The US Presidentâ€™s Malaria Initiative (USAID) in Ghana is supporting malaria in pregnancy programming capacity building with the Ghana Health Services through two of its partners, ACCESS and Quality Health Partners.Â We made site visits to four health facilities to get an idea of what is happening on the ground before reviewing both pre-service and in-service curricula for training midwives on malaria in pregnancy (MIP) control.
This was by no means a scientific sample, but we did visit antenatal clinics at an urban polyclinic, a district hospital, a sub-district health center and a regional hospital. Of the three main components of malaria in pregnancy control, intermittent preventive treatment (IPTp) was uniformly well implemented. Case management of malaria illness for pregnant women also appeared to be well organized. ITN stocks were available at only one facility, and sold for about Â¢2.5 (about $2 US).
While there were good stocks of sulphadoxine-pyrimethamine (SP) for IPTp, in most cases women had to buy sachets of â€˜pureâ€™ water in order to take the SP as directly observed treatment.Â ANC clinic registers and womenâ€™s ANC booklets were set up for IPTp recording, but coverage appears low.Â Ghana requires 3 doses of IPTp. At the district hospital less than half of those registering for ANC got the first dose, and only 23% got three, and in the rural sub-district, only 17% got IPTp3. Unfortunately SP was still being sold as treatment in nearby pharmacy shops.
Case management was the responsibility of a clinician, not the midwives.Â The midwives must refer women suspected of having malaria. In two clinics referral was made easier by having a rotating doctor posted in the ANC daily. Diagnosis was based on laboratory testing â€“ blood films in the three larger facilities and RDTs at the rural clinic.Â Unfortunately the latter had been without RDTs for some months.Â Clinic pharmacies were well stocked with ACTs and quinine.
ITNs were not directly available in any ANC visited. Even at the hospital where they were seen, a woman had to buy it at the childrenâ€™s outpatient department.Â Staff at the remaining clinics said they had some stock in the past.Â There was no place to record ITN provision in the womanâ€™s ANC booklet. One district malaria focal person had erroneously advised the midwives to give bednets after delivery as in incentive, thus leaving the woman exposed to malaria during pregnancy. ITNs were on sale at nearby pharmacies for between Â¢8 and Â¢12. A voucher scheme that provided a Â¢4 discount was no longer operating.
Ghana has most of the elements for good MIP control within its grasp.Â Better coordination, improved coverage and access to ITNs must be achieved.