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Prevention and Control of Malaria during Pregnancy. A Workshop for Healthcare Providers. Facts about Malaria . 300 million cases each year worldwide 9 of 10 cases occur in Africa A person in Africa dies of malaria every 10 seconds Women and young children are most at risk

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prevention and control of malaria during pregnancy

Prevention and Control of Malaria during Pregnancy

A Workshop for Healthcare Providers

facts about malaria
Facts about Malaria
  • 300 million cases each year worldwide
  • 9 of 10 cases occur in Africa
  • A person in Africa dies of malaria every 10 seconds
  • Women and young children are most at risk
  • Affects five times as many people as AIDS, leprosy, measles, and tuberculosis combined

Prevention and Control of Malaria during Pregnancy

facts about malaria and pregnancy
Facts about Malaria and Pregnancy
  • 30 million African women are pregnant yearly
  • Malaria is more frequent and complicated during pregnancy
  • In malaria-endemic areas, malaria during pregnancy may account for:
    • Up to 15% of maternal anemia
    • 5–14% of low birthweight
    • 30% of “preventable” low birthweight

Prevention and Control of Malaria during Pregnancy

roll back malaria
Roll Back Malaria
  • Worldwide partnership
  • Governments, private groups, research organizations, civil society, media
  • Aim to reduce malaria by half by 2010
  • Free advocacy resources and tools: http://www.rbm.who.int
  • Priority: Prevent poor outcomes caused by malaria in pregnancy
  • Abuja declaration: Goal is for 60% of women in Africa to be sleeping under insecticide-treated nets (ITNs) and getting intermittent preventive treatment (IPT) by 2005

Prevention and Control of Malaria during Pregnancy

malaria prevention and treatment during pregnancy
Malaria Prevention and Treatment during Pregnancy
  • Focused antenatal care (ANC) with health education about malaria
  • Use of insecticide-treated nets (ITNs)
  • Intermittent preventive treatment (IPT)
  • Case management of women with symptoms and signs of malaria

Prevention and Control of Malaria during Pregnancy

focused antenatal care chapter objectives
Focused Antenatal Care: Chapter Objectives
  • Describe four main components of focused antenatal care (ANC)
  • Discuss frequency and timing of ANC visits
  • Describe essential elements of a birth plan that includes complication readiness
  • Describe interpersonal skills for effective ANC
  • Describe components of record keeping for ANC

Prevention and Control of Malaria during Pregnancy

focused antenatal care
Focused Antenatal Care

An approach to ANC that emphasizes:

  • Evidence-based, goal-directed actions
  • Individualized, woman-centered care
  • Quality vs. quantity of visits
  • Care by skilled providers

Prevention and Control of Malaria during Pregnancy

goal of focused antenatal care
Goal of Focused Antenatal Care

To promote maternal and newborn health and survival through:

  • Early detection and treatment of problems and complications
  • Prevention of complications and disease
  • Birth preparedness and complication readiness
  • Health promotion

Prevention and Control of Malaria during Pregnancy

traditional antenatal care
Traditional Antenatal Care
  • Emphasizes:
    • Ritualistic, “routine” care vs. evidence-based, goal-directed actions
    • Frequent visits
  • Does not emphasize individual client needs

Prevention and Control of Malaria during Pregnancy

no longer recommended
No Longer Recommended
  • Numerous, routine visits
    • Burden to women and healthcare system
  • Routine measurements and examinations:
    • Maternal height and weight
    • Ankle edema
    • Fetal position before 36 weeks
  • Care based on risk assessment

Prevention and Control of Malaria during Pregnancy

risk approach
Risk Approach

Not an effective ANC strategy because:

  • Complications cannot be predicted—all pregnant women are at risk for developing complications
  • Risk factors are usually not direct cause of complications
  • Many “low risk” women develop complications
    • Have false sense of security
    • Do not know how to recognize/respond to problems
  • Most “high risk” women give birth without complications
    • Inefficient use of scarce resources

Prevention and Control of Malaria during Pregnancy

focused antenatal care services
Focused Antenatal Care Services

Evidence-based, goal-directed actions:

  • Address most prevalent health issues affecting women and newborns
  • Adjusted for specific populations/regions
  • Appropriate to gestational age
  • Based on firm rationale

Prevention and Control of Malaria during Pregnancy

focused antenatal care services cont d
Focused Antenatal Care Services (cont’d.)

Individualized, woman-centered carebased on each woman’s:

  • Specific needs and concerns
  • Circumstances
  • History, physical examination, testing
  • Available resources

Prevention and Control of Malaria during Pregnancy

focused antenatal care services cont d1
Focused Antenatal Care Services (cont’d.)

Quality vs. quantity of ANC visits:

  • WHO multi-center study
    • Number of visits reduced without affecting outcome for mother or baby
  • Recommendations
    • Content and quality vs. number of visits
    • Goal-oriented care
    • Minimum of four visits

Prevention and Control of Malaria during Pregnancy

scheduling and timing of anc visits
Scheduling and Timing of ANC Visits
  • First visit: By 16 weeks or when woman first thinks she is pregnant
  • Second visit: At 24–28 weeks or at least once in second trimester
  • Third visit: At 32 weeks
  • Fourth visit: At 36 weeks
  • Othervisits: If complication occurs, followup or referral is needed, woman wants to see provider, or provider changes frequency based on findings (history, exam, testing) or local policy

Prevention and Control of Malaria during Pregnancy

focused antenatal care services cont d2
Focused Antenatal Care Services (cont’d.)

Care by a skilled provider who:

  • Has formal training and experience
  • Has knowledge, skills, and qualifications to deliver safe, effective maternal and newborn healthcare
  • Practices in home, hospital, health center
  • May be a midwife, nurse, doctor, clinical officer, etc.

Prevention and Control of Malaria during Pregnancy

early detection and treatment
Early Detection and Treatment
  • Malaria—history and physical exam
    • Fever and accompanying signs/symptoms
    • Region
    • Complicated vs. uncomplicated cases
  • Severe anemia—physical exam, testing
  • Pre-eclampsia/eclampsia—measurement of blood pressure
  • HIV—voluntary counseling and testing
  • Sexually transmitted infections, including syphilis— testing

Prevention and Control of Malaria during Pregnancy

prevention key preventive measures
Prevention: Key Preventive Measures
  • Malaria:
    • Intermittent preventive treatment (IPT)
    • Use of insecticide-treated nets (ITNs)
  • Tetanus toxoid, iron/folate supplements
  • Country/region-specific interventions as appropriate
    • Vitamin A supplements
    • Iodine supplements
    • Presumptive treatment for hookworm

Prevention and Control of Malaria during Pregnancy

birth preparedness and complication readiness objectives
Birth Preparedness and Complication Readiness: Objectives
  • Develop birth plan—exact plan for normal birth and possible complications:
    • Arrangements made in advance by woman and family (with help of skilled provider)
    • Usually not a written document
    • Reviewed/revised at every visit
  • Minimize disorganization at time of birth or in an emergency
  • Ensure timely and appropriate care

Prevention and Control of Malaria during Pregnancy

essential elements of a birth plan
Essential Elements of a Birth Plan
  • Facility or Place of Birth: Home or health facility for birth, appropriate facility for emergencies
  • Skilled Provider: To attend birth
  • Provider/Facility Contact Information
  • Transportation: Reliable, accessible, especially for odd hours
  • Funds: Personal savings, emergency funds
  • Decision-Making: Who will make decisions, especially in an emergency

Prevention and Control of Malaria during Pregnancy

essential elements of a birth plan cont d
Essential Elements of a Birth Plan (cont’d.)
  • Family and Community Support: Care for family in woman’s absence and birth companion during labor
  • Blood Donor: In case of emergency
  • Needed Items: For clean and safe birth and for newborn care
  • Danger Signs/Signs of Advanced Labor

Prevention and Control of Malaria during Pregnancy

danger signs of pregnancy
Danger Signs of Pregnancy
  • Vaginal bleeding
  • Difficulty breathing
  • Fever
  • Severe abdominal pain
  • Severe headache/blurred vision
  • Convulsions/loss of consciousness
  • Labor pains before 37 weeks

Prevention and Control of Malaria during Pregnancy

health education objectives
Health Education: Objectives
  • Inform and educate the woman with health messages and counseling appropriate to:
    • Individual needs, concerns, circumstances
    • Gestational age
    • Most prevalent health issues
  • Support the woman in making decisions and solving actual or anticipated problems
  • Involve partner and family in supporting/adopting healthy practices

Prevention and Control of Malaria during Pregnancy

health education topics addressed
Health Education: Topics Addressed
  • Prevention of malaria:
    • Intermittent preventive treatment (IPT)
    • Use of insecticide-treated nets (ITNs)
    • Other methods
  • Other important issues to be discussed include:
    • Nutrition
    • Care for common discomforts
    • Use of potentially harmful substances
    • Hygiene
    • Rest and activity

Prevention and Control of Malaria during Pregnancy

health education topics addressed cont d
Health Education: Topics Addressed (cont’d.)
  • Sexual relations and safer sex
  • Early and exclusive breastfeeding
  • Prevention of tetanus and anemia
  • Voluntary counseling and testing for HIV
  • Prevention of other endemic diseases/deficiencies

Prevention and Control of Malaria during Pregnancy

interpersonal skills
Interpersonal Skills
  • Speak in a quiet, gentle tone of voice
  • Listen to woman/family and respond appropriately
  • Encourage them to ask questions and express concerns
  • Allow them to demonstrate understanding of information provided
  • Explain all procedures/actions and obtain permission before proceeding
  • Show respect for cultural beliefs and social norms
  • Be empathetic and nonjudgmental
  • Avoid distractions while conducting the visit

Prevention and Control of Malaria during Pregnancy

record keeping
First ANC Visit

History

Physical examination

Testing

Care provision, including provision of IPT for malaria, if appropriate

Counseling, including birth plan and use of ITNs

Date of next ANC visit

Subsequent ANC Visits

Interim history

Targeted physical examination, testing

Care provision, including provision of IPT for malaria, if appropriate

Counseling, including birth plan and use of ITNs (and relevant information on how client obtained and used ITN)

Date of next ANC visit

Record Keeping

Record all information on the ANC chart and clinic card:

Prevention and Control of Malaria during Pregnancy

malaria transmission chapter objectives
Malaria Transmission: Chapter Objectives
  • Define malaria and how it is transmitted
  • Describe extent of malaria in Africa
  • Identify groups at highest risk of malaria infection
  • List effects of malaria on pregnant women and their unborn babies
  • Describe effects of malaria on pregnant women with HIV/AIDS

Prevention and Control of Malaria during Pregnancy

malaria transmission
Malaria Transmission
  • Caused by Plasmodium parasites
  • Spread by female Anopheles mosquitoes infected with parasites
  • Anopheles mosquitoes usually active at night
  • Infected mosquito bites a person
  • Malaria parasites reproduce in human blood
  • Mosquito bites infected person, and goes on to bite and infect another person

Prevention and Control of Malaria during Pregnancy

populations most affected by malaria
Populations Most Affected by Malaria
  • Children under 5 years of age
  • Pregnant women
  • Unborn babies
  • Immigrants from low-transmission areas
  • HIV-infected persons

Prevention and Control of Malaria during Pregnancy

effects of malaria on pregnant women
Effects of Malaria on Pregnant Women
  • All pregnant women in malaria-endemic areas are at risk
  • Parasites attack and destroy red blood cells
  • Malaria causes up to 15% of anemia in pregnancy
  • Can cause severe anemia
  • In Africa, anemia due to malaria causes up to 10,000 maternal deaths per year

Prevention and Control of Malaria during Pregnancy

effects on unborn babies
Effects on Unborn Babies
  • Parasites hide in placenta
  • Interferes with transfer of oxygen and nutrients to the baby, increasing risk of:
    • Spontaneous abortion
    • Preterm birth
    • Low birthweight—single greatest risk factor for death during first month of life
    • Stillbirth

Prevention and Control of Malaria during Pregnancy

effects on communities
Effects on Communities
  • Causes missed work and wages
  • Results in frequent school absences
  • Uses scarce resources
  • Causes preventable deaths: increases maternal, newborn, and infant mortality rates

Prevention and Control of Malaria during Pregnancy

hiv aids and malaria during pregnancy
HIV/AIDS and Malaria during Pregnancy
  • HIV/AIDS reduces a woman’s resistance to malaria
  • Intermittent preventive treatment (IPT) given 3 times during pregnancy is effective for women with HIV/AIDS

Prevention and Control of Malaria during Pregnancy

summary of health education points
Summary of Health Education Points
  • Malaria transmitted through mosquito bites
  • Pregnant women and children are most at risk
  • Pregnant women infected with malaria may have no symptoms
  • Women with HIV/AIDS are at higher risk
  • Malaria can lead to severe anemia, spontaneous abortion, low-birthweight babies
  • Malaria is preventable

Prevention and Control of Malaria during Pregnancy

preventing malaria chapter objectives
Preventing Malaria: Chapter Objectives
  • List the elements of counseling women about the use of insecticide-treated nets (ITNs) and intermittent preventive treatment (IPT) during pregnancy
  • Describe the use of sulfadoxine-pyrimethamine (SP) for IPT during pregnancy

Prevention and Control of Malaria during Pregnancy

insecticide treated nets
Insecticide-Treated Nets
  • Kill or repel mosquitoes
  • Prevent physical contact with mosquitoes
  • Kill or repel other insects:
    • Lice
    • Ticks
    • Bedbugs
    • Cockroaches

Prevention and Control of Malaria during Pregnancy

insecticide treated nets cont d
Untreated Nets

Provide some protection against malaria

Do not kill or repel mosquitoes that touch net

Do not reduce number of mosquitoes

Do not kill other insects like lice, roaches, and bedbugs

Are safe for pregnant women, young children, and infants

Insecticide-Treated Nets

Provide a high level of protection against malaria

Kills or repels mosquitoes that touch the net

Reduce number of mosquitoes in/outside net

Kills other insects such as lice, roaches, and bedbugs

Are safe for pregnant women, young children, and infants

Insecticide-Treated Nets (cont’d.)

Prevention and Control of Malaria during Pregnancy

benefits of insecticide treated nets
Benefits of Insecticide-Treated Nets
  • Prevent mosquito bites
  • Protect against malaria, resulting in less:
      • Anemia
      • Prematurity and low birthweight
      • Risk of maternal and newborn death
  • Help people sleep better
  • Promote growth and development of fetus and newborn

Prevention and Control of Malaria during Pregnancy

benefits of insecticide treated nets community
Benefits of Insecticide-Treated Nets: Community
  • Cost less than treating malaria
  • Reduce number of sick children and adults (helping children grow to be healthy and helping working adults remain productive)
  • Reduce number of deaths

Prevention and Control of Malaria during Pregnancy

where to find insecticide treated nets
Where to Find Insecticide-Treated Nets
  • General merchandise shops
  • Drug shops/pharmacies
  • Markets
  • Public and private health facilities
  • Community health workers
  • NGOs, community-based organizations

Prevention and Control of Malaria during Pregnancy

how to use insecticide treated nets
How to Use Insecticide-Treated Nets
  • Hang above bed or sleeping mat
  • Tuck under mattress or mat
  • Use every night, all year long
  • Use for everyone, if possible, but give priority to pregnant women, infants, and children

Prevention and Control of Malaria during Pregnancy

caring for insecticide treated nets
Caring for Insecticide-Treated Nets
  • Handle gently to avoid tears
  • Tie net up during day to avoid damage
  • Regularly inspect for holes, repair if found
  • Nets need to be re-treated regularly to stay effective
  • Keep away from smoke, fire, direct sunlight

Prevention and Control of Malaria during Pregnancy

intermittent preventive treatment
Intermittent Preventive Treatment

Based on the assumption that every pregnant woman living in an area of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria

Prevention and Control of Malaria during Pregnancy

intermittent preventive treatment1
Intermittent Preventive Treatment

Although a pregnant woman with malaria may have no symptoms, malaria can still affect her and her unborn child

Prevention and Control of Malaria during Pregnancy

intermittent preventive treatment who recommendation
Intermittent Preventive Treatment: WHO Recommendation
  • All pregnant women should receive at least two doses of IPT after quickening, during routinely scheduled ANC visits (WHO recommends a schedule of four visits, three after quickening)
  • Presently, the most effective drug for IPT is sulfadoxine-pyrimethamine (SP)
  • Women should receive at least two doses of IPT with SP at ANC visits after quickening, but no more frequently than monthly

Prevention and Control of Malaria during Pregnancy

intermittent preventive treatment dose and timing
Intermittent Preventive Treatment: Dose and Timing
  • A single dose is three tablets of sulfadoxine 500 mg + pyrimethamine 25 mg
  • Healthcare provider should dispense dose and directly observe client taking dose

Prevention and Control of Malaria during Pregnancy

instructions for giving intermittent preventive treatment
Instructions for Giving Intermittent Preventive Treatment
  • Ensure woman is at least 16 weeks pregnant and that quickening has occurred
  • Inquire about use of SP in last 4 weeks
  • Inquire about allergies to SP or other sulfa drugs (especially severe rashes)
  • Explain what you will do; address the woman’s questions
  • Provide cup and clean water

Prevention and Control of Malaria during Pregnancy

instructions for giving intermittent preventive treatment cont d
Instructions for Giving Intermittent Preventive Treatment (cont’d.)
  • Directly observe woman swallow three tablets of SP
  • Record SP dose on ANC and clinic card
  • Advise the woman when to return:
    • For her next scheduled visit
    • If she has signs of malaria
    • If she has other danger signs

Reinforce the importance of using ITNs

Prevention and Control of Malaria during Pregnancy

intermittent preventive treatment contraindications to using sp
Intermittent Preventive Treatment: Contraindications to Using SP
  • Do NOT give during first trimester: Be sure quickening has occurred and woman is at least 16 weeks pregnant
  • Do NOT give to women with reported allergy to SP or other sulfa drugs: Ask about sulfa drug allergies before giving SP
  • Do NOT give to women taking co-trimoxazole, or other sulfa-containing drugs: Ask about use of these medicines before giving SP
  • Do not give SP more frequently than monthly: Be sure at least 1 month has passed since the last dose of SP

Prevention and Control of Malaria during Pregnancy

chemoprophylaxis with chloroquine for women allergic to sulfa drugs

Dose

Chloroquine

Timing

150 mg

1

4 tablets

First ANC visit after 16 weeks

2

4 tablets

Second day after first dose

3

2 tablets

Third day after first dose

Weekly

2 tablets

Every week during pregnancy

Chemoprophylaxis with Chloroquine: For Women Allergic to Sulfa Drugs*

*If chloroquine resistance rates in the country are high, chemoprophylaxis with chloroquine is not recommended.

Prevention and Control of Malaria during Pregnancy

summary of health education points1
Summary of Health Education Points
  • Pregnant women should sleep under ITNs every night
  • By preventing malaria, IPT reduces the incidence of maternal anemia, spontaneous abortion, preterm birth, stillbirth, and low birthweight
  • IPT should be administered to pregnant women at regularly scheduled ANC visits after quickening, but not more often than monthly

Prevention and Control of Malaria during Pregnancy

prevention and control of malaria during pregnancy4

Prevention and Control of Malaria during Pregnancy

Chapter IV: Detection and Treatment

malaria detection and treatment chapter objectives
Malaria Detection and Treatment: Chapter Objectives
  • Identify causes of fever during pregnancy
  • List the signs and symptoms of uncomplicated and complicated malaria
  • Describe the treatment for uncomplicated malaria during pregnancy
  • Explain the steps to appropriately refer a pregnant woman who has complicated malaria

Prevention and Control of Malaria during Pregnancy

detecting malaria
Detecting Malaria
  • Symptoms
    • Fever
    • Chills
    • Headaches
    • Muscle/joint pains
  • Lab exam of blood from a finger prick

Prevention and Control of Malaria during Pregnancy

fever during pregnancy
Fever during Pregnancy
  • Temperature of 38° C or higher
  • May be caused by malaria, but also by:
    • Bladder or kidney infection
    • Pneumonia
    • Typhoid
    • Uterine infection
  • Careful history and physical required to rule out other causes

Prevention and Control of Malaria during Pregnancy

fever during pregnancy cont d
Fever during Pregnancy (cont’d.)

Ask about or examine for:

  • Type, duration, degree of fever
  • Signs of other infections:
    • Chest pain/difficulty breathing
    • Foul-smelling watery vaginal discharge
    • Tender/painful uterus or abdomen
    • Frequency/urgency/pain in urinating
  • Signs of complicated malaria or other danger signs

Prevention and Control of Malaria during Pregnancy

types of malaria
Types of Malaria
  • Uncomplicated
    • Most common
  • Complicated
    • Life threatening, can affect brain
    • Pregnant women more likely to get complicated malaria than non-pregnant women

Prevention and Control of Malaria during Pregnancy

recognizing malaria in pregnant women
Uncomplicated Malaria

Fever

Shivering/chills/rigors

Headaches

Muscle/joint pains

Nausea/vomiting

False labor pains

Complicated Malaria

Signs of uncomplicated malaria PLUS one or more of the following:

Dizziness

Breathlessness/difficulty breathing

Sleepy/drowsy

Confusion/coma

Sometimes fits, jaundice, severe dehydration

Recognizing Malaria in Pregnant Women

Prevention and Control of Malaria during Pregnancy

recognizing malaria in pregnant women cont d
Recognizing Malaria in Pregnant Women (cont’d.)

Refer the woman

immediately

if you suspect anything

other than

uncomplicated malaria

Prevention and Control of Malaria during Pregnancy

case management
Case Management
  • Determine whether malaria is uncomplicated or complicated
  • Uncomplicated: Manage according to national protocol
  • Complicated: Refer immediately to higher level of care; consider giving first dose of anti-malarial if available and healthcare provider is familiar with its use

Prevention and Control of Malaria during Pregnancy

case management drugs
Case Management: Drugs
  • First-line drug therapy is indicated for uncomplicated malaria
  • Second-line drug therapy is indicated for uncomplicated malaria that has failed to respond to first-line drug
  • In almost all countries, quinine is the drug of choice for complicated malaria

Prevention and Control of Malaria during Pregnancy

managing uncomplicated malaria
Managing Uncomplicated Malaria
  • Provide first-line anti-malarial drugs
    • Follow country guidelines
  • Manage fever
    • Analgesics, tepid sponging
  • Diagnose and treat anemia
  • Provide fluids

Prevention and Control of Malaria during Pregnancy

treating uncomplicated malaria
Treating Uncomplicated Malaria
  • Observe client taking anti-malarial drugs
  • Advise client to:
    • Complete course of drugs
    • Return if no improvement in 48 hours
    • Consume iron-rich foods
    • Use ITNs and other preventive measures

Prevention and Control of Malaria during Pregnancy

sp contraindications
SP: Contraindications
  • Before 16 weeks of pregnancy
  • SP dose in last 4 weeks
  • Allergies to sulfa drugs (e.g., co-trimoxazole)
  • Currently taking other sulfa drugs
    • Substitute other drug before giving SP

Prevention and Control of Malaria during Pregnancy

treatment problems
Treatment Problems
  • Vomiting within 30 minutes
    • Repeat dose of SP
  • Itching
    • Warm or cool baths
    • Use lotions/skin creams
    • Give Piriton™ or Phenergan®
  • Stomach upset/irritation
    • Take chloroquine with food or sugar
    • Reduce intake of caffeine and greasy foods

Prevention and Control of Malaria during Pregnancy

treatment followup
Treatment Followup
  • Arrange followup within 48 hours
  • Advise to return if condition worsens
  • Review danger signs
  • Reinforce use of ITNs

Prevention and Control of Malaria during Pregnancy

second line drug
Second-Line Drug
  • Most clients will respond to malaria treatment and begin to feel better within 48 hours
  • However, if the client’s condition does not improve or worsens, give second-line treatment for uncomplicated malaria

Prevention and Control of Malaria during Pregnancy

second line drug cont d
Second-Line Drug (cont’d.)
  • If the woman’s condition does not improve or worsens within 48 hours of starting treatment with a second-line drug, and/or other symptoms appear, REFER IMMEDIATELY
  • If signs of complicated malaria are present, REFER IMMEDIATELY

Prevention and Control of Malaria during Pregnancy

referral preparation
Referral Preparation
  • Explain situation to the client/family
  • Help arrange transport to other facility if possible
  • Write referral note
  • Treat any urgent conditions and stabilize

Prevention and Control of Malaria during Pregnancy

referral note
Referral Note
  • Brief history of client’s condition
  • Details of any treatment provided
  • Reason for referral
  • Significant findings from history, physical exam, or lab
  • Any important details of current pregnancy
  • Copy of client’s ANC record, if possible
  • Referring provider contact information

Prevention and Control of Malaria during Pregnancy

summary of health education points2
Summary of Health Education Points
  • Uncomplicated malaria can be easily treated if recognized early, but it is very important to finish the course of treatment to be effective
  • Because complicated malaria requires specialized management, women with complicated malaria should be referred immediately to avoid complications and death

Prevention and Control of Malaria during Pregnancy