What is Malaria?  

Malaria is a mosquito-borne disease that affects humans and other animals. It is caused by a parasitic protozoan (a group of single celled microorganisms) belonging to the genus Plasmodium (WHO, 2014). Malaria is one of the most common killer diseases affecting African countries, especially those in tropical and subtropical areas (WHO, 2010). 

In 2019, Nigeria had the highest number of deaths (23%) resulting from malaria infections globally (WHO, 2019) and in 2020, Nigeria also had the highest number of global malaria cases (27%) (USAID, 2020). 

Malaria in Pregnancy  

Malaria during pregnancy is a major public health concern and an important factor contributing to maternal and infant mortality in malaria-endemic countries (WHO, 2015). Pregnant women are particularly more prone to malaria, and in low transmission settings, they usually have a greater risk of severe Plasmodium falciparum malaria (McGready et al., 2011). 

In Nigeria, malaria is responsible for about 60% of out-patient visits to health facilities (NMIS, 2015). In addition, about 52% of pregnant women suffer from malaria, which contributes to maternal anaemia, low birth weight, still births, abortions and other malaria related complications (Okpua et al., 2018). The financial loss as a result of malaria is estimated to be about 132 billion Naira annually, in the form of treatment costs (Noland et al., 2014). In figure 1, we see that the highest deaths from malaria in the year 2020, occurred in the North-Western region (NHMIS, 2020). Similarly, only 22% of pregnant women aged 15-49 years in that region received at least one dose of intermittent preventive treatment (IPT) during pregnancy (fig. 2) ( NNHS, 2018). 

Fig 1: Maternal mortality rate as distributed by geopolitical zones in Nigeria (NHMIS, 2020).

 Fig 2: Percentage of women aged 15-49 years who received at least one IPT dose during pregnancy (NNHS, 2018) (Source: The MSDAT).

Effects Of Malaria On The Mother 

In comparison to the general population, the risk of developing complications is more in pregnant women with malaria (WHO, 2009). Particularly, malaria complications in pregnant women with low immunity include; 

1, Anaemia; 

2, Acute pulmonary oedema; 

3, Immunosuppression; 

4, Malaria nephropathy (WHO, 2009). 

1, Anaemia: Malaria can cause or aggravate anaemia (Meghna et al., 2007), which can be due to the following causes or reasons; 

a, Haemolysis of parasitized red blood cells. 

b, Profound haemolysis which aggravates folate deficiency. 

Anaemia due to malaria is more common and usually severe between 16-29 weeks of pregnancy (Meghna et al., 2007). In fig. 3 below, Sokoto had the highest anaemia rate among the women attending antenatal care while Anambra state recorded the least (NHMIS, 2020).

Fig 3: Anaemia rate among pregnant women attending Antenatal care (ANC) across states in Nigeria (NHMIS, 2020). 

2, Acute pulmonary oedema: This is also a common complication of malaria in pregnancy when compared to the non-pregnant population. This feature is more common in the second and third trimesters. This condition is aggravated by pre-existing anaemia and hemodynamic changes in pregnancy (Meghna et al., 2007). 

3, Immunosuppression: This is also another effect of malaria in pregnancy and it brings about reduced synthesis of immunoglobulins. Patients may have more frequent paroxysms of fever and frequent relapses. Secondary infections (UTI and pneumonias) and algid malaria (septicaemic shock) are more common in pregnancy due to immunosuppression (Manan et al., 2006).   

4, Malarial nephropathy: This is a renal failure attributed to malaria infection in pregnancy and it is often the most life threatening (Barsoum & Rashad, 2000). Malaria acute renal failure has also emerged as a serious problem due to its high mortality rate in non-immune adult patients (Manan et al., 2006).   

Effects of Malaria on The Foetus 

Malaria in pregnancy is detrimental to the foetus. The prenatal and neonatal mortality may vary from 15 to 70%. P. falciparum can cause complications that can affect the foetus. The estimated foetal mortality rate is about 43% (Getachew et al., 2012), and the common problems for the foetus include: 

1, Spontaneous abortion; 

2, Preterm birth/delivery; 

3, Intrauterine growth restriction (IUGR);

4, Low birth weight;

5, Perinatal mortality; 

6, Congenital malaria (Seal et al., 2010). 

A study conducted in Cameroon (describing the effects of malaria in pregnancy) showed that the rate of abortion or miscarrige due to malaria was high (>35%) in the respondents while low birth weight was observed in less than 5% of the respondents (Helen et al., 2014). However, this can be argued as another study conducted in Anambra state (south-eastern Nigeria), showed that 32% of the women who had malaria in pregnancy had low birth weight babies compared to their uninfected counterparts (5.5%) (Boniface et al., 2013). 

The effects of malaria on the foetus include:

1, Spontaneous abortion: This is also known as miscarriage and is the loss of a foetus before the 20th week of pregnancy, which is known to have been caused by the malaria infection present in the mother. More than 80% of miscarriages occur within the first three months of pregnancy and those that occur later are termed late miscarriages (McGready et al., 2011). 

2, Preterm delivery and intrauterine growth restriction (IUGR): This refers to a condition in which the foetus is unable to achieve its genetically expected potential size. IUGR occurs when gas exchange and nutrient delivery to the foetus is not sufficient to allow the foetus thrive well in the uterus. This is as a result of the placental damage caused by the maternal malaria infection present (Gardosi et al., 1998). 

3, Low birth weight: This is defined as the birth weight of an infant which is less than 2.5kg regardless of the gestational age, this is usually caused by preterm birth (that is, a low gestational age at birth) or it may result from intrauterine growth restriction (Pope et al., 2010). 

Low birth weight has also been reported to be caused by malaria. Malaria is one of the important contributors to the 3.5 million low birth weight babies born annually in sub-Saharan Africa (Brabin, 2009). 

4, Perinatal mortality: Malaria during pregnancy reduces birth weight, and low birth weight is a major determinant factor in infant mortality (Nosten et al., 1994). Pregnant women with little or no pre-existing immunity are at a high risk of foetal and perinatal loss which can be as high as 60-70% (Shulman and Dorman, 2009). 

5, Congenital malaria: Malaria during pregnancy may result in foetal exposure to malaria (if parasites are transmitted across the placenta) and could result in congenital malaria (Egwunyenga et al., 1997). A recent review has shown that congenital malaria is more common than previously thought with prevalence ranging from 1.5% to 54.2% (Uneke, 2007). 

Signs and Symptoms of Malaria Infection 

There are no specific signs and symptoms of malaria infection in pregnancy, it may appear like a flu-like illness (Taylor et al., 2006). The symptoms include the following; 

a, Fever/chills/sweats; 

b, Headaches; 

c, Muscle pain; 

d, Nausea; 

e, Vomiting; 

f, Diarrhoea; 

g, Cough (Taylor et al., 2006). 

Diagnosis 

The gold standard of malaria diagnosis has been the microscopic examination of blood through the use of blood films; thick and thin films (Krafts et al., 2011). Although blood is the sample most commonly used to make diagnosis, both saliva and urine have been investigated to serve as alternatives, though these two specimens are less invasive (Sutherland and Hallett, 2009). Antigen tests, molecular methods and the use of rapid diagnostic test kits are now being used in the diagnosis of malaria. 

Prevention of Malaria in Pregnant Women 

Methods used to prevent malaria include mosquito elimination and prevention of bites. Prevention of malaria may be more cost-effective than the treatment of the disease in the long run (Sabot et al., 2010). 

a, Mosquito elimination: This involves the control of the vector transmitting the infection. Vector control refers to methods that can be used to decrease malaria by reducing the levels of transmission by mosquitoes. For individual protection, the most effective method is the use of insect repellents (Kajfasz, 2009) and also indoor residual spraying (IRS) has been highly effective in preventing malaria in areas where malaria is endemic (Tanser et al., 2010). 

b, Prevention of bites: Insecticide-treated mosquito nets (ITNs) is also an effective way of preventing malaria. Mosquito nets help keep mosquitoes away from people and reduce infection rates and transmission of malaria (Raghavendra et al., 2011). 

Management of malaria illness 

Appropriate management should be available to all women with clinical cases of malaria (WHO, 2000). Management of malaria involves three different aspects and these include: 

1, Treatment of malaria; 

2, Management of complications; 

3, Management of labour (WHO, 2000). 

1, Treatment of malaria 

Treatment should be initiated as early as possible; drugs should be chosen according to the severity of the disease. Over/under dose of drugs should be avoided, drugs that are contraindicated should not be used and adequate intake of calories should be maintained (National drug policy on malaria, 2013). 

Antimalarials: Parenteral anti-malarials should be given to pregnant women with severe malaria in full doses without delay. In the first trimester, the risk of hypoglycaemia associated with quinine is reduced, hence it can be administered and chloroquine can also be considered in mild form of the disease. Artesunate or artemether are preferred over quinine in the second and third trimesters because quinine is associated with recurrent hypoglycaemia (Meghna et al., 2007). Treatment should not be delayed and any of the available drugs should be administered immediately (National drug policy on malaria, 2013). Contraindicated drugs include: Doxycycline, Primaquine, Tetracycline, Halofantrine.

2, Management of complications:  

Hypoglycemia: 25%-50% Dextrose 50-100ml followed by 10% dextrose infusion may be considered, but fluid overload should be assessed and monitored. Blood sugar should be monitored every 4-6 hours in case of recurrent hypoglycaemia (WHO, 2003). 

Anaemia: Packed cells should be transfused if the haemoglobin content of the blood is less than 7g (Meghna et al., 2007). 

Renal failure: Renal failure could be pre-renal due to unrecognised dehydration and heavy parasitaemia. Diuretics, careful fluid management and dialysis is the treatment for this complication (WHO, 2003). 

3, Management of labour 

Severe malaria is accompanied with high mortality. Maternal and foetal distress may not be recognised, falciparum malaria induces uterine contractions, resulting in premature labour. This uterine contraction is usually related to the level of the fever therefore all efforts to control body temperature should be made by cold sponging and antipyretics like paracetamol should be given (Meghna et al., 2007).  

Conclusion and Recommendation 

Malaria during pregnancy is a significant public health problem with substantial risks for the pregnant woman and her unborn child. As a result of this, proper preventive measures should be employed such as the use of insecticide-treated mosquito nets (ITN’s) and indoor residual spraying (IRS). Intermittent preventive treatment in pregnancy (IPTp), whenever administered during antenatal care, should be strictly adhered to. Other control measures should be practiced regularly and immediate treatment should be administered on the detection of malaria parasites. 

References 

Barsoum W, Rashad GE. (2000). Kidney failure as in relation to malaria infection in pregnant 

mothers. Lancet Infect. Dis. 10:134. 

Boniface, U.O. et al., 2013. Effect of placental malaria on birth weight of babies in Nnewi, 

Anambra state, Nigeria. J. Vector Borne Dis. 

Brabin BJ. Malaria in pregnancy: current issues. Africa health (2007): 19: 19-20. 

Egwunyenga OA, Ajayi JA, Duhlinska-Popova DD. Transplacental passage of Plasmodium 

falciparum and sero-evaluation of newborns in northern Nigeria. Southeast Asian J. Trop. 

Med. Public health. (1997); 28; 741-745. 

Gardosi J, Mul T, Mongelli M, Fagan D (1998). Analysis of birth weight and gestational age in         antepartum stillbirths. Br. J. obstet. Gynaecol. May. 105 (5): 524.

Getachew M, Yewhalaw D, Tafess K, et al; Anaemia and associated risk factors among   

pregnant women in Gilgel Gibedam area, southwest Ethiopia. Parasite vectors. (2012) 

December 17; 5: 296. 

Helen, K., Sarah, N., Judith, N.N., Irene, S., Julius, A. and Mary, A. 2014. Knowledge and  

         perceptions towards malaria prevention among vulnerable groups in Cameroon. BMC

Public Health. 14. 

Kajfasz P (2009). Malaria prevention. International Maritime Health. 60 (1-2): 67-70. 

Krafts K, Hempelmann E, Oleksyn B. (2011). “The colour purple: from royalty to laboratory, 

with apologies to Malachowski”. Biotech Histochem. 86 (1): 7-35. 

Manan J. et al., (2006). The effects of malaria on pregnant women. Cochrane Database of 

Systematic Reviews. 340

McGready R, Lee SJ, Wiladphaingem J, Ashley EA, Rijken MJ, Boel M, Simpson JA, Paw

MK, Pimanpanarak M, Oh Mu, Singhasivonon P, White NJ, Nosten FH (2011). Adverse

effects of falciparum and vivax malaria and the safety of antimalarial treatment in early 

pregnancy: a population – based study. The Lancet Infectious Diseases 11

Meghna D, Feiko O ter kuile, Francois Nosten, McGready R, Kwame A, Bernard B, Newman 

D. Epidemiology and burden of malaria in pregnancy. Lancet Infect. Dis. (2007); 7: 93-

104. 

National Drug Policy on malaria (2013). Directorate of National Vector Borne Disease Control 

Programme. Govt of India. New Delhi. 2013. 

National Malaria Indicator Survey (2015). Abuja, Nigeria. Available from:

 Downloads/ddi-documentation (Last accessed on 2018 May 19).

NDHS, 2018. Statistics on maternal mortality and under-5 mortality rate in Nigeria. 

NHMIS 2020. Statistics on health outcomes in Nigeria. 

Noland GS, Graves PM, Sallau A, Eigege A, Emukah E, Patterson AE, Ajiji J, Okorofor I,Oji 

OU, Umar M. (2014). Malaria prevalence, anaemia and baseline intervention coverage prior to mass net distributions in Abia and Plateau States, Nigeria. BMC infectious diseases; 14. 

Nosten F, Ter kuile F, Maelankin L et al., (1994). Mefloquine prophylaxis prevents malaria

during pregnancy: a double blind, placebo-controlled study. J. Infect. Dis. 169: 595-603. 

Okpua, C. and Uduituma, O. 2018. Prevalence of malaria among women who sleep under

 insecticide treated nets in Abakaliki: a retrospective study. Journal of Medicine and 

Medical Sciences: 9(2): 15-20.

Pope DP, Mishra V, Thompson L, et al. Risk of low birth weight and stillbirth associated with 

 indoor air pollution from solid fuel used in developing countries. Epidemiol. Rev. (2010)

Apr; 32 (1): 70-81. 

Raghavendra K, Bank TK, Reddy BP, Sharma P, Dash AP (2011). “Malaria vector control: 

From past to future”. Parasitology research. 108 (4): 757-799. 

Sabot O, Cohen JM, Hsiang MS, Kahn JG, Basu S, Tang L, Zheng B, Gao Q, Zai L, Tatarsky 

A, Aboobakar S, Usas J, Barrett S, Cohen JL, Jamison DT, Feachem RG (2010). “Costs 

and financial feasibility of malaria elimination”. Lancet 376 (9752): 1604-1715. 

Seal SL, Mukhopadhay S, Ganguly RP; Malaria in pregnancy. J. Indian Med. Assoc. (2010). 

Aug; 108 (8): 487-490. 

Shulman CE and Dorman EK, (2009). Reducing childhood mortality in poor countries.    

Importance and prevention of malaria in pregnancy. Trans. R. Soc. Trop. Med. Hyg.

97:30- 35. 

Sutherland CJ, Hallett R (2009). “Detecting malaria parasites outside the blood”.  J. Infect. 

Dis. 199(11): 1561. 

Tanser FC, Lengeler C, Sharp BL (2010). Lengeler C, ed. “ Indoor residual spraying for 

preventing malaria”. Cochrane Database of Systematic Reviews (4): CD006657. 

Taylor WR, Canon V, White NJ. (2006). Pulmonary manifestations of malaria: recognition and 

management. Treat. Respir. Med. 5: 28-419. 

Uneke CJ. (2007) Congenital Plasmodium falciparum malaria in Sub-Saharan Africa: a rarity or

  frequent occurrences? Parasitol. Res; 101 (4): 835-842. 

USAID, 2020. President’s Malaria Initiative FY 2020 Nigeria Malaria Operational Plan  

WHO Expert Committee on malaria, twentieth report Geneva, WHO (2000). (WHO technical 

report series no: 892). 

WHO, The African Malaria Report, World Health Organization, Geneva, Switzerland, (2003). 

WHO; The African malaria report, World Health Organization, Geneva, (2009).  

WHO; The African malaria report, World Health Organization, Geneva, Switzerland, (2010). 

World Health Organization: World malaria report (2014). Geneva             

(http://www.who.int/malaria/publications/world – malaria – report – 2014/en/).   

World Health Organization (2015). World malaria report. WHO, Geneva, Switzerland. 

WHO, 2018. Statistics on exposure to malaria in pregnancy across Africa. 

World Health Organisation 2019. World Malaria Report.