The study published today in the Lancet Infectious Diseases Journal shows that Intermittent Preventive Treatment (IPTp) and Insecticide Treated Nets (ITNs) are not being fully utilised to protect pregnant women from malaria in sub-Saharan Africa (SSA). The study, which reviewed national control strategies from 47 countries across sub-Saharan Africa, showed that 23 million pregnancies in 2007 were unprotected by an insecticide-treated bednet and 19 million were unprotected by intermittent preventive treatment in countries with a national policy for these interventions. The paper concludes that, despite success in a few countries, coverage of insecticide-treated bednets and intermittent preventive treatment in pregnant African women is inadequate and needs to be rapidly scaled up.

Malaria risk must be mapped

Prof Bob Snow, of the Malaria Public Health and Epidemiology Group at the KEMRI-Wellcome Trust Research Programme and one of the lead researchers in the study said that "it is important to map malaria risk, map progress toward improving coverage of interventions in pregnant women and identify what we need to do to increase coverage in high risk areas.

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This paper shows that much remains to be done for many vulnerable pregnant women in highly malarious areas of Africa". Viola Kirui, also a researcher at the KEMRI Wellcome Trust as well as a co-author of the paper added that: "Kenya had commendably begun implementing the distribution of insecticide treated nets to pregnant women and children under five through maternal and child health clinics. We however need to scale up these efforts if we intend to meet and surpass the targets set in the new Kenyan National Malaria Strategy."

Professor Feiko ter Kuile, the Malaria in Pregnancy Consortium leader and co-author also said: "Ten years after the Abuja declaration, it is encouraging that the majority of malaria endemic countries in SSA have now adopted ITNs and IPTp and the number of countries with nationally representative coverage data has increased to 40 out of 47.

Urgent strategies needed

However, very few countries have reached either the Abuja targets or their own policy ambition, and countries are even further away from the more recent RBM targets set for 2010. In addition, coverage was lowest in areas with high malaria transmission, where the need is greatest.

"In general, low coverage with IPTp and ITNs contrasts with correspondingly high ANC attendance, indicating that there are missed opportunities for coverage and the attainment and maintenance of high coverage of ITNs remains challenging.

"With only five years in which to meet the Millennium Development Goals, it is sobering that in countries with a national policy for IPT and/or ITN, an estimated 23 million pregnancies remain unprotected by an ITN and 19 million remain unprotected by IPTp. Greater effort to fully understand the reasons why coverage is so low and to develop strategies to combat this is urgently needed to protect the tens of millions of pregnancies in sub-Saharan Africa threatened by malaria every year." Prof Kuile added.

Major health concern

Malaria in pregnancy is a major public health concern in Kenya and other sub-Saharan African countries. The World Health Organisation (WHO) Expert Committee on Malaria recommends that Intermittent preventive treatment (IPTp) and Insecticide treated Nets (ITNs) be used to mitigate the effects of malaria in pregnancy.

Intervention with Intermittent preventive treatment (IPTp) requires that an effective anti-malarial drug be provided to pregnant women in highly endemic malaria zones as a routine part of antenatal care while Insecticide treated Nets (ITNs) require for pregnant women to sleep under insecticide treated mosquito nets to reduce the risk of malaria infection. These policy recommendations have fed into the work of the Roll Back Malaria initiative (RBM), which aims to ensure that 100% of pregnant women receive Intermittent preventive treatment (IPTp) and at least 80% of people at risk from malaria are using Insecticide treated Nets (ITNs) in areas of high transmission by 2010.