The malaria prevention strategy for pregnant women with sulfadoxine-pyrimethamine treatment recommended by the WHO in 1998 was adopted by the Beninese government in 2004. However, it was only implemented in the field starting in 2006. The present study covered the period from 2005 to 2009, including all the available data since the year preceding the protocol's implementation. The objective was to assess the ITP-SP coverage rate in two regions in the south and north of the country from its implementation until 2009. The results showed that the ITP coverage rate had evolved rapidly since implementation of the protocol even if this varied in the study's eight maternity hospitals. Since these were factors associated with ITP administration, the results show that ITP administration may be associated with the type of town (rural or urban) and the geographical area (north or south), as well as the number of prenatal consultations.
Overall, in 2005 we observed a low "ITP-at least one dose" and "ITP-two doses" coverage rate, confirming that in this period the administrative decision had not been applied in the field. During this period, 92.6% of the women in the study still received chloroquine treatment. The rapid progression of the coverage rate observed after start-up in 2006 is probably the consequence of awareness campaigns and training maternity hospital personnel in the application of this new protocol. This progression continued for the 2008-2009 period, although at a slower pace.
However, this overall progression hides substantial disparity between the maternity hospitals. We noted a globally faster progression in maternity hospitals located in the north of Benin. A possible explanation would be that ITP-SP may have been adopted earlier in this area and therefore that personnel training may have taken place earlier than in the south.
In total, in 2009, 3 years after starting up ITP-SP, all the maternity hospitals in the north (Birni Lafia, Guéné, Hôpital de zone, and Health Center) showed more than 80% coverage in "ITP-at least one dose." Also in the south, the Tori Cada, Avamè, and Zogbo health centers also showed a coverage rate higher than 80%. Only the CNHU was below this percentage, with a 67% "ITP-at least one dose" coverage rate. The maternity hospitals in the south, except for CNHU, were no longer behind those in the north, as observed in 2006-2007.
However, in 2009, only two maternity hospitals out of eight reached the 80% "ITP-two doses" coverage threshold, as established as the objectives of the WHO Roll Back Malaria  program and Benin's PNLP  for 2010. The coverage rate varied from 45% at the CNHU to 85% at Birni Lafia in 2009. Overall, the coverage rate was 68% in 2009.
The difference between the number of women receiving at least one dose and those having received two does of SP could be explained by several factors:
too few consultations or consultations too far apart, precluding SP administration (which cannot be administered after the 36th week of amenorrhea);
a stock shortage of the drug in certain maternity hospitals;
late consultations for certain pregnant women (the first prenatal consultation occurred after 32 weeks for 5% of women), thus leaving insufficient time for the second administration before giving birth;
abortions or premature births occurring before the second administration;
This study also showed that the CNHU was the center where coverage ("ITP-two doses" and "ITP-at least one dose") was the lowest. Various factors can explain this:
First, the CNHU receives a large number of pregnant women and may have been hit more severely by the stock shortage of SP than expected. In this case, it was observed that women sometimes received another antimalarial such as chloroquine, proguanil or the association of the two antimalarials, for example. This may protect the pregnant woman but does not match the national or WHO recommendations;
A greater proportion of women consulting at the CNHU have an at-risk pregnancy than in the other health centers. This is the case, for example of sulfamide allergies and HIV seropositivity for which a different protocol is recommended .
Comparable studies have been conducted in Benin and in other African countries.
In Benin, the PNLP evaluated the strategies of malaria control during pregnancy was conducted in 2007, in a transversal study throughout the country. It showed that 60.7% of the women surveyed in healthcare training and 66.6% of the women in the general population had received ITP-SP appropriately (two doses), for a total of 63.7% . This percentage is close to that found in the present study for the overall population of pregnant women: 59.0% in 2007. This study also reported that the availability of SP is unstable in the university-affiliated hospitals and the departmental hospitals . However, it should be noted that the ITP coverage rate was calculated based on data collected on the maternal cards in our study, whereas it was based on interviews with women in the PNLP study.
Several studies, in the Gambia in 2008 , two others in Kenya in 2004  and 2008 , and in Malawi in 2000 , showed less rapid progression of the ITP-two dose coverage rate than in the present study.
The authors suggest that these results may be related to poor awareness on the part of women, most of whom seemed not to return for the follow-up doses, or problems of geographic accessibility of the center, or socioeconomic problems .
The differences between these studies and ours could also be related to the methods used. First of all, the study periods were different, and for the studies conducted in Kenya and Malawi, the data were obtained from interviews of pregnant women, certain of whom could have forgotten that they had received ITP-SP, resulting in an underestimation of ITP coverage. In addition, in Benin, where the coverage rate seems better than that found in other studies, SP is subsidized and distributed free.
Another factor is that in the present study the coverage rate reflects women who came for prenatal consultations and does not take into account women who were not seen in these visits. In 2008 for example, the coverage rate in prenatal consultations was estimated at 76.9% for the Alibori department in the northern area and 89.2% for the Atlantique department where the Tori Cada and Tori Avamè maternity hospitals are located. Our protocol therefore overestimates the real ITP coverage rate to a certain extent.
Except for the study period, the geographical area (with a higher probability of receiving ITP in the north than in the south), and the type of town (with a higher probability of receiving ITP in rural areas than in towns), the results of this study show that women who had had at least four prenatal consultations had a better chance of receiving ITP than the others. This result confirms the WHO recommendations  and the PNLP's recommendations as well , according to which pregnant women should have at least four prenatal consultations, three of which after active fetal movements (or after the 16th week of amenorrhea). If SP was administered during these last three prenatal visits, a large proportion of pregnant women would receive the two recommended doses.