Category Archives: Malaria in Pregnancy

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.

Accelerating IPTp uptake through updated WHO IPTp guidance in Malawi

A poster entitled “Building Capacity to accelerate IPTp uptake through the adoption of 2012 WHO IPTp guidance in Malawi” was presented by John Munthali, Lolade Oseni, Dan Wendo, Kabango Malewezi, and Tambudzai Rashidi from Jhpiego’s Malawi Team at the

Community activities encourage IPTp uptake in Malawi

Community activities encourage IPTp uptake in Malawi

65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

Malawi adopted the World Health Organization’s updated guidance on intermittent preventive treatment in pregnancy (IPTp) in 2013. Support from the US President’s Malaria Initiative through USAID funded health projects, enabled collaboration between the National Malaria Control Program (NMCP) and the Reproductive Health Directorate (RHD) of the Ministry of Health, to build capacity from national to district to frontline health facility levels to implement the updated IPTp policy.

iptpaccessThese partners updated IPTp policy in the National Malaria Treatment Guidelines, and developed appropriate training manuals. All 5708 health workers from the 304 facilities in the 15 project districts were trained on the IPTp policy and guidelines. Post-training test scores of health staff increased over pre-test by an average of 40 percentage points.

The community action cycle approach engages community volunteers and local community based organizations to identify and solve local problems and was used to encourage pregnant women to attend antenatal care (ANC) and receive IPTp and long lasting insecticide-treated nets.

Sample page from ANC register showing delivery of IPTp3 and 4, but these data are not yet recorded on summary HMIS forms

Sample page from ANC register showing delivery of IPTp3 and 4, but these data are not yet recorded on summary HMIS forms

Health information system data from the 15 Districts were used to compare ANC and IPTp coverage for 2012 and 2015 fiscal years (Oct.-Sept.). ANC registration in the project area rose from 113,683 to 394,116. IPTp1 as a proportion of ANC registration rose from 52% to 87%, and IPTp2 increased from 17% to 62%. While IPTp3 doses were recorded in the ANC registers, reporting forms in 2015 still did not include space to enter this IPTp3.

Observations at clinics showed IPTp3 and 4 were provided. Malawi’s experience shows that collaboration between NMCP and RHD as well as between clinics and communities not only disseminated knowledge of the new policy, but resulted in increased uptake of services and protection of pregnant women from malaria.

Collaborative efforts to improve prevention of malaria in pregnancy in Burkina Faso through use of IPTp-SP

Mathurin Dodo, Stanislas Paul Nebie, Ousmane Badolo, Thierry Ouedraogo, Rachel Waxman, Danielle Burke, William R. Brieger, and Elaine Roman of Jhpiego’s USAID sponsored Improving Malaria Care project based in Ouagadougou, Burkina Faso will be presenting a poster on improving intermittent treatment of malaria in pregnancy at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene on Monday 14th November in Atlanta. Their Abstract follows:

Ensuring the inclusion of IPTp3 doses and higher in the national health information system enabled documentation of improved coverage

Ensuring the inclusion of IPTp3 doses and higher in the national health information system enabled documentation of improved coverage

Malaria remains the first cause of consultation (47%), hospitalization (62%) and death (31%) in health facilities in Burkina Faso (2014 Statistical Yearbook). Pregnant women are among the most vulnerable to malaria. Intermittent preventive treatment in pregnancy (IPTp) is a priority intervention in the Burkina Faso 2011-2015 National Malaria Strategic Plan. In 2012, IPTp2 was low across the country at 53%.

The President’s Malaria Initiative (PMI) supported the National Malaria Control Program (NMCP) in implementing the national malaria control strategic plans. IPTp was promoted through 3 strategies: advocacy and policy updates, capacity building, and behavior change communication. Malaria prevention and management guidelines and job aids updated stressed IPTp in line with WHO recommendations.

iptp-for-blog185 trainers were trained who in turn organized one-day briefings for over 1,300 healthcare providers from 1081 health facilities (61.3% of health facilities nationally) on the revised guidelines, which were distributed along with job aids. Health information system tools now reflect new IPTp guidance, and 190 district and regional level data managers were trained in their use.

208 community health workers were trained in sensitization and community mobilization around early ANC attendance. Over 3000 radio and TV spots were aired on 28 stations on the importance of IPTp.

iptpIn 21 project districts in 2013, IPTp2 and IPTp3 coverage rates based on ANC registration were 54% and 0%. Following the interventions, rates in these districts increased to 72% (IPTp2) and 23% (IPTp3) in 2014 compared to 63% and 8% in the other 42 districts.

These efforts have resulted in improvements in IPTp service delivery and reporting. Based on successes, training and guideline dissemination continued in 2015 across the country so that all health facilities received copies of the new guidelines and 82% of districts received training.

Kenya: Tackling stock-outs of medicines for intermittent preventive treatment of malaria in pregnancy

Augustine Ngindu of Jhpiego/MCSP Kenya shared with the Jhpiego Malaria Team at their pre-ASTMH 2016 Annual Meeting retreat the experience in Kenya of drug stock-outs and efforts to combat this.

dscn0339Kenya has experienced periods of Sulfadoxine-Pyrimethamine (SP) stock-outs thus threatening the coverage of intermittent preventive treatment to prevent malaria in pregnant women (IPTp). The situation has stabilized from March 2016 through efforts by Jhpiego and the USAID Maternal and Child Survival Program (MCSP) in collaboration with Kenyan health authorities and partners at national, county and facility levels.

Jhpiego’s key interventions focused at several levels. At the national level technical assistance was provided to relevant Ministry of Health (MOH) departments (e.g. malaria, reproductive health and community strategy). In particular the situation on the ground has been used for advocacy with decision makers and managers on prioritizing procurement of SP.

At the County level Jhpiego is building capacity of counties in provision of MIP services by developing clinical mentors. Again advocacy was carried out on prioritizing inclusion of budget itesp-stock-out-affects-iptp-coveragem for SP.

At the health facility level Jhpiego is strengthening the capacity of health facilities to provide MIP services. These activities include training of health care workers and monitoring their performance in terms of maintaining, ordering and redistribution of SP stocks. In addition Jhpiego worked with the MOH to establish malaria in pregnancy (MIP) service standards to enhance the provision of quality services in 336 facilities providing ANC services.

Then at the community level Jhpiego and partners promote MIP service utilization at community level by sensitizing pregnant women to start IPTp early in second trimester. Community health volunteers sensitize pregnant women to start IPTp early in second trimester. Hopefully increased demand will also pressure program managers to supply regular SP stocks.

Concerning the service standards, baseline data collected after immediately training found that 50% of facilities were maintaining SP stocks. A second assessment done during supportive supervision 3 months after training found 86% of facilities now met the standard. As a result of county level advocacy, redistribution of SP was done from over-stocked to under-stocked health facilities.

In conclusion, advocacy is a powerful tool in getting things done as evidenced by responses of County Directors of Health, national government and health development partners on prioritizing procurement of SP. This led to availability of adequate SP stocks to last the country up to 2019.

Malaria Excerpts from WHO’s New Antenatal Care Recommendations

new-who-anc-recommendations-2016Many years ago WHO formulated guidance for encouraging 4 Focused Antenatal Care (FANC) that addressed the reality that 1) ANC attendance schedules were not standardized, 2) service package elements were not clearly laid out, and 3) women found it difficult to attend ANC as many times as some countries recommended. The New York Times reported that WHO now recommends 8 ANC visits in large part because greater action is needed in light of the fact that …

“About 300,000 women die in pregnancy or childbirth each year, the agency said, and more than six million babies die in the womb, during birth or within their first month. Many of those deaths can by prevented through simple interventions.”

The new recommendations number 49 and strongly consider the roles of all health workers from auxiliaries to doctors – stressing task shifting to ensure that women have access to life saving services.  Below are extracted some of the aspects that relate to malaria.

  • In areas with endemic infections that may cause anaemia through blood loss, increased red cell destruction or decreased red cell production, such as malaria and hookworm, measures to prevent, diagnose and treat these infections should be implemented.
  • Malaria prevention: intermittent preventive treatment in pregnancy (IPTp): In malaria-endemic areas in Africa, intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommended for all pregnant women. Dosing should start in the second trimester, and doses should be given at least one month apart, with the objective of ensuring that at least three doses are received.

The above recommendation has been, “Integrated from the WHO publication Guidelines for the treatment of malaria (2015), which also states: ‘WHO recommends that, in areas of moderate-to-high malaria transmission of Africa, IPTp-SP be given to all pregnant women at each scheduled ANC visit, starting as early as possible in the second trimester, provided that the doses of SP are given at least 1 month apart. WHO recommends a package of
interventions for preventing malaria during pregnancy, which includes promotion and use of insecticide-treated nets, as well as IPTp-SP’. To ensure that pregnant women in endemic areas start IPTp-SP as early as possible in the second trimester, policy-makers should ensure health system contact with women at 13 weeks of gestation.”

  • anc-attendance-4-countriesTask shifting components of antenatal care delivery: Task shifting the distribution of  recommended nutritional supplements and intermittent preventive treatment in  pregnancy (IPTp) for malaria prevention to a broad range of cadres, including auxiliary
    nurses, nurses, midwives and doctors is recommended.

Readers should download the full set of recommendations for more details on the above. We do offer a challenge. Since the 4-visit FANC processes, that was adopted in part because of the difficulty in getting pregnant women to attend ANC many times, is still not fully achieved (see graph), we must now strengthen community involvement, mobilization and education to double that target to 8 visits. Efforts must focus on women, men, elders and even youth. Health workers also need education and motivation to adopt a client-friendly attitude to make this new schedule work.

Kenya – the long road to controlling malaria in pregnancy

Augustine Ngindu, the Technical Advisor for Malaria in Kenya’s Maternal and Child Survival Program (USAID, Jhpiego) shares with us the steps and processes in building a national response to controlling malaria in pregnancy (MIP) in Kenya.

Recently Stephanie Dellicour and colleagues wrote about the challenges in the delivery of interventions to prevent malaria in pregnancy in Kenya in Malaria Journal. They examined MIP services in Nyanza Province of western Kenya between February and May 2010. At that time they found that, “… delivery of  IPTp (intermittent preventive treatment in pregnancy) and ITNs (insecticide treated nets) through ANC (antenatal care) was ineffective and more so for higher-level facilities. This illustrates missed opportunities and provider level bottlenecks to the scale up and use of interventions to control malaria in pregnancy delivered through ANC.”

Kenya National malaria StretegySince that time the National Malaria Control Program (NMCP) has made efforts to address these problems by building on the national malaria strategy (NMS) 2009-2017 that recommend provision of IPTp only in high malaria transmission areas based on strong epidemiological evidence.  In 2010 NMCP revised the national guidelines on diagnosis, treatment and prevention of malaria in line with the NMS 2009-2017. Then in 2011 NMCP in collaboration with Jhpiego developed simplified MIP guidelines on provision of IPTp in line with the national guidelines (each pregnant woman to receive at least 2 IPTp doses starting from 16 weeks of pregnancy at 4 weeks interval). Also in 2011 Maternal and Child  health care workers in all 14 high malaria transmission areas were trained on provision of MIP using the simplified guidelines.

Trends in IPTp in Malaria Endemic Areas fromIn 2012 health facility in-charges in the same high transmission areas were trained on MIP quality performance improvement. Then in 2013 promotion of early start of  IPTp in the second trimester through sensitization of pregnant women was started in two out of the 14 malaria endemic counties. This resulted in increased IPTp2 coverage from 25% as reported in the kenya Malaria Indicator Survey) (KMIS 2010) to 63% (US-CDC survey 2013).

From 2014 to date the practice of sensitizing pregnant women using community health workers/volunteers has been replicated in other counties. IPTp2 coverage has increased from known 25% (KMIS 2010) to 56% (KMIS 2015) in the malaria endemic counties. Likewise use of ITNs by pregnant women increased from 50% in 2010 to 79% in 2015.

Although IPTp coverage is still below national target, the lost opportunities are being addressed. Kenya is still confronting multiple challenges including SP stock-out and devolution of health services to county governments but is set on making progress and saving mothers’ lives.

Husbands, Wives and Malaria: what do we know about male involvement?

A recent article in PLoS One highlights the positive role husbands’ involvement can have in saving the lives of their pregnant wives. A 9-item scale of husband involvement was developed, and although it did not include malaria related content because the Tigre Region of Ethiopia is not malaria endemic, the items relating to support for antenatal care attendance are certainly relevant to malaria elsewhere. Overall, maternal survival was strongly associated with higher levels of husbands’ involvement.

DSCN7129a pregnant women get ITNs when register for ANC RwandaThe importance of male or husband involvement in malaria in pregnancy services is usually assumed. For example, in Rwanda husbands are encouraged to attend at least the first ANC visit with their wives where HIV testing is done and ITNs provided.

Unfortunately the assumption about male involvement is backed by little published literature. In Mali, for example, “health facilities operating under the cost-recovery model strive to provide free IPTp, their own financial constraints often make this impossible.” When costs are connected to this malaria preventive service, “Costs … complicate household budgeting for health care, particularly as women often rely on their husbands for money.”  In Uganda husbands’ encouragement was a significant factors influencing adherence to IPTp with SP.

Use of insecticide treated bednets in prevention of malaria by women in India was indirectly influenced by their husbands. Use was positively associated by women’s decision making power as well as by husband’s educational level, with an implication that husbands are important in understanding women’s decision making.

DSCN7276There is more information about male involvement in antenatal care generally. These studies show positive outcomes in terms of ANC services uptake, and from that one may make the assumption that greater access to and use of these services can help prevent maternal deaths.

In Indonesia, “full family, particularly husband’s, support” is associated with adherence to maternal iron-folic acid (IFA) supplementation during pregnancy. The researchers concluded that husband’s support is especially important for less educated women. A study in Pakistan reported that “restriction from husband or mother-in-law” was a barrier to ANC attendance. Likewise in Uganda lack of support from husband/partner was a barrier to attending ANC and skilled delivery.

A qualitative study in Ghana aptly titled, “What men don’t know can hurt women’s health” showed a reluctance to be involved. Findings suggested that, “Although many men recognize the importance of skilled care during pregnancy and childbirth, and the benefits of their involvement, most did not actively involve themselves in issues of maternal healthcare unless complications set in during pregnancy or labor. Less than a quarter of male participants had ever accompanied their wives for antenatal care or postnatal care in a health facility.” Four barriers to male involvement included –

  1. perceptions that pregnancy care is a female role
  2. belief that men who accompany their wives are being dominated by their wives
  3. unfavorable service factors – hours, staff attitudes
  4. high costs associated with accompanying women to seek maternity care (direct and indirect)

Finally, going back to Rwanda, making male involvement a requirement, might in some cases backfire. The recommendation was seen as “a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners.” Clearly not every pregnancy is the result of a loving mother-father dyad.

Since malaria is a major cause of maternal morbidity and mortality, more work is needed in malaria endemic areas to understand the life-saving role of male/husband involvement. This role will vary by culture, the local economy and the structure of health services, but a better understanding of the male role and practical interventions based on the findings will be valuable investments.

Malaria and Stillbirths – preventable scourges

silence around stillbirthsThis month The Lancet is publishing a series of articles and commentaries about the unspeakable silence around the problem of stillbirths. Luc de Bernis and co-authors state the political side of the equation: “Stillbirths have had even less political attention than other important public health issues, such as HIV or malaria, even though the burden is greater and solutions exist that would benefit women and children.” By their estimate in, “sub-Saharan Africa … malaria in pregnancy is estimated to be associated with about 20% of stillbirths.”

A summary of the series makes it clear that, “Most result from preventable conditions such as maternal infections (notably syphilis and malaria), non-communicable diseases, and obstetric complications.” The key role of malaria is not surprising since “75% (of stillbirths occur) in sub-Saharan Africa and south Asia” where malaria is endemic.

DSCN8010 Providing IPTp in ANCAs part of the Lancet Series Joy Lawn and colleagues explain that, “Many disorders associated with stillbirths are potentially modifiable and often coexist, such as maternal infections (population attributable fraction: malaria 8·0% and syphilis 7·7%).” Of course action against malaria takes recognition of the problem. In a commentary as part of the Lancet series Juliet Kiguli et al. present a case study of a woman who reported several bouts of malaria prior to her stillbirth, but they lamented that a greater understanding of social and cultural factors is needed because in many communities people attribute stillbirths to spirits and super-natural forces and may fail to see a simple solution like preventing malaria in pregnancy.

Unfortunately methods to prevent malaria in pregnancy through intermittent preventive treatment and insecticide treated nets lag far behind targets. The Global Call to Action to defeat malaria in pregnancy reported that …

  • While IPTp increased from <5 % (2003) >20 % (2010) average coverage rates have stagnated between 22 % and 24 %, which is very much lower than global targets o 80 % by 2010, and 100 % (universal coverage) by 2015
  • ITN coverage is comparatively better that IPTp but is still unacceptably low at 38 % overall

Women do attend antenatal care clinics where these preventive services are offered, but health systems failures such as poor commodity planning lead to stockouts. Community delivery of MIP services helps, but only if health staff accept community partnership and make commodities available. Until we can break the silence on stillbirths and the lack of action of malaria in pregnancy prevention, unborn children and their mothers will continue to suffer.

Community Directed Interventions to Enhance PHC and MCH

William Brieger of the Department of International Health, JHU Bloomberg School of Public Health, delivered the keynote address to the Community Based Primary Health Care Working Group at the 2015 American Public Health Association in Chicago. The focus was on Community Directed Interventions (CDI) as a way to enhance implementation of primary health care and maternal and child health. Some excerpt from the talk follow.

Ivermectin coverageThe origins of the CDI Approach are based in Onchocerciasis Control and the implementation research done by the Tropical Disease Research (TDR) Program of WHO and collaborating agencies to help establish the foundational guidance of the African Program for Onchocerciasis Control in 1995. Since then we have seen an expansion of CDI into other health issues

We should start discussion with an understanding of ‘community’ which Rifkin et al. (1988) defined as a group of people living in the same defined area sharing basic values, organization, and interests. White (1982) proposed that community is an informally organized social entity which is characterized by a sense of identity. Manderson et al. (1992) in their work for TDR defined community as a population which is geographically focused but which also exists as a discrete social entity, with a local collective identity and corporate purpose.

Communities are people sharing values and institutions. Community is based on locality (geographic), interdependent social groups, interpersonal relationships expressed through social networks and built on s culture that includes values, norms, and attachments to the community as a whole as well as to its parts. Prior to developing any community intervention we must understand the boundaries, composition and structure of a community from the perspectives of its own members, as their local knowledge and participation are central to success.

community systemsCommunity Systems Strengthening has been taken up by the Global Fund in order to enhance coverage of various health interventions such as HIV drugs and bednets to prevent malaria. Community systems are community?led structures and mechanisms used by communities through which community members and community based organizations and groups interact, coordinate and deliver their responses to the challenges and needs affecting their communities. Many community systems are small?scale and/or informal. Others are more extensive – they may be networked between several organizations and involve various sub?systems. For example, a large care and support system may have distinct sub?systems for comprehensive home?based care, providing nutritional support, counselling, advocacy, legal support, and referrals for access to services and follow?up.

Efficacy, Social Control and Cohesion are important characteristics of communities that enable them to take on project and solve problems. Collective Efficacy is a perceived ability to work together. Social control provides evidence that communities are able to enforce their norms. Cohesion describes social interaction that brings people together. A strong sense of identity and a sense of belonging describe communities that can get things done. These characteristics lead to community competency to collaborate effectively in identifying the problems/needs of the community, achieve a working consensus on goals and priorities, agree on ways and means to implement the agreed-upon goals, and collaborate effectively in the required actions.

Communities chooseIt is important to distinguish between Community Based Intervention (CBI) and Community Directed Intervention. CBI takes place in the community but a Health/Development agency exercises authority over decisions on project design and implementation. Project activities (e.g., service delivery dates and procedures) are designed by the agency. Activities simply happen in the community.

With CDI the community exercises authority over decisions and decides on acceptable method to implement projects. This ensures sensitivity to local decision-making structures and social life. Activities happen both in and by the community; the community is in control.

CDI was pioneered for Onchocerciasis (River Blindness) Control as community directed treatment with ivermectin (CDTI). When communities are in charge, coverage is better than when ivermectin distribution is centrally organized by a health agency. The original 1995 CDI field testing showed better ivermectin coverage when the community was in charge of distribution. Since the beginning of CDTI, over 200,000 villages in 18 African countries have been distributing ivermectin annually through their own efforts. Lessons learned over the years are that CDI works best when 1) the smallest level of an organized community is the basis of action (e.g. a hamlet, a clan/kin group) and 2) communities are encouraged to choose as many CDDs as they think they need to get the job done. This means that the community is in charge, not individual volunteers who can be replaced anytime the community finds the need.

With CDI for onchocerciasis or any other health program, Communities plan and chose how to deliver services. This may be house-to-house, central place distribution or a combination. Health workers provide training and supervision to volunteer village health workers called community directed distributors (CDDs).

CDI study 2008TDR observed that CDI naturally expanded to include other services wanted by the community such as immunization, community development, water and sanitation, agriculture and forestry, HIV-AIDS, family planning, guinea worm, Vitamin A. TDR and APOC then decided that CDI with other service components should be systematically tested. The project sites added in a systematic manner other interventions to existing CDTI programs including home management of malaria, ITN distribution & promotion, TB DOTS, Vitamin A in addition to continued ivermectin distribution. These services varied in complexity and communities responded by dividing the work among several different volunteers.

Appropriate malaria treatment CDI studyCoverage of interventions like malaria case management, ITN promotion and Vitamin A distribution was higher in the intervention areas compared to the delivery of these services through the routine health system. TB DOTS presented the only challenge because of the social stigma associated with the disease. The study concluded that CDI can effectively incorporate high impact, evidence based interventions while at the same time maintaining and increasing ivermectin coverage. Since CDI does not rely on one volunteer but whole community effort, the problem of overburdening on community health worker did not arise. Other incterventions ould benefit from CDI such as Misoprostol, Intermittent Preventive Treatment, Deworming, Oral Rehydration solution, Zinc, Cotrimoxazole, Amoxicillin, Soap for handwashing and WaterGuard treatment kits.

MIPJhpiego an NGO affiliate of the Johns Hopkins University used CDI to deliver malaria in pregnancy (MIP) prevention services in Nigeria including Intermittent Preventive Treatment and Insecticide Treated Nets. Contrary to fears that CDI would detract from antenatal care attendance, the work of CDDs actually ensured that ANC attendance increased over time. Through CDI IPTp coverage increased compared to control communities and more pregnant women slept under ITNs regularly.

Community-Clinic modelJhpiego next expanded CDI for MIP into integrated Community Case Management (iCCM), thus taking community case management beyond community based care. Giving communities responsibility for organizing and managing their services using the CDI approach meant greater access to services whenever people need them. Using the CDI approach to iCCM CDDs reached 7,504 clients who presented signs and symptoms of malaria. CDDs successfully conducted malaria diagnosis using the rapid diagnostic test (RDT) kits. Overall, 47.8% tested positive while 52.2% tested negative. CDDs adhered to guidelines and all the 3,587 clients with positive RDT results received appropriate anti-malarial medicines. As appropriate 21.0% were treated for diarrhoea, 11.0% for pneumonia (of whom 68.0% were referred to the health facility)

CDDsA Supervisory Checklist and Performance Standards were developed and used for Assessing CDD performance. The results were discussed at monthly CDD meetings at their nearest health facilities. This led to further improvements in History taking, Examination, Conducting RDTs for Malaria and Illness Management.

TDR has done further scoping to learn if CDI would be acceptable by health workers and community members in Urban, Nomadic and Underserved Rural Communities. CDI was favorable received. In conclusion we have learned over the years that CDI can involve women, families and communities in meeting their own health needs.

Factors associated with the uptake of malaria prophylaxis during pregnancy among female caretakers in Madagascar

Grace N. Awantang, Stella O. Babalola, Hannah Koenker, and Nan Lewicky of the Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs presented a poster today on IPTp uptake in Madagascar. Their Abstract follows:

Grace imageIntermittent preventive treatment of malaria in pregnancy (IPTp) is one of the key interventions promoted for combatting maternal mortality and malaria. In Madagascar, supply side factors such as SP availability and ANC attendance are barriers to practicing IPTp.

Less than one fifth of women (18.4%) at risk for malaria take the recommended two doses of sulfadoxine/pyrimethamine (SP) to prevent malaria during pregnancy whereas about half (49.7%) visit a health provider at least four times during pregnancy. Understanding the significant predictors of IPTp2 is crucial in order to inform interventions that can effectively promote this behavior.

Prior research has shown that both communication campaigns and individual cognitive, social and emotional factors, ideation, play a role in determining other health behaviors including malaria. We examined the correlates of IPTp2 using cross-sectional household survey data collected from female caretakers of children under five years of age.

madagascarCaregiver recall of any anti-malaria messages during the past year was used to determine their exposure to health communication.  Knowledge of IPTp, response-efficacy of IPTp, attitudes towards antenatal care (ANC), attitudes towards ANC, discussion of IPTp, and descriptive norm about ANC determined a person’s ideation score.

Of 1,589 female caretakers, over half (56.8%) were exposed to an anti-malarial message and a tenth (10.8%) mentioned SP as the drug used by pregnant women to prevent malaria.  Message exposure, IPTp ideation and education level were all significant predictors of IPTp2 uptake in multivariate analysis.

Uptake was lowest among caretakers in the Highland transmission zone where transmission is unstable and highest in the Sub-desert transmission zone. Results suggest that both individual ideation and exposure to anti-malaria behavior change communication play a significant role in IPTp uptake among women in Madagascar.

The small portion of the variation in IPTp2 uptake explained by the measured covariates suggests that programmatic efforts should address supply-side factors that hinder access to ANC and preventive treatment of malaria during pregnancy.