Okonofua, FE

Bioline International

Although malaria affects men and women ofall ages in highly endemic areas, it exerts itsmost deleterious clinical effects in adultsduring pregnancy. Of all the known types ofmalaria parasites, Plasmodium falciparium isthe most common parasite responsible fordisease and clinical manifestations inpregnant women.  During pregnancy, there isa significant reduction in cell-mediated aswell as humoral immunity to malaria, result-ing in more severe clinical effects in pregnantthan non-pregnant women.  Young primigravidwomen are at greater risk of malaria ascompared to older women of high parity.There is now substantial evidencesuggesting that malaria is responsible for alarge number of complications in pregnancyincluding moderate to severe anemia, lowbirth weight babies, premature onset of labourand increased risk of stillbirths.1 Malaria isnow accepted to be the principal cause of thehigh prevalence of anaemia in pregnantwomen in holo-endemic areas, contributingsignificantly to high rates of perinatal andmaternal mortality in these areas.2 In view ofthese effects of malaria in pregnancy, theprevention of malaria has been accepted bythe World Health Organization to be animportant public health measure forimproving perinatal and maternal health indeveloping countries.Of the known methods of malariaprevention, chemoprophylaxis is the mostpractical and most cost-effective in pregnantwomen. Indeed, the WHO has identifiedchemoprophylaxis as key to preventingmalaria in pregnant women and reducing thescale of its adverse clinical consequences.Other measures such as insecticide-treatedbed nets and vector control have not provento be as effective as chemoprophylaxis largelybecause malaria in pregnant women appearsto be a recrudescence of previously dormantinfections rather than being new infections.Despite the apparent simplicity ofchemoprophylaxis, there has beenconsiderable difficulty in applying itsprinciples as a public health measure toprevent malaria in pregnant women.  The firstproblem has been that of drug efficacy andeffectiveness.  For many years, no single drugor combinations of drugs could be identifiedas the indisputable leader in terms of efficacyand effectiveness in preventing malaria inpregnancy. Several drug regimens were usedin the past including cholorquine,pyrimethamine, proguanil and mefloquine,1but none was consistently effective due to theemergence of drug resistance and otherrelated factors. More recently, based on trialsconducted in East Africa,1,3,4 the WHO hasrecommended the use of intermittentpreventive treatment with suphadoxine-pyrimethamine (IPT) with two or three-dosetreatment regimens once during the secondtrimester and once or twice during the thirdtrimester.4 This regimen has proven to bemore effective than traditional regimens and© CMS UNIBEN JMBR 2004; 3(1): 5-6Prevention of malaria in pregnancy: an importantpublic health challengeFE Okonofua*EDITORIALJMBR: A Peer-review Journal of Biomedical SciencesJune 2004, Vol. 3 No. 1 pp 5–6* Editor & Professor, Department of Obstetrics and Gynecology, College of Medical Sciences, University of Benin, Benin City, Nigeria6   Journal of Medicine and Biomedical Researchhas been adopted by a number of countriesincluding Nigeria.5Having identified this reasonablyeffective chemoprophylactic regimen, thesecond challenge is to ensure that high-riskpregnant women have access to the drug forthe prevention of malaria.  Access is limitedby many factors including low providers’awareness of the regimen, poor health-seekingbehaviour of pregnant women who tend notto receive antenatal care and poor availabilityof drugs.  Of these, the first two may be themost important reasons for poor access to IPTin many developing countries. There isevidence that a large number of healthprofessionals in these countries are still notfamiliar with IPT, while only a smallproportion of pregnant women in malariaendemic areas receive evidence-basedantenatal care.  Among pregnant womenreceiving antenatal care, only a few are givenanti-malarial chemoprophylaxis, while themajorities are often given antimalarialregimens of doubtful efficacy. Indeed, IPT isstill relatively unknown in many clinicalsettings in regions with high prevalence ratesof malaria in pregnant women.Thus, as part of public health measuresto reduce the impact of malaria in pregnancy,there is a need to build the capacity of healthproviders on IPT, disseminate relatedinformation to providers and the generalpublic, and to integrate the method intoclinical practices at all levels of the healthcare system. More specifically, women needto be made aware of the method, and theyneed to be encouraged to seek facility-basedmethods of antenatal care rather than home-based care to increase their chances ofreceiving IPT in pregnancy.  Also, in view ofthe apparent simplicity of IPT, it may bepossible in future to explore its use by lowcadre health workers such as communityhealth extension workers and traditional birthattendants. IPT can also be included as amajor component of home-based antenatalcare offered by midwives to women whowould not attend facility-based antenatalcare.In conclusion, the prevention of malariais an important public health measure forimproving maternal and perinatal health indeveloping countries.  Intermittent preventivetreatment (IPT) with sulphadoxine-pyrimethamine is the current “best practice”for preventing malaria in pregnant women inendemic countries.  However, more researchis needed to determine the effectiveness andrelative effectiveness of the method in variousclinical settings, as well as research todetermine how best to integrate the methodinto existing levels of the health care deliverysystem. Clearly, the prevention of malaria isone of the most important interventions forpromoting safe motherhood in tropical andsub-tropical climates at the present time, andwarrants more active promotion.References1. Somwumi A. Malaria in pregnancy. In:Okonofua FE and Odunsi K (Eds.). Contem-porary Obstetrics and Gynecology for Develop-ing Countries. Benin City: Women’s Health andAction Research Centre, 2003, pp 502–513.2. Ogunbode O.  Anaemia in pregnancy. In:Okonofua FE and Odunsi K (Eds.). Contem-porary Obstetrics and Gynecology for Devel-oping Countries. Benin City: Women’s Healthand Action Research Centre, 2003, pp 514–529.3. Verhoeff FH, Brabin BJ, Hart CA, ChimsukuL, Kazembe P, Russell WB and Broadhead RL.An evaluation of the effects of intermittentsulfadoxine-pyrimethamine treatment inpregnancy on the parasite clearance and riskof low birth weight in rural Malawi. Ann TropParasitol 1998; 92: 141–150.4. World Health Organization.  The use of anti-malarial drugs.  Report of a WHO informalconsultation. Geneva WHO/CDS/RBM/201.335. Federal Ministry of Health, Nigeria.  Inter-mittent preventive treatment of malaria inNigeria – strategy for preventing malaria inpregnancy. Report of a national consultation,May 2004.©  CMS UNIBEN JMBR 2004; 3(1): 7-20

Prevention of malaria in pregnancy: an important public health challenge

Abstract

Similar works

Full text

Available Versions

Bioline International