Tropical Health Matters

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?

Providing an insecticide treated bednet (ITNs) for all pregnant women as early in pregnancy as possible is a key malaria control strategy that not only protects the woman from malaria but improves birth outcomes and child survival. Ideally ITNs for pregnant women should be a routine service provided through antenatal care (ANC) since in many countries over 80% of pregnant women attend ANC at least once.

A major problem in achieving this goal is that in many malaria endemic communities, pregnant women who do attend ANC do not register until well into their third trimester after many months of exposure to malaria transmitting mosquitoes. At the same time, campaigns to distribute ITNs in the community usually target children under 5 years of age, not pregnant women.

A number of social and cultural factors explain poor access and timely acquisition of ITNs by pregnant women. In some cases pregnancy is considered normal and thus there is no need to register early for ANC. Pregnant and unmarried teens,who are among the most vulnerable to the effects of malaria in pregnancy (MIP), are often embarrassed to register and thus make their pregnancy publicly known.[1,2] ANC requires payments in some countries, and even when free, attendance at ANC has indirect economic costs when women miss work.

Poor service quality is another issue that keeps many women from attending ANC early or often. Finally a cultural issue that has been documented in many countries, is the reluctance of revealing one is pregnant until ‘it shows’ due to fears that jealous or evil people may curse or damage the pregnancy.[3-6]

One solution to this problem of ensuring that pregnant women get and sleep under ITNs is to give all women of reproductive age an ITN. This would make access easier and would also avoid any embarrassments or cultural fears that would come from singling out a pregnant women for a net. The Global Fund has created the capacity to distribute ITNs to over 30 million people by mid-2007. This ITN capacity should be extended to include all women.

References:

1. Sow F. To be a woman in Africa. On the danger of being a mother. Mortality [Article in French] Vivre Autrement. 1994 Oct:13-4.
2. Magadi MA, Agwanda AO, Obare FO. A comparative analysis of the use of maternal health services between teenagers and older mothers in sub-Saharan Africa: evidence from Demographic and Health Surveys (DHS). Soc Sci Med. 2007; 64(6): 1311-25.
3. Ndiaye P, Dia AT, Diedgiou A, Dieye EH, Dione DA. Socio-cultural determinants of the lateness of the first prenatal consultation in a health district in Senegal [Article in French] Sante Publique. 2005; 17(4):531-8.
4. Morse JM. Cultural variation in behavioral response to parturition: childbirth in Fiji. Med Anthropol. 1989; 12(1): 35-54.
5. Beninguisse G, De Brouwere V.Tradition and modernity in Cameroon: the confrontation between social demand and biomedical logics of health services. Afr J Reprod Health. 2004; 8(3): 152-75.
6. Chapman RR.Chikotsa–secrets, silence, and hiding: social risk and reproductive vulnerability in central Mozambique. Med Anthropol Q. 2006; 20(4): 487-515.

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.

The US Embassy in Tanzania has announced a donation of about 50 insecticide-treated nets to HIV/AIDS orphans. While this is a relatively small effort, it sets a good example for possible synergies between HIV and Malaria programming and funding.

The attached map from WHO shows the geographical overlap of the two diseases. According to WHO’s Global Malaria Program, “The resulting co-infection and interaction between the two diseases have major public health implications.

• HIV-infected people must be considered particularly vulnerable to malaria;
• Antenatal care needs to address both diseases and their interactions;
• Where both diseases occur, more attention must be given to specific diagnosis for febrile patients.”

It is important therefore that ITNs are not only given to orphans, but all HIV infected people, particularly pregnant women. Malaria enhances transmission of HIV to the child, and therefore ITNs are an important component of PMTCT. Therefore, all donor programs that have both malaria and HIV components need to plan together to serve those in need and not think only in vertical control paradigms.

PS – Thanks for your support and interest. This is our 100th malaria blog.

At our panel on malaria in pregnancy during the Women Deliver conference, a participant asked about the importance of cerebral malaria (CM) in pregnancy. Below is a brief review of recent available literature, which does indeed highlight CM as an important danger to pregnant women in certain settings.

For the most part the literature mentions the problem of CM in the form of review without presenting original data. For example, malaria is cited as one of the most frequent parasitic diseases in pregnancy in tropical countries, with CM as an important complication. [1] Such reviews distinguish that CM is more common and dangerous in low or seasonal transmission areas where the population has not built some natural immunity. CM has a wide geographic scope according to Karnad and Guntupalli who said that, “Infections such as cerebral malaria and acute viral hepatitis with fulminant hepatic failure are common causes of coma and seizures during pregnancy in tropical regions of Asia, Africa, and Latin America. [2]

As noted by Duffy and Fried, “In low transmission areas, women of all parities are at risk for severe syndromes like cerebral malaria, and maternal and fetal mortality are high. In high transmission areas, where women are most susceptible during their first pregnancies, severe syndromes like cerebral malaria are uncommon.” [3] Likewise, “Acute and severe consequences of pregnancy-associated malaria (PAM), such as materno-fetal death or cerebral malaria, seem limited to unstable malaria areas.” [4]

An example of a specific study came from Ethiopia where Mengistu et al., observed that, “Out of 204 reproductive age women admitted with severe malaria 57.8% were pregnant. Signs of severity occurred more frequently in the pregnant women and rural dwellers. The several neurological manifestations were most common complications for more than 70.0% of the pregnant women and in 60.0% of the non-pregnant women, namely cerebral malaria, convulsions, altered mental state and prostration. The case fatality rate 33.1% among the pregnant women was found to he significantly higher than the non pregnant (p = 0.03, OR 2.2. 95% confidence interval 1.1-4.2).” [5] Much of malaria in Ethiopia is of the highland and seasonal variety.

In addition a 10-year review of malaria in pregnancy cases in Karnataka, India, which had risen to an incidence1.3% in 1998, found that, “Complications noted in our study were haemolysis, renal failure, hepatopathy and cerebral malaria.” [6] In the Arusha highlands a study of maternal death documented, “cerebral malaria [as a cause] of indirect death, accounting for 20 cases, with most of them occurring during an epidemic season.” [7]

Although at present the biggest attention to malaria in pregnancy is focused on stable transmission areas of the African region, this brief review suggests that vigilance to protect pregnant women from CM in all malaria zones is required. Not only are preventive interventions needed early in antenatal care, but staff involved in emergency obstetric care need to be trained to manage CM.

References.

1. Bourée P, Bisaro F. Parasitic diseases and pregnancy [Article in French] Rev Prat. 2007; 57(2):137-47

2. Karnad DR, Guntupalli KK.Neurologic disorders in pregnancy. Crit Care Med. 2005 Oct;33(10 Suppl):S362-71.

3. Duffy PE, Fried M. Malaria in the pregnant woman. Curr Top Microbiol Immunol. 2005; 295:169-200.

4. Cot M, Deloron P.Malaria prevention strategies. Br Med Bull. 2003;67:137-48.

5. Mengistu G, Diro E, Kassu A. Outcomes of pregnancy in severe malaria with emphasis on neurological manifestations in Gondar Hospital northwest Ethiopia. Ethiop Med J. 2006; 44(4):321-30.

6. Sitalakshmi S, Srikrishna A, Devi S, Damodar P, Mathew T, Varghese J. Changing trends in malaria–a decade’s experience at a referral hospital. Indian J Pathol Microbiol. 2003 Jul;46(3):399-401.

7. Olsen BE, Hinderaker SG, Bergsjø P, Lie RT, Olsen OH, Gasheka P, Kvåle G.Causes and characteristics of maternal deaths in rural northern Tanzania. Acta Obstet Gynecol Scand. 2002; 81(12): 1101-9.

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.

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.