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Malaria in Pregnancy and its contribution to Anemia: Sharing the PMI experience

Global Nutrition Symposium April 14, 2013

Koki Agarwal, Director, MCHIP/Jhpiego Co-Chair RBM MIP WG

Malaria in Pregnancy (MIP)

MIP the basics

Stable Transmission Most of sub-Saharan Africa Pregnant women have some level of immunity 1st and 2nd pregnancies most at risk MiP contributes each year to:

400,000 cases of severe anemia every year Maternal death: 10,000 Infant death: 200,000 11% of neonatal deaths in malaria endemic African countries are due to low birth weight resulting from P. falciparum infections in pregnancy

-WHO. A Strategic Framework for malaria Prevention and Control During Pregnancy in the African Region. 2004. -Guyatt HL, Snow RW. Malaria in pregnancy as an indirect cause of infant mortality in sub-Saharan Africa. Trans R. Soc Trop Med Hyg 2001; 95: 569-76

MIP the basics (2)

Unstable Transmission Pregnant women have little acquired immunity Similar risk across pregnancies MiP contributes to:

Severe malaria Anemia Stillbirths Abortions Low Birth Weight Premature delivery, when infection occurs in 3rd trimester

WHO. A Strategic Framework for malaria Prevention and Control During Pregnancy in the African Region. 2004.

WHO Recommendations
WHO recommends a three-pronged approach to prevent and treat MIP:
1. Intermittent preventive treatment in pregnancy

(IPTp) with sulfadoxine-pyrimethamine (SP), in areas of stable malaria transmission

As early as possible in 2nd trimester During routine ANC One month apart SP can be given to a pregnant woman safely up until the time of delivery

2. Use of insecticide treated bed-net (ITN) 3. Diagnosis and treatment of malaria case mgt.
Updated WHO Policy Recommendation (October 2012)- Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP)

Effect of Malaria on Pregnancy 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.

Malaria during

Effect of Malaria on Pregnancy in Unstable Transmission Areas

Acquired Immunity Low

Clinical Illness

Severe Disease

Risk to Mother

Risk to Fetus

Source: WHO 2002.

Malaria during

MiP and Neonatal Mortality (1)

Retrospective birth cohort from 32 national crosssectional datasets in 25 African countries from 20002010 Among pregnant women in 1st or 2nd pregnancy, who had taken at least 2 doses of IPTp-SP and/or had ITN in household:
18% decrease in neonatal mortality (p <0.006) 21% decrease in LBW (p<0.001)

Malaria prevention in pregnancy is associated with substantial reductions in neonatal mortality and low birth weight under routine program conditions

Thomas P Eisele, David A Larsen, Philip A Anglewicz, Joseph Keating, Josh Yukich, Adam Bennett, Paul Hutchinson, Richard W Steketee. Malaria prevention in pregnancy, birthweight, and neonatal mortality; a meta-analysis of 32 national cross-sectional datasets in Africa. The Lancet. Published online Sept 18, 2012.

MiP and Neonatal Mortality (2)

Randomized, placebo controlled trial of IPTp-SP in 1030 pregnant Mozambican women found use of IPTp was associated with a 61.3% reduction in neonatal mortality. These results have not been replicated The results of this trial showed that, maternal malaria may have a direct effect on neonatal mortality; prevention of malaria during pregnancy can reduce neonatal mortality An increase in birth weight or gestational age is unlikely to be the explanation Presences of parasites in the placenta or in cord blood may have had a negative effect on neonatal survival.
1. Clara Menndez, Azucena Bardaji, Betuel Sigauque, Sergi Sanz, John J. Aponte, Samuel Mabunda, Pedro L. Alonso. Malaria Prevention with IPTp during Pregnancy Reduces Neonatal Mortality. PLoS ONE; Feb 2010; Vol. 5, Issue 2.

Cost Effectiveness of IPTp

Based on same study (Menedez et al), IPTpSP was highly cost effective for both prevention of maternal malaria and reduction of neonatal mortality Incremental cost-effectiveness ratio of US$1.02 per disability-adjusted life year averted.
Elisa Sicuri, Asucena Bardaji, Tacita Nhampossa, Maria Maixenchs, Ariel Nhacolo, Delino Nhalungo, Pedro L. Alonso, Clara Menndez. CostEffectiveness of Intermittent Preventive Treatment of Malaria in Pregnancy in Southern Mozambique. PLoS ONE; Oct. 2010; Volume 5, Issue 10

Malaria & Anemia

Anemia (clinical test or pallor) may be the only sign that a woman has malaria Women with anemia should be tested for malaria Women with anemia should be treated and receive an integrated package of interventions to address all its causes

Needed: an integrated package

The impact of MiP is increased when complementary interventions are given to increase intake of essential nutrients For example, an integrated package of interventions is needed to address all the causes of anemia

Complementary interventions to prevent & treat anemia

Iron-folic acid supplementation during pregnancy (currently 60 mg of iron/400 mcg of folic acid for 180 days)additional IFA for anemia Deworming during the second trimester and third trimester (where prevalence is high)
Improving maternal diet to ensure adequate intake of anemia-related micronutrients (e.g., iron, vitamin A) Decrease work load Delayed cord clamping at birth

Caveats for IPTp & IFA supplementation

WHO recommends the administration of folic acid at a dose of 0.4mg daily; this dose may be safely used in conjunction with SP- In countries with a combined IFA pill (60 mg of iron & 0.4mg folic acid) no problem Folic acid at a daily dose equal or above 5mg should not be given together with SP as this counteracts its efficacy as an antimalarial. Transition from the 5 mg dose to the combined IFA When treating of anemia in pregnancy, providers should include testing of & treatment for malaria

Results from Zambia

DHS MIS 2001/2 2006 91.4% 71.6% N/A N/A DHS 2007 94.3% 60.3% MIS 2008 N/A N/A MIS 2010 N/A N/A Attended 2+ ANC Attended 4+ ANC

Attended first ANC at <4 months of pregnancy *% of weighed newborns <2.5 KGs
Prevalence of HIV among women % pregnant women receiving IPTp 1 % pregnant women receiving IPTp 2+ % pregnant women sleeping under a mosquito ITN the previous night

4.6% N/A N/A N/A 8%

N/A N/A 69.1% 58.6% 25%

4.4% 16.1% N/A 66% 33%

N/A N/A 73% 66% 43.2%

N/A N/A N/A 70% 46%


The road to effective programs

Strengthen the ANC platform to ensure comprehensive services Develop effective policies to support programs Train providers to address all elements of FANC

Address Stock-outs of SP & ITNs at ANC Avoid inappropriate use of SP Make ITNs free for pregnant women and available through ANC


Quality Assurance
Ensure performance standards in place Drinking water for DOTS available Routine supportive supervision


Community Involvement, Awareness

Engage community to raise awareness of importance of MIP and anemia
Have women understand the

dangers Come in early for their first visit

Explore community based distribution of IPTp and IFA


Monitoring and Evaluation

IPTp uptake to be recorded in registers for HMIS Collect other data like % of women with severe anemia Collect information on ITN distribution through ANC