1. Applying Community-Directed Intervention (CDI) to Intermittent Preventive Treatment in Pregnancy (IPTp)
Module 6
Version 2

2. Overview
ITNs/LLINS
IPTp
Case management
Malaria in pregnancy (MiP) control has three major components:
Sleeping inside insecticide- treated bed nets or long-lasting insecticidal nets (ITNs/LLINs)
IPTp
Prompt and appropriate case management
This module will focus mainly on IPTp

3. Learning objectives
By the end of this module, learners will be able to:
Describe their country’s specific malaria data
Describe the basis for IPTp and the use of sulfadoxine- pyrimethamine (SP) for IPTp
Identify special IPTp target groups
State the difference between chemoprophylaxis and IPTp
Describe the benefits of IPTp
Identify who should be given IPTp
Identify who should NOT be given IPTp
Describe when and how to give IPTp

4. MiP in Africa is responsible for...
3%‒15% of maternal anemia (Steketee et al. 2001)
5%‒14% of low birthweight (LBW) in newborns
30% of “preventable” LBW in newborns
7%‒10% of congenital malaria in newborns (Mosha et al. 2010)
20% of stillbirths (Lawn et al. 2016)
200,000 newborn deaths per year (Dellicour et al. 2010)
Each year, more than 30 million women in Africa become pregnant in malaria-endemic areas. In these areas, malaria accounts for significant morbidity in pregnant women.

5. Why is MiP important in your country?
Each year, more than ___ women in your country become pregnant in malaria-endemic areas
At any given time, nearly ___% of pregnant women in your country may have malaria parasites in their blood
Facilitators: Fill in your country’s MiP data on this slide.

6. IPTp
IPTp is a prevention strategy for areas of high, stable malaria transmission
In these areas, pregnant women may have malaria, especially infection of the placenta, and not always show any signs such as fever
A full course of malaria treatment can clear these malaria parasites
The more stable malaria transmission an area has, the darker red it appears on this map.
Source: United States Agency for International Development (USAID) The President’s Malaria Initiative: Fifth Annual Report to Congress; Executive Summary. Washington, DC; USAID. Accessed September 26, 2018.

7. IPTp is based on...
...the assumption that every pregnant woman living in an area of moderate to high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms or signs of malaria
Photo by Karen Kasmauski

8. IPTp: Special target groups
We target all pregnant women in areas of high, stable transmission, but especially:
Women in their first or second pregnancies
Women with HIV
Adolescents (10‒19 years of age)
Women with sickle cell disease
All pregnant women with unexplained anemia

9. IPTp: World Health Organization (WHO) recommendations
All pregnant women should receive at least three doses of IPTp (IPTp3), during routinely scheduled antenatal care (ANC) visits:
No more frequently than monthly starting from the 13th week of gestation
Under the health care provider’s direct observation (directly observed therapy, or DOT)
The WHO recommends a schedule of at least eight patient contacts in the clinic or at home.

10. IPTp: World Health Organization (WHO) recommendations, cont.
IPTp with SP continues to be highly effective in preventing the adverse consequences of MiP.
Pregnant women who are already receiving co-trimoxazole prophylaxis should not receive IPTp with SP. Taking both drugs will increase the risk of adverse effects from SP.

11. The use of SP for IPTp
Remember that IPTp is based on the assumption that every pregnant woman living in an area of moderate to high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria:
A pregnant woman with malaria may have no symptoms, but malaria can still affect her and her unborn child
IPTp with SP reduces:
Severe antenatal anemia in the mother
LBW
Perinatal deaths (to a lesser extent)
These beneficial effects are most pronounced in women in their first or second pregnancies

12. The use of SP for IPTp, cont.
IPTp with SP continues to be highly effective in preventing the adverse consequences of MiP
All pregnant women should receive at least three treatment doses of SP after quickening (baby has started moving in the womb), and at intervals of at least 4 weeks
HIV-positive pregnant women not taking co-trimozaxole should receive at least three treatment doses of SP after quickening (baby has started moving in the womb), and at intervals of at least 4 weeks

13. Clearing parasites
The majority of fetal growth occurs between 24 and 36 weeks of gestation
So, if the woman receives the minimum of three recommended doses beginning as early as possible in the second trimester (e.g., at 13 weeks):
The parasites will be cleared from the placenta, reducing anemia for mother and fostering intrauterine fetal growth
Note that it is safe to give SP up to the time of delivery because clearing placental malaria can help prevent postpartum hemorrhage and congenital malaria in the newborn

14. Timing of monthly IPTp doses in relation to fetal growth velocity when gestational age is known
Quickening
IPTp1
IPTp4
IPTp3
IPTp2
Fetal growth velocity
13 wks.
Weeks of pregnancy
Conception 13 16 20 30 36
Birth
IPTp with SP should be given before and during the period of rapid growth of the baby starting from 13 weeks!

15. Timing of monthly IPTp doses in relation to fetal growth velocity where exact fetal gestational age cannot be determined (use experience of quickening)
Quickening
IPTp1
IPTp4
IPTp3
IPTp2
Fetal growth velocity
Weeks of pregnancy
Conception 10 16 20 30 36
Birth
Where the exact gestational age is unknown, IPTp may start after experience of quickening!

16. The difference between chemoprophylaxis and IPTp
IPTp is the use of antimalarial drugs given in treatment doses at predefined intervals beginning as early as possible in the second trimester to clear a presumed burden of parasites
IPTp is a curative dose of SP given at least three times during pregnancy
These curative doses clear the placenta of parasites at each dose

17. The difference between chemoprophylaxis and IPTp, cont.
IPTp works differently from chemoprophylaxis
Chemoprophylaxis requires a treatment dose, then subtherapeutic doses of the drug during and after pregnancy to prevent reinfection of the placenta

18. IPTp through community health workers (CHWs)
Informs community leader of readiness to begin distribution of drugs
Collects SP from the agreed point (usually from the health facility [HF])

19. IPTp through community health workers (CHWs), cont.
Gives health education to the women (home visits, women’s society meetings, marketplace, etc.) using the Interpersonal Communication for Prevention and Control of Malaria in Pregnancy: Community Health Workers’ Counseling Flip Chart
Identifies pregnant women eligible for IPTp dose

20. IPTp through community health workers (CHWs), cont.
Issues drug to eligible women and ensures they swallow full dose (DOT)*
Records the information about giving IPTp in CHW register
Refers pregnant woman to ANC for follow-up doses and ITN/LLIN if she has not already received one
*Important note: In Madagascar and Mozambique, all pregnant women must receive the first dose of IPTp through ANC at the HF.

21. Health education by CHWs
Use the following methods to provide information:
Group talk to villagers
One-on-one counseling
Posters/flip charts
Storytelling and proverbs
CHWs should use the information, education, and communication materials supplied by the health service to give community members accurate information about malaria control measures

22. Sample counseling card for MiP
Sleep under an insecticide-treated net
Take three tablets (one dose) of SP after the 13th week of pregnancy
Take a second dose of SP at least 4 weeks after the first
Take a third dose of SP at least 4 weeks after the second
Malaria is bad for your health and the health of your unborn child

23. Key health education messages
Provide general information about the:
Recognition of malaria
Causes of malaria
Prevention of malaria
Dangers of MiP
Explain that it is:
Very important to report any adverse events (e.g., rashes, red swollen painful tongue, diarrhea, nausea and vomiting)
Also important to take SP in the correct dosage and at the correct time
Explain the benefits of pregnant women registering early for ANC
SP package insert. Image source: Medicines for Malaria Venture.

24. Benefits of IPTp
Remind the pregnant woman that IPTp protects her from having malaria and thereby lowers the risk of:
Severe maternal anemia by 38%
LBW in the newborn by 43%
Perinatal mortality by 27%
Other malaria-related complications (abortions, stillbirths, preterm delivery, placental parasitemia) in pregnancy

25. How to give IPTp through CDI
Obtain quality-assured SP (500 mg/25 mg fixed ratio) from the facility-based CDI focal person
Follow the procedure in the job aids (see Training in Community-Directed Intervention to Address Malaria in Pregnancy: Facilitators’ Guide Appendix F) to:
Determine whether the woman is eligible for SP
Administer dose if she is eligible
Document
Refer (for ANC, follow-up doses, etc.)
Plan follow-up visit

26. DOT for IPTp
Women taking SP by DOT in a primary health center in Nigeria. Photo by Bright Orji, Jhpiego.

27. Folic acid (FA) FA is usually given to pregnant women
SP is an antifolate and should not be given in combination with folates (e.g., FA)
Remind the pregnant woman not to take her FA for 7 days after taking SP
IPTp IPTp IPTp IPTp4
| wks | wks | wks. | wks.
*FA
* = Stop FA for 7 days after taking SP

28. After giving IPTp
Advise the woman to visit the nearest HF for the comprehensive ANC that all pregnant women should receive
Advise her not to take FA for 1 week
Ask her to report to her community’s HF if she has:
Signs/symptoms of malaria:
Fever (hotness of the body)
Chill
Aches (headaches, body aches)
Joint pain or weakness
Nausea and vomiting
Loss of appetite
Or other complaints in pregnancy

29. Summary
Regular dosing of SP during pregnancy reduces the incidence of complications of malaria in pregnancy (e.g., maternal anemia, stillbirths, low birthweight, and neonatal deaths)
WHO recommends that all pregnant women in areas of high malaria transmission should receive at least 3 monthly doses of SP starting from as early as 13 weeks gestation
Trained health care workers and CHWs should follow the IPTp job aid to provide SP to eligible pregnant women with DOT

30. References
Dellicour S, Tatem AJ, Guerra CA, Snow RW, ter Kuile FO Quantifying the number of pregnancies at risk of malaria in 2007: a demographic study. PLoS Med. 7(1):e doi: /journal.pmed
Lawn JE, Blencowe H, Waiswa P, et al Stillbirths: rates, risk factors, and acceleration towards Lancet. 387(10018):587–603. doi: /S (15)
Mosha TC, Ntarukimana D, John M Prevalence of congenital malaria among neonates at Morogoro Regional Hospital, Morogoro, Tanzania. Tanzan J Health Res. 12(4):241– Accessed October 19, 2018.
Steketee RW, Nahlen BL, Parise ME, Menendez C The burden of malaria in pregnancy in malaria-endemic areas. Am J Trop Med Hyg. 64(1–2 Suppl):28–35.

31. Thank you!
Any questions or comments?