The Rapid Assessment of the Burden of Malaria ... - ReproLinePlus

The Rapid Assessment
of the Burden of
Malaria during Pregnancy

Rapid Assessment Manual
The Rapid Assessment of the Burden of
Malaria during Pregnancy
Package Contents
Executive Summary
Acknowledgements
Abbreviations
1 Malaria during Pregnancy: Addressing the Burden
2 Planning a Rapid Assessment
3 Conducting the Assessment
4 Data Management and Analysis
5 Report Preparation and Use
References
Glossary
Rapid Assessment Modules and Tools
For each survey tool, a module is provided.
1: Antenatal Clinic Survey
2: Delivery Unit Survey
3: Hospital Surveillance of Malaria Disease
4: Antenatal Clinic Facility Assessment
5: Health-Care Worker Observation
6: Focus Group/Individual Interviews with Health-Care Workers
7: Focus Group/Individual Interviews with Traditional Birth Attendants and Midwives
8: Client Exit Interview
9: Focus Group/Individual Interviews with Recently/Currently Pregnant Women
10: Individual Interviews with Key Informants
Rapid Assessment Resources
Note: The CD-ROM enclosed
in the inside back pocket of
this hard copy contains all
the package contents.
The manual, modules, tools,
and most resources are
also available in Word files;
when pdfs and Word files
differ, use the pdfs, as they
are most up-to-date.
Resource 1: Articles and Guidelines
• Relevant Articles: Malaria in Pregnancy
• Guidelines: A Strategic Framework for Malaria Prevention and Control During Pregnancy in the African Region.
WHO, 2004. In English, French, and Portuguese (only on CD-ROM).
Resource 2: Resources for the Qualitative Assessment
• Sample Interviewer Training Manual
• List of Resources
Resource 3: PowerPoint Presentations for Training Sessions
(On CD-ROM only)
• Overview of rapid assessment: Rapid assessment: general issues
• Overview of modules: 1 & 2; 3; 4, 5 & 8; 6, 7, 9 & 10
• Epidemiology of malaria: Epidemiology and control of malaria in pregnancy
• Clinical and laboratory methods: Assessment of gestational age, Body measurements, Laboratory methods
• Other assessment topics: Data management and sample size calculation
Resource 4: Software and Planning Tools
• Costing Tool
• Epi Info (for information and to download go to www.cdc.gov/epiinfo/)

For further information, please contact:
Malaria Branch/DPD
Centers for Disease Control and Prevention
1600 Clifton Rd, Atlanta, GA 30333, U.S.A
nciddpdmalaria@cdc.gov ▪ www.cdc.gov/malaria
Department of Making Pregnancy Safer
Global Malaria Programme
World Health Organization
20 Avenue Appia-CH-1211 Geneva 27
infogmp@who.int ▪ www.who.int/malaria ▪ www.who.int/making_pregnancy_safer

The Rapid Assessment of the Burden of
Malaria during Pregnancy
Contents
1. The Manual
Executive Summary.....................................................................................................................................................................ii
Acknowledgements.....................................................................................................................................................................iii
Abbreviations................................................................................................................................................................................iv
1 Malaria during Pregnancy: Addressing the Burden.................................................................................. 1
1.1 The Burden of Malaria during Pregnancy........................................................................................................................ 2
1.1.1 Infection with Plasmodium falciparum.............................................................................................................................. 2
1.1.2 Infection with Other Malaria Parasites.............................................................................................................................. 3
1.2 Malaria Prevention Interventions for Pregnant Women............................................................................................ 3
1.3 Information for Action.............................................................................................................................................................. 6
1.4 Use of the Rapid Assessment Package............................................................................................................................... 8
2 Planning the Rapid Assessment....................................................................................................................... 9
2.1 Objectives of the Rapid Assessment................................................................................................................................... 9
2.2 Potential Information Sources............................................................................................................................................... 9
2.3 Designing the Rapid Assessment.........................................................................................................................................12
3 Conducting the Rapid Assessment..................................................................................................................13
3.1 Selecting a Time Period............................................................................................................................................................13
3.2 Determining a Timetable and Budget................................................................................................................................13
3.3 Building and Organizing the Assessment Team.............................................................................................................14
3.4 Selecting Assessment Areas, Sites, and Sample Sizes..................................................................................................18
3.5 Adapting, Translating, and Preparing Assessment Materials..................................................................................21
3.6 Conducting Assessment Training.........................................................................................................................................21
3.7 Assuring Assessment Quality................................................................................................................................................23
3.8 Providing Information about the Survey/Obtaining Informed Consent.............................................................25
3.9 Providing Treatment for Malaria and Anemia................................................................................................................25
4 Data Management and Analysis.......................................................................................................................26
4.1 Data Management ......................................................................................................................................................................26
4.2 Data Analysis.................................................................................................................................................................................29
5 Report Preparation and Use of Results.........................................................................................................31
References .....................................................................................................................................................................................33
Glossary .....................................................................................................................................................................................34
The Manual
i

Executive Summary
Each year, more than 30 million women living in areas where malaria is transmitted
become pregnant, and an estimated 200,000 newborns die as a result of their mothers’
infection. Nine of 10 malaria deaths worldwide occur in Sub-Saharan Africa, the part of the
world most affected by malaria, and in that region, as many as 10,000 pregnant women
die each year of malaria-related causes, chiefly anemia. Less is known about the effects of
malaria during pregnancy in other parts of the world, but large numbers of pregnant women
are at risk. Safe and effective interventions for pregnant women—intermittent preventive
treatment, insecticide-treated mosquito nets, and febrile case management—can help
prevent the consequences of malaria infection. Malaria-affected countries vary widely in their
knowledge of the burden of malaria in pregnancy within their borders and of the impact of
any interventions or programs.
This rapid assessment package is designed to help countries obtain the information they
need to assess the burden of malaria during pregnancy, to develop a policy or program, to
assess program implementation, and to evaluate impact. The information can also be used
to advocate for policy change and to provide baseline data. When planning assessments,
countries are encouraged to make use of pertinent recent data from reliable sources. However,
because data may be lacking and because worldwide a relatively high number of women visit
an antenatal clinic at least once during pregnancy (in sub-Saharan Africa, a high proportion
visit at least once), this package provides sample surveys and interview guides that can be
used to conduct assessments in health facilities that serve pregnant women. By conducting
an assessment, health staff can increase their knowledge of issues regarding malaria during
pregnancy, while improving their ability to conduct operational research related to malaria
during pregnancy.
The package provides most of the materials needed to conduct a rapid assessment: general
guidance about planning and conducting a rapid assessment (including where to locate
existing data); sample assessment instruments, both quantitative and qualitative, which can
and should be adapted to local circumstances; specific information about how to use each tool;
and guidance about the use of the information obtained. Other resources, including relevant
guidelines, sample PowerPoint presentations for training sessions, training videos, and data
analysis software (Epi Info), are also included.
The assessment has been piloted in several countries in sub-Saharan Africa and in Asia.
Thelessons learned from conducting assessments in these regions are reflected in
this package.
ii
The Rapid Assessment of the Burden of Malaria during Pregnancy

Acknowledgements
We thank malaria control programs in the countries that have participated in conducting
rapid assessments — Bangladesh, Benin, Burkina Faso, Ethiopia, India, Indonesia,
Kenya, Madagascar, Mali, Mauritania, Myanmar, Niger, and Senegal — and all the women
(and their babies) in those countries who participated. In particular, we thank our key
collaborators: Dr. Rukhsana Ahmed, Dr. Ralisimalala Andriamampianina, Dr. Eleonore
Antoinette Ba-Nguz, Dr. Kaounde Calixte, Dr. Magda Robalo Correia e Silva, Dr. Amadou
Baïlo Diallo, Dr. Ogobara Doumbo, Dr. M. Abdul Faiz, Dr. Ibrahima Socé Fall, Dr. Afework
Hailemariam, Dr. Mohamed Nezhir Ould Hamed, Dr. Kaythwe Han, Ms. Jenny Hill, Dr. Daddi
Jima, Dr. Ranjalahary Rasolofomanana Justin, Dr. Midou Kailou, Dr. Edward Kamau, Dr. Ardi
Kaptiningsih, Dr. Kassoum Kayentao, Dr. Mamadou Kodio, Dr. Amadou Konate, Dr. Ravi Kumar,
Dr. Gita Maya, Mr. Etienne Minkoulou,Dr. Saroj K. Mishra, Ms. Allisyn Moran, Dr. Richard Muga,
Dr. Bernard L. Nahlen, Dr. Jean Louis Ndiaye, Dr. S.K. Sharif, Dr. Neeru Singh, Dr. Sodiomon B.
Sirima, Dr. Madion Silé Nguembayo Souam-Nguelé, Dr. Dianne Terlouw, Dr. Feiko ter Kuile,
Dr. Anniemieke Van Eijk, and Dr. Holly Williams. We thank also health professionals in Asia
and Africa who have attended training workshops for rapid assessments and have offered
suggestions for making this package more useful. We thank the World Health Organization,
in particular the Global Malaria Programme and Making Pregnancy Safer Department,
Regional and Country offices, for reviewing and approving this publication and supporting the
workshops. We are indebted to Dr. Penny Phillips-Howard, who first conceived of the idea
of a rapid assessment manual in order to share this methodology with others.
Suggested citation: US Centers for Disease Control and Prevention (CDC) and World Health
Organization. The Rapid Assessment of the Burden of Malaria during Pregnancy: A Toolkit.
Atlanta: Centers for Disease Control and Prevention, 2009.
The contents of this toolkit do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
Cover credit: Virginia Jacobs, Centers for Disease Control and Prevention
The Manual
iii

Abbreviations
CDC
DHS
HCW
ID
IPTp
ITN
LBW
MICS
MIPESA
MoH
MIS
RAOPAG
RBM
SP
UNICEF
USAID
WHO
Centers for Disease Control and Prevention
Demographic and Health Survey
health-care worker
identification
intermittent preventive treatment for
pregnant women
insecticide-treated net
low birth weight
Multiple Indicator Cluster Survey
Malaria in Pregnancy East and Southern Africa:
Coalition for Prevention and Control
Ministry of Health
Malaria Indicator Survey
Réseau d’Afrique de l’Ouest contre le Paludisme
pendant la grossesse
Roll Back Malaria
sulfadoxine-pyrimethamine
United Nations Children’s Fund
U.S. Agency for International Development
World Health Organization
iv
The Rapid Assessment of the Burden of Malaria during Pregnancy

1. Malaria during Pregnancy: Addressing the Burden
1.1 The Burden of Malaria during Pregnancy
Pregnant women and children are particularly vulnerable to infection with any of the
parasites that cause malaria in humans: Plasmodium falciparum, P. vivax, P. malariae, and P.
ovale. Each year, approximately 50 million women in malaria-endemic areas (25 million of
these live in Africa) become pregnant and are at risk of the adverse consequences of malaria
during pregnancy [1, 2]. Malaria is a threat both to themselves and their babies, leading
to about 200,000 newborn deaths each year as a result of malaria in pregnancy [1, 3]. The
problem of malaria in pregnant women has not been extensively studied outside sub-Saharan
Africa, and limited information exists about the burden of the problem in other areas.
The infecting parasite and the level of transmission (high or low) are key determinants of the
consequences of malaria infection during pregnancy. 1
Global Malaria Transmission (Endemicity) Levels
Pregnant women
and children
are particularly
vulnerable to
infection with
any of the parasites
that cause malaria
in humans.
Source: WHO and UNICEF, 2005 World Malaria Report.
1 Other determinants can include gravidity, parity, age, HIV infection, and access to prompt and
effective treatment.
The Manual
1

1.1.1 Infection with Plasmodium falciparum
Areas of High (or Stable) Transmission
Sub-Saharan Africa is the region of the world most affected by malaria, and in high (or
stable) transmission areas in that region, P. falciparum, the most lethal of the four parasites,
predominates.
While most adults in areas of high or stable transmission (the majority of sub-Saharan
Africa) have developed a partial immunity to malaria that largely prevents clinical illness, a
woman’s immune system changes during pregnancy, making her more vulnerable to malaria
infection. Infected red blood cells can sequester in the placenta, evading immune detection
and clearance. This infection can endanger the pregnant woman’s health, as well as that of the
unborn baby she is carrying, and cause maternal anemia, fetal loss, prematurity, intrauterine
growth retardation, and low birth weight (LBW)(

1.1.2 Infection with Other Malaria Parasites
The effects of the other three malaria parasites are less well-known. Pregnant women in
Africa at risk of P. vivax infection live principally in areas of low or unstable transmission, and
in these areas, P. vivax infections are likely to result in febrile illness. Most data on P. vivax
infections are from outside Africa, where women have been shown to be at increased risk of
P. vivax during pregnancy, although the risk is less pronounced than it is among women with
P. falciparum[16]. A study among nonimmune pregnant women in Thailand reported that
even single infections with P. vivax in the peripheral blood are associated with reductions in
birthweight and maternal hemoglobin but to a lesser extent than are those with P. falciparum
[17, 18]. Robust data on the prevalence of P. ovale and P. malariae are currently unavailable in
any population.
1.1.3 Malaria and HIV
In sub-Saharan Africa, where more than three-fourths (13.5 million) of the world’s HIVinfected
women reside approximately 25 million pregnant women are at risk of P. falciparum
infection every year. A review of studies in Africa shows that coinfection with HIV exacerbates
the burden of malaria in pregnancy. HIV increases the degree to which malaria is associated
with severe anemia and low birth weight beyond the effect of HIV itself on these outcomes.
HIV also puts women of all gravidities at risk for placental infection with malaria, not only
women in their first or second pregnancy [19].
1.2 Malaria Prevention Interventions
for Pregnant Women
In areas of high (or stable) malaria transmission, prevention of the ill effects of malaria during
pregnancy requires a preventive approach because most women do not become clinically ill.
The World Health Organization (WHO) has recommended a three-pronged strategy (IPTp,
ITNs, case management) for controlling malaria during pregnancy in areas of high or stable
transmission in Africa [2] (see box). WHO recommends intermittent preventive treatment
(IPTp) as an essential component of antenatal care for all pregnant women in areas of high or
stable transmission. IPTp involves the administration of an effective antimalarial at treatment
doses at predefined intervals during pregnancy and at regularly scheduled antenatal visits.
The remaining two interventions, insecticide-treated mosquito nets (ITNs) and effective case
management, are recommended for all pregnant women, regardless of the area’s malaria
transmission level. ITNs are intended to prevent infection, while case management with
an effective antimalarial is a treatment intervention. Each intervention is safe, effective,
affordable, and deliverable.
The Manual
3

If these interventions are offered through antenatal clinics, they can reach many to most
pregnant women, since surveys show that a relatively high proportion of women worldwide
have at least one antenatal visit with a skilled provider during pregnancy. In many countries in
sub-Saharan Africa, East Asia and the Pacific, and Latin America and the Caribbean, more than
70% attend an antenatal clinic at least once.
Antenatal Care Coverage by Region
Prevention and control of malaria in pregnant women should therefore be a critical component
of antenatal services, and WHO’s strategic framework for prevention and control of malaria
during pregnancy in the African region underscores the need for close collaboration between
malaria and reproductive health programs [2].
4 The Rapid Assessment of the Burden of Malaria during Pregnancy

WHO’s Recommended Interventions for
Malaria Prevention and Control during Pregnancy
in Areas of Stable Transmission in Africa
The policy for malaria prevention and control during pregnancy in areas of stable
transmission in the African region should emphasize a preventive package of intermittent
preventive treatment (IPTp) and insecticide-treated bed nets (ITNs) and ensure effective case
management of malaria illness and anemia.
Intermittent Preventive Treatment
All pregnant women in areas of stable malaria transmission should receive at least 2 doses of
IPTp after quickening. The World Health Organization recommends a schedule of 4 antenatal
clinic visits, with 3 visits after quickening. The delivery of IPTp with each scheduled visit after
quickening will likely assure that a high proportion of women receive at least 2 doses. IPTp
doses should not be given more frequently than monthly.
Prevention and
control of malaria
in pregnant
women is a critical
component of
antenatal services.
The most effective drug for IPTp is sulfadoxine-pyrimethamine (SP) because of its safety for use
during pregnancy, effectiveness in reproductive-age women, and feasibility for use in programs,
as it can be delivered as a single-dose treatment under observation by the health worker.*
Insecticide-Treated Bed Nets
ITNs should be provided to pregnant women as early in pregnancy as possible, and their use
should be encouraged for women throughout pregnancy and during the postpartum period.
ITNs can be provided either through the antenatal clinic or through other systems in the
private and public sectors that may be available at the community level.
Effective Case Management of Malaria Illness and Anemia
Effective case management of malaria illness for all pregnant women in malarious areas must
be assured. Iron/folate supplementation for anemia, an important consequence of malaria
infection, should be given to pregnant women as part of routine antenatal care package.
Pregnant women should also be screened for anemia, and those with moderate to severe
anemia should be managed according to national reproductive health guidelines.
* Current scientific evidence suggests the following: 1) At least 2 IPTp doses are required to achieve optimal
benefit in most women; 2) HIV-infected pregnant women receiving daily cotrimoxazole (CTX) should not
receive IPTp with SP due to concerns with additive sulfa toxicity; 3) In settings where the HIV prevalence in
pregnant women is greater than 10%, and where the daily CTX recommendation is not implemented among
HIV-infected individuals, it is more cost effective to treat all women with at least a 3-dose IPTp regimen
than to screen for HIV and provide this regimen only to HIV-infected women; 4) In HIV-uninfected pregnant
women, there is no evidence that a third dose of IPTp causes any additional risk, that more than 3 IPTp doses
during pregnancy offers additional benefit, or that receiving 3 or more doses of IPTp with SP will result in an
increased risk of adverse drug reactions. Research to assess the safety, efficacy, and program feasibility of other
antimalaria drugs for use in IPTp among both HIV-uninfected pregnant women, and HIV-infected pregnant
women receiving daily CTX, is ongoing.
Source: World Health Organization. A Strategic Framework for Malaria Prevention and Control during
Pregnancy in the African Region. Brazzaville: WHO Regional Office for Africa, 2004. AFR/MAL/04/01.
However the details of the specific interventions and tools used within this strategy have been updated in
subsequent documents. The updated treatment recommendation of uncomplicated and severe malaria in
pregnancy is part of the WHO Guidelines for the treatment of malaria, (http://www.who.int/malaria/docs/
TreatmentGuidelines2006.pdf), while an updated recommendation on intermittent preventive treatment in
pregnancy (IPTp) is in this report: http://www.who.int/malaria/docs/IPTp/TechnicalExpertMtgIPTpReport.pdf
The Manual
5

1.3 Information for Action
The following four scenarios describe potential information gaps malaria-endemic countries
may have. Each numbered scenario highlights the key unanswered questions and suggests what
implications the answers might have for action.
1. The magnitude of the problem of malaria during pregnancy is not well known.
• Does malaria present a problem for pregnant women and their infants in this area? Does
malaria affect women in their first trimester? How big is the problem? Does malaria
infection during pregnancy affect maternal morbidity and mortality?
Even though it can be assumed that malaria during pregnancy is a significant problem and
requires intervention in areas with high transmission of P. falciparum infections, a more
precise documentation of the problem locally can also be used to advocate for increased
resources and commitment to develop or enhance a program that addresses malaria during
pregnancy. Also, in areas with other malaria transmission patterns (low-intermediate,
seasonal, unstable), relatively little may be known about the burden of malaria during
pregnancy. If malaria infection affects women in their first trimester, women will need to be
encouraged to come in for care early, and the National Malaria Control Program will need to
look for a strategy to control the adverse effects of malaria during pregnancy that includes
women in their first trimester.
2. The burden of malaria in pregnancy is known, but policy and program strategy have
not yet been developed.
• What proportion of pregnant women seek antenatal care in antenatal clinics? What is the
coverage of antenatal clinics? What barriers do pregnant women face when obtaining care
from antenatal clinics?
If antenatal clinics provide services for the majority of pregnant women in the area,
resources should be directed to provide or improve interventions in antenatal clinics.
If antenatal clinic coverage is not high, it is important to learn why and address
the causes.
• What should be done if the prevalence of malaria infection in pregnant women is low? Does
it make a difference if pregnant women are symptomatic or asymptomatic?
If prevalence is low, IPTp should not be offered. If most cases of malaria infection are
symptomatic, the country may decide to treat cases rather than offer IPTp; if most
cases are asymptomatic, then preventive treatment is necessary.
3. Policy has been developed, programs have begun, and information is needed on
program implementation.
Coverage of interventions
• What percentage of pregnant women is the program reaching?
If coverage is low, it will be important to determine the causes, which can be better
understood by examining issues relating to the facility and the clients themselves.
6 The Rapid Assessment of the Burden of Malaria during Pregnancy

Facility-dependent aspects of providing interventions
• Are antenatal clinics equipped to provide the recommended interventions? Do they have
trained health workers who can provide the needed interventions and care? Are drugs and
supplies available? Are health workers aware of what the policy says? Are the antenatal
clinic health workers providing the needed interventions appropriately?
Lack of needed supplies point to the need for improvement. Any deficiencies
revealed in health-care worker knowledge or provision of services can identify
specific training needs.
Client-dependent aspects affecting acceptance and use of malaria interventions
• Are pregnant women able to obtain and willing to take antimalarial medications for
IPTp and treatment of malaria illness? Do women have access to and do they use ITNs?
What are pregnant women’s knowledge of and attitudes about malaria and its effects
during pregnancy? What cultural taboos affect how they seek care if they have malaria
infection during pregnancy? Where do they receive their information and advice
about malaria prevention? What is the best way to provide information about malaria
prevention?
Understanding what facilitators and barriers exist to women’s access and use of
needed interventions can help in understanding program implementation issues.
Understanding where and how they receive information about malaria can aid in
the development of health education and communication campaigns, if needed.
4. Intervention coverage is substantial, and the country wants to determine the
impact of the program.
• Are the programs achieving their goals—improved health for pregnant women and
their infants?
Measures of coverage, placental infection, and LBW, as well as other indicators can give
a snapshot of the effectiveness of the current program. These measures can also serve
as baseline data against which to evaluate the impact of new interventions.
Information alone is not sufficient to respond to the problem of malaria during pregnancy.
Commitment and resources are needed to translate this information into action.
►Commitment by malaria programs and reproductive health programs at national
levels and below to use the information obtained to develop or refine policy and
guide successful program implementation. The conduct of the assessment may seem
to raise awareness of malaria in pregnancy among stakeholders and policymakers—a
crucial step toward mobilizing necessary human and capital resources.
►Adequate human and financial resources to conduct the assessment, develop
strategies for local and subregional programs, and provide ongoing monitoring
and evaluation of these activities. In the process of conducting the assessment and
obtaining necessary information, the country strengthens its capacity to conduct
operational research, which will likely be needed to continue to guide programs
focusing on malaria as well as other diseases that threaten the health of its people.
The Manual
7

1.4 Use of the Rapid Assessment Package
The manual does
not lay out a
"one-size-fits-all"
approach and is
intended to be
adapted for use
by countries in
all regions of the
world affected by
malaria.
This rapid assessment 2 package is intended to assist a country quickly and comprehensively
gather information it needs about the problem of malaria during pregnancy and opportunities
for successful intervention.
A country may be able to take advantage of a wealth of information about the problem of
malaria during pregnancy — current, relevant, available at no cost —within the Ministry of
Health (MoH), for example. Information may also be available from other reliable sources,
including Demographic Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS),
and Malaria Indicator Surveys (MIS). Regional information from networks such as Malaria
in Pregnancy East and Southern Africa: Coalition for Prevention and Control (MIPESA) and
Réseau d’Afrique de l’Ouest contre le Paludisme pendant la grossesse (RAOPAG) can be
another important source of information.
Available sources may not supply all the information needed; thus, this assessment package
was developed. The tools in this package are largely designed to obtain information from
antenatal clinics and delivery units, even though not all women seek care from antenatal
clinics or deliver their babies at a health facility. The currently recommended interventions are
facility-based, and most countries that provide interventions for pregnant women concentrate
their efforts on expanding implementation in facilities. See Chapter 4 for limitations of this
approach.
The package contains a manual with general guidance:
• Chapter 2 outlines the design of a rapid assessment.
• Chapter 3 gives general information about preparing for and conducting
a rapid assessment.
• Chapter 4 outlines how to manage, analyze, and interpret the data collected.
• Chapter 5 provides information about preparing a report and using the
assessment information gathered.
The rest of the package has more specific tools and information:
• Modules 1-10 have assessment tools ready to be adapted to the needs of each
country. Each module contains most of the information and written materials needed
for that part of the assessment.
• Resources 1-4 contain a list of relevant articles, guidelines, sample PowerPoint
presentations useful for training, and data analysis software (Epi Info).
The manual does not lay out a “one-size-fits-all” approach and is intended to be adapted for
use by countries in all regions of the world affected by malaria.
2 The term “rapid assessment” can be used in multiple ways. As described in this manual, a rapid assessment
provides a “snapshot” at one point in time of the problem of malaria and opportunities for intervention.
A rapid assessment does not replace program monitoring and evaluation activities, but can form part of a
monitoring and evaluation strategy.
8 The Rapid Assessment of the Burden of Malaria during Pregnancy

2. Planning the Rapid Assessment
2.1 Objectives of the Rapid Assessment
Depending on a country’s information needs, its rapid assessment could have one or
more of the following objectives:
• Determine the burden of malaria
• Determine what sort of policy and program should be developed
and implemented
• Assess implementation progress
• Assess the program’s impact on infant and maternal health.
It is important to note that regardless of which malaria-related objectives are selected,
another objective—to build national capacity to conduct operational research—will be
achieved through the process of planning, conducting, and analyzing the assessment.
2.2 Potential Information Sources
Information may be readily available that fills some, although perhaps not all, of the
information gaps. Sources 3 of ready and recent (e.g., within the previous 5 years data are
various and may include
• Demographic Health Surveys (DHS) (see 2.2.1)
• Multiple Indicator Cluster Surveys (MICS) (see 2.2.2)
• Malaria Indicator Surveys (MIS) (see 2.2.3)
• Roll Back Malaria (RBM) baseline surveys
• National routine health information systems
• Reports by nongovernmental organizations
• Published scientific articles about malaria in pregnancy in the country
or the region
Numerous household surveys have been conducted since 2000, including DHS, MICS,
Population Services International surveys, and RBM baseline surveys.
The following Web site tracks major household surveys and data collection tools:
http://www.internationalsurveynetwork.org/home/
Pertinent studies include those conducted not only in the country or district itself, but
also in the subregion (“subregion” denotes an area that is part of a WHO-defined “region”).
Subregional data are an often underutilized source of information and may provide adequate
information, especially about the magnitude of the problem (e.g., prevalence of malaria
infection in pregnant women’s blood and placenta) from a country with similar geoclimatic
characteristics. In addition, since customs and taboos vary by ethnic group, data from the
same ethnic group in a neighboring country may provide sufficient information about the
cultural aspects of malaria and its treatment and prevention.
3 It is important to note that some of the surveys above, for example DHS and MICS, are population-based
rather than facility-based, and thus cannot be used to validate results of this facility-based assessment.
The Manual
9

In recognition of the importance of subregional information and approaches to malaria
control and prevention, several subregional networks have been established in the African
region that focus on the prevention and control of malaria during pregnancy. MIPESA was
created in 2002 to bring together five countries (Kenya, Malawi, Tanzania, Uganda, Zambia),
all of which had adopted policy for control of malaria in pregnancy (IPTp, ITNs, and effective
case management), in line with WHO recommendations. In West Africa, RAOPAG was formed
in 2003 and includes malaria-endemic countries of West Africa. These organizations routinely
share their data and experiences at network meetings.
Because using available data can save time and money,
• Determine if a recent 4 study has been done either in the country or in a country with a
similar malaria profile.
• If a recent study has been done, consider when, where, and among whom it was
conducted.
2.2.1 Demographic and Health Surveys
Demographic and Health Surveys (DHS) are nationally representative household surveys that
focus on reproductive and child health. Organized by Macro International, Calverton, MD,
USA, and sponsored by the United States Agency for International Development (USAID), a
typical DHS has a large sample size (usually between 5,000 and 30,000 households) and uses
a multiple-stage cluster design. Because questionnaires are standardized and structured and
change little between surveys, DHS outcomes are comparable between countries and over
time. The average interval between two DHS is approximately 5 years.
Since 1998, some DHS have used specific questions relevant to malaria prevention and
treatment, including
• antenatal clinic coverage
• delivery unit coverage
• type of antimalarial drugs given, timing, and dosage
• possession of mosquito nets and their use for children less than 5 years old and
pregnant women
• use of IPTp by pregnant women.
• prevalence of anemia by hemoglobin measurement in children less than 5 years old
and pregnant women.
The DHS survey package also includes an optional malaria module, which can be used in all
surveys conducted in malarious countries.
Data are available at http://www.measuredhs.com. For more information about DHS, consult
http://www.measuredhs.com/ or contact MEASURE DHS+, Macro International Inc., 11785
Beltsville Drive, Suite 300, Calverton MD 20705 USA; tel: 301-572-0456; fax: 301-572-0999;
e-mail: measure@orcmacro.com.
4 The meaning of “recent” varies by situation. In some cases, where no new programs have been initiated,
no initiatives to improve services have been instituted, and the malaria transmission level is considered to
be about the same, a 5-year-old survey may provide adequate information.
10 The Rapid Assessment of the Burden of Malaria during Pregnancy

2.2.2 Multiple Indicator Cluster Surveys
Multiple Indicator Cluster Surveys (MICS) are also nationally representative household
surveys. They use a two-stage cluster sampling design, with an average sample size of around
6,000 households. The questionnaire covers living conditions and household assets, allowing
the data to be stratified by such factors as place of residence, education of the mother, and
wealth quintile of the household. MICS are conducted approximately every 3 years in about 70
countries worldwide.
This survey also has questions about
• prevalence of fever in the previous 2 weeks
• type of treatment received and place of treatment
• use of any nets and of ITNs by children less than 5 years old.
Data are collected on indicators such as all-cause mortality among children less than 5 years
old and coverage of antenatal care.
Survey results and questionnaires are available at http://www.childinfo.org/. Like DHS, most
MICS are conducted outside the peak malaria season.
2.2.3 Malaria Indicator Survey Package
RBM’s Monitoring and Evaluation Reference Group has a package of tools for assessing
coverage of key RBM interventions at the household level: coverage of ITNs, antimalarial
treatment among children under 5 with fever, and IPTp. It includes defined indicators;
questionnaire and data tabulation plans for calculation of indicators; and guidance on
conducting surveys, designing sampling frames, and calculating sample sizes. The sample size
is usually about 3,000 households, smaller than that required for a DHS or MICS. The MIS
should be conducted during the peak malaria season. The MIS package can be accessed at
http://www.rollbackmalaria.org/
The following information taken from WHO's World Malaria Report 2008 provides an
example of data available from recent surveys.
Survey data: Percentage of pregnant women who
slept under an insecticide-treated net the night before the survey
Africa Year Source Percentage
Benin 2006 DHS 2006 20.0
Congo 2005 DHS 2005 4.0
Ethiopia 2007 MIS 2007 35.0
Guinea 2005 DHS 2005 1.0
Kenya 2003 DHS 2003 5.0
Malawi 2004 DHS 2004 15.0
Mali 2006 DHS 2006 29.0
Niger 2006 DHS 2006 7.0
Rwanda 2005 DHS 2005 17.0
Senegal 2006 MIS 2006 17.0
Tanzania 2004 DHS 2004-05 16.0
Uganda 2006 DHS 2006 10.0
Zambia 2006 MIS 2006 24.0
The Manual
11

2.3 Designing the Rapid Assessment
The table below links potential information needs with the appropriate assessment tools in
this package.
Scenarios, Information, Assessment Tools
Scenario Information Tool(s)
Size of problem
of malaria
in pregnancy
Development
of policy and
strategy
Program
implementation
Program
impact
Measures of impact:
• Prevalence of peripheral and placental
malaria and anemia
• Relationship of malaria to LBW and
prematurity
• Illness and adverse pregnancy outcomes
due to severe malaria
Sources of care:
• Where pregnant women receive care
• Antenatal clinic coverage
Prevalence profile:
• Level of prevalence, prevalence
by gravidity and locale, symptoms
associated with infection
Coverage of interventions:
• Percentage of pregnant women
reached by program
Facility-dependent aspects of
providing interventions:
• Availability of equipment, supplies
(including ITNs), medications
• Staffing patterns; schedule; services
• Current practices
• Medications dispensed
• Health education
• Relationship between community
services (traditional birth
attendants 1 ) & facility-level staff
Client-dependent aspects of offering
interventions:
• Sources of information and advice
about malaria prevention
• Barriers to obtaining antenatal
are and using recommended
interventions
Measures of impact:
• Prevalence of peripheral parasitemia
and anemia
• Prevalence of placental and cord
parasitemia
• Severe malaria outcomes
• Low birth weight
• Incidence of prematurity
1: Antenatal clinic surveys
2: Delivery unit surveys
3: Hospital surveillance of malaria
disease
Note: No assessment tools will yield
this information. DHS and MIS can
supply information on source of
care; MICS can supply some of this
information.
1: Antenatal clinic surveys
2: Delivery unit surveys
3: Hospital surveillance of malaria
Note: No assessment tools will yield
this information. DHS and MIS can
supply information on source of
care; MICS can supply some of this
information.
4: Antenatal clinic facility assessment
5: Health-care worker (HCW)
observation
6: Individual interviews and focus
groups with HCWs
7: Individual interviews and focus
groups with midwives 2 and
traditional birth attendants.
6: Individual interviews and focus
groups with HCWs
7: Individual interviews and focus
groups with midwives and
traditional birth attendants
8: Antenatal clinic client exit
interview
9: Individual interviews and focus
groups with pregnant women
10: Individual interviews with key
informants
1: Antenatal clinic surveys
2: Delivery unit surveys
3: Hospital surveillance of malaria
disease
Tools 1, 2, 3, 4, 5, and 8 are quantitative; Tools 6, 7, 9, and 10 are qualitative. Ideally, if
Tool 6, 7, or 9 is selected, both interviews and focus group techniques should be used, as
they may provide different data and can also serve to validate data from other techniques
(“triangulation”). If both cannot be done, the more appropriate technique should be chosen
based on the local situation. See Modules 6, 7, and 9 for each technique’s advantages and
disadvantages of each technique.
1 Traditional birth attendant refers to a person without formal training who delivers babies.
2 Midwife refers to a person who has professional training in the delivery of babies.
12 The Rapid Assessment of the Burden of Malaria during Pregnancy

3. Conducting the Rapid Assessment
This chapter provides information about specific activities that are relevant to all assessment
instruments: selecting a time period for the assessment; determining a general timetable and
budget; building a team; selecting assessment areas and sites and determining sample sizes;
selecting and organizing team members; adapting and translating questionnaires; training of
the assessment team; and conducting the assessment (including assuring assessment quality
and providing information to participants about the survey/informed consent).
3.1 Selecting a Time Period
The following are important considerations for deciding when to conduct the assessment:
• Seasonal patterns of malaria transmission: It is ideal to maximize the number of cases
of malaria parasitemia by attempting to schedule the assessment during periods of high
transmission (i.e., during or soon after the rainy season). Assessments during this time
capture the worst-case scenario and are important for planning and advocacy purposes.
In addition, data can be collected most efficiently during these periods. However, if
prevalence differs markedly by season, it might be preferable to conduct the assessment
during both high and low transmission periods. The benefit of obtaining this information
would need to be balanced against the additional use of resources required to repeat the
assessment.
Demographic and
Health Surveys,
Multiple Indicator
Surveys, and
Malaria Indicator
Surveys contain
questions related
to malaria
interventions
and outcomes.
• Road conditions and facility/community access: All data collection must take place when
facilities and communities are accessible by road. Travel can be difficult during the rainy
season. In addition, one must confirm that the health facilities that
will be included in the assessment will be open and in use during the proposed
assessment dates.
• Availability of assessment staff: Assessment staff must be available for the training and
during the entire assessment period.
3.2 Determining a Timetable and Budget
The total duration of the assessment, as well as the cost, depends on which, how many, and in
what sequence (simultaneously or sequentially) the rapid assessment tools are conducted. It
also depends on the number of areas where the assessment is conducted and the number of
participants selected. See Modules 1 and 2 for sample survey timetables for the antenatal clinic
and delivery unit surveys.
If all tools are to be used, it is recommended that the qualitative components of the assessment
(e.g., focus groups, individual interviews) be conducted at the same time as the quantitative
component. This could be facilitated by, for example, having a local university or other
institution of higher learning conduct the individual and focus group interviews while the MoH
conducts the other studies.
It is possible that both national and external sources of funding may be found to help
finance the assessment. A sample costing tool is provided in Resource 4 to assist in
determining a budget.
The Manual
13

3.3. Building and Organizing the Assessment Team
3.3.1 Roles, Responsibilities, and Requirements
Assessment Coordinator
An assessment coordinator is essential for planning and supervising all assessment activities.
He or she may do this alone or in conjunction with his or her supervisor. The assessment
coordinator is key to building assessment teams that can successfully conduct the assessment.
If the assessment will include collection of qualitative data, ideally the assessment coordinator
will have had experience in qualitative data collection. If not, a coordinator for that portion
of the assessment should be selected and should work closely with the overall assessment
coordinator. No activities should occur before an assessment coordinator is selected.
Note: If the assessment coordinator will also supervise and conduct qualitative research, he/
she will also have the responsibilities listed below for the qualitative data coordinator.
Responsibilities
• Discuss the assessment with health authorities, local partners, and
community leaders
• Select assessment sites
• Select site supervisors, interviewers, and laboratorians
• Ensure procurement of assessment equipment and supplies (See modules for list)
• Organize and manage the training of site supervisors, interviewers, and
laboratorians
• Collect data from facility assessments and health-care worker observations
• Establish quality control and supervisory mechanisms in each assessment site
• Troubleshoot and make adjustments as needed
• Ensure appropriate analysis and report results from the rapid assessment,
in conjunction with assessment coordinator of the qualitative component,
if different
Requirements
• Have experience working in or have links with the health system
• Be familiar with the local health system and health divisions
• Have experience conducting facility- and community-based surveys
• Have some technical knowledge in the areas of reproductive health
and malaria (optimal)
• Be able to troubleshoot and adjust accordingly
• If possible, have experience administering, budgeting, managing public
health programs
14 The Rapid Assessment of the Burden of Malaria during Pregnancy

Qualitative Data Coordinator
Responsibilities
• Discuss the assessment with health authorities, local partners, and
community leaders
• Select interviewers, facilitators, recorders
• Organize and manage training of interviewers, facilitators, and recorders
• Revise interview guides as necessary
• Supervise interviewers and data management
• Communicate with facilities before the site visits to organize interviews so as to not
disrupt patient care, select key informants, select focus group venues
• Ensure procurement of assessment equipment and supplies (See modules)
• Establish quality control and supervisory mechanisms
• Ensure appropriate analysis and report results from the rapid assessment
Requirements
• Have experience working in/have links with the health system
• Be familiar with the local health system and health divisions
• Have knowledge of qualitative methodology (including differences between
individual and focus group interviews)
• Understand elements of qualitative debriefings (See 3.7 and Modules 6, 7, 9, 10)
• Have experience conducting qualitative assessments
• Have skills in qualitative data management (working knowledge of computer
programs such as Word, Excel; production of field notes; ability to track data
across facilities)
• Have reasonable technical knowledge of reproductive health and malaria (optimal)
• Be able to troubleshoot and adjust accordingly
Laboratory Component Supervisor
A laboratory component supervisor is critical for an assessment that conducts antenatal clinic
and/or delivery unit surveys.
Responsibilities
• Ensure control of laboratory procedures in all assessment sites
• Oversee all laboratorians working on the assessment
Requirements
• Have experience working in/have links with the public health system
• Have technical expertise in malaria microscopy (optimally, has several years’
experience reading thick and thin blood films)
• Has been trained to read placental blood smears by the time the study starts
• Be competent in the training and management of laboratorians
The Manual
15

Site Supervisors, Interviewers, and Laboratorians
Site supervisors, interviewers, and laboratorians should be selected carefully by the persons
organizing the assessment. These team members are essential to the success of the rapid
assessment. It is important that they be well trained.
Responsibilities
Site supervisors:
Interviewers:
Laboratorians:
• Ensure assessment quality (See 3.7)
• May also assist in administering the questionnaires and in conducting
clinical procedures
• Troubleshoot, in consultation with the assessment supervisor
• Administer questionnaires and conduct all clinical procedures
• Conduct all laboratory procedures
Data Management Coordinator
Responsibilities
• Ensure that data are kept securely
• Assist in data analysis
3.3.2 Staffing Approaches for the Assessment
Quantitative Component
Depending on which tools are selected for the rapid assessment, the assessment coordinator
could use either or both of the following approaches to select assessment team members for
the quantitative portion of the assessment (e.g., antenatal clinic survey, delivery unit survey,
severe disease surveillance, client exit interview, health-care worker observation, health
facility assessment):
• Hire new staff
• Use existing antenatal clinic and delivery staff.
New staff hired specifically for the quantitative portion of the assessment should be organized
by teams, with each team composed either of one laboratorian and three interviewers or one
laboratorian, two interviewers, and one site supervisor. If existing antenatal clinic and delivery
unit staff are used, one of the staff members at each antenatal clinic or delivery unit should be
designated as the site supervisor.
The antenatal clinic teams can rotate between antenatal clinics included in the assessment
until the desired sample size is obtained. Ideally, for the delivery unit survey one team member
will be available 24 hours per day in the delivery unit to promptly process placental samples.
It may be helpful to include an additional interviewer for this purpose. If this is not possible, a
cooler and icepacks should be available so that placentas can be stored.
16 The Rapid Assessment of the Burden of Malaria during Pregnancy

Advantages and Disadvantages of Staffing Approaches
Staffing
Approach
Hire new
staff
Use existing
health staff
Advantages
• Assessment is staff’s priority
• Payment is simple
• Rapid assessment does not
compromise delivery of
clinical care
• Builds capacity
• Facilitates enrollment
• Facilitates clinical treatment
when indicated
• Builds morale
• Ownership of assessment
• Buy-in for future
interventions
Disadvantages
• No capacity building of existing staff
• Existing staff may resent outsiders if
effective linkages to clinic staff not made
• May be more expensive
• May compromise assessment quality if
nonmedical staff do not have sufficient
training
• May be more difficult to ensure treatment
of women with anemia or malaria
• MoH may feel less invested in the
assessment
• May overburden busy staff
• Assessment work (if paid) may take
priority over regular work
• Payment issues are delicate
• Staff may think that any work requires
extra payment
• May compromise quality of assessment
in busy settings
• May be competing with projects going
on simultaneously
The choice of whether or not to hire new staff should be guided by
• Consideration of personnel available and able to conduct these activities
• Financial constraints. The project budget may make it difficult to hire outside staff,
which is the more expensive option.
If existing staff members make up the assessment team, the following could help show
appreciation for their assistance in assuming additional responsibilities outside their normal
workload:
• Improve the working environment by supplying equipment, books, and/or teaching
materials or by improving the facility (for example, buying teapot and tea supplies,
painting walls)
• Invite staff to dissemination activities/presentation of results at the end of
the assessment
• Pay a “per diem” for attending assessment training, but not for conducting
the assessment
• Provide payment (an “incentive”) for the extra work the staff does as part
of the assessment
• Provide certificate of participation in study.
See Modules 1-10 for a list of specific personnel needed to conduct each tool.
The Manual
17

Qualitative Component
If the assessment includes a qualitative portion, it is important to consider the approach that
will be used for managing data collected from individual and focus group interviews (see
4.2). Each approach has implications for the personnel and software needed to manage and
analyze the data. New staff may need to be hired (current staff is unlikely to be trained in this
type of research), or a university or another institution with expertise in qualitative research
may be involved. However, if insufficient resources and opportunities exist, current staff can
be provided intensive training. This can be an excellent opportunity to build local/national
capacity to conduct qualitative studies. See Resource 2.
Six to eight people are needed to conduct the qualitative portion of the assessment. For
individual interviews, the number of staff needed depends on staff experience. An experienced
staff member could both interview and record; if more junior or inexperienced staff members
are used, individual interviews will require one person to interview and another to record.
Focus groups require one person to facilitate (i.e., ask questions) and at least two people to
record, if at all possible.
3.4 Selecting Assessment Areas, Sites, and Sample Sizes
3.4.1 Assessment Areas
The objective(s) of the rapid assessment will guide the selection of the assessment area
or areas. For example, a country may wish to obtain information on the problem and
interventions countrywide, or in one or more geographic regions, or in one or more districts,
or in urban versus rural areas.
Whether the assessment focuses on an entire country or only one region of a country, the
most important selection criterion is the transmission pattern of malaria. If the transmission
pattern differs markedly within the area of interest, an attempt should be made to collect
information from subareas with different transmission patterns. The chief concern should be
to obtain representative data from the area of interest. Although an ideal assessment might involve
sampling a variety of sites within the country, resources often dictate choosing one site,
or a number of sites in a well-defined geographic area such as a district, which are likely to be
representative of the general situation of malaria during pregnancy.
18 The Rapid Assessment of the Burden of Malaria during Pregnancy

3.4.2 Assessment Sites
Quantitative Component
Within the country, region, or district of interest, the following criteria can be used to select
specific sites for facility-based surveys, observations, and interviews:
• A sufficiently high volume of antenatal clinic clients (antenatal clinic survey) or facilitybased
deliveries (delivery unit survey) to ensure that numbers are adequate to reach the
desired sample size most expeditiously and within the allotted time for the study
• Facilities with both an antenatal clinic and a delivery unit (for the sake of efficiency in
conducting the assessment)
• Ability to gain access to antenatal clinics and delivery units during the assessment
• Representativeness of the facility population (in terms of ethnicity, urban/rural
residence, socioeconomic status)
• Geographic area to ensure coverage from different geographic areas. This may be
difficult to achieve in reality, as previously noted.
The more facilities involved, the more representative the data. However, the larger the
number of facilities selected, the more resources (human, financial, logistic) will be
required to conduct the assessment. Thus, those selecting sites should balance the need for
representativeness of data with the availability of resources.
Experience with rapid assessments shows that a total of two delivery units and four antenatal
clinics from a selected district or region is feasible and reasonably efficient for assessment
of burden of disease, but these are not “magic” numbers. The needed sample size and client
volume in the assessment area may affect the number of sites selected per region or district.
See modules.
Qualitative Component
Participants can be selected from the chosen health facility catchment areas or from a larger
number of districts or regions, depending on the budget. If participants are chosen from a
broader number of districts or regions, they should be chosen in much the same way that
districts or regions selected for the quantitative surveys have been chosen.
Focus groups and individual interviews can be held in health facilities, homes, and community
venues, depending on who is being interviewed.
The Manual
19

3.4.3 Sample Sizes
Sample sizes for antenatal clinic and delivery unit surveys depend largely on point estimates
of key indicators of burden and desired level of accuracy. Sample sizes recommended for
other tools derive from experience conducting assessments. Modules 1 and 2 contain more
information on how to calculate sample sizes for antenatal clinic and delivery unit surveys.
Summary of Required Sample Sizes, by Tool
Assessment Tool
1. Antenatal clinic
surveys
2. Delivery unit
surveys
3. Hospital surveillance
of malaria disease
4. Antenatal clinic
facility assessment
Assessment Tool
5. Health-care worker
observation
6. Focus groups
and individual
interviews with
health-care workers
7. Focus groups
and individual
interviews with
midwives and
traditional birth
attendants
8. Antenatal clinic
client exit interview
9. Focus groups
and individual
interviews with
pregnant women
10. Individual
interviews with
key informants
Sample Size/Notes
Sample size will depend on the coordinator’s estimate of
peripheral parasitemia and 3 rd trimester anemia, as well as the
margin of error the coordinator thinks acceptable. See Module 1
for more detail.
Sample size will depend on the coordinator’s estimate of
placental parasitemia and LBW, as well as the margin of error the
coordinator thinks acceptable. See Module 2 for more detail.
All ill women admitted to the hospital during the time data are
being collected during the antenatal clinic and delivery unit
surveys.
Each of the antenatal clinics selected for an antenatal clinic survey
(and may be expanded if this sample is believed to be too small).
Sample Size/Notes
Observation of approximately 20-25 health-care worker/patient
encounters per each antenatal clinic selected for an antenatal
clinic survey.
Individual interviews are preferable if timing is not an issue.
Could interview as many health-care workers as feasible during
the assessment period, probably no more than 5-10 per facility,
but sometimes as few as 1-2 is all that is possible.
At least one focus group with 5 to 15 participants per facility
area. May wish to conduct interviews as well, depending on the
available pool of potential participants.
Approximately 15 per site. Note: Women selected for interviews
should be different from the women selected for the antenatal
clinic surveys.
At least one focus group with 5 to 15 participants per facility. Four
to five individual interviews per facility.
Individual interviews with 2-4 key informants per facility area.
20 The Rapid Assessment of the Burden of Malaria during Pregnancy

3.5 Adapting, Translating, and Preparing
Assessment Materials
Once the assessment teams have been formed, assessment instruments (questionnaires,
information sheets/informed consent forms, observation forms, interview guides) and
logbooks will need to be prepared. Each module in this packet contains sample survey
materials, which will likely need to be tailored for use in the particular local context. For
example, changes may need to be made to reflect the drugs and the drug trade names used in
a particular country. Additional questions may need to be added to obtain other variables of
interest, for example, such socioeconomic and demographic variables as caste, ethnic group,
or family income. One country may wish to exclude pregnant women younger than 15; others
may have no lower age limit.
The materials should be reviewed, pretested, and adapted as much as possible prior to
assessment training and then again during the training sessions, at which time they may
require additional adjustment.
Focus groups
and individual
interviews can
be held in health
facilities, homes,
and community
venues, depending
on who is being
interviewed.
After the survey instruments are adapted, they and the information sheet (or informed
consent form if used) should be translated into the national language and the primary
language spoken by women in the assessment area, if different. This initial translation
should be followed by a back-translation (by individuals who did not produce the original
translation) into the national language to check the accuracy of the translation.
If the primary language is not a written language, it will be important to work to achieve
correct, consistent phrasing of survey questions and information on the information sheet
(or informed consent form). It is important to hold a discussion with all interviewers present
to agree on phrasing and to give the interviewers an opportunity to practice. Each participant
should still receive a copy of the information sheet.
It is critical to maintain participants’ confidentiality according to the laws of the country or
jurisdiction. If appropriate to the local situation, questionnaires can be designed with a tearoff
identifier page, which can be removed once data entry and validation are complete. The
removal of the identifier page ensures that recorded data cannot be linked to the participant.
3.6 Conducting Assessment Training
Whether or not the qualitative and quantitative components are conducted simultaneously
largely depends on the tools selected and the availability of assessment team members.
In turn, the timing of these components may help determine how and when training is
conducted, although ideally training should be done within a few days before the start of the
assessment. Training of the teams can occur after the preassessment activities described in
the previous section and will take approximately 4-5 days.
If training for both will occur during the same time period, the quantitative and qualitative
teams should meet the first day of the training session to receive an overview of the entire
assessment. Some topics are relevant to both teams, including providing information/
obtaining informed consent, general information on the effect of malaria infection during
pregnancy, politics of and sensitivities to conducting an assessment in health-care facilities
(if assessment staff is hired from outside the system), and approaching potential participants.
The teams can then separate to learn their specific tasks. The training period can also be used
The Manual
21

to ensure that the assessment tools are linguistically and culturally consistent. After this,
ideally, the entire team should be brought back together to review assessment timing, learn
who will work at each facility, and review who will assume supervisory roles. Regardless of
when training is conducted, each team should understand what the other teams are doing, the
types of data that they are gathering, and the methods they are using. The entire team should
be prepared to answer questions about the assessment as a whole.
Quantitative Component
During training, each question on the questionnaire should be reviewed, and team members
should be given a chance to practice conducting the questionnaire with other team members
and then with clients in local antenatal clinics. Team members should become familiar
with how to fill out logbooks. The coordinator should explain why an information sheet (or
informed consent) is necessary (see 3.8).
Training will also focus on ensuring that team members can perform the needed clinical
procedures including collecting blood using fingersticks, preparing slides, and weighing a
newborn. They should practice these skills in a working facility. Because women in the surveys
should receive treatment according to national policy, if they are found to be anemic or are
suspected or confirmed to have malaria infection, interviewers should be prepared to ensure
that women and neonates receive proper treatment. Laboratorians should be trained in how
to read peripheral, placental, and umbilical cord blood films. See each module for additional
information about training.
Note: Because many countries may choose to conduct both an antenatal clinic and
delivery unit survey and because it is more efficient to conduct training for these two
simultaneously, this manual describes combined training in Modules 1 and 2, which
can be modified, if necessary.
Qualitative Component
During training, qualitative teams should focus on learning and practicing how to interview,
as well as how to record notes during an interview. Ideally, several days should be allowed for
training. The coordinator or facilitator should review the essential elements of interviewing,
particularly recording (i.e., taking notes on) interviews. Recording individual interviews or
focus groups, while not difficult, must be done well, as it determines the quality of the data.
Team members should be observed role playing and giving mock interviews with people who
are not members of the assessment teams. Teams can often practice in local clinics where
the assessment will not be conducted to assess the individual team members’ strengths and
weaknesses. Practice might show that one person is a better focus group facilitator than an
interviewer, for example. Team members’ positions should closely match their strengths.
Consult the Sample Interviewer Training Manual in Resource 2 for additional information
about training.
22 The Rapid Assessment of the Burden of Malaria during Pregnancy

3.7 Assuring Assessment Quality
A quality assurance mechanism for data collection, transport, and storage should be
established to ensure that data are of high quality. To oversee quality control, a supervisory
system should be in place that ensures that questions, concerns, and technical issues are
addressed in a timely manner.
Quantitative Component
The site supervisor (one per team) is responsible for the following:
• Reviewing all questionnaires, enrollment, laboratory, and treatment logbooks
(and written consent forms, if used) each day for accuracy and completeness
• Maintaining a daily logbook that shows the identification (ID) numbers of the
interviews that were completed during that day, in which facility they were
completed, date of interview, and name of interviewer
• Ensuring that each consecutive page of the interview has an ID number in case
the pages become separated
• Giving feedback to interviewers regarding accuracy and completeness of
questionnaires and logbooks
• Discussing issues and concerns and developing solutions (e.g., completeness
of logbooks, inconsistent completion of questionnaires, patient flow, lack of supplies,
equipment failures)
To oversee
quality control, a
supervisory system
should be in place
that ensures
that questions,
concerns, and
technical issues
are addressed in a
timely manner.
The laboratory component supervisor is responsible for:
• Ensuring that adequate reagents and other needed materials are available
• Reviewing laboratory logbooks and ensuring that they are accurate and complete
• Reread a sample (for example, 10%) of all assessment blood films weekly for
accurate diagnosis
• Evaluating quality of slides (both blood film preparation and staining), and
providing technical support when needed for slide reading
The assessment coordinator also plays an important role in ensuring the quality of the entire
rapid assessment by:
• Making at least weekly visits to review all logbooks and questionnaires from all
assessment teams and giving feedback to site supervisors and the microscopy
supervisor as appropriate. The coordinator should transport completed forms and
blood films to a secure central location on a weekly basis.
• Establishing a mechanism to distribute and re-stock assessment supplies. During
the assessment start-up, the assessment coordinator is responsible for assuring
that each assessment site has adequate equipment and supplies for at least 2 weeks
of data collection. During the assessment, site supervisors are responsible for
inventory of all supplies and equipment throughout the assessment period at each
assessment site to assure that data collection is not interrupted.
• Ensuring that adequate copies of antenatal clinic and delivery unit questionnaires
are available at each assessment site. During the assessment start-up, the
assessment coordinator is responsible for assuring that each assessment site has
adequate copies of antenatal clinic and delivery unit questionnaires and informed
consent forms (or information sheets) for at least 2 weeks of data collection. During
the assessment, site supervisors are responsible for inventory of questionnaires
throughout the assessment period and at each assessment site to assure that data
collection is not interrupted.
• Ensuring adequate numbers of focus group and interview guides are available.
• Ensuring participant confidentiality.
The Manual
23

Qualitative Component
The coordinator for the qualitative part of the assessment (individual and focus group
interviews), if different from the overall assessment coordinator, has primary responsibility
for that portion of the assessment but should work closely with the overall assessment
coordinator.
The qualitative assessment coordinator is responsible for
• Observing groups and interviews periodically to ensure that the facilitators and
interviewers are using proper technique, e.g., that they are using questions in the
guide but adapting them as necessary in order to elicit the intended responses
• Reviewing all recorded interviews for completeness and accuracy of recording
• Ensuring accurate and consistent use of traditional terms for illnesses, symptoms,
and prevention and treatment strategies, including usage and spelling.
• Ensuring that the needed information is being obtained by reviewing recorded
interviews and focus group notes and adjusting (e.g., adding new questions, making
questions more specific) the interview/focus group guides accordingly.
At the end of the interview before the respondent leaves, qualitative interviewers who also
serve as recorders should examine their data to make sure the information is understandable.
During training, they can learn to use standard abbreviations to help them record quickly. In
addition, they can use symbols (such as an asterisk in the column) to alert them to a question
that they might have for the end of the interview. The interviewers should be trained to look
for such symbols and to ask the respondent for clarification. Once the respondent leaves, the
interviewer should again review the interview, spelling out abbreviations and making sure the
handwriting is legible. If both an interviewer and recorder are involved in the interview, both
need to review the data together.
Supervisors should also check interviews at the end of the day, as well as hold a “debriefing.”
A debriefing helps determine: 1) whether the questions are adequate to obtain the needed
data (qualitative methods are iterative; thus, questions can be changed as needed during
the assessment), 2) whether people have understood the question (for example: is the
misunderstanding a sentence structure, content, or a translation problem?), 3) whether data
are similar across facilities or show wide variability, which might require adding questions
to understand the variability, and 4) whether expressions in the local language are being
translated appropriately. The debriefing should be led by the coordinator or another facilitator.
The team listens to what each interviewer has learned, identifies what is common or different,
and mutually agrees on what local expressions mean (particularly important when the team
is trying to understand local beliefs about malaria and/or drugs during pregnancy). During
the debriefings, the coordinator or facilitator should keep notes on the outcomes of each
debriefing, explanations for trends seen in the data, and local language terms, as well as the
agreed-upon translations.
The supervisor should ensure that each consecutive page of the interview has an ID number in
case the pages become separated. The supervisor should also have a logbook for each day that
shows the ID numbers of the interviews that were completed during that day, in which facility
they were completed, date of interview, and name of interviewer.
24 The Rapid Assessment of the Burden of Malaria during Pregnancy

3.8 Providing Information about the Survey
and Obtaining Informed Consent
Each country’s human subjects requirements should be followed in the conduct of the rapid
assessment. Some countries may require that a participant give informed consent and sign a
form; others may require that each prospective participant simply be given information. The
assessment described here is usually classified as program evaluation rather than research
and as such, may not require formal institutional review board (IRB) or ethics committee
review. However, depending on the modifications to the assessment tools and local rules
and regulations, the assessment may require such formal IRB or ethics committee review
and approval. Generally, if blood will be collected and stored or kept longer than the local
guidelines suggest, documentation of informed consent will probably be required.
Each country’s
human subjects
requirements
should be followed
in the conduct
of the rapid
assessment.
If it is decided that participants should be given an information sheet, it should be written in
their primary language and include the following information, if applicable:
• Purpose
• Procedures
• Alternatives to participation
• Risks and discomforts
• Potential benefits
• Provisions of confidentiality
• Voluntary participation and right to discontinue without penalty
• Contacts for questions/additional information
• Any other relevant information (e.g., who is conducting the survey, how many people
will participate)
If the participants cannot read or they have low literacy skills, the information on the sheet
can be read to them. The sheet would then serve as a script for the interviewer. In either
case, the participants should be given a copy. If true informed consent is being obtained, then
there should be a witness present for those persons who cannot sign and whose consent to
participate will be documented with a thumb print. Both the copy retained and the copy given
to the participant should be signed. The supervisors should keep a record of the number of
refusals and the reasons for refusal. For example, often the women in antenatal clinic do not
want to participate in an interview because it would extend the length of their visit.
3.9 Providing Treatment for Malaria and Anemia
In addition to gathering information about a pregnant woman’s experience and practices with
regard to malaria, the antenatal clinic survey will also gather information on the proportion
of women with anemia and malaria. Blood slides for women who are currently or recently
(as defined by country guidelines, e.g., within the previous 7 days) febrile should be read
promptly. Ideally, such slides would be read the same day. These women should wait to receive
their blood results before leaving clinic that day. If the slides are positive, they should receive
treatment with the appropriate antimalarial drug, according to national policy. If women are
found to be anemic, they should also receive appropriate treatment, according to national
policy. If it is determined that a neonate has malaria infection, that neonate should also be
treated as outlined in national policy.
The Manual
25

4. Data Management and Analysis
This chapter is devoted to the management and analysis of data gathered from the
assessment; individual modules contain further guidance.
4.1 Data Management
Quantitative Component
A statistical computer package should be used to enter and analyze the quantitative data from
the assessment. Epi Info is available free of charge and has been included in this package
(Resource 4). It is also available from the U.S. Centers for Disease Control and Prevention
(CDC) Web site (www.cdc.gov/epiinfo). Other packages such as SAS or SPSS may also be used,
although they are not available free; thus, their cost should be included in the budget for the
assessment.
Ideally two computers should be available for data entry. Since all data should be entered
twice to ensure accuracy, two computers could speed the process by allowing simultaneous
entry.
Before the rapid assessment begins, the assessment coordinator should identify a data
management coordinator with experience in using statistical computer software and
managing data entry and analysis activities (see 3.3). Possible candidates for this position
include
• Assessment coordinator
• Local program data manager or other local program staff
• National-level program staff
• Outside consultant, if necessary (one of the intended outcomes of the assessment is to
develop national capacity; therefore, use of an outside consultant is not ideal).
Step 1: Modify (or create) data entry programs
Epi Info can be used to create data entry files for the assessment instruments. Epi Info’s
data entry files consist of questionnaire (.QES), checking (.CHK), and record (.REC) files. The
checking file (.CHK) should specify valid (allowed) variables for each question as well as skip
patterns, which could be defined as sequences of questions asked and omitted in a survey
instrument.
Note: Data entry files for Tools 1, 2, and 3 are included in this package in Resource 4. They
should be modified to reflect any changes made to the surveys that reflect the local situation
or concerns. These Microsoft Access–based .MDB files contain essentially all information that
would be contained in the .QES, CHK, and .REC files mentioned in the next paragraph and can
be opened by Epi Info 2000 and higher.
26 The Rapid Assessment of the Burden of Malaria during Pregnancy

Step 2: Test programs
The assessment coordinator should test the data entry files for each questionnaire by entering
data from pilot or initial questionnaires. Each file should be tested several times and reviewed
to ensure that the data entry files are working correctly.
Step 3: Identify and train data management staff
It is recommended that two people be identified to enter data and trained by the assessment
coordinator or data manager; the training should not take more than a few hours.
Step 4: Enter and store data
It is critical
to maintain
participants’
confidentiality
according to the
laws of the
country/
jurisdiction.
Data can be entered throughout the data collection period or all at once at the end of data
collection. It is strongly recommended that data be entered throughout the time data are being
collected. During the process of data entry, problems in questionnaire design or completion can
be revealed and corrected. The assessment coordinator is responsible for determining which
method is best suited to the setting.
The following suggestions may help improve the process of data entry:
• Find an appropriate pace for data entry. If data entry is attempted too quickly, errors
are more likely to occur.
• Enter data from all questionnaires of one type sequentially (e.g., all antenatal clinic
questionnaires).
• If Epi Info6 is used, the program will assign a record number. Write that number on
the questionnaire.
• Mark each questionnaire with a check or cross after data entry of questionnaire
information to indicate that data entry has been completed. Make sure that after the
data are double entered, the questionnaires have two checks or crosses.
• Encourage data entry clerks to mark items that appear erroneous with a
“post-it” note. Data entry clerks often uncover logical errors in questionnaire design
which can be corrected early on. However, data clerks should be encouraged to note
errors or problems they encounter throughout data entry
and notify the assessment coordinator.
• Back up all data files regularly on a diskette or other storage device such as a zip
disk or flash card, both during data entry and at the end of the day.
• File questionnaires by type of questionnaire and enrollee’s number.
To ensure that all data have been entered accurately, the data management coordinator
(or assessment coordinator) should
• Run the data validation program in Epi Info to uncover possible data entry
errors. This needs to be done at the end of data entry. Note that questionnaires will
need to be available for review during the validation process in order to reconcile
discrepancies.
• If .REC files are used, review the file for each questionnaire by running frequencies
for each variable, identifying inconsistencies, and investigating possible errors (and
then correcting the data file based on the hard copies of the questionnaires). This is
best done at the end of data entry.
• Supervise data entry and periodically check quality of data entry by randomly
selecting questionnaires for review.
The Manual
27

To store data safely
• Store questionnaires (and backed-up data files) in a locked cabinet available only
to the assessment coordinator and data management team to ensure participants’
confidentiality.
• If the questionnaire was designed with a tear-off identifier page, the page with
information identifying the participant should be removed once data entry and
validation are complete.
It is critical to maintain participants’ confidentiality according to the laws of the
country/jurisdiction.
Qualitative Component
Some decisions about the management of qualitative data will need to be made.
• Will the interviews be tape recorded?
• Will the recorders’ field notes be expanded to a full transcript of the interviews?
• Will the qualitative data be entered into a computer for analysis?
• What types of software are likely to be useful?
The assessment team may consider at least three approaches for managing data collected
from individual and focus group interviews. All have implications for the personnel and
software needed to manage and analyze the data. Choosing between the options will
involve a trade-off for the level of detail.
• The simplest approach is to record short open-ended responses directly on the
interview forms. The responses can later be grouped by hand or coded using
relatively limited qualitative analysis software such as CDC EZ - Text (http://www.
cdc.gov/hiv/software/ez-text.htm). This approach gleans the least detail but may
be appropriate when experienced qualitative researchers and data collectors are not
available.
• A second approach would be to have the data recorders expand the notes taken
during the interview into a structured report of the responses.
• A third would be to tape record 5 the interview and then have it transcribed word
for word.
Expanded field notes and interview transcripts can be managed by a more experienced
qualitative researcher and will contain far more detail. However, data in these formats will
require much more time for coding and analysis. The analysis can be completed by hand, but
when a large number of data are generated, software products like NUDIST, the Ethnograph, or
ATLAS.ti can be helpful.
Choosing among these approaches, or choosing another alternative, should be left to the
individual responsible for coordinating and analyzing the qualitative data and needs to be
decided prior to recruiting and training data collectors.
5 Although tape recorders can capture everything that is said, the tape recorder may malfunction without its
being realized, and all data will be lost. Transcribing a 1-hour tape takes 2-3 hours. In addition, if the interviews
are held outdoors (which occurs in many facility and home interviews), the tape often picks up ambient
noises, which obscure what is said. Focus groups interviews are difficult to listen to, as often, more than one
person is speaking at a time. The cost of the tape recorders, tapes, and transcription also need to be considered.
For these reasons, it is often preferable to record the interviews and focus groups by hand.
28 The Rapid Assessment of the Burden of Malaria during Pregnancy

4.2 Data Analysis
Quantitative Component
The assessment coordinator should work with the assessment and data management teams
to develop an analysis plan before the survey begins. This plan should include key indicators
that will affect policy and program.
For each quantitative tool included in the package, its respective module specifies outcome
variables and samples of tables that are critical for analysis. Additional indicators could
be selected and further analyses could be done, but this may not be essential for action.
Whatever indicators are selected, there must be a plan for how that information can be used
to affect the policy and program.
Two months should be sufficient to enter and analyze data, write the report, and disseminate
the results.
A software program can be used to run the analysis on quantitative data to determine
• Point estimates of the proportion of women who have peripheral parasitemia, anemia,
placental parasitemia, and LBW (as well as their 95% confidence intervals)
• Estimated gravidity-specific parasitemia, anemia, and LBW rates
• Frequencies of key variables collected from the facility assessment and
antenatal clinic health-care worker observation.
It is useful to generate a table summarizing basic sociodemographic variables. If the
assessment involves more than one site, it may be useful to present data by site, with one site
per column. Alternatively, if sites are similar, data may be aggregated. Data from antenatal
clinics and delivery units should be presented separately.
It is also generally useful to analyze parasitemia, anemia, and LBW by gravidity, using these
categories: primigravidae, secundigravidae, and multigravidae.
If there is a functioning malaria prevention program, it may be useful to analyze the data
by degree of self-reported adherence to the intervention (e.g., chemoprophylaxis or IPTp).
Categories of adherence might be complete, incomplete, or none.
Limitations
The limitations of the antenatal clinic and delivery unit data will affect interpretation of
results. Both antenatal clinic and delivery unit surveys use a convenience sample, not a
randomly selected sample. Therefore, women attending antenatal clinics and delivering
in delivery units are not completely representative of all pregnant women. In countries
with high antenatal clinic coverage, the pregnant women surveyed are likely to be more
representative of the general population of pregnant women. As is often the case, more
women visit antenatal clinics during their pregnancies than deliver in facilities, and so women
in the delivery units are usually less representative of all pregnant women. In countries with
low coverage, a facility-based rapid assessment will not give a very accurate picture of the
burden of malaria in pregnancy nationwide.
The Manual
29

Qualitative Component
Regardless of the approach used to record and manage data, analysis of qualitative data ideally
begins at the start of data collection, and the supervisor should begin reviewing data as they
are collected in order to identify the need to expand or revise the interview/focus group
guides to capture detail that might not have been anticipated. Daily debriefing sessions can
be used to identify and track themes as they emerge. See 3.7 and Modules 6, 7, 9, and 10 for
further discussion of debriefing.
Content analysis of completed qualitative data can be performed by hand or using one of
several software tools (see 4.1). Usually one person or several will review all of the data and
assign codes to the passages of text that contain each theme.
Content analysis can be performed on qualitative data, with data aggregated into general
themes to reflect the consensus of the participants. For example, a question might focus on
barriers to care. Responses might include “distance,” “need to farm,” “lack of money during
planting season,” “bad relationships with health-care facility staff,” “no drugs available at
the health-care facility,” “being mocked at the facility for being poor or not dressing well,”
and “need to obtain permission from family.” These responses could then be grouped into
higher level codes, for example those reflecting facility issues (lack of equipment/drugs, poor
provider-patient relationships), financial concerns (need to maintain income, seasonal income
sources), and statements about the locus of power within households (need permission). It is
often the case that ideas for new codes will occur to researchers while the analysis is under
way. The process of qualitative analysis can accommodate this by incorporating new ideas
and codes as they emerge. If more than one person is involved in coding text-based data, it is
important that the coders apply a common approach and work together closely to ensure that
the codes are applied consistently and newly identified themes are incorporated as they are
identified.
Generally, qualitative findings are presented in terms of the most typical responses.
Occasionally the statements of participants with exceptional views are useful as well. Direct
quotes from participants can be a powerful way to illustrate the key themes identified in
qualitative studies. It is frequently helpful to quantify some qualitative data to indicate which
themes or opinions were stated most frequently. For example, responses to the question “If
you are sick during pregnancy, from whom would you seek advice?” might include husband,
traditional?? birth attendants, mothers-in-law, elders. Frequency counts can illustrate which
categories were mentioned most often. Frequencies derived from qualitative data are purely
illustrative and cannot be subjected to statistical tests. If a population-based frequency is
desired (e.g., to compare care-seeking preferences across study sites or sub-populations),
quantitative surveys are usually a more appropriate approach.
30 The Rapid Assessment of the Burden of Malaria during Pregnancy

5. Report Preparation and Use of Results
Once data analysis is complete, a report should be promptly drafted, finalized, and
disseminated to key stakeholders. It is important that the report reach the appropriate
officials and decision makers in the areas of malaria and reproductive health so that the
findings of the rapid assessment can promptly be used for action. The presentation and use of
results greatly depend on the focus of the assessment. Communications about an assessment
designed to determine the burden of malaria during pregnancy would probably be quite
different from an assessment designed to determine program impact.
Results of the assessment can be used to provide:
► Information to guide decisions about whether to recommend IPTp
Although there is agreement that in areas of stable (or high) transmission, the control
package for malaria in pregnancy should include IPTp, there is less agreement about whether
IPTp belongs in the control package in areas of unstable (or low) transmission or areas that
are epidemic-prone.
One commonly asked question is at (or above) what level of transmission IPTp should be
recommended and at (or below) what level IPTp should not be recommended. To date, there
has not been a formal cost-effectiveness or cost-benefit analysis to guide policy in this regard,
but several factors could be taken into account in decision-making:
It is important
that the report
reach the
appropriate
officials and
decision makers
in the areas of
malaria and
reproductive
health so that the
findings of the
rapid assessment
can promptly be
used for action.
Prevalence of P. falciparum malaria parasitemia. Studies show that if malaria prevalence
is high, IPTp will help prevent malaria’s ill effects on the health of pregnant women
and babies, and a policy of IPTp should be recommended. However, there have been no
studies that have examined the effects of IPTp in areas of low or unstable transmission. If
malaria prevalence is low and IPTp were recommended for all pregnant women, it would
be given to many women who, because they were not infected, would not benefit. As the
prevalence of parasitemia decreases, it becomes less compelling to recommend IPTp.
For example, consistent use of IPTp has been shown to bring prevalence rates down
to about 5% – 10% in the high and moderate transmission areas where studies have
been conducted. One might then argue that a cut-off prevalence of 10% could be used.
However, if the prevalence rate was 10% and all women were given IPTp, 90% would
receive a drug they did not need. The malaria community needs to address what cut-off
to recommend in areas of low prevalence.
The Manual
31

Effect of malaria parasitemia: A rapid assessment conducted in Ethiopia found that
women in low or unstable or epidemic-prone areas had relatively low rates of peripheral
parasitemia (1.8%) and low rates of placental parasitemia (2.5%), but that placental
parasitemia was associated with prematurity and a 7-fold increased risk of stillbirths.
These findings suggested that routine use of IPTp may be inappropriate given the low
prevalence of peripheral and placental parasitemia, but given the strong association
with adverse outcomes, malaria had the potential to contribute substantially to the
population-attributable risk of these adverse outcomes if disease prevalence increased,
for example, during an epidemic. In this situation, the researchers concluded that the
situation should be evaluated during an epidemic to examine prevention and intervention
opportunities [20].
Presence of symptomatic malaria: In areas of high transmission, pregnant women
who become infected are generally assumed not to have symptoms because they have
developed some level of immunity, even though this immunity is somewhat compromised
by pregnancy. Despite being asymptomatic, these women and their babies can still
be adversely affected by the infection. Therefore, IPTp was developed as a preventive
intervention to be given to all women. In areas of low transmission or epidemic-prone
areas, pregnant women have little or no immunity and may experience symptoms of
malaria infection and become ill. In these areas, IPTp would not necessarily keep a
woman parasite-free throughout gestation and thus women could still become very ill,
causing harm to themselves and their infants. Therefore, in areas of lower transmission
where women may develop severe malaria during pregnancy, IPTp will not prevent
severe disease, and prompt and effective case management is still critical. In these
settings, the role of case management based on proactive screening for malaria infection
of women attending ANC, compared to preventive approaches with IPTp or ITNs remains
to be established.
► Advocacy for policy development and change. The information gathered can
also be used to advocate for resources to change or implement a new policy
► Suggestions for improving ANC attendance. The assessment may discover multiple barriers
to women’s decisions to attend an antenatal clinic during pregnancy. To address this, more
effective information, education, and communication (IEC) campaigns need to be planned
and conducted, or structural factors, such as price of care, may need to be addressed.
► Suggestions for improving service delivery. Results may indicate, for example, that more
focused health-care worker training needs to be provided or that adequate supplies of
medications and ITNs need to be made accessible and affordable.
► A snapshot of the impact of current interventions. The country may never have evaluated
its policy and program, or an evaluation may not have been done recently. Therefore, a
rapid assessment may point to the need for routinely offering a different intervention. For
example, a rapid assessment in Burkina Faso showed that high coverage with chloroquine
chemoprophylaxis (as opposed to IPTp) did not decrease the adverse effects of malaria
during pregnancy and that IPTp was needed.
► Directions for further study. A rapid assessment may have equivocal findings. For example,
a rapid assessment conducted in Ethiopia found that women in low or unstable or
epidemic-prone areas had relatively low rates of peripheral parasitemia (1.8%) and low
rates of placental parasitemia (2.5%), but that placental parasitemia was associated with
prematurity and a 7-fold increased risk of stillbirths. These findings suggested that routine
use of IPTp may be inappropriate given the low prevalence of peripheral and placental
parasitemia, but given the association with adverse outcomes, the magnitude of the
burden of malaria during pregnancy should be evaluated during an epidemic to examine
prevention and intervention opportunities.
32 The Rapid Assessment of the Burden of Malaria during Pregnancy

References
1. Desai, M., et al., Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis,
2007. 7(2): p. 93-104.
2. WHO, A Strategic Framework for Malaria Prevention and Control During Pregnancy in
the African Region. 2004, Brazzaville: WHO Regional Office for Africa.
3. Steketee, R.W., et al., The burden of malaria in pregnancy in malaria-endemic areas.
American Journal of Tropical Medicine & Hygiene, 2001. 64(1-2 Suppl): p. 28-35.
4. Brabin, B., An assessment of low birthweight risk in primiparae as an indicator of
malaria control in pregnancy. International Journal of Epidemiology, 1991. 20(1):
p. 276-83.
5. Jelliffe, E.F., Low birth-weight and malarial infection of the placenta. Bulletin of the
World Health Organization, 1968. 38(1): p. 69-78.
6. McGregor, I.A., M.E. Wilson, and W.Z. Billewicz, Malaria infection of the placenta in
The Gambia, West Africa; its incidence and relationship to stillbirth, birthweight and
placental weight. Transactions of the Royal Society of Tropical Medicine & Hygiene,
1983. 77(2): p. 232-44.
7. Menendez, C., Malaria during pregnancy: a priority area of malaria research and
control. Parasitology Today, 1995. 11(5): p. 178-183.
8. Steketee, R.W., et al., The problem of malaria and malaria control in pregnancy in
sub-Saharan Africa. American Journal of Tropical Medicine & Hygiene, 1996. 55
(1 Suppl): p. 2-7.
9. Guyatt, H.L. and R.W. Snow, The epidemiology and burden of Plasmodium falciparumrelated
anemia among pregnant women in sub-Saharan Africa. American Journal of
Tropical Medicine & Hygiene, 2001. 64(1-2 Suppl): p. 36-44.
10. Bloland, P., et al., Rates and risk factors for mortality during the first two years of life in
rural Malawi. American Journal of Tropical Medicine & Hygiene, 1996. 55
(1 Suppl): p. 82-6.
11. McCormick, M.C., The contribution of low birth weight to infant mortality and
childhood morbidity. New England Journal of Medicine, 1985. 312(2): p. 82-90.
12. Kramer, M.S., Determinants of low birth weight: methodological assessment and metaanalysis.
Bulletin of the World Health Organization, 1987. 65(5): p. 663-737.
13. Steketee, R.W., J.J. Wirima, and C.C. Campbell, Developing effective strategies for
malaria prevention programs for pregnant African women. American Journal of
Tropical Medicine & Hygiene, 1996. 55(1): p. 95-100.
14. Guyatt, H. and R.W. Snow, Impact of malaria during pregnancy on low birth weight in
sub-Saharan Africa. Clin Microbiol Rev, 2004(17): p. 760-9.
15. Brabin, B.J., M. Hakimi, and D. Pelletier, An analysis of anemia and pregnancy-related
maternal mortality. Journal of Nutrition, 2001. 131(2S-2): p. 604S-614S; discussion
614S-615S.
16. Memórias do Instituto Oswaldo Cruz. Volume 99, Issue 1: p. 19-21
17. Nosten, F., et al., Effects of Plasmodium vivax malaria in pregnancy. Lancet, 1999.
354(9178): p. 546-9.
18. McGready, R., et al., The effects of Plasmodium falciparum and P. vivax infections on
placental histopathology in an area of low malaria transmission. Am J Trop Med Hyg,
2004. 70(4): p. 398-407.
19. ter Kuile, F.O., et al., The burden of co-infection with human immunodeficiency virus
type 1 and malaria in pregnant women in sub-saharan Africa. Am J Trop Med Hyg,
2004. 71(2 Suppl): p. 41-54.
20. Newman, R.D., et al., Burden of Malaria during Pregnancy in Areas of Stable and
Unstable Transmission in Ethiopia during a Nonepidemic Year. J Infect Dis, 2003.
187(11): p. 1765-72.
The Manual
33

Glossary
Anemia and severe anemia: Conditions in which hemoglobin is less than 11 and 7 grams/
deciliter, respectively.
Case management refers to treatment of malaria illness. Case management requires
proper diagnosis and prompt access to antimalarial drugs to treat the illness.
Chemoprophylaxis: The prevention of an infectious disease by the use of chemical agents at
subtherapeutic doses. Weekly chemoprophylaxis is no longer recommended as the preferred
malaria prevention strategy for pregnant women in areas of stable (high) P. falciparum
transmission.
Fetal loss: Expulsion or delivery of a fetus without evidence of cardiac or respiratory effort,
regardless of number of weeks’ gestation.
Fever: An axillary temperature >37.5 o C.
Insecticide-treated mosquito net (ITN): Mosquito nets treated with an effective insecticide
to repel or kill mosquitoes.
Intermittent preventive treatment (IPT): The administration of full, curative treatment
doses of an effective antimalarial drug during pregnancy in order to reduce placental malaria
infection, low birth weight babies, and maternal anemia. WHO no longer recommends weekly
chemoprophylaxis (administration of an antimalarial drug in subtherapeutic doses) for several
reasons, including poor adherence with a weekly or daily regimen and increasing resistance to
the most popular antimalarial drug used in chemoprophylaxis, chloroquine.
Low birth weight: Infants weighing less than 2,500 grams at birth.
Malaria infection: A woman or baby is considered to have a malaria infection if any asexual
blood stage parasites are seen on a thick blood smear.
Neonatal death: Death of a live-born infant during the first 28 days of life.
Parasitemia (in peripheral, placental, or umbilical cord blood): A condition in which the
blood contains asexual stage malaria parasites.
Premature: Assessed as less than 37 weeks gestation at birth by the
Ballard examination.
Small-for-gestational-age (SGA) newborn: Weight for gestational age at birth can be
used to categorize infants as having normal or subnormal growth in utero. A newborn can
be considered small for gestational age if the birth weight is less than the 10 th percentile of
weight for gestational age. However, for most rapid assessments, it is not necessary to make
this determination. Note: Existing data on weight for gestational age are from industrialized
countries.
34 The Rapid Assessment of the Burden of Malaria during Pregnancy

Module 1: Conducting an Antenatal Clinic Survey
An Antenatal Clinic (ANC) Survey is designed to determine the
magnitude of the burden of malaria during pregnancy, specifically:
• What is the prevalence of peripheral parasitemia in
pregnant women?
• What is the prevalence of maternal anemia?
• Does the prevalence of peripheral parasitemia vary by
gravidity or locale?
This module contains sample materials for an Antenatal Clinic Survey (and in some
cases for the Delivery Unit Survey also). These materials can and should be adapted
to suit local needs. General guidance for conducting an Antenatal Clinic Survey
and managing data can be found in Chapters 3-4 of the manual. See Resource 3 for
presentations that address some of the topics below.
A. Antenatal Clinic Survey Timetable
B. Selecting Sample Sizes
C. Eligibility Criteria
D. List of Supplies and Equipment
E. Assessment Teams
F. Assessment Team Training
Contents
G. Supervisor’s Check List for Assessment Start-Up
H.
I.
Supervisor’s Guide to Conducting Antenatal Clinic and Delivery
Unit Surveys
Supervisor’s Guide to Data Management for Antenatal Clinic and Delivery
Unit Surveys
J. Sample Logbooks: Enrollment and Laboratory
K. Handbook for Assessment Teams
L.
Blood Test Procedures: HemoCue for Determination of Hemoglobin Level
M. Blood Test Procedures: Thick and Thin Films for Microscopic Diagnosis of
Malaria Infection/Finger-Stick Blood Collection
N. Antenatal Clinic Survey Information Sheet
O. Analysis of Antenatal Clinic Data
Module 1: Conducting an Antenatal Clinic Survey
1

A. Antenatal Clinic Survey Timetable
This timetable outlines key steps in planning for and conducting Antenatal Clinic and
Delivery Unit Surveys and the approximate length of time to allow. Many key steps will
require advance planning.
Planning the
assessment
Period Time Activities
2-4
weeks
Preassessment 2-3
weeks
• Determine what assessment components, if any, need to
be conducted
• Determine what approvals (ethical, scientific, other
ministerial) are needed and initiate approval process
• Secure funding
• Select site(s)
• Explain the assessment to the community
• Procure assessment equipment and supplies
• Hire assessment team and/or identify
existing staff
• Adapt and translate questionnaires
• Pretest questionnaires
• Identify site for training
• Identify responsible persons for all presentations that
will be given during training (See Resource 3 for sample
presentations)
• Manage logistics of training, including per diem,
transportation, meals, and lodging
• Arrange for on-site training in delivery units and
antenatal clinics
Assessment training 1 week • Conduct training course (4-5 days)
• Finalize questionnaires based on pretest and make adequate
copies for final day of training
• Meet with supervisors to coordinate assessment start-up in
clinical facilities
Start-up of assessment 2 weeks • Make adequate copies of antenatal clinic and delivery
unit questionnaires, enrollment logbooks, and laboratory
logbooks, and ensure questionnaires are at assessment sites
• Distribute supplies to each assessment site
and ensure a system of re-stocking supplies is in place
• Establish quality control mechanism for data collection,
including clinical and laboratory procedures, transport,
and storage
• Establish a supervisory system that addresses logistics
(staffing, supplies), quality of interviewing, quality of data
collected on questionnaires, quality of obtaining specimens,
laboratory quality (slide and staining, HemoCue calibration),
logbook maintenance
Assessment 8-9
weeks
• Enroll women and collect data
• Ensure supervisory system and quality control mechanisms
are functioning
• Ensure adequate supplies and equipment
are available and functioning at each assessment site
Postassessment 8 weeks Conduct data entry, cleaning, and analysis
Write final report
Disseminate results
Initiate policy discussions
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

B. Selecting Sample Sizes
The sample size needed for the Antenatal Clinic Survey depends on
1. the estimated prevalence of women with parasitemia and with anemia,
2. the acceptable margin of error, AND
3. the design effect
The sample size required to measure each of the survey’s main indicators (peripheral
parasitemia and anemia) can be calculated by using Statcalc in EPI-INFO. The EPI-INFO
calculation should include an adjustment (i.e., design effect [see note at end of this section,
Selecting Sample Sizes]) for the fact that the survey uses cluster sampling, rather than
random sampling.
If the sample size required to measure one indicator is larger than the sample size
required for the other indicator, the larger of the two sample sizes should be selected. The
sample size may need to be modified to account for other factors (see example below).
The sample size for the Antenatal Clinic Survey can be determined using
1. Point estimates of the proportion of women with peripheral parasitemia and the
proportion with anemia. Because hemoglobin levels change throughout pregnancy,
the prevalence of anemia should be estimated for women in the same trimester
(e.g., third). If no estimates are available from the district or region where the
survey is being conducted, data from a neighboring area or national data could be
used.
2. Level of accuracy desired, for example + 10%.
3. The design effect.
Antenatal Clinic Survey Sample Size Calculation: An Example
Point estimates: In this example, the assessment coordinator estimates the prevalence
of peripheral parasitemia in the area to be 35%, on the basis of a previous study done in
the area. The prevalence of anemia (Hgb

Peripheral
parasitemia
Third
trimester
anemia
Total
sample
size
Estimated
prevalence*
Margin
of error
Needed sample
size (from
Statcalc)
Other
factors
35% 10% 174 --- 174
50% 10% 192
% women
attending
antenatal
clinic
during third
trimester:
50%
Sample
size (after
adjusting
for other
factors)
384
384
* If the prevalence of peripheral parasitemia during the high transmission season is unknown,
assume a level of 50% for calculating sample size. This level is the most conservative estimate,
as it yields the largest required sample size.
If the assessment is being used as a baseline that will be repeated after an intervention
in order to demonstrate impact, the sample required will be larger and the sample size
calculations more complex. It is advisable to consult a statistician for further guidance.
Note on design effect:
Large surveys are often conducted using cluster surveys, meaning that the population is
divided into clusters and sampled accordingly. Clusters are selected by random sampling and
then random samples are taken within the selected clusters. The benefits of cluster sampling
are that it is often easier and less expensive to conduct than simple random sampling as the
needed sample size is smaller. However, its disadvantage is that there is a loss of precision
because the elements within the cluster are generally more correlated (similar) than those
between the clusters. Selecting an additional member from the same cluster adds less
new information than would a completely independent selection. As the cluster size and
intracluster correlation increase, cluster variances increase more than one would find in a
simple random sample. The benefits of cluster sampling often outweigh the disadvantage of
the loss in precision.
Because cluster sampling results in a loss of precision and a smaller sample size, an
adjustment called the design effect should be used to determine survey sample size when
clustering is involved. The design effect is basically the ratio of the actual variance 1 , under the
sampling method actually used, to the variance computed under the assumption of simple
random sampling. The main components of the design effect are the intraclass correlation and
the cluster sample sizes. The design effect is calculated as follows:
DEFF = 1 + ρ (n – 1),
where Deff is the design effect, ρ is the intraclass correlation for the statistic in question, and
n is the average size of the cluster. The interpretation of a value of DEFF of, say, 3.0 is that the
sample variance is 3 times bigger than it would be if the survey were based on the same
1 Variation measured in a set of data for one variable, defined as the sum of squares of the deviation of each
data point from the mean for the data, divided by the degrees of freedom (sample observation – 1).
4 The Rapid Assessment of the Burden of Malaria during Pregnancy

sample size but selected randomly. It can be seen that the design effect increases as the cluster
sizes increase, and as the intraclass correlation increases. The square root of the design effect
shows how much the sample standard error, and consequently the confidence intervals,
will increase because of the clustering. The intraclass correlation represents the likelihood
that two elements in the same cluster have the same value, for a given statistic, relative to
two elements chosen completely at random in the population. A value of 0.10 is interpreted,
therefore, to mean that the elements in the cluster are about 10% more likely to have the same
value than if the two elements were chosen at random in the survey.
Design effects vary from survey to survey and even within the same survey will vary from
question to question. In summary, using a cluster sample generally requires either a larger
sample size than a simple random sample or a wider confidence interval. The design effect
is used to determine how much larger the sample size or confidence interval needs to be.
In general, for a well-designed study, the design effect usually ranges from 1 to 3. It is not
uncommon, however, for the design effect to be much larger.
The survey methodology recommended for both the Antenatal Clinic Surveys and the Delivery
Unit surveys use cluster sample methodology and thus require that a design effect be used.
C. Eligibility Criteria
• Women who participate in the assessment should be as representative as possible
of all women attending the antenatal clinic.
Women are eligible for the survey if they meet the following requirements:
Stage of Gestation: Women who have experienced “quickening” (i.e., the recognition of fetal
movement).
Gravidity: All gravidities. Although primigravidae and secundigravidae are typically most
affected in high transmission areas, women of all gravidities should be eligible so that the local
situation can be confirmed.
Age: The youngest age at which women are eligible to participate should be the age at which
most women in the assessment area have their first child. This is to ensure that primigravidae
and secundigravidae (the groups at highest risk) are included in the assessment. The age of
the youngest participants may well be less than the age of majority and should be consistent
with any country policy or norm regarding this type of survey. Many countries consider a
woman with a child and her own household to be an emancipated minor regardless of age.
However, 15 years is often chosen as a minimum age.
Note: Women who have not yet experienced quickening should not be included in the survey.
This exclusion criterion helps avoid use of drugs in the first trimester other than what would
be recommended in the national policy. For example, in this survey, women may be treated for
asymptomatic parasitemia, but would not otherwise, according to national policy.
Module 1: Conducting an Antenatal Clinic Survey
5

D. List of Supplies and Equipment
Make sure that each antenatal clinic has the necessary supplies and equipment
before the start of the survey.
Item
Quantity per
ANC
Comments/Use
# in
stock/
Balance
needed
Date
Ordered
Screening &
Clinical Evaluation
Electronic
thermometers
Laboratory
2
Temperature
measurement;
if electronic
thermometers are
unavailable, mercury
glass thermometers
are an acceptable
alternative.
Count-down timer 1 For laboratory use.
Slides 1/participant Allow extras for waste.
Lancets 1/participant Allow extras for waste.
Isopropyl alcohol
Enough to
clean 1 finger/
participant
Premoistened alcohol
wipes are an acceptable
alternative.
Cotton wool or
gauze
Giemsa stain
Toilet paper (or
slide boxes)
Container for used
lancets
Staining jars
Slide drying rack
Enough to
clean 1 finger/
participant
Sufficient
to wrap (or
store) all
slides from
assessment
2/site
2/lab
1/lab
Based upon sample size.
In addition to Giemsa
powder, need all other
materials to mix stain,
including distilled
water, buffer, glycerol,
and glassware to mix
and store.
Sharps container;
should only be used
for lancets (or other
sharps), microcuvettes,
and microhematocrit
tubes.
6 The Rapid Assessment of the Burden of Malaria during Pregnancy

Item
Quantity per
ANC
Comments/Use
# in
stock/
Balance
needed
Date
Ordered
Basin/bleach
1 basin
Bleach for disinfecting
and cleaning spreader
slides if using thin films.
Hair dryer
1/lab
May be needed,
depending on climate.
Optional.
Microhematocrit
tubes
1/participant
Centrifuge for
microhematocrit
tubes
1
HemoCue machine and
microcuvettes may
be substituted when
available.
Microscope
1/lab
Spare light bulbs
for microscope
3/lab
Immersion oil
3 tubes/lab
Lens cleaner
1 bottle/lab
Lens cleaning
tissue
2 sheets/day
of survey
Sharpie markers
(ultra fine)
3/team/site
Examination gloves
1 pair/
participant
Extra for breakage,
extra for lab personnel.
Trash can/trash
bags
1 can and bags
as needed
For non-sharp waste
(gloves, cotton, etc.).
Tally counters
2/laboratory
If using 2-channel
counter, 1 is sufficient.
Computer 1-2
2 is ideal, 1 is adequate;
with at least Windows
2000.
Epi-Info or another
statistical software
package (Epi Info is
preferred)
Office Supplies
1-2
Installed on each
computer.
AA batteries
If using HemoCue.
Module 1: Conducting an Antenatal Clinic Survey
7

Item
Quantity per
ANC
Comments/Use
# in
stock/
Balance
needed
Date
Ordered
Clipboards
1/interviewer
Pencils
1/interviewer
Only if preparing thin
films.
Pencil sharpener
1/interviewer
Only if preparing thin
films.
Pens
2/interviewer
Stapler 1
Staples
2 boxes
Ink pad/Ink
1/site
For fingerprinting
women if signature
needed and woman
cannot sign.
Logbooks
Drug Supplies
Antimalarials for
IPTp (if IPTp is the
policy); should be
available as part
of routine ANC
supplies
2/clinical site
and 1/lab
Should be bound books,
not spiral-bound or
perforated. 2 in clinical
site: 1 for register, 1 for
hemoglobin. 1 in lab for
slide results.
Antimalarial for
treatment
Iron and folate
8 The Rapid Assessment of the Burden of Malaria during Pregnancy

E. Assessment Teams
The number of assessment teams depends on the number
of antenatal clinics used.
The following example assumes that 4 antenatal clinics will be surveyed.
Title
Number needed
Assessment coordinator 1
Laboratorian supervisor 1
Site supervisors
4 (1 per site)
Interviewers
8 (2 per site)
Laboratorians
4 (1 per site)
Data management coordinator 1
Data entry clerks 2
There is no magic formula for how to staff the assessment. If the antenatal clinic sites
see patients every day, it may be advantageous to staff them continuously, and therefore have a
complete team at each site. If there are antenatal clinic sites that are not open daily, then it may
be more efficient to have a team of newly hired staff who rotate among two or more sites.
F. Assessment Team Training
The training for site supervisors, interviewers, and laboratorians should be held after
preassessment activities. Training will take approximately 4-5 days.
The text below explains how to conduct the training. A sample schedule follows the
explanation.
Note: If both Antenatal Clinic and Delivery Unit Surveys will be conducted, it is more
efficient to conduct training for both surveys simultaneously. Therefore, this module
describes simultaneous training. If only one of the surveys is conducted,
this module will need to be modified accordingly.
Note: If qualitative studies will be conducted about the same time as the quantitative
studies, it would be beneficial to conduct the training simultaneously. Consult the
qualitative training manual (or the modules that accompany the qualitative surveys)
for guidance on how to combine the two.
Module 1: Conducting an Antenatal Clinic Survey
9

Day 1:
Morning: The assessment coordinator should present background information on malaria
during pregnancy and assessment objectives. (See Resource 3 for sample presentations)
Afternoon: The assessment coordinator reviews antenatal clinic and delivery unit policies and
procedures located in the assessment team member’s handbook (see K in this Module). This
provides a general overview of the assessment. Once the overview is complete, the assessment
coordinator should split the interviewers into teams. Each team will rotate through antenatal
clinic and delivery unit clinical procedures. Depending on the size of the assessment team,
the logistics can be varied. In a small team, everyone might work together to go through all
procedures. In a large team with a sufficient number of facilitators, it may be worthwhile to
divide teams into groups that rotate around a series of workstations. The important thing is
that each staff member has the opportunity to learn and practice each procedure that he/she
will be conducting.
Antenatal clinic procedures include: 2
• Exercise universal precaution for handling blood (prior to this exercise,
presentation on lab safety [see Resources] could be shown)
• Take and read axillary temperature
• Collect blood samples (fingersticks) from each other
• Prepare slide (recording date and ID number on slide) (see M)
• Prepare thick films (and thin films in an area with substantial P. vivax
transmission) (see M)
• Collect blood on cuvette and use HemoCue machine to perform the Hb
reading (see L)
Delivery unit procedures include: 2
• Take woman’s temperature
• Measure woman’s mid-upper arm circumference
• Measure woman’s height
• Prepare slides—peripheral, placental, and cord blood
• Weigh newborn using scale
• Conduct the Ballard examination and apply the scoring system (See Resource
3 for Ballard video; see also Module 2 for Ballard check list)
Day 2:
Morning: The assessment coordinator arranges for interviewers to visit a delivery unit site
for practice of delivery unit procedures. At the same time, the laboratorian supervisor trains
assessment laboratorians on how to read peripheral, placental and cord films.
Afternoon: In a group setting, the assessment coordinator reviews each question on antenatal
clinic and delivery unit questionnaires and the information sheet (or consent form), depending
on which is being used. The coordinator also describes why there is a consent form if a consent
form has been determined necessary. Interviewers should be encouraged to ask questions and
offer suggestions. After reviewing each questionnaire, the interviewers should break into small
groups and practice each questionnaire one-on-one using copies of actual antenatal clinic
2 In some circumstances it may be possible to conduct polymerase chain reaction (PCR) on filter paper samples
or to examine tissue specimens preserved in formalin. However, in many settings these are neither possible
nor necessary.
10 The Rapid Assessment of the Burden of Malaria during Pregnancy

cards from the clinic. It is important that the antenatal clinic cards have had all identifiers
removed. Any discrepancies regarding data extraction from antenatal clinic cards should be
addressed with the assessment coordinator, and questionnaires revised as necessary.
Day 3:
Morning: After the survey instruments are adapted, the survey instruments, as well as the
information sheet (or informed consent form if used), should be translated into the national
language and the primary language spoken by women in the assessment area, if different.
This initial translation should be followed by a back-translation (by individuals who did not
produce the original translation) into the national language to check the adequacy of the
translation. Once the translation is complete, pretesting can begin. While the surveys are being
pretested, laboratorians could practice film reading.
Note: If the primary language is not a written language, it will be important to use correct,
consistent phrasing of survey questions and information on the information sheet (or
informed consent form) so that questions are asked in a standardized manner. All interviewers
should work together to achieve correct, consistent phrasing of the questions and have the
opportunity to practice.
Afternoon: The assessment coordinator arranges for interviewers to visit two antenatal clinic
sites to practice the antenatal clinic questionnaire with clients.
NOTE: The delivery unit questionnaire is very similar to the antenatal clinic
questionnaire, which will have been pretested. Because of this, it is not necessary to
pretest the delivery unit questionnaire. This avoids the need to ask women who may be
in physical discomfort to practice interviews.
Divide the interviewers into two teams. Each team should visit one of the selected sites to
pretest the antenatal clinic questionnaires with at least 15 clients (total, not per interviewer)
in each facility.
Day 4:
Morning: The assessment coordinator will explain the purpose of antenatal clinic and delivery
unit enrollment and laboratory logbooks. Then, the coordinator should demonstrate and
review these log books. It is important that all assessment team members understand that
the enrollment logbooks are used to record everyone who is enrolled in the assessment as
well as those who are excluded for any reason. The interviewers should be divided into pairs
to continue practicing the revised questionnaires. The rest of the morning should be used to
resolve outstanding issues, and conclude the training.
Module 1: Conducting an Antenatal Clinic Survey
11

Day 5:
If the training is scheduled for 5 days, Day 5 can be reserved for work on any remaining issues.
Sample Training Schedule
Day 1 Day 2 Day 3 Day 4
Introduction/
Overview
Delivery
Unit Clinical
Procedures
Pretest
questionnaires
Wrap-up
Morning
-Welcome
-Training objectives
-Malaria situation in
country
-Epidemiology of
malaria during
pregnancy
-Rapid assessment
objectives
See Resource 3 for
sample presentations
Microscopy training
for laboratorians
On site delivery
unit clinical
procedures training
and practice for
interviewers
Practice
questionnaires
and consent form
administration in
local language(s)
with translator
Practice
questionnaires
and consent form
administration in
local language(s) in
small groups
Introduce enrollment
and laboratory registers
Practice questionnaires
in pairs (using
antenatal clinic cards
and antenatal clinic and
delivery unit registers).
Conclusion of training
Afternoon
Policy and procedures
in antenatal clinic and
delivery unit (worker’s
handbook)
Practice clinical
procedures for
antenatal clinic and
delivery unit (show
video of Ballard)
if available. Live
demonstrations
using an adult model
before practicing on
live newborns can be
useful.
Review antenatal
clinic and delivery
unit questionnaires
and consent forms
Practice
questionnaires
in pairs (using
antenatal clinic
cards). Resolve
discrepancies
regarding data
extraction from
antenatal clinic
cards.
Pretest
questionnaires on
site in antenatal
clinic facilities
Meet with supervisors
to discuss assessment
start-up:
-Make copies of
antenatal clinic
and delivery unit
questionnaires
-Ensure antenatal clinic
and delivery unit log
books are at each
assessment site
-Distribute supplies to
each assessment site
-Establish quality
control mechanism
-Establish a supervisory
system
Evening
Team members to read
questionnaires and
consent forms
Assessment
coordinator finalizes
both questionnaires
based on pretests.
12 The Rapid Assessment of the Burden of Malaria during Pregnancy

G. Supervisor’s Check List for Assessment Start-Up
The following guide contains worksheets to assist the supervisor during the
start-up phase of the assessment.
Note: This list pertains to both Antenatal Clinic and Delivery Unit Surveys, as most likely
both will be conducted. If only one of the surveys is conducted, the list will need to be
modified accordingly.
Explain the purpose of the assessment to the “community,” through direct communication
where possible, and also through the display of malaria posters in the clinic, and any other
communication means.
Set up the supply management system:
• Verify that all supplies on the list are available.
• Provide the delivery unit, antenatal clinic unit, and the lab each with a set of supplies
(papers, laboratory materials, examination materials, antimalarial drugs and
hematinics) to last at least one week.
• If supply shortages (batteries, slides, etc.) are noticed, find a solution to continue the
assessment uninterrupted.
• Keep spare supplies in a safe place, preferably a locked cupboard or box.
• Keep a record of available stocks.
Have planning meeting with the assessment team:
• Make sure every person understands what is expected of him/her.
• Draw up a time and duty schedule for each team member, aiming for 8 hrs/day
antenatal clinic presence, and 24 hrs/day delivery room presence.
• Rehearse every team member’s interviewer number, and go over the patient number
system once more.
Also:
• Instruct the night staff of the delivery room to routinely store ALL placentas for the
assessment in individually marked plastic bags in the ice box if no assessment team
member happens to be present
• Assign responsibility for the ice box and for replacing the ice packs to an assessment
team member
• Arrange additional laboratory support, if needed
• Identify possible translators for local languages among the hospital staff. Where
possible, make them familiar with the questionnaire beforehand.
Module 1: Conducting an Antenatal Clinic Survey
13

Set up instruments:
• Set up measuring tape, scales and Ballard chart in the delivery room
• Set up HemoCue instructions in the antenatal clinic room, if using HemoCue. Set up
the HemoCue and calibrate. Recalibrate daily.
• Find a safe and stable place for the infant weighing scale. Make sure that it is never
lifted by the cradle, as this will damage it.
• Keep instrument instructions in a safe place for future reference.
Set up data management system:
• Provide staff with enough information sheets (or consent forms, if used) and
questionnaires for at least one week.
• Make the arrangements for daily review of assessment results by the supervisor
together with the antenatal clinic and delivery unit staff.
• Make arrangements for daily storing of papers and slides (and filter papers and test
tubes, if being used).
• Make arrangements for weekly storing of papers and slides (and filter papers and
test tubes, if being used).
• Go through the data management system with the team members.
Set up assessment logs:
• Antenatal clinic logbook, delivery unit logbook, laboratory logbooks
(one for malaria, one for hemoglobin results)
14 The Rapid Assessment of the Burden of Malaria during Pregnancy

H. Supervisor’s Guide for Conducting Antenatal Clinic
and Delivery Unit Surveys
The following guide contains worksheets to assist the supervisor in noting the progress
of the survey, reminding the supervisor of important tasks (e.g., calibrating the HemoCue
machine daily), and guiding the supervisor in reviewing questionnaires.
These worksheets should be filled out on a regular basis, as determined by the supervisor.
Note: The worksheets pertain to both Antenatal Clinic and Delivery Unit Surveys, as most
likely both will be conducted. If only one of the surveys is conducted, the forms will need to
be modified accordingly.
Site: _______________________________________________________________________________________________________
Date: __ __ /__ __ /__ __
1. Enrollment and rates of positivity
Antenatal clinic enrolled to date (No): ________________________________________________________________
Number positive: ________________________________________________________________________________________
Last antenatal clinic ID number used: _________________________________________________________________
Delivery enrolled to date (No): _________________________________________________________________________
Number positive (Mother): _____________________________________________________________________________
Number positive (Placenta): ___________________________________________________________________________
Number positive (Cord): ________________________________________________________________________________
Last delivery ID number used:__ __ /__ __ /__ __
2. Staff, supplies and samples
Have any staff left the assessment?_____________________________________________________________________
____________________________________________________________________________________________________________
Are all nights on the delivery unit being covered by the assessment team? ________________________
If this is not possible, are sufficient coolers (with icepacks) available for placental storage? ____
Using the supply list above, note if supplies are adequate.
YES =1 NO = 2
Any other missing supplies: ____________________________________________________________________________
If any supplies are needed, what is the plan for restocking?_ ________________________________________
Are questionnaires and samples well organized and in a safe place?_______________________________
____________________________________________________________________________________________________________
If not, plan to improve situation:_______________________________________________________________________
Samples and questionnaires taken to central location
Module 1: Conducting an Antenatal Clinic Survey
15

ANC:
Questionnaire numbers __ __ - __ __ __ to __ __ - __ __ __
Slide numbers: to Delivery __ __ - __ __ __ to __ __ - __ __ __
Questionnaire numbers __ __ - __ __ __ to __ __ - __ __ __
Slide numbers (M,P,C):__ __ - __ __ __ to __ __ - __ __ __
Tissue sample numbers, if collected: __ __ - __ __ __ to __ __ - __ __ __
Filter paper numbers (M,P), if collected: __ __ - __ __ __ to __ __ - __ __ __
3. Antenatal Care Survey
Is the HemoCue machine being calibrated daily?_____________________________________________________
Check calibration today: ________________________________________________________________________________
Examine the logbooks. Are they being filled out correctly? __________________________________________
(Note: Enrollment logbook should contain all patients, whether or not enrolled in
assessment.]
Note any problems with logbooks: ____________________________________________________________________
____________________________________________________________________________________________________________
What is the plan to correct any problems with logbooks? ___________________________________________
____________________________________________________________________________________________________________
What is the average enrollment per day? (look at last 10 days): ____________________________________
If it is too high or too low, examine reasons, and make a plan for correction: ______________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Examine at least 5 questionnaires per assessment team member. Note any problems, and
discuss with that person. Pay particular attention to whether hemoglobin, temperature, and
blood smear results are completed.
Note any important problems and what measures were taken to fix them: ________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Are women with anemia receiving iron? ______________________________________________________________
If not, why not? __________________________________________________________________________________________
____________________________________________________________________________________________________________
Are women with positive blood smears receiving treatment for malaria?_________
If not, why not? __________________________________________________________________________________________
____________________________________________________________________________________________________________
If consent forms are used, examine. Have women signed them in accordance with assessment/
country policy? Is the name of a contact person for questions written in as instructed? _ ________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
16 The Rapid Assessment of the Burden of Malaria during Pregnancy

4. Delivery Unit Survey
Examine logbooks. Are they being filled out correctly?_______________________________________________
(Note: Enrollment logbook should contain all women who deliver, whether or not enrolled
in assessment)
Note any problems with logbook: ______________________________________________________________________
____________________________________________________________________________________________________________
What is the plan to correct any problems with the logbook: ________________________________________
____________________________________________________________________________________________________________
What is the average enrollment per day? (look at last 10 days): ____________________________________
____________________________________________________________________________________________________________
If it seems very low, examine reasons, and make a plan for correction: _ ___________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Are enrollments evenly spaced throughout the day (i.e., not all in the a.m. or p.m.)?______________
____________________________________________________________________________________________________________
Examine at least 5 questionnaires per assessment team member. Note any problems, and
discuss with that person. Pay particular attention to ensure that the following are completed:
height, arm circumference, baby weight, Ballard gestational age, blood smear results and
treatment.
Note any specific problems and what measures were taken to fix them: ___________________________
____________________________________________________________________________________________________________
Is the baby’s sex being documented on the Delivery Unit questionnaire?__________________________
Are women with positive blood smears receiving treatment for malaria? _ ________________________
If not, why not? __________________________________________________________________________________________
If consent forms are used, examine. Have women signed them in accordance with assessment/
country policy? Is the name of a contact person for questions written in
as instructed? ____________________________________________________________________________________________
Are sample sets complete for each delivery patient (that is, do they contain a questionnaire, 3
slides (M, P, C), and, if collected, 2 filter papers (M, P), and a tissue sample? ______________________
If not, why not? __________________________________________________________________________________________
5. Laboratory (Supervisor may need assistance from Laboratory Supervisor on first few
items below.)
Examine the results books. Are the books being completed correctly? _____________________________
If problems are found, document here, and make a plan for correction: ___________________________
____________________________________________________________________________________________________________
Are the results for mothers from antenatal clinic with fever, and mothers and babies from
delivery, being given promptly to assessment team? _________________________________________________
If not, what steps can be taken to improve the speed of obtaining results? ________________________
____________________________________________________________________________________________________________
Reread 10% of the slides of each type (ANC, Delivery M, Delivery P, Delivery C).
Rate the accuracy of slides:
Thick: (1 to 5, 5 is highly accurate): ___________________________________________________________________
Module 1: Conducting an Antenatal Clinic Survey
17

Thin: (1 to 5, 5 is highly accurate): _____________________________________________________________________
If quality is poor, examine reasons (e.g., smears badly done, thick specimen is fixed, or stain
coloration is bad), and try to find a solution to the problem: ________________________________________
____________________________________________________________________________________________________________
Are slides being stored in a good manner (in slide boxes or, if slide boxes cannot be obtained,
rolled in tissue paper)?: ________________________________________________________________________________
____________________________________________________________________________________________________________
If not, plan for correction: ______________________________________________________________________________
____________________________________________________________________________________________________________
Does the laboratory have adequate supplies? ________________________________________________________
If not, plan to correct the problem: ____________________________________________________________________
____________________________________________________________________________________________________________
6. Data Entry
Review at least 5 questionnaires that have been entered in the computer.
Number of errors found in 5 ANC: _____________________________________________________________________
Number of errors found in 5 Delivery: ________________________________________________________________
Is the record number being written at the top of each questionnaire on each page?______________
____________________________________________________________________________________________________________
Other comments, observations or problems not mentioned above____________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
18 The Rapid Assessment of the Burden of Malaria during Pregnancy

I. Supervisor’s Guide to Data Management for Antenatal Clinic
and Delivery Unit Surveys
The following guide contains worksheets to assist the supervisor in managing and collecting
data. Worksheets outline tasks for assessment team members, as well as the supervisor.
Note: The worksheets pertain to both Antenatal Clinic and Delivery Unit Surveys,
as most likely both will be conducted. If only one of the surveys is conducted, the forms can
be modified accordingly.
1. Enrollment targets:
List for each site:
Desired # of antenatal clinic visits: _____ at least x/day
Desired # of deliveries: _____ at least x/day
2. Target data collection period:
ANC
Deliveries
List months during which to collect these data
List months during which to collect these data
3. Assigning an ID number
1 st digit: assessment site
Site #1 1
Site #2 2
Site #3 3
Site #4 4
2 nd digit: type of health service
ANC A
Delivery D
3 rd – 5 th digit: consecutive number identifying each patient
Example: 35 th antenatal clinic woman in Site#3 = 3A – 035
46 th delivery in Site#1 = 1D – 046
Note: If the woman has been assigned an ID number but enrollment has to be abandoned for
whatever reason, file all related papers and test results, and assign the next woman the next
number. ID numbers should only be used once. All ID numbers should be accounted for at the
final data analysis.
• All data must be entered in computer
• All data items must be returned to designated location for re-entering into computer
(for double data entry) and quality control of slide readings
Mark ID NUMBERS on each item and each page!!
Module 1: Conducting an Antenatal Clinic Survey
19

4. Assigning an interviewer number
The supervisor should assign each interviewer a unique number to be used throughout
assessment.
For example:
Site #1 01 – 20
Site #2 21 – 40
Site #3 41 – 60
Site #4 61 – 80
5. Hints to provide interviewers for filling out questionnaires
• Keep all pages of the consent forms (if used) and of the questionnaires stapled together
• Number all pages immediately with the ID number
• Write clearly
• ………….. is a connecting line
• ________ is a line to write on
• Feel free to make notes in the margin of the questionnaire form if the answer
you received was not very clear or if you have doubts. The more information
the better.
• If it states “check all that apply,” please do not enter dashes for negative. Just leave those
spaces blank. Otherwise it may confuse the data entry.
• Make sure to write the right information in the right places: Some information comes from
asking the woman, some from the antenatal clinic card, and some from the examination
done for the assessment.
• Completed consent forms (if used), questionnaires, slides, filter papers (if used), placenta
tubes (if used), and logbooks should be guarded very carefully: Any missing or mislabeled
items will compromise the final interpretation of the assessment.
20 The Rapid Assessment of the Burden of Malaria during Pregnancy

Antenatal Clinic Survey
Each antenatal clinic enrollment will have at least 2 loose pieces of information
• Signed consent form, if used
• Completed questionnaire (…pages)
• 1 blood slide (thick and thin)
Data management tasks of antenatal clinic staff:
Each enrollment:
• Mark ID number clearly on each item and each page
• Mark ID number clearly on blood slide result from the lab
Before woman leaves:
During the day:
• Verify that questionnaire is completed, and iron/folate given as indicated
•If woman is febrile or had a fever recently: Ensure that lab results are returned
as soon as possible. If the slide was positive, treat the woman with appropriate
antimalarial drug as per national policy before she leaves that clinic that day (or
when you visit the woman at home with results.)
• Obtain lab results from all other women and if any were positive, prepare for treatment
when the woman returns that afternoon or the next day
Data management tasks of supervisor:
At the end of each day:
Each week:
• Keep antenatal clinic log of enrollment and refusals up to date
• Collect and review for completeness all data items
• File all forms together each day
• Store all papers chronologically by assessment number
• Store all slides chronologically by assessment number
• Mark patient number range on each set of items, e.g.: 41.001 – 41.035
• Put all items aside in a safe place
Module 1: Conducting an Antenatal Clinic Survey
21

Delivery Unit Survey
Each delivery will have at least 4 and as many as 8 loose pieces of information
• Signed consent form, if used
• Completed questionnaire (…pages)
• 3 blood slides:
Mother (thick and thin)
Placenta (thick and thin)
Cord (thick and thin)
• 2 filter papers:, if used:
Mother
Placenta
• Placenta tissue in tube, if used:
Data management tasks of delivery unit staff:
Each enrollment:
• Mark patient number clearly on each item and each page
• Mark M or P or C clearly on blood slides and filter papers, if used
• Mark patient number + M or P or C in the laboratory logbook
Before woman leaves:
• Verify that questionnaire is completed
• Verify that M and C slide results are back from laboratory, and treat her if positive
Data management tasks of supervisor:
At the end of each day:
Each week:
• Keep delivery log of enrollment and refusals up to date
• Collect and review all data items for completeness
• File all forms together each day
• Store all papers chronologically by assessment number
• Store all slides chronologically by assessment number
• Mark patient number range on each set of items, e.g.: 42.001 – 42.035
• Put all items aside in a safe place
22 The Rapid Assessment of the Burden of Malaria during Pregnancy

J. Sample Logbooks: Enrollment and Laboratory
• Enrollment logbook: Records a list, by facility, of the pregnant women visiting the site
each day of the survey, her antenatal clinic number, and whether or not she was enrolled
(and if not, why not).
• Laboratory logbooks (two): One records information about the malaria blood films of
enrolled women and the other records information about enrolled women’s hemoglobin
or hematocrit, by facility.
During the assessment start-up, the assessment coordinator is responsible for ensuring that
each site has prepared enrollment and laboratory logbooks.
During the assessment, site supervisors are responsible for monitoring the use of the logbooks
and preparing additional books as necessary.
Malaria During Pregnancy Rapid Assessment - Enrollment Antenatal Clinic Logbook
Facility: __________________________________________________________________________________________________
District/Region: ________________________________________________________________________________________
Date
Woman’s
antenatal
clinic
number
Name of
Woman
Age
G/P*
Mother
tongue
Enrolled?
Yes/No
Woman’s
ID
number
Comments**
*Gravidity/parity
**It may be helpful to make a list of reasons for nonenrollment, along with a code number for each
reason, and place it on the face page of the logbook. For example, if the first reason on the list was
“woman refused to participate” and the code for that reason was “1,” “1” could be written in the
comments column above.
Malaria During Pregnancy Rapid Assessment – Laboratory Antenatal Clinic Logbook for
Malaria Facility: ________________________________________________________________________________________
District/Region:________________________________________________________________________________________
Date
Woman’s
ID
number
Blood
smear
+/-
Species* Density Comments
*In some settings may need a column for malaria species.
Malaria During Pregnancy Rapid Assessment – Laboratory Antenatal Clinic Logbook for
Hemoglobin Facility: _ _________________________________________________________________________________
District/Region: ________________________________________________________________________________________
Date
Woman’s ID
number
Hb
Comments
Module 1: Conducting an Antenatal Clinic Survey
23

K. Handbook for Assessment Teams
Each member of the assessment team should receive a handbook during
assessment training.
The handbook briefly describes the enrollment procedure and postenrollment activities,
including the questionnaire, measurements and laboratory specimens, medications, and
follow-up activities.
Note: The team member’s handbook has space for including the number of women to be
enrolled each day.
HANDBOOK FOR ASSESSMENT TEAMS
Antenatal Clinic Survey
Contents
I. Enrollment
Identification of eligible women
Inclusion criteria
Exclusion criteria
Provision of information or consent (if necessary)
II. Postenrollment
Questionnaire
Measurements and laboratory specimens
Medications
Follow-up
(Throughout woman’s stay at antenatal clinic unit: follow normal procedures to ensure safety of
mother and baby. Ensure proper medical care.)
Goal: Enroll ____ women/day
24 The Rapid Assessment of the Burden of Malaria during Pregnancy

Procedures
Comments
Enrollment
1. Identify eligible women.
Check antenatal clinic card
Confirm information with woman
Note regarding gravidity: All pregnancies count, not just live
births. Inquire if the woman has had any pregnancies end in
death of the fetus for completeness of gravidity history.
Not previously enrolled in this assessment
All pregnancies; have experienced quickening.
Note: Record for all women attending antenatal
clinic in the enrollment logbook:
Date
Woman’s antenatal clinic number
Name
Age
Gravidity/parity
Mother tongue
Whether or not enrolled
Woman’s ID number
Reasons for nonenrollment:
• refused to participate, already enrolled, not
selected, etc.
2. Ask every eligible woman to participate. Note: If antenatal clinic volume is high, it may be
necessary to select every other eligible woman to
avoid selection bias. It is not a good idea to select
the first 10 women for example, as those who come
early for antenatal clinic may be different from
women who come later in the day.
3. Verify criteria. Exclusion criteria:
Gestational age before quickening
Age

L. Blood Test Procedures: HemoCue for Determination of
Hemoglobin Level
The following describes how to take a blood sample for use in a HemoCue machine.
Note: Not all countries and sites routinely use the HemoCue method and so should use the
method currently used. However, if a choice exists, use of the HemoCue system is preferable
as it allows a quick assessment of hemoglobin level that can be easily compared across
countries and sites.
• Organize the supplies you need:
gloves
cotton
disinfectant swab
lancet
HemoCue
HemoCue cuvette
sharps disposal container
hospital waste basket
slide marker
• Take one HemoCue cuvette from the container and close the lid again.
• Switch HemoCue ON and open cuvette holder to loading position.
• Put on gloves.
• Use the third or fourth finger for sampling. Clean puncture site with disinfectant and
allow to dry.
• Use your thumb to lightly press the finger from top of the knuckle to the tip (to increase
blood flow).
• Using disposable lancet, prick the side of the fingertip. (See steps 1-3 in Figure A-1 in the
next section.) Immediately dispose of the lancet in a sharps container.
• Wipe away the first 2-3 drops of blood. If necessary, apply light pressure again, until
another drop of blood appears. Avoid “milking.”
• Fill HemoCue cuvette in one continuous process. Wipe off excess blood on outside of
cuvette tip. Place in cuvette holder. Push HemoCue cuvette holder into the measuring
position.
• Wipe and clean puncture site.
• Note Hb value (within 10 minutes of reading).
• Take cuvette out of holder and throw away.
• Clean up and be careful with sharps.
• Switch HemoCue OFF.
26 The Rapid Assessment of the Burden of Malaria during Pregnancy

M. Blood Test Procedures: Thick and Thin Films for the Microscopic
Diagnosis of Malaria Infection 3
The following describes how to make thick and thin films for the determination of malaria
infection. If there are a substantial number of non–Plasmodium falciparum infections in the
area, both thick and thin films should be made. Otherwise, thick films are generally adequate.
Note: Rapid tests are available that can detect the presence of malaria parasites in peripheral
blood. These tests, although expensive, perform well when conducted by trained personnel.
They show decreased sensitivity in persons/settings with low parasite load. There are
currently not enough data to recommend the use of rapid Organize the supplies you need:
lab coat
gloves
cotton
disinfectant swab
2 slides (labeled slide & swipe slide)
lancet
sharps disposal container
hospital waste basket
slide marker
Thick blood films are more sensitive in detecting malaria parasites because the blood is
concentrated, allowing a greater volume of blood to be examined. However, thick films are
difficult to read. Thick films are stained unfixed after drying.
Thin films should be used if there are a substantial number of non—P. falciparum infections in
the area, as thin films make it easier to identify species. The thin film should be air-dried, fixed
with methanol, and allowed to dry before staining.
For best results, both thick and thin films should be stained with a 3% Giemsa solution (pH of
7.2) for 30--45 minutes. A Wright-Giemsa stain can also indicate malaria parasites but does
not demonstrate Schüffner’s dots as reliably as Giemsa.
Plasmodium parasites are always intracellular, and they demonstrate, if stained correctly, blue
cytoplasm with a red chromatin dot. Common errors in reading malaria films are caused by
platelets overlying a red blood cell and the misreading of artifacts as parasites.
Thick blood films are more sensitive in detecting malaria parasites because the blood is
concentrated, allowing a greater volume of blood to be examined. WHO recommends that
at least 100 fields, each containing approximately 20 white blood cells (WBCs), be screened
before calling a thick smear negative.
To quantify malaria parasites against WBCs (i.e., determine parasite density) on the thick
smear: Tally the parasites against the WBCs, until you have counted 500 parasites or 1,000
WBC, whichever comes first. Express the results as parasites per microliter of blood, using the
WBC count if known, or otherwise assuming 8,000 WBCs per microliter blood.
3 We have slightly adapted the following article for this section: Shah S, Filler S, Causer L et al. MMWR.
Surveillance Summary. Malaria surveillance --- United States, 2002. April 30, 2004. 53 (SS01); 21-34.
Module 1: Conducting an Antenatal Clinic Survey
27

Parasites/microliter blood = (parasites/WBCs) x WBC count per microliter (or 8,000).
Thin smears are useful for species identification of parasites already detected on thick smears.
They are also useful for screening for parasites if adequate thick smear are not available and as
a rapid screen while the thick smear is still drying.
To quantify parasites (i.e., determine parasite density) against red blood cells (RBCs) on thin
smear: Count the parasitized RBCs among 500-2,000 RBCs on the thin smear and express the
results as % parasitemia.
% parasitemia = (parasitized RBCs/total RBCs) x 100. If the parasitemia is high (>10%)
examine 500 BBCs; if it is low (

Figure A-1
Figure A-2
Module 1: Conducting an Antenatal Clinic Survey
29

N. Antenatal Clinic Survey Information Sheet 4
The following information sheet should be given to each potential survey participant.
If the potential survey participant cannot read or has low literacy skills, the
information should be read aloud to her. All potential participants should receive a
copy of the information sheet to take home.
Note to Interviewer: If the potential survey participant cannot read or if she has
low literacy skills, read this information aloud to her. Give each potential survey
participant a copy of this information sheet to take home.
Introduction
The [Ministry of Health] is doing an assessment to find out how many pregnant women in this
[assessment area] have malaria. This will help us find the best ways to prevent the effects of
malaria on pregnant women and their babies. As you know, sometimes you may get malaria
and feel sick. What you may not know is that sometimes you may have malaria without
feeling sick. The only way for us to know how many women may have this problem is to check
women’s blood. We plan to assess this problem in about _____ women in antenatal clinics in the
[assessment area].
Purpose of the Survey
We plan to check women’s blood for malaria to know how many women in the [assessment
area] are infected. This will help us plan and measure the effects of programs to decrease
malaria in pregnant women.
Procedures
If you agree to participate in this survey, we will ask you some questions about yourself and
your health since you have been pregnant. We will not be telling anyone about your individual
answers to the questions, and we will keep all assessment information about you safe and
secure. You also do not need to answer any questions on the survey forms that you do not
want to. We will review your clinic card and take your temperature. We will take a few drops of
blood from a finger stick to check your blood for anemia and malaria. You will still go through
the usual clinic exam by the clinic staff. If we find that you have malaria, we will treat you
with a drug called ___________ (enter appropriate drug name). If we find you need treatment for
anemia, we will inform the clinic staff so they will be sure to give you treatment for it. If you
participate in the survey, it will take about x number of minutes more than if you did not.
If you do not wish to participate in this survey, it will not affect the care given to you by the
clinic. If you have questions later, please feel free to ask. You can ask me today or if you have
questions later, you can ask _________________ (responsible assessment team member).
4 It is very important that the country’s human subjects or ethics requirements be followed with regard to
whether provision of information only is sufficient or documentation of participant’s informed consent is
necessary. It may also be required to obtain consent of the baby’s father.
30 The Rapid Assessment of the Burden of Malaria during Pregnancy

Risks or discomforts
You will feel a “pinch” that lasts for a few seconds when the finger stick is done to take blood
from your finger.
Benefits
One of the benefits to you of participating in this survey is that if we find that you have malaria,
we will give you___________ (enter appropriate drug name) to cure it. If you have anemia, you’ll
receive treatment for it.
Treatment
__________ (enter appropriate drug name) works very well to treat malaria. Studies have shown
that this drug is very safe for you to take while you are pregnant and that it will not harm your
baby. We believe that treating you for the malaria and recent fever outweighs any risk from the
drug.
We are always concerned that abnormal events may occur when you are pregnant that might
affect the baby inside of you. You may have seen babies that were born with some defects.
Most of these we cannot do anything about and it was no fault of the woman or clinic workers.
If we treat you with any drug, we would only use one that we think is very safe and would not
cause any of these problems. If you have any questions about this, please ask now, or you can
ask _______ (assessment team member) at the clinic at any time during the assessment. (Be sure
to give enough information so that the woman can find them.) If you have any questions about
your rights as a survey participant, you may contact _________ (name and address to be filled in).
Thank you very much for your time. Would you like to participate?
Please keep this information sheet in case you have questions later on.
Module 1: Conducting an Antenatal Clinic Survey
31

O. Analysis of Antenatal Clinic Data: Key Indicators
and Summary Tables
Below are key indicators for the Antenatal Clinic Survey and summary tables of survey
results. Further data analysis may be helpful, but it is generally not necessary for decision
making.
Tables can be useful for showing relationships between outcome variables.
• Table 1 shows how representative the women in the survey are of the women in the
country.
• Table 2 shows women’s reported use of prevention and control measures, such as IPTp,
ITNs, and antimalarial drugs for treatment of illness.
• Table 3 focuses on parasitemia, fever, and anemia by use of antenatal clinics and malaria
prevention interventions.
• Table 4 looks at the relationship between peripheral parasitemia, fever, and anemia.
Note: The tables can also break down the numbers and percentages by locale (e.g., region,
site, urban vs. rural).
32 The Rapid Assessment of the Burden of Malaria during Pregnancy

Outcome Variables
No. Outcome Variable (%) Numerator/Denominator
1 Pregnant women with peripheral
parasitemia
Number of pregnant women with positive
peripheral parasitemia blood films/
Number of women with valid blood films
2 Pregnant women with anemia
(Hb

Table 1. Characteristics of Women in the Antenatal Clinic Survey and Women
Country-Wide
Characteristic
Median age in years [range]
Median gravidity [range]
Antenatal clinic visits, median no. [range]
Able to read
Attended school (any)
Married
Owns own home
Owns moped
Owns bike
Owns radio
Works for cash
Grows cash crops
TOTAL
Women in Antenatal
Clinic Survey* (n= # )
Women in national
DHS**
*Data are % of participants unless otherwise indicated.
**If available, national data (e.g., from Demographic and Health Surveys) can be used to
compare how similar women in the assessment are to women nationally.
34 The Rapid Assessment of the Burden of Malaria during Pregnancy

Table 2. Use of Prevention and Control Measures by Women in the Antenatal
Clinic Survey
Treatment and Prevention Measures
(#sites) (#women)
Gestational age at 1 st antenatal clinic visit
Owns insecticide-treated bed net (ITN)
Uses ITN
Slept under ITN previous night
Used antimalarial drug during pregnancy for prevention (IPTp)
Used antimalarial drug during pregnancy for treatment of malaria
illness
Module 1: Conducting an Antenatal Clinic Survey
35

Table 3. Status of Peripheral Parasitemia, Fever, and Anemia among
Women in the Antenatal Clinic Survey
All
women
(n=#)
Women
with no
prior
ANC
(n=#)
Women
with at
least 1
prior
antenatal
clinic visit
(n=#)
Slept
under
bednet
previous
night
(n=#)
Use of antimalarial drug for IPTp
during pregnancy among women
with at least 1 prior antenatal
clinic visit (n=#)
Complete Incomplete None
Parasitemia
Overall
Primigravidae
Secundigravidae
Multigravidae
(>3 pregnancies)
Fever
Reported
fever or
malaria during
pregnancy and
took antimalarial
drug
Reported fever
within 7 days of
enrollment
Fever (>37.5ºC)
at visit
Anemia
(Hb3 pregnancies)
Moderate to
severe anemia
(Hb

Table 4. Relationship between Peripheral Parasitemia, Fever, and Anemia
among Women in the Antenatal Clinic Survey
Characteristic
Reported fever
within week before
enrollment
Parasitemic
(n=#)
Aparasitemic
(n=#)
Risk
ratio
95%
Confidence
interval
P
Anemia (Hb

38 The Rapid Assessment of the Burden of Malaria during Pregnancy

Woman’s full name:____________________________________________________________________________________
ID #_____A________
Tool 1: Antenatal Clinic Questionnaire
Today’s date: ______/_______/______
Day/Month/Year
ID number: ___ _1__ -- ___ ___ ___
Digit 1 = facility number Digit 2 = A (for antenatal clinic)
Digits 3, 4 & 5 = woman’s consecutive number
SCREENING QUESTION
Interviewer number _______
1. Age (years):: [ ]
(If the mother does not know her age, then estimate her age using the categories below)
less than 15 years [ ] 30-34 years [ ]
15-19 years [ ] 35-39 years [ ]
20-24 years [ ] 40-44 years [ ]
25-29 years [ ] more than 44 years [ ]
If the woman is less than an age deemed appropriate, thank her for her time and
DO NOT enroll her in this survey.
2. Have you felt the baby move inside you? [ ]
YES = 1
NO = 2
UNKNOWN = 9
If the woman has not experienced quickening, thank her for her time, and
DO NOT enroll her in this survey.
DEMOGRAPHIC INFORMATION
3. Village/town: ____________________________________________
Interviewer: Skip the next question; it will be coded later so that it is done uniformly.
4. Is this a rural or urban area? [ ]
Urban = 1
Rural = 2
Periurban = 3
Unknown = 9
5. What language do you usually speak with family members at home? [ ]
Language a = 1
Language b = 2
Language c = 3
Other = 8 (specify) ______________________________________
6. Are you married? [ ]
yes, married and living with husband = 1
yes, married but do not live with husband = 2
not married but living with a man = 3
separated or divorced = 4
widow of the father of this baby = 5
never married or lived with a man = 6
Tool 1: Antenatal Clinical Questionnaire
1

EDUCATION
7. What is the highest level of school you attended? [ ]
Primary = 1
Secondary = 2
Higher = 3
Never attended = 4
Unknown = 9
8. Can you read? [ ]
YES = 1
NO = 2
SOCIOECONOMIC INDICATORS
9. What is the roof of your house made of? [ ]
corrugated iron = 1
cement or concrete = 2
wood and mud = 3
thatch or grass = 4
reed or bamboo = 5
plastic sheet = 6
mobile roofs of nomads = 7
other = 8 (specify) ________________________________
10. What kind of floor does your house have? [ ]
earth or sand = 1
dung = 2
wood planks = 3
reed or bamboo = 4
vinyl tiles or carpet = 5
cement = 6
cement tiles or brick = 7
other = 8 (specify) ________________________________
11. What is the main job of the head of household/husband? [ ]
job a = 1
job b = 2
job c = 3
job d = 4
12. What is the monthly household income for your family? [ ]
income bracket a = 1
income bracket b= 2
income bracket c=3
FOR THE NEXT QUESTION, PLEASE ENTER A 1 OR 2 FOR EACH LINE
13. Do you or any member of your family living in the same compound own:
YES = 1
NO = 2
A bicycle/scooter/moped? [ ]
A radio? [ ]
A TV? [ ]
Own the house you are living in? [ ]
Own crop land? [ ]
Grow cash crops? [ ]
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

REPRODUCTIVE AND CLINICAL HISTORY
14. How many times have you become pregnant? [ ]
(including this one and all other pregnancies, including abortions and miscarriages)
14a. How many pregnancies with a live-born child? [ ]
14b. How many pregnancies with loss of the fetus? [ ]
MALARIA PREVENTION
15. Did you take malaria medicine during this pregnancy to prevent/protect from malaria to keep illness from coming into
the body when you did not have symptoms?
(NOTE: This question does NOT concern treatment for malaria illness.) [ ]
YES = 1
NO = 2
UNKNOWN = 9
If NO OR UNKNOWN, skip to question 16
If YES:
15a. What type of medicine did you take?
Chloroquine [ ]
Sulfadoxine-Pyrimethamine (SP, Fansidar) [ ]
Proguanil [ ]
Other [ ]
(specify): ______________________________
Unknown [ ]
15b. When you started taking the medicine, how many months pregnant were you? [ ]
15c. For the first time you took the medicine, how many total tablets did you take? [ ]
15d. How many times in a week did you take the medicine? [ ]
15e. How many tablets did you take each time? [ ]
15f. After the first dose, how often did you take this medicine? [ ]
Every week = 1
Almost every week = 2
Some weeks = 3
Monthly = 4
Rarely = 5
Do not know = 6
16. Did you sleep under a bed net during this pregnancy? [ ]
YES = 1
NO = 2
UNKNOWN = 9
If no, skip to question 17
16a. If yes, how frequently? [ ]
all the time = 1
most of the time = 2
sometimes = 3
rarely = 4
16b. Did you sleep under the net last night? [ ]
YES = 1
NO = 2
UNKNOWN = 9
Tool 1: Antenatal Clinical Questionnaire
3

16c. Has this net ever been treated with insecticide? [ ]
YES = 1
NO = 2
UNKNOWN = 9
16d. If yes, has the net been treated with insecticide in the past one year? [ ]
YES = 1
NO = 2
UNKNOWN = 9
16e. Is the net a long-lasting insecticide-treated net (LLN)? [ ]
YES = 1
NO = 2
UNKNOWN = 9
HISTORY OF FEVER OR MALARIA
17. Have you had a fever that you thought was malaria during this pregnancy? [ ]
YES = 1
NO = 2
UNKNOWN = 9
If NO, skip to question 18
17a. Did you get a convulsion with fever/malaria? [ ]
YES = 1
NO = 2
UNKNOWN = 9
17b. Did you stay in hospital overnight for treatment of fever/malaria? [ ]
YES = 1
NO = 2
UNKNOWN = 9
17c. Did you get a blood transfusion? [ ]
YES = 1
NO = 2
UNKNOWN = 9
17d. Did you take iron and folic acid tablets? [ ]
YES = 1
NO = 2
UNKNOWN = 9
17e. Have you taken a medication to treat malaria or fever during this pregnancy? [ ]
YES = 1
NO = 2
UNKNOWN = 9
4 The Rapid Assessment of the Burden of Malaria during Pregnancy

17f. Type of medication taken (check all that apply)
Chloroquine [ ]
Sulfadoxine-Pyrimethamine (SP) [ ]
Quinine [ ]
Antipyretics [ ]
Coartem [ ]
Other [ ]
(specify):_________________________________
Unknown [ ]
18. Have you had a fever that you thought was malaria during the past week? [ ]
(IF yes, perform a rapid diagnostic test and treat accordingly.)
ANTENATAL RECORD INFORMATION
(Copy the following information from the antenatal record)
19. ANTENATAL CLINIC VISITS
19a. Total number of visits (including this one) [ ]
19b. Timing of visits:
Date of visit______________Gestational age______________Fundal______________ (weeks)______________height______________
first visit: ___ ___ / ___ ___ / ___ ___ [ ] [ ]
this visit: ___ ___ / ___ ___ / ___ ___ [ ] [ ]
19c. Last menstrual period (LMP)(if recorded)… ___ __/_____/____
TODAY’S EXAMINATION BY ASSESSMENT TEAM
20. Hemoglobin (g/dl): _____ _____ . _____
If Hgb < 11, ensure that treatment for anemia is given
If Hgb < 7, ensure that treatment for severe anemia given and refer to ANC staff
21. Temperature ____ ____.____ (Celsius)
(If temperature >37.5, do a rapid diagnostic test.)
22. Rapid diagnostic test result [ ]
Positive = 1
Negative = 2
Result available and examined, but undetermined = 9
23. Blood film result [ ]
Positive = 1
Negative = 2
Result available and examined, but undetermined = 9
(If febrile, or history of fever in past 7 days with negative RDT, then read the slide in the clinic immediately.)
24. Malaria species. Check all that apply.
Plasmodium falciparum = 1 [ ]
P. vivax = 2 [ ]
P. malariae = 3 [ ]
P. ovale = 4 [ ]
Undetermined = 9 [ ]
25. Parasite density [ ]
Tool 1: Antenatal Clinical Questionnaire
5

26. Antimalarial drug given? [ ]
YES = 1
NO = 2
If NO, skip to Q27
26a. If YES, what type [ ]
Chloroquine = 1
Sulfadoxine-pyrimethamine (SP) = 2
Chloroquine and SP = 3
Quinine = 4
Coartem = 5
Other = 8 (specify and explain): ____________________________________________________________
26b. Date administered: ___ ___ / ___ ___ / ___ ___
26c. Name of person administering antimalarial drugs _________________________________________
27. Treatment given for anemia, according to national policy? [ ]
YES = 1
NO = 2 (If no, go to end of questionnaire)
27a. What was the dose? _________
27b. Was she given the appropriate amount to take home and complete her
anemia treatment?
Note to Interviewer: If a woman is currently febrile or reports having had a fever in the last 7 days, she should
wait to receive her blood smear results prior to leaving clinic that day, and her blood slides should be promptly
read. If the slide is positive, she should receive treatment with the appropriate antimalarial drug. If a woman
is currently afebrile, with no history of fever in the past week, she need not wait for smear results but can
return for them the following day. If a woman is anemic or severely anemic, she should receive appropriate
treatment.
OR
If above differs from the country’s national policy, follow national policy.
PLEASE CHECK OVER THE QUESTIONNAIRE NOW TO MAKE SURE THAT ALL QUESTIONS HAVE BEEN ANSWERED, THEN
CHECK THIS BOX [ ]
Thank the woman for her time.
28. QUALITY CONTROL
Site supervisor should check all questionnaires for completeness every day at the end of all interviews.
Data entry clerks should initial at the end of every entry.
Person Name/Signature Date
28a Site Supervisor
28b Data Entry Clerk 1
28c Data Entry Clerk 2
28d Assessment Coordinator
6 The Rapid Assessment of the Burden of Malaria during Pregnancy

Module 2: Conducting a Delivery Unit Survey
A Delivery Unit Survey is designed to determine the magnitude
of the problem of malaria, specifically:
• What is the prevalence of peripheral, placental, and umbilical cord
parasitemia in pregnant women?
• What is the prevalence of low birth weight and premature delivery?
• Is there a relationship between parasitemia and low birth weight or
premature delivery?
• Does the prevalence of placental parasitemia vary by gravidity or locale?
This module contains sample materials for a Delivery Unit Survey. These
materials can and should be adapted to suit local needs. General guidance for
conducting a Delivery Unit Survey and managing data can be found in Chapters
3 and 4 of the manual.
Contents
Consult Resource 3 for presentations that address some of the
topics below.
A. Delivery Unit Survey Timetable
B. Selecting Sample Sizes
C. Eligibility Criteria
D. List of Supplies and Equipment
E. Assessment Teams
F. Assessment Team Training (Resource 3)
G. Supervisor’s Check List for Assessment Start-Up
H. Supervisor’s Guide to Conducting Antenatal Clinic
and Delivery Unit Surveys
I. Supervisor’s Guide to Data Management for Antenatal Clinic and
Delivery Unit Surveys
J. Sample Logbooks: Enrollment and Laboratory
K. Handbook for Assessment Teams
L. Guide for Night-time Admissions to the Delivery Unit
M. Ballard Score Sheet for Determining Gestational Age
(see also Resource 3)
N. Blood Test Procedures: Making Thick and Thin Films for the Microscopic
Detection of Malaria Infection
O. Taking Blood Samples from a Finger, Placenta,
and Umbilical Cord
P. Making a Placental Impression Smear
Q. Information Sheet
R. Analysis of Delivery Unit Survey Data
Module 2: Delivery Unit Survey
1

A. Delivery Unit Survey Timetable
The timetable below outlines key steps in planning for and conducting Delivery Unit (and
antenatal clinic) survey activities and the approximate length of time to allow for these steps.
Note that this timetable is the same as that for the ANC survey and that these preparations and
activities should be undertaken simultaneously.
Period Time Activities
Planning the
assessment
2-4 weeks •Determine what assessment components, if any, need
to be conducted
• Determine what approvals (ethical, scientific, other
ministerial) are needed and initiate approval process
Preassessment 2-3 weeks • Select Site(s)
• Explain the assessment to the community
• Procure assessment equipment and supplies
• Hire assessment team and/or identify existing staff
• Adapt and translate questionnaires
• Pretest questionnaires
• Identify site for training
• Identify responsible persons for all presentations
(See Resource 3 for sample presentations)
• Manage logistics of training, including per diem,
transportation, meals, and lodging
• Arrange for on-site training in DUs and in ANCs
Assessment
training
Start-up of
assessment
1 week • Conduct training course
• Finalize questionnaires based on pretest and make
adequate copies for final day of training
• Meet with supervisors to coordinate assessment
start-up in clinical facilities
2 weeks • Make adequate copies of ANC and Delivery Unit
questionnaires, enrollment logbooks, and laboratory
logbooks, and ensure questionnaires are at assessment
sites
• Distribute supplies to each assessment site and ensure
a system of re-stocking supplies is in place
• Establish quality control mechanism for data collection,
including clinical and laboratory procedures,
transport, and storage
• Establish a supervisory system that addresses logistics
(staffing, supplies), quality of interviewing, quality
of questionnaires, quality of obtaining specimens,
laboratory quality (slide and staining, Hemocue
calibration), logbook maintenance
Assessment 8-9 weeks • Enroll women and collect data
• Ensure supervisory system and quality control
mechanisms are functioning
• Ensure adequate supplies and equipment are available
and functioning at each assessment site
Postassessment 8 weeks • Conduct data entry, cleaning, and analysis
• Write final report
• Disseminate results
• Initiate policy discussions
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

B. Selecting Sample Sizes
The sample size needed for the Delivery Unit Survey depends on
1) the estimated prevalence of women with placental parasitemia and of LBW babies,
2) the acceptable margin of error, and
3) the design effect
The sample size required to measure each of the survey’s main indicators (placental
parasitemia and low-birth-weight babies) can be calculated by using Statcalc in EPI-INFO. The
EPI-INFO calculation should include an adjustment (i.e., design effect [see note at end of this
section, Selecting Sample Sizes]) for the fact that the survey uses cluster sampling, rather than
random sampling.
If the sample size required to measure one indicator is larger than the sample size required for
the other indicator, the larger of the two sample sizes should be selected. The sample size may
need to be modified to account for other factors (see example below).
Determination of the sample size for the Delivery Unit Survey begins with
1. Point estimates of the proportion of women with placental parasitemia and
the proportion of babies with LBW
2. The level of accuracy desired, for example + 10%, and
3. The design effect
Delivery Unit Survey Sample Size Calculation: An Example
Point estimates: The prevalence of placental parasitemia during high transmission season
among women of all gravidities is estimated at 35%, and the prevalence of LBW is estimated to
be 14%.
Level of accuracy: The assessment coordinator determines that it is acceptable if the survey
can estimate the prevalence of placental parasitemia within 10% (that is, the prevalence of
parasitemia could be between 25% and 45%) and the prevalence of low birth weight within
5% [that is, low birth weight could be between 9% and 19%].
These numbers are then entered in Statcalc, with a design effect=2 (to correct for the fact that
this is not a random community sample) for each indicator. The design effect of 2 is chosen on
the basis of previous similar studies. EPI-INFO then calculates sample sizes: 174 for placental
parasitemia and 370 for LBW. The larger of these two is 370, and thus this is the sample size
for the Delivery Unit Survey.
Estimated
prevalence
Margin of
error
Needed
sample size
(from Statcalc)
Other
factors
Placental 35% 10% 174 --- 174
parasitemia
during high
transmission
season
LBW 14% 5% 370 --- 370
Total
delivery unit
Sample size
(after adjusting
for other factors)
Note: If the prevalence of placental parasitemia during high transmission season is unknown,
assume a level of 50% for calculating sample size. This level is the most conservative estimate,
as it yields the largest required sample size. If the prevalence of LBW is unknown, countries
could use the following estimates from UNICEF and WHO to calculate sample sizes:
East Africa, 13.5%; Middle Africa, 12.3%; Southern Africa, 14.6%; and Western Africa, 15.4%.
370
Module 2: Delivery Unit Survey
3

Note: If the assessment is being used as a baseline that will be repeated after an intervention
in order to demonstrate impact, the sample required will be larger and the sample size calculations
more complex. It is advisable to consult a statistician for further guidance.
Note on design effect:
Large surveys are often conducted using cluster surveys, meaning that the population is
divided into clusters and sampled accordingly. Clusters are selected by random sampling and
then random samples are taken within the selected clusters. The benefits of cluster sampling
are that it is often easier and less expensive to conduct than simple random sampling as the
needed sample size is smaller. However, its disadvantage is that there is a loss of precision
because the elements within the cluster are generally more correlated (similar) than those
between the clusters. Selecting an additional member from the same cluster adds less
new information than would a completely independent selection. As the cluster size and
intracluster correlation increase, cluster variances increase more than one would find in a
simple random sample. The benefits of cluster sampling often outweigh the disadvantage of
the loss in precision.
Because cluster sampling results in a loss of precision and a smaller sample size, an
adjustment called the design effect should be used to determine survey sample size when
clustering is involved. The design effect is basically the ratio of the actual variance , under the
sampling method actually used, to the variance computed under the assumption of simple
random sampling. The main components of the design effect are the intraclass correlation and
the cluster sample sizes. The design effect is calculated as follows:
DEFF = 1 + þ (n – 1),
where Deff is the design effect, þ is the intraclass correlation for the statistic in question, and
n is the average size of the cluster. The interpretation of a value of DEFF of, say, 3.0 is that
the sample variance is 3 times bigger than it would be if the survey were based on the same
sample size but selected randomly. It can be seen that the design effect increases as the cluster
sizes increase, and as the intraclass correlation increases. The square root of the design effect
shows how much the sample standard error, and consequently the confidence intervals,
will increase because of the clustering. The intraclass correlation represents the likelihood
that two elements in the same cluster have the same value, for a given statistic, relative to
two elements chosen completely at random in the population. A value of 0.10 is interpreted,
therefore, to mean that the elements in the cluster are about 10% more likely to have the same
value than if the two elements were chosen at random in the survey.
4 The Rapid Assessment of the Burden of Malaria during Pregnancy

Design effects vary from survey to survey and even within the same survey will vary from
question to question. In summary, using a cluster sample generally requires either a larger
sample size than a simple random sample or a wider confidence interval. The design effect
is used to determine how much larger the sample size or confidence interval needs to be.
In general, for a well-designed study, the design effect usually ranges from 1 to 3. It is not
uncommon, however, for the design effect to be much larger.
The survey methodology recommended for both the antenatal clinic surveys and the Delivery
Unit Surveys use cluster sample methodology and thus require that a design effect be used.
C. Eligibility Criteria
All women who are delivering babies should be asked to participate in the survey.
Women are eligible for the survey if they meet the following requirements:
Gravidity: All gravidities. Although primigravidae and secundigravidae are the groups
typically most affected in high transmission areas, women of all gravidities should be eligible
so that the burden of malaria during pregnancy can be estimated for all pregnant women.
Age: The youngest age at which women are eligible to participate should be the age at which
most women in the assessment area have their first child. This is to ensure that primigravidae
and secundigravidae (the groups at highest risk) are included in the assessment. The usual
minimum age is 15 years. The age of the youngest participants may well be less than the age
of majority and should be consistent with any country policy or norm regarding this type of
survey.
Notes: Women who participated in the ANC survey are eligible to also participate in the
Delivery Unit Survey, but should not be selected for the Client Exit Interview.
Module 2: Delivery Unit Survey
5

D. List of Supplies and Equipment
Make sure that each delivery unit has the necessary supplies and equipment before the
start of the survey.
Item Quantity Comments/Use # in
stock/
Balance
needed
Screening
& Clinical
Evaluation
Electronic
thermometers
2 Temperature collection; if electronic
thermometers are unavailable,
mercury glass thermometers are an
acceptable alternative.
Baby scale 1 Ideally, an electronic digital scale.
A well-calibrated balance scale is
also acceptable.
Tape measure 1 Mother’s mid-upper arm
circumference.
Height stick 1 Can make height measuring area on
wall of DU.
Laboratory
Count-down 1 For laboratory use.
timer
Slides 3/participant Allow extras for waste
Lancets 2/participant Allow extras for waste;
1 for peripheral blood film and 1 to
pierce the umbilical cord.
Isopropyl
alcohol
Cotton wool
or gauze
Giemsa stain
Toilet paper
(or slide boxes)
Container for
used lancets
Staining jars
Slide drying rack
Enough
to clean
1 finger/
participant
Enough
to clean
1 finger/
participant
Premoistened alcohol wipes are an
acceptable alternative.
Gauze is preferable to wool as it
leaves fewer fibers on the placenta
and therefore on the slide.
Based upon sample size. In addition
to Giemsa powder, need all
other materials to mix stain, including
distilled water, buffer, glycerol,
and glassware to mix and store.
Sufficient to wrap (or store) all
slides from assessment
1 Sharps container
2/lab
1/lab
Hair dryer 1/lab May be needed, depending on
climate. Optional.
Microscope 1/lab
Surgical scissors 6 pairs/site
Forceps
6/site
Date
Ordered
6 The Rapid Assessment of the Burden of Malaria during Pregnancy

Item Quantity Comments/Use # in
stock/
Balance
needed
Date
Ordered
Wooden
applicator sticks
or plastic
transfer pipettes
1/participant
To transfer placental blood to slide
Spare light bulbs
for microscope
Immersion oil
Lens cleaner
Lens cleaning
tissue
Sharpie markers
(ultra fine)
Examination
gloves
1/lab
3 tubes/lab
3 pairs/
participant
Need 1 pair for peripheral film
and 2 pairs for placental sampling.
Need extra for laboratory and extra
for breakage
Tally counters 2/laboratory
Computer 1-2 2 is ideal, 1 is adequate
(with at least
Windows 2000)
Epi-Info or another
1-2 Installed on each computer
statistical
software package
(Epi Info is
preferred)
Goggles 2 pairs/site For use when handling placenta to
prevent splashes to eyes.
Tray
1/site
Tissue paper
Filter paper
Bleach
Beaker and 1/site
basin
Office Supplies
AA batteries
If using digital baby scale.
Clipboards 1/interviewer
Pencils
1/interviewer
Only if preparing thin films.
Pencil sharpener 1/interviewer
Only if preparing thin films.
Pens
2/interviewer
Stapler 1
Staples
2 boxes
Ink pad/Ink 1/site For fingerprinting women if signature
needed and woman cannot
sign. Should be bound books, not
spiral-bound or perforated.
Logbooks 1/site and 1/
lab
Module 2: Delivery Unit Survey
7

E. Assessment Teams
The number of assessment teams depends on the number of delivery units used.
The following example assumes that 4 delivery units will be used.
Title
Number needed
Assessment coordinator 1
Laboratorian supervisor 1
Site supervisors
Interviewers
Laboratorians
Data management coordinator 1
Data entry clerks 2
4 (1 per site)
8 (2 per site)
4 (1 per site)
Note: At least one assessment team member should be available 24 hours per day to enroll all
women who are delivering and promptly process placentas. If this is not possible, a cooler and
icepacks should be available in order to store placentas.
F. Assessment Team Training
The training for site supervisors, interviewers, and laboratorians should be held after
preassessment activities. Training will take approximately 4-5 days.
Below is a detailed explanation of how to conduct the training. A sample schedule follows the
explanation.
Note: If both antenatal clinic (ANC) and Delivery Unit (DU) surveys will be conducted, it is
more efficient to conduct training for both surveys simultaneously. Therefore, this module
describes simultaneous training. If only one of the surveys is conducted, this module will need
to be modified accordingly.
Note: If qualitative studies will be conducted about the same time as the quantitative studies,
it would be beneficial to conduct the training simultaneously. Consult the qualitative training
manual (or the modules that accompany the qualitative surveys) for guidance on how to
combine the two.
Day 1:
Morning: The assessment coordinator should present background information on malaria
during pregnancy and assessment objectives. (See Resource 3 for sample presentations)
Afternoon: The assessment coordinator reviews ANC policies and procedures located in
the assessment team member’s handbook (see K in this Module). This provides a general
overview of the assessment. Once the overview is complete, the assessment coordinator
should split the interviewers into teams. Each team will rotate through ANC and delivery unit
clinical procedures. Depending on the size of the assessment team, the logistics can be varied.
In a small team, everyone might work together to go through all procedures. In a large team
with a sufficient number of facilitators, it may be worthwhile to divide teams into groups that
rotate around a series of workstations. The important thing is that each staff member have the
opportunity to learn and practice each procedure that he/she will be conducting.
8 The Rapid Assessment of the Burden of Malaria during Pregnancy

ANC procedures include 1 :
• Exercise universal precaution for handling blood
Take and read axillary temperature
• Collect blood samples (fingersticks) from each other
Prepare slide (recording date and ID number on slide)
• Prepare thick films (and thin films in an area with substantial P. vivax transmission)
• Prepare Hemocue cuvette for hemoglobin reading; or Measure Hb or Hct by methods
used in that clinic
Delivery unit procedures include:
• Measure women’s mid-upper arm circumference
• Measure woman’s height
• Prepare slides—peripheral, placental, and cord blood
• Weigh newborn using scale
• Conduct the Ballard examination and apply the scoring system
(See Resource 3 for Ballard video)
Day 2:
Morning: The assessment coordinator arranges for interviewers to visit a delivery unit site
for practice of delivery unit procedures. At the same time, the laboratorian supervisor trains
assessment laboratorians on how to read peripheral, placental and cord films. (See N and O in
this module)
Afternoon: In a group setting, the assessment coordinator reviews each question on ANC and
delivery unit questionnaires and the information sheet (or consent form), depending on which
is being used. The coordinator also describes why there is a consent form if a consent form
has been determined necessary. Interviewers should be encouraged to ask questions and offer
suggestions. After reviewing each questionnaire, the interviewers should break into small
groups and practice each questionnaire one-on-one using copies of actual ANC cards from the
clinic. Any discrepancies regarding data extraction from ANC cards should be addressed with
the assessment coordinator, and questionnaires revised as necessary.
Day 3:
Morning: After the survey instruments are adapted, the survey instruments, as well as the
information sheet (or informed consent form if used), should be translated into the national
language and the primary language spoken by women in the assessment area, if different.
This initial translation should be followed by a back-translation (by individuals who did not
produce the original translation) into the national language to check the adequacy of the
translation. Once the translation is complete, pretesting can begin. While the surveys are
being pretested, laboratorians could practice film reading.
Note: If the primary language is not a written language, it will be important to use correct,
consistent phrasing of survey questions and information on the information sheet (or
informed consent form) so that questions are asked in a standardized manner. All
interviewers should work together to achieve correct, consistent phrasing of the questions
and have the opportunity to practice.
Afternoon: The assessment coordinator arranges for interviewers to visit two ANC sites to
practice the ANC questionnaire with clients. NOTE: Since the delivery unit questionnaire
is very similar to the ANC questionnaire, it is not necessary to pretest the delivery unit
questionnaire due to ethical considerations related to practicing interviewing women in labor
without their being enrolled in the assessment.
Divide the interviewers into two teams. Each team should visit one of the selected sites to pretest
the ANC questionnaires with at least 15 clients (total, not per interviewer) in each facility.
1 In some circumstances it may be possible to conduct polymerase chain reaction (PCR) on filter paper
samples or to examine tissue specimens preserved in formalin. However, in many settings these are neither
possible nor necessary.
Module 2: Delivery Unit Survey
9

Day 4:
Morning: The assessment coordinator will explain the purpose of ANC and delivery unit
enrollment and laboratory logbooks. Then, the coordinator should demonstrate and review
these logbooks. Many people may not understand that the logbooks are used to record
everyone who is enrolled in the assessment as well as those who are excluded for any reason.
The interviewers should be divided into pairs to practice the revised questionnaires. The rest
of the morning should be used to resolve outstanding issues, and conclude the training.
Day 5:
If training is scheduled for 5 days, Day 5 can be reserved for work on any remaining issues.
Sample Training Schedule
Day 1 Day 2 Day 3 Day 4
Introduction/ Overview
Delivery Unit Clinical
Procedures
Pretest
questionnaires
Wrap-up
Morning
• Welcome
• Training objectives
• Malaria situation in
country
• Epidemiology of
malaria during
pregnancy
• Rapid assessment
objectives
See Resource 3 for
sample presentations.
Microscopy training
for laboratorians
On site delivery unit
clinical procedures
training and practice
for interviewers
Practice
questionnaires
and consent form
administration in
local language(s)
with translator
Practice
questionnaires
and consent form
administration in
local language(s) in
small groups
Introduce enrollment and
laboratory registers
Practice questionnaires
in pairs (using ANC cards
and ANC and delivery unit
registers).
Conclusion of training
Afternoon
Policy and procedures
in ANC and delivery unit
(worker’s handbook)
Practice clinical
procedures for ANC and
delivery unit (video of
Ballard) if available.
Use live demonstrations
using an adult model
before practicing on live
newborns.
Review ANC and
delivery unit
questionnaires and
consent forms
Practice
questionnaires in
pairs (using ANC
cards). Resolve
discrepancies
regarding data
extraction from ANC
cards.
Pretest
questionnaires on
site in ANC facilities
• Meet with supervisors
to discuss assessment
start-up:
• Make copies of ANC
and delivery unit
questionnaires
• Ensure ANC and
delivery unit log books
are at each assessment
site
• Distribute supplies to
each assessment site
• Establish quality control
mechanism
• Establish a supervisory
system
Evening
Read questionnaires
and consent forms
Assessment
coordinator
finalizes ANC
and delivery unit
questionnaires
based on pretests.
10 The Rapid Assessment of the Burden of Malaria during Pregnancy

G. Supervisor’s Check List for Assessment Start-Up
The following contains worksheets to assist the supervisor during the start-up phase of the
assessment. These sheets pertain to both Antenatal Clinic and Delivery Unit Surveys, as most
likely both will be conducted. If only one of the surveys is conducted, the list will need to be
modified accordingly.
Explain the purpose of the assessment to the “community,” through direct communication
where possible, and also through the display of malaria posters in the clinic, and any other
communication means.
Set up the supply management system:
• Verify that all supplies on the list are available.
• Provide the delivery unit, antenatal clinic unit, and the lab each with a set of supplies
(papers, laboratory materials, examination materials, antimalarial drugs and hematinics)
to last at least one week.
• If supply shortages (batteries, slides, etc.) are noticed, find a solution to continue the
assessment uninterrupted.
• Keep spare supplies in a safe place, preferably a locked cupboard or box.
• Keep the record of available stocks.
Have planning meeting with the assessment team:
• Make sure every person understands what is expected of him/her.
• Draw up a time and duty schedule for each team member, aiming for 8 hrs/day antenatal
clinic presence, and 24 hrs/day delivery room presence.
• Rehearse every team member’s interviewer number, and go over the patient number
system once more.
Also:
• Instruct the night staff of the delivery room to routinely store ALL placentas for the
assessment in individually marked plastic bags in the ice box if no assessment team
member happens to be present
• Assign responsibility for the ice box and for replacing the ice packs to an assessment
team member
• Arrange additional laboratory support, if needed
• Identify possible translators for local languages among the hospital staff. Where
possible, make them familiar with the questionnaire beforehand.
Module 2: Delivery Unit Survey
11

Set up instruments:
• Set up measuring tape, scales and Ballard chart in the delivery room
• Set up Hemocue instructions in the antenatal clinic room, if using Hemocue. Set up the
Hemocue and calibrate. Recalibrate daily.
• Find a safe and stable place for the infant weighing scale. Make sure that it is never lifted
by the cradle, as this will damage it.
• Keep instrument instructions in a safe place for future reference.
Set up data management system:
• Provide staff with enough information sheets (or consent forms, if used) and
questionnaires for at least one week.
• Make the arrangements for daily review of assessment results by the supervisor together
with the antenatal clinic and delivery unit staff.
• Make arrangements for daily storing of papers and slides (and filter papers and test
tubes, if being used).
• Make arrangements for weekly storing of papers and slides (and filter papers and test
tubes, if being used).
• Go through the data management system with the team members.
Set up assessment logs:
• Antenatal clinic logbook, delivery unit logbook, laboratory logbooks
(one for malaria, one for anemia)
12 The Rapid Assessment of the Burden of Malaria during Pregnancy

H. Supervisor’s Guide to Conducting Antenatal Clinic
and Delivery Unit Surveys
The following guide contains worksheets to assist the supervisor in noting the progress of the
survey, reminding the supervisor of important tasks (e.g., calibrating the Hemocue machine
daily), and guiding the supervisor in reviewing questionnaires.
These worksheets should be filled out on a regular basis, as determined by the supervisor.
Note: The worksheets pertain to both Antenatal Clinic and Delivery Unit Surveys, as most likely
both will be conducted. If only one of the surveys is conducted, the forms can be modified
accordingly.
Site: ______________________________
Date: ___ ___ / ___ ___ / ___ ___
1. Enrollment and rates of positivity
Antenatal clinic enrolled to date (No): ___________ Number positive: __________
Last antenatal clinic ID number used: ___ ___ - ___ ___ ___
Delivery enrolled to date (No):___________
Number positive (Placental): __________
Number positive (Maternal): __________
Number positive (Cord): __________
Last delivery ID number used: ___ ___ - ___ ___ ___
2. Staff, supplies and samples
Have any staff left the assessment?
Are all nights on the delivery unit being covered by the assessment team? ______
If this is not possible, are sufficient coolers (with icepacks) available for placental storage? ____
____________________________________________________________________________________________________________
Using the supply list above, note if supplies are adequate.
YES =1 NO = 2
Any other missing supplies: ______________________________________
If any supplies are needed, what is the plan for restocking? _________________________________________
____________________________________________________________________________________________________________
Are questionnaires and samples well organized and in a safe place?_______________________________
____________________________________________________________________________________________________________
If not, plan to improve situation:_______________________________________________________________________
____________________________________________________________________________________________________________
Samples and questionnaires taken to central location:
Module 2: Delivery Unit Survey
13

ANC:
Questionnaire numbers
Slide numbers:
___ ___ - ___ ___ ___ to ___ ___ - ___ ___ ___
___ ___ - ___ ___ ___ to ___ ___ - ___ ___ ___
Delivery
Questionnaire numbers
Slide numbers (M,P,C):
Tissue sample numbers, if collected:
Filter paper numbers (M,P), if collected:
___ ___ - ___ ___ ___ to ___ ___ - ___ ___ ___
___ ___ - ___ ___ ___ to ___ ___ - ___ ___ ___
___ ___ - ___ ___ ___ to ___ ___ - ___ ___ ___
___ ___ - ___ ___ ___ to ___ ___ - ___ ___ ___
3. Antenatal Care
Is the Hemocue machine being calibrated daily?______________________________________________________
____________________________________________________________________________________________________________
Check calibration today: ________________________________________________________________________________
Examine the logbooks. Are they being filled out correctly? __________________________________________
(Note: Enrollment logbooks should contain all patients, whether or not enrolled in
assessment]
Note any problems with logbooks:_____________________________________________________________________
____________________________________________________________________________________________________________
What is the plan to correct any problems with logbooks? ___________________________________________
____________________________________________________________________________________________________________
What is the average enrollment per day? (look at last 10 days): ____________________________________
If it is too high or too low, examine reasons, and make a plan for correction:______________________
____________________________________________________________________________________________________________
Are enrollments evenly spaced throughout the day (i.e., not all in the a.m. or p.m.)? _____________
Examine at least 5 questionnaires per assessment team member. Note any problems, and
discuss with that person. Pay particular attention to whether hemoglobin, temperature, and
blood smear results are completed.
Note any important problems and what measures were taken to fix them:
Are women with anemia receiving iron or iron/folate? ________
If not, why not? ______________________________________________________________________
Are women with positive blood smears receiving treatment for malaria?__________________________
If not, why not?__________________________________________________________________________________________
If consent forms are used, examine. Have women signed them in accordance with assessment/
country policy? Is the name of a contact person for questions written in as instructed?__________
____________________________________________________________________________________________________________
14 The Rapid Assessment of the Burden of Malaria during Pregnancy

4. Delivery Unit
Examine logbooks. Are they being filled out correctly? ______________________________________________
(Note: Enrollment logbook should contain all deliveries, whether or not enrolled in
assessment)
Note any problems with logbook: ______________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What is the plan to correct any problems with the logbook: ________________________________________
___________________________________________________________________________
What is the average enrollment per day? (look at last 10 days): __________
If it seems very low, examine reasons, and make a plan for correction:
___________________________________________________________________________
___________________________________________________________________________
Examine at least 5 questionnaires per assessment team member. Note any problems, and
discuss with that person. Pay particular attention to ensure that the following are completed:
height, arm circumference, baby weight, Ballard gestational age, blood smear results and
treatment.
Note any specific problems and what measures were taken to fix them:___________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Is the baby’s sex being documented on the Delivery Unit questionnaire ?__________________________
Are women with positive blood smears receiving treatment for malaria?__________________________
If not, why not?__________________________________________________________________________________________
____________________________________________________________________________________________________________
If consent forms are used, examine. Have women signed them in accordance with assessment/
country policy? Is the name of a contact person for questions written in as instructed?__________
____________________________________________________________________________________________________________
Are sample sets complete for each delivery patient (that is, do they contain a questionnaire, 3
slides (M, P, C), and, if collected, 2 filter papers (M, P), and a tissue sample? ______________________
____________________________________________________________________________________________________________
If not, why not? __________________________________________________________________________________________
____________________________________________________________________________________________________________
Module 2: Delivery Unit Survey
15

5. Laboratory
Examine the results books. Are the books being completed correctly?_____________________________
If problems are found, document here, and make a plan for correction: ___________________________
____________________________________________________________________________________________________________
Are the results for mothers from antenatal clinic with fever, and mothers and babies from
delivery, being given promptly to assessment team? _________________________________________________
____________________________________________________________________________________________________________
If not, what steps can be taken to improve the speed of obtaining results? ________________________
____________________________________________________________________________________________________________
Reread 10% of the slides of each type (ANC, Delivery M, Delivery P, Delivery C).
Rate the accuracy of slides:
Thick: (1 to 5, 5 is highly accurate):_______________
Thin: (1 to 5, 5 is highly accurate): _______________
If quality is poor, examine reasons (e.g., smears badly done, thick specimen is fixed, or stain
coloration is bad), and try to find a solution to the problem: ________________________________________
____________________________________________________________________________________________________________
Are slides being stored in a good manner (in slide boxes or, if slide boxes cannot be obtained,
rolled in tissue paper)?: ________________________________________________________________________________
If not, plan for correction: ______________________________________________________________________________
Does the laboratory have adequate supplies?_________________________________________________________
If not, plan to correct the problem: ____________________________________________________________________
____________________________________________________________________________________________________________
7. Data Entry
Review at least 5 questionnaires that have been entered in the computer.
Number of errors found in 5 ANC: _____________________________________________________________________
Number of errors found in 5 Delivery:_________________________________________________________________
Is the record number being written at the top of each questionnaire on each page? ______________
Other comments, observations or problems not mentioned above_________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
16 The Rapid Assessment of the Burden of Malaria during Pregnancy

I. Supervisor’s Guide to Data Management for Antenatal Clinic
and Delivery Unit Surveys
The following guide contains worksheets to assist the supervisor in managing and collecting
data. Worksheets outline tasks for assessment team members, as well as the supervisor.
Note: The worksheets pertain to both Antenatal Clinic and Delivery Unit Surveys, as most
likely both will be conducted. If only one of the surveys is conducted, the forms will need to be
modified accordingly.
Enrollment targets:
• List for each site:
Desired # of antenatal clinic visits: at least x/day
Desired # of deliveries:
at least x/day
Target data collection period:
• ANC
• Deliveries
Assigning an ID number:
List months during which to collect these data
List months during which to collect these data
1st digit: assessment site
Site #1 1
Site #2 2
Site #3 3
Site #4 4
2nd digit: type of health service
ANC
Delivery
A
D
3rd – 5th digit: consecutive number identifying each patient
Example: 35th antenatal clinic woman in Site#3 = 3A – 035
46th delivery in Site#1 = 1D – 046
Note: If the woman has been assigned an ID number but enrollment has to be abandoned for
whatever reason, file all related papers and test results, and assign the next woman the next
number. ID numbers should only be used once. All ID numbers should be accounted for at the
final data analysis.
• All data must be entered in computer
• All data items must be returned to designated location for re-entering into computer (for
double data entry) and quality control of slide readings
Mark ID NUMBERS on each item and each page!!
Module 2: Delivery Unit Survey
17

Assigning an interviewer number:
The supervisor should assign each interviewer a unique number to be used throughout
assessment.
For example:
Site #1 01 – 20
Site #2 21 – 40
Site #3 41 – 60
Site #4 61 – 80
Hints to provide interviewers for filling out questionnaires:
• Keep all pages of the consent forms (if used) and of the questionnaires stapled together
• Number all pages immediately with the ID number
• Write clearly
•………….. is a connecting line
•________ is a line to write on
• Feel free to make notes in the margin of the questionnaire form if the answer you
got was not very clear or if you have doubts. The more information the better.
• If it states “check all that apply,” please do not enter dashes for negative. Just leave
those spaces blank. Otherwise it may confuse the data entry.
• Make sure to get the right information in the right places: Some information comes
from asking the woman, some from the antenatal clinic card, and some from the
examination done for the assessment.
Completed consent forms (if used), questionnaires, slides, filter papers (if used), placenta
tubes (if used), and logbooks should be guarded very carefully: Any missing or
mislabeled items will compromise the final interpretation of the assessment.
Antenatal Clinic Survey
Each antenatal clinic enrollment will have at least 2 loose pieces of information
• Signed consent form, if used
• Completed questionnaire (…pages)
• 1 blood slide (thick and thin)
Data management tasks of antenatal clinic staff:
Each enrollment:
• Mark patient number clearly on each item and each page
• Mark patient number clearly on blood slide result from the lab
Before woman leaves:
• Verify that questionnaire is completed, and iron/folate given as indicated
• If woman is febrile or had a fever recently: Ensure that lab results are returned as soon as
possible and treat the woman with appropriate antimalarial drug as per national policy
before she leaves the clinic that day (Monica has a question here) if the slide was positive
During the day:
• Obtain lab results from all other women and if any were positive, prepare for treatment
when the woman returns that afternoon or the next day
18 The Rapid Assessment of the Burden of Malaria during Pregnancy

Data management tasks of supervisor:
At the end of each day:
• Keep antenatal clinic log of enrollment and refusals up to date
• Collect and review for completeness all data items
• File all forms together each day
Each week:
• Store all papers chronologically by assessment number
• Store all slides chronologically by assessment number
• Mark patient number range on each set of items, e.g.: 41.001 – 41.035
• Put all items aside in a safe place
Delivery Unit Survey
Each delivery will have at least 4 and as many as 8 loose pieces of information
• Signed consent form, if used
• completed questionnaire (…pages)
• 3 blood slides:
• Mother (thick and thin)
• Placenta (thick and thin)
• Cord (thick and thin)
• 2 filter papers:, if used:
• Mother
• Placenta
• Placenta tissue in tube, if used:
Data management tasks of delivery unit staff:
Each enrollment:
• Mark patient number clearly on each item and each page
• Mark M or P or C clearly on blood slides and filter papers, if used
• Mark patient number + M or P or C in the laboratory logbook
Before woman leaves:
• Verify that questionnaire is completed
• Verify that M and C slide results are back from laboratory, and treat her if positive
Data management tasks of supervisor:
At the end of each day:
• Keep delivery log of enrollment and refusals up to date
• Collect and review all data items for completeness
• File all forms together each day
Each week:
• Store all papers chronologically by assessment number
• Store all slides chronologically by assessment number
• Mark patient number range on each set of items, e.g.: 41.001 – 41.035
• Put all items aside in a safe place
Module 2: Delivery Unit Survey
19

J. Sample Logbooks: Enrollment and Laboratory
• Enrollment logbook: Records a list, by facility, of the pregnant women visiting the site
each day of the survey, her survey number, and whether or not she was enrolled (and if
not, why not).
• Laboratory logbooks: One records information about enrolled women’s malaria blood
films, and the other records information about enrolled women’s hemoglobin or
hematocrit, by facility.
During the assessment start-up, the assessment coordinator is responsible for ensuring that
each site has prepared enrollment and laboratory logbooks. During the assessment, site
supervisors are responsible for monitoring the use of the logbooks and preparing additional
books as necessary.
Malaria During Pregnancy Rapid Assessment - Enrollment Delivery Unit Logbook
Facility: __________________________________________________________________________________________________
District/Region:________________________________________________________________________________________
Date
Woman’s
DU
number
Name of
Woman
Age G/P* Mother
tongue
Enrolled?
Yes/No
Woman’s
ID number
Comments**
*Gravidity/parity
**It may be helpful to make a list of reasons for nonenrollment, along with a code number for
each reason, and place it on the face page of the logbook. For example, if the first reason on
the list was “woman refused to participate” and the code for that reason was “1,” “1” could be
written in the comments column above.
Malaria During Pregnancy Rapid Assessment –
Laboratory Delivery Unit Logbook for Malaria
Facility: __________________________________________________________________________________________________
District/Region:________________________________________________________________________________________
Date
Woman’s
ID number
Blood
smear
+/-
Maternal:
Placenta:
Cord:
M:
P:
C:
Species*
Density (only
for maternal
sample)
*Some settings may need a column for malaria species.
Pigment
Comments
20 The Rapid Assessment of the Burden of Malaria during Pregnancy

K. Handbook for Assessment Teams
Each member of the assessment team should receive a handbook during assessment training.
The handbook briefly describes the enrollment procedure and postenrollment activities,
including the questionnaire, measurements and laboratory specimens, medications, and
follow-up activities.
Note: The team member’s handbook has space for including the number of women to be
enrolled each day.
Throughout woman’s stay at delivery unit: Follow normal procedures to ensure safety
of mother and baby. Ensure proper medical care.
Ensure that either an interviewer is available 24 hours/day in the delivery unit to enroll
all women and process placentas OR that an ice pack and cooler is available for storage
and the interviewer arriving in the morning can retrospectively enroll women who
arrived during the night.
Procedures
Enrollment
1. Identify eligible women.
• Confirm information with woman
Note: Enroll all women at delivery, even
those who may have participated in the
ANC survey.
Comments
All deliveries
Mothers at least 15 years old
(or minimum age limit)
Note: Record for all women attending delivery
unit in the enrollment logbook:
Date
Woman’s delivery unit number
Name
Age
Gravidity/parity
Mother tongue
Whether or not enrolled
Woman’s ID number
Reasons for no enrollment:
• Refused to participate, placenta not available,
left delivery unit without being enrolled, less
than minimum age.
2. Verify criteria. Exclusion criteria:
• Allergic to antimalarial drugs being used or
related drugs
• Age

Postenrollment
Mother
4. Complete the questionnaire, collecting
information on the current pregnancy.
Note: Peripheral blood samples are taken
before and after delivery. Parasitemia
often clears quickly after delivery.
Baby
5. Examine the baby within 24 hours of
delivery.
Note: Nonlive births should be enrolled, if
feasible and culturally appropriate.
• Administer questionnaire.
• Mark the thick film slide with the date, woman’s
enrollment number, and the letter “M” to
indicate that slide is mother’s peripheral blood
film.
• Take mother’s height and midupper arm circumference
If live birth:
• Determine sex
• Weigh (in grams)
• Assign a Ballard score (see directions later in
this module)
• Determine gestation age in weeks
• Note any physical abnormalities
If nonlive birth:
• Take placental and umbilical cord samples
• Weigh
• Record probable cause of death
Placenta
6. Take placenta samples
(see directions later in this module)
7. Give treatment to the mother if she has
a positive peripheral blood film and
to the baby if the baby has a positive
umbilical cord film.
Note re: night-time deliveries: Ideally, interviewers
will be available 24 hours/day to enroll
women who deliver at night and to promptly
process placentas. If not, ensure that ice packs
and coolers are available for placenta storage.
Mark two separate slides with the following
information:
• Mark the placental thick film slide with the
date, woman’s enrollment number, and the letter
“P” to indicate that this slide is the mother’s
placental film.
• Mark the umbilical cord thick film slide with
the date, woman’s enrollment number, and the
letter “C” to indicate slide as cord film.
• Provide treatment according to the
country policy
• A thin blood film may be required in areas with high prevalence of mixed or pure non—P.
falciparum species.
22 The Rapid Assessment of the Burden of Malaria during Pregnancy

L. Guide for Night-Time Admissions to the Delivery Unit
Ideally, interviewers will be available 24 hours per day to enroll women who deliver at
night and to promptly process placentas, but this is not always possible. Coolers (with
ice packs) should be available for storing placentas.
The following describes how to handle enrollment and placenta samples for women
who are admitted during the night if no interviewer is present.
At night if no team member is present:
•Store all placentas in individual bags in the cooler (outfitted with ice packs). Mark patient
name and hospital registration number on the bag.
• Enter patient data in the hospital’s delivery ward admissions book.
• Encourage women to stay in the hospital until the assessment team arrives in the morning.
In the morning on arrival of the assessment team member:
• Check hospital’s delivery ward admissions book for deliveries, copy into assessment log.
• Check placenta box to see if all are there.
• See if mothers and newborns are still on the ward.
• Enroll patients for whom placentas are available. Do questionnaire, obtain Mother’s thick
and thin blood smear and examine mother and child. Encourage mother to wait for slide
results from the laboratory. Submit M slide with priority to the laboratory.
• Once all questionnaires and clinical examinations are done, take the placenta samples.
Batch placenta testing together, submit C slide with priority to the laboratory.
• Get lab results back and treat mother and newborn if slides were positive.
Note: Leave the placenta tests for after you have finished with the mother and baby.
The placentas will stay in the ice box, but the mother might otherwise leave the hospital.
Module 2: Delivery Unit Survey
23

M. Ballard Score Sheet for Determining Gestational Age
The Ballard score sheet can be used to determine gestational age. A video that
describes the Ballard method is included on the accompanying CD-ROM, with the kind
permission of Dr. Jeanne Ballard.
Some researchers have proposed a modification of the Ballard examination in
which only the external criteria are evaluated and the neurologic examination is not
performed [Verhoeff FH, Milligan P, Brabin BJ, Mlanga S, Nakoma N. 1997. Gestational
age assessment by nurses in a developing country using the Ballard method, external
criteria only. Annals of Tropical Paediatrics, 1997. 17: 333-342]. The resulting score is
then doubled to arrive at a total Ballard score with which an estimated gestational age
may be correlated. This modification can be useful for stillbirths. While the results
from these researchers suggest that the approach compares favorably with other
approaches for estimating gestational age, there is less experience with the Ballard
external-only method than there is with the standard Ballard examination.
Note: If several or many interviewers are working on the rapid assessment in one
site, the Ballard score results should be assessed by a smaller subset of interviewers.
This would help improve consistency of the results by reducing the possibility of
interpersonal differences. In addition, those who are assigned the responsibility of
determining gestational age will gain substantial experience. The supervisor should
check to make sure that age is being assessed consistently.
24 The Rapid Assessment of the Burden of Malaria during Pregnancy

Physical Maturity
Skin
Sticky, friable,
transparent
Gelatinous,
red,
translucent
Smooth,
pink;
visible
veins
Superficial
peeling and/
or rash; few
veins
Cracking,
pale
areas; rare
veins
Parchment,
deep
cracking; no
vessels
Lanugo None Sparse Abundant Thinning Bald areas Mostly bald
Plantar
surface
Heel-toe
40-50 mm:-1
50 mm;
no crease
Breast Imperceptible Barely
perceptible
Eye/Ear
Genitals
(male)
Genitals
(female)
Lids fused
loosely: -1
Tightly: -2
Scrotum flat,
smooth
Clitoris
prominent,
labia flat
Lids open;
pinna
flat: stays
folded
Scrotum
empty, faint
rugae
Clitoris
prominent,
small labia
minora
Faint red
marks
Flat areola,
no bud
Slightly
curved
pinna: soft;
slow recoil
Testes
in upper
canal, rare
rugae
Clitoris
prominent,
enlarging
minora
Anterior
transverse
crease only
Stippled
areola, 1-2
mm bud
Well-curved
pinna: soft but
ready recoil
Testes
descending,
few rugae
Majora and
minora equally
prominent
Creases
anterior
2/3
Raised
areola, 3-4
mm bud
Formed
and firm,
instant
recoil
Testes
down,
good
rugae
Majora
large,
minora
small
Creases
over entire
sole
Full areola,
5-10 mm
bud
Thick
cartilage, ear
stiff
Testes
pendulous,
deep rugae
Majora cover
clitoris and
minora
Leathery,
cracked,
wrinkled
Score
Maturity
Rating
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
Weeks
Module 2: Delivery Unit Survey
25

N. Blood Test Procedures: Making Thick and Thin Films for the
Microscopic Diagnosis of Malaria Infection
The following describes how to make thick and thin films for the determination of
malaria infection. If there are a substantial number of non–Plasmodium falciparum
infections in the area, both thick and thin films should be made. Otherwise, thick films
are generally adequate.
Note: Rapid tests are available that can detect the presence of malaria parasites in
peripheral blood. These tests, although expensive, perform well when conducted by
trained personnel. They show decreased sensitivity in persons/settings with low
parasite load. There are currently not enough data to recommend the use of rapid tests
to detect malaria infection in placental blood.
Organize the supplies you need:
lab coat
gloves
cotton
disinfectant swab
2 slides (labeled slide & swipe slide)
lancet
sharps disposal container
hospital waste basket
slide marker
Thick blood films are more sensitive in detecting malaria parasites because the blood is
concentrated, allowing a greater volume of blood to be examined. However, thick films are
difficult to read. Thick films are stained unfixed after drying.
Thin films should be used if there are a substantial number of non—P. falciparum infections in
the area, as thin films make it easier to identify species. The thin film should be air-dried, fixed
with methanol, and allowed to dry before staining.
For best results, both thick and thin films should be stained with a 3% Giemsa solution (pH of
7.2) for 30--45 minutes. A Wright-Giemsa stain can also indicate malaria parasites but does
not demonstrate Schüffner’s dots as reliably as Giemsa.
Plasmodium parasites are always intracellular, and they demonstrate, if stained correctly, blue
cytoplasm with a red chromatin dot. Common errors in reading malaria films are caused by
platelets overlying a red blood cell and the misreading of artifacts as parasites.
Thick blood films are more sensitive in detecting malaria parasites because the blood is
concentrated, allowing a greater volume of blood to be examined. WHO recommends that
at least 100 fields, each containing approximately 20 white blood cells (WBCs), be screened
before calling a thick smear negative.
To quantify malaria parasites against WBCs (i.e., determine parasite density) on the thick
smear: Tally the parasites against the WBCs, until you have counted 500 parasites or 1,000
WBC, whichever comes first. Express the results as parasites per microliter of blood, using the
WBC count if known, or otherwise assuming 8,000 WBCs per microliter blood.
26 The Rapid Assessment of the Burden of Malaria during Pregnancy

Parasites/microliter blood = (parasites/WBCs) x WBC count per microliter (or 8,000).
Thin smears are useful for species identification of parasites already detected on thick smears.
They are also useful for screening for parasites if adequate thick smear are not available and
as a rapid screen while the thick smear is still drying.
To quantify parasites (i.e., determine parasite density) against red blood cells (RBCs) on thin
smear: Count the parasitized RBCs among 500-2,000 RBCs on the thin smear and express the
results as % parasitemia.
% parasitemia = (parasitized RBCs/total RBCs) x 100. If the parasitemia is high (>10%)
examine 500 RBCs; if it is low (

O. How to Take Blood Samples from a Finger, Placenta,
and Umbilical Cord
Finger Prick:
Organize the supplies you will need:
gloves
cotton gauze
2 slides per finger-stick (1 labeled M for maternal peripheral blood and 1 swipe slide)
lancet
sharps disposal container
The figure below shows how blood may be obtained by pricking the patient’s finger.
* In Figure A-1, the hands are illustrated ungloved to better indicate their placement during the procedures. However,
wearing gloves while processing blood specimens is recommended to prevent transmission of bloodborne pathogens
(MMWR 1988;37:377--82, 387--8 and MMWR 1987;36[No. S2]).
Placenta and Umbilical Cord:
Organize the supplies you need:
gloves
cotton gauze
3 slides per placenta (1 labeled P for placenta, 1 labeled C for cord, and 1 swipe slide)
tweezers
scissors
lancet
sharps disposal container
basin with disinfectant for tweezers, scissors
1. Label all slides with ID number, date, and site obtained (i.e., P or C)
2. Put on gloves
3. Keep placentas in plastic bags whenever possible
4. Wipe cord
5. Use lancet to puncture cord
6. Obtain cord slide by touching from above, make thick and thin film
7. Turn placenta over and find maternal side
8. Wipe off placenta
9. Make placenta thick and thin film
10. Clean up and be careful with sharps
If more than one placenta is done at once: Be careful not to cross-contaminate. Change
gloves and instruments after sampling each placenta.
28 The Rapid Assessment of the Burden of Malaria during Pregnancy

P. Making a Placental Impression Smear
Although both impression smears and thick smears require taking blood samples,
impression smears require more manipulation of the placenta than do thick smears.
Thus, the benefit of the additional information gained from an impression smear needs
to be balanced against the potential risk incurred.
Materials and equipment needed to collect the sample:
Tray
Blunt-ended scissors
Forceps with blunt tips
Scissors/scalpel knife
Gloves
Marking pen
Absorbent material such as paper towel
Safety cover or transparent disposable plastic face shield to cover the face to protect against
any blood splash
Beaker containing 10% bleach
How to make a smear:
1. Label the slide with a marking pen, include the sample/placenta number and date.
2. Place the whole placenta in the tray.
3. Open up the membranes covering the maternal side of the placenta and move them aside.
4. Holding the piece of placenta with forceps, cut a small (about 5mm3) piece with scissors
or a scalpel knife.
5. Absorb the excess blood with absorbent material.
6. Blot several times on a piece of absorbent material.
7. Make 3 to 6 impressions of the tissue along one long edge of the slide by gently dabbing
the tissue. The blood impression should be no thicker than a thin smear.
8. For increased surface area for smear reading, make smears along the other long edge of
the slide using short, diagonal strokes.
9. Place the forceps and scissors/scalpel knife in the beaker containing 10% bleach.
10. Allow the slide to dry.
11. Process as for thin blood smears.
For an impression smear, the level of infection should be reported as percent parasitemia
rather than number of parasites/ul of blood.
Module 2: Delivery Unit Survey
29

Q. Delivery Unit Survey Information Sheet 2
The following information sheet should be given to each potential survey participant.
If the potential survey participant cannot read or has low literacy skills, the information
should be read aloud to her. All potential participants should receive a copy of the
information sheet to take home.
Note to Interviewer: If the potential survey participant cannot read or has low literacy
skills, read this information aloud to her. Give all potential participants a copy of this
information sheet to take home.
Introduction
The [Ministry of Health] is doing an assessment to find out how many pregnant women in this
[assessment area] have malaria. This will help us find the best ways to prevent the effects of
malaria on pregnant women and their babies. As you know, sometimes you may get malaria
and feel sick. What you may not know is that sometimes you may have malaria without feeling
sick. When you are pregnant and you have malaria, the baby can be born small and weak, even
if you have not felt sick. The only way for us to know how many women may have this problem
is to check blood from the placenta (afterbirth) after the woman gives birth. We plan to assess
this problem in about ________ women in the [assessment area].
Purpose of the Survey
We plan to check blood from the placenta for malaria to know how many women in the
[assessment area] are infected. This will help us plan and measure the effects of programs
to decrease malaria in pregnant women.
Procedures
If you agree to be in this assessment, we will ask you some questions about yourself and
your health since you have been pregnant. We will not be telling anyone about your individual
answers to the questions, and we will keep all assessment information about you safe and
secure. You also do not need to answer any questions on the survey forms that you do not
want to. We will review your clinic card. You will be measured for height and have a
measurement done of the width of your arm. Before you have the baby, we will take a few
drops of blood from a finger stick to check your blood for malaria. After you give birth, we
will weigh and examine your baby. We will also take another finger stick to look for malaria,
and we’ll also be looking for malaria in the placenta and in the cord that goes to the baby after
you have the baby.
2 It is very important that the country’s human subjects or ethics requirements be followed with regard to
provision of information and documentation of participant’s consent.
30 The Rapid Assessment of the Burden of Malaria during Pregnancy

[Note: The two paragraphs that follow have been used in assessments in areas of high
transmission; they should be adapted to reflect policy and practice in the country where the
assessment is being conducted. ] If we find malaria in your blood before you give birth, we will
treat you with _____________ (enter appropriate drug name).
We rarely find malaria in the cord that goes to the baby but, if we do, we will treat the baby
with____________ (enter appropriate drug name).
If you join the assessment, it will probably take about x number of minutes more than if you
didn’t join the assessment. How much extra time will depend on if we find malaria in your
blood or the cord that goes to your baby.
If you do not wish to join in the assessment, you and your baby will still get the best possible
care from the hospital. If you join the assessment, but then decide you don't want to be in the
assessment, you can withdraw yourself from the assessment at any time. This will not affect
the health care you get here.
Risks or discomforts
You will feel a “pinch” that lasts for a few seconds when the finger stick is done to take blood.
Benefits
You and/or your baby will be treated if you or the baby has malaria after birth. The
information we get from the assessment will help us know how best to prevent malaria in
pregnant women in this [assessment area].
Treatment
_________ (enter appropriate drug name) works well to treat malaria and has been used safely to
treat malaria in adults and in children. If you or the baby has any side effect which you think
might be due to _________ (enter appropriate drug name), please come back to the hospital right
away to be checked and treated by one of the doctors.
If you join the assessment and have questions later, please feel free to ask. You can ask me
today or if you have questions later, you can ask _________________ (responsible assessment team
member).
Thank you very much for your time. Would you like to join in the assessment?
Please keep this information sheet in case you have questions later.
Module 2: Delivery Unit Survey
31

R. Analysis of Delivery Unit Survey Data
Below are outcome variables for the Delivery Unit Survey and summary tables of survey
results. Further data analysis may be helpful, but is not necessary for decision making.
Tables can be useful for showing relationships between outcome variables.
• Table 1 shows how representative the women in the survey are of the women in the
country.
• Table 2 shows women’s reported use of prevention and control measures, such as
IPTpp, ITNs, and antimalarial drugs for treatment of illness.
• Table 3 focuses on prevalence of parasitemia and fever among pregnant women and
low birth weight, and prematurity among their babies.
• Table 4 looks at the relationship between placental and peripheral malaria
parasitemia, low birth weight, and premature delivery.
No. Outcome Variable Numerator/Denominator
1. Women with peripheral
parasitemia
2. Women with placental
parasitemia
Number of pregnant women with a positive result of
peripheral blood film/ Total number of pregnant women
with peripheral blood films
Number of pregnant women with a positive result of
placental blood film/ Total number of pregnant women
with placental blood film
3. Infants with umbilical cord parasitemia Number of infants with positive result of umbilical cord
blood film/ Total number of infants with umbilical cord
blood film
4. Infants with low birth weight (

Table 1. Characteristics of Women in the Delivery Unit Survey and Women Country-Wide
Characteristic
Median age in years [range]
Median gravidity [range]
ANC visits, median no. [range]
Able to read
Attended school (any)
Married
Owns own home
Owns moped
Owns bike
Owns radio
Works for cash
Grows cash crops
TOTAL
Women in Delivery
Unit Survey* (n= # )
Women in national
DHS**
*Data are % of participants unless otherwise indicated.
**If available, national data (e.g., Demographic and Health Surveys) can be used to compare
how similar women in the assessment are to women nationally.
Table 2. Use of Prevention and Control Measures by Women in the Delivery Unit Survey
Treatment and Prevention Measures
Gestational age at 1st ANC visit
Owns insecticide-treated bed net (ITN)
Uses ITN
Slept under ITN previous night
Used antimalarial drug during pregnancy for prevention (IPTpp)
Used antimalarial drug during pregnancy for treatment of malaria
illness
Used the correct dose of antimalarial drug for treatment
(#sites) (#women)
Module 2: Delivery Unit Survey
33

Table 3. Rates of Peripheral and Placental Parasitemia, Reported Fever, Low Birth
Weight, and Prematurity among Delivering Women
Characteristic All women (n= ) Use of IPTp or Chemoprophylaxis P
Peripheral parasitemia
Overall
Primigravidae
Secundigravidae
Multigravidae
Placental parasitemia
Overall
Primigravidae
Secundigravidae
Multigravidae
Umbilical cord parasitemia
Fever during pregnancy
Self-reported use of an
antimalarial for treatment
during pregnancy
Fever within week before
enrollment
Singleton live-born birth
weight (g) ± SD
Low birth weight (liveborn
singletons

Table 4. Relationship between Placental Malaria Parasitemia and Peripheral Malaria
Parasitemia, Low Birth Weight, and Premature Delivery among Delivering Women
Characteristic
Positive result of
peripheral blood film
Low birth weight
(

36 The Rapid Assessment of the Burden of Malaria during Pregnancy

Woman’s full name:
ID #_____A________
Tool 2: Delivery Unit Questionnaire
Today’s date: ______/_______/______
Day/Month/Year
ID number: ___ _1__ -- ___ ___ ___
Digit 1 = facility number Digit 2 = D (for Delivery Unit)
Digits 3, 4 & 5 = woman’s consecutive number
SCREENING QUESTION
Interviewer number _______
1. Age (years): [ ]
If the mother does not know her age, estimate her age using the categories below.
less than 15 years [ ] 30-34 years [ ]
15-19 years [ ] 35-39 years [ ]
20-24 years [ ] 40-44 years [ ]
25-29 years [ ] more than 44 years [ ]
If the woman is less than an age deemed appropriate, thank her for her time and
DO NOT enroll her in this survey.
DEMOGRAPHIC INFORMATION
2. Village/town: ____________________________________________
Interviewer: Skip the next question; it will be coded later so that it is done uniformly.
3. Is this a rural or urban area? [ ]
Urban = 1
Rural = 2
Periurban = 3
Unknown = 9
4. What language do you usually speak with family members at home? [ ]
Language a = 1
Language b = 2
Language c = 3
Other = 8 (specify) ______________________________________
5. Are you married? [ ]
yes, married and living with husband = 1
yes, married but do not live with husband = 2
not married but living with a man = 3
separated or divorced = 4
widow of the father of this baby = 5
never married or lived with a man = 6
Tool 2: Delivery Unit Questionnaire
1

EDUCATION
6. What is the highest level of school that you attended?..[ ]
Primary = 1
Secondary = 2
Higher = 3
Never attended = 4
Unknown = 9
7. Can you read [ ]
YES = 1 NO = 2
SOCIOECONOMIC INDICATORS
8. What is the roof of your house made of? [ ]
corrugated iron = 1
cement or concrete = 2
wood and mud = 3
thatch or grass = 4
reed or bamboo = 5
plastic sheet = 6
mobile roofs of nomads = 7
other = 8 (specify) __________________________________
9. What kind of floor does your house have? [ ]
earth or sand = 1
dung = 2
wood planks = 3
reed or bamboo = 4
vinyl tiles or carpet = 5
cement = 6
cement tiles or brick = 7
other = 8 (specify) ___________________________________
10. What is the main job of the head of household/husband? [ ]
job a = 1
job b = 2
job c = 3
job d = 4
11. What is the monthly household income for your family? [ ]
income bracket a = 1
income bracket b= 2
income bracket c=3
(FOR THE NEXT QUESTION, PLEASE ENTER A 1 OR 2 FOR EACH LINE)
12. Do you or any member of your family living in the same compound:
YES = 1 NO = 2
Own a bicycle/scooter/moped? [ ]
Own a radio? [ ]
Own a TV? [ ]
Own the house you are living in? [ ]
Own crop land? [ ]
Grow cash crops? [ ]
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

REPRODUCTIVE AND CLINICAL HISTORY
13. How many times have you become pregnant? [ ]
(including this one and all other pregnancies, including abortions and miscarriages)
13a. How many pregnancies with a live-born child?
13b. How many pregnancies with loss of the fetus?
MALARIA PREVENTION
14. Did you take medicine during pregnancy to protect you from malaria and keep illness from coming into the body when
you did not have symptoms? [ ]
(NOTE, NOT treatment for malaria illness)
YES = 1
NO = 2 If NO, skip to question 16
UNKNOWN = 9
If YES:
14a. What type of medicine did you take?
Chloroquine [ ]
Sulfadoxine-Pyrimethamine (SP, Fansidar) [ ]
Proguanil [ ]
Other [ ]
(specify): ______________________________
Unknown [ ]
14b. When you started taking the medicine, how many months pregnant were you? [ ]
14c. For the first time you took the medicine, howmany total tablets did you take? [ ]
14d. How many times in a week did you take the medicine? [ ]
14e. How many tablets did you take each time? [ ]
14f. After the first dose, how often did you take this medicine? [ ]
Every week=1
Almost every week=2
Some weeks=3
Monthly=4
Rarely=5
Do not know=6
15. Did you sleep under a bed net during this pregnancy? [ ]
YES = 1
NO = 2
UNKNOWN = 9
If no, skip to question 17
15a. If yes, how frequently? [ ]
all the time = 1
most of the time = 2
sometimes = 3
rarely = 4
15b. Did you sleep under the net last night? [ ]
YES = 1
NO = 2
UNKNOWN = 9
Tool 2: Delivery Unit Questionnaire
3

15c. Has this net ever been treated with insecticide? [ ]
YES = 1
NO = 2
UNKNOWN = 9
15d. If yes, has the net been treated with insecticide in the past one year? [ ]
YES = 1
NO = 2
UNKNOWN = 9
15e. Is the net a long-lasting insecticide-treated net (LLN)? [ ]
YES = 1
NO = 2
UNKNOWN = 9
HISTORY OF FEVER OR MALARIA (DURING THE PRESENT PREGNANCY)
16. Have you had a fever or malaria during this pregnancy? [ ]
YES = 1
NO = 2
UNKNOWN = 9
If NO, skip to question 17
16a. Did you get a convulsion with fever/malaria? [ ]
YES = 1
NO = 2
UNKNOWN = 9
16b. Did you stay in hospital overnight for treatment of fever/malaria? [ ]
YES = 1
NO = 2
UNKNOWN = 9
16c. Did you get a blood transfusion: [ ]
YES = 1
NO = 2
UNKNOWN = 9
16d. Did you take iron and folic acid tablets? [ ]
YES = 1
NO = 2
UNKNOWN = 9
16e. Have you taken a medication to treat malaria or fever during this pregnancy? [ ]
YES = 1
NO = 2
UNKNOWN = 9
16f. Type of medication taken (check all that apply)
Chloroquine [ ]
Sulfadoxine-Pyrimethamine (SP) [ ]
Quinine [ ]
Antipyretics [ ]
Other [ ]
(specify):______________________________________
Unknown [ ]
4 The Rapid Assessment of the Burden of Malaria during Pregnancy

ANTENATAL CARE CLINIC VISITS AND ANC CARD DETAILS
17. Have you previously attended antenatal clinic for this pregnancy? [ ]
YES = 1 NO = 2
18. Did you bring your ANC card today? [ ]
YES = 1 NO = 2
If yes, RECORD THE INFORMATION BELOW FROM THE ANC CLINIC CARD.
19. Total number of ANC visits [ ]
20. Timing of visits:
Date of visit Gestational age Fundal
(weeks) height
first visit: ___ ___ / ___ ___ / ___ ___ [ ] [ ]
most recent visit: ___ ___ / ___ ___ / ___ ___ [ ] [ ]
21. Last menstrual period (LMP) if recorded: ________/___/____
22. Estimated date of delivery ___ ___ / ___ ___ / ___ ___
23. Risk factors during the current pregnancy:
(Check if any of the following are written in the antenatal record –
Please put a 1 or 2 for each risk factor)
YES = 1 NO = 2
Anemia (Hb < 7 g/dl) [ ]
BP > 140/90 [ ]
Pre-eclampsia [ ]
Gestational diabetes [ ]
APH (antepartum hemorrhage) [ ]
Malpresentation [ ]
Other [ ]
(specify) ____________________________
RECENT MALARIA MORBIDITY HISTORY
24. Have you had a fever or malaria during the past week? [ ]
YES = 1
NO = 2
UNKNOWN = 9
If NO, skip to question 25
24a. If YES, Have you received any treatment for this illness? [ ]
YES = 1
NO = 2
24b. If YES, check treatments received (check all that apply)
Chloroquine [ ]
Sulfadoxine-Pyrimethamine (Fansidar) [ ]
Quinine [ ]
Artemisinin-combination therapy (ACT) [ ]
If an ACT, specify : ___________________________
Other [ ]
(Specify): _____________________________________
Not known [ ]
Tool 2: Delivery Unit Questionnaire
5

DELIVERY DATA (from hospital records and observation of present delivery)
25. Date of Delivery ____ / ____ / ____
26. Type of Delivery: [ ]
Spontaneous vaginal delivery = 1
Caesarian section = 2
Forceps/vacuum = 3
Other = 8 Specify: _____________________________________
27. Number of babies delivered [ ]
1 = singleton (1 baby)
2 = twins
3 = more than two
27a. If singleton (1 baby), please describe if the baby was
1 = born alive, left hospital alive (Skip to Q. 30)
2 = born alive, died before leaving hospital (Skip to Q. 27c)
3 = born dead/stillbirth (Skip to Q. 27b)
9 = unknown (Skip to Q. 30)
27b. (For all singletons), did the baby move arms and legs after birth? [ ]
YES = 1 NO = 2 (If NO, skip to Q. 27d)
27c. (For singletons) If the baby was born alive but died before leaving hospital, what was the cause of death?
(Answer this question and then skip to Q. 30)
____________________________________________________________________________________________
27d. (For singletons born dead) If the baby was born dead, what was the estimated gestational age?
________________weeks
28. If the singleton child was born dead, check all possible causes
[ ] Malaria
[ ] Fever
[ ] Spontaneous without explanation
[ ] Infection (septic)
[ ] Trauma
[ ] Intentional
[ ] Cephalopelvic disproportion (head too big, baby got stuck)
[ ] Weak expulsion
[ ] Prolonged labor
[ ] Fetal distress
[ ] Asphyxia
[ ] Nuchal cord
[ ] Placental abruption
[ ] Chorioamnionitis
[ ] Hydrops fetalis
[ ] Not known
[ ] Other (specify): _____________________________________
29. If the singleton was born dead, was the fetus:
Fresh? = 1
Macerated? = 2
Not known = 9
6 The Rapid Assessment of the Burden of Malaria during Pregnancy

EXAMINATION: BEFORE DELIVERY
30. Mother’s axillary temperature _____._____ degrees C
31. Mother's height (centimeters): ____ ____ ____
32. Mother’s mid-upper arm circumference (centimeters) ____ ____
34. Was a rapid diagnostic test (RDT) for malaria done? [ ]
YES = 1
NO = 2 (If “no” or “unknown” skip to Q36.
UNKNOWN = 9
35. RDT result [ ]
Positive = 1
Negative = 2
Result available, examined, but undetermined = 9
36. Was a blood sample taken from a prick of the mother’s finger? [ ]
YES = 1
NO = 2 (If “no” or “unknown” skip to Q39.
UNKNOWN = 9
37. Blood smear result [ ]
Positive = 1
Negative = 2
Result available, examined, but undetermined = 9
38. Malaria species. Check all that apply .[ ]
Plasmodium falciparum = 1 [ ]
P. vivax = 2 [ ]
P. malariae = 3 [ ]
P. ovale = 4 [ ]
Undetermined = 9
39. If either of the tests above was positive, was an antimalarial given? [ ]
YES = 1 NO = 2
39a. If YES, what type [ ]
Chloroquine = 1
Sulfadoxine-pyrimethamine (SP) = 2
Chloroquine and SP = 4
Quinine = 3
Coartem = 4
Other = 8 (specify and explain): ______________________
39b. Date administered: ___ ___ / ___ ___ / ___ ___
39c. Name of person administering antimalarials:______________________________________
Note: All women who are currently febrile or report having had a fever in the last 7 days should wait to receive their
blood smear results prior to leaving clinic that day. Their blood slides should be promptly read. If positive, they will
receive treatment with appropriate antimalarial drug. Women who are presently afebrile with no history of fever in
the past week need not wait for smear results but can return for the results the following day.
OR
If above differs from the country’s national policy, follow national policy.
Tool 2: Delivery Unit Questionnaire
7

EXAMINATION OF LIVE-BORN SINGLETON BABY
40. Weight of baby (g) ____ . ____ ____
FROM SCALE, NOT FROM DELIVERY RECORD
41. Sex of baby [ ]
Male = 1
Female = 2
42. Ballard score ____ ____
43. Gestational age (weeks) by Ballard score………………..[ ]
44. Physical abnormalities? [ ]
YES = 1 NO = 2
If yes, list any abnormalities__________________________________
MATERNAL OUTCOMES
45. Maternal death [ ]
YES = 1
NO = 2
If maternal death, list cause: ______________________________
If not known, please state: “Unknown”
46. Were there any other complications of labor? [ ]
0 = No other complications
1 = Puerperal sepsis
2 = Pre-eclampsia
3 = Eclampsia
4 = Obstructed labor
5 = Breech delivery
6 = Antepartum hemorrhage
7 = Postpartum hemorrhage
8 = Uterine rupture
9 = Other (specify) _______________________________________
PLEASE CHECK OVER THE QUESTIONNAIRE NOW TO MAKE SURE THAT ALL QUESTIONS HAVE BEEN ANSWERED, THEN
CHECK THIS BOX [ ]
Thank the woman for her time.
47. QUALITY CONTROL
Site supervisor should check all questionnaires for completeness every day at the end of all interviews.
Data entry clerks should initial at the end of every entry.
Person Name/Signature Date
47a Site Supervisor
47b Data Entry Clerk 1
47c Data Entry Clerk 2
47d Assessment
Coordinator
8 The Rapid Assessment of the Burden of Malaria during Pregnancy

Module 3: Hospital Surveillance of Malaria
Disease: Data Abstraction Form
Gathering information about malaria disease among all hospitalized women can
provide descriptive information about whether or not pregnant women have
more malaria illness, which in turn can be used to determine if intermittent
preventive treatment (IPTp) should be recommended or if the focus should be on
case management and use of insecticide-treated bed nets (ITNs).
A data abstraction form is used to collect the following information about all
hospitalized women: history of illness and treatment, admission and discharge
diagnoses, laboratory results of tests for malaria, and indicators related to severe
malaria, treatment, and clinical outcome for the mother and fetus.
This module contains sample materials for hospital surveillance of malaria
disease. These materials can and should be adapted to suit local needs. General
guidance for conducting assessment surveys and managing data can be found in
Chapters 3 and 4.
A. Eligibility Criteria
Contents
B. Surveillance Team
C. Notes for Assessment Team
D. Sample Logbook
E. Severe Plasmodium falciparum Malaria in Adults: WHO’s List of Clinical
Manifestations and Laboratory Findings
F. Analysis of Data
1
Module 3: Hospital Surveillance of Malaria Disease: Data Abstraction Form 1

A. Eligibility Criteria
Women and units/wards: All women (both pregnant and nonpregnant) admitted to these
hospital units/wards: women’s internal medicine unit, gynecology, or delivery. The choice
of units/wards should be individualized to the local situation so as to capture as many
admissions by women---both pregnant and nonpregnant---as possible. The hospital may be
operated by the government or by private concerns.
Note: If the surveillance is conducted only in maternity units, it will not provide data on the
difference between how many pregnant and nonpregnant women become ill with malaria.
B. Surveillance Team
The abstraction form involves interpretation of medical records as well as making clinical
judgments; therefore, the surveillance team should be made up of persons with clinical
training, e.g., physicians, nurses, midwives.
C. Notes for Assessment Team
A record will need to be kept of all women who are admitted, pregnant or nonpregnant, with
or without malaria or anemia. Data abstraction forms need to be filled out only for those with
malaria.
It is important to ask about last menstrual period in order not to omit women early in their
pregnancy.
Questions 7 and 19 should be adapted to reflect the medications that are available and used in
the country. It might be helpful to list both generic and trade names.
Questions 10-18 (Laboratory Results) should also be adapted to reflect laboratory tests used
in the country.
Note that the laboratory results recorded in Q. 10-18 may serve to validate symptoms and
conditions noted in Q.9.
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

D. Sample Logbook
Date Ward Newly
admitted
women
(total #)
Malaria and anemia admissions—
women only
Number
of forms
completed
Comments
Day/mo/yr
Day/mo/yr
Int
Gyn
Delivery
Int
Gyn
Delivery
Total Preg Nonpreg
E. Severe Plasmodium falciparum Malaria in Adults: WHO’s List of
Clinical Manifestations and Laboratory Findings
Clinical manifestations and laboratory findings of severe P. falciparum in adults
include:*
Prostration
Impaired consciousness
Respiratory distress (acidotic breathing)
Multiple convulsions
Circulatory collapse
Pulmonary edema (radiological)
Abnormal bleeding
Jaundice
Hemoglobinuria
Severe anemia
*Adapted from: World Health Organization. Severe falciparum malaria. Royal Society of
Tropical Medicine and Hygiene, 2000. 94 (1 Suppl): p. 2.
F. Analysis of Data
Important outcome variables include:
• Percentage of women admitted to the hospital with malaria, anemia, or severe malaria
who were pregnant,
by level of transmission (if surveillance is conducted in areas of both stable and unstable
malaria)
• Percentage of pregnancies with a fatal outcome for the fetus or for the mother
Module 3: Hospital Surveillance of Malaria Disease: Data Abstraction Form
3

4 The Rapid Assessment of the Burden of Malaria during Pregnancy

Woman’s full name:________________________________________________________________ ID #_____A________
Tool 3: Hospital Surveillance of Malaria Disease
Data Abstraction Form
NOTE: Abstract data only from forms of women who are of reproductive age.
Abstracter name ____________________
Today’s date ____/____/_____
Day Month Year
Interviewer number _______
Patient record ID# (or patient hospital file #): ______________________
Type of facility_____________________________________
PATIENT DETAILS
1. Age of patient (years): [ ]
2. Last menstrual period
Not applicable [ ]
Date of last menstrual period ____ ___ / ___ ___ / ___ ___
if UNKNOWN, mark this box [ ]
3. Pregnant [ ]
YES = 1, NO = 2, UNKNOWN = 3
3a. If YES, what is the gestational age (weeks) [ ]
3b. If NO, has she ever been pregnant? [ ]
YES = 1, NO = 2, UNKNOWN = 3
3c. If YES, what is the date of the last delivery ____ ___ / ___ ___ / ___
If UNKNOWN, mark this box [ ]
4. Patient’s village/town/district_________________________
Tool 3: Hospital Surveillance of Malaria Disease: Data Abstraction Form
1

HISTORY OF CURRENT ILLNESS AND TREATMENT
5. How long has the patient been ill?[days]
6. Prior to admission, did the patient have
YES = 1, NO = 2, UNKNOWN = 3
a. Convulsions [ ]
b. Decreased consciousness [ ]
c. Coma [ ]
7. Did patient receive any antimalarial treatment in the 7 days before admission [ ]
YES = 1, NO = 2, UNKNOWN = 3
If YES, mark all that apply
Chloroquine [ ]
Sulfadoxine-Pyrimethamine (SP) [ ]
Quinine [ ]
Artesunate [ ]
Other [ ]
(specify and explain): ________________________
ADMISSION DATA
8. Admitting diagnosis: (mark all that apply)
malaria = 1 [ ]
severe malaria = 2 [ ]
cerebral malaria = 3 [ ]
anemia = 4 [ ]
other = 5 (specify): ____________________________________________
9. Any manifestations of severe or cerebral malaria (mark all that apply)
Prostration [ ]
Respiratory distress (acidotic breathing) [ ]
Multiple convulsions [ ]
Circulatory collapse (shock) [ ]
Pulmonary oedema (radiological) [ ]
Abnormal bleeding [ ]
Jaundice [ ]
Haemoglobinuria [ ]
Severe anemia [ ]
Impaired consciousness [ ]
Hypoglycemia [ ]
Decreased consciousness [ ]
Coma [ ]
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

LABORATORY RESULTS (provide if available)
10. Malaria blood film done [ ]
YES = 1, NO = 2
10a. If YES, result [ ]
Positive = 1
Negative = 2
Result available, examined, but undetermined = 9
10b. If positive, parasite count: __________
10c. If positive, species (mark all that apply) [ ]
Plasmodium falciparum = 1 [ ]
P. vivax = 2 [ ]
P. malariae = 3 [ ]
P. ovale = 4 [ ]
Not determined = 5 [ ]
11. Hemoglobin/Hematocrit (lowest) ____ ____
12. Glucose (lowest) _______________
13. Creatinine (highest) _______________
14. Bilirubin (highest) _______________
15. Plasma bicarbonate ________________
16. Mean cell volume ________________
17. Lumbar puncture
Glucose_________
Protein__________
Cell Count
RBC: _______ WBC: _______ WBC differential: _______
18. Other [ ]
(specify): ___________________________________
Tool 3: Hospital Surveillance of Malaria Disease Data Abstraction Form
3

TREATMENT
19. Antimalarial medications given (mark all that apply)
Chloroquine [ ]
Sulfadoxine-pyrimethamine (SP) [ ]
Quinine [ ]
Artesunate [ ]
Primaquine [ ]
Proguanil [ ]
Artemisinin-containing combination therapy (ACT) [ ]
If ACT, specify __________________________________
Other [ ]
(specify and explain): _________________________
20. Other therapy given (mark all that apply)
Anticonvulsant [ ]
Transfusion of whole blood / packed RBC [ ]
Glucose [ ]
Furosemide (or other diuretic) [ ]
Oxygen [ ]
Vitamin K [ ]
Other [ ]
(specify): ___________________________________
DISCHARGE INFORMATION
21. Woman’s outcome [ ]
Full recovery = 1
Recovered with some residual disability = 2
Died = 3
Unknown = 9
4 The Rapid Assessment of the Burden of Malaria during Pregnancy

22. Pregnancy outcome (for pregnant women only):
Did woman deliver [ ]
YES = 1, NO = 2, UNKNOWN = 3
22a. If YES, outcome [ ]
alive = 1
fetal loss = 2
22b. If NO, outcome [ ]
no labor = 1
false labor = 2
23. Discharge diagnosis: (mark all that apply)
uncomplicated malaria = 1 [ ]
severe malaria = 2 [ ]
anemia = 3 [ ]
other = 4 [ ]
(specify):_________________________________
24. Additional comments:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
25. QUALITY CONTROL
Site supervisor should check all questionnaires for completeness every day at the end
of all interviews.
Data entry clerks should initial at the end of every entry.
Person Name/Signature Date
25a Site Supervisor
25b Data Entry Clerk 1
25c Data Entry Clerk 2
25d Assessment Coordinator
Tool 3: Hospital Surveillance of Malaria Disease Data Abstraction Form
5

6 The Rapid Assessment of the Burden of Malaria during Pregnancy

Module 4: Conducting an Antenatal Clinic
Facility Assessment
The antenatal clinic facility assessment is designed to determine
• Antental clinic services provided
• Stockouts of medicine/vaccine/laboratory supplies
• Facility staffing and equipment
• Cost of services
This module contains sample materials for an antenatal clinic facility assessment.
These materials can and should be adapted to suit local needs. General guidance for
conducting assessment tools survey and managing data can be found in Chapters 3-4.
Contents
A. Antenatal Clinic Facility Assessment Timetable
B. Sample Size
C. Assessment Team
D. Data Analysis
Module 4: Conducting an Antenatal Clinic Facility Assessment
1

A. Antenatal Clinic Facility Assessment Timetable
The Antenatal Clinic Facility Assessment can be conducted before, during, or after the
Antenatal Clinic Surveys take place.
B. Sample Size
An Antenatal Clinic Facility Assessment should be conducted with the manager, or his/
her designee, of each antenatal clinic in which an Antenatal Clinic Survey is conducted.
C. Assessment Team
The site supervisor or his or her designee should serve as the interviewer.
D. Data Analysis
Outcome Variables
No. Outcome Variable
1 Proportion of facilities with a written protocol on malaria during pregnancy
2 Proportion of facilities reporting stock-out of antimalarial drugs in
antenatal clinic within the last calendar month
3 Proportion of facilities that distribute/sell insecticide treated nets (ITNs)
Summary Tables
Table 1. Services provided to women in antenatal clinics by site or region,
by percentage of clinics.
Service Region X (%) Region Y (%)
IPTp
Counseling on use
of ITNs
Hemoglobin test
Iron
Folate
Iron and folate
combined
Blood films
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

Table 2. Availability of medication and supplies by site or region,
by percentage of clinics
Item Region X (%) Region Y (%)
Iron
Folate
Iron and folate combined
Chloroquine
Proguanil
Quinine
SP
Hemoglobin tests
Materials for blood films
Thermometer
Alcohol
Gloves
Glass slides
Lancets
Microscope
Giemsa and staining equipment
Hemoglobin measuring supplies
Clean water
Cups to drink from
Module 4: Conducting an Antenatal Clinic Facility Assessment
3

4 The Rapid Assessment of the Burden of Malaria during Pregnancy

Name of person interviewed: ________________________
Facility number:_______________
TOOL 4: ANTENATAL CLINIC FACILITY ASSESSMENT
Interviewer name ___________________________________________
Interviewer number __________
Facility number: ____________________________
Facility name:________________________________
Today’s Date: ____/_____/_______
Day Month Year
Instructions for the interviewer: Please administer this assessment to the manager of the health facility. Respond
to each question as completely as possible and add all comments in the space provided at the end of the assessment.
Please read the following paragraph to the respondent before beginning the interview:
I am here today to conduct an assessment of antenatal care facilities to learn more information regarding malaria
during pregnancy. We would like to ask you several questions about the prevention of malaria during pregnancy in
your facility. The information gathered will be used to ______________________. Your participation in this process is very
important. Your responses will be kept confidential. No institution or individual will be identified by name in the final
report. This assessment will not last more than 30 minutes.
We ask you to respond to each question to the best of your ability. If you have questions at any moment during the
interview, do not hesitate to ask. Do you agree to participate in this assessment?
Instructions to the interviewer: If the respondent agrees to participate in the assessment, place an « X » in the
following box.
The respondent agreed to participate in the assessment.
Tool 4: Antenatal Clinic Facility Assessment
1

BACKGROUND
1. Name of the facility:______________________________________________
2. Type of facility: [ ]
Regional hospital = 1
District hospital = 2
Health center = 3
Health dispensary = 4
Other = 9 (specify) _____________________________________________
3. District: _______________________________________________________
4. Region: ________________________________________________________
5. Title of the respondent: __________________________________________
6. Number of years of service in the facility: [ ] Years
7. Training of the respondent: [ ]
Doctor = 1
Nurse = 2
Midwife = 3
Other = 9 (specify) ______________________________________
ASSESSMENT OF ANC SERVICES
8. Are ANC cards used in this facility? [ ]
Yes = 1
No = 2 (SKIP TO Q11)
Don’t know = 98 (SKIP TO Q11)
If yes, are ANC cards provided free by the facility or are women required to purchase them? [ ]
Provided by the clinic for free = 1
Provided by the clinic for a fee = 2
Used at the clinic, but woman must provide = 3
Don’t know = 98
9. Do these cards have a place to record antimalarial drug use?
Yes = 1
No = 2
Don’t know = 98
If yes, do the cards have a place to record (check all that apply)
Treatment of malaria illness ________
Intermittent preventive treatment (IPTp)_________
Chemoprophylaxis__________
10. If yes, Interviewer should examine at least 20 ANC cards of women making second or greater ANC visit and
note how many cards have any information recorded on antimalarial drug use 1 [ ]
All have antimalarial drug use information recorded = 1
Half have antimalarial drug use information recorded = 2
Fewer than half have antimalarial drug use information = 3
Other = 9 (specify): ____________________________________________
Don’t know = 98
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

11. How many ANC visits are recommended in your clinic?
11a. Number of recommended visits: [ ]
11b. Average gestational age at first ANC visit (weeks) [ ] weeks
11c. Number of visits per trimester
First [ ]
Second [ ]
Third [ ]
12. Actual practices in ANC services:
Interviewer: Read each practice to respondent and record appropriate response.
PRACTICE
12a. Intermittent preventive
treatment
12b. Counseling on
use of ITNs
12c. Hemoglobin test
12d. Iron
12e. Folate
12f. Iron and folate
(combined tablet)
12g. Blood films
NEVER
PROVIDED
PROVIDED TO
ALL WOMEN
PROVIDED TO
CERTAIN WOMEN
If provided to certain
women, reason why
13. Are health education sessions held during ANC visits? [ ]
Yes = 1
No = 2 (SKIP TO Q15)
Don’t know = 98 (SKIP TO Q15)
If Yes,
13a. Number of days with health education sessions/week: [ ]
13b. Is the location for these sessions adequate? [ ]
Women can sit down = 1
Certain women remain standing = 2
All women are standing, but can fit in the room = 3
The room is too full and women cannot enter into the room = 4
Other = 9 (specify): ___________________________________
13c. Themes covered that are relevant to malaria: ______________________________________________
__________________________________
14. Are visual aids used during these sessions? [ ]
Yes = 1
No = 2
Don’t know = 98
14a. If Yes,
Are there materials that women can take home with them? [ ]
Yes = 1 No = 2 Don’t know = 98
Tool 4: Antenatal Clinic Facility Assessment
3

15. Are there any job aids related to malaria during pregnancy
available for the health-care workers (for example, wall posters, laminated sheets)? [ ]
Yes = 1
If yes, specify:___________________________________________________
No = 2
Don’t know = 98
16. How do the women usually obtain their antimalarial drugs? [ ]
Directly from the ANC (by the health provider) = 1
From the pharmacy on site at the ANC after getting
a prescription from the provider = 2
Having a prescription filled elsewhere = 3
Other = 9 (SPECIFY)________________
Don’t know = 98
17. Quantities of medicines available at facility:
Note the estimated number of boxes of pills or containers present. (If pregnant women’s medicines are
stored together with medicines for all other patients, note the total number. If pregnant women’s medicines are
stored separately, note the number set aside for pregnant women.)
Number of boxes of pills, containers
17a. Chloroquine [ ]
17b. Paracetamol [ ]
17c. Sulfadoxine-Pyrimethamine [ ]
17d. Quinine [ ]
17e. Iron sulfate [ ]
17f. Folate [ ]
17g. Iron/folate [ ]
18. Number of stock-outs: (Collect the following information from facility records)
Medicine/vaccines/laboratory
18a. Iron
18b. Folate
18c. Iron/folate
18d. Chloroquine
18e. Proguanil
18f. Quinine
18g. Sulfadoxine-pyrimethamine (SP)
18h. Hemoglobin tests
18i. Materials for blood films
18j. Other (specify): ___________________
___________________________
Number Total number Not available
of stock- outs in the
last 6 months*
*If 6 months is not feasible, could specify 3 months.
of days with stockouts
in the last 6
months*
4 The Rapid Assessment of the Burden of Malaria during Pregnancy

19. Facility Equipment:
Present and working =1
Present but not working = 2
Not present = 3
19a. Thermometer [ ]
19b. Alcohol [ ]
19c. Gloves [ ]
19d. Cotton [ ]
19e. Glass slides [ ]
19f. Lancets [ ]
19g. Microscope [ ]
19h. Giemsa and staining equipment [ ]
19i. Hemoglobin measuring supplies [ ]
19j. Clean water [ ]
19k. Cups to drink from [ ]
MALARIA DURING PREGNANCY
20. If malaria prophylaxis is recommended, does the clinic have a written copy of the national protocol? [ ]
Yes = 1
No = 2 (SKIP TO Q21)
Don’t know = 98 (SKIP TO Q21)
If yes,
20a. Can the respondent show you the written protocol? [ ]
Yes = 1 No = 2 Don’t know = 98
20b. Treatment recommended in the protocol: [ ]
Chloroquine treatment dose then once per week = 1
Two doses of SP = 2
None = 3
Other = 9 (specify): _______________________________________
21. Are insecticide-treated mosquito nets (ITNs) available for distribution or sale in your facility? [ ]
Yes = 1
No = 2 (SKIP TO Q22)
Don’t know = 98 (SKIP TO Q22)
If Yes:
21a. Approximate cost to the ANC client of one ITN ___________________
21b. Average number of ITNs distributed/sold per month: [ ]
22. Are re-impregnation kits available for distribution or sale in your facility? [ ]
Yes =1
No = 2 (SKIP TO Q23)
Don’t know = 98 (SKIP TO Q23)
If yes
22a. Approximate cost of one re-impregnation kit (to the ANC client)?: ___________________
22b. Average number of kits distributed/sold per month [ ]
Tool 4: Antenatal Clinic Facility Assessment
5

23. If ITNs are not available directly for sale, are vouchers/coupons distributed to women?
Yes=1 No=2 Don’t know=98
If Yes:
23a. How much is the voucher/coupon worth? ____________
COSTS OF ANC SERVICES
24. Do women pay for ANC services? [ ]
Yes = 1
No = 2 (SKIP TO Q26)
Don’t know = 98 (SKIP TO Q26)
24a. If women pay for ANC services, what is the schedule of payments? [ ]
Pay each visit = 1
One payment for all ANC services = 2
One payment for ANC and childbirth services = 3
Other = 9 (specify): ______________________________________________
24b. How much do they pay? ___________ per _____________
25. Please indicate in the table below what women pay for each of the following medications:
Medicines/Vaccinations/ Laboratory
25a. Iron
25b. Folate
25c. Iron/Folate
25c. Chloroquine (treatment)
25d. Chloroquine (chemoprophylaxis)
25e. SP (treatment)
25f. SP (IPTp)
25g. Other antimalarial drug for
treatment (specify): ___________________
25h. Other antimalarial drug for
prevention (specify):__________________
Cost to the woman
Free = 0
Included in cost of ANC services = 1
Purchase at pharmacy part of the
facility = 2
Purchase elsewhere = 3
Not available = 4
If purchased at the facility, cost
(per quantity) (For example, 10
packets for US$1)
26. Which of the following information is routinely collected each month and forwarded on to the district health
management team? (Check all that apply)
26a. Number of first antenatal clinic consultations _______
26b. Number of repeat antenatal clinic consultations _______
26c. Number of tetanus toxoid vaccinations delivered _______
26d. Number of 1st dose of IPTp delivered _______
26e. Number of 2nd dose of IPTp delivered _______
26f. Number of chemoprophylaxis doses delivered _______
26g. Number of ITNs sold and distributed _______
Thank the respondent for his or her time!
6 The Rapid Assessment of the Burden of Malaria during Pregnancy

INTERVIEWER COMMENTS:
(Please note any additional observations in the following space):
Tool 4: Antenatal Clinic Facility Assessment
7

8 The Rapid Assessment of the Burden of Malaria during Pregnancy

Module 5: Conducting a Health-Care Worker
Observation
The health-care worker observation is designed to
• Determine whether health-care workers are providing the needed healthcare
services, specifically whether health-care workers are providing IPTp ,
antimalarial drugs for a febrile illness, and tetanus toxoid
This module contains sample materials for a health-care worker observation.
These materials can and should be adapted to suit local needs. General guidance for
conducting assessment tools survey and managing data can be found in Chapters 3
and 4 of the manual.
A. Sample Size
B. Assessment Team Members
C. Data Analysis
Contents
A. Sample Size
Approximately 20-25 health-care worker/patient encounters per each ANC clinic
selected for an ANC survey should be observed and recorded.
B. Assessment Team Members
The health-care worker observations can be done by the assistant coordinator or his or
her designee.
C. Data Analysis
No.
Outcome variables
1 Proportion of health providers who universally prescribed/distributed
iron/folate during the ANC visit
2 Proportion of health providers who universally prescribed/distributed
antimalarial drug during the ANC visit
3 Proportion of health providers who performed at least 90% of ANC
services correctly
Module 5: Conducting a Health-Care Worker Observation
1

2 The Rapid Assessment of the Burden of Malaria during Pregnancy

Provider’s name: ________________
Observation ID #____________________________
TOOL 5: HEALTH-CARE WORKER OBSERVATION
Observer name _____________________________________________________ Today’s date: ____/____/____
Observer number _______
Day Month Year
Observation ID number: ___ -- ___ ___ ___
Digit 1 = facility number
Digits 2, 3 & 4 = provider’s consecutive number
1. Woman’s arrival time: ___:___ AM/PM
2. Training of health care worker [ ]
Physician = 1
Health Officer = 2
Midwife = 3
Nurse = 4
Health assistant = 5
Sanitarian = 6
Other = 9 (specify) ___________________________
3. Number of ANC visits during this pregnancy (including this one) [ ]
Obtain information from ANC card. If no ANC card is available, skip this question.
3a. Check this box if woman’s first ANC visit
4. Observation of health care worker with woman (check if behavior was performed
by any of the clinic staff):
YES NO
___ ___ Checks if has ANC card
___ ___ Takes history (during 1st ANC visit):
___ ___ Age
___ ___ Gravidity
___
___ Last menstrual period
YES NO
___ ___ Pregnancy symptoms
___ ___ Contraceptive history
___ ___ Reproductive history - prior deliveries/outcomes; complications
___ ___ Medical history
___ ___ Asks woman about HIV status
___ ___ Counsels women about HIV/AIDS during pregnancy, childbirth, postpartum
Tool 5: Health-Care Worker Observation
1

Physical examination (during each ANC visit):
___ ___ Measures blood pressure
___ ___ Measures fundal height (abdominal exam)
___ ___ Listens to fetal heart
___ ___ Screens for anemia (physical signs)
___ ___ Prescribes or dispenses iron/folate
___ ___ Prescribes or dispenses antimalarial prophylaxis
___ ___ Administers tetanus toxoid if needed
Laboratory examination:
___ ___ Orders urine test
___ ___ Orders hemoglobin
___ ___ Orders syphilis test
___ ___ Treats for syphilis, if positive ____
___ ___ Arranges partner follow up, if syphilis (+) ____
Procedure related to problems:
___ ___ Checks temperature, if reports fever ____
___ ___ Refer for blood smear, if reports fever and malaria is suspected ____
___ ___ Prescribes/dispenses antimalarial, if reports fever___
General care during each ANC visit:
___ ___ Social history & support
___ ___ Assesses for woman’s complaints
___ ___ Asks woman if has questions
___ ___ Answers questions, if woman has questions
___ ___ Discusses individualized birth plan
(including clean and safe delivery)
___ ___ Gives individual health education (specify) ________________
___ ___ Washes hands before touching patient
___ ___ Uses gloves if genital examination performed, disposes of
gloves properly
___ ___ Fills out ANC card
___ ___ Marks next visit
___ ___ Reminds woman of next visit
___ ___ Other (specify) ______________________________________
5. Time spent with woman for exam (minutes) _____
6. Time seen by health-care worker (minutes) _____
7. Time woman leaves clinic ___:___AM/PM
8. Total time (minutes) _____
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

Module 6: Conducting Individual Interviews and
Focus Groups with Health-Care Workers
Individual interviews and focus groups with health-care workers are designed
to determine
• The health-care workers’ knowledge of the problem of malaria
• Role of health-care workers in influencing pregnant women’s behavior in
seeking antenatal care at health facilities
• What types of preventive and treatment measures they currently
recommend and provide
• Factors that motivate or inhibit women from using antenatal care
• Best methods for promoting health education messages to pregnant women
This module contains sample materials relevant to conducting a focus group or an
individual interview. These materials can and should be adapted to meet the needs of
the local situation.
Contents
A. Interview/Focus Group Timetable
B. Focus Group or Individual Interview or Both?
C. Number of Individual Interviews/Focus Group Size
D. Eligibility Criteria
E. Venues and Equipment
F. Assessment Team Members
G. Assessment Team Training
H. Notes Regarding the Focus Group/Interview Guide
I. Information Sheet
J. Debriefing
K. Focus Group/Interview Analysis
In addition, please see Resource 2, which includes a Sample Interviewer Training
Manual and a Resource List.
Module 6: Conducting Individual Interviews and Focus Groups with Health-Care Workers
1

A. Focus Group/Interview Timetable
To prepare for focus groups or individual interviews, it is important to alert health facilities
and community leaders well in advance (ideally, 2 weeks) of the qualitative team’s visits to the
facilities so that potential participants know that this activity will be occurring and that they
will be asked to participate. In addition, advance notice is needed so that community and/
or facility focus groups can be established and that arrangements can be made for interview
venues. It is helpful to follow up a week before the assigned meeting times.
After planning for the focus groups and interviews, selecting sites, and training interviewers,
the focus groups/interviews can begin.
B. Focus Group or Individual Interview or Both?
It may not always be possible to conduct both focus groups and individual interviews and
thus “triangulate” the data. If both cannot be done, the more appropriate technique should be
chosen based on the local situation.
• Individual interviews are a better choice when individual variability within communities
is of interest.
• Focus group interviews elicit community norms.
• Focus group interviews might help stimulate thinking and expose conflicting feelings–
they can ‘remind’ people of events or things that any one individual might have forgotten.
Focus groups are best at helping participants express opinions and perceptions of which
they might individually be unaware or not often think about.
• Individual interviews are often better if a topic is contentious or associated with strong
individual opinions or emotions.
• Focus group interviews are better for a small number of issues.
• Individual interviews lend themselves to a larger number of issues.
• Focus group interviews may be more efficient when resources—time, distance (e.g.,
vehicles), and money—are limited.
C. Number of Individual Interviews/Focus Group Size
Individual interviews are preferable if timing is not an issue. Could interview as many healthcare
workers as feasible during the assessment period, probably no more than 5-10 per
facility, but sometimes only 1 or 2 is all that is possible.
D. Eligibility Criteria
HCWs who routinely provide antenatal care or care for sick pregnant women who
have malaria.
E. Venues and Equipment
The focus group will ideally be held in a quiet space in a health facility or within a village.
Writing materials/stationery to record notes of the focus group will be needed, as will a tape
recorder if the decision to use one has been made.
Sufficient seating is needed for the members of the group, as well as for the facilitator and
the persons who serve as recorders. Because a focus group may draw a crowd of interested
people, ask that a member of the health-care facility or a community member politely dismiss
the crowd, with a brief explanation of what is occurring.
Individual interviews can also be conducted at health facilities.
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

The decision about how to record what is said (and whether to use a tape recorder) should
have been made before interviewers are selected and trained (see 4.1 in the Manual). Note
that for focus group interviews, it is wise to have at least 2 people recording the session, even
if a tape recorder is used.
F. Assessment Team Members
For each focus group, a facilitator and a recorder are needed. Sometimes tape recorders are
used to record the group’s discussion. The facilitator/recorder should write up the summary
of findings.
An interviewer who can speak the woman’s mother tongue will be needed to conduct
interviews.
G. Assessment Team Training
The training can be conducted concurrently, but separately, with training for Antenatal Clinic
and Delivery Unit Surveys.
Training can include the following subjects:
• an overview of the local malaria program implementation plan
• a review of malaria (transmission cycle, symptoms, diagnosis, prophylaxis and
treatment, epidemiology of malaria, consequences of malaria during pregnancy, and
local beliefs related to malaria)
• differences between qualitative and quantitative studies
• interviewing techniques
• data recording techniques
• differences between individual and focus group interviews
For most of the training, the team conducting focus groups and individual interviews team
can train alone, although both assessment teams can meet together for the training related
to proper interviewing techniques. Practice sessions can include role-playing of interview
sessions.
To assist in building capacity in qualitative research methodologies, all team members can be
given information on qualitative assessments and methodology, as well as written handouts on
interviewing techniques.
The training period can also be used to ensure that the interview instruments are linguistically
consistent. In addition, using the team members as community experts, each interview guide
should be reviewed to ensure that questions are relevant to the context of this district, and
minor modifications in the interview guides can be made.
H. Notes Regarding the Focus Group/Interview Guide
Both the focus group facilitator and the recorder should have a copy of the guide. The guide
will serve as a script for the facilitator and will help familiarize the recorder with the questions
that will be discussed.
The interviewer will need a copy of the guide.
It is important that the guide be flexible. If the questions as written in the guide do not elicit
the intended responses, they should be adapted as necessary. See J below, Debriefing.
Note that the guide included in this package may need to be adapted depending on whether it
is used for a focus group or an individual interview.
Module 6: Conducting Individual Interviews and Focus Groups with Health-Care Workers
3

I. Information Sheet
The following information sheet should be given to each potential interview participant. If the
person cannot read or has low literacy skills, the information should be read aloud to her. All
potential participants should receive a copy of the information sheet to take home.
Notes to interviewer:
• Explain everything in the local language or language of choice of the participant. Use
words that are easily understood and tailor your explanations to the level of education of
the participant.
• Do not force the person to agree to participate. You may need to explain the survey in
several different ways if the person does not seem to understand. If the person looks
confused or scared, try to clarify their concerns.
• If participant refuses to participate, please remember that this was an INVITATION to
participate. Thank the person for their time and trouble and go onto the next person.
• KEEP A RECORD of the number of participants who accept and refuse. For those that
refuse, keep a record of their reason for refusing, if possible.
Introduction
The Ministry of Health is trying to find out the best ways prevent the effects of malaria on
pregnant women and their babies. To do this, we need to know what women know about
malaria and its effects on pregnant women. We also need to know the places that women
seek health care when they are pregnant and what sorts of things they do to prevent malaria
when they are pregnant. We plan to talk to ____________ (describe about how many women and
others will be involved in this component of the assessment).
Purpose
What we learn about women’s ideas and actions about malaria and what they do when they
are pregnant will help us plan programs to decrease malaria in pregnant women.
Procedures
Being part of this individual interview/focus group is up to you. If you agree to participate/
be part of this interview/focus group, we will ask you some questions about what you think
and do about malaria, and about where you get help and information about malaria. You also
do not need to answer any questions that we ask that you do not want to. If you agree to
participate and during the interview/focus group, decide that you do not want to continue, you
can withdraw at any time. We will not be asking for any blood or urine samples.
Benefits
Although what we learn might not help you directly, it will help us know how best to prevent
malaria in pregnant women in this district.
Risks or discomforts
We will not be telling anyone about your individual answers to the questions.
Would you like to participate?
Thank you very much for your time.
Please be sure to give this information sheet to the person with whom you spoke.
4 The Rapid Assessment of the Burden of Malaria during Pregnancy

J. Debriefing
Daily debriefings are an essential element of good qualitative work. At the end of each day that
focus groups or individual interviews are conducted, it is useful for the assessment team to
hold a debriefing session lasting approximately 1 - 1.5 hours. The debriefing should be led by
the coordinator or another facilitator.
Debriefings are a method to determine if a) the questions are adequate to obtain the needed
data (qualitative methods are iterative, thus, you can change questions as needed as you
conduct the assessment), b) if people have understood the question (for example: is it a
sentence structure, content or a translation problem?), if c) data are similar across facilities or
show wide variability, which might require adding questions to understand the variability, and
if d) expressions in the local language are being translated appropriately.
The team listens to what each interviewer has learned (aggregate summary of the data they
collected that day), identifies what is common, what is different, and mutually agrees on what
local expressions mean. This is particularly important when the team is trying to understand
local beliefs, including taboos, about malaria and/or drugs during pregnancy. Debriefings
tend to be difficult as the team is tired and the process can be tedious, but having high-quality,
clearly understandable data when analysis begins rewards the time spent in daily debriefings.
During the debriefings, the coordinator or facilitator should keep notes on the outcomes of
each debriefing, explanations for trends seen in the data, and local language terms (using the
local language), as well as the agreed-upon translations.
During this time, all recorded interviews can be reviewed for completeness and accuracy of
the recording. In addition, concepts can be clarified, traditional terms used for prevention
and treatment strategies can be reviewed for linguistic accuracy and consistency, and
understanding of local pregnancy taboos can be discussed.
These types of surveys can require the addition of new questions or probes to the survey tool
during the survey period in order to make the questions wider, narrower, or more specific in
order to obtain the needed information.
K. Focus Group/Interview Analysis
Recording and analyzing information for a focus group is somewhat different from recording
and analyzing information for an individual interview.
For focus groups:
• The recorder must be able to record general themes during the interview and fill in the
details afterwards.
• Counting the number of responses is not important, but noting that most or many
participants felt the same way is.
• It is important to note if one person in the focus group has thoughts or behaviors very
different from those of the rest of the group. This person is called an “outlier.”
• Names should not be used in recording themes, although speakers can be identified by
their job description (for example, “the nurses felt…”) or other pertinent descriptors.
When there is a good quote in the local language, make sure it is written as it is said in the
local language and then reach consensus (perhaps during debriefing) on what it means in the
primary language used in the rapid assessment, if different.
Module 6: Conducting Individual Interviews and Focus Groups with Health-Care Workers
5

6 The Rapid Assessment of the Burden of Malaria during Pregnancy

TOOL 6: INDIVIDUAL INTERVIEW/FOCUS GROUP GUIDE FOR
HEALTH-CARE WORKERS
This guide can be adapted to be used as a guide for conducting either focus groups or individual interviews.
Region_______________________________
Name of facility/facility area_______________
Date: ____/____/____
Month Day Year
Time_________________________
Interviewer_____________________
Recorder_______________________
INTRODUCTION: Introduce yourself and team members, describe your roles, and obtain agreement to
participate (or informed consent if required). Tell the participant(s) the goal of the focus group.
A. Demographics:
Age:
Level of education: Highest level of school attended (primary, secondary, higher, unknown)
Job description at health facility:
B. Topical area: Prevailing health problems and malaria in pregnancy
1. What are the 3 most serious health problems among pregnant women in this area?
List them in order of how serious they are.
2. (Ask if malaria is not mentioned in Question 1) Is malaria a serious or common health problem among
pregnant women in this community?
C. Topical area: Signs and symptoms of fever and malaria during pregnancy
1. What are the common signs and symptoms of malaria among pregnant women?
D. Topical area: Causes and consequences of malaria in pregnancy
1. What effect does malaria have on pregnant women? On the fetus? On the neonate?
2. Are pregnant women more susceptible to malaria? Do pregnant women with malaria get more severely
ill than other people?
Tool 6: Individual Interview/ Focus Group Guide for Health-Care Workers
1

E. Topical area: Sources of advice for malaria prevention/treatment during pregnancy
1. From whom do women seek advice regarding malaria or pregnancy issues in general?
2. Who influences women the most when they need information about pregnancy or malaria? For example, someone
at the health facility, a traditional birth attendant, a midwife, someone else in the community (example village elder),
or someone in their family?
What is the order of seeking advice? First, second, third?
3. Do husbands play a role in deciding what to do if their pregnant wife gets malaria?
IF YES: please describe their role.
4. What is the best (most effective) way to reach women in this community in order to provide them malaria
prevention and treatment information?
F. Topical area: Preventive strategies
1. In general, how do people protect themselves in this area against malaria when they are pregnant? (Probe for
traditional remedies, use of insecticides, insecticide-treated nets or curtains, mosquito coils, dress, etc.)
Are any of these strategies harmful to a pregnant woman or her baby? Yes___No___ IF YES: Which ones?
IF YES: please describe how it will hurt the woman or the baby.
2. What preventive methods are provided at the clinic?
3. For intermittent preventive treatment (IPTp), what drugs are given?
• When are these given? How many doses do the women get?
• Do you use directly observed treatments? Yes___ No___
• Are there any times when you can not do this? (Probes: for example, no drinkable water or drug shortages, woman
complains that she has not eaten?)
• If you do not see the woman taking the pill, do you think most women are compliant?
• How are you recording the doses? For example, do you have a written record of women receiving doses or do you
only ask the women if they have received a dose? Is it written in their clinic cards?
• When did this facility start implementing IPT?
• What has been the response of the women to the IPTp? (Probe: Do they see it as a welcome addition to antenatal
care, are they concerned about toxic effects to the baby?)
4. What has been their response to insecticide-treated nets/nets?
• Are these provided to pregnant women? Yes___No___
• Do you think most women sleep under these nets? Yes___No___ IF NO: who sleeps under the net in most of these
families?
• What comments have you heard from the women about the nets?
• How are they provided:
o given free
o given as a cost-sharing mechanism (If so, how much do you charge for the net?)
o If using a cost-sharing mechanism, can most women afford them? Yes___No___
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

G. Topic area: Treatment strategies
1. What treatment do you use for a pregnant woman with uncomplicated malaria? Does this vary with gestational age?
2. Are there any antimalarials you will not use in pregnant women? Why? Does this vary with gestational age?
3. What concerns do most women express regarding malaria treatments during pregnancy? (Probes: Are women
concerned that the medicines are too harsh for the baby? Is the medicine worse for the baby or is the malaria worse?
Will taking treatments during pregnancy put a curse on the baby?)
H. Topical area: Acceptance of antenatal care (from health facilities and
traditional birth attendants)
1. How can health-care workers work better with traditional birth attendants? With other community-based workers?
2. In your opinion, what could be done to improve the services of the health facility?
3. How could services for pregnant women regarding the prevention and treatment of malaria be improved?
4. Do you feel that you have had adequate training regarding malaria during pregnancy?
BE SURE TO THANK THE HEALTH CARE WORKER FOR HIS OR HER TIME, AND ASK IF HE OR SHE HAS ANY
QUESTIONS FOR YOU.
Tool 6: Individual Interview/ Focus Group Guide for Health-Care Workers
3

4 The Rapid Assessment of the Burden of Malaria during Pregnancy

Module 7: Conducting Individual Interviews and
Focus Groups with Traditional Birth
Attendants (TBAs)
Individual interviews and focus groups with traditional birth attendants
(TBAs) are designed to determine
• Role of TBAs in influencing pregnant women’s behavior in seeking antenatal
care at health facilities
• What types of preventive and treatment measures are currently being
recommended and used
• Factors that motivate or inhibit women from using antenatal care
• Best methods for promoting health education messages to pregnant women
This module contains sample materials relevant to conducting a focus group or an
individual interview. These materials can and should be adapted to meet the needs of
the local situation.
Contents
A. Interview/Focus Group Timetable
B. Focus Group or Individual Interview or Both?
C. Number of Individual Interviews/Focus Group Size
D. Eligibility Criteria
E. Venues and Equipment
F. Assessment Team Members
G. Assessment Team Training
H. Notes Regarding the Focus Group/Interview Guide
I. Information Sheet
J. Debriefing
K. Focus Group/Interview Analysis
In addition, please see Resource 2, which includes a Sample Interviewer Training
Manual and a Resource List.
Module 7: Conducting Individual Interviews and Focus Groups with Traditional Birth Attendants (TBAs)
1

A. Focus Group/Interview Timetable
To prepare for focus groups or individual interviews, it is important to alert community
leaders well in advance (ideally, 2 weeks) of the qualitative team’s visits so that potential
participants know that this activity will be occurring and that they will be asked to participate.
In addition, advance notice is needed so that community and/or facility focus groups can be
established and that arrangements can be made for interview venues. It is helpful to follow up
a week before the assigned meeting times.
After planning for the focus groups and interviews, selecting sites, and training interviewers,
the focus groups/interviews can begin.
B. Focus Group or Individual Interview or Both?
It may not always be possible to conduct both focus groups and individual interviews and
thus “triangulate” the data. If both cannot be done, the more appropriate technique should be
chosen based on the local situation.
• Individual interviews are a better choice when individual variability within communities is
of interest.
• Focus group interviews elicit community norms.
• Focus group interviews might help stimulate thinking and expose conflicting feelings–they
can ‘remind’ people of events or things that any one individual might have forgotten.
• Focus groups are best at helping participants express opinions and perceptions of which they
might individually be unaware or not often think about.
•Individual interviews are often better if a topic is contentious or associated with strong
individual opinions or emotions.
• Focus group interviews are better for a small number of issues.
• Individual interviews lend themselves to a larger number of issues.
• Focus group interviews may be more efficient when resources—time, distance (e.g.,
vehicles), and money—are limited.
C. Number of Individual Interviews/Focus Group Size
At least one focus group with 5 to 15 participants per facility area. May wish to conduct
interviews as well, depending on the available pool of potential participants.
Note: Community health workers, church leaders, and primary school teachers can help
identify TBAs who attend home births.
D. Eligibility Criteria
TBAs who attend home births and advise pregnant women are eligible.
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

E. Venues and Equipment
The focus group will ideally be held in a quiet space within a village.
Writing materials/stationery to record notes of the focus group will be needed, as will a
tape recorder if the decision to use one has been made.
Sufficient seating is needed for the members of the group, as well as for the facilitator
and the persons who serve as recorders. Because a focus group may draw a crowd of
interested people, ask that a community member politely dismiss the crowd, with a brief
explanation of what is occurring.
Homes in villages near the health facilities can also serve as interview sites.
The decision about how to record what is said (and whether to use a tape recorder) should
have been made before interviewers are selected and trained (see 4.1 in the Manual). Note
that for focus group interviews, it is wise to have at least 2 people recording the session, even
if a tape recorder is used.
F. Assessment Team Members
For each focus group, a facilitator and a recorder are needed. Sometimes tape recorders
are used to record the group’s discussion. The facilitator/recorder should write up the
summary of findings.
An interviewer who can speak the woman’s mother tongue will be needed to conduct
interviews.
G. Assessment Team Training
The training can be conducted concurrently, but separately, with training for Antenatal
Clinic and Delivery Unit Surveys.
Training can include the following subjects:
• an overview of the local malaria program implementation plan
• a review of malaria (transmission cycle, symptoms, diagnosis, prophylaxis and treatment,
epidemiology of malaria, consequences of malaria during pregnancy, and local beliefs
related to malaria)
• differences between qualitative and quantitative studies
• interviewing techniques
• data recording techniques
• differences between individual and focus group interviews
For most of the training, the team conducting focus groups and individual interviews team
can train alone, although both assessment teams can meet together for the training related
to proper interviewing techniques. Practice sessions can include role-playing of interview
sessions.
To assist in building capacity in qualitative research methodologies, all team members can be
given information on qualitative assessments and methodology, as well as written handouts on
interviewing techniques.
Module 7: Conducting Individual Interviews and Focus Groups with Traditional Birth Attendants (TBAs)
3

The training period can also be used to ensure that the interview instruments are linguistically
consistent. In addition, using the team members as community experts, each interview guide
should be reviewed to ensure that questions are relevant to the context of this district, and
minor modifications in the interview guides can be made.
H. Notes Regarding the Focus Group/Interview Guide
Both the focus group facilitator and the recorder should have a copy of the guide. The
guide will serve as a script for the facilitator and will help familiarize the recorder with
the questions that will be discussed.
The interviewer will need a copy of the guide.
It is important that the guide be flexible. If the questions as written in the guide do not elicit
the intended responses, they should be adapted as necessary. See H below, Debriefing.
Note that the guide included in this package may need to be adapted depending on whether it
is used for a focus group or an individual interview.
I. Information Sheet
The following information sheet should be given to each potential interview participant.
If the person cannot read or has low literacy skills, the information should be read
aloud to her. All potential participants should receive a copy of the information sheet
to take home.
Notes to interviewer:
• Explain everything in the local language or language of choice of the participant. Use words
that are easily understood and tailor your explanations to the level of education of the
participant.
• Do not force the person to agree to participate. You may need to explain the survey in several
different ways if the person does not seem to understand. If the person looks confused or
scared, try to clarify their concerns.
• If participant refuses to participate, please remember that this was an INVITATION to
participate. Thank the person for their time and trouble and go on to the next person.
• KEEP A RECORD of the number of participants who accept and refuse. For those that refuse,
keep a record of their reason for refusing, if possible.
4 The Rapid Assessment of the Burden of Malaria during Pregnancy

Introduction
The Ministry of Health is trying to find out the best ways prevent the effects of malaria on
pregnant women and their babies. To do this, we need to know what women know about
malaria and its effects on pregnant women. We also need to know the places that women
seek health care when they are pregnant and what sorts of things they do to prevent malaria
when they are pregnant. We plan to talk to ____________ (describe about how many women and
others will be involved in this component of the assessment).
Purpose
What we learn about women’s ideas and actions about malaria and what they do when they
are pregnant will help us plan programs to decrease malaria in pregnant women.
Procedures
Being part of this individual interview/focus group is up to you. If you agree to participate/
be part of this interview/focus group, we will ask you some questions about what you think
and do about malaria, and about where you get help and information about malaria. You also
do not need to answer any questions that we ask that you do not want to. If you agree to
participate and during the interview/focus group, decide that you do not want to continue,
you can withdraw at any time. We will not be asking for any blood or urine samples.
Benefits
Although what we learn might not help you directly, it will help us know how best to prevent
malaria in pregnant women in this district.
Risks or discomforts
We will not be telling anyone about your individual answers to the questions.
Would you like to participate?
Thank you very much for your time.
Please be sure to give this information sheet to the person with whom you spoke.
Module 7: Conducting Individual Interviews and Focus Groups with Traditional Birth Attendants (TBAs)
5

J. Debriefing
Daily debriefings are an essential element of good qualitative work. At the end of each day that
focus groups or individual interviews are conducted, it is useful for the assessment team to
hold a debriefing session lasting approximately 1 - 1.5 hours. The debriefing should be led by
the coordinator or another facilitator.
Debriefings are a method to determine if a) the questions are adequate to obtain the needed
data (qualitative methods are iterative, thus, you can change questions as needed as you
conduct the assessment), b) if people have understood the question (for example: is it a
sentence structure, content or a translation problem?), if c) data are similar across facilities or
show wide variability, which might require adding questions to understand the variability, and
if d) expressions in the local language are being translated appropriately.
The team listens to what each interviewer has learned (aggregate summary of the data they
collected that day), identifies what is common, what is different, and mutually agrees on what
local expressions mean. This is particularly important when the team is trying to understand
local beliefs, including taboos, about malaria and/or drugs during pregnancy. Debriefings
tend to be difficult as the team is tired and the process can be tedious, but having high-quality,
clearly understandable data when analysis begins rewards the time spent in daily debriefings.
During the debriefings, the coordinator or facilitator should keep notes on the outcomes of
each debriefing, explanations for trends seen in the data, and local language terms (using the
local language), as well as the agreed-upon translations.
During this time, all recorded interviews can be reviewed for completeness and accuracy of
the recording. In addition, concepts can be clarified, traditional terms used for prevention
and treatment strategies can be reviewed for linguistic accuracy and consistency, and
understanding of local pregnancy taboos can be discussed.
These types of surveys can require the addition of new questions or probes to the survey tool
during the survey period in order to make the questions wider, narrower, or more specific in
order to obtain the needed information.
K. Focus Group/Interview Analysis
Recording and analyzing information for a focus group is somewhat different from recording
and analyzing information for an individual interview.
For focus groups:
• The recorder must be able to record general themes during the interview and fill in the
details afterwards.
• Counting the number of responses is not important, but noting that most or many
participants felt the same way is.
• It is important to note if one person in the focus group has thoughts or behaviors very
different from those of the rest of the group. This person is called an “outlier.”
• Names should not be used in recording themes, although speakers can be identified by their
job description (for example, “the nurses felt…”) or other pertinent descriptors.
When there is a good quote in the local language, make sure it is written as it is said in the
local language and then reach consensus (perhaps during debriefing) on what it means in the
primary language used in the rapid assessment, if different.
6 The Rapid Assessment of the Burden of Malaria during Pregnancy

TOOL 7: INDIVIDUAL INTERVIEW/FOCUS GROUP GUIDE FOR
TRADITIONAL BIRTH ATTENDANTS
This guide can be adapted to be used as a guide for conducting either focus groups or individual interviews.
Region_______________________________
Name of facility/facility area_______________
Date: ____/____/____
Month Day Year
Time_________________________
Interviewer_____________________
Recorder____________________________
INTRODUCTION: Introduce yourself and team members, describe your roles, and obtain agreement to
participate (or informed consent if required). Tell the participant(s) the goal of the focus group.
A. Demographics: For each of the participants, record the following information:
Age:
Level of education: Highest level of school attended (primary, secondary, higher, unknown)
For traditional birth attendants, number of years of experience as a traditional birth attendant:
Ethnic group (If group is diverse):
B. Topical area: Prevailing health problems and malaria in pregnancy
1. What are the 3 most important health problems among pregnant women in this area?
List them in order of importance.
2. (If malaria is not already mentioned in Question 1) Is malaria a serious or common health problem among pregnant
women in this community?
C. Topical area: Signs and symptoms of fever and malaria during pregnancy
1. What are the common signs and symptoms of malaria among pregnant women?
D. Topical area: Causes and consequences of malaria in pregnancy
1. What effect does malaria have on pregnant women? On the fetus? On the neonate?
2. Are pregnant women more susceptible to malaria? Do pregnant women with malaria get more severely ill than
other people?
E. Topical area: Sources of advice for malaria prevention/treatment during pregnancy
1. From whom do women seek advice regarding malaria or pregnancy issues in general?
2. Who influences women the most when they need information about pregnancy or malaria? For example, someone
at the health facility, a traditional birth attendant, someone else in the community (example village elder), or
someone in their family?
What is the order of seeking advice? First, second, third?
Tool 7: Individual Interview/ Focus Group Guide for Traditional Birth Attendants
1

3. Do husbands play a role in deciding what to do if their pregnant wife gets malaria?
IF YES: please describe their role.
4. What is the best (most effective) way to reach women in this community in order to provide them malaria
prevention and treatment information?
F. Topical Area: Preventive strategies
1. In general, how do women protect themselves in this area against malaria when they are pregnant?
(Probe for traditional methods: infusions, teas, smoke, leaves for dousing the walls, going to bed earlier; and
modern methods: insecticides, use of nets or treated curtains; clothes)
Are any of these strategies harmful to a pregnant woman or the baby? Yes___No___
IF YES: please describe how it will hurt the woman or the baby.
2. Which preventive strategies do you think work best to prevent malaria when someone is pregnant? Please identify
which method you think is most effective to use.
G. Topical Area: Treatment sources
1. What concerns do most women voice regarding malaria treatments during pregnancy?
2. If a pregnant woman experiences a fever or malaria during pregnancy, what recommendations would you make?
H. Topical Area: Acceptance of antenatal care
1. When do most pregnant women in this area start to get antenatal care from a traditional birth attendant?
2. How do traditional birth attendants give support and advice to pregnant women?
(Probe: Do they routinely make visits to a woman’s house?)
3. Does the distance to the health care facility limit the number of women who can attend antenatal clinics in this
district?
4. What reasons have you heard as to why women in this community might not want to go to the health facility for
antenatal care?
(Probes: What types of complaints have you heard about the health facility?
What have you heard about the attitudes of health care workers toward women in
the clinics?)
5. What could be done to improve the services of the health facility?
6. What could be done to improve your services?
7. What is the best way to encourage women to obtain antenatal care?
(Probes: Have you seen successful strategies being used to increase the number of women who attend
antenatal clinics?)
I. Topical Area: Role of traditional birth attendants in influencing behaviors
1. What advice do you give to pregnant women in regard to starting antenatal care? (Probe: Do you routinely make
visits to a woman’s house?)
2. Do you routinely refer pregnant women to antenatal care at a health facility? Yes__No__
If not, why not?
Under what circumstances?
Do you give pregnant women cards to refer them?
3. Is there a policy stating that traditional birth attendants should refer all pregnant women to the health care
facilities?
4. Do you follow up with women that you have referred to ask if they have actually gone to the health facility after you
have referred them?
5. If a pregnant woman comes to you experiencing fever/malaria during her pregnancy, what advice is routinely given
to her?
6. How can health care workers work better with traditional birth attendants?
(Probes: Should health care workers provide any training to traditional
birth attendants?)
7. Do you think your own training is sufficient in the area of malaria during pregnancy?
BE SURE TO THANK THE PARTICIPANTS FOR THEIR TIME, AND ASK IF THEY HAVE ANY QUESTIONS FOR YOU.
2 The Rapid Assessment of the Burden of Malaria during Pregnancy

Module 8: Conducting an Antenatal Clinic
Client Exit Interview
An antenatal clinic client exit interview is designed to determine
• Client’s knowledge of malaria and experience with malaria prevention
and treatment methods
• Services received that day in the antenatal clinic
• Satisfaction with services received
This module contains sample materials for an Antenatal Clinic Client Exit Interview. These materials can
and should be adapted to suit local needs, including translating the information sheet into the pregnant
woman’s primary language. General guidance for conducting assessment tools survey and managing data
can be found in Chapters 3-4.
A. Sample Sizes
B. Study Site
C. Eligibility Criteria
D. Information Sheet
E. Data Analysis
Contents
Module 8: Conducting an Antenatal Clinic
31

A. Sample Sizes
Note that the clients participating in the client exit interviews should not be the same clients
that participate in the antenatal clinic survey. Approximately 15 women per site should be
selected.
B. Study Site
The survey should be conducted at antenatal clinics. In countries with clinics that have
specific antenatal care days, it would be most appropriate to conduct this survey on those
days.
C. Eligibility Criteria
Women who participate in the Antenatal Clinic Client Exit Interview should be as
representative as possible of all women attending the antenatal clinic. The eligibility
criteria are the same as those for the antenatal clinic and delivery unit surveys. However,
if women have participated in the antenatal clinic survey, they should be excluded from
participating in the exit interview.
Women are eligible for the survey if they meet the following requirements :
Gestation: Women who have experienced “quickening” (i.e., the recognition of fetal
movement) are eligible.
Gravidity: All gravidities. Although primigravidae and secundigravidae are the groups
typically most affected by malaria in high transmission areas, women of all gravidities should
be eligible so that the local situation can be confirmed.
Age: The youngest age at which women are eligible to participate should be the age at which
most women in the assessment area have their first child. This is to ensure that primigravidae
and secundigravidae (the groups at highest risk) are included in the assessment. The age of
the youngest participants may well be less than the age of majority and should be consistent
with any country policy or norm regarding this type of survey.
Women are not eligible for the client exit interview if they have participated in the
Antenatal Clinic Survey.
D. Information Sheet
The following information sheet should be given to each potential survey participant.
If the potential survey participant cannot read or has low literacy skills, the information
should be read aloud to her. All potential participants should receive a copy of the
information sheet to take home.
Note to Interviewer: If the potential survey participant cannot read or if she has low literacy
skills, read this information aloud to her. Give each potential survey participant a copy of this
information sheet to take home.
2
The Rapid Assessment of the Burden of Malaria during Pregnancy

Introduction
The [Ministry of Health] is doing an assessment to find out how many pregnant women in this
[assessment area] have malaria and to find out the best ways to prevent the effects of malaria
on pregnant women and their babies. We plan to assess this problem in about _____ women in
antenatal clinics in the [assessment area].
Purpose of the Survey
In this survey, we’d like to find out more about the services you received today in the antenatal
clinic and how satisfied you are with the services you received.
This will help us better plan programs to decrease malaria in pregnant women.
Procedures
If you agree to participate in this survey, we will ask you some questions about yourself and
your antenatal care visit. We will not be telling anyone about your individual answers to the
questions, and we will keep all assessment information about you safe and secure. You also do
not need to answer any questions on the survey forms that you do not want to. The survey will
take about “x” minutes.
If you do not wish to participate in this survey, it will not affect the care given to you by the
clinic. If you have questions later, please feel free to ask. You can ask me today or if you have
questions later, you can ask _________________ (responsible assessment team member).
Thank you very much for your time. Would you like to participate?
Remind participant to keep this information sheet in case there are questions later on.
E. Data Analysis
Antenatal Clinic Client Exit Interview results can be summarized as tables or graphs.
Outcome variables include the following:
Percentage of pregnant women satisfied with the services they received
Percentage of women who use antimalarial drugs for treatment and prevention of malaria
Percentage of women who use ITNs
Module 8: Conducting an Antenatal Clinic
3

4
The Rapid Assessment of the Burden of Malaria during Pregnancy

Woman’s full name:
ID #_____A________
TOOL 8: CLIENT EXIT INTERVIEW
Today’s date: _____/_____/_____
Day Month Year
ID number: ___ _A__ -- ___ ___ ___
Digit 1 = facility number Digit 2 = A (for Antenatal Clinic)
Digits 3, 4 & 5 = woman’s consecutive number
SCREENING INFORMATION:
Interviewer number _______
1. Age (years):: [ ]
(If the mother does not know her age, then estimate her age using the categories below)
less than 15 years [ ] 30-34 years [ ]
15-19 years [ ] 35-39 years [ ]
20-24 years [ ] 40-44 years [ ]
25-29 years [ ] more than 44 years [ ]
If the woman is less than an age deemed appropriate, thank her for her time, and DO
NOT enroll her
in this survey.
2. Did you receive antenatal care services today? [ ]
YES = 1
NO = 2 (skip to end of interview)
UNKNOWN = 9
If the woman did not receive antenatal care services, thank her for her time, and DO
NOT enroll her in this survey.
3. Have you felt the baby move inside you yet? [ ]
YES = 1
NO = 2
UNKNOWN = 9
If the woman has not experienced quickening, thank her for her time, and
DO NOT enroll her in this survey.
4. What village/town do you live in? _______________________________________________________________
Interviewer: skip the next question; to be coded later so that it is done uniformly.
5. Is this a rural or urban area? [ ]
Urban = 1
Rural = 2
Periurban = 3
Unknown = 9
6. What language do you usually speak with family members at home? [ ]
Language a = 1
Language b = 2
Language c = 3
Other = 8 (specify) ______________________________________
Tool 8: Conducting an Antenatal Clinic 1

EDUCATION
7. What is the highest level of school you attended? [ ]
Primary = 1
Secondary = 2
Higher = 3
Never attended = 4
Unknown = 9
8. Can you read? [ ]
YES = 1 NO = 2
SOCIOECONOMIC INDICATORS
9. What is the roof of your house made of? [ ]
corrugated iron = 1
cement or concrete = 2
wood and mud = 3
thatch or grass = 4
reed or bamboo = 5
plastic sheet = 6
mobile roofs of nomads = 7
other = 8 (specify) __________________________________
10. What kind of floor does your house have? [ ]
earth or sand = 1
dung = 2
wood planks = 3
reed or bamboo = 4
vinyl tiles or carpet = 5
cement = 6
cement tiles or brick = 7
other = 8 (specify) ___________________________________
11. What is the main job of the head of household/husband? [ ]
job a = 1
job b = 2
job c = 3
job d = 4
12. What is the monthly household income for your family? [ ]
income bracket a = 1
income bracket b= 2
income bracket c=3
(FOR THE NEXT QUESTION, PLEASE ENTER A 1 OR 2 FOR EACH LINE)
13. Do you or any member of your family living in the same compound:
YES = 1 NO = 2
Own a bicycle/scooter/moped? [ ]
Own a radio? [ ]
Own a TV? [ ]
Own the house you are living in? [ ]
Own crop land? [ ]
Grow cash crops? [ ]
2
The Rapid Assessment of the Burden of Malaria during Pregnancy

MARITAL STATUS
14. Are you married? [ ]
yes, married or living with a man = 1
was married or living with a man, but separated or divorced = 2
widow of the father of this baby = 3
never married or lived with a man = 4
ANTENATAL CARE
Pregnancy and Antenatal Care
15. How many times have you been pregnant in your life (including this one)?[ ]
16. How many months pregnant are you now? [ ] (Months)
Antenatal Care Received
Interviewer please read to respondent: Now I am going to ask you about your visit today.
17. Were you asked how you are feeling? [ ]
YES = 1
NO = 2
UNKNOWN = 9
18. Was the place (abdomen) where the baby is growing (fundal height) measured? [ ]
YES = 1
NO = 2
UNKNOWN = 9
19. Did someone listen to your baby’s heart? [ ]
YES = 1
NO = 2
UNKNOWN = 9
20. Was your blood pressure taken? [ ]
YES = 1
NO = 2
UNKNOWN = 9
21. Did someone check your urine? [ ]
YES = 1
NO = 2
UNKNOWN = 9
22. Did you receive counseling or health education? [ ]
YES = 1
NO = 2 (skip to question 23)
UNKNOWN = 9 (skip to question 23)
22a. If YES, what topics did the service provider discuss?
______________________________________________________________
______________________________________________________________
______________________________________________________________
Tool 8: Client Exit Interview
3

23. Did someone help you make up or review your special birth plan that tells where you’ll be giving birth,
who will be there, and what you’ll need at the birth for yourself and the baby? [ ]
YES = 1
NO = 2
UNKNOWN = 9
24. Were you given an insecticide-treated bednet? [ ]
YES = 1
NO = 2
UNKNOWN = 9
24a. Is today the first time you are attending the clinic for antenatal care during this pregnancy? [ ]
YES = 1
NO = 2
UNKNOWN = 9
25. Were you given or prescribed any tablets or drugs? [ ]
YES = 1
NO = 2
UNKNOWN = 9
Medications/Tablets
Instructions to interviewer: Mark down each kind of tablet provided to the client
26. Please show me the medication/tablets you received today. [ ] [ ] [ ] [ ]
Combined iron and folate = 1
Fansidar = 2
Chloroquine = 3
Hookworm medications = 4
STI medications = 5
Other = 9 (specify) ________________________________________________
27. What is the purpose of each of the medications/ tablets that you received
today? [ ] [ ] [ ] [ ]
(Mark all that apply)
Prevent anemia = 1
Prevent malaria = 2
Treat malaria = 3
Prevent congenital malformations = 4
Treat worms = 5
Treat STIs = 6
Did not receive any = 7
Other = 9 (specify) _____________________________________________
Unknown = 9
4
The Rapid Assessment of the Burden of Malaria during Pregnancy

28. Did you receive any medications/tablets during your last antenatal care visit? [ ]
Yes = 1
No = 2 (skip to question 29)
First antenatal care visit = 3 (skip to question 29)
Unknown/can’t remember = 9 (skip to question 29)
28a. If YES, did you take all the tablets you received during your last antenatal
care visit? [ ]
YES = 1
NO = 2
Don’t know/can’t remember = 9
CLIENT SATISFACTION
Interviewer please read to respondent: Now I am going to ask you a few questions about the services that you
received today at the clinic.
29. About how long did you wait between the time you first arrived at the clinic and the time you received antenatal
services? [ ]
Less than 15 minutes = 1
16-30 minutes = 2
31-45 minutes = 3
46-60 minutes = 4
more than 60 minutes = 5
Unknown = 9
30. Do you feel that your waiting time was reasonable or too long? [ ]
No waiting time = 1
Reasonable/short = 2
Too long = 3
Unknown = 9
31. Did you have enough privacy during your consultation? [ ]
YES = 1
NO = 2
UNKNOWN = 9
32. Did you feel comfortable to ask the provider questions during your visit today? [ ]
YES = 1
NO =2
UNKNOWN = 9
33. Did the provider answer all of your questions today? [ ]
YES = 1
NO = 2
UNKNOWN = 9
Tool 8: Client Exit Interview
5

34. Do you feel the information you shared about yourself with the provider will be kept confidential? [ ]
YES = 1
NO = 2
UNKNOWN = 9
35. During your visit today, how were you treated by the service provider(s)? [ ]
Very well = 1
Well = 2
Badly = 3
Very badly = 4
Other = 9 (specify) ___________________________________________
Unknown = 9
36. How satisfied are you, overall, with the services that you received today? [ ]
Very satisfied = 1
Somewhat satisfied = 2
Not very satisfied = 3
Completed unsatisfied = 4
Unknown = 9
37. Do you plan to come to another visit at this clinic? [ ]
YES = 1
NO = 2
UNKNOWN = 9
38. Would you encourage a friend or relative of yours to come to this facility for antenatal care services? [ ]
YES = 1
NO = 2
UNKNOWN = 9
Thank respondent for her time.
INTERVIEWER COMMENTS:
(Please note any additional observations in the space below):
6
The Rapid Assessment of the Burden of Malaria during Pregnancy

Module 9: Conducting Interviews and Focus
Groups with Recently or Currently Pregnant Women
Individual interviews or focus groups with recently/currently pregnant women are
designed to determine
• How pregnant women understand the problem of malaria in pregnancy
• What types of preventive and treatment measures are currently being recommended and used
• Factors that motivate or inhibit women from using antenatal care
• Best methods for promoting health education messages to pregnant women
• Acceptance and usage of antimalarials during pregnancy.
This module contains sample materials relevant to conducting a focus group or an individual interview. These
materials can and should be adapted to meet the needs of the local situation.
A. Focus Group/Interview Timetable
Contents
B. Focus Group or Individual Interview or Both?
C. Number of Individual Interviews/Focus Group Size
D. Eligibility Criteria
E. Venues and Equipment
F. Assessment Team Members
G. Assessment Team Training
H. Notes Regarding the Focus Group/Interview Guide
I. Information Sheet
J. Debriefing
K. Focus Group/Interview Analysis
Please see Resource 2, which includes a Sample Interviewer Training Manual and a Resource List.
Module 9: Conducting Interviews and Focus Groups with Recently or Currently Pregnant Women
1

A. Focus Group/Interview Timetable
To prepare for focus groups or individual interviews, it is important to alert health facilities
and community leaders well in advance (ideally, 2 weeks) of the qualitative team’s visits to the
facilities so that potential participants know that this activity will be occurring and that they
will be asked to participate. In addition, advance notice is needed so that community and/
or facility focus groups can be established and that arrangements can be made for interview
venues. It is helpful to follow up a week before the assigned meeting times.
After planning for the focus groups and interviews, selecting sites, and training interviewers,
the focus groups/interviews can begin.
B. Focus Group or Individual Interview or Both?
It may not always be possible to conduct both focus groups and individual interviews and
thus “triangulate” the data. If both cannot be done, the more appropriate technique should be
chosen based on the local situation.
• Individual interviews are a better choice when individual variability within communities is
of interest.
• Focus group interviews elicit community norms.
• Focus group interviews might help stimulate thinking and expose conflicting feelings–they
can ‘remind’ people of events or things that any one individual might have forgotten.
• Focus groups are best at helping participants express opinions and perceptions of which they
might individually be unaware or not often think about.
• Individual interviews are often better if a topic is contentious or associated with strong
individual opinions or emotions.
• Focus group interviews are better for a small number of issues.
• Individual interviews lend themselves to a larger number of issues.
• Focus group interviews may be more efficient when resources—time, distance (e.g.,
vehicles), and money—are limited.
C. Number of Individual Interviews/Focus Group Size
At least one focus group with 5 to 15 participants for each facility. Four to five individual
interviews per facility.
D. Eligibility Criteria
The only criterion is that the women who are in the focus group or who are participating in the
interview should either be pregnant or have been recently pregnant (within the last 2 years).
E. Venues and Equipment
The focus group will ideally be held in a quiet space in a health facility or within a village.
Writing materials/stationery to record notes of the focus group will be needed, as will a
tape recorder if the decision to use one has been made.
Sufficient seating is needed for the members of the group, as well as for the facilitator and
the persons who serve as recorders. Because a focus group may draw a crowd of interested
people, ask that a member of the health-care facility or a community member politely
dismiss the crowd, with a brief explanation of what is occurring.
Individual interviews can also be conducted at health facilities. Homes in villages near the
health facilities can also serve as interview sites.
62
The Rapid Assessment of the Burden of Malaria during Pregnancy

The decision about how to record what is said (and whether to use a tape recorder) should
have been made before interviewers are selected and trained (see 4.1 in the Manual). Note
that for focus group interviews, it is wise to have at least 2 people recording the session,
even if a tape recorder is used.
F. Assessment Team Members
For each focus group, a facilitator and a recorder are needed. Sometimes tape recorders
are used to record the group’s discussion. The facilitator/recorder should write up the
summary of findings.
An interviewer who can speak the woman’s mother tongue will be needed to conduct
interviews.
G. Assessment Team Training
The training can be conducted concurrently, but separately, with training for Antenatal
Clinic and Delivery Unit Surveys.
Training can include the following subjects:
• an overview of the local malaria program implementation plan
• a review of malaria (transmission cycle, symptoms, diagnosis, prophylaxis and treatment,
epidemiology of malaria, consequences of malaria during pregnancy, and local beliefs
related to malaria)
• differences between qualitative and quantitative studies
• interviewing techniques
• data recording techniques
• differences between individual and focus group interviews
For most of the training, the team conducting focus groups and individual interviews team
can train alone, although both assessment teams can meet together for the training related
to proper interviewing techniques. Practice sessions can include role-playing of interview
sessions.
To assist in building capacity in qualitative research methodologies, all team members
can be given information on qualitative assessments and methodology, as well as written
handouts on interviewing techniques.
The training period can also be used to ensure that the interview instruments are
linguistically consistent. In addition, using the team members as community experts, each
interview guide should be reviewed to ensure that questions are relevant to the context of
this district, and minor modifications in the interview guides can be made.
H. Notes Regarding the Focus Group/Interview Guide
Both the focus group facilitator and the recorder should have a copy of the guide.
The guide will serve as a script for the facilitator and will help familiarize the recorder
with the questions that will be discussed.
The interviewer will need a copy of the guide.
It is important that the guide be flexible. If the questions as written in the guide do not elicit
the intended responses, they should be adapted as necessary. See J below, Debriefing.
Note that the guide included in this package may need to be adapted depending on whether
it is used for a focus group or an individual interview.
Module 9: Conducting Interviews and Focus Groups with Recently or Currently Pregnant Women
13

I. Information Sheet
The following information sheet should be given to each potential interview participant.
If the person cannot read or has low literacy skills, the information should be read aloud to
her. All potential participants should receive a copy of the information sheet to take home.
Notes to interviewer:
• Explain everything in the local language or language of choice of the participant. Use words
that are easily understood and tailor your explanations to the level of education of the
participant.
• Do not force the person to agree to participate. You may need to explain the survey in several
different ways if the person does not seem to understand. If the person looks confused or
scared, try to clarify their concerns.
• If participant refuses to participate, please remember that this was an INVITATION to
participate. Thank the person for their time and trouble and go onto the next person.
• KEEP A RECORD of the number of participants who accept and refuse. For those that refuse,
keep a record of their reason for refusing, if possible.
Introduction
The Ministry of Health is trying to find out the best ways prevent the effects of malaria on
pregnant women and their babies. To do this, we need to know what women know about
malaria and its effects on pregnant women. We also need to know the places that women seek
health care when they are pregnant and what sorts of things they do to prevent malaria when
they are pregnant. We plan to talk to ____________ (describe about how many women and others
will be involved in this component of the assessment).
Purpose
What we learn about women’s ideas and actions about malaria and what they do when they
are pregnant will help us plan programs to decrease malaria in pregnant women.
Procedures
Being part of this individual interview/focus group is up to you. If you agree to participate/
be part of this interview/focus group, we will ask you some questions about what you think
and do about malaria, and about where you get help and information about malaria. You also
do not need to answer any questions that we ask that you do not want to. If you agree to
participate and during the interview/focus group, decide that you do not want to continue, you
can withdraw at any time. We will not be asking for any blood or urine samples.
Benefits
Although what we learn might not help you directly, it will help us know how best to prevent
malaria in pregnant women in this district.
Risks or discomforts
We will not be telling anyone about your individual answers to the questions.
Would you like to participate?
Thank you very much for your time.
Please be sure to give this information sheet to the person with whom you spoke.
4
The Rapid Assessment of the Burden of Malaria during Pregnancy

J. Debriefing
Daily debriefings are an essential element of good qualitative work. At the end of each day that
focus groups or individual interviews are conducted, it is useful for the assessment team to
hold a debriefing session lasting approximately 1 - 1.5 hours. The debriefing should be led by
the coordinator or another facilitator.
Debriefings are a method to determine if a) the questions are adequate to obtain the needed
data (qualitative methods are iterative, thus, you can change questions as needed as you
conduct the assessment), b) if people have understood the question (for example: is it a
sentence structure, content or a translation problem?), if c) data are similar across facilities or
show wide variability, which might require adding questions to understand the variability, and
if d) expressions in the local language are being translated appropriately.
The team listens to what each interviewer has learned (aggregate summary of the data they
collected that day), identifies what is common, what is different, and mutually agrees on what
local expressions mean. This is particularly important when the team is trying to understand
local beliefs, including taboos, about malaria and/or drugs during pregnancy. Debriefings
tend to be difficult as the team is tired and the process can be tedious, but having high-quality,
clearly understandable data when analysis begins rewards the time spent in daily debriefings.
During the debriefings, the coordinator or facilitator should keep notes on the outcomes of
each debriefing, explanations for trends seen in the data, and local language terms (using the
local language), as well as the agreed-upon translations.
During this time, all recorded interviews can be reviewed for completeness and accuracy of
the recording. In addition, concepts can be clarified, traditional terms used for prevention
and treatment strategies can be reviewed for linguistic accuracy and consistency, and
understanding of local pregnancy taboos can be discussed.
These types of surveys can require the addition of new questions or probes to the survey tool
during the survey period in order to make the questions wider, narrower, or more specific in
order to obtain the needed information.
K. Focus Group/Interview Analysis
Recording and analyzing information for a focus group is somewhat different from recording
and analyzing information for an individual interview.
For focus groups:
• The recorder must be able to record general themes during the interview and fill in the
details afterwards.
• Counting the number of responses is not important, but noting that most or many
participants felt the same way is.
• It is important to note if one person in the focus group has thoughts or behaviors very
different from those of the rest of the group. This person is called an “outlier.”
• Names should not be used in recording themes, although speakers can be identified by their
job description (for example, “the nurses felt…”) or other pertinent descriptors.
When there is a good quote in the local language, make sure it is written as it is said in the
local language and then reach consensus (perhaps during debriefing) on what it means in the
primary language used in the rapid assessment, if different.
Module 9: Conducting Interviews and Focus Groups with Recently or Currently Pregnant Women
5

6
The Rapid Assessment of the Burden of Malaria during Pregnancy

TOOL 9: INDIVIDUAL INTERVIEW/FOCUS GROUP GUIDE FOR
PREGNANT WOMEN AND RECENTLY PREGNANT WOMEN
This guide can be adapted to be used as a guide for conducting either focus groups or individual interviews.
Interview information
Region___________________________
Name of facility/facility area___________________________
Date: ____/____/____
Month Day Year
Time______________________________________
Interviewer_________________________________
Recorder___________________________________
INTRODUCTION: Introduce yourself and team members, describe your roles, and obtain agreement to
participate (or informed consent if required). Tell the participant(s) the goal of the focus group.
A. Demographics:
For each of the participants, record the following information:
Age
Marital status
Level of education: Highest level of school attended (primary, secondary, higher, unknown)
Total number of pregnancies, including this one
Date of last delivery
Ethnic group
Religion
B. Topical Area: Preventive strategies
1. In general, how do people protect themselves in this area against malaria when they are pregnant? (Probes: types
of traditional remedies...infusions, teas, smoke, leaves for dousing the walls; use of nets or treated curtains; going to
bed earlier; clothes)
Are any of these strategies harmful to a pregnant woman? YES/NO
IF YES: please describe how it will hurt the woman or the baby.
2. What do you personally do to protect yourself against malaria when you are pregnant? (Probes: Would you be
willing to try anything else? For example, would you be willing to take the drug Fansidar to guard against malaria?)
3. Which things do you think work best to prevent malaria when someone is pregnant? [Can rank items]
4. Do you routinely use a mosquito net? YES/NO
IF YES: is it treated with an insecticide? YES/NO
How many persons live in your house? ________ How many sleep under a net?__________
If you have only one net, who sleeps under it? (Who made that decision?)
5. What effect does malaria have on you when you are pregnant? (Probes: how does malaria affect the baby?
What happens to you?)
6. Do you take medicine at the antenatal clinic to help prevent malaria?
Tool 9: Conducting Interviews and Focus Groups with Recently or Currently Pregnant Women
1

C. Topical Area: Treatment sources
1. Where do you go for antenatal care?
2. In this area, where is the best place to go for antenatal care? Why?
3. If you got sick with malaria when you were pregnant, what would you do?
4. Have you ever taken the drug (insert the name of the recommended treatment drug) when you were pregnant?
YES/NO
IF YES: did you have any problems taking the drug? YES/NO
5. Did the malaria go away/Did you feel better? YES/NO
6. Have you ever taken the drug Fansidar when you were pregnant? YES/NO
If YES: Was it given to you to prevent malaria? YES/NO
IF YES: Did you have any problems taking the drug? YES/NO
7. Did the malaria go away/Did you feel better? YES/NO
8. What types of things have people recommended that you should do to treat malaria in pregnancy?
9. Of these, are there any that you will not or can not do? WHY? (Probes: it is unsafe for you? Is it unsafe for the baby?
Is it too expensive? Do you understand why they are suggesting it?)
D. Topical Area: Acceptance of antenatal care
1. How far do you live from the clinic/hospital (probe: Where could you receive care for the pregnancy)?
2. When you come for a visit, how do you get to the health care facility? (Probe: Is there transport available? What do
you do in emergency situations? How many hours must you travel for care?)
3. Have you been referred to a higher level health facility for care during your pregnancy? YES/NO
IF YES, did you follow-up and go to the clinic? YES/NO
4. When do most pregnant women in this area start to get antenatal care from a clinic?
IF SHE ANSWERS “IN SECOND or THIRD TRIMESTER”: Why do women wait until then
to get care?
5. When did you first get care?
IF ANSWERS “IN SECOND OR THIRD TRIMESTER”: Why did you wait until then to get care?
6. What is the cost of basic antenatal care in this community? [ ]
Is that too expensive? YES/NO (Probes: How do you get the money to pay for it?
Are there times in the year that you can not come because you don’t have enough money? Does someone help you
pay for it? IF YES: who? Do you ever barter goods for service?)
7. When you come for care, are you satisfied with the services? (Probes: Are you treated well, do you receive any
education while here? IF YES: from whom? Do you feel comfortable in asking questions?)
What could be done to improve the services of the health care center?
2
The Rapid Assessment of the Burden of Malaria during Pregnancy

E. Topical Area: Acceptability of treatments for malaria during pregnancy
1. Do you routinely go to the clinic/hospital for antenatal care? YES/NO
If YES: Do you go during pregnancy because you have an appointment or because you think you need to go?
IF YES to QE1: Do they give you any medicine to prevent malaria in pregnancy? YES/NO
IF YES: What do they give you?
Did anyone talk to you about the drug? What things did they tell you? (Probes: When and how often should you take
the drug? What side effects should you look for? When should you return to the clinic?}
Are you currently using it?
IF YES: how often?
2. Are there other treatments to use against malaria that can be used when you are pregnant? (Probes: Have you
taken chloroquine, Fansidar, or other pills? How often? Are there traditional medicines that can be used?)
3. Can you please tell me all the traditional medicines, home remedies, or treatments that you know of that can be
used to treat malaria in a pregnant woman?
OF THIS LIST: which ones work best?
4. Can you tell me about traditional taboos related to pregnancy and malaria in this area?
F. Topical Area: Sources of advice for malaria prevention/treatment during pregnancy
1. If you had a problem with the pregnancy, or got sick while pregnant, to whom would you ask advice?
2. Who provides the best information about how to manage malaria when you are pregnant?
What information have you been given about malaria from that person?
3. What kind of roles do husbands in families play in deciding whether a woman should seek antenatal care or advice
from lay midwives? (Probes: Do husbands play an active role in assisting pregnant women, or is this normally done
by women in the household? Do you normally go to your mother or mother-in-law for advice? Do husbands ever go
to clinic with you when you are pregnant?)
Do husbands also play a role in deciding what to do if their pregnant wife gets malaria?
4. If there was a new treatment for malaria during pregnancy, how would you hear about it? (Probes: How do you hear
about important news in your village? Is there one person to whom everyone goes to ask advice, such as a village
headman?)
G. Topical Area: Drug-purchasing behaviors
1. If you get sick when you are pregnant, where do you get medicine? (Probes: do you take bottles to the clinic with
you and get drugs from the dispensary? Do you buy drugs from the regular market or other types of shops? Mobile
drug vendors? If so, where? Do traditional healers in this area give out western medicines?)
FOR EACH SOURCE OF MEDICINE MENTIONED ABOVE, ASK THE FOLLOWING QUESTION:
2a. Do/does __________ offer advice about how to take antimalarial drugs during pregnancy? YES/NO
If YES: Is it helpful?
2b. Do/does __________offer advice about how to take antimalarial drugs during pregnancy? YES/NO
If YES: Is it helpful?
Tool 9: Individual Interview/ Focus Group Guide for Pregnant and Recently Pregnant Women
3

2c. Do/does __________offer advice about how to take antimalarial drugs during pregnancy? YES/NO
If YES: Is it helpful?
2d. Do/does __________offer advice about how to take antimalarial drugs during pregnancy? YES/NO
If YES: Is it helpful?
3. Once you feel better, do you ever save the remaining pills to take the next time you are have malaria? YES/NO
4. Where is the BEST place to get drugs to treat malaria when you are pregnant? WHY?
5. What drugs would you take for malaria when you are pregnant?
6. Who do you trust most in giving advice about drugs when you are pregnant?
H. Topical Area: Role of traditional birth attendants and health care workers in
influencing behaviors
1. How do traditional birth attendants and health care workers give support and advice to pregnant women?
2. Do traditional birth attendants and health care workers in this community recommend that pregnant women
attend antenatal clinics or do they leave that decision to individual women?
3. Is it better to see a traditional birth attendant or go to a health center for antenatal care? Why?
THANK RESPONDENT FOR HER TIME, AND ASK HER IF THERE ARE ANY QUESTIONS.
PLEASE NOTE ANY ADDITIONAL OBSERVATIONS IN THE SPACE BELOW.
4
The Rapid Assessment of the Burden of Malaria during Pregnancy

Module 10: Conducting Interviews with
Key Informants
Individual interviews with key informants are designed to determine
• How pregnant women understand the problem of malaria in pregnancy
• What types of preventive and treatment measures are currently being recommended and used
• Factors that motivate or inhibit women from using antenatal care
• Best methods for promoting health education messages to pregnant women
This module contains sample materials relevant to conducting an individual interview.
These materials can and should be adapted to meet the needs of the local situation.
A. Focus Group/Interview Timetable
B. Number of Individual Interviews
C. Eligibility Criteria
D. Venues and Equipment
E. Assessment Team Members
F. Assessment Team Training
Contents
G. Notes Regarding the Focus Group/Interview Guide
H. Information Sheet
I. Debriefing
J. Focus Group/Interview Analysis
See Resource 2, which includes a Sample Interviewer Training Manual and a
Resource List.
Module 10: Conducting Interviews with Key Informants
1

A. Interview Timetable
To prepare for individual interviews, it is important to alert health facilities and community
leaders well in advance (ideally, 2 weeks) of the qualitative team’s visits to the facilities so
that potential participants know that this activity will be occurring and that they will be asked
to participate. In addition, advance notice is needed so that arrangements can be made for
interview venues. It is helpful to follow up a week before the assigned meeting times.
After planning for the interviews, selecting sites, and training interviewers, the interviews can
begin.
B. Number of Individual Interviews
Individual interviews with two to four key informants per site. Individual interviews are
strongly preferred to focus groups.
C. Eligibility Criteria
Key informants can include esteemed members of the community (“opinion leaders”), elders,
someone who is trusted for advice and others. Key informants can be identified by asking
other assessment participants and health facility team members to identify community
members from whom women sought advice concerning pregnancy. Names of key informants
usually emerge consistently as people start to identify a few people known to have knowledge/
expertise in this area. A leader of a local women’s group, for example, might be named as a key
informant.
D. Venues and Equipment
Individual interviews can be conducted at health facilities or homes in villages near the health
facilities.
The decision about how to record what is said (and whether to use a tape recorder) should
have been made before interviewers are selected and trained (see 4.1 in the Manual).
E. Assessment Team Members
An interviewer who can speak the woman’s mother tongue will be needed to conduct
interviews.
F. Assessment Team Training
The training can be conducted concurrently, but separately, with training for Antenatal Clinic
and Delivery Unit Surveys.
Training can include the following subjects:
• an overview of the local malaria program implementation plan
• a review of malaria (transmission cycle, symptoms, diagnosis, prophylaxis and treatment,
epidemiology of malaria, consequences of malaria during pregnancy, and local beliefs
related to malaria)
• differences between qualitative and quantitative studies
• interviewing techniques
• data recording techniques
• differences between individual and focus group interviews
42
The Rapid Assessment of the Burden of Malaria during Pregnancy

For most of the training, the team conducting focus groups and individual interviews team
can train alone, although both assessment teams can meet together for the training related
to proper interviewing techniques. Practice sessions can include role-playing of interview
sessions.
To assist in building capacity in qualitative research methodologies, all team members can be
given information on qualitative assessments and methodology, as well as written handouts on
interviewing techniques.
The training period can also be used to ensure that the interview instruments are linguistically
consistent. In addition, using the team members as community experts, each interview guide
should be reviewed to ensure that questions are relevant to the context of this district, and
minor modifications in the interview guides can be made.
G. Notes Regarding the Interview Guide
The interviewer will need a copy of the guide.
It is important that the guide be flexible. If the questions as written in the guide do not elicit
the intended responses, they should be adapted as necessary. See I below, Debriefing.
H. Information Sheet
The following information sheet should be given to each potential interview participant. If the
person cannot read or has low literacy skills, the information should be read aloud to her. All
potential participants should receive a copy of the information sheet to take home.
Notes to interviewer:
• Explain everything in the local language or language of choice of the participant. Use words
that are easily understood and tailor your explanations to the level of education of the
participant.
• Do not force the person to agree to participate. You may need to explain the survey in several
different ways if the person does not seem to understand. If the person looks confused or
scared, try to clarify their concerns.
• If participant refuses to participate, please remember that this was an INVITATION to
participate. Thank the person for their time and trouble and go onto the next person.
• KEEP A RECORD of the number of participants who accept and refuse. For those that refuse,
keep a record of their reason for refusing, if possible.
Module 10: Conducting Interviews with Key Informants
3

Introduction
The Ministry of Health is trying to find out the best ways prevent the effects of malaria on
pregnant women and their babies. To do this, we need to know what women know about
malaria and its effects on pregnant women. We also need to know the places that women seek
health care when they are pregnant and what sorts of things they do to prevent malaria when
they are pregnant. We plan to talk to ____________ (describe about how many women and others
will be involved in this component of the assessment).
Purpose
What we learn about women’s ideas and actions about malaria and what they do when they
are pregnant will help us plan programs to decrease malaria in pregnant women.
Procedures
Being part of this individual interview/focus group is up to you. If you agree to participate/
be part of this interview/focus group, we will ask you some questions about what you think
and do about malaria, and about where you get help and information about malaria. You also
do not need to answer any questions that we ask that you do not want to. If you agree to
participate and during the interview/focus group, decide that you do not want to continue, you
can withdraw at any time. We will not be asking for any blood or urine samples.
Benefits
Although what we learn might not help you directly, it will help us know how best to prevent
malaria in pregnant women in this district.
Risks or discomforts
We will not be telling anyone about your individual answers to the questions.
Would you like to participate?
Thank you very much for your time.
Please be sure to give this information sheet to the person with whom you spoke.
4
The Rapid Assessment of the Burden of Malaria during Pregnancy

I. Debriefing
Daily debriefings are an essential element of good qualitative work. At the end of each day that
focus groups or individual interviews are conducted, it is useful for the assessment team to
hold a debriefing session lasting approximately 1 - 1.5 hours. The debriefing should be led by
the coordinator or another facilitator.
Debriefings are a method to determine if a) the questions are adequate to obtain the needed
data (qualitative methods are iterative, thus, you can change questions as needed as you
conduct the assessment), b) if people have understood the question (for example: is it a
sentence structure, content or a translation problem?), if c) data are similar across facilities or
show wide variability, which might require adding questions to understand the variability, and
if d) expressions in the local language are being translated appropriately.
The team listens to what each interviewer has learned (aggregate summary of the data they
collected that day), identifies what is common, what is different, and mutually agrees on what
local expressions mean. This is particularly important when the team is trying to understand
local beliefs, including taboos, about malaria and/or drugs during pregnancy. Debriefings
tend to be difficult as the team is tired and the process can be tedious, but having high-quality,
clearly understandable data when analysis begins rewards the time spent in daily debriefings.
During the debriefings, the coordinator or facilitator should keep notes on the outcomes of
each debriefing, explanations for trends seen in the data, and local language terms (using the
local language), as well as the agreed-upon translations.
During this time, all recorded interviews can be reviewed for completeness and accuracy of
the recording. In addition, concepts can be clarified, traditional terms used for prevention
and treatment strategies can be reviewed for linguistic accuracy and consistency, and
understanding of local pregnancy taboos can be discussed.
These types of surveys can require the addition of new questions or probes to the survey tool
during the survey period in order to make the questions wider, narrower, or more specific in
order to obtain the needed information.
J. Interview Analysis
Recording and analyzing information for a focus group is somewhat different from recording
and analyzing information for an individual interview.
When there is a good quote in the local language, make sure it is written as it is said in the
local language and then reach consensus (perhaps during debriefing) on what it means in the
primary language used in the rapid assessment, if different.
Module 10: Conducting Interviews with Key Informants
5

6
The Rapid Assessment of the Burden of Malaria during Pregnancy

TOOL 10: INDIVIDUAL INTERVIEW GUIDE
FOR KEY INFORMANTS
Region___________________________
Name of facility/facility area___________________________
Date: ____/____/____
Month Day Year
Time______________________________________
Interviewer_________________________________
Recorder___________________________________
INTRODUCTION: Introduce yourself and team members, describe your roles, and obtain agreement to
participate (or informed consent if required). Tell the participant(s) the goal of the information, as applicable
A. Demographics
Age:
Level of education: Highest level of school attended (primary, secondary, higher, unknown)
Ethnic group:
Profession or position in the community:
B. Topical area: Prevailing health problems and malaria in pregnancy
1. What are the 3 most common health problems among pregnant women in this area?
List them in order of how common they are.
2. Which of these 3 problems is the most severe?
3. (Ask if malaria is not mentioned in Question 1) Is malaria a serious or common health problem among pregnant
women in this community?
C. Topical area: Signs and symptoms of fever and malaria during pregnancy
1. What are the 3 most common illnesses in pregnancy that cause fever in this area?
(Be sure to note local terms.)
2. What are the common signs and symptoms of malaria?
3. Are these signs and symptoms different for pregnant women? If so, how?
Tool 10: Conducting Interviews with Key Informants
1

D. Topical area: Causes and consequences of malaria in pregnancy
1. What are the causes of malaria?
2. Are the causes different for pregnant women than for other people?
3. Are pregnant women more susceptible to malaria? If so, why? At what months of gestation?
4. Do pregnant women with malaria get more severely ill than other people?
5. What effect does malaria have on pregnant women? On the fetus? On the neonate?
E. Topical area: Sources of advice for malaria prevention/treatment during pregnancy
1. Do husbands play a role in deciding what to do if their pregnant wife gets malaria?
If YES: Please describe their role.
2. If there were a new treatment for malaria during pregnancy, what would be the best way to get that information to
pregnant women?
(Probes: How do you hear about important news in your village? Is there one person to whom everyone goes to ask
advice, such as a village headman?)
3. In the community, who provides the best information about how to treat malaria when someone is pregnant?
F. Topical area: Preventive strategies
1. In general, how do women protect themselves in this area against malaria when they are pregnant? (Probe
for traditional methods: infusions, teas, smoke, leaves for dousing the walls, going to bed earlier; and modern
methods: insecticides, use of nets or treated curtains; clothes)
Are any of these strategies harmful to a pregnant woman?
IF YES: please describe how it will hurt the woman or the baby.
2. Which things do you think work best to prevent malaria when someone is pregnant?
(Can rank items from most effective at top to least effective at bottom.)
3. Do most pregnant women routinely use a mosquito net?
4. Who in the family makes the decision about who sleeps under the net?
G. Topical area: Treatment strategies
1. What are available sources of care for fever or malaria during pregnancy in this area?
2. What types of things do people (anybody) recommend that women should do to treat malaria in pregnancy?
Of these, what is the most effective strategy, in your opinion?
3. Can you please tell me all the traditional medicines or treatments that can be used to treat malaria in a pregnant
woman?
(Be sure to note local names.)
OF THIS LIST: Which ones work best?
Which ones are used most often in this community?
4. Can you tell me about traditional taboos for pregnant women? (examples: foods, medicines, or plants that should
be avoided) Can you list the taboos?
Are there any specific taboos related to malaria?
Do most pregnant women in this community listen to these taboos?
2
The Rapid Assessment of the Burden of Malaria during Pregnancy

H. Topical Area: Acceptance of antenatal care from health facilities and traditional
birth attendants
1. Are there traditional birth attendants in this community? Are there other community-based workers that give care
to pregnant women?
IF YES: what are they called and how do their roles differ from traditional birth attendants? (Note to interviewer:
Add the name for the site-specific community-based worker in the questions where community-based worker is
mentioned.)
2. If yes, how do the traditional birth attendants or other community-based workers give support and advice to
pregnant women?
(Probe: do they routinely make visits to a woman’s house?)
3. Do traditional birth attendants and other community-based workers in this community advise that pregnant
women attend antenatal clinics? (Note any differences between traditional birth attendants and community-based
workers.)
4. Where do most women in this community go for antenatal care?
5. At how many months’ gestation do most pregnant women in this area start to get
antenatal care:
from a traditional birth attendant or other community-based worker?
from a health facility?
why at this gestational age?
6. What are the reasons why women go to antenatal care?
7. What is the cost of basic antenatal care in the health facility?
Is that cost acceptable?
8. What could be done to improve the services of the traditional birth attendants? Of the other community-based
workers?
9. What could be done to improve the services of the health facility?
10. What roles do husbands in families play in deciding whether a woman should seek antenatal care or advice?
(Probes: do husbands play an active role in assisting pregnant women? Do husbands
ever go to clinic with pregnant women?)
11. How could services for pregnant women regarding the prevention and treatment of malaria be improved?
12. What is the best way to encourage women to receive antenatal care?
I. Topical Area: Drug purchasing behaviors
1. Where do pregnant women obtain antimalarials? Which is the best place to buy
these medicines?
BE SURE TO THANK THE PERSON FOR HIS OR HER TIME, AND ASK IF HE OR SHE HAS ANY QUESTIONS FOR YOU.
Tool 10: Individual Interview Guide for Key Informants
3

24
The Rapid Assessment of the Burden of Malaria during Pregnancy

Resource 1: Articles
Relevant Articles : Malaria in Pregnancy
The Malaria in Pregnancy Consortium maintains a Malaria in Pregnancy (MiP) Library, a bibliographic database of
published and unpublished literature relating to malaria in pregnancy, including a trial registry of planned and ongoing
trials, for use by scientists, policy makers, funding agencies, industry and other interested parties, at
http://www.mip-consortium.org/resource_centre/index.htm. Many of the articles listed below are in this database.
Ashwood-Smith, H., Y. Coombes, et al. (2002). "Availability and use of sulphadoxine-pyrimethamine (SP) in pregnancy
in Blantyre District: A Safe Motherhood and Blantyre Integrated Malaria Initiative (BIMI) Joint Survey." Malawi Medical
Journal 14(1): 8-11.
Ayisi, J., A. van Eijk, et al. (2004). "Maternal malaria and perinatal HIV transmission, western Kenya." Emerging
Infectious Diseases 10(4): 643-652.
Brabin, B. (1991). "An assessment of low birthweight risk in primiparae as an indicator of malaria control in
pregnancy." International Journal of Epidemiology 20(1): 276-83.
Brabin, B. J., S. O. Agbaje, et al. (1999). "A birthweight nomogram for Africa, as a malaria-control indicator." Annals of
Tropical Medicine & Parasitology 93 Suppl 1: S43-57.
Brabin, B. J., M. Hakimi, et al. (2001). "An analysis of anemia and pregnancy-related maternal mortality." Journal of
Nutrition 131(2S-2): 604S-614S; discussion 614S-615S.
Briggs, G. G., R. K. Freeman, et al. (1998). Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk.
Baltimore, Williams & Wilkins.
Browne, E. N., G. H. Maude, et al. (2001). "The impact of insecticide-treated bednets on malaria and anaemia in
pregnancy in Kassena-Nankana district, Ghana: a randomized controlled trial." Tropical Medicine & International
Health 6(9): 667-76.
Crawley, J., J. Hill, et al. (2007). "From evidence to action? Challenges to policy change and programme delivery for
malaria in pregnancy." Lancet Infectious Diseases 7(2): 145-55.
D'Alessandro, U. (1999). "A rational approach to malaria control in pregnancy in sub-Saharan Africa: the need for a
link between scientific research and public-health interventions." Annals of Tropical Medicine & Parasitology 93
Suppl 1: S75-7.
D'Alessandro, U., P. Langerock, et al. (1996). "The impact of a national impregnated bed net programme on the
outcome of pregnancy in primigravidae in The Gambia." Transactions of the Royal Society of Tropical Medicine &
Hygiene 90(5): 487-92.
Desai, M., F. O. ter Kuile, et al. (2007). "Epidemiology and burden of malaria in pregnancy." Lancet Infectious Diseases
7(2): 93-104.
Dolan, G., F. O. ter Kuile, et al. (1993). "Bed nets for the prevention of malaria and anaemia in pregnancy." Transactions
of the Royal Society of Tropical Medicine & Hygiene 87(6): 620-6.
Goodman, C. A., P. G. Coleman, et al. (2001). "The cost-effectiveness of antenatal malaria prevention in sub-Saharan
Africa." American Journal of Tropical Medicine & Hygiene 64(1-2 Suppl): 45-56.
Greenwood, B., P. Alonso, et al. (2007). "Malaria in pregnancy: priorities for research." Lancet Infectious Diseases
7(2): 169-74.
Resources
1

Guyatt, H. L., M. H. Gotink, et al. (2002). "Free bednets to pregnant women through antenatal
clinics in Kenya: a cheap, simple and equitable approach to delivery." Tropical Medicine and
International Health 7(5): 409-20.
Guyatt, H. L. and R. W. Snow (2001). "The epidemiology and burden of Plasmodium falciparumrelated
anemia among pregnant women in sub-Saharan Africa." American Journal of Tropical
Medicine & Hygiene 64(1-2 Suppl): 36-44.
Hawley WA, Phillips-Howard PA, ter Kuile FO, Terlouw DJ, Vulule JM, Ombok M et al. (2003).
"Community-wide effects of permethrin-treated bed nets on child mortality and malaria
morbidity in western Kenya." American Journal of Tropical Medicine & Hygiene; 68 (4
Suppl);121-7.
Hawley WA, ter Kuile FO, Steketee RW, Nahlen BL, Terlouw DJ, Gimnig JE et al. (2003).
Implications of the Western Kenya permethrin-treated bed net study for policy, program
implementation, and future research. American Journal of Tropical Medicine & Hygiene;
68 (4 Suppl): 168-73.
Inion, I., F. Mwanyumba, et al. (2003). "Placental malaria and perinatal transmission of human
immunodeficiency virus type 1." Journal of Infectious Diseases 188(11): 1675-8.
Kayentao K, Kodio M, Newman RD, Maiga H, Doumtabe D, Ongoiba A, Coulibaly D, Keita AS,
Maiga B, Mungai M, Parise ME, Doumbo O. (2005). "Comparison of intermittent preventive
treatment with chemoprophylaxis for the prevention of malaria during pregnancy in Mali."
Journal of Infectious Diseases 1;191(1):109-16.
Ladner, J., V. Leroy, et al. (2002). "HIV infection, malaria, and pregnancy: a prospective cohort
study in Kigali, Rwanda." American Journal of Tropical Medicine & Hygiene 66(1): 56-60.
Le Hesran, J. Y., M. Cot, et al. (1997). "Maternal placental infection with Plasmodium falciparum
and malaria morbidity during the first 2 years of life." American Journal of Epidemiology
146(10): 826-31.
Leke, R. F., R. R. Djokam, et al. (1999). "Detection of the Plasmodium falciparum antigen
histidine-rich protein 2 in blood of pregnant women: implications for diagnosing placental
malaria." Journal of Clinical Microbiology 37(9): 2992-6.
Luxemburger, C., R. McGready, et al. (2001). "Effects of malaria during pregnancy on infant
mortality in an area of low malaria transmission." American Journal of Epidemiology 154(5):
459-65.
Luxemburger, C., F. Ricci, et al. (1997). "The epidemiology of severe malaria in an area of low
transmission in Thailand." Transactions of the Royal Society of Tropical Medicine & Hygiene
91(3): 256-62.
Marchesini, P. and K. Crawley (2004). Reducing the burden of malaria in pregnancy. Geneva,
Roll Back Malaria, World Health Organization.
McCormick, M. C. (1985). "The contribution of low birth weight to infant mortality and
childhood morbidity." New England Journal of Medicine 312(2): 82-90.
McGready, R. (2002). The use of artemisinin derivatives in pregnancy: the experience on the
Thai-Burma border. PREMA-EU. 1: 6-11.
McGready, R., K. A. Hamilton, et al. (2001). "Safety of the insect repellent N,N-diethyl-Mtoluamide
(DEET) in pregnancy." American Journal of Tropical Medicine & Hygiene
65(4): 285-9.
2
The Rapid Assessment of the Burden of Malaria during Pregnancy

McGready, R., J. A. Simpson, et al. (2001). "A double-blind randomized therapeutic trial of insect repellents for the
prevention of malaria in pregnancy." Transactions of the Royal Society of Tropical Medicine & Hygiene 95(2): 137-8.
Menendez, C. (2003). Anaemia in pregnancy in developing areas: its causes and consequencies. Malaria and Anemia in
Pregnancy, Amsterdam, PREMA-EU.
Menendez, C. (1999). "Priority areas for current research on malaria during pregnancy." Annals of Tropical Medicine
& Parasitology 93 Suppl 1: S71-4.
Menendez, C., U. D'Alessandro, et al. (2007). "Reducing the burden of malaria in pregnancy by preventive strategies."
Lancet Infectious Diseases 7(2): 126-35.
Menendez, C., A. F. Fleming, et al. (2000). "Malaria-related anaemia." Parasitology Today 16(11): 469-76.
Menendez, C., J. Ordi, et al. (2000). "The impact of placental malaria on gestational age and birth weight." Journal of
Infectious Diseases 181(5): 1740-5.
Msyamboza, K., E. Senga, et al. (2007). "Estimation of effectiveness of interventions for malaria control in pregnancy
using the screening method." International Journal of Epidemiology.
Mutabingwa, T. K. (2002). Antimalarial Intermittent Treatment during Pregnancy in Africa. PREMA-EU Newsletter.
Liverpool. 1: 4-6.
Mwapasa, V., S. J. Rogerson, et al. (2004). "The effect of Plasmodium falciparum malaria on peripheral and placental
HIV-1 RNA concentrations in pregnant Malawian women." Aids 18(7): 1051-1059.
Nahlen, B. L. (2000). "Rolling back malaria in pregnancy. [letter; comment]." New England Journal of Medicine
343(9): 651-2.
Newman, R. D., A. Hailemariam, et al. (2003). "Burden of Malaria during Pregnancy in Areas of Stable and Unstable
Transmission in Ethiopia during a Nonepidemic Year." Journal of Infectious Diseases 187(11): 1765-72.
Newman, R. D., M. E. Parise, et al. (2003). "Safety, efficacy and determinants of effectiveness of antimalarial drugs
during pregnancy: implications for prevention programmes in Plasmodium falciparum-endemic sub-Saharan Africa."
Tropical Medicine and International Health 8(6): 488-506.
Nosten, F., R. McGready, et al. (2007). "Case management of malaria in pregnancy." Lancet Infectious Diseases
7(2): 118-25.
Nosten, F., R. McGready, et al. (1999). "Effects of Plasmodium vivax malaria in pregnancy." Lancet 354(9178): 546-9.
Nosten, F., F. ter Kuile, et al. (1991). "Malaria during pregnancy in an area of unstable endemicity." Transactions of the
Royal Society of Tropical Medicine & Hygiene 85(4): 424-9.
Ouma, P., M. E. Parise, et al. (2006). "A Randomized Controlled Trial of Folate Supplementation When Treating Malaria
in Pregnancy with Sulfadoxine-Pyrimethamine." PLoS Clin Trials 1(6): e28.
Parise, M. E., J. G. Ayisi, et al. (1998). "Efficacy of sulfadoxine-pyrimethamine for prevention of placental malaria in an
area of Kenya with a high prevalence of malaria and human immunodeficiency virus infection." American Journal of
Tropical Medicine & Hygiene 59(5): 813-22.
Parise, M. E., L. S. Lewis, et al. (2003). "A rapid assessment approach for public health decision-making related to the
prevention of malaria during pregnancy." Bulletin of the World Health Organization 81(5): 316-23.
Phillips-Howard, P. A. (1999). "Epidemiological and control issues related to malaria in pregnancy." Annals of Tropical
Medicine & Parasitology 93 Suppl 1: S11-7.
Rogerson, S. J., L. Hviid, et al. (2007). "Malaria in pregnancy: pathogenesis and immunity." Lancet Infectious Diseases
7(2): 105-17.
Resources
3

Rogerson, S. J., E. Chaluluka, et al. (2000). "Intermittent sulfadoxine-pyrimethamine in
pregnancy: effectiveness against malaria morbidity in Blantyre, Malawi, in 1997-99."
Transactions of the Royal Society of Tropical Medicine & Hygiene 94(5): 549-53.
Saute, F., C. Menendez, et al. (2002). "Malaria in pregnancy in rural Mozambique: the role of
parity, submicroscopic and multiple Plasmodium falciparum infections." Tropical Medicine and
International Health 7(1): 19-28.
Schultz, L. J., R. W. Steketee, et al. (1994). "The efficacy of antimalarial regimens containing
sulfadoxine-pyrimethamine and/or chloroquine in preventing peripheral and placental
Plasmodium falciparum infection among pregnant women in Malawi." American Journal of
Tropical Medicine & Hygiene 51(5): 515-22.
Schultz, L. J., R. W. Steketee, et al. (1995). Malaria prevention during pregnancy: an antenatal
intervention strategy whose time has come. The female client and the health-care provider. J. H.
Roberts and C. Vlassoff. Ottawa, International Development Research Centre: 113-128.
Schultz LJ, Steketee RW, Chitsulo L, Macheso A, Kazembe P, Wirima JJ. (1996). "Evaluation of
maternal practices, efficacy, and cost-effectiveness of alternative antimalaria regimens for use
in pregnancy:chloroquine and sulfadoxine-pyrimethamine." American Journal of Tropical
Medicine and Hygiene 55(1 Suppl): 87-94.
Shulman, C. E. (1999). "Malaria in pregnancy: its relevance to safe-motherhood programmes."
Annals of Tropical Medicine & Parasitology 93 Suppl 1: S59-66.
Shulman, C. E. and E. K. Dorman (2003). "Importance and prevention of malaria in pregnancy."
Transactions of the Royal Society of Tropical Medicine & Hygiene 97(1): 30-5.
Shulman, C. E., E. K. Dorman, et al. (2002). "Malaria as a cause of severe anaemia in pregnancy."
Lancet 360(9331): 494.
Shulman, C. E., E. K. Dorman, et al. (1999). "Intermittent sulphadoxine-pyrimethamine to
prevent severe anaemia secondary to malaria in pregnancy: a randomised placebo-controlled
trial." Lancet 353(9153): 632-6.
Shulman, C. E., E. K. Dorman, et al. (1998). "A community randomized controlled trial of
insecticide-treated bednets for the prevention of malaria and anaemia among primigravid
women on the Kenyan coast." Tropical Medicine & International Health 3(3): 197-204.
Singh, N., R. K. Mehra, et al. (2001). "Malaria during pregnancy and infancy, in an area of intense
malaria transmission in central India." Annals of Tropical Medicine & Parasitology 95(1): 19-29.
Singh, N., A. Saxena, et al. (1998). "Studies on malaria during pregnancy in a tribal area of
central India (Madhya Pradesh)." Southeast Asian Journal of Tropical Medicine & Public Health
29(1): 10-7.
Singh, N., M. M. Shukla, et al. (1999). "Epidemiology of malaria in pregnancy in central India."
Bulletin of the World Health Organization 77(7): 567-72.
Sirima, S. B., R. Sawadogo, et al. (2003). "Failure of a Chloroquine Chemoprophylaxis Program
to Adequately Prevent Malaria during Pregnancy in Koupela District, Burkina Faso." Clinical
Infectious Diseases 36(11): 1374-82.
Steketee RW, Nahlen BL, Parise ME, Menendez C (2001). The burden of malaria during
pregnancy in malaria-endemic areas. American Journal of Tropical Medicine & Hygiene; 64 (1-2
Suppl): 28-35.
Steketee, R. W., B. L. Nahlen, et al. (2001). "The burden of malaria in pregnancy in malariaendemic
areas." American Journal of Tropical Medicine & Hygiene 64(1-2 Suppl): 28-35.
4
The Rapid Assessment of the Burden of Malaria during Pregnancy

Steketee RW, Wirima JJ, Campbell CC (1996). Developing effective strategies for malaria prevention programs for
pregnant African women. American Journal of Tropical Medicine & Hygiene; 55(1 Suppl): 95-100.
Steketee RW, Wirima JJ, Slutsker L, Heymann DL, Breman JG (1996). The problem of malaria and malaria control in
pregnancy in sub-Saharan Africa. American Journal of Tropical Medicine & Hygiene; 55 (1 Suppl): 2-7.
Steketee, R. W., J. J. Wirima, et al. (1996). "Impairment of a pregnant woman's acquired ability to limit Plasmodium
falciparum by infection with human immunodeficiency virus type-1." American Journal of Tropical Medicine & Hygiene
55(1 Suppl): 42-9.
ter Kuile, F. O., A. M. van Eijk, et al. (2007). "Effect of sulfadoxine-pyrimethamine resistance on the efficacy of
intermittent preventive therapy for malaria control during pregnancy: a systematic review." Jama 297(23): 2603-16.
ter Kuile, F. O., D. J. Terlouw, et al. (2003). "Reduction of malaria during pregnancy by permethrin-treated bed nets in an
area of intense perennial malaria transmission in western Kenya." American Journal of Tropical Medicine & Hygiene
68(4 Suppl): 50-60.
van Eijk, A. (2004). "Effectiveness of intermittent preventive treatment with sulfadoxine-pyrimethamine for control
of malaria in pregnancy in western Kenya: a hospital-based study." Tropical Medicine & International Health 9(3):
351-360.
van Eijk, A. M., J. G. Ayisi, et al. (2003). "HIV increases the risk of malaria in women of all gravidities in Kisumu, Kenya."
Aids 17(4): 595-603.
Verhoeff, F. H., B. J. Brabin, et al. (1998). "An evaluation of the effects of intermittent sulfadoxine-pyrimethamine
treatment in pregnancy on parasite clearance and risk of low birthweight in rural Malawi." Annals of Tropical Medicine
& Parasitology 92(2): 141-50.
Verhoeff, F. H., P. Milligan, et al. (1997). "Gestational age assessment by nurses in a developing country using the
Ballard method, external criteria only." Annals of Tropical Paediatrics 17(4): 333-42.
Ward, S. A., E. J. Sevene, et al. (2007). "Antimalarial drugs and pregnancy: safety, pharmacokinetics, and
pharmacovigilance." Lancet Infectious Diseases 7(2): 136-44.
Williams HA and Jones COH (2004). Review. A critical review of behavioral issues related to malaria control in sub-
Saharan Africa: what contributions have social scientists made? Social Sciences and Medicine; 59: 501-523.
Wolfe, E. B., M. E. Parise, et al. (2001). "Cost-effectiveness of sulfadoxine-pyrimethamine for the prevention of malariaassociated
low birth weight." American Journal of Tropical Medicine & Hygiene 64(3-4): 178-86.
World Health Organization (2003). Assessment of the safety of artemisinin compounds in pregnancy: Report of two
informal consultations convened by WHO in 2002. Geneva, World Health Organization.
World Health Organization (2000). "Severe falciparum malaria. World Health Organization, Communicable Diseases
Cluster." Transactions of the Royal Society of Tropical Medicine & Hygiene 94 Suppl 1: S1-90.
World Health Organization and UNICEF (year). Antenatal Care in Developing Countries: Promises, achievements and
missed opportunities. 1-32. (http://www.childinfo.org/eddb/antenatal/antenatal_full.pdf
Resources
5

6
The Rapid Assessment of the Burden of Malaria during Pregnancy

Resource 2: Resources for the
Qualitative Assessment
Sample Interviewer Training Manual
List of Resources
Sample Interviewer Training Manual
II. Overview
A. Introduction
B. Health impacts caused by malaria
II. Qualitative research components
A. Differences between qualitative and quantitative research
III. Qualitative research methods
I. OVERVIEW:
A. Introduction:
We are here to help learn about [insert statement to describe purpose of study]. For example
for a study about pregnant women and malaria: We are here to find out how women in the
XXX District [insert name of specific district] deal with malaria when they are pregnant. We
are trying to find out what women know about malaria and the risks that are associated with
the illness when you are pregnant, what care women get when they are pregnant, things that
women in this area do to try to prevent malaria, and what they think about the various places
that they can go in order to obtain care during their pregnancy. We want to understand also
how women get support during their pregnancy and where they get advice regarding what to
do if they get sick while being pregnant.
In addition to talking to women who are currently pregnant or who were recently pregnant
(defined as having delivered in the past two years), we will be talking to some health care
workers, and lay midwives and traditional birth attendants (TBAs).
This project is part of a bigger study that will look at (insert statement). It will first try to
determine the extent of the problem in this area, looking at levels of parasitemia (how many
parasites that cause malaria are in a person’s blood), levels of anemia, degree of placental
parasitemia, and how many babies with low-birth weight are being born (a complication of
having malaria during pregnancy). All the information gathered in the different parts of the
study will help us (insert statement). [insert names of assessment team members] Dr. XX will
be leading the one part of the study and Dr. XX will be doing the qualitative part—the aspect of
the study for which you were hired.
Resources
7

B. Health Impacts Caused by Malaria:
Malaria: Why is malaria important? Malaria is a very serious illness, particularly in sub-
Saharan Africa. Each year between 300 and 500 million people in the world develop malaria
and 1.5 to 2.7 million people die each year from malaria. Young children (those under 5
years) who have not yet developed immunity (limited protection) against the illness are most
vulnerable to the effects of malaria. Pregnant women, especially during their first pregnancy,
are also at risk.
Malaria is caused by a parasite carried by a female Anopheles mosquito. She bites a person
to take a blood meal and injects parasites. They take several weeks to develop and eventually
attack the red blood cells in your body. The red blood cells carry oxygen, which is essential for
your body to work. Destroying the red blood cells causes anemia, which is why people with
malaria often feel very tired. In order for the infection to spread, another female Anopheles
mosquito must bite a person who is infected with malaria and the cycle starts again. If the
parasites go to the brain, it is called “cerebral malaria,” and it is a grave sign. This is often when
people develop convulsions (seizures, or “fitting”) and need to be treated with quinine.
There are four types of malaria: Plasmodium vivax, Plasmodium ovale, Plasmodium malariae,
and Plasmodium falciparum. Of the four types, P. falciparum is the only one that can
potentially be fatal. P. ovale and P. vivax are the two relapsing forms, which means that the
illness can re-appear months to years later.
Usually, malaria in Africa is diagnosed by clinical symptoms. [Note: this may not be pertinent
depending in which area the study will occur.] When someone complains of fever, they are
treated for malaria. However, the only way to really know if someone has the parasite that
causes malaria is to examine their blood under the microscope. We take a small sample of
blood from a finger stick and put it on a glass slide. The laboratory technologists can then
“read” the smear and tell us if the person has malaria or not. However, as many places in
Africa do not have laboratory facilities, standard treatment is to assume someone has malaria
if they have fever or history of fever. Since malaria can kill quickly, the practice is to over-treat
for malaria so that we don’t miss someone who may die if not treated.
We can determine the type of malaria by looking at a blood smear under the microscope. We
can also determine how severe the infection is by the number of parasites that we can count.
Probably all of you in this room have experienced malaria as an illness. Symptoms include
fever, chills, headache, vomiting, diarrhea and feeling bad. Problems related to malaria often
are related to late diagnosis or inadequate or inappropriate treatment. Part of our job now is
to try to figure out the best ways to insure that pregnant women in XX [insert name of district]
District use preventive measures to guard against malaria. In addition, we need to help them
learn how to get prompt and effective treatment when they develop malaria.
Malaria and Pregnancy: Malaria causes serious complications in pregnancy that can affect not
only the pregnant woman, but can also hurt the baby. Chloroquine (CQ) used to be the main
drug that was used to treat malaria, but CQ is no longer working well in most parts of sub-
Saharan Africa. Malaria can cause severe anemia, which means that you have fewer red blood
cells to carry oxygen, which is needed for our body to work each day. Malaria can cause early
labor, which means
that the baby does not have sufficient time to develop fully, or it can cause higher rates of
miscarriage (losing the pregnancy). Malaria infections during pregnancy can also cause lowbirth
weight babies and babies that are born “stillborn” (dead at birth).
Antenatal care is an accepted means of finding complications in pregnancy and can help us
teach women what to expect from malaria in pregnancy, and how to prevent it. We now know
that if pregnant women use intermittent preventive treatment (IPTp) with an effective drug,
Fansidar (called SP), during their second and third trimesters, we can reduce
8
The Rapid Assessment of the Burden of Malaria during Pregnancy

the problems caused by malaria. Part of this research will look at how we can best get women to accept using IPTp
during pregnancy.
Local Beliefs about Malaria: Many people think that malaria is caused by different things. For example, some people
believe that you get malaria from sleeping beside someone who is infected. Others believe that eating unripe sugar
cane or getting soaked from the rains causes the illness, or that malaria occurs after a long trip. Some people believe
that malaria comes with “fitting.” Others believe that malaria is caused by witchcraft. Have any of you heard of other
causes of malaria?
Why do people believe these things? Do any of these explanations make sense when we know that malaria is caused by
parasites carried by a female mosquito? How do people make up these explanations?
If you think about what people are telling you, you will start to see and understand that people’s beliefs often merge
with scientific understandings. People base their beliefs on years of experience, watching the environment and how
things happen. People look for sameness, for patterns in explanations, and their thinking reflects what has happened to
them personally, as well as what they see in their communities. Most behavior has purpose and the purpose is derived
from a meaning system. People actively make choices in their environments based on these meanings.
Let’s look at some of these explanations:
“Eating unripe fruit”—Mosquitoes are most plentiful when the outside conditions are warm and wet. At the end of the
rains come the harvest - this coincides with transmission season for malaria.
“Sleeping with someone” —is often because a mosquito can bite two people in one night (the mosquitoes that carry
malaria bite between dusk and dawn).
“At the end of a long trip” —often traveling involves being outside at night, which is when these mosquitoes bite.
“Getting wet and rain soaked” —coincides with transmission season, the rainy time of the year.
“Sleeping outside” —again, this increases your chance of being bitten.
During this research, we will be looking at some of the beliefs that pregnant women have in regard to causes of
malaria and how to best prevent it. It will be important to understand the complexities of how people create these
explanations.
Patterns of Treatment: For example, if you ask what do pregnant women do when they have a fever or think they have
malaria, they may come up with several different patterns of behavior:
Day #1, 1st Day of Illness: go to a shop and buy medicines to take at home
Day #2 of Illness: rest and see if the medicines are working
Day #3 of Illness: seek advice from someone they respect
Day #4 of Illness: go to the health care facility.
We need to ask how/why/when people make these decisions and what are the factors that influence such decisions.
For example, the first decision to go to a shop may be based on the perceived cause of the illness. If the person thinks it
is due to “malaria,” then seeking out shop medicines may be the accepted practices of that community. If the illness was
perceived to be caused by something spiritual (e.g., personal transgressions), the person may instead go to a traditional
healer on Day #1.
Resources
9

Other factors that might influence how people make treatment decisions may include:
• co-sharing cost of medications or treatments at health care facilities
• perceived seriousness of illness
• timing of illness (If illness starts during the day, the person may first go to a drug vendor
or shop keeper. However, if illness starts at night, treatment options are more limited
and they may chose to wait until morning before seeking care. At this point, the person is
much sicker and may go straight to the hospital or health care facility)
• geographical distance to care (e.g., a shop keeper may be much closer than a health
care facility)
• availability of credit schemes for payment at a shop
• advice from someone who is respected.
Using these examples, it becomes clearer how complicated the process is to understand how
people think about things or make decisions about their behavior.
Proposed Activities: We hope to do the activities in XX different sites [insert number of sites]
throughout the district. We will be in health care facilities, as well as in individual homes or
maybe a common gathering area. Each site should take about (insert estimate). We will start
with “pilot” testing our activities prior to formally conducting the research, which means that
we will practice our interviews with people who are not part of the study team. Piloting the
interview guides helps us to see what might need to be changed and we can change things
before we start the assessment.
1. Individual Interviews: These will be done with currently or recently pregnant women, and
health-care workers. In each site, we will aim to interview 4-5 pregnant or recently pregnant
women, but we will need to see how much time this takes. In addition, we will be working with
“key informants,” people in the area who have a particularly strong knowledge about what
happens to pregnant women in this area. These key informants will be identified by village
leaders, community health care workers, community members or health care facility workers.
Usually we will try to interview 2-4 key informants per facility area. We will also interview
facility-based health care workers, interviewing from 1-10 per facility, depending on the
numbers employed in that facility.
2. Focus Group Interviews: These will be done with currently or recently pregnant women,
as well as lay midwives and TBAs. For each focus group, we hope to have 5 -15 pregnant or
recently pregnant participants and 5 -15 lay midwives and TBAs. We may also do health care
worker interviews.
II. Qualitative Research Components:
A. Differences between Qualitative and Quantitative Research:
We will be doing what is called “qualitative” research. It differs from quantitative research,
which deals primarily with studying things that can be easily counted. Qualitative research
focuses on what people think about things, what makes sense to them (individually and from
a community perspective), how they describe things and the meaning of those things, to
mention a few areas. In addition, qualitative research can be used to understand how much
someone knows about something, such as what causes malaria or what are common childhood
10
The Rapid Assessment of the Burden of Malaria during Pregnancy

febrile illnesses. Another area that we look at involves describing how people do things—what are common patterns of
behaviors, such as what parents actually do when their child has a fever, or what nurses say to patients when they see
them at a health care facility.
A key element in qualitative research is to remain “value-free” while listening to the information provided by the
participants. At the end of the assessment, it is also important to provide feedback about what was learned. Providing
feedback acknowledges the participants’ contributions and may encourage participants to assist in future projects.
While “quantitative” research strives to understand exactly how many people say something or how often an event
happens, the same type of counting can be used with qualitative research. Qualitative research can be quantified,
meaning that we can attach numbers to some of the information that we gather. For example, there are times when we
can count how many persons interviewed said that they always first go to a traditional healer when they are sick. We
might also be able to count how many different illnesses are named when we ask participants (people who are being
interviewed for the study) to tell us illnesses that cause fever in children or pregnant women.
However, there are other times when we listen to general themes in conversations and want to summarize the thoughts
without counting them. For example, if we were to ask about something like “hope,” it would be very difficult to put a
number on how much hope someone has.
Certain activities that we will be doing, like focus groups, will be directed towards listening to understand general
things people are telling us. Other activities, such as individual or personal interviews, will allow us to count how
many people do something. Both quantitative and qualitative research is important as they give us different types of
information. Neither is better than the other, they just are different. It is important to know what types of information
you need, and that will guide you in the type of research to do.
Summary of Differences Between Qualitative and Quantitative Research Methods
QUALITATIVE
Tries to understand meaning—to make
sense of things that are observed in the “real
world.”
Looks at perceptions, knowledge, beliefs,
ways of thinking, levels of understandings
(meaning systems, ways of acting) behaviors,
norms of behaviors
Examples: research examining local terms for
fever illnesses in children, or research asking
about how people treat malaria.
Researcher very involved with interviewing
research participants. Often, community is
very involved in process—both with data
collection (finding out the information) and
analysis (making sense of the information).
More open to interpretation.
Uses open or semi-structured questions
(asking people to tell you about something).
Depending on the question, you can use
quantitative measures to analyze at times.
QUANTITATIVE
Primarily focuses on quantifying or using
objective measurements.
Uses research methods that allow the
variable (what you are studying) to be
counted in some manner. For example,
laboratory-controlled experiments, research
on behaviors that can be observed (such as
drug efficacy testing), or surveys to find out
amounts of things.
Examples: surveillance data that tell us the
number of people diagnosed with malaria
at the health care facilities, the number of
stillborn babies born to pregnant women
with malaria, or the number of children that
get fever a few days after stopping malaria
treatments.
Researcher may or may not be involved much
in process of data collection. Community
rarely involved.
Seeks to define outcomes in numbers.
Generally has close-ended (“yes/no”) type
questions, or asking for a count of something
and often has pre-determined categories of
answers.
Qualitative techniques are used in the writing
of the research results.
Resources
11

III. Qualitative Research Methods:
Often people confuse research methodologies. For example, people talk about surveys and
interviews as if they are the same thing. I will first show you how they differ, and then we will
talk more in detail about interviewing. A survey may be done without personal contact, or
with limited interaction with the research team.
SURVEY
(CAN BE EITHER QUALITATIVE OR
QUANTITATIVE)
1. Structured 1. Unstructured
2. How many? (counting) 2. Why?
3. Surveyor is expert: uses pre-determined
responses
INTERVIEW
(QUALITATIVE)
3. Community is expert: uses open-ended
questions
4. Quicker to administer 4. Slower to administer
5. Done with limited involvement of research 5. Research team members are part of
the process
6. Example: knowledge, attitudes, and
practices (KAP) survey
6. Example: determining what malaria
treatments are.
Interviews:
In a situation where you have some knowledge about something (e.g., malaria) but want to
learn more (e.g., information related to pregnancy women and malaria), we usually use the
technique of interviewing with “semi-structured” questions. For example, we start with a
base of information about a topic, such as malaria. We know how malaria is caused and what
happens when a pregnant woman gets malaria during her pregnancy, but we don’t know
what women in this area do to prevent malaria. We also don’t know the best way to give them
information. So, we need to ask them what they do to prevent malaria and we need to ask the
women to identify the best people for offering information.
Our questions are “structured” or guided by the information that we know, as well as by what
we need to know. “Semi” means that although we direct or focus the questions, we allow
participants to offer more information than we requested—in essence, we are asking them
to tell us stories and to share their knowledge and their viewpoints with us. Building on what
information you know is important when time and money are issues, such as when you are
doing a rapid community assessment (e.g., what we will be doing). We have limited time to
find out a lot of information, and so we must focus on several specific areas and build on what
we already know.
Another way to interview is to do what is called an “open” interview. Generally that happens
when you know almost nothing about a topic or when you want to just find out what happens
in a new area. For example, if someone comes to XX District [insert name of district] from a
European country, they may need to do open interviews to learn the rules about courtship
and marriage, or to learn what to do if someone gets sick in the village. Sometimes an open
interview has one or two main questions and participants can freely talk for hours. Once the
participants talk, new questions are formed and they may differ interview by interview, even
though the interviews may all happen in the same village. During this research, we will be
using the semi-structured approach, rather than the open approach.
12 The Rapid Assessment of the Burden of Malaria during Pregnancy

1. Individual Interviews: This type of interview is done with a single person being interviewed by an interviewer. We are
looking for the individual perspective, as compared to a group or community perspective. Often, they can take a long
time to complete (more than one hour) but you obtain very specific information. These interviews usually yield a lot of
information. You need someone to interview, an interviewer, and sometimes you may need an additional person to help
record the responses. You might want to use a tape recorder to record the information.
2. Focus Group Interviews: These are done in a group, usually composed of 5-15 people. The purpose of this type of
interview is to obtain the “normative” view of the community—what people generally think or what behaviors are
considered acceptable, i.e., the norms of the community. For example, the normative view in an area may be that a
person should only marry someone from his or her own specific sub-tribe or clan, and that is what most people do.
However, some individual behaviors may differ from that as people do marry outside their clans or sub-tribes.
For focus groups, you need a “facilitator” (someone who will direct the questions of the group, and guide its
interactions), people to participate, and a “recorder,” who is someone who will write down what is happening in the
group. As with an individual interview, sometimes, audio tape players are used to also record the responses.
The advantages of this type of interview are that you can explore a wide range of topics and then narrow down the
topics. Ideas can be explored freely and many people can offer their perspectives. Often when one person talks, it
will stimulate the memory or thoughts of someone else in the group, and serves to move the discussion along. As
participants raise new issues, you can go from topic to topic. It will also give you a sense of how well the community
or group works together, or whether the group/community is splintered in their thoughts. Focus group data can be
“triangulated” with data collected from individual interviews to see if there are similarities (thus strengthening the
overall results), or it will show you that there are big differences within the community. “Triangulation” is a research
term used to describe using several different research methods to ask the same questions).
Disadvantages to this method are that unless the facilitator and recorder are very good, there may be problems using
this method. The expectation for a focus group is that everyone should participate. The facilitator needs to be able to
limit people who talk too much and monopolize the conversations, and also to be able to encourage shy, quiet people.
The recorder must be able to listen for themes and fill in the details later. He/she needs to be able to record the
dynamics of the group (for example, the group got very argumentative over a certain question) and needs to be able
to focus when several people are talking at one time. Another disadvantage, particularly when you hold focus groups
outside, such as in a village, is that their size may grow quickly and soon be too big as many people are interested and
want to be part of this activity. When the group becomes larger than 15 people, it becomes too difficult to manage the
group, to make sure everyone is participating, and to record. Lastly, it may be time-consuming and difficult to convene
such a group.
Recording the focus group is a bit different than recording an individual interview as the recorder must be able to
record general themes. Counting responses is not important, but identifying themes and noting that most or many of
the participants felt the same way about issues is important. It is important to note if someone is very different from
the group with their behaviors or thoughts. We call this type of person an “outlier” and we need to understand this
dynamic of the group when we analyze the data. Names are never used in the recording, although you might identify a
speaker by their job description, should you know it. For example, “the nurses in the group felt...”
Resources
13

Conducting an Interview:
1) Components of interview:
a) The person being interviewed: “interviewee,” (assessment or research participant)
b) The person who does the interview: “interviewer” (staff)
c) Subject matter:
i) Coherent list of questions around theme
ii) 1 - 2 broad questions that allow a person to talk freely
iii) Historical perspective: “tell me what used to be done for malaria control”
d) Venue (where to hold interview):
i) Use a quiet space that is free of distractions
ii) Ensure that it is as private as possible
e) Equipment:
i) Chairs for participants, interviewer and recorders
ii) Copies of interview field guide
iii) Writing materials (paper, pencils/pens with extra supplies as needed)
iv) Optional: tape recorders (not recommended)
2) Process of the interview:
a) Introduction of study team
b) Explain purpose of interview
c) Types of information to be obtained
d) Benefit to participant or to greater good
e) Obtain informed consent (this depends on what is required in a particular country)
f) Conduct interview
g) Conclude, check for missing data and thank participant:
i) Acknowledge that you understand that the participant came voluntarily and
committed a length of time
to be with you
ii) Show respect for what they have told you
iii) Reassure them that they have given you valuable information
14
The Rapid Assessment of the Burden of Malaria during Pregnancy

3) Characteristics that improve interviewing skills:
a) Values:
i) Patience
ii) Good sense of humor
iii) Flexibility
iv) Tolerance
b) Ability to recognize the need to change interviewing style:
i) May need to speed up or slow down
ii) May require a different way of phrasing a question:
(1) Use of paraphrasing, which is re-phrasing what you think the participant said (e.g.., “I understand that
you just said that you think most women use antenatal care in this area—have I understood correctly
what you meant?”)
(2) Use of “third party” technique (e.g., “Someone told me that they think… [insert a statement that you
want the participant to respond to]. Do you agree with that?”]
(3) Use of reflexive questioning, which is changing the responses into question format (e.g., Do I
understand that you think XX drug is the best to use for malaria?)
(4) Clarifying when something the participant said does not make sense to you (e.g., “I am sorry, I do not
understand what you mean. Could you please help me by giving me an example of what you mean?”)
iii) May need to direct participants back to the question if their response focuses on other issues
c) Interviewer behaviors that encourage participants:
i) Knowing the interview guide questions very well:
(1) Practicing the questions many times before you start the assessment or study
(2) Use the guide to only glance at the questions, rather than reading it
(3) Recognizing if the participant has already given you information that would answer a later question (if
you know the guide well enough, you will know where participants’ answers belong)
ii) Demonstrating relaxed body language, leaning slightly forward in the direction of the participant, not
appearing restless
iii) Making direct eye contact with participant, nodding head or showing another physical sign that you are
hearing what the participant is saying (NOTE: this does not signify that you necessarily agree with the
participant, only that you are paying attention to what they are saying)
iv) Not interrupting the participant until he or she is finished
v) Using encouraging language: e.g., “That is really interesting, no one ever told me that before.”
Resources
15

d) Demonstrating good “listening” skills:
i) Be attentive while you write
ii) Write quickly and use abbreviations that are known to you
iii) Ask participant to slow down if needed
iv) Record major themes and fill in gaps later
v) Write legibly:
(1) Remember that sometimes other people must do the transcribing and analysis.
Your data must be able to be read by them or else it is considered “lost” data.
vi) Make sure you do a thorough check of the data at the end of the interview:
(1) Ensure that all questions have been answered BEFORE the participant leaves.
If something is missing, ask the question.
(2) Correct any abbreviations used and fill in gaps to make the data
understandable to others
(3) Spell correctly
(4) If including a quote given in a local language, write the quote exactly as given
in the local language and include a translation. You can discuss the translation
in debriefing sessions.
4) Solutions to common problems during interviewing:
a) Interviewer can not understand the words being used:
i) Ask participant to slow down, ask for clarity, ask for a spelling of the word
b) Interviewer can not understand the concepts or ideas expressed by participant:
i) Ask for examples
c) Answers given are too long or complicated:
i) Re-phrase what you think you heard and ask participant if you have missed anything
BEFORE going on
to next question
16
The Rapid Assessment of the Burden of Malaria during Pregnancy

d) Environment is noisy and you cannot hear what is being said:
i) Stop interview and see if you can change venue or position of where you are seated to
maximize your hearing
e) Participant seems uncomfortable with a question or topic:
i) Acknowledge to participant that you understand it is a difficult or sensitive topic
ii) Identify the benefit for the participant (e.g., “I understand that it is difficult to discuss your child’s serious
illness. You might feel better if you are able to talk about your feelings. As well, your experience might assist
other parents in this situation as we can learn from your experience.”)
iii) Move to another question if participant is too uncomfortable
iv) Make notation in interview guide why question was not answered
List of Resources
Green, J. Qualitative Methods for Health Research. Thousand Oaks: Sage Publications, 2004.
Johns Hopkins University. January 2000. Qualitative research for improved health programs: A Guide to Manuals for
Qualitative and Participatory Research on Child Health, Nutrition, and Reproductive Health. (a review of manuals on
rapid assessment procedures (RAP)http://sara.aed.org/publications/cross_cutting/qualitative/qualitative.pdf
Patton, MQ. How to use Qualitative Methods in Evaluation. Thousand Oaks: Sage Publications, 1987.
Resources
17

18 The Rapid Assessment of the Burden of Malaria during Pregnancy

Resource 3: Resources for Training Sessions
(PowerPoint presentations)
Overview of rapid assessment: Rapid assessments:
general issues
Overview of modules: 1 & 2; 3, 4, 5 & 8; 6, 7, 9 & 10
Epidemiology of malaria: Epidemiology and control of
malaria in pregnancy
Clinical and laboratory methods: Assessment of gestational age, Body
measurements, Laboratory methods
Other assessment topics: Data management and sample size calculation
The Presentations are available only on the CD-ROM.
Note: A CD-ROM will be enclosed that contains all the items listed.
The entire package will be available electronically on
CDC's Malaria Web site: www.cdc.gov/malaria.
Resources
19

20 18 The Rapid Assessment of the Burden of Malaria during Pregnancy

Resource 4: Software and Planning Tools
(Costing Tool included in review package)
Costing Tool
Epi Info (for information and to download go to www.cdc.gov/epiinfo/)
Note: A CD-ROM will be enclosed that contains all the items listed.
The entire package will be available electronically on
CDC's Malaria Web site: www.cdc.gov/malaria.
Resources
21

Costing Tool for Rapid Assessment
Adapted from UNICEF’s Multiple Indicator Cluster Survey End
Decade Assessment, as accessed at http://www.childinfo.org/MICS2/
finman/M2finM.htm, March 1, 2005.
Table 1
Assessment Budget Items and Estimates for a Rapid Assessment
Using Both Quantitative and Qualitative Components
Budget item
Basis for calculation
Personnel (salaries plus indirect costs) Quantitative Component
Quantitative assessment coordinator
Data management coordinator
Site supervisors
Laboratory supervisor
Interviewers
Laboratorians
Data entry clerks
Computer programmers
Drivers
Qualitative Component
Qualtitative assessment coordinator
Interviewers
Drivers
Transportation
Vehicle rental
Public transportation allowance (urban areas)
Fuel
Contingency costs (repairs, ferries, etc.)
Consumables
Stationery (paper, pencils, pens, etc.)
Identification cards
Envelopes for filing
Computing supplies
(paper, diskettes, ribbons, cartridges)
Lab supplies
(microscope, RDTs, hemocues, etc.)
Other costs
Questionnaire and form printing
Photocopies of maps, listings and
instruction manuals
Anthropometric equipment
(weighing scales, height/length boards, etc.)
Communications (phone, fax, postage, etc.)
Report writing and printing
Training
Hospital costs
1 coordinator x 24 weeks
1 coordinator x 12 weeks?
4 supervisors x 8 - 9 weeks
1 supervisor x 8-9 weeks
8 interviewers x 8 - 9 weeks
4 laboratorians x 8-9 weeks
2 clerks x 5 weeks
1 programmer x 8 weeks?
4 drivers x 8 - 9 weeks
1 coordinator x 24 weeks
6 - 8 interviewers x 8 - 9 weeks
1 driver x 8 - 9 weeks
5 cars x 8 -9 weeks
variable
provision for 5 cars x 8 - 9 weeks
variable
variable
variable
120 envelopes
variable
variable
variable
variable
variable
variable
variable
variable
variable
22
The Rapid Assessment of the Burden of Malaria during Pregnancy

Table 2
Costing Framework: Items Included in Cost and Activity Categories
Personnel (salaries)
Cost categories
Assessment coordinator (Quantitative,
qualitative)
Data management coordinator
Site supervisors
Laboratory supervisor
Interviewers
Laboratorians
Drivers
Data entry clerks
Computer programmers
Drivers
Transportation
Vehicle rental
Public transportation allowance
Fuel
Maintenance costs
Consumables
Stationery
(papers, pencils, pens, etc.)
Identification cards
Envelopes for filing
Computing supplies
(paper, diskettes, ribbons,
cartridges)
Lab supplies
(microscopes, RDTs, hemocues, etc.)
Equipment
Anthropometric equipment (weighing
scales, height/length boards, etc.)
Other costs
Printing (questionnaire, etc.)
Photocopies of maps, listings,
instruction manuals
Equipment maintenance
Communications (phone, fax, postage,
etc.)
Report writing and printing
Training
Hospital costs
Activity categories
Preparation/sensitization
Adaptation of questionnaire
Translation and back-translation
Pre-testing of questionnaire
Survey design and sample calculation
Planning
Sample calculation
Training
Preparation of training materials
Translation into training language
Implementation of training,
including piloting
Assessment implementation
Implementation
Monitoring and supervision
Data retrieval
Data input
Data entry
Error checking
Data processing and analysis
Data processing
Data cleaning
Tables of analysis
Report writing
Dissemination and further analysis
Report printing
Distribution
Feedback meetings, if needed
Further analysis, if needed
Resources
23

Table 3
Costing Framework
COST
CATEGORIES
TOTAL
COSTS
ACTIVITY CATEGORIES
Preparation/
sensitization
Pilot
study
Survey
adaptation
and
calculation
of sample
size
Training
Assessment
implementation
Data
input
Data
processing
and
analysis
Report
writing
Dissemination
and further
analysis
Personnel
Transportation
Consumables
Equipment
Other costs
TOTAL COSTS
Any
participating
agencies or
institutions
(names)
Supplementary details
1. Sample size: ________
2. Number of interviewers/laboratorians/supervisors
Interviewers: ______ Laboratorians: ______ Supervisors: ______
3. Duration of training for assessment team (number of days): ________
4. Duration of assessment (number of days): ________
24
The Rapid Assessment of the Burden of Malaria during Pregnancy

Resources 25

26
The Rapid Assessment of the Burden of Malaria during Pregnancy