IPTp – are controversies preventing prevention?

According to WHO, “Malaria in pregnancy increases the risk of maternal anaemia, stillbirth, spontaneous abortion, low birth weight and neonatal death.” We have interventions to help, but are we giving them our full support?Intermittent preventive treatment for malaria among pregnant women (IPTp) using the drug Sulfadoxine-pyrimethamine (SP) has been in use in antenatal clinics in Africa for over a decade. Even so, controversies remain that may deprive pregnant women of malaria protection at a time when they are most vulnerable. These controversies include questions of parasite resistance to SP and appropriate venues for administration of IPTp.

Currently WHO recommends a minimum of two doses of IPTp during pregnancy, but because of questions raised about parasite resistance to SP, WHO convened a Technical Expert Group* that concluded …

  1. Even though the IPTp policy was recommended and adopted in 1998 based on limited data, subsequent evidence has confirmed that IPTp is a useful intervention
  2. Given the possible detrimental effect that increasing SP resistance would have on the benefits and cost-effectiveness of SP-IPTp, there is uncertainty as to how long this intervention with SP will remain useful.
  3. Currently available SP efficacy data are insufficient to make specific and meaningful changes to current WHO recommendations on SP-IPTp. SP efficacy as currently measured in children cannot be extrapolated directly to the efficacy of IPTp. Therefore, in the absence of new data, the recommendation be streamlined to state that all countries in stable malaria transmission situations should deploy and scale up the strategy of SP-IPTp, until relevant data on its effectiveness under current conditions becomes available for WHO to review this recommendation.

Rwanda has already stopped using IPTp because of fears of SP resistance, although its neighbors have not made this move. The challenge of not providing IPTp is ensuring that two additional key interventions are in place, 1) provision of insecticide treated nets in the first trimester and 2) availability of prompt parasitological diagnosis and artemisinin-based combination therapy in antenatal clinics. iptp-mozambique.jpg

Unfortunately, countries are not achieving adequate coverage of these additional interventions to help pregnant women. It does not make sense to throw out an intervention like IPTp when we are so far from achieving RBM targets for protecting pregnant women. At present the effect of SP resistance may be more of reducing the duration of protection – not a reason to completely abandon IPTp until we have an alternative.

In the meantime people are raising questions about most of delivering IPTp.  Recently Ndyomugyenyia and Katamanywa reported from Uganda that ANC attendance does not guarantee that pregnant will get a full course of IPTp.  Problems of staff training and procurement and supply distribution may be in play.  Also there are concerns that although most women in Africa attend ANC sometime, they may not do so early enough and at the right intervals to successful complete two IPTp doses.

These ANC attendance concerns have given rise to community approaches. A basic community mobilization approach had positive effects in attendance and coverage in Burkina Faso. A Ugandan intervention showed that provision of SP by volunteer community agents could increase IPTp coverage.  While community volunteers did help increase coverage in Malawi, researchers there found that ANC attendance decreased in communities where volunteers were used. An ongoing study in Nigeria is testing community IPTp delivery that is strongly linked into ANC service provision (see abstract #632 at link).

Even if we can harness and improve the resources at antenatal clinics to achieve malaria prevention targets, we have problems in the wider environment. In most countries, contrary to official pronouncements, SP is still being sold to treat malaria in private pharmacies and shops. This inappropriate usage of SP will in fact contribute to increasing parasite resistance and decreasing efficacy of IPTp.  Until countries can get proper control on their drug supplies, IPTp and even appropriate treatment generally, will be threatened.

The lack of concern about protecting SP leads one to wonder whether endemic countries and donors are really concerned about protecting pregnant women from malaria and are just using SP controversies to continue their neglect of this vulnerable group.

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*Technical Expert Group meeting on intermittent preventive treatment in pregnancy (IPTp) WHO HEADQUARTERS, GENEVA, 11–13 JULY 2007.

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