utilization of Insecticide Treated Nets among pregnant women in Nigeria
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CHAPTER ONE
INTRODUCTION
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BACKGROUND OF THE STUDY
Malaria continues to pose a major threat to public health worldwide as 91 countries reported a total of 228 million cases in 2018 with 405,000 deaths [WHO. Malaria. 2020]. The latest World Malaria Report reported that sub-Saharan Africa (SSA) accounts for 93% of all malaria cases and 94% malaria deaths [WHO, 2020]. Although malaria affects persons of all ages and gender, it is phenomenal among pregnant women and children under 5 years [Centre for Disease Prevention and Control. 2017]. Pregnant women are prone to malaria largely because of declined immunity and conducive milieus for malaria parasites created by the placenta [WHO,2020].
Children under the age of five years are also prone to severe forms of malaria as they have lost maternal immunity and yet to develop specific immunity towards infections [Singh M, Brown G, Rogerson SJ, 2013]. Malaria during pregnancy constitutes a substantial risk for the mother, her fetus and newborn [Fana SA, Bunza MDA, Anka SA, Imam AU, Nataala SU, 2015]. Compared to non-pregnant women, pregnant women have a threefold increased risk of malaria opportunistic diseases [WHO, 2020]. It is also estimated that the malaria related mortality rate among pregnant women is about 50% higher [WHO, 2020]. Malaria increases risks of intra-uterine growth retardation, low birth weight and neonatal deaths [Roman E, Wallon M, Brieger W, Dickerson A, Rawlins B, Agarwal K, 2014].
In 2018, Nigeria accounted for the highest prevalence of malaria worldwide by recording 25% of all malaria cases, and 24% of all malaria deaths worldwide [WHO. Malaria, 2020]. This represents a 6% (3.2 million) increase in the absolute number of cases from 2017. Malaria remains endemic in Nigeria with pregnant women and children under five years of age bearing the highest risk [Do M, Babalola S, Awantang G, Toso M, Lewicky N, Tompsett A, 2018].
Pregnant women and mothers of children under five years sometimes lack comprehensive knowledge about malaria [Amusan VO, Umar YA, Vantsawa PA, 2017] but may be aware of the malaria disease [Oladimeji KE, Tsoka-Gwegweni JM, Ojewole E, Yunga ST, 2019]. Given the menace of malaria, the Federal Government of Nigeria has since 2001 implemented four National Strategic Malaria Strategic Plans (NSMSP) (2001–2005; 2006–2010; 2009–2013 and 2014–2020). In the year 2000, the Roll Back Malaria (RBM) Partnership was initiated in Abuja, Nigeria where it was recommended that pregnant women sleep under insecticide-treated nets (ITN) [WHO, 2019].
The aim of the current NSMSP, under the National Malaria Elimination Programme (NMEP), is to reduce the incidence rate of malaria to less than 5000 per 100,000 persons and reduce deaths attributable to malaria to zero by 2020. The first of seven objectives of this goal is to provide at least 80% of the targeted population with appropriate preventive measures by 2020, including a universal access to ITNs [Federal Ministry of Health., Nigeria. 2014].
ITN ownership in Nigeria has since increased from 8% in 2018 to 61% in 2018 [NPC, 2019]. There are two points to note here; firstly, ITN ownership in Nigeria is likely to vary by region, place of residence or other maternal demographic characteristics [Andrada A, Herrera S, Inyang U, Mohammed AB, Uhomoibhi P, Yé Y, 2019]. Secondly, ITN ownership does not necessarily imply utilization, which is more related to malaria prevention. In a peri-urban city in Nigeria, Tobin-West and Kanu [Tobin-West CI, Kanu EN, 2016] observed that while 49% of surveyed women owned ITN, only 18% used it consistently.
Moreover, a number of ITN campaigns have been initiated in the country. These initiatives have targeted rural and urban locations and across the various states. For instance, the NMEP adopted a mixed-model approach for ITN distribution and this included free mass distribution campaigns and continuous distribution of ITNs [Nigeria Malaria Indicator Survey, 2016].
The dominant channels for distribution included community-based distribution and integrated maternal, newborn and child health weeks as well as antenatal clinics. Through this, 77% households within the catchment locations received ITNs [Nigeria Malaria Indicator Survey, 2016]. Community-based distribution was piloted around 2013 but was not scaled up. State specific mass campaigns include the mass ITN replacement campaign in Zamfara State, northwest Nigeria [Toso M, 2020], central Nigeria based integrated insecticide-treated bed net distribution programme and the universal insecticide-treated net campaigns in northern Nigeria.
In the case of Zamfara State, mass ITN replacement exercise took place and over two million nets were distributed in all. The National Malaria Control Programme (NMCP) Strategic Plan 2009–2013 targeted children and aimed at ensuring that at least 80% of children under five and pregnant women consistently use ITN. Other similar interventions focused on both rural and urban locations in twenty-one states using mass media campaigns through national radio and television stations [Ankomah A, Adebayo SB, Arogundade ED, Anyanti J, Nwokolo E, Inyang U, 2014].
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STATEMENT OF THE PROBLEM
It has been estimated that malaria in pregnancy has a prevalence of about 48% in health facilities in Nigeria. This figure is likely an underestimation considering the fact that 40% of pregnant women in Nigeria do not attend health facilities for antenatal care (Onyeneho, 2014). Furthermore, 70% of pregnant women in Nigeria suffer from malaria, thereby putting them at risk of negative pregnancy outcome (Adebayo et al., 2015).
Nigeria has one of the highest maternal mortality in the world with 814 maternal deaths per 100,000 live births and an estimated 58,000 maternal deaths with malaria in pregnancy being responsible for 33% (WHO, 2016c; Ezire, 2015). Other major causes of maternal mortality in Nigeria include; Obstetrics hemorrhage, eclampsia, obstructed labour and complications from unsafe abortions (Ezugwu, 2014). It is also responsible for 12-30% of under-five mortality (Ezire, 2015; FMH, 2009), thus making it one of the most serious public health problem in Nigeria (WHO, 2016c).
Furthermore, it results in significant danger to the mother, her foetus and infant which leads to increased morbidity and mortality (Salihu and Sanni, 2013; WHO, 2007). It also leads to abortion, intrauterine foetal death, low birth weight and infant mortality (Ankoma, 2012).
Evidence has shown that the prevalence and susceptibility to malaria parasitaemia is highest during the second trimester and may persist into early postpartum period (NMCP, 2014). Pregnant women are also susceptible to sub-clinical malaria infection which may lead to negative consequences such as maternal anaemia, preterm delivery and low birth weight (Obieche, 2015; NMCP, 2014).It has been estimated that malaria in pregnancy causes about 15% of maternal anaemia and 35% of preventable low birth weight and neonatal mortality (Onyeneho, 2014).
Recent estimates in developing countries including Nigeria have shown that 60% of pregnant women are anaemic with 7% being severely anaemic (Olatunbosun, 2014). And the severity of anaemia is directly related to the density of parasitaemia especially among primigravidas (Agan, 2010).
This is compounded by the fact that most pregnant women in Nigeria have background nutritional deficiency anaemia which results from lack of healthy diet especially in women due to poverty (Oye-adeniran et al., 2014). This is even more severe in pregnant women with sickle cell anaemia considering the fact that Nigeria has one of the highest prevalence of sickle cell anaemia globally (Adewoyin, 2015).
On the other hand, low birth weight secondary to malaria is also responsible for between 3 and 17 deaths per 1000 live births and has been associated with increased risk of foetal and neonatal morbidity and mortality, growth inhibition and impairment in cognitive development (Ezire, 2015; Onyeneho, 2014). Furthermore, malaria in pregnancy causes an estimated 11.4% of neonatal deaths and 5.7% of infant deaths in malaria endemic areas of Africa (Onyeneho, 2014).