title: Treatment policy change to dihydroartemisinin-piperaquine contributes to the reduction of adverse maternal and pregnancy outcomes.
abstract: BACKGROUND
  In Papua, Indonesia, maternal malaria is prevalent, multidrug resistant and associated with adverse outcomes for mother and baby. In March 2006, anti-malarial policy was revised for the second and third trimester of pregnancy to dihydroartemisinin-piperaquine (DHP) for all species of malaria. This study presents the temporal analysis of adverse outcomes in pregnancy and early life following this policy change.
  
  
  METHODS
  From April 2004 to May 2010, a standardized questionnaire was used to collect information from all pregnant women admitted to the maternity ward. A physical examination was performed on all live birth newborns. The relative risks (RR) and the associated population attributable risks (PAR) of adverse outcomes in women with a history of malaria treatment to the risk in those without a history of malaria during the current pregnancy were examined to evaluate the temporal trends before and after DHP deployment.
  
  
  RESULTS
  Of 6,556 women enrolled with known pregnancy outcome, 1,018 (16%) reported prior anti-malarial treatment during their pregnancy. The proportion of women with malaria reporting treatment with DHP rose from 0% in 2004 to 64% (121/189) in 2010. In those with history of malaria during pregnancy, the increasing use of DHP was associated with a 54% fall in the proportion of maternal malaria at delivery and a 98% decrease in congenital malaria (from 7.1% prior to 0.1% after policy change). Overall policy change to more effective treatment was associated with an absolute 2% reduction of maternal severe anaemia and absolute 4.5% decrease in low birth weight babies.
  
  
  CONCLUSIONS
  Introduction of highly effective treatment in pregnancy was associated with a reduction of maternal malaria at delivery and improved neonatal outcomes. Ensuring universal access to arteminisin combination therapy (ACT) in pregnancy in an area of multidrug resistance has potential to impact significantly on maternal and infant health.
authors.affiliation: Mimika District Health Authority, District Government Building, Jl. Cendrawasih, Timika, 99910, Papua, Indonesia. didot2266@yahoo.com.|Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, 99910, Papua, Indonesia. didot2266@yahoo.com.|Department of Child Health, Faculty of Medicine, University Gadjah Mada, Jl. Kesehatan no 1, Sekip, Yogyakarta, 55284, Indonesia. didot2266@yahoo.com.
authors.forename: Jeanne Rini
authors.initials: JR
authors.lastname: Poespoprodjo
authors.affiliation: Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, 99910, Papua, Indonesia. timikaresearchfacility@gmail.com.
authors.forename: Wendelina
authors.initials: W
authors.lastname: Fobia
authors.affiliation: Mimika District Health Authority, District Government Building, Jl. Cendrawasih, Timika, 99910, Papua, Indonesia. ennykenangalem@yahoo.com.|Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, 99910, Papua, Indonesia. ennykenangalem@yahoo.com.
authors.forename: Enny
authors.initials: E
authors.lastname: Kenangalem
authors.affiliation: Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, 99910, Papua, Indonesia. aditimika@yahoo.com.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Lampah
authors.affiliation: Mitra Masyarakat Hospital, Jl. SP2-SP5-Charitas, Timika, 99910, Indonesia. sugiartopaulus@gmail.com.
authors.forename: Paulus
authors.initials: P
authors.lastname: Sugiarto
authors.affiliation: National Institute of Health Research and Development, Ministry of Health, Jl. Percetakan Negara, Jakarta, 10560, Indonesia. emil@litbang.depkes.go.id.
authors.forename: Emiliana
authors.initials: E
authors.lastname: Tjitra
authors.affiliation: Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, PO Box 41096, Casuarina, NT, 0811, Australia. nicholas.anstey@menzies.edu.au.|Division of Medicine, Royal Darwin Hospital, Darwin, NT, 0810, Australia. nicholas.anstey@menzies.edu.au.
authors.forename: Nicholas M
authors.initials: NM
authors.lastname: Anstey
authors.affiliation: Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, PO Box 41096, Casuarina, NT, 0811, Australia. rprice@menzies.edu.au.|Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX37LJ, UK. rprice@menzies.edu.au.
authors.forename: Richard N
authors.initials: RN
authors.lastname: Price
mesh_terms: D000293:Adolescent; D000328:Adult; D000962:Antimalarials / Q000008:administration & dosage*; D037621:Artemisinins / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D007214:Indonesia / Q000453:epidemiology; D007231:Infant, Newborn; D008288:Malaria / Q000150:complications* / Q000188:drug therapy*; D011247:Pregnancy; D015597:Pregnancy Complications, Parasitic / Q000453:epidemiology* / Q000469:parasitology; D011256:Pregnancy Outcome / Q000453:epidemiology*; D011804:Quinolines / Q000008:administration & dosage*; D055815:Young Adult; D010879:Piperazines
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D011804:Quinolines; C039060:artenimol; C034759:piperaquine; D010879:Piperazines