Antenatal Care and Malaria in Mozambique Health Alliance International ManicaSofala, Mozambique Kenn

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Antenatal Care and Malaria in MozambiqueHealth
Alliance InternationalManica/Sofala, Mozambique
Kenneth Sherr 

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Overview of presentation

• Background to HAI
• Background to Malaria in Pregnancy
• Background to impact area
• ITN experience
• Opportunities planned activities for antenatal
  care

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Background - Health Alliance International

• Active in Central Mozambique since 1987
• Principal strategies include
• Strengthening h/services (quantitatively and
  qualitatively)
• Mobilizing communities to utilize improved
  services
• Affiliated to University of Washington SPHCM

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Background - Malaria in Pregnancy

• Placental infections during 1st and 2nd
  pregnancies in Africa estimated to account for
• 5-12 of Low Birth Weight
• 35 of preventable Low Birth Weight
• 3-5 of infant mortality
• Maternal Mortality (MM) increased due to anemia
• Primagravidae and segundigravidae most at risk
• Parasitemia prevalence highest at 20-36 weeks
• Clinical susceptibility highest 2nd/3rd
  trimesters, but persists 2 months into
  postpartum period

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WHO 20th Expert Committee, 2000

• Recommends package of comprehensive health care
  for pregnant women
• Prophylaxis or Intermittent Presumptive Therapy
  (IPT)
• ITNs
• Case Management
• Treatment of Anemia

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Manica Province -2000 pop. 1,103,000 -95 ANC
attendance -75 h/facilities -41 w/ MCH
staff -1979 p/p/h/worker Sofala Province -2000
pop 1,424,000 -90 ANC attendance -101
h/facilities -32 w/ MCH staff -1441
p/p/h/worker
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Background - Manica Sofala Provinces

• Manica - peak transmission from December through
  March rainy season
• Sofala - endemic throughout the year
• Growing CQ Resistance
• In Vivo therapeutic efficacy 70-53 (mean 61 )
• SP resistance 4 in S. Mozambique (Dgedge, 2001

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Manica Sofala - Cont

• Data inadequate, underestimate of incidence
• Routine reporting in Manica since 1998, none in
  Sofala
• No data on prevalence of malaria or anemia in
  pregnancy
• 42.8 pregnant women report suspected malaria in
  last pregnancy, 40.3 of those treated with
  anti-malarials (HAI, 1998)
• High Maternal Mortality - 1,100/100,000 (UNICEF,
  1998)

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ITN Sales Trial - Objective

• During 1 year period, compare 2 methods of
  selling ITNs
• Shopkeepers
• Community Leader Councils (CLC) members
• Conduct OR on effectiveness in sales
• rates of net sales/re-treatment
• changes in KAP

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Methodology

• 2 analogous semi-urban communities along primary
  transport corridor selected
• Dondo (pop ?25,000), Nhamatanda (pop ? 17,000)
• Community Leaders (CLCs) as sales agents in Dondo
  (40 trained), main shopkeeper in Nhamatanda
• No difference in community mobilization
  education
• radio, street theater, CLCs, h/staff

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Community Leader Councils

• Link between community and formal h/system
• Activities include
• planning h/services
• Community mobilization education

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CLC Components
Health Facility
Shopkeepers
TBA
Local Politicians
Religious Leaders
Ametramo
Traditional Authorities
O O O O O O O CLC O O O O O O O
Organic Leaders
Mães Modelos
Labor Leaders
Teachers
Youth
Women
CBOs
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CLC - Program Coverage

• Manica - 95 of h/facilities
• Sofala - 22
• 20 leaders in each CLC
• 70 active (meet regularly, carry out activities,
  and produce quarterly reports)

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ITNs

• Procured from PSI/UNICEF
• 2 types
• Conical (cost to consumer USD 5.00)
• Rectangular (cost USD 3.00)
• Retreatment packs (cost USD .50)

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Figura 1 Cumulative ITN Sales by Type of Vendor
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Figura 2 Monthly Sales by Type of Vendor
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ITN Results

• ITN utilization (n349)
• CLCs
• 23 reported using night before
• 56 protected with insecticide
• Commercial vendor
• 43 reported using night before
• 34 protected with insecticide

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ITN Results - cont.

• Follow-up by CLC arm (n200)
• 8 reported pregnant woman in HH
• 94 reported using during pregnancy
• 60 ITNs protected with insecticide
• Good acceptance by both groups
• Commercial vendor more sustainable, but CLCs have
  better follow-up (enhanced retreatment)

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Antenatal Care

• high ANC coverage
• 90 Sofala, 95 Manica at least 1 ANC
• 75 2 ANC visits
• Syphilis testing and treatment experience shows
  possibilities
• Syphilis screening increased from lt4 to 80 in
  18 months (1993)
• Presently, 90 screening, over 85 RPR treated
  (60,000 screened, ?3,000 perinatal deaths
  averted)
• No current donor inputs

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ANC - current activities

• Training monitoring of h/workers in
• case management
• iron supplementation
• Difficulties include
• Current policy not followed (weekly
  chemoprophylaxis unrealistic)
• poor lab quality and coverage complicates case
  management
• Stock ruptures common

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ANC - Potential of SP Intermittent Presumptive
Therapy (IPT)

• 40 h/centers over 2 years
• 25,000 ANCs per year (50,000 over 2 years)
• provide data on
• program inputs
• anemia prevalence
• malaria prevalence in ANC
• barriers to quality of care/compliance (both IPT
  and iron prophylaxis)

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Expected Problems

• Create new needs for h/system
• IPT in high HIV environment
• Month of gestation (continued late ANC
  attendance)

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Prenatal Consults by Month of GestationManica
Province 1993-1994