To protect pregnant women and their unborn babies from malaria, the World Health Organization recommends a package of interventions that includes the administration of IPTp-SP (intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine).1 In malaria-endemic areas in Africa, all eligible pregnant women should receive at least 3 doses of quality-assured SP as part of antenatal care.2 IPTp-SP reduces maternal anaemia, neonatal mortality, and low birthweight,3 but uptake has remained low in many countries in sub-Saharan Africa.4 In 2020, the RBM Partnership’s Malaria in Pregnancy working group launched an urgent appeal to African leaders to expand coverage of IPTp-SP. To mark Universal Health Coverage Day, MMV caught up with Keziah L. Malm about how Ghana has scaled up this lifesaving intervention.
Ghana has scaled up coverage with IPTp over the last decade.5 What impact has the country seen?
Malaria affects everybody in Ghana, but it most affects pregnant women and children under 5. That’s why IPTp has been adopted for pregnant women in the country for over 10 years now. The use of IPTp in Ghana, in addition to all the other things that we are doing like the distribution of insecticide-treated nets (ITN), is having great impact. We have seen a reduction in maternal anaemia, in malaria cases in the mother and in low birthweight and stillbirths in children. A recent study from Ghana indicated that at least 3 doses of IPTp-SP significantly protected the mother from malaria in pregnancy as well as the baby from preterm delivery and its associated low birthweight.6 Another study showed that the uptake of 3 or more doses of IPTp-SP was associated with an increase in birthweight,7 which means that babies are healthier and have a better chance at survival.
What has been key to increasing and sustaining coverage with IPTp-SP in Ghana?
Ghana has incorporated IPTp into the set of interventions that are given to pregnant women when they visit an antenatal clinic. So, it’s not a stand-alone intervention. Once IPTp is integrated, we aim to ensure it remains available. That has been one of our pillars – ensuring IPTp is one of the key interventions available to pregnant women when they visit the antenatal clinic.
How does Ghana adopt global policies on IPTp-SP and ensure they are widely implemented, down to the community level?
We have a country policy for malaria in pregnancy that clearly highlights the use of IPTp. Our policies are generally revised every 2 to 3 years. We form a committee of experts from various stakeholders who look at the information in the country and globally to adapt the guidelines to the national context. This committee takes into consideration global policies as they become available. We make the necessary adjustments, and the updates are incorporated into the job aids, the trainings and the supervision that we undertake. The trainings are usually implemented every 2 to 3 years, together with the revision.
What best practices or innovations have been implemented to overcome barriers to IPTp uptake in Ghana?
IPTp has been incorporated into the set of interventions available to pregnant women at antenatal clinics. That, I think, is major. We have also improved on the way data is collected and collated. IPTp data is difficult to collect, so we developed tally sheets to help the midwives at the antenatal clinic carry out this task. We also work with NGOs to help us with follow-up on women that come for the first and second doses of IPTp but are not coming for the other doses, and continue to work with mass media to send out information to pregnant women to raise awareness on IPTp. Those are the innovations that help us achieve what we have set out to do.
How can the international community help support IPTp scale-up with efficacious medicines in Ghana and the rest of Africa?
The international community can continue to work with countries to provide more evidence on how efficacious IPTp is, to encourage people to continue using it. We should also support the production of SP. We realized that once SP is available, we have overcome a huge barrier, and the intervention can go on. Interventions like intermittent preventive treatment in pregnancy, seasonal malaria chemoprevention, and the use of insecticide treated nets can protect people from malaria. Let’s promote these interventions, so that we can save people from getting the disease.
1. World Health Organization. Implementing Malaria in Pregnancy Programs in the Context of World Health Organization Recommendations on Antenatal Care for a Positive Pregnancy Experience. 2018
2. World Health Organization. Guidelines for the treatment of malaria. Third edition. April 2015.
3. World Health Organization. World Malaria Report 2019.
4. World Health Organization. World Malaria Report 2020.
5. The 2019 Ghana Malaria Indicator Survey indicates that the proportion of women in Ghana receiving the third dose of IPTp-SP increased from 28% to 61% between 2014 and 2019.
6. Amoakoh-Coleman M, Arhinful DK, Klipstein-Grobusch K, Ansah EK, Koram KA. Coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) influences delivery outcomes among women with obstetric referrals at the district level in Ghana. Malaria Journal. 2020;19 (1):222.
7. Quakyi, I., Tornyigah, B., Houze, P. et al. High uptake of Intermittent Preventive Treatment of malaria in pregnancy is associated with improved birth weight among pregnant women in Ghana. Scientific Reports 9, 19034 (2019).