Implementation research studies on the access and use of MiP interventions

Project Coordinator:   Dr Jenny Hill (LSTM, UK)

Prof Jayne Webster (LSHTM, UK), Dr Annemieke van Eijk (LSTM, UK), Dr Patrick Walker (Imperial College, UK)

Dr Kassoum Kayentao (MRTC, Mali), Dr Peter Ouma (KEMRI-CDC, Kisumu, Kenya), Dr Stephanie Dellicour (LSTM, UK)

To achieve public health impact with new or existing interventions to control malaria in pregnancy through a series of studies to: 1) determine the burden, coverage and impact of current interventions to prevent MiP; 2) determine the effectiveness of MiP service delivery through antenatal clinics; 3) assess the acceptability of MiP interventions among pregnant women; and 4) develop data driven rapid assessment tools for use by decision makers at various levels of the health system.

Objective 1: Systematic reviews and modelling studies.

Objectives 2-3: Mixed methods observational studies involving household and facility-based surveys and qualitative methods, conducted in non-trial settings in Mali and Kenya. Systematic reviews were also conducted.

Objective 4: An intervention study to improve health management information systems for MiP in Mali and Kenya.

Objective 5: Advocacy for the scale-up of interventions to control MiP.

Burden: Until 2010, comprehensive and contemporary estimates of the number of pregnancies at risk of malaria and its consequent impact on maternal and newborn health were not available. We derived global estimates of the annual number of women who became pregnant in areas with malaria transmission, showing that 125m pregnancies are at risk, more than double previous World Health Organisation (WHO) estimates (Dellicour et al, 2010). Modelling studies estimated, for the first time, the geographical distribution of placental infection and low birth weight,and predicted that prevention of malaria pre-conception and in early pregnancy has a huge impact on LBW and the underlying life-time risk of LBW (Walker et al, 2014). Modelling was also used to estimated impact on birth weight of scaling up intermittent preventive treatment of malaria in pregnancy given sulphadoxine-pyrimethamine resistance showing that, even accounting for SP resistance, extending IPTp-SP to all women attending ANC would have a sizeable impact upon maternal and infant health in sub-Saharan Africa (Walker et al, 2017). Systematic reviews of the contribution of malaria control to maternal and newborn health and coverage, illustrate the importance of continuing to invest in scaling up MiP interventions (van Eijk et al, 2011, 2013; Hill and van Eijk, 2014).

Barriers to scale-up of MiP interventions: Our studies showed that there are substantial missed opportunities for the delivery of MiP interventions in the context of integrated service at antenatal clinics (Webster et al, 2013; Dellicour et al, 2016). Data from household surveys showed that ANC access and timing was not the main barrier to receiving two doses of IPTp (Hill et al, 2013, Hill et al, 2014, Hill et al 2015). A systematic review of factors effecting access, delivery, and use of IPTp and ITNs identified key interacting barriers many of which could be resolved in the short term by simplification and standardisation of country IPTp policies and improved guidance to health providers on the timing, frequency, and safety of taking SP on an empty stomach (Hill et al, 2013). A second systematic review on case management of malaria during pregnancy found substandard practices were widespread in both public and private sectors in all endemic regions including the continued use of monotherapies and use of artemisinin combination therapies (ACTs) in the first trimester, not currently recommended by WHO (Hill et al, 2014).

The publication of the new global estimates of the number of women who became pregnant at risk of malaria in pregnancy remains widely used as the go-to reference, cited in more than 390 articles (Dellicour et al, 2014). The report of the contribution of malaria control to maternal and newborn health (Hill and van Eijk, 2014) is used as a reference for key malaria stakeholders, such as MMV (RBM Progress and Impact series)

Findings from the observational studies and systematic reviews of IPTp-SP have informed messaging in the WHO policy brief on the 2012 IPTp policy update (World Health Organization, 2013. WHO policy brief for the implementation of IPTp using sulfadoxine-pyrimethamine (IPTp-SP) April 2013). A Global Call to Action to scale up IPTp was launched in collaboration with the Roll Back Malaria Working Group on malaria in pregnancy (Agarwal et al 2015, Chico et al, 2015).

A standardized tool that was developed to evaluate effectiveness of MiP programme was presented to WHO’s ERG on MiP in 2013 (see Malaria Policy Advisory Committee Meeting 11-13 September 2013, WHO Evidence Review Group on (IPT) of malaria in pregnancy: Draft Recommendations on Intermittent Preventive Treatment in Pregnancy (IPTp).