Overcoming Barriers to Eliminating Malaria in Pregnancy

During its final day the Malaria in Pregnancy meeting in Istanbul addressed barriers to achieving malaria in pregnancy (MIP) goals at four levels: community, district/facility, national and global.

The Global Level Group  looked at global issues.  At the Global Level there is need to stress and strengthen multiple intervention package for antenatal care including malaria in pregnancy services. The group stressed that we can learn from the HIV community who promote PMTCT in ANC to and thus better promote MIP interventions in ANC.

The group also emphasized the need revise global guidance on essential drugs so Sulphadoxine-Pyrimethamine (SP) is used only for IPTp in MIP, not for malaria treatment. The group noted that there are many manufacturers of SP, but are not part of WHO pre-qualification (drug quality) process – improve quality of MIP drugs.

The Global Group observed that it takes long time for policies and evidence to filter to local level – need speed up dissemination of MIP information. The group  also pushed for harmonization of MIP guidance needed even within global organizations like WHO. We must also identify and address inconsistencies in MIP policies and messages from global level to health facility level.

They recommended MIP champions to help prioritize high burden malaria and maternal mortality areas and promote scale-up MIP services. This champion or advocacy process should take advantage of global fora and initiatives such as ‘Every Woman, Every Child’, Woman Deliver, ALMA and GMHC to share the latest evidence based information on MIP. Global advocacy should also include  publications in international journals like The Lancet on MIP and ANC packages.

The National level working group pointed out confusing guidelines as a major barrier to IPTp uptake. We cannot always wait for clarification from international partners, they noted – What to do while we wait? We we do update guidelines we need to ensure representation of all programs when updating guidelines (malaria, RH, MCH) for malaria in pregnancy. Also, countries need to simplify MIP guidelines based on learning about their own implementation barriers that can be easily overcome locally.

At national level we must focus on more than guidelines. We also need harmonized training and Monitoring and Evaluation across programs (malaria, RH, MCH) on malaria in pregnancy service delivery. At present there is often ack of coordination and harmonization across programs for that deliver MIP services. We must sit together but also harmonization implementation.

The group addressing district and facility level barriers to MIP service uptake called for user friendly services. They noted that health services must also be ‘friendly’ to the provider. In order to retain providers we must also address quality of life for staff.

Standards based management/performance improvement processes at district and facility level based on incentives including recognition may not only enhance MIP performance but give staff at these levels the tools needed to identify and solve their own problems using locally available resources and ideas.

Better tracking of commodities is needed to ensure that clients are not disappointed. We can redistribute commodities like SP within or among districts to ensure services succeed. We must prioritize SP provision as part of an essential ANC supply package.

The group stated emphatically that traditional cascade training out, that we need innovative and facility based approaches like champions at facility and text based training for malaria in pregnancy instead. Clinical mentoring and checklists can help promote malaria in pregnancy service skills, which can lead to greater consumer satisfaction and utilization.

Even when there has been traditional workshop based training the problem is that staff are often not trained on national guidelines. There is need for supervision that is also based on guidelines, not the personal beliefs and references of the supervisors. Also, without the commodities, staff can not practice what they learned.

The community focused working group started with a recognition that the ‘knowledge’ problem is a two-way street. It is not only that community members may not understand our scientific approach to defining, treating and preventing malaria. We too may fail to communicate with the community and create demand for services because we do not understand their perspectives.

The community group suggested that we combine community resource people and media and private sector actions for comprehensive malaria communication.  Mass medial can reinforce information that is shared by trusted community leaders and health volunteers.

The group debated the cost problems communities face in in accessing MIP servivces. This may include direct costs of services in some countries as well as indirect costs to the family. Women’s access to funds and income need to be considered, hence collaboration withy other sectors of the development community such as micro-finance.

The problem of linear communication from health workers to community without learning community knowledge and dialogue can be overcome if health workers are encouraged to engage in deeper dialogue with mothers, fathers, grandmothers and community leaders and become learners first, before they hope to teach about MIP.

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