This blog was originally posted by WHO.
Wani Kumba Lahai, or Sister Wani as she is known, is a midwife, mother and grandmother. She is also a public health specialist who leads Sierra Leone’s nationwide malaria-in-pregnancy programme for the Ministry of Health and Sanitation. Her responsibilities include overseeing a community awareness programme that engages more than 7300 community health workers (CHWs) implementing different health interventions across the country.
“Some CHWs may be working in hard-to-reach areas, behind those mountains, those rivers,” says Sister Wani. “Women don’t like to disclose their pregnancy. They’ll keep it a secret from their neighbours, friends and distant relatives, but have trust and confidence to tell a female community health worker.”
Through the programme, trained CHWs go door-to-door, encouraging pregnant women to attend their antenatal care appointments at the closest health centre, where staff not only monitor the health of the mother and fetus but can also deliver the first dose of sulfadoxine-pyrimethamine, a medicine given after the first trimester to prevent malaria in pregnancy. The CHWs in Sierra Leone then follow up with subsequent doses, at least one month apart, and continued promotion of antenatal care services.
Sierra Leone is one of 8 countries in sub-Saharan Africa that have piloted in recent years a new community-based approach to malaria prevention during pregnancy. The projects and programmes build on WHO guidance for the prevention of malaria in pregnancy.
Preventing malaria in pregnancy: WHO guidance
The 2012 WHO guidance called for the administration of at least 3 doses of intermittent preventive treatment in pregnancy (IPTp) with quality-assured sulfadoxine-pyrimethamine (SP). It specified that doses of the preventive medicine should be delivered as part of antenatal care (ANC) visits, beginning as early as possible in the second trimester, and at least 1 month apart.
WHO updated this guidance in June 2022, recommending that other IPTp delivery methods, such as the use of community health workers, may be explored in areas where there are inequities in access to antenatal care (see box below). The recommendation notes that “IPTp is generally highly cost-effective, widely accepted, feasible for delivery and justified by a large body of evidence generated over several decades.”
In addition, WHO has issued guidance on antenatal care for a positive pregnancy experience. Published in November 2016, the guidance calls for a minimum of 8 contacts between a pregnant woman and health care providers – versus the previously recommended 4 antenatal care visits – offering an increased number of opportunities to deliver IPTp.
Updated WHO recommendation on intermittent preventive treatment in pregnancy (June 2022)
Antenatal care (ANC) contacts remain an important platform for delivering IPTp. Where inequities in ANC service and reach exist, other delivery methods (such as the use of community health workers) may be explored, ensuring that ANC attendance is maintained and underlying inequities in ANC delivery are addressed.
Community health workers can make a difference
The issue of access is key. If untreated, malaria in pregnancy can lead to maternal and neonatal death. It can also cause anaemia, stillbirth, and low birth weight, which is a major cause of infant mortality.
According to the latest World malaria report, there were some 234 million malaria cases and 593 000 malaria deaths in the African Region in 2021 – representing an estimated 95% of the burden of the disease worldwide. Women and children are most vulnerable. In 2021, in 38 malaria-endemic African countries, more than 13 million pregnancies were exposed to malaria infection, placing the mother and fetus in danger.
Visits to an antenatal care facility are optimal as they offer both IPTp-SP to prevent malaria and comprehensive health services for a safe pregnancy. However, not every woman has ready access.
Barriers to seeking care include, for example, the long distances that many pregnant women must travel to reach a health facility, travel conditions and cost, and work and family responsibilities. Such inequities, among other factors, have contributed to a low IPTp-SP coverage rate in sub-Saharan Africa; in 2021, only about one third of pregnant women received the 3-dose IPTp regimen.
Community-based delivery of IPTp, or c-IPTp, is an innovative approach aimed at increasing coverage of IPTp with SP, while not detracting from ANC. It complements ANC, giving all eligible pregnant women the opportunity to receive IPTp in the communities close to where they live, as well as at an antenatal care facility. This can ensure optimal outcomes for the pregnant woman and her fetus.
Along with Sierra Leone, Burkina Faso, Senegal and Malawi developed their own projects and programmes to pilot c-IPTp. In addition, from 2017 to 2022, the Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) project tested the c-IPTp approach in 4 more countries: the Democratic Republic of the Congo, Madagascar, Mozambique and Nigeria.
Managed by Jhpiego, an affiliate of Johns Hopkins University in Baltimore, Maryland, the Unitaid-funded TIPTOP project aimed to increase the uptake of IPTp3 among eligible pregnant women in designated geographies (3 districts per country), without detracting from ANC. TIPTOP also aimed to generate evidence to determine the feasibility, acceptability and cost effectiveness of c-IPTp.
The project research findings and complementary data showed that coverage of 3 or more doses of the preventive therapy (IPTp3+) expanded significantly in TIPTOP geographies while the number of antenatal care visits were maintained or increased.
Improved coverage of IPTp3+ and ANC 4+ visits in TIPTOP countries
[From TIPTOP project video: https://www.youtube.com/watch?v=aKLWdxP5uBc]
Considerations for implementation and scale-up of c-IPTp in eligible areas
Country pilots yielded a wealth of experience and insights. Here we highlight just a few:
Pay attention to site selection
Where coverage of antenatal care and IPTp3 are high, the added value of c-IPTp may be limited. A favourable national policy framework and an existing strong CHW programme can also make a big difference.
Training and motivation of CHWs are essential
Community health workers need to know exactly what to do based on each country’s guidelines,” said Dr Dorothy Achu, Regional Malaria Advisor for the WHO Regional Office for Africa. “In some countries such as the Democratic Republic of the Congo and Nigeria, for example, CHWs can administer the first dose of SP. In other countries, like Mozambique and Sierra Leone, the first dose of SP needs to be administered at an antenatal care clinic, with CHWs then providing subsequent doses.”
Dr Achu further notes that CHWs can play a critical role in ensuring that pregnant women maintain the required intervals between SP doses, and that they are referred to health facilities to receive the full antenatal care package. High quality training, coaching and ongoing supervision are all essential.
In addition, motivation is key. It can come from the prestige of working with a midwife, cash stipends or the joy of supporting healthy mothers and babies. “The quality of the CHWs, their commitment and dedication are what made TIPTOP so successful,” says Kristen Vibbert, TIPTOP Programme Manager with Jhpiego.
Cultivate strong community engagement
“It was great to see the participation of elders, youth, women’s associations, religious associations –they were all involved,” said Dr Seynabou Gaye, who has worked in infectious disease and malaria control in Senegal for 15 years. That engagement helped Senegal increase IPTp3 coverage from 49% in 2019 to 63% in 2021, while maintaining coverage of ANC.
Prevent medicine stock-outs
Stock-outs of SP early in the Democratic Republic of the Congo pilot project prompted TIPTOP to form a taskforce that improved data collection, analysis, and forecasting of SP needs, helping to solve the problem. Moreover, to expand the supplier base for quality-assured SP, in the context of the Unitaid-funded Supply Grant, Medicines for Malaria Venture (MMV) has supported manufacturers in achieving WHO prequalification for their SP products.
Expect the unexpected
Health worker strikes, extreme weather conditions (e.g. cyclones, floodings), local conflicts and insecurity, the COVID-19 pandemic and more have posed disruptions to the c-IPTp projects. However, when health and development are in the hands of – and led by – communities, in partnership with health facilities, solutions can be found.
For example, COVID-19, if anything, showed the integral role of communities and the importance of CHWs during a pandemic, noted Ms Vibbert. “They helped dispel misinformation, encouraged women to seek medical care, and continued the distribution of SP when people were afraid to go to health facilities.”
Strong data guides strong malaria programmes
Quality data collection, sound data analysis, and a targeted use of the information collected laid the basis for the c-IPTp projects and their continual improvement. However, data collection and analysis can be a heavy lift without adequate support, and there is a need for investments and resources to assure data quality.
While the pilot phase of the c-IPTp projects has ended, most countries have scaled up with government and/or partner support. In Senegal, for example, the initial 10 districts have been expanded to 30 with funding from the United States President’s Malaria Initiative (PMI), said Dr Gaye, and c-IPTp is now part of the National Malaria Control Programme.
In addition, further operational guidance from WHO is under development. “We have to pay attention to how we accompany countries in thinking about this policy,” said Dr Achu, noting that many factors influence its effectiveness in different settings. The upcoming WHO c-IPTp field guide will address a range of considerations in the selection of c-IPTp sites.
In addition, countries need financial support to bring programmes to scale – and initial funding is coming from PMI and from the Global Fund to Fight AIDS, Tuberculosis and Malaria.
“We all bridge the gap to prevent malaria,” Sister Wani said. “We invest, we implement, we innovate.” Now, c-IPTp adds one more innovation in efforts to drive down malaria cases among the most vulnerable.
One woman’s story of support through pregnancy in Madagascar
When Brigitte (pictured right) was pregnant with her first child at age 20, she hesitated to seek antenatal care at the local health centre. Many doubts kept her away. She thought of it as a place only for sick people. She feared there may be expenses that she and her husband could not afford. There was also the widely held belief that if you talk about pregnancy before it is noticeably visible, you could lose your baby.
But when Brigitte consulted with a community health worker (CHW) in her village of Andranomadio, Madagascar, she was reassured. The CHW listened to Brigitte’s concerns, promised her the consultation would be free of charge, and explained the advantages of regular antenatal care visits at the health centre for her and her baby, including free malaria prevention and screening for sexually transmitted infections.
Brigitte decided to visit the health centre and soon realized the benefits. In addition to medicine to prevent malaria, she received services such as the tetanus vaccine and folic acid supplements.
By the time she was 23 weeks into her pregnancy, Brigitte had completed her third ANC visit. She received her first dose of IPTp at the health centre and the next 2 doses at the community level from the CHW.
“Prevention is better than cure,” Brigitte said. “And the more you go to the [health centre], the better you are reassured.” She became a champion for encouraging pregnant women in her village to go to their antenatal care appointments and receive IPTp-SP to prevent malaria.
Brigitte’s experience echoes that of many women across the African countries that piloted c-IPTp, a community-based approach to prevent malaria during pregnancy.
Story and photo provided by TIPTOP project