1. Lives at Risk: Malaria in pregnancy
Malaria Epidemiology Branch, Division of Parasitic Diseases
U.S. Centers for Disease Control and Prevention

2. The burden of malaria in pregnancy
45 million pregnancies in malarious areas; 23 million in sub-Saharan Africa
Estimated 200,000 Low Birth Weight pregnancies/year
Placental infection contributes to:
15% of maternal anemia
8-14% of all low birth weight
30% of preventable low birth weight
3-8% of infant mortality

3. Malaria is old and familiar
Malaria has been in this area shown for millenia
Communities and families know malaria
Often it goes unnoticed, or at least unresponded to

4. High Transmission Areas
Malaria in Pregnancy
High Transmission Areas
Acquired immunity - high
Asymptomatic infection
1st & 2nd pregnancies
Placental Sequestration
HIV infection extends this to all pregnancies, and makes it worse
Anaemia
Altered Placental Integrity
Less Nutrient Transport
Low Birth Weight
Excess Infant Mortality

5. Neonatal Mortality Rates by Birthweight Mangochi, Malawi -- September 1987 - June 1989
1000
800
800
600
Deaths per 1000 Live Births
400
300
200 49 26
<1500
³ 2500
Relative Risk 31
11.7
2.4
1.0

6. Placental parasitemia by pregnancy number, Kisumu, Kenya, 1996-98
Parasite density/mm3
% parasitemic
772
402
479
Pregnancy number

7. Placental parasitemia by HIV status and pregnancy number, Kisumu, Kenya, 1996-98
Parasite density/mm3
% parasitemic
231
159
197
772
402
479
HIV (+)
HIV (-)
Total n = 2263
Summary RR = 1.63 ( ), p<0.001

8. Low birth weight

9. Factors Contributing to Low Birth Weight - Developing Countries
Short stature
Nonwhite race
Malaria
Maternal LBW/History LBW
Small paternal size/other
General morbidity
Low prepregnancy wt
Female sex
Primiparity
Low caloric intake or wt gain

10. Factors Contributing to Low Birth Weight – that are amenable to intervention during pregnancy
General morbidity
Malaria
Low caloric intake or wt gain

11. *Neonatal Mortality Rate
Contribution of Prematurity and IUGR to Low Birth Weight Mangochi, Malawi
Normal Birthweight
Prematurity
NMR* 245/1000 8
82%
18%
Low Birthweight
IUGR
NMR* 52/1000 18
All Infants
N=1,618
Low Birthweight
N=297
*Neonatal Mortality Rate
Adapted from Steketee et al.

12. Frequency of Low Birth Weight by placental malaria infection, Malawi 1988-9135 30 25 20
Placental + 15
Placental - 10 5
Grav 1
Grav 2
Grav 3+

13. Malaria in Pregnancy Opportunities for Intervention
Program opportunity
in areas of Africa with greatest LBW > 60% women attend ANC
Drugs
Intermittent Preventive Treatment (IPT)
Case Management
Insecticide Treated Nets (ITN)
Treatment of anemia
Iron/folate
Nutritional counseling

14. Antenatal care in Africa Proportion of Pregnant Women Seeking Antenatal Clinic Care
Demographic and Health Surveys

15. Interventions to address malaria in pregnancy
Preventive intermittent treatment (PIT)
Insecticide treated nets (ITN)
Treatment and Care of acute cases of malaria during pregnancy

16. Preventive intermittent treatment (PIT)
Providing antimalarial treatment dose at scheduled antenatal clinic visits
Shown to:
Substantial improvement in maternal anemia
>50% reduction in placental malaria rates
20-25% reduction in low birth weight rates

17. Intermittent Preventive Therapy - the monthly clinic dosing strategy-Rx Rx Rx Rx 10 20 30
Conception
Quickening
Birth
Weeks of gestation

18. Insecticide Treated Materials

19. Bednets: Birth Outcome
Gravidae 1-4
ter Kuile 2001
Kenya

20. Impact of ITNs on maternal and infant health, western Kenya
During pregnancy
38% reduction in peripheral parasitemia
21% reduction in all cause anemia (Hb < 11 g/dl)
47% reduction in severe malarial anemia
At delivery
23% reduction in placental malaria
28% reduction in LBW
25% reduction in any adverse birth outcome
In summary, this study involving 2754 pregnant women of all gravidae groups living in an areas of intense malaria transmission showed that women in their first 4 pregnancies in bednet villages, and this is data I have not been able to show you, had less malaria and particulary severe malaria associated anemia during pregnancy, defined as a Hb < 8 g/dl in the presence of any parasitaemia.
The the mean birth weights and gestational ages were higher, and the risk of any adverse outcome, including LBW and fetal loss was reduced by 25%.
The data also clearly does not support the hypothesis of a trend towards decreasing efficacy with increasing transmission pressure.

21. Interventions to address malaria in pregnancy
Intermittent preventive treatment
Insecticide-treated materials
Case management
UNICEF/C-55-10/Watson

22. Malaria in Mothers and Infants
Insecticide-treated nets
IPT
Non-pregnant
Pregnancy
Post-partum
Infancy
Case management

23. Malaria Control during Pregnancy Implementation Package(s)
Private
Sector
IPT
ITNs
ANC
Facilities
Community CM

24. The effect of malaria during pregnancy on morbidity and mortality is:
Summary
The effect of malaria during pregnancy on morbidity and mortality is:
documented; consistent across studies; amenable to interventions applied during the current pregnancy
The malaria effect is linked with anemia & HIV
Today, the tragedy rests in the failure to apply existing effective control measures