Category Archives: IPTp

Committing to Preventing Malaria in Pregnancy From the National to State to Local Level in Nigeria

Bright Orji recently shared an overview of the Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) Project in Nigeria, a joint venture to protect pregnant women from malaria organized by Jhpiego with support from Unitaid, the National Malaria Elimination Program, The State Ministries of Health in Ebonyi, Niger and Ondo and the local communities.  He shares some highlights from the project launch this past week. The project will strengthening antenatal care services to reach out and involve communities in the grassroots delivery of intermittent preventive treatment of malaria in pregnancy (IPTp).

Her Excellency Chief (Mrs.) Rachel Umahi wife Executive Governor Ebonyi State flags off TIPTOP

Among those in attendance were wife of the Ebonyi State Executive Governor and representatives from the State Ministry of Health, the State Malaria Elimination Program, the State Primary Health Care Development Agency, the Ebonyi State House of Assembly, the Ministry of Justice, the Ministry of Local Government, the Ministry of Women Affairs, the School of Nursing and Midwifery, the School of Health Technology Ngbo, the Ohaukwu local government council and the community members.

The media documented the active participation, involvement and commitment by all stakeholders. Other partners present were the World Health Organization representing all UN Agencies in Nigeria and ISGlobal of Barcelona. Furthermore, the villages, families, and traditional rulers of the 16 communities that made up Ohaukwu Communitywelcomed the new project.

In order to emphasize an integrated approach to preventing malaria in pregnancy Ebonyi State, pregnant women given long lasting nets during the TIPTOP launch

Her Excellency Rachel Umahi, wife of the Ebonyi Governor said that, “TIPTOP project came at the right time, and I pledge to join hands to stop malaria in the state.”  She was joined by the Ohaukwu Local Government Chairman Barr Clement Oda who shared that, “Today marks a special day in the history of Ohaukwu LGA, Ebonyi State and Nigeria at large as TIPTOP project launch will put the state and her people in the global map. This TIPTOP project will receive a very good support and cooperation from my administration. We shall not relent on what or things we need to do to make this project a success in Ohaukwu LGA worthy for this project.”

The National Coordinator National Malaria Elimination Program, Dr. Bala Audu, explained that, “The choice of Ebonyi state and Ohaukwu LGA in particular is not unconnected with the low utilization of the antenatal care services and low performance in IPTp utilization when compared with other LGAs in the southeastern region. We hope the LGA and the state will use this opportunity to redeem her image in malaria in pregnancy performance in Nigeria.” He pledged his support to Jhpiego and the malaria programs in the three participating states.

Dr. Ugo Okoli, Deputy Country Director Jhpiego in Nigeria pointed out the synergies possible within the state through noting that the, “Maternal and Child Survival Project funded by USAID will collaborate with TIPTOP in Ebonyi State to ensure that ANC is strengthened, and communities mobilized to utilize services.”

Bright Orji will provide updates from time to time in these efforts to reduce the high mortality through community efforts from malaria in pregnancy in Nigeria.

Transforming Intermittent Preventive Treatment For Optimal Pregnancy (TIPTOP) Project in Ebonyi State Nigeria

Bright Orji who is the Project Manager for the Jhpiego and UNITAID Transforming Intermittent Preventive Treatment For Optimal Pregnancy (TIPTOP) Project in Nigeria shares remarks that introduce the program in Ebonyi State of Nigeria.

The project will help protect pregnant women from malaria. Malaria is very dangerous to pregnant women and unborn babies. It causes abortion, low birth weight in babies as well as responsible for about 11% (6,050) of maternal deaths of Nigerian women

Jhpiego’s original community IPTp in Akwa Ibom State involved community volunteers in preventing malaria in pregnancy

Building on Jhpiego’s effort to ensure Intermittent preventive treatment in pregnancy (IPTp) reaches all women in the community. Between 2007 and 2010, Jhpiego collaborated with the National Malaria Elimination Program (NMEP), Reproductive Health division of the Federal Ministry of Health and provided technical assistance to the Ministry of Health in Akwa Ibom State to introduce a community directed approach with a focus on malaria in pregnancy with support from the ExxonMobil Foundation. That project reached over 35,000 pregnant women representing an increase in IPTp uptake by 35.3% going from 21.7% at baseline to 57.0% at the endline.

With support coming from Unitaid, Jhpiego and her partners will be implementing Transforming Intermittent Preventive Treatment for optimal pregnancy – shortened to TIPTOP project reach all pregnant women in Ohaukwu, Ebonyi State (South-East), Suleja in Niger State (North Central and Akure south in Ondo State (South West).

Bright Orji and Colleagues review clinic records on malaria in pregnancy

These States were selected on the basis of malaria prevalence rate; national commitment to generate evidence across the six geographical zones; given that similar project has been implemented in Akwa Ibom State representing South-South, and Sokoto state representing North West. Poor status of IPTp interventions in the selected Local government areas; and to further complement our on-going efforts with Maternal and Child Survival Project funded by the United States Agency for International Development (USAID/MCSP); Presidential Malaria Initiatives (PMI), Global Health Funds for Tuberclosis, HIV/AIDs and Malaria.

In this effort, we will work with the National Malaria Elimination Program (NMEP) that is charged with the responsibility of coordinating all malaria prevention and control activities in Nigeria; Reproductive Health Division of the Family health department, Federal Ministry of Health, State Ministries of Health, Local Governments authorities, communities development partners including World Health Organization (WHO); UNICEF, World Bank and other stakeholders (PMI/USAID, AFENTH etc).

To do this, TIPTOP project Nigeria will use a two-pronged approach that will increase the number of pregnant women in the three states who receive key malaria in pregnancy interventions by:

  • Strengthening ANC services in health facilities, ensuring that a strong foundation for MIP services is in place; and
  • Using community directed intervention approach where Community health workers,

Supervised by these strengthened ANC facilities, to initiate MIP interventions at the community level and refer women to the nearest ANC facility

Antenatal Clinics are the base for organizing training and community involvement in delivering Intermittent malaria Preventive Treatment in Pregnancy

Both parts of this approach will also strengthen local capacity in training, supervision, project implementation and evaluation by working with local civil society organizations that have strong ties to the community. As a component of this project, TIPTOP will seek a model for integrating MIP and other prevention services on the platform of ANC. TIPTOP project has planned for operations research that will provide some lessons and evidence and these include:

  • Household surveys to gain understanding how pregnant women think, where they receive services if they are not coming to the health centers, and how we can prove services they receive
  • Anthropological study – that would investigate community acceptability of community IPTp
  • Sulfadoxine-pyrimethamine (SP) resistance monitoring study and
  • Economic study – cost-benefit analysis

We are aware of the challenges ahead, Prof. ‘Dipo Otolorin the former Country Director for Jhpiego and now the Snr. Technical and Programmatic Advisor will always say, “a stick of broom cannot sweep the street, but when you have a bunch of sticks sweeping becomes delightful”. This is an African aphorism for team building.

So, from beginning of the grant application and subsequent development of the approved country operational plan (COP); we have engaged the key stakeholders that work on malaria in Nigeria. This is because we need the collaboration, coordination and cooperation of everyone. We will work together to mobilize all the communities in these three states, conduct community census that will guide us to estimate adequate number of SP doses; enter every kindred, family, household and home of pregnant women. We will identify all the pregnant women, refer them to attend ANC, as well as administer the life-saving medicines to the eligible ones both at facility and community levels. NO PREGNANT WOMAN SHOULD DIE OF MALARIA, BECAUSE IT IS PREVENTABLE, TREATABLE AND WE HAVE EVIDENCE-BASED INTERVENTIONS TO PROTECT THEM.

By the end of the project we would have achieved the goal of increasing the number of women who receive MIP services through strengthened ANC and community-level interventions. TIPTOP project expects additional outcomes from this initiative and these include:

  • Generate evidence for WHO policy change
  • set stage for scale up of community intermittent preventive treatment during pregnancy (IPTp)
  • Increased demand for quality assured sulfadoxine–pyrimethamine (SP) for IPTp and

With this project no pregnant woman should die from malaria. So let us all join hands to stop malaria – and make Nigeria a Malaria free nation!!!

Liberia’s Fight against Malaria Continues

Liberia was making steady progress against malaria in the years after the civil war. Despite the devastation of Ebola, the health authorities have continued to push against malaria. The DHS Program has released key findings from the 2016 Malaria Information Survey. We have compared those against the 2011 MIS, and while there is progress, much work needs to be done in this highly endemic area – not just in fighting malaria, but in rebuilding health systems damaged by war and Ebola.

Targets for Intermittent Preventive Treatment in pregnancy of malaria have risen from at least 2 doses in 2011 to three or more when the 2016 data were collected. While the IPTp2+ doses have increased by a little less than 5%, the challenge of IPTp3 and greater has become quite evident. It is interesting that coverage of IPTp is slightly better in rural areas, but there is still a long way to go to protect pregnant Liberian women.

The situation with access to and use of insecticide treated nets has also improved over the 5-year period, but still remains well below the targets of universal coverage. Even though nearly two-thirds of households have at least one ITN, only a quarter have enough nets to reach the goal of one net for every two people. Net use by children below the age of 5 years is better than that of pregnant women, though in both cases less that half of these vulnerable populations are covered. Nets are particularly important for pregnant women who cannot take IPTp in the first trimester.

Care for febrile children also has improved, but questions remain about appropriate care due to the nature of the questioning processes in the MIS.  Seeking advice increased by 20% as did getting blood tests (RDT or microscopy) once care is sought.  Double the number of febrile children received artemisinin-based combination therapy in 2016 compared to 2011, but since the rate of testing is low, we do not know if they were being appropriately treated – given ACT only is tests were positive.

Liberia does receive support from donors such as the Global Fund and the US President’s Malaria Initiative. These and other partners need to strategize with the Liberian Ministry of Health and other local partners (NGOs, Businesses, etc.) in order to mobilize the support to put Liberia more squarely on the road to malaria elimination.

Burundi: when will citizens see real protection from malaria?

Preliminary findings from Burundi’s 2015-16 DHS have been made available. The country has a long way to go to meet targets for basic control of malaria.

LLIN availability by household is an overall disappointing 32%. Ironically there is greater coverage of households in in urban areas (50%) than rural (30%). There is also great variation among the provinces with 52% coverage in Bujumbura metropolitan but only 19% in Canzuko. The overall average is less than one treated net per household.

A major concern is equity. The chart above shows a steep gradation from 19% coverage among the lowest fifth of the wealth quintile, up to 48% in the highest. Even in households that have at least one net, only 17% of of people slept under a net the night before the survey.

In terms of use by those traditionally defined as vulnerable, the DHS shows only 40% of children below 5 years of age overall slept under a treated net the night prior to the survey. Even in households that own at least one net, 78% of these children slept under one.

A similar pattern is seen for treated net use by pregnant women. Overall 44% slept under a treated net, and 84% did so in households that owned at least one treated net. The internal household dynamics of net use where one is available does appear to favor these two groups.

Overall coverage of Intermittent Preventive Treatment for pregnant women is very low. Less than 30% of pregnant women received even the first dose of SP. This decreased to 21% for two doses and 13% for three. In contrast to net coverage, more rural women (31%) received the first dose of IPTp than urban ones (19%).

Nearly 40% of children below five years of age were found to have had a fever in the two weeks preceding the survey. Among those care was sought for only two-thirds. Eleven percent of those with fever received an artemisinin-based combination therapy drug. The report did not mention whether these children had received any testing prior to treatment, so appropriateness of treatment cannot be judged. Prevalence testing of the children in the sample found 38% with parasitemia. Therefore one might assume that more children should have received ACTs.

Burundi still faces major political and social challenges. Even so Burundi is the recipient of malaria support from the Global Fund. For example 18 million LLINs were distributed in 2015 and 19 million in 2016.

Much work is needed to bring Burundi even close to universal coverage of malaria interventions. In today’s climate of questionable donor commitment, it is hoped that regional partners may play a role since malaria knows no boundaries.

Ghana – spotlight on malaria indicators

The Demographic and Health Surveys has released a brief on key indicators from the Ghana Malaria Indicator Survey of 2016. While much of the malaria community is discussing the elimination framework and processes, the reality is that many high burden countries are still trying to scale up basic interventions to achieve universal coverage.

The overall prevalence across the country in children aged 6-59 months at the time of the survey was 27% using Rapid Diagnostic test and 20% using microscopy.  Among children reporting fever in the previous two weeks care/advice was sought for only 72%. Although only only 30% received some sort of blood based diagnostic test, 61% of the febrile children were given the antimalarial artemisinin-based combination therapy drugs.

Children are still being treated without the benefit of parasitological testing, a key procedure highlighted in WHO case management guidelines. Presumptive treatment for malaria without testing means that a child could inappropriately receive antimalarial drugs and die of another underlying febrile illness. Appropriate testing and adherence to test results is one of the main areas of focus of Ghana’s grants from the US President’s Malaria Initiative. Improved testing is also an important element in Ghana’s current Global Fund support. Clearly more value for money is needed from these inputs.

Preventive measures as documented in the MIS fare somewhat better., but at present only 73% of households own an insecticide treated bednet. When considering the recommended 1 net for every 2 household members, the indicator drops to 50%. Concerning the typical ‘vulnerable’ populations, we see that only 52% of children below the age of 5 years slept under an ITN the night before the survey; only 50% of pregnant women did likewise.

Malaria prevention in pregnancy results reflect the fact that Ghana has promoted at least three IPTp doses for around ten years. Most pregnant women (78% ) had received the previously recommended minimum of two doses, and now 60% have received at least three doses.

One of the important issues stressed in WHO’s new malaria elimination framework is stratifying the country by prevalence to the lowest level possible in order to plan appropriate interventions. Fortunately the Ghana 217 MIS key indicator brief does stratify prevalence and intervention coverage by region.  Prevalence through RDT testing ranges from nearly 5% in the urbanized greater Accra area to 44% in the Central Region. Interestingly ITN use is nearly 20% higher in Central than greater Accra.

Hopefully future planning in Ghana will build on this stratification. Better mobilization of donor, national and private sector resources will address likely issues of stock-outs and increase the likelihood of universal coverage of basic interventions that is needed to move the country along the road to malaria elimination.

Supporting Midwives to Prevent Malaria on International Day of the Midwife

Midwives play at least two crucial roles when it comes to saving the lives of pregnant women in malaria endemic areas. First as the health staff responsible for providing intermittent preventive treatment for malaria in pregnancy (IPTp), midwives can ensure that women do not suffer the consequences and complications of malaria in the first place. Secondly, knowing that we may not be able to reach all pregnant women with the full package of malaria interventions in a timely manner, midwives are there to save lives from the complications to the mother and fetus arising from malaria-associated anemia and low birth weight. Today we focus on prevention.

Today on the International Day of the Midwife is a good time to examine how to strengthen midwives’ roles in preventing malaria and protecting women from its consequences. This year’s theme, “Midwives, Mothers and Families: Partners for Life!” is in line with our overall concern about ending malaria through partnership at all levels.

In providing antenatal/prenatal care (ANC) in stable malaria endemic areas, midwives are tasked with ensuring that pregnant women get an adequate number of doses of IPTp at the right time in their pregnancy. Previously only two doses were required, but now a pregnant woman can receive IPTp monthly from the beginning of the second trimester. The ability of the midwife to attract women to ANC and ensure that once there gets the required doses can be daunting.

A study in Uganda found that many pregnant women did not get the full regimen of IPTp and learned that several factors were responsible. Midwives’ education level and professional experience had a positive effect. Management issues such as the availability of safe drinking water and the drugs for intermittent preventive treatment were crucial. “Midwives who provided frequent health education to pregnant women, cooperated with village health team members and received in-service training were likely to provide effective anti-malaria services to pregnant women.” In short there are training and management interventions that can enable midwives to protect pregnant women better.

Examination of malaria prevention in ANC clinics in Malawi showed that providers generally did have correct information about IPTp, but at times did know understand the exact timing of doses. They knew that those on HIV infection prevention prophylaxis should not take IPTp and that IPTp should be given as directly observed treatment, but in many clinics there were lack of official written guidelines to help them recall procedures post-training.

Again, we can see that a variety of learning and management interventions can help midwives prevent malaria. Additional work in Uganda has shown the valuable role midwives can play as community health educators in encouraging ANC attendance and thus IPTp uptake. They need full support from the health system to do this important outreach.

Preventing Malaria in Pregnancy – fill the coverage gaps

In a press release for World Malaria Day 2017, the World Health Organization called for the global community to “Prevent malaria – save lives” as part of the WHO push for prevention on World Malaria Day, 25th April. WHO recommended that, “Together with diagnosis and treatment, WHO recommends a package of proven prevention approaches, including insecticide treated nets, spraying indoor walls with insecticides, and preventive medicines for the most vulnerable groups: pregnant women, under-fives and infants.” This package has averted 663 million cases have been averted since 2001.

That said, WHO also identified gaps.

  • Approximately 69% of pregnant women in 20 African countries did not have access to the recommended 3 or more doses of preventive treatment.
  • An estimated 43% of people at risk (including pregnant Women) of malaria in the region were not protected by either a net or indoor insecticide spraying in 2015

This gap became evident on a recent visit to Ouargaye Health District in Burkina Faso where National Malaria Control Program and Jhpiego, with support from US President’s Malaria Initiative and USAID’s Mother and Child Survival Project, are setting up a pilot program to test community delivery of IPTp through the existing network of community health workers.

Normally IPTp is delivered as part of antenatal/prenatal care and the new project will use the ANC clinic as a base for training and supervising the CHWs. Health Statistics from the District from 2016 show the challenge that the community approach hopes to address.

Among the approximately 20408 pregnant women in the District, 75% attended ANC once, 67% twice, 58% more than thrice and 56% four or more times. At present IPTp coverage is lower than ANC attendance: 61% received one dose, 56% got 2, 41% received 3, 14% got 4 and only 3% received 5 or more doses.

The pilot project intends to use CHWs mobilize more women to register for ANC and get their first IPTp dose. Then the CHWs, under supervision of the health center staff will deliver additional doses at the appropriate monthly interval.

More and more health interventions, including integrated community case management, are moving into the community. Universal health coverage requires that the health system meet people where they are – let the health system adapt to the clients, not the clients adjust to the convenience of health workers. With this approach the gap in ANC attendance and IPTp coverage will hopefully close, saving more women’s lives through prevention.

Malaria in Pregnancy Progress in Nigeria – the 2015 Malaria Indicator Survey

With an eye toward the future Nigeria’s National Malaria Control Program also refers to itself as the National Malaria Elimination Program (NMEP). Given that Nigeria has the highest burden of malaria in Africa, along with around one-quarter of sub-Saharan Africa’s population, the elimination goal will take a lot of work.

Recently the 2015 Malaria Information Survey (MIS) for Nigeria was released and gives a perspective on how far we have some and how far we need to go. We will focus on malaria in pregnancy (MIP) interventions today.

Intermittent Preventive Treatment for pregnant women (IPTp) using sulfadoxine-pyrimethamine (SP) remains the key MIP intervention due to the high and stable malaria transmission that still persists. There is always a challenge in delivering health interventions that require multiple contacts, and IPTp is not exception. The difficulty in achieving two doses when that was policy was clear. Now that WHO recommends monthly dosing from the second trimester forward (giving the possibility of 3, 4 or more doses), the service delivery challenge is heightened.

We can see in the attached graph from the MIS report that while there is progress, it remains well below the 2010 Roll back malaria Target of 80%. Part of the problem resides in the fact that the 2013 DHS showed only 61% of pregnant women attended even one antenatal care visit while 51% attended four or more.

The second lesson of the graph is missed opportunities. There is a gap between IPTp1 coverage of 37% and at least one ANC visit of 61%. Granted, 18% of women made their first visit in the first trimester when SP is not given, but not all of those stopped ANC then. The next evidence of missed opportunities is the gap between IPTp1 and IPTp2, almost a quarter of women who started IPTp did not get a second dose. We cannot say that the women’s own attendance gaps account for all the missed opportunities; some are likely due to health systems weaknesses such as stock-outs and health staff attention.

Key demographic factors are linked to receiving two or more IPTp doses. Only 30% or rural women received two or more compared to 50% of urban. There was a steady progression from 21% of the poorest women to 55% of those in the highest wealth quintile. A second chart also shows variation by section of the country. These access gaps are why we have advocated for supplementary distribution of IPTp through trained community health workers.

Use of insecticide treated bed nets by pregnant women shows a similar increase over time. The dip in 2013 probably related to fact that mass campaigns had occurred between 2009 and 2011 and thus by the time of the survey some nets had become damaged and abandoned. A major challenge in achieving net coverage is NOT relying on periodic distribution campaigns only, but ensuring regular and reliable supplies during routine services such as antenatal care. This again is a health systems problem that must be solved.

Net access is not only a health systems issue, bit may be factor of internal household dynamics. Even when the household possesses nets, only 63% of pregnant women therein slept under one the night before the survey. Community education needs strengthening – more than just telling people what to do but involving them is solving the problems of net use.

So as mentioned earlier, progress is being made, but more effort is needed. We are especially concerned because of the precariousness of global financial support for disease control. Nigeria needs to strategize how it can meet its own needs in protecting pregnant women and their unborn children from malaria, disability and death.

Gaining an early start to IPTp through promotion of MIP at the community level in Kenya

posterA poster entitled “Community health: Improving start of IPTp early in second trimester through promotion of MIP at the community level in Kenya” was presented by Augustine Ngindu, Gathari Ndirangu, E Nyapada, David Omoit, and Mildred Mudany from Jhpiego’s Kenya Team at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

WHO policy recommends that pregnant women living in moderate to high malaria transmission areas start receiving intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine pyrimethamine (SP) early in second trimester to prevent malaria in pregnancy (MIP).

Training Community Health Volunteers in Bungoma

Training Community Health Volunteers in Bungoma

In Bungoma County, Kenya, 52% of pregnant women start IPTp in their third trimester. Between June and September 2015, 197 Community Health Assistants (CHAs) were trained, who in-turn trained 2,344 Community Health Volunteers (CHVs) in Bungoma County.

Following the training, CHVs  registered new pregnant women at their homes and encouraged them to seek antenatal care (ANC)  and start taking IPTp early in the second trimester. The CHVs also helped to identify previously registered women who were not attending ANC and refer them to ANC for MIP services.

The CHVs, with CHA supervision, reached 44,133 pregnant women with MIP messages on starting IPTp early in the second trimester and use of a net. Data from 70 health facility registers was collected biannually and showed a 12% increase (24%-36%) in the proportion of pregnant women starting ANC attendance ? 20 weeks of pregnancy between October 2014 and March 2016.

Community Health Volunteers Encourage ANC Attendance

Community Health Volunteers Encourage ANC Attendance

Although there was a decline in the proportion of women receiving IPTp-SP between October 2014 and January 2015 and between October 2015 and February 2016 due to SP stock-outs, this did not significantly affect ANC attendance. The 12% increase in early ANC attendance is likely associated with CHV efforts in sensitizing women to start IPTp early in the second trimester and indicates a positive change in health seeking behaviour that can be sustained over time provided the commodities are available.

The success with CHVs promoting MIP at the community level has led to it being replicated in three additional counties and it will be extended in phases in other malaria endemic counties.

Joint efforts, a key to success for the Malaria in Pregnancy Program in Luanda, Angola

A poster entitled “Joint efforts, a key to success for the Malaria in Pregnancy Program in Luanda, Angola” was presented by Jhony Juarez, Adolfo Sampaio, William R. Brieger, and Domingos F. Gueve from Jhpiego’s Angola Team at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

sbmr-visit-baia-farta-dscn0523Angola, in response to WHO’s 2012 updated guidance on Intermittent Preventive Treatment in pregnancy (IPTp), revised its national malaria protocol to better address the fact that 25% of maternal mortality is caused by the disease. The new protocol was a collaborative effort of a national technical working group assisting the National Malaria Control Program (NMCP) including the National Reproductive Health Program, the national AIDS Institute, WHO, UNICEF, UNFPA and implementing partners of the U.S. Presidents Malaria Initiative (PMI).

The updated Prevention and Treatment Manual for Malaria in Pregnancy, based on the revised protocol, was approved in 2014, and efforts continued with reviewing and updating training modules, job aids and monitoring tools that would reflect the additional doses of IPTp. The Ministry of Health, with support from partners, then disseminated these materials in the provinces and municipalities where they worked. USAID’s ForçaSaúde program, with support from PMI, worked with the Provincial Health Directorate of Luanda to build capacity of 297 health professionals to implement the new guidance in 78 health facilities of four municipalities, Belas, Cazenga, Cacuaco and Viana, with a combined population of 4.3 million.

ipt-1234Comparing the IPTp data from the four municipalities between 2014 and 2015, one can see that the new guidance has started to take effect. In both years approximately 70,000 pregnant women received the first dose or around 60% of women registering for antenatal care (ANC). For the new third dose there was an increase of 85% (from 12,490 women to 23,046), and receipt of the fourth dose rose by 164% (3,345 to 8,839).

Two major challenges remain: increasing ANC registration and addressing missed opportunities to provide ANC doses for those who do attend including ensuring regular supplies of sulfadoxine-pyrimethamine for IPTp. Future progress requires continued inter-departmental collaboration among NMCP, Reproductive Health and the AIDs Institute, on-the-job training, enhanced statistical capacity, and supervision.