Although there are interventions against malaria in pregnancy in place, there are still gaps that could jeopardise efforts.
In her 36th week of pregnancy, Miracle Okoro should have known better than not to register for antenatal care. She, however, did not do so, until malaria hit her hard. She then swung into action for fear of the unknown.
Ms Okoro lives in Abakaliki, Ebonyi State. Available at Alex Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA), a public health facility, are packs of an anti-malaria medication, Fansidar, provided by the federal government for pregnant women. Yet, many of them ignore this free gesture.
Ms Okoro later received three free doses of Fansidar from AEFUTHA in October which she used to recover from the malaria.
Victoria Moemeke, a resident of Lagos State, who is 15 weeks pregnant has not in this period been diagnosed with malaria or taken any prophylaxis, but sleeps under an insecticide net to protect herself from mosquito bites.
Zaliha Auwal is a resident of Gulumbe in Kebbi State, who is seven months pregnant and had never been to the hospital for antenatal care until she had malaria.
When Ms Auwal came into the maternal ward at General Hospital Zauro, her tongue was as white as snow; she already had severe malaria with anaemia. She was eventually treated at the hospital.
Malaria is one of the many woes of pregnant women, especially in Nigeria where it is endemic. Their situations could quickly deteriorate, as their immune systems are largely under significant pressure.
An Obstetrics and Gynaecology consultant at Lagos University Teaching Hospital (LUTH), Opeyemi Akinajo, said malaria affects not only the pregnant woman, but also the foetus in her womb, “whose health is compromised by whatever affects the mother.”
“Once a woman is affected and not properly treated, it can result in several complications that can also affect the life of the child,” she told PREMIUM TIMES.
Malaria in pregnant women leads to a number of complications, ranging from anaemia, low birth weight, miscarriages, placental parasitemia, neonatal mortality and death.
Malaria is also responsible for 11 per cent of maternal mortality in Nigeria, with pregnant women being one of the groups most vulnerable to this.
Malaria is endemic in Nigeria with about 53 million cases annually (one in four residents) and 81,640 deaths annually (nine deaths per hour). This is in addition to a quarter (25 per cent) of the global burden, which Nigeria bears, according to the World Health Organisation (WHO) 2019 annual malaria report.
It is against this backdrop of the endemic nature of malaria in Nigeria that the country embarked on a ‘malaria control’ journey in 1948.
This transitioned from the National Malaria Service in 1948 to the National Malaria Control Programme in 1986, and then the National Malaria Elimination Programme in 2013, reflecting Nigeria’s desire for a malaria-free country.
The National Malaria Elimination Programme, which is the overarching framework, and its localised versions in the State Elimination Programmes are domiciled in the ministries of health and departments of public health at the federal and state levels.
Nigeria’s National Malaria Strategic Plans (NMSP) have, over the years, served as the blueprint for malaria control and elimination in the country, encompassing the objectives and targets.
Four NMSPs have been designed and been in use from 2001-2005, 2006-2010 and 2009-2013, with the latest being the 2014-2020 Plan that ends this year.
The most recent Strategic Plan aims to achieve a Malaria-Free Nigeria by attaining pre-elimination and zero mortality from the disease, with specific targets including the reduction of malaria in pregnancy to the barest minimum.
The targets also seek to achieve by this year, 2020, 95 per cent of pregnant women sleeping under long-lasting insecticide nets, “and all pregnant women being able to receive intermittent treatment during antenatal care visits.”
However, as the year 2020 closes, findings show that Nigeria is still unable to meet these goals.
Margeret Opoke, who was seven months pregnant as of the time of this report, said she receives intermittent treatment, but says she has never received treated nets from the hospital.
Blessing Nwankwo, who is eight months pregnant, also says she did not receive any at the public antenatal clinic she attends adding that she does not know she is expected to sleep under a treated net for protection.
Interviews conducted by the reporter with several pregnant women show that many of them do not sleep under insecticide-treated nets.
“In terms of where we are, the strategic plan tried to ensure that every pregnant woman, at least 80 per cent, must have access to. You also know that the mode of delivery is through the antenatal clinics during antenatal care.
“We know that coverage for antenatal is still very low and so you would expect that if the mode of delivery for these interventions is through the antenatal clinics, the access to IPTp and LLIN is affected,” said Lynda Ozor, WHO malaria programme manager in Nigeria.
Ms Ozor told PREMIUM TIMES: “the problems could be multi-faceted and it will be anecdotal to say it is one problem because it is multifactorial, however, supply chain challenges are the biggest impediment… “
While the drugs are largely available in public health facilities for free, nets are continuously in short supply.
“We just received these nets and they are only available for first-time registration,” Mercy Obio, matron in charge of the antenatal clinic at AE-FUTHA said.
Mary Yaro, matron in charge of the maternity clinic at General Hospital Zauro, Kebbi State, said the facility has not received nets for almost a year.
Regardless of these shortfalls, experts still credit the interventions for improved maternal health.
“I would also like to say it (maternal mortality from malaria) is not as common as it used to be when I was still in training as a young doctor and the reason is the awareness and the various preventive measures that have been put in place,” said Modupe Adedeji, a consultant Obstetrician and Gynaecologist at the Lagos State University Teaching Hospital (LASUTH).
The implementation of the national malaria strategic plan is coordinated at state and federal levels.
These yearly plans are developed in a manner to align and feed into broader annual health sector plans, just as the national malaria strategic plan feeds into the national health sector strategic development plans.
Every state in the country domesticates the national plan adopting it to suit the peculiarities of their state.
The State Malaria Programmes provide leadership for state-level coordination with support from NMEP while coordination at the community and local levels is the responsibility of the Primary Health Care department of the LGAs.
Some donors to the eradication move include Global Fund for AIDS, Tuberculosis and Malaria (GFATM), World Bank (WB), Presidential Malaria Initiative (PMI-USAID), United Kingdom’s Department for International Development (DFID), United Nation agencies (WHO and UNICEF) and private organisation/sector donors.
The Ebonyi example
In Ebonyi State, for instance, the State Malaria Elimination Programme (SMEP) fully adopted the national plan and is implementing it in the state in partnership with various donor organisations who provide varying support.
These donor organisations include Presidential Malaria Initiative (PMI-USAID), Jhipiego (TIPTOP), Breakthrough Action Nigeria, Global Health Supply Chain, Vector Links in addition to the state’s effort.
The tripartite approach for malaria in pregnancy prevention: use of Sulfadoxine Pyrimethamine, sleeping under long lasting insecticide net and undelayed case management recommended by the WHO and the NMEP is wholly adopted in Ebonyi State, said Lawrence Nwankwo, the Manager SMEP, Ebonyi State.
Mr Nwankwo said these commodities/interventions are accessed through the antenatal clinic.
However, antenatal clinic (ANC) attendance and in turn usage or access to these commodities is low, he adds. This has led to a pioneer programme in one of the local governments (TIPTOP) to increase ANC attendance and in turn the number of women who take sulfadoxine pyrimethamine.
Mr Nwankwo said the various interventions have translated to a drastic reduction in the number of stillbirths.
He also noted that despite the availability of these commodities in the state, “there are times when facilities run out of stock and as a result of logistics challenges, they are unable to restock in real time.”
Felicia Chris-Okafor, the State Social Mobilisation officer USAID-John Hopkins University Breakthrough Action Nigeria, said although continuous sensitisation on malaria in pregnancy happens in Ebonyi, with pregnant women fully aware of the reason they should register for antenatal, “they cannot confidently say there is 100 per cent adherence or compliance.”
Ebonyi State has a malaria prevalence of 31 per cent.
With two per cent prevalence, Lagos State according to the NDHS 2018, has the lowest malaria prevalence in Nigeria despite being without funders since 2018.
According to Bimbo Oshinowo, SMEP manager Lagos State, the state has had to depend on itself alongside partners like Malaria Consortium, Creating Health Access initiative among others for support.
She said the state, “adopted and adapted all aspects of the NSMP as well as addressing other peculiarities like collaborating with traditional birth attendants; training and enlightening them because of the patronage they still enjoy from some pregnant women.”
The training of these traditional birth attendants also lets them know when to refer patients they cannot handle.
However, the state is still unable to meet the needs of its population in terms of nets, SPs, ACT and other malaria commodities due to funding gaps.
“The funders were a major source of commodities, what had happened is that we do not have as much commodities as we should.
“… this will result to a stock out in facilities which means end users will not get what is required in terms of commodities,” she said.
She added that although the state is doing well on its own, “it definitely could use some donor support.”
From findings in states visited and research, it is obvious that although there are interventions against malaria in pregnancy in place, there are still gaps that could jeopardise efforts.
One among these is the unavailability of current data that speaks specifically to malaria in pregnancy. Over the years, the data has remained the same (malaria is responsible for 11 per cent of maternal mortality in Nigeria).
Paucity of vital commodities also militates against the malaria fight. Lack of funding for health budgets and also the expiration of donor funding programmes are also critical.
Nigeria has missed its goal for 2014-2020 NMSP and as it signs the next strategic plan, it must put into consideration all the gaps of the previous plan.
Timothy Obot, Deputy Director Program Management NMEP, said Nigeria did not meet a lot of its set targets.
“Not meeting these goals is as a result of a number of factors, part of which is the burden of finance, inadequate collaboration from the private sector,” he said.
“Part of the issue is that the private sector is not doing much when it comes to health care delivery; the government alone cannot have all the resources to tackle malaria. There are also other disease controls the government supports,” he said.
Although targets were not met, “reduction of national prevalence from 42 per cent in 2010 to 23 per cent in 2018 is an achievement for the programme,” says an optimistic Bala Audu, National Coordinator NMEP.
This story was produced with the support of a reporting grant from Maternal Figures.