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Malaria Continues to Threaten Pregnant Women and Infants. What is Sierra Leone Doing About It?

Almost half the world’s population is at risk of malaria. Pregnant women are particularly vulnerable to the disease when they become infected because pregnancy reduces a woman’s immunity, increasing the risk of illness, severe anemia, and death. For the fetus, maternal malaria increases the risk of miscarriage, stillbirth, premature delivery, and low birth weight—a leading cause of child mortality.

Globally, malaria in pregnancy (MIP) contributes to about 10,000 maternal deaths and up to 200,000 newborn deaths each year. The World Health Organization (WHO) and the U.S. President’s Malaria Initiative (PMI) agree that MIP is a significant global health problem that has been neglected for too long. In Africa, 30 million women living in malaria-endemic areas become pregnant each year. As PMI’s flagship global service delivery project, PMI Impact Malaria (IM) is supporting numerous sub-Saharan African countries in their efforts to combat MIP.

Following WHO guidelines, IM supports a three-pronged approach to the prevention and management of MIP:

  • Provide long-lasting insecticidal nets (LLINs) and promote their use;
  • Administer intermittent preventive treatment in pregnancy (IPTp) in all areas with moderate to high malaria transmission in Africa; and
  • Promptly diagnose and effectively treat malaria infections.

WHO updated its IPTp guidelines in 2012 to recommend providing the medicine sulfadoxine-pyrimethamine (SP) at every scheduled antenatal care (ANC) visit after the first trimester, with doses administered at least one month apart until delivery.

In Sierra Leone, where the entire estimated population of 6.5 million is vulnerable to malaria, IM is working with the National Malaria Control Program (NMCP) and the Directorate of Reproductive and Child Health (DRCH) to improve the quality and accessibility of the three-pronged approach through ANC facilities and in communities. Despite progress achieved in recent years, key indicators show that health providers in the country are struggling to follow MIP guidelines.

While three-quarters of pregnant women in Sierra Leone attend at least four ANC visits, IPTp administration falls after the first visit and drops dramatically after that (1st dose: 96% of women; 2nd dose: 69%; and 3rd dose: 27%). Other critical roadblocks are also apparent. These include:

  • Delayed first ANC visit which, in turn, postpones the first dose of IPTp;
  • Minimal guidance to pregnant women from Community Health Workers on ANC services;
  • Stock-outs of SP, particularly at the facility level; and
  • Noncompliance within the private sector to NMCP policies.

To tackle these challenges, IM is supporting the NMCP and the DRCH to reinvigorate Sierra Leone’s MIP Technical Working Group (TWG), creating a structure to coordinate stakeholder efforts, advocate for funds and strategic prioritization, monitor progress towards targets, and strengthen national integration and collaboration across all levels of the health system. The MIP TWG consists of government directorates, academic institutions, civil society, international donors, implementing organizations, and other key stakeholders.

The Working Group is heavily focused on ensuring that all guideline, policy, job aid, and strategy documents pertaining to MIP and ANC at the national level are aligned with WHO recommendations. This includes reviewing and updating supportive supervision checklists to reflect the latest guidance, including the Outreach, Training and Supportive Supervision Plus (OTSS+) MIP checklist. IM created this tool using country learnings to improve provider performance through quality supportive supervision at the facility level.

Another avenue for reduced malaria burden comes from the fact that Sierra Leone is one of the only PMI focus countries that promotes IPTp through traditional birth attendants (TBAs) at the community level. The MIP TWG will coordinate centrally to ensure maximum uptake of IPTp by pregnant women through the country’s 1,888 TBAs.

Many other countries in sub-Saharan Africa are doubling down on activities to better prevent and manage MIP, which includes experimenting with service delivery outside of just ANC visits. IM will collaborate with Sierra Leone’s NMCP to share best practices and lessons learned from the country’s renewed focus on advancing MIP activities. Broader knowledge of Sierra Leone’s experience enhances cross-country and global learning which will help to keep greater numbers of women and infants safe and healthy from the burden of malaria.

Written by Keith Esch, PMI Impact Malaria (IM) Technical Advisor; Kwabena Larbi, IM Sierra Leone Chief of Party; and Kumba Wani Lahai, MIP Focal Point from Sierra Leone’s NMCP. Contributions from Gladys Tetteh, Malaria Director at Jhpiego and IM technical leader, and Anne Bulchis, IM Communications Manager.

Sources: WHO, U.S. President's Malaria Initiative Technical Guidance (Feb 2017), Sierra Leone Multiple Indicator Cluster Survey (2017)

PMI Impact Malaria is funded and technically assisted by the U.S. President's Malaria Initiative (PMI), and led by Population Services International (PSI) in partnership with JhpiegoMedical Care Development International (MCDI), and the Malaria Elimination Initiative (MEI) at UC San Francisco.

Photography credit: Mwangi Kirubi for PMI Impact Malaria, Kenya, 2018.

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