Scaling Up Malaria in Pregnancy Services in Tanzania

1. Scaling Up Malaria in Pregnancy Services in Tanzania Patricia P. Gomez Clinical Specialist, ACCESS Program/JHPIEGO

2. Acknowledgments • The ACCESS/Tanzania team: • Maryjane Lacoste • Muthoni Magu-Kariuki • Gaudiosa Tibaijuka • The ACCESS/Baltimore team: • Natalie Hendler • Nancy Caiola • Barbara Rawlins • Sarla Chand • Steve Bruno

3. Overview • What is the ACCESS Program? • Why is MIP important to address? • What are Tanzania’s health indicators? • Why scale up MIP services? • How are MIP services being scaled up? • What has the program accomplished and learned, and where does it go from here?

4. The ACCESS Program • Access to clinical and community maternal, neonatal and women’s health services • 5-year, $75 million USAID flagship maternal and newborn health program • Partners: JHPIEGO, Save the Children-US, Constella Futures, Academy for Educational Development, American College of Nurse-Midwives, IMA World Health • Goals: advocacy and policy in maternal/newborn health issues at the global level; scale up known cost-effective evidence-based interventions to reduce maternal and newborn mortality

5. The ACCESS Program (2) • Currently working in 25 countries • Collaborate with Ministries of Health; international bodies (WHO, UNICEF, UNFPA, PMNCH, CDC, etc.) and USAID-funded global and bi-lateral programs • Special Initiatives • Prevention of postpartum hemorrhage • Newborn survival - KMC • Prevention and treatment of malaria in pregnancy • Pre-service education • Safe Birth Africa Initiative, Rwanda • Based on household-hospital continuum of care

6. Household-to-Hospital Continuum of Care Model Community Champions and Change Agents Household Women Newborns Family PeripheralFacility Hospital Community Groups (e.g., FBOs) * Community Leaders Service Providers * Policymakers * Private Sector Donors/Partners * USAID Missions and other CAs SocioculturalEnvironment Policy Intersectoral Stakeholders/Partners

7. President’s Malaria Initiative Launched 2005: Funding Levels and Coverage Possible plus-up of $25 million

8. PMI Goal and Targets • Goal: • To reduce malaria-related mortality by 50% in 15 selected countries • Targets: • To achieve 85% coverage of vulnerable groups with four key interventions

9. PMI Interventions • Artemisinin-based combination therapy (ACTs) • Insecticide-treated bed nets (ITNs) • Intermittent preventive treatment in pregnancy (IPTp) • Indoor residual spraying (IRS) (where appropriate)

10. Addressing MIP • 90% of all malaria illness and death in the world occurs in sub-Saharan Africa • 50 million women who live in malaria-endemic regions become pregnant each year; over 50% of them live in sub-Saharan Africa • Most common and virulent species of the malaria parasite is Plasmodium falciparum • Infection with P. falciparum may result in: • maternal anemia (2 – 15%) • fetal loss, IUGR (13 – 70%), and low birth weight (8 – 36%)

11. Why should MIP be addressed? (2) • Malaria is usually asymptomatic but leads to severe maternal anemia and low birthweight • Up to 200,000 infant deaths/year could be prevented by control of MIP • HIV increases risk of contracting malaria and worsens the disease; reduces antimalarial efficacy

12. Stable areas, e.g. Tanzania People are frequently bitten by infective mosquitoes Levels of acquired immunity are high (pregnant women are semi-immune to malaria) Low peripheral parasitemia Heavy placental infection Unstable areas, e.g. South Africa People are infrequently exposed to malaria Levels of acquired immunity are low (pregnant women are not immune) Heavy peripheral parasitemia Low or undetectable placental infection Characteristics of Malaria Transmission

13. Effect of MIP in Stable Transmission Areas Plasmodium falciparum malaria Asymptomatic Infection Placental Sequestration Altered Placental Integrity Reduced Nutrient and Oxygen Transport Anemia Low Birth Weight (IUGR) Risk of Newborn Mortality Source: WHO 2002.

14. Acquired Immunity – Low Clinical Illness Severe Disease Risk to Mother Risk to Fetus Effect of MIP Unstable Transmission Areas Source: WHO 2002.

15. Effects on the Pregnant Woman ( +++ =Very Common, ++ =Common, + =Infrequent, -- =Rare)

16. Effects on the Fetus and Newborn ( +++=Very Common, ++=Common, +=Infrequent, -- =Rare)

17. Placental Malaria Prevalence of Placental Malaria in African Women by Gravidity in Eight Studies

18. 35 30 25 20 With placental parasites 15 Without placental parasites 10 5 0 Low Birth Weight Frequency of Low Birth Weight by Placental Malaria Infection % Low Birth Weight First Pregnancy Second Pregnancy Three or more pregnancies Source: Steketee 2001: Malawi 1988-1991

19. Placental Parasitemia and HIV Placental Parasitemia by HIV Status and Pregnancy Number, Kenya, 1996-1998 (N = 2263) Parasite density/mm3 % parasitemic 231 159 197 772 402 479 HIV (+) HIV (-) Summary RR = 1.63 (1.41-1.89), p <0.001 Source: van Eijk AM et al 2001.

20. Intermittent Preventive Treatment in Pregnancy • IPTp is an approach for effectively preventing and controlling malaria during pregnancy that • Is based on an assumption that every pregnant woman in a malaria-endemic area is infected with malaria, and • Recommends that every pregnant women receive at least two treatment doses of an effective antimalarial drug as a preventive measure • Sulfadoxine-pyrimethamine (SP) currently considered the most effective drug for IPTp

21. IPTp with Sulfadoxine-Pyrimethamine • SP is a combination of two different drugs. Each tablet of SP contains: • 500 mg of sulfadoxine, and • 25 mg of pyrimethamine • A single dose consists of three tablets taken at once, preferably under direct observation of the healthcare provider • Fansidar is the most common brand name. Others include Falcidin, Laridox, Maladox, Orodar, Maloxine • SP is generally more effective than chloroquine which is no longer effective in most countries because of parasite resistance

22. Effect of IPTp with SP • Case management alone does not reduce effects of malaria in pregnancy as well as IPTp • Not all women with malaria parasites have symptoms, and therefore would not receive treatment if we relied solely on case management • IPTp produced better outcomes in terms of reducing • Maternal and placental parasitemia • Low birth weight • IPTp is as effective as case management in terms of improving hemoglobin levels

23. Rationale for the Timing of the SP Doses Fetal growth velocity  Rx Rx Last month Quickening 10 16 20 30 Weeks of gestation Birth Conception Source: WHO 2002.

24. Key Issues About Timing of Doses • SP should be avoided during the first 16 weeks of pregnancy which is the period of initial development of the fetus • It is best to clear the placenta of parasites during the period of maximum fetal growth • IPTp allows the mother to recover from anemia by clearing peripheral parasitemia • A note for the future – SP resistance is growing, and at some point a new medicine for IPTp will be found

25. Steps for Providing IPTp with SP • Determine quickening has occurred • Inquire about history of severe skin rash from previous SP use • Inquire about use of SP in last month • Provide three tablets of SP with clean water in a clean cup • Observe the patient swallowing all three tablets (Directly Observed Treatment or DOT strategy) • DOT is one reason to ensure that IPTp is an essential component of an integrated ANC program • Do not encourage women to undertake IPTp on their own

26. Steps for Providing IPTp with SP (2) • Ask about side effects from previous dose before giving the next dose, which should not be less than 4 weeks from the last dose • Record SP on the antenatal card and the clinic record • Instruct client to return at next scheduled visit or earlier if she is feeling ill • Drop-out is a major challenge for successful IPTp programs • From 20-50% of women do not receive a second dose

27. Use ITNs/LLINs • The use of ITNs/LLINs have been shown to result in reduction of low birth weight or prematurity • ITNs reduce transmission by physically preventing vector mosquitoes from landing on sleeping persons

28. ITN/LLIN Benefits • Repel and kill mosquitoes that come in contact with the net • Kill other insects like cockroaches, lice, ticks and bed bugs • Should be used by pregnant women as early during pregnancy as possible and use should be encouraged throughout pregnancy and in the postpartum period

29. ITN: Impact on Fetal Growth and Duration of Gestation • Pregnant women protected by insecticide-treated nets were less likely • To deliver prematurely or • To have small-for-gestational-age newborns • Compared to control groups who were not protected by the nets • This finding holds true irrespective of the woman’s parity, except for the incidence of small-for-gestational-age babies born to women with 4 or more pregnancies Source: ter Kuile et al 1999

30. ITN/LLIN Procurement and Management • ITNs are often provided during childhood immunization campaigns • It is less common to find ITNs allocated in adequate numbers to be an essential component of focused ANC • The district health management team needs to meet and plan for adequate nets for children <5 as well as pregnant women • ITN/LLIN provision can be an important incentive to attend ANC • A woman should get a net on her first ANC visit when it can offer the most protection during pregnancy • Issues of subsidized v. free ITNs

31. Let’s take a trip to Tanzania!

32. GENERAL Population: 34.4 million Crude birth rate: 43 Crude death rate: 14 Total fertility rate: 6.3 Life expectancy: 51 years MMR: 578/100,000 live births NMR: 32/1000 live births IMR: 68/live births HIV prevalence: 7% MALARIA-RELATED Malaria illness accounts for 40% of all outpatient visits ITN ownership: 23% Use of ITN by pregnant women: 16% One ANC visit: 94% Four ANC visits: 62% 1st ANC visit by 16 weeks: 14% IPTp1: 52% IPTp2: 22% SBA: 56% Health Indicators in Tanzania Source: Tanzania DHS 2004-2005

33. How to ensure MIP services • WHO recommends four ANC visits for women experiencing normal pregnancy • First visit should be before 16 weeks • Using ANC as a platform women receive: • Basic ANC services – iron/folate; syphilis testing/treatment; tetanus toxoid vaccination; PMTCT; health counseling – nutrition, birth spacing, breastfeeding, etc. • Counseling on use of ITNs • ITNs or vouchers to buy them at subsidized price • Intermittent preventive treatment (IPTp) • Appropriate case management of malarial illness

34. How to ensure MIP services (2) • Orientation package developed: Focused ANC/Syphilis/Malaria in pregnancy (FANC/SIP/MIP) • Providers (midwives) trained as clinical trainers at national, provincial, and district levels • Module on quality improvement added and process integrated

35. Building the training system Advanced Training Skills Workshop for FANC (One 2-week course) Participants: ZPOs, ZTC Counterparts and ZRCH Coordinators (45- 50 from all 8 zones + Zanzibar) Trainers: ACCESS Staff FANC orientation and Clinical Training Skills Workshops/FANC TOTs (Multiple 2-week courses) Participants: Regional and District RCH Coordinators; ANC in-charges; strong service providers; goal is 5 trainers/district, or 20 – 40 in each region Trainers: National trainers with support from ACCESS staff Basic FANC Orientation Workshops (Multiple 6-day courses) Participants: all FANC providers from hospitals, HCs and dispensaries Trainers: all FANC trainers

36. Issues in scaling up training • Orientation package needs approval by MOH/MCH section as well as the NMCP and must incorporate new guidelines as they come out • Districts had to commit funds to get providers trained at all levels of the system – to health center and health post levels • Tension between MOH desires for sustainable training framework and USG emphasis on numbers trained

37. Issues in scaling up (2) • Monitoring of all facilities was difficult, so system of sentinel sites (30) was introduced, but each is at a different level of development • Stockouts of SP more frequent than MOH admitted; now reported through EPI system • Zonal, regional, and district supervisors must be involved in monitoring and supervision so that providers can provide care they learned in training

38. How are MIP services being scaled up? • A total of 441 in-service trainers have been trained since 2004 • 415 from facilities in 21 regions • 26 are Zonal and Regional RCH Coordinators from all 8 zones • 2,431 providers (41% of those offering FANC) have been trained since 2004 • 25% of facilities (1,199) offering FANC have trained providers

39. How are MIP services being scaled up? (3) • Tutors and preceptors trained from all 51 nursing and midwifery schools (includes FBOs) • 28 diploma level • 23 certificate level • This year 1600 students will graduate from these programs, exposed to FANC/MIP/SIP

40. Scaling up with FBOs • About 42% of health care in Tanzania is provided by faith-based organizations • 21 providers from 15 FBO facilities trained in Mwanza region • Advocacy meetings targeting religious leaders carried out to increase dissemination of health messages to men and women

41. Scaling up through demand creation • Communities must be aware of the importance of FANC and must demand the services • Partnership formed with media groups to formulate radio messages • Advocacy to religious leaders • Some training of community workers and good support through the White Ribbon Alliance

42. How are MIP services being scaled up? (4) • Thus in sentinel sites coverage is: • IPT1 = 59%(52% DHS) • IPT2 = 41% (22% DHS) • ITN voucher distribution = 93%(75% TDHS) • Challenges include • Stock outs of SP • Data reporting/collecting • Supervision Source: TDHS 2004/5

43. How are MIP services being scaled up? (5) • Quality improvement process using performance standards is incorporated into provider training

44. ANC QI Assessment Tool

45. Assessed Sections in the ANC QI Type of assessment: Baseline= 58% -------------------------- Internal Assessment # : -------------------- External Assessment #:------------------------------------ Date: -------------------------------------------------------- % ACHIEVED = ACHIEVED STANDARDS / ASSESSED STANDARDS x 100 N.B. ALL STANDARDS HAVE TO BE ASSESSED THROUGH OBSERVATION, INTERVIEW OR RECORD REVIEW

46. Lessons Learned • Scale up = coverage + systems strengthening; FANC must be platform for integration of services • Training systems must be sustainable and should include both in-service and pre-service systems • Quality improvement processes should be built in but must be supported at the outset • Link with faith-based and private sectors • M&E paramount to guide understanding of program results and next steps

47. Conclusions • MIP coverage improves through interventions that • Strengthen the service provision platform of ANC • Mobilize community acceptance • Coverage is remarkable in districts/provinces where technical support has been offered • Effective training with simple messages • A comprehensive approach leads to improved coverage and must be adapted to country needs

48. Thank you! • Contacts: • pgomez@jhpiego.net • www.accesstohealth.org • www.rollbackmalaria.org • www.fightingmalaria.gov

49. Provoking thought • What is the role of community-based distribution in meeting the PMI goal of 85% coverage of IPTp2? • Should ITNs be given free to all pregnant women or should they have to pay a fee through social marketing?