Tropical Health Matters

Jhpiego’s Malaria in Pregnancy (MIP) project in Akwa Ibom State, Nigeria flagged off its community component in July.  Prior to that primary health clinic (PHC) staff at 15 local government facilities had been trained in focused antenatal care, malaria in pregnancy and community directed intervention. These staff in turn recruited and trained 734 volunteer community directed distributors (CDDs) who represent 459 kindreds in the 87 communities surrounding the PHCs.

Field monitoring is underway to document the first month’s activities. This includes attending the monthly meetings that CDDs have with their nearby health facility staff and review of both CDD and ANC clinic registers. CDDs are expected to provide health education on MIP prevention, provide the first does of IPTp if appropriate and refer pregnant women to ANC clinic. Baseline assessments showed that women were not utilizing ANC at local government facilities, so Jhpiego has started working with staff on quality improvement so that referred women will want to use the services.

ANC attendance has increased. Review of the registers in three small clinics showed a total of 8 ANC clients in April, 7 in May and 2 in June. This rose to 44 in July and 25 for the first half of August for the three clinics combined. Before one starts to get excited, one must look at the work of CDDs in distributing sulfadoxine-pyrimethamine for IPTp.  For example, at one of the large operational base clinics, 84 women attended ANC in July. Only 24 of 44 CDD/kindred records for July had been collected by the staff, but these showed that the CDDs had seen 670 pregnant women. A similar pattern emerged at all facilities.

CDDs were interviewed individually and during their group meetings. They said that it has been so long since women utilized the local government clinics that it was difficult to convince them to be referred.  Some women preferred checking in with TBAs near the time of delivery, while others relied on their churches for prenatal supervision and delivery.  There were concerns about poor state of the infrastructure. Many complained of fees for registration, cards and medicines (although IPTp is free). Nurses often turn back those who cannot pay instead of at least providing them the free services that exist.

While free services such as blood pressure monitoring and tetanus toxoid immunization are free, the various fees and charges can amount to US $4.50 or more assuming a woman makes up to four ANC visits. This may sound inexpensive, but for people living on the proverbial dollar a day, it is a major cash outlay.

Advocacy visits are underway to local government chairpersons and supervisory councilors for health to encourage them to make all aspects of ANC free and improve the health facilities.  While the CDDs are starting to reach pregnant women earlier with IPTp, their job is not done until the women attend ANC and get the full range of services intended to protect their pregnancy.

Malaria Journal has published experiences from Luwero, Uganda that show the difficulties of getting two appropriately times doses of intermittent preventive treatment (IPTp) to women even if they attend antenatal care (ANC) clinics frequently. Among the over 750 post-partum women who were surveyed in 2005, 94% had attended ANC once and 88% at least twice.

Only 36% of the women received two or more doses of IPTp, and 31% used a bednet during their last pregnancy, well below the 60% target set for 2005 for IPTp and ITN use by the RBM partnership. Educational level was positive associated with taking any IPTp. Even these figures look good compared to the 2006 DHS in Uganda where only 10% of pregnant women said they had slept under a bednet the previous night and 16% reported receiving IPTp twice. The DHS did agree with ANC attendance wherein it was reported that 89% of women attended two or more times.

This pattern of good ANC attendance and poor malaria control coverage is not uncommon. It demonstrates the neglect of routine MCH and Reproductive Health services by national malaria control programs. ANC clinics do not receive regular net supplies and pregnant women do not benefit from community campaigns that mainly target children under five years of age. Countries phase out SP for treatment and forget to keep it on hand for IPTp during ANC.

A priority for all funders – PMI, GFATM, World Bank, DfID, UNICEF and others should be to foster integration of ANC strengthening into malaria control efforts in order to prevent maternal anemia and morbidity and ultimately low birth weight and neonatal mortality. Alternative approaches that involve the community should also be considered.

Tanzania has been noted for its high levels of antenatal care (ANC) attendance. Four out of five health facilities offer ANC. Over 94% of pregnant women attend ANC offered by a trained provider including nurse/midwifes, other clinicians and MCH Aids. It appears that 95% of these attend ANC two or more times, making it theoretically possible for Tanzania to achieve the RBM target of 80% of pregnant women receiving two doses of Intermittent Preventive Treatment (IPTp). National Policy has supported IPTp in ANC for over six years. Unfortunately the DHS also shows less than 22% of pregnant women receiving two doses.

Tarimo (2007) offers some explanations for this “IPTp Gap” in the East African Journal of Public Health. ANC clinic exit interviews revealed that only 60% of women received IPT and some of the reasons for the gap. A key problem was unavailability of sulfadoxine-pyrimethamine (SP) for IPTp. About 40% of those who actually received SP did not take it as directly observed treatment in the clinic for reasons including not wanting to take it on an empty stomach and aversion to sharing drinking cups with other women. Who knows what they did with the SP when they got home?

Finally while 90% were aware of IPTp, only 30% knew the correct timing and dosage. Thus, they were not even in a position to make educated demands on service providers for timely and adequate provision of IPTp. These problems represent a clear failure of the health system: failure to stock SP, failure to ensure conducive conditions to take SP and failure to educate clients thoroughly.

We have previously raised the question about community delivery of IPTp, which while effective in increasing coverage, raises concerns about reducing utilization of ANC and delivery services. But what do we do when the health service is clearly squandering an opportunity to deliver this live saving intervention through ANC?

The 2006 Demographic and Health Survey report for Uganda is now available. It was possible to compare the malaria indicators with the survey done in 2000-01. Some progress can be seen in the attached picture. The definition of the indicators is somewhat different between the two periods. For example IPTp did not begin as a national policy/program until 2002, so the comparison indicator in 2000 was the proportion of women who received antimalarial prophylaxis at Antenatal Clinic. Likewise, distinctions between types of nets were not reported for all users in 2000.

While there have been increases in all the indicators, none reached the 2005 RBM targets of 60%. Uganda has been fortunate to receive donor support for its malaria efforts. Uganda’s $23m Round 2 Global Fund Grant started in 2004, and by September 2006 over 91% of the funds had been disbursed. The final grant progress report (2006) indicates that 15% of children under 5 years had slept under an ITN the night before, compared to 9.7% in the 2006 DHS. The progress report shows that 35% of pregnant women had received IPTp2 compared to 16.2% in the DHS. The Global Fund Round 4 Grant in Uganda focused primarily on treatment with ACTs.

Uganda is also fortunate to be one of the first recipients of the US President’s Malaria Initiative. PMI selected Uganda in part because it envisioned potential synergies and scale ups because of the presence of GFATM efforts. Now that RBM targets are 80%, it is incumbent on Uganda to make the most of this multiple donor funding achieve better and faster results while the opportunity exists.

We are lucky that there are various monitoring tools like the DHS to compare reported achievements from progress reports to donors. Other countries should take similar advantage of such tools in order to monitor and improve their malaria control performance.

This posting looks at some of the issues in the debate of whether Intermittent Preventive Treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) should be based on a platform of Antenatal Care (ANC) or delivered through community volunteers or even a combination of strategies. (References for the information provided herein are found as an attached comment.) Roll Back Malaria has set minimum target 80% coverage of two IPTp doses (IPTp2) by 2010, but even though a high proportion of African women attend ANC during pregnancy, IPTp2 coverage is below target.

Those in favor of a community approach believe this is the best way to reach out to all women and achieve the 2010 high coverage targets. Those against the idea think that community distribution will detract from ANC attendance and deprive women of the services that come with ANC and thus, adversely affect women’s health.

What is actually feasible? Eckert, Hyslop and Snow analyzed recent Demographic and Health Survey data from 20 African countries to see what proportion of pregnant women attended ANC in a way that was compatible with receiving two doses of IPTp. This ranged from 17-91% with a median of 70%. Even when ANC attendance seems good, IPTp2 coverage may not meet targets as for example in Malawi a in 2004 where 78% received one dose of SP but only 47% got two doses. Even more discouraging was a study from Kenya which reported that while 91.9% of pregnant women made more than one ANC visit, only 19.1% received IPTp1 and 6.8% received more than one dose.

Different studies have identified factors associated with not receiving IPTp2. These are a combination of system and personal variables as seen below. Some may be addressed through quality improvement of ANC services while others might require a community based strategy.

• Charges at some types of facilities
• Health worker confusion about spacing of IPTp doses
• Less access and utilization in rural compared to urban areas
• Clinic logistics including overcrowding, lack of resources to provide clean water and inadequate supply/distribution systems
• Community perceptions about side effects and need to take with food
• Late first registration
• Being multigravida

Alternatively a pilot community based distribution in Malawi achieved 95% IPTp2 coverage, and another in Uganda reached 67.5% for IPTp2 among the community distribution group compared to 39.9% in the control group. The former may have detracted from ANC attendance while the latter apparently did not make a difference in ANC utilization.

As resistance to SP grows, health programs are not abandoning the drug, but may start to give it monthly. This may put additional pressure on coverage based solely on ANC attendance. The solution appears to lie first in a thorough situation analysis of the current levels of ANC acceptance and factors influencing IPTp delivery. In cases with existing high levels of ANC attendance strengthening ANC quality may be the best approach, while in those with low attendance, a community approach may be needed. Ultimately a combination may work best, but programs need to be flexible to investigate what is appropriate in each setting.

Over 2500 people have gathered in London to observe the 20^th anniversary of the launching of the Safe Motherhood Initiative at the Women Deliver Conference. While progress has been reported over half a million women still die annually of pregnancy and child birth related causes. In fact there has been little progress in sub-Saharan Africa since 1995 where the maternal mortality rate (MMR) still hovers around 900/100,000. Not coincidentally, this is the region where the threat of malaria in pregnancy (MIP) is highest.

Big disparities and inequities were reported not only between developed and developing countries (the former having a MMR of only 9/100,000), but even between rich and poor women within developing countries. A major concern is the lack of access to quality antenatal and obstetric care. In fact it is challenges in the health care system that make it deliver malaria in pregnancy control services effectively through ANC.

In recognition of the role of malaria in maternal health, the Women Deliver Conference is holding a panel on Malaria in Pregnancy, organized by JHPIEGO. I am moderating the panel and have able input from four colleagues.

• Scott Filler from the US Centers from Disease Control is talking about the importance and efficacy of sulfadoxine-pyrimethamine as the foundation of Intermittent Preventive Treatment
• Kaende Munguti of JHPIEGO’s Kenya office is sharing success stories from Kenya, Tanzania, Burkina Faso and Madagascar in improving the quality of ANC and IPTp coverage
• Lori Jackson of ExxonMobil is discussing the corporate role in promoting women’s health and sharing experiences from the ExxonMobil supported MIP projects of JHPIEGO in Nigeria and Kenya
• Juliana Yartey of WHO is stressing the importance of integrating MIP control into maternal and reproductive health services as the way to sustain MIP services
• Scott Filler again is explaining the role of the US President’s Malaria Initiative in providing IPTp, ITNs and malaria medicines to support MIP activities in its 15 countries.

Join us on the Women Deliver website to learn how to ensure that safe motherhood will become the reality promised in the Millennium Development Goals before 2015.

For the past several years a consortium has been investigating whether intermittent preventive treatment with sulfadoxine-pyrimethamine (SP) for infants (IPTi) could be as effective a malaria control tool as its counterpart for pregnant women (IPTp). According to Ghanaweb.com on Friday, “Professor John Gyapong, Director of the Health Research Unit of the GHS (Ghana Health Service, noted that IPTi with SP had been found to be very efficacious, safe and cost effective.” Reductions in malaria and related factors found in the Ghana research are seen in the attached graph.
Although Prof. Gyapong appeared to advocate for quick adoption of IPTi in Ghana, he also did note that WHO has yet to endorse the practice. In fact some would say that a verdict on IPTi is overdue considering the volume of research generated so far and available for review on the IPTi Consortium website. This delay may not be surprising based on the reluctance of WHO’s Global Malaria Program to embrace IPTp even though evidence of its effectiveness persists.

Of course, there are some legitimate concerns about expanding IPT, which need to be addressed, even based on the data generated in Ghana. Among these issues are the following:

• resistance of parasites to SP
• appropriateness of EPI as a delivery mechanism for IPTi
• equity of access to IPTi
• timing of IPTi dosages
• concerns about seasonality of transmission

These issues are explored in detail in the various journal articles available for free download at the IPTi website. Fortunately, Dr. Andrea Egan from IPTi Consortium has assured that, “a comprehensive research and implementation agenda had been developed to resolve any outstanding scientific questions on whether IPTi was safe and effective to use as a malaria control intervention and move the intervention into policy and practice.”

Clearly IPTi would not be implemented as a stand alone intervention, but would and should be integrated with other control measures including ITNs and prompt case management with ACTs. There is always benefit to having another strategy to add to a comprehensive malaria program in order to outwit mosquitoes and parasites.

Population Action International made an important point that the Global Fund to Fight AIDS, TB and Malaria could save even more lives it it addressed reproductive health issues. In particular PAI explains that, “After just a few short years, the Global Fund has saved over 1.8 million lives worldwide. Just think what can be accomplished—how many more lives saved—if the Global Fund partnered with the life-saving work of sexual and reproductive health providers.”

In the area of Malaria control, GFATM funds to contribute toward improving reproductive health through a variety of malaria in pregnancy (MIP) interventions including 1) Intermittent Preventive Treatment (IPTp) with sulfadoxine-pyrimethamine (SP), 2) long lasting insecticide-treated bednets (LLINs) and prompt and appropriate case management with artemisinin-based combination therapy (ACTs)

Of course the potential for including MIP in GF proposals and the actual emphasis on MIP in reality are sometimes different. Since SP is so cheap, its procurement is often overlooked. A recent visit to rural Kenyan clinics found plenty of ACT stocks, but stockouts of SP. ACTs are procured with GAFTM funds through international contracts, while SP is often purchased locally when funds are available in national health budgets.  LLINs are often distributed widely to children under five years of age through well publicized campaigns, while it is difficult to get a bednet as part of regular antenatal care in come countries.  Often GFATM projects are implemented through the vertical disease units in health agencies, leaving little opportunity for reproductive health, or even integrated management of childhood illness units to become involved.
So in short, while we might point out that reproductive health issues can already be part of GFATM activities in principle, we agree with Population Action International that active involvement of reproductive health services, particularly in our area of malaria control, is urgently needed.

Last week WHO’s Global Malaria Program (GMP) launched its new guidance for Insecticide Treated Nets. Two key features of the guidance is the stress on providing free nets and the need to achieve total population coverage in endemic areas. The position paper begins by stating that the three primary interventions to be scaled up for effective malaria control include:

• diagnosis of malaria cases and treatment with effective medicines;
• distribution of insecticide-treated nets (ITNs), more specifically long-lasting insecticidal nets (LLINs), to achieve full coverage of populations at risk of malaria; and
• indoor residual spraying (IRS) to reduce and eliminate malaria transmission.

Nowhere in the document, let alone in this highly visible opening paragraph, is there mention of Intermittent Preventive Treatment/Therapy for pregnant women (IPTp). Thus, once again the GMP misses an important opportunity to stress a crucial and well proven intervention to protect the lives of pregnant women, their unborn babies and newborn infants from morbidity and mortality from the most dangerous form of malaria, P. falciparum.

A recent review by ter Kuile et al., has shown once again, that even in areas where there is up to 50% resistance to sulfadoxine-pyrimethamine (SP) in small children, IPTp with SP is still efficacious in controlling maternal malaria and reducing both maternal anemia and low birthweight in newborns.

We are not sure why the GMP itself has high levels of resistance to acknowledging the lifesaving effects of IPTp, and regret the poor example being set by a leader in world health. Fortunately other major development partners who actually have money to spend are still willing to help countries that suffer from malaria by supporting IPTp.

The Ministry of Health in Uganda estimates that private, not-for-profit health (PNPH) facilities account for 30% of all facilities in Uganda, and importantly around 85% of these are located in rural communities. USAID’s ACCESS project has demonstrated that FBO health facilities, an important component of the PNPH sector, can play a major role in increasing the delivery and uptake of malaria in pregnancy (MIP) control interventions in the Kasese District of Uganda. The project was a joint effort of ACCESS partners, particularly Interchurch Medical Assistance (IMA) and JHPIEGO.

The project worked with the Uganda Catholic, Muslim and Protestant Medical Bureaus in five health facilities and upgraded the malaria technical skills of all antenatal care (ANC) staff using JHPIEGO training materials. In addition “community owned resource persons” (village volunteers) and religious leaders were trained to help mobilize women to attend ANC. ANC is a key platform for delivering malaria in pregnancy control interventions.

Over the nine-month intervention 27% of women attending ANC were given Insecticide Treated Nets (ITNs), which were supplied by the project. The facilities normally stocked sulfadoxine-pyrimethamine (SP) for intermittent preventive therapy (IPT). By the end of the project the the proportion of ANC attendees receiving their first dose of IPT rose from 43% to 94%, while those receiving IPT2 increased from 27% to 71%. The Uganda Demographic and Health Survey for 2006 found only 50% of pregnant women nationally had received IPT1, and 17%, IPT2.

Often donor in-service training programs focus exclusively on public sector health workers and neglect those in the private and NGO sectors. In many malaria-endemic countries religious mission health services deliver a large portion of care, and as seen in this Ugandan example, can play a major role in delivering malaria in pregnancy control services if their capacity is improved. Fortunately, these FBO facilities did stock SP from which they could plan and deliver IPT. At the time they did not benefit from supplies of ITNs, although the country was receiving ITNs through Global Fund Grants. It is therefore important for National Malaria Control Programs to integrate FBOs and PNPH facilities into both training and commodity supply programs to ensure full protection of pregnant women from malaria. Since this project was done in collaboration with the Ministry of Health (MOH) in Uganda there is hope that collaboration will continue between the faith mission medical boards and the MOH to expand these MIP services to other FBO facilities.