The American Journal of Tropical Medicine and Hygiene published a unique article in its May 2007 issue that documents how the timing and number of malaria infections during pregnancy influences child birth weight outcomes in Burkina Faso. Infection after 6 months of pregnancy was the strongest factor associated with low birth weight (LBW), but LBW was also associated with infection in early pregnancy. The challenge in determining the latter is that women in the study, as is the case in much of Africa, tended to register for antenatal care later in pregnancy. Fortunately in this study one-third of the women enrolled had first attended ANC in the first trimester and could be followed longer. This helped provide information for another important finding, that LBW is also more likely when women are infected with malaria multiple times during pregnancy.
These findings highlight the challenges of reaching pregnant women in a timely manner with malaria prevention measures including insecticide treated nets (ITNs) and intermittent preventive therapy during pregnancy (IPTp). The authors note the value of a full course of IPTp in preventing LBW, but lament that there are currently no safe drugs to use for IPTp in the first trimester. An additional challenge is that many women register for ANC too late or attend too infrequently to benefit from at least two doses after quickening at one month apart.
This points to the need to ensure that all ANC clinics have ITNs to give women on their very first visit. For those who attend and are not yet eligible for IPTp, ITNs too, prevent LBW and will provide the protection for the early infections that lead to LBW. Then if a woman gets a net early in pregnancy, she will be less likely to suffer multiple malaria infections, another risk factor for LBW.
The challenge if one of policy versus logistics. Although most malaria endemic countries point to guidelines that say a pregnant should sleep under an ITN, few have figured out the logistics of guaranteeing a regular and dedicated supply of ITNs for ANC clinics. At present ITN distribution favors campaigns as opposed to integration into routine Maternal and Child Health services. While this may favor achieving large targets among children under five years of age, it usually bypasses pregnant women.
Last week a colleague at JHPIEGO suggested that all women of reproductive age should be given an ITN. This would certainly help keep them safe from malaria whenever they get pregnant. Are donors willing to take up this challenge?