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OPINION

By Dr Daniel Orit

Malaria in pregnancy has a devastating effect on the health of mothers and their babies, and is an important cause of severe maternal anemia, low-birth-weight babies, premature delivery, miscarriage, and stillbirth. The World Health Organization (WHO) promotes three strategies for the control of malaria in pregnancy, which include provision of intermittent preventive treatment for malaria in pregnancy with Fansidar (monthly malaria prevention drug given to pregnant women during antenatal care visits), use of insecticide-treated nets (ITNs), and prompt diagnosis and treatment of confirmed malaria.

In 2012, the WHO updated its policy for intermittent preventive treatment for malaria in pregnancy recommending an increase in the number of doses of Fansidar to be administered at each scheduled antenatal care visit, starting as early as possible in the second trimester. However, according to the 2020 World Malaria Report, just over one third (34%) of pregnant women in 36 African countries received the recommended three or more doses of Fansidar.

In Uganda, a 6 year trend analysis on intermittent preventive treatment for malaria in pregnancy utilization revealed a modest increase (2% in 2017 to 48% in 2022), but not to the set 66% target utilization of Fansidar among pregnant mothers attending antenatal care. This below target intermittent preventive treatment for malaria in pregnancy utilization tells us of the many challenges facing malaria control during pregnancy. Some of the challenges 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 Fansidar.

Additionally, malaria in pregnant women living with HIV is challenging, especially in view of the fact that Fansidar is contra-indicated for HIV-infected pregnant women receiving co-trimoxazole prophylaxis to prevent opportunistic infections associated with HIV disease. Ongoing studies to evaluate the possibility of using another drug as an alternative is underway. Currently, HIV positive pregnant women are required to take only co-trimoxazole and not Fansidar to avoid drug reactions with Fansidar during pregnancy.

Generally, the main challenge for reducing the burden of malaria in pregnancy is partly, related to laxity by the health systems and community in adopting effective implementation and scale-up of programs for malaria control in pregnancy.

To address the highlighted challenges towards control of malaria in pregnancy, Ministry of Health and Stakeholders supporting malaria activities need to utilize available structures like the health workers working in antenatal care, community opinion leaders, and village health teams to encourage pregnant women to demand for antenatal services packages like Fansidar for malaria in pregnancy.

Emphasis on research should include coming up with strategies to address the low uptake of preventive interventions for malaria in pregnancy, and evaluation of alternative antimalarial drugs to replace Fansidar because of increasing resistance to this antimalarial drug.

Additionally, collective teamwork between malaria control programs and maternal newborn health programs is urgently required. Together, these programs must address both supply and demand challenges, such as maximization of coverage through community-directed interventions delivered by community health workers.

In conclusion, the burden of malaria in pregnancy, will only be addressed if both the supply and demand challenges are put into consideration. We need to encourage pregnant mothers to demand for antenatal care packages especially Fansidar, as well as ensure health facilities never run out of stock of drugs used for malaria in pregnancy.

The writer is a Field Epidemiology fellow at the Uganda Public Health Fellowship Programme, hosted at the National Malaria Control Division, Ministry of Health