How free is free – costs of malaria in pregnancy services

The Nigerian Tribune announced today that, “Dr. Saraki [Kwara State Governor] will today flag off the ‘Malaria-free Kwara State’ as pregnant women and children below five years are expected to receive free malaria treatment throughout the state.” In addition, “The government had released N200 million for the procurement of insecticide-treated mosquito-nets which were expected to be distributed free to the people of the state.”

Service costs are definitely a barrier for women who need protection against malaria during pregnancy.  While the Tribune’s story does not mention other costs associated with antenatal care (ANC) where malaria services are provided to pregnant women, experiences in other states show that while long lasting insecticide-treated nets and intermittent preventive treatment are provided free to pregnant women, they must pay registration and other fees for the complete package of ANC services.  In Akwa Ibom State these fees vary from one local government to another, but basic registration can cost between US $2-5 and routine medicines like folic acid and iron can add another 50 cents – $1 each month.

What happens in Akwa Ibom and possibly elsewhere is that if women are not able to pay for the registration fees, they are not given the free services.  In the local governments where Jhpiego has a malaria in pregnancy control project, efforts have been taken to convince ANC clinic staff to provide the free services even if a woman cannot pay other fees, but some staff are reluctant because they fear entering a woman’s name for the free services unless they can also record fees collected from the same person.

In other places, like Mali, IPTp and LLINs are free, but malaria treatment for adults (including pregnant women) has costs. In many places there are time and transportation costs for pregnant women who attend ANC.  Proposals to keep ANC visits (and thus their costs) to a rational minimum through WHO’s Focused Antenatal Care (FANC) approach are often not understood or valued by health workers who believe the old schedule of an ever increasing series of monthly, then fortnightly and then weekly ANC visits is desirable even when statistical reality shows that few women attend ANC two or more times.

The challenge is not providing free malaria control services but in visualizing malaria control within integrated health care delivery – in this case antenatal care. Until efforts are made to strengthen systems and integrate services, malaria in pregnancy will remain a burden to women and newborns.

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Some recent Malaria in Pregnancy References:

  • Technical Expert Group meeting on intermittent preventive treatment in pregnancy (IPTp) WHO HEADQUARTERS, GENEVA, 11–13 JULY 2007
  • Duffy PE. Plasmodium in the placenta: parasites, parity, protection, prevention and possibly preeclampsia. Parasitology. 2007;134(Pt 13):1877-81
  • Uneke CJ. CID 2008:47 (15 October) Effects of Placental Malaria on Perinatal Outcome; Malaria and HIV. Yale Journal of Biology and Medicine, 2007; 80: 95-103
  • Schwarz et al. Placental Malaria Increases Malaria Risk in the First 30 Months of Life. Clinical Infectious Diseases 2008:47 (15 October)
  • van Geertruyden et al., The Contribution Of Malaria In Pregnancy To Perinatal Mortality. Am. J. Trop. Med. Hyg., 71(Suppl 2), 2004, pp. 35–40.
  • Brahmbhatt et al., Association of HIV and Malaria With Mother-to-Child Transmission, Birth Outcomes, and Child Mortality. J Acquir Immune Defic Syndr _ Volume 47, Number 4, 472-476.
  • Hommerich  et al., Decline of placental malaria in southern Ghana after the implementation of intermittent preventive treatment in pregnancy Malaria Journal 2007, 6:144
  • Ter Kuile, et al., Reduction Of Malaria During Pregnancy By Permethrin-Treated Bed Nets In An Area Of Intense Perennial Malaria Transmission In Western Kenya. Am. J. Trop. Med. Hyg., 68(Suppl 4), 2003, pp. 50–60.
  • Sirima et al., Malaria Prevention During Pregnancy: Assessing The Disease Burden One Year After Implementing A Program Of Intermittent Preventive Treatment In Koupéla District, Burkina Faso. Am. J. Trop. Med. Hyg., 75(2), 2006, pp. 205–211.
  • Falade ei al., Intermittent preventive treatment with sulphadoxine-pyrimethamine is effective in preventing maternal and placental malaria in Ibadan, south-western Nigeria. Malaria Journal. 2007, 6:88
  • Brentlinger PE et al., Bull World Health Organ. 2007;85 (11): 873-9. LBW in women taking IPTp 3 times was 7% vs 12% in those taking none. (Mozambique)
  • Anders et al. Timing of intermittent preventive treatment for malaria during pregnancy and the implications of current policy on early uptake in north-east Tanzania. Malaria Journal 2008, 7:79 : Exit interviews in Tanzania found that while mean gestational month of first ANC attendance was 4.5 months, first provision of IPTp on average was at 6 months. Ultimately half of women did not get any IPTp.
  • Holtz et al., Use of antenatal care services and intermittent preventive treatment for malaria among pregnant women in Blantyre District, Malawi. Tropical Medicine and International Health volume 9 no 1 pp 77–82, January 2004
  • Roman E, Rawlins B, Gomez P, Dineen R, Dickerson A, Brieger W. Malaria in Pregnancy: The Dynamic Relationship between Policy and Program Implementation. Harvard Health Policy Review 2008; 9(1): 198-209.

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