Prevention and Control of Malaria during Pregnancy

1
Prevention and Control of Malaria during Pregnancy

• A Workshop for Healthcare Providers

2
Facts about Malaria

• 300 million cases each year worldwide
• 9 of 10 cases occur in Africa
• A person in Africa dies of malaria every 10
  seconds
• Women and young children are most at risk
• Affects five times as many people as AIDS,
  leprosy, measles, and tuberculosis combined

3
Facts about Malaria and Pregnancy

• 30 million African women are pregnant yearly
• Malaria is more frequent and complicated during
  pregnancy
• In malaria-endemic areas, malaria during
  pregnancy may account for
• Up to 15 of maternal anemia
• 514 of low birthweight
• 30 of preventable low birthweight

4
Roll Back Malaria

• Worldwide partnership
• Governments, private groups, research
  organizations, civil society, media
• Aim to reduce malaria by half by 2010
• Free advocacy resources and tools
  http//www.rbm.who.int
• Priority Prevent poor outcomes caused by malaria
  in pregnancy
• Abuja declaration Goal is for 60 of women in
  Africa to be sleeping under insecticide-treated
  nets (ITNs) and getting intermittent preventive
  treatment (IPT) by 2005

5
Malaria Prevention and Treatment during Pregnancy

• Focused antenatal care (ANC) with health
  education about malaria
• Use of insecticide-treated nets (ITNs)
• Intermittent preventive treatment (IPT)
• Case management of women with symptoms and signs
  of malaria

6
Prevention and Control of Malaria during Pregnancy

• Chapter I Focused Antenatal Care

7
Focused Antenatal Care Chapter Objectives

• Describe four main components of focused
  antenatal care (ANC)
• Discuss frequency and timing of ANC visits
• Describe essential elements of a birth plan that
  includes complication readiness
• Describe interpersonal skills for effective ANC
• Describe components of record keeping for ANC

8
Focused Antenatal Care

• An approach to ANC that emphasizes
• Evidence-based, goal-directed actions
• Individualized, woman-centered care
• Quality vs. quantity of visits
• Care by skilled providers

9
Goal of Focused Antenatal Care

• To promote maternal and newborn health and
  survival through
• Early detection and treatment of problems and
  complications
• Prevention of complications and disease
• Birth preparedness and complication readiness
• Health promotion

10
Traditional Antenatal Care

• Emphasizes
• Ritualistic, routine care vs. evidence-based,
  goal-directed actions
• Frequent visits
• Does not emphasize individual client needs

11
No Longer Recommended

• Numerous, routine visits
• Burden to women and healthcare system
• Routine measurements and examinations
• Maternal height and weight
• Ankle edema
• Fetal position before 36 weeks
• Care based on risk assessment

12
Risk Approach

• Not an effective ANC strategy because
• Complications cannot be predictedall pregnant
  women are at risk for developing complications
• Risk factors are usually not direct cause of
  complications
• Many low risk women develop complications
• Have false sense of security
• Do not know how to recognize/respond to problems
• Most high risk women give birth without
  complications
• Inefficient use of scarce resources

13
Focused Antenatal Care Services

• Evidence-based, goal-directed actions
• Address most prevalent health issues affecting
  women and newborns
• Adjusted for specific populations/regions
• Appropriate to gestational age
• Based on firm rationale

14
Focused Antenatal Care Services (contd.)

• Individualized, woman-centered care based on each
  womans
• Specific needs and concerns
• Circumstances
• History, physical examination, testing
• Available resources

15
Focused Antenatal Care Services (contd.)

• Quality vs. quantity of ANC visits
• WHO multi-center study
• Number of visits reduced without affecting
  outcome for mother or baby
• Recommendations
• Content and quality vs. number of visits
• Goal-oriented care
• Minimum of four visits

16
Scheduling and Timing of ANC Visits

• First visit By 16 weeks or when woman first
  thinks she is pregnant
• Second visit At 2428 weeks or at least once in
  second trimester
• Third visit At 32 weeks
• Fourth visit At 36 weeks
• Other visits If complication occurs, followup or
  referral is needed, woman wants to see provider,
  or provider changes frequency based on findings
  (history, exam, testing) or local policy

17
Focused Antenatal Care Services (contd.)

• Care by a skilled provider who
• Has formal training and experience
• Has knowledge, skills, and qualifications to
  deliver safe, effective maternal and newborn
  healthcare
• Practices in home, hospital, health center
• May be a midwife, nurse, doctor, clinical
  officer, etc.

18
Early Detection and Treatment

• Malariahistory and physical exam
• Fever and accompanying signs/symptoms
• Region
• Complicated vs. uncomplicated cases
• Severe anemiaphysical exam, testing
• Pre-eclampsia/eclampsiameasurement of blood
  pressure
• HIVvoluntary counseling and testing
• Sexually transmitted infections, including
  syphilis testing

19
Prevention Key Preventive Measures

• Malaria
• Intermittent preventive treatment (IPT)
• Use of insecticide-treated nets (ITNs)
• Tetanus toxoid, iron/folate supplements
• Country/region-specific interventions as
  appropriate
• Vitamin A supplements
• Iodine supplements
• Presumptive treatment for hookworm

20
Birth Preparedness and Complication Readiness
Objectives

• Develop birth planexact plan for normal birth
  and possible complications
• Arrangements made in advance by woman and family
  (with help of skilled provider)
• Usually not a written document
• Reviewed/revised at every visit
• Minimize disorganization at time of birth or in
  an emergency
• Ensure timely and appropriate care

21
Essential Elements of a Birth Plan

• Facility or Place of Birth Home or health
  facility for birth, appropriate facility for
  emergencies
• Skilled Provider To attend birth
• Provider/Facility Contact Information
• Transportation Reliable, accessible, especially
  for odd hours
• Funds Personal savings, emergency funds
• Decision-Making Who will make decisions,
  especially in an emergency

22
Essential Elements of a Birth Plan (contd.)

• Family and Community Support Care for family in
  womans absence and birth companion during labor
• Blood Donor In case of emergency
• Needed Items For clean and safe birth and for
  newborn care
• Danger Signs/Signs of Advanced Labor

23
Danger Signs of Pregnancy

• Vaginal bleeding
• Difficulty breathing
• Fever
• Severe abdominal pain
• Severe headache/blurred vision
• Convulsions/loss of consciousness
• Labor pains before 37 weeks

24
Health Education Objectives

• Inform and educate the woman with health messages
  and counseling appropriate to
• Individual needs, concerns, circumstances
• Gestational age
• Most prevalent health issues
• Support the woman in making decisions and solving
  actual or anticipated problems
• Involve partner and family in supporting/adopting
  healthy practices

25
Health Education Topics Addressed

• Prevention of malaria
• Intermittent preventive treatment (IPT)
• Use of insecticide-treated nets (ITNs)
• Other methods
• Other important issues to be discussed include
• Nutrition
• Care for common discomforts
• Use of potentially harmful substances
• Hygiene
• Rest and activity

26
Health Education Topics Addressed (contd.)

• Sexual relations and safer sex
• Early and exclusive breastfeeding
• Prevention of tetanus and anemia
• Voluntary counseling and testing for HIV
• Prevention of other endemic diseases/deficiencies

27
Interpersonal Skills

• Speak in a quiet, gentle tone of voice
• Listen to woman/family and respond appropriately
• Encourage them to ask questions and express
  concerns
• Allow them to demonstrate understanding of
  information provided
• Explain all procedures/actions and obtain
  permission before proceeding
• Show respect for cultural beliefs and social
  norms
• Be empathetic and nonjudgmental
• Avoid distractions while conducting the visit

28
Record Keeping
Record all information on the ANC chart and
clinic card

• First ANC Visit
• History
• Physical examination
• Testing
• Care provision, including provision of IPT for
  malaria, if appropriate
• Counseling, including birth plan and use of ITNs
• Date of next ANC visit

• Subsequent ANC Visits
• Interim history
• Targeted physical examination, testing
• Care provision, including provision of IPT for
  malaria, if appropriate
• Counseling, including birth plan and use of ITNs
  (and relevant information on how client obtained
  and used ITN)
• Date of next ANC visit

29
Prevention and Control of Malaria during Pregnancy

• Chapter II Malaria Transmission

30
Malaria Transmission Chapter Objectives

• Define malaria and how it is transmitted
• Describe extent of malaria in Africa
• Identify groups at highest risk of malaria
  infection
• List effects of malaria on pregnant women and
  their unborn babies
• Describe effects of malaria on pregnant women
  with HIV/AIDS

31
Malaria Transmission

• Caused by Plasmodium parasites
• Spread by female Anopheles mosquitoes infected
  with parasites
• Anopheles mosquitoes usually active at night
• Infected mosquito bites a person
• Malaria parasites reproduce in human blood
• Mosquito bites infected person, and goes on to
  bite and infect another person

32
Populations Most Affected by Malaria

• Children under 5 years of age
• Pregnant women
• Unborn babies
• Immigrants from low-transmission areas
• HIV-infected persons

33
Effects of Malaria on Pregnant Women

• All pregnant women in malaria-endemic areas are
  at risk
• Parasites attack and destroy red blood cells
• Malaria causes up to 15 of anemia in pregnancy
• Can cause severe anemia
• In Africa, anemia due to malaria causes up to
  10,000 maternal deaths per year

34
Effects on Unborn Babies

• Parasites hide in placenta
• Interferes with transfer of oxygen and nutrients
  to the baby, increasing risk of
• Spontaneous abortion
• Preterm birth
• Low birthweightsingle greatest risk factor for
  death during first month of life
• Stillbirth

35
Effects on Communities

• Causes missed work and wages
• Results in frequent school absences
• Uses scarce resources
• Causes preventable deaths increases maternal,
  newborn, and infant mortality rates

36
HIV/AIDS and Malaria during Pregnancy

• HIV/AIDS reduces a womans resistance to malaria
• Intermittent preventive treatment (IPT) given 3
  times during pregnancy is effective for women
  with HIV/AIDS

37
Summary of Health Education Points

• Malaria transmitted through mosquito bites
• Pregnant women and children are most at risk
• Pregnant women infected with malaria may have no
  symptoms
• Women with HIV/AIDS are at higher risk
• Malaria can lead to severe anemia, spontaneous
  abortion, low-birthweight babies
• Malaria is preventable

38
Prevention and Control of Malaria during Pregnancy

• Chapter III Preventing Malaria

39
Preventing Malaria Chapter Objectives

• List the elements of counseling women about the
  use of insecticide-treated nets (ITNs) and
  intermittent preventive treatment (IPT) during
  pregnancy
• Describe the use of sulfadoxine-pyrimethamine
  (SP) for IPT during pregnancy

40
Insecticide-Treated Nets

• Kill or repel mosquitoes
• Prevent physical contact with mosquitoes
• Kill or repel other insects
• Lice
• Ticks
• Bedbugs
• Cockroaches

41
Insecticide-Treated Nets (contd.)

• Untreated Nets
• Provide some protection against malaria
• Do not kill or repel mosquitoes that touch net
• Do not reduce number of mosquitoes
• Do not kill other insects like lice, roaches, and
  bedbugs
• Are safe for pregnant women, young children, and
  infants

• Insecticide-Treated Nets
• Provide a high level of protection against
  malaria
• Kills or repels mosquitoes that touch the net
• Reduce number of mosquitoes in/outside net
• Kills other insects such as lice, roaches, and
  bedbugs
• Are safe for pregnant women, young children, and
  infants

42
Benefits of Insecticide-Treated Nets

• Prevent mosquito bites
• Protect against malaria, resulting in less
• Anemia
• Prematurity and low birthweight
• Risk of maternal and newborn death
• Help people sleep better
• Promote growth and development of fetus and
  newborn

43
Benefits of Insecticide-Treated Nets Community

• Cost less than treating malaria
• Reduce number of sick children and adults
  (helping children grow to be healthy and helping
  working adults remain productive)
• Reduce number of deaths

44
Where to Find Insecticide-Treated Nets

• General merchandise shops
• Drug shops/pharmacies
• Markets
• Public and private health facilities
• Community health workers
• NGOs, community-based organizations

45
How to Use Insecticide-Treated Nets

• Hang above bed or sleeping mat
• Tuck under mattress or mat
• Use every night, all year long
• Use for everyone, if possible, but give priority
  to pregnant women, infants, and children

46
Caring for Insecticide-Treated Nets

• Handle gently to avoid tears
• Tie net up during day to avoid damage
• Regularly inspect for holes, repair if found
• Nets need to be re-treated regularly to stay
  effective
• Keep away from smoke, fire, direct sunlight

47
Intermittent Preventive Treatment

• Based on the assumption that every pregnant woman
  living in an area of high malaria transmission
  has malaria parasites in her blood or placenta,
  whether or not she has symptoms of malaria

48
Intermittent Preventive Treatment

• Although a pregnant woman with malaria may have
  no symptoms, malaria can still affect her and her
  unborn child

49
Intermittent Preventive Treatment WHO
Recommendation

• All pregnant women should receive at least two
  doses of IPT after quickening, during routinely
  scheduled ANC visits (WHO recommends a schedule
  of four visits, three after quickening)
• Presently, the most effective drug for IPT is
  sulfadoxine-pyrimethamine (SP)
• Women should receive at least two doses of IPT
  with SP at ANC visits after quickening, but no
  more frequently than monthly

50
Intermittent Preventive Treatment Dose and Timing

• A single dose is three tablets of sulfadoxine 500
  mg pyrimethamine 25 mg
• Healthcare provider should dispense dose and
  directly observe client taking dose

51
Instructions for Giving Intermittent Preventive
Treatment

• Ensure woman is at least 16 weeks pregnant and
  that quickening has occurred
• Inquire about use of SP in last 4 weeks
• Inquire about allergies to SP or other sulfa
  drugs (especially severe rashes)
• Explain what you will do address the womans
  questions
• Provide cup and clean water

52
Instructions for Giving Intermittent Preventive
Treatment (contd.)

• Directly observe woman swallow three tablets of
  SP
• Record SP dose on ANC and clinic card
• Advise the woman when to return
• For her next scheduled visit
• If she has signs of malaria
• If she has other danger signs
• Reinforce the importance of using ITNs

53
Intermittent Preventive Treatment
Contraindications to Using SP

• Do NOT give during first trimester Be sure
  quickening has occurred and woman is at least 16
  weeks pregnant
• Do NOT give to women with reported allergy to SP
  or other sulfa drugs Ask about sulfa drug
  allergies before giving SP
• Do NOT give to women taking co-trimoxazole, or
  other sulfa-containing drugs Ask about use of
  these medicines before giving SP
• Do not give SP more frequently than monthly Be
  sure at least 1 month has passed since the last
  dose of SP

54
Chemoprophylaxis with Chloroquine For Women
Allergic to Sulfa Drugs
If chloroquine resistance rates in the country
are high, chemoprophylaxis with chloroquine is
not recommended.
55
Summary of Health Education Points

• Pregnant women should sleep under ITNs every
  night
• By preventing malaria, IPT reduces the incidence
  of maternal anemia, spontaneous abortion, preterm
  birth, stillbirth, and low birthweight
• IPT should be administered to pregnant women at
  regularly scheduled ANC visits after quickening,
  but not more often than monthly

56
Prevention and Control of Malaria during Pregnancy

• Chapter IV Detection and Treatment

57
Malaria Detection and Treatment Chapter
Objectives

• Identify causes of fever during pregnancy
• List the signs and symptoms of uncomplicated and
  complicated malaria
• Describe the treatment for uncomplicated malaria
  during pregnancy
• Explain the steps to appropriately refer a
  pregnant woman who has complicated malaria

58
Detecting Malaria

• Symptoms
• Fever
• Chills
• Headaches
• Muscle/joint pains
• Lab exam of blood from a finger prick

59
Fever during Pregnancy

• Temperature of 38 C or higher
• May be caused by malaria, but also by
• Bladder or kidney infection
• Pneumonia
• Typhoid
• Uterine infection
• Careful history and physical required to rule out
  other causes

60
Fever during Pregnancy (contd.)

• Ask about or examine for
• Type, duration, degree of fever
• Signs of other infections
• Chest pain/difficulty breathing
• Foul-smelling watery vaginal discharge
• Tender/painful uterus or abdomen
• Frequency/urgency/pain in urinating
• Signs of complicated malaria or other danger signs

61
Types of Malaria

• Uncomplicated
• Most common
• Complicated
• Life threatening, can affect brain
• Pregnant women more likely to get complicated
  malaria than non-pregnant women

62
Recognizing Malaria in Pregnant Women

• Uncomplicated Malaria
• Fever
• Shivering/chills/rigors
• Headaches
• Muscle/joint pains
• Nausea/vomiting
• False labor pains

• Complicated Malaria
• Signs of uncomplicated malaria PLUS one or more
  of the following
• Dizziness
• Breathlessness/difficulty breathing
• Sleepy/drowsy
• Confusion/coma
• Sometimes fits, jaundice, severe dehydration

63
Recognizing Malaria in Pregnant Women (contd.)

• Refer the woman
• immediately
• if you suspect anything
• other than
• uncomplicated malaria

64
Case Management

• Determine whether malaria is uncomplicated or
  complicated
• Uncomplicated Manage according to national
  protocol
• Complicated Refer immediately to higher level of
  care consider giving first dose of anti-malarial
  if available and healthcare provider is familiar
  with its use

65
Case Management Drugs

• First-line drug therapy is indicated for
  uncomplicated malaria
• Second-line drug therapy is indicated for
  uncomplicated malaria that has failed to respond
  to first-line drug
• In almost all countries, quinine is the drug of
  choice for complicated malaria

66
Managing Uncomplicated Malaria

• Provide first-line anti-malarial drugs
• Follow country guidelines
• Manage fever
• Analgesics, tepid sponging
• Diagnose and treat anemia
• Provide fluids

67
Treating Uncomplicated Malaria

• Observe client taking anti-malarial drugs
• Advise client to
• Complete course of drugs
• Return if no improvement in 48 hours
• Consume iron-rich foods
• Use ITNs and other preventive measures

68
SP Contraindications

• Before 16 weeks of pregnancy
• SP dose in last 4 weeks
• Allergies to sulfa drugs (e.g., co-trimoxazole)
• Currently taking other sulfa drugs
• Substitute other drug before giving SP

69
Treatment Problems

• Vomiting within 30 minutes
• Repeat dose of SP
• Itching
• Warm or cool baths
• Use lotions/skin creams
• Give Piriton or Phenergan
• Stomach upset/irritation
• Take chloroquine with food or sugar
• Reduce intake of caffeine and greasy foods

70
Treatment Followup

• Arrange followup within 48 hours
• Advise to return if condition worsens
• Review danger signs
• Reinforce use of ITNs

71
Second-Line Drug

• Most clients will respond to malaria treatment
  and begin to feel better within 48 hours
• However, if the clients condition does not
  improve or worsens, give second-line treatment
  for uncomplicated malaria

72
Second-Line Drug (contd.)

• If the womans condition does not improve or
  worsens within 48 hours of starting treatment
  with a second-line drug, and/or other symptoms
  appear, REFER IMMEDIATELY
• If signs of complicated malaria are present,
  REFER IMMEDIATELY

73
Referral Preparation

• Explain situation to the client/family
• Help arrange transport to other facility if
  possible
• Write referral note
• Treat any urgent conditions and stabilize

74
Referral Note

• Brief history of clients condition
• Details of any treatment provided
• Reason for referral
• Significant findings from history, physical exam,
  or lab
• Any important details of current pregnancy
• Copy of clients ANC record, if possible
• Referring provider contact information

75
Summary of Health Education Points

• Uncomplicated malaria can be easily treated if
  recognized early, but it is very important to
  finish the course of treatment to be effective
• Because complicated malaria requires specialized
  management, women with complicated malaria should
  be referred immediately to avoid complications
  and death