MALARIA IN PREGNANCY

Guidelines for measuring key

monitoring and evaluation indicators
MALARIA IN PREGNANCY
Guidelines for measuring key
monitoring and evaluation indicators
Malaria in pregnancy
Acknowledgements
This document is a collaborative effort of the Global Malaria Programme and
Making Pregnancy Safer departments of the World Health Organization (WHO)
at Headquarters and the Malaria Control and Reproductive Health departments
at the WHO Regional Ofce for Africa, led by Juliana Yartey, Paola Marchesini
and Bernard Nahlen. The Global Malaria Programme and Making Pregnancy
Safer departments wish to acknowledge the valuable contributions of numerous
experts around the world, particularly those from malaria-endemic countries,
technical institutions, the Centers for Disease Control and Prevention in the
United States, the Maternal and Neonatal Health Program of the Johns Hopkins
Program for International Education in Gynecology and Obstetrics in the
United States, the London School of Hygiene and Tropical Medicine, the
Makerere University Uganda, the Regional Centre for Quality of Health Care,
the United States Agency for International Development, the United Nations
Childrens Fund (UNICEF), networks (PREMAEU) and others who reviewed
drafts and attended meetings and workshops to draw up and rene the
document. Special thanks to Fatoumata Toure, Jane Crawley, Wilson Were,
Nathan Bakyaita, Magda Robalo, Seipati Mothebesoanne-Anoh, Antoine
Serulira, Antoinette Ba-Nguz, Amadou Bailo Diallo, Noel Chisaka, Anna
Betran, Mathews Mathai, Allisyn Moran, Alison Bell, Sarah OBrien, Chilunga
Puta, Barbara Rawlings, Kwame Asamoa, Monica Parise, Robert Newman and
Rick Steketee for contributions to this document and for their enthusiasm and
commitment to the prevention and control of malaria during pregnancy.
World Health Organization 2007
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ii
Contents
Abbreviations used ...................................................................................iv
1. Introduction .................................................................................... 1
2. Framework for monitoring and evaluation .................................. 5
3. Indicators to be measured at health facilities ............................... 8
Percentage of antenatal clinic staff trained in the control
of malaria during pregnancy in the past 12 months ............................. 8
Percentage of health facilities reporting stock-out
of the recommended drug for IPT ...................................................... 10
Percentage of pregnant women attending antenatal care
who receive a rst dose of IPT under direct observation ....................... 11
Percentage of pregnant women attending antenatal care
who receive a second dose of IPT under direct observation ................... 13
4. Indicators to be measured in household surveys ........................ 17
Percentage of pregnant women who report having slept under
an ITN the previous night................................................................. 17
Percentage of low birth-weight singleton live births, by parity ............... 19
Percentage of screened pregnant women with severe anaemia
in third trimester by gravidity ............................................................ 21

References ..................................................................................... 23

Summary tables ............................................................................. 24

Annex 1. Monthly data collection form for ANC clinics
providing IPT ................................................................................ 29

Annex 2. Forms for data collection of information
at ANC clinics ................................................................................ 30

Annex 3. Boxes to be added to existing ANC forms ................... 32
Annex 4. Example of form for collecting information
from a maternity register ............................................................. 33
Annex 5. Supervisory visit form................................................... 34

iii
Contents
Malaria in pregnancy
Abbreviations used

HIV human immunodeciency virus
ITN insecticide-treated net
IPT intermittent preventive treatment
IPT1 rst dose of intermittent preventive treatment
IPT2 second dose of intermittent preventive treatment
PREMA-EU Pregnancy, Malaria, Anaemia-European
Union-funded project
RBM Roll Back Malaria
WHO World Health Organization
iv
1
Introduction
Malaria infection during pregnancy is an enormous public health
problem, with substantial risks for the mother, her fetus and the neonate.
In areas of low transmission of Plasmodium falciparum, where levels of
acquired immunity are low, women are susceptible to episodes of severe
malaria, which can result in stillbirths or spontaneous abortion or in the
death of the mother (Luxemburger et al., 1997). In areas of high trans-
mission of P. falciparum, where levels of acquired immunity tend to be
high, women are susceptible to asymptomatic infection, which can result
in maternal anaemia and placental parasitaemia, both of which can
subsequently lead to low birth weight (Steketee, Wirima & Campbell,
1996). Although there are fewer data about the role of P. vivax, there is
evidence that it can also cause anaemia and low birth weight (Nosten et
al., 1999). Low birth weight is an important contributor to infant
mortality (McCormick, 1985; McDermott et al., 1996). It has been
estimated that malaria during pregnancy is responsible for 512% of all
low birth weight and 35% of preventable low birth weight (Steketee,
Wirima & Campbell, 1996) and contributes to 75 000 to 200 000 infant
deaths each year (Steketee et al., 2001).The World Health Organization
(WHO) currently recommends a package of interventions for control-
ling malaria during pregnancy in areas with stable (high) transmission
of P. falciparum (WHO, 2004), which includes the use of insecticide-
treated nets (ITNs), intermittent preventive treatment (IPT) and
effective case management of malaria and anaemia (Box 1).
Effective implementation of the recommended strategy for malaria
in pregnancy requires close collaboration between malaria control and
reproductive health programmes at all levels, including policy develop-
ment, planning, logistics, procurement, training and service delivery.
Expanding programme coverage will require careful monitoring of
implementation and evaluation of impact. Monitoring and evaluation of
the interventions for malaria prevention and control during pregnancy
require close collaboration between the two programmes.
To assess progress in and effectiveness of the delivery of interven-
tions for the control of malaria during pregnancy, core indicators of
process, outcome and impact have been identied (Box 2). The goal is
to ensure that these indicators are collected, either routinely at health
facilities and incorporated into national health information systems or
through regular surveys and other Roll Back Malaria monitoring and
evaluation mechanisms. Examples of the questionnaires used to elicit
Introduction
2 Malaria in pregnancy
BOX 1. Recommended interventions for malaria prevention
and control during pregnancy
Policies for malaria prevention and control during pregnancy in areas of stable
transmission should emphasize a package of intermittent preventive treatment
and use of insecticide-treated nets and ensure effective case management of
illness and anaemia. Insecticide-treated nets and prompt effective case manage-
ment are recommended for all pregnant women living in malarious areas.
Intermittent preventive treatment
All pregnant women in areas of stable (high) malaria transmission should receive
at least two doses of intermittent preventive treatment after quickening, the rst
noted movement of the fetus (WHO, 2004). WHO recommends a schedule of
four antenatal clinic visits, with three visits after quickening. Intermittent preven-
tive treatment at each scheduled visit after quickening will ensure that a high
proportion of women receive at least two doses. Doses should not be given more
frequently than monthly.
Currently, the recommended drug for intermittent preventive treatment is sulf-
adoxinepyrimethamine, because it is safe for use during pregnancy, effective in
women of reproductive age and can be delivered as a single dose under observa-
tion by a health worker.*
Insecticide-treated nets
Insecticide-treated nets should be provided as early in pregnancy as possible to
all pregnant women living in malarious areas, including epidemic and disaster
situations, according to the perceived need in the locality. Their use should be
encouraged for women throughout pregnancy and postpartum. Nets can be
provided in the antenatal clinic or through other sources in the private and public
sectors.
Effective case management of malaria illness and anaemia
Effective case management of malaria illness for all pregnant women in malarious
areas must be ensured. Iron supplementation for the prevention and treatment of
anaemia should be given to pregnant women as part of routine antenatal care.
Pregnant women should also be screened for anaemia, and those with anaemia
should be managed according to national reproductive health guidelines.
___________________
*Current scientic evidence suggests:
At least two doses are required to achieve optimal benet in most women.
One study of intermittent preventive treatment in HIV-infected pregnant women showed that
monthly dosing (most women receiving 34 doses) was necessary to achieve optimal benet.
In settings with an HIV prevalence among pregnant women greater than 10%, it is more cost-
effective to treat all women with a 3-dose regimen than to screen for HIV and provide the regimen
only to HIV-infected women.
There is no evidence that a third dose carries any additional risk, that more than 3 doses during
pregnancy offers additional benet or that receiving 3 or more doses of sulfadoxinepyrimethamine
increases the risk for adverse drug reactions. Research to assess the safety, efcacy and programme
feasibility of other antimalarials in intermittent preventive treatment is under way.
3
information are provided in Annexes 15, and the household survey
questionnaires are available on the internet (http://rbm.who.int/
merg).
The indicators were chosen by an expert technical meeting organized
by WHO (Headquarters and the Regional Ofce for Africa). Participants
included academic institutions, development agencies, the Centers for
Disease Control and Prevention in the United States, the Maternal and
Neonatal Health Program of the Johns Hopkins Program for International
Education in Gynecology and Obstetrics in the United States, the Malaria
Consortium and the Pregnancy, Malaria, Anaemia-European Union-
funded project. The indicators were selected on the basis of the following
guiding principles:
Monitoring of malaria during pregnancy should be part of National
Malaria Control and Making Pregnancy Safer reproductive health
programmes.
Data collection, interpretation and corrective actions within routine
health management information systems should primarily be
conducted by reproductive health making pregnancy safer
programmes, with support from malaria control programmes.
Data collection at survey sentinel surveillance sites should primarily
be conducted by malaria control programmes.
Data should be easily collected.
Data should be quickly summarized and analysed and feedback
given to the persons at the health units that collected the data.
Data should be locally useful.
The creation of new or parallel systems of data collection should be
avoided.
The indicators were subsequently pilot tested in three sub-Saharan
African countries (Kenya, Nigeria and Uganda) to assess the feasibility of
collecting data for these indicators through routine health management
information systems. The protocol for this pilot study was prepared by
WHO (Headquarters and the Regional Ofce for Africa) and various
Roll Back Malaria (RBM) partners who are members of the Malaria in
Pregnancy Working Group of the RBM Partnership and discussed with
the three countries.
The current guidelines are based on experience gained from initial
implementation and pilot testing in the three African countries.
The objective is to provide guidance to malaria control and reproductive
health care workers, particularly those in antenatal care clinics, for moni-
toring and evaluation of key indicators of malaria in pregnancy.
Introduction
4 Malaria in pregnancy
The target audience includes national malaria control programme
managers, reproductive health programme managers, health workers at
the health facility level and policy-makers.
The indicators are grouped into two categories, according to whether
they could be measured through existing health management informa-
tion systems or through routine or regular household surveys, such as a
malaria indicator survey, multiple indicator cluster surveys, demographic
and health surveys and other RBM monitoring and evaluation tools and
mechanisms (e.g. demographic surveillance sites). For each indicator,
the rationale for data collection and a precise denition are given,
followed by a description of the source and method of measurement
and the strengths and limitations of the indicator. Summary tables are
provided on pages 2428 of this document. A summary of the types of
survey that can be used to derive information on indicators is shown in
Box 3.
BOX 2. Recommended indicators for monitoring and evaluation
of programmes to control malaria during pregnancy
Output indicators
percentage of antenatal clinic staff trained: pre-service, in-service or during
supervisory visits) in the control of malaria during pregnancy during the past
12 months (including intermittent preventive treatment, counseling on use of
insecticide-treated nets and case management for pregnant women;
percentage of health facilities reporting stock-out of the recommended drug for
intermittent preventive treatment (currently sulfadoxine-pyrimethamine) in the
past month or in the determined period (according to national guidelines).
Outcome indicators
percentage of pregnant women receiving intermittent preventive treatment
under direct observation (rst dose, second dose, third dose, according to
national guidelines);
percentage of pregnant women who report having slept under an insecticide-
treated net the previous night.
Impact indicators*
percentage of low-birth-weight singleton live births (< 2500 g), by parity;
percentage of screened pregnant women with severe anaemia (haemoglobin
< 7g/dl) in third trimester, by gravidity.
_________________________________
* Inuenced by other factors, such as nutrition, hookworm infection and pre-term birth
5
Framework for monitoring
and evaluation
Monitoring and evaluation are needed to measure progress in and
effectiveness of health programmes at all levels. Monitoring can help to
verify that activities are being implemented as planned, ensure account-
ability and detect problems and constraints, to provide local feedback to
the relevant authorities and to support them in better planning.
Evaluation of outcomes and impact is needed to document periodically
whether dened strategies and implemented activities are leading to
expected results. Monitoring is continuous, while evaluation should be
conducted intermittently.
A number of frameworks are used in selecting indicators for moni-
toring and evaluation. Indicators are used to measure what goes into a
programme or project and what comes out of it. A widely accepted
framework that has commonly been used is the inputprocessoutput
outcomeimpact. For a programme or project to achieve its goals,
inputs such as money and staff time must result in outputs, such as new
or improved services, trained staff or persons reached with services.
These outputs are the result of specic processes, such as training of
staff, which should be included as key activities for achieving the outputs.
If these outputs are well designed and reach the populations for which
they were intended, the programme or project is likely to have positive
short-term effects or outcomes, for example increased use of ITNs or
adherence to IPT. These short-term outcomes should lead to changes in
the longer-term impact of the programme, measured as fewer new cases
of malaria and related burden of disease among those infected and
affected, such as pregnant women and vulnerable children. In the case
of malaria during pregnancy, a desired impact among infected women
includes improved birth outcomes. The use of standard indicators
provides national programmes with valuable measures of the same
indicator in different populations, permitting analysis of trends. This
helps to direct resources to regions or sub-populations with greater need
and to identify areas for intensication or reduction of effort at the
national level, ultimately improving the overall effectiveness of the
national response. Over time, the use of standard indicators also ensures
comparability of information across countries. When data from different
sources are combined for analysis, such triangulation of data allows
national, regional or local evaluation of programme efforts (WHO,
2006).
Framework for monitoring and evaluation
6 Malaria in pregnancy
BOX 3. Surveys that provide information on malaria indicators
Three main types of surveys are relevant to monitoring and evaluation of inter-
ventions to prevent and control malaria in pregnancy in malaria control
programmes.
Demographic and health surveys
1
and multiple indicator cluster surveys
2

Nationally representative surveys of 400012 000 women aged 1549 years,
living in households that are sampled in a multiple-stage cluster design, are
conducted in many developing countries at 5-year intervals. As the question-
naires are standardized and structured, the results are reasonably comparable
between countries and over time. The indicators measured include mortality of
children under 5 from all causes, possession and use of insecticide-treated nets
by children under 5 and pregnant women, use of antimalarial treatment for
children under 5 with fever, and use of intermittent preventive treatment by
pregnant women. Recent demographic and health surveys also measured the
prevalence of anaemia by measuring haemoglobin in children under 5 and
women. The results are freely available on the internet.
Malaria indicator surveys
To supplement the standardized data collected from the demographic and health
and multiple indicator cluster surveys, in 2004 the Roll Back Malaria programme
and MACRO International developed a package that can be used at national or
sub-national level. The sample size proposed for these surveys is smaller than
that required for demographic and health and multiple indicator cluster surveys,
because the malaria indicator survey is used mainly to monitor intervention
coverage and not child mortality. Malaria indicator surveys are therefore less
expensive than the other surveys and could be conducted at sub-national level.
A malaria indicator survey could be used to design surveys in countries where no
other surveys are being conducted or to ll gaps in the 5-year intervals between
demographic and health or multiple indicator cluster surveys, for more rapid
assessment of progress.
For operational reasons, both demographic and health and multiple indicator
cluster surveys are conducted during the dry season, therefore outside the peak
malaria transmission season. In contrast, malaria indicator surveys can be
conducted at the time of peak transmission and combined with measurements of
haemoglobin and parasite prevalence, in areas where these are considered
relevant indicators of malaria burden or impact. The entire malaria indicator
survey package (including questionnaire, training manual, guidance on sampling
and sampling sizes with costing and analysis plans) is available for use by
countries in hard copy, on CD ROM and on the internet (http://rbm.who.int/
merg, section Survey and Indicator Guidance Task Force).
A scaled-down version of the malaria indicator survey is also available, called
the lean malaria module, with standard questions on malaria intervention
coverage that could be added to other planned household surveys.
__________________________
1 Demographic and health surveys are organized by MACRO International, Calverton, Maryland, USA, and are funded
primarily by the United States Agency for International Development (USAID) (http://www.measuredhs.com).
2 Multiple indicator cluster surveys are organized and supported by UNICEF (http://www.childinfo.org).
7
Although countries rely on surveys, such as demographic and health
surveys or multiple indicator cluster surveys (see Box 3), these produce
data that are valuable for broader monitoring and evaluation but might
not be easy to integrate into the usual sources of health information,
such as national health information and surveillance systems. Building
or strengthening national health management information systems is a
prerequisite for proper monitoring of malaria in pregnancy control
programmes and the necessary responses. An effective health manage-
ment information system provides a solid basis for evaluating large-scale
programmes, ultimately leading to improved planning and decision-
making. On the basis of these ndings, urgent decisions, such as how to
allocate new resources to achieve the best overall results, will become
easier to make (WHO, 2006).
For effective monitoring and evaluation of services being provided
for malaria during pregnancy, disease control programmes should put
in place systems for supervision at all levels of health care. This system
must ensure that supervisors focus on the needs of the staff they oversee,
to help them to conduct monitoring activities effectively, thus producing
high-quality data. The approach should stress mentoring, joint problem-
solving and dialogue. Supervisors must recognize lapses in skills and
identify opportunities for training. It is the responsibility of the super-
visor to manage workloads and to lobby for human and nancial
resources where necessary. Supervisors should themselves be good
communicators, be knowledgeable about monitoring and evaluation
and be conversant with the monitoring tools. Supervisors must be ready
to review and discuss the tools with those they are supervising to ensure
they are used properly. Supervisors must also analyse the data collected
with the persons who collected them and encourage them to use the
data for decision-making at their own level of operation. A supervisory
schedule of 36 months is recommended.
Framework for monitoring and evaluation
8 Malaria in pregnancy
Indicators to be measured
at health facilities
Percentage of antenatal clinic staff trained in the control
of malaria during pregnancy in the past 12 months
Rationale
Successful control of malaria during pregnancy requires delivery of
the recommended interventions by skilled, well-informed health workers
in the facility.
Denition
This is an indicator of the proportion of health workers who, among
all health workers providing antenatal services, have received training in
the prevention and control of malaria during pregnancy at the time of
data collection, within the last calendar year.
Numerator: number of antenatal clinic staff trained in the control of
malaria during pregnancy in the past 12 months
Denominator: total number of antenatal clinic staff during the same
period
Measurement and data collection
Data for this indicator should be collected during supervisory visits
and training activities and from annual reports. If a routine reproductive
health supervisory form exists, it should be modied to include:
the number of antenatal clinic staff and other health workers, and
the number of staff trained in the control of malaria during
pregnancy in the past 12 months.
If no supervisory form exists, it should be designed accordingly.
Health workers who provide antenatal care are dened locally. The
frequency of supervisory visits is often determined locally; however, it is
recommended that at least one supervisory visit per facility per year is
ensured.
9
Strengths and limitations
Strengths
Data for this indicator can readily be collected at supervisory visits.
In malarious areas where less than 100% of antenatal clinic staff are
trained in malaria control, feedback can be given rapidly to the ante-
natal clinic supervisor or clinic manager to take corrective action.
Limitations
The denominator might be difcult to determine, as some countries
have limited information on the pool of human resources available
in various facilities, and transfers of personnel between facilities are
frequent. In this case, the numerator should be considered an
adequate indicator on its own.
The indicator does not provide any information about the quality of
the training or the quality of services provided.
Comments
Training of clinic staff in the prevention and control of malaria in
pregnant women should, at a minimum, include guidelines for IPT,
effective case management, including referral when necessary, and
counselling about the use of ITNs. The training should also include data
collection, analysis, interpretation and use for local decision-making. To
avoid duplication of efforts, the training should be integrated as much as
possible into predened or existing curricula (e.g. pre-service and in-
service programmes) or other Making Pregnancy Safer training orienta-
tion courses. It should also be a part of malaria control training
programmes for implementing new antimalarial drug policies.
Quality assurance methods and tools for improving the quality of
malaria in pregnancy service delivery (Regional Centre for Quality of
Health Care Institute of Public Health, 2006) should be used to
strengthen supervision of health workers. Frequent supportive supervi-
sion might be needed to reinforce knowledge and skills acquired during
training. The frequency of supervisory visits is often determined locally;
however, it is recommended that at least one supervisory visit per facility
per year be ensured. A system should be developed for training new staff
in case of high staff turnover.
Indicators to be measured at health facilities
10 Malaria in pregnancy
Percentage of health facilities reporting stock-out of the
recommended drug for intermittent preventive treatment
(currently sulfadoxine-pyrimethamine) in the past month
Rationale
Ensuring adequate supplies of the recommended antimalarial drug
for IPT is key to the success of prevention and control of malaria during
pregnancy in areas of stable (high) malaria transmission. This indicator
assesses the frequency and adequacy of supply of the recommended
drug for IPT in health facilities over a dened period.
Denition
This indicator provides information about the proportion of health
facilities that were out-of-stock of the recommended drug for IPT during
the past month.
Numerator: Number of health facilities reporting stock-out of the recom-
mended drug for IPT (currently sulfadoxine-pyrimethamine) in antenatal
clinics within the past calendar month
Denominator: Total number of health facilities offering antenatal
services
Measurement and data collection
Data for this indicator should be obtained during periodic (monthly)
supervisory visits. Stock-outs of sulfadoxine-pyrimethamine should be
measured at the level of antenatal clinics, not pharmacies, because stocks
in pharmacies do not necessarily reect those in antenatal clinics.
To avoid multiple, overlapping data collection forms, relevant questions
should be included in the routine reproductive health supervisory form.
The frequency of data collection should be monthly but could be
determined locally to ensure that data collection is in tandem with other
supervisory and data collection activities and schedules.
Strengths and limitations
Strengths
Data for this indicator can readily be collected during supervisory
visits.
The collected data can be used locally for prompt corrective action.
11
Limitations
Although the recommended frequency for collection of data for this
indicator is monthly, supervision might not be regular enough for
effective monitoring of the availability of drug supplies and stock-
outs, which can then be reported and rectied. Regular, constant
supervision and reporting of data might be needed to avoid disrup-
tion of the delivery of IPT in antenatal clinics. Such data could also
be included in health management information system reports if
sulfadoxine-pyrimethamine is listed as a tracer drug that is reported
to districts monthly.

Percentage of pregnant women attending antenatal care who
receive a rst dose of intermittent preventive treatment (IPT1)
under direct observation
Rationale
In areas of stable (high) malaria transmission, IPT with two to three
doses of the recommended antimalarial medicine (currently sulfadoxine-
pyrimethamine) during pregnancy has been shown to reduce the risk
for severe maternal anaemia, placental parasitaemia and low birth weight
signicantly. Therefore, WHO recommends that all pregnant women in
areas of stable malaria transmission receive at least two doses of IPT,
during regularly scheduled antenatal visits under direct observation of a
health worker.
Denition
This indicator assesses the proportion of women attending antenatal
clinics who receive IPT1 as directly observed treatment by a health
worker to maximize compliance.
Numerator: Number of pregnant women who receive IPT1 under obser-
vation
Denominator: Number of rst antenatal clinic visits
Measurement and data collection
Data for this indicator should be collected at routine antenatal visits
on an antenatal clinic register. To facilitate data collection and avoid
Indicators to be measured at health facilities
12 Malaria in pregnancy
duplication of work, the existing register should be modied to include
columns to record the doses of IPT (rst, second or third) dispensed.
Antenatal clinic cards should also be adapted to include a record of the
doses received.
To facilitate data abstraction for reporting, it is advisable that records
for each month be started on a new page. The frequency of data collec-
tion should be daily, with monthly summaries and monthly reporting
within health management information systems, and should link to the
data collection schedule for health management information systems .
The indicator can also be measured at the population level through
household surveys, in which case the denominator would be the total
number of pregnant women in the population surveyed.
Strengths and limitations
Strengths
Data on IPT1 can readily be collected and analysed.
The results might be comparable across countries.
This indicator can be useful locally, as it can be linked to impact
indicators such as low birth weight and severe anaemia to determine
corrective action. A visual indication or presentation of the effective-
ness of IPT in reducing the number of severe malaria and anaemia
cases observed in an antenatal clinic can boost the morale of health
workers.
Limitations
Data on IPT coverage at national level can be misleading in countries
with mixed transmission patterns, as malaria transmission is often
localized and IPT might not be implemented in all areas of the
country. Therefore, the indicator should be calculated only for areas
in which the IPT strategy is implemented, and rst antenatal visits in
these areas should be used as the denominator.
Antenatal clinic data might be incomplete and not reect the true
situation in settings where a substantial number of women have
antenatal care at private clinics. Private clinics should be encouraged
to provide IPT to pregnant women according to national guidelines
and maintain appropriate records.
Most women attend antenatal clinics for the rst time during the
second trimester and are therefore eligible for IPT1 at that time. A
few women, however, make their rst antenatal visit during the rst
13
trimester, at which time they are not eligible for a rst dose of
treatment. The total number of rst visits used as the denominator
in this calculation is therefore an overestimate of the total number
of women eligible for a rst dose of treatment.
Comments
The column for IPT should not be marked if dosing is not observed
directly. If no rst dose is dispensed, the reasons should be marked in a
column of the register designated for comments (e.g. stock-out, allergy,
refusal, treatment for malaria illness, see Annex 1).
Treatment received for acute malaria illness episodes during
pregnancy should not be recorded as IPT, which is administered for
prevention. The antenatal clinic register should include a column for
recording treatment of malaria illness episodes during pregnancy with
the nationally recommended drug for pregnant women.
The denominator, i.e. rst antenatal clinic visits (new attendances),
is an approximation of the total number of pregnant women attending
antenatal clinics during a specied period. To avoid difculties in
counting new attendance versus re-attendance, health workers should
determine appropriate ways of identifying new attendees in the antenatal
clinic register, such as adding a column labelled visit for recording the
visit number (e.g. visit 1, 2, 3, 4).
Receipt of IPT as recorded on antenatal clinic cards can also be
reected in maternity registers. A column could be included in the
delivery register that indicates the number of doses of IPT received. Such
data are easily linked to impact indicators and can be used to assess the
effectiveness and impact of national programmes.

Percentage of pregnant women attending antenatal care who
receive a second dose of intermittent preventive treatment (IPT2)
under direct observation
Rationale
In areas of stable (high) malaria transmission, IPT with two to three
doses of the recommended antimalarial medicine (currently sulfadoxine-
pyrimethamine) during pregnancy has been shown to reduce the risk
for severe maternal anaemia, placental parasitaemia and low birth weight
Indicators to be measured at health facilities
signicantly. Therefore, WHO recommends that all pregnant women in
areas of stable malaria transmission receive at least two doses of IPT,
during regularly scheduled antenatal clinic visits under direct observa-
tion of a health worker.
Denition
This indicator assesses the proportion of women attending antenatal
clinics who receive IPT2 under direct observation by a health worker.
Numerator: Number of pregnant women who receive IPT2 under obser-
vation
Denominator: Number of rst antenatal clinic visits
Measurement and data collection
Data for this indicator should be collected at routine antenatal visits
in the antenatal clinic register. To facilitate data collection and avoid
duplication of work, the existing antenatal clinic register should be
modied to include columns to record the doses of IPT dispensed (rst,
second, third). Antenatal clinic cards should also be adapted to include
a record of IPT doses received.
IPT2 should be administered under direct observation by a health
worker, to maximize compliance. To facilitate data abstraction for
reporting, it is advisable that records for each month be started on a new
page. The frequency of data collection should be daily, with monthly
summaries and monthly reporting within the health management infor-
mation systems, and should be linked to the data collection schedule for
health management information systems.
The indicator can also be measured at the population level through
household surveys, in which case the denominator would be the total
number of pregnant women in the population surveyed.
Strengths and limitations
Strengths
Data on IPT2 can readily be collected and analysed.
The results are comparable across countries.
This indicator can be useful locally, as it can be linked to impact
indicators such as low birth weight and severe anaemia to determine
corrective action. A visual indication or presentation of the effective-
15
ness of IPT in reducing the number of severe malaria and anaemia
cases observed in an antenatal clinic can boost the morale of health
workers.
Limitations
The denominator, i.e. the number of rst antenatal clinic visits, is an
approximation of the total number of pregnant women attending
antenatal clinics, and therefore the number of women who should
receive IPT. Month-to-month variations in patient ow could,
however, lead to short-term inaccuracies. For example, if the number
of women returning for IPT2 exceeds the number of rst antenatal
clinic visits in a particular month, the percentage of women receiving
the second dose could theoretically exceed 100%. Coverage estimates
obtained over a long period tend, however, to be reliable and robust,
and the short-term inaccuracies have little signicant impact on
periodic estimates. These data should therefore be collected monthly
but analysed on an annual or half-yearly basis.
The indicator might be misleading at national level in countries with
mixed transmission patterns, as malaria transmission is usually
localized. Therefore, the indicator should be calculated only for
areas in which the IPT strategy is implemented, and rst antenatal
clinic visits in these areas should be used as the denominator.
Antenatal clinic data can be incomplete and not reect the true
situation in settings where a substantial number of women access
antenatal care at private clinics or do not access antenatal care at all.
The indicator reects the situation of women attending antenatal
clinics and not use of IPT in the general population, except where
antenatal care use is very high, as in most African countries.
Comments
The column for IPT2 should not be marked if dosing is not observed
directly. If no second dose is dispensed, the reasons should be marked in
a column of the register designated for comments (e.g. stock-out, allergy,
refusal, treatment for malaria illness, see Annex 3).
Treatment received for acute malaria illness episodes occurring
during pregnancy should not be recorded as IPT, which is administered
for prevention. The antenatal clinic register should include a column
for recording treatment of malaria illness episodes during pregnancy
with the nationally recommended drug for pregnant women, according
to national guidelines.
Indicators to be measured at health facilities
16 Malaria in pregnancy
The denominator, i.e. rst antenatal clinic visits (new attendances),
is an approximation of the total number of pregnant women attending
antenatal clinics. To avoid difculties in counting new attendance versus
re-attendance, health workers should determine appropriate ways of
identifying new attendees in the antenatal clinic register, such as adding
a column labelled visit for recording the visit number (e.g. visit 1, 2, 3, 4).
Receipt of IPT2 as recorded on antenatal clinic cards can also be
reected in maternity registers. A column could be included in the
delivery register that indicates the number of doses of IPT received. Such
data are easily linked to impact indicators and can be used to assess the
effectiveness and impact of national programmes.
17
Indicators to be measured
in household surveys
Percentage of pregnant women who report having slept
under an insecticide-treated net (ITN) the previous night
Rationale
In areas of stable endemic malaria, where most malaria infections in
adults are asymptomatic, use of ITNs by pregnant women has been
shown to reduce malaria-related maternal morbidity signicantly and
improve birth outcomes, including the incidence of low birth weight.
Denition
This indicator measures the level of use of ITNs by pregnant women
at risk for malaria at the population level. An insecticide-treated mosquito
net is: (i) a pre-treated net obtained in the past 12 months, (ii) a net that
has been treated with insecticide in the past 12 months, or (iii) a
permanent or long-lasting treated net that does not require re-treatment.
Numerator: Number of pregnant women at risk for malaria who reported
having slept under an insecticide-treated net the night preceding the
survey
Denominator: Total number of pregnant women at risk for malaria who
reside within surveyed households
Measurement and data collection
Information on use of ITNs by pregnant women is best collected
through household surveys, because data from health facilities are not
representative of the population at large, including women who do not
attend antenatal clinics. In highly endemic countries such as in most of
sub-Saharan Africa, nationally representative household surveys are
preferred. Data should be collected every 23 years. Nevertheless,
ownership and use of ITNs can also be measured at antenatal clinics,
especially if nets are provided by the clinic, and can be included on the
antenatal clinic card and register. The benet of including this informa-
tion in antenatal clinic cards and registers is that the data can be included
in routine monitoring systems to guide programme planning.
Indicators to be measured in household surveys
18 Malaria in pregnancy
In countries where only part of the population is at endemic risk,
ITNs are relevant only for households in high risk areas. Surveys should
be conducted to take a representative sample of the area at risk, and the
report should clearly describe the sampling design and denition of
population-at-risk used. Alternatively, in such countries, areas without
endemic malaria must be identied so that they can be excluded from
this indicator during analysis of data collected through nationally repre-
sentative household surveys.
Household surveys include malaria indicator surveys, multiple
indicator cluster surveys, demographic and health surveys and other
nationally representative surveys. Guidelines for conducting household
surveys can be found in UNICEF (2004)
Strengths and limitations
Strengths
The limited number of questions required to ascertain this indicator
can readily be added to any nationally representative survey of
households.
The presence of a net can be veried at the time of interview.
Various methods of assessment and questions allow the interviewer
to assess whether the net has recently been treated with insecticide.
The results are comparable across countries, if appropriate and
consistent sampling procedures are followed and confounding factors
are accounted for.
Limitations
Including all pregnant women in a household survey is difcult
because many women either do not know that they are pregnant or
do not want to divulge the information.
A large sample size is required to obtain precise estimates.
There may be some bias if reluctance to discuss pregnancy is also
associated with rst birth, adolescence and other demographic
factors.
Reliable estimates of net re-treatment status might not be obtained
because of poor date recall.
The results might be biased by the seasonality of survey data collec-
tion, which is usually done during the dry season when net use is
likely to be at its lowest.
19
In countries in which only part of the population is at risk for malaria,
national coverage might give an underestimate of effective coverage
of populations at risk.

Percentage of low birth-weight singleton live births, by parity
Rationale
The burden of malaria-associated maternal anaemia and its effect on
the fetus, resulting in low birth weight, has been increasingly recognized
during the past decade. Measuring the incidence of low birth weight is
necessary to show the impact of malaria control interventions in pregnancy.
As the risk for low birth weight has been shown to be higher among
primiparous than multiparous women, measurement of low birth weight
must be differentiated by parity.
Denition
Low birth weight is dened as weight less than 2500 g obtained
within 24 h of birth, regardless of gestational age. A low birth weight
reects both small-for-gestational age and prematurity. As it is difcult to
assess gestational age in most settings, however, the two are often not
differentiated.
The numerator and denominator are dened according to parity.
For primiparous women, the indicator is dened as follows:
Numerator: Number of low-birth-weight singleton live births to women
with rst birth
Denominator: Number of singleton live births to women with rst birth
The indicator for multiparous women is dened as:
Numerator: Number of low-birth-weight singleton live births to women
with two or more births
Denominator: Number of singleton live births to women with two or
more births
Measurement and data collection
This indicator is best measured from nationally representative
household surveys, such as malaria indicator surveys, multiple indicator
Indicators to be measured in household surveys
cluster surveys, demographic and health surveys and other nationally
representative surveys. This is because facility-based data are not repre-
sentative, as they are limited to the few women who deliver in facilities.
Data from health facilities or delivery records are nevertheless the main
source of data on birth weights obtained during household surveys
(Blanc & Wardlaw, 2005). It is therefore critical to ensure that measure-
ment of weight at birth in health facilities is strengthened and routinely
recorded on maternity cards and registers.
These data are included in health management information systems
in most countries. It is, however, important to ensure the quality of the
data collected. Training of health workers in accurate data collection,
analysis, interpretation and use of data at health facility and local levels is
critical for programme decision-making. Data should be interpreted
cautiously, as low birth weight has multiple causes.
The frequency of routine data collection in health facilities with
regular national surveys is to be determined locally. As imprecise estimates
are obtained from household surveys with inadequate sample sizes,
sentinel sites can be used for assessing this indicator, with standardized
methods and adequate sample sizes for comparison among sites and
countries.
Strengths and limitations
Strengths
Data collected in household surveys are nationally representative.
The results are comparable across countries, if appropriate and
consistent sampling procedures are followed and confounding
factors are accounted for.
This is a useful indicator at health facility level, allowing health
workers and programme managers to observe the effects of maternal
and newborn health interventions and to take corrective action
where necessary.
It is a useful global indicator for population health and development
Limitations
A large sample size is required to obtain precise estimates.
The women surveyed may not know or recall the birth weights of all
their children, or they may report them incorrectly. Promoting
childbirth in health facilities where infants are weighed at birth is
likely to improve the quality of data on birth weight.
21
Low birth weight has multiple causes, including malaria; therefore,
trends in its prevalence should be interpreted with caution.

Percentage of screened pregnant women with severe anaemia
(haemoglobin less than 7 g/dl) in third trimester, by gravidity
Rationale
The burden of malaria-associated anaemia among pregnant women
in malarious areas has been increasingly recognized during the past
decade. Measuring the prevalence of severe maternal anaemia in
countries is important to show the impact of malaria in pregnancy and
other maternal health interventions. As the risk for anaemia has been
shown to be higher among primigravidae than multigravidae, measure-
ment of anaemia must be differentiated by gravidity.
Denition
Severe anaemia is dened as a haemoglobin concentration less than
7 g/dl.
The numerator and denominator are dened according to gravidity
Among primigravidae, the indicator is dened as follows:
Numerator: Number of women with severe anaemia (haemoglobin less
than 7g/dl) during the third trimester of rst pregnancy
Denominator: Number of pregnant women screened for anaemia during
the third trimester of rst pregnancy
For multigravidae, the indicator is dened as:
Numerator: Number of pregnant women with two or more pregnancies
with severe anaemia (haemoglobin less than 7 g/dl) during the third
trimester
Denominator: Number of pregnant women with two or more pregnan-
cies screened for anaemia during the third trimester
Measurement and data collection
Data on anaemia as an indicator of malaria control during pregnancy
should be collected from nationally representative household surveys,
Indicators to be measured in household surveys
22 Malaria in pregnancy
such as malaria indicator surveys, multiple indicator cluster surveys,
demographic and health surveys and other nationally representative
surveys.
Although anaemia is assessed for prevention and management
during antenatal clinic visits starting from the rst trimester, the data
collected at health facilities might not be representative because:
Haemoglobin screening is not available at all health facilities.
Screening, if done, is usually clinical and performed during the rst
antenatal clinic visit.
Screening is done with various methods and is therefore not stand-
ardized. Sentinel surveillance sites can be used to obtain consistent
data obtained by standard methods for comparison among sites and
countries.
Screening is often offered for a fee and is therefore limited to
pregnant women who can afford to pay for the test or who are ill.
The frequency of data collection is to be decided locally within
planned national surveys. As imprecise estimates are obtained from
household surveys with inadequate sample sizes, sentinel sites can be
used for assessing this indicator.
Strengths and limitations
Strengths
Data collected in household surveys are nationally representative.
The results are comparable across countries, if appropriate and
consistent sampling procedures and methods are used and
confounding factors are accounted for.
Limitations
A large sample size is required to obtain precise estimates.
Anaemia has multiple causes, including malaria; therefore, trends in
anaemia prevalence should be interpreted with caution. Seasonal
inuence is also an important factor in the measurement of anaemia.
Malaria is less likely to contribute signicantly to anaemia if haemo-
globin is measured in the dry season, which is usually the case if data
are collected as part of demographic and health surveys, than in the
wet season, when malaria is more prevalent.
23
References
1. Blanc AK, Wardlaw T (2005). Monitoring low birth weight: an evalu-
ation of international estimates and an updated estimation
procedure. Bulletin of the World Health Organization, 83:178185.
2. Luxemburger C et al. (1997). The epidemiology of severe malaria in
an area of low transmission in Thailand. Transactions of the Royal
Society of Tropical Medicine and Hygiene, 91:256262.
3. McCormick MC (1985). The contribution of low birth weight to
infant mortality and childhood mortality. New England Journal of
Medicine, 312:8290.
4. McDermott JM et al. (1996). The effect of placental malaria infection
on perinatal mortality in rural Malawi. American Journal of Tropical
Medicine and Hygiene, 55:6165.
5. Nosten F et al. (1999). Effects of Plasmodium vivax malaria in
pregnancy. Lancet, 354:546549.
6. Regional Centre for Quality of Health Care Institute of Public Health.
Improving the quality of malaria control services. Makerere University,
Kampala, 2006.
7. Steketee RW, Wirima JJ, Campbell CC (1996). Developing effective
strategies for malaria prevention programs for pregnant African
women. American Journal of Tropical Medicine and Hygiene, 55:95100.
8. Steketee RW et al. (2001). The burden of malaria in pregnancy in
malaria-endemic countries. American Journal of Tropical Medicine and
Hygiene, 6:2835.
9. Roll Back Malaria, MEASURE Evaluation, World Health Organization,
UNICEF (2004). Guidelines for Core Population Coverage Indicators
for Roll Back Malaria: To Be Obtained from Household Surveys.
MEASURE Evaluation: Calverton, Maryland.
10. WHO (2004). A strategic framework for malaria prevention and control
during pregnancy in the African Region. Brazzaville. Regional Ofce for
Africa (AFR/MAL/04/01).
11. WHO (2006). Monitoring and evaluation toolkit, HIV/AIDS, tuberculosis
and malaria. Geneva, World Health Organization, Second Edition,
January 2006. ISBN 92 9224 029 3.
12. Web links
http://rbm.who.int/merg
http://www.measuredhs.com
http://www.childinfo.org
http://www.rcqhc.org/index.php
http://www.rollbackmalaria.org/mpwg.html
http://www.who.int/making_pregnancy_safer/en/
References
24 Malaria in pregnancy
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l
i
n
i
c

u
s
e

i
s

h
i
g
h
,

a
s

i
n

m
o
s
t

A
f
r
i
c
a
n

c
o
u
n
t
r
i
e
s
.
1
.

T
r
a
i
n
i
n
g

o
f

c
l
i
n
i
c

s
t
a
f
f

i
n

p
r
e
v
e
n
t
i
o
n

a
n
d

t
r
e
a
t
m
e
n
t

o
f

m
a
l
a
r
i
a

i
n

p
r
e
g
n
a
n
t

w
o
m
e
n

s
h
o
u
l
d
,

a
t

a

m
i
n
i
m
u
m
,

i
n
c
l
u
d
e

g
u
i
d
e
l
i
n
e
s

f
o
r

I
P
T
,

e
f
f
e
c
t
i
v
e

c
a
s
e

m
a
n
a
g
e
m
e
n
t

i
n
c
l
u
d
i
n
g

r
e
f
e
r
r
a
l

w
h
e
n

n
e
c
e
s
s
a
r
y
,

a
n
d

c
o
u
n
s
e
l
i
n
g

a
b
o
u
t

t
h
e

u
s
e

o
f

I
T
N
s
.
2
.

T
i
m
e

c
a
n

b
e

d
e
t
e
r
m
i
n
e
d

l
o
c
a
l
l
y
,

e
.
g
.

3

m
o
n
t
h
s
3

.
T
h
e

d
e
n
o
m
i
n
a
t
o
r

f
o
r

b
o
t
h

I
P
T
1

a
n
d

I
P
T
2
,

i
.
e
.

n
u
m
b
e
r

o
f

r
s
t

a
n
t
e
n
a
t
a
l

c
l
i
n
i
c

v
i
s
i
t
s
,

i
s

a
n

a
p
p
r
o
x
i
m
a
t
i
o
n

o
f

t
h
e

t
o
t
a
l

n
u
m
b
e
r

o
f

p
r
e
g
n
a
n
t

w
o
m
e
n
,

t
h
e

t
a
r
g
e
t

p
o
p
u
l
a
t
i
o
n

w
h
o

s
h
o
u
l
d

r
e
c
e
i
v
e

t
h
e

t
r
e
a
t
m
e
n
t
.
Summary
26 Malaria in pregnancy
S
u
m
m
a
r
y
:

G
u
i
d
e
l
i
n
e
s

f
o
r

m
e
a
s
u
r
i
n
g

i
n
d
i
c
a
t
o
r
s

f
o
r

m
o
n
i
t
o
r
i
n
g

a
n
d

e
v
a
l
u
a
t
i
o
n

o
f

m
a
l
a
r
i
a

i
n

p
r
e
g
n
a
n
c
y

I
n
d
i
c
a
t
o
r
s

t
o

b
e

m
e
a
s
u
r
e
d

i
n

h
o
u
s
e
h
o
l
d

s
u
r
v
e
y
s
I
n
d
i
c
a
t
o
r
T
y
p
e
D
e

n
i
t
i
o
n
D
a
t
a

c
o
l
l
e
c
t
i
o
n
S
t
r
e
n
g
t
h
s

a
n
d

l
i
m
i
t
a
t
i
o
n
s
P
e
r
c
e
n
t
a
g
e

o
f

p
r
e
g
n
a
n
t

w
o
m
e
n

w
h
o

r
e
p
o
r
t

h
a
v
i
n
g

s
l
e
p
t

u
n
d
e
r

a
n

I
T
N

t
h
e

p
r
e
v
i
o
u
s

n
i
g
h
t
O
u
t
c
o
m
e
N
u
m
e
r
a
t
o
r
:

N
u
m
b
e
r

o
f

p
r
e
g
n
a
n
t

w
o
m
e
n

a
t

r
i
s
k

f
o
r

m
a
l
a
r
i
a

w
h
o

r
e
p
o
r
t
e
d

h
a
v
i
n
g

s
l
e
p
t

u
n
d
e
r

a
n

I
T
N

t
h
e

n
i
g
h
t

p
r
e
c
e
d
i
n
g

t
h
e

s
u
r
v
e
y

4
D
e
n
o
m
i
n
a
t
o
r
:

T
o
t
a
l

n
u
m
b
e
r

o
f

p
r
e
g
n
a
n
t

w
o
m
e
n

a
t

r
i
s
k

f
o
r

m
a
l
a
r
i
a

w
h
o

r
e
s
i
d
e

i
n

s
u
r
v
e
y
e
d

h
o
u
s
e
h
o
l
d
s
H
o
u
s
e
h
o
l
d

s
u
r
v
e
y
s

(
s
u
c
h

a
s

d
e
m
o
g
r
a
p
h
i
c

a
n
d

h
e
a
l
t
h

s
u
r
v
e
y
s
,

m
u
l
t
i
p
l
e

i
n
d
i
c
a
t
o
r

c
l
u
s
t
e
r

s
u
r
v
e
y
s
,

m
a
l
a
r
i
a

i
n
d
i
c
a
t
o
r

s
u
r
v
e
y

a
n
d

o
t
h
e
r

n
a
t
i
o
n
a
l
l
y

r
e
p
r
e
s
e
n
t
a
t
i
v
e

s
u
r
v
e
y
s
)

5
S
t
r
e
n
g
t
h
s

T
h
e

l
i
m
i
t
e
d

n
u
m
b
e
r

o
f

q
u
e
s
t
i
o
n
s

r
e
q
u
i
r
e
d

t
o

a
s
c
e
r
t
a
i
n

t
h
i
s

i
n
d
i
c
a
t
o
r

c
a
n

r
e
a
d
i
l
y

b
e

a
d
d
e
d

t
o

a
n
y

n
a
t
i
o
n
a
l
l
y

r
e
p
r
e
s
e
n
t
a
t
i
v
e

s
a
m
p
l
e

s
u
r
v
e
y

o
f

h
o
u
s
e
h
o
l
d
s
.

T
h
e

p
r
e
s
e
n
c
e

o
f

a

n
e
t

c
a
n

b
e

v
e
r
i

e
d

a
t

t
h
e

t
i
m
e

o
f

i
n
t
e
r
v
i
e
w
.

V
a
r
i
o
u
s

m
e
t
h
o
d
s

o
f

a
s
s
e
s
s
m
e
n
t

a
n
d

q
u
e
s
t
i
o
n
s

a
l
l
o
w

t
h
e

i
n
t
e
r
v
i
e
w
e
r

t
o

a
s
s
e
s
s

w
h
e
t
h
e
r

t
h
e

n
e
t

h
a
s

r
e
c
e
n
t
l
y

b
e
e
n

t
r
e
a
t
e
d

w
i
t
h

i
n
s
e
c
t
i
c
i
d
e
.

R
e
s
u
l
t
s

a
r
e

c
o
m
p
a
r
a
b
l
e

a
c
r
o
s
s

c
o
u
n
t
r
i
e
s
,

i
f

a
p
p
r
o
p
r
i
a
t
e

a
n
d

c
o
n
s
i
s
t
e
n
t

s
a
m
p
l
i
n
g

p
r
o
c
e
d
u
r
e
s

a
r
e

f
o
l
l
o
w
e
d

a
n
d

c
o
n
f
o
u
n
d
i
n
g

f
a
c
t
o
r
s

a
r
e

a
c
c
o
u
n
t
e
d

f
o
r
.
L
i
m
i
t
a
t
i
o
n
s

C
o
v
e
r
i
n
g

a
l
l

p
r
e
g
n
a
n
t

w
o
m
e
n

i
n

a

h
o
u
s
e
h
o
l
d

s
u
r
v
e
y

i
s

d
i
f

c
u
l
t

b
e
c
a
u
s
e

m
a
n
y

w
o
m
e
n

e
i
t
h
e
r

d
o

n
o
t

k
n
o
w

t
h
a
t

t
h
e
y

a
r
e

p
r
e
g
n
a
n
t

o
r

d
o

n
o
t

w
a
n
t

t
o

d
i
v
u
l
g
e

t
h
e

i
n
f
o
r
m
a
t
i
o
n
.

A

l
a
r
g
e

s
a
m
p
l
e

s
i
z
e

i
s

r
e
q
u
i
r
e
d

t
o

o
b
t
a
i
n

p
r
e
c
i
s
e

e
s
t
i
m
a
t
e
s
.

T
h
e
r
e

m
a
y

b
e

s
o
m
e

b
i
a
s

i
f

r
e
l
u
c
t
a
n
c
e

t
o

d
i
s
c
u
s
s

p
r
e
g
n
a
n
c
y

i
s

a
l
s
o

a
s
s
o
c
i
a
t
e
d

w
i
t
h

r
s
t

b
i
r
t
h
,

a
d
o
l
e
s
c
e
n
c
e

a
n
d

o
t
h
e
r

d
e
m
o
g
r
a
p
h
i
c

f
a
c
t
o
r
s
.

T
h
e

d
a
t
a

m
i
g
h
t

n
o
t

p
r
o
v
i
d
e

r
e
l
i
a
b
l
e

e
s
t
i
m
a
t
e
s

o
f

n
e
t

r
e
-
t
r
e
a
t
m
e
n
t

s
t
a
t
u
s

b
e
c
a
u
s
e

o
f

p
o
o
r

r
e
c
a
l
l

o
f

d
a
t
e

o
f

l
a
s
t

t
r
e
a
t
m
e
n
t

o
f

t
h
e

n
e
t
.

T
h
e

r
e
s
u
l
t
s

m
i
g
h
t

b
e

b
i
a
s
e
d

b
y

t
h
e

s
e
a
s
o
n
a
l
i
t
y

o
f

s
u
r
v
e
y

d
a
t
a

c
o
l
l
e
c
t
i
o
n
,

w
h
i
c
h

i
s

u
s
u
a
l
l
y

d
o
n
e

d
u
r
i
n
g

t
h
e

d
r
y

s
e
a
s
o
n

w
h
e
n

n
e
t

u
s
e

i
s

l
i
k
e
l
y

t
o

b
e

a
t

i
t
s

l
o
w
e
s
t
.
4
.

A
n

I
T
N

i
s
:

(
i
)

a

p
r
e
-
t
r
e
a
t
e
d

n
e
t

o
b
t
a
i
n
e
d

i
n

t
h
e

p
a
s
t

1
2

m
o
n
t
h
s
,

(
i
i
)

a

n
e
t

t
h
a
t

h
a
s

b
e
e
n

t
r
e
a
t
e
d

w
i
t
h

i
n
s
e
c
t
i
c
i
d
e

i
n

t
h
e

p
a
s
t

1
2

m
o
n
t
h
s

o
r

(
i
i
i
)

a

p
e
r
m
a
n
e
n
t

o
r

l
o
n
g
-
l
a
s
t
i
n
g

t
r
e
a
t
e
d

n
e
t

t
h
a
t

d
o
e
s

n
o
t

r
e
q
u
i
r
e

r
e
-
t
r
e
a
t
m
e
n
t
.

5
.

A
l
t
h
o
u
g
h

i
t

i
s

r
e
c
o
m
m
e
n
d
e
d

t
h
a
t

t
h
i
s

i
n
d
i
c
a
t
o
r

b
e

m
e
a
s
u
r
e
d

i
n

h
o
u
s
e
h
o
l
d

s
u
r
v
e
y
s
,

I
T
N

u
s
e

s
h
o
u
l
d

a
l
s
o

b
e

a
s
c
e
r
t
a
i
n
e
d

a
t

a
n
t
e
n
a
t
a
l

c
l
i
n
i
c

v
i
s
i
t
s

a
n
d

r
e
c
o
r
d
e
d

o
n

a
n
t
e
n
a
t
a
l

c
l
i
n
i
c

c
a
r
d
s

t
o

p
r
o
m
o
t
e

i
t
s

u
s
e

a
m
o
n
g

p
r
e
g
n
a
n
t

w
o
m
e
n
.
27
S
u
m
m
a
r
y
:

G
u
i
d
e
l
i
n
e
s

f
o
r

m
e
a
s
u
r
i
n
g

i
n
d
i
c
a
t
o
r
s

f
o
r

m
o
n
i
t
o
r
i
n
g

a
n
d

e
v
a
l
u
a
t
i
o
n

o
f

m
a
l
a
r
i
a

i
n

p
r
e
g
n
a
n
c
y

I
n
d
i
c
a
t
o
r
s

t
o

b
e

m
e
a
s
u
r
e
d

i
n

h
o
u
s
e
h
o
l
d

s
u
r
v
e
y
s
I
n
d
i
c
a
t
o
r
T
y
p
e
D
e

n
i
t
i
o
n
D
a
t
a

c
o
l
l
e
c
t
i
o
n
S
t
r
e
n
g
t
h
s

a
n
d

l
i
m
i
t
a
t
i
o
n
s
P
e
r
c
e
n
t
a
g
e

o
f

l
o
w
-
b
i
r
t
h
-
w
e
i
g
h
t

s
i
n
g
l
e
t
o
n

l
i
v
e

b
i
r
t
h
s

(
<

2
5
0
0

g
)
,

b
y

p
a
r
i
t
y

I
m
p
a
c
t
A
m
o
n
g

p
r
i
m
i
p
a
r
o
u
s

w
o
m
e
n
,

t
h
e

i
n
d
i
c
a
t
o
r

i
s

d
e

n
e
d

a
s

f
o
l
l
o
w
s
:

N
u
m
e
r
a
t
o
r
:

N
u
m
b
e
r

o
f

l
o
w
-
b
i
r
t
h
-
w
e
i
g
h
t

s
i
n
g
l
e
t
o
n

l
i
v
e

b
i
r
t
h
s

t
o

w
o
m
e
n

w
i
t
h

r
s
t

b
i
r
t
h
D
e
n
o
m
i
n
a
t
o
r
:

N
u
m
b
e
r

o
f

s
i
n
g
l
e
t
o
n

l
i
v
e

b
i
r
t
h
s

t
o

w
o
m
e
n

w
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t
h

r
s
t

b
i
r
t
h
T
h
e

i
n
d
i
c
a
t
o
r

f
o
r

m
u
l
t
i
p
a
r
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u
s

w
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m
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n

(
t
w
o

o
r

m
o
r
e
)

i
s

d
e

n
e
d

a
s

f
o
l
l
o
w
s
:

N
u
m
e
r
a
t
o
r
:

N
u
m
b
e
r

o
f

l
o
w
-
b
i
r
t
h
-
w
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i
g
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t

s
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n
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l
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t
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n

l
i
v
e

b
i
r
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h
s

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o

w
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m
e
n

w
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t
h

t
w
o

o
r

m
o
r
e

b
i
r
t
h
s

D
e
n
o
m
i
n
a
t
o
r
:

N
u
m
b
e
r

o
f

s
i
n
g
l
e
t
o
n

l
i
v
e

b
i
r
t
h
s

t
o

w
o
m
e
n

w
i
t
h

t
w
o

o
r

m
o
r
e

b
i
r
t
h
s
H
o
u
s
e
h
o
l
d

s
u
r
v
e
y
s

(
s
u
c
h

a
s

d
e
m
o
g
r
a
p
h
i
c

a
n
d

h
e
a
l
t
h

s
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r
v
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y
s
,

m
u
l
t
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p
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e

i
n
d
i
c
a
t
o
r

c
l
u
s
t
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r

s
u
r
v
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y
s
,

m
a
l
a
r
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a

i
n
d
i
c
a
t
o
r

s
u
r
v
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y

a
n
d

o
t
h
e
r

n
a
t
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o
n
a
l
l
y

r
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p
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n
t
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v
e

s
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y
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)
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t
r
e
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g
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s

D
a
t
a

c
o
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l
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c
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d

i
n

h
o
u
s
e
h
o
l
d

s
u
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v
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y
s

a
r
e

n
a
t
i
o
n
a
l
l
y

r
e
p
r
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s
e
n
t
a
t
i
v
e
.

T
h
e

r
e
s
u
l
t
s

a
r
e

c
o
m
p
a
r
a
b
l
e

a
c
r
o
s
s

c
o
u
n
t
r
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e
s
,

i
f

a
p
p
r
o
p
r
i
a
t
e

a
n
d

c
o
n
s
i
s
t
e
n
t

s
a
m
p
l
i
n
g

p
r
o
c
e
d
u
r
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s

a
r
e

f
o
l
l
o
w
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d

a
n
d

c
o
n
f
o
u
n
d
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n
g

f
a
c
t
o
r
s

a
r
e

a
c
c
o
u
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t
e
d

f
o
r
.

T
h
i
s

i
s

a

u
s
e
f
u
l

i
n
d
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c
a
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o
r

a
t

h
e
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f
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c
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y

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,

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l
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o
w
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g

h
e
a
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w
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r
k
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s

a
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d

p
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r
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m
m
e

m
a
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a
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t
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o
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m
p
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f

m
a
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a
l

a
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d

n
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w
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r
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h
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t
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r
v
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n
t
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o
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s

a
n
d

t
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a
k
e

c
o
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r
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c
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e

a
c
t
i
o
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s

w
h
e
r
e

n
e
c
e
s
s
a
r
y
.

I
t

i
s

a

u
s
e
f
u
l

g
l
o
b
a
l

i
n
d
i
c
a
t
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r

f
o
r

p
o
p
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l
a
t
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o
n

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a
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a
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d

d
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v
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p
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.
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m
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t
a
t
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o
n
s

A

l
a
r
g
e

s
a
m
p
l
e

s
i
z
e

i
s

r
e
q
u
i
r
e
d

t
o

o
b
t
a
i
n

p
r
e
c
i
s
e

e
s
t
i
m
a
t
e
s
.

T
h
e

w
o
m
e
n

s
u
r
v
e
y
e
d

m
i
g
h
t

n
o
t

k
n
o
w

o
r

r
e
c
a
l
l

t
h
e

b
i
r
t
h

w
e
i
g
h
t
s

o
f

a
l
l

t
h
e
i
r

c
h
i
l
d
r
e
n
,

o
r

t
h
e
y

m
i
g
h
t

r
e
p
o
r
t

t
h
e
m

i
n
c
o
r
r
e
c
t
l
y
.

P
r
o
m
o
t
i
n
g

c
h
i
l
d
b
i
r
t
h

i
n

h
e
a
l
t
h

f
a
c
i
l
i
t
i
e
s

w
h
e
r
e

i
n
f
a
n
t
s

a
r
e

w
e
i
g
h
e
d

a
t

b
i
r
t
h

i
s

l
i
k
e
l
y

t
o

i
m
p
r
o
v
e

t
h
e

q
u
a
l
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t
y

o
f

d
a
t
a

o
n

b
i
r
t
h

w
e
i
g
h
t
.

L
o
w

b
i
r
t
h

w
e
i
g
h
t

h
a
s

m
u
l
t
i
p
l
e

c
a
u
s
e
s
,

i
n
c
l
u
d
i
n
g

m
a
l
a
r
i
a
;

t
h
e
r
e
f
o
r
e
,

t
r
e
n
d
s

i
n

i
t
s

p
r
e
v
a
l
e
n
c
e

s
h
o
u
l
d

b
e

i
n
t
e
r
p
r
e
t
e
d

w
i
t
h

c
a
u
t
i
o
n
.
Summary
28 Malaria in pregnancy
S
u
m
m
a
r
y
:

G
u
i
d
e
l
i
n
e
s

f
o
r

m
e
a
s
u
r
i
n
g

i
n
d
i
c
a
t
o
r
s

f
o
r

m
o
n
i
t
o
r
i
n
g

a
n
d

e
v
a
l
u
a
t
i
o
n

o
f

m
a
l
a
r
i
a

i
n

p
r
e
g
n
a
n
c
y

I
n
d
i
c
a
t
o
r
s

t
o

b
e

m
e
a
s
u
r
e
d

i
n

h
o
u
s
e
h
o
l
d

s
u
r
v
e
y
s
I
n
d
i
c
a
t
o
r
T
y
p
e
D
e

n
i
t
i
o
n
D
a
t
a

c
o
l
l
e
c
t
i
o
n
S
t
r
e
n
g
t
h
s

a
n
d

l
i
m
i
t
a
t
i
o
n
s
P
e
r
c
e
n
t
a
g
e

o
f

s
c
r
e
e
n
e
d

p
r
e
g
n
a
n
t

w
o
m
e
n

w
i
t
h

s
e
v
e
r
e

a
n
a
e
m
i
a

(
h
a
e
m
o
g
l
o
b
i
n

<

7
g
/
d
l
)

i
n

t
h
i
r
d

t
r
i
m
e
s
t
e
r

7
,

b
y

g
r
a
v
i
d
i
t
y
I
m
p
a
c
t
A
m
o
n
g

p
r
i
m
i
p
a
r
o
u
s

w
o
m
e
n
,

t
h
e

i
n
d
i
c
a
t
o
r

i
s

d
e

n
e
d

a
s

f
o
l
l
o
w
s
:

F
o
r

p
r
i
m
i
g
r
a
v
i
d
a
e
,

t
h
e

i
n
d
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c
a
t
o
r

i
s

d
e

n
e
d

a
s

f
o
l
l
o
w
s
:

N
u
m
e
r
a
t
o
r
:

N
u
m
b
e
r

o
f

w
o
m
e
n

w
i
t
h

s
e
v
e
r
e

a
n
a
e
m
i
a

(
h
a
e
m
o
g
l
o
b
i
n

<

7
g
/
d
l
)

d
u
r
i
n
g

t
h
i
r
d

t
r
i
m
e
s
t
e
r

o
f

r
s
t

p
r
e
g
n
a
n
c
y

D
e
n
o
m
i
n
a
t
o
r
:

N
u
m
b
e
r

o
f

p
r
e
g
n
a
n
t

w
o
m
e
n

s
c
r
e
e
n
e
d

f
o
r

a
n
a
e
m
i
a

d
u
r
i
n
g

t
h
i
r
d

t
r
i
m
e
s
t
e
r

o
f

r
s
t

p
r
e
g
n
a
n
c
y
F
o
r

m
u
l
t
i
g
r
a
v
i
d
a
e
,

t
h
e

i
n
d
i
c
a
t
o
r

i
s

d
e

n
e
d

a
s
:

N
u
m
e
r
a
t
o
r
:

N
u
m
b
e
r

o
f

p
r
e
g
n
a
n
t

w
o
m
e
n

w
i
t
h

t
w
o

o
r

m
o
r
e

p
r
e
g
n
a
n
c
i
e
s

w
i
t
h

s
e
v
e
r
e

a
n
a
e
m
i
a

(
h
a
e
m
o
-
g
l
o
b
i
n

<

7

g
/
d
l
)

d
u
r
i
n
g

t
h
i
r
d

t
r
i
m
e
s
t
e
r
D
e
n
o
m
i
n
a
t
o
r
:

N
u
m
b
e
r

o
f

p
r
e
g
n
a
n
t

w
o
m
e
n

w
i
t
h

t
w
o

o
r

m
o
r
e

p
r
e
g
n
a
n
c
i
e
s

s
c
r
e
e
n
e
d

f
o
r

a
n
a
e
m
i
a

d
u
r
i
n
g

t
h
i
r
d

t
r
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m
e
s
t
e
r
H
o
u
s
e
h
o
l
d

s
u
r
v
e
y
s

(
s
u
c
h

a
s

H
o
u
s
e
h
o
l
d

s
u
r
v
e
y
s

(
s
u
c
h

a
s

d
e
m
o
g
r
a
p
h
i
c

a
n
d

h
e
a
l
t
h

s
u
r
v
e
y
s
,

m
u
l
t
i
p
l
e

i
n
d
i
c
a
t
o
r

c
l
u
s
t
e
r

s
u
r
v
e
y
s
,

m
a
l
a
r
i
a

i
n
d
i
c
a
t
o
r

s
u
r
v
e
y

a
n
d

o
t
h
e
r

n
a
t
i
o
n
a
l
l
y

r
e
p
r
e
s
e
n
t
a
t
i
v
e

s
u
r
v
e
y
s
)
S
t
r
e
n
g
t
h
s

D
a
t
a

c
o
l
l
e
c
t
e
d

i
n

t
h
e
s
e

h
o
u
s
e
h
o
l
d

s
u
r
v
e
y
s

a
r
e

n
a
t
i
o
n
a
l
l
y

r
e
p
r
e
s
e
n
t
a
t
i
v
e
.

T
h
e

r
e
s
u
l
t
s

a
r
e

c
o
m
p
a
r
a
b
l
e

a
c
r
o
s
s

c
o
u
n
t
r
i
e
s
,

i
f

a
p
p
r
o
p
r
i
a
t
e

a
n
d

c
o
n
s
i
s
t
e
n
t

s
a
m
p
l
i
n
g

p
r
o
c
e
d
u
r
e
s

a
n
d

m
e
t
h
o
d
s

a
r
e

u
s
e
d

a
n
d

c
o
n
f
o
u
n
d
i
n
g

f
a
c
t
o
r
s

a
r
e

a
c
c
o
u
n
t
e
d

f
o
r
.

L
i
m
i
t
a
t
i
o
n
s

A

l
a
r
g
e

s
a
m
p
l
e

s
i
z
e

i
s

r
e
q
u
i
r
e
d

t
o

o
b
t
a
i
n

p
r
e
c
i
s
e

e
s
t
i
m
a
t
e
s
.

A
n
a
e
m
i
a

h
a
s

m
u
l
t
i
p
l
e

c
a
u
s
e
s
,

i
n
c
l
u
d
i
n
g

m
a
l
a
r
i
a
;

t
h
e
r
e
f
o
r
e
,

t
r
e
n
d
s

i
n

a
n
a
e
m
i
a

p
r
e
v
a
l
e
n
c
e

s
h
o
u
l
d

b
e

i
n
t
e
r
p
r
e
t
e
d

w
i
t
h

c
a
u
t
i
o
n
.
6
.

L
o
w

b
i
r
t
h

w
e
i
g
h
t

i
s

d
e

n
e
d

a
s

<

2
5
0
0

g

w
i
t
h
i
n

2
4

h

o
f

b
i
r
t
h
,

r
e
g
a
r
d
l
e
s
s

o
f

g
e
s
t
a
t
i
o
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29
ANNEX 1. Monthly data collection form for antenatal clinic units providing
intermittent preventive treatment
District: ...........................................................................................
Health facility ....................................................................................
Month ........................................ Year.............................................
FIRST
ANTENATAL
CLINIC VISIT








Total
First dose
of intermittent
preventive treatment
(IPT1)








Second dose
of intermittent
preventive treatment
(IPT2)








Third dose
of intermittent
preventive treatment
(IPT2)








Fourth dose
of intermittent
preventive treatment
(IPT2)








Annex 1
30 Malaria in pregnancy
ANNEX 2. Forms for data collection at antenatal clinics
Use of insecticide-treated nets Second antenatal clinic visit
Did you sleep under an insecticide-treated net last night? Total
YES






NO





Anaemia (third trimester)
Gravidity Severely anaemic
(Hb < 7 g/dl)
Total Not severely anaemic Total
FIRST
PREGNANCY

TWO OR
MORE
PREGNANCIES

31
Low birth weight (only singleton live births)
Parity Low birth weight
(< 2500 g)
Total Normal birth weight
(> 2500 g)
Total
FIRST
BIRTH

TWO OR
MORE
BIRTHS

Annex 2
ANNEX 3. Boxes to be added to an existing form that already contains
information on the number of rst antenatal clinic visits, ages of patients
and in which trimester they were at the time of the visit.
District: ...........................................................................................
Health facility ....................................................................................
Month ........................................ Year.............................................
Total number of rst antenatal clinic visits.............................................
Intermittent preventive treatment dose Number
1.
2.
3.
4.
5.
Number Total
Pregnant women who report having slept under an
insecticide-treated net the previous night (second visit)
YES NO
Number Total
Severe anaemia (Hb < 7 g/dl) in women during rst
pregnancy (third trimester)
YES NO
Severe anaemia (Hb < 7 g/dl) in women with two or
more pregnancies
Number Total
Number of low-birth-weight singleton live births to
women with rst birth
YES NO
Number of low-birth-weight singleton live births to
women with two or more births
33
A
N
N
E
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Annex 4
34 Malaria in pregnancy
ANNEX 5. Supervisory visit form
Suggestions for questions that could be included, depending on the country.
The responses should be integrated into the reproductive health supervisory form.
To be completed by the supervisor before a visit.
District ...................................................................................................................................................
Health facility ......................................................................................................................................
Supervisor .............................................................................................................................................
Date of last supervision ............................................. Todays date ............................................
Data from routine collection ...........................................................................................................
% rst dose of intermittent preventive treatment ....................................................................
% second dose of intermittent preventive treatment ..............................................................
% screened for anaemia in third trimester ................................................................................
% of primigravid women with severe anaemia ........................................................................
% of multigravid women with severe anaemia ........................................................................
% who report sleeping under insecticide-treated nets ...........................................................
% low birth weight in primiparous women ...............................................................................
% low birth weight in multiparous women ...............................................................................
For further information, please contact:
Global Malaria Programme
World Health Organization
20. avenue Appia CH-1211 Geneva 27
infogmp@who.int
www.who.int/malaria
ISBN : 978 92 4 159563 6