ANALYSIS OF MIP CARE AMONG 1ST ANC MOTHERS IN UGANDA

MIP: MALARIA IN PREGNANCY: A CASE OF KAMULI HOSPITAL

CHAPTER ONE:

1.0 Introduction

This chapter shall deal with the background of the study, statement of the problem, the objectives of the study, research questions, study scope of the study and significance of the study.

• Background

Globally, maternal mortality has reduced by 38%. Despite such an improvement, it is reported that in 2017 approximately 295,000 women died from preventable causes related to pregnancy and childbirth. Over 94% of these deaths occurred in low and middle income countries, with the majority of them occurring among adolescents as compared to older women (Woldeamanuel, & Belachew, 2021). It has been argued that, the high maternal mortality ratios in developing countries including sub-Saharan Africa were strongly correlated to low antenatal care service utilization and in countries like Uganda malaria during pregnancy was one of the causes (Ukaegbu, 2020).

Over 125 million pregnancies are exposed to malaria each year, with sub-Saharan Africa 67 (SSA) accounting for 25% of this total burden, while the overall consequences of malaria 68 in pregnancy on maternal and birth outcomes have been well documented, the influence of the timing, particularly the effect of infections in the 1st trimester, remains under-investigated.  Pregnant women are more susceptible to malaria infections than their non-gravid peers in malaria endemic areas (Belay et al., 2022), pregnant women are 3 times more likely to suffer severe malaria than their non-pregnant counterparts and have a mortality rate from severe malaria that approaches 50%. Furthermore, malaria parasites sequester and replicate in the placenta. Malaria associated maternal illness and low birth weight is mostly associated with Plasmodium falciparum infection and predominantly occurs in Africa (WHO, 2017)

The median age at first marriage (for persons aged 25 -49 years) is at 19 years for women and 23 years for men  60% of pregnant women attend antenatal care (ANC) visits for at least four (4) or more times as recommenced during their entire pregnancy, an increase from 48% in 2011. Malaria in pregnancy (MiP) remains a leading cause of miscarriage, preterm delivery, intrauterine growth restriction (IUGR) and low birth weight (LBW) in malaria-endemic areas of sub-Saharan Africa, Asia and South America. As a result, MiP increases the risk of perinatal mortality as well as reducing the capacity of the child to develop to his/her full potential in these settings. The impact of MiP on infant growth and infant risk of malaria or morbidity, in contrast to adverse birth outcomes, is infrequently reported (Hu et al., 2021).

In Uganda, like in many developing countries, the percentage of mothers who attend antenatal care (ANC) services during the first trimester of pregnancy is relatively low. According to data from the Uganda Demographic and Health Survey (UDHS) 2016, only about 52% of pregnant women attended ANC within the first trimester of their pregnancy (Tripathy, & Mishra, 2023).

The timely utilization of antenatal care services is considered as one of the most important strategy for reducing maternal and infant morbidity and mortality. WHO in its previous focused ANC framework prescribed four ANC visits for every normal pregnancy, since 2016 the framework was updated from four to eight contacts, with the first contact to occur within three months (12 weeks) (Engdaw et al., 2023). Early and adequate utilization of ANC from a skilled provider is associated with improved maternal health, reduced low birth weights, and lower neonatal mortality. Besides, timely utilization of ANC also act as a mediating factor for health facility delivery and utilization of postnatal care services (Tawfiq et al., 2023).

In 2003, Uganda adopted the focused antenatal care framework for reducing the high maternal mortality in the country. The framework prescribed that a pregnant woman must use antenatal care services at least four times, of which the first visit must occur during the first trimester. However, of recent, the Ministry of Health in Uganda have updated its framework to suit the new WHO guidelines which prescribed a continuum of care for pregnant women to make eight contacts, deliver in health facility, and be attended by skilled health personnel (Tessema et al., 2021), Further, the 2016 Uganda Demographic and Health Survey (UDHS) show that 97% of women received at least one antenatal care from skilled health personnel. However, a lower proportion of these women utilized ANC services in the first trimester (30%), and maternal morbidity and mortality remained high in Uganda with little progress regarding abating maternal deaths over the past two decades (Chilot et al., 2023).

Malaria to a pregnant woman is not only limited to the woman it also affects the unborn child, Malaria parasites destroy red blood cells, leading to a decrease in hemoglobin levels and resulting in anemia (Tackie, Seidu, & Osei, 2021), Pregnant women with malaria are at an increased risk of developing severe anemia, which can cause weakness, fatigue, dizziness, and shortness of breath (Buhuguru Nasanairo, 2021).

According to Sangho, et al., (2021), Malaria infection during pregnancy can increase the risk of several complications, including, Preterm Birth: Malaria can disrupt the normal development of the placenta, leading to preterm birth (delivery before 37 weeks of gestation) can impair the transfer of nutrients from the mother to the fetus through the placenta, resulting in inadequate fetal growth and low birth weight (less than 2,500 grams, which are a risk of health problems and have an increased likelihood of neonatal mortality (Tarekegn et al., 2021). Severe malaria infections can increase the risk of miscarriage (spontaneous abortion) and stillbirth (fetal death after 20 weeks of gestation), Pregnant women with malaria are at an increased risk of developing complications such as cerebral malaria, organ failure, and severe anemia, which can be life-threatening if not promptly treated (Maduka, et al., 2020).

Globally, malaria remains a public health threat of concern. In 2016, an estimated 216 million cases of malaria occurred worldwide, a slight rise from 211 million cases in 2015, but a significant drop compared to 237 million cases in 2010. These cases resulted in 445,000 and 446,000 deaths in 2016 and 2015, respectively (Anchang-Kimbi, (2020), over 88% of malaria burden occurs in the African region, with children under 5 years of age and pregnant women bearing the biggest burden. Plasmodium falciparum accounts for over 95% of all malaria infections in the continent, the other four parasite species accounting for the remainder (Etefia, 2020). In Africa, malaria is highly endemic and is the leading cause of morbidity and mortality. It contributes 4–19% to low birth weight, 3–15% to maternal anemia, and 3–8% to infant deaths, while maternal anemia contributes 7–18% to low birth weight, (Olarewaju, 2020).

Malaria remains a leading cause of morbidity and mortality among pregnant women in Uganda with over 90% of the pregnant women at risk of developing the disease. Uganda is ranked fourth among the highest malaria-burden countries in the world, with some of the highest transmission rates in the world (Ameyaw, 2022). Malaria accounts for up to 50% of outpatient visits among pregnant women in Uganda, 15–20% of admissions and up to 20% of hospital deaths (Chijioke, 2020).  According to the Uganda Malaria Indicator Survey 2018 in Uganda, malaria parasitaemia was high in most regions of the country, with hyper-endemicity (prevalence of 50–75%) demonstrated in three regions, meso-endemicity (prevalence 10–50%) in six, and hypo-endemicity (prevalence < 10%) in one region (UDHS, 2021).

1.2 Statement of the problem.

Globally the World Health Organization (WHO), indicates that malaria infection during pregnancy is estimated to cause approximately 10,000 maternal deaths globally each year, while the government of Uganda in conjunction with other non-government organizations have put a lot of effort to curb the malaria infection in pregnant women in Uganda, but malaria still claims a lot of morbidity with 40 percent comparison to other diseases.  Pregnant women with malaria are at an increased risk of developing severe anemia, which can cause weakness, fatigue, dizziness, and shortness of breath (Buhuguru Nasanairo, 2021). Malaria accounts for up to 50% of outpatient visits among pregnant women in Uganda, 15–20% of admissions and up to 20% of hospital deaths (Chijioke, 2020).  According to the Uganda Malaria Indicator Survey 2018 in Uganda, malaria parasitaemia was high in most regions of the country, with hyper-endemicity (prevalence of 50–75%) demonstrated in three regions, meso-endemicity (prevalence 10–50%) in six, and hypo-endemicity (prevalence < 10%) in one region (UDHS, 2021).

Pregnant women face a heightened vulnerability to severe malaria due to a compromised immune response during pregnancy compared to non-pregnant women this susceptibility contributes annually to the deaths of approximately 10,000 pregnant women and 200,000 infants (Hartman and Fischer, 2010). Malaria in pregnancy is associated with adverse outcomes such as miscarriages, low birth weight, premature delivery, congenital infections, and perinatal deaths (CDC, 2019).

Malaria in pregnancy is particularly prevalent during the first antenatal visit, correlating with adverse health outcomes for both mother and fetus, including maternal anemia, low birth weight, and intrauterine growth restrictions. The asymptomatic nature of malaria parasitemia during pregnancy complicates detection and treatment, exacerbated by placental sequestration of parasites, which further hinders accurate diagnosis. It is against this Background that this study intends to investigate into analysis of MIP care among 1st ANC mothers in Uganda, MIP: malaria in pregnancy, A Case of Kamuli Hospital.

1.3   Objectives of the Study

1.3.1   General Objective:

The general objective of the study is to analyze of MIP care among 1st ANC mothers in Uganda, MIP: malaria in pregnancy, A Case of Kamuli Hospital

1.3.2 Specific Objectives of the Study

1. To examine community related factors for malaria prevalence among pregnant mothers.
2. To analyze health related factors for malaria prevalence among pregnant mothers.

• To determine Individual factors associated with malaria in pregnant mothers.

1.4 Research Questions

1. What are the community related factors for malaria prevalence among pregnant mothers?
2. What are the health related factors for malaria prevalence among pregnant mothers?

• What are the Individual factors associated with malaria prevalence among pregnant mothers?

1.5 Conceptual frame work

Malaria in pregnancy                                   CARE AMONG 1ST ANC MOTHERS

CHAPTER TWO

LITERATURE REVIEW

2.0 Literature Review

This section presents the discussion in line with; community related factors for malaria prevalence among pregnant mothers, health related factors for malaria prevalence among pregnant mothers and Individual factors associated with malaria in pregnant mothers.

2.1 Community related factors for malaria prevalence among pregnant mothers

Community-related factors can have a significant impact on malaria prevalence among pregnant mothers. Malaria is a complex disease influenced by a variety of social, environmental, and healthcare factors. Here are some community-related factors that can contribute to malaria prevalence among pregnant mothers; Geographic Location and Climate, Malaria transmission is often linked to specific geographic areas with suitable climates for the mosquito vectors that carry the disease. Communities located in malaria-endemic regions are at higher risk (Semakula et al., 2023).

Communities with limited access to healthcare facilities, diagnostics, and proper treatment are more vulnerable to malaria. Pregnant women in such areas might not receive timely interventions to prevent or treat the disease (Aschale et al., 2019).

Communities with poorly developed healthcare infrastructure may lack proper antenatal care, malaria testing, and access to insecticide-treated bed nets or other preventive measures (Watson et al., 2019). Communities with low levels of health education and awareness about malaria transmission, prevention, and treatment might not take appropriate measures to protect themselves, especially pregnant women who are more susceptible (Edwards et al., 2019).

Lower socioeconomic communities might lack resources to afford protective measures like bed nets, insect repellents, or even transportation to healthcare facilities for antenatal care and treatment and Inadequate housing and living conditions can lead to increased mosquito exposure. Houses without proper screens or ventilation can facilitate mosquito entry, increasing the risk of malaria transmission (Edwards et al.,2019).

2.2 Health related factors for malaria prevalence among pregnant mothers

Health-related factors play a critical role in the prevalence of malaria among pregnant mothers. Malaria can have severe consequences for both the mother and the developing fetus. Here are some health-related factors that contribute to malaria prevalence among pregnant mothers:

Immune Suppression During Pregnancy since Pregnancy naturally suppresses a woman’s immune system to prevent rejection of the fetus. This immune suppression can make pregnant women more susceptible to infections like malaria (Yirsaw et al., 2021).

Malaria infection during pregnancy can lead to severe complications such as maternal anemia, placental insufficiency, low birth weight, preterm birth, and stillbirth. These complications are especially dangerous for both the mother and the baby and Pregnant women tend to have a higher level of circulating malaria parasites in their bloodstream, which increases the risk of complications (Pandey, & Sharma, 2021).

Malaria parasites have the ability to accumulate in the placenta, causing placental malaria. This can lead to poor maternal and fetal outcomes, including intrauterine growth restriction and preterm birth, Women living in malaria-endemic regions might develop some degree of immunity to malaria over time. However, pregnancy can weaken this immunity, leaving pregnant women susceptible to new infections (Rouamba et al., 2021).

Pregnant women may not have developed immunity to all strains of malaria prevalent in their region, which increases the risk of infection and complications, Delayed or insufficient antenatal care visits can result in missed opportunities for preventive interventions, early detection of malaria, and appropriate treatment (Wafula et al., 2021).

Some healthcare facilities might not routinely screen pregnant women for malaria during antenatal care visits, leading to undiagnosed and untreated infections and in addition to that Pregnant women might not consistently use insecticide-treated bed nets, which are crucial for preventing mosquito bites and malaria transmission (Yaro et al., 2021).).

Resistance to Antimalarial Drugs: In regions where resistance to antimalarial drugs has developed, pregnant women might not receive effective treatment for their infections, The knowledge and training of healthcare providers in recognizing, diagnosing, and treating malaria in pregnant women can influence the quality of care received (Azhar,, Islam, & Karim, 2021)..

2.3 Individual factors associated with malaria in pregnant mothers

Individual factors can significantly contribute to the risk of malaria among pregnant mothers. These factors are often related to the pregnant woman’s behavior, health status, and personal circumstances. Here are some individual factors associated with malaria in pregnant mothers:

Pregnant women who travel to malaria-endemic areas without taking proper preventive measures, such as using insecticide-treated bed nets or taking prophylactic antimalarial medication, are at higher risk of contracting malaria (Wafula, et al., 2021).

Residence in Malaria-Endemic Areas like sub-Saharan Africa, living in or near areas with high malaria transmission rates increases the risk of exposure to infected mosquitoes, thereby raising the risk of contracting malaria (Nyaaba et al., 2021).

Pregnant women who do not consistently use insecticide-treated bed nets or other preventive measures are more susceptible to mosquito bites and malaria infection. Regular attendance at antenatal care visits provides opportunities for health education, malaria testing, and interventions such as intermittent preventive treatment (Kumar et al., 2021).

A lack of knowledge about malaria transmission, prevention, and treatment can result in inadequate protective measures and delayed or inappropriate treatment, Delayed initiation of antenatal care increases the likelihood of missed opportunities for malaria prevention and early detection (Kumar, & Farzeen, 2021).

Pregnant women who have had previous episodes of malaria may be more susceptible to subsequent infections and this can also be coupled by, Poor nutrition and anemia can weaken the immune system, making pregnant women more vulnerable to malaria and its complications (Tarekegn, Tekie, Dugassa, & Wolde-Hawariat, 2021).

Underlying Health Conditions, Pregnant women with pre-existing health conditions, such as HIV/AIDS, may have compromised immune systems, increasing their risk of severe malaria, Younger pregnant women and those with a higher number of pregnancies (parity) might have weaker immunity and be more susceptible to malaria (Keokenchanh et al., 2021).

CHAPTER THREE

METHODOLOGY

3.1 Introduction

This chapter presents the research methods that will be used to carry out the study.

3.2 Research Design

The study will adopt a cross-sectional survey research design.

3.3 Study Population

The total population will specifically the employees of Kamuli   hospital and patients who will be present at the time of research.

3.4 Determination of the sample size

Using Krejcie and Morgan’s (1970) table for sample size determination approach, a sample size of 36 respondents will be selected from the total population of 40 employees and patients.

3.5 Sampling techniques and procedure

The study will use Purposive sampling technique because it saves time and also enables the researcher to get information from the right people.

3.6 Data collection methods

The section presents data collection methods which include questionnaire survey, interview and documentary review.

3.6.1 Questionnaire Survey

Questionnaire Survey method will be used to obtain the opinion of the respondents regarding the topic under study.

3.6.2    Interview

Face-to-face interview is a data collection method where the interviewer directly communicates with the respondent in accordance with the prepared questionnaire (Polak & Green, 2015).

3.7 Data collection instruments

For each deployed data collection method, there is a corresponding data collection instrument that will be used. The study will use, Questionnaire Guides, Interview Guide and Document review checklist as described in the sub-sections below.

3.8 Quantitative Data Analysis

Data processing will be done by entering the data into a statistics package for social sciences (SPSS) version 24.0 in line with the research questions.

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