While its infectious cycle, treatment, and prevention are well understood, malaria remains one of the most dangerous endemic infectious diseases in the world. The World Health Organization has reported significant declines in malaria deaths in recent years. Further, the Institute for Health Metrics and Evaluation reports a similar decrease in maternal mortality rates, suggesting progress towards Millennium Development Goal 5 – to reduce the maternal mortality ratio by three quarters in between 1990 and 2015. Despite these successes, coverage of malaria control in pregnant women remains very low, and malaria in pregnancy (MiP) continues to contribute to maternal and neonatal morbidity and mortality.
At the end of June, doctors, public health professionals, researchers, and scientists convened in Istanbul to attend “Malaria in Pregnancy: A Solvable Problem," a conference organized by the Harvard School of Public Health’s Maternal Health Task Force. The objective of the meeting was to share successes and challenges in MiP coverage from different countries, with the goal of identifying steps to improve coverage and reduce malaria in pregnancy. Coverage of the conference can be accessed at the Maternal Health Task Force’s blog and at the Malaria Matters blog.
Malaria in pregnancy is dangerous for a number of reasons. Pregnancy reduces a woman's immunity to malaria, making her more susceptible to malaria infection. Upon infection, pregnant women are at an increased risk of severe anemia and death. Maternal malaria is equally dangerous to the unborn child. An infected mother increases the risk of spontaneous abortion, stillbirth, premature delivery and low birth weight – a leading cause of child mortality. The WHO estimated, in 2011, that approximately 8,000 newborns died each day from preventable causes. The WHO also reinforces that maternal health and neonatal mortality are closely linked. This high number of newborn deaths is one of the main health issues conference attendees are working to prevent.
The standard recommendation for addressing MiP is through antenatal care. In antenatal care, there are three prongs through which to address MiP: insecticide treated nets, intermittent preventive treatment in pregnancy, and case management. Insecticide treated nets (ITNs) are the first line of defense in malaria prevention. The second, called intermittent preventive treatment of pregnant women for malaria (IPTp), requires pregnant women to receive an anti-malarial drug during antenatal care visits – whether they are infected or not. Case management means that a trained health care provider will be working with and monitoring a pregnant woman throughout the pregnancy. While this strategy for combatting malaria is seemingly simple, researchers at the conference noted that lack of access, education, and resources add complexity to the potential success of these treatments.
Jayne Webster, of the Liverpool School of Tropical Medicine, found that the delivery of ITN and IPTp was ineffective in Mali and Kenya. Specific challenges she noted were stock outs and lack of knowledge and misinformation about malaria risks to pregnant women and their fetuses. Population Services International’s Elena Olivi also addressed the cost of ITN, stating that while they work, they expire after three years. If the funding isn’t there to buy more, the public health community faces a severe set back. Marcia Castro, of the Harvard School of Public Health, investigated the relationship between MiP and the geographic location of antenatal care services in Kenya. Fortunately, cost was not found to be a barrier in her analysis, but distance from facilities and long wait times reduced uptake of preventative services.
Another challenge addressed at the conference was the lack of harmonization between the local, national, and international levels of care and policy. Participants emphasized that confusion at one level (global), inevitably leads to confusion at another level (local). For this reason, leadership and partnership need to be improved. The “next steps” and “ways forward” have not yet been published. Please check back on the Maternal Health Task Force blog to learn more.
There is hope for the future. Rapid diagnostic tests that perform on par with traditional microscopic diagnosis of malaria create the potential for all women to be screened for malaria during antenatal care. A 2008 study in Ghana showed that these tests fit nicely into antenatal care procedures. Increased funding specific to maternal malaria could also prove fruitful. The Global Fund, for example, currently only allocates 2% of its malaria budget to pregnancy initiatives. Despite challenges, all conference attendees would agree the problem is solvable and a greater emphasis on MiP is needed to guarantee healthy mothers and children in malaria endemic areas.