Malaria prevention and treatment during pregnancy is only one component of antenatal care and must compete with the other myriad demands on antenatal providers such as providing nutritional advice, screening for hypertensive complications of pregnancy, treating anemia and identifying obstetric complications. Nonetheless, this study highlights sporadic gaps in malaria diagnostic and treatment capabilities and an overall underutilization of malaria prevention strategies at the 7 participating antenatal clinics in eastern India.
In areas of both stable and unstable malaria transmission, timely diagnosis of malaria episodes is crucial to preventing the adverse sequelae of such infections during pregnancy. At the time that the surveys were conducted, the Directorate of Health Services in both states--Jharkhand and Chhattisgarh--recommended early diagnosis and treatment with effective antimalarials for pregnant women attending ANCs [18, 19], guidelines that were consistent with those advised by the National Vector Borne Disease Control Program . All participating facilities had onsite capability to perform malaria blood smears and, with the exception of one site whose microscope was broken, the equipment was functional and the relevant supplies well stocked. Rapid diagnostic tests were not used in any of the study ANCs. These might be a useful addition to the repertoire of diagnostic tools, particularly in facilities that lack the onsite capability to perform or interpret malaria blood smears .
Blood smears were not routinely ordered but more typically obtained in situations where fever or other malarial symptoms were divulged. Yet, queries about the presence of fever were made in only a minority of the ANC visits (36%), thus highlighting a potential way to improve case recognition. Asking each pregnant client about current or past fevers since the last visit and reflexively ordering blood smears for those who respond affirmatively would add minimal additional time to a routine visit and may be a more realistic strategy in areas of unstable malaria transmission when compared with routine collection of blood smears. Although our study did not ascertain the proportion of moderate to severe anemic women who were subsequently screened for malaria, such targeted blood smears would be an additional relevant consideration for improving case recognition among women with underlying partial immunity who might not mount a febrile response to the parasite. Such targeted blood smears, in the presence of a fever or moderate to severe anemia, should be considered by the government in future antenatal policy recommendations.
In addition to malaria diagnostic capacity, case management requires ready access to effective antimalarial drug regimens suitable for a pregnant population. Chloroquine, with its longstanding safety profile in pregnancy , was widely available at all of the antenatal facilities in relatively ample supply with only a single stockout at one facility. Nonetheless, chloroquine resistance has been reported in India, as elsewhere, particularly in areas of intense P. falciparum transmission such as the northeastern states [6, 12]. Artemisinin combination therapy was introduced for nonpregnant individuals as early as 2006 by the government in areas showing chloroquine resistance . Alternatives to chloroquine for malaria treatment during pregnancy are urgently needed yet we found that other antimalarials, including quinine, sulfadoxine-pyrimethamine and artemisinin derivatives, were much less widely available. Oral artesunate was available at only one site. By contrast, arte-ether for parenteral treatment of severe malaria was available at all seven study sites. Furthermore, little guidance is provided to HCWs caring for pregnant women regarding appropriate antimalarial treatment in the National Drug Policy on Malaria 2007 guidelines available at the time our study was conducted . Certain antimalarials are prohibited from use during pregnancy--primaquine and parenteral artemesin derivatives. Yet, recommendations for which regimens to use for treatment of complicated or uncomplicated malaria during pregnancy are notably absent. To improve appropriate treatment of women with malaria in pregnancy, government agencies should outline treatment guidelines specific to pregnancy and target educational efforts to antenatal providers.
Malaria Prevention Measures
A keystone of the Enhanced Malaria Control Program, active in both Jharkhand and Chattisgarh just prior to the initiation of our study, was the enhanced provision of ITNs and their regular retreatment. In addition to a policy of increasing ITN use, both state governments also had existing vector control strategies that primarily consisted of indoor residual spraying with either dichlorodiphenyltrichloroethane (DDT) or synthetic pyrethroids [18, 19]. It was encouraging to note that a culture of bednet use by pregnant women existed in Jharkhand despite the fact that distribution occurred at none of the facilities during routine antenatal visits. We acknowledge that bednet use was self-reported and not verified by research staff. It is possible that women may have over-reported their use of bednets since they were aware of the study's focus upon malaria.
Availability of bednets at ANCs was higher in Chhattisgarh, but the majority of pregnant women did not regularly sleep under the nets. Except in Bastar district, there was an almost universal lack of insecticide treatment of the nets in both Jharkhand and Chhattisgarh. Approaches to bednet distribution, particularly ITNs, and improved community awareness of the importance of their use need to be addressed. Long-lasting ITNs may be preferable given the additional challenges of retreatment. The ANC visit is an ideal setting for distribution of ITNs and education in the importance of their use during pregnancy since the majority of pregnancy women attend at least one antenatal visit, 85% in Jharkhand  and 80% in Chhattisgarh .
Weekly chloroquine prophylaxis has generally fallen out of favor worldwide given several drawbacks: increased parasite resistance to the drug with consequent decreased efficacy and poor adherence to the prolonged regimen [28–30]. Chloroquine prophylaxis was rarely utilized for prevention of malaria in pregnancy at our study sites despite being recommended officially at the time the study was conducted . This recommendation subsequently was dropped in the most recent Indian national drug policy guidelines on malaria, which were published in 2008 .
An alternative to weekly chemoprophylaxis widely adopted in Africa is IPTp, a strategy which delivers at least two curative doses of antimalarial treatment beyond the first trimester. Sulfadoxine-pyrimethamine is the most commonly administered drug for IPTp. The advantages of IPTp over weekly chemoprophylaxis include improved adherence and ease of delivery. Sulfadoxine-pyrimethamine was not widely available at the participating ANCs as it was not officially endorsed by the government for preventive use during pregnancy. The current national drug policy guidelines on malaria do not mention IPTp . Given that the intensity of transmission is lower in Jharkhand  and Chhattisgarh [21, 22] relative to many areas of sub-Saharan Africa, widespread implementation may unnecessarily expose pregnant women and their fetuses to the medications. However, there may be circumstances that warrant IPTp use, for example more intense transmission in remote tribal villages or during episodic outbreaks.
Participating HCWs and pregnant women were cognizant that study personnel were affiliated with a malaria research study which may have biased our results by overinflating the emphasis on malaria during ANC visits. Nevertheless, this study suggests that a disconnect remains between routine antenatal practices in India and known strategies to prevent and treat malaria in pregnancy. The use of ITNs in particular, which may be useful even in settings of unstable transmission, appears underutilized. Maintaining a sufficient supply of malaria diagnostic materials and antimalarials safe for use in pregnancy is crucial to effective case recognition and management. Gaps highlighted by this study combined with recent estimates of the prevalence of malaria in pregnancy specific to India should be used to revise governmental policy and target increased educational efforts among health care workers and pregnant women.