This post is part of a blog series on Malaria in Pregnancy. To view the entire series, click here.
Take Away Messages from Day One, June 26th, 2012, at Malaria in Pregnancy: A Solvable Problem—Bringing the Maternal Health and Malaria Communities Together.
Day one at Malaria in Pregnancy: A Solvable Problem—Bringing the Maternal Health and Malaria Communities Together focused on understanding the scope of malaria in pregnancy with special attention to coverage of interventions and the state of antenatal care (ANC) as a platform for prevention in sub-Saharan Africa (SSA).
David Brandling-Bennett, Senior Advisor of Infectious Diseases at the Bill & Melinda Gates Foundation, and Ana Langer, Director of the Maternal Health Task Force, opened the meeting. Brandling-Bennett explained that ambitious goals have been made for malaria prevention, significant achievements have been made, but coverage of malaria interventions for pregnant women is a missed opportunity. He made the point that in order to overcome barriers, we must create stronger linkages between the maternal health and malaria communities.
Langer provided important context for the issue of malaria in pregnancy. She explained that while maternal deaths due to direct obstetric complications are on the decline, maternal mortality and morbidity due to indirect causes are on the rise. She also cited a recent study published in the Lancet that showed that more adults are dying of malaria complications than we previously thought. While there are no concrete numbers for malaria deaths among pregnant women, she said, we do know that pregnant women are a particularly vulnerable group.
Feiko ter Kuile, of Liverpool School of Tropical Medicine, provided an overview of malaria in pregnancy (MiP) in SSA. He also discussed issues of messaging around dosing—pointing out the need to harmonize messages with both the evidence-base and national and global policies. He explained that promoting 3-4 doses of SP might be a better option than the current standard of “at least 2.” Ter Kuile said that harmonizing the dosing with the number of recommended ANC visits might actually increase uptake of IPTp. He also discussed growing resistance to SP in certain areas and explained that whatever the new combination of drugs turns out to be, it will likely be much more complicated and expensive to deliver. For this reason, it is critical to strengthen the ANC platform now so that it is prepared to adopt these changes if and when they come.
Thom Eisele, of Tulane School of Public Health and Tropical Medicine, discussed recent research on the association between malaria prevention in pregnancy and risk of low birth weight (LBW) babies as well as neonatal mortality. Eisele explained that malaria prevention in pregnancy was associated with a significant reduction in odds of LBW and neonatal mortality in 1st and 2nd parities under routine program conditions across Africa—and that prevention efforts were also protective against LBW and neonatal mortality in 3rd or higher parities. The findings of the research, he said, support the continued effort to scale-up access of both IPTp and ITNs to pregnant women of all parities in areas of stable malaria transmission.
Annemieke van Eijk, of Liverpool School of Tropical Medicine, talked in more depth about coverage of MiP interventions in malaria-endemic African countries. She described slow increases in MiP coverage overall, and large discrepancies between countries. Van Eijk also made the point that external funding and assistance are important for coverage, but not the most important factors. She mentioned determination at multiple levels as a critical factor. She also stressed the importance of paying attention to countries with inequities in coverage—and called on implementers to remember that malaria is mainly found in rural areas and, for this reason, rural women should be the priority!
Jenny Hill, also of Liverpool School of Tropical Medicine, described a recent systematic review of the determinants of IPTp and ITN coverage among pregnant women in SSA. She explained that many of the barriers to the delivery of IPTp and ITNs reflect broader weaknesses in health systems. Hill said that a better understanding of malaria and IPTp are important and needed for both providers and pregnant women. She stressed the importance of paying attention to demand and supply side issues. Hill explained that while alternative distribution strategies exist for ITNs, free ITNs through ANC appear to be the most effective approach to distribution. She also discussed a need for decentralised data for decision-making and accountability at the national and sub-national levels. She concluded by explaining that the issue of malaria in pregnancy needs to have champions.
Ana Langer, of the MHTF, and Stephen Munjanja, of University of Zimbabwe, provided an overview of the coverage and quality of antenatal care in SSA, pointing out that ANC should be seen as an invaluable tool for the management of indirect causes of maternal mortality and morbidity—such as malaria. They explained that integration could simultaneously strengthen malaria programs as well as ANC efforts and ease some of the burden on healthcare workers. They reiterated Brandling-Bennett’s earlier point that crafting and maintaining strong partnerships between the malaria and MNCH communities will be key.
The final session of the day was a country level roundtable focused on learning from the experiences of Mozambique, Nigeria, and Zambia. Roundtable participants included Leonardo Chavane, of MCHIP in Mozambique, Chioma Amajoh, of the National Malaria Control Program in Nigeria, Abosede Adeniran, of the Ministry of Health of Nigeria, and David Hamer, of Boston University School of Public Health and the Zambia Center for Applied Health Research and Development. The roundtable participants each took five minutes to talk through some of the major issues relating to malaria in pregnancy in their contexts. Striking similarities arose from each of their presentations. Common themes included:
- Funding is not the most important issue—partnership and leadership (at all levels) are crucial!
- The ANC platform is swamped with interventions—and often times PMTCT seems to take over.
- Chronic shortages of human resources as well as supply chain management and commodities issues are major barriers to coverage with MiP prevention.
- The situation at the country level can be seen as a mirror of what is happening at the global level. Confusion at the global level about integration between maternal health and malaria is mirrored by confusion at the country level.
Day two discussions will focus on distilling what we know, overcoming barriers, maximizing impact of proven interventions, and exploring innovative approaches to preventing malaria in pregnancy.