Reducing the risk of malaria in pregnancy in Uganda – observations from the field

Alany and Majole are South Sudanese women living in refugee camps in West Nile province, Northern Uganda. Both are pregnant.

I met Alany and Majole as I travelled to a rural health facility, where they were attending their first antenatal care (ANC) visit.  The midwife sat with each of the women and gave them a basic health education lesson. Then there were the physical examinations, followed by the provision of required medicines for their stage of pregnancy – including intermittent preventive treatment in pregnancy (IPTp) to reduce the risk of malaria for themselves and their babies. Before they returned home under the shelter of their sun umbrella, they were each given a mosquito net to protect them further from malaria. These last two aspects of the ANC visit are especially important since pregnant women are at increased risk of malaria – as are their unborn babies.

Malaria in pregnancy (MIP) is a significant public health threat which affects more than 30 million pregnant women each year in malaria-endemic areas. It poses substantial risks to mother and unborn child, including maternal anaemia, stillbirth, miscarriage and low birth weight – a leading cause of child mortality. To prevent malaria infections among pregnant women living in areas of moderate or high transmission, the World Health Organization recommends IPTp, a full therapeutic course of antimalarial medicine given to pregnant women regardless of whether or not they are infected with malaria.

Uganda’s Malaria Control Strategic Plan identifies IPTp as one of three main elements to prevent MIP. It is delivered as part of the focused ANC package and has been implemented countrywide since 2002. Yet, despite having made significant progress, Uganda is far from meeting the government’s target of 85 percent of pregnant women receiving two doses of IPTp by the end of 2015. In 2014-15, less than half of pregnant women in Uganda received two or more doses of IPTp, despite overall one time ANC attendance being 94 percent in Uganda.

What we are doing about it

To explore the factors that continue to impede IPTp uptake, Malaria Consortium is leading a research project to assess and address barriers to pregnant women taking IPTp in Uganda. The study is conducted through COMDIS-HSD, a Research Programme Consortium, and also through our programme partnership arrangement  with funding from the UK government.

We discovered a range of barriers. In particular, health workers were found to have mixed knowledge of IPTp guidelines with regard to dosage, timing, and frequency. They did not always offer IPTp and encourage pregnant women to take it, at times incorrectly judging them to be ineligible.

Based on these findings, we designed a pilot intervention to align with the Ministry of Health training programme on MIP. This pilot intervention is being implemented in West Nile province, complementing the standard training course on MIP by sending daily reminder text messages for five weeks, summarising the key points relating to IPTp of the training. The intervention is being implemented in eight health facilities. A neighbouring district acts as control with a further eight health facilities receiving the training but not the text messages.

How things are progressing

With the text messages having been sent out in June and July, I travelled to Uganda to check up on progress and to gain a better understanding of the project sites. I also visited health facilities in the study districts to observe how things are managed and the processes involved in an ANC visit.  This will feed into the evaluation of the pilot intervention in December, which will also look at data on ANC attendance, IPTp doses, IPTp stock levels, as well as follow up with a random sample of pregnant women who visited the health facilities for their ANC visits.  In preparation for this evaluation, I looked at all of the ANC registers and other records in close detail. I met with health facility staff to ask questions about their ANC clinics – roughly how many pregnant women they see, and how many midwives they have. I also met with some of the midwives to discuss ANC services they provide, specifically relating to malaria.

The visit was a great opportunity to see the hard work going into protecting pregnant women from malaria in West Nile. The pregnant women who visit these clinics return home better equipped to protect themselves and their babies from malaria.

By observing visits and discussing with staff at the ANC clinics, I could see first-hand some of the challenges and barriers to uptake of IPTp and other malaria control measures. For example, some steps of the process are not completed as they should be; medicines which should be taken at the health facility and in front of the midwife are being given to women to take at home at a later time; and shortages of some medicines and of ANC cards have led to difficulties administering the drugs and making sure women attend all of their ANC appointments on the correct dates.

However these obstacles are not insurmountable – and with further study and appropriate action they can be overcome. Obstacles such as these which get in the way of pregnant women receiving the best possible prevention and treatment from malaria are the motivation for studies such as the IPTp study in Uganda, as well as our other work in sub-Saharan Africa and Southeast Asia.

Georgia Gore-Langton is the COMDIS-HSD Research Officer at Malaria Consortium in London.