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With the knowledge that an efficacious antimalarial administered to pregnant women would markedly reduce placental malaria and its associated risk of low birth weight (LBW), investigations were conducted to identify an antimalarial regimen practical for nationwide implementation through the antenatal clinic (ANC) system. Maternal practices, including ANC utilization and malaria treatment and prevention during pregnancy were evaluated as part of a national malaria knowledge, attitudes, and practices survey. A second study was conducted to evaluate the efiicacy and cost of selected alternative antimalarial regimens. Women in their first or second pregnancy were placed on chloroquine (CQ) treatment (25 mg/kg) followed by weekly CQ (300 mg) (CQ/CQ); sulfadoxine-pyrimethamine (SP) treatment followed by CQ (30O mg weekly) (SP/CQ); or SP treatment during the second trimester and repeated at the beginning of the third trimester (SP/SP). With 87% of women attending ANC two or more times during pregnancy, most pregnant women in Malawi could be reached with an antimalarial intervention. Among 159 women in their first or second pregnancy receiving CQ/CQ, SP/CQ, and SP/SP, placental malaria parasitemia rates were 32%, 26%, and 9%, respectively (P = O.OO6, by chi-square test). The SP/SP regimen was also markedly more cost-effective in preventing infant deaths, costing $75 per infant death prevented, compared with $481 for SP/CQ and $542 for CQ/CQ. These investigations suggest that a regimen consisting of two treatment doses of SP during pregnancy is an efficacious and cost-effective intervention to prevent placental malaria, and LBW-associated mortality, that can be delivered to pregnant women through ANCs in settings similar to those found in rural Malawi.
Authors’ addresses: Linda J. Schultz, National Immunization Program, Mailstop E-61, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333. Richard W Steketee, Epidemiology Branch, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, STD, and TB Prevention, Centers for Disease Control and Prevention, Mailstop E-45, 1600 Clifton Road, Atlanta, GA 30333. Lester Chitsulo, Ministry of Health, Unit, PO Box 30377, Lilongwe-3, Malawi. Alan Macheso, Community Health Sciences Unit, PO Box 30377, Lilongwe-3, Malawi. Peter Kazembe, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi. Jack J. Wirima, University of Malawi School of Medicine and Ministry of Health, Blantyre, Malawi.