Abstract
BackgroundAt least 39 sub-Saharan African countries have policies on preventing malaria in pregnancy (MIP), including use of long-lasting insecticidal nets (LLINs), intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) and case management. However, coverage of LLINs and IPTp-SP remains below international targets in most countries. One factor contributing to low coverage may be that MIP policies typically are developed by national malaria control programmes (NMCPs), but are implemented through national reproductive health (RH) programmes.MethodsNational-level MIP policies, guidelines, and training documents from NMCPs and RH programmes in Kenya, Mali, Mozambique, mainland Tanzania and Uganda were reviewed to assess whether they reflected WHO guidelines for prevention and treatment of MIP, and how consistent MIP content was across documents from the same country. Documents were compared for adherence to WHO guidance concerning IPTp-SP timing and dose, directly observed therapy, promotion and distribution of LLINs, linkages to HIV programmes and MIP case management.ResultsThe five countries reviewed had national documents promoting IPTp-SP, LLINs and MIP case management. WHO guidance from 2004 frequently was not reflected: four countries recommended the first dose of IPTp-SP at 20 weeks or later (instead of 16 weeks), and three countries restricted the first and second IPTp-SP doses to specific gestational weeks. Documents from four countries provided conflicting guidance on MIP prevention for HIV-positive women, and none provided complete guidance on management of uncomplicated and severe malaria during pregnancy. In all countries, inconsistencies between NMCPs and RH programmes on the timing or dose of IPTp-SP were documented, as was the mechanism for providing LLINs. Inconsistencies also were found in training documents from NMCPs and RH programmes in a given country. Outdated, inconsistent guidelines have the potential to cause confusion and lead to incorrect practices among health workers who implement MIP programmes, contributing to low coverage of IPTp-SP and LLINs.ConclusionsMIP policies, guidelines and training materials are outdated and/or inconsistent in the countries assessed. Updating and ensuring consistency among national MIP documents is needed, along with re-orientation and supervision of health workers to accelerate implementation of the 2012 WHO Global Malaria Programme policy recommendations for IPTp-SP.
Highlights
At least 39 sub-Saharan African countries have policies on preventing malaria in pregnancy (MIP), including use of long-lasting insecticidal nets (LLINs), intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) and case management
In October 2012, the World Health Organization (WHO) Malaria Policy Advisory Committee reviewed evidence on the effectiveness of Intermittent preventive treatment in pregnancy (IPTp)-SP in light of growing resistance to SP for treatment of Plasmodium falciparum malaria infection, and determined that use of Intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) is effective in reducing the consequences of MIP, even in areas with high levels of SP resistance
The current WHO recommendation, updated in 2012, states that in areas of moderate to high malaria transmission in Africa, IPTp-SP should be given as early as possible in the second trimester and at each scheduled antenatal care (ANC) visit thereafter, with SP doses provided at least one month apart [5]. This same document states that high dose folate (≥5 mg) should not be given concomitantly with IPTp-SP, and reiterates the WHO recommendations that pregnant women receive 30–60 mg of elemental iron and 0.4 mg of folic acid daily to reduce the risk of maternal anaemia and iron deficiency at term
Summary
At least 39 sub-Saharan African countries have policies on preventing malaria in pregnancy (MIP), including use of long-lasting insecticidal nets (LLINs), intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) and case management. The current WHO recommendation, updated in 2012, states that in areas of moderate to high malaria transmission in Africa, IPTp-SP should be given as early as possible in the second trimester and at each scheduled antenatal care (ANC) visit thereafter, with SP doses provided at least one month apart [5]. This same document states that high dose folate (≥5 mg) should not be given concomitantly with IPTp-SP, and reiterates the WHO recommendations that pregnant women receive 30–60 mg of elemental iron and 0.4 mg of folic acid daily to reduce the risk of maternal anaemia and iron deficiency at term. It notes that women receiving daily cotrimoxazole (CTX) prophylaxis should not receive IPTpSP due to an increased risk of side effects; daily CTX provides prophylaxis against malaria [6]
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