Category Archives: Malaria in Pregnancy

Baseline for Coverage of Intermittent Preventive Treatment of Malaria in Pregnancy for Planning Community Interventions in Burkina Faso

Under supervision from health center Community Health Worker provides SP for IPTp to Pregnant Woman

Now that the World Health Organization recommends that pregnant women in high and stable malaria transmission areas receive three or more doses of Intermittent Preventive Treatment (IPTp) with Sulfadoxine-pyrimethamine, it is necessary to learn ways to reach more women with this intervention. William R. Brieger, Mathurin Dodo, Danielle Burke, Ousmane Badolo, Justin Tiendrebeogo, Kristen Vibbert, Susan J Youll, and Julie R Gutman conducted a baseline household survey of recently pregnant women in Burkina Faso to learn about the extent of current IPTp coverage and where improvements are needed. With support from the US President’s Malaria Initiative and the USAID Maternal and Child Survival Program Their findings were made available at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

The World Health Organization recommends intermittent preventive treatment (IPTp) to prevent the adverse effects of malaria in pregnancy in high burden settings; IPTp coverage has lagged behind international targets. In Burkina Faso, the 2014 Malaria Indicator Survey found that 22% of women received 3 or more doses of IPTp (IPTp3). In 2014, Burkina Faso’s IPTp policy was updated from recommending 2 doses to providing at least 3 doses of IPTp. Prior studies have suggested that use of community health workers to deliver IPTp can increase coverage.

To improve IPTp coverage, we will pilot community delivery of IPTp within 3 southern districts: Po, Ouargaye, and Batie. Here we report results from a baseline assessment in the selected districts. Health Management Information System (HMIS) data for 2015 were collected in each district, and IPTp3 coverage was 37%. Four health facilities per district were randomly selected to participate in the pilot. In 2017, a baseline household survey was conducted among recently pregnant women in the catchment areas of these health facilities.

Women were asked to recall the number of antenatal care (ANC) visits and IPTp doses they had received during their most recent pregnancy. The same information was extracted from their ANC cards. A total of 374 women were interviewed during the baseline survey.

ANC attendance was reported to be 98% for any visit, and 84% for four visits; these rates were 90% and 62% as documented on the ANC cards. Over 95% of women recalled receiving the first dose of IPTp, while over 80% of cards verified that the first dose was given.

Receipt of the third IPTp dose was 62% by recall and 52% as recorded on the ANC cards, while receipt of 4 doses was 32% by recall and 19% per the ANC cards. IPTp3 coverage was not associated with parity or educational level.

Following implementation of the revised IPTp policy, there has been a substantial improvement in IPTp coverage, though more work is needed to achieve the national 85% coverage target.

Our pilot will examine the impact that delivery of IPTp by community workers has on IPTp coverage, with endline surveys planned for 2018.

Improving Quality of Data to Advance Malaria in Pregnancy Indicator Coverage in Ebonyi State, Nigeria

Progress in preventing malaria in pregnancy depends on good data. Bright Orji, Gladys Olisaekee, Onyinye Udenze, Enobong Umoekeyo, Chika Nwankwo, Boniface Onwe, Chibugo Okoli, and Emmanuel Otolorin of Jhpiego discussed ways to improve data quality in Nigeria  at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene with support from the USAID Maternal and Child Health Program. A summary of their points follows:

Reviewing Health Facility Data

Quality data are crucial for informed decision-making to address health challenges and improve malaria service delivery among countries on the pathway to malaria elimination. This emphasis on better data quality was reflected in the World Malaria Day theme of “Counting Malaria Out” in 2009 and 2010.

In Nigeria, improving malaria data quality has been difficult due to critical health system challenges including poor coordination across different departments, institutional complexities, and a shortage of medical record officers and service providers sufficiently trained in data visualization and use of data for decision-making. In response, the Maternal and Child Health Survival Program (MCSP) in Nigeria embarked on the implementation of key activities to improve quality of malaria data in Ebonyi State.

These activities included training on record keeping and use of data for decision-making; post training follow-up; dash boards at the frontline for better data visualization; monthly data collation meetings; improved synergy among service departments; and quarterly data quality assurance visits.  As a result, more than 75% of facilities graphed malaria indicators thereby increasing data visualization and use of data for decision-making.

An example of data improvements leading to service increases was Intermittent Preventive Treatment for malaria in pregnancy (IPTp). IPTp1 service statistics in MCSP-supported facilities improved from 54.1% in Oct-Dec 2015 to 81.3% by Jul-Sept 2016 compared to 54.7% to 67.8% in the same periods for non-MCSP facilities.

Similarly, IPTp2 service statistics in MCSP-supported facilities improved from 52.8% to 70.5%compared to 46.5% to 58.0% in the same period for non-MCSP facilities.

Data quality improvement interventions such as monthly data collation and validation meetings prior uploading data to DHIS can contribute to improved quality of malaria performance indicators, better coordination between antenatal care, outpatient and pharmacy departments and increased IPTp coverage.

Potential Contribution of Community-Based Health Workers to Improving Prevention of Malaria in Pregnancy

Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Danielle Burke, and Bill Brieger of Jhpiego have designed and are implementing a study to determine the effect of delivering Intermittent Preventive Treatment for Malaria in Pregnancy through community health workers in Burkina Faso with the support of the US President’s Malaria Initiative and the USAID Maternal and Child Survival Project. They have shared the design and start-up activities for the study at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene. A summary follows:

CHW Flipchart Page

The Ministry of Health of Burkina Faso with the support of its partners initiated a study on the feasibility of increasing provision of Intermittent Preventive Malaria Treatment in pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP) by involving existing community-based health workers (CBHWs). As Burkina Faso adopted the WHO recommendations for more doses of IPTp during pregnancy, it was proposed that the challenge of achieving coverage of third, fourth and additional doses could be met using CBHWs.

The approved protocol calls for CBHWs to refer pregnant women to antenatal care (ANC) to receive their first IPTp dose. Subsequent doses at one-month intervals would be provided by trained CBHWs, who would report back to supervising midwives at the ANC clinics. Several steps were taken to gain approval and set up the intervention.

CHW Using Flipchart

First, IPTp data from the health information system was gathered. IPTp coverage based on ANC registration in the 6 intervention clinics was 69% IPTp1, 68% IPTp2, 56% IPTP3, and 1% IPTp4. Similar information was obtained from the 6 control clinic catchment areas. Situation analysis found that while CBHW curriculum stresses the importance of ANC, it does not address IPTp at community level.

In response updated training materials have been developed. The study team also collected information on village size and availability of CBHWs, especially females. Among the villages in the catchment of the 6 intervention ANC clinics, 33 were found to lack female CBHWs.

Supervisory Meeting

As a result, the team needed to recruit additional female CBHWs, as revised national recruitment guidance stressed attainment of primary school certificate over gender, meaning mainly men had been hired previously. Two institutional review boards were involved and suggested the need to address the potential rare side effects of SP and concerns that community IPTp would not detract from ANC clinic attendance.

Since district and clinic level health staff will be involved in implementing the program using the national CBHW program, lessons learned from this effort to expand the work of CBHWs in preventing malaria in pregnancy should be applicable and adaptable to the whole country.

Improving Early ANC Attendance and IPT Uptake through Community Health Volunteers

Community health workers are playing an increasing role in maternal health programming.  Augustine Ngindu, Susan Ontiri, Gathari Ndirangu, Beth Barasa, Evans Nyapada, David Omoit, Johnstone Akatu, and Mildred Mudany of The Matewrnal and Child Survival Program, The Kenya Ministry of Health and Jhpiego share their experiences in Kenya at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene in Baltimore on 2017-11-06.  If you are in Baltimore, hear more at Scientific Session 13. Below is an abstract of their presentation

Kenya adopted the use of intermittent preventive treatment with sulfadoxine pyrimethamine in 1998 but the proportion of pregnant women receiving at least two doses (22% (2010) and 56% (2015) has remained below the national target of 80%. In 2015, the country adopted an IPTp3 indicator for monitoring IPTp uptake; that year, the proportion of women taking at least 3 doses was 38% (2015).

Some of the factors leading to low IPTp coverage include poor knowledge on the need for early antenatal care (ANC), distances to health facilities, sociocultural practices and a lack of financial resources. In 2012, community health volunteers (CHVs) were enlisted through a pilot program in one county to deliver messages aimed at increasing the proportion of women starting ANC ? 20 weeks of gestation and thus expand the proportion of women receiving IPTp early in the second trimester.

A community survey in 2013 showed an increase in IPTp2 from 22% in 2010 to 63%. The practice was considered a success story, and was subsequently replicated in 30 sub-counties, in 4 out of 14 malaria endemic counties. The rollout involved training of 9,042 CHVs, in 761 community units. Between 2015 and 2016, the CHVs reached 86,433 women with MiP messages. During this time, there was an average increase in IPTp1 from 51% to 68%, and IPTp2 increased from 42% to 55% (p? 0.001). This could be attributed to early ANC attendance, which increased from 32% to 48% in the same period.

The use of CHVs to sensitize pregnant women to start IPTp early in the second trimester and continue with scheduled ANC visits increases the probability that women will receive the recommended IPTp-SP doses. The rollout of the practice to other malaria endemic counties is likely to have contributed to increase in IPTp uptake in the four target counties.

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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!!!

Population Health: Malaria, Monkeys and Mosquitoes

On World Population Day (July 11) one often thinks of family planning. A wider view was proposed by resolution 45/216 of December 1990, of the United Nations General Assembly which encouraged observance of “World Population Day to enhance awareness of population issues, including their relations to the environment and development.”

A relationship still exists between family planning and malaria via preventing pregnancies in malaria endemic areas where the disease leads to anemia, death, low birth weight and stillbirth. Other population issues such as migration/mobility, border movement, and conflict/displacement influence exposure of populations to malaria, NTDs and their risks. Environmental concerns such as land/forest degradation, occupational exposure, population expansion (even into areas where populations of monkeys, bats or other sources of zoonotic disease transmission live), and climate warming in areas without prior malaria transmission expose more populations to mosquitoes and malaria.

Ultimately the goal of eliminating malaria needs a population based focus. The recent WHO malaria elimination strategic guidance encourages examination of factors in defined population units that influence transmission or control.

Today public health advocates are using the term population health more. The University of Wisconsin Department of Population Health Sciences in its blog explained that “Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” World Population Day is a good time to consider how the transmission or prevention of malaria, or even neglected tropical diseases, is distributed in our countries, and which groups and communities within that population are most vulnerable.

World Population Day has room to consider many issues related to the health of populations whether it be reproductive health, communicable diseases or chronic diseases as well as the services to address these concerns.

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.

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.