Full Project – PREVALENCE AND EFFECTS OF MALARIA IN PREGNANCY

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Abstract

This study investigated the prevalence and effects of malaria in pregnancy. Malaria in pregnancy constitutes a risk for both the mother and her unborn child but there is paucity of data regarding the magnitude of the problem in our region. This study was conducted with the main objective of determining the prevalence of malaria parasitaemia among our pregnant women and its consequences.Four hundred pregnant women who attended antenatal care and delivered at the UMTH, Maiduguri were studied from 24th July 2007 to 12th January 2008. They were followed from booking to delivery. Blood samples were collected at booking and delivery in to an EDTA bottle and a thick blood smear were prepared on a glass slide and read under microscope for malaria parasite while capillary tube, centrifuge machine and micro-haematocrit reader were employed for packed cell volume. Malaria parasite was also looked for in the cord blood of the babies and placental tissue using blood film and histology respectively. The prevalence of malaria parasitaemia at booking was 60.3% (241/400) and the mean parasite density was 701.04±382.22 parasite/µl. However at 12 delivery both the malaria parasitaemia and mean parasite density were lowered to 28.8%(115/400) and 405.17±310.43 parasite/µl respectively. The prevalence of malaria parasitaemia was highest among primigravidas and secondigravidas at 77%(97/126) and 72.4%(42/58) respectively while the grandmultiparous women had the lowest prevalence of 26.7%(16/60) at booking(χ 2=53.29, p=0.000) and a similar trend was also noticed at delivery(χ 2=28.81, p=0.000). There was a direct relationship between the malaria parasitemia and anaemia. The prevalence of anaemia was highest, 81.8%(9/11) among those with parasite density of 1501-2000 parasite/µl and lowest at 7.1%(9/126) among those with parasite density of ≤500 parasite/µl(ᵡ 2=65.62,p=0.000) at booking. Also at delivery there was increased prevalence of anaemia with increasing malaria parasite density, 50%(2/4) among those with parasite density of 1001-1500 parasite/µl compared to 6%(6/101) when the parasite density was<500parasite/ µl (χ2=24.37, p=0.000). Malaria parasitaemia at delivery was associated with preterm delivery (OR=2.47,CI=1.12-5.23), low birth weight (OR=10.47 , CI=4.37-25.12) and cord parasitaemia (OR=16.89,CI=8.50-33.55).

Table of Content

Abstract

Chapter One: Introduction

1.1 Background of the Study

1.2 Statement of the Problem

1.3 Objective of the Study

1.4 Research Questions

1.5 Significance of the Study

1.6 Scope of the Study

1.7 Limitation of the Study

1.8 Definition of Terms

1.9 Organization of the Study

Chapter Two: Review of Literature

2.1 Conceptual Framework

2.2 Theoretical Framework

2.3 Empirical Review

Chapter Three: Research Methodology

3.1 Research Design

3.2 Study Area

3.3 Population of the Study

3.4 Sample Size Determination

3.5 Sample Size Selection Technique and Procedure

3.6 Research Instrument and Administration

3.7 Method of Data Analysis

3.8 Validity of the Study

3.9 Reliability of the Study

3.10  Ethical Consideration

Chapter Four: Data Presentation and Analysis

4.1 Data Presentation

4.2 Answering Research Questions

4.3 Discussion of Findings

CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATION

5.1       Summary of Findings

5.2       Conclusion

5.3       Recommendation

References

Appendix

CHAPTER ONE

INTRODUCTION

• Background to the Study

There is documented evidence in the current literature of the negative impact of malaria pregnancy (MiP). MiP is a public health concern that is impacting huge economic and human resources at various levels of society (WHO, 2020). The United Nation International Children’s Emergency Fund (UNICEF) stated that malaria is an urgent public health concern, and all stakeholders should concentrate efforts for the elimination (reduction of the incidence rate of a disease to zero levels in a defined geographical location via thoughtful interventions) and eradication (permanent reduction of the incidence of a particular disease to zero levels at global level via calculated efforts and subsequent interventions are not required) of the disease globally (UNICEF, 2020; WHO, 2016).

). Onyemaechi and Malann (2020) reported that parturients are a high-risk group for malaria due to their suppressed immunity by pregnancy. The disease burden of malaria in Nigeria is enormous; among parturients, it accounts for 70% morbidity, 15% anemia, and 5% to 14% prevalence of low birth weight (LBW). An estimated 3.2 million people are at risk to produce the hoped outcome for decades. An estimated 125 million parturients are at risk of malaria infection globally. Researchers have stated that parturients are a reservoir of the Plasmodium species via asymptomatic and submicroscopic presentation with placental parasitemia (Onyemaechi & Malann, 2020).

Malaria is a global public health problem with at least 40% of the world population at risk.1 In Africa, 30 million women living in malaria endemic areas become pregnant each year and they constitute the main adult risk group for malaria infection; for these women malaria is a threat for themselves and their unborn child. Malaria is said to be responsible for up to 200,000 newborn deaths per year(Achu et al., 2016). In Sub-Saharan Africa, the area hardest hit by malaria, malaria in pregnancy causes 400,000 cases of severe anaemia with estimated 10,000 maternal deaths annually.4 In Nigeria, malaria is responsible for about 11% of maternal mortality.

The clinical features of malaria in pregnancy depends to a large extend on the immune status of the woman, which is determined by her previous exposure to malaria. Women living in endemic areas have high immunity to malaria and the infection is frequently asymptomatic and severe disease is uncommon. During pregnancy, this immunity to malaria is altered but infection is still frequently asymptomatic(Agomo et al., 2016) . Therefore many cases go undetected, however even the asymptomatic malarial parasitaemia may be associated with placental parasitaemia and congenital malaria. This often leads to low birth weight, an important contributor to early infant death.

The worldwide annual prevalence of malaria is estimated to be in the order of 300-500 million clinical cases while mortality is estimated to be over 1 million deaths (WHO, 1998). The vast majority of deaths occur among young children in Africa especially in remote rural areas with poor access to health services (UNICEF, 2000). In most endemic areas of the world, pregnant women are the main adult risk group for malaria (Ebrahim, 1996).

Malaria infection during pregnancy has also been a major public health problem in tropical and subtropical regions throughout the world. Every year, at least 30 million women in malarious areas of Africa become pregnant most of which live in areas of relatively stable malaria transmission. The physiological changes of pregnancy and the pathological changes due to malaria have a synergistic effect on each other. The risk of abortion, stillbirth, premature delivery, intrauterine growth retardation and low birth weight has been associated with malaria infection in pregnancy (Leontsini, 1994; Taha et al., 1993; Ebrahim, 1996; Steketee, 1996).

In Nigeria, there is an estimated 3,000 death from malaria resulting in 40% of health expenditures, 50% hospital visits, and up to 50% of hospital admissions annually (Onyemaechi & Malann, 2020). The complications of malaria disease vary based on the level of immunity. In Nigeria, malaria accounts for 70% of morbidity and 11% of mortality among pregnant women and was the reason for 63% of hospital visits in Nigeria in 2018. Parturients are four times as likely to get malaria and two times as likely to die of malaria than their nonpregnant counterparts (Onyemaechi & Malann, 2020). The clinical signs of malaria include fever, chills, loss of consciousness, convulsion, breathlessness, anemia, jaundice, and vital organ dysfunction. (Onyemaechi & Malann, 2020).

Multifaceted factors account for the high malaria burden in Nigeria. Data from the 2015 Nigeria Malaria Indicator Survey (NMIS) and the 2018 Nigeria Demographic and Health Survey (NDHS) revealed that the country is not making noticeable progress in malaria elimination and eradication (National Population Commission [NPC] Nigeria and ICF, 2019; National Malaria Elimination Program [NMEP], National Population Commission [NPopC], National Bureau of Statistics [NBS], and ICF International, 2016). This study may help support a policy design of an appropriately focused intervention that will yield the visible oand control strategies. The study outcome may result in the mobilization of a multilevel support system of the socioecological model (SEM) framework for parturients to improve pregnancy outcome via an informed understanding and enhanced utilization of the existing malaria interventions. The Parturients and their neonates could benefit from reduction in the loss of lives and an increased economic resource in the study location and beyond. There could be an increase in malaria interventions uptake via an increased knowledge of effective interventions with cultural acceptance. The findings from this study may result in a reduction in the prevalence of MiP, and the morbidity and mortality associated with the infection via the knowledge from the study could result in better compliance to malaria interventions. There may be an improvement in the health, economic status, investment opportunity, and available income to parturients. Besides, the government may channel the vast resources spent on preventing and controlling malaria into enhancing community well-being.

1.2       Statement of the Research Problem

The malaria problem in Nigeria is life-threatening as 97% of the people are at risk. There are various collaborations (individual, national, and international) to reduce the disease but have not yielded the expected result. Malaria is the second leading cause of death in Africa. The statistics of malaria disease morbidity and mortality are highest in Nigeria (Okeke, 2012). According to Gontie et al. (2020), malaria risk factors in pregnancy to both mother and fetus are enormous. The enumerated risk factors from previous studies on MiP include educational attainments, age, ANC visit, gestational age, parity (the total number of pregnancies beyond 20 weeks), gravidity (the total number of confirmed pregnancies irrespective of the outcome), IPTp-SP compliance, and insecticide treated net (ITN) use (Gontie et al., 2020). Asymptomatic malaria is deadly, especially among parturients, children, and visitors from nonmalarial areas. This is because it is often undetected, therefore not treated. After 8 to 30 days of infection, the condition begins with flu-like symptoms such as fever, headache, joints and muscular aches, vomiting, diarrhea, chills, and sweats.  Untreated malaria infection can result in brain damage and damage to other vital organs including the liver and kidneys. Pregnant women are among the most impacted by malaria because their previously acquired immunoglobulin (in endemic settings) is reduced during pregnancy (CDC, 2020). Research indicates that malaria induced-anemia accounts for an estimated 10,000 maternal death in Africa each year (WHO, 2020). The infection of the placental by P. falciparum impacts maternal and neonatal exchange patterns causing miscarriages, premature births, imparted fetal growth, development, and death (CDC, 2020). The WHO via the global technical group set a new goal on malaria eradication for 2030. The goal is aimed at reducing malaria by 90% via its elimination in 35 countries globally (WHO, 2016). The objective of this study was to examine the use of some malaria interventions (IPTp-SP and ITN) and to identify some risk factors (listed in current literature from studies in various locations) that relate to PMPM and pregnancy outcome in the study location.

1.3       Objective of the study

The main objective of this study is to investigate the prevalence and effects of malaria in pregnancy. Specific objectives include :

1. To determine the prevalence of malaria parasitaemia among pregnant women attending antenatal care at the University of Maiduguri Teaching Hospital (UMTH).
2. To determine the association of malaria parasitaemia with maternal anaemia and possible effect on fetal outcome.
3. To determine the prevalence of placental parasitaemia among parturients in UMTH.

1.4       Research Questions

The following research questions cropped up in this study:

1. What is the extent of the prevalence of malaria parasitaemia among pregnant women attending antenatal care at the University of Maiduguri Teaching Hospital (UMTH).?
2. What is the association of malaria parasitaemia with maternal anaemia and possible effect on fetal outcome?
3. What is the the prevalence of placental parasitaemia among parturients in UMTH.

1.5 Significance of the Study

This study is important to students and scholars in the field of medical sciences as well as the general public. This is attributable to the fact that the research work is concerned with giving birth. The study is especially very important mothers and intending mothers. In other words, the findings of this study will provide a guide for pregnant woman on how to prevent and treat malaria in the course of pregnancy.The findings of this study would help prevent maternal mortality significantly. The recommendations of this study will also be beneficial to stakeholders in the health sector and the Nigerian government.

1.6       Scope of the Study

Maiduguri, the capital city of Borno state is a malaria mesoendemic10 city located in the northeastern part of Nigeria with about 138,625 women11 of reproductive age, these women are at risk of malaria infection in pregnancy but the prevalence is unknown. The level of malaria parasitaemia at booking may be a reliable index for subsequent development of active malaria in pregnancy. Detection of the prevalence of malaria parasitaemia at booking may further justify the routine use of malaria prophylaxis in pregnancy. This study sets out to find the prevalence of malaria parasitaemia in these women during pregnancy, quantify the magnitude of the problem and advise health workers, policy makers and the general public on the importance of malaria prevention during pregnancy. Malaria is the second most important cause of anaemia in pregnancy after nutritional deficiency and the anaemia due to malaria is density dependant.

1.7       Limitations of the Study

One limitation of this study is that a few of the survey questions depends on selfreporting by subjects, therefore, recall and misreporting bias may not be ruled out. The questionnaire was administered in a face-to-face interview for subjects that are not literate by me, while literate subjects filled the questionnaire within few minutes in my presence. This approach has the benefit of mitigating the non-response bias but may not guarantee anonymity and truthfulness in sensitive question especially on the use of herbal/plant medicine during this pregnancy (for concern that the healthcare officials does not support the use of CAM).

1.8       Definition of Terms

Malaria parasitaemia: the presence of asexual forms of plasmodium parasite in the peripheral blood.  Parasite rate: refers to the prevalence of asymptomatic asexual malaria parasite .

Spleen rate: refers to the prevalence of spleenomegaly in people with asymptomatic asexual malaria parasitaemia.

Malaria endemicity: refers to the amount or severity of malaria in a given community or region. Holoendemic: refers to parasite or spleen rate persistently greater than 75% with low adult spleen rate.

Hyperendemic : refers to parasite or spleen rate persistently greater than 50% with adult spleen rate greater than 25%.

Mesoendemic : refers to parasite or spleen rate of 11-50% . Hypoendemic : refers to parasite or spleen rate of 0-10%

Stable malaria: malaria is stable when there is high degree of transmission with little or no changes from season to season or year to year.

Unstable malaria: transmission varies considerably from year to year or season to season while community immunity is low and epidemics of malaria may occur with plasmodium falciparum as the commonest species.

Anaemia:packed cell volume.

Organization of the Study

This research work is categorized in five chapters, for easy understanding, as follows. Chapter one is concern with the introduction, which consist of the (overview, of the study), background to the study, statement of problem, objectives of the study, research questions, significance of the study, scope and limitation of the study, definition of terms. Chapter two encompasses the conceptual review theoretical review and empirical reviews on which the study is based. Chapter three deals on the research design and methodology adopted in the study. Chapter four concentrate on the data collection and analysis and presentation of finding. Chapter five gives summary, conclusion, and recommendations made of the study.

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