Introduction Despite reports of high ITN coverages in the

IntroductionMalaria,caused by protozoa of the genus Plasmodium,is a disease that claimed lives of approximately 445 000 people globally in2016 1. The public health concern of malaria goes beyond thegeneral population to vulnerable groups such as under-fives and pregnantwomen.  The impact of malaria inpregnancy (MIP) is well documented with effects such maternal anemia, pretermdelivery and low birthweight observed on the women, fetus and the newborn 2, 3. Sub-Saharan Africa remains thehardest hit with 85% of the 25 million pregnancies at risk of malaria globally,occurring in the region 4. This results inMIP accounting for 20% and 11% of stillborn and neonatal deaths in the region,respectively 2, 3.

Toreduce the burden of MIP, World Health Organization (WHO) developed threestrategies namely; Insecticide Treated Nets (ITN), Intermittent PreventiveTreatment use (IPTP) and active case management 5. Despite reports of high ITN coverages in theSub-Saharan Africa region, the use of the same remains problematic 6-8.InMalawi, ITN has been at the center of malaria control with a nationwide massITN distribution campaign taking place in 2012 9.  In addition tothe campaign, the ITN policy also recommends that free ITNs should be given to;women at antenatal care (ANC) visits; children born in health facilities orattending their first visit under the Expanded Program on Immunization (EPI) ifan ITN was not received at birth 9. The policy, coupledwith the periodic mass ITN distribution campaigns  and traditional social marketing throughprivate outlets has seen ITN use among pregnant women rise from 35% in 2010 to62% in 2014 10, 11.  However, a recent Malawian study revealed adrop in ITN use among women of child bearing age (WOCBA) visiting ANC to 53% 12. This is ofconcern considering that ITN is one of the most reliable vector control methodsin malaria prevention hence crucial in achieving malaria elimination by 2030 13. A large body of research has demonstrated that factors such aswomen’s age 14, parity 15, education status 15, employment status 14, 16,household wealth 14, 17, andreligion 14 have significant effects on ITN utilization.

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For instance, womenwho had a higher education were two times more likely to use ITN than womenwith no formal education in Kenya 17. In Cameroon, 45% multigravida women as compared to 21%Primigravida women slept under ITN the previous night before the survey18. However, inconsistent results have been reported elsewhere withstudies revealing education 19, parity 16, and age 15 to have no significant association with ITN use among pregnantwomen. Community characteristics have also been previously shown to havesignificant influences on health outcomes and health care utilization acrossAfrica 20, 21. Communitiesprovide an environment in which people are exposed to different health risksand resources which in return affects their health. In Rwanda, community factors influenced ITN use among under-5 children22.

Under-5s living in communities with high education and highwealth were more likely to use ITN in comparison to those living in low educationand low wealth communities 22. However, little is known about the effects of community on ITNutilization among women. Few studies have investigated the influence of bothindividual and community factors on ITN use. Analyzing the contextualfactors is important to ensure that future interventions such as mass campaigns,and health education messages are tailor-made for both vulnerable communities andwomen. Therefore,drawing a nationally representative sample, this study aimed to investigate theindividual- and community-level factors associated with ITN use among WOCBA inMalawi.