Continental concerted efforts to control the seventh outbreak of Ebola Virus disease in Uganda: The first 90 days of the response.

On 20th September 2022, Uganda declared the 7th outbreak of Ebola virus disease (EVD) caused by the Sudan Ebola strain following the confirmation of a case admitted at Mubende Regional Referral Hospital. Upon confirmation, the Government of Uganda immediately activated the national incident management system to initiate response activities. Additionally, a multi-country emergency stakeholder meeting was held in Kampala; convening Ministers of Health from neighbouring Member States to undertake cross-border preparedness and response actions. The outbreak spanned 69 days and recorded 164 cases (142 confirmed, 22 probable), 87 recoveries and 77 deaths (case fatality ratio of 47%). Nine out of 136 districts were affected with transmission taking place in 5 districts but spilling over in 4 districts without secondary transmission. As part of the response, the Government galvanised robust community mobilisation and initiated assessment of medical counter measures including therapeutics, new diagnostics and vaccines. This paper highlights the response actions that contributed to the containment of this outbreak in addition to the challenges faced with a special focus on key recommendations for better control of future outbreaks.

Proportion, Characteristics and Maternal Outcome of women referred for childbirth to a tertiary hospital in northern Tanzania - A descriptive retrospective study based on a hospital birth registry.

OBJECTIVE: Timely identification of danger signs and prompt referral to higher level may prevent complication associated with childbirth. With a high MMR in Tanzania, there is need to highlight the information on the proportion of women referred to tertiary healthcare, their basic characteristics and outcomes. This study aimed to determine the proportion, basic characteristics and outcomes among women referred while in labour, from lower health facilities to a tertiary hospital in northern Tanzania. METHODS: A descriptive retrospective study based on a hospital birth registry was conducted using consecutive stored data on pregnant women referred while in labour and managed at a tertiary hospital in northern Tanzania, between the years 2000 and 2015. RESULTS: During the study period, a total of 53,662 deliveries were managed. Among these, 6066 women were referred from lower health facilities, with 4193 (69.2%) of them being referred while in labour. The main reason for referral was poor progress of labour (31.0%), followed by prolonged labour (27.1%) and obstructed labour (19.5%). The rate of caesarean section was 44.6%. A total of 292 maternal deaths occurred between 2000 and 2015. Of these, almost a quarter (22.6%) occurred in women referred from other health facilities while in labour. CONCLUSION: Majority of referred women while in labour from lower health facilities are linked to maternal complications associated with childbirth. This underscores the need to further explore the competence of lower health facilities to quickly detect complications and provide effective emergency obstetric care, as well as timely referral to higher-level facility.

Maternal obesity and intrapartum obstetric complications among pregnant women: Retrospective cohort analysis from medical birth registry in Northern Tanzania.

BACKGROUND: In the last decade, Tanzania has observed a dramatic increase in overweight and obesity among women of childbearing age, a demographic shift that has been associated with intrapartum obstetric complications in high-income countries. Similar increases in maternal morbidity including postpartum haemorrhage, hypertensive disorders of pregnancy, and rates of caesarean delivery have not yet documented in Tanzania. This analysis describes intrapartum obstetric complications associated with maternal obesity among pregnant women delivering at teaching hospital in Northern Tanzania. METHODS: A retrospective cohort analysis was conducted using the hospital's antenatal care (ANC) and birth registries from 2000 to 2015. The World Health Organization (WHO) body mass index (BMI) categories were applied to classify BMI status of pregnant women within 16 weeks of gestational age at their first ANC visit. Relative risk (RR) of obstetric complications with corresponding 95% confidence intervals (CIs) were estimated using multivariable log-binomial regression, adjusting for clustering effect for the correlation between multiple deliveries of the same woman. RESULTS: Among 11 873 women who delivered babies in the hospital during the study period, 3139 (26.5%) fit the definition of overweight and 1464 (12.3%) women with obesity. Compared with women with normal weight, women with obesity were at over 2.6 times at risks of experiencing pre-eclampsia/eclampsia (RR: 2.66; 95% CI, 2.08-3.40), pregnancy-induced hypertension (RR 2.13; 95% CI, 1.26-3.62), and postpartum haemorrhage (RR 1.22; 95% CI, 1.00-1.49). Additionally, women with obesity had also higher risk of either elective (RR 2.40; 95% CI, 1.88-3.06) or emergency (RR: 1.53; 95% CI, 1.34-1.75) caesarean delivery. CONCLUSION: Maternal obesity is an emerging health problem in Tanzania. This study clearly demonstrates an association between increased risk of intrapartum complications and obesity. A review of guidelines around ANC screening and intrapartum care practices considering BMI, as well as appropriate messages for women with obesity, should be considered to improve maternal and newborn outcomes.

Vulnerable at Each Step in the PMTCT Care Cascade: High Loss to Follow Up During Pregnancy and the Postpartum Period in Tanzania.

In 2013, Tanzania adopted the World Health Organization's Option B+ guidelines for prevention of mother-to-child transmission of HIV (PMTCT), whereby all HIV-infected pregnant women initiate lifelong antiretroviral therapy. This study examined retention in PMTCT across critical junctures in the care continuum. This was a retrospective study of patient-level data for a cohort of women enrolled in PMTCT during the first year of Option B+ in Tanzania. Retention in care was described across three periods: (1) the first month of antenatal care (ANC), (2) pregnancy, and (3) the postpartum period. Logistic regression was used to identify factors associated with loss to follow up (LTFU) during the first month of ANC. Survival analyses were used to identify factors associated with LTFU during pregnancy and the postpartum periods. 650 participants were included in the cohort; 262 (40.3%) were newly diagnosed with HIV. Two years after delivery, 383/650 (58.7%) were LTFU. Of the 383 LTFU, 73 (19.1%) were lost during the first month of ANC, 44 (11.5%) during pregnancy, and 266 (69.5%) after delivery. Being newly diagnosed with HIV predicted higher LTFU during the first month of ANC (aOR 1.76; 95% CI 1.06-2.94) and faster time to LTFU during the postpartum period (adjusted relative time, 0.68; 95% CI 0.51-0.89). High LTFU occurred across the PMTCT continuum, including immediately after enrollment into ANC and the postpartum period. Ongoing research is needed to encourage treatment uptake and sustained engagement after delivery.

Unpacking Loss to Follow-Up Among HIV-Infected Women Initiated on Option B+ In Northern Tanzania: A Retrospective Chart Review.

BACKGROUND: In 2014, Tanzania adopted the Option B+ policy for the prevention of mother-to-child transmission of HIV (PMTCT), which stipulates lifelong antiretroviral therapy (ART) for HIV-infected pregnant, postpartum and breastfeeding women, irrespective of CD4 count or WHO clinical staging. Loss to follow-up (LTFU) during pregnancy and the postpartum period may undermine the effectiveness of Option B+. Factors associated with no follow-up (NFU) care, may differ from those associated with LTFU at later time points. This study aimed to identify factors associated with NFU and LTFU among women who initiate ART under Option B+ in Moshi, Tanzania. METHODS: We conducted a retrospective chart review of patients initiating ART on Option B+ between February 2014 and December 2015 in Moshi Municipality, Tanzania. Multivariable log-binomial regression was used to analyse factors associated with NFU. Kaplan-Meier survival functions were used to estimate time to LTFU. Multivariable Cox proportion hazards regression models were used to evaluate variables associated with time to LTFU. RESULTS: Among 468 women initiating ART under the option B+ programme, 109 (23.3%) had NFU after the initial appointment. Factors associated with increased risk of NFU were: age < 25 years (adjusted hazard ratio [aRR] 1.7; 95% CI, 1.2 to 2.3), initiating ART at a hospital compared to a lower level health facilities (aRR 2.9; 95% CI, 2.1 to 3.9), and having no treatment supporter (aRR 1.5; 95% CI, 1.1 to 2.1). LTFU was higher in women aged < 25 years (aHR 1.4; 95% CI, 1.1 to 1.9), and in women with no treatment supporter (aHR 1.8; 95% CI, 1.4 to 2.3). In women who returned to the clinic after ART initiation, no factor was significantly associated with LTFU. CONCLUSION: The factors associated with NFU (being young, not having a treatment supporter, and being diagnosed at hospitals) reflect a vulnerable and potentially highly mobile population. Additional interventions are needed to support and retain this group at ART initiation on Option B+.

Prevalence, determinants and knowledge of antibacterial self-medication: A cross sectional study in North-eastern Tanzania.

Self-medication is very common especially in developing countries and is documented to be associated with many health risks including antibiotic resistance. This study investigated the prevalence, determinants and knowledge of self-medication among residents of Siha District in Tanzania. A cross-sectional study was conducted among 300 residents in a rural District of Kilimanjaro region, North-eastern Tanzania from 1st to 28th April 2017. A semi-structured questionnaire was used to collect information regarding drugs used, knowledge, history and reasons for antibiotic self-medication. Log-binomial regression analysis was done using STATA 13 to examine factors associated with self-medication. A slightly majority of the respondents (58%) admitted to self-medication. Antibiotics most commonly utilized were amoxycillin (43%) and an antiprotozoal drug metronidazole (10%). The most common symptoms that led to self-medication were cough (51.17%), headache/ fever/ malaria (25.57%) and diarrhoea (21.59%). The most common reasons for self-medication were emergency illness (24.00%), health facility charges (20.33%), proximity of pharmacy to home (17.00%) and no reason (16.66%). Almost all reported that self-medication is not better than seeking medical consultation, 98% can result into harmful effects and 96% can result to drug resistance. The level of self-medication in this study is comparable with findings from other studies in developing countries. Pharmacies were commonly used as the first point of medical care. There is therefore a need for educative antibiotic legislative intervention to mitigate the adverse effects of antibiotic self-medication in Siha district in Tanzania.

Predictors of residual antimalarial drugs in the blood in community surveys in Tanzania.

BACKGROUND: Understanding pattern of antimalarials use at large scale helps ensuring appropriate use of treatments and preventing the spread of resistant parasites. We estimated the proportion of individuals in community surveys with residual antimalarials in their blood and identified the factors associated with the presence of the most commonly detected drugs, lumefantrine and/or desbutyl-lumefantrine (LF/DLF) or sulfadoxine-pyrimethamine (SP). METHODS: A cross-sectional survey was conducted in 2015 in three regions of Tanzania with different levels of malaria endemicity. Interviews were conducted and blood samples collected through household surveys for further antimalarial measurements using liquid chromatography coupled to tandem mass spectrometry. In addition, diagnosis and treatment availability was investigated through outlet surveys. Multilevel mixed effects logistic regression models were used to estimate odds ratios for having LF/DLF or SP in the blood. RESULTS: Amongst 6391 participants, 12.4% (792/6391) had LF/DLF and 8.0% (510/6391) SP in the blood. Factors associated with higher odds of detecting LF/DLF in the blood included fever in the previous two weeks (OR = 2.6, p<0.001), living in districts of higher malaria prevalence (OR = 1.5, p<0.001) and living in a ward in which all visited drug stores had artemisinin-based combination therapies in stocks (OR = 2.7, p = 0.020). Participants in older age groups were less likely to have LF/DLF in the blood (OR = 0.9, p<0.001). Factors associated with higher odds of having SP in the blood included being pregnant (OR = 4.6, p<0.001), living in Mwanza (OR = 3.9, p<0.001 compared to Mbeya), fever in the previous two weeks (OR = 1.7, p<0.001) and belonging to older age groups (OR = 1.2, p<0.001). CONCLUSION: The most significant predictors identified were expected. History of fever in the past two weeks and young age were significant predictors of LF/DLF in the blood, which is encouraging. Antimalarial drug pressure was high and hence the use of recommended first-line drugs in combination with malaria Rapid Diagnostics Tests should be promoted to ensure appropriate treatment.

Prevalence and antimicrobial sensitivity pattern of urinary tract infection among children with cerebral palsy, Moshi, Tanzania.

BACKGROUND: Urinary tract infection (UTI) in children with cerebral palsy (CP) is a challenging yet common clinical condition. Children with CP bare the greatest risk of contracting UTI because of their difficulties in neuromotor control which lead to delay of bladder control, causing incomplete bladder emptying and urine retention. METHOD: This was an analytical cross-sectional study that was conducted from September 2016 to March 2017 at Comprehensive Community Based Rehabilitation in Tanzania - Moshi and Kilimanjaro Christian Medical Centre Neurological Pediatrics Outpatient Clinic. All children who met the inclusion criteria were studied. Urine samples were collected at one point by catheterization, and urine dipstick and urine culture were done. Data were analyzed using SPSS version 20. RESULTS: A total of 99 children were enrolled in the study. The median age was 4 years (3-8 years); 53.5% were aged between 2 and 4 years. More than half were male. UTI was detected in 13.1% (n=13) of the children. Five causative agents of UTI were isolated, namely Escherichia coli, Proteus mirabilis, Klebsiella pneumonia, Staphylococcus aureus, and Enterococcus faecalis. The two most common organisms, E. coli and P. mirabilis, both had low sensitivity to ampicillin and co-trimoxazole while they were sensitive to ciprofloxacin and ceftriaxone. CONCLUSION: UTI is a common finding among children with CP. E. coli and P. mirabilis are the commonest causative agents and are sensitive to ciprofloxacin and ceftriaxone but have low sensitivity to ampicillin and co-trimoxazole.

Appropriateness of malaria diagnosis and treatment for fever episodes according to patient history and anti-malarial blood measurement: a cross-sectional survey from Tanzania.

BACKGROUND: Monitoring the impact of case management strategies at large scale is essential to evaluate the public health benefit they confer. The use of methodologies relying on objective and standardized endpoints, such as drug levels in the blood, should be encouraged. Population drug use, diagnosis and treatment appropriateness in case of fever according to patient history and anti-malarials blood concentration was evaluated. METHODS: A cross-sectional survey took place between May and August 2015 in three regions of Tanzania with different levels of malaria endemicity. Interviews were conducted and blood samples were collected by dried blood spots through household surveys for further anti-malarial measurements. Appropriate testing when individuals attended care was defined as a patient with history of fever being tested for malaria and appropriate treatment as (i) having anti-malarial in the blood if the test result was positive (ii) having anti-malarial in the blood if the person was not tested, and (iii) no anti-malarial in the blood when the test result was negative. RESULTS: Amongst 6391 participants included in the anti-malarial analysis, 20.8% (1330/6391) had anti-malarial drug detected in the blood. Only 28.0% (372/1330) of the individuals with anti-malarials in their blood reported the use of anti-malarials within the previous month. Amongst all participants, 16.0% (1021/6391) reported having had a fever in the previous 2 weeks and 37.5% of them (383/1021) had detectable levels of anti-malarials in the blood. Of the individuals who sought care in health facilities, 69.4% (172/248) were tested and 52.0% (129/248) appropriately treated. When other providers were sought, 6% (23/382) of the persons were appropriately tested and 44.2% (169/382) appropriately treated. Overall, the proportion of individuals treated was larger than that being tested [47.3% (298/630) treated, 31.0% (195/630) tested]. CONCLUSION: This study showed high prevalence of circulating anti-malarial drug in the sampled population. Efforts should be made to increase rapid diagnostic tests use at all levels of health care and improve compliance to test result in order to target febrile patients that are sick with malaria and reduce drug pressure. Objective drug measurements collected at community level represent a reliable tool to evaluate overall impact of case management strategies on population drug pressure.

Maternal and fetal risk factors for stillbirth in Northern Tanzania: A registry-based retrospective cohort study.

BACKGROUND: Stillbirth is a major cause of perinatal mortality and occurs disproportionately in developing countries including Tanzania. However, there is scant information regarding the predictors of this condition in Tanzania. This study aimed to determine maternal and fetal risk factors for stilbirth in northen Tanzania. METHODOLOGY: A retrospective cohort study was performed using maternally-linked data from the Kilimanjaro Christian Medical Centre birth registry. A total of 47681 women who had singleton delivery at KCMC between 2000 and 2014 were analyzed. Women with multiple gestations were excluded. Descriptive statistics were summarized using proportions and frequency. Chi-square test was used to determine risk factors for stillbirth in bivariate analysis. A multivariable regression model was used to estimate adjusted odds ratios (AOR) with 95% confidence intervals for maternal and fetal factors associated with stillbirth. A p-value of less than 0.05 was considered statistically significant. RESULTS: The frequency of stillbirth was 3.5%. Pre-eclampsia (AOR 3.99; 95% CI: 3.31-4.81) and placental abruption (AOR 22.62; 95% CI: 15.41-33.19) were the strongest maternal risk factors associated with still birth. While non-cephalic presentation (AOR 6.05; 95% CI: 4.77-7.66) and low birth weight (AOR 9.66; 95%CI: 8.66-10.77) were the fetal factors with the greatest impact on stillbirth. CONCLUSION: The rate of stillbirth in our study was consistent with past studies of developing countries. Numerous maternal and fetal factors risk factors were identified. Early identification of at risk pregnancies and appropriate intervention may help to reduce the occurrence of stillbirth.

Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality in rural Tanzania? The ETATMBA project.

OBJECTIVES: During late 2010, 36 trainees including 19 assistant medical officers (AMOs) 1 senior clinical officer (CO) and 16 nurse midwives/nurses were recruited from districts across rural Tanzania and invited to join the Enhancing Human Resources and Use of Appropriate Technologies for Maternal and Perinatal Survival in the sub-Saharan Africa (ETATMBA) training programme. The ETATMBA project was training associate clinicians (ACs) as advanced clinical leaders in emergency obstetric care. The trainees returned to health facilities across the country with the hope of being able to apply their new skills and knowledge. The main aim of this study was to explore the impact of the ETATMBA training on health outcomes including maternal and neonatal morbidity and mortality in their facilities. Secondly, to explore the challenges faced in working in these health facilities. DESIGN: The study is a pre-examination/postexamination of maternal and neonatal health indicators and a survey of health facilities in rural Tanzania. The facilities surveyed were those in which ETATMBA trainees were placed post-training. The maternal and neonatal indicators were collected for 2011 and 2013 and the survey of the facilities was in early 2014. RESULTS: 16 of 17 facilities were surveyed. Maternal deaths show a non-significant downward trend over the 2 years (282-232 cases/100,000 live births). There were no significant differences in maternal, neonatal and birth complication variables across the time-points. The survey of facilities revealed shortages in key areas and some are a serious concern. CONCLUSIONS: This study represents a snapshot of rural health facilities providing maternal and neonatal care in Tanzania. Enhancing knowledge, practical skills, and clinical leadership of ACs may have a positive impact on health outcomes. However, any impact may be confounded by the significant challenges in delivering a service in terms of resources. Thus, training may be beneficial, but it requires an infrastructure that supports it.

A qualitative process evaluation of training for non-physician clinicians/associate clinicians (NPCs/ACs) in emergency maternal, neonatal care and clinical leadership, impact on clinical services improvements in rural Tanzania: the ETATMBA project.

OBJECTIVES: The Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival in sub-Saharan Africa (ETATMBA) project is training non-physician clinicians as advanced clinical leaders in emergency maternal and newborn care in Tanzania and Malawi. The main aims of this process evaluation were to explore the implementation of the programme of training in Tanzania, how it was received, how or if the training has been implemented into practice and the challenges faced along the way. DESIGN: Qualitative interviews with trainees, trainers, district officers and others exploring the application of the training into practice. PARTICIPANTS: During late 2010 and 2011, 36 trainees including 19 assistant medical officers one senior clinical officer and 16 nurse midwives/nurses (anaesthesia) were recruited from districts across rural Tanzania and invited to join the ETATMBA training programme. RESULTS: Trainees (n=36) completed the training returning to 17 facilities, two left and one died shortly after training. Of the remaining trainees, 27 were interviewed at their health facility. Training was well received and knowledge and skills were increased. There were a number of challenges faced by trainees, not least that their new skills could not be practised because the facilities they returned to were not upgraded. Nonetheless, there is evidence that the training is having an effect locally on health outcomes, like maternal and neonatal mortality, and the trainees are sharing their new knowledge and skills with others. CONCLUSIONS: The outcome of this evaluation is encouraging but highlights that there are many ongoing challenges relating to infrastructure (including appropriate facilities, electricity and water) and the availability of basic supplies and drugs. This cadre of workers is a dedicated and valuable resource that can make a difference, which with better support could make a greater contribution to healthcare in the country.

Who is left behind on the road to universal facility delivery? A cross-sectional multilevel analysis in rural Tanzania.

OBJECTIVES: To examine factors associated with home delivery among women in Pwani Region, Tanzania, which has experienced a rapid rise in facility delivery coverage. METHODS: Cross-sectional data from a population-based survey of women residing in rural areas of Pwani Region were linked to health facility locations. We fitted multilevel logistic models to examine individual and community factors associated with home delivery. RESULTS: A total of 752 (27.95%) of the 2691 women who completed the survey delivered their last child at home. Women were less likely to deliver at home if they had any primary education [odds ratio (OR) 0.62; 95% confidence interval (CI): 0.50, 0.79], were primiparous (OR: 0.52; 95% CI: 0.37, 0.73), had more exposure to media (OR: 0.80; 95% CI: 0.66, 0.96) or had received more (OR: 0.78; 95% CI: 0.63, 0.96) or better quality antenatal care (ANC) services (OR: 0.48; 95% CI: 0.34, 0.67). Increased wealth was strongly associated with lower odds of home delivery (OR: 0.27; 95% CI: 0.18, 0.39), as was living in a village that grew cash crops (OR: 0.56; 95% CI: 0.35, 0.88). Farther distance to hospital, but not to lower level facilities, was associated with higher likelihood of home delivery (OR 2.49; 95% CI: 1.60, 3.88). CONCLUSIONS: Poverty, multiparity, weak ANC and distance to hospital were associated with persistence of home delivery in a region with high coverage of facility delivery. A pro-poor path to universal coverage of safe delivery requires a greater focus on quality of care and more intensive outreach to poor and multiparous women.

Medication exposure during pregnancy: a pilot pharmacovigilance system using health and demographic surveillance platform.

BACKGROUND: There is limited safety information on most drugs used during pregnancy. This is especially true for medication against tropical diseases because pharmacovigilance systems are not much developed in these settings. The aim of the present study was to demonstrate feasibility of using Health and Demographic Surveillance System (HDSS) as a platform to monitor drug safety in pregnancy. METHODS: Pregnant women with gestational age below 20 weeks were recruited from Reproductive and Child Health (RCH) clinics or from monthly house visits carried out for the HDSS. A structured questionnaire was used to interview pregnant women. Participants were followed on monthly basis to record any new drug used as well as pregnancy outcome. RESULTS: 1089 pregnant women were recruited; 994 (91.3%) completed the follow-up until delivery. 98% women reported to have taken at least one medication during pregnancy, mainly those used in antenatal programmes. Other most reported drugs were analgesics (24%), antibiotics (17%), and antimalarial (15%), excluding IPTp. Artemether-lumefantrine (AL) was the most used antimalarial for treating illness by nearly 3/4 compared to other groups of malaria drugs. Overall, antimalarial and antibiotic exposures in pregnancy were not significantly associated with adverse pregnancy outcome. Iron and folic acid supplementation were associated with decreased risk of miscarriage/stillbirth (OR 0.1; 0.08-0.3). CONCLUSION: Almost all women were exposed to medication during pregnancy. Exposure to iron and folic acid had a beneficial effect on pregnancy outcome. HDSS proved to be a useful platform to establish a reliable pharmacovigilance system in resource-limited countries. Widening drug safety information is essential to facilitate evidence based risk-benefit decision for treatment during pregnancy, a major challenge with newly marketed medicines.

Safety of artemether-lumefantrine exposure in first trimester of pregnancy: an observational cohort.

BACKGROUND: There is limited data available regarding safety profile of artemisinins in early pregnancy. They are, therefore, not recommended by WHO as a first-line treatment for malaria in first trimester due to associated embryo-foetal toxicity in animal studies. The study assessed birth outcome among pregnant women inadvertently exposed to artemether-lumefantrine (AL) during first trimester in comparison to those of women exposed to other anti-malarial drugs or no drug at all during the same period of pregnancy. METHODS: Pregnant women with gestational age <20 weeks were recruited from Maternal Health clinics or from monthly house visits (demographic surveillance), and followed prospectively until delivery. RESULTS: 2167 pregnant women were recruited and 1783 (82.3%) completed the study until delivery. 319 (17.9%) used anti-malarials in first trimester, of whom 172 (53.9%) used (AL), 78 (24.4%) quinine, 66 (20.7%) sulphadoxine-pyrimethamine (SP) and 11 (3.4%) amodiaquine. Quinine exposure in first trimester was associated with an increased risk of miscarriage/stillbirth (OR 2.5; 1.3-5.1) and premature birth (OR 2.6; 1.3-5.3) as opposed to AL with (OR 1.4; 0.8-2.5) for miscarriage/stillbirth and (OR 0.9; 0.5-1.8) for preterm birth. Congenital anomalies were identified in 4 exposure groups namely AL only (1/164[0.6%]), quinine only (1/70[1.4%]), SP (2/66[3.0%]), and non-anti-malarial exposure group (19/1464[1.3%]). CONCLUSION: Exposure to AL in first trimester was more common than to any other anti-malarial drugs. Quinine exposure was associated with adverse pregnancy outcomes which was not the case following other anti-malarial intake. Since AL and quinine were used according to their availability rather than to disease severity, it is likely that the effect observed was related to the drug and not to the disease itself. Even with this caveat, a change of policy from quinine to AL for the treatment of uncomplicated malaria during the whole pregnancy period could be already envisaged.