Insecticide-treated nets for preventing malaria in pregnancy.
BACKGROUND
Malaria in pregnancy is associated with adverse consequences for mother and fetus. Protection with insecticide-treated nets (ITNs) during pregnancy is widely advocated, but evidence of their benefit has been inconsistent.


OBJECTIVE
To compare the impact of ITNs with no nets or untreated nets on preventing malaria in pregnancy.


METHODS
We searched the Cochrane Infectious Diseases Group Specialized Register (January 2006), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to January 2006), EMBASE (1974 to January 2006), LILACS (1982 to January 2006), and reference lists. We also contacted researchers working in the field.


METHODS
Individual and cluster randomized controlled trials of ITNs in pregnant women.


METHODS
Three authors independently assessed trials for methodological quality and extracted data. Data were combined using the generic inverse variance method.


RESULTS
Six randomized controlled trials were identified, five of which met the inclusion criteria: four trials from sub-Saharan Africa compared ITNs with no nets, and one trial from Asia compared ITNs with untreated nets. Two trials randomized individual women and three trials randomized communities. In Africa, ITNs, compared with no nets, reduced placental malaria in all pregnancies (relative risk (RR) 0.79, 95% confidence interval (CI) 0.63 to 0.98). They also reduced low birthweight (RR 0.77, 95% CI 0.61 to 0.98) and stillbirths/abortions in the first to fourth pregnancy (RR 0.67, 95% CI 0.47 to 0.97), but not in women with more than four previous pregnancies. For anaemia and clinical malaria, results tended to favour ITNs, but the effects were not significant. In Thailand, one trial randomizing individuals to ITNs or untreated nets showed a significant reduction in anaemia and stillbirths/abortions in all pregnancies but not for clinical malaria or low birthweight.


CONCLUSIONS
ITNs have a beneficial impact on pregnancy outcome in malaria-endemic regions of Africa when used by communities or by individual women. No further trials of ITNs in pregnancy are required in sub-Saharan Africa. Further evaluation of the potential impact of ITNs is required in areas with less intense and Plasmodium vivax transmission in Asia and Latin America.
Gamble
C
C
University of Liverpool, Centre for Medical Statistics and Health Evaluation, Shelley's Cottage, Brownlow Street, Liverpool, UK, L69 3GS. c.gamble@liv.ac.uk
Ekwaru
J P
JP
ter Kuile
F O
FO
D000740:Anemia / Q000097:blood; D000818:Animals; D000962:Antimalarials; D001512:Bedding and Linens; D005260:Female; D006801:Humans; D007306:Insecticides; D008288:Malaria / Q000517:prevention & control*; D009032:Mosquito Control / Q000379:methods*; D009570:Nitriles; D026023:Permethrin; D011247:Pregnancy; D011250:Pregnancy Complications, Hematologic / Q000097:blood; D015597:Pregnancy Complications, Parasitic / Q000517:prevention & control*; D011722:Pyrethrins; D016032:Randomized Controlled Trials as Topic
D000962:Antimalarials; D007306:Insecticides; D009570:Nitriles; D011722:Pyrethrins; D026023:Permethrin; C052570:cyfluthrin