ANNALS OF IBADAN POSTGRADUATE MEDICINE
F.A. Bello1 and A.I. Ayede2
Background: Malaria complicates up to 58.1% of pregnancies in Nigeria. Preventive measures include intermittent preventive treatment and consistent use of insecticide-treated nets. However, uptake of these interventions can often be sub-optimal.
Objective: This study aimed to assess the prevalence of malaria in pregnancy in peri-urban and rural communities of Ibadan, Nigeria and its association with the use of preventive measures.
Methods: In this cross-sectional study, pregnant women were recruited from selected primary health centres and blood films were taken for malaria parasites. Explanatory variables were the use of bed nets and chemoprophylaxis; the primary outcome was presence of peripheral malaria parasitaemia.
Results: Malaria prevalence was 4.3% (67 of 1570 participants); two-thirds of women with parasitaemia had malaria symptoms. Four hundred and thirty-eight (27.9%) used prescribed sulphadoxine-pyrimethamine prophylaxis, 784 (49.9%) women reported that they consistently slept under insecticide-treated nets, and 236 (15%) complied with both interventions. Bed net use appeared more protective than chemoprophylaxis. However, the protection from malaria in those who used preventive measures was not statistically significant (p=0.075).
Conclusions: Malaria prevalence was low. No association was determined between malaria and the use of preventive measures; the lack of association may be due to the low prevalence.
Keywords: Malaria, Pregnancy, Chemoprevention, Insecticide-treated bed nets
Dr. A.I. Ayede
Department of Paediatrics,
University College Hospital,
Malaria causes about 11% of maternal deaths in Nigeria.1 Malaria complicates 8.4% to 58.1% of pregnancies in Nigeria.2,3 Pregnant women in their first or second pregnancies are particularly susceptible to malaria.4 Placental parasitaemia limits transfer of nutrients and oxygen to the foetus, leading to intrauterine growth restriction, low birth weight or intrauterine death.5
The World Health Organization (WHO)’s guidelines included at least two doses of intermittent preventive treatment in pregnancy (IPTp) after quickening, consistent use of insecticide-treated nets (ITNs), and effective case management of malaria.6 The most recent guideline recommends that IPTp is commenced from 14 weeks’ gestational age,7 then subsequently, at least one month apart at each scheduled antenatal visit until delivery (with no upper limit on the number of doses).7 This is, however, yet to be taken up by many facilities.8,9 The updated Nigerian National Guideline’s10 uptake has been slow; the initial policy is still in use in many places, including the study area.
Several studies have shown the impact of IPTp on prevalence of malaria in pregnancy.11,12,13 Direct Observation Therapy (DOT) is recommended for IPTp to ensure compliance.6 This is however not done in many clinic settings due to the high patient load, the medication not being dispensed free, or the impracticability of making drinking water available for clients. In rural South-west Nigeria, pregnant women did not use IPTp because of their uncertainty of drug safety in pregnancy (even though prescribed by their caregivers); many also say they would have used the drugs if allowed to bring their own water or cups.14 In low-resource environments such as this, availability of potable water and the unhygienic sharing of public cups, are reasonable deterrents to DOT.
Intermittent shortages of SP, which was being supplied by the government at the time, also limited DOT of IPTp .14
Despite awareness of insecticide-treated nets and their importance in prevention of malaria, the uptake is often poor. Reasons proffered include the cost of the nets, heat entrapment (in a tropical environment) over bed space when nets are spread, concerns with toxicity of insecticide, the mere inconvenience of having to tuck in a net every day, or even forgetting to use it.15,16 Even though ownership of a bed net does not always result in its utilization, wide distribution is important for universal coverage.17
The rationale behind the primary care setting employed in this study was based on the WHO model of community-based care, described as “care the consumer can access nearest to the home, which encourages participation by the people”. 18 The Comprehensive Community and Home-based Health Care Model (CCHBHC) is defined as “an integrated system of care designed to meet the health needs of individuals, families and communities in their local settings.”.19 Antenatal care in primary health centres (PHCs) falls under this definition. The investigators thus expected that the findings would mirror the community as closely as possible.
This study aimed to determine the prevalence of malaria in peri-urban and rural communities of Ibadan, Nigeria and assess its association with the use of malaria preventive measures.