Wednesday, 3 June 2009

Malaria in Pregnancy- The silent threat for mothers and unborns

A bite from a mosquito is usually not considered a big deal. It itches for a short time and if you do not scratch it you will forget about it in a few minutes. But this little sting can threaten the life of every pregnant woman and the unborn child, if that particular mosquito passes on the malaria parasite. Malaria is the leading indirect cause of maternal mortality, accounting for 11% of deaths during pregnancy or delivery, what comes down to 5830 Nigerian women annually. Further more, it accounts for one quarter of all deaths in under five children in Nigeria.
Malaria is caused by the Plasmodium parasite which is carried by the female Anopheles mosquito. Mosquitoes come out at night in search of a bloodmeal. If a mosquito now bites a person who has malaria parasites in his or her blood the mosquito becomes the transmitter of the disease: The next time it bites another person and inject Plasmodium parasites in the person's blood which will cause malaria. This cycle repeats itself endlessly, resulting in about 300 million of malaria infections each year globally, with 90% of occurring in Africa. It is estimated that a person dies of malaria every ten seconds, most at risk are pregnant women and children under five. WHO estimates malaria sickens about 247 million people and kills nearly 1 million every year. Malaria disproportionately affects the poor, with 58% of malaria deaths occurring in the poorest 20% of the world’s population – a higher percentage than for any other disease of major public health importance.

Taking into consideration that about 7.5 million pregnancies occur every year in Nigeria, the magnitude of the malaria problem reveals itself: Malaria is more frequent and serious during pregnancy, causing anaemia (low blood) a main cause of maternal mortality and morbidity. During an epidemic of malaria, pregnant women are up to three times more likely to develop serious malaria as other adults. Severe malaria is classified by all the signs of uncomplicated malaria (which are fever, shivering, headaches, muscle/joint pains, nausea, mild anaemia and bitter taste in the mouth) plus one ore more of the following danger signs: Dizziness, difficult breathing, feeling drowsy, confusion, coma, severe dehydration, and severe anaemia. At the occurrence of any of this danger signs the woman must be referred to the hospital immediately to avoid complications and death. Complicated malaria requires specialized management at the health facilities, whereas uncomplicated malaria can be easily treated at home if recognized early. It is, however, essential to finish the course of treatment to ensure its efficiency. Unfortunately, malaria in pregnancy not only endangers the mothers. It can also have severe effects on the growth and development of the unborn child. The parasites hide in the placenta where they interfere with the transfer of oxygen and nutrients to the baby. This increases the risk of a spontaneous abortion, stillbirth, pre-term birth, and low weight babies- the single greatest risk factor for newborn death within the first month of life. Malaria accounts for about 5-14% of low birth weight prevalence.

The health consequences of malaria and HIV co-infection are not yet fully understood, but studies show serious implications for pregnant women and their unborn babies. Co-infected pregnant women are at very high risk of anaemia, and their children will havelow birth weights and are more likely to die in infancy. Recent research revealed that levels of HIV in the blood almost doubled when pregnant women with HIV got malaria. Those with impaired immune systems due to HIV/AIDS may also experience more malaria treatment failure. But malaria not only causes huge numbers of preventable deaths, its effects are also influencing communities to a large extent. Malaria results in frequent school absenteeism, missed work and lower productivity, and spending of large sums on medication and treatment. The presence of malaria has also been shown to have a negative impact on macroeconomic growth, inhibiting long-term growth and development to a degree that was previously unimagined. A comparative study of countries with and without malaria suggest that the presence of a high malaria burden results in a 1.3% lowering of the annual growth of the Gross Domestic Product per capita.

Malaria influences socioeconomic decisions, such as the siting of industrial projects, and it impacts negatively on the ability to attract capital developments and skilled labour. The presence of malaria is also an obstacle to the development of tourism in many regions.
The good news is: Malaria is easily preventable, and if detected early is also curable without much effort. The old practice of malaria chemoprophylaxis in pregnancy prescribed a 4 tablets dose of chloroquine at the first antenatal care visit, followed by a weekly dose of pyrimethamine during pregnancy up to six weeks postpartum. This practice, despite its effectiveness, created various problems: Many women are allergic against chloroquine and experienced itching pains, the frequent, regular intake is not guaranteed and sometimes impossible because of the financial burden, and health care providers tend to be uninformed about the correct dosages. As a result, FMOH and malaria Action Coalition implemented a new policy for malaria in pregnancy. One of its key pillars is focused antenatal care, including health education on malaria aiming at malaria prevention. Pregnant women are advised to always sleep under insecticide treaed bed nets (ITNs).

The benefits of ITNs are clear: They repel and kill mosquitoes, prevent physical contact with mosquitoes and additionally kill and repel other insects as lice, bedbugs, and cockroaches. The cost factor must also be considered: ITNs are far cheaper than treatment of acute malaria and they furthermore reduce the number of sick children and adults, ensuring productivity. ITNs can be purchased at pharmacies, in markets, in public and private health facilities or they are distributed by community health workers or NGOs working in the area of disease prevention. If they are used correctly and persistently and are re-treated every six months, ITN have been shown to avert around 50% of malaria cases.

Other areas of focus of the new policy on malaria in pregnancy are early detection & prompt appropriate case management of symptomatic women and intermittent preventive treatment (IPT). IPT replaces the old practice of malaria chemoprophylaxis and is based on the assumption that every pregnant woman living in an area of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria. WHO recommends that every pregnant woman should receive two doses of IPT and attend at least 4 antenatal care visits. Presently, the most effective drug for IPT is sulfadoxine-pyrimethamine (SP). Overall coverage of IPT to every pregnant woman is targeted, but special target groups are women in their first or second pregnancies, HIV positive women, adolescent women (aged 10-19), and women with sickle cell disease, as they are more prone to high risk pregnancies.
IPT is best given when the foetal growth velocity is at its highest, in order to reduce placental parasitaemia and resultant foetal growth retardation. That means practically that the first dose should be given from week 16 of pregnancy on, and the second dose should follow with at least 4 weeks space in between up to week 36. But however, if any signs of malaria occur in the woman she still needs to seek medical care.

Without a doubt, these interventions on community level can only succeed if government and other stakeholders completely commit themselves towards the fight against malaria. The key message of the importance of preventing malaria in pregnant women by sleeping under ITNs and taking IPT medication must be passed on to every Nigerian citizen, using both English and the local dialects. The media must be engaged fully in the coverage of malaria issues and educate their audiences on prevention and treatment of the disease. The federal ministry of health need to ensure supply with adequate and sufficient drugs to every health facility and accelerate coverage of free or highly subsidized ITNs and otehr materials for pregnant women and children. All efforts aiming at prevention must be complemented by effective case management of malaria illness for all women of reproductive age, emphasizing screening and prompt treatment for anaemia.

If only detected early enough malaria can be cured, its effects on the unborn child can be prevented and maternal and newborn mortality can be effectively curbed. Antenatal care and treatment can save the lives of thousands of Nigerian mothers and children, so make sure every pregnant woman takes that opportunity!
---Sofia Krauss

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