Preventing malaria in pregnancy in remote African communities
Mercy Nkiruka Agbo steps out under an overcast sky in the remote area of Ohaukwu in Ebonyi State, Nigeria. Clipboard in hand, the 29-year old mother of one scans a list of names of pregnant women before deciding which she will visit first.
Agbo is a community health worker involved in TIPTOP1, an innovative pilot project aimed at protecting African mothers and newborns from malaria. In collaboration with ministries of health, TIPTOP volunteers like Agbo are working to expand community-based access to “intermittent preventive treatment in pregnancy” (IPTp) in 4 countries of sub-Saharan Africa, the region that carries the heaviest burden of the disease.
More than 50 million women in sub-Saharan Africa become pregnant each year and are at risk of exposure to Plasmodium falciparum, the deadliest malaria parasite globally. Left untreated, malaria in pregnancy can lead to maternal death, anemia and low birth weight – a major cause of infant mortality. IPTp with the quality-assured medicine sulfadoxine-pyrimethamine (SP) can prevent the development of these and other adverse consequences.
Since 2012, WHO has recommended the administration of 3 or more doses of IPTp-SP for pregnant women living in all areas of moderate-to-high malaria transmission in Africa. The medicine should be given during routine antenatal care (ANC) visits starting as early as possible in the second trimester, under the watch of a trained health care provider.
Coverage of IPTp-SP remains low
WHO’s recommendation of IPTp-SP as a safe and highly effective strategy for preventing malaria in pregnancy is underpinned by a wide body of evidence. However, access to the preventive therapy throughout pregnancy remains low. According to the World malaria report 2018, only 22% of eligible pregnant women received the recommended 3 or more doses of IPTp-SP in 33 African countries.
Barriers to access include the long distances that many pregnant women must travel to reach antenatal clinics, and related transportation costs. Those who reach health facilities may have difficulty accessing IPTp-SP due to stock-outs of the preventive medicine or insufficient information provided by health workers.
Several projects, including TIPTOP, aim to overcome these challenges. TIPTOP was launched in 2017 by Jhpiego, a non-profit organization affiliated with The Johns Hopkins University, in partnership with the Barcelona Institute for Global Health. The project is supported by WHO and the Medicines for Malaria Venture and funded by Unitaid.
Volunteer health workers like Agbo are key to the success of the TIPTOP strategy, which uses designated members of the community to dispense quality-assured IPTp-SP and, at the same time, encourage pregnant women to seek comprehensive care at ANC facilities. These efforts are expected to reinforce the partnership between ANC health facilities and communities.
Agbo has received specific training for this role. Eligible community health workers must come from the community and have a basic level of education.
As she makes her rounds in her community, Agbo is equipped with quality-assured SP, which is provided to her at regular intervals by an ANC clinic. Through monthly house calls, she is able to educate expectant mothers about the preventive malaria therapy and the importance of receiving comprehensive antenatal care at the nearest ANC facility; to recognize signs and symptoms of malaria; to determine when and how to administer IPTp with SP; and to encourage the use of insecticide treated bed-nets.
A heavy malaria burden
Nigeria is actively attempting to improve malaria control – with good reason: in 2017, the country carried 25% of the world’s malaria cases and nearly 1 in 5 (19%) malaria-related deaths. It is 1 of 4 countries that the TIPTOP project is supporting, along with the Democratic Republic of the Congo, Madagascar and Mozambique.
“Given Nigeria’s high malaria burden, the impact of malaria on pregnant women, very low antenatal care utilization rates generally, and the low uptake of IPTp in the country, Nigeria was an important country to implement the project in,” says Elaine Roman, TIPTOP Project Director at Jhpiego.
Over the 5-year duration of the project, TIPTOP will be rolled out in 3 Nigerian states – Ebonyi, in a first phase, followed by Niger and Ogun. The Ohaukwu area of Ebonyi, where Agbo works, reports the highest levels of malaria cases between April and October.
According to Dr Lynda Ozor, WHO National Programme Officer for Nigeria, fluctuations in transmission rates are in part linked to the rain cycle. “Peak transmission coincides with the rainy seasons, which sees mosquito breeding sites develop in and around where people live,” she explains “There is a very high prevalence of malaria in the population. So the mosquito just bites an infected person and the cycle keeps going.”
A year-round job
Agbo’s work as a community health worker, however, is year-round as transmission knows no single season, and because a pregnant woman should receive the full preventive course of SP regardless of whether or not she is infected with malaria. Agbo’s regular presence also serves to strengthen ties between the new community-based services offered through TIPTOP and antenatal care services.
Through the TIPTOP project, pregnant women gain immediate access to the recommended preventive treatment in the community and are encouraged to complete regular check-ups at full-service health facilities. These referrals to ANC facilities are critical: an increase in the number of contacts between health care providers and pregnant women creates opportunities to expand coverage of both IPTp and antenatal care.
“This project seeks to test the feasibility of introducing IPTp at the community level, while also increasing coverage among pregnant women and improving health outcomes for mother and newborn.”
Dr Lynda Ozor, WHO National Programme Officer for Nigeria
Since 2016, WHO has recommended a minimum of 8 contacts between pregnant women and the health system during pregnancy, versus the previously recommended 4 antenatal care visits. Each contact should provide an opportunity for high-quality care, including preventive and curative medical care, support, and the provision of timely and relevant information.
Building an evidence base
WHO does not currently endorse a community-based approach to delivering IPTp; according to WHO guidelines, IPTp should be administered by trained medical providers at antenatal care facilities. A key aim of the TIPTOP project is to generate evidence from sub-Saharan Africa on the delivery of IPTp at the community level. This evidence will be assessed in due course, along with evidence generated from other similar projects, which may guide future WHO policy recommendations to prevent malaria in pregnancy.
“This project seeks to test the feasibility of introducing IPTp at the community level, while also increasing coverage among pregnant women and improving health outcomes for mother and newborn,” says Dr. Ozor.
Although it is early days for TIPTOP — the roll-out of IPTp-SP at community level in Nigeria began in July 2018 — important groundwork has been laid. Partners have developed a training package for community health workers and antenatal care providers that complements existing national training materials. Together with ministries of health, TIPTOP partners are also working to ensure that project sites are stocked with the quality-assured preventive medicine.
1 Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) project