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Malaria in Maternal Health

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Presentation on theme: "Malaria in Maternal Health"— Presentation transcript:

1 Malaria in Maternal Health
William R Brieger Senior Malaria Adviser, Jhpiego June 11, 2011 National Press Foundation

2 Malaria Risk Measured by Parasites (top) and Aridity/Humidity (bottom)

3 Maternal Mortality – Deaths per 1000 Live Births

4 Does this occur by chance?
Malaria Maternal Mortality

5 Malaria is an Important Contributor to Maternal Mortality in Endemic Countries

6 Malaria during pregnancy: bad news
Each year, more than 30 million women in Africa become pregnant in malaria-endemic areas. Malaria during pregnancy in sub-Saharan Africa is estimated to account for: 400,000 cases of severe anemia in pregnant women ~ 35% of preventable low birth weight ~ 5% of infant mortality 75, ,000 infant deaths annually

7 Why Is Malaria in Pregnancy (MIP) Important?
MIP effects on Women 2-15% of maternal anemia Possibly up to 10,000 maternal deaths annually Possible effects on pre-eclampsia Increased post-partum hemorrhage Each year, more than 30 million women in Africa become pregnant in malaria-endemic areas. In these areas, malaria accounts for significant morbidity in pregnant women. For example, it accounts for 2–15% of maternal anemia and 5–14% of low birth weight. Of those newborns born with “preventable” low birth weight, 30% are due to malaria. Malaria also accounts for between 3–5% of all newborn deaths. Source: WHO Afro 2004

8 Placental Malaria in African Women: the First Pregnancy Is Most Dangerous
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. Placental malaria deprives the fetus of nutrients

9 MIP effects on fetus/child
13-70% intrauterine growth retardation As high as 20% of low birth weight newborns 30% of “preventable” low birth weight newborns 8-36% of preterm births ~5% congenital malaria in newborns 3-5% of newborn deaths, 3-8% of infant deaths Miscarriage and stillbirth

10 Frequency of Low Birth Weight by Placental Malaria Infection
Low Birth Weight Predisposes to Other Causes of Neonatal and Infant Death 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

11 Characteristics of Malaria Transmission
Stable Areas Year-round transmission e.g. Nigeria People receive frequent infective mosquito bites each month Levels of acquired immunity are high (pregnant women are semi-immune to malaria) Low peripheral parasitemia Heavy placental infection Unstable Areas Seasonal or epidemic transmission 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.

12 Effect of MIP in Stable Transmission Areas
Acquired immunity – high 1st & 2nd pregnancies at greatest risk Prevention essential (as most women are not symptomatic) Plasmodium falciparum malaria Asymptomatic Infection Placental Sequestration Altered Placental Integrity Reduced Nutrient and Oxygen Transport 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.

13 Effect of MIP Unstable Transmission Areas
Acquired immunity – low All pregnancies affected equally Prompt diagnosis and treatment needed in addition to prevention Acquired Immunity – Low Clinical Illness Severe Disease Risk to Mother Risk to Fetus 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

14 Interventions to Control Malaria in Pregnancy
WHO’s 3-pronged approach

15 Three Main Control Tools
IPTp = Intermittent preventive treatment in pregnancy ITNs = Use of insecticide-treated nets, including long lasting insecticide treated nets (LLINS) Case management of malaria disease Diagnosis with Rapid Tests, Microscopy Appropriate antimalarial drug for treatment Indoor Residual Spraying not specific to MIP, but where offered should be mentioned in health education to women

16

17 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.

18 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. Note that chloroquine is no longer for case management or prophylaxis in Africa. SP is reserved for IPTp only, not for treatment in the general population.

19 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 When used for IPTp, SP also reduces the effects of malaria better than case management alone. This is important since not all women with malaria parasites have symptoms and therefore would not receive treatment if case management was implemented without IPTp. An important study from Kenya presents evidence supporting the use of IPTp with SP. In the study three groups of pregnant women were analyzed: 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 and placental parasitemia compared to women seen with malaria illness. 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. Compared with case management, studies have also shown both IPTp and case management to be equally effective in improving hemoglobin levels.

20 Fetal Growth Velocity Fetal growth velocity  Weeks of gestation 10 16
Last month We give SP as IPTp at a particular time during pregnancy. The dotted line in this slide represents fetal growth velocity during pregnancy. Fetal growth velocity is relatively slow in the first half of pregnancy but increases rapidly in the second half of pregnancy. Because the presence of parasites in the placenta interferes with the transfer of nutrients to the fetus, it is important to ensure that the fetus’s placenta is free of malaria parasites when fetal growth velocity is fastest. 10 16 20 30 Weeks of gestation Birth Conception Source: WHO 2002.

21 Fetal Growth Velocity: Quickening
Last month Quickening Quickening refers to the time a mother feels the first movement of the fetus. It varies among women, with some women experiencing quickening as early as 16 weeks while others may not do so until 20 weeks gestation. 10 16 20 30 Weeks of gestation Birth Conception Source: WHO 2002.

22 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.

23 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 More on this later 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.

24 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 When providing IPTp with SP it is important to determine that quickening has occurred . Inquire about any history of allergy to sulfonamides, including severe skin rash. Also inquire about the use of SP or any sulfonamides in the past month. When administering 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.

25 Steps for Providing IPTp with SP (continued)
Record SP on the antenatal card and the clinic record Instruct clients 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 Inform clients that IPTp is most effective if they receive at least two doses Ask about side effects from previous dose before giving the next dose, which should not be less than 4 weeks from the last dose Monitoring and evaluation is important. Therefore record that “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.

26 SP Resistance and IPTp Waning efficacy of SP in treating symptomatic children <5 years does not equate with waning efficacy for prevention of malaria during pregnancy IPTp with SP remains efficacious even in settings with significant (<50%) treatment failure in symptomatic children 6-59 months of age More than 2 doses are likely beneficial given rising resistance

27 IPTp – Monthly Dosing Fetal growth velocity  Weeks of gestation SP SP
SP resistance shortens duration post-treatment prophylaxis 10 20 30 Conception Birth Weeks of gestation Source: CDC Scott Filler October 2007

28 Malawi Randomized Controlled Trial of IPTp:
Does monthly IPTp provide additional benefit over 2-dose IPTp? In preventing placental malaria For HIV-positive/negative women Is SP efficacious for IPTp despite 31% SP failure rate for treatment in young children?* For HIV-positive pregnant women, monthly SP IPTp more efficacious than 2-dose SP IPTp in reducing placental malaria For HIV-negative pregnant women, monthly SP IPTp may have benefit over 2-dose SP IPTp Despite treatment failures in children, SP remains efficacious for IPTp *Malawi Ministry of Health and Population Report, 2004

29 Appropriate case management
Parasitological diagnosis Treatment with appropriate medicines Counseling to ensure adherence

30 Case Management: Drug Efficacy
Malaria episodes in pregnancy are serious and must be treated promptly with an appropriate drug Effective drugs are needed for P. falciparum malaria as it can be fatal to both mother and child Remember differences between stable and unstable transmission areas Note importance of diagnosis The final component of the strategic framework for malaria control during pregnancy is case management. Effective drugs are needed for Plasmodium falciparum malaria because the disease can be fatal to both the mother and the newborn. The drug of choice for case management would depend on the profile of drug resistance in the country. For example, antimalarial drugs that would be considered appropriate for Uganda may be inappropriate for Tanzania. Chloroquine has been the drug of choice for many years and it will probably remain the drug of choice in some areas where it is still effective. But, because of the high incidence of chloroquine resistance in Africa, SP has become the alternative antimalarial drug of choice for treating uncomplicated malaria. Quinine given intramuscularly or intravenously is the drug of choice for the case management of complicated malaria.

31 Importance of diagnosis
Laboratory/slide diagnosis is still the gold standard Few front line clinics have labs and/or trained staff Rapid diagnostic tests are becoming more available Can reduce treatment costs only treat ‘real’ malaria cases Storage issues in terms of temperature, expirey dates

32 RDTs make diagnosis possible and save lives

33 Drug Choice Drug of choice depends on the geographic drug resistance profile and national malaria drug policies Quinine is the drug of choice for malaria in first trimester pg pregnancy SP is reserved for IPTp Artemisinin-based combination therapy (ACT) drugs can be used after the first trimester The drug of choice for case management would depend on the profile of drug resistance in the country. For example, antimalarial drugs that would be considered appropriate for Uganda may be inappropriate for Tanzania. Chloroquine has been the drug of choice for many years, but is declining in use because of the high incidence of chloroquine resistance in Africa, Quinine is the drug of choice in the first trimester or for the case management of severe malaria. As much as possible, SP is being reserved for IPTp, so it is not being used for case management in most countries. In many parts of Africa and worldwide, plasmodium falciparum malaria has become resistant to single-drug therapy. WHO therefore recommends that countries use a combination of drugs to fight malaria. A major advantage of combination therapy is that drug resistance is far less likely than with single-drug treatments. The simultaneous use of drugs that include a derivative of artemisinin, along with another antimalarial drug is called artemisinin-based combination therapy (ACT). This combination is currently the most effective treatment for malaria.

34 All Kinds of Malaria Drugs Are on the Market
… but not all are safe or appropriate

35 Resistance to Drugs Resistance of P. falciparum to antimalarial drugs is an ever increasing problem To minimize the problem of drug resistance, encourage women to complete their course of antimalarial drugs, even when they feel better Drug resistance is inevitable; therefore healthcare providers must stay informed about policy changes recommended by their Ministry of Health Resistance to drugs is an ever increasing problem and can occur very rapidly in as few as five years. To minimize this problem, women need to be encouraged to complete their medications as prescribed. For example, when women feel better on the second day after treatment with ACTs, they often tend to stop medication. This type of poor compliance encourages drug resistance. Service providers should educate clients about the importance of medication adherence whenever providing medications to clients to be taken outside the health facility. In any case, because drug resistance is virtually inevitable, healthcare providers must stay informed about the changing policy of malaria drug therapy in their countries.

36 Drugs Not To Be Used During Pregnancy
Tetracycline Cause abnormalities of skeletal and muscular growth, tooth development, lens/cornea Doxycycline Risk of cosmetic staining of primary teeth is undetermined Excreted into breast milk Primaquine Harmful to newborns who are relatively Glucose-6-Phosphatase-Dehydrogenase (G6PD) deficient Halofantrine No conclusive studies in pregnant women Has been shown to cause unwanted effects, including death of the fetus, in animals Some drugs should not be used during pregnancy. These include tetracycline, doxycycline, primaquine and halofantrine. Tetracycline can cause abnormalities of skeletal and muscular growth and damage the teeth of the newborns. While there are no controlled studies of doxycycline use in pregnant women to show safety, an expert review of published data on experiences with doxycycline use during pregnancy concluded that the available data are insufficient to state that there is no risk. The risk of cosmetic staining of the primary teeth by doxycycline is also undetermined (quantity and quality of data has been very limited). Doxycycline is excreted into breast milk. Short-term use by lactating women is not necessarily contraindicated; however, the effects of prolonged exposure to doxycycline in breast milk are unknown. Halofantrine has not been adequately studied in pregnant women. However, it has been found to cause unwanted effects in animals, including death of the fetus. Primaquine, on the other hand, can cause jaundice in newborns who are relatively deficient in Glucose-6-Phosphate-Dehydrogenase enzyme. The safety of other newer antimalarials such as mefloquine, artemisinin derivatives, malarone and co-artemether during pregnancy are still subjects of research. 

37 Insecticide Treated Nets
Start net use as early in pregnancy as possible Our third section continues with discussion of MIP interventions. Pregnant women must be included in plans to provide insecticide treated nets in the community. Planning is also needed to ensure there is adequate medicine available to treat pregnant women who develop malaria disease.

38 Insecticide-Treated Nets (ITNs)
An ITN is a mosquito preventing bednet (or other netting material such as curtains) that has been soaked in a safe insecticide The insecticide kills the mosquito when it comes near the sleeping person Traditional ITNs required re-treatment with insecticide every six months While ITNs are still available in many countries, most are switching to long lasting insecticide-treated nets (LLINs) where the insecticide is applied at the factory LLINs can withstand washing up to 20 times and may last over 4 years The third component of the strategic framework for malaria control during pregnancy is the use of insecticide-treated nets (ITNs) to protect mothers and their newborns. An ITN is a netted material that has been soaked in a safe insecticide. The most common use is in the form of a bednet, though the material can be used to protect windows and doors also. ITNs work through the insecticide that kills (or repels) the mosquito when it comes in contact with the net or near the sleeping person. Traditional ITNs require re-treatment with insecticide about every 6 months and are still available in many countries. However, most countries are switching to long lasting insecticide treated nets (LLINs). These factory-treated nets can withstand washing up to 20 times and may last 4 years or more.

39 Use ITNs/LLINs The use of ITNs/LLINs have been shown to result in reduction of newborns born with low birth weight or prematurely 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.

40 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. 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,

41 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 Source: ter Kuile et al 1999 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.

42 ITN: Impact on Fetal Growth and Duration of Gestation
% Premature LBW Premature or LBW 45 40 35 30 control Percentage 25 bednets 20 15 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. 10 5 G<3 G>4 G<3 G>4 G<3 G>4 Gravidity Source: ter Kuile et al 1999; LBW = Low Birth Weight

43 Impact of ITNs on Maternal and Newborn Health
Among Gravidae 1-4, ITNs were associated during pregnancy with: 38% reduction in peripheral parasitemia 21% reduction in all causes of anemia (Hb < 11 g/dl) 47% reduction in severe malarial anemia Among women in their first to fourth pregnancies, the use of insecticide-treated nets reduced the incidence of peripheral parasitemia by 38% and reduced the incidence of severe anemia by 47%. The use of insecticide-treated nets was also associated with a 23% reduction in placental malaria, 28% reduction in incidence of low birth weight newborns and a 25% reduction in any adverse birth outcome. There is, however, no evidence to suggest that the efficacy of insecticide-treated nets decreases with increasing levels of malaria transmission in the area. Source: Shulman 2001: Western Kenya

44 Impact of ITNs at Delivery
23% reduction in placental malaria 28% reduction in LBW 25% reduction in any adverse birth outcome No trend towards decreasing efficacy with increasing transmission rate

45 ITN/LLIN Procurement and Management
It is quite popular these days to provide ITNs within childhood immunization campaigns It is less common to find that ITNs have been allocated in adequate numbers to be given out as an essential component of focused ANC The district health management team needs to meet and plan for adequate nets, not only for children under five years of age, but also ensure that adequate nets are supplied to ANC clinics 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 While providing ITNs at childhood immunization campaigns have become popular, nets are not yet part of routine maternal and child health care, especially the provision of adequate ITNs as an essential component of focused ANC. District health management teams and/or other local authorities need to incorporate adequate planning and resource allocation to meet the urgent need for ITNs in both under-fives and pregnant women. Regular provision of an ITN/LLIN can be an important incentive for pregnant women to attend ANC. To get the maximum protection during pregnancy, an ITN should be offered to a woman on her first ANC visit.

46 Challenges Correct use and adequate coverage

47 Examples of MIP Data/Indicators (from surveys 2006-08)
80% was RBM target for 2010

48 Most women attend ANC in Africa, but they may not make two visits that support IPT compliance
Recall our earlier slide showing ANC attendance. Also remember that IPTp must be given at least twice after quickening with doses at least one month apart. This graph shows that although overall registration for ANC is good, not all women come back for a second visit, and if they do the timing may not be compatible with receiving IPTp twice as recommended. *E Eckert, A Hyslop, R Snow, MEASURE Evaluation, Macro International, APHA 2005

49 Senegal – who slept under a net?
RBM 2010 Target is 80% Senegal Malaria Indicator Survey

50 Can We Prevent Net Misuse?

51 An integrated approach to MIP Control
Improved Health Systems Focused Antenatal Care Attention to HIV/AIDS Community Involvement

52 Malaria in Pregnancy Systems Readiness
Component Indicators Policy Policy, strategy and service delivery guidelines developed and being used at all levels of the health system Commodities Drug procurement and distribution systems efficient; WHO-recommended medicines for malaria and/ or MIP are always available; ITNs always available Quality Assurance MIP quality assurance standards have been developed and are used in systematically; supportive supervision for MIP services utilized systematically In addition to country activities, readiness for implementing malaria in pregnancy strategies require that health and related system components are in place and working effectively. Examples of indicators include that policy, strategy and service delivery guidelines are developed and being used at all levels of the health system; Drug procurement and distribution systems efficient; WHO-recommended medicines for malaria and/ or MIP are always available; ITNs or LLINs are always available; MIP quality assurance standards have been developed and are used systemically and supportive supervision for MIP services are utilized systematically.

53 Malaria in Pregnancy Systems Readiness
Component Indicators Training In-service training on MIP conducted for all appropriate cadres of health service providers; updated pre-service nursing, midwifery and medical MIP curricula is being taught at all academic institutions Integration Joint strategies, planning and sharing of information between National Malaria Control Programs at national level; district level promotes integration of RH, HIV/AIDS and MIP in administration and supportive supervision; MIP, reproductive health and/or HIV/AIDS are provided together in health services Training indicators include: in service training on MIP conducted for all appropriate cadres of health service providers; updated pre-service nursing, midwifery and medical MIP curricula is being taught at all academic institutions; both in-service and pre-service curricula and faculty are updated as policies and protocols are updated Integration of MIP with related reproductive health systems and programs is crucial. Joint strategies, planning and sharing of information between National Malaria Control Programs at national level; district level promotes integration of RH, HIV/AIDS and MIP in administration and supportive supervision; MIP and reproductive health and/or HIV/AIDS are provided together in health services are main indicators for this component.

54 Malaria in Pregnancy Systems Readiness
Component Indicators Community-based MIP Programs Community action groups are strong partners in national MIP prevention efforts; appropriate resources widely available M&E HMIS systems strong; MIP indicators being collected regularly; some endline studies designed to capture achievements and / or impact studies being conducted Financing National government has committed and disbursed funds to MIP programs which significantly contribute to projected costs; ample donor funding exists Community action groups are strong partners in national and district-level MIP prevention efforts; appropriate resources widely available. M&E strategies should be developed during the planning phase of MIP programs. Indicators include: HMIS systems strong; MIP indicators being collected regularly; some endline studies designed to capture achievements and / or impact studies being conducted. Financing indicators relate to the availability, allocation and disbursement of resources and include: National government has committed and disbursed funds to MIP programs which significantly contribute to projected costs and ample donor funding exists.

55 Antenatal Care as a Platform for MIP Control
Antenatal visits provide a unique opportunity for: Monitoring of maternal and fetal health during pregnancy immunizations Provision of micronutrients (e.g., iron folate) Health education about malaria during pregnancy IPTp with sulfadoxine-pyrimethamine (SP) ITN distribution Prompt diagnosis and treatment of malaria Prevent mother-to-child transmission of HIV District health teams must promote timely ANC attendance if MIP interventions are to reach the maximum number of pregnant women For any program on malaria control during pregnancy to be successful, there must be a partnership between the providers of maternity services and malaria control staff. Antenatal clinic visits provide a unique opportunity to educate women about the effects of malaria on pregnancy and about what can be done to eliminate or minimize its adverse consequences. These interventions will include monitoring of maternal and fetal health, provision of micronutrient supplementation to reduce the risk of anaemia, education on the benefits of using insecticide-treated nets, application of intermittent preventive treatment and case management of malaria illness.

56 Focused Antenatal Care (FANC)
Early detection and treatment of problems and complications Prevention of complications and disease Birth preparedness and complication readiness Health promotion First visit: Within 16 weeks or when woman first thinks she is pregnant Second visit: At weeks or at least once in second trimester Third visit: At weeks Fourth visit: At 36 weeks or later

57 Summary of Malaria Activities at FANC
1st Visit 2nd Visit 3rd Visit 4th Visit IPTp Yes (if after 16 weeks) (if one month after 1st) (if one month after 2st) Additional if not all IPTp received ITN Provide Counsel on use Treatment As needed after test

58 Bad Combination: Placental Parasitemia and HIV
Placental Parasitemia by HIV Status and Pregnancy Number, Kenya, Parasite density/mm3 % parasitemic 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. 231 159 197 772 402 479 HIV (+) HIV (-) Summary RR = 1.63 ( ), p <0.001 Total n = 2263 Source: van Eijk AM et al 2001.

59 Nigeria MIP Community-Clinic Partnership for Community Directed Intervention
Training, Supervision, Mobilization, Commodities COMMUNITY MIP skills and responsibilities implemented through community-directed intervention CLINIC MIP performance standards developed and implemented Referrals, Records, Feedback

60 Community Directed Intervention Program Impact: Improved IPTp Uptake

61 ITN Use by Pregnant Women through Community Directed Intervention

62 The Good News: Save the Children Documents Progress in Maternal Survival

63 Summary Malaria during pregnancy has adverse consequences for mothers and their babies Malaria preventive package includes: Intermittent preventive treatment during pregnancy with SP during antenatal clinic visits Use of ITNs/LLINs throughout pregnancy and in the postpartum period Prevention must be complemented by effective case management of malaria illness for all women of reproductive age Health Systems issues must be addressed from national to facility level to ensure full delivery of MIP services In summary, malaria during pregnancy has been shown to have adverse consequences for both mothers and their babies. However, a malaria prevention package has also been shown to minimize these adverse events. An effective preventive package includes intermittent preventive treatment with a dose of SP given at each antenatal care visit after quickening (but no less than 4 weeks apart) to ensure that the pregnant woman receives at least two doses. The package also includes the use of insecticide-treated nets throughout pregnancy and during the postnatal period. Preventive efforts must be complemented by case management of malaria illness with effective antimalarial medication for all women of reproductive age and should emphasize screening and prompt treatment of anemia. Successful programs can only emerge from partnerships between malaria control and reproductive health units. For more information about malaria during pregnancy, including job aids, visit the Resources section of this tutorial.

64 Contact Information William Brieger    Senior Malaria Specialist, JHPIEGO -      Professor, Health Systems Program, Department of International Health, The Johns Hopkins Bloomberg School of Public Health       malaria updates at: http://twitter.com/bbbrieger


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