April 25th (this Sunday) is World Malaria Day. Recently, researchers from the Center for Global Health and Development at Boston University and the Indian National Institute of Malaria Research (NIMR) conducted studies to better understand the burden of malaria among pregnant women in east India. In honor of World Malaria Day, the Maternal Health Task Force invited Bram Brooks and David Hamer to share with our readers an overview of what they have learned.
Written by Bram Brooks, MPH & David Hamer, MD
Global Overview
Malaria in pregnancy (MiP) can have serious health outcomes for both the mother and infant and thus presents a major public health challenge. Studies have shown that MiP increases the chances of fetal death, prematurity, low birth weight, and maternal anemia [1-4]. An estimated 10,000 women and 200,000 of their infants die each year as a result of malaria infection during pregnancy [5].
Current Research
As most MiP studies were conducted in sub-Saharan Africa, limited epidemiological data exist for MiP outside of Africa. Several studies conducted by researchers at Boston University and the Indian National Institute of Malaria Research (NIMR) have been recently implemented in east India with the aim of building the empirical evidence to better define the global risk map of MiP.
The India MiP study consisted of a series of cross-sectional surveys and involved the collection of both quantitative and qualitative data in several urban and rural districts in the Indian states of Jharkhand and Chhattisgarh [6-8]. Between all the study sites, over 5,082 pregnant women were enrolled at antenatal clinics and 1,746 in delivery units. The study findings indicated that the prevalence of malaria among pregnant women in east India was approximately 2-3%. In addition, malaria parasites were more common in pregnant women with fever, those living in rural areas, and women who were pregnant for the first time. Furthermore, mean birth weight was lower among women with placental malaria versus those without placental infection. In terms of the use of malaria control measures as reported by the participants, indoor residual spraying and untreated bed nets were common, whereas insecticide-treated bed nets and malaria chemoprophylaxis were rarely used. It was also noted through qualitative interviews that misconceptions and use of unproven prevention and treatment methods are common among pregnant women in eastern India.
The results from the series of MiP studies in India support other findings that show malaria mortality and morbidity in pregnant women are much lower outside of Africa. Although the magnitude of malaria-associated morbidity outside of Africa is smaller, we must remember that the number of global individuals at risk is considerable. A recent study by the Malaria in Pregnancy Consortium estimated that approximately 125 million pregnancies around the world are at risk from malaria every year [9]. With large population numbers at risk, even small prevalence rates can translate into significant mortality and morbidity numbers.
Prevention and Management of MiP
The global community has in its arsenal several evidence-based strategies to control MiP that are recommended by WHO: insecticide treated nets, intermittent preventative therapy, and effective case management [5]. Meta-analyses of intervention trials suggest that successful prevention of MiP reduces the risk of severe maternal anemia by 38%, low birth weight by 43%, and fetal death by 27% among pregnant women [10]. Prevention and control of MiP is an important goal that can be achieved. The challenge is to implement these strategies within national guidelines and programs so that these are effective in reducing MiP-associated mortality and morbidity.
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3. Shulman CE, Graham WJ, Jilo H, Lowe BS, New L, Obiero J, et al. Malaria is an important cause of anaemia in primigravidae: evidence from a district hospital in coastal Kenya. Trans R Soc Trop Med Hyg 1996; 90(5):535-539.
4. Verhoeff FH, Brabin BJ, Chimsuku L, Kazembe P, Broadhead RL. Malaria in pregnancy and its consequences for the infant in rural Malawi. Ann Trop Med Parasitol 1999; 93(1):S25-S33
5. Marchesini P, Crawley J. Reducing the burden of malaria. MERA/RBM/WHO Jan 2004.
6. Hamer DH, Singh MP, Wylie BJ, Yeboah-Antwi K, Tuchman J, Desai M, Udhayakumar V, Gupta P, Brooks MI, Shukla MM, Awasthy K, Sabin L, MacLeod WB, Dash AP, Singh N. Burden of malaria in pregnancy in Jharkhand State, India. Malaria Journal 2009, 3:8:210.
7. Sabin LL, Rizal A, Brooks MI, Tuchman J, Wylie B, Gill CJ, Singh MP, Setterlund KG, Joyce KM, Yeboah-Antwi K, Singh N, Hamer DH. “Attitudes, knowledge, and practices regarding malaria prevention and treatment among pregnant women in Jharkhand, India: A qualitative study.” Am J Trop Med Hyg, in press.
8. Singh N, Singh MP, Hussain M, Shukla MM, Dash AP, Wylie B, Yeboah-Antwi K, Udhayakumar V, Desai M, Hamer D. “Burden of malaria in pregnancy in Chhattisgarh State India.” Abstract 010-O. International Symposium on Tribal Health, February 27-March 1, 2009. Jabalpur, India.
9. Dellicour S, Tatem AJ, Guerra CA, Snow RW, ter Kuile FO. Quantifying the number of pregnancies at risk of Malaria in 2007: A demographic study. PLOS Medicine 2010; 7(1):e1000221.
10. Desai M, ter Kuile FO, Nosten F, McGready R, Asamoa K, Brabin B, Newman RD. Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis 2007; 7 (2):93-104.