Harmonizing Malaria in Pregnancy Guidance: A Review from Five African Countries

by: Elaine Roman, Patricia Gomez and Aimee Dickerson Maternal and Child Health Integrated Program (MCHIP)/Jhpiego, an affiliate of Johns Hopkins University

Background
39 sub-Saharan African countries have IPTp and ITN

Kenya

policies in place for MIP, yet IPTp uptake and ITN coverage remains relatively low In October 2012, WHO issued an updated policy recommendation for IPTp-SP

IPTp Timing and Dosing For IPTp, all documents support:

Provision of IPTp during ANC, 1 month apart and up to time of delivery, starting at either 16 weeks or quickening Discordant guidance between training materials and

Recommendations
Review and update national-level MIP policies,

guidelines and materials:

RHP and NMCP as well as HIV and other relevant departments Integrate MIP as a component of comprehensive RH services Prioritize review and adaptation of WHO guidance on IPTp timing and dosing and folic acid administration Eliminate discordant guidance among national-level

To better understand: How closely national MIP documents (policies, guidelines, training and supervision materials) reflect WHO MIP guidance How consistent documents produced by the NMCP and RHP are with each other

Purpose

IPTp circular, malaria guidelines and supervision manual

Methods
Countries selected for review: Kenya, Mali,

Mozambique, Tanzania and Uganda Developed review framework, based on WHO MIP guidance:
IPTp timing and dosing Directly observed therapy Linkages to HIV programs Promotion and distribution of ITNs Diagnosis and treatment

Linkages to HIV The FANC reference manual states that HIV+ pregnant women should receive 3 doses of SP unless they are on daily cotrimoxazole The guidelines for free distribution of IPTp state that HIV+ women should receive 3 doses of SP but do not mention management of women on cotrimoxazole

Mali

documents Develop job aids with consistent and complete information for providers Establish national technical working groups to ensure quality of guidance Identify national champions of change for MIP Linkages to HIV Integration and coordinated program planning among RHP, NMCP and HIV/AIDS program Creation of consistent guidance across materials Promotion and Distribution of ITNs Continued emphasis on ITN promotion at ANC Procurement planning and distribution should prioritize top up at ANC Diagnosis and treatment Emphasize provider training in case management for pregnant women Develop clear algorithms for uncomplicated and complicated malaria:
Appropriate medications Doses Timing by trimester

Country Overview
Country IPTp2 Uptake ITN Use by Pregnant Women Year of MIP Policy Adoption
2001

15.1% 49% (200809 DHS) (200809 DHS) Kenya 25.4% 41.1% (2010 MIS) (2010 MIS) 11.2% 28.9% (2006 DHS) (2006 DHS) Mali 36% 55% (2011 HMIS) (2010 MICS) Mozam18.6% 19.5% (2011 DHS) (2011 DHS) bique 56.9% 26.7% (2010 DHS) Tanzania (2011 DHS) 19.5% (2011 DHS) 26.7% 46.9% Uganda (2011 DHS) (2011 DHS)

LLIN/ITN Promotion and Distribution The malaria policy recommends that all pregnant women receive a free LLIN during ANC ITN promotion is not mentioned in the malaria guidelines, RH policy, supervision tools or performance standards

Mozambique

2003

2006

Diagnosis The in-service training package recommends diagnosis via microscopy or RDTs for anyone admitted with severe malaria The pre-service education package makes no mention of diagnosis

Tanzania

2002

2000

Summary Findings
All countries have national-level documents

promoting IPTp, ITN use and treatment of malaria in pregnancy WHO evidence-based guidance is not always reflected in country-level documents All countries had discordant guidance between RH and NMCP in at least one official MIP guidance document

Treatment The malaria guidelines recommend treating any pregnant woman with a fever for malaria The RH guidelines do not mention treatment of malaria in pregnancy

Uganda

ANC: Antenatal Care DHS: Demographic and Health Survey FANC: Focused Antenatal Care HMIS: Health Management Information System IPTp: Intermittent Preventive Treatment during Pregnancy ITN: Insecticide-Treated Bed Net LLIN: Long-Lasting Insecticide-Treated Bed Net MIP: Malaria in Pregnancy MIS: Malaria Indicator Survey NMCP: National Malaria Control Program RDT: Rapid Diagnostic Test RHP: Reproductive Health Program SP: Sulfadoxine-Pyrimethamine

Abbreviations and Acronyms

Funding for the production of this poster was provided by USAID through the Maternal and Child Health Integrated Program (MCHIP) through Cooperative Agreement #GHS-A-00-08-00002-000. The opinions herein are those of the authors and do not necessarily reflect the views of USAID.