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Plasmodium falciparum infections in pregnant women are a cause of maternal anemia and low birth weight babies in high endemic areas such as sub-Saharan Africa. However, because of little overt clinical symptoms due to (partial) immunity, pregnant women are not challenged to seek medical care. Therefore, instead of case management, intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is given to pregnant women at antenatal visits. Although this strategy reduces low birth weight caused by malaria in pregnancy, the efficacy is threatened as a result of low coverage and resistance to sulfadoxine-pyrimethamine. In this thesis an intervention trial is described of deploying community health workers for home screening of malaria in pregnant women, by using rapid diagnostic tests, and treatment with artemether-lumefantrine in case of a positive test. Furthermore, resistance against sulfadoxine-pyrimethamine was assessed in the study area by studying mutations in two genes of P. falciparum, plus it was studied whether the mutation prevalence increases during pregnancy as a result of received IPTp-SP doses. In part two, it was studied whether host biomarkers might serve as a diagnostic tool for pregnancy malaria, since current diagnostics such as rapid tests have a detection limit that is insufficient in detecting a large part of infected women. Also the level of antibodies against the pregnancy-specific erythrocyte surface antigen of P. falciparum, VAR2CSA, was determined in pregnant women from second trimester up to delivery. These levels were evaluated against malaria infection status during pregnancy and at delivery, parasite densities and low birth weight babies.

It appears that malaria in Rwanda is not a major contributor to adverse outcomes of pregnancy anymore from a public health perspective but it can still give problems in individual patients, also in areas of low malaria transmission. This thesis shows that for individual cases the current treatment options are safe and sufficient but it remains of utmost important to closely follow pregnant women. Although most of malaria infected women will develop symptoms and seek help, active monitoring during pregnancy is important especially when their household members contract malaria parasitaemia should be treated. Only this special attention for the individual pregnant women, which is different from the IPT approach in other sub-Sahara countries, will ensure that malaria will not again cause the severe effects that it has in high endemic areas.