Antimalarial usage in pregnancy: a cross-sectional study in selected health facilities in the Brong Ahafo Region of Ghana

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Back ground: Malaria in pregnancy could be life threatening and has serious health implication for both the mother and the foetus if not managed well. In search of effective therapeutic regimen for malaria in pregnancy, the medicines used should be able to treat the disease without inducing any harm on the mother or developing foetus. Ghana has gone through policy changes regarding malaria treatment in pregnancy with a shift from chloroquine to quinine since 2004. The current policy recommendation faces an implementation challenge, because some prescribers are sceptical and thus reluctant to use quinine during pregnancy because of the reported risk of bleeding and abortions associated with its use. This study was aimed at assessing prescribers’ awareness of the national policy for malaria in pregnancy, the depth of knowledge of the prescribers on the policy and the pattern of use of antimalarials in pregnancy. Material and methods: This was a cross-sectional study involving three selected health facilities in the Brong Ahafo region of Ghana that were purposively selected. These include: the Regional hospital in Sunyani, the Holy Family hospital in Techiman and the Nkoranza Health Centre. Sixty prescribers from these facilities were systematically sampled to complete a structured questionnaire designed for data. The prescribers answered questions related to their knowledge on the national policy for malaria treatment in pregnancy and their experience with the use of quinine and the Artemisinin Combined Therapies (ACTs) in pregnancy. In addition, 310 prescriptions issued to pregnant women at the study sites with malaria were also reviewed and documented. The data obtained was coded, stored and analysed using SPSS version 16. Results: Eighty-five percent of prescribers (n=51) knew that quinine was a policy recommended medicine for malaria in the 1st trimester of pregnancy. Only 5% (n=3) vi identified both oral quinine with clindamycin as an alternative. Forty-three percent (n=26) knew that both oral quinine and the ACTs are recommended for malaria in the 2nd trimester of pregnancy. Thirty-seven percent (n=22) also knew that oral quinine and the ACTs are recommended medicines for malaria in the 3rd trimester of pregnancy. Fifty-one percent (n=31) had observed bleeding in early pregnancy and associated it with the use of quinine. Fifty-three percent (n=31) refused to prescribe quinine for malaria in pregnancy. Fifty-six percent (n=34) indicated that artemether-lumefantrine is tolerable and safer than quinine for uncomplicated malaria in pregnancy. Seventy-six percent of 1st trimester pregnant women with malaria (n=62) were prescribed artemether-lumefantrine. Ten percent in their 1st trimester (n=8) were prescribed quinine. 86.4% of pregnant women with malaria (n=197) in their 2nd and 3rd trimesters were prescribed artemether-lumefantrine. 3% (n=7) in their 2rd and 3rd trimesters were also prescribed quinine. Conclusion: Prescribers were aware of the national policy for malaria therapy in pregnancy but few knew that oral quinine plus clindamycin is also endorsed for malaria in early pregnancy. Reports of quinine induced bleeding in early pregnancy was confirmed by most of the prescribers interviewed. More than half of the prescribers refused to give quinine for malaria in pregnancy due to the risk of quinine induced bleeding or abortion (p=0.003). There was widespread use of parenteral artemisinins and artemether-lumefantrine in early pregnancy for uncomplicated malaria. To reduce non-adherence to quinine treatment regimen in pregnancy, prescribers should be educated and encouraged to use the 3-days treatment of quinine-clindamycin combination for uncomplicated malaria in pregnancy.
A thesis submitted to the Department of Clinical and Social Pharmacy, Kwame Nkrumah University of Science and Technology Kumasi, in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN CLINICAL PHARMACY