Motherhood and malaria: treating pregnant women in Thailand

What does the thalidomide tragedy have to do with controlling malaria in refugee camps on the Thai-Burmese border? According to Dr Rose McGready, Reader in Tropical Medicine and senior researcher at the Shoklo Malaria Research Unit in Thailand, it is one of the reasons that trials of drug treatments for malaria in pregnancy have been neglected. Trials of such treatments take longer because the perceived risk is high; drug companies lack incentives; more stringent controls are in place since the 1960s to ensure the safety of both mother and child; and there is an underlying fear of repeating the tragedy. As a result, there is a tendency to rely on old, safe antimalarials in pregnancy, even if they are no longer used in the general population because the malaria parasite has become resistant to them.

Dr McGready is a key member of the programme begun by the Shoklo Unit's director Professor François Nosten in 1986. This offers early diagnosis and treatment of malaria to pregnant mothers through a network of antenatal clinics along the border between Thailand and Burma, where the disease is highly endemic. The Shoklo Unit is an outpost of the Mahidol-Oxford Research Unit in Bangkok, one of the world's leading centres for research in malaria.

Most of the patients in the clinics are refugees or migrant workers from Burma. The refugees now live in a single large camp, Mae La, with a population of 45,000. Clinics are also operating in villages up and down the border that have a high population of migrant workers.

'It has made it very easy for any woman to have a malaria smear, and we encourage them to come every week', says Dr McGready. 'We can treat malaria before they become sick. When François started working, one woman died of malaria for every hundred live births – a huge burden. Within the first five or six years that figure was halved. And now we haven't had a death from malaria in pregnancy in the refugee camp for seven years.'

In the Mae La clinic Dr McGready and her colleagues see 700–800 women on a regular basis, mostly coming every week, and operate a 24-hour delivery room. Some of those who test positive for malaria are entered into drug treatment studies. Currently Dr McGready is testing three different short course (3–4 day) combination therapies that are likely to be better tolerated than the current option, which requires women to take two different medicines for seven days. 'If they don't show up, someone will go and find them', she says. 'It's really important for them to finish the course because of the danger that resistance will develop.' As to fears that the drugs might harm the baby, these have so far proved unfounded: malaria is a much bigger threat, and can cause miscarriage, low birthweight or anaemia even if the mother survives.

Dr McGready has helped to train 40 midwives from within the camp, and their role in educating their own community has been vital. 'One of the successes of the field research is that it's not a foreign doctor saying you must do this, it's their own people advising them on what to do'.