Uncomplicated malaria among pregnant women in the Brazilian Amazon: Local barriers to prompt and effective case management

Abstract

Malaria in pregnancy is associated with increased risks of maternal anemia, spontaneous abortion, low birth weight, premature delivery and other adverse effects on health. In Brazil, disease transmission is highly concentrated in the multi-state region that constitutes the Brazilian Amazon (more than 99% of all cases). This study, conducted between the first bimesters of 2007 and 2008, aims to identify the local barriers to prompt and effective case management of malaria in pregnancy and was carried out in health facilities located in three endemic municipalities of the Brazilian Amazon (Manaus, Presidente Figueiredo and Porto Velho). The study design combined both qualitative and quantitative descriptive methods. The qualitative design involved semi-structured interviews with health personnel who routinely deal with malaria care. The quantitative design involved a review of medical records of pregnant women in the visited health facilities. Additionally, data were abstracted from SIVEP-Malaria Epidemiological Surveillance Information System (Brasil, 2007) and Primary Care Information System (SIAB) databases. Flaws were detected in diagnosis (only 6.8% of women tested for malaria) and treatment (for Plasmodium falciparum infections, only 44.8% of patients received recommended first-line therapy; 10.2% of prescription presented treatments were not found in national guideline and 7.3% of the prescriptions for Plasmodium vivax and 17.9% of the prescriptions for P. falciparum were not sanctioned by the official guidelines). Training (only 37.3% had had some training), knowledge and counseling were also sub-optimal. These results indicated the need to improve the health-worker performance through training. Close supervision and feedback on the health-worker performance are also needed. These findings also highlighted the need to put into practice a series of government recommendations that encourage close collaboration between the National Malaria Control Program and Primary Health Care actions in order to achieve safer pregnancies.

Women's Access and Provider Practices for the Case Management of Malaria during Pregnancy: A Systematic Review and Meta-Analysis

“…Poor knowledge of and adherence to national treatment policy guidelines among healthcare providers was a consistent finding across countries in east [42],[51] and west Africa [21],[30],[37],[38],[40],[43],[44],[46],[47], Asia [16],[17], the Middle East [18], and Latin America [20], and knowledge was particularly poor among private providers [35],[39]. In Ghana, healthcare providers asserted that pregnant women were exceptions to the policy of testing prior to treatment, and provided treatment even when a malaria test was negative.…”

“…There was close agreement between the reviewers on the review of full text articles (K = 0.84). The majority of studies were conducted in Africa (30), with only four studies conducted in Asia (two in India [14],[15] and two in Cambodia [16],[17]), one in Yemen [18], and two in Brazil [19],[20]. Of the studies conducted in Africa, 17 were in west and central Africa and 12 in east and southern Africa, and one study had sites in east, west and southern Africa [21].…”

“…In Cambodia, only 4/27 pregnant women surveyed received the recommended drug, quinine, in the first trimester, and knowledge amongst private providers about first line treatment for malaria in pregnancy was poor [17]. In Brazil, while 93% of patients received the recommended first line therapy for Plasmodium vivax malaria, only 45% of patients received the recommended first line therapy for P. falciparum malaria, with 7% and 18% of prescriptions, respectively, not sanctioned by national guidelines [20].…”

“…Financial incentives and client demand have been reported to motivate private practitioners to sell medicines, even inappropriate medicines or more expensive brands [40], without parasitological testing [17]. Prescription practices were influenced by perceptions of low drug efficacy [20],[37],[38],[46], perceptions of increasing drug resistance [17],[38], concerns about drug safety [35],[37],[46], inadequate understanding and fear of potential side effects of drugs in pregnancy [17],[35],[40],[46],[47],[51], and the influence of patient preference [17], each contributing to poor quality of care. Many of the substandard practices reported are a consequence of factors operating at higher levels of the health system.…”

“…Lack of national guidelines in India led to healthcare provider confusion about treatment policy [15]. Elsewhere, lack of training for diagnosis [16],[20] and/or treatment [18],[20],[41]–[43],[51] and lack of supervision [16],[41],[47] contributed to poor service delivery. Poor provider knowledge was exacerbated by weak organisation at the level of the health facility, such as inadequate drug stocks [15], and poor record-keeping practices such as providing written prescriptions and infrequent recording of vital information [20] and clinical findings and diagnoses [36] in both in-patient and out-patient records.…”