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Prevention of malaria in pregnancy in Malawi

Prevention of malaria in pregnancy in Malawi. A successful collaboration between malaria control and reproductive health Peter Kazembe Allan Macheso Ministry of Health and Population Lilongwe MALAWI. Malawi in Africa. Blantyre. Malawi: Background data.

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Prevention of malaria in pregnancy in Malawi

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  1. Prevention of malaria in pregnancy in Malawi A successful collaboration between malaria control and reproductive health Peter Kazembe Allan Macheso Ministry of Health and Population Lilongwe MALAWI

  2. Malawi in Africa Blantyre

  3. Malawi: Background data • Total Population 9.9 million (1998) • GNP per capita US$170.00 (1995) • Literacy rate 44% (1995) • Pregnant women HIV positive 25% • Antenatal care from trained personnel 93% • Deliveries by Doctor/Nurse/Midwife 56% • Malaria cases / 100 000 population 49,400 • Source: Human Development Report 1998, • Malawi Demographic and Health Survey 2000

  4. Malaria in Pregnancy in sub-Saharan Africa • 23 million pregnancies in malarious areas • Infection during pregnancy contributes significantly to: • maternal anemia • low birth weight and their consequences • In Malawi malaria is endemic, most pregnant women • are at risk

  5. Malaria morbidity and mortalityin pregnancy • 59% pregnant women attending antenatal clinic anemic (Hb <11 gm) • Low birth weight (LBW) in Malawi contributes to: • - 80% of all neonatal deaths • - 46% of perinatal deaths • - 38% of infant mortality (1996, McDermott et al) • Prevention of malaria in pregnancy one of the main objectives of RBM

  6. Alleviating the burden of malaria in pregnancy in Malawi • Prior to 1993 weekly chloroquine (CQ) prophylaxis given with • no initial treatment dose • MMRP showed unacceptably high placental malaria infection • in women given CQ prophylaxis compared to those given • mefloquine • Current recommendation: two preventive intermittent treatment with sulfadoxine-pyrimethamine (SP) at 1st ANC visit (2nd trimester) and early in 3rd trimester (28 - 34 weeks) • The two SP doses given at same time and interval as TTV

  7. Placental malaria infection by gravidity and antimalarial drug regimen, MMRP, 1987 - 1990 % Chloroquine Mefloquine Drug regimen Steketee R.. et al, 1996

  8. WHO recommendation for malaria prevention during pregnancy “Intermittent treatment with an effective preferably one dose antimalarial drug delivered in the context of antenatal care”

  9. Abuja Declaration “At least 60% of all pregnant women who are at risk of malaria, especially those in their first pregnancies, will have access to chemoprophylaxis or presumptive intermittent treatment”

  10. Malaria prevention during pregnancy: essential players for successful implementation • Pregnant women - knowledge & willingness • Nurse / Midwife / Obstetrician • Pediatrician • Malaria control program • Reproductive health program • Antenatal clinic attendance and literacy - two most significant factors for LBW in adolescents mothers. • Brabin et al, 1998]

  11. Evidence to support preventive intermittent treatment (PIT) with SP • Two doses of SP compared to single dose in • pregnancy result in reduction in incidence of • LBW • from 33.9%to 13.5% in primigravidae • from 13.9% to 6.5% in multigravidae(Verhoeff et al, 1998) • Women taking two or more doses of SP • deliver babies 195g heavier than those among • women not taking SP(Rogerson et al, 2000)

  12. Implementation of PIT:example of adequate knowledge 90% women stated SP was best antimalarial drug 81% knew to take 3 tablets SP for malaria treatment 67% knew PIT should be taken 2 or more times in pregnancy 97% knew malaria was dangerous in pregnancy 82% thought SP was safe in pregnancy BIMI - Blantyre household KAP survey, Feb 2000

  13. Constraints to implementation of PIT • HIV sero-prevalence (documented low • efficacy of PIT-SP in sero-positive • women) • First ANC visit high (>90% in most studies) • however, subsequent attendance low • with resultant fall in PIT coverage

  14. Constraints to implementation:examples of low PIT coverage Chikwawa 43.1% primigravidae had full PIT 45.9% multigravidae had full PIT (Verhoeff et al,1998) Blantyre 30.0% received full PIT 24.0% did not get any SP dose (Rodgerson et al, 2000) Mangochi 24.0% received full PIT (Sullivan et al, 1999)

  15. Conclusions • Antenatal attendance is high in Malawi • Most women recognize malaria as a problem, and • PIT-SP as possible solution • Most pregnant women receive the 1st dose of PIT- SP but not the 2nd dose • Current national coverage of PIT-SP of 37% in Malawi far from the 60% Abuja objective; target achievable with careful collaboration between malaria control and reproductive health programs

  16. Conclusions Mothers have good knowledge of PIT, the 2 programs should provide opportunities to increase impact of interventions including promotion of ITM’s

  17. Acknowledgement Centers for Disease Control, Malaria Epidemiology Section

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