MALARIA IN PREGNANT

In Africa, 30 million women living in malaria-endemic areas become pregnant each year. For these women, malaria is a threat both to themselves and to their babies, with up to 200 000 newborn deaths each year as a result of malaria in pregnancy.

Pregnant women are particularly vulnerable to malaria as pregnancy reduces a woman’s immunity to malaria, making her more susceptible to malaria infection and increasing the risk of illness, severe anaemia and death. For the unborn child, maternal malaria increases the risk of spontaneous abortion, stillbirth, premature delivery and low birth weight - a leading cause of child mortality.
The problem has long been neglected, but new approaches and commitment offer hope for reducing the burden of malaria in pregnancy and improving the health of mothers and newborns.

Protecting pregnant women

Based on available evidence, WHO recommends a three-pronged approach to the prevention and management of malaria during pregnancy:

• Insecticide-treated nets (ITNs)
• Intermittent preventive treatment
• Effective case management of malarial illness.

Sleeping under ITNs remains an important strategy for protecting pregnant women and their newborns from malaria-carrying mosquitoes. In addition, in areas of high and moderate transmission of Plasmodium falciparum malaria (the most prevalent type of malaria in Africa), intermittent treatment with an antimalarial drug is a cost-effective means of preventing malaria in pregnancy. The current recommendation is to give at least two doses of a safe and effective antimalarial (currently, sulphadoxine-pyrimethamine) to all pregnant women living in these areas.
In areas of low or unstable malaria transmission, pregnant women have low immunity to malaria and a two- to threefold higher risk of severe malarial illness than non-pregnant women. In these areas, use of ITNs and prompt case management of pregnant women with fever and malarial illness are the main strategies for malaria prevention and treatment.

Delivering malaria interventions through antenatal care

About two thirds of pregnant women in sub-Saharan Africa attend antenatal clinics at least once during pregnancy, presenting a major opportunity to prevent and treat malaria. The aim is to deliver this package - especially intermittent preventive treatment - to pregnant women as part of their routine antenatal care, using and strengthening the existing antenatal care infrastructure. This strategy is now an integral part of WHO’s “Making Pregnancy Safer” initiative, which aims to strengthen antenatal services and provide preventive measures, treatment, care and counseling to improve all aspects of health in pregnant women and their newborns.

Overcoming challenges

At the first African Summit on Malaria in Abuja, Nigeria, 2000, African heads of state committed to providing effective malaria interventions to at least 60% of pregnant women by 2005. To achieve this goal, several challenges must be overcome:

• Delivery of malaria interventions through antenatal clinics in Africa needs to be widespread. This approach is currently the exception rather than the rule. However, large-scale programmes are now being developed, and several African countries are reviewing their policies in light of the WHO recommendations. A few have already adopted the strategy as policy.
• Major issues of concern still have to be addressed. These include drug resistance and the safe and appropriate use of different antimalarial drugs during pregnancy. As resistance to antimalarial drugs increases, the challenges of treatment and prevention of malaria among pregnant women become greater. Research in this area is therefore a high priority. There is also a need for research to develop prevention strategies for women residing in areas of low or unstable transmission, and in areas where the Plasmodium vivax type of malaria is a problem in pregnancy.
• Pregnant women who do not attend antenatal clinics or who attend only for the first visit or too late during pregnancy need to be reached. New strategies will be required to encourage these women to attend antenatal care early and consistently.

Within the Roll Back Malaria Global Partnership, WHO works with governmental, nongovernmental, bilateral and donor agencies to overcome challenges, meet the Abuja goal and reduce the burden of malaria in pregnancy. The availability of insecticide-treated nets, effective intermittent preventive treatment and a means of delivery through antenatal clinics, provides a unique opportunity that must be taken to protect the millions of African women who become pregnant each year, and their babies.