Malaria in Pregnancy: A Demographic and Clinical Surveillance at Mother and Child Hospital Ondo, South Western, Nigeria

This study is designed to screen the patients’ blood for Plasmodium falciparum and to relate some socio-cultural factors like age, trimester stage of pregnancy, use of drugs, use of insecticides, use of mosquito nets and use of herbs for malaria parasite infections. Blood samples were collected through venous collection process from 54 pregnant women who visited Mother and Child Specialist Hospital, Ondo, Ondo State, Nigeria for antenatal. Rapid test kit and microscopic test analysis was used in the detection of the presence of Plasmodium falciparum in the obtained blood samples. Out of the 54 pregnant women whose blood samples were taken, 3.7% were below 20 years, 72.2% (21-30 years); 22.2% (31-40 years) and 1.9% (above 40 years). Nine (23.1%) of age group, 21-30, showing prevalence rate with high susceptibility to malaria parasitemia infections. Of the 3 (5.6%) that were in the first trimester stage, no malaria parasitemia was seen in their blood sample and of the 27 (50%) that were in the second trimester stage, 6 (46.2%) were mp positive while 21 (51.2%) were mp negative, Of 24 (44.4%) that were in the third trimester stage, 7 (53.8%) show mp positive, while 17 (41.5%) were mp negative. Of 27 (50.0%) non-mosquito nets users 6 (46.2%) were mp positive while 21 (51.2%) were mp negative while 27 (50.0%) mosquito nets users 7 (53.8%) were mp positive while 20 (48.8%) were mp negative. 41 (75.9%) denied usage of herbs for treatment for malaria while 13 (24.1%) confirmed the use of herbs as treatment for malaria. Of 24 (44.4%) malarial drug users, 6 (46.2%) mp, positive and 18 (43.9%) negative. Of 24 (48.1) insecticide users, 8 (61.5%) were of mp positive while 18 (43.9%) negative. Of 26 (48.1%) pregnant women living in a clean and tidy environment, 4 (30.8%) were mp positive while 22 (53.7%) mp negative. To reduce maternal mortality during pregnancy, development of adequate information on P. falciparum infection risks is highly needed in the study area. Novel technologies to prevent, monitor, diagnose and efficient treatment of malaria mostly among pregnant women must be adopted through Local and National Malaria Control Programme.


Journal of Prevention & Infection Control 2471-9668
in congenital malaria [2]. In endemic areas, high prevalence of neonatal parasitemia has been reported, with majority of the parasitemic newborns being asymptomatic, however, the mortality was found to be higher in the parasitemic newborns compared with the aparasitemic and in the symptomatic compared with the asymptomatic [3]. Congenital malaria due to transplacental or perinatal infection of the fetus is being increasingly reported. It has been reported in 8-33% of pregnancies from both malaria-endemic and non-endemic areas [4]. It has been reported following maternal infections with all four species of human plasmodium, though most cases are reported following P. falciparum P. vivax. In non-endemic countries, P. malariae may cause a disproportionately higher number of congenital malaria cases due to its longer persistence in the host. In endemic areas symptomatic malaria in the neonate is rare despite a high incidence of maternal parasitemia and placental malaria as maternally derived IgG and the high proportion of fetal hemoglobin inhibit parasite development [5]. The symptoms of malaria during pregnancy differ with the intensity of malaria transmission and with the level of immunity acquired by the pregnant women [6].
This research work was designed to investigate the prevalence of malaria parasite among pregnant women who visit antenatal clinic at Mother and Child Specialist Hospital, Ondo, Nigeria. Their level of awareness, personal hygiene, use of various treatment such as anti-malaria drugs, herbs, use of insecticides and mosquito nets in preventing the transmission of the malaria parasites was assessed.

Study area and population
The study population consisted of 54 patients among pregnant women who came for antenatal at Mother and Child Specialist Hospital, Ondo, Ondo State, Nigeria between September and October, 2015. They were selected randomly without prior knowledge of their clinical and family history.

Sample collection
Blood samples were obtained from selected pregnant women using venous blood collection process. The collection was done by experts in the medical field. The blood samples were collected in EDTA bottles. The patients were swabbed with 70% alcohol and care was taken while using syringes Excessive bleeding was avoided.

Questionnaire
A structural questionnaire was used to elicit information from the patients. The questionnaire obtained information on: Age, Drugs Usage, Hygiene, Herbs Usage, Use of Mosquito Nets, Trimester Stages of the Pregnancy, Use of Insecticides. The questions in the questionnaires were asked from the patients and answers were given immediately. The answers to the questions were used for data analysis.

Rapid kit test method to detect plasmodium
Rapid Diagnostic Test (RDT), a lateral flow Immunochromatographic antigen-detection test was employed. It relied on the capture of dye-labeled antibodies to produce a visible band on a strip of nitro-cellulose. With malaria RDTs, the dye-labeled antibody first binds to a parasite antigen, and the resultant complex is captured on the strip by a band of bound antibodyforming a visible line (test line). A control line gives information on the integrity of the antibody-dye conjugate.

Microscopy
Microscopy, astandard for laboratory confirmation of malaria was employed. A drop of the patient's blood was collected by finger prick, or from a larger venous blood specimen. It was spread on a glass slide (blood smear), dipped in a reagent that stains the malaria parasites (Giemsa stain) and then examined under a microscope at a 1000-fold magnification. Malaria parasites are recognizable by their physical features and by the appearance of the red blood cells that they infect. They can then be counted using the following method: + 1-10 asexual parasites per 100 thick film fields ++ 11-100 asexual parasites per 100 thick film fields +++ 1-10 asexual parasites per single thick film field ++++ More than 10 asexual parasites per single thick film field

Data analysis
The data obtained from the information on the questionnaires were subjected to statistical analysis using statistical package (SPSS) to determine any significant relationship between: Age, Drugs usage, Hygiene, Herbs usage, Use of mosquito nets, Trimester stages of pregnancy, Use of insecticides.
Out of the 2 (3.7%) that were below 20 years 0 (0 %) were positive, while 2 (4.9%) were mp negative. Out of the 39 (72.2%) that were between 21 and 30 years, 9 (69.2%) were mp positive while 30 (73.2%) were mp negative. For the 12 (22.2%) that were between 31 and 40 years, 3 (23.1%) were mp positive and 9 (22.0%) were mp negative. On the bar chart, for the positive results of the test for Plasmodium falciparum using malaria kit, women within the age group 21 and 30 years had the highest prevalence rate of 9 (23.1%) followed by women within the age group 31 and 40 years with prevalence rate of 3 (25.0%) (Figure 1). This was followed by women at age group greater than 40 years with prevalence rate of 1 (100.0%). Women at age group lesser than 20 years had the least prevalence rate of 0 (0.0%).  total 54 women that were tested for the presence of Plasmodium falciparum using malaria kit 3 (5.6%) were in the first trimester stage, 27 (50.0%) were in the second trimester stage, 24 (44.4%) were in the third trimester stage.
On the bar chart ( Figure 3) showing positive result of the test for malaria parasite using malaria kit, women in the third trimester stage has the highest prevalence rate of 7 (29.2%), followed by women in the second trimester stage with prevalence rate of 6 (22.2%). The women in the first trimester stage has the lowest prevalence rate of 0 (0.0%)

ARCHIVOS DE MEDICINA ISSN 1698-9465
Journal of Prevention & Infection Control 2471-9668 Table 3 above shows the prevalence of malaria parasite in pregnant women in relation to the use of mosquito nets. Out of the total 54 women that were tested for the presence of Plasmodium falciparum using malaria kit, 27 (50.0%) said they did not use mosquito nets, while 27 (50.0%) said they did use mosquito nets.
On the bar chart, for the positive results of the test for malaria parasite using malaria kit, women who do always use mosquito nets had the highest prevalence rate 7 (25.9%) while the women who do not use mosquito nets had the lowest prevalence rate 6 (22.2%).
As observed in Table 4 above, of the total 54 individual tested for Plasmodium falciparum using malaria kit, 41 (75.9%) denied usage of herbs for treatment for malaria while 13 (24.1%) confirmed the use of herbs as treatment for malaria.
On the bar chart, for the positive results of the test for Plasmodium falciparum using malaria kit, women who denied the use of herbs as malaria treatment had the highest prevalence rate of 8 (19.5%) while the women who confirmed the use of herbs as treatment for malaria treatment had the lowest prevalence rate 5 (38.5%).
Out of the total 54 individual tested for Plasmodium falciparum using malaria kit, 30 (55.6%) denied the use of drugs as treatment for malaria, 24 (44.4%) confirmed the use of drugs as treatment for malaria (Table 5).
On the bar chart, for the positive results of the test for Plasmodium falciparum using malaria kit, women who denied the use of drugs as treatment for malaria had the highest prevalence rate 7 (23.3%). Women who confirmed the use of drugs as treatment of malaria had the lowest prevalence rate 6 (25.0%) ( Figure 5).
Out of the total 54 individuals tested for Plasmodium falciparum using malaria kit, 28 (51.9%) denied the use of insecticides as preventive measures against malaria. 26 (48.1%) confirmed the use of insecticides as preventive measures against malaria ( Table 6).
On the bar chart, for the positive result of the test for Plasmodium falciparum using malaria kit, women who confirmed the use of insecticides as preventive measures against malaria had the highest rate 8 (30.8%) and women who denied the use of insecticide as preventive measures against malaria had the lowest prevalence rate 5 (17.9%) ( Figure 6).
On the bar chart, for the positive results of the test for the Plasmodium falciparum using malaria kit, women that had mosquitoes in their environment had the prevalence rate of 6 (42.9%) followed by women who had a clean environment with prevalence rate of 3 (30.0%). Women who personally kept their environment clean had the lowest prevalence rate of 0 (0.0%) (Figure 7).
Out of the total 54 individual tested for Plasmodium falciparum using microscopic analysis. 3 (5.6%) were in the first trimester stage of pregnancy, 27 (50.0%) were in the second trimester stage, 24 (44.4%) were in the third trimester stage of pregnancy ( Table 9).

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Out of the total 54 individuals tested for Plasmodium falciparum using microscopic analysis. 28 (51.9%) denied using insecticides to prevent malaria. 26 (48.1%) confirmed using insecticides to prevent malaria (Table 13).

Discussion
The results obtained, from the laboratory diagnosis of the blood samples collected from the total 54 pregnant women screened using malaria rapid kit method and microscopic analysis showed that women within the age group 21 and 30 years had the highest prevalence rate compared to other age groups. Younger women seem to be more susceptible to malaria in this study area which contradicts the findings of Adefioye et al. who reported 36-39 From the results of this study, women in the third trimester stage have shown the highest prevalence rate of 7 (29.2%) followed by women in the second trimester stage with prevalence rate of 6 (22.2%). The women in the first trimester stage had the lowest prevalence rate. This report is consistent with the findings of Thomas. et al. who reported that pregnant women in their third trimester stage were more infected than those at their first trimester because at the first trimester stage of pregnancy, women tend to protect themselves more and as the stages increases, their level of malaria prevention decreases, increasing the infection rates and this might also be due to the weak immunity of the women in the third trimester stage [9]. It is usually when they are very close to delivery that they become able to re-acquire their pre-pregnancy immunity. Also most of these pregnant women registered late for antenatal, which does not gives them opportunity to be well taken care of and given  Table 11 The prevalence of malaria parasite among pregnant women tested for malaria based on their usage of herbs for treatment.  It is also advisable that the Food and Drug agencies of Nigeria should encourage more research into local herbs in order to develop new and more effective drug for prevention and control of malaria especially in the tropics where malaria is endemic.

Bar
Women who denied the use of drugs as control measures against malaria had the highest prevalence rate of infection while women who attested to the use of drugs had the lowest prevalence rate. This result further proves the effectiveness of chemoprophylaxis. This finding is consistent with reports from Ibadan and other African countries which found intermittent preventive treatment to be protective against malaria in pregnancy [8,11]. It has been reported that use the of un-recommended malaria chemo prophylactic medication such as chloroquine did not significantly reduce malaria infection among patients warning against wrong use of drugs [12]. Although prescription of drugs has a lot to do Bar chart showing the prevalence of malaria parasite among pregnant women screened for malaria using microscopic analysis of blood in relation to their usage of insecticides. Figure 13 Microscopic  Table 13 The prevalence of malaria parasite among pregnant women tested for malaria parasite using microscopic analysis of blood samples in relation to their usage of insecticides.
with the early detection of malaria parasite in pregnancy, once detected, effective drug usage depending on the trimester stage should be prescribed and administered immediately and should be well monitored to avoid complications. The use of drugs has been proven over the years to help in combating malaria and anaemia in pregnant women.
Women who confirmed the use of insecticides as effective in combating malaria infection had a higher prevalence rate than women who denied the use of insecticides. as effective combating the new species of mosquitoes now prevalent in some parts of tropical Nigeria. It is suggestive and most preferable to use mosquito nets and probably effective insecticide creams which also serves as powerful agent in preventing mosquito bites. The use of insecticide spray is not a policy in Nigeria, but it is equally an effective malaria control strategy and if properly implemented, will impact positively on malaria control in Nigerian communities. As a recommendation it is advised that various uses of different classes of insecticides in conjunction with strict monitoring and public education should be strengthened in Nigeria.
Women in mosquito infested environments had the highest prevalence rate as compared the other prevailing environments.
Mosquito infested environments pose a great deal of threat and risk to pregnant women. Women living in such environments stand 100% chances of contracting malaria parasite infections Environments such as stagnant pools, unkempt gutters, heaps of dirt, dirty and unused kitchens, keeping used water for long periods of time serve as factors promoting the breeding of different species of mosquitoes. This is consistent with the reports of Shr-jie et al. who in Ouagadougou, Burkina Faso found out that higher prevalence ratio of malaria occurred in areas where larvae breeding sites were semi-permanent [14]. Such sites include presence of dustbins, grasses, congesting, congestion, polluted gutter, stagnant waters and dirty surroundings covered with weeds in the rivers [15]. Therefore it is expedient to take good care of our environment and keep them well kept to avoid malaria parasite infection.

Conclusion
In conclusion, malaria in pregnant women is very threatening and could lead to high mortality rates. Therefore delivery of cost effective malaria prevention to pregnant women will require increased awareness of the problem among communities most affected with malaria. The use of insecticides, treated nets and drugs (chemoprophylaxis) may be beneficial to all women irrespective of their age or trimester stage during pregnancy. Also education and training programs in malaria prevention and early detection of malaria and treatment coupled with better health care delivery systems and enlightenment on the malaria transmission will be helpful [16].
It is also essential to avoid stagnant pools and poor environmental conditions which encourage the breeding and proliferation of mosquitoes. Much work needs to be done to educate the community and producer of herbs to strictly adhere to environmental hygiene since herbs are also effective in the prevention and cure of malaria.

Study Design Limitation
Based on our available procedures and constraint on Study Population at the center, the findings may not be translated to outcome of malaria parasitaemia associated with pregnant women of other Health Care Centers in the Country. However, the data obtained is of useful findings widely applicable as they will assist in control measures and effective therapeutic approach to malaria in pregnancy among women in all part of the world.