Improving Malaria Case Management by Health Care Providers in Antenatal Clinics in Akwa Ibom State of Nigeria

Bright Orji, William Brieger, Emmanuel Otolorin and John Orok

MIS 2011 Revealed Very Poor Indices

Large Problem: Approximately 11% of maternal deaths are caused by malaria in pregnancy (MIP) Poor Response: Malaria treatment is largely by presumptive diagnosis Ideally parasitological diagnosis followed by ACT if positive
70 60 50 40 30 20 10 0
ANC attendance at Pregnant women Pregnant women least once with with 2 or more who slept inside SBA doses of IPTp-SP ITN the previous night

66.2

Percentage

19.5

16.9

MICS, 2011 (FMoH, NBS, Abuja)

Promoting Integrated Management of Malaria and Fever in Pregnancy

Use of long-lasting insecticide-treated nets (LLINs), Intermittent preventive treatment (IPTp), and Prompt and effective case management of febrile illness:
With early and proper diagnosis of malaria using rapid diagnostic tests (RDTs) and microscopy

Study Aims
This study sought to learn whether the introduction of RDTs into government-owned antenatal care (ANC) clinics would influence the pattern of fever and malaria management in Akwa Ibom State, Nigeria
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Methods
At baseline, 597 client cards were reviewed at 6 government-owned ANC clinics in Onna and Ibeno Local Government Areas Staff were then trained in RDT use At endline, 472 cards were reviewed The ANC client cards were drawn from first non-follow-up visits where a complaint of fever was recorded
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Time Frame
Data extraction was conducted between February 2010 and March 2011 by trained nurses/midwives The State Ministry of Health approved the study: confidentiality, non-use of identifiers
6

Type of Prescriber
Midwives, 1.2% CHEWs, 11.7% Nurse/midwives, 32.6% Nurses, 13.2% CHOs, 1.9%

Medical doctors, 17.0%

Health workers not indicated, 22.4%

Training Nurses on RDT

Patients Records and Clinical Assessments

90 80 70
63.6 56.8 84.7

80.4
76.5

61.4

60

Percentage

50 40 30 20 10
36.4

Baseline Endline
23.5

19.6

0
Temp was taken Temp taken and Presumptive recorded diagnosis conducted

RDT conducted

RDT positive

RDT negative

Pattern of Prescription for Anti-Malarial Medicines

70 60 50 Percentage 40 30 27 Baseline 26 24 15 6 64

Endline

20 10
0 ACTs Quinine

12
6

11

SP

Quinine Injection

CQ

10

Record Quality Issues

The percentage of time that clients temperature was taken and recorded improved from 56.7% at baseline to 61.4%; difference between the two was statistically significant (p-value=0.00)
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Pattern of Prescription for Anti-Malarial Medicines after RDT

Anti-Malarial medicines Drug base Baseline (No RDTs at Baseline) Endline RDT Positive Result 45(64) 4(6) 11(15) 5(7) 6(8) 71 RDT Negative Result 52(64) 4(5) 9(11) 3(4) 13(16) 81
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ACTs Quinine Sulfadoxinepyrimethamine Quinine injection Chloroquine Total

138(27) 132(26) 122(24) 58(12) 56(11) 506

Pattern of Prescription for Antibiotics

Name of Antibiotics Baseline (no RDTs at Baseline) 11 0.5 21 37 8 1 7 1 2 0.5 1 198 Endline RDT RDT Positive Negative Result Result 25 2.5 2 62.5 22 5 1 2 1 2 174
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Septrin Chloamphnicol Ampiclox Amoxicillin Ampicillin Gentamycin Ciprofloxacin Amoxil Caps Flagyl Tetracycline Gentamycin injection Total N

32 30.5 12.5

Implications for Intervention

The review of records did show that nursing and midwifery staff at government clinics could in a relatively short time period adopt the use of RDTs They did improve their prescribing of appropriate anti-malarial medicines Gaps exist in history taking and malaria diagnosis, with inappropriate dispensing of anti-malarial medicines and antibiotics Continued follow-up and supervision will be needed to ensure that correct malaria diagnostic and treatment guidelines are fully practiced
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