This study shows that there is inappropriate treatment of malaria among pregnant women with fever attending outpatient clinics. Although ACT are the first-line anti-malarial drug, many patients with confirmed malaria were not given ACT but SP. This may lead to parasite resistance to SP. Similarly, inappropriate use of ACT in pregnant women with non-malarial fevers may also lead to resistance against these drugs. These results will contribute to the design of a further study to evaluate the efficacy of SP as IPTp in Uganda.
A recent study in health facilities in Uganda found out that there were constraints to parasite diagnosis like lack of microscopes and RDTs, inadequate personnel and infrastructure. This scenario impacts on appropriate treatment of malaria and other diseases. Similarly a study in Jinja, a neighbouring district in Eastern Uganda showed that 85% of self-reported febrile illnesses were treated with antimalarial drugs .
The present results compare with those from a study carried out in South-Western Uganda in an area of low malaria endemicity which found high prescription rates for antibiotics in febrile patients, the majority of whom were children aged less than 5 years, and concluded that testing negative for malaria increases the use of antibiotics . The present study, however, shows that antibiotic prescription among febrile patients was low and this is likely because these were adult patients and the risk of pneumonia could have been low. It is also possible that health workers may not be thinking of common diseases in pregnancy that may require antibiotics. A diagnosis and treatment alogorithm for helping health workers to treat malaria and other common diseases is recommended and could include confirming pregnancy and the gestation period; checking urine for infections, HIV testing, screening for lung infections and history of anti-malarial drugs especially of SP.
Our study shows that access to ACT is high, consistent with findings from another Ugandan study that the most commonly prescribed antimalarial drugs are artemether-lumefantrine and quinine with a relatively high adherence to the new antimalarial treatment policy . This contrasts with an earlier study conducted across six African countries that showed poor access to ACT in Benin (10%), DRC (5%), Madagascar (3%), Nigeria (5%), Uganda (21%) and Zambia (21%) . Increased access to ACT in Uganda is attributed to a recent government initiative through the Global Fund that supports local manufacturing of ACT and ARVs. Access and use of ARVs is however poor as noted in our results due to inadequate laboratory services to analyze CD4 count, a pre-requisite to start patients n ARVs.
In interpreting the results it is worth noting that this study targeted pregnant women with fevers reporting in outpatient clinics thus the drug use and prescription patterns in other groups were not included. Clinical examination was relied to estimate the gestation period and thus could have missed pregnancies in the first trimester. In addition, the study was limited in the capacity to identify the causes of non-malaria fevers. A study carried on Thai-Burmese border found that non-malaria fevers in pregnancy were mainly scrub and typhus fevers . Since such infections are not common in Uganda, it would be of interest to have a study to document the causes of non-malaria fevers among pregnant women in Uganda. This study looked at fever in pregnancy; however diagnosis of malaria in pregnancy is problematic since most pregnant women in highly endemic areas have immunity, are asymptomatic and peripheral blood may not show parasitaemia . Thus this study may have under-estimated the magnitude of malaria in pregnancy.
The implications of these results are to ensure that health workers adhere to laboratory test results and prescribe according to the treatment guidelines. This will ensure appropriate treatment and avoid indiscriminate drug use potentially leading to drug resistance. Printing and distributing treatment guidelines supported by technical supervision are urgently needed to address this situation. Further areas for research include evaluating the efficacy of SP as IPTp and the review of the guidelines for IPTp among HIV positive women since interaction of SP with cotrimoxazole could hamper the effectiveness of SP. There is also need to strengthen pharmacovigilance of antimalarial drugs to enable timely review of policies.