title: Knowledge and Adherence to the National Guidelines for Malaria Case Management in Pregnancy among Healthcare Providers and Drug Outlet Dispensers in Rural, Western Kenya.
abstract: BACKGROUND
  Although prompt, effective treatment is a cornerstone of malaria control, information on provider adherence to malaria in pregnancy (MIP) treatment guidelines is limited. Incorrect or sub-optimal treatment can adversely affect the mother and fetus. This study assessed provider knowledge of and adherence to national case management guidelines for uncomplicated MIP.
  
  
  METHODS
  We conducted a cross-sectional study from September to November 2013, in 51 health facilities (HF) and a randomly-selected sample of 39 drug outlets (DO) in the KEMRI/CDC Health and Demographic Surveillance System area in western Kenya. Provider knowledge of national treatment guidelines was assessed with standardized questionnaires. Correct practice required adequate diagnosis, pregnancy assessment, and treatment with correct drug and dosage. In HF, we conducted exit interviews in all women of childbearing age assessed for fever. In DO, simulated clients posing as first trimester pregnant women or as relatives of third trimester pregnant women collected standardized information.
  
  
  RESULTS
  Correct MIP case management knowledge and practice were observed in 45% and 31% of HF and 0% and 3% of DO encounters, respectively. The correct drug and dosage for pregnancy trimester was prescribed in 62% of HF and 42% of DO encounters; correct prescription occurred less often in first than in second/ third trimesters (HF: 24% vs. 65%, p<0.01; DO: 0% vs. 40%, p<0.01). Sulfadoxine-pyrimethamine, which is not recommended for malaria treatment, was prescribed in 3% of HF and 18% of DO encounters. Exposure to artemether-lumefantrine in first trimester, which is contraindicated, occurred in 29% and 49% of HF and DO encounters, respectively.
  
  
  CONCLUSIONS
  This study highlights knowledge inadequacies and incorrect prescribing practices in the treatment of MIP. Particularly concerning is the prescription of contraindicated medications in the first trimester. These issues should be addressed through comprehensive trainings and increased supportive supervision. Additional innovative means to improve care should be explored.
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, United States of America.
authors.forename: Christina
authors.initials: C
authors.lastname: Riley
authors.affiliation: Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Dellicour
authors.affiliation: KEMRI, Centre for Global Health Research, Kisumu, Kenya.
authors.forename: Peter
authors.initials: P
authors.lastname: Ouma
authors.affiliation: Malaria Control Unit, Ministry of Health, Nairobi, Kenya.
authors.forename: Urbanus
authors.initials: U
authors.lastname: Kioko
authors.affiliation: Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Feiko O
authors.initials: FO
authors.lastname: ter Kuile
authors.affiliation: Malaria Control Unit, Ministry of Health, Nairobi, Kenya.
authors.forename: Ahmeddin
authors.initials: A
authors.lastname: Omar
authors.affiliation: KEMRI, Centre for Global Health Research, Kisumu, Kenya.
authors.forename: Simon
authors.initials: S
authors.lastname: Kariuki
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, United States of America.|US President's Malaria Initiative, Nairobi, Kenya.
authors.forename: Ann M
authors.initials: AM
authors.lastname: Buff
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, United States of America.|Centers for Disease Control and Prevention, Kisumu, Kenya.
authors.forename: Meghna
authors.initials: M
authors.lastname: Desai
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, United States of America.
authors.forename: Julie
authors.initials: J
authors.lastname: Gutman
mesh_terms: D000328:Adult; D000962:Antimalarials / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000193:education*; D006801:Humans; D007630:Kenya; D008288:Malaria / Q000188:drug therapy*; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D055553:Prescription Drugs / Q000032:analysis* / Q000145:classification; D011897:Random Allocation; D012424:Rural Population; D055815:Young Adult
chemical_list: D000962:Antimalarials; D055553:Prescription Drugs