Dyspnea

SUPPORTING AGENCY – ROLL BACK MALARIA, WHO
Reducing the burden of

malaria in pregnancy
Drs Paola Marchesini and Jane Crawley,
Roll Back Malaria Department, World Health Organization, Geneva
Each year, more than 30 million African women in feature of infection during pregnancy, and the major
malaria-endemic areas become pregnant and are at risk detrimental effects of infection are low birth weight (LBW)
of infection with Plasmodium falciparum. Prevention of and maternal anaemia. In areas of stable transmission, it
malaria in pregnancy, which can have serious conse- is estimated that malaria during pregnancy causes up to
quences for both the mother and her unborn child, is a 10 000 maternal deaths each year, mainly as a result of
major public health challenge and a priority for the Roll severe anaemia, and accounts for approximately 8–14%
Back Malaria partnership. Roll Back Malaria recommends of LBW, and 3–8% of infant mortality. 1
a three-pronged approach for reducing the burden of
malaria among pregnant women, namely effective case Malaria and HIV
management of malaria infections, use of insecticide- HIV infection impairs a pregnant woman’s ability to
treated nets (ITNs) and, in areas of stable transmission, control P. falciparum infection. Women with HIV infection
Intermittent Preventive Treatment (IPT). are more likely to have symptomatic malaria infections
and to have an increased risk of an adverse birth outcome
due to malaria. In the presence of HIV infection, placental
Impact of malaria in pregnancy in malaria appears to be independent of the number of
different epidemiological settings pregnancies, so that the risk of placental malaria is similar
The symptoms and complications of malaria in preg- in HIV-infected multigravidae and HIV-negative
nancy vary according to transmission intensity and the primagravidae.
level of acquired immunity. Although these are pre-
sented as discrete epidemiological entities, the reality is
usually more of a continuum, with a range of transmis- Prevention and management of malaria
sion intensity, acquired immunity, and clinical presenta- during pregnancy
tion occurring within the same country. Areas of low or epidemic (unstable) transmission
In areas of low or unstable transmission, control of
Areas of low or epidemic (unstable) transmission malaria during pregnancy is achieved primarily by
Pregnant women living in areas of low or unstable prompt and effective treatment of acute episodes of
malaria transmission have little or no immunity to malaria, since IPT will be relatively ineffective in such
malaria, and are at a 2 to 3–fold higher risk of developing settings. Since malaria in a non-immune pregnant woman
severe disease as a result of malaria infection than are can rapidly progress to severe disease, any pregnant
non-pregnant adults living in the same area. In these woman with symptomatic malaria must receive urgent
areas, maternal death may result directly from the com- treatment with an effective antimalarial drug plus appro-
plications of severe malaria (hypoglycaemia, cerebral priate supportive treatment. Use of ITNs will decrease
malaria, and pulmonary oedema being particular prob- exposure to infective mosquito bites and would therefore
lems), or indirectly from malaria-related severe anaemia. be expected to provide protection from symptomatic
Malaria in pregnancy can also result in stillbirth, sponta- infection.
neous abortion, low birth weight (birth weight < 2.5 kg),
and neonatal death. Areas of high or moderate (stable) transmission
ITNs and IPT (see below) are the key components of the
Areas of high or moderate (stable) transmission preventive package for pregnant women living in areas of
Most pregnant women in malaria-endemic regions of stable transmission. P. falciparum parasites may be present
Africa live in areas of relatively stable transmission. In in the placenta and contribute to maternal anaemia even
these settings, the deleterious impact of malaria is par- in the absence of documented peripheral parasitaemia.
ticularly apparent in first and second pregnancies. Any pregnant woman with severe anaemia from a
Although parasite prevalence and density are higher malaria-endemic area must therefore be treated pre-
among pregnant women compared to non-pregnant sumptively with an effective antimalarial drug, whether
women, infection with P. falciparum is usually asympto- or not peripheral parasitaemia is present, and whether or
matic. Partial clinical immunity acquired during years of not she has a history of fever. In addition, all women in
exposure to the malaria parasite prior to pregnancy does malarious areas (regardless of endemicity) should receive
not prevent infection, but does reduce the risk of severe iron and folic acid supplementation as part of routine
disease. Clinical malaria is not, therefore, a prominent antenatal care.
January 2004 Mera iii

SUPPORTING AGENCY – ROLL BACK MALARIA, WHO
ITNs other antimalarial drug options. A WHO meeting to

In a large randomised trial recently conducted in an area review the pre-clinical (animal) and limited human data
of intense perennial malaria transmission in western on the use of artemisinins in pregnancy concluded that
Kenya, use of ITNs by pregnant women was associated these drugs have a good safety profile, particularly in the
with a 38% reduction in the incidence of malaria parasi- second and third trimesters of pregnancy and during
taemia, 47% reduction in malarial anaemia (Hb <8 g/dl lactation, and the use of artemisinin-based combination
plus parasitaemia), and 28% reduction in the prevalence therapy for IPT must now be evaluated.
of LBW. 2 (See July 2003 issue of Mera).
IPT The need for programming partnerships

IPT replaces the previous policy of weekly chloroquine for malaria control during pregnancy
chemoprophylaxis in pregnancy, which was limited by In two thirds of African countries recently undergoing a
poor compliance and increasing resistance of P. falciparum Demographic and Health survey, more than 70% of
to chloroquine. IPT involves the administration of a cura- women attended antenatal clinic (ANC) at least once
tive treatment dose of an effective antimalarial drug at during pregnancy. Roll Back Malaria has targeted the
predefined intervals during pregnancy, beginning after ANC for the accelerated programme implementation of
quickening (the time at which foetal movements are first malaria control during pregnancy in those areas with
felt by the mother) in the second trimester. stable malaria transmission and high ANC attendance. In
All women should receive at least 2 doses of IPT in the areas with low ANC coverage, emphasis is placed on the
second and third trimesters of pregnancy, ideally under development and strengthening of community-based
direct observation at the time of routinely scheduled programmes.
antenatal clinic visits. IPT ensures that the placenta is
cleared of parasites at the time of rapid foetal growth (see Summary
Figure 1). Maximum benefit is derived from 2–3 doses of Three evidence-based strategies (IPT, ITNs, and effective
IPT, although even a single dose is beneficial. case management) exist for the control of malaria in
pregnancy, but the widespread implementation of effec-
tive programmes remains a considerable challenge. Many
women in Africa, particularly those living in remote
areas, have limited access to medical care and effective
malaria control tools such as ITNs. Delivery of cost-
effective malaria prevention to pregnant women will
require strengthened antenatal care, integration of
malaria control with other health programmes targeted
at pregnant women and infants, increased community
awareness, and considerable financial investment. The
prize for achieving this will be safer pregnancies and a
reduction in infants deaths. Prevention of malaria during
pregnancy remains one of the most important and achiev-
able goals of the Roll Back Malaria partnership.
Figure 2 IPT dosing schedule
All women should receive at least 2 doses of IPT after quickening.
* IPT may also be given at the 4th visit, if she has not received the References
requisite number of doses 1. Steketee RW, Nahlen BL, Parise ME, Menendez C. The bur-
den of malaria in pregnancy in malaria-endemic areas. Am J
Trop Med Hyg 2001; 64: S28–35.
Studies in Kenya and Malawi 3,4,5 have shown that IPT 2. ter Kuile F, Terlouw DJ, Phillips-Howard PA, et al. Reduction
of malaria during pregnancy by permethrin-treated nets in an
with sulphadoxine-pyrimethamine (SP) significantly area of intense perennial malaria transmission. Am J Trop Med
reduces the prevalence of maternal anaemia and placen- Hyg 2003; 68 (suppl 4): 50–60.
tal parasitaemia, and the incidence of LBW. SP has a good 3. Parise EM, Ayisi JG, Nahlen BL, et al. Efficacy of sulfadoxine-
pyrimethamine for prevention of placental malaria in an area
safety profile in pregnancy, while the single-dose regi- of Kenya with a high prevalence of malaria and human
men allows the health worker to directly observe treat- immunodeficiency virus infection. Am J Trop Med Hyg 1998;
ment. In several studies, no evidence of an increase in 59: 813–22.
serious cutaneous side-effects or neonatal jaundice was 4. Shulman CE, Dorman EK, Cutts F, et al. Intermittent
sulphadoxine-pyrimethamine to prevent severe anaemia sec-
found when SP was delivered in the second and third ondary to malaria in pregnancy: a randomised placebo-con-
trimester of pregnancy. SP remains an excellent option for trolled trial. Lancet 1999; 353: 632–6.
IPT in areas of Africa where malaria transmission is stable 5. Verhoeff FH, Brabin BJ, Chimsuku L, et al. An evaluation of
the effects of intermittent sulfadoxine-pyrimethamine treat-
and resistance to SP is low. Since, however, resistance to ment in pregnancy on parasite clearance and risk of low
SP is increasing throughout Africa, there is an urgent birthweight in rural Malawi. Annals Trop Med Parasitol 1998;
need to evaluate the efficacy, effectiveness, and safety of 92: 141–50.
Mera iv January 2004

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SUPPORTING AGENCY – ROLL BACK MALARIA, WHO

Reducing the burden of

January 2004 Mera iii

ITNs other antimalarial drug options. A WHO meeting to

IPT The need for programming partnerships

Mera iv January 2004

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