Lifesaving backpacks: Unsung heroes combating malaria in expectant mothers

Mito Milambo, a Community Health Promoter tests a 17-year-old expectant teenager for malaria in Nyalenda slums, Kisumu. Rapid Diagnostic Test Kits have transformed the fight against malaria during pregnancy. [Harold Odhiambo, Standard] It is a typical day in the sprawling Nyalenda slums in Kisumu, nestled between the posh Milimani estate and Lake Victoria's shrubs and vast mass of water. The shrubs are home to millions of mosquitoes, a deadly insect whose buzzing sound and bites spell doom for a region classified as one of the malaria endemic zones in the country. Mito Milambo, a community health provider, grabs his backpack and puts the last item he rarely forgets before he leaves his house-his Bible-as he begins his journey through Nyalenda. Also in his backpack is a Rapid Diagnostic Test (RDT) kit, which has saved lives and transformed the fight to reduce malaria cases in pregnant women. For nearly four decades, the slum has been his home, and it does not take long before you realise his local hero status in the area. Here, even the youngest children playing in a puddle of water are quick to praise him. "Doctor, doctor, we need medicine," they joke, and he responds with a broad and assuring smile. A few metres from his house, Mito arrives at the door of his first client, a 17-year-old girl who is six months pregnant and is in dire need of regular checkups and tests for malaria. "I undertake rapid malaria tests on expectant women and refer those that have traces of malaria for specialised treatment in health facilities," Mito explains. In the larger Kisumu area, he is among over 2,000 Community Health Promoters (CHPs) who have become local heroes by helping diagnose, treat, and refer pregnant women with malaria to health facilities. They were identified as primary healthcare guides and trained intensively for one month to diagnose malaria. They are clustered to handle an average of 100 families per village. They say it is work; they do it nearly for free and are only paid a stipend of Sh2,000 per month. Through the introduction of the Rapid Diagnostic Test, CHPs have become a focal point in helping reduce malaria cases in pregnant women, consequently reducing child mortality. Although introduced in the country in 2012, RDTs started gaining traction in 2021 after the government adopted a policy of universal diagnosis before treatment. Malaria infection during pregnancy poses substantial risks for the mother and her unborn child. Notable complications include spontaneous abortions, maternal and fetal anaemia, and low-birth-weight babies. According to Kennedy Onyango, an obstetric paediatrician, and a medical researcher at Maseno University's School of Medicine, malaria in pregnancy can lead to miscarriage, fetal death, anaemia, breathing problems in the infant, and preterm labour. "Malaria in pregnancy is considered severe and requires urgent medical attention because it can have dire implications on the mother and the infant," he says. The county government procures the RDTs available in all level two health centres. According to the CHPs, they restock their supplies as soon as they replenish. The Kenya Malaria Strategy 2019-2023 recommends that all individuals with suspected malaria cases be tested and those confirmed as having malaria receive the recommended antimalarial treatment as soon as possible. Against this background, the Rapid Diagnostic Test done by CHPs is aiding the fight against malaria in pregnancy, one backpack at a time. After probing the teenager for a few minutes to confirm whether she attended her last antenatal visits, Mito removes a malaria testing kit and begins testing her. He takes a blood sample and puts it on the RDT strip before adding drops of a lysing agent. "If two lines appear on the cassette, it means she has the malaria parasite," he explains as he monitors the kit. Luckily, the teenager tested negative for malaria, and they slotted another date. In a month, he makes between two to three visits to pregnant women, a timetable that mirrors that of thousands of other CHPs in the region. This, however, was not the case for Maureen Awino, a 25-year-old pregnant mother of two who tested positive for the malaria vector and was referred to Nyalenda Health Centre. "The rapid diagnostic test has helped me a lot. I did not know that I had malaria, and I have only been taking painkillers," she explains. According to Eunice Ouma, another CHP who operates in Manyatta slums, most pregnant teenage girls do not adhere to prenatal clinical visits and are at a higher risk of contracting malaria. "Between January and February, I referred eight girls for malaria treatment at Manyatta Health Center. They were treated, and recovered. I am always glad when that happens because I know the complications of what untreated malaria can do to pregnant women," she says. She attributes the success to the introduction of RDTs, which have enabled them to track pregnant women and conduct diagnostic tests on them. They are also equipped with smartphones with an application that allows them to monitor their patients and keep their records. Mito Milambo, a Community Health Promoter in Nyalenda slums, Kisumu. [Harold Odhiambo, Standard] The CHV-NEO App is a communication messaging program between CHPs and pregnant women. It contains details of a patient's disease history, dates of subsequent clinical visits, and other important milestones during the nine-month pregnancy. The RDTs also include antimalarial drugs that the CHPs provide to those suspected of having malaria before they are transferred to health facilities. In Kisumu East, we meet Fredrick Obondo, another CHP clutching a backpack and trailing an expectant mother who was supposed to be due for delivery in two months. The woman had tested positive for malaria but had a problem adhering to her clinical visits, sparking fears in the concerned Obondo about the likely outcomes of the disease. "She missed her last clinical visit because she is allergic to sulphur, which is used in one of the malarial drugs given to expectant women," he says. According to Obondo, he managed to convince her to get treated for malaria. "At times, it is not easy to convince some of the pregnant women to take medication. However, using RDTs has been a great eye-opener in helping diagnose malaria cases," says the CHP. Dr Walter Otieno, a paediatrician, says the RDTs are accurate and have been instrumental in reducing malaria cases during pregnancy. "It is good as long as the procedures are followed. They have also been helping smaller facilities without electricity diagnose malaria in pregnant women," he says. According to County Health CEC Gregory Ganda, Kisumu has ensured that all health facilities are equipped with rapid detection test kits. "Prompt diagnosis and treatment are crucial in preventing malaria-related deaths," he says. For Christine Mwabe, a mother of three, her decision to ignore taking malaria treatment when she was pregnant was one of the worst decisions she says she regrets every day. She claims she was allergic to antimalarial medicine (sulfadoxine-pyrimethamine) given to pregnant women at routine antenatal care visits to prevent malaria in 2019. "I did not receive at least three doses after a doctor at Jaramogi Oginga Odinga Teaching and Referral Hospital confirmed that I was exhibiting allergic reactions," she says. After that, she declined to take any malarial tests and instead opted for painkillers, hoping that the disease would subside. "I was diagnosed with severe malaria a few weeks before I gave birth to my baby. Unfortunately, the baby was born with several health complications, including breathing problems," she says. Mwabe attributes her failure to get proper treatment for her malaria to her child's condition but claims the baby is now recovering well after several months and visits to several hospitals. "I believe the RDTs could have saved me at the time. At the moment, I am two months pregnant, and I am the one who calls the CHP to come and conduct tests on me before my clinical visits," she says. Data from the 2022 Kenya Demographic and Health Survey (KDHS) shows that under-five deaths have declined from 52 per 1,000 live births to 41. Cases of children dying between birth and their first birthday have also reduced from 39 deaths per 1,000 lives recorded in 2014 to 32. However, the number of children dying within 28 days of birth (neonatal mortality) in 2022 remained the same as in 2014, at 21 deaths per 1,000 births. Neonatal deaths account for 66 per cent of infant deaths and 51 per cent of under-five deaths. According to health data, the reduction in childhood deaths has been steady in the past ten years. Health experts and CHP believe that the RDTs have contributed to the decline in mortality rates that are directly linked to malaria. This is coupled with the civic education the CHPs provide pregnant women who need to sleep under treated mosquito nets. Josephine Achieng, a CHP based in Siaya, says several pregnant women have been confessing to sleeping under treated mosquito nets. Other counties, including Homa Bay and Migori counties, have also been rolling out mass distribution of treated nets. High coverage of ITNs helps decrease malaria risk at the individual and community levels by reducing the vector population. The KDHS report for 2022 indicates that at least 75 per cent of pregnant women sleep under an insecticide-treated net. "ITN ownership has been fairly steady since 2008-09, with at least half of households owning one mosquito net, except for 2020, when 49 per cent of households owned an ITN," reads the KDHS report. According to Kemri-CDC, malaria is responsible for 30 per cent of outpatient consultations, 19 per cent of hospital admissions, and 3-5 per cent of inpatient deaths. "Due to the heterogeneous nature of malaria distribution in the country, the burden is much higher in some areas such as western Kenya. In these areas, malaria transmission is high and perennial and is the cause of 65 per cent of sick visits to hospitals, 70 per cent of hospital admissions, and 20 per cent of deaths," says Kemri-CDC. In Siaya, Cynthia Anyango, a CHP, says that one of the pregnant women who developed malaria in pregnancy but did not seek medication was affected by a preterm birth. "The infant was also diagnosed with anaemia but is undergoing treatment," she says. According to data from the Department of Health in Siaya County, health volunteers treated at least 130,029 malaria patients in 2022. The county reported a total of 622,320 cases of malaria in 2022. The figure also indicates that about a quarter of the infections involved pregnant women. "Through the help of CHVs and the RDTs kits, patients access treatment at any time of the day, unlike dispensaries and health centres, which do not operate during the nights and on weekends," says Anyango. According to Dr Kendrick Muganda, the Medical Superintendent at Life Care Hospitals, malaria, stemming from plasmodium parasites, worsens with weather fluctuations and flooding, fostering ideal breeding grounds for mosquitoes, the disease's vectors. "When mosquitoes feed on infected individuals and proceed to bite others, they perpetuate the transmission. Hence, amid the climate change crisis, an upsurge in malaria cases is anticipated," he said. Consequently, early diagnosis through the use of RDTs is critical in helping to save the lives of expectant women and their infants. Health Cabinet Secretary Susan Nakhumicha says the government distributed 798,626 lasting insecticidal nets to families in March to help reduce malaria cases in the endemic zone of Kisumu. The programme also targeted the endemic counties of Migori and Homa Bay, where the government sprayed homes against malaria. "We have improved access to and timely malaria testing and treatment and have strengthened our surveillance systems to ensure availability of robust data that informs our decision making and planning," she says. According to her, the mortality rate has declined by 32 per cent thanks to the interventions, including RDTs. But the implementation is not all rosy. The CHPs claim the lack of remuneration is a significant setback for most of them. "We get paid only Sh2,000, and we have not been formally recognised with appointment letters," says Mito. The county government, on its part, cites delays in the supply of malaria drugs by the Kenya Medical Supplies Authority as a significant setback that affects their stockpiles.

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