How are Malaria in Pregnancy (MIP) Programs

Measuring Up?

Aimee Dickerson and Mary DrakeUSAID Mini-UniversityMarch 7, 2014

Learning objectives

Understand the latest WHO guidance on MIP

Understand the common issues affecting the quality of national-level MIP guidance and the key recommendations

Understand the common issues affecting the quality of MIP data and use through HMIS systems and the key recommendations

2

MIP is a maternal and child health issue

207 M cases in 2012 627,000 deaths 90% of cases in Africa 50M pregnant women at

risk 10,000 maternal

deaths/yr 200,000 infants

deaths/yr

3

World Health Organization guidance

For pregnant women in areas of moderate to high malaria transmission:1. Long-lasting insecticide-treated nets

(LLINs) 2. Intermittent preventive treatment in

pregnancy (IPTp)- currently with sulfadoxine-pyrimethamine

3. Effective case management of malaria and anemia in pregnancy

4

How are countries doing?

5

Review of MIP guidance

6

To better understand:1. How closely national MIP documents

(policies, guidelines, training & supervision materials) reflect WHO MIP guidance and

2. How consistent documents produced by the national malaria control program and reproductive health divisions are

MIP guidance review findings

COMMON ISSUES Kenya Mali Mozam-bique

Tanzania

Uganda Total # of

countries with issue

Need for interrupting folic acid intake after taking SP in countries that use high doses of folic acid (low-dose folic acid is recommended during pregnancy and is compatible with SP use)

  X

  X

  

    X 3

Unclear timing and dosing guidance for IPTp-SP X X X X X 5

Designation of IPTp-SP by specific week intervals X X

 X 4

Prohibition of IPTp-SP before 20 weeks

    X X   2

Prohibition of IPTp-SP after 36 weeks or in the last month of pregnancy

   X

   X

 2

7

MIP guidance review findings

8

COMMON ISSUES Kenya Mali Mozam-bique

Tanzania

Uganda Total # of

countries with issue

Unclear guidance regarding DOT for IPTp

  X       1

Inconsistent guidance about malaria prevention for HIV+ women

   X

 X

 X

 X 4

Unclear guidance on when and how pregnant women should obtain ITNs

 X

 X

 X

 X

 X 5

Lack of guidance on use of microscopy or RDTs for diagnosis

   X

   X

 X 3

Incomplete or confusing guidance on treatment of malaria by trimester

 X

 X

   X

 X 4

Recommendations to countries

9

Form national technical working groups (TWGs) to develop consistent and harmonized guidance on all aspects of MIP

IPTp guidance should be updated to reflect revised WHO 2012 IPTp policy recommendation

Review WHO’s guidance for administration of folic acid

Recommendations to countries

10

Coordinate with national HIV programs to ensure consistent guidance on prevention and treatment of MIP for HIV+ pregnant women

Emphasize distribution of ITNs and counseling on their use at antenatal care

Stress the need for diagnosis prior to treatment

Develop clear algorithms on treatment medications, doses and timing

Way forward

Dissemination at country level Encourage countries to use MIP

document review as starting point to update policy and national documents

11

MNH HMIS Review

Purpose: To better understand what information on MNH service

content, quality and health outcomes is currently included in national HMIS for select priority countries.

Specific objectives include: Document current MNH (ANC/L&D) indicators included in

the HMIS Document current MIP indicators in PMI focus countries Identify gaps and advocate at the national level for

incorporation of new indicators on content and quality of MNH services where

Provide recommendations to WHO on MIP-related indicators and data collection formats

Method

Focus on ANC, delivery and immediate post-natal care

Collected HMIS tools from 14 countries Content Analysis of:

Client record, Register, facility monthly/quarterly summary forms, commodity stock-out

Used standardized data abstraction template

Guidance/documents for completing tools13

Method (Cont.)

For PMI focus (6) countries Review of national policy documents,

M&E plans, and grey literature on MIP Identify key stakeholder in PMI focus

countries Conduct In-depth interviews on use of

MIP-related data• National MOH staff (RH and NMNCP)• Health care providers

14

Initial Findings: Emerging Themes (1 of 2)

1. Coordination of malaria and RH partners a gap- some work in progress

2. Recognition of lack of data on case management of malaria in pregnant woman

Concern for system/ people to be over-burdened, high cost of revisions to system

Synchronization with policy/ guidelines updates

15

Initial Findings: Emerging Themes (2 of 2)

4. Uptake of DHIS2 by many countries offers an opportunity to more easily share and review data and may have implications for quality and use

5. Strengthen NMCP & RH program capacity in data use and data quality improvement to address data quality concerns

6. Facility level coordination of data manager and in-charges a key opportunity to improve data quality

16

Discussion & Next Steps

Consensus among MNH community on key indicators, including MIP case management indicators, will move M&E of MNH forward

RBM M&E working group being engaged to consider standardized case management indicators

Where strong, consider surveillance site monitoring systems as a platform for gauging quality of MIP care

17

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