A study published today in The Lancet Infectious Diseases finds that methods to protect pregnant women from malaria are still underutilised in sub-Saharan Africa (SSA). A review of national control strategies by a team of international researchers, led by the Malaria in Pregnancy Consortium and funded by the Consortium and the Wellcome Trust, has concluded that despite major efforts, coverage is still inadequate in many areas and needs to be scaled up.

Malaria infection in pregnancy can lead to devastating consequences for both mother and child. The World Health Organization’s (WHO) recommended policy for malaria prevention and control is a package of intermittent preventive treatment (IPTp) and insecticide treated nets (ITNs). These interventions have the potential to substantially reduce the disease burden and adverse outcomes of malaria in pregnancy. The Roll Back Malaria initiative (RBM) has ambitions to ensure that 100% of pregnant women receive IPTp and at least 80% of people at risk from malaria are using ITNs in areas of high transmission by 2010.

Specific strategies for malaria control in pregnant women were extracted from national malaria policies and the most recent national household cluster-sample surveys recording IPTp and ITN use were reconciled to sub-national administrative units to compute the numbers of protected pregnancies. Malaria maps generated by the Malaria Atlas Project (MAP, http://www.map.ox.ac.uk) meant these estimates could be stratified against different levels of malaria risk.

The study found that 45 of 47 SSA countries had an ITN policy for pregnant women and that estimated coverage was 17% among the nearly 28 million pregnancies at risk of malaria in the 32 countries with information. Among 39 countries with an IPTp policy, 25% of pregnant women had received some IPTp, despite 77% visiting an antenatal clinic (ANC), the main delivery channel for reaching pregnant women with ITNs and IPTp.

Professor Feiko ter Kuile, MiP Consortium leader and co author said: “Ten years after the Abuja declaration, it is encouraging that the majority of malaria endemic countries in SSA have now adopted ITNs and IPTp and the number of countries with nationally representative coverage data has increased to 40 out of 47. However, very few countries have reached either the Abuja targets or their own policy ambition, and countries are even further away from the more recent RBM targets set for 2010. In addition, coverage was lowest in areas with high malaria transmission, where the need is greatest.

“In general, low coverage with IPTp and ITNs contrasts with correspondingly high ANC attendance, indicating that there are missed opportunities for coverage and the attainment and maintenance of high coverage of ITNs remains challenging.

“In summary, whilst most countries have adopted national policies aimed at reducing and controlling malaria in pregnancy, it is clear that, with some notable exceptions, not enough progress has been made towards the new RBM goals or the policy ambitions of each country.

“With only five years in which to meet the Millennium Development Goals it is sobering that in countries with a national policy for IPT and/or ITN, an estimated 23 million pregnancies remain unprotected by an ITN and 19 million remain unprotected by IPTp. Greater effort to fully understand the reasons why coverage is so low and to develop strategies to combat this is urgently needed to protect the tens of millions of pregnancies in sub-Saharan Africa threatened by malaria every year.”

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Contact: Alan Hughes
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Liverpool School of Tropical Medicine