The Economic Burden of Malaria in Pregnancy in the Sunyani Municipality

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Globally, malaria is the most important parasitic infection and ranks among the major health and developmental challenges facing large parts of the world, including some of the poorest countries. The health and wealth of nations and individuals alike are affected. In sub-Saharan Africa, malaria is understood to be both a disease of poverty and a cause of poverty. It serves as a barrier for millions of poor and vulnerable people, especially women, from engaging in economic activities to enable them escape from poverty. It accounts for the highest cause of mortality in Africa with 90% of the global malaria deaths occurring on this continent. It constitutes 9% of the disease burden to the people of Africa, and is responsible for 25% deaths below the ages of five years (WHO, 1998). Malaria in pregnancy is an obstetric, social and medical problem requiring multidisciplinary and multidimensional solution. Pregnant women constitute the main adult risk group for malaria and 80% of deaths due to malaria in Africa occur in pregnant women and children below five years. In Africa, perinatal mortality due to malaria is about 1500/day. In areas where malaria is endemic, 20-40% of all babies born have a low birth weight (Kakkikeya, 2002). Malaria and pregnancy are mutually aggravating conditions. The physiological changes of pregnancy and pathological changes due to malaria have a synergistic effect on the course of each other, thus making life difficult for the mother, and the unborn baby. Plasmodium falciparum malaria can run a turbulent and dramatic course in pregnant women. The non-immune, prime- gravidae are usually the most affected. The morbidity due to malaria in pregnancy includes anaemia, fever illness, hypoglycaemia, cerebral malaria, pulmonary oedema, puerperal sepsis and mortality may occur from severe malaria and haemorrhage. The problems in the new born include low birth weight, prematurity, intra-uterine growth retardation, malaria illness and mortality. Malaria is the number one public health problem in Ghana, and accounts for the major cause of hospitalization, morbidity and mortality among the vulnerable. Some 9% of deaths in this country are attributed to the disease which accounts for 30% of outpatient visits and 9% of hospital admissions (Asenso-Okyere, 1997). Malaria is endemic throughout Ghana and continues to be a major public health concern. It is one of the leading causes of morbidity and mortality, especially among pregnant women. The Ministry of Health (MOH) estimates over the past ten years showed that, there have been 2-3 million cases of malaria each year, representing 40% of outpatient cases, while severe malaria accounts for 33-36% of in-patients (GSS, 2004). During the launching of the Antimalarial Drug Policy in Accra, 2005, the then Minister of Health, Major Courage Quashigah confirmed that, two thousand women and fifteen thousand children under age five died of malaria in 2004 and attributed a quarter of all child mortality cases in Ghana to malaria. WHO strategic framework approach for malaria controls during pregnancy is a multi-pronged one which has been adopted by Ghana. The approach includes intermittent preventive treatment (IPT), insecticide-treated nets (ITN) and case management of malaria illness. With IPT, Sulfadoxine Pyrimethamine is administered three times in pregnancy under supervision. The first dose is given after quickening and the subsequent ones at a four week interval. This strategy replaces the previous weekly unsupervised Chloroquine prophylaxis of which only 11.6% of pregnant women complied. ITNs serve as mechanical barriers; repel mosquitoes from biting the individual and kill mosquitoes on contact. The Government of Ghana in an attempt to make ITNs more accessible and affordable to the populace especially the vulnerable has reduced tariffs on its importation. Some private companies such as Mobil Oil (Ghana) Limited have further subsidized the prices of the nets for the under-five and pregnant women, all in an attempt to reduce the disease burden among the vulnerable. Generally with all disease conditions, prognosis is good if the condition is detected early with prompt and proper management. That is the reason why the MOH has strategized early diagnosis followed by prompt and adequate treatment. Chemoprophylaxis therefore remains the main thrust for malaria control in Ghana. Although self-medication is not encouraged during pregnancy due to its effects on the pregnant woman and the developing foetus, most pregnant women do self-medicate, especially for febrile conditions. This behaviour is partly due to the cost involved in accessing health care in a facility. The cost involved in accessing health care usually serves as a barrier to most people. This can be attributed to the fact that malaria occurs in poor countries, and its presence has a strong negative correlation with economic growth in families, communities, and nations as a whole. Apart from the facility-based cost the individual incurs, there is an opportunity cost of travel time as well as time spent at the facility. These usually influence health seeking behaviour of pregnant women. The disappearance of malaria in parts of Europe was associated with economic development related to agricultural expansion rather than vector control or chemoprophylaxis. It has been argued that because the burden of malaria is concentrated in poor countries there is inequity in allocation of global research funds especially by the pharmaceutical industry, since domestic purchasing power for new products is very limited especially for antimalarial drugs (Najera, 1994). There is the need for cost effective health care resource allocation and programming of disease control based on a system that will reduce the greatest illness burden among the populace especially women and children.
A thesis submitted to the School of Graduate Studies, Kwame Nkrumah University of Science and Technology, (K.N.U.S.T.) in partial fulfilment of the requirements for the award of Degree in Population and Reproductive Health.