Uncomplicated malaria among pregnant women in the Brazilian Amazon: local barriers to prompt and effective case management.

Malaria in pregnancy is associated with increased risks of maternal anemia, spontaneous abortion, low birth weight, premature delivery and other adverse effects on health. In Brazil, disease transmission is highly concentrated in the multi-state region that constitutes the Brazilian Amazon (more than 99% of all cases). This study, conducted between the first bimesters of 2007 and 2008, aims to identify the local barriers to prompt and effective case management of malaria in pregnancy and was carried out in health facilities located in three endemic municipalities of the Brazilian Amazon (Manaus, Presidente Figueiredo and Porto Velho). The study design combined both qualitative and quantitative descriptive methods. The qualitative design involved semi-structured interviews with health personnel who routinely deal with malaria care. The quantitative design involved a review of medical records of pregnant women in the visited health facilities. Additionally, data were abstracted from SIVEP-Malaria Epidemiological Surveillance Information System (Brasil, 2007) and Primary Care Information System (SIAB) databases. Flaws were detected in diagnosis (only 6.8% of women tested for malaria) and treatment (for Plasmodium falciparum infections, only 44.8% of patients received recommended first-line therapy; 10.2% of prescription presented treatments were not found in national guideline and 7.3% of the prescriptions for Plasmodium vivax and 17.9% of the prescriptions for P. falciparum were not sanctioned by the official guidelines). Training (only 37.3% had had some training), knowledge and counseling were also sub-optimal. These results indicated the need to improve the health-worker performance through training. Close supervision and feedback on the health-worker performance are also needed. These findings also highlighted the need to put into practice a series of government recommendations that encourage close collaboration between the National Malaria Control Program and Primary Health Care actions in order to achieve safer pregnancies.