You are on page 1of 14

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

Elaine Roman* Patricia Gomez** Aimee Dickerson*


*Jhpiego/Maternal and Child Health Integrated Program *Jhpiego

Background and Purpose


Background 39 sub-Saharan African countries have IPTp and ITN 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. Purpose To better understand: How closely national MIP documents (policies, guidelines, training and supervision materials) reflect 2007 WHO MIP guidance, and How consistent documents produced by the NMCP and RHP are with each other.
2

Methods
Countries selected for review: Kenya, Mali, Mozambique, Tanzania and Uganda Developed review framework, based on WHO 2004 MIP guidance:
IPTp timing and dosing
Directly observed therapy Linkages to HIV programs Promotion and distribution of ITNs Diagnosis and treatment

Country Overview
Country IPTp2 Uptake ITN Use by Pregnant Women 49% (200809 DHS) 41.1% (2010 MIS) 28.9% (2006 DHS) 55% (2010 MICS) 19.5% (2011 DHS) 56.9% (2010 DHS) 46.9% (2011 DHS) Year of MIP Policy Adoption 2001

Kenya

Mali

15.1% (20082009 DHS) 25.4% (2010 MIS) 11.2% (2006 DHS) 36% (2011 HMIS)

2003 2006 2002 2000

Mozambique 18.6% (2011 DHS) Tanzania Uganda 27.2% (2010 DHS) 26.7 (2011 DHS)

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.
5

Kenya
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 IPTp circular, malaria guidelines and supervision manual
6

Mali
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.
7

Mozambique
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.
8

Tanzania
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.

Uganda
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.
10

Recommendations
Review and update national-level policies, guidelines and materials:

RHP and NMCP as well as HIV and other relevant departments Integration of MIP as a component of comprehensive RH services Prioritized review and adaptation of WHO guidance on IPTp timing and dosing and folic acid administration
11

Recommendations
Eliminate discordant guidance among national-level 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.
12

Recommendations
Linkages to HIV Integration and coordinated program planning among RHP, NMCP and HIV/AIDS program Create 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

13

Recommendations
Review and Update MIP Policies

Diagnosis and Treatment Emphasis on provider training in case management for pregnant women Development of clear algorithms for uncomplicated and complicated malaria:
Appropriate medications Doses Timing by trimester
14