Intermittent Preventive Treatment of Malaria in Pregnancy: Its Effects on Maternal Morbidity and Neonatal Birthweight in Offinso District of Ashanti Region, Ghana

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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 v 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.
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