WHO recommendation on intermittent preventive treatment of malaria in pregnancy

WHO recommendation on intermittent preventive treatment of malaria in pregnancy



In malaria-endemic areas in Africa, intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommended for all pregnant women. Dosing should start in the second trimester, and doses should be given at least one month apart, with the objective of ensuring that at least three doses are received.

(Context-specific recommendation)


Publication history

First published: December 2016

Updated: No update planned

Assessed as up-to-date: December 2016



  • This recommendation has been integrated from the WHO Guidelines for the treatment of malaria (2015), where it is considered to be a strong recommendation based on high-quality evidence (1).
  • Malaria infection during pregnancy is a major public health problem, with substantial risks for the mother, her fetus and the newborn. WHO recommends a package of interventions for preventing and controlling malaria during pregnancy, which includes promotion and use of insecticide-treated nets, appropriate case management with prompt, effective treatment, and, in areas with moderate to high transmission of Plasmodium falciparum, administration of IPTp-SP (1).
  • The high-quality evidence supporting this recommendation was derived from a systematic review of seven RCTs conducted in malaria-endemic countries, which shows that three or more doses of sulfadoxine-pyrimethamine (SP) is associated with reduced maternal parasitaemia, fewer low-birthweight infants and increased mean birth weight compared with two doses only (2).
  • The malaria GDG noted that most evidence was derived from women in their first and second pregnancies; however, the limited evidence on IPTp-SP from women in their third and subsequent pregnancies was consistent with benefit (1).
  • To ensure that pregnant women in endemic areas start IPTp-SP as early as possible in the second trimester, policy-makers should ensure health system contact with women at 13 weeks of gestation. Policy-makers could also consider supplying women with their first SP dose at the first ANC visit with instructions about the date (corresponding to 13 weeks of gestation) on which the medicine should be taken.
  • SP acts by interfering with folic acid synthesis in the malaria parasite, thereby inhibiting its life-cycle. There is some evidence that high doses of supplemented folic acid (i.e. 5 mg daily or more) may interfere with the efficacy of SP in pregnancy (3). Countries should ensure that they procure and distribute folic acid supplements for antenatal use at the recommended antenatal dosage (i.e. 0.4 mg daily).
  • The malaria GDG noted that there is insufficient evidence on the safety, efficacy and pharmacokinetics of most antimalarial agents in pregnancy, particularly during the first trimester (1).
  • Detailed evidence and guidance related to the recommendation can be found in the 2015 guidelines (1), available at: http://www.who.int/malaria/publications/atoz/9789241549127/en/



In 2016, 91 countries reported a total of 216 million cases of malaria, an increase of 5 million cases over the previous year. The global tally of malaria deaths reached 445 000 deaths, about the same number reported in 2015. Although malaria case incidence has fallen globally since 2010, the rate of decline has stalled and even reversed in some regions since 2014. Mortality rates have followed a similar pattern. The WHO African Region continues to account for about 90% of malaria cases and deaths worldwide. Fifteen countries – all but one in sub-Saharan Africa – carry 80% of the global malaria burden. Clearly, if we are to get the global malaria response back on track, supporting the most heavily affected countries in this region must be our primary focus. (4)



The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (5). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (6) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (7) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (8) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

  • For pregnant women (P), does IPTp (I) for malaria compared with no IPTp (C) improve health outcomes (O)?


Evidence summary

Detailed evidence and guidance related to the recommendation can be found in the 2015 guidelines (1), available at: http://www.who.int/malaria/publications/atoz/9789241549127/en/


Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.


Research implications

The GDG did not identify any priority question related to this recommendation


Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health





  1. Guidelines for the treatment of malaria, third edition. Geneva: World Health Organization; 2015 (http://apps.who.int/iris/ bitstream/10665/162441/1/9789241549127_ eng.pdf, accessed 28 September 2016).
  2. Kayentao K, Garner P, van Eijk AM, Naidoo I, Roper C, Mulokozi A et al. Intermittent preventive therapy for malaria during pregnancy using 2 vs 3 or more doses of sulfadoxine– pyrimethamine and risk of low birth weight in Africa: systematic review and meta-analysis. JAMA. 2013;309:594–604.
  3. Roll Back Malaria Partnership Malaria in Pregnancy Working Group. Consensus statement on folic acid supplementation during pregnancy. Geneva; 2015 (https://www.pmi.gov/ docs/default-source/default-document-library/ tools-curricula/consensus-statement-folicacid-supplementation-during-pregnancy.pdf, accessed 26 September 2016).
  4. WHO World malaria report 2017 (http://www.who.int/malaria/publications/world-malaria-report-2017/report...
  5. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  6. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  7. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  8. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).


Citation: WHO Reproductive Health Library. WHO recommendation on intermittent preventive treatment of malaria in pregnancy. (December 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.