25 April marks World Malaria Day 2014, an occasion for us all to come together to renew our efforts and energise our commitment in fighting malaria. We want to highlight the importance of greater investment in tackling malaria for Tanzanian mothers and newborns.
25 April marks
World Malaria Day, an occasion for us all to come together to renew our efforts and energise our commitment in fighting malaria. We want to highlight the importance of greater investment in tackling malaria for Tanzanian mothers and newborns.
Malaria in TanzaniaBig challenges remain in the fight against malaria in Tanzania. The World Health Organization estimates nine million cases and 8000 deaths from malaria in Tanzanian in 2012. (1)
Tanzania is one of the top 10 countries that together account for about 60% of all malaria deaths in Africa each year (1)Good information that links diagnosis and treatment is limited in Tanzania – we do not know for sure how many patients with confirmed malaria have actually received the antimalarial medicines that they need.It is great to know that excellent progress has been seen in Zanzibar/Unguja Island, which is now on track to achieving the World Health Assembly goal of 75% reduction in malaria mortality by 2015. (1) But the rest of Tanzania is not there yet, and much more needs to be done to protect the women and newborns whose lives are threatened by malaria.
Malaria during pregnancyIt is generally well-known across Tanzania that pregnant women have a high risk of getting malaria. (2)In places where malaria is common, adults usually develop a degree of immunity to the disease.
But women who are pregnant can lose this immunity, and it is the young, adolescent, and first-time mothers who have the highest risk of malaria and its adverse effects in pregnancy. (2)To make things worse, pregnant women with malaria may have no symptoms of the disease. (3)
What happens if a pregnant woman has malaria?Malaria can have a devastating effect on the mother and the newborn infant. Around one in ten pregnant African women may develop anaemia from malaria (4), which is a major cause of pregnancy loss, low birthweight, preterm birth, stillbirth and neonatal mortality. (2,3,4)If a woman has malaria during pregnancy,
the risk of having a low birthweight baby is doubled. (4)Malaria-induced low birthweight is estimated to be responsible for around
100,000 infant deaths every year in Africa. (3,5)It is estimated that 11·4% of neonatal deaths and 5·7% of all infant deaths in high-burden malaria areas of Africa are caused by low birthweight due to malaria in pregnancy. (6)For first-time mothers these figures rise to 17.6% of neonatal deaths and 9.8% of infant deaths. (6)
How can we protect pregnant women and newborns from malaria?The two key interventions for malaria control in Tanzania are
- Sleeping under an insecticide treated mosquito net (ITN)
- Intermittent preventive treatment of malaria during pregnancy (IPTp)
Bed nets are commonly used in Tanzania (DHS) – and since 2004 ITN use by pregnant women has increased from 16% to 75%. (2)
At least two doses of IPTp is recommended to be given as part of routine
antenatal care (ANC). (3)The risk of malaria infection for pregnant women is highest during her second trimester (4), therefore it is crucial that each mother receives prevention and treatment in the early stages of her pregnancy.Various schemes are in place in Tanzania to provide IPTp and bednets for pregnant women:
- The Tanzania National Voucher Scheme/Hati Punguzo programme provides vouchers for all pregnant women and infants who attend health facilities
- The RBM Initiative promotes IPTp among pregnant women
- The Global Malaria Action Plan on universal access to utilisation of prevention measures and advocates that, in malaria endemic areas, every person sleep under an ITN or a household that has been insecticide sprayed, and that every pregnant woman receive at least one dose of IPTp during each of the second and third trimesters of pregnancy
Despite these efforts, recent evidence in Tanzania shows that
only 32% of women received any IPTp during ANC (2), and very few received the full dosage. Mara region had the lowest, with only 10% of women receiving the treatment during ANC. (2)
Women who are poorer, least educated, or living in the Lake and Western Zone, are least likely to receive IPTp during ANC. (2)More needs to be done to provide IPTp for all pregnant women in Tanzania, with special efforts to address the needs of the poor and least educated, and women in the Western and Lake Zone, who are currently missing out on these life-saving services.Studies in Tanzania illustrate some of the challenges in protecting pregnant women with IPTp services and bednets
- The complex nature of ANC services and fees is discouraging for some women: participants complained about varied user fees, penalties and punishments for late attendance, and unnecessary referrals, which also had to be paid for (7)
- There are delays in accessing ANC services (8)
- Some women attend their ANC late in pregnancy (8)
- Some clinic staff are not distributing the ITN vouchers at the first ANC visit (8)
- Even at a discounted price some women are not able to afford the nets (2)
- Lack of clean water and cups at some clinics meant that ANC staff sometimes allow the women to swallow the IPTp medicines after leaving the clinic which can lead to treatment delays or treatment non-compliance (7)
We have the facts about malaria and pregnancy, so what are the solutions?The biggest challenges are often improved through small steps. The plans and policies are already in place in Tanzania, what is needed is more effective, and better quality implementation that addresses the needs of all pregnant Tanzanian women and newborns.Support to health staff and training on the importance of IPTp and provision of bed nets vouchers early in pregnancy is needed.Pregnant women and the community should be informed of the benefits for themselves and their unborn baby of seeking ANC early and receiving two doses of IPTp.What can we learn from Zanzibar, where significant progress has been achieved in the fight against malaria? Let us learn from other evidence that shows the social and biological vulnerability of pregnant adolescents, and the low coverage of IPTp during ANC for the poor, least educated and women in the Lake and Western Zone.Where progress has been made, let us continue to take strides in the global fight to defeat malaria.Where greater efforts, investment, and more equitable coverage is required, let us work together to overcome the challenges that we know about and find solutions that really work, to save more lives of Tanzania’s mothers and newborns!
References1. World Health Organization. (2013).
World Malaria Report 2013. Geneva: WHO. 2. Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF International 2013.
Tanzania HIV/AIDS and Malaria Indicator Survey 2011-12. Dar es Salaam, Tanzania: TACAIDS, ZAC, NBS, OCGS, and ICF International. 3. Pell C, Straus L, Andrew EVW, Meñaca A, Pool R (2011).
Social and Cultural Factors Affecting Uptake of Interventions for Malaria in Pregnancy in Africa: A Systematic Review of the Qualitative Research. PLoS ONE 6(7): e22452. 4. Desai, M., ter Kuile, F., Nosten, F., McGready, R., Asamoa, K., et al. (2007).
Epidemiology and burden of malaria in pregnancy. Lancet Infectious Diseases, 7, 93–104.5. Murphy SC, Breman JG.
Gaps in the Childhood Malaria Burden in Africa: Cerebral Malaria, Neurological Sequelae, Anemia, Respiratory Distress, Hypoglycemia, and Complications of Pregnancy. In: Breman JG, Egan A, Keusch GT, editors. The Intolerable Burden of Malaria: A New Look at the Numbers: Supplement to Volume 64(1) of the American Journal of Tropical Medicine and Hygiene. Northbrook (IL): American Society of Tropical Medicine and Hygiene; 2001 Jan. 6. Helen L. Guyatt and Robert W. Snow.
Malaria in pregnancy as an indirect cause of infant mortality in sub-Saharan Africa Trans R Soc Trop Med Hyg (November-December 2001) 95 (6): 569-576 7. Godfrey Mubyazi, Paul Bloch, Mathias Kamugisha, Andrew Kitua and Jasper Ijumba (2005).
Intermittent preventive treatment of malaria during pregnancy: a qualitative study of knowledge, attitudes and practices of district health managers, antenatal care staff and pregnant women in Korogwe District, North-Eastern Tanzania. Malaria Journal 2005, 4:318. Tanya Marchant, Kara Hanson, Rose Nathan, Hadji Mponda, Jane Bruce, Caroline Jones, Yovitha Sedekia, Hassan Mshinda, Joanna Schellenberg (2009).
Timing of delivery of malaria preventive interventions in pregnancy: results from the Tanzania national voucher programme. J Epidemiol Community Health 2011;65:1 78-82 Published Online First: 5 November 2009
