Prevention And Treatment Of Malaria In Pregnant Women

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ABSTRACT

Malaria in pregnancy is a major public health problem in Nigeria leading to increase in the risk of maternal mortality, low birth weight and infant mortality. Malaria accounts for about 11% of all maternal deaths in Nigeria, and indirectly contributes to additional 11% of maternal deaths mainly by being a leading cause of anaemia in pregnancy. Prevention tools such as use of insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp) with Sulphadoxine-pyrimethamine (SP) has been shown to be effective in preventing malaria in pregnancy. This study was carried out to assess  malaria prevention and treatment inpregnant women in Enugu. It was a descriptive cross-sectional study involving pregnant women at two ante-natal clinics in Enugu namely; Mother of Christ Specialist Hospital and Polly Clinics.A total of 330 pregnant women were recruited for this study by systematic random sampling. Data was collected using well structured close-ended questionnaires used to elicit information on socio-demographic characteristics, knowledge of malaria disease, ownership of insecticide treated nets (ITN), and ITN use in pregnancy, as well as the knowledge and uptake of intermittent preventive treatment in pregnancy (IPTp) and barriers to the use of these malaria preventive measures in pregnancy. At the end of the study, it was observed that Majority 94.5 % of the women were aware of the mode of malaria transmission.  A very high knowledge of malaria preventive measures like insecticide treated nets (ITNs) and the intermittent preventive therapy in pregnancy (IPTp) was also observed in this study.  A total of 65.5% of the respondents possess insecticide treated nets (ITNs). About 83.6% of the respondents use insecticide treated nets (ITNs) , while 63.7% of the respondents have received intermittent preventive therapy in pregnancy (IPTp).There was no significant association between parity and use of ITNs and parity and uptake of intermittent preventive treatment in pregnancy (IPTp) The use of these preventive measures use was still found to be poor. Non-availability, cost, erroneous belief and late booking for antennal care were also found to be affecting the use of these malaria preventive measures in pregnancy.

CHAPTER ONE

1.1     INTRODUCTION

Malaria is a parasitic infection caused by the five species of Plasmodium that infect humans.1 The infection is primarily transmitted by the bite of an infected female Anopheles mosquito, but infections can also occur through exposure to infected blood products (transfusion malaria) and by congenital transmission.2

Malaria has a worldwide distribution, affecting people of all ages, with an enormous burden amounting to 300-500 million clinical cases per year, 80% of which occur in Africa.3 SubSaharan Africa has the largest burden of malarial disease, with over 90% of the world’s malariarelated deaths occurring in this region.4, 5 In all malaria-endemic countries in Africa, between 20% and 50% of all hospital admissions are a consequence of malaria.6, 7 Every year, Malaria is said to cost Africa an estimated 12 billion dollars (US$ 12b) in lost productivity.6 It has been reported that malaria places a heavy burden on the African poor,this is becauseboth direct and indirect costs associated with a malaria episode represent a substantial burden on the poorer households. 7, 8

Malaria infection during pregnancy is an enormous public health problem due to its adverse effects on the mother as well as the fetus. It is a major, preventable cause of maternal morbidity, mortality, and poor birth outcomes in sub-Saharan Africa.11, 12 Pregnant women are at increased risk of more frequent and severe malaria, compared with non-pregnant women. In areas endemic for malaria, it is estimated that more than 30 million pregnant women are threatened by malaria annually and at least 25% of pregnant women are infected while about 10, 000 maternal deaths are attributed to the disease each year.3,9,10,12 

Recent World Malaria Report indicates that Nigeria accounts for a quarter of all malaria cases in the 45 malaria-endemic countries in Africa, this clearly shows the challenge of malaria in Nigeria.13 Malaria is transmitted throughout Nigeria with 97% of the population at risk. It is endemic and is responsible for annual economic loss of N132 billion according to the National Malaria Control Programme.14 It is also responsible for 60% of outpatient visits to health facilities and 30% of hospitalizations. In addition, at least 50% of the population has at least one episode of malaria annually.15 In Enugu State, for example, malaria is responsible for 70% of outpatient attendance at the secondary healthcare facilities and over 80% of all diseases reported by primary healthcare facilities.16, 17 

Malaria directly accounts for about 11% of all maternal deaths in Nigeria, and indirectly contributes to additional 11% of maternal deaths mainly by being a leading cause of anaemia in pregnancy.18, 19Pregnant women in Nigeria, are mostly infected with Plasmodium falciparum, the most virulent Plasmodium with serious health consequences including anaemia, still- birth, and premature delivery.19 This explains why national efforts to reduce the high maternal and infant mortality place high premium on effective control of malaria in pregnancy.18, 20 Recent studies have shown that among pregnant women, primigravidae are at highest risk of malarial infection and serious complications.20 Younger maternal age (particularly adolescence) carries a higher risk of infection and adverse effects. Second trimester is also known to carry one of the highest risks of infection.20, 21

In line with the recommendation of the World Health Organization (WHO), the Nigerian national strategy for malaria control in pregnancy focuses on three approaches:

  1. Use of insecticide-treated bed nets
  2. Intermittent preventive treatment (IPTp) (for women in high transmission areas).
  • Effective case management (diagnosis and treatment of illness).

Insecticide-Treated Bed Nets

Insecticide-treated bed nets (ITNs) are now a major intervention for malaria control in pregnancy. They are a form of personal protection that has been shown to reduce malaria illness, severe disease, and death due to malaria in endemic regions. Bed nets treated with an insecticide are much more protective than untreated nets. The insecticides that are used for treating bed nets kill mosquitoes, as well as other insects. Insecticide-treated nets should be provided as early in pregnancy as possible to all pregnant women living in malarious areas, including epidemic and disaster situations, according to the perceived need in the locality. Their use should be encouraged for women throughout pregnancy and postpartum. Long lasting insecticide treated nets (LLINs/ITNs) can be provided in the antenatal clinic or through other sources in the private and public sectors.22, 23

Intermittent Preventive Therapy in Pregnancy (IPTp)

Intermittent Preventive Therapy in Pregnancy (IPTp) entails administration of a curative dose of an effective antimalarial drug to all pregnant women whether or not they are infected with the malaria parasite. Sulphadoxine-pyrimethamine (SP) is the drug currently recommended by the World Health Organisation (WHO). The drug is administered under supervision during antenatal care visits,starting in the second trimester (after quickening).24

The Federal Ministry of Health in Nigeria in its National Strategic Plan for the control of malaria in 2001 recommended early case management, two doses of SP during the second trimester and early in the third trimester of pregnancy against the adverse consequences of malaria in

pregnancy.19, 23,25

Intermittent preventive therapy with Sulphadoxine-Pyrimethamine has been shown to reduce the risk of maternal anaemia, placental parasitaemia and low birth weight. In a study carried out in Ibadan, southwest Nigeria, IPTp-SP was found to be highly effective in preventing maternal and placental malaria among parturient women as well as in improving pregnancy outcomes such as delivery of bigger babies and lower prevalence of preterm deliveries and maternal anaemia.26 

A study in Malawi evaluating intermittent preventive therapy in pregnancy showed a decline in placental infection from 32% to 23% and in the number of low birth weight babies from 23% to 10%.27, 28Intermittent preventive therapy with sulphadoxine-pyrimethamine, given 2 or 3 times during pregnancy to women residing in areas of stable malaria transmission reduces the risk of low birth weight (LBW) in babies and hence increases the probability of child survival. Intermittent preventive therapy in pregnancy can reduce neonatal mortality by more than 60%. IPTp-SP is currently health policy in several African countries, and is being deployed and scaled up through reproductive health programmes3. However, scale-up of intermittent preventive therapy in pregnancy (IPTp) continues to be a challenge in Nigeria. The 2008 demographic health survey (DHS) reported that 5% of pregnant women received two or more of the recommended doses of IPTp, with an increase to 13% in the 2010 malaria information survey (MIS). A number of factors contribute to the low uptake of intermittent preventive therapy in pregnancy IPTp including sporadic availability of sulfadoxine-pyrimethamine, low antenatal care attendance, and poor quality of antenatal care service delivery.29

Effective Case Management for Malaria Illness in Pregnancy

Quinine is the most effective of the drugs considered safe for women with uncomplicated malaria in the first trimester and for severe malaria throughout pregnancy.21, 30 In the second and third trimesters, the artemisinin-based combination therapies (ACTs) that include artemisinin and its derivatives may be given.21 Case management of malaria should also include diagnosis and treatment of accompanying anemia according to national guidelines23Effective case management of malaria illness for all pregnant women in malarious areas must be assured. Iron/folate supplementation for anaemia should be given to pregnant women as part of routine antennal care

package.21, 23, 31

Other malaria preventive or control measures in pregnancy include:

  1. Environmental control
  2. Personal protection
  3. Indoor residual spraying
  4. Community mobilization,education and counseling
  5. Surveillance for malaria control and elimination.2, 32

Environmental Control

Involves the techniques to reduce mosquito breeding sites such as filling and draining areas of impounded water,prevent water logging, destroy unwanted water collections, keep water containers closed, clearing of vegetation around the houses.2

Personal Protection: 

Personal protection measures include protection against mosquito bites and chemoprophylaxis against malaria. People living in endemic areas as well as travellers to such areas should be educated and encouraged to use protective measures against mosquito bites. These include; using mosquito-repellant lotions, creams, or mosquito coils and regular use of bed nets.2

Indoor Residual Spraying (IRS):

Indoor residual spraying with liquid insecticide, usually dichlorodiphenyltrichloroethane (DDT), kills mosquitoes that come into contact with the sprayed surface and, in the case of DDT, reduces the number of mosquitoes entering indoor spaces.The most common insecticides used are DDT29 and pyrethroids. IRS is appropriate in epidemiological settings where vectors mainly stay indoors and in countries where the necessary logistical capabilities can be deployed.32An insecticide for Indoor residual spraying (IRS) is selected in a given area on the basis of data on resistance, the residual efficacy of the insecticide, costs, safety, and the type of surface to be sprayed.33

Community Mobilization, Education and Counselling:

As part of antenatal care, skilled providers give women information and counselling on the dangers of malaria, as well as the steps they can take to help protect themselves, their newborns and their children under five. Also, communities should be educated on the mode of transmission and on the means of controlling mosquitoes and reducing mosquito-man contact. Information about the symptoms of malaria should also be provided to the people so that they can seek prompt treatment for all cases of the disease.2, 34

Surveillance for Malaria Control and Elimination:

Information on the number and distribution of malaria cases and deaths is critical for the design and implementation of malaria control programmes especially in pregnancy. Information on the incidence of disease in relation to past levels is needed to alert programmers about epidemics, so that control measures can be intensified.32

Prevention of malaria in pregnancy is a major public health challenge and a priority for the Roll Back Malaria (RBM) Partnership.33,35 Current prevention tools such as use of insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp) with Sulphadoxinepyrimethamine (SP) though available, face a number of important limitations to their uptake in Nigeria. The Roll Back Malaria (RBM) African Summit held in Abuja, Nigeria in 2000 set a target of having at least 60% of children under-five years of age and 60% of pregnant women use insecticide-treated nets (ITNs) by 2010. 34,36The Nigerian government is also scaling up efforts at providing free insecticide-treated nets (ITN) to vulnerable groups, as part of the attainment of the millennium development goal, and the recognition by the Nigerian government that access to insecticide-treated nets (ITN) and other malaria preventive and curative services is a right to all vulnerable Nigerians, especially the pregnant women. On the other hand, Nigeria adopted intermittent preventive treatment in pregnancy (IPTp) as a strategy in 2005 to replace weekly prophylaxis.35,37

Despite these interventions in place to prevent malaria in pregnancy, the question is now to what extent are the pregnant women in Nigeria taking advantages of these malaria preventive measures in pregnancy? Moreover, malaria control still remains a challenge in Africa where 45 countries, including Nigeria, are endemic for the disease. Despite considerable improvement in healthcare delivery services in the African continent, the control of malaria in pregnant African women, one of several child survival strategies applied through antenatal care, continues to be particularly challenging.38, 39

The new policy of the Nigerian Federal Ministry of Health on malaria in pregnancy indicates the strategies for malaria prevention in pregnancy which include; focused antennal care, early detection and prompt appropriate case management of women with symptoms and signs of malaria.40 Furthermore it was pointed out that integrated vector management including environmental management should be taken into consideration and that effective health education programs should be observed.

1.2      PROBLEM STATEMENT

In areas of stable malaria transmission, pregnant women are particularly vulnerable to malaria infection. In Nigeria, 11% of maternal deaths are attributed to malaria, and 70.5% of morbidity in pregnancy is caused by malaria.14 Malaria in pregnancy is believed to contribute up to 15% of maternal anaemia in Nigeria.19 Malaria in pregnancy is also associated with significant degree of intrauterine growth restriction, 36% of preterm deliveries, 30% of preventable low birth weight deliveries, 14% of low birth weight deliveries and 15% of maternal anemia. Maternal malaria is associated with 3-8% of infant mortality in Nigeria.41 Parasite prevalence in pregnant women in Nigeria could be as high as 60-70%.19 A study by Ekejindu et al also reported a 21.3% prevalence rate of malaria among the 108 ante-natal women studied in Enugu State.42 Being a killer disease, malaria kills our poor pregnant mothers and children, hence the increase in maternal and child mortality in Nigeria.40

In recognition of the importance of protecting the vulnerable group against malaria infection, the Enugu State government together with its Roll Back Malaria partners commenced mass distribution of long-lasting insecticide-treated nets (LLINs).45This free distribution has no doubt helped to substantially increase mosquito net ownership in Enugu state. Also with the increased awareness of the intermittent preventive treatment in pregnancy (IPTp) services in antenatal care services as well as through the mass media, the trend of poor usage of malaria preventive measures in pregnancy is expected to have changed.

An important reason for this study will be to assess whether the mass distribution campaign of insecticide treated nets embarked upon by the state government and other roll back malaria partners was effective in achieving a substantial increase in its use among pregnant women. It will also seek to ascertain the effects of increased awareness of intermittent preventive treatment in pregnancy (IPTp) in the attitude of pregnant women towards its uptake.

Judging from the enormous challenge of preventing malaria in pregnancy,adequate assessment and evaluation of the utilization and uptake of these preventive measures is very important. It will also go a long way in providing base line data for malaria control programs with emphasis on malaria prevention and control in pregnancy.

There is a critical dearth of information on the knowledge of the mode of transmission of malaria in pregnancy, as well as the knowledge on the dangers of malaria in pregnancy among pregnant women in Enugu.Similarly,there is also paucity of information on the practice of environmental sanitation aimed at preventing the breeding of mosquitoes. Although there have been many previous studies on malaria preventive measures use by pregnant women in Enugu, these reports are scanty on the actual practice of malaria prevention in pregnancy, hence this research.

The result of this study will present a true picture on malaria preventive measures utilization in pregnancy and also suggest ways of improving access and utilization of these preventive measures.

1.3RESEARCH QUESTIONS

The research questions for this work include:

  1. To what extent are pregnant women in Enugu knowledgeable about malaria?
  2. What is the level of knowledge possess by pregnant women on malaria prevention and treatment?
  3. What are the preventive materials used by pregnant women in Enugu?
  4. What are the barriers preventing effective malaria prevention and treatment in Enugu?

1.4     RESEARCH OBJECTIVES

General Objective: This research is aimed at assessing malaria preventive and treatment on pregnant women in Enugu.

Specific Objectives:

  1. To ascertain the level of knowledge on malaria among pregnant women in Enugu.
  2. To determine level of knowledge of various malaria preventive and treatment measures.
  3. To assess the use of preventive materials by pregnant women in Enugu
  4. To identify barrier(s) to the use of malaria preventive measures.

1.5   JUSTIFICATION/RATIONALE

Malaria in pregnancy is an important cause of morbidity and mortality among pregnant mothers. This is because they are the main adult risk group for malaria.28Therefore pregnant women in endemic areas should be protected in order to avoid adverse outcomes. Scientific studies have documented high prevalence of malaria parasitaemia among pregnant women in Enugu.42, 43

Preventive measure like the use of long lasting insecticide treated nets (LLINs) is one of the best interventions for malaria vector control around the globe.2

Intermittent preventive therapy using sulphadoxinepyrimethamine (SP) is another important preventive measure available free of charge for pregnant women at antenatal care clinics in public and private health facilities using the strategy of directly observed therapy (DOT). 2, 44

Researches have identified that adherence to these preventive measures in pregnancy helps in reducing the adverse consequences of malaria in pregnancy such as reducing the risk of maternal anemia, placental parasitaemia and low birth weight.23,41

RESEARCH MORE ON PROJECT TOPICS AND MATERIALS PORTALS;prevention of malaria in pregnancy,prevention of malaria in pregnancy pdf,drugs for treatment of malaria in pregnancy,definition of malaria in pregnancy,treatment of malaria in first trimester of pregnancy,effects of malaria in pregnancy,symptoms of malaria in pregnancy,treatment of malaria in third trimester of pregnancy

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