Prevention of malaria in pregnancy in Malawi

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Prevention of malaria in pregnancy in Malawi

• A successful collaboration between malaria
  control and reproductive health
• Peter Kazembe
• Allan Macheso
• Ministry of Health and Population
• Lilongwe
• MALAWI

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Malawi in Africa
Blantyre
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Malawi Background data

• Total Population 9.9 million (1998)
• GNP per capita US170.00 (1995)
• Literacy rate 44 (1995)
• Pregnant women HIV positive 25
• Antenatal care from trained personnel 93
• Deliveries by Doctor/Nurse/Midwife 56
• Malaria cases / 100 000 population 49,400
• Source Human Development Report 1998,
• Malawi Demographic and
  Health Survey 2000
• 
  

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Malaria in Pregnancy in sub-Saharan Africa

• 23 million pregnancies in malarious areas
• Infection during pregnancy contributes
  significantly to
• maternal anemia
• low birth weight and their consequences
• In Malawi malaria is endemic, most pregnant
  women
• are at risk

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Malaria morbidity and mortalityin pregnancy

• 59 pregnant women attending antenatal clinic
  anemic (Hb lt11 gm)
• Low birth weight (LBW) in Malawi contributes
  to
• - 80 of all neonatal deaths
• - 46 of perinatal deaths
• - 38 of infant mortality (1996, McDermott et
  al)
• Prevention of malaria in pregnancy one of the
  main objectives of RBM

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Alleviating the burden of malaria in pregnancy in
Malawi

• Prior to 1993 weekly chloroquine (CQ)
  prophylaxis given with
• no initial treatment dose
• MMRP showed unacceptably high placental malaria
  infection
• in women given CQ prophylaxis compared to those
  given
• mefloquine
• Current recommendation two preventive
  intermittent treatment with sulfadoxine-pyrimetha
  mine (SP) at 1st ANC visit (2nd trimester) and
  early in 3rd trimester (28 - 34 weeks)
• The two SP doses given at same time and
  interval as TTV

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Placental malaria infection by gravidity and
antimalarial drug regimen, MMRP, 1987 - 1990

Chloroquine
Mefloquine
Drug regimen
Steketee R.. et al, 1996
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WHO recommendation for malaria prevention during
pregnancy
Intermittent treatment with an effective
preferably one dose antimalarial drug delivered
in the context of antenatal care
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Abuja Declaration
At least 60 of all pregnant women who are at
risk of malaria, especially those in their first
pregnancies, will have access to
chemoprophylaxis or presumptive intermittent
treatment
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Malaria prevention during pregnancy essential
players for successful implementation

• Pregnant women - knowledge willingness
• Nurse / Midwife / Obstetrician
• Pediatrician
• Malaria control program
• Reproductive health program
• Antenatal clinic attendance and literacy - two
  most significant factors for LBW in adolescents
  mothers.
• Brabin et al, 1998

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Evidence to support preventive intermittent
treatment (PIT) with SP

• Two doses of SP compared to single dose in
  
• pregnancy result in reduction in incidence of
  
• LBW
• from 33.9to 13.5 in primigravidae
• from 13.9 to 6.5 in multigravidae
  (Verhoeff et al, 1998)
• Women taking two or more doses of SP
  
• deliver babies 195g heavier than those among
  
• women not taking SP (Rogerson et al, 2000)

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Implementation of PITexample of adequate
knowledge
90 women stated SP was best antimalarial
drug 81 knew to take 3 tablets SP for malaria
treatment 67 knew PIT should be taken 2 or
more times in pregnancy 97 knew malaria was
dangerous in pregnancy 82 thought SP was safe
in pregnancy
BIMI - Blantyre household KAP survey, Feb 2000
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Constraints to implementation of PIT

• HIV sero-prevalence (documented low
• efficacy of PIT-SP in sero-positive
• women)
• First ANC visit high (gt90 in most studies)
• however, subsequent attendance low
• with resultant fall in PIT coverage

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Constraints to implementationexamples of low
PIT coverage
Chikwawa 43.1 primigravidae had full PIT 45.9
multigravidae had full PIT (Verhoeff et
al,1998) Blantyre 30.0 received full PIT 24.0
did not get any SP dose (Rodgerson et al,
2000) Mangochi 24.0 received full
PIT (Sullivan et al, 1999)
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Conclusions

• Antenatal attendance is high in Malawi
• Most women recognize malaria as a problem, and
• PIT-SP as possible solution
• Most pregnant women receive the 1st dose of
  PIT- SP but not the 2nd dose
• Current national coverage of PIT-SP of 37 in
  Malawi far from the 60 Abuja objective target
  achievable with careful collaboration between
  malaria control and reproductive health
  programs

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Conclusions
Mothers have good knowledge of PIT, the 2
programs should provide opportunities to
increase impact of interventions including
promotion of ITMs
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Acknowledgement
Centers for Disease Control, Malaria
Epidemiology Section