MALARIA: Nigeria: Pregnant women and battle against malaria

Oluwole Ige : 30 May 2011



Pregnant women at an ante-natal clinic

Malaria, from the medical point of view, is caused by female mosquito known as anopheles, which drops its Plasmodium into the system of individuals after biting. It is no respecter of status, gender and age. Besides, it is one of the highest killer-diseases in Africa. Some experts even claim that malaria kills more than the dreaded HIV/AIDS, especially in Sub-Saharan Africa. The new dimension to the scourge of the disease is its ravaging effects on the population of pregnant women in Nigeria.

Recently, the Ogun State Commissioner for Health, Dr Isiaq Salako, hinted that about 4, 500 pregnant women die of malaria in the country annually.
Though, the figure appears insignificant, considering the over 150 million population of Nigeria, it is an established fact that the disease remains a great threat to the population particularly expectant mothers.
According to Dr Adelakin Makanjuola, a consultant gynaecologist, malaria is a parasitic infection transmitted to humans through the bites of infected female anopheles mosquitoes. About 60 species of the anopheles mosquito are major transmitters of the disease. There are four different types of malaria parasites, plasmodium falciparum, P. malariae, P. ovale, and P. vivax. Within each species there are many variant strains. Worldwide, P. falciparum and vivax cause the vast majority of clinical cases and nearly all of the deaths and serious morbidity.
In Africa, P. falciparum, the most dangerous of the parasites, causes over 90 per cent of all malaria infections. So far, entomologists have identified over 2000 species of mosquito, but only the anopheles mosquito actually transmits malaria. In Africa, the major vector of malaria is An. gambiae, and there are many members of this group of mosquito. The parasite after spreading rapidly through the bloodstream to the liver, emerges again into the blood stream, finally to settle in the red blood cells, where it multiplies and emerges in bursts of new organisms.
These parasites, because of their large numbers, can cause particular damage to the nervous system, liver, and kidney. The resulting disease in humans can be devastating, especially in young children and adults including, pregnant mothers and their unborn babies as well as Nigerians in diaspora who have been away from Nigeria or other malarious zones for more than two years and have either not developed natural immunity or have lost it.
This group is also very vulnerable to cerebral malaria which can result in death within hours. Others die later from the infection either from overwhelming anaemia, liver or kidney failure. Generally speaking, with untreated malaria, up to 20 per cent of persons infected with falciparum malaria will die. The stark reality of this scourge in Nigeria is as follows: In Nigeria, there is an estimated 25 per cent -30 per cent of mortality in children under five, or an estimated 300,000 deaths each year due to malaria.
The campaign slogans aimed at battling the endemic disease are endless and their messages catchy to drive home the need to avoid environmental and sanitary conditions are, capable of fuelling the spread of the malaria. Such slogans include: “Roll back malaria; Counting malaria out; Effective malaria treatment, and Free Africa from malaria now, among others. The improper disposal of refuse, stagnant water, gross inadequate access to right medication and inability of many families to access preventive facilities like bed nets have been identified as factors aiding malaria infections.
Despite the aggressive campaigns against the disease and the huge financial and manpower commitments by the Federal Government, donor agencies, including the World Health Organisation (WHO), Global Fund and other stakeholders in the health sector, malaria continues to constitute a serious health challenge, with the 110 million clinically diagnosed cases in Nigeria annually.
From its debilitating effects, investigations by the United Nations Children Fund (UNICEF) revealed that the disease imposes a heavy social and economic burden, which resulted into a loss of about N132 billion annually in prevention, cost treatment and productivity loss in Nigeria. Such loss came in form of hours lost due to illness, deaths of members of the working population; impaired child development and absenteeism from work as a result of the disease.
Worst hit by the malaria endemic are the children and pregnant women. It adversely affects children under the age of five and pregnant women in Sub-Saharan Africa, leading to the death of nearly 3, 000 every day.
Apart from little children and infants, pregnant women are found to be highly susceptible to malaria attacks. Generally, expectant mothers have been medically proven to be four times more prone to malaria parasites than those not pregnant. Reports by medical experts indicate that when women become pregnant, their immunity and disease resistance level become low, therefore, they will be more or less helpless when malaria parasites strike.
It is not uncommon for some pregnant women, having frequent bouts of malaria fever and this has made it mandatory for them to seek medical treatment immediately, with a view to avoiding its negative consequences. Experts and consultant gynaecologists hold the view that malaria attack on pregnant women could lead to low blood pressure, premature labour, abortion, stillbirth, low weight babies, anaemia and possibly preventable death, if timely action is taken to reverse its trend.
The United Nations (UN) has done a lot in its quest to totally eradicate malaria. The Roll Back Malaria (RBM) and the Global Malaria Action Plan (GMAP) are some of the intervention strategies made by organisations and individuals to help deliver the world, including Nigeria from the shackles of malaria.
Despite the clear evidence that many pregnant women could be saved from the complications of malaria through the use of insecticide-treated nets (ITNs) and intermittent preventive treatment, many still succumb to death occasioned by malaria parasites. Towards this end, concerned health care practitioners have raised alarm, cautioning that if the situation is not checked on time, the target to checkmate the incidence of malaria in pregnancy will not be met and the gloomy pictures of the endemic disease will continue to wreck havoc on Nigerian women and their unborn babies.
The most pathetic development is that most times, the victims do not show any symptom of illness. Clinical records show that the malaria parasites attack the placenta even at low infection rates and this invasion of the placenta leads to ill health for the mother, which may precipitate abortion of the foetus as well as premature labour.
More frightening is the recent world malaria report, which indicated that Nigeria accounts for a quarter of all malaria cases in the 45 malaria-endemic countries in Africa. This revelation obviously brings to the front burner the daunting challenges of malaria in the country. Thus, pregnant women, who are identified as one of the groups at high risk of the effects of malaria infection, need special protective measures to ensure their survival and improve birth outcomes.
Therefore, sleeping under insecticide treated nets remains one of the key strategies for protecting expectant mothers and their newborns from malaria-carrying mosquitoes and seeking medical care after suspecting symptoms of malaria would also go a long way in combating the disease.
In an interview with the Nigerian Tribune, Dr Bukola Adesina, a gynaecologist, at the University College Hospital (UCH), Ibadan said malaria as a disease affects pregnant women in Nigeria, just like any other person. She described Nigeria as an endemic country as far as malaria infection is concerned.
“It is endemic in Nigeria. It is important to make a demarcation. It depends on what part of the world you are living because this determines to a large extent how you will react or respond to malaria,” she stated.
According to her, people get infected all year round, “though individuals, who live in endemic area or zone, have some level of immunity” but they still get infected after being bitten by mosquitoes that transmit malaria parasites into their body systems.
“When a woman becomes pregnant, her immunity mechanism will reduce. The malaria will live in the placenta of the woman. The placenta provides a safer abode for the malaria parasites and it is the supply link between the baby and the mother. After occupying the placenta region, malaria parasite will disturb the supply of nutrients to the baby; hence, the baby is starved and this negatively affects the weight of the baby,” Dr Adesina remarked.
While observing that Nigeria’s prenatal mortality ranked among one of the highest in the world, the gynaecologist maintained that malaria, which makes pregnant women to develop anaemia contributes to maternal mortality rate.
“It is observed that when the malaria parasite load is so much in the system of an expectant mother, the baby dies before delivery. There is no robust data capturing system in Nigeria. Worldwide, 10 per cent of maternal mortality is related to anaemia, which is a fallout of malaria,” Dr Adesina hinted.
She further listed reasons pregnant women die as a result of haemorrhage-bleeding, hypertension with seizures-convulsion, obstructed labour, abortion and infection, adding that part of the measures put in place by the federal government to combat maternal mortality include the provision of access to effective health care, Intermittent Preventive Therapy (IPT), Insecticide Treated Nets (ITNs) and prompt treatment of malaria with Artemisin Combination Therapy (ACT).
Dr Adesina, who canvassed for the effective education of the people, particularly pregnant women about the myths of malaria on the part of the government, said some people still believed erroneously that exposure to the sun could cause malaria infection, stressing the need for all to seek information about the disease.
According to her, poverty also contributed largely to the spread of malaria infection in Nigeria, advising that government should address poverty squarely as a veritable means of combating the scourge, saying that some people could not even seek medical services because of their inability to pay for the medicare.
Part of the short term measures that can be adopted by the government, Dr Adesina said, involve active collaboration with the mission homes and Traditional Birth Attendants (TBAs) because some pregnant women in Nigeria still patronise them for delivery services.
Said she, “the government should liaise with these mission homes and TBAs on the need to educate pregnant women to make use of Insecticide Treated Nets (ITNs) and create awareness about the danger that malaria poses to the health and survival of pregnant women in Nigeria”.
Continuing, Dr Adesina contended that “opinion leaders, religious groups, market women associations, civil society organisations, Non Governmental Organisations (NGOs) and health institutions are major stakeholders that government should work in synergy with to really have headway in the fight against malaria.
Some pregnant women who spoke to the Nigerian Tribune expressed concerns and fears over the debilitating effects of malaria parasites on their present status, lamenting that the infection had done irreversible damage to them in the past.
Mrs Sakirat Adebimpe regretted that she lost four months old pregnancy to malaria in 2009. She said “I do not treat malaria with kid’s gloves any longer because of the bitter experience I had in June 2009. I was attacked by malaria fever, though, I went to the hospital to treat it, I eventually had a miscarriage due to the extent of damage it had wrecked on my pregnancy then. The doctor observed that if I had reported at the hospital earlier, the malaria could not have affected the pregnancy.”
The 36 year-old woman, who is already carrying a six month pregnancy added that “nowadays, I attend ante-natal clinic regularly and if I feel or suspects any symptom of malaria, I hurriedly visit hospital to access appropriate medical services, with a view to warding off any advance from malaria parasites.”
In her own submission, Mrs Ijeoma Nwachukwu had this to say, “I have always adopted preventive measures to combat malaria. I am quite aware of the dangers that malaria poses to pregnant women and this has made it mandatory for me and my children to sleep inside Insecticide Treated Net [ITN] so as to avoid mosquitoes’ bites that cause malaria. Besides, I attend antenatal clinic and also go for medical checks regularly to avoid any untoward development”.
Several factors have been postulated as accounting for limited successes in eradicating malaria, which include lack of political will and commitment of successive Nigerian governments in tackling it, poor awareness and appreciation of the magnitude of the malaria burden right across the board, poor health facilities and practices by individuals and in communities and resistance to drugs and insecticides by malaria parasites.
http://tribune.com.ng/index.php/features/22651-pregnant-women-and-battle-against-malaria-scourge

POVERTY: Sub-Sahara Africa: More Skilled Attendants Needed to Reduce Maternal Mortality

May 9, 2011 (IPS) -Miriam Gathigah
 Credit: Peter Martell/IRIN
Motorcycle ambulance in South Sudan - distance to a healthcare facility and a shortage of trained personnel are key factors in maternal deaths.

Sub-Saharan African countries have claimed nine of the ten bottom places in a ranking of maternal health around the world. "The Mothers' Index", a new survey of motherhood by Save the Children, analyses health, education and economic conditions for women and children in 164 countries.
"Ironically, it is in giving birth - and multiple births for that matter - that a woman nears an approximate of the ideal of a wife," says Kolorinda James, a traditional birth attendant (TBA) in Juba, South Sudan. "Children are considered to be a sign of wealth. It is a case of the content being valued much more than the container - as thousands of women in this region continue to die from pregnancy related complications."

Contributing factors
Some 250,000 maternal deaths occur in Africa each year. There are several factors that make childbirth in Africa so dangerous. Millions of early marriages and teenage pregnancies mean riskier births to young women whose bodies have not developed to fully stand the rigors of childbirth.
Africa's health systems are inadequate to serve the needs of pregnant women, a majority of whom give birth without a skilled health worker present.
Across the continent, particularly in rural areas, a hospital or clinic with a trained midwife or doctor and facilities to deal with complications is often far away. The lack of good roads and transport – and the cost of transport - means a pregnant woman in trouble is unlikely to reach help in time.
Cost is also a factor for women and their families – even at highly subsidised public hospitals, the cost of giving birth can be beyond the reach of a woman living on a dollar or two a day. Many decide to give birth unaided at home, or with the help of an untrained attendant whose more modest fee can be paid in kind, with farm produce for example.
"Due to various factors such as poor infrastructure, most women deliver at home with no professional assistance and this leads to fatalities in many instances, because in case of a complication such as excessive bleeding, the woman will die," says Ousmane Hadari, a reproductive health consultant in Niger.
In Niger, cultural factors also lead many women to choose to give birth at home, regardless of the risk. "The trend has been that many women will attend the antenatal clinic - in fact, the percentages of pregnant women attending clinic has gone up in many countries - but most of them prefer to deliver at home for various cultural reasons."
Giving birth at home is seen as proof of a woman's fearlessness in the face of pain, says Hadari, adding that women also prefer to give birth at home so that they can carry out a custom to bury the placenta soon after birth.
James says cultural factors are also at work in South Sudan. "For many women the thought of being delivered by a male health attendant is taboo."

Birth attendants
But the shortage of skilled birth attendants is a key problem. James is one of roughly 2,000 TBAs registered by South Sudan's Ministry of Health who form the wafer-thin support for births in a population of 10 million. These TBAs have no formal qualifications, but James points out that TBAs have vast experience with deliveries acquired over years of practice. Traditional attendants enjoy the confidence of women in the community, and she says there are efforts to integrate TBAs into the health system as a means of drawing more women to hospitals for delivery.
"We are registered because we are not working in an ideal situation. There is a serious shortage of well-qualified nurses and midwives: what other options are there besides us?" says James.
Traditional birth attendants remain indispensable in a country where, according the Directorate of Nursing and Midwifery, there are barely more a thousand nurses - and only 40 who hold a diploma indicating basic knowledge of midwifery.
The World Health Organization (WHO) recommends that a skilled attendant be present at every birth, but in South Sudan there are only 10 nurses for every 100,000 births and just four adequately qualified registered nurses for every million children born.
South Sudan's Ministry of Health reports 2,037 maternal deaths for every 100,000 births. Hadari says Niger is not much better.
"The picture is not so different in Niger which has a staggering maternal mortality and morbidity rate particularly among the rural women and especially those with little or no education and consequently low or no income."
Niger ranked 163 in the Safe Motherhood Index, with 1,800 deaths per 100,000 births. One in seven Nigerien women will die from a pregnancy-related complication.

Models of success
Initiatives to improve maternal health are under way all over the continent, in an effort to meet Millennium Development Goal commitments to reduce maternal mortality by three-quarters from 1990 levels. Many countries seem unlikely to meet that target by 2015, but there are some positive models.
According to a 2010 World Health Organization report, maternal mortality in Ghana has fallen by a quarter in the last decade, to 560 per 100,000 births. Ghana has achieved this by revamping training, now adding 500 new midwives each year. The government has also made efforts to post health professionals to the areas with the worst maternal health statistics.
Mozambique is another success story. Mozambique's national health data shows maternal deaths fell from 1,000 deaths per 100,000 births in the 1990s, to 473 per 100,000 in 2007. This success has been built on the establishment of "waiting houses", which permit at-risk pregnant women to move to a temporary home near a local hospital in order to facilitate quick access to skilled health care once labor begins.
As 2015 draws nearer, these and other measures will need to be adopted and adapted across the continent if MDG targets are to be met.
Although Sudan is faring poorly, the country may be moving in the right direction with the continued development of maternal care at the Juba Teaching Hospital, where an initiative to train more nurses and midwives is based.
Janet Michael of the South Sudan Ministry of Health says the emphasis is being placed on the "need for trained birth attendants, high contraceptive prevalence, improved infrastructure to enhance access for women in need of various
institution based services and a budget that can sustain these initiatives."
http://ipsnews.net/news.asp?idnews=55539