it is estimated that 85 millions pregnancies occurred in plasmodium falciparum malaria - endemic areas .
this pathology is among the main causes of the low birth weight ( lbw )     [ 2 , 3 ] , resulting from 3% to 8% neonatal and infant deaths     .
this led the world health organization ( who ) to recommend a package of affordable interventions including the use of the insecticide - treated nets ( itns ) , the intermittent presumptive treatment ( ipt ) with sulfadoxine - pyrimethamine ( sp ) , and the effective case management of clinical malaria with recommended antimalarials .
the ipt with sp ( ipt - sp ) is given free of charge under direct observed therapy ( dot ) during the antenatal clinics ( ancs ) at regular predefined intervals of time , with the aim to achieve the clearance of the existing plasmodium falciparum asymptomatic infection ( therapeutic effect ) and the suppression of new maternal infections ( prophylactic effect ) over a period of time .
at least two doses of ipt - sp are recommended during the second and third trimesters of pregnancy .
the occurring of clinical malaria should be treated with quinine or artemisinin - based combinations .
quinine is considered to be a safe drug along all the period of the pregnancy , but safety data of artemisinin derivatives during the first trimester of pregnancy are limited , thus it should not be prescribed in this period .  
ongoing assessments on the compliance of health care providers with national policy on malaria treatment are needed .
actually , no published data on prescribing practices in accordance to these new strategies are available in central african republic ( car ) and elsewhere .
since 2006 , the car malaria control programme is implementing the who new guidelines on malaria management [ 4 , 6 ] .
the training seminars of the health care providers ( nurses , midwives and midwives assistants , medical officers ) from public and private health centers were achieved . the supervision and the field training visit
the aim of this study was to design a preliminary assessment on the compliance of a trained staff in the malaria control new strategies at the main district maternity in bangui .
thus , we identified the antimalarials prescribed for possible clinical malaria episodes during the pregnancy and the timing profile of those prescriptions according the gestational age .
our study was conducted from june to september 2009 at one of the two main maternities of bangui city , the maternity of the castors government health centre .
this health centre is located in the most populated area of the city and is purposely selected during this study as a representative pilot center for the practice of the trained health care providers in bangui , regarding antimalarials prescription to pregnant women .
the study involved all women who gave birth at the castors health centre maternity , and who have been clinically followed up in the antenatal care services at this same health centre .
in april 2006 , the anc staff ( 2 midwives and 6 midwives assistants ) has baseline training in the malaria control new strategies and is regularly supervised once per year accordingly .
this was the key indication for us to assess how the implementation of the new prescribing recommendations is progressing .
the average proportion of pregnant women in bangui who deliver in this maternity each year is estimated at 35% ( 2500 deliveries ) , and more than 95% of those women have their anc visits in this health centre ( data checked from the centre registers ) . after delivery , all the women from whom we got a written informed consent were immediately approached to record the prescribed antimalarials from their antenatal clinics ( anc ) cards . women who have not done all their anc visits at the castors health centre were excluded from this study .
all the sp records were the ipt - sp , which is the only antimalarial treatment given free of charge to the pregnant women ( direct observed therapy or dot ) .
this study was undertaken during a preliminary assessment of our project aiming at estimating the burden of hiv infection on the malaria prevention effectiveness during pregnancy in car .
this project was reviewed and approved by the scientific committee board of the university of bangui in charge of the validation of scientific protocol studies in car .
data were entered in epiinfo software version 3.5.1 ( cdc , atlanta , usa ) .
an investigator checked the epiinfo data base and corrected errors identified after referring to questionnaires .
data consistency was also verified using excel software ( microsoft corporation ) , and statistical analysis was achieved in stata 8.0 ( statacorp lp , usa ) .
proportions were compared with the -test ( or fisher test ) , and a p value at less than 0.05 was considered statistically significant .
their mean ( sd ) age was 24.7 ( 6.0 ) years ( range : 15 to 45 years ) .
a proportion of 21.8% ( n = 123 ) has been given at least one dose of ipt - sp .
only a proportion of 8.5% of them was given more than one dose of ipt - sp , as is recommended by the malaria control programme .  
overall , 163 pregnant women ( 28.8% ) were prescribed at least once an antimalarial for a possible clinical malaria episode .
eight anc cards contained 3 prescriptions ( 4.9% ) , and 29 anc cards contained 2 prescriptions ( 17.8% ) .
overall , four different groups of antimalarials were prescribed to the 163 women during the pregnancy , and the total number of those prescriptions was 208 ( the mean number of antimalarials prescription per women was 1.28 ) : quinine ( 56.7% ) , artemisinin - based combinations ( 26.8% ) , artemisinin monotherapies ( 14.4% ) , and other antimalarials monotherapies ( chloroquine , halofantrine , and amodiaquine ) .
the malaria laboratory microscopy diagnosis was available in the anc cards for only 18.9% antimalarials prescriptions ( 39/208 ) .
all those results were positive for a plasmodium falciparum , and the quinine was the only antimalarial prescribed accordingly .
antimalarials prescription began in the second month of gestation , reaching a peak at the sixth month of gestation .
the global proportion of those prescriptions significantly increased from the first trimester ( 16.8% ) to the second trimester ( 56.3% ) ( p value < 10 ) .
there were a total of 85 artemisinin components prescriptions during the current pregnancies ( 30 artemisinin monotherapies and 55 artemisinin - based combinations ) . among those prescriptions , four ( 13.3% ) prescriptions of artemisinin monotherapies and six ( 10.9% ) artemisinin - based combinations prescriptions occurred in the first trimester of pregnancy
the number of quinine prescription in the first trimester is 24/35 ( 68.6% ) and in the second trimester 65/117 ( 55.5% ) , while artemisinin - based combinations are 6/35 ( 17.1% ) for the first trimester and 40/117 for the second , and artemisinin monotherapy is 4/35 ( 11.4% ) for the first trimester and 22/117 ( 18.8% ) for the second .   within each category of antimalarials ,
the distribution trend increased from the first trimester to the second trimester : 24/118 ( 20.3% ) to 65/118 ( 55.1% ) for quinine , 6/55 ( 10.9% ) to 30/55 ( 54.5% ) for artemisinin - based combinations , and 4/30 ( 13.3% ) to 22/30 ( 73.3% ) for artemisinin monotherapies .  
details on the trend of those antimalarials prescription according to pregnancy age are showed on figure 1 ( see supplementary material available online at doi : 10.4061/2011/414510 ) .
this study showed that nearly three years following the change in national malaria control strategies during pregnancy , more than 80% of prescriptions represented the recommended antimalarials ( the quinine and artemisinin - based combinations ) .
the availability and affordability of this antimalarial in the health centre pharmacies ( a cure costs less than 2  us$ ) could have motivated this preference .
the quinine is also preferred by the prescribers during malaria management practices in bangui , and the predominant argument is the prompt evidence of its activity on malaria symptoms .  
antenatal exposures to antimalarial drugs during the pregnancy are a perpetual concern because there is limited information on their safety .
indeed , pregnant women are systematically excluded from clinical trials , hence the lack of evidence bases on the toxicity of antimalarial drugs in this population .
nevertheless , the obligation to treat ( to save lives ) led to the use of antimalarials drugs during pregnancy , as the experts agreed on the safety of the quinine along all the period of the pregnancy and the artemisinin - based combinations during the two last trimesters of the pregnancy .
thus , the prescription of the artemisinin derivatives which occurred in the first trimester of pregnancy is relevant because it is not advisable [ 4 , 9 ] and may cause embryotoxicity      or enhance embryolethality risks     .
thus , this regimen is no longer recommended by who due to its short plasmatic half - life , which could enhance the spreading of parasite resistance and compromise the efficacy of artemisinin - based combinations .
it is also surprising that there were 3 prescriptions of the chloroquine which has been withdrawn from the car market because of its lack of efficacy on malaria .
the first limitation was the method used to record the prescriptions of antimalarial drugs from solely anc cards .
indeed , other antimalarials taken by the women during their current pregnancies could not have been reported in the anc cards . however ,
recording antimalarials use through interview could lead to error because some pregnant women may not have accurately recalled the name of the antimalarial prescribed and/or taken , thus leading to biased findings on the health staffs compliance with the national recommended guidelines .
the second limitation is that laboratory malaria analysis results were poorly reported at the anc visits cards .
indeed , the clinical symptoms have not always the positive predictive value of malaria     [ 14 , 15 ] .
another limitation is that the findings from this study could be different in other health maternities centres due to changes of staff ( new health providers ) , or specificities related to prescribing habits .
the findings of this study from a district maternity in bangui provide the indicator of the antimalarials groups prescribed to pregnant women , during the period of the new malaria treatment guidelines implementation in car . the observation from this study is that there is a satisfying adherence by trained health care providers to the indicated categories of antimalarials during pregnancy from the anc staff of the castors health center of bangui . nevertheless , there are some errors of antimalarials prescription related to the period of gestation and to not recommended antimalarials prescriptions .
the activities focusing on the supervision of health care providers should be reinforced to assure adequate malaria treatment during pregnancy according to national guidelines .
in particular , our findings helped the national malaria programme to enhance supervision activities to the staff of castors maternity centre in bangui in order to limit the prescription errors in the future .
further studies assessing the indicators of the national antimalarial policy implementation to the pregnant population are needed in other areas of the country .
 
 introduction . 
 the aim of this study was to identify the antimalarials prescribed during the pregnancy and to document their timing . method . from june to september 2009 , a survey was conducted on 565 women who gave birth in the castors maternity in bangui . 
 the antenatal clinics cards were checked in order to record the types of antimalarials prescribed during pregnancy according to gestational age . 
 results . 
 a proportion of 28.8% anc cards contained at least one antimalarial prescription . 
 the commonest categories of antimalarials prescribed were : quinine ( 56.7% ) , artemisinin - based combinations ( 26.8% ) and artemisinin monotherapy ( 14.4% ) . among the prescriptions that occurred in the first trimester of pregnancy , 
 artemisinin - based combinations and artemisinin monotherapies represented the proportions of ( 10.9% ) and ( 13.3% ) . respectively . 
 conclusion . 
 this study showed a relatively high rate ( > 80% ) of the recommended antimalarials prescription regarding categories of indicated antimalarials from national guidelines . 
 but , there is a concern about the prescription of the artemisinin derivatives in the first trimester of pregnancy , and the prescription of artemisinin monotherapy . 
 thus , the reinforcement of awareness activities of health care providers on the national malaria treatment during pregnancy is suggested . 
1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusion