A long way to go to count malaria out in pregnancy

Malaria in pregnancy (MIP) has often been called the neglected arm of malaria control efforts.  The challenge may not be unconnected to the fact that MIP control activities are usually organized through antenatal care, which is based in a different section of most Ministries of Health than National Malaria Control Programs.  The US President’s Malaria Initiative (PMI) has included MIP control in all its 15 country programs, but even with added attention, MIP control targets have been difficult to meet.

pmi-2009-mop-mip-coverage-sm.jpgJhpiego’s Malaria Core Team recently reviewed all the FY 2009 Malaria Operations Plans (MOPs) for PMI countries and found that reports of MIP indicator coverage were still low. Data were not available for Liberia, and Zanzibar has been analyzed separately from the Tanzanian Mainland as seen in the attached chart. We recognize that the 2009 MOPs would may have drawn on data that were not always up-to-date.
Coverage with a minimum of two doses of intermittent preventive treatment in pregnancy (IPTp2) ranges from a low of 3% in Angola to 60% in Zambia. While the IPTp coverage for Zambia did reach RBM’s 2005 target, it is far from PMI’s 2010 target of 85%. Likewise coverage for pregnant women sleeping under an ITN ranged from 7% in Mozambique to 51% in Zanzibar.

Some key organizational bottlenecks make achievement of these targets difficult.  Campaigns that link ITN or LLIN distribution to childhood immunization can fall short on three counts –

  1. pregnant women may not be reached during these efforts
  2. even when women receive nets, they do not always sleep under them, and
  3. provision is not usually made to stock nets for women who become pregnant after the campaign

We reported recently from Ghana that even though clinics had good stocks of sulfadoxine-pyrmethamine (SP) to use in IPTp, IPTp coverage was low. In some clinics, not even half of those attending ANC received their first dose of IPTp.  Lack of coordination among the national health insurance scheme, the ANC clinic and the pharmacy may have been at play.  In Tanzania we found that SP stock-outs were responsible for low levels of coverage.  So even if we have the commodities, we cannot always guarantee they will reach pregnant women.

Child survival begins in pregnancy.  The pregnant woman with malaria can herself die from malaria and the anemia it causes. Even when she herself survives malaria infection, there may be resulting miscarriage or still birth.  Babies born to mothers who had malaria in pregnancy are more likely to be of low birth weight, and therefore at greater risk of dying in the neonatal period and infancy.

Malaria in pregnancy control must receive greater attention if we really want to count malaria out.

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