Coverage of malaria prevention services in pregnancy in the country is low and could hinder the World Health Organisation (WHO) set target to effectively curb the disease during pregnancy by up to 80 per cent by 2030. For experts, scaling up the number of antenatal visits from four to eight may improve chances of clients to prevent and treat malaria, which is projected to rise against the background of COVID-19, writes APPOLONIA ADEYEMI
As a life saver, malaria preventive treatment in pregnant women ought to be administered unhindered in the target group it is meant to assist to avert malaria during the delicate period of giving life to the new born. Given its potential to protect both pregnant women and their unborn babies in terms of pregnancy outcome, it is a key treatment given to every pregnant woman.
The sulphadoxine-pyrimethamine (SP) has been used as malaria intermittent preventive treatment in pregnancy (IPTp). SP, an ideal choice for IPTp, is a combination medication used to treat malaria.
It contains sulfadoxine (a sulfonamide) and pyrimethamine (an antiprotozoal). The medication, when used after the first trimester of pregnancy, is capable of preventing malaria during that pregnancy period.
Similarly, pregnant women who suffer malaria infection must, as a matter of urgency, be effectively treated with antimalarial medicine to avert any negative impact of the disease on both the foetus and the pregnant mother.
A professor of Paediatrics at the University of Ilorin, Olugbenga Mokuolu, who is also the Malaria Technical Director, National Malaria Elimination Programme (NMEP), Federal Ministry of Health (FMoH), Abuja, said malaria exacts some negative effects on pregnancy and pregnancy outcome and chief among them is the contribution of deliveries of babies that are low birth weight.
“Low birth weight babies have more challenges of survival and they contribute to maternal anaemia,” he stated. Similarly, Mokuolu said for a foetus that has been exposed to malaria, the ability of that baby to make that transition on delivery can be compromised.
“There is also the possibility of the child being short-changed in nutrient; that child can now become low birth weight,” he added. Being low birth weight can cause serious health problems for some babies.
A baby with low birth weight may have trouble eating, gaining weight and fighting off infections. Some low-birth weight babies may have long-term health problems too, according to experts.
“If a pregnant woman has malaria, there is a tendency for that malaria to take an abnormal turn and result in maternal mortality,” Makuolu said. Although there are national programmes embedded into the antenatal services, designed to enable pregnant women in Nigeria to take various treatments that address malaria in pregnancy, a few pregnant women only benefit from such treatments while millions miss them. Mrs. Joy Kelechi from Eziama in Imo State, but resident in Lagos, was one of those who failed to key into IPTp. Relating how she unintentionally fell into that group, Joy told the New Telegraph that early in January 2020, she found that she was pregnant.
Though unplanned, she and her husband accepted their fate and chose to have the baby, expected to be the fourth in the family. As the pregnancy advanced, almost getting towards the end of the second trimester, she wanted to register for antenatal care, but neither Joy nor her husband, Mr. Ogochukwu Kelechi, had the minimum fund, N4,000, required to register at the primary health centre (PHC) near their home at Ilasamaja, Lagos State.
“When my pregnancy was six months, I begged staff of the PHC to register me for antenatal with the required N4,000, but they rejected the money on the grounds that I came very late after my pregnancy had exceeded seven months.
“I had no choice than to abandon the registration and antenatal services. When labour was due, I was rushed to a traditional birth attendant (TBA) and after a prolonged labour, lasting two days, I was finally delivered of a stillbirth,” Joy said. She was, however, full of appreciation to God for sparing her life from that ordeal. “I almost died in the process. I thank God for sparing my life,” she told the New Telegraph.
The story of Joy is a common experience among pregnant women in Nigeria. In fact, many women, especially those in the low income group and most less-privileged women, delay going to register for antenatal until it is late.
“No matter how much you convince them, many pregnant women in Nigeria will not step out to access antenatal services until they are sure that a particular pregnancy has been established. By the time they get that assurance that pregnancy would have advanced so much,” Mokuolu said. Expectedly, care workers often turn them back whenever they go to health facilities with advanced pregnancies to register for antenatal care.
While some may end up going to private health facilities to register, the majority of them will go to TBAs who ultimately take the delivery of their babies. Some pregnant women even engage in home delivery, a pattern very common among the urban and rural poor, particularly women who live in far-toreach communities. Take another case, Mrs. Nana Echefu, a Ghanaian married to Mr. Darlington Echefu from Ebonyi State.
The couple, married for 12 years, lived at Ibafo, a rural community in Ogun State. However, throughout their 12 years marriage, Nana has been pregnant three times, all of which were delivered at home. Having experienced her first home delivery 10 years ago, which went without any hitch, it subsequently became her usual pattern of giving birth.
In all, for the three pregnancies, she did not bother about registering for antenatal care, nor did she care about accessing antenatal services. When asked why she did not go for antenatal care during all the three pregnancies, she said, “My husband and I couldn’t afford the exorbitant fees charged by private hospitals at Ibafo and PHCs that are public facilities, had not been established in that community during the period that I needed the services. “All my three babies came through natural vaginal birth. But two of the babies were delivered as stillbirths. Only one of the babies was delivered safely; I thank God for His mercy.”
Factors hindering services
High cost of care
A major reason why many pregnant women in Nigeria abandon antenatal care, which can pave the way for malaria-free pregnancy, is out-of-pocket payment for care. Most clients are poor. Cost of delivery in public facilities in Lagos State can be as high as N10,500, antenatal care costs N20,000, including fees for drugs. A caesarean section costs N45,000 or more depending on the condition of the patient. In private facilities, however, the cost of delivery and other related services are certainly higher. Many poor families will see the above bills as outrageous and may tend to seek cheaper services elsewhere.
Another obstacle hindering pregnant women from ensuring malaria-free pregnancy is ignorance. Many are not aware of the numerous benefits from accessing antenatal services. One major advantage is the prevention and treatment of malaria in pregnancy, which improves pregnancy outcome.
Impact of malaria in pregnancy
“Besides having an impact on maternal health, newborn health and maternal mortality, malaria has a big impact on stillbirth,” said Dr. Anshu Banerjee, Director, Department of Maternal, Newborn, Child, and Adolescent Health & Ageing at the World Health Organisation (WHO).
Banerjee, who holds a PhD from the University of Amsterdam, Netherlands and Masters in Public Health for Developing Countries from the London School of Medicine and Tropical Diseases in the United Kingdom (UK), said, “malaria is one of the causes of stillbirth in Africa and sub-Saharan Africa. Malaria could be up to 20 per cent the cause of stillbirth; a number of pregnant mothers in Africa have episodes of malaria.
“Around 50 million pregnant mothers in Africa are prone to getting malaria infection. Malaria is also the direct cause of maternal anaemia.” Similarly, the Director, Global Malaria Programme at the WHO in Geneva, Dr. Pedro Alonso, said malaria shouldn’t be experienced during pregnancy.
He said: “Malaria, if left untreated during preg-nancy, can and will lead to severe disease, death and low birth weight which is a key determinant of neonatal and infant mortality. “This is a very serious problem, one that has not been tackled sufficiently and aggressively up till now.”
Giving specific instances of what happened to pregnant women when malaria is allowed to thrive during pregnancy, Alonso said an estimated 11 million pregnant women in sub-Saharan Africa were infected with malaria in 2018 (29 per cent of pregnancies), resulting in nearly 900,000 children born with a low birth weight, a leading cause of child mortality.
Even when death is averted, low birth weight has adverse consequences on children’s growth and cognitive development. Each year, maternal malaria is also responsible for 20 per cent of stillbirths in sub-Saharan Africa. Given the delivery of a lot of babies with low birth weight, it is clear that the coverage of malaria prevention in pregnancy in Africa including Nigeria is low and therefore may not achieve the WHO set target to effectively reduce malaria in pregnancy by 80 per cent by 2030, according to Bernejee.
Up to 31 per cent target has so far been achieved globally. Consequently, to protect pregnant women in sub-Saharan Africa, he reasoned that it has become necessary to scale up the number of antenatal visits for every pregnant woman from four to eight, to improve chances to prevent and treat malaria in pregnancy.
Other plans, according to Alonso, are country implementations of WHO recommended three-pronged approach: sleeping under long-lasting insecticide-treated nets (LLINs), providing prompt diagnostic and effective malaria treatment, and providing malaria IPTp with SP.
The director of global malaria programme at the WHO stressed that SP should be given to pregnant women during routine antenatal care visits, starting as much as possible in the second trimester, usually from week 13 of the pregnancy, and ideally through the administration of the drug under the direct observation of a trained health care provider.
Alonso noted that the SP can be safely administered from the beginning of the second trimester until the delivery of the baby, provided the doses are given one month apart. On its part, the RBM Partnership to End Malaria, in October last year, issued an urgent appeal to leaders and health policymakers across Africa including Nigeria to better protect millions of pregnant women and their newborn children from the devastating consequences caused by malaria in pregnancy.
The RBM Partnership to End Malaria, comprising more than 500 partners, including malaria endemic countries, is the global platform for coordinated action against malaria. According to the RBM Partnership, malaria strikes hardest against pregnant women and children in sub-Saharan Africa, who are now at even higher risk from the disease due to the COVID-19 pandemic.
Despite progress over recent years, in 2018, more than two thirds of eligible women across 36 countries in sub-Saharan Africa did not receive the full course of life-saving preventive treatment against malaria during pregnancy.
Poor malaria service coverage/low
uptake Being a member state of WHO all the proposals and recommendations to tackle malaria in pregnancy are expected to be implemented in Nigeria. Sadly, the coverage and reach of the programmes as well as their uptake among clients is low, lamented Dr. Japhet Olugbogi, a Public Health Physician and Chairman, Nigeria Medical Association (NMA) Committee on Infectious Diseases in Lagos State.
Highlighting how the gaps came about, CONTINUED FROM PAGE 23 Olugbogi said in the recent past, governments in Nigeria used to make provisions for certain items for pregnant women who registered in PHCs for antenatal care.
The items, including SP, RDT kits, antimalarial drugs, LLINs, among others, used to be given free to all pregnant women during antenatal visits, but now the commodities are no longer provided.
He said: “Apart from doing routine malaria tests for pregnant women, using the rapid diagnostic test (RDT) kits, we also counsel them about the negative health impact of malaria in pregnancy, how they can prevent it, how they can protect themselves from the disease and on general health education.”
Furthermore, the public health physician said every pregnant woman and every woman who just gave birth, that comes to the PHC, gets a bed net. “Now, all these activities have stopped; the only one that we still do is the malaria test, which we do for clients that pay for the service,” he added.
Explaining why the commodities are no longer available, Olugbogi said an international Non-Governmental Organisation (NGO) used to supply these materials: mosquito nets, antimalarial drugs and random test kits, but it no longer supplies to Nigeria. According to him, that is the reason why Nigeria doesn’t have these free commodities again.
“Subsequently, when we have pregnant women that need ITPt, we prescribe for them to go and buy,” he added. Olugbogi, however, lamented that the current situation reduces the uptake of the programme and due to the low uptake there is an increase in the number of malaria cases in pregnancy in the country.
Considering the above, there is no doubt that the majority of deliveries take place outside public and private health facilities; many women prefer the services of TBAs who lack skilled care and that of the auxiliary nurses who mainly set up unlicensed services.
These are the local delivery services that pregnant women in the country patronise most. According to data from the Nigeria Demographic and Health Survey (NDHS) 2018, nearly four in 10 births (39 per cent) are delivered in a health facility, primarily in public sector facilities. Still, 59 per cent of births are delivered at home. What does this mean for the recent global call to end malaria in pregnancy with intermittent preventive treatment (IPTp)? Nigeria still has a long way to go if the majority of births are not taken by skilled providers.
“Overall, 43 per cent of births are assisted by a skilled provider,” the NDHS further shows. If this is the situation, there is no guarantee that clients involved in the 59 per cent deliveries at home, are exposed to IPTp treatment and other programmes aimed to ensure malaria-free pregnancies.
A critical look at the above data shows that the number of pregnant women who receive malaria-free treatment in pregnancy is undoubtedly low and this corroborates the views of Barnejee that the coverage of the malaria prevention in pregnancy in Africa is low; hence, cannot achieve the set goals to effectively tackle malaria in pregnancy on the African continent.
For instance, in Nigeria, only 39 per cent deliveries take place in health facilities, primarily in public sector facilities and this is the group that has the opportunity of getting malaria treatment, provided the clients can pay for the services. Cost of services is a hindrance for their uptake, said Olugbogi, adding that only clients that pay for treatments get them. “This is the reason why we still have high maternal mortality,” Olugbogi averred.
Maternal mortality ratio (MMR) for Nigeria is 512 deaths per 100,000 live births (lbs), according to NDHS, 2018. Olugbogi noted that malaria disease in pregnancy causes about 15 per cent of anaemia in pregnancy.
“If malaria occurs in pregnancy, you can be sure that maternal mortality will be high,” he added. However, the situation in Lagos is different. The Lagos State government, through its Ministry of Health, has over the years formed an alliance with TBAs operating in its area, educating them on implementing modern, international best practice on maternal/delivery services as a strategy to curb maternal, neonatal and child mortality. The policy hinges on the locals’ preference for TBA delivery services; the idea is to empower this cadre of providers with skills so as to improve pregnancy outcomes.
“We educate the TBAs in Lagos State on modern delivery practices and to refer cases to facilities that have skilled providers very early before it is late,” said Olugbogi. He urged the Federal Government to engage the NGO which hitherto supplied the commodities for malaria-free pregnancy in Nigeria, with a view to renewing the supplies of services or set aside some funds to procure materials such as bed nets, antimalarial drugs, SP, and random test kits, among others. Olugbogi urged government at all levels to stand up to their responsibilities and provide commodities for their citizens.
He said: “My message to pregnant women and fathers is that they should try as much as possible to procure any drug that medical doctors or the health workers prescribe for them.” According to him, families, particularly pregnant women and new babies, must try to live in a mosquito-free environment so that the women can be free from malaria.
“It is important that we play our roles. If the government cannot provide everything; every individual should endeavour to do the needful,” he suggested. During the virtual launch of the RBM Partnership To End Malaria’s ‘Speed Up Scale Up’ call to action last year, the First Lady of Ghana, Rebecca Akuffo-Addo, said, “Good health starts with proper care of pregnant women and children. Protecting pregnant women, their unborn babies and newborns from malaria will improve the health of mothers and their young children in those critical first years of life and can contribute towards the achievement of Africa’s broad health and development goals.”
Malaria cases are projected to rise against the backdrop of service disruptions occasioned by coronavirus pandemic. According to the RBM, giving at least three doses of quality-assured SP to all eligible women in sub-Saharan Africa including Nigeria, can increase the coverage and uptake of IPTp by 2025. Highlighting some of the challenges of services for preventing malaria in pregnancy in the country, the Malaria Technical Director, NMEP at the FMoH, Mokuolu, said late registration for antenatal care is a huge hindrance. He also blamed the perennial challenge of inadequate drug supply including SP for the setback.
“We need pregnant women to have increased uptake of antenatal services; we need them to register early for antenatal; we have had some logistics challenges with the provision of these drugs. No matter what you prepare and provide; it cannot be enough,” Mokuolu said. He also spoke on concerns that the large number of pregnant women that patronise TBAs and those doing home delivery could be missing needed services.
“We don’t promote home delivery; it takes a lot of campaign to get women to come out and access the drugs. Even recently, we have begun community directed IPTp” as a strategy to expand coverage.