAB critically reviewed and edited the manuscript. All authors have read and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe sincerely acknowledge MEASURE DHS and the World Health Organisation for providing access to the dataset and the HEAT software.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe dataset utilised in this study is accessible at: https://whoequity.shinyapps.io/heat/\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLi J, Docile HJ, Fisher D, Pronyuk K, Zhao L. Current Status of Malaria Control and Elimination in Africa: Epidemiology, Diagnosis, Treatment, Progress and Challenges. J Epidemiol Glob Health. 2024;14:561\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmpofo GD, Osarfo J, Aberese-Ako M, Asem L, Komey MN, Mohammed W, et al. Malaria in pregnancy control and pregnancy outcomes: a decade\u0026rsquo;s overview using Ghana\u0026rsquo;s DHIMS II data. Malar J. 2022;21:303.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMor G, Cardenas I. REVIEW ARTICLE: The Immune System in Pregnancy: A Unique Complexity. Am J Rep Immunol. 2010;63:425\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. Intermittent preventative treatment to reduce the risk of malaria during pregnancy [Internet]. 2023 [cited 2025 Aug 21]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/tools/elena/interventions/iptp-pregnancy\u003c/span\u003e\u003cspan address=\"https://www.who.int/tools/elena/interventions/iptp-pregnancy\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKayentao K, Garner P, Van Maria A, Naidoo I, Roper C, Mulokozi A, et al. Intermittent Preventive Therapy for Malaria During Pregnancy Using 2 vs 3 or More Doses of Sulfadoxine-Pyrimethamine and Risk of Low Birth Weight in Africa: Systematic Review and Meta-analysis. JAMA. 2013;309:594.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgyeman YN, Bassoumah B, Owusu-Marfo J. Predictors of optimal uptake of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine and outcome of pregnancy in selected health facilities: a cross-sectional study in Northern Ghana. Malar J. 2023;22:80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnsong D, Otoo DM, Mensah V, Knowledge. Uptake and Therapeutic Effectiveness of Sulfadoxine-Pyrimethamine (IPTp-SP) among Pregnant Women Attending the Antenatal Clinic at Ayeduase Health Centre in Oforikrom Municipality in the Ashanti-Region, Ghana [Internet]. 2023 [cited 2025 Sep 9]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchsquare.com/article/rs-3686754/v1\u003c/span\u003e\u003cspan address=\"https://www.researchsquare.com/article/rs-3686754/v1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnto F, Agongo IH, Asoala V, Awini E, Oduro AR. Intermittent Preventive Treatment of Malaria in Pregnancy: Assessment of the Sulfadoxine-Pyrimethamine Three-Dose Policy on Birth Outcomes in Rural Northern Ghana. J Trop Med. 2019;2019:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmpofo GD, Ahiakpa AK, Osarfo J. Interventions for malaria prevention in pregnancy; factors influencing uptake and their effect on pregnancy outcomes among post-natal women in a tertiary facility in the Volta Region of Ghana. SAGE Open Med. 2023;11:20503121231199653.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDarteh EKM, Buabeng I, Akuamoah-Boateng C. Uptake of intermittent preventive treatment in pregnancy for malaria: further analysis of the 2016 Ghana Malaria Indicator Survey. J Public Health (Berl). 2021;29:967\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGhana Statistical Service (GSS). and ICF. Ghana Demographic and Health Survey 2022. Accra, Ghana, and Rockville, Maryland, USA: GSS and ICF. [Internet]. 2024 [cited 2025 Apr 26]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.dhsprogram.com/pubs/pdf/FR387/FR387.pdf\u003c/span\u003e\u003cspan address=\"https://www.dhsprogram.com/pubs/pdf/FR387/FR387.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO policy brief for the implementation of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) [Internet]. 2013 [cited 2025 Jul 14]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/WHO-HTM-GMP-2014.4\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/WHO-HTM-GMP-2014.4\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHealth Equity Assessment Toolkit (HEAT). Software for exploring and comparing health inequalities in countries. Built-in database edition. Version 6.1. Geneva. World Health Organization; 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDarteh EKM, Dickson KS, Ahinkorah BO, Owusu BA, Okyere J, Salihu T, et al. Factors influencing the uptake of intermittent preventive treatment among pregnant women in sub-Saharan Africa: a multilevel analysis. Arch Public Health. 2021;79:182.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKlu D, Owusu L. Factors affecting the uptake of optimal doses of intermittent preventive treatment of malaria in pregnancy using sulfadoxine pyrimethamine in Ghana: new evidence from the 2019 malaria indicator survey. J Public Health (Berl). 2025;33:269\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTackie V, Seidu A-A, Osei M. Factors influencing the uptake of intermittent preventive treatment of malaria among pregnant women: a cross-sectional study. J Public Health (Berl). 2021;29:1205\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGonz\u0026aacute;lez R, Manun\u0026rsquo;Ebo MF, Meremikwu M, Rabeza VR, Sacoor C, Figueroa-Romero A, et al. The impact of community delivery of intermittent preventive treatment of malaria in pregnancy on its coverage in four sub-Saharan African countries (Democratic Republic of the Congo, Madagascar, Mozambique, and Nigeria): a quasi-experimental multicentre evaluation. Lancet Global Health. 2023;11:e566\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKalu GO, Francis JM, Ibisomi L, Chirwa T, Kagura J. Factors associated with the uptake of Intermittent Preventive Treatment (IPTp-SP) for malaria in pregnancy: Further analysis of the 2018 Nigeria Demographic and Health Survey. Ahmed SM, editor. PLOS Glob Public Health. 2023;3:e0000771.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYaya S, Uthman O, Amouzou A, Bishwajit G. Use of Intermittent Preventive Treatment among Pregnant Women in Sub-Saharan Africa: Evidence from Malaria Indicator Surveys. TropicalMed. 2018;3:18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld malaria report 2023. Licence: CC BY-NC-SA 3.0 IGO. Geneva: World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMuhammad FM, Majdzadeh R, Nedjat S, Sajadi HS, Parsaeian M. Socioeconomic inequality in intermittent preventive treatment using Sulphadoxine pyrimethamine among pregnant women in Nigeria. BMC Public Health. 2020;20:1860.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSarfo JO, Doe PF, Mireku DO. Individual- and community-level correlates of intermittent preventive treatment of malaria in pregnancy in Ghana: further analysis of the 2019 Malaria Indicator Survey. Res Health Serv Reg. 2024;3:22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health. National Malaria Elimination Strategic Plan (NMESP) 2024\u0026ndash;2028. Ministry of Health/ Ghana Health Service. 2023. 1\u0026ndash;70 p. [Internet]. [cited 2025 Aug 17]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://mesamalaria.org/resource-hub/national-malaria-elimination-strategic-plan-nmesp-of-ghana-2024-2028/\u003c/span\u003e\u003cspan address=\"https://mesamalaria.org/resource-hub/national-malaria-elimination-strategic-plan-nmesp-of-ghana-2024-2028/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmankwah S, Anto F. Factors Associated with Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy: A Cross-Sectional Study in Private Health Facilities in Tema Metropolis, Ghana. J Trop Med. 2019;2019:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuh A, Kota K, Bishwajit G, Yaya S. Prevalence and Associated Factors of Taking Intermittent Preventive Treatment in Pregnancy in Sierra Leone. TropicalMed. 2019;4:32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWere V, Buff AM, Desai M, Kariuki S, Samuels AM, Phillips-Howard P, et al. Trends in malaria prevalence and health related socioeconomic inequality in rural western Kenya: results from repeated household malaria cross-sectional surveys from 2006 to 2013. BMJ Open. 2019;9:e033883.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePons-Duran C, Llach M, Sacoor C, Sanz S, Macete E, Arikpo I, et al. Coverage of intermittent preventive treatment of malaria in pregnancy in four sub-Saharan countries: findings from household surveys. Int J Epidemiol. 2021;50:550\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnto F, Ayepah C, Awini E, Bimi L. Determinants of uptake of intermittent preventive treatment for malaria with sulfadoxine pyrimethamine in pregnancy: a cross-sectional analytical study in the Sekondi-Takoradi Metropolis of Ghana. Arch Public Health. 2021;79:177.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIbrahim H, Maya ET, Issah K, Apanga PA, Bachan EG, Noora CL. Factors influencing uptake of intermittent preventive treatment of malaria in pregnancy using sulphadoxine pyrimethamine in Sunyani Municipality, Ghana. Pan Afr Med J [Internet]. 2017 [cited 2025 Aug 17];28. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.panafrican-med-journal.com/content/article/28/122/full/\u003c/span\u003e\u003cspan address=\"http://www.panafrican-med-journal.com/content/article/28/122/full/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNakalega R, Nabisere-Arinaitwe R, Mukiza N, Kuteesa CN, Mawanda D, Natureeba P, et al. Attitudes and perceptions towards developing a health educational video to enhance optimal uptake of malaria preventive therapy among pregnant women in Uganda: a qualitative study involving pregnant women, health workers, and Ministry of health officials. BMC Health Serv Res. 2024;24:484.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKretchy IA, Atobrah D, Adumbire DA, Ankamah S, Adanu T, Badasu DM, et al. Enhancing the uptake of intermittent preventive treatment for malaria in pregnancy: a scoping review of interventions and gender-informed approaches. Malar J. 2025;24:49.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOdwe G, Matanda DJ, Zulu T, Kizito S, Okoth O, Kangwana B. Women\u0026rsquo;s empowerment and uptake of sulfadoxine\u0026ndash;pyrimethamine for intermittent preventive treatment of malaria during pregnancy: results from a cross-sectional baseline survey in the Lake endemic region, Kenya. Malar J. 2023;22:241.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXu X, Liang D, Zhao J, Mpembeni R, Olenja J, Yam EL, et al. The readiness of malaria services and uptake of intermittent preventive treatment in pregnancy in six sub-Saharan countries. J Glob Health. 2024;14:04112.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDoku DT, Zankawah MM, Adu-Gyamfi AB. Factors influencing dropout rate of intermittent preventive treatment of malaria during pregnancy. BMC Res Notes. 2016;9:460.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGogue C, Wagman J, Tynuv K, Saibu A, Yihdego Y, Malm K, et al. An observational analysis of the impact of indoor residual spraying in Northern, Upper East, and Upper West Regions of Ghana: 2014 through 2017. Malar J. 2020;19:242.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNdayishimiye JC, Teg-Nefaah Tabong P. Spatial distribution and determinants of intermittent preventive treatment for malaria during pregnancy: a secondary data analysis of the 2019 Ghana malaria indicators survey. BMC Pregnancy Childbirth. 2024;24:379.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarry I, Toure AA, Sangho O, Beavogui AH, Cisse D, Diallo A, et al. Variations in the use of malaria preventive measures among pregnant women in Guinea: a secondary analysis of the 2012 and 2018 demographic and health surveys. Malar J. 2022;21:309.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDun-Dery F, Meissner P, Beiersmann C, Kuunibe N, Winkler V, Albrecht J, et al. Uptake challenges of intermittent preventive malaria therapy among pregnant women and their health care providers in the Upper West Region of Ghana: A mixed-methods study. Parasite Epidemiol Control. 2021;15:e00222.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoita K, Kayentao K, Worrall E, Van Eijk AM, Hill J. Community-based strategies to increase coverage of intermittent preventive treatment of malaria in pregnancy with sulfadoxine\u0026ndash;pyrimethamine in sub-Saharan Africa: a systematic review, meta-analysis, meta-ethnography, and economic assessment. Lancet Global Health. 2024;12:e1456\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatsubara C, Dalaba MA, Danchaka LL, Welaga P. Situation Analysis of a New Effort of Community-Based Health Planning and Services (CHPS) for Maternal Health in Upper West Region in Rural Ghana. IJERPH. 2023;20:6595.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ghana Demographic and Health Surveys, Health Equity Assessment Toolkit, Intermittent Preventive Treatment, Malaria in Pregnancy","lastPublishedDoi":"10.21203/rs.3.rs-7574280/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7574280/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIntermittent preventive treatment during pregnancy (IPTp) is a key strategy for malaria control recommended by the World Health Organization (WHO). However, in Ghana, uptake of at least three doses (IPTp3⁺) remains below the WHO target of 80%. This study therefore examined the trends and inequalities in IPTp3⁺ uptake among pregnant women between 2003 and 2022.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis study analyzed data from the 2003, 2008, 2014, and 2022 Ghana Demographic and Health Surveys. The WHO Health Equity Assessment Toolkit was used to assess trends and inequalities in IPTp3⁺ uptake across wealth quintiles, educational attainment, place of residence, and subnational regions. Inequalities were quantified using absolute measures [Difference (D) and Population Attributable Risk (PAR)] and relative measures [Ratio (R) and Population Attributable Fraction (PAF)].\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNational IPTp3⁺ uptake increased markedly from 0.8% in 2003 to 60.2% in 2022. Regional inequalities were the largest, widening from D\u0026thinsp;=\u0026thinsp;2.0; PAF\u0026thinsp;=\u0026thinsp;138.3; PAR\u0026thinsp;=\u0026thinsp;1.2 in 2003 to D\u0026thinsp;=\u0026thinsp;34.4; R\u0026thinsp;=\u0026thinsp;1.8; PAF\u0026thinsp;=\u0026thinsp;30.8; PAR\u0026thinsp;=\u0026thinsp;18.6 in 2022. Economic disparities were minimal in 2003 (D = \u0026minus;\u0026thinsp;0.7; R\u0026thinsp;=\u0026thinsp;0.5; PAF\u0026thinsp;=\u0026thinsp;0.0; PAR\u0026thinsp;=\u0026thinsp;0.0) but grew substantially in 2008 (D\u0026thinsp;=\u0026thinsp;18.0; R\u0026thinsp;=\u0026thinsp;2.0; PAF\u0026thinsp;=\u0026thinsp;31.3; PAR\u0026thinsp;=\u0026thinsp;8.8) and persisted in 2022 (D\u0026thinsp;=\u0026thinsp;14.0; R\u0026thinsp;=\u0026thinsp;1.3; PAF\u0026thinsp;=\u0026thinsp;13.4; PAR\u0026thinsp;=\u0026thinsp;8.1). Educational inequalities were absent in 2003 but peaked in 2008 (D\u0026thinsp;=\u0026thinsp;29.0; R\u0026thinsp;=\u0026thinsp;2.4; PAF\u0026thinsp;=\u0026thinsp;78.2; PAR\u0026thinsp;=\u0026thinsp;21.9) before narrowing by 2022 (D\u0026thinsp;=\u0026thinsp;12.5; R\u0026thinsp;=\u0026thinsp;1.2; PAF\u0026thinsp;=\u0026thinsp;7.7; PAR\u0026thinsp;=\u0026thinsp;4.7). Urban\u0026ndash;rural differences remained modest across the study period, with disparities of D = \u0026minus;\u0026thinsp;0.1; R\u0026thinsp;=\u0026thinsp;0.9; PAF\u0026thinsp;=\u0026thinsp;0.0; PAR\u0026thinsp;=\u0026thinsp;0.0 in 2003 and D\u0026thinsp;=\u0026thinsp;4.8; R\u0026thinsp;=\u0026thinsp;1.1; PAF\u0026thinsp;=\u0026thinsp;4.3; PAR\u0026thinsp;=\u0026thinsp;2.6 in 2022.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eGhana has made significant progress in scaling up IPTp3⁺ coverage over the past two decades. However, persistent regional, economic, and educational disparities threaten equitable access to malaria prevention. Targeted, equity-focused interventions, particularly in underserved regions and among socioeconomically disadvantaged women, are critical for achieving universal IPTp3⁺ coverage and improving maternal and neonatal health outcomes.\u003c/p\u003e\u003ch2\u003eClinical trial number:\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Trends and inequalities in the uptake of at least three doses of intermittent preventive treatment (IPTp3⁺) among pregnant women in Ghana, 2003–2022","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 04:11:01","doi":"10.21203/rs.3.rs-7574280/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8bf8a5aa-9bc4-4570-ae5f-3f1407a59933","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-18T09:28:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 04:11:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7574280","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7574280","identity":"rs-7574280","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}