CDI Module 8: Applying CDI to Intermittent
Preventive Treatment in Pregnancy
©Jhpiego Corporation
The Johns Hopkins University
A Training Program on CommunityDirected Intervention (CDI) to Improve
Access to Essential Health Services
Overview
 Malaria in pregnancy (MIP) control has three
major components:
1. Intermittent preventive treatment in pregnancy
(IPTp)
2. Insecticide-treated nets (ITNs)
3. Prompt and appropriate case management
 We have addressed ITNs and case
management in previous modules
 This module will focus mainly on IPTp
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Module 8 Objectives
By the end of this module, learners will:
 State your country’s specific malaria data
 Identify IPTp special target groups
 Describe the basis for IPTp and the use of
sulfadoxine-pyrimethamine (SP) for IPTp
 State the difference between chemoprophylaxis and
IPTp
 Decide who should be given IPTp
 Decide who should NOT be given IPTp
 Describe how to give IPTp
 Describe the benefits of IPTp
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MIP in Africa is Responsible for …
 2%‒15% of maternal anemia
 8%‒14% of low birth weight in newborns
 30% of “preventable” low birth weight in
newborns
 8%‒36% of preterm births
 13%‒70% of intrauterine growth retardation
 5% of congenital malaria in newborns
 3%‒5% of newborn deaths
 3%‒8% of infant deaths
Source: WHO Afro 2004
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Why Is MIP Important in (Your Country)?
 Each year, more than
___ women in (your
country) become
pregnant in malariaendemic areas
 At any given time,
nearly ___% of
pregnant women in
(your country) may
have malaria parasites
in their blood
Facilitator’s note: Fill in your country’s
MIP data on this slide.
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Intermittent Preventive Treatment
in Pregnancy (IPTp)
 IPTp is a prevention
strategy for high and/or
stable malaria
transmission areas
 Here, pregnant women
may have malaria,
especially infection of
the placenta, and not
always show signs
 A full course of malaria
treatment can clear
these malaria parasites
Darker red shaded areas have more
stable malaria transmission
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IPTp: Special Target Groups
We target all pregnant women in high, stable
transmission areas, but especially:
 Women in their first or second
pregnancies
 HIV-infected women
 Adolescents (10‒19 years of age)
 Women with sickle cell disease
 All pregnant women with unexplained
anemia
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IPTp Is 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
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IPTp: World Health Organization (WHO)
Recommendation
 All pregnant women should receive at least two
doses of IPTp after quickening, during routinely
scheduled antenatal care (ANC) visits
 No more frequently than monthly
 Under the health care provider’s direct observation of
treatment (DOT)
 WHO recommends a schedule of four visits, three
after quickening
 Presently, the most effective drug for IPTp is SP
 HIV-positive pregnant women should receive at
least three doses of IPTp with SP at ANC visits after
quickening, but no more frequently than monthly
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The Use of SP for IPTp
 Remember that IPTp is 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
 A pregnant woman with malaria may have no symptoms,
but malaria can still affect her and her unborn child
 Drugs given routinely for malaria during pregnancy reduce:
– Severe antenatal anemia in the mother
– Low birth weight
– Perinatal deaths (to a lesser extent)
 These beneficial effects are most pronounced in
low-parity women (first and second pregnancies)
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The Use of SP for IPTp
 Presently, the most effective drug for IPTp is SP
 All pregnant women should receive two
treatment doses of SP after quickening (baby
has started moving in the womb), and at an
interval of at least four weeks
 HIV-positive pregnant women should receive at
least three treatment doses of SP after
quickening (baby has started moving in the
womb), but no more frequently than monthly
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The Difference between
Chemoprophylaxis and IPTp
 IPTp is the use of anti-malarial drugs given in
treatment doses at predefined intervals after
quickening to clear a presumed burden of parasites
 IPTp works differently from chemoprophylaxis
 Chemoprophylaxis requires a treatment dose, then
sub-therapeutic doses of the drug during and after
pregnancy to prevent re-infection of the placenta
 IPTp is a curative dose of SP given two times during
pregnancy
 These curative doses clear the placenta of parasites
at each dose
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Clearing Parasites
 The majority of fetal growth occurs between 24
and 36 weeks of gestation
 So, if the woman receives the minimum two
recommended doses after quickening:
 The parasites will be cleared from the placenta,
reducing anemia for mother and fostering child growth
 Note that it is safe to give SP up until near time
for delivery because clearing placental malaria
can help prevent postpartum hemorrhage
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IPTp through Community-Directed
Intervention (CDI)
The community-directed distributor (CDD):
 Collects SP from the agreed point, usually the ANC
clinic
 Informs community leader that SP is available
 Gives health education to the pregnant woman
 Gives SP to the woman and ensures that she
swallows the full dose in full view
 Records the information about giving IPTp in the
register
 Refers the pregnant woman to ANC for follow-up
dose and an ITN if she has not already received one
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DOT for IPTp
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Deciding Who Should NOT Be Given IPT
Do NOT give IPTp if the pregnant woman:
 Is in the first trimester of pregnancy
 Ever reacted to (i.e., has sensitivity to) SP or any
medicine containing sulfonamide (like Septrin or
co-trimoxazole)
 Received her last dose of IPTp less than four
weeks ago
 Is currently taking another sulfa drug
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Folic Acid
 We usually give folic
acid to pregnant
women
 SP is an anti-folate and
should not be given in
combination with
folates (e.g., folic acid)
 Remind the pregnant
woman not to take her
folic acid within seven
days after taking SP
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How to Give IPTp through CDI
 Obtain SP (500 mg‒25 mg fixed ratio) supplied by the ANC
staff
 Ask the woman if quickening (movement of the fetus) has
started
 Ask if the woman is allergic to sulfa drugs
If quickening has occurred and she is not allergic:
 Give full adult treatment dose, each time—three tablets
taken at once, under direct observation, with clean water
 Remind the woman to return in four weeks for the next dose
(a minimum of two doses in desired)
 The CDD can refer the woman to ANC for her next IPTp
 Record provision of service in the register
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After Giving IPTp
 Advise the woman to attend ANC so that she
can obtain other special care that is available for
pregnant women
 Ask her to report to the health facility providing
services to her community:
 If she has signs of malaria, OR
 If she has other danger signs
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Benefits of IPTp during Pregnancy
 Remind the pregnant woman that IPTp protects
her from having malaria
 IPTp thereby reduces the incidence of:
 Maternal anemia among pregnant women
 Low birth weight (LBW) in the newborn
 Other malaria-related complications (abortions,
stillbirths, pre-term delivery maturity, placental
parasitemia) in pregnancy
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Health Education by CDDs
 Use the following methods to provide
information:
 Group talk to villagers
 One-on-one counseling
 Posters/flip charts
 Storytelling and proverbs
 CDDs should use the information, education and
communication (IEC) materials given by the
health service to communicate correct
information about malaria control measures
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Reminder: Health Education Information
 Provide general information about the:




Recognition of malaria
Causes of malaria
Prevention of malaria
Dangers of MIP
 Explain that it is:
 Very important to report any adverse events
 Also important to take SP in the correct dosage/at the
correct time
 Explain the benefits of pregnant women registering
early for ANC
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Sample Counseling Card for MIP
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Summary
 Ensure that the woman is at least 16
weeks pregnant and that movement
(quickening) of the fetus has occurred
 Inquire about use of SP in last four weeks
 Inquire about allergies to SP or other sulfa
drugs (especially severe rashes)
 Explain what you will do; address the
woman’s questions
 Ensure that the woman takes SP with
clean water while you watch her
 Always keep records of IPTp given
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