Tropical Health Matters

The Malaria in Pregnancy Working Group of the Roll Back Malaria Partnership has compiled a briefing document on the importance and effectiveness of available interventions to protect pregnant women from malaria. Below are some of the highlights. The full document can be accessed at the MCHIP website.

The devastating consequences of Plasmodium falciparum malaria in pregnancy (MiP) are well documented; these include higher rates of maternal anemia and low birth weight (LBW) babies in areas of stable malaria transmission. In areas of unstable P. falciparum malaria transmission, pregnant women are at increased risk of severe malaria, death and still birth of the fetus. Approximately 11% of neonatal deaths in malaria endemic African countries are due to low birth weight resulting from P. falciparum infections in pregnancy. However, until recently, there was limited documented evidence of the protective effect of malaria prevention in pregnancy on neonatal mortality.

A recent meta-analysis of national survey datasets by Eisele et al. (2012) showed exposure to intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine pyrimethamine (SP) and insecticide treated bed nets (ITNs) to be associated with reductions of both neonatal mortality and LBW under routine program conditions. Menéndez et al. (2010) also showed the protective role of IPTp-SP in reducing neonatal mortality under trial conditions. Further, Sicuri et al. (2010) in the context of the Menéndez trial showed IPTp to be highly cost effective in the context of routine antenatal care (ANC) services. These studies highlight the critical importance of continuing IPTp as well as ITN use among pregnant women to prevent the adverse consequences of malaria in pregnancy.

In October 2012, the WHO Malaria Policy Advisory Committee (MPAC) reviewed guidance based on the most recent evidence of the efficacy and effectiveness of IPTp-SP in light of growing SP resistance in children and also potential SP resistance in pregnant women receiving IPTp-SP. Based on the review the MPAC determined that frequent dosing (3 doses or monthly) of IPTp-SP is effective in reducing the consequences of MIP.

WHO concluded that prioritizing IPTp as a key intervention for pregnant women (combined with ITN use and effective case management) should remain a priority across stable malaria transmission countries. The WHO’s recent policy update, confirms the critical importance of increasing the frequency of IPT-SP, in addition to ITN use among pregnant women and effective case management.

IPTp-SP and ITNs continue to have an important and significant effect on reducing neonatal mortality and LBW (low birth weight) and need to be recognized as interventions to reduce newborn mortality. IPTp and ITNs reduce neonatal mortality even in programmatic settings, where use may be less than optimal and where SP resistance may exist.

Although the majority of women attend ANC at least once during pregnancy and often twice, IPTp-SP uptake as well as ITN coverage among pregnant women is alarmingly low across most countries. This is a major missed opportunity, at present.

Key References:

• Guyatt HL, Snow RW. Malaria in pregnancy as an indirect cause of infant mortality in sub-Saharan Africa. Trans R. Soc Trop Med Hyg 2001; 95: 569-76.
• Elisa Sicuri, Asucena Bardaji, Tacita Nhampossa, Maria Maixenchs, Ariel Nhacolo, Delino Nhalungo, Pedro L. Alonso, Clara Menéndez. Cost-Effectiveness of Intermittent Preventive Treatment of Malaria in Pregnancy in Southern Mozambique. PLoS ONE; Oct. 2010; Volume 5, Issue 10
• Clara Menéndez, Azucena Bardaji, Betuel Sigauque, Sergi Sanz, John J. Aponte, Samuel Mabunda, Pedro L. Alonso. Malaria Prevention with IPTp during Pregnancy Reduces Neonatal Mortality. PLoS ONE; Feb 2010; Vol. 5, Issue 2.
• Thomas P Eisele, David A Larsen, Philip A Anglewicz, Joseph Keating, Josh Yukich, Adam Bennett, Paul Hutchinson, Richard W Steketee. Malaria prevention in pregnancy, birthweight, and neonatal mortality; a meta-analysis of 32 national cross-sectional datasets in Africa. The Lancet. Published online Sept 18, 2012.
• Anna Maria van Ejik, Jenny Hill, Victor A Alegana, Viola Kirui, Peter W Gething, Feiko O ter Kuile, Robert W Snow. Coverage of malaria protection in pregnant women in sub-Saharan Africa: as synthesis and analysis of national survey data. The Lancet. Vol. 11. March 2011.
• WHO. http://www.who.int/malaria/iptp_sp_updated_policy_recommendation_en_102012.pdf October 2012
• Guyatt HL, Snow RW. Malaria in pregnancy as an indirect cause of infant mortality in sub-Saharan Africa. Trans R. Soc Trop Med Hyg 2001; 95: 569-76.

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