1. Scaling Up Malaria in Pregnancy Services in Tanzania
Patricia P. Gomez
Clinical Specialist, ACCESS Program/JHPIEGO

2. Acknowledgments The ACCESS/Tanzania team: The ACCESS/Baltimore team:
Maryjane Lacoste
Muthoni Magu-Kariuki
Gaudiosa Tibaijuka
The ACCESS/Baltimore team:
Natalie Hendler
Nancy Caiola
Barbara Rawlins
Sarla Chand
Steve Bruno

3. Overview What is the ACCESS Program? Why is MIP important to address?
What are Tanzania’s health indicators?
Why scale up MIP services?
How are MIP services being scaled up?
What has the program accomplished and learned, and where does it go from here?

4. The ACCESS Program
Access to clinical and community maternal, neonatal and women’s health services
5-year, $75 million USAID flagship maternal and newborn health program
Partners: JHPIEGO, Save the Children-US, Constella Futures, Academy for Educational Development, American College of Nurse-Midwives, IMA World Health
Goals: advocacy and policy in maternal/newborn health issues at the global level; scale up known cost-effective evidence-based interventions to reduce maternal and newborn mortality

5. The ACCESS Program (2) Currently working in 25 countries
Collaborate with Ministries of Health; international bodies (WHO, UNICEF, UNFPA, PMNCH, CDC, etc.) and USAID-funded global and bi-lateral programs
Special Initiatives
Prevention of postpartum hemorrhage
Newborn survival - KMC
Prevention and treatment of malaria in pregnancy
Pre-service education
Safe Birth Africa Initiative, Rwanda
Based on household-hospital continuum of care

6. Household-to-Hospital Continuum of Care Model
Intersectoral Stakeholders/Partners
Community Groups (e.g., FBOs) * Community Leaders
Service Providers * Policymakers * Private Sector
Donors/Partners * USAID Missions and other CAs
Household
Women
Newborns
Family
Hospital
Peripheral Facility
Community Champions and Change Agents
Sociocultural Environment
Policy

7. Anticipated Funding Level
President’s Malaria Initiative Launched 2005: Funding Levels and Coverage
Year
Anticipated Funding Level
Coverage
2006
$30 million
3 countries
2007
$135 million*
7 countries
2008
$300 million
15 countries
2009
2010
$500 million
TOTAL
$1.265 billion
Possible plus-up of $25 million

8. PMI Goal and Targets Goal:
To reduce malaria-related mortality by 50% in 15 selected countries
Targets:
To achieve 85% coverage of vulnerable groups with four key interventions

9. PMI Interventions Artemisinin-based combination therapy (ACTs)
Insecticide-treated bed nets (ITNs)
Intermittent preventive treatment in pregnancy (IPTp)
Indoor residual spraying (IRS) (where appropriate)

10. Addressing MIP
90% of all malaria illness and death in the world occurs in sub-Saharan Africa
50 million women who live in malaria-endemic regions become pregnant each year; over 50% of them live in sub-Saharan Africa
Most common and virulent species of the malaria parasite is Plasmodium falciparum
Infection with P. falciparum may result in:
maternal anemia (2 – 15%)
fetal loss, IUGR (13 – 70%), and low birth weight (8 – 36%)

11. Why should MIP be addressed? (2)
Malaria is usually asymptomatic but leads to severe maternal anemia and low birthweight
Up to 200,000 infant deaths/year could be prevented by control of MIP
HIV increases risk of contracting malaria and worsens the disease; reduces antimalarial efficacy

12. Characteristics of Malaria Transmission
Stable areas, e.g. Tanzania
People are frequently bitten by infective mosquitoes
Levels of acquired immunity are high (pregnant women are semi-immune to malaria)
Low peripheral parasitemia
Heavy placental infection
Unstable areas, e.g. South Africa
People are infrequently exposed to malaria
Levels of acquired immunity are low (pregnant women are not immune)
Heavy peripheral parasitemia
Low or undetectable placental infection
The intensity of malaria transmission in an area determines the effect of malaria on pregnancy. In areas of stable transmission, malaria is frequently transmitted by mosquitoes from one person to another resulting in high levels of acquired immunity. Pregnant women in these areas are semi-immune to malaria and have a low prevalence of peripheral parasitemia but a high prevalence of placental infection.
On the other hand, in areas of unstable transmission, malaria is infrequently transmitted from one person to another. Therefore, pregnant women in these areas have low levels of acquired immunity with heavy peripheral parasitemia and low or undetectable levels of placental infection.

13. Effect of MIP in Stable Transmission Areas
Plasmodium falciparum malaria
Asymptomatic Infection
Placental Sequestration
Altered Placental Integrity
Reduced Nutrient and Oxygen Transport
How does malaria infection lead to low birth weight newborns?
This slide summarizes the sequence of events in stable areas of malaria transmission. In these areas, women have a high level of acquired immunity to Plasmodium falciparum malaria and are often asymptomatic due to low peripheral parasitemia. Pregnancy naturally lowers cell-mediated immunity and causes immunosuppression. In areas of stable transmission, the placenta is a protected site for parasite sequestration and growth. Its effect during pregnancy appears to be “parity-specific”. During the first malaria-exposed pregnancy (that is, in primigravida), local immunity to malaria develops in the placenta. This immunity has no effect in the first pregnancy but is retained in the uterus and increases cumulatively in subsequent pregnancies. This is why women in their first and second pregnancies are more affected by malaria than women in subsequent pregnancies.
The malaria parasites in the placenta damage placental integrity and interfere with the ability of the placenta to transport nutrients and oxygen to the fetus, thereby causing intrauterine growth retardation, a factor for delivery of low birth weight newborns. A low birth weight newborn is defined as one that is born weighing 2500 grams or less. Another pathway to low birth weight is severe maternal anemia which is also caused by the malaria infection. In general, low birth weight babies have a higher risk of dying in infancy.
Anemia
Low Birth Weight (IUGR)
Risk of Newborn Mortality
Source: WHO 2002.

14. Effect of MIP Unstable Transmission Areas
Acquired Immunity – Low
Clinical Illness
Severe Disease
Risk to Mother
Risk to Fetus
What happens in areas of unstable malaria transmission?
Women in these areas have lower levels of acquired immunity. Therefore, they have an increased frequency and severity of malaria and anemia. Delayed recognition and inappropriate treatment may lead to a progression to severe disease, which has serious consequences for both the mother and the fetus. This effect is seen in virtually all pregnancies, irrespective of parity.
Source: WHO 2002.

15. Effects on the Pregnant Woman
Primigravidae in Stable areas
All parities in Unstable areas
High fever (symptomatic)
Placental infection
Puerperal sepsis
Complicated malaria
Severe anemia
Cerebral malaria
Hypoglycemia
Pulmonary edema
Acute renal failure
Increased maternal mortality +
+++ ++ -
As stated earlier, the effect of malaria infection depends on the intensity of malaria transmission in the area, which in turn determines the woman’s level of acquired immunity to malaria. Furthermore, birth order is also known to be a determining factor in the frequency and severity of malaria during pregnancy.
This table shows that primigravid women living in areas of stable malaria transmission have an increased risk of placental infection and severe anemia. They are less likely to suffer from complicated malaria which may present in the form of cerebral malaria, hypoglycemia, pulmonary edema and acute renal failure. On the other hand, women of any parity living in areas of unstable transmission have a higher risk of malaria fever illness, severe anemia and complicated malaria.
Anemia lowers the woman’s resistance to infection, thereby increasing the likelihood of puerperal sepsis. The risk of maternal mortality from malaria is higher among women living in areas of unstable malaria. The causes of death may include severe anemia, postpartum haemorrhage, puerperal sepsis or anemic heart failure.
( +++ =Very Common, ++ =Common, + =Infrequent, -- =Rare)

16. Effects on the Fetus and Newborn
Primigravidae in stable malaria areas
All parities in unstable malaria areas
Low birth weight
IUGR
Prematurity
Abortion
Stillbirth
Congenital malaria
Fetal anemia
Infant mortality
+++ + - ? ++
With regards to the fetus and the newborn, primigravid women living in areas of stable malaria transmission are at higher risk of delivering low birth weight babies due to intrauterine growth retardation. Women of all parities living in areas of unstable malaria are at higher risk of premature delivery (that is, delivery before 37 completed weeks of gestation). They are also at higher risk of spontaneous abortions, stillbirths and congenital malaria. The consequences of these adverse effects is an increased risk of infant mortality among all babies born to mothers living in areas of unstable malaria transmission.
( +++=Very Common, ++=Common, +=Infrequent, -- =Rare)

17. Placental Malaria
Prevalence of Placental Malaria in African Women by Gravidity in Eight Studies
This slide summarizes results from studies in eight countries in Africa. In virtually all the countries listed, primigravid women had a higher prevalence of placental parasitemia when compared to multigravid women.

18. Low Birth Weight
Frequency of Low Birth Weight by Placental Malaria Infection 5 10 15 20 25 30 35
With placental parasites
Without placental parasites
% Low Birth Weight
This slide summarizes another study from Malawi examining the relationship between birth order, presence of malaria parasites in the placenta and the incidence of low birth weight. As shown, newborns with malaria parasites in their placenta (represented by the left bar in each cluster) had a higher risk of being born with a low birth weight when compared with newborns with no malaria parasites in their placenta (represented by the right bar in each cluster). This is true regardless of the birth order, which could be the first, the second or later pregnancy.
First
Pregnancy
Second
Pregnancy
Three or more
pregnancies
Source: Steketee 2001: Malawi

19. Placental Parasitemia and HIV
Placental Parasitemia by HIV Status and Pregnancy Number, Kenya, (N = 2263)
Parasite density/mm3
% parasitemic
231
What is the relationship between HIV/AIDS and malaria during pregnancy?
HIV infection, which is becoming more prevalent in women of reproductive age, may diminish a pregnant woman’s capacity to control Plasmodium falciparum malaria infections and lead to decreased efficacy of antimalarial interventions.
This graph summarizes the findings from a study in Kenya. The cluster of bars to the left represent HIV-positive mothers, and the bars to the right represent HIV-negative mothers. The data shows that, irrespective of placental parasite density or whether the women are in their first, second or later pregnancies, those who are HIV-positive are more likely to have malaria parasitemia when compared with those who are HIV-negative. Because the HIV virus is an immunodeficiency virus, HIV-positive women have lower levels of acquired immunity for all infections including malaria. The implication of this finding for treatment is that HIV-positive women have a reduced efficacy to antimalarial medication and need more doses of the medication than their HIV-negative counterparts.
159
197
772
402
479
HIV (+)
HIV (-)
Summary RR = 1.63 ( ), p <0.001
Source: van Eijk AM et al 2001.

20. Intermittent Preventive Treatment in Pregnancy
IPTp is an approach for effectively preventing and controlling malaria during pregnancy that
Is based on an assumption that every pregnant woman in a malaria-endemic area is infected with malaria, and
Recommends that every pregnant women receive at least two treatment doses of an effective antimalarial drug as a preventive measure
Sulfadoxine-pyrimethamine (SP) currently considered the most effective drug for IPTp
The second component of the strategic framework for malaria control during pregnancy is “intermittent preventive treatment”. Intermittent preventive treatment is an intervention for effectively preventing and controlling malaria during pregnancy. It is based on the assumption that every pregnant woman living in an area of stable or unstable malaria transmission has malaria parasites in the blood or in the placenta, and therefore, should be treated to minimize its effects on the mother and her fetus. Intermittent preventive treatment with SP is currently the most effective approach for the use of antimalarial drugs during pregnancy and is particularly attractive for use in areas with a high level of chloroquine resistance.

21. IPTp with Sulfadoxine-Pyrimethamine
SP is a combination of two different drugs. Each tablet of SP contains:
500 mg of sulfadoxine, and
25 mg of pyrimethamine
A single dose consists of three tablets taken at once, preferably under direct observation of the healthcare provider
Fansidar is the most common brand name. Others include Falcidin, Laridox, Maladox, Orodar, Maloxine
SP is generally more effective than chloroquine which is no longer effective in most countries because of parasite resistance
Sulfadoxine-pyrimethamine is the drug of choice in many countries for intermittent preventive treatment of malaria. SP, as it is often called, is a combination of two drugs. Each tablet contains 500 mg of sulfadoxine and 25 mg of pyrimethamine. A single dose consists of three tablets taken at once, preferably under direct observation by the healthcare provider. Fansidar is the most common brand of SP, but there are other brands such as Falcidin, Laridox and Maladox. SP is generally more effective than chloroquine due to the increasing prevalence of chloroquine resistance in many parts of Africa.

22. Effect of IPTp with SP
Case management alone does not reduce effects of malaria in pregnancy as well as IPTp
Not all women with malaria parasites have symptoms, and therefore would not receive treatment if we relied solely on case management
IPTp produced better outcomes in terms of reducing
Maternal and placental parasitemia
Low birth weight
IPTp is as effective as case management in terms of improving hemoglobin levels
NOTE – former slide was table – changed to text:
Shown here is evidence in support of the use of intermittent preventive treatment with SP. This table summarizes a study from Kenya in which data from three groups of pregnant women were analyzed. These were women who had case management for malaria illness, women who were protected by the two-dose SP regimen, and women protected by a monthly SP regimen. The groups protected with the two-dose or monthly SP regimens had higher mean blood hemoglobin levels than those in the malaria group. Also, the groups protected with SP had lower incidence rates of Shown here is evidence in support of the use of intermittent preventive treatment with SP. This table summarizes a study from Kenya in which data from three groups of pregnant women were analyzed. These were women who had case management for malaria illness, women who were protected by the two-dose SP regimen, and women protected by a monthly SP regimen. The groups protected with the two-dose or monthly SP regimens had higher mean blood hemoglobin levels than those in the malaria group. Also, the groups protected with SP had lower incidence rates of maternal parasitemia (9 and 7%) and placental parasitemia (12 and 9%) compared to women seen with malaria illness (27%).
maternal parasitemia (9 and 7%) and placental parasitemia (12 and 9%) compared to women seen with malaria illness (27%).
The incidence of low birth weight newborns among those who were protected with SP (8%) was also lower than among those not protected with SP (which was 14%). The conclusion is that intermittent preventive treatment offers some protection from the adverse consequences of malaria during pregnancy.

23. Rationale for the Timing of the SP Doses
Fetal growth velocity  Rx Rx
Last
month
Quickening
The World Health Organization or WHO recommends a schedule of four antenatal clinic visits, with three visits occurring after quickening. At least two doses of IPT should be delivered at scheduled antenatal care visits after quickening until delivery. SP should not be given more frequently than every four weeks. The concern about neonatal jaundice resulting from SP given after 36 weeks of gestation does not appear to be a major one at this time.
Kenya, Malawi, Tanzania, Uganda and Zambia have embraced a two-dose SP regimen. In these countries, the first dose of SP is given between weeks and the second dose is given between weeks of pregnancy. No SP is given after 36 weeks. Countries with no policy should consider adopting a three-dose regimen that is in line with WHO’s 3 recommended scheduled antenatal visits after quickening. 10 16 20 30
Weeks of gestation
Birth
Conception
Source: WHO 2002.

24. Key Issues About Timing of Doses
SP should be avoided during the first 16 weeks of pregnancy which is the period of initial development of the fetus
It is best to clear the placenta of parasites during the period of maximum fetal growth
IPTp allows the mother to recover from anemia by clearing peripheral parasitemia
A note for the future – SP resistance is growing, and at some point a new medicine for IPTp will be found
SP should be avoided during the first 16 weeks of pregnancy which corresponds to the period of organ formation in order to avoid congenital malformations. It is best to clear the placenta of parasites during the period of maximum fetal growth as shown in the previous graph. IPT of malaria during pregnancy allows the mother to recover fully from anemia by clearing peripheral parasitemia.
The question arises as to what protection a woman can have during these early weeks of pregnancy. The answer lies in early attendance at ANC where an Insecticide Treated Net can be received.

25. Steps for Providing IPTp with SP
Determine quickening has occurred
Inquire about history of severe skin rash from previous SP use
Inquire about use of SP in last month
Provide three tablets of SP with clean water in a clean cup
Observe the patient swallowing all three tablets (Directly Observed Treatment or DOT strategy)
DOT is one reason to ensure that IPTp is an essential component of an integrated ANC program
Do not encourage women to undertake IPTp on their own
What are some of the steps that should be taken when providing IPT with SP?
Determine that quickening has occurred
Inquire about any history of allergy to sulfonamides, including severe skin rash
Inquire about the use of SP or any sulfonamides in the past month.
If there are no contraindications for giving SP,
Provide three tablets of SP with clean water in a clean cup, and
Directly observe the woman taking the SP tablets in the clinic. This helps to ensure compliance.

26. Steps for Providing IPTp with SP (2)
Ask about side effects from previous dose before giving the next dose, which should not be less than 4 weeks from the last dose
Record SP on the antenatal card and the clinic record
Instruct client to return at next scheduled visit or earlier if she is feeling ill
Drop-out is a major challenge for successful IPTp programs
From 20-50% of women do not receive a second dose
Record “SP given” in the woman’s antenatal card and clinic record
Instruct the woman to return at her next scheduled visit or earlier if she is feeling ill.
Before giving any follow-up dose at the next visit, ask about side effects from the previous dose. A follow-up dose should not be given less than 4 weeks from the last dose.

27. Use ITNs/LLINs
The use of ITNs/LLINs have been shown to result in reduction of low birth weight or prematurity
ITNs reduce transmission by physically preventing vector mosquitoes from landing on sleeping persons
The use of insecticide-treated nets have been shown to result in a reduction in the proportion of newborns born with low birth weight or born prematurely (that is, before 37 completed weeks of pregnancy). Insecticide-treated nets also reduce malaria transmission by serving as a physical barrier between the vector mosquitoes and people sleeping inside the nets. They repel or kill mosquitoes that land on the net and can also kill bed bugs, lice, ticks, cockroaches and other insects around the house. They should be used by pregnant women as early as possible during pregnancy and their use should be continued throughout pregnancy and in the postpartum period.
A study from western Kenya showed that women who were protected by insecticide-treated nets every night during their first four pregnancies delivered approximately 25% fewer newborns who were either small for gestational age or born prematurely when compared to women who were not protected by insecticide-treated nets.

28. ITN/LLIN Benefits
Repel and kill mosquitoes that come in contact with the net
Kill other insects like cockroaches, lice, ticks and bed bugs
Should be used by pregnant women as early during pregnancy as possible and use should be encouraged throughout pregnancy and in the postpartum period
Nets have a variety of benefits and should be provided to a pregnant woman as early in pregnancy as possible.

29. ITN: Impact on Fetal Growth and Duration of Gestation
Pregnant women protected by insecticide-treated nets were less likely
To deliver prematurely or
To have small-for-gestational-age newborns
Compared to control groups who were not protected by the nets
This finding holds true irrespective of the woman’s parity, except for the incidence of small-for-gestational-age babies born to women with 4 or more pregnancies
Shown here is the result of a study that examined the impact of insecticide-treated nets on fetal growth and the duration of gestation. The study showed that pregnant women protected by insecticide-treated nets (represented by the right bar in each cluster), were less likely to deliver prematurely or to have small-for-gestational-age newborns compared to control groups who were not protected by the nets (represented by the left bars). This finding holds true irrespective of the patient’s parity, except for the incidence of small-for-gestational-age babies born to women with 4 or more pregnancies.
Source: ter Kuile et al 1999

30. ITN/LLIN Procurement and Management
ITNs are often provided during childhood immunization campaigns
It is less common to find ITNs allocated in adequate numbers to be an essential component of focused ANC
The district health management team needs to meet and plan for adequate nets for children <5 as well as pregnant women
ITN/LLIN provision can be an important incentive to attend ANC
A woman should get a net on her first ANC visit when it can offer the most protection during pregnancy
Issues of subsidized v. free ITNs
Although ITNs have been around for over a decade, their use as a staple component of ANC has been less common. Countries are under pressure to report numbers, and campaigns are a fast way to get nets out into the community, primarily to children under five years of age. Rarely are ITNs part of routine child immunization programs or ANC. Therefore there are major logistical challenges to overcome if ITNs are to be supplies to ANC clinics on a regular basis.

31. Let’s take a trip to Tanzania!

32. Health Indicators in Tanzania
GENERAL
Population: million
Crude birth rate: 43
Crude death rate: 14
Total fertility rate: 6.3
Life expectancy: 51 years
MMR: 578/100,000 live births
NMR: 32/1000 live births
IMR: 68/live births
HIV prevalence: 7%
MALARIA-RELATED
Malaria illness accounts for 40% of all outpatient visits
ITN ownership: 23%
Use of ITN by pregnant women: 16%
One ANC visit: 94%
Four ANC visits: 62%
1st ANC visit by 16 weeks: 14%
IPTp1: 52%
IPTp2: 22%
SBA: 56%
Source: Tanzania DHS

33. How to ensure MIP services
WHO recommends four ANC visits for women experiencing normal pregnancy
First visit should be before 16 weeks
Using ANC as a platform women receive:
Basic ANC services – iron/folate; syphilis testing/treatment; tetanus toxoid vaccination; PMTCT; health counseling – nutrition, birth spacing, breastfeeding, etc.
Counseling on use of ITNs
ITNs or vouchers to buy them at subsidized price
Intermittent preventive treatment (IPTp)
Appropriate case management of malarial illness

34. How to ensure MIP services (2)
Orientation package developed: Focused ANC/Syphilis/Malaria in pregnancy (FANC/SIP/MIP)
Providers (midwives) trained as clinical trainers at national, provincial, and district levels
Module on quality improvement added and process integrated

35. Building the training system
Advanced Training Skills Workshop for FANC (One 2-week course)
Participants: ZPOs, ZTC Counterparts and ZRCH Coordinators ( from all 8 zones + Zanzibar)
Trainers: ACCESS Staff
FANC orientation and Clinical Training Skills Workshops/FANC TOTs (Multiple 2-week courses)
Participants: Regional and District RCH Coordinators; ANC in-charges; strong service providers; goal is 5 trainers/district, or 20 – 40 in each region
Trainers: National trainers with support from ACCESS staff
Basic FANC Orientation Workshops
(Multiple 6-day courses)
Participants: all FANC providers from hospitals, HCs and dispensaries
Trainers: all FANC trainers

36. Issues in scaling up training
Orientation package needs approval by MOH/MCH section as well as the NMCP and must incorporate new guidelines as they come out
Districts had to commit funds to get providers trained at all levels of the system – to health center and health post levels
Tension between MOH desires for sustainable training framework and USG emphasis on numbers trained

37. Issues in scaling up (2)
Monitoring of all facilities was difficult, so system of sentinel sites (30) was introduced, but each is at a different level of development
Stockouts of SP more frequent than MOH admitted; now reported through EPI system
Zonal, regional, and district supervisors must be involved in monitoring and supervision so that providers can provide care they learned in training

38. How are MIP services being scaled up?
A total of 441 in-service trainers have been trained since 2004
415 from facilities in 21 regions
26 are Zonal and Regional RCH Coordinators from all 8 zones
2,431 providers (41% of those offering FANC) have been trained since 2004
25% of facilities (1,199) offering FANC have trained providers

39. How are MIP services being scaled up? (3)
Tutors and preceptors trained from all 51 nursing and midwifery schools (includes FBOs)
28 diploma level
23 certificate level
This year 1600 students will graduate from these programs, exposed to FANC/MIP/SIP

40. Scaling up with FBOs
About 42% of health care in Tanzania is provided by faith-based organizations
21 providers from 15 FBO facilities trained in Mwanza region
Advocacy meetings targeting religious leaders carried out to increase dissemination of health messages to men and women

41. Scaling up through demand creation
Communities must be aware of the importance of FANC and must demand the services
Partnership formed with media groups to formulate radio messages
Advocacy to religious leaders
Some training of community workers and good support through the White Ribbon Alliance

42. How are MIP services being scaled up? (4)
Thus in sentinel sites coverage is:
IPT1 = 59% (52% DHS)
IPT2 = 41% (22% DHS)
ITN voucher distribution = 93% (75% TDHS)
Challenges include
Stock outs of SP
Data reporting/collecting
Supervision
Source: TDHS 2004/5

43. How are MIP services being scaled up? (5)
Quality improvement process using performance standards is incorporated into provider training

44. VERIFICATION CRITERIA
ANC QI Assessment Tool
PERFOMANCE STANDARDS
The health care provider properly conducts individualized care based on national guidelines and according to findings
VERIFICATION CRITERIA
PROVIDE ROUTINE CARE – TAKE ACTION
Gives on DOT 3 tablets of sulfadoxine–pyrimethamine according to the national guidelines
Explains that in case she vomits within 30 minutes, the dose should be repeated
Provides ferrous sulfate and folic acid or FEFOL in enough amounts to last until next visit
Provides mebendazole tablets 500 mg DOT once by mouth after first trimester
Give tetanus toxoid (TT) based on woman’s need according to standard guidelines
Y,N, NA
____
COMMENTS
ANC QI tool is completed at each assessment through observation, interview or records review against each performance standard by N, Y or NA.
Comments are written especially where there is a N for No to help facility staff to understand actual performance gap followed by developing strategies to address the gaps.
In this case the performance standard is …. And one of the verification criteria is provider gives…. Followed by a Y if ….or N… or NA if the gestational age is before 20 weeks or had finished the 2 doses of SP.

45. Assessed Sections in the ANC QI
TOTAL
PERFORMANCE
STANDARDS
ACHIEVED %
1. FOCUSED ANTENTAL CARE 17 12 71
2. INFORMATION, EDUCATION AND COMUNICATION (IEC) 5 4 80
3. INFECTION PREVENTION 3 75
4. MANAGEMENT SYSTEM 7 57
5. HUMAN, PHARMACY AND LABORATORY RESOURCES 10 50 43 28
ANC QI is comprised of 5 sections. Sec 1 is actual client care while others are core support and supply processes to provide FANC services
Achieved standards are calculated against the total and converted into score in % for objective comparison by section, by facility or by type of assessment
The slide is a simulated situation where a facility score is 58% in baseline assessment
Type of assessment: Baseline= 58% Internal Assessment # : External Assessment #: Date:
% ACHIEVED = ACHIEVED STANDARDS / ASSESSED STANDARDS x 100
N.B. ALL STANDARDS HAVE TO BE ASSESSED THROUGH OBSERVATION, INTERVIEW OR RECORD REVIEW

46. Lessons Learned
Scale up = coverage + systems strengthening; FANC must be platform for integration of services
Training systems must be sustainable and should include both in-service and pre-service systems
Quality improvement processes should be built in but must be supported at the outset
Link with faith-based and private sectors
M&E paramount to guide understanding of program results and next steps

47. Conclusions MIP coverage improves through interventions that
Strengthen the service provision platform of ANC
Mobilize community acceptance
Coverage is remarkable in districts/provinces where technical support has been offered
Effective training with simple messages
A comprehensive approach leads to improved coverage and must be adapted to country needs

48. Thank you! Contacts: pgomez@jhpiego.net www.accesstohealth.org

49. Provoking thought
What is the role of community-based distribution in meeting the PMI goal of 85% coverage of IPTp2?
Should ITNs be given free to all pregnant women or should they have to pay a fee through social marketing?