Prevention and Control of
Malaria during Pregnancy
A Workshop for Healthcare Providers
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
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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
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Roll Back Malaria
 Worldwide partnership
 Governments, private groups, research organizations, civil
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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
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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
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Prevention and Control of
Malaria during Pregnancy
Chapter I: Focused Antenatal Care
Focused Antenatal Care: Chapter
Objectives
 Describe four main components of focused
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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
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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
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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
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Traditional Antenatal Care
 Emphasizes:
 Ritualistic,
“routine” care vs. evidence-based,
goal-directed actions
 Frequent visits
 Does not emphasize individual client needs
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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
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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
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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
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Focused Antenatal Care Services
(cont’d.)
Individualized, woman-centered care based on
each woman’s:
 Specific needs and concerns
 Circumstances
 History, physical examination, testing
 Available resources
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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
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Scheduling and Timing of ANC Visits
 First visit: By 16 weeks or when woman first thinks she
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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
Other visits: 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
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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.
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Early Detection and Treatment
 Malaria—history and physical exam
 Fever
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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
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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
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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
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Essential Elements of a Birth Plan
 Facility or Place of Birth: Home or health facility
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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
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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
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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
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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
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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
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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
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Interpersonal Skills
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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
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Record Keeping
Record all information on the ANC chart and clinic card:
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
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Prevention and Control of
Malaria during Pregnancy
Chapter II: Malaria Transmission
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
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Malaria Transmission
 Caused by Plasmodium parasites
 Spread by female Anopheles mosquitoes infected
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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
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Populations Most Affected by Malaria
 Children under 5 years of age
 Pregnant women
 Unborn babies
 Immigrants from low-transmission areas
 HIV-infected persons
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Effects of Malaria on Pregnant
Women
 All pregnant women in malaria-endemic areas are at
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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
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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
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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
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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
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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
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Prevention and Control of
Malaria during Pregnancy
Chapter III: Preventing Malaria
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
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Insecticide-Treated Nets
 Kill or repel mosquitoes
 Prevent physical contact with mosquitoes
 Kill or repel other insects:
 Lice
 Ticks
 Bedbugs
 Cockroaches
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Insecticide-Treated Nets (cont’d.)
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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
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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
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 Help people sleep better
 Promote growth and development of fetus and
newborn
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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
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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
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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
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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
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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
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Intermittent Preventive Treatment
Although a pregnant woman with malaria may have
no symptoms, malaria can still affect her and her
unborn child
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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
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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
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Instructions for Giving Intermittent
Preventive Treatment
 Ensure woman is at least 16 weeks pregnant and
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that quickening has occurred
Inquire about use of SP in last 4 weeks
Inquire about allergies to SP or other sulfa drugs
(especially severe rashes)
Explain what you will do; address the woman’s
questions
Provide cup and clean water
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Instructions for Giving Intermittent
Preventive Treatment (cont’d.)
 Directly observe woman swallow three tablets of SP
 Record SP dose on ANC and clinic card
 Advise the woman when to return:
 For her next scheduled visit
 If she has signs of malaria
 If she has other danger signs
Reinforce the importance of using ITNs
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Intermittent Preventive Treatment:
Contraindications to Using SP
 Do NOT give during first trimester: Be sure quickening has
occurred and woman is at least 16 weeks pregnant
 Do NOT give to women with reported allergy to SP or other
sulfa drugs: Ask about sulfa drug allergies before giving SP
 Do NOT give to women taking co-trimoxazole, or other sulfacontaining drugs: Ask about use of these medicines before
giving SP
 Do not give SP more frequently than monthly: Be sure at
least 1 month has passed since the last dose of SP
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Chemoprophylaxis with Chloroquine:
For Women Allergic to Sulfa Drugs*
Dose
1
Chloroquine
150 mg
4 tablets
Timing
2
4 tablets
Second day after first dose
3
2 tablets
Third day after first dose
Weekly
2 tablets
Every week during pregnancy
First ANC visit after 16 weeks
*If chloroquine resistance rates in the country are high,
chemoprophylaxis with chloroquine is not recommended.
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Summary of Health Education Points
 Pregnant women should sleep under ITNs every night
 By preventing malaria, IPT reduces the incidence of
maternal anemia, spontaneous abortion, preterm
birth, stillbirth, and low birthweight
 IPT should be administered to pregnant women at
regularly scheduled ANC visits after quickening, but
not more often than monthly
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Prevention and Control of
Malaria during Pregnancy
Chapter IV: Detection and Treatment
Malaria Detection and Treatment:
Chapter Objectives
 Identify causes of fever during pregnancy
 List the signs and symptoms of uncomplicated and
complicated malaria
 Describe the treatment for uncomplicated malaria
during pregnancy
 Explain the steps to appropriately refer a pregnant
woman who has complicated malaria
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Detecting Malaria
 Symptoms
 Fever
 Chills
 Headaches
 Muscle/joint pains
 Lab exam of blood from a finger prick
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Fever during Pregnancy
 Temperature of 38° C or higher
 May be caused by malaria, but also by:
 Bladder or kidney infection
 Pneumonia
 Typhoid
 Uterine infection
 Careful history and physical required to rule out
other causes
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Fever during Pregnancy (cont’d.)
Ask about or examine for:
 Type, duration, degree of fever
 Signs of other infections:
 Chest
pain/difficulty breathing
 Foul-smelling watery vaginal discharge
 Tender/painful uterus or abdomen
 Frequency/urgency/pain in urinating
 Signs of complicated malaria or other danger signs
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Types of Malaria
 Uncomplicated
 Most common
 Complicated
 Life threatening, can affect brain
 Pregnant women more likely to get complicated
malaria than non-pregnant women
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Recognizing Malaria in Pregnant
Women
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Uncomplicated Malaria
Fever
Shivering/chills/rigors
Headaches
Muscle/joint pains
Nausea/vomiting
False labor pains
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Complicated Malaria
Signs of uncomplicated
malaria PLUS one or more
of the following:
Dizziness
Breathlessness/difficulty
breathing
Sleepy/drowsy
Confusion/coma
Sometimes fits, jaundice,
severe dehydration
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Recognizing Malaria in Pregnant
Women (cont’d.)
Refer the woman
immediately
if you suspect anything
other than
uncomplicated malaria
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Case Management
 Determine whether malaria is uncomplicated or
complicated
 Uncomplicated: Manage according to national
protocol
 Complicated: Refer immediately to higher level of
care; consider giving first dose of anti-malarial if
available and healthcare provider is familiar with its
use
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Case Management: Drugs
 First-line drug therapy is indicated for
uncomplicated malaria
 Second-line drug therapy is indicated for
uncomplicated malaria that has failed to respond to
first-line drug
 In almost all countries, quinine is the drug of choice
for complicated malaria
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Managing Uncomplicated Malaria
 Provide first-line anti-malarial drugs
 Follow country guidelines
 Manage fever
 Analgesics, tepid sponging
 Diagnose and treat anemia
 Provide fluids
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Treating Uncomplicated Malaria
 Observe client taking anti-malarial drugs
 Advise client to:
 Complete course of drugs
 Return if no improvement in 48 hours
 Consume iron-rich foods
 Use ITNs and other preventive measures
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SP: Contraindications
 Before 16 weeks of pregnancy
 SP dose in last 4 weeks
 Allergies to sulfa drugs (e.g., co-trimoxazole)
 Currently taking other sulfa drugs
 Substitute other drug before giving SP
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Treatment Problems
 Vomiting within 30 minutes
 Repeat dose of SP
 Itching
 Warm or cool baths
 Use lotions/skin creams
 Give Piriton™ or Phenergan®
 Stomach upset/irritation
 Take chloroquine with food or sugar
 Reduce intake of caffeine and greasy foods
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Treatment Followup
 Arrange followup within 48 hours
 Advise to return if condition worsens
 Review danger signs
 Reinforce use of ITNs
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Second-Line Drug
 Most clients will respond to malaria treatment and
begin to feel better within 48 hours
 However, if the client’s condition does not improve
or worsens, give second-line treatment for
uncomplicated malaria
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Second-Line Drug (cont’d.)
 If the woman’s condition does not improve or
worsens within 48 hours of starting treatment with
a second-line drug, and/or other symptoms appear,
REFER IMMEDIATELY
 If signs of complicated malaria are present, REFER
IMMEDIATELY
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Referral Preparation
 Explain situation to the client/family
 Help arrange transport to other facility if possible
 Write referral note
 Treat any urgent conditions and stabilize
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Referral Note
 Brief history of client’s condition
 Details of any treatment provided
 Reason for referral
 Significant findings from history, physical exam, or
lab
 Any important details of current pregnancy
 Copy of client’s ANC record, if possible
 Referring provider contact information
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Summary of Health Education Points
 Uncomplicated malaria can be easily treated if
recognized early, but it is very important to finish
the course of treatment to be effective
 Because complicated malaria requires specialized
management, women with complicated malaria
should be referred immediately to avoid
complications and death
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