Geospatial analysis of Malaria-in-Pregnancy Service Gaps using Routine Health Data in Cross River State, Nigeria.

Substantial inefficiencies persist along the antenatal care (ANC) to intermittent preventive treatment (IPTp) in Nigeria despite global progress in malaria prevention during pregnancy. National level aggregated indicators often mask sub-national and facility-level disparities, limiting the ability of health systems to target persistent service delivery failures. In this study, we analysed monthly health facility records from the Nigeria DHIS2 platform covering January 2022 to December 2025, aggregated annually at health-facility catchment, ward, and Local Government Area (LGA) levels in Cross River State. Two core cascade indicators were computed: IPT3/ANC1 (conversion of ANC entry into IPTp3 completion) and IPT3/IPT1 (retention from IPTp initiation to completion). To identify locations where high ANC utilisation failed to translate into IPTp3 delivery, we developed a composite ANC→IPTp inefficiency intensity index combining standardized ANC contact volume, IPTp completion shortfall, and ANC–IPTp delivery gaps. Spatial dependence was assessed using Moran’s I and Local Indicators of Spatial Association (LISA), while temporal persistence and k-means clustering were used to classify structural versus transient underperformance. Statewide IPT3/ANC1 improved from 0.34 (2022) to 0.47 (2025), while IPT3/IPT1 increased from 0.41 to 0.52, indicating overall strengthening of the ANC→IPTp cascade. However, pronounced spatial inequalities persisted. In 2025, IPT3/ANC1 ranged from 0.26 to 0.69 across LGAs, with Bakassi, Odukpani, and Akpabuyo consistently underperforming, while Obubra, Ogoja, and Yakurr achieved high conversion efficiency. Ward-level intensity analysis revealed a right-skewed distribution (mean = 0.083; SD = 0.521), with inefficiency driven primarily by ANC–IPTp delivery gaps (r = 0.69) and ANC contact intensity (r = 0.58). Significant positive spatial autocorrelation confirmed clustering of high-inefficiency wards, and several catchments exhibited persistent low performance across three or more consecutive years. Improvements in ANC attendance alone are insufficient to ensure effective IPTp3 delivery. In Cross River State, malaria-in-pregnancy service inefficiencies are heterogeneous, underscoring the need for catchment-specific interventions that prioritise service conversion and continuity rather than uniform statewide strategies.