Malaria and syphilis: leading infectious causes of stillbirth at global level

by Matthew Chico & Rosanna Peeling, London School of Hygiene & Tropical Medicine
Tuesday, 19 January 2016 16:31 GMT

Pregnant women wait for health checks at Salesian Sisters Diocese in Wau May 28, 2010. REUTERS/Mohamed Nurdldin Abdallh

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Malaria and syphilis cause more than 420,000 stillbirths every year - but these can be prevented

Losing a child late in pregnancy is a cause of extraordinary grief. For many reasons, stillbirths are routinely under-reported, which has made it difficult to quantify the global burden, to determine the various causes, and to develop appropriate interventions to tackle the problem.

New research on ending preventable stillbirths, published today in the Lancet medical journal, estimates that 2.6 million pregnancies ended in stillbirth worldwide last year. Of these, 98 percent occurred in low- and middle-income countries.

Malaria and syphilis are responsible for more stillbirths than any other infections, causing more than 420,000 stillbirths between them every year. In sub-Saharan Africa, three of every 10 stillbirths are due to malaria or syphilis. Although these figures are grim, there is reason for hope.  We know how to intervene.

An anti-malarial medication called SP (sulphadoxine-pyrimethamine) should be given to pregnant women who live in areas with moderate to high malaria transmission to help protect against malaria, and in turn, safeguard against a range of associated problems including stillbirth, preterm birth, low birthweight, maternal anaemia, and neonatal death.  This is part of the Global Call to Action recommended by the World Health Organization.

Some may wonder whether screening for malaria parasites – and then providing treatment if parasites are found – might be better than giving preventive treatment to all pregnant women. However, today’s diagnostic tests are not sensitive enough to detect the presence of malaria parasites in the placenta.

Consequently, pregnant women in endemic areas may be considered malaria free based on a blood test, while unknowingly carrying malaria parasites in the placenta.  The evidence is clear: preventive treatment is superior to current screen-and-treat approaches.

The best course of action is to provide SP at a cost of just $0.20 per course until a better option is available, coupled with using insecticide-treated bednets at night to prevent the malaria-transmitting mosquitoes from biting women.

Indeed, evidence has shown SP is able to protect against low birthweight until very low levels of malaria transmission, suggesting that preventive treatment of malaria for pregnant women may be an important component in the antenatal care package until malaria has been eradicated from endemic areas of the world.

As for syphilis, around 4 or 5 percent of pregnant women in East and Southern Africa are infected with it. A recent study in Tanzania showed 25 percent of pregnant women with untreated infection delivered a stillborn baby and 50 percent of all stillbirths were attributed to syphilis in women who had not been screened.

second study in the same setting showed that treatment with a single dose of penicillin before 28 weeks of pregnancy cured maternal and congenital syphilis and prevented stillbirth and low birthweight attributable to the infection. The cost of intervention was just $1.4 per woman screened.  

Although screening for syphilis is recommended policy in most countries, coverage is poor as access to laboratories is limited, and it is often difficult for women to return to health facilities to receive test results and treatment.

There is now an affordable solution to these problems. Point of care tests that are quick and easy to use, requiring only one drop of blood and no equipment, are available at a cost of $0.5. These tests can be used anywhere and will give a result within 15 minutes so that women can be screened and, if necessary, treated during the same visit.

Indeed, a new test has recently been shown to rapidly identify individuals who are infected with syphilis, HIV, or both, meaning screening during antenatal visits could be much simpler. These tests should be made everywhere laboratory facilities are not readily available for antenatal care.

It is abundantly clear that we have the tools today for preventing stillbirths attributable to malaria and syphilis.  Let us not be remembered for our failure to act.

Matthew Chico is a lecturer in the Department of Disease Control at the London School of Hygiene & Tropical Medicine

Rosanna Peeling is a professor and the chair of diagnostics research at the London School of Hygiene & Tropical Medicine

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Malaria and syphilis: leading infectious causes of stillbirth at global level

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