Standards

for Maternal and

Malaria prevention Neonatal Care
and treatment
INTEGRATED MANAGEMENT OF PREGNANCY AND CHILDBIRTH (IMPAC)

The standard
In malarious areas, all pregnant women should sleep under an insecticide-
treated bednet (ITN). In addition, in areas of stable transmission of
Š•Œ’™Š›ž–ȱ–Š•Š›’ŠǰȱŠ••ȱ™›Ž—Š—ȱ ˜–Ž—ȱœ‘˜ž•ȱ‹Žȱ’ŸŽ—ȱ’—Ž›–’ĴŽ—ȱ
preventive treatment (IPT). Pregnant women suspected of having malaria
should be assessed and treated in accordance with national protocols. In
the postnatal period, both the mother and the baby should sleep under an
insecticide-treated bednet.

Aim
To reduce the incidence of negative outcomes in women and their babies due to
malaria during pregnancy.

Requirements
A national policy and guidelines on prevention, diagnosis and treatment of malaria in
pregnancy are available and are correctly implemented.
Health providers have been trained and are competent in: malaria-related risks during
pregnancy; administration of IPT; advising on the use of ITNs; and diagnosis and
treatment of malaria during pregnancy, delivery and the postpartum period.
Women have access to maternity care, particularly in the antenatal period.
Antimalarials for IPT and treatment of symptomatic malaria and ITNs are available and
Šě˜›Š‹•Žǯ
Health education activities to increase community awareness of malaria prevention and
treatment are carried out.

Applying the standard

Providers of maternal and neonatal health care must:

World Health Organization

In areas of stable falciparum malaria transmission give all pregnant women at least two
˜œŽœȱ˜ȱȱŠĞŽ›ȱšž’Œ”Ž—’—ȱǻؗȱŠ—ȱř›ȱ›’–ŽœŽ›ǼȱŠ—ȱŠŸ’œŽȱ‘Ž–ȱ˜ȱœŽŽ”ȱŒŠ›Žȱ’—ȱ
case of fever. Doses should be given at an interval at least one month. To ensure that
women receive at least two doses, IPT should be carried out during routine visits to the
antenatal clinic. WHO currently recommends a schedule of four antenatal clinic visits,
‘›ŽŽȱ˜ȱ‘Ž–ȱŠĞŽ›ȱšž’Œ”Ž—’—ǯ
In malaria-endemic areas, encourage all pregnant women to sleep under an ITN from
as early in pregnancy as possible and to continue using an ITN during the postpartum
period, together with their babies. They should also be encouraged to seek care if the
‹Š‹¢ȱœ‘˜ œȱŠ—Ž›ȱœ’—œȱœžŒ‘ȱŠœȱŽŸŽ›ȱ˜›ȱ’ĜŒž•ȱ‹›ŽŠ‘’—ǯ
2006

Assess any pregnant woman with anaemia and/or fever who has been exposed to
malaria and treat her for malaria according to country guidelines.
Standards 1.7 M a l a r i a preve nti o n and t reat m ent 2

Give advice on preventive measures to all pregnant women living in or travelling to malarious
areas.
Record the treatment provided in the woman’s antenatal care card.

Audit
Input indicators
A national policy and standards and locally adapted guidelines on malaria in pregnancy are
available in health facilities.
Antimalarial drugs and ITNs are available in antenatal clinics and/or accessible through the
commercial market.

Process and output indicators

Proportion of pregnant women receiving IPT.
Proportion of pregnant women using ITN.
Appropriate case management of malaria illness.

Outcome indicators
Incidence of complications (anaemia, severe malaria, abortion, preterm delivery) in the mother.
Perinatal/neonatal mortality and morbidity (stillbirth, premature birth, low birth weight,
anaemia, congenital malaria).
Awareness of women and their families of the risk of malaria for themselves and their babies.

Rationale
ž›Ž—ȱ˜ȱœžěŽ›’—
‘ŽȱŽ•ŽŽ›’˜žœȱŽěŽŒœȱ˜ȱ–Š•Š›’Šȱ’—ŽŒ’˜—ȱ maternal anaemia. Maternal malaria infection
during pregnancy on maternal, fetal and ŠŒŒ˜ž—œȱ˜›ȱŠ•–˜œȱřŖƖȱ˜ȱŠ••ȱ‘ŽȱŒŠžœŽœȱ
’—Š—ȱ‘ŽŠ•‘ȱŠ›ŽȱŒŠžœŽȱŒ‘’ŽĚ¢ȱ‹¢ȱPlasmodium of low birth weight that can be prevented
falciparumǯȱ—ȱ›’ŒŠǰȱŠȱ•ŽŠœȱŘśȱ–’••’˜—ȱ during pregnancy. Maternal malaria infection
pregnancies are threatened by malaria each ’œȱŽœ’–ŠŽȱ˜ȱŠŒŒ˜ž—ȱ˜›ȱřȮŞƖȱ˜ȱŠ••ȱ’—Š—ȱ
¢ŽŠ›ǰȱ›Žœž•’—ȱ’—ȱŠ—ȱŽœ’–ŠŽȱŘȮŗśƖȱ˜ȱ deaths (1). In areas of high and moderate
(stable) malaria transmission, adult women
ŠŒšž’›Žȱ’––ž—’¢ǰȱŠ—ȱ–˜œȱ–Š•Š›’Šȱ’—ŽŒ’˜—œȱ
in pregnant women are asymptomatic.
Malaria during pregnancy in areas Nevertheless, these asymptomatic infections
of high or moderate (stable) transmission contribute to the development of severe
anaemia in the mother, resulting in an
increased risk of maternal mortality and
Acquired immunity high In the absence of HIV morbidity. The health of the fetus and infant
’—ŽŒ’˜—ǰȱꛜȱŠ—ȱ ’œȱŠěŽŒŽȱ‹¢ȱ–ŠŽ›—Š•ȱ’—ŽŒ’˜—ȱž›’—ȱ‘Žȱ
second pregnancies at
second half of pregnancy. Malarial infection
Asymptomatic infection highest risk
of the placenta and maternal anaemia due
IPT, ITNs, case to malaria contribute to low birth weight
management of malaria and preterm birth, which lead to higher
Placental sequestration and anaemia infant mortality and morbidity and impaired
Altered placental integrity
Anaemia development of the child. Stable transmission
predominates in Africa south of the Sahara,
Less nutrient transport
Š—ȱŒ˜—œŽšžŽ—•¢ȱ‘’œȱ›Ž’˜—ȱ‹ŽŠ›œȱ‘Žȱ›ŽŠŽœȱ
burden of malaria infections during pregnancy.
In these areas of high or moderate (stable)
Higher infant
Low birth weight –Š•Š›’Šȱ›Š—œ–’œœ’˜—ǰȱ‘Žȱ’••Ȭ‘ŽŠ•‘ȱŽěŽŒœȱŠ›Žȱ
mortality and
morbidity
™Š›’Œž•Š›•¢ȱŠ™™Š›Ž—ȱ’—ȱ‘ŽȱꛜȱŠ—ȱœŽŒ˜—ȱ
pregnancies exposed to malaria (2).
Standards 1.7 M a l a r i a preve nti o n and t reat m ent 3

In areas of epidemic and low (unstable) coverage is relatively high and will further
malaria transmission, adult women have no ’—Œ›ŽŠœŽǯȱ˜—œŽšžŽ—•¢ǰȱȱ›Ž™›ŽœŽ—œȱ‘Žȱ
œ’—’ęŒŠ—ȱ•ŽŸŽ•ȱ˜ȱ’––ž—’¢ȱŠ—ȱ ’••ȱŽŸŽ•˜™ȱ best entry point for reaching pregnant women
clinical illness if they have parasitaemia. with this intervention (7,9,10).
Pregnant women with no immunity are at
risk of dying from severe malarial disease Studies in Kenya and Malawi have
and/or experiencing spontaneous abortion, demonstrated that more doses of IPT may be
premature delivery, low birth weight or ‹Ž—ŽęŒ’Š•ȱ’—ȱ
Ȭ’—ŽŒŽȱ™›Ž—Š—ȱ ˜–Ž—ǯȱ—ȱ
stillbirth. All pregnant women are at similar œžŒ‘ȱ ˜–Ž—ǰȱ‘›ŽŽȱ˜œŽœȱŠĞŽ›ȱšž’Œ”Ž—’—ȱ–Š¢ȱ
risk for malarial infection, irrespective of ‹Žȱ—ŽŽŽȱ˜ȱŽ›’ŸŽȱ‹Ž—Žęœȱœ’–’•Š›ȱ˜ȱ‘˜œŽȱ
™Š›’¢ǯȱ‹˜›’˜—ȱ’œȱŒ˜––˜—ȱ’—ȱ‘Žȱꛜȱ obtained in uninfected women with two doses
trimester, and prematurity is common in the over the entire pregnancy (5). No adverse
‘’›ȱ›’–ŽœŽ›ǯȱ‘Ž›ȱŒ˜—œŽšžŽ—ŒŽœȱž›’—ȱ ŽěŽŒœȱŠ›ŽȱŠ™™Š›Ž—ǰȱ’—ȱŽ’‘Ž›ȱ–˜‘Ž›œȱ˜›ȱ‘Ž’›ȱ
pregnancy commonly associated with P. infants, of IPT given in the second and third
falciparum infection include hypoglycaemia, trimesters of pregnancy (2,5).
hyperpyrexia, severe haemolytic anaemia and
pulmonary oedema (2). The use of an ITN by a pregnant woman
‹Ž—Žęœȱ‘Žȱ ˜–Š—ȱŠ—ȱ‘Ž›ȱŠ–’•¢ǯȱž’Žœȱ
HIV infection diminishes a pregnant woman’s on adults and children indicate that ITNs
ability to control P. falciparum infections. The reduce the risk of malarial infection and
prevalence and intensity of malaria infection overall mortality (11,12). In highly malarious
during pregnancy is higher in women who are western Kenya, studies indicate that women
HIV-infected. Women with HIV infection are ™›˜ŽŒŽȱ‹¢ȱœȱŽŸŽ›¢ȱ—’‘ȱ’—ȱ‘Ž’›ȱꛜȱ
more likely to have symptomatic disease and four pregnancies delivered approximately
to be at increased risk of malaria-associated ŘśƖȱŽ Ž›ȱ‹Š‹’Žœȱ ‘˜ȱ Ž›ŽȱŽ’‘Ž›ȱœ–Š••ȱ˜›ȱ
adverse birth outcomes. Multigravidae with gestational age or born prematurely than
HIV infection are similar to primigravidae women who were not protected by ITNs (13).
without HIV infection in terms of their In endemic areas, priority should be given to
œžœŒŽ™’‹’•’¢ȱ˜ȱŠ—ȱ—ŽŠ’ŸŽȱŒ˜—œŽšžŽ—ŒŽœȱ˜ȱ developing antenatal clinic-based programmes
malaria infection. that provide both IPT and ITNs, along with
other essential preventive interventions. ITNs
‘ŽȱŽěŽŒœȱ˜ȱ‘Žȱ˜‘Ž›ȱ‘›ŽŽȱ™Š›Šœ’Žœȱ‘Šȱ ›ŽžŒŽȱ‘ž–Š—ȮŸŽŒ˜›ȱŒ˜—ŠŒȱ‹¢ȱ™‘¢œ’ŒŠ••¢ȱ
cause malaria in humans (P. vivax, P. malariae Ž¡Œ•ž’—ȱ–˜œšž’˜ŽœȱŠ—ȱŽ’‘Ž›ȱ”’••’—ȱ˜›ȱ
and P. ovale) are less clear. There is a need for repelling them, thereby driving them from
œž’Žœȱ˜ȱ‹ŽĴŽ›ȱŽę—Žȱ‘Žȱ’–™ŠŒȱ˜ȱP. vivax the vicinity of sleepers. Because of their
infection on the health of pregnant women and ˜Œž–Ž—ŽȱŽěŽŒȱ’—ȱœŽŸŽ›Š•ȱœž’Žœȱ˜—ȱ
neonates. reducing malaria-related illness and death,
ITNs are being promoted for use through both
public and private sector outlets in African
ĜŒŠŒ¢ȱŠ—ȱŽěŽŒ’ŸŽ—Žœœ
countries.
ȱœŽŽ–œȱ˜ȱ‹ŽȱŠȱŽŠœ’‹•ŽȱŠ—ȱŽěŽŒ’ŸŽȱ
strategy for reducing the risk of severe ITNs are still recommended for areas with
anaemia (2,3), placental and peripheral unstable malaria transmission, whereas IPT
parasitaemia (2–5), low birth weight (4–6) cannot be recommended for these areas
and perinatal death (3) in primigravidae and because of lack of evidence. Studies should be
secundigravidae living in malaria-endemic carried out in areas of low/unstable malaria
Š›ŽŠœǰȱŠ—ȱ’ȱ’œȱ–˜›ŽȱŽĜŒ’Ž—ȱ‘Š—ȱœŽ•ŽŒ’ŸŽȱ transmission and where the parasite is P. vivax.
case management of clinical malaria (5).
ž››Ž—•¢ǰȱ‘Žȱ–˜œȱŽěŽŒ’ŸŽȱ›žȱ˜›ȱȱ’œȱ —Žȱ›Š—˜–’£ŽȱŒ˜—›˜••Žȱ›’Š•ȱœ™ŽŒ’ęŒŠ••¢ȱ
sulfadoxine-pyrimethamine, because of its assessed the willingness of people to pay for
œŠŽ¢ȱ˜›ȱžœŽȱž›’—ȱ™›Ž—Š—Œ¢ǰȱŽĜŒŠŒ¢ȱ’—ȱ ITNs in an Indian rural area (14)ǯȱ˜–ŽȱŘŖƖȱ
reproductive-age women and feasibility for
of the population was unwilling to pay any
use in programmes as it can be delivered as
amount of money for ITNs. Of those willing
a single-dose treatment under observation
˜ȱ™Š¢ǰȱŠ•–˜œȱřŖƖȱ™›ŽŽ››Žȱ˜ȱ˜ȱœ˜ȱ˜—ȱŠ—ȱ
by the health worker (1,2,5,7). Nevertheless,
’—œŠ•–Ž—ȱ‹Šœ’œȱŠ—ȱ˜ȱ™Š¢ȱ—˜ȱ–˜›Žȱ‘Š—ȱǧŗȮŘȱ
a study in Malawi showed that, even if IPT
per net.
is adopted as national policy, obtaining a
wide coverage of pregnant women and
Operational problems relate, among others, to
Šœœž›’—ȱŽěŽŒ’ŸŽȱ’–™•Ž–Ž—Š’˜—ȱ’œȱ—˜ȱŽŠœ’•¢ȱ
‘Žȱ’ĜŒž•¢ȱ˜ȱ’–™•Ž–Ž—ȱȱ’—ȱŠ›ŽŠœȱ˜ȱ•˜ ȱ
achievable (8)ǯȱ˜œȮŽěŽŒ’ŸŽ—Žœœȱœž’Žœȱ˜ȱ
ANC coverage (7).
IPT are based on the assumption that ANC
 Standards 1.7 M a l a r i a preve nti o n and t reat m ent 4

The table below summarizes the evidence from the most relevant studies. The level of evidence is
™›ŽœŽ—Žȱžœ’—ȱ‘Žȱȱ–Ž‘˜˜•˜¢ȱ ‘’Œ‘ȱŠ™™•’ŽœȱŠȱŒ˜’—ȱ›˜–ȱŗȱǻ‘’‘ȱ•ŽŸŽ•Ǽȱ˜ȱŚȱǻ•˜ ȱ•ŽŸŽ•Ǽǯȱȱȱȱ
For details, see also the Introduction to the Standards for Maternal and Neonatal Care and the Process to
develop the Standards for Maternal and Neonatal Careȱ˜—ȱ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ–Š”’—ȏ™›Ž—Š—Œ¢ȏœŠŽ›Ȧ
publications/en. For an overview of a comprehensive list of evidence, please refer to the reference
section of the standard.

Study Outcomes
‹“ŽŒ’ŸŽȱǭȱ
ǻ¢™ŽȱǭȱŽŸŽ•ȱ ˜™ž•Š’˜—ȱǭȱŽĴ’— linked for the Results
—Ž›ŸŽ—’˜—
˜ȱŽŸ’Ž—ŒŽǼ Standard
řǯȱ Š›—Ž›ȱǭȱ ŗŚȱ›’Š•œǰȱŞŝŜŞȱ ˜–Ž—ȱ To assess drug Š•Š›’Šȱ™›˜™‘¢•Š¡’œȱŸœȱŒ˜—›˜•
Gülmezoglu (in some studies ŽěŽŒ’ŸŽ—Žœœȱ’—ȱ
1st and 2nd All women
ŘŖŖř only primigravidae preventing clinical
pregnancies only
included) malaria and its
Most recent
Œ˜—œŽšžŽ—ŒŽœȱŠ–˜—ȱ Maternal NSb NS
substantive ŗřȱ›’Š•œȱ’—ȱ›’ŒŠ—ȱ
pregnant women mortality Řȱœž’ŽœǰȱŝŝŘȱ ŗœž¢ǰȱŗŖŚşȱ ˜–Ž—
amendment, Œ˜ž—›’Žœǰȱŗȱ’—ȱ‘Š’•Š—
living in malarious women
ž•¢ȱŘŖŖŘ Baseline risk areas
Severe antenatal Severe antenatal min. NNT cȱŜřȱǻŚŞȮ —
Interventions: ŗŖŞǼȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
anaemia anaemia
Systematic antimalarial drug
Ȯȱ–’—’–ž–ȱŚƖȱ (haemoglobin –Š¡ǯȱȱŗŗȱǻŞȮŗşǼ
›ŽŸ’Ž  regimens described
Ȯȱ–Š¡’–ž–ȱŘŚƖȱ ǀސȦ•Ǽȱ Śȱœž’ŽœǰȱŘŞŖşȱ
as “prophylaxis”
1++ ǻ¢™’ŒŠ••¢ȱŒ‘•˜›˜šž’—Žȱ women
Perinatal death
Ȯȱ–’—’–ž–ȱŗŗȦŗŖŖŖȱ given weekly) or Antenatal ȱśȱǻśȮŝǼȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱŗŖȱǻŝȮřřǼȱȱȱȱȱȱȱȱȱȱȱȱ
Ȯȱ–Š¡’–ž–ȱŗŝŞȦŗŖŖŖȱ as “presumptive parasite Ŝȱœž’ŽœǰȱŘŚşśȱ Řȱœž’ŽœǰȱřŘŞȱ ˜–Ž—
treatment” prevalence women
Low birth weight (typically SP a given
Ȯȱ–’—’–ž–ȱşƖȱ ’—Ž›–’ĴŽ—•¢Ǽ
Ȯȱ–Š¡’–ž–ȱřŚƖ Perinatal death –’—ǯȱȱřřŝȱ NS
ǻŗşřȮşŖşŖǼȱȱȱȱȱȱȱȱȱȱȱȱ Śȱœž’ŽœǰȱŘŞşŖȱ
–Š¡ǯȱȱŘŗȱ neonates
ǻŗŘȮśŜŘǼȱȱȱȱȱȱȱȱ
řȱœž’ŽœǰȱŗşŞŜȱ
neonates
Low birth –’—ǯȱȱŘśȱǻŘŖȮřŝǼȱ NS
weight –Š¡ǯȱȱŜȱǻśȮŗŖǼȱȱ Řȱœž’ŽœǰȱŗŚřŞ
Ŝȱœž’ŽœǰȱŗşŚŝȱ
neonates
ŗŗǯȱŽ—Ž•Ž›ȱ ŗŚȱŒ•žœŽ›ȱŠ—ȱŞȱ ˜ȱŠœœŽœœȱ‘ŽȱŽěŽŒœȱ ITNs vs all controls
ŘŖŖŚ individual randomized of ITNs or curtains in Child mortality Ž•Š’ŸŽȱ›’œ”ȱŖǯŞřȱǻ0.76–0.89)
controlled trials, more preventing malaria from all causes
Most recent śȱœž’ŽœǰȱŗŚşȱŘŘŗȱŒ‘’•›Ž—
‘Š—ȱŗśŖȱŖŖŖȱ™Ž˜™•Ž
substantive
amendment, Africa, South America, Bednets were Lives potentially śǯśȦŗŖŖŖȱŒ‘’•›Ž—ȱ™›˜ŽŒŽȦ¢ŽŠ›
Š—žŠ›¢ȱŘŖŖŚ Middle Asia and South- treated with saved in
East Asia synthetic pyrethroid Œ‘’•›Ž—ȱŗȮśşȱ
’—œŽŒ’Œ’ŽȱŠȱ’쎛Ž—ȱ months
Systematic concentrations Severe malaria ŚśƖȱ™›˜ŽŒ’ŸŽȱŽĜŒŠŒ¢
›ŽŸ’Ž ȱ
(area of stable
1++ malaria)
Average —Œ›ŽŠœŽȱ‹¢ȱŗǯŝƖȱ™ŠŒ”ŽȱŒŽ••ȱŸ˜•ž–Ž
haemoglobin
level in children
a
Sulfadoxine-pyrimethamine
b
˜—Ȭœ’—’ęŒŠ—
c
ȱž–‹Ž›ȱ—ŽŽŽȱ˜ȱ›ŽŠǯȱǻşśƖȱŒ˜—ꍮ—ŒŽȱ’—Ž›ŸŠ•Ǽ
Standards 1.7 M a l a r i a preve nti o n and t reat m ent 5

References
ŗǯȱ A strategic framework for malaria prevention and control during pregnancy in the African region.

Š›Š›Žǰȱ˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŽ’˜—Š•ȱĜŒŽȱ˜›ȱ›’ŒŠǰȱŘŖŖŚȱǻ˜Œž–Ž—ȱȦ
ȦŖŚȦŖŗǼǯ
Řǯȱ ‘ž•–Š—ȱȱŽȱŠ•ǯȱ—Ž›–’ĴŽ—ȱœž•™‘Š˜¡’—ŽȬ™¢›’–Ž‘Š–’—Žȱ˜ȱ™›ŽŸŽ—ȱœŽŸŽ›ŽȱŠ—ŠŽ–’ŠȱœŽŒ-
ondary to malaria in pregnancy: a randomised placebo-controlled trial. Lancet,ȱŗşşşǰȱřśřDZŜřŘȮ
ŜřŜǯ
řǯȱ Š›—Ž›ȱǰȱ û•–Ž£˜•žȱǯȱ›žœȱ˜›ȱ™›ŽŸŽ—’—ȱ–Š•Š›’ŠȬ›Ž•ŠŽȱ’••—Žœœȱ’—ȱ™›Ž—Š—ȱ ˜–-
en and death in the newborn (Cochrane Review). In: The Cochrane Library, Issue 4, 2004.
‘’Œ‘ŽœŽ›ǰȱ˜‘—ȱ’•Ž¢ȱǭȱ˜—œǰȱŘŖŖŚǯ
Śǯȱ Ȃ•ŽœœŠ—›˜ȱȱŽȱŠ•ǯȱ‘Žȱ’–™ŠŒȱ˜ȱŠȱ—Š’˜—Š•ȱ’–™›Ž—ŠŽȱ‹Žȱ—Žȱ™›˜›Š––Žȱ˜—ȱ‘Žȱ˜ž-
come of pregnancy in primigravidae in The Gambia. Transactions of the Royal Society of Tropical
Medicine and Hygiene,ȱŗşşŜǰȱşŖDZŚŞŝȮŚşŘǯ
śǯȱ Š›’œŽȱȱŽȱŠ•ǯȱĜŒŠŒ¢ȱ˜ȱœž•Š˜¡’—ŽȬ™¢›’–Ž‘Š–’—Žȱ˜›ȱ™›ŽŸŽ—’˜—ȱ˜ȱ™•ŠŒŽ—Š•ȱ–Š•Š›’Šȱ
’—ȱŠ—ȱŠ›ŽŠȱ˜ȱ Ž—¢Šȱ ’‘ȱŠȱ‘’‘ȱ™›ŽŸŠ•Ž—ŒŽȱ˜ȱ–Š•Š›’ŠȱŠ—ȱ‘ž–Š—ȱ’––ž—˜ŽęŒ’Ž—Œ¢ȱŸ’›žœȱ
infection. American Journal of Tropical Medicine and Hygiene,ȱŗşşŞǰȱśşDZŞŗřȮŞŘŘǯ
Ŝǯȱ Ž—Ž—Ž£ȱȱŽȱŠ•ǯȱŠ•Š›’ŠȱŒ‘Ž–˜™›˜™‘¢•Š¡’œǰȱ’—ŽŒ’˜—ȱ˜ȱ‘Žȱ™•ŠŒŽ—ŠȱŠ—ȱ‹’›‘ȱ Ž’‘ȱ’—ȱ
Gambian primigravidae. Journal of Tropical Medicine and Hygiene,ȱŗşşŚǰȱşŝDZŘŚŚȮŘŚŞǯ
ŝǯȱ ˜˜–Š—ȱǰȱ’••œȱǯȱ‘ŽȱŽŸ’Ž—ŒŽȱ‹ŠœŽȱ˜—ȱ‘ŽȱŒ˜œȮŽěŽŒ’ŸŽ—Žœœȱ˜ȱ–Š•Š›’ŠȱŒ˜—›˜•ȱ–ŽŠœ-
ures in Africa. Health Policy and Planning,ȱŗşşşǰȱŗŚDZřŖŗȮřŗŘǯ
Şǯȱ ˜Ž›œ˜—ȱȱŽȱŠ•ǯȱ—Ž›–’ĴŽ—ȱœž•Š˜¡’—ŽȬ™¢›’–Ž‘Š–’—Žȱ’—ȱ™›Ž—Š—Œ¢DZȱŽěŽŒ’ŸŽ—Žœœȱ
ŠŠ’—œȱ–Š•Š›’Šȱ–˜›‹’’¢ȱ’—ȱ•Š—¢›ŽǰȱŠ•Š ’ǰȱ’—ȱŗşşŝȮşşǯȱTransactions of the Royal Society of
Tropical Medicine and Hygiene,ȱŘŖŖŖǰȱşŚDZśŚşȮśśřǯ
şǯȱ ˜˜–Š—ȱǰȱ˜•Ž–Š—ȱ ǰȱ’••œȱǯȱ˜œȮŽěŽŒ’ŸŽ—Žœœȱ˜ȱ–Š•Š›’ŠȱŒ˜—›˜•ȱ’—ȱœž‹ȬŠ‘Š›Š—ȱ
Africa. Lancet,ȱŗşşşǰȱřśŚDZřŝŞȮřŞśǯ
ŗŖǯȱ ˜˜–Š—ȱǰȱ˜•Ž–Š—ȱ ǰȱ’••œȱǯȱ‘ŽȱŒ˜œȮŽěŽŒ’ŸŽ—Žœœȱ˜ȱŠ—Ž—ŠŠ•ȱ–Š•Š›’Šȱ™›ŽŸŽ—-
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ž™™•ǯǼDZŚśȮśŜǯ
ŗŗǯȱ Ž—Ž•Ž›ȱǯȱ—œŽŒ’Œ’ŽȬ›ŽŠŽȱ‹Ž—ŽœȱŠ—ȱŒž›Š’—œȱ˜›ȱ™›ŽŸŽ—’—ȱ–Š•Š›’Šȱǻ˜Œ‘›Š—Žȱ
Review). In: The Cochrane Library, Issue 2, 2004.ȱ¡˜›ǰȱ™ŠŽȱ˜Ğ Š›ŽǰȱŘŖŖŚǯ
ŗŘǯȱ Ž œ˜–ŽȱǯȱŽŸ’Ž ǯȱ—œŽŒ’Œ’ŽȬ›ŽŠŽȱ‹Ž—ŽœȱŠ—ȱŒž›Š’—œȱ›ŽžŒŽȱ˜ŸŽ›Š••ȱ–˜›Š•’¢ȱŠ—ȱ
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an area of intense transmission in western Kenya. American Journal of Tropical Medicine and
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ŗŚǯȱ ‘Š’Šȱǰȱ˜¡ȱžœ‘‹¢ȱǯȱ’••’——Žœœȱ˜ȱ™Š¢ȱ˜›ȱ›ŽŠŽȱ–˜œšž’˜ȱ—Žœȱ’—ȱž›Šǰȱ—’Šǯȱ
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ŗŝDZŚŖŘȮŚŗŗǯ

Links and additional sources

I. Mother–baby package: implementing safe motherhood in countries. Geneva, World Health
›Š—’£Š’˜—ǰȱŗşşŜȱǻ˜Œž–Ž—ȱ
Ȧ
ȦȦȱşŚǯŗŗǼȱǻ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ›Ž™›˜žŒ’ŸŽȬ
‘ŽŠ•‘Ȧ™ž‹•’ŒŠ’˜—œȦȏşŚȏŗŗȦȏşŚȏŗŗȏŠ‹•Žȏ˜ȏŒ˜—Ž—œǯŽ—ǯ‘–•ǰȱŠŒŒŽœœŽȱŗřȱ
ŽŒŽ–‹Ž›ȱŘŖŖŚǼǯ
II. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva, World

ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖřȱǻ‘Ĵ™DZȦȦ ‘š•’‹˜Œǯ ‘˜ǯ’—Ȧ™ž‹•’ŒŠ’˜—œȦŘŖŖřȦşŘŚŗśşŖŞŚǯ™ǰȱ
ŠŒŒŽœœŽȱŝȱŽŒŽ–‹Ž›ȱŘŖŖŚǼǯ
 Standards 1.7 M a l a r i a preve nti o n and t reat m ent 6

Š—Š›œȱ˜›ȱŠŽ›—Š•ȱŠ—ȱŽ˜—ŠŠ•ȱŠ›ŽȱŽŽ›’—ȱ˜––’ĴŽŽȱȱ
Chair: Paul Van Look, Director, Department of Reproductive Health and Research;
This document This document is part of the ›—Ž••Šȱ’—ŒŽĴ˜ǰȱ
Ž•Šȱ˜œŠǰȱŽ••Šȱ‘Ž››ŠĴǰȱ——’Žȱ˜›Ž•Šǰȱ’Šȱ Š‹›ŠȱŠ—ȱžŒȱŽȱŽ›—’œȱ
is not a formal Standards for Maternal and Neonatal (Department of Making Pregnancy Safer).
publication of
Š›ŽȱŽŸŽ•˜™Žȱ‹¢ȱ‘ŽȱŽ™Š›–Ž—ȱ
the World Health Acknowledgments
of Making Pregnancy Safer,
Organization ‘’œȱœŠ—Š›ȱ ŠœȱŽŸŽ•˜™Žȱ‹¢ȱ›—Ž••Šȱ’—ŒŽĴ˜ȱ ’‘ȱŸŠ•žŠ‹•Žȱ’—™žœȱ›˜–ȱ–Ž–‹Ž›œȱ˜ȱ‘Žȱ
World Health Organization.
(WHO), and Š‹˜ŸŽȱŽŽ›’—ȱ˜––’ĴŽŽȱŠ—ȱ
ȱŽ’˜—Š•ȱĜŒŽœȱŠ—ȱ›ŽŸ’Ž ŽȱŠȱŠȱŽŒ‘—’ŒŠ•ȱ˜—œž•Š’˜—ȱ
all rights are ’—ȱ Ž—ŽŸŠǰȱŗŚȬŗŜȱŒ˜‹Ž›ȱŘŖŖŘǯȱŽ–‹Ž›œȱ˜ȱ‘ŽȱŽ—Ž›ȱ˜›ȱŽŸŠ•žŠ’˜—ȱ˜ȱŽěŽŒ’ŸŽ—Žœœȱ˜ȱ‘ŽŠ•‘ȱ
For further information please ŒŠ›ŽȬŽȱǻ’–˜—Šȱ’ȱŠ›’˜ǰȱ’Ĵ˜›’˜ȱŠœŽŸ’ǰȱ ’Š—›Š—Œ˜ȱ ˜›’ǰȱŠ—’Ž•Šȱ™ŽĴ˜•’ǰȱŠ—Žȱ
reserved by the
contact: Baronciani and Nicola Magrini) developed the table of evidence and provided additional
Organization.
Department of Making Pregnancy insightful review of the evidence section. We thank Nahlem Bernard, Paola Marchesini and
The document
Safer (MPS) ž•’Š—ŠȱŠ›Ž¢ȱ˜›ȱ‘Ž•™ž•ȱŒ˜––Ž—œȱ˜—ȱ‘Žȱꗊ•ȱ›ŠĞǰȱ›Š—”ȱŽŒ”œ˜—ȱ˜›ȱ‘ŽȱŽ’’—ȱŠ—ȱȱȱȱȱȱȱ
may, however, be
World Health Organization (WHO) Duke Gyamerah for the layout.
freely reviewed,
ŘŖȱŸŽ—žŽȱ™™’Š
abstracted, 
ȱŠŒ”—˜ •ŽŽœȱ‘ŽȱŽ—Ž›˜žœȱŒ˜—›’‹ž’˜—ȱ˜ȱ˜ŸŽ›ȱŞŖȱ’—’Ÿ’žŠ•œȱŠ—ȱ˜›Š—’£Š’˜—œȱ’—ȱ
ŗŘŗŗȱ Ž—ŽŸŠȱŘŝ
reproduced and ‘Žȱꎕȱ˜ȱ–ŠŽ›—Š•ȱŠ—ȱ—Ž˜—ŠŠ•ȱ‘ŽŠ•‘ȱ ‘˜ȱ˜˜”ȱ’–Žȱ˜ȱ›ŽŸ’Ž ȱ‘’œȱ˜Œž–Ž—ȱŠȱ’쎛Ž—ȱ
Switzerland stages of its development.
translated, in part
Ž•DZȱƸŚŗȱŘŘȱŝşŗȱřřŝŗ
or in whole, but
Š¡DZȱƸŚŗȱŘŘȱŝşŗȱśŞśř The funding towards the preparation and production of this document provided by the
not for sale nor for ˜ŸŽ›—–Ž—œȱ˜ȱžœ›Š•’ŠǰȱŠ•¢ȱŠ—ȱȱ’œȱ›ŠŽž••¢ȱŠŒ”—˜ •ŽŽǯȱ—ȱŠ’’˜—ǰȱ
Ȃœȱ
Email: MPSinfo@who.int
use in conjunction Making Pregnancy Safer Department is grateful to the Governments of Denmark, Ireland,
Ž‹ȱœ’ŽDZȱ   ǯ ‘˜ǯ’—Ȧ–Š”’—ȏ
with commercial Ž‘Ž›•Š—œǰȱ˜› Š¢ǰȱ ŽŽ—ǰȱŠ—ȱ‘Žȱ—’Žȱ ’—˜–ǰȱŠ—ȱ˜ȱ‘Žȱ˜›•ȱŠ—”ǰȱȱȱȱȱ
purposes. ™›Ž—Š—Œ¢ȏœŠŽ›Ȧ™ž‹•’ŒŠ’˜—œȦŽ—Ȧ
Š—ȱȱ˜›ȱž—œ™ŽŒ’ꮍȱ™›˜›Š––Žȱœž™™˜›ǯȱ