Although most countries in Africa have adopted national policies to reduce and control malaria during pregnancy, protection remains inadequate, concludes an Article published Online First in The Lancet Infectious Diseases. In 2007, an estimated 23 million pregnancies were unprotected by insecticide-treated nets (ITNs) and 19 million pregnant women failed to receive intermittent preventive treatment (IPT)—two of the key WHO recommended interventions to prevent malaria during pregnancy. These findings highlight the urgent need for increased efforts towards scale-up if the new Roll Back Malaria Initiative targets and the Millennium Development Goals are to be met.
In sub-Saharan Africa an estimated 32 million pregnant women are at risk of malaria every year. In 2000, African governments pledged to ensure that 60% of pregnant women were given access to effective prevention interventions within 5 years. Additionally, the Roll Back Malaria Initiative set targets for 80% coverage of ITNs in all populations, and for all pregnant women to receive IPT by 2010.
ITNs and IPT in pregnancy with sulfadoxine-pyrimethamine are cheap and cost-effective interventions that substantially reduce the burden of disease and adverse outcomes during pregnancy. However, little information exists about the level of coverage of these interventions at a regional and local level in sub-Saharan Africa. This subnational data could provide valuable information on inequities of coverage and ensure that resources are targeted at areas at high risk of malaria.
An international team led by Anna Maria van Eijk from the Liverpool School of Tropical Medicine, Liverpool, UK, combined information from 48 of the most recent national household cluster-sample surveys on the use of ITNs, IPT, and antenatal care with transmission data and the estimated number of pregnancies at risk of malaria in each sub-Saharan country. They matched intervention coverage estimates to provincial, state, or regional boundaries and used modelling to calculate the number of pregnant women protected by these interventions in 2007.
45 of 47 sub-Saharan countries surveyed had a policy for the provision of ITNs and 39 an IPT policy for pregnant women. In 32 countries with available data and a national policy for using ITNs, an estimated 17% (4.7 million of 27.7 million) of pregnancies were protected by ITNs in 2007.
In 31 countries with data and an IPT in pregnancy policy, an estimated 25% (6.4 million of 25.6 million) of pregnant women received at least one dose of sulfadoxine-pyrimethamine treatment and 77% (19.8 million) visited an antenatal clinic at least once. An estimated 13.4 million pregnant women who attended antenatal clinics in 2007 missed opportunities to receive IPT.
Findings also showed that estimated coverage was lower in areas of high-intensity malaria transmission where women are in most need of protection.
They conclude: "[Although] most countries in sub-Saharan Africa have adopted national policies aimed at reduction and control of malaria in pregnancy…we show not enough progress has been made towards the new Roll Back Malaria Initiative goals or the policy ambitions of each country. With only 5 years in which to meet the Millennium Development Goals (and specifically for malaria, goals 4, 5, and 6), coverage rates of two key interventions are not on course in most countries in sub-Saharan Africa to meet targets."
In a linked Comment, Dr Julie Gutman, Centers for Disease Control and Prevention; Emory University School of Medicine; and Children's Healthcare of Atlanta, Atlanta, GA, USA, and Dr Laurence Slutsker, Centers for Disease Control and Prevention, Atlanta, GA, USA, conclude: "van Eijk and colleagues' analysis8 is a reminder that cost-effective techniques to scale up malaria control interventions are needed. High rates of attendance at antenatal clinic can provide an effective platform to deliver these services; success will require strengthened systems through training of health workers, education of clients, and robust supply chains to ensure goals are achieved."
Alan Hughes, Communications Manager, Malaria in Pregnancy Consortium, Liverpool School of Tropical Medicine, Liverpool, UK. T) +44 (0)151 705 3308 / +44 (0)7759 243969 (mobile) E) a.p.hughes@liv.ac.uk
Dr Julie Gutman, Centers for Disease Control and Prevention; Emory University School of Medicine; and Children's Healthcare of Atlanta, Atlanta, GA, USA. E) gutmanjr@gmail.com
For full Article and Comment see: http://press.thelancet.com/tlidmalpreg.pdf
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Journal
The Lancet Infectious Diseases