WHO recommendations on antenatal care for a positive pregnancy experience

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C.6: Intermittent preventive treatment of malaria in pregnancy (IPTp) RECOMMENDATION C.6: In malaria-endemic areas in Africa, intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommended for all pregnant women. Dosing should start in the second trimester, and doses should be given at least one month apart, with the objective of ensuring that at least three doses are received. (Context-specific recommendation) <strong>WHO</strong> <strong>recommendations</strong> on antenatal care for a positive pregnancy experience Remarks • This recommendation has been integrated from the <strong>WHO</strong> Guidelines for the treatment of malaria (2015), where it is considered to be a strong recommendation based on high-quality evidence (153). • Malaria infection during pregnancy is a major public health problem, with substantial risks for the mother, her fetus and the newborn. <strong>WHO</strong> recommends a package of interventions for preventing and controlling malaria during pregnancy, which includes promotion and use of insecticide-treated nets, appropriate case management with prompt, effective treatment, and, in areas with moderate to high transmission of Plasmodium falciparum, administration of IPTp-SP (153). • The high-quality evidence supporting this recommendation was derived from a systematic review of seven RCTs conducted in malaria-endemic countries, which shows that three or more doses of sulfadoxine-pyrimethamine (SP) is associated with reduced maternal parasitaemia, fewer low-birthweight infants and increased mean birth weight compared with two doses only (154). • The malaria GDG noted that most evidence was derived from women in their first and second pregnancies; however, the limited evidence on IPTp-SP from women in their third and subsequent pregnancies was consistent with benefit (153). • To ensure that pregnant women in endemic areas start IPTp-SP as early as possible in the second trimester, policy-makers should ensure health system contact with women at 13 weeks of gestation. Policy-makers could also consider supplying women with their first SP dose at the first ANC visit with instructions about the date (corresponding to 13 weeks of gestation) on which the medicine should be taken. • SP acts by interfering with folic acid synthesis in the malaria parasite, thereby inhibiting its life-cycle. There is some evidence that high doses of supplemented folic acid (i.e. 5 mg daily or more) may interfere with the efficacy of SP in pregnancy (155). Countries should ensure that they procure and distribute folic acid supplements for antenatal use at the recommended antenatal dosage (i.e. 0.4 mg daily). • The malaria GDG noted that there is insufficient evidence on the safety, efficacy and pharmacokinetics of most antimalarial agents in pregnancy, particularly during the first trimester (153). • Detailed evidence and guidance related to the recommendation can be found in the 2015 guidelines (153), available at: http://www.who.int/malaria/publications/atoz/9789241549127/en/ 72
C.7: Pre-exposure prophylaxis for HIV prevention RECOMMENDATION C.7: Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) should be offered as an additional prevention choice for pregnant women at substantial risk of HIV infection as part of combination prevention approaches. (Context-specific recommendation) Remarks • This recommendation has been integrated from the <strong>WHO</strong> guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV (2015), where it is considered to be a strong recommendation based on high-quality evidence (99). The evidence and further guidance related to the recommendation can be found in this guideline. • “Substantial risk” is provisionally defined as HIV incidence greater than 3 per 100 person-years in the absence of PrEP, but individual risk varies within this group depending on individual behaviour and the characteristics of sexual partners. Local epidemiological evidence concerning risk factors and HIV incidence should be used to inform implementation. • Thresholds for offering PrEP may vary depending on a variety of considerations, including resources, feasibility and demand. • The level of protection is strongly correlated with adherence. • Detailed evidence and guidance related to this recommendation can be found in the 2015 guideline (99), available at: http://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en/ Chapter 3. Evidence and <strong>recommendations</strong> 73
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WHO recommendations on antenatal care for a positive pregnancy experience

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