Despite considerable improvement in health care delivery services in the African continent, the control of malaria in pregnant African women, one of several child survival strategies applied through antenatal care, continues to be particularly challenging. Prevention and control recommendations for typical areas of high P. falciparum
transmission have promoted the use of antimalarial chemoprophylaxis to prevent placental infection and its associated adverse perinatal outcome. This confirms prior findings [47
]. Other randomized trials show a protective effect of prophylaxis on placental infection or peripheral parasitemia [46
]. However, persistently low program coverage coupled with diminishing intervention effectiveness has forced a re-evaluation of the relative importance of malaria in pregnancy [50
]. The prophylactic medicines include sulfadoxine pyremethamine, proguanil and pyremethamine, while the curative ones include artesunate, chloroquine and amodiaquine. These drugs are relatively safe in pregnancy and are widely used in malarious areas of sub-Saharan Africa [51
In the face of the mounting evidence of the relative failure of many traditional antimalarial drugs, particularly chloroquine, the World Health Organization (WHO) has put forward new guidelines for combating and preventing malaria during pregnancy [24
]. The guidelines recommend that women living in high transmission areas of Africa receive intermittent preventive treatment (IPT) with an effective antimalarial agent such as sulfadoxine-pyrimethamine (SP) at scheduled antenatal visits and that all pregnant women in targeted areas should undergo at least two sessions of IPT after first fetal movements (i.e., between 20 and 35 weeks) [51
]. Unfortunately, the implementation of the WHO guidelines has been burdened by the notorious problems complicating health service delivery in the developing world, particularly in the African continent, namely, the logistical challenges of reaching remote regions, resource scarcity, lack of infrastructure, inadequate treatment, continuing poverty, and armed conflict.
It is well established that women in Africa use prenatal care extensively when it is available and accessible. This opportunity must be used to implement evidence-based actions with appropriate and realistic goals. There is an urgent need to improve access of rural women to antenatal clinic services in sub-Saharan Africa, either through increasing the number of rural health centers or by establishing functioning outreach services. The distribution of insecticide-treated bed nets needs to become implemented on a large scale.
Since pregnant women have increased specific risks of complications from both malaria and HIV infection, the financial and human resource constraints of health systems in countries most affected by malaria and HIV and the shared determinants of vulnerability for both diseases indicate the need for integration of preventive and curative services for malaria and HIV. The health systems that deliver these services must be strengthened [22
]. Reproductive health services offer a critical opportunity for routine provider-initiated HIV testing and counseling. They can provide follow-up care with prevention of MTCT interventions according to national policy for those who test positive, coupled with entry to antiretroviral therapy programs for those sick and in need of immediate therapy. These services need to be strengthened to ensure the delivery of the WHO-recommended antenatal care schedule of four visits (focused antenatal care), which includes a minimum package of interventions for the prevention of both malaria and HIV [52
Studies in malarious regions have demonstrated that substantial reductions in maternal malaria, anemia, and low birth weight have been achieved by intervention programs, including the use of preventive intermittent treatment, chemoprophylaxis, and the use of insecticide-treated nets. In fact, studies suggest that between 25 percent and 90 percent of these adverse events might be prevented by full implementation of existing interventions [12
]. Interventions therefore should also exist for maternal anemia (e.g., good nutrition, iron and folate supplementation, and hookworm treatment) and for reduction of mother-to-infant HIV transmission (e.g., short-course zidovudine or nevirapine), and such can be provided through antenatal care programs [22
]. Better application of these malaria, anemia, and HIV interventions could markedly reduce the infant mortality burden of these diseases.
Finally, collaboration between scientists, policy makers and control programs should be strengthened and community-level research encouraged in order to guide programs and monitor and evaluate markers of success.