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|Title: ||Intermittent Preventive Treatment of Malaria in Pregnancy: Its Effects on Maternal Morbidity and Neonatal Birthweight in Offinso District of Ashanti Region, Ghana|
|Authors: ||Osei Tutu, Emmanuel|
|Issue Date: ||21-Jun-2009|
|Abstract: ||The World Health Organization (WHO) has adopted the use of Sulphadoxine –
Pyrimethamine (SP) to control malaria during pregnancy in the sub–Saharan Africa
region. Implementation of this programme in Ghana is less than 10% nationwide
probably due to lack of knowledge on its efficacy and benefits to the pregnant woman
and the neonate. The present study, therefore evaluated the effect of SP use in pregnancy
on malaria–associated maternal morbidity and neonatal birthweight in Offinso District
of Ashanti Region, Ghana.
Two analytical cross–sectional studies were conducted on pregnant women of
gestational age of 16 weeks to term, in Offinso District of Ashanti Region between
November 2005–July 2007 of which haemoglobin level (Hb) determination,
parasitaemia level, anthropometric and other quantitative determinants were assessed.
Qualitative study using in-depth interviews (IDIs) and focus group discussions (FGDs)
were used to assess the malaria burden and the effect of SP–IPTp in the district. Routine
deliveries during pre–IPTp period (January 2000–July 2004) and onset of the IPTp
programme (January 2005- October 2007) were reviewed to assess the trend and effect
of SP on birthweights of neonates in these periods, respectively. Diversity of the
parasite, Plasmodium falciparum, was also studied in the women in the district.
In the first analytical study, where the effect of SP in the IPTp programme in control of
malaria was assessed; 444 pregnant women were involved of which 190 (43%) took SP.
Of these, 82 (43%) took first dose only, 57 (30%) and 51(27%) respectively took second
and third doses of SP. One hundred and twenty three (28%) of the 444 pregnant women
had parasitaemia. Of the parasitaemic group, 65 (53%) took no dose of SP, 29 (24%), 18
(15%) and 11 (9%) respectively took 1, 2 and 3 doses of SP. The influence of SP intake
on malaria infection was insignificant (Pearson correlation: r = 0.0008, p = 0.986).
However, there was a tendency towards reduced prevalence of parasitaemia as number
of SP doses taken increased: one dose: 29/82 (35%), two doses: 18/57 (32%) and three
doses: 11/51(22%). Anaemia (Hb<11g/dl) was found in 266 /444(60%) of the study
subjects. The mean Hb level (10.4±1.69g/dl) for the SP group (all doses combined) was
significantly higher than that (9.9±1.64g/dl) in the no SP group (p < 0.002).
Furthermore, there was a significant positive association between IPTp using SP and
haemoglobin level (p < 0.01) with a dose-response relationship.
In the second analytical study, where the effect of SP in IPTp programme, knowledge on
malaria and antenatal clinic (ANC) attendance during pregnancy were assessed; 306
pregnant women were studied, of which 92 (30%) took 1 dose of SP, 100 (33%) 2 doses
and 114 (37%) 3 doses of SP. Of 115 (38%) of these 306 pregnant women who were
followed up to delivery in the health centres, 104(90%) delivered babies of normal
birthweight (birthweight ≥ 2.5 kg) and 11 (10%) had low birthweight babies
(birthweight < 2.5 kg). There was significant association between gravida and the doses
of SP taken (Pearson χ
2 =18.9, p < 0.001). One hundred and thirteen (37%) of these
pregnant women reported adverse effects such as nausea, dizziness, anorexia, general
malaise, fatigue and others. However, these effects had no significant association
between the use of SP and the number of doses of SP taken (Pearson’s χ
2 = 2.3, p ≥
0.32). Forty seven (15%) of the pregnant women who took SP had peripheral
parasitaemia. Regression analysis did show that a unit increase in dose of SP decreased
peripheral parasitaemia levels by 19% (p ≥ 0.25). However, generally, there was poor
negative relationship of doses of SP taken with peripheral, placental and cord blood
parasitaemia (r = -0.06, r = -0.05, r = -0.07) respectively, (p ≥1). Mean haemoglobin
(Hb) level was 11.3±1.6 g/dl (95% CI: 11.1 to 11.4), with 118 (39%) of the pregnant
women being anaemic (Hb < 11.0 g/dl) whilst 187 (61%) had normal Hb levels (Hb
≥11.0 /dl). There was a significant positive correlation of SP use with Hb level (r = 0.15,
p < 0.008). Haemoglobin levels among those who took various doses of SP did show
significant difference (p < 0.007).
Over 70% of respondents in both the 307 questionnaires administered and the qualitative
studies were knowledgeable on the malaria menace in their communities and how it
could be prevented. FGDs (four held) with pregnant women showed that SP was good
for their health, produced mild side effects and had reduced malaria and anaemia
prevalence among them. Fifty five IDIs conducted with health staff, chiefs and opinion
leaders in the district showed that SP is effective in the IPTp programme, had helped
reduce maternal morbidity and mortality, had also improved birthweight of neonates and
reduced mortality in them.
The delivery data in the two periods (pre–IPTp and onset of IPTp) showed that male
neonates have significantly higher birthweights as compared to the female neonates and
thus, sex of neonates, age of pregnant women, gravida of women and terms of
pregnancy have great influence on birthweight of babies (p < 0.0001). Increased dose of
SP significantly reduced the proportion of low birthweights in the neonates (p < 0.001).
However, in the IPTp period, seasonal variation had no significant impact on
birthweight of neonates (p ≥1.8).
On diversity of the parasite, MSP2 gene was found to be more diverse in the women,
with GLURP genes being most common in them.
Results of the present study, thus, suggest that effective implementation of the IPTp
using SP is an evidence-based measure for control of malaria-related anaemia in
pregnancy. Reduction in maternal anaemia impacts positively on both maternal and
neonatal health. Strategies should therefore, be designed and implemented by the Ghana
Health Service to increase the proportion of pregnant women (especially primigravid
women) who take three doses of SP during pregnancy. Nevertheless, stringent measures
should be put in place to guide against abusing the drug hence, rendering it ineffective.
Attitudinal change and discipline would go a long way to curb the malaria menace and
its effects on pregnancy in Ghana.|
|Description: ||A thesis submitted to the Department of Theoretical and
Applied Biology, College of Science, Kwame Nkrumah
University of Science and Technology, Kumasi
for the degree of
DOCTOR OF PHILOSOPHY (Biological Sciences),2009|
|Appears in Collections:||College of Science|
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