zika virus

Zika virus disease and pregnancy

 

A baby with a small head, characteristic of microcephaly
A baby with a small head, characteristic of microcephaly

Zika virus disease is mainly spread by mosquitoes. For most people it is a very mild infection and isn’t harmful.However, it may be more serious for pregnant women, as it’s been linked to birth defects – specifically, abnormally small heads (microcephaly).

Zika does not naturally occur in the UK. Zika outbreaks have been reported in the Pacific region, and the virus has now spread to South and Central America and the Caribbean.

Experts expect the Zika virus to spread to all countries in the Americas (including the Caribbean), with the exception of Chile and Canada. The Zika virus is expected to spread to the Gulf States of the USA (such as Texas and Florida) in the summer, as the mosquitoes usually spread to these areas at this time.

Symptoms of Zika virus infection

Most people don’t have any symptoms. If symptoms do occur, they are usually mild and last around two to seven days.
Commonly reported symptoms include:

  • a mild fever
  • joint pain (with possible swelling, mainly in the smaller joints of the hands and feet)
  • itching
  • rash, which is sometimes itchy
  • conjunctivitis (red eyes)
  • headache
  • eye pain

How you catch Zika virus infection

Most cases of Zika virus disease are spread by infected mosquitoes biting humans. Unlike the mosquitoes that spread malaria, affected mosquitoes (the Aedes mosquito) are most active during the day, especially during mid-morning, then late-afternoon to dusk.

There have been reports that the Zika virus may spread through sexual intercourse, although the risk is thought to be very low.

A small number of cases have occurred by transmission from an expectant mother to her unborn child via the placenta.

Advice for pregnant women 

There is evidence to suggest that pregnant women who contract the virus at any point during pregnancy may have an increased risk of giving birth to a baby with microcephaly (this means the baby will have an abnormally small head and can be associated with abnormal brain development).

Current advice is that women who are pregnant or planning to become pregnant should discuss their travel plans with their doctor.

If already pregnant, they should consider postponing travel to any region where a known outbreak of the Zika virus is occurring. If travel is unavoidable, then they should take extra care to avoid being bitten by mosquitoes.

If you are pregnant and have recently travelled to a country where there is an ongoing Zika virus outbreak, see your GP or midwife and mention where you have been, even if you have not been unwell. Your midwife or hospital doctor will discuss the risk with you and can arrange an ultrasound scan of your baby to monitor growth.

If there are any issues, you will be referred to a specialist foetal medicine service for further monitoring.

If you are experiencing Zika symptoms, your GP will arrange for you to have a blood test to check for Zika virus.

If your partner has travelled to a country where there is an ongoing Zika virus outbreak, you should use a condom for 28 days after his return home, even if he has no Zika symptoms.

If he does experience Zika symptoms or a Zika virus infection has been confirmed by a doctor, you should use a condom for six months.

If you are trying to get pregnant

If you are trying to get pregnant and have travelled in the last 28 days to a country where there is an ongoing Zika virus outbreak, see your GP or midwife and mention where you have been, even if you have not been unwell. It is recommended that you take folic acid supplements for 28 days before trying to get pregnant.

If you have experienced Zika symptoms within two weeks of returning home, it is recommended that you wait at least six months after full recovery before you try to get pregnant.

Even if you have not been unwell, it is recommended that you wait at least 28 days after you return home from a country where there is an ongoing Zika virus outbreak before you try to get pregnant.

If your partner has travelled to a country where there is an ongoing Zika virus outbreak, you should use a condom for 28 days after his return home, even if he has no Zika symptoms.

If he does experience Zika symptoms or a Zika virus infection has been confirmed by a doctor, you should use a condom for six months.

How Zika virus infection is treated

There is no specific treatment for Zika virus symptoms.

Drinking plenty of water and taking paracetamol may help relieve symptoms.

If you feel unwell after returning from a country that has malaria as well as an ongoing outbreak of Zika virus, you should seek urgent (same day) advice to help rule out a malaria diagnosis.

If you remain unwell and malaria has been shown not to be the cause, seek medical advice.

What if I’m worried that my baby has been affected by Zika?

Speak to your midwife or doctor for advice. If you are still concerned after receiving assurances from your healthcare professional and feel anxious or stressed more than usual, you can ask your GP or midwife for referral to further counselling.

To reduce your risk of infection, you should avoid being bitten by an Aedes mosquito. The most effective bite prevention methods, which should be used during daytime and night-time hours, include:

  • Using insect repellent that contains DEET (N, N-diethyl-meta-toluamide) on exposed skin, after sunscreen has been applied. DEET can be used by pregnant or breastfeeding women in concentrations up to 50%, and in infants and children older than two months. It should not be used on babies younger than two months.
  • Wearing loose clothing that covers your arms and legs.
  • Sleeping under a mosquito net in areas where malaria is also a risk.

Zika virus and blood donation

As a precaution, the NHS Blood and Transplant service has recommended that people who have travelled to countries where the Zika virus is active wait 28 days before donating blood.

source

http://www.nhs.uk/conditions/zika-virus/

 

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Pregnancy and exercise

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Maintaining a regular exercise routine throughout your pregnancy can help you stay healthy and feel your best. Regular exercise during pregnancy can improve your posture and decrease some common discomforts such as backaches and fatigue. There is evidence that physical activity may prevent gestational diabetes (diabetes that develops during pregnancy), relieve stress, and build more stamina needed for labour and delivery.

If you were physically active before your pregnancy, you should be able to continue your activity in moderation. Don’t try to exercise at your former level; instead, do what’s most comfortable for you now. Low impact aerobics are encouraged versus high impact.

The pregnant competitive athlete should be closely followed by an obstetrician.

If you have never exercised regularly before, you can safely begin an exercise program during pregnancy after consulting with your health care provider, but do not try a new, strenuous activity. Walking is considered safe to initiate when pregnant.

The American College of Obstetrics and Gynaecology recommends 30 minutes or more of moderate exercise per day on most if not all days of the week, unless you have a medical or pregnancy complication.

Who Should Not Exercise During Pregnancy?

If you have a medical problem, such as asthmaheart disease, or diabetes, exercise may not be advisable. Exercise may also be harmful if you have a pregnancy-related condition such as:

  • Bleeding or spotting
  • Low placenta
  • Threatened or recurrent miscarriage
  • Previous premature births or history of early labour
  • Weak cervix

Talk with your health care provider before beginning an exercise program. Your health care provider can also give you personal exercise guidelines, based on your medical history.

What Exercises Are Safe During Pregnancy?

exercise picture

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Most exercises are safe to perform during pregnancy, as long as you exercise with caution and do not overdo it.

The safest and most productive activities are swimming, brisk walking, indoor stationary cycling, step or elliptical machines, and low-impact aerobics (taught by a certified aerobics instructor). These activities carry little risk of injury, benefit your entire body, and can be continued until birth.

Tennis and racquetball are generally safe activities, but changes in balance during pregnancy may affect rapid movements. Other activities such as jogging can be done in moderation, especially if you were doing them before your pregnancy. You may want to choose exercises or activities that do not require great balance or coordination, especially later in pregnancy.

What Exercises Should Be Avoided During Pregnancy?

There are certain exercises and activities that can be harmful if performed during pregnancy. They include:

  • Holding your breath during any activity.
  • Activities where falling is likely (such as skiing and horseback riding).
  • Contact sports such as softball, football, basketball, and volleyball.
  • Any exercise that may cause even mild abdominal trauma such as activities that include jarring motions or rapid changes in direction.
  • Activities that require extensive jumping, hopping, skipping, bouncing, or running.
  • Deep knee bends, full sit-ups, double leg raises, and straight-leg toe touches.
  • Bouncing while stretching.
  • Waist-twisting movements while standing.
  • Heavy exercise spurts followed by long periods of no activity.
  • Exercise in hot, humid weather.

Warning for pregnant women.

Stop exercising and consult your health care provider if you:

 source

webMD baby guide.

babies under blue light to break down bilirubin and clear jaundice

Newborn jaundice a preventable cause of disability and death of babies

Kaa is a four-year-old boy who cannot sit on his own, has a hearing problem and frequent convulsions. His parents are very frustrated as a result and are on the verge of divorce. His mother blames his paternal grandmother for his condition as she was told by a prophet that his grandmother is the cause of the illness.

Kaa’s mother noticed that his eyes were very yellow when he was only three days old. His maternal grandmother told his mother to put him under the sun in the early morning for two days. She also supplied her with “camelion”, a locally made string which is tied to the baby’s hand (It is believed to ward off all evil eyes (ani bone) and turn every evil into good). Mother had also used that. By the seventh day, mother had noticed that Kaa had become weak and sent Kaa to a nearby health centre which referred her to a hospital in the city.

The hospital staff did everything possible to save his life.The doctors told Kaa’s parents that he had been brought in too late and that the jaundice had gone into his brain and caused brain damage. As a result, his growth would be delayed. In summary, Kaa had suffered brain damage from severe newborn jaundice.

Newborn jaundice defined

Newborn jaundice is the yellowing of the white portion of the eye (sclera) and or skin occurring in babies less than one month old. It is a common finding in newborns.

In the Child Health Out-Patients Department of the Korle Bu Teaching Hospital, no day passes without a baby coming in with neonatal jaundice. Unfortunately, some of them come in too late and end up with brain damage or even die. It leads to a condition called cerebral palsy which means the movement of the child is affected.

Any newborn baby can get neonatal jaundice. It is not “discriminatory”. Babies born to the rich, poor, educated, uneducated, antenatal care attendants and those who do not attend antenatal care can all develop jaundice after delivery.

You will notice yellowing of the white portion of the eye or the skin. This is always abnormal if it happens within the first day of life.

Causes of newborn/neonatal jaundice

There are several conditions that cause neonatal jaundice. Examples are an infection in the baby, G6PD deficiency, differences in blood group of the baby and mother, Biliary atresia and Galactosemia.

Breast milk jaundice also exists. One may think of breast milk jaundice if tests for all other causes are negative.

There are so many known specific causes for neonatal jaundice. Once the baby is brought to the hospital early for treatment, he or she becomes well. Ani bone (evil eyes) is not the cause of jaundice in babies.

Jaundice may be present at birth. If present at birth, it is very serious and requires immediate attention. It may also develop a few days after the baby is born. When the jaundice is severe, the compound that causes the jaundice (bilirubin) can go to the brain and cause serious damage to it and this may result in cerebral palsy.

Other things to look out for

The baby’s stool (pupu) may become pale (almost white) which may be an indication of a very serious condition called biliary atresia. This is an indication that the baby requires immediate medical attention.

A word of caution against the use of herbal medicine to treat neonatal jaundice:

There are a few people who try herbal medications and end up causing brain damage to the baby or even death. Your baby may develop brain damage which may affect their growth and development. They may not be able to grow normally. They may have hearing problems or mental retardation even if they survive. There are also some who may die from severe neonatal jaundice.

A study done  in the Child health Department of the Korle Bu Teaching Hospital found severe neonatal jaundice to be the most significant and preventable cause of cerebral palsy among Ghanaian children.

Tests and treatment

Lab tests are conducted in which blood samples will be taken from the baby to determine the level of the bilirubin (jaundice) in the blood and the baby’s blood group. The level of the bilirubin will determine how the baby will be treated. The other causes of jaundice in babies will also be looked out for on an individual baby basis. Blood will be taken from the mother to check her blood group as well.

If the level of the bilirubin is low, the baby may be asked to go home and return a few days later for reassessment.

Phototherapy

If the level of jaundice (bilirubin) is not too high the baby is put under blue light which helps to break down the bilirubin and clear the jaundice. Baby is put under the light naked, with the eyes and genital area covered in order to protect them from damage.

Exchange blood transfusion

If the level of jaundice (bilirubin) is very high, the baby may need an exchange blood transfusion. This involves taking some of the baby’s blood out and giving him or her blood transfusion. The aim of this procedure is to bring down the level of the bilirubin quickly to avoid brain damage to the baby.

Surgery

If a surgical cause of the jaundice is seen, surgery is performed to save the baby.

Sunbathing

Leaving the baby under early morning sun does tame neonatal jaundice.  It is, however, not recommended because the sun also has other rays which are harmful to the baby. Baby can easily get worse and develop brain damage.

A note to health workers in small centres

There are several causes of neonatal jaundice. Just looking at the baby will not reveal the cause.  Lab tests and other investigations may be necessary to make a diagnosis. If you are not trained in the management of neonatal jaundice or do not have phototherapy at your facility, prompt referral to a higher health facility for treatment is the only way to prevent disability from brain damage or death of the baby.

The intensive phototherapy unit (e.g. Firefly) in our experience is a very effective piece of equipment to manage neonatal jaundice.

In sum, neonatal jaundice is common. Its complications are several, severe and preventable. No baby should, therefore, die or develop brain damage from newborn jaundice.

source

http://www.graphic.com.gh/

 

A baby at Save the Children's Kangaroo Mother Care clinic in the

The Benefits of Kangaroo Care

A baby at Save the Children's Kangaroo Mother Care clinic in the

Kangaroo care is a form of developmental care that has benefits for all newborns, especially those who are in the neonatal intensive care unit (NICU). It is also known as skin-to-skin contact or kangaroo mother care, kangaroo care involves direct contact when a newborn is placed skin-to-skin on mom or dad’s bare chest. Mom or dad may gently hold their baby where they can be rocked, cuddled and hear comforting sounds of their parent’s heartbeat and voice. Even in the stressful environment of the NICU, parent and child can quietly bond and get to know one another. Kangaroo care is easy to do, inexpensive and highly rated by parents 4.

Benefits

Many of the benefits of kangaroo care to a newborn revolve around their feelings of safety, warmth and comfort. Research shows greater bonding with parents and as a result calmer and less stress, which positively impacts their brain and emotional development

Kangaroo care can help NICU babies

  • Regulate their heart rate, breathing and temperature
  • Improve head circumference growth and weight gain
  • Stabilize their organ function and self-regulation abilities
  • Experience less pain and less crying
  • Facilitate better sleep patterns
  • Avoid infections
  • Take advantage of improved nutrition from mothers’ increase in breastmilk production
  • Be more willing to breastfeed
  • Enjoy a shorter hospital stay

In addition to benefits that are observable in the NICU, research points to long-term advantages as well. Newborns who experienced kangaroo care in the NICU were more attached and bonded to their mothers over time. Babies were more alert after six months and their mothers were more attuned to their infant’s cues and experienced less depression. In early childhood, children receiving kangaroo care also show increased social competence, a positive sense of self and improved cognitive and motor development. These benefits are all signs of healthy brain development.

 

When to Start

Depending on your baby’s condition, kangaroo care can begin immediately after delivery or may start after they are more stable. Even very small babies with major health issues or on a mechanical ventilator can benefit from these short sessions. Once your baby is stabilized, sessions should be at least an hour (even up to 24 hours though NICU policies vary) as anything less can be stressful for your baby. Your nurse or other neonatal professional should be able to give advice about when a baby is ready for kangaroo care and help prepare parents for this special time together.

Getting Ready for the Big Moment

Kangaroo care usually requires a comfortable place to sit with several pillows for support and to help position the baby, though it can also be done standing up. Many hospitals provide a privacy curtain or screen to make it easier for a parent to undress from the waist up to prepare to hold their child. If a privacy screen is not available, parents may be offered a wrap or a stretchy shirt with a large neck opening that can be worn with space for baby to be tucked inside for privacy.

During kangaroo care, a baby will be undressed down to the diaper and placed directly on mom or dad’s chest. Any wires or tubes will be carefully positioned, and parent and child will be covered with a lightweight blanket or wrap to stay warm and for privacy. The nurse will likely take your baby’s temperature several times to make sure they are maintaining their temperature and will probably watch the monitors pretty closely the first few times.

Dads Have a Role to Play, too

It is not uncommon for dads to feel like a visitor or spectator when their baby is in the NICU. Moms often spend more time in the NICU and have the role of providing breast milk. Kangaroo care can empower dads so they also feel like a significant person in their infant’s life. Fathers also learn specific knowledge about caring for their baby, become a part of their schedule, and as well by participating in skin-to-skin care. Kangaroo care is a great time for dads to practice practical skills related to caring for their child, while building a lasting bond.

 

 

Sources
1Neu, M. & Robinson, J. (2010). Maternal holding of preterm infants during the early weeks after birth and dyad interaction at six months. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 39, 401-414; DOI: 10.111/j.1552-6909.2010.01152.x.
2World Health Organization. (1993). Kangaroo mother care: a practical guide. Retrieved July 12, 2013 from

http://www.who.int/maternal_child_adolescent/documents/9241590351/en/

 

 

 

 

 

 

 

 

 

 

 

 

 

PRETERM BIRTH

Preterm birth

Overview

Preterm is defined as babies born alive before 37 weeks of pregnancy are completed. There are sub-categories of preterm birth, based on gestational age:

  • extremely preterm (<28 weeks)
  • very preterm (28 to <32 weeks)
  • moderate to late preterm (32 to <37 weeks).

An estimated 15 million babies are born too early every year. That is more than 1 in 10 babies. Almost 1 million children die each year due to complications of preterm birth. Many survivors face a lifetime of disability, including learning disabilities and visual and hearing problems.

Globally, prematurity is the leading cause of death in children under the age of 5. And in almost all countries with reliable data, preterm birth rates are increasing.

Inequalities in survival rates around the world are stark. In low-income settings, half of the babies born at or below 32 weeks (2 months early) die due to a lack of feasible, cost-effective care, such as warmth, breastfeeding support, and basic care for infections and breathing difficulties. In high-income countries, almost all of these babies survive.

 

Key facts

  • Every year, an estimated 15 million babies are born preterm (before 37 completed weeks of gestation), and this number is rising.
  • Preterm birth complications are the leading cause of death among children under 5 years of age, responsible for nearly 1 million deaths in 2013.
  • Three-quarters of them could be saved with current, cost-effective interventions.
  • Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born.

 

The solution

More than three-quarters of premature babies can be saved with feasible, cost-effective care, e.g. essential care during child birth and in the postnatal period for every mother and baby, antenatal steroid injections (given to pregnant women at risk of preterm labour and under set criteria to strengthen the babies’ lungs), kangaroo mother care (the baby is carried by the mother with skin-to-skin contact and frequent breastfeeding) and antibiotics to treat newborn infections.

To help reduce preterm birth rates, women need improved care before, between and during pregnancies. Better access to contraceptives and increased empowerment could also help reduce preterm births.

Some Causes of Preterm birth

Preterm birth occurs for a variety of reasons. Most preterm births happen spontaneously, but some are due to early induction of labour or caesarean birth, whether for medical or non-medical reasons.

Common causes of preterm birth include multiple pregnancies, infections and chronic conditions such as diabetes and high blood pressure; however, often no cause is identified. There could also be a genetic influence. Better understanding of the causes and mechanisms will advance the development of solutions to prevent preterm birth.

Where and when does preterm birth happen?

More than 60% of preterm births occur in Africa and South Asia, but preterm birth is truly a global problem. In the lower-income countries, on average, 12% of babies are born too early compared with 9% in higher-income countries. Within countries, poorer families are at higher risk.

Of 65 countries with reliable trend data, all but 3 show an increase in preterm birth rates over the past 20 years. Possible reasons for this include better measurement, increases in maternal age and underlying maternal health problems such as diabetes and high blood pressure, greater use of infertility treatments leading to increased rates of multiple pregnancies, and changes in obstetric practices such as more caesarean births before term.

There is a dramatic difference in survival of premature babies depending on where they are born. For example, more than 90% of extremely preterm babies (<28 weeks) born in low-income countries die within the first few days of life; yet less than 10% of babies of this gestation die in high-income settings.

 

Guidelines to improve preterm birth outcomes

Who has developed new guidelines with recommendations for improving outcomes of preterm births. This set of key interventions can improve the chances of survival and health outcomes for preterm infants. The guidelines include interventions provided to the mother – for example steroid injections before birth, antibiotics when her water breaks before the onset of labour, and magnesium sulfate to prevent future neurological impairment of the child. As well as interventions for the newborn baby – for example thermal care (e.g. kangaroo mother care when babies are stable) , safe oxygen use, and other treatments to help babies breathe more easily.

 

reference

Blencowe H, Cousens S, Oestergaard M, Chou D, Moller AB, Narwal R, Adler A, Garcia CV, Rohde S, Say L, Lawn JE. National, regional and worldwide estimates of preterm birth. The Lancet,

Fistula In Sub-saharan Africa

We  read the recent report by Mathieu Maheu-Giroux and colleagues (May, 2015) of a meta-analysis of Demographic and Health Survey data on fistula prevalence in sub-Saharan Africa. This study can only provide an estimate of urinary incontinence symptoms, and since there was no confirmation of fistula diagnosis, the data cannot be used to represent fistula prevalence. Indeed, Maheu-Giroux and colleagues report that women with fistula are older and of greater parity than women without fistula. This finding should have alerted them to an obvious error in the data because women classically experience fistula during their first delivery (at a young age) and frequently have no further pregnancies, whereas women with other causes of incontinence, such as uterine prolapse and stress incontinence, are older and multigravid.

Moreover, the data on Ethiopia’s fistula prevalence are in profound contrast to our experience and the results of two studies we have recently undertaken in Ethiopia, both of which are currently being considered for publication. The first is a community-based study of 23 023 women surveyed for fistula and uterine prolapse, with suspected fistula cases being followed up for diagnostic confirmation. The second is of surgical fistula treatment in three Ethiopian fistula hospitals, where around 70% of the country’s treatments are provided. Both studies reveal a significant decline in fistula prevalence and illustrate that Ethiopia is far from having “deficiencies in national treatment planning”, and it has been successful in improving maternal health care and delivering an effective patient identification programme and high-quality fistula.

References

  1. Maheu-Giroux, M, Fillipi, V, Samadoulougou, S et al. Prevalence of vaginal fistula symptoms in 19 sub-Saharan African countries: a meta-analysis of national household survey data. Lancet Glob Health. 2015; 3: e271–e278
  2. Ahmed, S and Tuncalp, O. Burden of obstetric fistula: from measurement to action. Lancet Glob Health. 2015; 3: e243
  3. THE LANCET Global World, fistula in sub-saharan Africa,vol. 3, no_8, e441, August 2015

Saving Lives Through Breastfeeding: Kenya

What helps save the lives of about 800,000 babies every year and doesn’t cost a dime? Breastfeeding.

Of all preventive health interventions, breastfeeding—done within the first hour of life, exclusively for the first six months, and until age two—has the greatest potential impact on child survival, with the ability to avert 13% of deaths in children under five in the developing world (Lancet 2013).

midwife mother weigh scale breastfeed smile mom baby woman child kenya

 

In Kenya, national rates of exclusive breastfeeding in the first six months of life have increased dramatically — from 32% in 2008/09 to 61% in 2014 (KDHS 2008/09 and KDHS 2014, preliminary results). With this in mind, USAID’s flagship Maternal and Child Survival Program(MCSP) is working closely with the Ministry of Health in Kenya to scale-up the Baby-Friendly Community Initiative (BFCI). Our efforts include comprehensive support to mothers at the community level to improve maternal, infant and young child health and nutrition – with an emphasis on initiation and exclusive breastfeeding in the first six months.

To have impact, we know we must work closely with communities to understand and address their unique needs and challenges to support timely initiation and to ensure women breastfeed for the full duration of six months. MCSP involves key community influencers—fathers, grandmothers, mother-in-laws and local leaders—in this process, while we build capacity of health care workers and community health volunteers to deliver services at the health facility and community levels. This includes the provision of information and support to mothers for optimal breastfeeding, complementary feeding, and maternal nutrition practices.

kenya mother women support group breastfeed male involvement community health worker

 

BFCI is a new concept in Kenya that was field-tested under USAID’s predecessor Maternal and Child Health Integrated Program (MCHIP) in Kenya’s Bondo and Igembe North Constituencies and showed marked improvements in maternal, infant and young child nutrition indicators. An assessment conducted of two groups of mothers—those who did and did not attend BFCI support groups—revealed greatly improved breastfeedng practices among the former group.

  • Mothers who attended support groups were more likely to attend more than three antenatal care visits (63% vs 38%) and to deliver in health facilities (86% vs. 51%), than non-attenders.
  • Those who were actively involved in support groups improved their knowledge of both initiation of breastfeeding within the first hour after birth and non-use of prelacteal feeds, and noted being better equipped to resolve any breastfeeding problems in comparison with non-attenders.
  • Most non-attenders had a shorter duration of exclusive breastfeeding and tended to introduce complementary foods early, prior to six months of age.

These efforts are part of MCSP’s larger scope of work in Kenya to build on the strong technical platforms established under MCHIP, while strengthening the health systems that deliver these lifesaving interventions to women and families

Please take a moment to check out these related links of interest:

This post originally appeared on the blog of the Maternal and Child Survival Program and has been lightly edited.

Malaria in pregnancy: challenges for control and the need for urgent action

Malaria in pregnancy has a devastating effect on the health of mothers and their babies, and is an important cause of maternal and infant mortality and morbidity.1 The greatest effect of malaria in pregnancy is concentrated in sub-Saharan Africa and is associated with Plasmodium falciparum infection. However, pregnant women are also at risk of Plasmodium vivax malaria. Although its burden seems to be lower than that of P falciparum, P vivax malaria is still associated with harmful consequences for maternal and infant health.

WHO promotes three strategies for the control of P falciparum infection in pregnancy in Africa, which include provision of intermittent preventive treatment for malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), use of insecticide-treated nets (ITNs), and prompt diagnosis and treatment of confirmed infections. Unlike in stable transmission areas, no global recommendations currently exist for the prevention of malaria in pregnancy in low-transmission areas or those P vivaxpredominates.

In 2000, under the Roll Back Malaria Partnership, Abuja targets were set for at least 60% of pregnant women who are at risk of malaria to have access to antimalarial chemoprophylaxis or IPTp-SP by 2005, and at least 80% use of ITNs by 2010.3 These targets were subsequently reset with even more ambition to 100% use of both interventions by 2015. However, coverage estimates for IPTp-SP and long-lasting ITNs in the sub-Saharan region have increased only modestly in past years, reaching about 21% coverage for two doses of IPTp-SP and 41% for ITNs on average in 2010.4 Problems with the delivery of control interventions for malaria in pregnancy are linked to weaknesses within the health system, such as insufficient resources, inadequate or poorly trained staff, and ineffective procurement and supply chain management of SP and ITNs. In 2012, WHO updated its policy for IPTp-SP, recommending an increase in the number of doses of SP to be administered at each scheduled antenatal care visit, starting as early as possible in the second trimester. Countries currently face many obstacles in the scale-up of the provision of IPTp-SP, including inconsistencies between the WHO guidelines and national policies, which have increased the number of missed opportunities for control of malaria in pregnancy.

Accordingly, the main challenge for reducing the burden of malaria in pregnancy in Africa is related to the adoption of national policies that incorporate WHO guidance, and effective implementation and scaling-up of programmes. Health systems need to be strengthened to successfully provide interventions for the prevention and treatment of malaria in pregnancy as part of the platform for antenatal care. Innovative approaches to increase demand must be explored so more women can be reached and earlier in pregnancy. Harmonisation of policies between malaria control and reproductive, maternal, newborn, and child health programmes is urgently needed and will be crucial to meet global targets. Together, these programmes must address both supply and demand challenges and derive clear lessons from assessment of new approaches to the delivery of preventive strategies, such as maximisation of coverage through community-directed interventions delivered by community health workers.

Challenges for effective prevention of malaria in pregnancy are increased in pregnant women living with HIV, especially in view of the fact that IPTp-SP is contraindicated for HIV-infected pregnant women receiving cotrimoxazole prophylaxis to prevent opportunistic infections. This has several implications for health systems: first, it tends to create confusion among front-line health workers, sometimes leading to both drugs being given and, second, because of frequent stock-outs of HIV screening tests, women often do not receive any preventive drugs. Additionally, suitable approaches for the prevention of malaria infection in the first trimester of gestation, for both pregnant women living with HIV and those not infected, have yet to be identified. None of the currently recommended antimalarial drugs can be given in this critical period because of safety risks for the embryoThus, malaria protection in the first trimester relies mostly on vector control measures, mainly ITNs that are usually provided later in pregnancy.

Research priorities should include the assessment of innovative programming to address the low uptake of preventive interventions for malaria in pregnancy; ensuring effective protection in particularly susceptible groups such as HIV-infected pregnant women; improving of malaria control in the first trimester of gestation; and evaluation of alternative antimalarials to replace SP because of increasing resistance to this antimalarial drug. Research is also needed with respect to the malaria elimination agenda, including identification of the most suitable strategies for control of malaria in pregnancy and for radical cure of P vivax and P falciparum infections in low-transmission settings that are on track towards malaria elimination.

Targets for malaria control in pregnancy are far from being reached, despite global gains in malaria investment during the past decade, which have resulted in substantial overall reductions in deaths from malaria and the existence of highly cost-effective tools for malaria in pregnancy that have potential to save many maternal and neonatal lives. The challenges for effective control of malaria in pregnancy need a multidisciplinary approach that includes the coordination and integration of programmes for malaria and maternal and reproductive health, increased provision of resources to provide the best antenatal care, and investigation of the role of new and innovative delivery approaches to maximise coverage of interventions to prevent malaria. To have an immediate effect, a global call to action is urgently needed to increase national coverage and protect mothers and babies from the devastating consequences of malaria in pregnancy.

References

  1. Desai M, ter Kuile FO, Nosten F, et al. Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis 7: 93–104.
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