Background

Pregnant women, particularly during the first and second pregnancies, have reduced immunity to malaria and are therefore at increased risk of infection.

Malaria in pregnancy has serious adverse effects on the mother, foetus and newborn. It increases the risk of anaemia and mortality in the mother, and the risk of still births and preterm delivery on pregnancy outcomes and intrauterine growth retardation, low birth weight, anaemia and mortality in newborns. Malaria in pregnancy may also have long term effects in children such as growth retardation and poor cognitive outcomes. 

In areas where malaria is highly prevalent, malaria in pregnancy accounts for:

• up to 25% of severe anaemia cases in pregnancy, which in turn increases the risk of maternal mortality.
• about 20% of low-birth-weight deliveries.
• about 33% of congenital malaria among newborns of mothers with malaria in pregnancy

Malaria in pregnancy is therefore a major public health challenge in sub-Saharan Africa where the global burden of malaria is highest.

To avert the consequences of malaria in pregnancy, WHO recommends:

• prompt diagnosis and treatment among pregnant women
• chemoprevention with at least three doses of sulfadoxine-pyrethemine (IPTp3)
• distribution of Insecticide Treated Nets during Antenatal Care (ANC) for all pregnant women living in moderate and high malaria transmission areas

Malaria in pregnancy indicators used in malaria and RMNCAH scorecards

ALMA has supported over 40 countries to develop and implement malaria and/or RMNCAH scorecard tools which enable ministries of health to monitor programme performance using priority indicators and identify and act on bottlenecks promptly.  

An analysis of 30 of the 40 countries was done to assess the use of the scorecards actively implementing malaria scorecards track malaria in pregnancy indicators – either percent of pregnant women who receive ITNs during ANC or percent of pregnant women who receive IPTp3 (or IPTp3+) during ANC or both (22 countries track both). Additionally:  

• four countries track the percent of pregnant women diagnosed with malaria
• 16 countries track ANC4 coverage
• 7 countries track low birth weight
• 5 countries track still birth rate

The latter three indicators are primarily tracked through RMNCAH scorecards.  

Community scorecards compliment malaria and RMNCAH scorecards

ALMA is also supporting countries to roll out community scorecard tools which complement programme scorecards and are used at community level. Community members use community scorecards to track qualitative service delivery indicators related to areas such as:

• availability of clinical, laboratory and referral services
• health facility infrastructure
• availability of medicines
• client satisfaction

Community scorecards enhance community engagement and contribute to oversight of disease control programmes and primary health care. So far, nine countries have rolled out or are in the process of rolling out community scorecards.

Examples of actions taken in response to malaria in pregnancy bottlenecks

Scorecard tools are updated at least every quarter and reviewed by ministries of health leadership and programme staff, health partners, health workers, civil society and communities – among other stakeholders.

During scorecard reviews, priority areas for improvement are identified and actions are triggered to address performance bottlenecks. Community scorecards include scores of quality of care indicators ranked by community members who then agree with health workers on corrective action plans to address priority shortfalls in service delivery.

Low coverage of IPTp3 in Zambia

In Zambia, the malaria scorecard showed low coverage of IPTp3 nationwide. In-depth discussions revealed the need for intensified resource mobilisation to meet the country’s total sulfadoxine-pyrimethamine need for IPTp3. In response, discussions between top management of the Ministry of Health and the Ministry of Finance led to the release of government funding for the urgent procurement of sulfadoxine-pyrimethamine.

Additionally, following a request from the Minister of Health to partners, the Clinton Health Access Initiative procured sufficient doses for a high burden high burden province and US PMI suspended its policy of not procuring sulfadoxine-pyrethemine to contribute to the total need worth US$230,000. As a result, the national IPTp3 coverage increased from 28% in quarter 4, 2019 to 55% in quarter 3, 2021.

High prevalence of malaria in pregnancy in Tanzania

The malaria scorecard highlighted increased malaria cases in pregnant women in Kigoma region. Low ITN use was identified as a major contributory factor. This led to intensified health education sessions in the highest malaria risk communities to sensitise the communities on the importance of use of ITNs. Malaria in pregnancy cases subsequently reduced from 10% in quarter 4, 2020 to 6% in quarter 4, 2022.

Reduction in ITN distribution to pregnant women in Tanzania

The malaria scorecard showed a decline in the percent of pregnant women receiving ITNs during ANC in Geita region as a result of a delay in procurement linked to changes in stakeholder responsibilities. The regional malaria focal person communicated the need for urgent supply of ITNs which alleviated the stock out problem and led to an increase in ITN coverage from 64% to 74% between quarter 4, 2019 and quarter 1, 2020.

Low utilisation of health facility for ANC services in Ghana

In a locality in Ghana, the RMNCAH and community scorecards showed low ANC coverage which was partly attributed to low utilisation of health facilities with poor infrastructure. The community in the catchment area of an affected facility contributed to construction of a delivery room and an additional midwife being assigned to the facility. This was followed by a 20% increase in ANC visits.

Low ANC coverage in Nigeria

The RMNCAH scorecard in Nigeria showed low ANC coverage in Roni local government area. A number of actions were taken including:

• community sensitisation to raise awareness of the importance of early ANC attendance
• support to health care workers to conduct home visits to reach pregnant women in hard-to-reach settlements
• ensuring stock of ANC routine drugs

This was associated with an increase in ANC coverage from 48% to 95% in the local government area.

Low performance of maternal and child health indicators including early ANC attendance in the Democratic Republic of the Congo

The RMNCAH scorecard showed poor performance of ANC attendance and other maternal and child health indicators in Equateur Province. A bottleneck analysis identified frequent stock outs of commodities as a major contributory factor. The Ministry of Health leadership released emergency funding of US$45,000 for the procurement and distribution of ANC commodities including for malaria in pregnancy prevention in quarter 4, 2023.

Conclusion

Malaria and RMNCAH scorecard tools support countries to strengthen real-time use of data to track progress towards malaria in pregnancy targets and maternal and child health more broadly. The scorecard accountability cycle provides health programmes and their partners with a mechanism to systematically identify performance shortfalls and involve diverse stakeholders in analysing and resolving identified bottlenecks.

Scorecards have shown common reasons for low malaria in pregnancy intervention coverage including:

• Low ANC coverage due to inadequacies of health systems such as long distances between health facilities and communities, poor infrastructure and service delivery
• Shortfalls in ANC and malaria in pregnancy services due to frequent commodity stock outs, staff shortages and other health systems constraints
• Low demand for services due to poor community understanding of the importance of ANC and malaria in pregnancy control and lack of financial capacity to seek care.

Countries should use scorecards to clearly assess and amplify effective and efficient actions to resolve these and other common bottlenecks. Furthermore, as countries move towards implementing the recently issued WHO recommendation to extend the delivery of IPTp to the community level, they should intensify actions to address negative community perceptions towards early ANC and IPTp. Community scorecards provide an effective channel for targeted health education and institutionalised community engagement.