https://www.inosr.

net/inosr-experimental-sciences/
Gwolo
INOSR Experimental Sciences 12(1):33-45, 2023.
©INOSR PUBLICATIONS
International Network Organization for Scientific Research ISSN: 2705-1692

Malaria Infection Prevalence and Risk Factors in Pregnant Women at

Kampala International University Hospital
Gwolo Charles Koboji

Faculty of Medicine Surgery, Kampala International University Western Campus Uganda

ABSTRACT
Malaria and pregnancy are mutually aggravating conditions, with pregnancy reducing
immunity to malaria, making pregnant women more susceptible to infection. In sub-
Saharan Africa, malaria affects 24 million pregnant women, with the region accounting for
90% of all deaths. A study aimed to determine the prevalence and risk factors associated
with malaria infection among pregnant women attending antenatal care at Kampala
International University Teaching Hospital (KIU-TH). The study found a 4.1% prevalence of
malaria among the 241 pregnant women, with factors such as young age, urban residency,
unemployment, low education, lower gravidity, less or equal to three ANC visits, non-usage
of ITNs, and not taking intermittent preventive treatment (IPT) as major risk factors. The
malaria prevalence was low among the pregnant women studied, suggesting the need for
strengthening the use of intermittent preventive treatment and ITNs among all pregnant
women.
Keywords: Malaria in pregnancy, maternal mortality, pregnant women, Antenatal care.

INTRODUCTION
The first description of malaria was in this disease in a way that completely
ancient Chinese medical records of 2700 rejected its demonic origins and linked it
BC, and 1200 years later in the Ebers with evaporation from swamps which,
Papyrus [1]. The military leader Alexander when inhaled, caused the disease. That
the Great died from malaria. The evidence interpretation was maintained until
that this disease was present within all October 20, 188,0 when Charles Louis
layers of society is in the fact that Alphonse Laveran (1845-1922), a French
Christopher Columbus, Albrecht Dürer, army doctor during the Franco-Prussian
Cesare Borgia, and George Washington all War discovered the cause of the disease
suffered from it [2]. Although the ancient by observing crescent-shaped bodies that
people frequently faced malaria and its were nearly transparent except for one
symptoms, the fever that would occur in small dot of pigment [1], In preceding
patients was attributed to various decades the brownish-black pigment
supernatural forces and angry divinities. hemozoin (now known to be the product
For example, in 270 BC, the Chinese of haemoglobin digestion by the malaria
medical canon known as the Nei parasite) had been found in cadaveric
Chin linked tertian (every third day) and spleens and blood of malaria victims by
quartan (every fourth day) fevers with several investigators including Meckel,
enlargement of the spleen (a common Virchow, and Frerichs. The Mosquito-
finding in malaria), blamed malaria's malaria theory (or sometimes mosquito
headaches, chills, and fevers on three theory) was a scientific theory developed
demons—one carrying a hammer, another in the latter half of the 19th century that
a pail of water, and the third a stove[1]. In solved the question of how malaria was
the 4th century BC, Hippocrates described transmitted. The theory basically

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proposed that malaria was transmitted were an estimated 33.2 million
by mosquitoes, in opposition to the pregnancies, of which 35% (11.6 million)
centuries-old medical dogma that malaria were exposed to malaria infection[13].
was due to bad air, or miasma [3]. Central Africa takes the lion’s share (40%)
The four species of Plasmodium that followed by West Africa (39%), and the
infect humans are: vivax, ovale, malariae, prevalence was 24% in East and Southern
and falciparum. Of these, Plasmodium Africa [14]. In Lagos Nigeria, the
falciparum is the most deadly as it can prevalence rate was 27.3% and ranges
progress to severe illness leading to dead from 19.7% to 72% in Nigeria[15]. It varies
within 24 hours if not treated early [3, 4]. from place to place even within the same
Malaria is a protozoan disease transmitted country and depends on the level of
by the bite of infected Anopheles endemicity of the area, environmental and
mosquitoes[5]. It is the most important of demographic factors, and the social status
the parasitic diseases of humans, with of the pregnant women. Other
transmission in 103 countries affecting 1 determinants such as, mother’s age,
billion people and causing between 1 and gestational age, and parity further
3 million deaths each year [6, 7]. Recent threaten the wellbeing of the mother and
estimates have put the number of child, leading to some of the highest
episodes of clinical malaria at 515 million levels of maternal, infant and child
cases per year, with two-thirds of these mortality rates globally [14]. It is reported
occurring in sub-Saharan Africa, to be more common among primigravidas,
especially amongst children and pregnant with the highest rate of infection during
women [8]. Although regarded as the most the second trimester [16, 17]. Given this
climate-sensitive vector-borne diseases in high burden of the disease, the World
pregnancy [9], several other risks factors Health Organization (WHO) recommended
have been identified as contributing to its the implementation of malaria preventive
emergence and spread. These include measures in all African countries where
environmental, demographic, socio- Plasmodium falciparum remains endemic,
economic status, and some obstetric and including the use of long lasting,
health related factors for example insecticide-treated nets (LLINs) and
gestational age and parity [5, 10]. intermittent preventive treatment during
There is no time in memory when malaria pregnancy (IPTp) with sulfadoxine-
was not a global health problem. It was pyrimethamine (SP) [5]. In Uganda, despite
common in many parts of the world until significant improvement in the use of
well into the 20th century when it was long lasting insecticidal nets (LLIN) by
eliminated in Europe, North America, and pregnant women (80% reported to be
parts of other continents through using) in 2019 and about 68% of pregnant
deliberate programs of mosquito control women who attended ANC received one or
and clinical treatment, as well as through more does of IPT in 2017/2018 [18]. The
generally improved social and living prevalence of malaria infection among
conditions. The muscle behind pregnant women is reported to be high
eradication efforts elsewhere was never (30%) [19]. Anemia is the most common
applied in Africa’s highly endemic areas symptoms of malaria [20, 21]. A decline in
[11]. Today, sub-Saharan Africa remains hemoglobin, red blood cells and packed
the area of greatest malaria concentration, cell volume are markers of anemia [22,
but significant problems exist in Asia, in 23]. Malaria during pregnancy exacerbates
Latin America, and focally in other areas. the severity of other diseases like
Although its chief sufferers today are the HIV/AIDs, and other negative pregnancy
poor of sub-Saharan Africa, Asia, the outcomes [24, 25]. This study was aimed
Amazon basin, and other tropical regions, at determining the prevalence and the risk
40 percent of the world's population still factors associated with malaria infection
lives in areas where malaria is transmitted among pregnant women attending
[11, 12]. In 33 moderate to high antenatal care at Kampala International
transmission countries in African, there University Teaching Hospital.

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METHODOLOGY
Study design 1.962 0.195 (1 − 0.195)
This was a retrospective descriptive and 𝑛 =
0.052
analytic cross-sectional study which
utilized quantitative methods of data 3.8416 𝑥 0.195 𝑥 0.805
𝑛= 𝑛 = 241
collection to establish an association 0.0025
between the study variables Therefore, data was collected from 241
Area of Study study participants at KIU-TH.
This study was conducted in the antenatal Sampling Techniques
clinic of Kampala International University- Convenient sampling was employed to get
Teaching Hospital. KIU-TH is the first and a list of women who attended ANC and
biggest teaching hospital in Uganda, with tested for malaria from the register. Then
a bed capacity of 700, according to systematic random sampling was used to
the Hospital Administrator and is located get the sample required.
in the town of Ishaka, Bushenyi District, Study Procedure
Western Uganda. It’s about 320km from Prior to starting data collection process,
Kampala and 65km from Mbarara. the researcher obtained an introductory
Bushenyi district had Rubirizi, Buhweju, letter from the dean faculty of clinical
Sheema, Mitooma and Rukungiri as medicine and dentistry and the researcher
bordering districts and as of (Uganda used the letter to seek permission from
bureau of statistics, 2021), the district the Chief Executive Officer, KIU-TH and
had population of 250,000 (124,136 males the in-charge of antennal clinic KIU-TH.
and 125,864 females). Data collection methods
Study Population Data was collected by reviewing records
The study population included all women from the antenatal register, using a
who attended ANC at KIU-TH. structured pretested checklist developed
Inclusion criteria according to the research questions and
Records of pregnant women who attended the objectives of the study. The
ANC at KIU-TH from April 2020 to August thoroughly trained research assistants
2021 and tested for malaria extracted the information and entered it
Exclusion criteria into the checklist for approximately 10
 Pregnant women who did not test for minutes each. The checklist consisted of
malaria. information on socioeconomic factors,
 Pregnant women who attended ANC demographic factors, obstetric factors,
before April 2020 or after August 2021 and health-related factors.
Sample Size Determination Quality control techniques
The sample size required for the study A pretest was done 2 weeks before the
was calculated based on the formula by actual study to check if the checklists
Kish to estimate a single population were easily understood and if the tool
proportion [26]. was capturing what it was intended to
2
Z 𝑝(1 − 𝑝) capture. They were then fully developed
𝑛= 2 before the actual study was undertaken.
𝑑
Where, During the period of the actual study, all
N = estimated sample size completed forms from the field were
P = anticipated proportion of reviewed daily and on the spot, and
pregnant women with malaria. A feedback was provided with follow-up
similar study at Ishaka Adventist and /or undertaken. Data was verified,
Hospital found only a prevalence coded and entered into the computer.
of 19.5% (Byabashaija J, 2018), so P Data processing and analysis
is taken to be 0.195 Data from the hard copy checklists was
Z = standard normal variation ant coded and entered into a computer, and
95% confidence (1.96) cleaning and analyses were done.
δ = margin of error (5%) Frequencies and percentages of the
Thus by using this formula, patient’s characteristics were produced.

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At a descriptive level, the variables were Gynaecology and another to the charge of
compared between the entire study the antenatal clinic. Mother’s names were
samples. This was done using tables. not included anywhere in the data
Ethical consideration collected. Paper checklists were kept in
An ethical clearance was obtained from lockable cabins meanwhile data was
the faculty of clinical medicine and entered into password-protected
dentistry and a copy was taken to the computers.
head of the Department of Obstetrics and
RESULTS
Demographic characteristics number were those of the age group of
The demographic characteristics of the ≥35 with 16.6 %. More than half of the
pregnant women that participated in this participants (69.7%) were from urban
study are summarized in Table 1. The sitting with a third (30.3%) from rural
highest number of women was in the age areas.
groups of 25-34 (57.3%) while the least

Table 1: Demographic characteristics of the study participants

Variables Frequency percentage
Age ( years)
18-24 63 26.1
25-34 138 57.3
≥35 40 16.6
Total 241 100%
Area of residents
Urban 168 69.7
Rural 73 30.3
Total 241 100%

Social characteristics study participants 145 (60.2%) while only

The social- economic characteristics of 40 (16.6%) were employed. More than half
the pregnant women that participated in of the pregnant women (70.1%) had
this study are summarized in Table2. education of primary or below while only
House wives constituted over half of the (9.1%) had tertiary education.

Table 2: Social characteristics of the study population

Variables Frequency percentage
Occupation
House wife 145 60.2
Employed 40 16.6
Business 56 23.2
Total 241 100%
Level of education
≤ primary 169 70.1
Secondary 50 20.8
Tertiary 22 9.1
Total 241 100%

Obstetric characteristics 74 (30.7%) were primigravidae. Most of

The obstetric characteristics of the the participants 121 (50.2%) were in the
pregnant women that participated in this second trimester while those in the third
study are summarized in Table 3. trimester were only 45 (18.7%). 214
Multigravida constituted over half of the (88.8%) of the women had attended ANC
study participants 167 (69.3%) while only

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for ≤3 times and only 27 (11.2%) attended ≥ 4 times.
Table 3: Obstetric characteristics of the study participants
Variables Frequency percentage
Gestational age
First trimester 75 31.1
Second trimester 121 50.2
Third trimester 45 18.7
Total 241 100%
Gravity
Primigravida 74 30.7
Muti-gravida 167 69.3
Total 241 100%
Number of ANC attended
≤3 214 88.8
≥4 27 11.2
Total 241 100%

Health related characteristics the participants 193 (80.1%) were using

The health related characteristics of the ITN, and the majority 193 (80.1%) had
pregnant women that participated in this taken IPT (80%).
study are summarized in Table 4. Most of

Table 4: Health-related characteristics of the study population

Variables Frequency percentage
ITN use
Yes 193 80.1
No 48 19.9
Total 241 100%
IPTp use
Yes 193 80.1
No 48 19.9
Total 241 100%

Malaria Prevalence among pregnant study. 10 (4.1%) tested positive while 231
women who attended ANC at KIU-TH (95.9%) tested negative. Therefore, the
During the 1 year and 5-months study prevalence of malaria among the pregnant
period, a total of 241 pregnant women women who attended ANC at KIU-TH was
who attended ANC participated in the 4.1%.

Table 5: Prevalence of malaria infection among pregnant women who attended ANC at
KIU-TH
Malaria diagnosis Total number of study
participants
Yes No
10 (4.1%) 231 (95.9%) 241 (100%)

Factors associated with malaria infection among pregnant women who attended ANC at
KIU-TH
Demographic factors the highest number of malaria cases
The demographic characteristics (5.1%) and participants≥35 years had the
associated with malaria infection are lowest number of cases 2.5%. In terms of
reported in Table 5 below. The study residence, women residing in urban areas
participants in the age group 25-34 had had a higher malaria prevalence (4.8%)

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compared to those residing in rural settings (2.7%).

Table 6: Demographic factors associated with malaria infection among pregnant

women who attended ANC at KIU-TH
Variables Malaria diagnosis Total
Yes No
Age (years)
18-24 2 (3.2%) 61 (96.8%) 63 (100%)
25-34 7 (5.1%) 131 (94.9%) 138 (100%)
≥35 1 (2.5%) 39 (97.5%) 40 (100%)
Total 10 (4.1%) 231 (95.9%) 241(100%)
Resident
Urban 8 (4.8%) 160 (95.2%) 168 (100%)
Rural 2 (2.7%) 71 (97.3%) 73 (100%)
Total 10 (4.1%) 231 (95.9%) 241 (100%)

Social factors education, the highest number of malaria

The social- Economic factors associated cases (4.7%) was among pregnant women
with malaria infection are reported in who had education of primary or below
table 6 below. Women who were compared to 4.0% of cases for those who
housewives had the highest percentage of had education level of secondary.
malaria cases (4.8%) compared to 3.6% Participants who had education of tertiary
who were doing business. Participants level didn’t have any case of malaria
who were employed had the lowest (0.0%).
percentage of malaria (2.5%). In terms of

Table 7: Social factors associated with malaria infection among pregnant women who
attended ANC at KIU-TH
Variables Malaria diagnosis Total
Yes No
Occupation
Housewife 7 (4.8%) 138 (95.2%) 145 (100%)
Employed 1 (2.5%) 39 (97.5%) 40 (100%)
Business 2 (3.6%) 54 (96.4%) 56 (100%)
Total 10 (4.1%) 231 (95.9%) 241 (100%)
Level of Education
≤ primary 8 (4.7%) 161 (95.3%) 169 (100%)
Secondary 2 (4%) 48 (96%) 50 (100%)
Tertiary 0 (0%) 22 (100%) 22 (100%)
Total 10 (4.1%) 231 (95.9%) 241 (100%)

Obstetrics factors of cases 5 (4.1%), followed by those in the

The obstetric factors associated with first trimester 4 (5.3%), and those in the
malaria infection are reported in Table 7 third trimester had the least number of
below. The prevalence of malaria among cases 1 (2.2%). Participants who had
primigravidae in this study was (8.1%) attended ANC ≤3 times had the highest
while multigravidae had the least number of malaria cases 9 (4.2%)
percentage (2.4%). Pregnant women in the compared to those who had attended ≥4
second trimester had the highest number times 1 (3.7%).

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Table 8: Obstetric factors associated with malaria infection among pregnant women
who attended ANC at KIU-TH
Variables Malaria diagnosis Total
Yes No
Gestational age
First trimester 4 (5.3%) 71 (94.7%) 75 (100%)
Second trimester 5 (4.1%) 116 (95.9%) 121 (100%)
Third trimester 1 (2.2%) 44 (97.8%) 45 (100%)
Total 10 (4.1%) 231 (95.9%) 241 (100%)
Gravity
Primigravida 6 (8.1%) 68 (91.9%) 74 (100%)
Multi-gravida 4 (2.4%) 163 (97.6%) 167 (100%)
Total 10 (4.1%) 231 (95.9%) 241 (100%)
ANC attendance
≤3 9 (4.2%) 205 (95.8%) 214 (100%)
≥4 1 (3.7%) 26 (96.3%) 27 (100%)
Total 10 (4.1%) 231 (95.9%) 241 (100%)

Health related factors was 14.6% while only 1.6% of those who
The health relator factors associated with used ITN had malaria. Among those who
malaria infection are reported in Table 8 had not used IPT, 16.7% had malaria while
below.The prevalence of malaria among only 1.0% of those who took IPT had
pregnant women who had not used ITN malaria infection.

Table 9: Health-related factors associated with malaria infection among pregnant

women who attended ANC at KIU-TH
Variables Malaria diagnosis Total
Yes No
ITN use
Yes 3 (1.6%) 190 (98.4%) 193 (100%)
No 7 (14.6%) 41 (85.4%) 48 (100%)
Total 10 (4.1%) 231 (95.9%) 241 (100%)
IPTp use
Yes 2 (1.0%) 191(99.0%) 193 (100%)
No 8 (16.7%) 40 (83.3%) 48 (100%)
Total 10 (4.1%) 231 (95.9) 241 (100%)

DISCUSSION
Prevalence of malaria infection among restrictions related to the response have
pregnant women caused disruptions in essential malaria
In this study, the prevalence of malaria services for example; insecticide-treated
was 4.1%. This finding is higher than that nets needed regular renewal, but
reported by a survey conducted in KIU-TH distribution campaigns have been delayed
Ishaka-Bushenyi, Uganda from January to or cancelled. For detection and treatment
September 2013 which found a prevalence of malaria, individuals may stop attending
of 2.3% [27]. The difference in prevalence health facilities, out of fear of exposure to
could have resulted from COVID 19 COVID-19, or because they cannot afford
pandemic that has led many countries transport. Furthermore, early messaging
including Uganda to impose restrictions. targeted at reducing coronavirus
Lone and Ahmad [28], found sufficient transmission advised the public to stay at
evidence that the COVID-19 pandemic and home if they had a fever, potentially

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disrupting treatment-seeking for febrile was highest among pregnant women who
diseases such as malaria. The prevalence are housewives (4.8%) as compared to
in this study is comparable to findings by those employed (2.5%) and the business
a study in Kiryandongo General Hospital- class (3.6%). This is attributed to the fact
Kiryandongo district - western Uganda that pregnant women who are employed
from June to November 2018 which or are doing business have the power to
reported a prevalence of 5.4% [29, 30]. purchase health-promoting resources and
This is attributed to the fact that both are treatment [37]. Egwu et al. [10],
areas in western Uganda with cold discovered that the poor are less likely to
weather as malaria parasites thrive well in use effective preventive measures
warmer areas compared to cold areas. because they live in poor houses, and
However, the prevalence in this study was vulnerable rooms, and normally can’t
low compared to a survey done in Ishaka afford medicines or good hospitals.
Adventist Hospital- Bushenyi district from Pregnant women who were educated
February to July 2018 which found a either at the level of secondary (4%) or
prevalence of 19.8% [31]. The low tertiary (0%) had the lowest or no risk as
prevalence in this study could be compared to those who were at the level
explained by the fact that many pregnant of primary or below (4.7%). This could
women go to government hospitals stem from the fact that an educated
compared to private hospitals like pregnant woman knows the ways of
Kampala International University- reducing malaria cases. For example, she
teaching hospitals. can recognize the signs and symptoms
Risk factors associated with malaria earlier and seek medical attention. And
infection among pregnant women can play an active role in the eradication
Studies have shown that age, residence, of breeding grounds for mosquitoes, thus
occupation, level of education, gravidity, cutting down the risk of transmission
gestation, ANC attendance, ITN use, and among people [38]. This study discovered
the use of IPT are associated with malaria that pregnant women in the first and
in pregnancy [32]. In this study, older second trimesters had the highest number
women (≥35 years) had the least cases of of malaria cases 5.3% and 4.1%
malaria (2.5%) compared to younger respectively as compared to those in the
(5.1%). This may be attributed to mothers third trimester (2.2%). This could result
with increased age having better exposure from the lack of adequate immunity to
to health services and gaining a good variant surface proteins expressed by the
awareness about the disease and the ways parasite on the surface of infected red
of prevention. Also, due to previous blood cells especially in the first
frequent malaria exposures, older trimester, allowing the infected cells to
mothers might develop immunity to sequester in the placenta [39,40,41]. The
malaria [33]. In terms of residence, study also showed that primigravidas
women residing in urban areas had a were at the greatest risk of malaria
higher malaria prevalence (4.8%) infection (8.1%) compared to
compared to those residing in rural multigravidas who have been noted to
settings (2.7%). A study of the risk factors have lower effects of malaria in
associated with malaria infection in north- pregnancy (2.4%). A low risk of malaria
western Nigeria by [34, 35]., found that among multigravidae mothers may be
subjects residing in urban areas were associated with the development of pre-
more prone to malaria compared to those immunity to malaria with increased
living in rural areas. got the same findings gravidity and previous exposures [42,43].
in Nigeria [36]. This may be attributed to In terms of the number of ANC attended,
the fact that rapidly developing urban pregnant women who attended ≤3 times
areas are crowded with poor houses and a had the highest number of malaria cases
lot of stagnant water that acts as breeding 4.2% compared to those who attended≥4
spaces for mosquitoes. This study found times 3.7%. This could result from the fact
that the prevalence of malaria infection that those who attended ≤ 3 times might

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have missed being given IPT hence (1.6%). The use of IPT has been shown to
predisposing them to malaria infection reduce malaria prevalence in pregnancy
[14] significantly. In this study, participants
(Ssempiira et al., 2017) indicate that the who had not taken IPT were 4 times more
use of ITN substantially reduces the risk likely to have malaria than those who had
of malaria in pregnancy. Indeed, WHO has taken IPT. A similar finding was also
advocated for a three-pronged approach observed in a study in Mali of IPT use in
to tackling malaria and part of the pregnancy (IPTp) where 3 or more doses
strategy is the use of ITN [12]. In this of sulfadoxine-pyrimethamine (SP) have
study, women who did not use ITN had been shown to prevent malaria in
the highest number of cases 14.7% pregnant women living in high-risk areas
compared to those who had used ITN [39].
CONCLUSION
The prevalence of malaria infection ii. Awareness of malaria prevention
among pregnant women who attended measures during pregnancy should
ANC at KIU-TH was low (4.1%) target young women even before
Young maternal age and urban marriage preferably at schools and in
residency contributed to nearly half of social and religious gatherings places.
all cases as compared to older women Stagnant water around houses in
and those who reside in rural areas. urban areas should be sprayed with
Women who were not employed and insecticides.
ended primary or lower level of iii. The government and its development
education, had the greatest risk of partners should promote girl child
malaria infection. education and provide loans to
Lower gravidity and less or equal to 3 unemployed women for them to start
ANC visits, were found to be businesses.
significantly related to malaria iv. All pregnant women should start
infection. attending ANC early and should be
Non-usage of ITNs and not taking IPT able to attend at least 4.
were some of the factors associated v. The control measures available in the
with an increased risk of malaria area should be reviewed and emphasis
infection in pregnancy. should.
Recommendations vi. be placed on adequate sensitization
i. Future research should be conducted on the usage of ITNs. IPT should be
in different transmission settings to taken from the health facility to
provide current data on the national ensure high coverage.
prevalence of malaria among pregnant
women.
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Sciences 12(1):33-45.

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