Table 3 WHO guidance for key MIP areas and summary of document review results

IPTp timing and dose

IPTp timing: Pregnant women should receive IPTp as early as possible in the second trimester of pregnancy and at every scheduled ANC visit thereafter, up to the time of delivery, at least one month apart. [5]

In all countries there were either no specific guidelines stating SP dose and gestational age at which IPTp-SP should be administered, or there was conflicting or inconsistent guidance; some countries recommended the first dose of IPTp-SP at 16 weeks, others after quickening, and others at 20–24 weeks; two countries prohibited IPTp-SP administration before 20 weeks and after 36 weeks. Four countries recommended specific weeks of pregnancy for IPTp-SP (i.e., first dose at 20–24 weeks, and second dose at 28–32 weeks).

IPTp dose: Three tablets SP (each tablet containing 500 mg/25 mg SP). [5]

(WHO guidance from 2004: IPTp timing: at least two doses of IPTp-SP after quickening at least one month apart) [13]

Prevention and treatment of anaemia

Prevention and treatment of anaemia: Folic acid at a daily dose equal or above 5 mg should not be given together with SP as this counteracts its efficacy as an antimalarial. Daily iron and folic acid supplementation of 30–60 mg of elemental iron and 0.4 mg of folic acid, to reduce the risk of low birth weight infants, maternal anaemia and iron deficiency at term [15].

Two countries that recommended high dose (5 mg) folic acid daily during pregnancy recommended interrupting folic acid intake: one country recommended one week after taking IPTp-SP, the other two weeks after taking IPTp-SP.

DOT

IPTp should be administered by DOT [15].

One country’s malaria policy and RH guidelines on case management did not specify that IPTp-SP be given by DOT. In that country, the malaria guidelines for IPTp stated that a prescription must be given to the pregnant woman who should be proceed to the on-site medication depot where an “agent” administers the IPTp-SP by DOT. All other countries recommend DOT by the ANC provider.

Linkages to HIV: Prevention of MIP for HIV-positive women

IPTp-SP is contraindicated for HIV-positive pregnant women taking CTX [5].

One country’s documents were consistent and reflected WHO guidelines. Three countries’ documents either made no mention of use of IPTp-SP for HIV-positive pregnant women or provided unclear guidance or guidance that conflicts with that of WHO.

(WHO guidance from 2004: HIV-positive pregnant women will benefit from three to four doses of IPTp-SP at least one month apart) [13]

LLIN promotion and distribution

ITNs should be provided to women as early in the pregnancy as possible, at the ANC clinic or through other sources in the public or private sectors [12].

All countries had policy recommendations for the use of LLINs as early as possible in pregnancy, but none had clear guidelines about when and how women should obtain them during ANC.

The WHO Global Malaria Programme recommends distribution of ITNs, more specifically LLINs, to achieve full coverage of populations at risk of malaria. The best opportunity for rapidly scaling up malaria prevention is free or highly subsidized distribution of LLINs through existing public health services (both routine and campaigns) [2].

Diagnosis

Diagnosis of MIP with microscopy or rapid diagnostic tests (RDTs) is recommended whenever possible [15].

Three countries had conflicting, incomplete and/or inconsistent guidelines about whether diagnostic tests should be performed prior to providing treatment to pregnant women for clinical malaria.

Treatment

Uncomplicated malaria

Two countries had at least one document that gave correct guidelines for treatment per trimester and severity of disease. But all countries had documents with incomplete and/or inconsistent guidelines for treatment of malaria by trimester.

First Trimester: Quinine plus clindamycin to be given for seven days (artesunate plus clindamycin for seven days is indicated if this treatment fails). An artemisinin-based combination therapy (ACT) is indicated only if this is the only treatment immediately available, or if treatment with seven-day quinine plus clindamycin fails, or if there is uncertainty about patient compliance with a seven-day treatment. Note: If clindamycin is unavailable or unaffordable, then quinine monotherapy should be given.

Second and Third Trimester: ACT known to be effective in the country/region or artesunate plus clindamycin to be given for seven days or quinine plus clindamycin to be given for seven days (with the exception of DHA-PPQ (dihydroartemisinin-piperaquine) for which there is insufficient information to use it as a first-line therapy in second and third trimesters of pregnancy).

Severe malaria:

Parenteral anti-malarials should be given to pregnant women with severe malaria in full doses without delay. Parenteral artesunate is preferred over quinine in the second and third trimesters, because quinine is associated with recurrent hypoglycaemia. In the first trimester, the risk of hypoglycaemia is lower and uncertainties over the safety of artemisinin derivatives are greater, thus the two drugs are considered equivalent [15].