Prevention and Control of Malaria during Pregnancy

1. Prevention and Control of Malaria during Pregnancy A Workshop for Healthcare Providers

2. Facts about Malaria • 300 million cases each year worldwide • 9 of 10 cases occur in Africa • A person in Africa dies of malaria every 10 seconds • Women and young children are most at risk • Affects five times as many people as AIDS, leprosy, measles, and tuberculosis combined Prevention and Control of Malaria during Pregnancy

3. Facts about Malaria and Pregnancy • 30 million African women are pregnant yearly • Malaria is more frequent and complicated during pregnancy • In malaria-endemic areas, malaria during pregnancy may account for: • Up to 15% of maternal anemia • 5–14% of low birthweight • 30% of “preventable” low birthweight Prevention and Control of Malaria during Pregnancy

4. Roll Back Malaria • Worldwide partnership • Governments, private groups, research organizations, civil society, media • Aim to reduce malaria by half by 2010 • Free advocacy resources and tools: http://www.rbm.who.int • Priority: Prevent poor outcomes caused by malaria in pregnancy • Abuja declaration: Goal is for 60% of women in Africa to be sleeping under insecticide-treated nets (ITNs) and getting intermittent preventive treatment (IPT) by 2005 Prevention and Control of Malaria during Pregnancy

5. Malaria Prevention and Treatment during Pregnancy • Focused antenatal care (ANC) with health education about malaria • Use of insecticide-treated nets (ITNs) • Intermittent preventive treatment (IPT) • Case management of women with symptoms and signs of malaria Prevention and Control of Malaria during Pregnancy

6. Prevention and Control of Malaria during Pregnancy Chapter I: Focused Antenatal Care

7. Focused Antenatal Care: Chapter Objectives • Describe four main components of focused antenatal care (ANC) • Discuss frequency and timing of ANC visits • Describe essential elements of a birth plan that includes complication readiness • Describe interpersonal skills for effective ANC • Describe components of record keeping for ANC Prevention and Control of Malaria during Pregnancy

8. Focused Antenatal Care An approach to ANC that emphasizes: • Evidence-based, goal-directed actions • Individualized, woman-centered care • Quality vs. quantity of visits • Care by skilled providers Prevention and Control of Malaria during Pregnancy

9. Goal of Focused Antenatal Care To promote maternal and newborn health and survival through: • Early detection and treatment of problems and complications • Prevention of complications and disease • Birth preparedness and complication readiness • Health promotion Prevention and Control of Malaria during Pregnancy

10. Traditional Antenatal Care • Emphasizes: • Ritualistic, “routine” care vs. evidence-based, goal-directed actions • Frequent visits • Does not emphasize individual client needs Prevention and Control of Malaria during Pregnancy

11. No Longer Recommended • Numerous, routine visits • Burden to women and healthcare system • Routine measurements and examinations: • Maternal height and weight • Ankle edema • Fetal position before 36 weeks • Care based on risk assessment Prevention and Control of Malaria during Pregnancy

12. Risk Approach Not an effective ANC strategy because: • Complications cannot be predicted—all pregnant women are at risk for developing complications • Risk factors are usually not direct cause of complications • Many “low risk” women develop complications • Have false sense of security • Do not know how to recognize/respond to problems • Most “high risk” women give birth without complications • Inefficient use of scarce resources Prevention and Control of Malaria during Pregnancy

13. Focused Antenatal Care Services Evidence-based, goal-directed actions: • Address most prevalent health issues affecting women and newborns • Adjusted for specific populations/regions • Appropriate to gestational age • Based on firm rationale Prevention and Control of Malaria during Pregnancy

14. Focused Antenatal Care Services (cont’d.) Individualized, woman-centered carebased on each woman’s: • Specific needs and concerns • Circumstances • History, physical examination, testing • Available resources Prevention and Control of Malaria during Pregnancy

15. Focused Antenatal Care Services (cont’d.) Quality vs. quantity of ANC visits: • WHO multi-center study • Number of visits reduced without affecting outcome for mother or baby • Recommendations • Content and quality vs. number of visits • Goal-oriented care • Minimum of four visits Prevention and Control of Malaria during Pregnancy

16. Scheduling and Timing of ANC Visits • First visit: By 16 weeks or when woman first thinks she is pregnant • Second visit: At 24–28 weeks or at least once in second trimester • Third visit: At 32 weeks • Fourth visit: At 36 weeks • Othervisits: If complication occurs, followup or referral is needed, woman wants to see provider, or provider changes frequency based on findings (history, exam, testing) or local policy Prevention and Control of Malaria during Pregnancy

17. Focused Antenatal Care Services (cont’d.) Care by a skilled provider who: • Has formal training and experience • Has knowledge, skills, and qualifications to deliver safe, effective maternal and newborn healthcare • Practices in home, hospital, health center • May be a midwife, nurse, doctor, clinical officer, etc. Prevention and Control of Malaria during Pregnancy

18. Early Detection and Treatment • Malaria—history and physical exam • Fever and accompanying signs/symptoms • Region • Complicated vs. uncomplicated cases • Severe anemia—physical exam, testing • Pre-eclampsia/eclampsia—measurement of blood pressure • HIV—voluntary counseling and testing • Sexually transmitted infections, including syphilis— testing Prevention and Control of Malaria during Pregnancy

19. Prevention: Key Preventive Measures • Malaria: • Intermittent preventive treatment (IPT) • Use of insecticide-treated nets (ITNs) • Tetanus toxoid, iron/folate supplements • Country/region-specific interventions as appropriate • Vitamin A supplements • Iodine supplements • Presumptive treatment for hookworm Prevention and Control of Malaria during Pregnancy

20. Birth Preparedness and Complication Readiness: Objectives • Develop birth plan—exact plan for normal birth and possible complications: • Arrangements made in advance by woman and family (with help of skilled provider) • Usually not a written document • Reviewed/revised at every visit • Minimize disorganization at time of birth or in an emergency • Ensure timely and appropriate care Prevention and Control of Malaria during Pregnancy

21. Essential Elements of a Birth Plan • Facility or Place of Birth: Home or health facility for birth, appropriate facility for emergencies • Skilled Provider: To attend birth • Provider/Facility Contact Information • Transportation: Reliable, accessible, especially for odd hours • Funds: Personal savings, emergency funds • Decision-Making: Who will make decisions, especially in an emergency Prevention and Control of Malaria during Pregnancy

22. Essential Elements of a Birth Plan (cont’d.) • Family and Community Support: Care for family in woman’s absence and birth companion during labor • Blood Donor: In case of emergency • Needed Items: For clean and safe birth and for newborn care • Danger Signs/Signs of Advanced Labor Prevention and Control of Malaria during Pregnancy

23. Danger Signs of Pregnancy • Vaginal bleeding • Difficulty breathing • Fever • Severe abdominal pain • Severe headache/blurred vision • Convulsions/loss of consciousness • Labor pains before 37 weeks Prevention and Control of Malaria during Pregnancy

24. Health Education: Objectives • Inform and educate the woman with health messages and counseling appropriate to: • Individual needs, concerns, circumstances • Gestational age • Most prevalent health issues • Support the woman in making decisions and solving actual or anticipated problems • Involve partner and family in supporting/adopting healthy practices Prevention and Control of Malaria during Pregnancy

25. Health Education: Topics Addressed • Prevention of malaria: • Intermittent preventive treatment (IPT) • Use of insecticide-treated nets (ITNs) • Other methods • Other important issues to be discussed include: • Nutrition • Care for common discomforts • Use of potentially harmful substances • Hygiene • Rest and activity Prevention and Control of Malaria during Pregnancy

26. Health Education: Topics Addressed (cont’d.) • Sexual relations and safer sex • Early and exclusive breastfeeding • Prevention of tetanus and anemia • Voluntary counseling and testing for HIV • Prevention of other endemic diseases/deficiencies Prevention and Control of Malaria during Pregnancy

27. Interpersonal Skills • Speak in a quiet, gentle tone of voice • Listen to woman/family and respond appropriately • Encourage them to ask questions and express concerns • Allow them to demonstrate understanding of information provided • Explain all procedures/actions and obtain permission before proceeding • Show respect for cultural beliefs and social norms • Be empathetic and nonjudgmental • Avoid distractions while conducting the visit Prevention and Control of Malaria during Pregnancy

28. First ANC Visit History Physical examination Testing Care provision, including provision of IPT for malaria, if appropriate Counseling, including birth plan and use of ITNs Date of next ANC visit Subsequent ANC Visits Interim history Targeted physical examination, testing Care provision, including provision of IPT for malaria, if appropriate Counseling, including birth plan and use of ITNs (and relevant information on how client obtained and used ITN) Date of next ANC visit Record Keeping Record all information on the ANC chart and clinic card: Prevention and Control of Malaria during Pregnancy

29. Prevention and Control of Malaria during Pregnancy Chapter II: Malaria Transmission

30. Malaria Transmission: Chapter Objectives • Define malaria and how it is transmitted • Describe extent of malaria in Africa • Identify groups at highest risk of malaria infection • List effects of malaria on pregnant women and their unborn babies • Describe effects of malaria on pregnant women with HIV/AIDS Prevention and Control of Malaria during Pregnancy

31. Malaria Transmission • Caused by Plasmodium parasites • Spread by female Anopheles mosquitoes infected with parasites • Anopheles mosquitoes usually active at night • Infected mosquito bites a person • Malaria parasites reproduce in human blood • Mosquito bites infected person, and goes on to bite and infect another person Prevention and Control of Malaria during Pregnancy

32. Populations Most Affected by Malaria • Children under 5 years of age • Pregnant women • Unborn babies • Immigrants from low-transmission areas • HIV-infected persons Prevention and Control of Malaria during Pregnancy

33. Effects of Malaria on Pregnant Women • All pregnant women in malaria-endemic areas are at risk • Parasites attack and destroy red blood cells • Malaria causes up to 15% of anemia in pregnancy • Can cause severe anemia • In Africa, anemia due to malaria causes up to 10,000 maternal deaths per year Prevention and Control of Malaria during Pregnancy

34. Effects on Unborn Babies • Parasites hide in placenta • Interferes with transfer of oxygen and nutrients to the baby, increasing risk of: • Spontaneous abortion • Preterm birth • Low birthweight—single greatest risk factor for death during first month of life • Stillbirth Prevention and Control of Malaria during Pregnancy

35. Effects on Communities • Causes missed work and wages • Results in frequent school absences • Uses scarce resources • Causes preventable deaths: increases maternal, newborn, and infant mortality rates Prevention and Control of Malaria during Pregnancy

36. HIV/AIDS and Malaria during Pregnancy • HIV/AIDS reduces a woman’s resistance to malaria • Intermittent preventive treatment (IPT) given 3 times during pregnancy is effective for women with HIV/AIDS Prevention and Control of Malaria during Pregnancy

37. Summary of Health Education Points • Malaria transmitted through mosquito bites • Pregnant women and children are most at risk • Pregnant women infected with malaria may have no symptoms • Women with HIV/AIDS are at higher risk • Malaria can lead to severe anemia, spontaneous abortion, low-birthweight babies • Malaria is preventable Prevention and Control of Malaria during Pregnancy

38. Prevention and Control of Malaria during Pregnancy Chapter III: Preventing Malaria

39. Preventing Malaria: Chapter Objectives • List the elements of counseling women about the use of insecticide-treated nets (ITNs) and intermittent preventive treatment (IPT) during pregnancy • Describe the use of sulfadoxine-pyrimethamine (SP) for IPT during pregnancy Prevention and Control of Malaria during Pregnancy

40. Insecticide-Treated Nets • Kill or repel mosquitoes • Prevent physical contact with mosquitoes • Kill or repel other insects: • Lice • Ticks • Bedbugs • Cockroaches Prevention and Control of Malaria during Pregnancy

41. Untreated Nets Provide some protection against malaria Do not kill or repel mosquitoes that touch net Do not reduce number of mosquitoes Do not kill other insects like lice, roaches, and bedbugs Are safe for pregnant women, young children, and infants Insecticide-Treated Nets Provide a high level of protection against malaria Kills or repels mosquitoes that touch the net Reduce number of mosquitoes in/outside net Kills other insects such as lice, roaches, and bedbugs Are safe for pregnant women, young children, and infants Insecticide-Treated Nets (cont’d.) Prevention and Control of Malaria during Pregnancy

42. Benefits of Insecticide-Treated Nets • Prevent mosquito bites • Protect against malaria, resulting in less: • Anemia • Prematurity and low birthweight • Risk of maternal and newborn death • Help people sleep better • Promote growth and development of fetus and newborn Prevention and Control of Malaria during Pregnancy

43. Benefits of Insecticide-Treated Nets: Community • Cost less than treating malaria • Reduce number of sick children and adults (helping children grow to be healthy and helping working adults remain productive) • Reduce number of deaths Prevention and Control of Malaria during Pregnancy

44. Where to Find Insecticide-Treated Nets • General merchandise shops • Drug shops/pharmacies • Markets • Public and private health facilities • Community health workers • NGOs, community-based organizations Prevention and Control of Malaria during Pregnancy

45. How to Use Insecticide-Treated Nets • Hang above bed or sleeping mat • Tuck under mattress or mat • Use every night, all year long • Use for everyone, if possible, but give priority to pregnant women, infants, and children Prevention and Control of Malaria during Pregnancy

46. Caring for Insecticide-Treated Nets • Handle gently to avoid tears • Tie net up during day to avoid damage • Regularly inspect for holes, repair if found • Nets need to be re-treated regularly to stay effective • Keep away from smoke, fire, direct sunlight Prevention and Control of Malaria during Pregnancy

47. Intermittent Preventive Treatment Based on the assumption that every pregnant woman living in an area of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria Prevention and Control of Malaria during Pregnancy

48. Intermittent Preventive Treatment Although a pregnant woman with malaria may have no symptoms, malaria can still affect her and her unborn child Prevention and Control of Malaria during Pregnancy

49. Intermittent Preventive Treatment: WHO Recommendation • All pregnant women should receive at least two doses of IPT after quickening, during routinely scheduled ANC visits (WHO recommends a schedule of four visits, three after quickening) • Presently, the most effective drug for IPT is sulfadoxine-pyrimethamine (SP) • Women should receive at least two doses of IPT with SP at ANC visits after quickening, but no more frequently than monthly Prevention and Control of Malaria during Pregnancy

50. Intermittent Preventive Treatment: Dose and Timing • A single dose is three tablets of sulfadoxine 500 mg + pyrimethamine 25 mg • Healthcare provider should dispense dose and directly observe client taking dose Prevention and Control of Malaria during Pregnancy