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The Time Has Come to Maximize the Public Health Impact of Intermittent Preventive Treatment of Malaria in Pregnancy in Sub-Saharan Africa

By: Matthew Chico, Lecturer, London School of Hygiene and Tropical Medicine

women sierra leone community meeting malaria in pregnancy

Women gathering in a community meeting in Freetown, Sierra Leone. Photo: Martine Perret/UN

In sub-Saharan Africa, 10,000 women and 200,000 children under the age of one die each year as a consequence of malaria infection during pregnancy [1, 2]. On this year’s World Malaria Day, the global public health community is coming together to highlight the important and lifesaving role of intermittent preventive treatment in pregnancy (IPTp). IPTp using sulfadoxine-pyrimethamine (SP) is a highly cost-effective intervention with the potential to reduce maternal morbidity and neonatal mortality [3]. Meta-analyses of women in their first and second pregnancies have shown that IPTp reduces the incidence of low birth weight (LBW) by 27%, severe maternal anaemia by 40% [4], and neonatal mortality by 38% [5]. For this reason, the World Health Organisation (WHO) recommends IPTp as a key strategy in its three pronged approach for protecting the close to 50 million pregnancies which occur every year in areas of stable malaria transmission. In addition, WHO recommends the use of insecticide treated bed-nets, and effective case management [5, 6].

Despite being a straightforward intervention that can be delivered to pregnant women under direct observation during routine antenatal care (ANC) visits, IPTp has the lowest coverage among all interventions delivered to pregnant women through the ANC platform, including the provision of long-lasting insecticide-treated nets [7]. The discrepancy between high ANC attendance (75% of women in sub-Saharan Africa attend at least twice) and low IPTp coverage points to substantial missed opportunities at ANC facilities [8, 9]. In 2013, the average coverage of at least two doses of IPTp among pregnant women in sub-Saharan African countries was 24%, well below national and international targets, and only marginally higher than a decade ago when coverage was 14% [9]. Only six countries in sub-Saharan Africa have reached the 60% coverage target for 2005 set by the Roll Back Malaria Partnership (RBM) and not one country has reached the 2010 RBM target of 80% coverage [10, 11]. The WHO estimates that 15 million of the 35 million pregnant women in sub-Saharan Africa malaria endemic countries did not receive a single dose of IPTp in 2013 [12].

What can be done to close this gap?

The recent RBM report on the contribution of malaria control to maternal and newborn health highlighted key programme areas for improvement that will support the scale-up of MiP interventions [13]. The report states that many barriers to IPTp uptake are common across countries and can be overcome with relative ease and speed [13]. These obstacles include a lack of integration and coordination between national reproductive health and malaria control programmes. Healthy coordination across health services is central to preventing MiP given that interventions are delivered through ANC clinics with management from staff in reproductive health and technical oversight from counterparts in malaria control. Other obstacles include: inconsistent, unclear and poorly disseminated information on IPTp policy; confusion among healthcare providers as to when and how to administer IPTp; SP stock-outs at ANC clinics [14], and general barriers to accessing ANC services that have been well-documented [15]. Additional obstacles relate to broader health systems issues and necessitate strengthening the health system overall and ANC services specifically.

What can you do?

As a member of the international public health community, it is important to know what can be done in order to improve access to IPTp. The Global Call to Action provides information on how stakeholders can support global and national strategies to save mothers’ and newborns’ lives from the scourge of malaria.

The Global Call to Action calls upon donors to increase their financial support to health system strengthening generally, and the ANC platform more specifically, support operational research on the quality of delivery of IPTp, promote the inclusion of IPTp and other MiP control strategies in grant proposals, and facilitate private sector engagement for improved outcomes.

The research community can improve the dissemination and translation of research and lessons learned within malaria endemic countries and internationally, validate practical tools for scaling up IPTp, evaluate and promote successful health education campaigns and strategies, conduct research on alternative delivery strategies for IPTp but also on innovative alternatives and work closely with local governments and the WHO to establish monitoring and evaluation plans and support in country ownerships of research.

Civil society also has an important role to play in the reduction of MiP, communicating the importance of IPTp to individuals at risk of malaria and, importantly, can hold governments accountable for the quality delivery of IPTp to pregnant women.

For a full list of recommendations of actions to stakeholders, please visit the RBM website.

“It has been 15 years since the Abuja Declaration called for the scale up of preventive treatment for malaria in pregnancy – and the need is every bit as real today. The time has come!” says Matthew Chico, Lecturer in the Department of Disease Control at the London School of Hygiene & Tropical Medicine. “We have the tools that can save the lives of so many women and newborns; we need to focus our attention and resources to improve access, quality and uptake. If support is broad and spans local to global levels, we can achieve historic impact that touches so many lives.”

Click here to listen to an interview with Matthew Chico talking about MiP on Africa Digest

To find out more about how LSHTM is working on malaria in pregnancy, please visit the London School’s websites for the Maternal, Adolescent, Reproductive, and Child Health Centre (MARCH) and the Malaria Centre.

Chico_Matthew6-cropped-2-1-150x150Matthew Chico, Lecturer, Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine

This post originally appeared on the blog of the IDEAS project and has been republished with permission.

References

  1. Steketee, R.W., et al., The burden of malaria in pregnancy in malaria-endemic areas. Am J Trop Med Hyg, 2001. 64(1-2 Suppl): p. 28-35.
  2. Murphy, S.C. and J.G. Breman, Gaps in the childhood malaria burden in Africa: cerebral malaria, neurological sequelae, anemia, respiratory distress, hypoglycemia, and complications of pregnancy. Am J Trop Med Hyg, 2001. 64(1-2 Suppl): p. 57-67.
  3. Sicuri, E., et al., Cost-effectiveness of intermittent preventive treatment of malaria in pregnancy in southern Mozambique. PLoS One, 2010. 5(10): p. e13407.
  4. Radeva-Petrova, D., et al., Drugs for preventing malaria in pregnant women in endemic areas: any drug regimen versus placebo or no treatment. Cochrane Database Syst Rev, 2014.10: p. Cd000169.
  5. Dellicour, S., et al., Quantifying the number of pregnancies at risk of malaria in 2007: a demographic study. PLoS Med, 2010. 7(1): p. e1000221.
  6. World Health Organization, A strategic framework for malaria prevention and control during pregnancy in the Africa region., W.R.O.f. Africa, Editor. 2004, WHO Regional Office for Africa: Brazzaville.
  7. World Health Organization and UNICEF, Building a Future for Women and Children: The 2012 Report, in Countdown to 2015: Maternal, Newborn and Child Survival, WHO, Editor. 2012: Geneva.
  8. Hill, J. and P. Kazembe, Reaching the Abuja target for intermittent preventive treatment of malaria in pregnancy in African women: a review of progress and operational challenges. Trop Med Int Health, 2006. 11(4): p. 409-18.
  9. van Eijk, A.M., et al., Coverage of intermittent preventive treatment and insecticide-treated nets for the control of malaria during pregnancy in sub-Saharan Africa: a synthesis and meta-analysis of national survey data, 2009-11. Lancet Infect Dis, 2013. 13(12): p. 1029-42.
  10. Roll Back Malaria Partnership. The Global Malaria Action Plan. 2008; Available from:http://www.rbm.who.int/gmap/gmap.pdf
  11. Roll Back Malaria Partnership. Refined/updated global malaria action plan objectives, targets, milestones and priorities beyond 2011. 2011; Available from:http://wwwrbmwhoint/gmap/gmap2011updatepdf
  12. World Health Organization, World malaria report 2014, WHO, Editor. 2014: Geneva.
  13. Roll Back Malaria Partnership, The contribution of malaria control to maternal and newborn health, in Progress and Impact series, WHO, Editor. 2014, RBM: Geneva.
  14. Hill, J., et al., Factors affecting the delivery, access, and use of interventions to prevent malaria in pregnancy in sub-Saharan Africa: a systematic review and meta-analysis. PLoS Med, 2013. 10(7): p. e1001488.
  15. Simkhada, B., et al., Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. J Adv Nurs, 2008. 61(3): p. 244-60.

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