Combined iron/folic acid supplements and malaria prophylaxis reduce neonatal mortality in 19 sub-Saharan African countries

In nonmalaria regions, iron/folic acid supplementation during pregnancy protects newborns against preterm delivery and early neonatal death. Other studies from malaria-endemic areas have reported an adverse effect of iron supplements on malaria prevalence in pregnant women. We examined the association between iron/folic acid supplements and prenatal antimalaria prophylaxis on neonatal mortality in malaria-endemic countries of sub-Saharan Africa. This analysis used the most recent data from Demographic and Health Surveys of 19 malaria-endemic countries in sub-Saharan Africa. Survival information of 101,636 singleton live-born infants from the most recent delivery of ever-married women ≤5 y before each survey was examined. The effect of each potential predictor on neonatal deaths was analyzed by using Cox proportional hazards regression models. Infants whose mothers received any iron/folic acid supplements and sulfadoxine-pyrimethamine intermittent preventive treatment (SP-IPTp) for malaria during pregnancy were significantly protected from neonatal death [hazard ratio (HR): 0.76; 95% CI: 0.58, 0.99]. The protective effect was not significant in mothers who received only iron/folic acid supplements (HR: 0.90; 95% CI: 0.73, 1.12) or only SP-IPTp (HR: 1.08; 95% CI: 0.74, 1.57). Among the sociodemographic and birth characteristics, factors that significantly increased the risk of neonatal death included first-born infants, a birth interval of <2 y, maternal age at delivery of ≥30 y, smaller than average-sized infants, and male infants. The use of antenatal iron/folic acid supplements combined with appropriate intermittent preventive treatment of malaria during pregnancy is an important intervention to reduce neonatal mortality in malaria-endemic regions.