By Chioma Obinna
Malaria remains one of the most common diseases in Nigeria. In fact, it is so popular that even children under age five could tell you that they are suffering from malaria.
It ranks among killer – diseases in the country and the costs of treatment have continued to impoverish families. According to the World Health Organisation, WHO, although malaria is preventable, treatable and curable, it is endemic in Nigeria and remains the number one public health problem, with its greatest toll on children under age 5 and pregnant women.
Records show that Africa still bears over 80 percent of the global malaria burden out of which Nigeria accounts for about 29 percent. The World Malaria Report 2014 revealed that, together with the Democratic Republic of Congo (DRC), Nigeria contributes up to 40 percent of the global burden. It is estimated that about 110 million clinically diagnosed cases of malaria and nearly 300,000 malaria related childhood deaths occur each year in Nigeria.
Just last week, a report from WHO revealed that about 3.7 million people in Borno State alone are at risk of malaria and that, every week, around 8,500 people are infected with the disease in the state. Although, statistics from the 2015 Nigeria Malaria Indicator Survey showed a marginal decline in malaria mortality with prevalence from 35 percent down to 27 percent, experts are worried that the most vulnerable groups, pregnant women and newborns, are paying with their lives due to low uptake of the recommended therapy in pregnancy.
Today, malaria contributes 11 percent of maternal deaths in Nigeria. It has also been linked to several miscarriages, 15 percent of maternal anaemia, 30 percent of “preventable” low birth weight and 5 to 14 percent of low birth weights in newborn babies. Despite this grim picture, only 19 percent of Nigerian pregnant women take the WHO recommended malaria prevention therapy in pregnancy, Intermittent Preventive Treatment with Sulphadoxine Pyrimethamine, IPTp.
Sunday Vanguard examines how low uptake of IPTp others are fuelling poor outcomes in pregnancy.
Lying on the couch and shivering was 32 -year- old Mrs. Rose Emeliee. It was around 2:00pm that Saturday when this reporter visited. “I feel so cold and tired. Due to my condition, I cannot take any medicine now,” she managed to mumble those words.
Heavy with about seven months pregnancy, Rose never knew she was down with malaria. According to her, the maternity home which she attended for antenatal care had told her not to take any malaria drug as it was dangerous to the unborn baby.
With the help of this reporter, she was taken to one of the government- owned hospital in Lagos where a laboratory test was carried out on her and it was discovered that she had malaria.
Apparently, due to ignorance on the part of Rose, she never accessed three or more doses of medicine recommended by the World Health organization, WHO, to protect mothers and unborn children from malaria infection, despite the fact that the medicine is available for free.
Rose was given full treatment of malaria. She was also given a dose of malaria preventive therapy known as Intermittent Preventive Treatment in Pregnancy, IPTp. Today, Rose is counted among the 60.2 percent women in the urban areas that are more likely to have access to IPTp.
Whereas she was lucky, some pregnant women like Beatrice Agboola were not. Beatrice was six weeks pregnant when she had malaria. But there was no sign to show that she had malaria then. Beatrice would not sleep under Insecticide Treatment Nets, ITNs, and took no recommended treatment for malaria in pregnancy. Just like many other women in her environment, the thought of registering for antenatal early was like a waste of time and money.
She never visited hospital even at six months.
No one had told her of the need to take IPTp; so when she developed a fever and headache, she suspected malaria and went to a nearby hospital for a test. “While I was waiting for the lab results, my condition worsened. I lost appetite and I was extremely thirsty,” she said. Her troubles ranged from headaches and body aches to difficulty to walk. She decided to go to hospital. “It happened in a flash. I was six months pregnant. I had gone to my doctor for check-up a week before and I was told my pregnancy was progressing well and that the baby was showing normal movements.”
A few days later, it was discovered she was having spontaneous abortion. In the emergency room, the doctors discovered that many of her red blood cells were infected with the malaria parasite indicating a rather severe episode. The unfortunate development led to miscarriage.
Her story is no different from Oluwaseyi Ade’s. Seven weeks into pregnancy, she had malaria. She never accessed treatment until it was discovered that the foetus was no longer breathing. Oluwaseyi was induced and, in the process, it was discovered she had malaria. Unfortunately, it affected the foetus.
Stories abound of women losing their unborn babies due to malaria in Nigeria. These women would have prevented these deaths if they had accessed IPTp. Unfortunately, neither Beatrice nor Oluwaseyi registered early for antenatal care which would have afforded them the opportunity of accessing the Federal Government introduced preventive therapy, known as Sulphadoxine-Pyrimethamine (SP)) for Intermittent Preventive Treatment under direct observation of a skilled service provider. The IPTp is designed to ensure the safety of mothers and their unborn babies, but the uptake of this life-saving therapy remains terribly low in Nigeria.
Malaria is a mosquito-borne disease caused by a parasite. When the parasite interferes with the transfer of oxygen and nutrients to the baby, it increases the risk of spontaneous abortion, stillbirth, preterm birth, low birth weight—single greatest risk factor for death during the first month of life.
According to WHO, in 2015, there were 214 million malaria cases that led to 438,000 deaths globally.
WHO recommended that every pregnant woman living in malaria endemic areas must receive Intermittent Preventive treatment with Sulphadoxine Pyrimethamine and must be done by directly observed therapy during scheduled Antenatal Clinic at least one month apart and after first trimester or quickening.
Unfortunately, in Nigeria, achieving 100 percent of IPTp remains a mirage. Studies have also shown that the therapy saved 2, 522 women of reproductive age group with history of a live birth in the two years preceding the survey.
And despite the efficacy of the IPTp, the 2015 Malaria Indicator Survey, MIS, showed that only 19 percent of Nigerian women had at least 3 doses of the therapy while 37 percent had one or two doses.
Health experts are worried that the uptake is still very low compared to the importance of the therapy. To these experts, early Antenatal Care (ANC), and booking as well as administering of IPTp are critical in preventing malaria during pregnancy.
They also identified late antenatal booking as one of the major factors affecting the uptake of the life- saving therapy.
According to the WHO Malaria Containment Programme Officer, Lagos, Dr. Tolu Arowolo, malaria causes over 4,500 maternal deaths yearly in Nigeria.
And to stop these deaths and other complications caused by the parasite’s interference with the transfer of oxygen and nutrients to the baby, every pregnant woman must initiate antenatal as soon as she is confirmed pregnant.
According to the 2015 MIS, in Nigeria, South West has the highest proportion of women who received at least one dose of IPTp, while North East and South East have the highest proportions of women who received three or more doses.
She stated that early commencement of antenatal care by pregnant women which aids early diagnosis would increase uptake of IPTp among Nigeria women and help prevent malaria in pregnancy.
She said IPTp is based on the assumption that every pregnant woman living in an area of high malaria transmission has malaria in her blood stream or placenta, whether or not she has symptoms of malaria.
Arowolo said WHO is targeting 100 percent of pregnant women attending Antenatal Clinic receive at least 3 doses of SP-IPT by 2020.
She said there is a need to further investigate factors affecting IPTp uptake and access in the rural areas, adding that a bottleneck analysis is desirable to identify reasons for missed opportunities for IPTp.
In her own contribution, the Head of Advocacy, Communication and Social Mobilisation in National Malaria Elimination Programme, NMEP, Mrs. Itohowo Uko, said the 19 percent of pregnant women reportedly receiving at least 3 doses of SP as at 2015 was insignificant, if Nigeria wants to eliminate malaria and protect mothers and babies.
“Malaria in pregnancy had grave consequences, especially as it accounted for 11 per cent of maternal deaths. It can cause anaemia, lead to miscarriages, still births, pre-term and low birth weight babies and in unfortunate situations, death.”
In 2008, according to Nigeria Demographic Health Survey, NDHS, only 5 percent accessed IPTp , in 2010 Malaria Indicator Survey, MIS, only 2 percent, also in 2013 NDHS, only 15 percent and 2015 MIS, only 47 percent of women accessed IPTp.
However, health watchers believe that although there was marginal progressive improvement in the uptake of IPTp services, the missed opportunities for IPTp remain.
Continuing, Uko said to address malaria in pregnancy, NMEP is focusing on WHO’s 4-pronged approach, Focused Antenatal care and health education as well as creating awareness on early diagnosis and treatment, ensuring that all women gets at least three doses of IPTp as well as sleep under LLINs.
“The strategies are grounded on the evidence that it is safer and more cost effective to prevent malaria infection during pregnancy. However, in the event it occurs, prompt and adequate treatment must be provided.”
Lamenting the effect of malaria in pregnancy, she said malaria can occur with or without symptoms and if not treated promptly, can become complicated especially in pregnant women and children under 5 years.