Roll Back Malaria Progress & Impact Series
The contribution of malaria control to maternal and newborn health
Prevention of malaria in pregnancy is a key component of malaria control and an important contributor to maternal and child health. National policies and effective delivery of available preventive measures in the antenatal setting will directly contribute to achieving the Millennium Development Goals (MDGs).
Interventions that substantially reduce adverse outcomes of malaria in pregnancy have been available for more than two decades yet the coverage of such interventions is generally poor.
Malaria in pregnancy must be a priority component of antenatal care.
Malaria in pregnancy interventions save the lives of pregnant women and their newborns (1–28 days of age),b and should be an integral component of all reproductive, maternal, newborn and child health programmes. Malaria in pregnancy is a significant contributor to maternal and neonatal mortality. It is a major cause of anaemia in pregnant women, which contributes to maternal death at delivery due to haemorrhage, and causes stillbirths, preterm birth, and low birth weight increasing the risk of neonatal death. In Africa, 10 000 women and between 75 000 and 200 000 infants (children under the age of 12 months) are estimated to die annually as a result of malaria infection during pregnancy, and approximately 11% (100 000) of neonatal deaths are due to low birth weight resulting from Plasmodium falciparum infections in pregnancy. These outcomes are entirely preventable, and optimizing the delivery of malaria in pregnancy interventions will lead to direct improvements in maternal, newborn and infant health.
Malaria in pregnancy interventions can substantially improve maternal, newborn and infant health.
Under routine programme conditions, intermittent preventive treatment during pregnancy (IPTp) or insecticide-treated mosquito net (ITN)c use in first and second pregnancies in 25 African countries was significantly associated with an 18% decrease in the risk of neonatal mortality and 21% decrease in low birth weight. According to the Lives Saved Tool (LiST), about 94 000 deaths (uncertainty interval: 19 000–251 000) among newborns were averted between 2009 and 2012 thanks to the scale-up of prevention of malaria in pregnancy interventions. Had an 80% coverage of prevention of malaria in pregnancy interventions been achieved over these three years in these same countries, about 300 000 neonatal deaths could have been averted. Countries with high coverage and use of malaria control interventions saw child mortality rates fall by about 20%. Continued focus on scaling up coverage and access to these interventions will substantially increase the magnitude of these health benefits.
Cost-effective interventions to prevent and treat malaria in pregnancy are widely available.
Highly cost-effective interventions to prevent and treat malaria in pregnancy are available. Effective, prompt diagnosis and case management provide benefits to pregnant women infected with the malaria parasite and to their unborn children.
Intermittent preventive treatment during pregnancy and ITNs are highly effective: research has shown that IPTp reduced severe maternal anaemia by 38%, low birth weight by 43%, and perinatal mortality by 27% among women in the first or second pregnancies; and that ITNs reduced miscarriages/stillbirths by 33%.
Despite global gains in malaria control and the known effectiveness of malaria in pregnancy interventions, coverage in some sub-Saharan African countries remains extremely low. Even though most countries have high antenatal care (ANC) coverage for one and two ANC visits, there is not a commensurate level of delivery of life-saving malaria control interventions, i.e. IPTp and ITNs.
IPTp and ITNs are delivered to pregnant women through antenatal clinics, IPTp at every ANC visit in the second and third trimester, and ITNs at the first ANC visit, as early as possible. However, despite relatively high antenatal care coverage (>77% of pregnant women attending ANC at least once [ANC 1+]) in most countries, IPTp and ITN coverage rates are well below global and national targets. IPTp coverage and ITN use among pregnant women increased only modestly between 2004–2008 and 2009–2012, respectively from 14% to 22% and from 17% to 39%.
Many obstacles to increasing coverage with intermittent preventive treatment can be overcome relatively quickly but others will require more integral and complex health system strengthening.
Research has shown that many obstacles to delivering IPTp are relatively simple barriers that are specific to IPTp and could be resolved in the short term. Other obstacles are more entrenched within the overall health system context, and will require increased support for health system strengthening. Improvements in the quality of ANC services and creating demand at the community level will also lead to higher attendance and better maternal and newborn health outcomes.
Malaria control interventions must be harmonized with other reproductive health policies and antenatal care services.
Focused antenatal care (FANC) aims to provide a comprehensive package of evidence-based services for all pregnant women; however there is fragmentation across programmes using the ANC platform for service delivery. Improved policy and programme coordination between reproductive, maternal, newborn and child health programmes, and other health programmes is required, with special attention to integrated mechanisms for budgeting and funding as part of the FANC package, and effective and appropriate integration at the service-delivery level (e.g. integrated laboratory services, integrated procurement/supply chain management, and task-shifting for improving human resources bottlenecks).
The World Health Organization (WHO) updated its malaria in pregnancy policy in 2012 with the key recommendation of extending the provision of IPTp to four times during the course of gestation and also made key recommendations on timing of the intervention. Critical next steps are for countries to harmonize malaria and maternal health policies, national guidelines and training materials based on the new policy including simplified guidance on how to deliver IPTp in the antenatal care setting. Strategies to encourage women to attend ANC as early as possible in pregnancy are also needed.
Partners from the RBM Malaria in Pregnancy Working Group recently released a consensus statement to engender further commitment, momentum and partnership between reproductive, maternal, newborn and child health programmes and malaria control programmes. Specifically, the aim is to reprioritize malaria in pregnancy as a core component of focused antenatal care, advocate for harmonized policy-making and integrated programme implementation and reinforce key interventions to optimize the delivery of malaria in pregnancy programmes, and prevent adverse maternal and newborn outcomes.