Malaria Prevention During Pregnancy: An Antenatal Intervention Strategy Whose Time Has Come

Linda J. Schultz; Richard W. Steketee; Monica Parise; Jack J. Wirima; Aggrey Oloo; Bernard Nahlen

Summary: In sub-Saharan Africa, infection with Plasmodium falciparum during pregnancy is a major contributor to both maternal morbidity and perinatal morbidity and mortality. However, because maternal malaria infection is one of the few contributors to morbidity and mortality that is amenable to intervention once a woman becomes pregnant, effective antimalarials should be provided as part of an antenatal care package. In Malawi and in the Kisumu district of western Kenya, women's knowledge and attitudes, delivery of services at antenatal clinics (ANCs), and utilization of ANCs to assess the opportunities for and obstacles to delivery of antimalarials and other selected interventions were examined. In both settings, approximately 90% of women perceived malaria as a health threat during pregnancy and believed that antimalarials could be an effective treatment. In Malawi, where the antenatal program included weekly chloroquine (CQ) prophylaxis, over 25% of women reported that they had not received any CQ. Antimalarials were not routinely delivered through ANCs in Kenya, resulting in 96% of women not receiving CQ. Delivery of other key antenatal interventions, including tetanus toxoid (TT), hematinics, and syphilis testing and treatment, was also poor, despite the finding that over 85% of pregnant women attended ANCs at least twice during their pregnancy. Pregnant women are therefore accessing ANCs, yet health care systems are failing to deliver appropriate interventions. Efforts to improve antenatal care must concentrate on the delivery of interventions known to be effective.

Introduction

Approximately half a million women die each year during pregnancy or childbirth. Of these deaths, 99% occur in developing countries (WHO 1991). Pregnant women in sub-Saharan Africa experience the highest risk, with reported maternal mortality rates ranging from 500 to 700 per 100,000 live births, a rate approximately 200 times that for women in developed countries (WHO 1991). Similarly, stillbirths and neonatal deaths (deaths within the first 28 days of life) are common and occur disproportionately in developing countries; reported perinatal mortality rates in sub-Saharan Africa range from 45 to 75 deaths per 1000 births (Greenwood et al. 1987; Nordbeck et al. 1984; Steketee et al. 1994) compared with about 9 deaths per 1000 births in developed countries (Booth 1979; National Center for Health Statistics 1992). Reduction of maternal and perinatal morbidity and mortality needs a focused effort to deliver effective antenatal care, which is one of the four critical strategies of the Safe Motherhood Initiative (Mahler 1987).

In sub-Saharan Africa, Plasmodium falciparum malaria is an important contributor to maternal morbidity and perinatal morbidity and mortality. During pregnancy, particularly among primi- and secundigravidas, women are at increased risk of malaria parasitemia, malarial illness (McGregor 1984; Steketee et al. 1988; Keuter et al. 1990), and anemia (Gilles et al. 1969; Kortmann 1972; Fleming et al. 1986). Furthermore, maternal P. falciparum parasitemia may result in placental parasitemia, which in turn can compromise placental function and increase the risk of low birth weight (LBW) (MacGregor and Avery 1974; Brabin 1983; Steketee et al. 1994). Neonatal and early infant mortality is a common consequence (McCormick 1985).

Effective antimalarials have recently been demonstrated to reduce the effects of malaria infection during pregnancy (Steketee et al. 1984; Greenwood et al. 1989; Schultz et al. in press). In sub-Saharan Africa, where women often do not seek antenatal care until mid-pregnancy, administration of antimalarials represents one of the few interventions which could be given during the second and third trimesters, still effectively promote maternal health, and reduce the incidence of LBW and prematurity (Steketee et al. 1984).

Similar to other interventions which should be included in the package of antenatal care services (such as tetanus toxoid, syphilis testing and treatment, and iron and folate supplementation), antimalarial intervention requires appropriate patient behaviour and beliefs, proper utilization of services, and adequate service delivery to ensure program effectiveness. To support this assumption, we examined client and health worker practices and health system support in Malawi and Kenya to identify opportunities for and obstacles to delivery of an antimalarial intervention within antenatal service packages.

Background

Studies document lower maternal and perinatal mortality rates among women receiving antenatal care (US Congress 1988; Greenberg 1983). Early onset of antenatal care and appropriate frequency of visits is also associated with improved pregnancy outcome (Gortmaker 1979; Ryan et al. 1980). A minimum number of services have been accepted as standard practice for developing countries. Figure 1 and Table 1 provide an example of service delivery.

Table 1. Key services that should be available to pregnant women in sub-Saharan Africa. ServiceVisits requiredComments Maternal risk assessmentEach visitScreening for small pelvis, high blood pressure, twins, abnormal presentation, etc. Risk managementVariableShould include referral to facility for delivery for primigravidas, grand multigravidas (5 or more pregnancies) and other high-risk pregnancies Tetanus toxoid (TT)TwiceDose 1, first visit; dose 2, 1 month later (if previously vaccinated, one dose at first visit) Ferrous sulfate/folate (Fe/fol)MonthlyMonthly supply dispensed for daily self-administration at home Syphilis testing and treatmentTwiceTest, first visit; treat positives, second visit AntimalarialTwiceDose 1, first visit; dose 2, 1 month later Record keeping (ANC card)Each visitStandard recording form recommended Patient educationVariableRotating schedule of messages is often provided. Identified high-risk patients should be counseled individually about their condition and delivery at a health facility

For an antenatal intervention to be effective, services must be available and women must use ANCs. Assuming the first visit occurs at the beginning of the second trimester, women should complete a minimum of five visits to ensure that they receive the full antenatal care package. Many countries in sub-Saharan Africa do have high rates of ANC attendance; for instance, ANC attendance has been reported to be as high as 95% in Tanzania (Moller et al. 1989), and greater than 80% in Zambia (Ratnam et al. 1982), The Gambia (WHO 1991), Togo, and Zaire (Steketee et al. 1994). Service delivery, however, is often inadequate. It was discovered during one study in Zambia that fewer than half the women were screened for anemia, and only one-third of the anemic women received iron supplements (Ransjo-Arvidson et al. 1989). Although high-risk women should be identified at ANC visits and referred to facilities for delivery, home delivery rates are often as high as 73% (Voorhoeve et al. 1984), with more than 60% delivering at home without the assistance of trained personnel (WHO 1991). The high proportion of home deliveries may be due to a variety of determinants, including distance from the facility and sociobehavioural factors.

Despite recommendations by WHO that pregnant women living in P. falciparum endemic areas should receive an initial treatment dose followed by regular prophylaxis with an effective and safe antimalarial drug (WHO 1986), few African countries have a formal policy concerning maternal malaria control. Even fewer have operational programs for the delivery of antimalarials through ANCs (USAID 1994). This programmatic inertia may be attributable in part to the emergence and spread of chloroquine (CQ) resistance, resulting in difficulties in identifying an efficacious, safe, and affordable antimalarial for use during pregnancy.

Studies in Malawi have established that a highly efficacious antimalarial administered during the second and third trimesters of pregnancy significantly decreased LBW among primi- and secundigravidas (Steketee et al. 1994). More recent work has demonstrated that an antimalarial regimen, consisting of two doses of sulfadoxine-pyrimethamine (SP/SP), the first administered during the second trimester and the second administered at the beginning of the third trimester, was highly efficacious in reducing the prevalence of peripheral and placental parasitemia, well-tolerated (Schultz et al. in press a), and more economical than the commonly recommended regimen of CQ in both total cost and cost per infant death prevented (Schultz et al. in press b). Similarly, in The Gambia, chemoprophylaxis with another sulfapyrimethamine combination (Maloprim 27) was efficacious in preventing placental malaria, decreasing LBW, and was well tolerated (Greenwood et al. 1989). When viewed together, these studies identify antenatal antimalarial strategies that are efficacious, safe, affordable, and practical to deliver.

Methods

In Malawi and in the Kisumu district of western Kenya, a series of investigations was conducted to examine women's knowledge, attitudes, and practices regarding malaria illness, treatment, and prevention; evaluate the opportunity for delivery of an intervention within the current ANC system; and examine women's utilization of the current ANC programs in Malawi and Kenya.

Malaria Knowledge and Attitudes

In 1992, a nationwide survey examining malaria knowledge, attitudes, and practices (KAP) was conducted in Malawi. A modified Expanded Program for Immunization cluster-sampling method (Henderson and Sundaresan 1982) was used to select a total sample of 1531 households, in 30 clusters of 51 or 52 households. One section of the survey focused on women who had completed a pregnancy within the past 5 years. Questions regarding ANC use, services received, and place of delivery were asked, in addition to those on malaria treatment and prevention. A similar survey focusing strictly on women pregnant within the past 5 years was conducted in the Kisumu district in 1994. A total of 216 women in 30 clusters of 7–8 women each were interviewed. In both surveys, interviews were conducted by female nationals of childbearing age and efforts were made to conduct the interviews in the first language of the woman interviewed. When this was not possible, interviews were conducted in the national language.

Delivery of Antenatal Services

As part of the KAP surveys, women were asked about services received during ANC visits. Reported rates of TT immunization and administration of Fe/fol and CQ were compared with antenatal care record cards, among the women still possessing them, to verify reporting accuracy. Facility assessment was performed to verify available supplies and medicines. A sample of women attending ANC was followed through the clinic, and health care worker practices were recorded.

Utilization of Antenatal Clinics

Using reported initial and return ANC attendance rates, estimates were made of the proportion of women available for delivering various interventions to pregnant women. We examined ANC use and place of delivery for high-risk women to assess the need for more effective referral. For Malawian women, age categories were used as a surrogate for parity. Previous studies documented that 89% of women less than age 18 years at delivery were primigravidas, while 93% of women at least 35 years old were grand multigravidas (5th pregnancy or greater) (Steketee, personal communication). We defined women in these age groups as high risk and compared them with women delivering at 20 to 34 years of age. Kenyan women were classified as high risk on the basis of parity. The number of women available to receive the full benefit of antenatal services and referral for hospital delivery was estimated.

Results

In Malawi, 809 recently pregnant women were interviewed. The mean age of the Malawian women was 29 years, and 669 (83%) reported being currently married. In Kisumu district, the mean age of the 216 interviewed women was 27 years, of which 118 (87%) reported being currently married. Figure 2 shows further demographic characteristics of the pregnant women in the two countries. Most women in Malawi reported their principal occupation as farming, and most had little formal education.

Malaria Knowledge and Attitudes

Malaria was considered a problem during pregnancy by 87% and 96% of pregnant women in Malawi and Kisumu, respectively. Detrimental health effects of malaria reported by respondents in both countries included maternal illness, spontaneous abortion, and illness in the baby. Antimalarial medication was perceived to be potentially harmful to a pregnant woman or her unborn child by 37% and 74% of women in Malawi and Kenya, respectively. Most women in both countries reported that antimalarials were effective for treatment and prevention of malarial illness.

Delivery of Services

Over 95% of ANC attenders reported receiving an ANC card; however, only 26% of Malawian attenders and 13% of Kenyan attenders could produce a ANC card for examination. Correlation between reported number of visits and number recorded on the ANC card, when available, was high (Schultz et al. 1994). Reported receipt of TT immunization was common in both countries. Among primigravidas, however, fewer than 80% in Malawi and 60% in Kenya reported receiving two doses TT. More than 70% of women in Malawi and more than 90% in Kenya reported having received Fe and/or fol from the ANCs. With prevalence of anemia (defined by WHO as haemoglobin level below 11 g/dL) as high as 82% and 79% in the study areas (Brabin 1983), coverage with Fe and fol is important. Syphilis testing was not routinely available in Malawi (Steketee et al. 1994). In Kenya, a policy existed for syphilis testing; however, testing was often unavailable for months at a time because of shortages of reagents (Schultz, unpublished). Reflective of the difference in malaria control policy between the two countries, 73% of Malawian women reported receiving CQ, compared with 4% of Kenyan women. Of the Malawian women, however, only 61% of those receiving CQ reported taking the recommended dose of two tablets weekly.

Utilization of Antenatal Clinics

In both Malawi and Kenya, over 90% of women reported attending an ANC at least once. The total number of reported visits was similar in Malawi and Kenya, with 87% and 92%, respectively, attending two or more times. More than 40% of the women in both countries reported attending five or more times. ANC attendance rates were applied to the model in Figure 3 to estimate the proportion of women available for interventions during pregnancy. In both Malawi and Kenya, more than 85% of pregnant women were available to benefit from a two-dose antimalarial regimen, coverage with two-dose TT, syphilis testing and treatment, initial Fe/fol supplementation, and risk assessment with one follow-up. In contrast, fewer than 45% were available for continued risk management and Fe/fol coverage throughout their pregnancy.

Fifty-six percent of Malawian women and 37% of Kenyan women delivered in a hospital or clinic setting (Figure 4). In both countries, women who attended ANCs were significantly more likely to deliver at a hospital or clinic than women who had never attended an ANC. For those delivering at a health facility, 68% of Malawian women and 52% of Kenyan women walked to the facility; 80% of Malawian women and 95% of Kenyan women reported waiting until the onset of labour to travel to the facility. Only 55% of women with high-risk pregnancies in Malawi and 33% in Kenya gave birth in a health care facility. In both countries, rates of ANC attendance and hospital delivery were similar among high- and low-risk pregnancies.

Discussion

The recent identification of an efficacious, safe, affordable, and cost-effective antimalarial intervention represents a technologic advancement for improving maternal and infant health. However, its identification alone does not ensure its delivery. Malaria has long been recognized as a health problem during pregnancy, yet few African countries have implemented an antimalarial strategy with wide coverage among pregnant women. Our study showed that in Malawi, which has a national policy of administering CQ during pregnancy, more than 25% of women attending ANC failed to receive CQ. Many more received it irregularly or at an inadequate dosage. In Kenya, where a clear policy does not yet exist, only 4% of women received an antimalarial drug. These findings are consistent with community-based surveys of seven regions in four other sub-Saharan African countries which showed that although 34–68% of women reported attending ANCs, only 1–18% reported using weekly antimalarial prophylaxis (Steketee et al. 1994). These findings suggest that a clear policy for antimalarial use in pregnancy is needed but is not sufficient to ensure appropriate antimalarial drug use in pregnancy.

In recent years, antimalarial interventions may not have been actively promoted because of the lack of an identified efficacious and safe drug in the face of widespread CQ-resistance. However, prevention of malaria is not the only intervention that is not being delivered to pregnant women. Although most women in sub-Saharan Africa appear to be using ANCs, the health care system is failing to provide uniformly basic services which could greatly reduce the risk of pre- and perinatal complications. We observed that 16–38% of primigravidas failed to receive two doses of TT, and that few women underwent testing and treatment for syphilis, despite visiting an ANC two or more times. Similar findings have been reported elsewhere: in Zambia, although the mean number of ANC visits was more than five, only 50% of the primiparous women received two doses of TT (Ransjo-Arvidson et al. 1989); 72% were tested for syphilis, and almost 25% of women testing positive for syphilis did not receive appropriate treatment (Henderson and Sundaresan 1982).

Our investigations in Malawi and Kenya identified certain opportunities for the delivery of antimalarial interventions. The finding that women recognize malaria as a health threat during pregnancy and believe medicine is capable of preventing malarial illness will help to ensure acceptance of an antimalarial intervention. Although compliance with antimalarial home-dosing has limited program effectiveness for previous regimens (Heymann et al. 1984), the recent identification of a two-dose SP regimen which can be administered during ANC visits in the second and third trimesters should eliminate the obstacle of low compliance. An additional opportunity exists in linking the two-dose SP regimen to an existing program, such as tetanus toxoid immunization, that has similar timing for its two-dose schedule among primigravidas. The existing widespread support of immunization programs for antenatal packages could offer the necessary support for a linked delivery program with antimalarials.

The provision of high-quality antenatal care is one strategy aimed at reducing the high risk of maternal mortality among African women and perinatal mortality among their infants (WHO 1991). Although further efforts to find new or improved methods of promoting both maternal and infant health should continue, the fact remains that a package of antenatal services already exists which is not being delivered. For sub-Saharan Africa, this package includes providing effective antimalarials. Understanding specific health problems, the necessary interventions, patient attitudes and behaviours, and the ability of the ANC system to deliver interventions is essential to design and implement a successful antenatal care package. Data that identify opportunities for delivery of antenatal interventions, such as these presented here, should enable programs to better focus efforts at improved antenatal care. Program effectiveness can, in part, be judged by our ability to provide and women's choice to use these services. Application of current technology can decrease maternal and infant mortality through affordable, effective, and deliverable antenatal interventions - and pregnant women are accessing the health care system. We must seize the opportunity to improve the delivery of antenatal services lest we fail to reach women at the threshold of safe motherhood.

References

· Brabin, B.J. 1983. An analysis of malaria in pregnancy in Africa. Bulletin of the World Health Organization, 61, 1005–1016.

· Fleming, A.F. et al. 1986. The prevention of anemia in pregnancy in primigravidae in the guinea savanna of Nigeria. Ann Trop Med Parasitol, 80, 211–33.

· Gilles, H.M.; Lawson, J.B.; Sibelas, M; Voller, A; Allan, N. 1969. Malaria, anemia, and pregnancy. Ann Trop Med Parasitol, 63, 245–263.

· Gortmaker, S.L. 1979. The effects of prenatal care upon the health of the newborn. Am J Public Health, 69, 653–660.

· Greenberg, R.S. 1983. The impact of prenatal care in different social groups. Am J Obstet Gynecol, 145, 797–803.

· Greenwood, A.M.; Greenwood, B,M.; Bradley, A.K.; Williams, K.; Shenton F.C.; Tulloch, S.; Bypass, P.; Oldfield, F.S.J. 1987. A prospective survey of the outcome of pregnancy in a rural area of The Gambia. Bulletin of the World Health Organization, 65, 635–643.

· Greenwood, B.M.; Greenwood, A.M.; Snow, R.W.; Byass, P.; Bennett, S.; Hatib-N'Jie, A.B. 1989. The effects of malaria chemoprophylaxis given by traditional birth attendants on the course and outcome of pregnancy. Trans R Soc Trop Med Hyg, 83, 589–594.

· Henderson; R.H.; Sundaresan, T. Cluster sampling to assess immunization coverage: a review of experience with a simplified sampling method. Bulletin of the World Health Organization, 60, 253–260.

· Heymann, D.L.; Steketee, R.W.; Wirima, J.J.; McFarland, D.A.; Khoromana, C.O.; Campbell, C.C. 1984. Antenatal chloroquine chemoprophylaxis in Malawi: Chloroquine resistance, compliance, protective efficacy and cost. Trans R Soc Trop Med Hyg, 496–498.

· Hira, S.K.; Bhat, C.J.; Ratnam, A.V.; Chintu, C.; Mulenga, R.C. 1982. Congenital syphilis in Lusaka II: Incidence at birth and potential risk among hospital deliveries. East Afr Med J, 59, 306–310.

· Jelliffe, E.F.P. 1968. Low birth weight and malaria infection of the placenta. Bulletin of the World Health Organization, 38, 69–78.

· Keuter, M; van Eijk, A.; Hoogstrate, M; Raasveld, M; van de Ree, M; Ngwawe, W.A.; Watkins, W.M.; Were, J.B.O.; Brandling-Bennett, A.D. 1990. Comparison of chloroquine, pyrimethamine and sulfadoxine, and chlorproguanil and dapsone as treatment for falciparum malaria in pregnant and non-pregnant women, Kakamega district, Kenya. Brit Med J, 301, 466–470.

· Kortmann, H.F.C. 1972. Malaria and pregnancy. M.D. Thesis, University of Amsterdam.

· MacGregor, J.D.; Avery, J.G. 1974. Malaria transmission and fetal growth. Brit Med J, 3, 433–436.

· Mahler, H. 1987. The safe motherhood initiative: A call to action. Lancet, 2, 668–670.

· McCormick, M.C. 1985. Contribution of low birth weight to infant mortality and childhood morbidity. N Engl J Med, 312, 82–90.

· McGregor, I.A. 1984. Epidemiology, malaria and pregnancy. Am J Trop Med and Hyg, 33, 517–525.

· Moller, B.; Lushino, O.; Meirik, O.; Gebre-Medhin, M.; Lindmark, G. 1989. A study of antenatal care at village level in rural Tanzania. Int J Gynecol Obstet, 30, 123–131.

· National Center for Health Statistics. 1993. Health, United States, 1992. Public Health Service, Hyattsville, MD, USA. pp. 35.

· Nordbeck, H.J.; Voorhoeve, A.M.; van Ginnekin, J.K. 1984. Use of perinatal mortality data in antenatal screening. In Van Ginneken, J.K.; Muller, A.S. (ed.). Maternal and child health in rural Kenya: An epidemiological study. Croom Helm, London, UK. Pp. 241–256.

· Quick, J.; Greenlick, M.; Roghmann, K. 1981. Prenatal care and pregnancy outcome in an HMO and general population: A multivariate cohort analysis. Am J Public Health, 71, 381–390.

· Ransjo-Arvidson, A.B.; Christensson, K.; Darkwah, G.; Lungu, F.; Kakoma, C.; Chikamata, D.; Diwan, V.K.; Sterky, G. 1989. Maternity care routines in a teaching hospital in Zambia. East Afr Med J, 7, 427–436.

· Ratnam, A.V.; Din, S.N.; Hira, S.K.; Bhat, G.J.; Wacha, D.S.O.; Rukmini, A.; Mulenga, R.C. 1982. Syphilis in pregnant women in Zambia. British Journal Venereal Disease, 58, 355–358.

· Rooney, C. 1992. Antenatal care and maternal health: How effective is it? A review of the evidence. World Health Organization, Geneva, Switzerland. Document WHO/MSM/92.4.

· Rooth, G. 1979. Better perinatal health: Sweden. Lancet.

· Ryan, G.; Sweeney, P.; Solola, A. 1980. Prenatal care and pregnancy outcome. Am J Obstet Gynecol, 137, 876–881.

· Schultz, L.J.; Steketee, R.W.; Chitsulo, L.; Macheso, A.; Nyasulu, Y.; Ettling, M. 1994. Malaria and childbearing women in Malawi: Knowledge, attitudes, and practices. Trop Med Parasitol, 45, 65–69.

· Schultz, L.J.; Steketee, R.W.; Macheso, A.; Kazembe, P.; Chitsulo, L.; Wirima, J.J. The efficacy of antimalarial regimens containing sulfadoxine-pyrimethamine and/or chloroquine in preventing peripheral and placental Plasmodium falciparum infection during pregnancy. (in press, Am J Trop Med Hyg).

· Schultz, L.J.; Steketee. R.W.; Chitsulo, L.; Wirima, J.J. Antimalarials during pregnancy: A cost-effectiveness analysis. (in press, Bull World Health Organ).

· Steketee, R.W.; Breman, J.G.; Paluku, K.M.; Moore, M.; Roy, J.; Ma-Disu, M. 1988. Malaria infection in pregnant women in Zaire: The effects and the potential for intervention. Ann Trop Med Parasit, 82, 113–120.

· Steketee, R.W.; Wirima, J.J.; Slutsker, L.; et al. 1994. Malaria prevention in pregnancy: The effects of treatment and chemoprophylaxis on placental malaria infection, low birth weight, and fetal, infant, and child survival. African Child Survival Initiative - Combatting Childhood Communicable Diseases. Project Document 099-4048. Atlanta, Ga.

· USAID (United States Agency for International Development). 1994. Controlling malaria in Africa: Progress and priorites. African Child Survival Initiative - Combatting Childhood Communicable Diseases Project Document 099-4050. Atlanta, Ga.

· US Congress, Office of Technology Assessment. 1988. Healthy children: Investing in the future. OTA, Washington, DC, USA. OTA-H-345. Pp. 73–90.

· Voorhoeve, A.M.; Kars, C.; Van Ginneken, J.K. 1984. Modern and traditional antenatal and delivery care. In Van Ginneken, J.K.; Muller, A.S. (ed.). Maternal and child health in rural Kenya: An epidemiological study. Croom Helm, London, UK. Pp. 309–322.

· World Health Organization. Expanded Program on Immunization. 1986. Prevention of neonatal tetanus through immunization. World Health Organization, Geneva, Switzerland. Document WHO/EPI/GEN/86.9.

· World Health Organization. WHO Expert Committee on Malaria. 1986. World Health Organization, Geneva, Switzerland. WHO Technical Report Series no 735. pp. 57–59.

· World Health Organization. 1991. Maternal mortality: A global factbook. WHO Division of Family Health, Geneva, Switzerland. Pp. 1170–1172.

Linda J. Schultz, Richard W. Steketee, Monica Parise, and Bernard Nahlen are with the Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Jack J. Wirima is at the University of Malawi, Blantyre, Malawi; Aggrey Oloo and Bernard Nahlen are with the Kenya Medical Research Institute, Kisumu, Kenya.