Abstract
According to the WHO, in 2021, about 32% of pregnant women in sub-Saharan
Africa were infected with malaria during pregnancy. Malaria infection during
pregnancy can cause various adverse birth outcomes such as low birthweight.
Over the past two decades, while some sub-Saharan African areas have
experienced a large reduction in malaria prevalence due to improved malaria
control and treatments, others have observed little change. Individual-level
interventional studies have shown that preventing malaria infection during
pregnancy can improve birth outcomes such as birthweight; however, it is still
unclear whether natural reductions in malaria prevalence may help improve
community-level birth outcomes. We conduct an observational study using 203,141
children's records in 18 sub-Saharan African countries from 2000 to 2018. Using
heterogeneity of changes in malaria prevalence, we propose and apply a novel
pair-of-pairs design via two-stage bipartite and non-bipartite matching to
conduct a difference-in-differences study with a continuous measure of malaria
prevalence, namely the Plasmodium falciparum parasite rate among children aged
2 to 10 ($\text{PfPR}_{2-10}$). The proposed novel statistical methodology
allows us to apply difference-in-differences without dichotomizing
$\text{PfPR}_{2-10}$, which can substantially increase the effective sample
size, improve covariate balance, and facilitate the dose-response relationship
during analysis. Our outcome analysis finds that among the pairs of clusters we
study, the largest reduction in $\text{PfPR}_{2-10}$ over early and late years
is estimated to increase the average birthweight by 98.899 grams (95% CI:
$[39.002, 158.796]$), which is associated with reduced risks of several adverse
birth or life-course outcomes. The proposed novel statistical methodology can
be replicated in many other disease areas.
Citation
ID:
283587
Ref Key:
heng2024reevaluating