Malaria in pregnancy … and beyond

Roll Back Malaria reminds us that, ” In areas of Africa with stable malaria transmission, P. falciparum infection during pregnancy is estimated to cause as many as 10,000 maternal deaths each year,” many of which are associated with “malaria-related anaemia.”  We also know that the effects malaria in pregnancy (MIP) go beyond the birth of the child. The presence of parasites in the placenta leads to fetal growth retardation such that, “8% to 14% of all low birth weight babies, and 3% to 8% of all infant deaths” are due to MIP.

Now Malhotra and colleagues have provided new insight into additional ways that MIP can harm the newborn. Their research identified three groups of newborns based on maternal experience with malaria infection:

  1. sensitized (and thus exposed)
  2. exposed not sensitized
  3. not exposed” based on evidence of malaria parasites in the mother and cord blood.

The authors concluded that Group 1 “children exposed to malaria in utero acquire a tolerant phenotype to blood-stage antigens that persists into childhood and is associated with an increased susceptibility to malaria infection and anemia.” Group 1 children had more malaria during follow-up and were more anemic.

An accompanying editorial in PLoS Medicine pointed out that, “However, the prevalence of placental infection peaks in the second trimester, and undoubtedly many infections with the potential to affect the immune system of the fetus have been resolved well before delivery.” Thus, the reported results do not account for the overall history of MIP in a woman – an area for further research.

anc-health-education.jpgEven so, based on this research and what is already known about the dangers of MIP, there is increasing need to protect pregnant women from malaria for their own sake and that of the unborn child. Unfortunately MIP programming may be the weakest link in our efforts to roll back malaria.

The campaign approach to distribution of long lasting insecticide-treated nets (LLINs) can easily bypass pregnant women.  Even efforts at universal coverage of nets that aim to place two nets in a household or one net per two people in a community does not guarantee that pregnant women will actually have access to and use of a LLIN.  Family power dynamics and weaknesses in follow-up health education on net use are problematic.

Also many countries do not take intermittent preventive treatment in pregnancy (IPTp) seriously.  Drug regulatory agencies allow the main drug for IPTp – sulphadoxine pyrimethamine (SP) – to be sold on the open market for treatment of the general public. This drug has obviously been experiencing problems of developing parasite resistance, and continued use for general treatment will only speed up that process.

Antenatal clinics should be the only place where SP is stocked and dispensed only to pregnant women. LLIN supplies in ANC clinics should be adequate to cover all pregnant women in a community – how else will the keep up component of LLIN interventions be maintained? RDTs and ACTs also need to be accessible to ANC clients.  When will we be ready to make a serious commitment to protecting pregnant women from malaria?

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