Malaria infection during pregnancy and the use of insecticide-treated nets in northern Uganda
Situation:
Pregnant women are particularly vulnerable to malaria as they and their unborn child are more likely to suffer a range of complications: the mother may develop severe malaria, severe anaemia, placental malaria, hypoglycaemia, puerperal fever, pulmonary oedema and death; the child is more likely to be born with low birth weight, or be aborted or stillborn.
In areas of high transmission malaria transmission it is recommended that pregnant women receive two doses of a presumptive malaria treatment (sulphadoxine-pyrimethamine) during their pregnancy to mitigate the harmful affects of any malaria infection that may occur.
Insecticide-treated nets (ITNs) and Long Lasting Insecticide-treated Nets (LLINs) are known to reduce malaria transmission and complications in mother and child, if used throughout pregnancy and for the first few months, post parturition. Ideally all pregnant women should sleep under an LLIN throughout their pregnancy.
Response:
The Malaria Consortium works in partnership with the Ministry of Health in Uganda to strengthen the services offered at ANCs and deliver free LLINs through the ANC clinics to all pregnant women in northern Uganda. ANC services are improved and the availability of the nets helps to increase uptake of the service, with a long term aim of reducing malaria transmission and lessening infant mortality rates.
The system of delivering LLINs through routine antenatal services to pregnant women was based on the principle of partnership and ownership: the system was designed as an integral part of the Ministry of Health services at the district level. Planning and training was done in partnership with the District Health Services with on-going distribution to health facilities and supervision integral to routine district activities.
During the design, linkages to existing services and community-based organisations were stressed. LLINs are distributed at the end of the first antenatal visit to the pregnant woman.
As the net is handed over pregnant women are educated on key messages about the importance of the nets. The project emphasized raising awareness on issues around LLIN use, the safety of insecticides and the family members most in need of protection, carried out through interpersonal communication between the health facility staff and the mothers. Talk shows on the local radio have also been used and proven particularly popular with the public's questions being addressed and the answers able to reach a wide audience.
During the project 16,629 LLINs were delivered to pregnant women through ANC services covering 50-60% of the expected numbers of pregnant women in the two districts served during this period. Over three years 210,000 nets have been distributed. There was a 50% increase in the proportion of expected pregnant women attending ANC with some health facilities seeing double the number they would have previously seen.
Six months after the start up of distributions a net retention and use survey was carried out, demonstrating high retention with 86-93% of LLINs still in the possession of the women but only 47% of the targeted women having used the net the previous night. A refocusing on health education messages then took place to address specific concerns of the mothers (e.g. not wanting to use th net during pregnancy but saving it for when the baby was delivered). This was extremely effective with a recent survey carried out (2 years after the previous survey) showing over 85% use of nets by pregnant women who had received one through the ANC system 6 months ago.
Points to note:
This ANC LLIN delivery has been funded by Irish Aid, DFID and UNICEF in the past three years. UNICEF remains a major supporter of this project and USAID through the US President's Malaria Initiative and our AFFORD project have provided funding for massive scale up of this approach. The Ministry of Health is committed to continuing the delivery of LLINs through health facilities and our delivery mechanism is a standardized model which can be scaled up to other areas of the country.
In northern Uganda, the cost of delivering an LLIN to a pregnant woman is around $1.50 US.
Photo: Malaria Consortium