We did four separate systematic reviews, one for each of the major topic areas: efficacy and effectiveness, cost-effectiveness, acceptability and feasibility, and modelling impact. The respective search strategies are outlined in the appendix. Our general approach followed PRISMA guidelines; we searched multiple databases for studies and reviews of the prevention of malaria in pregnancy. For each of the four topic areas, we used a two-step strategy whereby we identified and summarised data from
SeriesPrevention of malaria in pregnancy
Introduction
Plasmodium infections are notable causes of adverse birth outcomes, including fetal loss, intrauterine growth retardation, and preterm delivery.1, 2 In areas in Africa where malaria is endemic, WHO recommends a combination of insecticide-treated nets (ITNs) and either intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine–pyrimethamine for women who are HIV-negative,3, 4 or daily co-trimoxazole prophylaxis for HIV-positive women.5 In areas in Asia and Latin America with low transmission, control of malaria in pregnancy mostly relies on early detection by screening asymptomatic women for malaria at the first antenatal visit, passive case detection of symptomatic cases, and ITNs given as part of antenatal care.
In sub-Saharan Africa, effectiveness of IPTp with sulfadoxine–pyrimethamine is threatened by parasite resistance. In the past decade, several trials have aimed to find alternative drugs for IPTp or alternative strategies that can replace IPTp with screen-and-treat approaches. Herein, we review the effect of resistance to sulfadoxine–pyrimethamine on the effectiveness of IPTp, and summarise trials to prevent malaria in pregnancy, with a focus on the cost-effectiveness, acceptability, operational feasibility, and modelled effect of existing and newer strategies. In addition, we reviewed the status of prevention trials done in endemic areas outside of sub-Saharan Africa.
Section snippets
Efficacy, effectiveness, and cost-effectiveness
For the efficacy component, we found 865 articles, of which 65 (44 reviews and 21 studies) were included. For the cost-effectiveness component, we found 106 articles; 15 of these articles met the inclusion criteria for qualitative synthesis, while none met the criteria for quantitative synthesis (figure 1). The characteristics of the included articles and important results related to efficacy and cost-effectiveness are included in the appendix.
Acceptability, feasibility, and public health impact of malaria prevention in pregnancy
For the acceptability, operational feasibility, and public health impact component, we found 1043 articles, of which 52 were included (36 quantitative, 15 qualitative, and one mixed methods; figure 1). The characteristics of the included articles and important results related to acceptability, operational feasibility, and public health impact are included in the appendix.
Modelling malaria in pregnancy and the effect of interventions
Our search found 62 articles, five of which were included (figure 1). Only three models of the link between malaria transmission and the risk or burden of malaria in pregnancy have been reported (appendix).111, 112, 113 The first relates to the burden of neonatal mortality to malaria in pregnancy and prevalence of malaria transmission by use of a simple empirical hazard-based model.111 The second model covers the relationship between maternal mortality and malaria, including a measure of
Discussion
The past decade has generated substantial evidence to address the research gaps in the prevention of malaria in pregnancy highlighted in 2007.116 Several observational studies15, 16 have shown that sulfadoxine–pyrimethamine has a beneficial effect on birthweight that is surprisingly resilient, even in areas where about 50% of paucigravidae had recurrent infections within 42 days of their first course of IPTp with sulfadoxine–pyrimethamine,15 and this finding is supported by mathematical
Search strategy and selection criteria
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