Findings add weight to WHO malaria pregnancy guidance

Pregnant women who receive three or more doses of malaria preventive therapy have higher birthweight babies than those who only receive two, conclude the authors of a meta-analysis.

The findings support the most recent World Health Organization (WHO) recommendation that women in high malaria prevalence areas should receive sulfadoxine-pyrimethamine at every scheduled antenatal care visit during the last two trimesters of pregnancy, say authors Feiko ter Kuile (Liverpool School for Tropical Medicine, UK) and colleagues.

The analysis, reported in JAMA, included five studies comparing monthly treatment against a two-dose regimen, and two studies comparing three- versus two-dose regimens, totaling 6281 pregnancies.

The median birthweight was significantly higher among women who received three or more doses, at 2215 g compared with 2870 g among women who received two doses. And women who received three or more doses were 20% less likely to have a low-birthweight (<2500 g) baby than women who only received two doses (134 vs 167 per 1000 births). These associations held true regardless of HIV status or the number of prior pregnancies.

The authors also found that women who received three or more doses were around half as likely to have placental malaria compared with those in the two-dose group, and around a third less likely to test positive for the malaria parasite. However, this was only found in women in their first and second pregnancies, and not in those who had had several prior pregnancies.

Women who received three doses also had slightly higher mean hemoglobin levels at term compared with women in the two-dose group, but a significant association between dosage and moderate to severe anemia was only observed in women in their first and second pregnancies.

The authors explain that the two-dose preventive schedule, which provides up to 12 weeks' prophylaxis, has been widely adopted in areas of sub-Saharan Africa where malaria is endemic, after it was shown to reduce the incidence of low birthweight.

However, doubts have been raised that it provides sufficient protection during the final 4-10 weeks of pregnancy.

"Future research should focus on how best to implement the updated WHO guidelines for intermittent preventive therapy during pregnancy with sulfadoxine-pyimethamine and specifically their integration with focused antenatal care," ter Kuile and colleagues conclude.

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