Importance of Malaria in Pregnancy (MiP) Module 2 Version 2

Learning objectives By the end of this module, learners will be able to: Describe the global burden of MiP Enumerate the adverse effects of MiP List the recommended approaches to prevent MiP Counsel pregnant women about MiP Source: Gathany J. 2005. Public Health Image Library. Centers for Disease Control and Prevention website. https://phil.cdc.gov/details.aspx?pid=7861. Updated December 20, 2017. Accessed September 24, 2018.

Brainstorming session: Why is it important to prevent MiP?

Global malaria belt

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 Source: Maya Clinic. 2014. http://mayaclinic.in/patient-education/wp-content/uploads/2014/08/anemia-image.png. Accessed September 24, 2018.

Facts about MiP In 2007, 125.2 million women became pregnant in malaria- endemic areas (Dellicour et al. 2010) Malaria is more frequently contracted and complicated during pregnancy In malaria-endemic areas, malaria during pregnancy may account for (Yatich et al. 2010): Up to 15% of maternal anemia 5%–14% of low birthweight 30% of preventable low birthweight* *Preventable low birthweight includes low birthweight caused by intrauterine growth restriction, which itself can be caused by malaria, hypertensive diseases in pregnancy, iatrogenic preterm delivery, etc.

Effects of Malaria on Pregnant Women, Babies, and Communities Photo by Karen Kasmauski

Why is MiP an important public health issue? In areas of stable malaria transmission acquired immunity is HIGH Asymptomatic infection Increased maternal mortality 10,000 annually (Dellicour et al. 2010) HIV INFECTION FURTHER REDUCES IMMUNITY TO MALARIA INFECTION Preterm labor Increased fetal/infant mortality 20% stillbirths in sub-Saharan Africa (Lawn et al. 2016) 11% neonatal deaths 200,000 newborns annually (Schantz-Dunn and Nour 2009) Low-birthweight babies Intrauterine growth restriction Reduced nutrient support to the fetus Placental sequestration/altered placental integrity Why is MiP an important public health issue? Maternal anemia Maternal morbidity

Effects of malaria on pregnant women Effects range from mild to severe, depending on the level of malaria transmission in a particular setting and the pregnant woman’s level of immunity The level of immunity depends on several factors: Intensity of malaria transmission Number of previous pregnancies Presence of other conditions, such as HIV, which can lower a woman’s immune response during pregnancy

Effects of malaria on pregnant women, cont. All pregnant women in malaria-endemic areas are at risk. Parasites attack and destroy red blood cells. Malaria causes up to 25% of anemia in pregnancy (Schantz- Dunn and Nour 2009) which can be severe. In Africa, malaria-related anemia causes up to 10,000 maternal deaths per year (Schantz-Dunn and Nour 2009)

Effects of malaria on fetus During pregnancy, malaria parasites hide in the placenta. The placenta becomes susceptible to malaria infection at the end of the first trimester (Walker et al. 2014). This interferes with the transfer of oxygen and nutrients to the fetus, increasing the risk of the following: Spontaneous abortion Preterm birth Low birthweight—the single greatest risk factor for death during the first month of life

Effects of malaria on fetus, cont. Results include: 20% of stillbirths in sub-Saharan Africa (Lawn et al. 2016) 11% neonatal deaths 200,000 newborn deaths annually (Schantz-Dunn and Nour 2009)

Effects of malaria on newborn Approximately 11% of newborn deaths in malaria- endemic African countries are due to low birthweight resulting from Plasmodium falciparum infections during pregnancy (Maternal and Child Survival Program 2018). Low-birthweight infant Normal-birthweight infant

Effects of malaria on communities Causes sick individuals to miss work (and wages) Causes sick children to miss school May cause chronic anemia in children, inhibiting growth and intellectual development and affecting future productivity Uses scarce resources Puts strain on financial resources (treatment is more costly than prevention) Cost of drugs can be a burden on the community Causes preventable deaths, especially among children and pregnant women

Co-infections: HIV/AIDS during pregnancy Reduces a woman’s resistance to malaria Increases likelihood of developing malaria fever and death Causes malaria treatment to be less effective Increases risk of malaria-related problems in pregnancy Increases risk of intrauterine growth restriction Increases risk of preterm birth Increases risk of maternal anemia

Co-infections: HIV/AIDS during pregnancy, cont. Pregnant women who are co-infected with HIV and malaria are at a very high risk for anemia and malarial infection of the placenta. Their newborns are therefore more likely to have low birthweight and to die during infancy.

World Health Organization core interventions for the control of MiP in areas of moderate to high malaria transmission 1. ITNs/LLINs 2. IPTp 3. Case management MiP control delivered on the platform of antenatal care: Sleeping inside an insecticide-treated bed net (ITN) or long-lasting insecticidal net (LLIN) nightly from as early in pregnancy as possible Intermittent preventive treatment in pregnancy (IPTp) with at least three doses of sulfadoxine-pyrimethamine (SP) given at monthly intervals Prompt and effective malaria case management

Impact of access to IPTp with SP Reduces severe maternal anemia by 38% Reduces low birthweight of babies by 43% Reduces infant deaths by 27% Source: Roll Back Malaria Partnership 2014

Summary All pregnant women in malaria-endemic areas are at risk of adverse consequences. Malaria can lead to severe anemia, spontaneous abortion, and low-birthweight newborns. MiP is preventable and treatable. Use of IPTp with SP has significant impact on maternal and newborn health. We will learn more during the workshop.

References Dellicour S, Tatem AJ, Guerra CA, Snow RW, ter Kuile FO. 2010. Quantifying the number of pregnancies at risk of malaria in 2007: a demographic study. PLoS Med. 7(1):e1000221. doi: 10.1371/journal.pmed.1000221. Lawn JE, Blencowe H, Waiswa P, et al. 2016. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet. 387(10018):587–603. doi: 10.1016/S0140-6736(15)00837-5. Maternal and Child Survival Program (MCSP). 2018. Malaria in pregnancy (MiP) resources. MCSP website. https://www.mcsprogram.org/resource/malaria-pregnancy-resources/. Published January. Accessed October 18, 2018. Roll Back Malaria Partnership. 2014. The Contribution of Malaria Control to Maternal and Newborn Health. Geneva, Switzerland: World Health Organization. http://apps.who.int/iris/bitstream/handle/10665/126340/9789241507219_eng.pdf. Progress & Impact Series 10. Published July. Accessed September 2, 2018. Schantz-Dunn J, Nour NM. 2009. Malaria and pregnancy: a global health perspective. Rev Obstet Gynecol. 2(3): 186–192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760896/. Accessed September 24, 2018. Walker PG, ter Kuile FO, Garske T, Menendez C, Ghani AC. 2014. Estimated risk of placental infection and low birthweight attributable to Plasmodium falciparum malaria in Africa in 2010: a modelling study. Lancet Glob Health. 2014 2(8):e460–467. doi: 10.1016/S2214-109X(14)70256-6. Yatich NJ, Jolly PE, Funkhouser E, et al. 2010. The effect of malaria and intestinal helminth coinfection on birth outcomes in Kumasi, Ghana. Am J Trop Med Hyg. 82(1):28–34. doi: 10.4269/ajtmh.2010.09-0165.