Malaria in pregnancy, risk perceptions and care seeking practices among adolescents in Mukono district Uganda

Malaria in pregnancy is a serious health problem that contributes greatly to maternal morbidity and mortality. This study investigated risk perceptions and care seeking practices for malaria in pregnancy among adolescents. Data were collected using focus group disusions(FGDs) and key informant interviews (KIIs). Results showed that malaria was perceived as the leading cause of morbidity and mortality among pregnant women. However, adolescent girls did not consider themselves at risk of malaria even when pregnant. Anaemia and low birth weight were not well understood and not related to malaria in pregnancy. Self-medication was common including over the counter drugs, herbs or a combination of both. When this failed, several options were taken such as seeking care at health units. People preferred to visit heath units with laboratory facilities, since investigations were valued and perceived useful. These investigations were locally known as okukebera omusayi, which translates to examining blood This local term is non-specific and used when patients are referred to laboratories to investigate diseases like HIV, syphilis and malaria. The use of this term however, discourages some people who are afraid of knowing their HIV status. Similarly, the notion that HIV/AIDS is spread thorough contaminated needles and syringes discourages people from giving blood for laboratory tests. In addition, the cost of investigations, fear of pain due to pricking, and the rudeness of laboratory technicians negatively influence seeking laboratory tests. Implications of these findings include developing a health promotion package that explains the dangers of self medication and advocates prompt seeking for malaria treatment especially for adolescents and primigravidae. Policy decisions to introduce rapid diagnostic kits (RDTs) in primary care units including drug shops are required in order to improve effective treatment of malaria.     

Prevention of anaemia in pregnancy using insecticide-treated bednets and sulfadoxine-pyrimethamine in a highly malarious area of Kenya: a randomized controlled trial

To compare the effects of intermittent treatment with sulfadoxine-pyrimethamine (SP) given during the second and third trimester of pregnancy, the use of insecticide-treated nets (ITN), or the combination of both on haemoglobin (Hb) levels during pregnancy, a randomized, placebo-controlled intervention trial was conducted in a malaria-endemic area of western Kenya from July 1997 to September 1999. Primigravidae and secundigravidae were enrolled into the study and randomized into 4 intervention groups: (i) ITNs and SP, (ii) ITNs and placebo SP, (iii) SP alone, and (iv) placebo SP. All groups were offered case management and iron and folic acid supplementation. Seven hundred and fifty-two women were followed until delivery (53.2% were primigravidae and 46.8% secundigravidae). Among primigravidae in all the groups there was a significant improvement in Hb levels at delivery (107.6 g/L) compared with recruitment (101.9 g/L) (P < 0.006) with the greatest improvement in the combination ITNs + SP group. The protective efficacy of ITNs + SP on anaemia was 55.8% (95% CI 30.6-71.8), of SP alone 50.9% (95% CI 22.2-69.0), and of ITNs 41.6% (95% CI 9.8-62.3). Among secundigravidae, Hb levels were slightly lower at delivery compared with recruitment (P = 0.03). It was concluded that malaria is a major cause of anaemia in primigravidae but that other causes play a more significant role in secundigravidae, and that intermittent treatment with SP or use of ITNs benefits primigravidae more than secundigravidae.     

Importance and prevention of malaria in pregnancy

Malaria in pregnancy is one of the most important preventable causes of low birthweight deliveries worldwide. It is also a major cause of severe maternal anaemia contributing to maternal mortality. It is estimated that 40% of the world's pregnant women are exposed to malaria infection during pregnancy. The clinical features of Plasmodium falciparum malaria in pregnancy depend to a large extent on the immune status of the woman, which in turn is determined by her previous exposure to malaria. In pregnant women with little or no pre-existing immunity, such as women from non-endemic areas or travellers to malarious areas, infection is associated with high risks of severe disease with maternal and perinatal mortality. Women are at particular risk of cerebral malaria, hypoglycaemia, pulmonary oedema and severe haemolytic anaemia. Fetal and perinatal loss has been documented to be as high as 60-70% in non-immune women with malaria. Adults who are long-term residents of areas of moderate or high malaria transmission, including large parts of sub-Saharan Africa, usually have a high level of immunity to malaria. Infection is frequently asymptomatic and severe disease is uncommon. During pregnancy this immunity to malaria is altered. Infection is still frequently asymptomatic, so may go unsuspected and undetected, but is associated with placental parasitization. Malaria in pregnancy is a common cause of severe maternal anaemia and low birthweight babies, these complications being more common in primigravidae than multigravidae. Preventative strategies include regular chemoprophylaxis, intermittent preventative treatment with antimalarials and insecticide-treated bednets.     

Use and misuse of a discount voucher scheme as a subsidy for insecticide-treated nets for malaria control in southern Tanzania

Since 1997, discount vouchers for insecticide-treated nets (ITNs) have been used in two rural districts of southern Tanzania as a way to target subsidies to children under 5 years and pregnant women. We assessed appropriate use and misuse of discount vouchers through a follow-up study of 104 randomly selected vouchers. We traced these vouchers from their original issue in mother-and-child health (MCH) clinics through to being redeemed at a sales agent. We found that all vouchers that reached the target population (100%, 56/56) were used to buy an ITN. Moreover, 94% of the ITNs bought with vouchers were used by those intended, women and children under 5 years. However, up to 48% (50/104) of the vouchers had been misused at the clinics that issued them. Nevertheless, large-scale misuse occurred only at three of 21 clinics. Although most women slept under a net while pregnant, the use of voucher-subsidized ITNs during pregnancy was low despite widespread knowledge of the scheme. Parents had apparently decided to buy the subsidized ITNs once the child was born and not during pregnancy. Importantly, in 20% of households the only existing net had been bought with a voucher. Our findings suggest that vouchers are properly used by the target population, and that to minimize voucher leakage, control measures are needed at MCH clinics and to a certain extent for commercial sales agents. Increased awareness among the whole community on the right to receive a discount voucher may also help to control misuse at health facilities.     

Efficacy of malaria prevention during pregnancy in an area of low and unstable transmission: an individually-randomised placebo-controlled trial using intermittent preventive treatment and insecticide-treated nets in the Kabale Highlands, southwestern Uganda

Intermittent preventive treatment of malaria during pregnancy (IPTp) and insecticide-treated nets (ITN) are recommended malaria interventions during pregnancy; however, there is limited information on their efficacy in areas of low malaria transmission in sub-Saharan Africa. An individually-randomised placebo-controlled trial involving 5775 women of all parities examined the effect of IPTp, ITNs alone, or ITNs used in combination with IPTp on maternal anaemia and low birth weight (LBW) in a highland area of southwestern Uganda. The overall prevalence of malaria infection, maternal anaemia and LBW was 15.0%, 14.7% and 6.5%, respectively. Maternal and fetal outcomes were generally remarkably similar across all intervention groups (P > 0.05 for all outcomes examined). A marginal difference in maternal haemoglobin was observed in the dual intervention group (12.57 g/dl) compared with the IPTp and ITN alone groups (12.40 g/dl and 12.44 g/dl, respectively; P = 0.04), but this was too slight to be of clinical importance. In conclusion, none of the preventive strategies was found to be superior to the others, and no substantial additional benefit to providing both IPTp and ITNs during routine antenatal services was observed. With ITNs offering a number of advantages over IPTp, yet showing comparable efficacy, we discuss why ITNs could be an appropriate preventive strategy for malaria control during pregnancy in areas of low and unstable transmission. [ClinicalTrials.gov identifier: NCT00142207]     

Artesunate and sulfadoxine-pyrimethamine combinations for the treatment of uncomplicated Plasmodium falciparum malaria in Uganda: a randomized, double-blind, placebo-controlled trial

Drug-resistant malaria is spreading in Africa. The few available drugs might be safeguarded if combined with an artemisinin derivative. We investigated the efficacy, safety, and tolerability of 2 combinations of artesunate with sulfadoxine-pyrimethamine (SP) in a mesoendemic region in Uganda with SP resistance, from September 1999 to June 2000. In a randomized, double-blind, placebo-controlled trial, 420 children aged 6-59 months with uncomplicated Plasmodium falciparum malaria were assigned SP alone (25 mg/kg sulfadoxine, 1.25 mg/kg pyrimethamine) or combined with artesunate (AS; 4 mg/kg/d) for either 1 d (SPAS1) or 3 d (SPAS3). Children were followed-up for 28 d. Day 14 cure rates were 84.6% (99/117) with SPAS3 and 61.9% (73/118) with SPAS1 compared with 55.8% (86/154) with SP. Corresponding day 28 results were 74.4% (87/117) and 45.2% (52/115) compared with 40.5% (62/153). A significant improvement was obtained with the addition of 3 d, but not 1 d, of artesunate (risk ratio [RR] = 1.5, 95% CI 1.3-1.8 at 14 d and RR = 1.8, 95% CI 1.5-2.3 at 28 d). Both AS regimens achieved significantly faster parasite clearance and lower gametocyte carriage. All drug regimens were well tolerated, but SP alone was ineffective. Treatment efficacy improved with SPAS3 but the cure rate at day 28 was modest. The combinations were well tolerated and safe. In areas where SP resistance is prevalent other combinations should be considered.     

Associations between mild-to-moderate anaemia in pregnancy and helminth, malaria and HIV infection in Entebbe, Uganda

It is suggested that helminths, particularly hookworm and schistosomiasis, may be important causes of anaemia in pregnancy. We assessed the associations between mild-to-moderate anaemia (haemoglobin >8.0 g/dl and <11.2 g/dl) and helminths, malaria and HIV among 2507 otherwise healthy pregnant women at enrolment to a trial of deworming in pregnancy in Entebbe, Uganda. The prevalence of anaemia was 39.7%. The prevalence of hookworm was 44.5%, Mansonella perstans 21.3%, Schistosoma mansoni 18.3%, Strongyloides 12.3%, Trichuris 9.1%, Ascaris 2.3%, asymptomatic Plasmodium falciparum parasitaemia 10.9% and HIV 11.9%. Anaemia showed little association with the presence of any helminth, but showed a strong association with malaria (adjusted odds ratio (AOR) 3.22, 95% CI 2.43-4.26) and HIV (AOR 2.46, 95% CI 1.90-3.19). There was a weak association between anaemia and increasing hookworm infection intensity. Thus, although highly prevalent, helminths showed little association with mild-to-moderate anaemia in this population, but HIV and malaria both showed a strong association. This result may relate to relatively good nutrition and low helminth infection intensity. These findings are pertinent to estimating the disease burden of helminths and other infections in pregnancy. [Clinical Trial No. ISRCTN32849447].     

Intermittent preventive treatment of malaria in pregnancy: evaluation of a new delivery approach and the policy implications for malaria control in Uganda

The impact of intermittent preventive treatment (IPT) on malaria in pregnancy is well known. In countries where this policy is implemented, poor access and low compliance to this intervention has been widely reported. A study was designed to assess a new approach to deliver IPT to pregnant women through traditional birth attendants (TBAs), drug-shop vendors (DSVs), community reproductive health workers (CRHWs) and adolescent peer mobilisers (APMs); and compared this approach with IPT at health units. We evaluated this approach to assess user perceptions, its acceptability and sustainability. Results show that the new approach increased access and compliance to IPT. Mean gestational age at first dose of IPT was 21.0 weeks with the community approaches versus 23.1 weeks at health units, P>0.0001. Health units accessed a high proportion of adolescents, 28.4%, versus 25.0% at the new approaches, P<0.03; most primigravidae, 23.6%, versus 20.0% at the new approaches, P<0.04. The proportion of women who received two doses of SP was 67.5.2% with the new approaches versus 39.9% at health units, P<0.0001. The new approach was associated with a three-fold increase in use of ITNs from 8.8% at baseline to 23.4%. The factors that most influenced acceptability and use of IPT were trusted and easy accessible resource persons, their ability to make home visits especially with CRHWs and APMs; the support of spouses. Another factor was the high awareness on dangers of malaria in pregnancy and the benefits of IPT created by the resource persons. The women perceived better health using the first dose of sulphadoxine-pyremethamine (SP) and this compelled them to go for the second dose. IPT with this approach was highly acceptable with 89.1% of women at the new approaches intending to use it for the next pregnancy, while 48.0% of them had recommended it to other women. We suggest a review of the current policy on malaria prevention in pregnancy to allow provision of IPT through community structures that are feasible, practical and acceptable.     

Socio-economic status and malaria-related outcomes in Mvomero District,Tanzania

While policies often target malaria prevention and treatment – proximal causes of malaria and related health outcomes – too little attention has been given to the role of household- and individual-level socio-economic status (SES) as a fundamental cause of disease risk in developing countries. This paper presents a conceptual model outlining ways in which SES may influence malaria-related outcomes. Building on this conceptual model, we use household data from rural Mvomero, Tanzania, to examine empirical relationships among multiple measures of household and individual SES and demographics, on the one hand, and malaria prevention, illness, and diagnosis and treatment behaviours, on the other. We find that access to prevention and treatment is significantly associated with indicators of households’ wealth; education-based disparities do not emerge in this context. Meanwhile, reported malaria illness shows a stronger association with demographic variables than with SES (controlling for prevention). Greater understanding of the mechanisms through which SES and malaria policies interact to influence disease risk can help to reduce health disparities and reduce the malaria burden in an equitable manner.     

District-based malaria epidemic early warning systems in East Africa: perceptions of acceptability and usefulness among key staff at health facility, district and central levels

Malaria epidemics represent a significant public health problem in the highlands of Africa. Many of these epidemics occur in low resource settings, where the development of an effective system for malaria surveillance has been a key challenge. Between 2001 and 2006, the Highland Malaria Project (HIMAL) established a programme to develop and test a district-based surveillance system for the early detection and control of malaria epidemics in four pilot districts in Kenya and Uganda. An innovative feature of the programme was the devolution of responsibility for the detection of epidemics from the central Ministry of Health to District Health Management Teams. The implementation of the programme offered the opportunity to test both the technical aspects of the system and to examine the practical issues relating to the operation of the programme in the context of the existing health system. To investigate the attitude of key staff towards the programme, and their perceptions of its impact on their working practices, interviews were carried out among 52 health staff at district level and in the Ministries of Health in Kenya and Uganda. The transfer of responsibility for the early detection of epidemics to the districts had resulted in perceptions of individual empowerment among district-based staff. This, together with improved support supervision, was a key factor in sustaining motivation and improved surveillance. The enhanced support supervision also produced capacity benefits that extended beyond improved malaria surveillance. However, these improvements occurred in the context of increased logistical support (the provision of transport, fuel and travel allowances) which the participants believed was essential to the functioning of an effective system. With this proviso, the district-based malaria early warning system was perceived to be manageable, effective and sustainable in the context of the current health system.     

The financial burden of malaria in Tanzania: implications for future government policy

Malaria is the cause of more mortality and morbidity in Tanzania than any other disease, in large part due to growing resistance to anti-malarial drugs. This study estimates that over 1% of GDP is devoted to the disease, representing US$2.2 per capita, and 39% of total health expenditure nationally. Government facilities devote almost one-third of their resources to the disease. Private expenditure, primarily on drugs, coils, sprays and bed-nets, represents 71% of total expenditures. Given the dominance of malaria treatment outside Government facilities, strategies to control behaviour in the private sector are critical. Together with regulations on private providers, and other interventions such as promoting the use of bed-nets in rural areas, greater research into and use of information strategies is required. Public policies should be designed to influence behaviour, to encourage households to seek adequate diagnosis of fever and to complete appropriate treatment with the right drugs.     

Perceptions on use of sulfadoxine-pyrimethamine in pregnancy and the policy implications for malaria control in Uganda

In malaria endemic areas intermittent treatment with sulfadoxine-pyrimethamine (SP) is recommended for malaria prevention in pregnancy. Yet, data on perceptions regarding use of this drug are scarce. An exploratory study was conducted to assess perceptions on SP in Mukono district, Uganda. This is an initial step towards a review of the policy aimed at improving access and use of SP in pregnancy, which is currently low. Results show that SP is perceived to be an effective drug that cures malaria quickly. However there are negative perceptions related to its use in pregnancy. SP is believed to be strong and weakens pregnant women, causes abortions and foetal abnormalities. There is also a perception that resorting first to SP for malaria treatment may lead to the development of drug resistance. This perception may limit access to effective treatment of malaria in this community since the policy in Uganda recommends SP in combination with chloroquine as the first-line treatment. The policy implications of these findings include developing a health promotion package to demystify the misconceptions on the strength of SP, to explain its benefits and side-effects. This package will involve giving health workers refresher training on communication and counselling on use of SP in pregnancy targeting special groups like pregnant adolescents. These results provide important lessons to policy makers and programme managers who aim at scaling up access of SP for malaria prevention in pregnancy.     

Coverage and use of insecticide-treated bed nets in households with children aged under five years in Liberia

Setting:

St John’s District, Grand Bassa County, Liberia.

Objectives:

In households with children aged <5 years, to examine the coverage and use of long-lasting insecticide-treated bed nets (LLINs), factors associated with non-use and the characteristics and conditions of bed nets.

Design:

Cross-sectional study involving interviews with mothers and visual inspection of LLINs.

Results:

Of 663 households visited, 492 (74%) had no LLIN and 135 (20%) had one LLIN. Of 171 households with LLINs, these were consistently used by 73 (43%) children. The main reasons for inconsistent use included LLINs being old or damaged, and LLINs generating too much heat for 20–30% of children. Visual inspection of LLINs in 130 households showed that 98% of LLINs were white, 20% were not hung above the child’s sleeping place, 30% had holes, 84% were double-bed sized and 82% had been washed in the previous 6 months.

Conclusion:

Despite reports of 100% LLIN coverage in St John’s District, this study showed that only a quarter of households had an LLIN, over half of the children used LLINs inconsistently and the LLINs had several deficiencies. More surveys should be conducted to determine the true coverage of LLINs in Liberia, and measures must be taken to improve the use of LLINs.     

Health service quality and users' perceptions in West Nile, Uganda

Save the Children (UK) has been working in health in the West Nile region of Uganda since 1980. Between 2000 and 2002, a number of operational research studies have been conducted which shed light on patient perceptions of the quality of services, of barriers to access and utilization patterns. These are brought together in this paper. They show that despite considerable progress in rebuilding infrastructure, training staff and investing in health systems in these districts, there is still a long way to go to provide services of an acceptable quality to users.     

The psychological effect of orphanhood in a matured HIV epidemic: An analysis of young people in Mukono,Uganda

As the HIV pandemic progresses, the number of orphans is expected to rise. Uganda is one of the countries that has been most impacted by the pandemic. A few studies have explored the effects of orphanhood on psychological well-being; however, most of these studies have not explored potential pathways through which orphanhood could affect psychological well-being. Using a school-based sample, this study sought to examine the differences in depressive symptoms and hopelessness between orphans and non-orphans in Mukono District, Uganda. The study also explored the potential mediating role of the family environment. The study included 1500 young people from 10 randomly selected schools in Mukono Town Council. Data on school characteristics also were collected from the head teachers or their designees. Linear regression methods were used for multivariate models. We found that orphanhood was associated with psychological ill health among the males. Male double and male maternal orphans had a significantly higher level of hopelessness than their non-orphaned counterparts. Male double orphans also had more depressive symptoms, but this association was mediated by the family environment. No differences were noted between orphaned and non-orphaned females. The cause and timing of parental death was important only among the males, and loss of a parent to HIV was associated with worse psychological outcomes among the males and not the females. Lower parent/guardian connectedness, having a chronically ill adult in the household and ill treatment in residence were associated with a higher level of depression, especially among the males. The data show that the effect of orphanhood on psychological outcomes may vary by gender and type of outcome. This study also suggests an attenuated effect of orphanhood on psychological well-being among school-going youth. Programs seeking to improve psychological well-being among youth must pay attention to the family situations of these youth.     

Marriage,violence and HIV: the shifting policy context in Uganda

The policy environment for vulnerable women in Uganda is rapidly changing, with the aim of introducing more punitive measures for violent offenders and more options for women seeking help. This paper examines HIV-positive women who experienced intimate partner violence in two regions of Uganda prior to the enactment of the Domestic Violence Act of 2010. Based on in-depth interviews and observations, it reports on women’s views of marriage and relationships, and their strategies for help seeking to show the interaction between the two phenomena within the local cultural and political context. HIV-positive women in Uganda reshape their notions of marriage and love based on experiences of violence, illness management and broader social factors. Their narratives of relationships and conflict reveal an ambivalence toward formal marriage because of both its security and rights and its potential to inhibit leaving, as well as a reluctance to seek help through formal means. This construction of marriage is intertwined with the shifting social backdrop in Uganda, in particular the increasing rollout of antiretroviral treatment for HIV and the development of new policies surrounding violence, marriage and divorce. Women’s experiences show potential points of intervention and the need for multi-sectoral responses to violence.     

Effect of a community-based delivery of intermittent preventive treatment of malaria in pregnancy on treatment seeking for malaria at health units in Uganda

BACKGROUND: The impact of intermittent preventive treatment (IPTp) on malaria in pregnancy is well known. However, in countries where this policy is implemented, poor access and low compliance have been widely reported. Novel approaches are needed to deliver this intervention. OBJECTIVE: To assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilizers can administer IPTp with sulphadoxine-pyrimethamine (SP) to pregnant women, reach those at greatest risk of malaria, and increase access and compliance with IPTp. STUDY DESIGN: An intervention study compared the delivery of IPTp in the community with routine delivery of IPTp at health units. The primary outcome measures were the proportion of adolescents and primigravidae accessed, and the proportion of women who received two doses of SP. The study also assessed the effect of the intervention on access to malaria treatment, antenatal care, other services and related costs. RESULTS: More women (67.5%) received two doses of SP through the community approach compared with health units (39.9%; P<0.0001). Women who accessed IPTp in the community were at an earlier stage of pregnancy (21.0 weeks of gestation) than women who accessed IPTp at health units (23.1 weeks of gestation; P<0.0001). However, health units were visited by a higher proportion of primigravidae (23.6% vs 20.0%; P<0.04) and adolescents (28.4% vs 25.0%; P<0.03). Generally, women who accessed IPTp at health units made more visits for malaria treatment (2.6 (1.0-4.7) vs 1.8 (1.4-2.2); P<0.03). At recruitment, more women who accessed IPTp at health units sought malaria treatment compared with those who accessed IPTp in the community (56.9% vs 49.2%). However, at delivery, a high proportion of women who accessed IPTp in the community had sought malaria treatment (70.3%), suggesting the possibility that the novel approach had a positive impact on care seeking for malaria. Similarly, utilization of antenatal care, insecticide-treated nets and delivery care by women in the community was high. The total costs per woman receiving two doses of SP for IPTp were 4093 Uganda shillings (US$ 2.3) for women who accessed IPTp at health units, and 4491 Uganda shillings (US$ 2.6) for women who accessed IPTp in the community. CONCLUSION: The community approach was effective for the delivery of IPTp, although women still accessed and benefited from malaria treatment and other services at health units. However, the costs for accessing malaria treatment and other services are high and could be a limiting factor in mitigating the burden of malaria in Uganda.     

Exploring perceptions,motivations, and practices regarding outsourcing support services by general hospitals in Uganda: A mixed methods study

Research on outsourcing in a developing country using a mixed methods approach can provide insights on outsourcing decisions and practices. This study investigated motivations, practices, perceived benefits, and barriers to outsourcing by general hospitals in Uganda. An explanatory sequential mixed methods design was used. Quantitative data were collected using a self‐administered questionnaire from managers in 32 randomly selected hospitals. Qualitative data were latter collected from eight purposively selected managers using an interview guide. Quantitative data were statistically analyzed using SAS 9.3. Qualitative data were managed using ATLAS ti 7 and coded manually, and content analysis was conducted. Quantitative findings indicate that outsourcing of support services was prevalent (72% of hospitals). The key motivation for outsourcing was to gain access to quality service (68%). Limited availability of service providers was a key challenge during outsourcing (57%). Managers perceive improved productivity and better services as key benefits of outsourcing (90%). The main barrier to outsourcing is limited financing. These findings were confirmed and explained by the qualitative data. Findings and recommendations from this study are critical in developing interventions to encourage effective outsourcing by hospitals in Uganda and other developing countries.     

Artesunate-atovaquone-proguanil rescue treatment of multidrug-resistant Plasmodium falciparum malaria in pregnancy: a preliminary report

Pregnant women are particularly vulnerable to malaria infections. Multidrug resistance in Plasmodium falciparum seriously compromises treatment in some endemic areas. Between April 1999 and October 2001, we treated and prospectively followed 27 Karen pregnant women with multiple recrudescent P. falciparum infections who were resistant to all other antimalarials with a triple combination of artesunate-atovaquone-proguanil. The treatment was well tolerated and we found no evidence of toxicity for the mothers and the fetus. All but 1 woman were cured (cure rate 96%, 95% CI 89-100). The triple combination of artesunate (4 mg/kg/d), atovaquone (20 mg/kg/d), and proguanil (8 mg/kg/d) may provide a much needed, albeit expensive, 3-d rescue treatment for pregnant women exposed to multidrug- resistant P. falciparum malaria.