research proposal on malaria in pregnancy pdf

• Research article
• Open access
• Published: 05 August 2020

Prevalence and associated factors of malaria among pregnant women in Sherkole district, Benishangul Gumuz regional state, West Ethiopia

• Girma Bekele Gontie 1 ,
• Haileab Fekadu Wolde 2 &
• Adhanom Gebreegziabher Baraki 2  

BMC Infectious Diseases volume  20 , Article number:  573 ( 2020 ) Cite this article

31k Accesses

30 Citations

Metrics details

Malaria during pregnancy leads to serious adverse effects on mothers and the fetus. Approximately 25 million pregnant women in sub-Saharan Africa live at risk of malaria. This study would help to achieve Sustainable Development Goals (SDGs) by improving programs that deal with the prevention of malaria. Therefore, this study aimed to assess the prevalence and associated factors of malaria among pregnant women.

A community-based cross-sectional study was conducted from July to August 2018 in Sherkole district, West Ethiopia. A multi-stage sampling technique was used to select 504 pregnant women. The interviewer-administered semi-structured questionnaire was used for data collection. Malaria was also diagnosed using a rapid diagnostic test. The data was entered using EPI info version 7.2.2.2 and transferred to SPSS version 20 for analysis. Descriptive statistics were done using frequency and percentages. Both bivariable and multivariable logistic regression models were employed. Variables having p -value < 0.2 were included in the final multivariable model. Variables having p -values < 0.05 from the multivariable model were considered to be significantly associated with the dependent variable. The adjusted odds ratio with its 95% confidence interval (CI) was used as a measure of association.

Of the total 498 pregnant women who participated in this study, 51(10.2, 95% CI: 7.72–13.24) were found to have malaria. Of these, 46 (90.2%) and 5 (9.8%) were caused by Plasmodium falciparum and Plasmodium vivax, respectively. Decreasing Age (Adjusted Odds Ratio (AOR) 0.78; 95% CI 0.67–0.911), not using insecticide-treated bed net (ITN) (AOR 12.5; 95% CI 4.86–32.21), lack of consultation and health education about malaria prevention (AOR 7.18; 95% CI 2.74–18.81), being on second-trimester pregnancy (AOR 7.58; 95% CI 2.84–20.2), gravidae II (AOR 5.99; 95% CI 1.68–21.44) were found to be significantly associated with malaria during pregnancy.

Malaria is still a public health problem among pregnant women in the Sherkole district. Age, ITN use, gravidity, gestational age, and health education had a significant association with malaria. Screening pregnant women for asymptomatic malaria infection and educating and consulting on the appropriate malaria preventive methods shall be provided.

Peer Review reports

Malaria is caused by parasites of the genus Plasmodium and transmitted by female Anopheles mosquitoes. There are five different human malaria species such as P. falciparum , P. vivax , P. malariae, P. knowlesi and P. ovale . In 2016, an estimated 216 million cases of malaria and 445,000 deaths occurred worldwide [ 1 ]. Most, (90%), malaria cases and 91% of all malaria death in 2015 and 2016 were reported from the WHO African Region. Of the 91 countries reporting indigenous malaria cases worldwide, around 80% of the total cases were from sub-Saharan African countries [ 1 , 2 ].

Malaria during pregnancy is a serious public health problem in sub-Saharan Africa. It is estimated that each year approximately 25 million pregnant women in sub-Saharan Africa live at risk of P. falciparum malaria infection [ 3 ]. Two institution-based studies done among pregnant women attending antenatal care (ANC) in Nigeria showed the prevalence of malaria to be 41.6% [ 4 ] and 7.7% [ 5 ]. Another institution based study in Eastern Sudan showed 13.7% of pregnant women were infected with P. falciparum [ 6 ]. Studies conducted in Burkina Faso [ 7 ], and Malawi [ 8 ] also showed the prevalence to be 18.1%, and 19.% respectively. Besides, two institution and one community-based studies conducted in different parts of Ethiopia also showed the prevalence of malaria among pregnant women to be between 2.83 and 16.3% [ 9 , 10 , 11 ].

Malaria infection during pregnancy causes an enormous risk to the mother, fetus, and neonates [ 12 ]. Indeed although malaria during pregnancy might be asymptomatic due to a high level of acquired immunity in mothers residing in high transmission areas, it is still associated with an increased risk of maternal anemia, spontaneous abortion, stillbirth, prematurity, and low birth weight [ 3 , 13 , 14 ]. Moreover, severe maternal anemia increases the mother’s risk of death. Malaria-related anemia is estimated to cause as many as 10,000 maternal deaths each year in Africa [ 15 ].

Different risk factors for malaria among pregnant women were identified by previous studies. These include educational status [ 7 , 16 ], age [ 5 , 17 ], ANC visit, gestational age [ 18 ], parity [ 7 , 18 ], gravidity, and ITN utilization [ 11 ].

In Benishangul Gumuz regional state, almost all districts (98%) of the landmass are malarious areas and 97% of the population are at risk for malaria infection. Despite the high risk of malaria transmission in the area, there is limited evidence about the burden and risk factors of malaria among pregnant women which can be used for reducing maternal and child mortality due to the disease. Therefore, this study aimed to assess the prevalence of malaria and its associated factors among pregnant women in Sherkole District, Benishangul Gumuz regional state, West Ethiopia.

Study area and period

The study was conducted in Sherkole district, Benishangul Gumuz Regional state (BGRS) from July 20 to August 30, 2018. Sherkole district is one of the 21 BGRS administration districts which is found 756 km to the West of Addis Ababa, the capital city of the country, and 96 km far away from region city, Assosa. The district is found at a latitude of 13.169308 and longitude of 39.987117 and the altitude of the district is 680–800 m above sea level. The climatic condition of the district is hot and the annual temperature is estimated to be between 25 °C and 41 °C. The Annual range of rainfall in the district is 900–1200 mm. In this district, all kebeles are malarious with 39,373 populations at risk of the disease. In 2016/2017, the annual malaria incidence rate in the district was 263 cases per 1000 population. There were 1243 pregnant women, 1196 under 1 year, and 6370 under 5 years old of children in the district (Fig.  1 ).

Location of the study area

Study design and population

A community-based cross-sectional study was conducted. The source population for this study was all pregnant women at any gestational age living in the district. The study population was those pregnant women in the selected kebeles and who were available during the data collection period. Pregnant women with mental illness and severely debilitating diseases were excluded from the study.

Sample size determination and sampling procedure

The sample size was determined using a single proportion formula using a 50% prevalence of malaria among pregnant women, 95% confidence level, 5% margin of error, and design effect of 2. To compensate for the non-response rate, 10% of the determined sample size was added. Finally, finite population correction was done to adjust the final sample size which gives a total sample size of 504. A multi-stage sampling technique was used to select the determined sample size. At the first stage, from a total of 20 kebeles in the district, 8 kebeles with a a total of 1243 pregnant women were selected by using a simple random sampling technique. In the second stage, the sample size was distributed proportionally for the 8 kebeles based on the number of pregnant women in the kebeles with a range of 41 to 79 housholds for each kebele and then households were selected using a simple random sampling technique. Finally, pregnant women in the household were taken and in the presence of more than one eligible woman in a single household, a lottery method was used to select one.

Variable measurement and data collection procedure

The outcome variable for this study was malaria infection which was assessed using RDT and pregnant mother with any type of Plasmodium species from the test were considered as having malaria infection. The independent variables include socio-demographic factors (age, marital status, educational status, and occupational status); obstetric factors (gravidity, parity, trimester of pregnancy, history of abortion); malaria prevention measures (ITN ownership, indoor residual spraying (IRS) use, personal protective measures, and ITN utilization); health service use (accessibility of ANC, gestational age at the first visit, number of ANC visit, place of delivery for the previous child, previous history of malaria infection during pregnancy, and health education about malaria prevention methods during ANC follow up).

The interviewer-administered Semi-structured questionnaire was used to collect the required information. For those pregnant women who were on ANC followup, the data collector reviewed their antenatal followup cards to cross-check the information given by them. Card information checked includes; gravidity, parity, and gestational age at first ANC visit. Following the interviews, blood was obtained from the third finger of women’s left hand. First, the tip of the finger was wiped with a piece of cotton wool lightly soaked in alcohol. Then piercing with sterile lancet was done and the blood allowed to flow freely without squeezing the finger. Then, 5 μl (μl) blood was collected and a single small drop was added on the CareStart RDT to examine the presence or absence of malaria and to differentiate its species. The RDT read and determine the species qualitatively after 15–20 min of putting the blood to the kit. Ten percent of the randomly selected negative slides were rechecked and reread. Eight trained diploma nurses and midwives collected the data and they were supervised by two health professionals with a qualification of BSc degree. The questioner was pretested and one-day training was given for supervisors and data collectors on the basic technique of the data collection.

Data processing and analysis

The data were entered using EPI-Info 7.2.2 and then transferred to SPSS version 20 statistical package for further analysis. Data cleaning and management were done. Descriptive statistics (frequencies, mean, SD, and percentage) were done to explain the study population in relation to relevant variables. The Chi-square assumption was checked for all categorical independent variables and multicollinearity was also checked using the Variance inflation factor (VIF). Both bi-variable and multi-variable logistic regressions were used to assess the association between outcome and explanatory variables. Factors with p -value ≤0.2 from the bi-variable model were included in the final model. Variables having a p -value < 0.05 from the multivariable model were considered as having a statistically significant association with the outcome. Adjusted Odds ratio with 95% CI was used as a measure of association. The model goodness of fit was assessed using the Hosmer lemisho test.

Socio-demographic characteristics, obstetric characteristics, and malaria prevention methods adopted by pregnant women

A total of 498 pregnant women participated in this study with a response rate of 98.8%. The majority, 208(41.8%), of the pregnant women were in the age group of 25–29 years. Concerning the educational status, more than three fourth, 384(77.1%), of the mothers had no formal education. Almost all, 482 (96.8%), study participants were farmers and traditional gold miners. About 478 (96%) of respondents owned at least one mosquito bed net, and 405 (81.3%) of them sleep under mosquito nets in the previous night. Almost all, 485 (97.8%), of the households had Indoor Residual Spray (IRS) in the last 12 months. All women 431 (86.5%) who had ANC follow-up were given health education about the prevention methods of malaria infection during their ANC follow-up. The majority, 323 (64.9%), of the study participants were multi-gravida, and more than half, 292 (58.6%), of the study participants were in their third trimester of pregnancy (Table  1 ).

Prevalence of malaria infection among pregnant women

In our study, the prevalence of malaria was found to be 10.2% (95% CI: 7.72–13.24). Of these, 46(90.2%) were P. falciparum cases and 5 (9.8%) were P. vivax cases. From the total confirmed cases, the majority, 35 (68.8%) were asymptomatic.

Factors affecting malaria infection among pregnant women

From the bi-variable logistic regression, malaria was significantly associated with all of the variables at a significance level of 0.2. However, from the multivariable logistic regression model only age, ITN utilization, consultation about malaria prevention methods during ANC, trimester of pregnancy, and gravidity were significantly associated with malaria infection during pregnancy. For 1 year increase in the age of the pregnant women, the odds of malaria infection was decreased by 22%(AOR = 0.78, 95% CI: 0.67, 0.91). The odds of malaria infection was 14.98 times higher among pregnant women who did not utilize ITN compared to their counterparts (AOR = 14.98, 95% CI: 5.24, 42.27). Pregnant women who had no education about malaria prevention methods during their ANC follow up had 7.15 times increased odds of malaria infection compared to their counterparts (AOR = 7.15, 95% CI: 2.44, 20.96). Women who were in their first trimester of pregnancy had 23.33 times increased odds of having malaria infection compared to mothers on their third trimester (AOR = 23.33, 95% CI: 1.90, 28.20). Women who are in their second trimester of pregnancy also had 7.78 times increased odds of having malaria infection compared to mothers on their third trimester (AOR = 7.78, 95% CI:2.77, 21.87). The odds of malaria infection was 5.87 times higher among women who had their second pregnancy compared to multi gravid women (AOR = 5.87, 95% CI: 1.61, 21.37) (Table  2 ).

This study assessed the prevalence of malaria infection and associated factors among pregnant women in Sherkole district, Benishangul Gumuz regional state, West Ethiopia. Different studies reported different factors that affect the rate of malaria infection among pregnant women. Our study also assessed socio-demographic, obstetric, and ITN ownership and utilization factors. As a result, Age the woman, ITN utilization, health education about prevention methods during pregnancy, gestational age, and gravidity were found to be significantly associated with malaria infection.

In this study, the prevalence of malaria was found to be 10.2%. This result was higher than studies conducted in Felege Hiwot referral hospital and Addis Zemen health center, Ethiopia (2.83%) [ 9 ], rural district surrounding Arbaminch town, Ethiopia (9.1%) [ 11 ], coastal Ghana (5%) [ 19 ], South-West Nigeria (7.7%) [ 5 ], Southern Laos (8.3%) [ 20 ] and India (5.4%) [ 21 ]. This difference might be attributed to the difference in geographical location among the study areas. For instance, our study was conducted in a malaria-endemic area with a high rate of transmission. Therefore, individuals living in malaria-endemic areas have a greater chance of developing asymptomatic malaria, while those living in low transmission areas have a low chance of being infected, which can lead to a low prevalence of the diseases in such areas. Another reason for the difference could be the inclusion criteria used by the studies because our study included both symptomatic and asymptomatic pregnant women which might increase the prevalence but most of the other studies included only asymptomatic pregnant women. On the other hand, the prevalence in our study was found to be lower than studies conducted in Pawe hospital, Ethiopia (16.3%) [ 10 ], Sudan (13.7%) [ 6 ], Nigeria (41.6%) [ 4 ], Malawi (19.6%) [ 8 ] Burkinafaso (18.1%) [ 7 ] and a systematic review and meta-analysis in Ethiopia 12.7% [ 22 ]. It is also found to be much lower than the findings from two studies conducted in Nigeria which showed the prevalence to be 58% [ 23 ] and 59.9% [ 24 ]. This difference may be due to better implementation of improved malaria interventions including increased coverage in the distribution of Long Lasting Insecticide Treated Nets (LLINs), and indoor residual spraying in our study area which showed 96 and 81.3% of respondents own and utilize ITN, respectively. Almost all (98%) of participants in our study area also lived in residual sprayed households. Therefore, these interventions might reduce the malaria burden in the study area. Another possible reason for the low prevalence in our study could be, the study was done during the low malaria transmission season (July – August). However, the major transmission for malaria occurs between September and December.

In this study, 90.2% of the cases were caused by P.falciparum species. This result was in line with the study conducted in tropical Africa which showed 80–95% of malaria infections are caused by P. falciparum [ 19 ]. However, our result was higher than the national prevalence reports of the species which was 60–70% [ 25 ]. This high proportion of this malaria species in our study is a clear implication that there is a need for aggressive prevention and control of the diseases, especially among pregnant women. Because P. falciparum causes the most severe form of the disease and it can cause devastating complications not only for the mother but also for the fetus. This result also implies that there is a need for early screening of pregnant women for early detection and treatment of the cases to prevent possible complications. On the other hand, the proportion of malaria cases caused by P.falciparum in our study was lower than the WHO malaria 2017 report which revealed over 99% of malaria cases were due to P.falciparum [ 1 ]. The possible reason for these variations might be due to marked seasonal, inter-annual, and spatial variability. It may also be due to large differences in climate (temperature, rainfall, and relative humidity), human settlement, and population movement patterns.

In this study mothers with an increased age were found to have lower odds of developing malaria infection. This is in line with studies conducted in different tropical African countries [ 5 , 17 ] which reported pregnant women of young age are at the greatest risk of malaria infection, as well as having the highest parasite densities. This may be attributed to mothers with increased age have better exposure to health services and gain a good awareness about the disease and the ways of prevention. Also, due to previous frequent malaria exposures, older aged mothers might develop immunity to malaria. However, according to the studies conducted in rural surroundings of Arbaminch Town, Ethiopia [ 11 ], and Sudan [ 6 ], age had no significant association with malaria infection.

According to our study, pregnant women who were in the second trimester of pregnancy were at increased odds of developing malaria infection compared to mothers in the third trimester. Besides, and women who were gravidae II have increased odds of malaria infection compared to the multi gravid. Similar results were found from studies done in sub-Saharan Africa countries [ 7 , 11 , 18 ], which showed a higher risk of malaria infection among primigravidae and gravida two than multigravidae. Low risk of malaria among multigravidae mothers may be associated with the development of pre-immunity to malaria with increased gravidity and previous exposures. It might be also linked to infection-specific immunological factors. Some Plasmodium -infected erythrocytes sequester/arrest in the maternal placenta by producing surface antigens mainly variant surface antigens that adhere to chondroitin sulphate-A (CSA) receptors expressed by syncytiotrophoblasts in the placenta. These antibodies are associated with protection against placental infection. Therefore, primigravidae and secundigravidae mothers lack these anti-adhesion antibodies against CSA binding parasites, which develop only after successive pregnancies and this makes them more susceptible to infection [ 26 ].

In our study, getting a consultation and health education about malaria preventive methods during ANC follow up significantly decreased the odds of developing malaria infection during pregnancy. A similar association was found in studies conducted different parts of Ethiopia [ 27 , 28 ]. Health education and consultation specifically on prevention and control program of malaria during pregnancy ensures the use of antimalarials and other intervention measures effectively.

In this study, not using ITN increases the odds of developing malaria infection during pregnancy. Indeed, WHO, MoH, and presidents malaria initiatives (PMI) have advocated for a three-pronged approach to tackle malaria and one of the strategies is the use of ITN [ 1 , 25 , 29 ]. This study’s finding was also in agreement with the study conducted in Malawi [ 8 ], Nigeria [ 30 ], and Arbaminch, Ethiopia [ 11 ], which showed that the use of bed nets has a significant impact on decreasing malaria infection. The possible explanation for this association could be ITNs effectively reduce human-mosquito contact which can prevent diseases.

Since our study used a cross-sectional study design, it does not show a direct temporal relationship. Though using PCR and blood film microscopy may have higher sensitivity, we could not do these tests because the study is done in rural areas and there is no electricity in the area. Therefore, the result of this study could be affected by the inherent performance of the RDT utilized.

The prevalence of malaria infection among pregnant women was relatively low in Sherkole district and P. falciparum is the most predominant Plasmodium species in the area. Age of respondents, ITN use, gravidity, gestational age, and health education about malaria prevention methods during ANC had a significant association with malaria infection. Health professionals should give health education about malaria prevention methods during ANC and they should also give special attention to those pregnant women with the identified risk factors. Besides, further research is recommended by using more sensitive diagnostic methods like PCR and blood film microscopy for the diagnosis of malaria.

Availability of data and materials

The data upon which the result based could be accessed a reasonable request.

Abbreviations

Adjusted Odds Ratio

Antenatal Care

Benishangul Gumuz Regional state

Chondroitin Sulphate-A

Confidence Interval

Insecticide Treated Net

Long Lasting Insecticide Treated Nets

Ministry of Health

Presidents Malaria Initiatives

Rapid Diagnostic Test

World Health Organization

WHO. World malaria report 2017 World health organization 2017.

WHO. World malaria report 2016. 2016.

Steketee RWNB, Parise MEMC. The burden of malaria in pregnancy in malaria-endemic areas. Am J Trop Med Hyg. 2001;64:28–35.

Article   CAS   PubMed   Google Scholar  

Kagu M, Kawuwa M, Gadzama G. Anaemia in pregnancy: a cross-sectional study of pregnant women in a Sahelian tertiary hospital in northeastern Nigeria. J Obstet Gynaecol. 2007;27(7):676–9.

Agomo CO, Oyibo WA, Anorlu RI, Agomo PU. Prevalence of malaria in pregnant women in Lagos, south-West Nigeria. Korean J Parasitol. 2009;47(2):179.

Article   PubMed   PubMed Central   Google Scholar  

Adam I, Khamis AH, Elbashir MI. Prevalence and risk factors for Plasmodium falciparum malaria in pregnant women of eastern Sudan. Malar J. 2005;4(1):18.

Cisse M, Sangare I, Lougue G, Bamba S, Bayane D, Guiguemde RT. Prevalence and risk factors for Plasmodium falciparum malaria in pregnant women attending antenatal clinic in Bobo-Dioulasso (Burkina Faso). BMC Infect Dis. 2014;14(1):631.

Boudová S, Divala T, Mawindo P, Cohee L, Kalilani-Phiri L, Thesing P, et al. The prevalence of malaria at first antenatal visit in Blantyre, Malawi declined following a universal bed net campaign. Malar J. 2015;14(1):422.

Asmamaw T, Alemu A, Alemu A, Unakal C. Prevalence of malaria and HIV among pregnant women attending antenatal clinics at felege hiwot referral hospital and Addis zemen health center. Int J Life Sci Biotechnol Pharma Res. 2013;2(1–13).

Geleta G, Ketema T. Prevalence of malaria and frequency of severe symptoms among pregnant women in Pawe hospital, North Western Ethiopia. Ann Clin Pathol. 2017;5:1109.

Google Scholar  

Nega D, Dana D, Tefera T, Eshetu T. Prevalence and predictors of asymptomatic malaria parasitemia among pregnant women in the rural surroundings of Arbaminch town, South Ethiopia. PLoS One. 2015;10(4):e0123630.

Gajida A, Iliyasu Z, Zoakah A. Malaria among antenatal clients attending primary health care facilities in Kano state, Nigeria. Annals of African medicine. 2010;9(3)..

BJ B. An analysis of malaria in pregnancy in Africa. Bull World Health Organ 1983; 61:1005–1016.

WHOAFRG. African Region 2010 malaria report. 2010.

WHO. A Strategic Framework for Malaria Prevention and Control During Pregnancy in the African Region, In World Health Organization RegionalOffice for Africa. AFR/MAL/04/01. 2004.

Fana SA, Bunza MD, Anka SA, Imam AU, Nataala SU. Prevalence and risk factors associated with malaria infection among pregnant women in a semi-urban community of North-Western Nigeria. Infect Dis Poverty. 2015;4:24.

Jäckle MJ, Blumentrath CG, Zoleko RM, Akerey-Diop D, Mackanga J-R, Adegnika AA, et al. Malaria in pregnancy in rural Gabon: a cross-sectional survey on the impact of seasonality in high-risk groups. Malar J. 2013;12(1):412.

Mario J Jäckle CGB, Rella M Zoleko, Daisy Akerey-Diop, Jean-Rodolphe Mackanga,, Ayôla A Adegnika BL, Pierre-Blaise Matsiegui, Peter G Kremsner, Ramharter GM-NaM Malaria in pregnancy in rural Gabon: a cross-sectional survey on the impact of seasonality in high-risk groups malaria journal 2013;12:412.

Steffen R. debernardis C, Baños A. Travel epidemiology—a global perspective. Int J Antimicrob Agents. 2003;21(2):89–95.

Briand V, Le Hesran JY, Mayxay M, Newton PN, Bertin G, Houze S, et al. Prevalence of malaria in pregnancy in southern Laos: a cross-sectional survey. Malar J. 2016;15(1):436.

Sohail M, Shakeel S, Kumari S, Bharti A, Zahid F, Anwar S, et al. Prevalence of malaria infection and risk factors associated with Anaemia among pregnant women in Semiurban Community of Hazaribag, Jharkhand, India. Biomed Res Int. 2015;2015:740512.

Tegegne Y, Asmelash D, Ambachew S, Eshetie S, Addisu A, Jejaw ZA. The prevalence of malaria among pregnant women in Ethiopia: a systematic review and meta-analysis. J Parasitol Res. 2019;8396091.

Ifeanyi U, Onyebuchi V, Ukamaka T, Ugochukwu B. Asymptomatic Plasmodium parasitaemia in pregnant Nigerian women : almost a decade after roll Back malaria. Malar J. 2009;24:16–20.

Ogbodo S, Nwagha, U., Okaka, A., Ogenyi, S., Okoko, R., & Nwagha, T. . Malaria parasitaemia among pregnant women in a rural community of eastern Nigeria; need for combined measures. Nigerian Journal of Physiological Science. (2009);24(2)..

MOH. Four years NMSP of Ethiopia from2014/2015–2019/2020. 2014.

FriedM N, Brockman A, Brabin BJ, Duffy PE. Maternalantibodiesblockmalaria. Nature. 1998;95:852.

Deribew A, Alemseged F, Birhanu Z, Sena L, Tegegn A, Zeynudin A, et al. Effect of training on the use of long-lasting insecticide-treated bed nets on the burden of malaria among vulnerable groups, south-West Ethiopia: baseline results of a cluster randomized trial. Malar J. 2010;9(1):1303–13.

Belay M DW. Use of insecticide treated nets by pregnant women and associated factors in a pre-dominantly rural population in northern Ethiopia. Trop Med Int Health. 2008;13(10).

INITIATIVE PSM, ETHIOPIA. Malaria Operational Plan FY 2017 2017.

Oyibo COAaWA. Factors associated with risk of malaria infection among pregnant women in Lagos. Nigeria: Infect Dis Poverty; 2013.

Download references

Acknowledgments

We would like to express our deepest thanks to the University of Gondar College of Medicine and Health Sciences and Health Officer Department, for facilitating the research work. We also want to thank all pregnant women who participated in this study for their contribution.

Not applicable.

Author information

Authors and affiliations.

Benishangul Gumuz Regional State Health Bureau, Asosa, Ethiopia

Girma Bekele Gontie

Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Haileab Fekadu Wolde & Adhanom Gebreegziabher Baraki

You can also search for this author in PubMed   Google Scholar

Contributions

All authors actively participate in the conception and design, acquisition of data, or analysis and interpretation of data. GBG, HFW, and AGB critically revise the manuscript. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Haileab Fekadu Wolde .

Ethics declarations

Ethics approval and consent to participate.

Ethical clearance was obtained from the Ethical review board of the University of Gondar and the permission letter was also obtained from Benishangul Gumuz regional state administration Health Bureau. Then this letter was delivered to Sherkole district Health office and the respected villages. The purpose and importance of the study were explained to the participants and since the majority of our study participants cannot read and write, verbal consent was obtained from each participant above the age of 18. Assent was also obtained for participants below the age of 18 from their parents or guardian. Pregnant women who tested positive were linked to the nearby health center for treatment. Confidentiality of the information was maintained by omitting their names and personal identification.

Consent for publication

Competing interests.

All authors declared that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Gontie, G.B., Wolde, H.F. & Baraki, A.G. Prevalence and associated factors of malaria among pregnant women in Sherkole district, Benishangul Gumuz regional state, West Ethiopia. BMC Infect Dis 20 , 573 (2020). https://doi.org/10.1186/s12879-020-05289-9

Download citation

Received : 29 May 2019

Accepted : 26 July 2020

Published : 05 August 2020

DOI : https://doi.org/10.1186/s12879-020-05289-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Pregnant women
• Benishangul Gumuz

BMC Infectious Diseases

ISSN: 1471-2334

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Malaria in pregnancy: priorities for research

Affiliation.

• 1 Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. [email protected]
• PMID: 17251087
• DOI: 10.1016/S1473-3099(07)70028-2

Research on the important topic of malaria in pregnancy has been relatively neglected. The seven technical reviews in this special issue on malaria in pregnancy provide an overview of current knowledge on key aspects of malaria in pregnancy and highlight the gaps where more research is needed. In this paper, we prioritise research needs, focusing on areas of research likely to lead to improvements in maternal and child health in malaria endemic areas in the near or mid term. We have selected the following as the highest priorities for research: identification of new safe and effective drugs to treat malaria in pregnancy; identification of new drugs to replace sulfadoxine-pyrimethamine for intermittent preventive treatment in pregnancy; identification of optimum combinations of control measures in different epidemiological settings; and determination of optimum ways of scaling-up the use of insecticide-treated mosquito nets and intermittent preventive treatment.

Publication types

• Research Support, Non-U.S. Gov't
• Antimalarials / adverse effects
• Antimalarials / therapeutic use
• Drug Design
• Insecticides / adverse effects
• Malaria / drug therapy
• Malaria / prevention & control*
• Mosquito Control / methods
• Pregnancy Complications, Parasitic / drug therapy
• Pregnancy Complications, Parasitic / prevention & control*
• Antimalarials
• Insecticides

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.12(8); 2022

Original research

Prenatal malaria exposure and risk of adverse birth outcomes: a prospective cohort study of pregnant women in the northern region of ghana, hawawu hussein.

1 Department of Statistical Sciences, Faculty of Applied Science and Technology, Tamale Technical University, Tamale, Ghana

Mansour Shamsipour

2 Department of Research Methodology and Data Analysis, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)

3 Center for Air Pollution Research (CAPR), Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)

Masud Yunesian

4 Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)

Mohammad Sadegh Hassanvand

Percival delali agordoh.

5 Department of Nutrition and Dietetics, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana

Mashoud Alabi Seidu

6 Department of Research, Tamale Teaching Hospital, Tamale, Ghana

Akbar Fotouhi

7 Epidemiology and Biostatistics, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)

Associated Data

Data are available upon reasonable request.

Malaria remains endemic in most of sub-Saharan Africa and has a negative impact among pregnant women, resulting in morbidity and poor birth outcomes. The purpose of this study was to assess the relationship between malaria and adverse birth outcomes among prenatal women in the Northern Region of Ghana.

This is a prospective cohort study of singleton pregnancies at 28 weeks of gestational age and above recruited between July 2018 and May 2019 from four public hospitals in the Northern Region of Ghana.

Outcome measures

Low birth weight (LBW), preterm birth and perinatal death.

A total of 1323 pregnant women completed the study out of the 1626 recruited, with an average age of 27.3±5.2 years. The incidence of malaria in this population was 9.5% (95% CI 7.9 to 11.1). After adjusting for newborn admissions to the neonatal intensive care unit, parity, maternal age and glucose-6-phosphate dehydrogenase, women who were exposed to malaria during the third trimester of pregnancy had 2.02 times (95% CI 1.36 to 2.99) higher odds of premature delivery. Furthermore, they had 2.06 times (95% CI 1.09 to 3.93) higher chance of giving birth to babies with LBW, irrespective of their socioeconomic status. With an OR of 1.02 (95% CI 0.26 to 4.01), there was no difference in perinatal mortality between pregnant women with malaria and those without malaria after adjusting for caesarean section.

This study confirms that prenatal malaria increases the odds of both preterm and LBW deliveries. A decisive policy to eradicate or minimise perinatal malaria is needed to contribute to the prevention of LBW and adverse pregnancy outcomes.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• This was a prospective cohort study done to investigate the relationship between maternal malaria in the third trimester and birth outcomes in Tamale, Ghana.
• The study provides detailed information on malaria and adverse birth outcomes that is not otherwise readily available due to the challenges of under-reporting and poor record linkage of surveillance data.
• Rapid diagnostic tests were used to diagnose malaria during pregnancy as a routine procedure among state-licensed laboratory practitioners, which may be a limitation.
• We were unable to account for the effects of malaria on birth outcomes during the early stages of pregnancy.

Introduction

Malaria claimed over 600 000 lives in 2020, with sub-Saharan Africa accounting for 95% of deaths. 1 Malaria exposure can be fatal to persons with inadequate immunity, particularly pregnant women and small children. It also has an economic cost to the family and the government, with a direct cost of around $12 billion every year. 2

In malaria-endemic areas in sub-Saharan Africa, women face significant risks throughout their pregnancy. Examples of these risks pregnant women are exposed to include low birth weight (LBW), premature birth and spontaneous abortions. 3 Prenatal malaria is responsible for 5%–12% of LBW and accounts for between 75 000 and 200 000 infant deaths each year. 4 In sub-Saharan Africa, 11 million women were infected with malaria in 2018, resulting in approximately 872 000 newborns born with LBW. 5 In 2018, the Central and Western Africa subregions reported the highest prevalence of malaria in pregnant women, each with 35% prevalence. Furthermore, West Africa had the highest frequency of LBW due to malaria. 5 In particular, the effect of malaria exposure on fetal growth was observed during the third trimester of pregnancy regardless of period of exposure. 6

Malaria cases increased by half a million in Ghana in 2018 compared with the year before. 5 Regarding treatment, a research conducted in the War Memorial Hospital in the Upper East Region found that children born to mothers on artemether–lumefantrine intermittent screening and treatment of malaria in pregnancy had a lower risk of malaria than those delivered to mothers on sulfadoxine/pyrimethamine intermittent preventive treatment of malaria in pregnancy (IPTp-SP). 7 Yet the prevalence of malaria and poor birth outcomes was 9.0% and 22.2%, respectively, in Kumasi. 8 In Navrongo, uptake of intermittent preventive treatment of malaria in pregnancy using sulfadoxine/pyrimethamine at three doses was 76%, while uptake of five doses was 16%, with women who received at least three doses having better health outcomes. 8 Given that Ghana is in an endemic malaria zone, these studies highlight implementation gaps and provide information that is useful to improve our malaria prevention policies and programmes. Unfortunately, there is a dearth in the Ghanaian literature relating to the role of malaria in poor birth outcomes in pregnant women in urban settlements in Northern Ghana.

Furthermore, due to insufficient linkages between malaria control and prenatal care data, progress in attaining malaria control among pregnant women has been slow. 9 In addition, inconsistencies in data management practices were discovered during a data quality evaluation in several health institutions, posing problems in data reporting, analysis and application. 10 Therefore, the precision of aggregate data collected from these facilities through surveillance is compromised by these discrepancies. We designed this prospective cohort research as an independent evaluation of birth outcomes among people with prenatal malaria in light of these difficulties. This study sought to provide considerably more detailed information on the links between prenatal malaria and poor birth outcomes in pregnant women in Northern Ghana.

Data for this substudy were drawn from a prospective cohort study that took place in four hospitals in Ghana’s Northern Region. Three of the hospitals are located in Tamale, the Northern Region capital, the fourth largest city in Ghana. The fourth hospital is located in the Savelugu Municipality bordered by Tamale to the west. These areas are located within the Guinea Savannah Belt, 11 with little seasonal variations in prevalence, and as such Oheneba-Dornyo and colleagues 12 found the prevalence of malaria to be positively correlated with rainfall, with nearly a borderline significance. The Plasmodium falciparum peripheral parasitaemia prevalence in pregnant women in the Northern Savannah Zone ranged between 26% and 13.4% from 2013 to 2019, respectively. 13

The study was designed from a parent cohort study that sought to answer the primary research question of whether or not different cooking fuel types influenced pregnancy outcomes and infant respiratory problems. 14 15 Therefore, the original sample size calculation was based on the proportion of pregnant women developing the outcome (respiratory symptoms) with cooking fuel type as an exposure. The present study answers a secondary research question about the relationship between prenatal malaria exposure and the risk of adverse birth outcomes. Thus, this study design leverages on the advantages of the large sample size of the original prospective cohort study. As our main results were statistically significant, we assumed that the sample size for this study was reasonable.

The study recruited pregnant women in their third trimester, who primarily cooked their family meals, were non-smokers and were confirmed to carry singleton pregnancies. The process began in July 2018 and ended in May 2019. The main study was planned with three phases of data collection. At the beginning of the study, women were screened and recruited. In phase 1, during the third trimester, we collected demographics, medical history, exposure data for the primary objective (fuel type) and exposure for secondary objective (malaria). The endpoint for this study was birth outcomes and these data were collected from the labour wards of various hospitals during phase 2. The final part was the phase 3 follow-up that involves collection of newborn data. 15

The original study encountered a methodological shortcoming during its implementation as we initially assumed recruited pregnant women will return to the hospitals where they attended antenatal care (ANC) (ie, a recruitment centre) to deliver. However, a few months into the study, we observed that most of them did not return to deliver, and given the project’s limited funding we were unable to follow them up. Therefore, we replaced them with women who strictly agreed to return to the recruitment centre to give birth. This increased our initial sample size from 1472 to 1776, as published in Hussein et al . 16 Consequently, we followed up 1323 pregnant women in this study; more details can be found in Hussein et al . 15

Baseline data were collected at recruitment using a structured questionnaire at the ANC centre of each hospital. Gestational age was routinely ascertained through an ultrasound during ANC; therefore, our study relied on a midwife-validated gestational age. Data on pregnancy outcome were collected at the labour ward of all hospitals by trained research assistants using a predesigned questionnaire. Only 88% of our final sample received at least one sulfadoxine/pyrimethamine (IPTp-SP).

Laboratory procedures

Rdt malaria diagnosis.

The SD BIOLINE Malaria Ag P.f/Pan rapid diagnostic test kit (RDT) for malaria was used in all hospitals, 17 with specificity and sensitivity of 99.5% and 99.7%, respectively. The principal investigator and the research assistants made efforts to observe and monitor adherence to standard testing protocols at each hospital to ensure that they complied with both the manufacturer’s guide and the fundamental laboratory principles for the test. RDT was performed during the third trimester whenever possible to determine whether or not the study participants had parasitaemia in peripheral blood. Still, we were unable to control for possible measurement bias among the laboratory personnel for malaria.

Haemoglobin estimation

All hospitals used a blood analyser to estimate full blood count (FBC), and haemoglobin (Hb) was extracted from the FBC results of all participating pregnant women. Blood sample (5 mL) for Hb estimation was collected into an EDTA tube and mixed with an EDTA anticoagulant. In this study, anaemia was defined as Hb <11.0 g/L.

Glucose-6-phosphate dehydrogenase test

The methaemoglobin reduction test was used in all hospitals to screen pregnant women for glucose-6-phosphate dehydrogenase (G6PD). The test result was reported as no defect/normal, partial defect or full defect.

Data collection

Computer-assisted personal interviewing was used to gather all data, which was done using the KoboCollect Android app. The data collection procedure is described in detail elsewhere. 15

The main outcomes of this study were LBW, preterm birth and perinatal death. These were all gathered during delivery in the labour ward of various hospitals. On the seventh day, women were contacted by mobile phone to enquire about the baby’s well-being to ensure that the infant was still alive and to capture neonatal mortality after discharge from the hospital. Preterm birth was defined as <37 weeks gestational age, while LBW was defined as <2.5 kg as previously published. 15

The study aimed to appraise the association of birth outcomes among people with prenatal malaria. The exposure variable was a positive RDT verifying that a pregnant woman had malaria during her third trimester or just before birth.

Statistical analysis

Data were exported from the KoboCollect application database into an MS Excel sheet, and cleaned and transferred to STATA V.13 for analysis. Individual confounders were added into the simple logistic regression model, and a significant variable of >0.05 or near significant was retained in the multiple logistic regressions to evaluate the potential associations between adverse birth outcomes and malaria. For each model, we set out to adjust potential confounders such as maternal age at birth, neonatal admissions at birth, mode of delivery, marital status, parity, G6PD status, genotype, anaemia, socioeconomic status (SES), drinking of alcohol and maternal respiratory condition, and initially added to logistic regression with significance set at p≤0.05. Those with significance were retained in the multiple logistic regression model and the non-significant ones were dropped. Consequently, genotype, anaemia, respiratory condition and drinking of alcohol were all dropped during the initial univariate analysis, which is why some confounders were found in the final model while others were not. Maternal age was, however, non-significant but was retained in the models given its relevance as a confounder and its previously established association with adverse birth outcomes. 18 19 For SES, assets from the 2014 Ghana Demographic Health Survey were used to calculate the total assets. We divided the total SES scores into quantiles and considered all scores less than 50 quantiles as poor, from 50 to 75 as moderately rich, and at least 75 or more as rich. 15 Missing data of more than 10% from any observation were dropped in order to prevent bias, and a single manual imputation was used to address some missing data based on previous patterns of questions. 20 Sensitivity analysis was assessed in both univariate and multiple log binomial regression models compared with logistic regression model used in the main analysis.

Patient and public involvement

There was no patient and public involvement.

Figure 1 shows an elaborate detail of the plan for follow-up during this study, which was published in Hussein et al . 15 At baseline, 1626 third trimester pregnant women were recruited, with 1323 women completing the study. The age of pregnant women ranged between 15 and 48 years, and 59.1% were between 25 and 34 years.

Follow-up plan.

In terms of medical history, 14.8% had a parity of four or more children. The incidence of malaria in this cohort was 9.5% (95% CI 7.9 to 11.1). About 6.4% tested positive for sickle cells, and out of these 50.0% who checked for their genotypes were sickled (SS). About 47.9% of women were anaemic, with Hb levels of less than 11 g/dL within their third trimester of pregnancy, while 4.7% had G6PD full defect ( table 1 ).

Baseline characteristics of pregnant women

Hb, haemoglobin; JHS, Junior High School; SHS, Senior High School.

The incidence of preterm birth among women with malaria was 52.0%. Moreover, the prevalence of LBW was 10.4% among women with malaria and 5.1% among women without malaria. In both mothers with and without malaria, newborn deaths and live births were equally 1.6% ( table 2 ).

Incidence of pregnancy outcome and malaria

Pregnant women with malaria had 2.02 times (95% CI 1.39 to 2.93) increased odds of preterm birth compared with those without malaria after adjusting for parity, maternal age, G6PD deficiency and neonatal admission ( table 3 ).

Logistic regression of preterm and malaria

*Significant confounders adjusted in the multiple log binomial model: parity, maternal age, G6PD and neonatal admissions at birth.

G6PD, glucose-6-phosphate dehydrogenase.

Furthermore, pregnant women with malaria had 2.06 times (95% CI 1.09 to 3.93) increased odds of LBW compared with those without malaria after adjusting for parity, maternal age and SES ( table 4 ).

Logistic regression of LBW and malaria

*Significant confounders adjusted in the multiple log binomial model: parity and socioeconomic status.

LBW, low birth weight.

Lastly, with an OR of 1.02 (95% CI 0.26 to 4.01), there was no difference in perinatal mortality between pregnant women with malaria and those without malaria after adjusting for caesarean section. Women who underwent caesarean section had a five times greater risk of perinatal death than those who did not have caesarean section ( table 5 ).

Logistic regression of perinatal mortality and malaria

*Significant confounder adjusted in the multiple log binomial model: mode of delivery.

Sensitivity analysis in both the univariate and multiple log binomial regression models did not change the direction or strength of the estimates compared with the logistic regression model for preterm birth, even though the OR marginally exaggerated the relative risk to some magnitude ( table 6 ).

Sensitivity analysis using log binomial regression for preterm and malaria

†RR, Relative Risk

In this study, malaria was found in nearly 10% of pregnant women. The study also investigated the associations between malaria and preterm birth, LBW and perinatal mortality.

Prenatal malaria was found to be substantially linked with preterm birth and LBW after correcting for parity, mother’s age, G6PD, SES and neonatal hospitalisation at birth, but not with perinatal death after adjusting for caesarean section. Indeed, Nkwabong et al 21 previously reported that third trimester malaria increased the chance of preterm delivery by 5 times and LBW by 2.8 times, which is consistent with our findings. Similarly, Vogel and colleagues 22 found that exposure to malaria increased the risk of spontaneous preterm term birth by 1.67 times with a secondary analysis of data from 22 low-income and middle-income countries. van den Broek and colleagues 23 similarly conclude from their data that maternal malaria significantly increased the risk of preterm birth by 1.99 times. In Tanzania, similar studies have shown that malaria parasites in mothers’ red blood cells are associated with 3.2 times the risk of premature birth. 24 Compared with people without placental malaria, preterm birth rates increased by 4.7% to 5.6% among pregnant women with placental malaria. 25 26

In Brazil, researchers reported that P. falciparum species were significantly associated with preterm births, although accounting for less than 40% of the total. 27 In contrast, some authors suggest that such correlations are non-significant. For example, a recent comprehensive study of malaria at birth in Uganda that studied three different parasite detection methods, including peripheral and placental blood microscopy, placental blood loop-mediated isothermal amplification (LAMP), and placental histopathology, found no statistically significant link between malaria and preterm birth for any of the methods. 28 In this study, it was not possible to distinguish between the various species of malaria. However, previous studies have shown that, regardless of the species, malaria can lead to poor birth outcomes. For example, P. falciparum in placental blood increased the risk of LBW by around 1.7 times in Malawi 29 and about 3.7-fold increase in Zaire. 30 Furthermore, in Nigeria and Uganda, approximately 33% and 19% of mothers with placental malaria, respectively, delivered LBW babies compared with those without placental malaria. 26 31

One interesting aspect that emerged from the analysis is the finding that women who delivered via caesarean section were about five times more likely to suffer perinatal mortality. Notwithstanding, we found that there was no significant increase in the odds of pregnancy mortality in both adjusted and unadjusted models. In contrast, other studies, such as the one conducted in Zaire in 1993, reported that maternal malaria with chloroquine prophylaxis increased the risk of perinatal death by 12 times after adjusting for parity and prenatal clinic visits. 30 In addition, P. falciparum malaria during pregnancy increased the risk of neonatal deaths by 2.6 times. 32 Infants delivered to mothers with acute placental infections had a fivefold risk of death. 33

Multiple variables such as gender, mother’s age and SES can result in adverse birth outcomes. Therefore, in this study, we adjusted for these significant confounders in the multiple logistic regressions and maintained the significant confounders. Women with multiple pregnancies are protected from premature birth. This is apparently due to the extra protection provided by antibodies in subsequent pregnancies against the parasite variant surface antigen VAR2CSA. 34 35

Furthermore, regardless of the period of exposure, the effect of malaria exposure on fetal development was detected during the third trimester of pregnancy and has been blamed for poor birth outcomes. 6 25 36 This might be because the pathway that connects the mother to the baby throughout pregnancy may impact the fetus’ survival at delivery or even beyond, since the placenta delivers nutrition to the newborn via the umbilical cord. For example, Ouédraogo and his colleagues 37 found a connection between umbilical cord parasitaemia and maternal peripheral blood parasitaemia. Also, malaria during pregnancy may have induced excessive stimulation and dysregulated Hb-scavenging system and bioavailability of nitric oxide and L-arginine, which may be associated with poor vascular development and adverse birth outcomes. 38 Although we used RDT with peripheral blood, our findings were consistent with the majority of studies on placental malaria. 34 35 This is because peripheral blood infections may promote the sequestration of parasites in the placenta and activate immune reactions of antibodies and antigens that may cause complications during delivery. 34 35 Furthermore, Kapisi et al 25 found that women who had a high burden of malaria had a 14-fold increased risk of placental malaria by blood microscopy and a fourfold increased risk of LAMP. This could indicate that our group had a higher malaria burden, correlating with previous research using a different technique for diagnosis. 25

This study benefited from a large sample size. To date, we have not found any studies that examined the relationship between maternal malaria during delivery and the results of birth in Tamale in the Northern Region of Ghana. In this cohort, RDT was used to diagnose malaria, although the sensitivity to malaria was 19% lower than a microscopic examination of peripheral and placenta blood. However, RDT has been reported to have outperformed microscopy in identifying malaria in other settings. 36 39 Furthermore, RDT is useful in environments like ours because it produces quick results, requires fewer training and equipment, and has virtually no power interruption. Consequently, especially in hospitals with limited human resources and equipment, rapid malaria detection techniques are imperative for initiating care.

A potential drawback of our study was that we relied on standard laboratories at each hospital to collect data on malaria. While we took every attempt to observe and monitor compliance with established testing techniques, we were unable to account for any measurement bias among laboratory staff for the exposure variable (malaria). However, it should be noted that the RDT method for malaria diagnosis during pregnancy is used routinely in our context and is performed by state-licensed laboratory professionals to diagnose malaria in our population. We also cannot explain the impact of malaria on birth outcomes during the early stages of pregnancy since we only included pregnant women in their third trimester as long as they had done at least one RDT prior to recruitment. This study also failed to account for the number of doses of sulfadoxine/pyrimethamine taken by pregnant women. This denied us the opportunity to measure its confounding effect on malaria and birth outcomes. Nevertheless, our research is comparable with similar studies on the subject matter.

Taken together, these findings indicate that maternal malaria within the third trimester of pregnancy may be a major contributor to LBW and preterm birth in the Northern Region of Ghana.

Supplementary Material

Acknowledgments.

We appreciate the Tamale Teaching Hospital and the Ghana Health Service for giving us the opportunity to collect data in their facilities.

Contributors: HH: investigation, writing the draft, data analysis and guarantor. MS: writing, review and editing. MY: conceptualisation and validation. MSH: visualisation and resources. MAS: project administration. PDA: data curation. AF: supervision and acquisition of funds. All authors reviewed and approved the final manuscript.

Funding: This study was supported by the Tehran University of Medical Sciences.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Ethics statements, patient consent for publication.

Not required.

Ethics approval

This study involves human participants and was approved by the ethical review committees of the Ghana Health Service and the Tehran University of Medical Sciences (ethical approval numbers GHS-ERC010/12/17 and IR.TUMS.SPH.REC.1396.4066, respectively). Information sheets with accompanying verbal clarifications were provided to adequately explain all concerns of risk to the study participants. A signed or thumb-printed informed consent was obtained from each participant prior to recruitment. Participants gave informed consent to participate in the study before taking part.