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Annex L: Effective Strategies to Promote Quality Maternal and Newborn Care (May 3-5, 1999), CORE Group Workshop Presentation Summary on Malaria and Pregnancy (Dr. Monica Parise)
(from the workshop proceedings)
Dr. Parise emphasized that malaria in pregnant women is significant because it can lead to adverse consequences for both the mother and child. Most of the existing data relates to Plasmodium falciparum, though there appears to be emerging information that P. vivax may also contribute to adverse maternal/fetal outcomes. When we consider the spectrum of malaria illness that occurs in pregnant women, we must distinguish between areas of high and low malaria transmission as malaria's effects depend on the degree of maternal immunity (and, thus, on the intensity of transmission).
In areas of low transmission, generally all pregnant women have low levels of immunity and therefore, women of all parities are at risk of malaria and its complications at any time during gestation. These complications include: severe malaria illness (high fevers, anemia, cerebral malaria, and death), abortions, stillbirths, and congenital malaria. In areas of high malaria transmission (e.g. much of sub-Saharan Africa), where women have acquired substantial malarial immunity, severe malarial illness is uncommon but placental infection, which is associated with low birth weight (LBW), can occur; primigravidae and secundigravidae are most affected. In both high and low transmission settings, malaria often contributes to anemia, which is also associated with LBW.
The main intervention for prevention of malaria during pregnancy has been the use of antimalarial drugs. Antimalarial drugs that are contraindicated during pregnancy include tetracyclines and primaquine. Chloroquine (CQ), quinine, pyrimethamine, proguanil, clindamycin, and sulfadoxine-pyrimethamine (SP) are safe. There is limited safety data on halofantrine, the artemisinin derivatives, and atovaquone. In low transmission areas, because women are symptomatic when they have parasitemia, the focus is on prompt recognition of illness and appropriate case management. In high transmission areas, because many women are asymptomatic, the intervention focus is on prevention, i.e. chemoprophylaxis or presumptive management-such as intermittent presumptive therapy (IPT). IPT with SP, one dose at the first antenatal clinic visit in the second trimester and a second dose in the third trimester, has been demonstrated to be safe, efficacious, easily deliverable, and cost-effective for the prevention of placental malaria in areas of high transmission.
Although it appears that HIV-seropositive women require more doses of SP (i.e. at least three) than HIV-seronegative women, this must be confirmed in other studies. The efficacy of IPT with CQ in areas where P. falciparum remains sensitive to CQ is also under investigation.
Before beginning a program for prevention of malaria in pregnant women, it is useful to have a baseline evaluation of the impact of malaria during pregnancy in that geographical area and an assessment of how the intervention may fit into existing antenatal care services. The baseline evaluation of the extent of the problem, which is also useful for comparison purposes when one is evaluating program impact, includes: an assessment of prevalence of frebrile illness, anemia, peripheral/placental parasitemia, and LBW in women in antenatal clinics and delivery units. The evaluation of the opportunities for intervention within the existing antenatal care system includes: an assessment of client- and facility-dependent factors to assess women's attitudes about malaria, antimalarial drugs during pregnancy, their use of antenatal care (especially timing and number of visits), and barriers to their use of services. The important data necessary to evaluate potential barriers related to use of health care facilities include: an assessment of current clinic policies and practices, interactions between health care workers and women, and availability of equipment, supplies and drugs.
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