A SYSTEMATIC SCOPING REVIEW OF MALARIA PREVENTION PROGRAMS IN PREGNANCY

There are few guidelines for health workers to follow when providing and managing malaria prevention therapy during pregnancy, but due to a lack of effective treatment options, malaria management during pregnancy has become non-standard in many countries. This study aims to assess the malaria prevention program in pregnancy, including its advantages, challenges


Introduction
Malaria is a vector-borne disease that affects global health with approximately 3,4 billion people at risk (Ingabire et al., 2014); (Dako-Gyeke & Kofie, 2015). Despite being preventable and curable, the disease continuously has a devastating impact on people's health and livelihoods across the world (Flaherty et al., 2017). The World Health Organization (WHO) reported that malaria cases decrease from 238 million to 229 million in 87 malaria-endemic countries, with cases per 1000 population at risk, which reduced from 80 in 2000 to 57 in 2019 (Liu et al., 2021); (WHO, 2021). Apart from Africa, the disease's prevalence in Southeast Asian countries needs to be addressed because they have the world's second-highest case rate. In 2019, the Southeast Asia Region had nine malaria-endemic countries, accounting for about 3% of global cases. Since 2000, the number of active cases has fallen by 74%, from 23.0 million in 2000 to around 6.3 million in 2019. According to a previous study, India had the largest absolute reduction from around 20 million cases in 2000 to approximately 5.6 million, followed by According to the Indonesian Ministry of Health, the Annual Parasite Index (API) (per 1000 cases) in 2020 is 0.9, and three provinces have values higher than the national figure, namely Papua (63.12), West Papua (10.15), and NTT. (2.76) (Flaherty et al., 2017).
Although malaria control has resulted in a 47% reduction in malaria-related mortality since 2000, prevention of the disease during pregnancy (MiP) has been less impressive. This is because approximately 50 million women in malaria-endemic countries become pregnant each year. During pregnancy, this disease kills an estimated 100.000 of these women and 200.000 of their children (Agarwal et al., 2015); (Bharatwajan & Mahapatra, 2009). It was also discovered that pregnant women and newborn children are the most vulnerable to infection and require special protection to avoid disease and death (Bharatwajan & Mahapatra, 2009); (Chico et al., 2015).
Pregnant women and women of childbearing age will require special attention during mass malaria eradication campaigns. Because malaria susceptibility increases during pregnancy, pregnant women serve as a major parasite reservoir in their communities (Fried & Duffy, 2017). They are especially vulnerable to the disease because pregnancy weakens a woman's immune system and makes her more susceptible to infection, increasing the risk of severe anemia and death. Maternal malaria also increases the risk of spontaneous abortion, stillbirth, premature birth, and low birth weight in the fetus (Bharatwajan & Mahapatra, 2009).
The World Health Organization (WHO) recommends a three-pronged approach to MiP control: intermittent preventive treatment in pregnancy (IPTp) with sulfadoxinepyrimethamine (SP), the use of insecticidetreated nets (ITNs), and effective case management of malaria illness and anemia. It was also suggested that every woman attend an antenatal clinic to receive at least two doses of SP after the first trimester for malaria prevention, and three doses for HIV-positive patients. During the COVID-19 pandemic, however, there was a shift in the administration of necessary doses, with the recommendation to maintain quality MiP services, including ITNs and IPTp for dealing with malaria in pregnancy.
It was suggested that an RDT be used for early detection and that ACTs be used for treatment. Sulfadoxine Pyrimethamine IPTp supply must be guaranteed, and direct observations of SP and ITN's treatment must be considered. It was also suggested that pregnant women with malaria symptoms be tested with RDTs and COVID-19 and that all healthcare workers be adequately protected. COVID-19 safety precautions apply to routine ANC services, including MiP, and MiP services must be kept separate from potential hazards (Fried & Duffy, 2017).
Because of several unique host-parasite interactions that make malaria difficult to treat during pregnancy, elimination strategies must be tailored. Malaria is more common in pregnant women than in other adults, but it is difficult to diagnose and treat. Malaria patients should be treated with an effective drug that kills the parasites quickly (Fried & Duffy, 2017); (Omo-Aghoja et al., 2008). Although there is no convincing evidence that any of the current antimalarial drugs cause teratogenic effects in humans, there are theoretical concerns about the safety of antimalarial drugs for the fetus. In addition, there is insufficient evidence that they are safe to use during pregnancy (Nwagha et al., 2014). WHO recommends that every woman attending an antenatal clinic receive at least two doses of SP after the first trimester for malaria prevention. There are, however, few guidelines for health workers to follow when providing and managing malaria prevention therapy during pregnancy. Malaria management during pregnancy has thus become non-standard in many countries. Various community-based efforts, such as the combination of laboratory diagnosis, therapy, and vector control, were also undertaken, but their successes and challenges have yet to be fully identified. Therefore, this study aims to examine several malaria prevention programs that have been implemented in different countries. It was carried out by considering some specific goals such as: 1. Determining malaria prevention programs for pregnant women in different countries. 2. Identify how the programs have worked in different countries.
3. Learn about the challenges and obstacles that various programs faced in different countries.

Method
The preparation of the systematic scoping review of literature consists of several stages, including:

Making Study Questions
Before starting the literature review, the objectives and study questions were formulated to guide the literature search (Khan et al., 2003). The study question developed is "How are the malaria elimination programs in pregnancy among various countries and what are the successes and obstacles that they faced?"

Searching for Data Sources and Literature
After developing study questions, the next step is to search for journal articles published through electronic databases. A systematic search of the literature between 2010 and 2021 was performed using data from PubMed and Google Scholar. During the examination of the Malaria in Pregnancy Prevention Program worldwide, keyword searches in data-based such as PubMed Central (PMC), and Google Scholars for PubMed were used, which involve the term "Malaria in Pregnancy [All Fields] AND ("Program" [MeSH Terms] OR ("Community" [All Fields]). For Google Scholar, Scopus, and Springerlink, the keywords used were "Malaria in Pregnancy, Prevention Program".
Meanwhile, articles were included in this review when they identify Malaria in Pregnancy Program in various countries.

Inclusion/Exclusion Criteria
Articles were eligible when they met the following criteria, (1) Acces: Full paper, (2) Design: Randomized and non-randomized controlled trial (RCTs), Cross-sectional, Survey, case study, and quasi-experiment, (3) Outcome: Malaria in Pregnancy prevention and treatment program, and (4) Relevance: Articles published in English and Indonesian addressed eliminating malaria in the pregnancy program.

Articles Selection
The database contained a total of 1299 titles/abstracts. After excluding duplicates, there were 1200 articles left, with 230 duplicated copies removed, and 1069 titles/abstracts obtained. Following that, fulltext articles were thoroughly reviewed, and the 580 articles were screened. A total of 351 articles were excluded because they did not focus on the prevention and management of malaria in pregnancy, 128 were not research articles, and 84 were biomedical, genetic, and drug research articles. Only 17 articles met the inclusion criteria. This review focused on malaria prevention and management programs in various countries. All included articles were evaluated to reduce the risk of bias. The selection process is illustrated in Figure 1.  (Khan et al., 2003).

Result and Discussion
Based on the result of the screening of 17 articles selected from 2010 to 2021, all articles were analyzed using qualitative methods, with a content analysis design. The summary of the review literature is presented in Table 1 Pyrimethamine therapy. Pregnant women receive these screening services as part of a comprehensive ANC package. Furthermore, the effects of the drugs on the mother and fetus during therapy must be taken into account. IPTp (Intermittent Preventive Therapy) with SP or AS + AQ has the same effect on malaria prevention in pregnancy as SP. IPTp with dihydroartemisinin-piperaquine is a more cost-effective option for malaria screening and treatment than single malaria screening and treatment. In comparison to screening and treatment, intermittent delivery is more effective, with a lower prevalence of malaria. According to (Unwin et al., 2020), the performance of ADT was not significantly different from that of cs RDT for Rapid Diagnostic Treatment of P. falciparum infections. c. Pregnant women with higher education prefer to be served by community health workers in carrying out IPTp and therapy with three doses of SP in Case Management Implementation, which can affect the success of malaria prevention programs during pregnancy. It was also discovered that community-based interventions increased the use of IPTp and ITNs significantly. The inclusion of communitybased programs can significantly improve malaria prevention and access to formal health care assessments in general, and antenatal attendance in particular. The Community Scheduled Screening Treatment program is intended to be a lowcost intervention for pregnant women that will have an immediate impact on the malaria burden in resource-constrained countries. 2. Malaria prevention programs in pregnancy have worked in different countries. Several articles reported that the three malaria prevention programs in pregnancy based on WHO recommendations can function effectively, with the keys to success being the integration of malaria prevention programs in pregnancy (prevention and treatment) with ANC services, community involvement in program implementation (screening and treatment), integration of malaria prevention strategies with existing community programs, and increasing public awareness of perceptions and understanding of malaria. 3. The challenges and obstacles that different malaria prevention programs in pregnancy face in different countries.
At the facility level, LLIN distribution must be accompanied by detailed information about the socio-cultural context in which women live. Antimalarial SP was commonly prescribed without regard for gestational age. MiP public health education should be expanded throughout the community. Malaria research has been discovered to aid in the development of evidence-based education. In the meantime, community-based malaria prevention programs appear to be a costeffective way of improving malaria prevention. The ADT performed similarly to currently used csRDTs in detecting P. Falciparum in asymptomatic pregnant women. In areas of Asia Pacific with moderate to high malaria transmission, IPT with dihydroartemisininpiperaquine is a promising alternative to SST. Furthermore, more research on highly sensitive malaria rapid diagnostic tests is required.
Malaria in pregnancy has adverse consequences for both mother and baby. During pregnancy, infections can lead to symptomatic malaria in areas of low or unstable transmission, where women have little acquired immunity (Hill et al., 2013); (Hoyt et al., 2018). WHO recommends IPTp with SP, ITNs, and effective case management to treat the disease during pregnancy (WHO, 2020). This requires several efforts and the program must be properly designed to give maximum results (Tagbor et al., 2010);(Yaya et al., 2018). Many studies have been conducted on malaria prevention programs in pregnancy and their effectiveness in various countries. However, important lessons from these practices can be used in the future to design and develop malaria prevention programs. This study will summarize various malaria prevention efforts and programs in various countries, including their successes and challenges. The results obtained are as follows: Malaria elimination programs in pregnancy are carried out in various countries, including those in WHO recommendations, which consist of: 1. Prevention of mosquito bites using insecticide-treated mosquito nets is obtained through the consistent use of ITNs in pregnant women. This is also influenced by the availability, ownership, knowledge, and perceptions of mothers and families on the effect and dangers of malaria during pregnancy. Although the most frequently mentioned prevention method was the use of bed nets, knowledge and practice contributed to the use of ITNs. In a study conducted in Nigeria, it was discovered that with the low overall ITN coverage in rural communities, people were knowledgeable about malaria and the benefits of prevention (Uneke et al., 2018). The negative association of relative wealth with bed net ownership can be explained by the area's severe poverty and the prohibitive cost of purchasing bed nets from shops and markets. Compared to older women, young mothers were more likely to mention the use of bed nets as a preventive measure. This is because, in comparison to previous years, young mothers are more aware of the benefits of using antenatal facilities. Pregnant women are also given free bed nets at such facilities (Masangwi et al., 2012); (Nsagha et al., 2011); (Ogwang et al., 2012). This showed that the mother believes in the efficiency of ITNs to prevent mosquito bites, thereby effectively preventing malaria during pregnancy. This condition is affected by the ITN's' ownership, while its use is significantly influenced by the mother's knowledge, belief, and understanding of the dangers of malaria during pregnancy. (Wagbatsoma & Aigbe, 2010) Therefore, the role of health workers in providing health promotion and appropriate information about malaria in pregnancy and the use of ITNs is critical as pregnant women continuously use them. (Nkunzimana & Babale, 2020). 2. Intermittent malaria screening for pregnant women (IPTp) and therapy with Sulfadoxine Pyrimethamine. Malaria screening services are provided to pregnant women as part of a comprehensive ANC package. Attention must be paid to the effects of these drugs on the mother and fetus during therapy. IPTp (Intermittent Preventive Therapy) with SP or AS + AQ has an effect on malaria prevention in pregnancy that is similar to giving SP. Furthermore, IPTp with dihydroartemisininpiperaquine is a more cost-effective alternative to single malaria screening and treatment. Compared to single screening and treatment, intermittent methods are more effective at delivery, with a lower prevalence of malaria. discovered that the performance of ADT was not significantly different from the cs RDT for Rapid Diagnostic Treatment for P. Falciparum infections (Unwin et al., 2020).
In early 2020, WHO recommended IPTp for pregnant women in malariaendemic areas, with at least 2 curative doses of the antimalarial drug SP, one in the second and the other in the third semester of pregnancy. The recommendation was updated in 2012, increasing the number of SP doses to 3 or more. Women in moderate and high malaria transmission areas need to receive SP at each antenatal visit during the second and third trimesters, with one-month intervals between doses. However, IPTp strategies do not completely prevent MiP, and the protective effects are dependent on the timing of the first dose and between treatments. Other studies showed that replacing SP with Dihydroartemisinin-Piperaquine, Mefloquine, and Chloroquine Azithromycin Combination is an alternative to IPTp SP. The Intermittent Screening and Treatment in Pregnancy (ISTp) strategy involves the use of RDT to screen women for malaria infection during antenatal clinic visits and to treat an infection with an antimalarial drug (Bharatwajan & Mahapatra, 2009);(Fried & Duffy, 2017); (Lagerberg, 2008).
Since pregnant women are at a higher risk, screening for malaria during pregnancy through an antenatal visit is recommended. This demographic group has become an important parasite reservoir in the community and a key target for interventions during elimination efforts. Meanwhile, pregnant women and women of childbearing age will require special consideration during any mass administration campaigns.

Case Management Implementation,
Pregnant women with higher education prefer to be served by community health workers in carrying out IPTp and therapy with 3 doses of SP, which can affect the success of malaria prevention programs during pregnancy. It was also discovered that community-based intervention showed a significant increase in the use of IPTp and ITNs. The inclusion of community-based programs can significantly increase effective malaria prevention as well as access to formal health care assessments in general, and antenatal attendance. Community Scheduled Screening Treatment is designed for low-cost intervention in pregnant women, which will have an immediate impact on the malaria burden in resource-limited countries.
Community Health Workers (CHWs) have demonstrated a willingness to engage and correctly carry out CCMm. Other studies from different countries also reported that CHWs can perform RDTs correctly and adhere to test results. This showed that with proper training and supervision, CHWs can be trusted to carry out in communities. Since the program has also been accepted by community members, it can be successful when implemented properly. However, for the CCMm program to be sustainable, CHWs must be motivated, because they are the foundation for implementation (Arnaldo et al., 2019);(Habimana et al., 2020); (Malpass et al., 2020). Commodities such as RDTs and drugs must be available in health facilities for CHWs to use in their community work. Meanwhile, the program cannot be successful unless clinicians, health facility in-charges, and technicians are involved in its implementation (Boakye et al., 2018); ; (Fried & Duffy, 2017); (Oppong et al., 2019); (Salam et al., 2014).
All studies showed that implementing case management for malaria in the community is more effective, based on the evaluation of health who reached the targets. However, this program will not succeed when there are no adequate tools and drugs as well as health workers, doctors, and health facilities to support the program. 2. Malaria prevention programs in pregnancy have worked in different countries. Increasing public awareness and understanding of malaria in pregnancy, as well as screening and treatment, will contribute to the success of malaria prevention and treatment programs in pregnancy (Tunçalp et al., 2017); (WHO, 2020). Several articles reported that the 3 malaria prevention programs can function effectively. For the control of malaria in pregnancy, 3 evidence-based strategies, namely ITNs, IPT, and effective case management are available, but the widespread implementation of effective programs remains a significant challenge (Rollback Malaria Working Groups, 2018); (WHO, 2020). Therefore, this study summarizes malaria prevention practices from various countries that have produced positive results. Some points to emphasize in the practice of preventing and treating malaria in pregnancy include the availability of policies and supervision of their implementation, integration between health workers and the community in ensuring the program's sustainability, and the supply chain of malaria prevention and control tools. Furthermore, some of the practical efforts that have yielded good results include supporting as well as considering cultural and environmental factors in designing malaria prevention programs, increasing cases of ANC clicks, and improving the capacity of ANC workers and communities regarding malaria prevention programs.
The challenges and obstacles that different malaria prevention programs in pregnancy face in different countries. The distribution of LLINs at the facility level needs to be accompanied by detailed information about the socio-cultural context in which the women live. Antimalarial SP was frequently prescribed without considering the gestational age, therefore, MiP public health education must be expanded in the community. Malaria studies can also aid in the development of evidence-based education. Based on the discoveries, community-based malaria prevention programs appear to be cost-effective methods to improve malaria prevention. In detecting P. Falciparum in asymptomatic pregnant women, the ADT performed similarly to currently used csRDTs. IPT with dihydroartemisinin-piperaquine is a promising alternative to SST in areas of Asia Pacific with moderate to high malaria transmission. More investigations need to be carried out on highly sensitive malaria rapid diagnostic tests. Many women, specifically those living in remote areas, have limited access to medical care and effective malaria control tools such as ITNs.
The delivery of cost-effective malaria prevention to pregnant women will necessitate improved antenatal care. It was also reported that the integration of malaria control with other health programs for pregnant women and infants increased community awareness and financial investment. The reward for accomplishing the program will be safer pregnancies and fewer infant deaths. However, in the future, the mother's and ANC attendants' compliance needs to be closely monitored. This is because the need for malaria prevention and treatment guidelines for mothers, communities, and health workers during pregnancy is still being considered.

Conclusion
The results showed that the prevention and treatment of malaria in pregnancy is still a concern. This is because pregnant women who have the plasmodium parasite can be asymptomatic and become a reservoir of parasites for their environment. This made different countries carry out several efforts which include implementing strategies according to WHO recommendations (ITNs, IPTp, and good case management). However, there is difficulty in the implementation of these programs. This is because some good practices by various countries are integrating the efforts with existing community programs and involving community workers in carrying out the program without adequate policies, prevention tools, and antimalarial drugs. Supervision and competent staff also affect the success of the program. Some investigations also stated that there is a challenge in the prevention and management of malaria in pregnancy, which include the availability of guidelines for mothers, health workers, and the community. This aims to improve the knowledge, perceptions, and beliefs of mothers, health workers, and the public about malaria in pregnancy.
This study indicates the need for developing integrated health promotion, prevention, and interventions to prevent and treat malaria in pregnancy. Integrative prevention and interventions need to use multisectoral approaches that involve health care professionals, families, government, and communities.