Treatment To Prevent Malaria in Pregnancy Is Making A Big Difference In Kenya’s Kilifi County – Elyne’s Story
Elyne Kaingu, a 33-year old mother and her 2 -year old son Abdul. Elyne benefitted from IPTp treatment during her second pregnancy.

Kilifi County, Kenya – Elyne Kaingu, a 33-year old mother from the beautiful Mnarani area of Kilifi County, overlooking the Indian Ocean, was extremely wary during her first pregnancy about the silent killer in her midst – malaria.  She knew some other first time mothers had fallen ill with the disease, and had even lost their babies or had premature births.

“I had to be very careful, given the pain caused by the disease to first time mothers, which I had witnessed,” recounts the homemaker, who was born and raised in Kilifi.  

For example, she was aware of the complications that might arise from maternal aneamia attributable to malaria.

Kaingu therefore took extra precautions by seeking medical advice from the village antenatal care (ANC) clinic, “where I was given iron and folic acid tablets, that prevented anemia while helping the development of the baby,” she says.

She was one of the lucky first-time mothers who had a successful and safe birth.

When she became pregnant for a second time in 2018, she discovered something that allowed her to feel even more reassured.  

During a prenatal check at the Mafumbini Dispensary she heard about the fact that Intermittent preventive treatment of malaria in pregnancy (IPTp) could help protect mothers and their babies from malaria, and she decided to take the treatment. 

“For every [ANC] clinic visit, I was given the malaria medicine which had to be taken at the dispensary before leaving for home,” Kaingu said, recalling the trips she made from the second trimester onward. 

There are good reasons for requiring the treatment be done at the clinic, she says, explaining that since the medicine sometimes causes nausea, some women might not take it within the confines of their homes.  

Even so, she made sure to arrive at the clinic with a good meal in her stomach. “It was not advisable to take the medicine on an empty stomach, according to the advice of the clinicians,” she says, explaining this helped ward off possible nausea.

Intermittent preventive treatment in Pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is effective in preventing maternal death and reducing maternal malaria episodes.

A minimum of three doses of sulfadoxine-pyrimethamine (SP) from the second trimester onwards has been shown to help prevent maternal malaria episodes, maternal and foetal anaemia, and related adverse outcomes like low birth weight and premature birth, according to the Geneva-based Medicines for Malaria Venture.  MMV is working with the World Health Organization, Roll Back Malaria and other partners to help ramp up IPTp treatment worldwide in the malaria-endemic zones at highest risk.  

About 31% of pregnant women that need IPTp treatment in Sub-Saharan Africa get at least two doses of the preventive medicine, according to WHO’s 2019 World Malaria Report. That is a big leap since 2010 when only about 2% of women received treatment, but still a long way to go in terms of ensuring full coverage.    

IPTp Offered in an Integrated Package of Services 

Integrating IPTp treatment with other services important to pregnant women has been one of the scale-up strategies stressed by MMV and others. 

In Kaingu’s case, the integrated approach was evident from the start – giving her extra motivation to return for more ANC care – and IPTp treatments. 

During her visits, for instance, she was provided with an insecticide-treated mosquito net: “Up until that time, I was using an ordinary, untreated mosquito net in my home.” 

Other benefits included being tested for breast cancer; advice on breastfeeding and on saving money specifically to meet the needs of the newborn baby.  Finally, there was the assurance that she could remain safe from malaria. 

“The treatment and the clinic visits have been beneficial to me and my baby, because I have never been attacked by malaria,” says Kaingu.

IPTp reduced malaria in pregnancy – even while Kilifi saw an overall rise in malaria cases
Malaria is still a concern in seaside Kilifi County, nestled by the Indian Ocean in southeast Kenya.

IPTp is one of the most widely used preventive interventions in this coastal region of Kenya as well as in Kenya’s Lake Victoria area – where malaria is endemic and incidence has even risen in recent years.

Expanding access to IPTp is the first objective of the six-phase Kenya Malaria Strategy adopted in 2019, which aims to help everyone in at-risk areas adopt appropriate measures to prevent malaria from the outset – as compared to only taking a curative approach.

Whereas some parts of Kenya have seen gradual declines in malaria incidence, heavy rains seen in the coastal area have led to a rising disease rate in some counties, such as Kilifi, where Kaingu lives. 

In 2018, there were an estimated 20-50 confirmed malaria cases, per 1,000 people, in Kilifi County, according to county malaria records. By 2019, that rate had doubled.  

Even so, malaria incidence among pregnant women in the rural area where Kaingu lives, actually declined over that same period, according to the records of the Kadzinuni Kendrick Dispensary, which serves her area. And the IPTp rollout has had a lot to do with that, in the opinion of Daniel Karisa, the clinical officer in charge of the Dispensary, which covers the northern rural part of Kilifi County. 

Daniel Karisa, a clinician at Kendrick Dispensary Kadzinuni in Kilifi, attending to a patient and his parent.

“There is a significant reduction of malaria cases among pregnant women even though there is an upsurge of malaria cases in the general population, during the rainy season,” Karisa said in an interview with Health Policy Watch. 

Some 200 pregnant women visited the dispensary for ANC treatment last year Karisa said in the interview, in which he constantly referred to the carefully kept dispensary records. Of those, only nine developed malaria in their second trimester and thereafter  – or 4.5% of pregnant women. The rate was 9% per cent on average before IPTp treatment was started.

Karisa believes that the integrated approach taken by the clinic to providing the treatment, in combination with bednets, advice about breastfeeding and breast cancer prevention, has   yielded other benefits. Out of their exposure to such issues, many women have developed better health-seeking behaviors. 

“IPTp is a big part of this change,” Karisa says.

Less Maternal Anaemia, Low-Weight Babies and Involuntary Abortions
Kendrick Dispensary Kadzinuni in Kilifi County on the Kenyan coast, where mothers receive IPTp treatment and other pregnancy-related care.

Karisa cites a long list of other benefits that he has observed, in terms of pregnancy outcomes: 

“There was reduced hospitalization resulting from severe maternal anaemia,” he asserts, referring again to the records. He notes that out of 100 mothers receiving IPTp, and reviewed during their ANC visits, only one was found to be severe anaemic. IPTp treatment helps prevent maternal anaemia by killing malaria parasites in the placenta. 

None of the babies born at the dispensary over the past year were low-birth weight (less than 1.5 kilograms).  Says Karisa: “Following the introduction of IPTp in the community, it is now rare to have low birth weight deliveries.”  

Finally, there has also been a reduced incidence of premature labour as well as a decline in involuntary abortions, he says, noting that the facility used to record an average of 4 cases of involuntary abortion per month for expectant mothers, before IPTp treatment was introduced. 

This year, between January and June, there was only a single case of miscarriage. This occurred among a total of 10 pregnant women who were found to be infected with malaria in their first trimester – when current forms of IPTp cannot be safely administered.  

“This is caused by the malaria parasites lodging inside the womb,” Karisa explains.

COVID-19 Slowed but Didn’t Stop IPTp Services  

In Kenya’s priority areas, IPTp coverage appears to already be slightly higher than it is Africa-wide. According to the Kenya Malaria Indicator Survey (KMIS) some 38 percent of pregnant women in the priority areas of Kilifi and Lake Victoria received IPTp treatment in 2015, the last year for which national data is available.

Based on observations at clinics such as Kadzinuni, the proportion of women being reached also seems to have increased further over the past five years. However, it will be some time before new national data is forthcoming, since the updated malaria survey that had been due to take place in 2020 has been pushed back to 2021, in light of the  COVID-19 pandemic. 

Indeed, coronavirus has been another new challenge that local health facilities have had to address – along with the unusually heavy rains, Karisa says. 

“The fear was that the new disease could severely handicap our ability to dispense malaria treatment to patients,” he explains.  “Fortunately this has not come to pass.”

Initially, in April and May, the number of mothers seeking ANC services dropped by about half, as COVID-19 cases started to spike nationwide.

While the clinic used to receive 100 individuals on average per day, the number dropped to between 50 and 60 in that period. As there was no lockdown in Kilifi, this was largely due to women’s fears of getting infected with the new disease.

“This however, is not to say that the services were interrupted per se; they were delayed,” Karisa says, noting that in June, numbers of women visiting the clinic rebounded  – even though COVID-19 cases began to climb sharply around the country.

Fortunately so far, COVID-19 case counts in Kilifi have also remained relatively low. On 19 July, for instance, six new COVID cases were recorded in the county, out of 603 cases nationally. 

Healthcare workers, like Daniel Karisa, are providing essential malaria care against the background of the COVID-19 pandemic and unusually heavy rains.

Against the uncertain landscape of the pandemic, the determination of health workers like Karisa to maintain routine health services, such as treatment for malaria in pregnancy, is good news to David Reddy, CEO of MMV.  

“As responding to COVID-19 will be a marathon, not a sprint, it is critical that prevention and treatment of leading killers such as malaria not be left behind,” Reddy told Health Policy Watch. “This is particularly the case in sub-Saharan Africa where the malaria disease burden remains so very high particularly among children and pregnant women. In that context, preservation and scale up of essential services such as those that prevent malaria in pregnancy remains critical.”

Malaria Remains a Major Burden to Communities
Elyne Kaingu, a 33-year old mother in Kilifi and her 2 -year old son Abdul.

And despite the progress seen recently on reducing malaria in pregnancy, the parasitic disease  remains a big burden, socially and economically, to communities in Kilifi County, Karisa underlines. 

As many as 40% of people visiting health facilities may receive a malaria diagnosis – at least in the rainy season.  And some people are discouraged from seeking treatment, because they have to travel such long distances to get to a clinic. 

Just like many mothers in her community, Kaingu also has been more wary of visiting the clinic for routine care for fear of COVID-19. “Honestly, I stopped going to the clinic, unless my child fell ill,” she says. 

However, she remains keenly aware of how important IPTp treatment is to pregnant women, even in the coronavirus period, and is actively encouraging other women to seek it. 

She now volunteers to mobilize women in her community whenever there is a health-related drive in her village.

She notes that malaria remains a huge concern, “especially at this time, when we are experiencing a lot of rains.” Mothers like her are particularly vigilant as spikes in early childhood mortality from malaria have been observed.  

In speaking out about the issues, Kaingu is also a model to other women – some of whom may still be fearful about getting treatment, but also fearful about speaking out about the risks.  Indeed, malaria in pregnancy remains a traumatic issue to talk about among women in Kilifi – as there are more than a few women who have suffered the tragic consequences. 

Kaingu says more action is still needed:

“Even though a lot of effort has been made in encouraging expectant women to visit health facilities and seek ANC services, I think more still need to be done to sensitize this population group in the community, on the importance of guarding against malaria in pregnancy.”

A view of the Indian Ocean in Kilifi County, Kenya.

Image Credits: HP-Watch/G Kamadi, Karel Prinsloo/Jhpiego.