CHAPTER ONE

1.0 Introduction

This chapter presents the background to the study, statement of the problem, objectives of the study, research questions, scope of the study, conceptual framework, and significance of the study.

1.1 Background of the Study

Maternal health remains a major public health concern worldwide despite significant improvements over the past decades. Globally, maternal mortality declined by approximately 38% between 2000 and 2017. However, an estimated 295,000 women still died from preventable pregnancy- and childbirth-related causes in 2017, with over 94% of these deaths occurring in low- and middle-income countries. Sub-Saharan Africa bears the largest burden, and adolescents are disproportionately affected compared to older women (Woldeamanuel & Belachew, 2021). One of the major contributors to maternal morbidity and mortality in developing countries, including Uganda, is inadequate utilization of antenatal care (ANC) services and the high prevalence of malaria during pregnancy (Ukaegbu, 2020).

Malaria in pregnancy (MiP) remains a major public health challenge globally, particularly in malaria-endemic regions. It is estimated that over 125 million pregnancies are exposed to malaria annually, with approximately 25% of this burden occurring in sub-Saharan Africa (Belay et al., 2022). Pregnant women are more susceptible to malaria infection due to physiological and immunological changes associated with pregnancy. They are approximately three times more likely to develop severe malaria than non-pregnant women, and severe malaria in pregnancy can result in mortality rates approaching 50%. The malaria parasite, particularly Plasmodium falciparum, can accumulate and multiply within the placenta, causing adverse maternal and fetal outcomes such as maternal anemia, low birth weight, and neonatal mortality (WHO, 2017).

Malaria in pregnancy is a leading cause of miscarriage, preterm birth, intrauterine growth restriction (IUGR), and low birth weight in malaria-endemic regions of Africa, Asia, and South America. These adverse outcomes increase the risk of perinatal mortality and may impair the child’s growth and development. Evidence further suggests that exposure to malaria during pregnancy may increase the infant’s susceptibility to infections and poor health outcomes during early childhood (Hu et al., 2021).

Antenatal care is recognized as one of the most effective interventions for improving maternal and neonatal health outcomes. The World Health Organization (WHO) initially recommended a minimum of four ANC visits under the Focused Antenatal Care model but revised these guidelines in 2016 to recommend at least eight contacts during pregnancy. The first ANC contact should occur within the first trimester (before 12 weeks of gestation) to facilitate early detection and management of pregnancy-related complications, including malaria (Engdaw et al., 2023).

In Uganda, the Ministry of Health adopted the Focused Antenatal Care framework in 2003 to reduce maternal and neonatal mortality. More recently, Uganda aligned its ANC policy with WHO recommendations, encouraging pregnant women to attend at least eight ANC contacts, deliver in health facilities, and receive care from skilled health professionals (Tessema et al., 2021). Although ANC attendance has improved over the years, early initiation of ANC remains low. According to the Uganda Demographic and Health Survey (UDHS) 2016, while 97% of women attended at least one ANC visit, only about 30% initiated ANC during the first trimester of pregnancy (Chilot et al., 2023).

Malaria poses serious risks to both the mother and the unborn child. The disease destroys red blood cells, resulting in anemia, which can lead to fatigue, weakness, dizziness, and other complications during pregnancy (Tackie, Seidu, & Osei, 2021). Severe malaria infection can also lead to placental insufficiency, miscarriage, stillbirth, premature delivery, and low birth weight, thereby increasing neonatal morbidity and mortality (Sangho et al., 2021).

Globally, malaria remains one of the leading infectious diseases. In 2016, approximately 216 million malaria cases and 445,000 malaria-related deaths were reported worldwide, with over 88% occurring in Africa (Anchang-Kimbi, 2020). Children under five years and pregnant women are among the most vulnerable groups. In Africa, malaria contributes significantly to maternal anemia, low birth weight, infant mortality, and poor pregnancy outcomes (Olarewaju, 2020).

Uganda is among the countries with the highest malaria burden worldwide and ranks among the top malaria-endemic countries globally. More than 90% of pregnant women in Uganda are at risk of malaria infection. Malaria accounts for approximately 50% of outpatient visits, 15–20% of hospital admissions, and nearly 20% of hospital deaths among pregnant women (Chijioke, 2020). According to the Uganda Malaria Indicator Survey (2018), malaria prevalence remains high across most regions of the country, with several areas classified as hyper-endemic (UDHS, 2021). Despite the implementation of preventive measures such as intermittent preventive treatment in pregnancy (IPTp), insecticide-treated mosquito nets (ITNs), and health education programs, malaria continues to significantly affect pregnant women in Uganda.

Therefore, understanding the quality and utilization of malaria in pregnancy care among women attending their first ANC visit is critical for strengthening maternal healthcare services and reducing malaria-related complications among pregnant women. This study therefore seeks to analyze malaria in pregnancy care