Antenatal Care: Malaria in Pregnancy
A Persistent Threat to Maternal and Neonatal Health
Malaria in pregnancy (MiP) remains a significant public health challenge, especially in malaria-endemic regions, where it poses serious risks to both mothers and their unborn children. Pregnant women are more vulnerable to malaria infection due to physiological and immunological changes that compromise their ability to fight off disease. As a result, malaria in pregnancy often presents with atypical symptoms and can lead to severe complications, including maternal anemia, stillbirth, preterm birth, and low birth weight.
According to the World Health Organization (WHO), malaria in pregnancy causes approximately 10,000 maternal deaths and 200,000 neonatal deaths annually, contributing to nearly 11% of all neonatal mortality in sub-Saharan Africa. Each year, an estimated 125 million pregnancies occur in malaria-endemic areas, placing over 30 million women at risk of malaria-related complications (WHO, 2022).
Plasmodium falciparum, the most dangerous malaria parasite, is transmitted via the bite of infected female Anopheles mosquitoes. Once in the bloodstream, the parasite infects red blood cells, leading to fever, chills, and anemia, and in severe cases, organ failure. In pregnant women, malaria parasites accumulate in the placenta, disrupting the flow of nutrients and oxygen to the fetus. This can result in fetal growth restriction, preterm birth, and stillbirth, particularly among first-time mothers and those with low malaria immunity.
Anemia due to malaria is especially common and severe between 16–29 weeks of gestation, as malaria increases red blood cell destruction and can worsen folate deficiency – a dangerous combination during pregnancy.
Preventing and managing malaria in pregnancy is essential to reducing maternal and neonatal morbidity and mortality. This section of the toolkit offers healthcare workers and policymakers evidence-based guidance on the prevention, diagnosis, and treatment of malaria in pregnancy, in alignment with WHO recommendations, to improve health outcomes for mothers and babies.
What Are the Benefits of Preventing Malaria in Pregnancy?
How to Implement
1. Integrate Malaria Services into Antenatal Care
- Incorporate malaria prevention and treatment into all routine ANC visits in malaria endemic regions/areas.
- Educate pregnant women about the risks of malaria and available prevention methods.
- Provide intermittent preventive treatment in pregnancy (IPTp) using sulfadoxine-pyrimethamine (SP) according to national and WHO guidelines.
- Ensure every pregnant woman receives a long-lasting insecticidal net (LLIN) during ANC.
2. Administer IPTp-SP Effectively
- Begin IPTp-SP as early as possible in the second trimester, continuing at monthly intervals throughout pregnancy.
- Give three tablets per dose (each containing 500 mg sulfadoxine and 25 mg pyrimethamine).
- Use directly observed therapy (DOT) to ensure proper adherence.
- Screen for contraindications, including allergy to sulfonamides.
3. Promote Use of Long-Lasting Insecticidal Nets (LLINs)
- Distribute LLINs at the first ANC visit.
- Teach women how to use and care for LLINs effectively.
- Encourage consistent use throughout pregnancy and postpartum.
- Support mass distribution campaigns to increase coverage in the community.
4. Ensure Prompt Diagnosis and Treatment
- Provide access to rapid diagnostic tests (RDTs) and microscopy for early malaria detection.
- Treat all confirmed malaria cases using artemisinin-based combination therapy (ACT) as per national and WHO protocols.
- Offer supportive care for severe malaria, including referral when needed.
5. Engage the Community
- Work with community health workers (CHWs) and local leaders to raise awareness about malaria in pregnancy.
- Conduct community outreach to promote ANC attendance and LLIN use.
- Address harmful cultural beliefs or practices that may hinder malaria prevention efforts.
6. Strengthen the Health System for MiP Response
- Ensure a consistent supply of IPTp-SP, LLINs, RDTs, and ACT in all health facilities.Â
- Train healthcare providers on current MiP guidelines and protocols.
- Strengthen health information systems for malaria tracking and surveillance.
- Make updated guidelines and protocols easily accessible at all service delivery points.
Diagnosing and Treating Malaria in Pregnancy
1. Diagnosing Malaria in Pregnancy
Timely and accurate diagnosis of malaria in pregnancy is essential to ensure prompt treatment and prevent adverse maternal and fetal outcomes. Routine screening of pregnant women for malaria during ANC visits is recommended in high-endemic areas to ensure early detection and management of infections. The following diagnostic approaches are recommended:
- Clinical Diagnosis: Malaria in pregnancy often presents with non-specific symptoms, including fever, chills, malaise, headache, and body aches. However, due to the risk of asymptomatic infections and overlapping symptoms with other febrile illnesses, laboratory confirmation is essential.
- Microscopy: Light microscopy of Giemsa-stained peripheral blood smears remains the gold standard for malaria diagnosis. It allows for parasite identification and quantification, which helps determine disease severity.
- Thick smear: rapid diagnosis
- Thin smear: species identification
- Rapid Diagnostic Tests (RDTs): RDTs detect Plasmodium antigens in blood and provide quick results, making them particularly useful in low-resource settings. However, they may have limitations in detecting low parasite densities.
- Placental Histology: In cases of stillbirth or pregnancy loss, placental histology can confirm malaria infection, particularly if maternal peripheral blood smears are negative.
- Polymerase Chain Reaction (PCR): PCR testing is highly sensitive and useful for detecting submicroscopic infections. While not routinely available in all settings, it can be valuable in research and surveillance.
2. Treating Uncomplicated Malaria in Pregnancy
First-line Treatment for Uncomplicated Malaria in Pregnancy
- First Trimester: Use oral quinine plus clindamycin for seven days.
- Quinine dosage: 10 mg/kg every 8 hours
- Clindamycin dosage: 10 mg/kg every 12 hours
- Artemisinin-based combination therapies (ACTs) are not recommended in the first trimester unless no other treatment is available and the benefits outweigh the risks.
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Second and Third Trimesters: Use oral artemether–lumefantrine (AL) or artesunate–amodiaquine.
- AL dosage: Six doses over three days – 80 mg artemether + 480 mg lumefantrine per dose, administered at 0, 8, 24, 36, 48, and 60 hours.
3. Treating Severe Malaria in Pregnancy
- First-line Treatment: Intravenous (IV) or intramuscular (IM) artesunate (2.4 mg/kg body weight at 0, 12, and 24 hours, then once daily until oral therapy is possible).
- Alternative Treatment: If artesunate is unavailable, IV quinine (10 mg/kg every 8 hours) should be administered with careful monitoring for hypoglycemia.
- Full Course: Once the patient can tolerate oral therapy, a full course of ACT should be administered.
- Supportive Care: Management of anemia, fever, and hydration, should be provided.
Key Indicators
- Percentage of pregnant women attending at least one ANC visit.
- Percentage of pregnant women receiving at least three doses of IPTp-SP.
- Percentage of pregnant women sleeping under LLINs.
- Prevalence of malaria parasitemia in pregnant women.
- Incidence of severe malaria in pregnant women.
- Rate of low birth weight.
- Case fatality rate for malaria in pregnancy.
- Percentage of pregnant women that have been tested for malaria.
- Percentage of pregnant women with a positive malaria test that received ACT treatment.
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Tips
- Integrate malaria interventions into routine ANC services to maximize coverage.
- Strengthen supply chain management to prevent stockouts of IPTp drugs, LLINs, and diagnostics.
- Use mobile health (mHealth) solutions for tracking IPTp uptake and LLIN use.
- Foster collaborations with community-based organizations to enhance outreach efforts.
Challenges
- Late first ANC Attendance: Improve ANC service accessibility and awareness.
- Drug Stockouts: Strengthen procurement and supply chain systems.
- Low Adherence to IPTp: Provide counseling on benefits and address myths.
- Drug Resistance: Monitor resistance to sulfadoxine-pyrimethamine and other antimalarials.
- LLIN Non-Use: Conduct behavior change communication to increase uptake.
Key Resources
- Recommendations on antenatal care for a positive pregnancy experience. WHO 2016
- Malaria in pregnancy: Guidelines for measuring key monitoring and evaluation indicators. WHO 2007
- Guidelines for malaria. WHO 2024
- Updated recommendations for malaria chemoprevention among children and pregnant women. WHO 2022
