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Prevention and Control of Malaria during Pregnancy A Workshop for Healthcare Providers Prevention and Control of Malaria during Pregnancy 2 Facts about Malaria 300 million cases each year worldwide
9 of 10 cases occur in Africa
A person in Africa dies of malaria every 10 seconds
Women and young children are most at risk
Affects five times as many people as AIDS, leprosy, measles, and tuberculosis combined Prevention and Control of Malaria during Pregnancy 3 Facts about Malaria and Pregnancy 30 million African women are pregnant yearly
Malaria is more frequent and complicated during pregnancy
In malaria-endemic areas, malaria during pregnancy may account for:
Up to 15% of maternal anemia
5–14% of low birthweight
30% of “preventable” low birthweight Prevention and Control of Malaria during Pregnancy 4 Roll Back Malaria Worldwide partnership
Governments, private groups, research organizations, civil society, media
Aim to reduce malaria by half by 2010
Free advocacy resources and tools: http://www.rbm.who.int
Priority: Prevent poor outcomes caused by malaria in pregnancy
Abuja declaration: Goal is for 60% of women in Africa to be sleeping under insecticide-treated nets (ITNs) and getting intermittent preventive treatment (IPT) by 2005 Prevention and Control of Malaria during Pregnancy 5 Malaria Prevention and Treatment during Pregnancy Focused antenatal care (ANC) with health education about malaria
Use of insecticide-treated nets (ITNs)
Intermittent preventive treatment (IPT)
Case management of women with symptoms and signs of malaria Prevention and Control of Malaria during Pregnancy Chapter I: Focused Antenatal Care Prevention and Control of Malaria during Pregnancy 7 Focused Antenatal Care: Chapter Objectives Describe four main components of focused antenatal care (ANC)
Discuss frequency and timing of ANC visits
Describe essential elements of a birth plan that includes complication readiness
Describe interpersonal skills for effective ANC
Describe components of record keeping for ANC
Prevention and Control of Malaria during Pregnancy 8 Focused Antenatal Care An approach to ANC that emphasizes:
Evidence-based, goal-directed actions
Individualized, woman-centered care
Quality vs. quantity of visits
Care by skilled providers
Prevention and Control of Malaria during Pregnancy 9 Goal of Focused Antenatal Care To promote maternal and newborn health and survival through:
Early detection and treatment of problems and complications
Prevention of complications and disease
Birth preparedness and complication readiness
Health promotion Prevention and Control of Malaria during Pregnancy 10 Traditional Antenatal Care Emphasizes:
Ritualistic, “routine” care vs. evidence-based, goal-directed actions
Frequent visits
Does not emphasize individual client needs
Prevention and Control of Malaria during Pregnancy 11 No Longer Recommended Numerous, routine visits
Burden to women and healthcare system
Routine measurements and examinations:
Maternal height and weight
Ankle edema
Fetal position before 36 weeks
Care based on risk assessment Prevention and Control of Malaria during Pregnancy 12 Risk Approach Not an effective ANC strategy because:
Complications cannot be predicted—all pregnant women are at risk for developing complications
Risk factors are usually not direct cause of complications
Many “low risk” women develop complications
Have false sense of security
Do not know how to recognize/respond to problems
Most “high risk” women give birth without complications
Inefficient use of scarce resources Prevention and Control of Malaria during Pregnancy 13 Focused Antenatal Care Services Evidence-based, goal-directed actions:
Address most prevalent health issues affecting women and newborns
Adjusted for specific populations/regions
Appropriate to gestational age
Based on firm rationale Prevention and Control of Malaria during Pregnancy 14 Focused Antenatal Care Services (cont’d.) Individualized, woman-centered care based on each woman’s:
Specific needs and concerns
Circumstances
History, physical examination, testing
Available resources Prevention and Control of Malaria during Pregnancy 15 Focused Antenatal Care Services (cont’d.) Quality vs. quantity of ANC visits:
WHO multi-center study
Number of visits reduced without affecting outcome for mother or baby
Recommendations
Content and quality vs. number of visits
Goal-oriented care
Minimum of four visits Prevention and Control of Malaria during Pregnancy 16 First visit: By 16 weeks or when woman first thinks she is pregnant
Second visit: At 24–28 weeks or at least once in second trimester
Third visit: At 32 weeks
Fourth visit: At 36 weeks
Other visits: If complication occurs, followup or referral is needed, woman wants to see provider, or provider changes frequency based on findings (history, exam, testing) or local policy Scheduling and Timing of ANC Visits Prevention and Control of Malaria during Pregnancy 17 Focused Antenatal Care Services (cont’d.) Care by a skilled provider who:
Has formal training and experience
Has knowledge, skills, and qualifications to deliver safe, effective maternal and newborn healthcare
Practices in home, hospital, health center
May be a midwife, nurse, doctor, clinical officer, etc. Prevention and Control of Malaria during Pregnancy 18 Early Detection and Treatment Malaria—history and physical exam
Fever and accompanying signs/symptoms
Region
Complicated vs. uncomplicated cases
Severe anemia—physical exam, testing
Pre-eclampsia/eclampsia—measurement of blood pressure
HIV—voluntary counseling and testing
Sexually transmitted infections, including syphilis— testing
Prevention and Control of Malaria during Pregnancy 19 Prevention: Key Preventive Measures Malaria:
Intermittent preventive treatment (IPT)
Use of insecticide-treated nets (ITNs)
Tetanus toxoid, iron/folate supplements
Country/region-specific interventions as appropriate
Vitamin A supplements
Iodine supplements
Presumptive treatment for hookworm Prevention and Control of Malaria during Pregnancy 20 Birth Preparedness and Complication Readiness: Objectives Develop birth plan—exact plan for normal birth and possible complications:
Arrangements made in advance by woman and family (with help of skilled provider)
Usually not a written document
Reviewed/revised at every visit
Minimize disorganization at time of birth or in an emergency
Ensure timely and appropriate care Prevention and Control of Malaria during Pregnancy 21 Essential Elements of a Birth Plan Facility or Place of Birth: Home or health facility for birth, appropriate facility for emergencies
Skilled Provider: To attend birth
Provider/Facility Contact Information
Transportation: Reliable, accessible, especially for odd hours
Funds: Personal savings, emergency funds
Decision-Making: Who will make decisions, especially in an emergency
Prevention and Control of Malaria during Pregnancy 22 Essential Elements of a Birth Plan (cont’d.) Family and Community Support: Care for family in woman’s absence and birth companion during labor
Blood Donor: In case of emergency
Needed Items: For clean and safe birth and for newborn care
Danger Signs/Signs of Advanced Labor
Prevention and Control of Malaria during Pregnancy 23 Danger Signs of Pregnancy Vaginal bleeding
Difficulty breathing
Fever
Severe abdominal pain
Severe headache/blurred vision
Convulsions/loss of consciousness
Labor pains before 37 weeks
Prevention and Control of Malaria during Pregnancy 24 Health Education: Objectives Inform and educate the woman with health messages and counseling appropriate to:
Individual needs, concerns, circumstances
Gestational age
Most prevalent health issues
Support the woman in making decisions and solving actual or anticipated problems
Involve partner and family in supporting/adopting healthy practices Prevention and Control of Malaria during Pregnancy 25 Health Education: Topics Addressed Prevention of malaria:
Intermittent preventive treatment (IPT)
Use of insecticide-treated nets (ITNs)
Other methods
Other important issues to be discussed include:
Nutrition
Care for common discomforts
Use of potentially harmful substances
Hygiene
Rest and activity Prevention and Control of Malaria during Pregnancy 26 Health Education: Topics Addressed (cont’d.) Sexual relations and safer sex
Early and exclusive breastfeeding
Prevention of tetanus and anemia
Voluntary counseling and testing for HIV
Prevention of other endemic diseases/deficiencies
Prevention and Control of Malaria during Pregnancy 27 Interpersonal Skills Speak in a quiet, gentle tone of voice
Listen to woman/family and respond appropriately
Encourage them to ask questions and express concerns
Allow them to demonstrate understanding of information provided
Explain all procedures/actions and obtain permission before proceeding
Show respect for cultural beliefs and social norms
Be empathetic and nonjudgmental
Avoid distractions while conducting the visit Prevention and Control of Malaria during Pregnancy 28 Record Keeping First ANC Visit
History
Physical examination
Testing
Care provision, including provision of IPT for malaria, if appropriate
Counseling, including birth plan and use of ITNs
Date of next ANC visit Subsequent ANC Visits
Interim history
Targeted physical examination, testing
Care provision, including provision of IPT for malaria, if appropriate
Counseling, including birth plan and use of ITNs (and relevant information on how client obtained and used ITN)
Date of next ANC visit Record all information on the ANC chart and clinic card: Prevention and Control of Malaria during Pregnancy Chapter II: Malaria Transmission Prevention and Control of Malaria during Pregnancy 30 Malaria Transmission: Chapter Objectives Define malaria and how it is transmitted
Describe extent of malaria in Africa
Identify groups at highest risk of malaria infection
List effects of malaria on pregnant women and their unborn babies
Describe effects of malaria on pregnant women with HIV/AIDS Prevention and Control of Malaria during Pregnancy 31 Malaria Transmission Caused by Plasmodium parasites
Spread by female Anopheles mosquitoes infected with parasites
Anopheles mosquitoes usually active at night
Infected mosquito bites a person
Malaria parasites reproduce in human blood
Mosquito bites infected person, and goes on to bite and infect another person Prevention and Control of Malaria during Pregnancy 32 Populations Most Affected by Malaria Children under 5 years of age
Pregnant women
Unborn babies
Immigrants from low-transmission areas
HIV-infected persons Prevention and Control of Malaria during Pregnancy 33 Effects of Malaria on Pregnant Women All pregnant women in malaria-endemic areas are at risk
Parasites attack and destroy red blood cells
Malaria causes up to 15% of anemia in pregnancy
Can cause severe anemia
In Africa, anemia due to malaria causes up to 10,000 maternal deaths per year Prevention and Control of Malaria during Pregnancy 34 Effects on Unborn Babies Parasites hide in placenta
Interferes with transfer of oxygen and nutrients to the baby, increasing risk of:
Spontaneous abortion
Preterm birth
Low birthweight—single greatest risk factor for death during first month of life
Stillbirth
Prevention and Control of Malaria during Pregnancy 35 Effects on Communities Causes missed work and wages
Results in frequent school absences
Uses scarce resources
Causes preventable deaths: increases maternal, newborn, and infant mortality rates Prevention and Control of Malaria during Pregnancy 36 HIV/AIDS and Malaria during Pregnancy HIV/AIDS reduces a woman’s resistance to malaria
Intermittent preventive treatment (IPT) given 3 times during pregnancy is effective for women with HIV/AIDS Prevention and Control of Malaria during Pregnancy 37 Summary of Health Education Points Malaria transmitted through mosquito bites
Pregnant women and children are most at risk
Pregnant women infected with malaria may have no symptoms
Women with HIV/AIDS are at higher risk
Malaria can lead to severe anemia, spontaneous abortion, low-birthweight babies
Malaria is preventable Prevention and Control of Malaria during Pregnancy Chapter III: Preventing Malaria Prevention and Control of Malaria during Pregnancy 39 Preventing Malaria: Chapter Objectives List the elements of counseling women about the use of insecticide-treated nets (ITNs) and intermittent preventive treatment (IPT) during pregnancy
Describe the use of sulfadoxine-pyrimethamine (SP) for IPT during pregnancy
Prevention and Control of Malaria during Pregnancy 40 Insecticide-Treated Nets Kill or repel mosquitoes
Prevent physical contact with mosquitoes
Kill or repel other insects:
Lice
Ticks
Bedbugs
Cockroaches Prevention and Control of Malaria during Pregnancy 41 Insecticide-Treated Nets (cont’d.) Untreated Nets
Provide some protection against malaria
Do not kill or repel mosquitoes that touch net
Do not reduce number of mosquitoes
Do not kill other insects like lice, roaches, and bedbugs
Are safe for pregnant women, young children, and infants Insecticide-Treated Nets
Provide a high level of protection against malaria
Kills or repels mosquitoes that touch the net
Reduce number of mosquitoes in/outside net
Kills other insects such as lice, roaches, and bedbugs
Are safe for pregnant women, young children, and infants Prevention and Control of Malaria during Pregnancy 42 Benefits of Insecticide-Treated Nets Prevent mosquito bites
Protect against malaria, resulting in less:
Anemia
Prematurity and low birthweight
Risk of maternal and newborn death
Help people sleep better
Promote growth and development of fetus and newborn Prevention and Control of Malaria during Pregnancy 43 Benefits of Insecticide-Treated Nets: Community Cost less than treating malaria
Reduce number of sick children and adults (helping children grow to be healthy and helping working adults remain productive)
Reduce number of deaths
Prevention and Control of Malaria during Pregnancy 44 Where to Find Insecticide-Treated Nets General merchandise shops
Drug shops/pharmacies
Markets
Public and private health facilities
Community health workers
NGOs, community-based organizations Prevention and Control of Malaria during Pregnancy 45 How to Use Insecticide-Treated Nets Hang above bed or sleeping mat
Tuck under mattress or mat
Use every night, all year long
Use for everyone, if possible, but give priority to pregnant women, infants, and children Prevention and Control of Malaria during Pregnancy 46 Caring for Insecticide-Treated Nets Handle gently to avoid tears
Tie net up during day to avoid damage
Regularly inspect for holes, repair if found
Nets need to be re-treated regularly to stay effective
Keep away from smoke, fire, direct sunlight
Prevention and Control of Malaria during Pregnancy 47 Intermittent Preventive Treatment Based on the assumption that every pregnant woman living in an area of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria
Prevention and Control of Malaria during Pregnancy 48 Intermittent Preventive Treatment Although a pregnant woman with malaria may have no symptoms, malaria can still affect her and her unborn child
Prevention and Control of Malaria during Pregnancy 49 Intermittent Preventive Treatment: WHO Recommendation All pregnant women should receive at least two doses of IPT after quickening, during routinely scheduled ANC visits (WHO recommends a schedule of four visits, three after quickening)
Presently, the most effective drug for IPT is sulfadoxine-pyrimethamine (SP)
Women should receive at least two doses of IPT with SP at ANC visits after quickening, but no more frequently than monthly
Prevention and Control of Malaria during Pregnancy 50 Intermittent Preventive Treatment: Dose and Timing A single dose is three tablets of sulfadoxine 500 mg + pyrimethamine 25 mg
Healthcare provider should dispense dose and directly observe client taking dose Prevention and Control of Malaria during Pregnancy 51 Instructions for Giving Intermittent Preventive Treatment Ensure woman is at least 16 weeks pregnant and that quickening has occurred
Inquire about use of SP in last 4 weeks
Inquire about allergies to SP or other sulfa drugs (especially severe rashes)
Explain what you will do; address the woman’s questions
Provide cup and clean water Prevention and Control of Malaria during Pregnancy 52 Instructions for Giving Intermittent Preventive Treatment (cont’d.) Directly observe woman swallow three tablets of SP
Record SP dose on ANC and clinic card
Advise the woman when to return:
For her next scheduled visit
If she has signs of malaria
If she has other danger signs
Reinforce the importance of using ITNs Prevention and Control of Malaria during Pregnancy 53 Intermittent Preventive Treatment: Contraindications to Using SP Do NOT give during first trimester: Be sure quickening has occurred and woman is at least 16 weeks pregnant
Do NOT give to women with reported allergy to SP or other sulfa drugs: Ask about sulfa drug allergies before giving SP
Do NOT give to women taking co-trimoxazole, or other sulfa-containing drugs: Ask about use of these medicines before giving SP
Do not give SP more frequently than monthly: Be sure at least 1 month has passed since the last dose of SP Prevention and Control of Malaria during Pregnancy 54 Chemoprophylaxis with Chloroquine: For Women Allergic to Sulfa Drugs* Dose Chloroquine 150 mg Timing 1 4 tablets First ANC visit after 16 weeks 2 4 tablets Second day after first dose 3 2 tablets Third day after first dose Weekly 2 tablets Every week during pregnancy *If chloroquine resistance rates in the country are high, chemoprophylaxis with chloroquine is not recommended. Prevention and Control of Malaria during Pregnancy 55 Summary of Health Education Points Pregnant women should sleep under ITNs every night
By preventing malaria, IPT reduces the incidence of maternal anemia, spontaneous abortion, preterm birth, stillbirth, and low birthweight
IPT should be administered to pregnant women at regularly scheduled ANC visits after quickening, but not more often than monthly Prevention and Control of Malaria during Pregnancy Chapter IV: Detection and Treatment Prevention and Control of Malaria during Pregnancy 57 Malaria Detection and Treatment: Chapter Objectives Identify causes of fever during pregnancy
List the signs and symptoms of uncomplicated and complicated malaria
Describe the treatment for uncomplicated malaria during pregnancy
Explain the steps to appropriately refer a pregnant woman who has complicated malaria Prevention and Control of Malaria during Pregnancy 58 Detecting Malaria Symptoms
Fever
Chills
Headaches
Muscle/joint pains
Lab exam of blood from a finger prick Prevention and Control of Malaria during Pregnancy 59 Fever during Pregnancy Temperature of 38° C or higher
May be caused by malaria, but also by:
Bladder or kidney infection
Pneumonia
Typhoid
Uterine infection
Careful history and physical required to rule out other causes Prevention and Control of Malaria during Pregnancy 60 Fever during Pregnancy (cont’d.) Ask about or examine for:
Type, duration, degree of fever
Signs of other infections:
Chest pain/difficulty breathing
Foul-smelling watery vaginal discharge
Tender/painful uterus or abdomen
Frequency/urgency/pain in urinating
Signs of complicated malaria or other danger signs Prevention and Control of Malaria during Pregnancy 61 Types of Malaria Uncomplicated
Most common
Complicated
Life threatening, can affect brain
Pregnant women more likely to get complicated malaria than non-pregnant women Prevention and Control of Malaria during Pregnancy 62 Recognizing Malaria in Pregnant Women Uncomplicated Malaria
Fever
Shivering/chills/rigors
Headaches
Muscle/joint pains
Nausea/vomiting
False labor pains Complicated Malaria
Signs of uncomplicated malaria PLUS one or more of the following:
Dizziness
Breathlessness/difficulty breathing
Sleepy/drowsy
Confusion/coma
Sometimes fits, jaundice, severe dehydration Prevention and Control of Malaria during Pregnancy 63 Recognizing Malaria in Pregnant Women (cont’d.) Refer the woman
immediately
if you suspect anything
other than
uncomplicated malaria Prevention and Control of Malaria during Pregnancy 64 Case Management Determine whether malaria is uncomplicated or complicated
Uncomplicated: Manage according to national protocol
Complicated: Refer immediately to higher level of care; consider giving first dose of anti-malarial if available and healthcare provider is familiar with its use Prevention and Control of Malaria during Pregnancy 65 Case Management: Drugs First-line drug therapy is indicated for uncomplicated malaria
Second-line drug therapy is indicated for uncomplicated malaria that has failed to respond to first-line drug
In almost all countries, quinine is the drug of choice for complicated malaria Prevention and Control of Malaria during Pregnancy 66 Managing Uncomplicated Malaria Provide first-line anti-malarial drugs
Follow country guidelines
Manage fever
Analgesics, tepid sponging
Diagnose and treat anemia
Provide fluids Prevention and Control of Malaria during Pregnancy 67 Treating Uncomplicated Malaria Observe client taking anti-malarial drugs
Advise client to:
Complete course of drugs
Return if no improvement in 48 hours
Consume iron-rich foods
Use ITNs and other preventive measures Prevention and Control of Malaria during Pregnancy 68 SP: Contraindications Before 16 weeks of pregnancy
SP dose in last 4 weeks
Allergies to sulfa drugs (e.g., co-trimoxazole)
Currently taking other sulfa drugs
Substitute other drug before giving SP Prevention and Control of Malaria during Pregnancy 69 Treatment Problems Vomiting within 30 minutes
Repeat dose of SP
Itching
Warm or cool baths
Use lotions/skin creams
Give Piriton™ or Phenergan®
Stomach upset/irritation
Take chloroquine with food or sugar
Reduce intake of caffeine and greasy foods Prevention and Control of Malaria during Pregnancy 70 Treatment Followup Arrange followup within 48 hours
Advise to return if condition worsens
Review danger signs
Reinforce use of ITNs
Prevention and Control of Malaria during Pregnancy 71 Second-Line Drug Most clients will respond to malaria treatment and begin to feel better within 48 hours
However, if the client’s condition does not improve or worsens, give second-line treatment for uncomplicated malaria Prevention and Control of Malaria during Pregnancy 72 Second-Line Drug (cont’d.) If the woman’s condition does not improve or worsens within 48 hours of starting treatment with a second-line drug, and/or other symptoms appear, REFER IMMEDIATELY
If signs of complicated malaria are present, REFER IMMEDIATELY
Prevention and Control of Malaria during Pregnancy 73 Referral Preparation Explain situation to the client/family
Help arrange transport to other facility if possible
Write referral note
Treat any urgent conditions and stabilize Prevention and Control of Malaria during Pregnancy 74 Referral Note Brief history of client’s condition
Details of any treatment provided
Reason for referral
Significant findings from history, physical exam, or lab
Any important details of current pregnancy
Copy of client’s ANC record, if possible
Referring provider contact information Prevention and Control of Malaria during Pregnancy 75 Summary of Health Education Points Uncomplicated malaria can be easily treated if recognized early, but it is very important to finish the course of treatment to be effective
Because complicated malaria requires specialized management, women with complicated malaria should be referred immediately to avoid complications and death
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