Running head: MALARIA PREVENTION PRACTICES AND BARRIERS

Malaria Prevention: Practices and Barriers among Pregnant Women in Uganda

Michelle Carrillo
Western Washington University

MALARIA PREVENTION PRACTICES AND BARRIERS

Introduction
In Uganda, malaria continues to be a significant problem for more than 3 million
individuals, which constitutes 90% of the population and 95% of this country is endemic
(Ministry of Health, Uganda, 2016). Malaria is a leading problem of public health in Uganda, in
both private and public health facilities, and is strongly correlated with poverty and delayed
socio-economic development. The transmission rates of malaria in Uganda continue to be one of
the highest in the world, with an estimated 16 million reported cases in 2013; and in Africa,
ranks as the sixth highest cause of death, claiming more than 10,500 lives each year (Ministry of
Health, Uganda, 2016). Uganda has one of the worlds highest fertility rates and is ranked third,
and in Africa, more than 30 million women who are pregnant are at risk for contracting malaria
(Odongo, Bisaso, Byamugisha, & Obua, 2014). Contracting Malaria disease becomes especially
significant for women who are pregnant.
During pregnancy the immune system changes and increases a womans susceptibility for
contracting malaria. The risk of malaria disease in pregnancy becomes greater because of the
placenta which creates an additional binding site for malarial parasites and further decreases
maternal immunity (The Centers for Disease Control and Prevention (CDC), 2015). Malaria
disease in pregnancy can affect the fetus and cause premature birth, low birth weight, fetal death,
and severe maternal anemia (CDC, 2015). Although iron-deficiency anemia frequently
accompanies pregnancy, it can become more severe when it is coupled with malaria.
If a pregnant woman contracts malaria, the severity of the clinical manifestations depends
on the level of immunity before pregnancy, as well as the intensity and stability of malaria
transmission (Mbonye, Mohamud, & Bagonza, 2016). In areas of low malaria transmission, the
degree of immunity is low; therefore when a pregnant woman contracts it, she and the fetus are

MALARIA PREVENTION PRACTICES AND BARRIERS

likely to suffer severe consequences of the disease (CDC, 2015). In areas where there is a high
transmission of malaria, immunity to it is also higher. Women who are pregnant for the first time
are more affected by malaria than women who have been pregnant more than once (World
Health Organization (WHO), 2016a). The purpose of this paper is to understand the barriers that
prevent pregnant women who are living in Uganda from receiving the recommended preventive
treatment measures against malaria.

MALARIA PREVENTION PRACTICES AND BARRIERS

Transmission
The CDC reports that malaria is a serious disease that may be preventable although it can
be deadly. Malaria is caused by a parasite that infects selective types of mosquitoes that feed on
human flesh. There are four types of malaria parasites that infect humans which are: Plasmodium
falciparum, P. vivax, P. malariae, and P. ovale (CDC, 2016). Humans contract malaria if they are
bitten by a mosquito carrying the disease, typically from the female mosquito anopheles. The
ability of the anopheles mosquito to transmit malaria to humans is only possible if they have
previously taken blood from an infected person. The blood taken from an infected person
contains microscopic malaria parasites that mixes with the mosquitos saliva and is transmitted
when they inject and feed on the next person. Since malaria is found in human red blood cells,
other forms of transmission can occur via an organ transplant, sharing needles or syringes
contaminated with blood, blood transfusions, as well as congenital malaria transmission which
can occur from mother to fetus before or during delivery (CDC, 2016). Presenting symptoms of
malaria are described as a flu-like illness, including a high fever and shaking chills.
Preventive Treatment
There are many ways to prevent malaria transmission. In the household setting, closing
windows and doors in the early evening and using screens, helps to lessen the chance of
mosquitoes entering the home. Having water near the home is a source for mosquitoes to habitat.
Removing standing water from around the home as well as vegetation helps eliminate breeding
sources for mosquitoes (Musoke, D., Karani, Ndejjo, Okui, & Musoke, M. B., 2016). Mosquito
repellents, indoor residual spraying and insecticide-treated nets (ITN) aid to protect humans from
being bitten by mosquitoes and help to control vectors. These are just some ways in which

MALARIA PREVENTION PRACTICES AND BARRIERS

malaria transmission can be reduced. Although malaria is a serious disease there are preventive
treatment measures that can be taken to lessen the chance of contracting it. There are also
specific interventions recommended for pregnant women.
The WHO outlines key interventions and methods for preventive treatment that are
effective in reducing the incidence of malaria during pregnancy. The use of ITNs during
pregnancy, are effective in reducing the incidence of low birth weight, placental infections and
maternal anemia (WHO, 2016a). Intermittent preventive treatment in pregnancy (IPTp) includes
administration of an antimalarial drug called sulfadoxine-pyrimethamine (sp) and is given to
women at antenatal care (ANC) visits. SP can be administered to pregnant women whether they
have malaria or not (CDC, 2015). Malaria in pregnancy can lead to devastation for the fetus and
the mother. When pregnant women contract malaria, the placenta can become infected by the
malaria parasite and no longer be able to provide nutrients to the fetus (CDC, 2015). Folic acid is
a common supplement that is recommended during pregnancy to prevent neural tube defects in
the fetus, however SP counteracts its effect and so women need to take higher doses of it. In
2012, the WHO (2016b) policy was updated, recommending that women should receive at least
three doses of SP during their second and third trimester of pregnancy and attend four ANC
visits. IPTp decreases the incidence of placental parasitaemia, low birth weight, neonatal
mortality, fetal and maternal anemia, as well as maternal malaria (WHO, 2016a). It is absolutely
necessary for pregnant women to utilize both ITNs and have access to IPTp to decrease the
incidence of malaria (Muhumuza, Namuhani, Balugaba, Namata, & Kiracho, 2016).

MALARIA PREVENTION PRACTICES AND BARRIERS

IPTp Treatment
A qualitative study of interviews among pregnant women who utilize ANC services was
conducted in Uganda in order to gain an in-depth understanding of barriers that impede pregnant
women from receiving the recommended IPTp treatment. The study also included interviews
with opinion leaders, district health officials, and health care workers. Research revealed
important barriers related to perceptions and experiences regarding IPTp and ANC. Although it is
not a requirement for women to be accompanied by their partner at each ANC visit, women who
are unable to do so will either delay seeking ANC services for a time, or entirely throughout their
pregnancy.
Women who have gone to ANC visits without their partners have been turned away. A
pregnant women reported that her husband accompanied her on two ANC visits, and when she
went alone, her wait times were much longer (Rassi et al., 2016). Another barrier noted was
dress. Women who go to ANC visits in their skirts arent seen, they are told to come back another
time; the nurses/health workers only want to attend to women who are wearing maternity
clothing - such as a dress that is loose fitting. Many women may delay seeking ANC services out
of embarrassment or shame of not having the right clothes to wear as they may not have the
finances or resources to obtain maternity clothing (Rassi et al., 2016). Some clinics only take the
first 20 pregnant women and tell the rest to leave and come back another time, other lower level
facilities dont offer ANC services due to the lack of qualified staff and/or funds, while others
suffer from limited staffing to meet the demand for ANC (Rassi, et al., 2016). Poor attitudes and
behavior of health workers was linked to low job satisfaction. Rude or disrespectful behavior by
health workers was noted when pregnant women arrived too early or late in initiating ANC, as
well as missing appointments (Rassi et al., 2016).

MALARIA PREVENTION PRACTICES AND BARRIERS

Neither the health workers nor district officials who were interviewed were aware of the
conflicting guidelines. One district official said that women at 36 weeks gestation may be told
that they arent eligible for IPTp because it has to be given no later than 28 weeks gestation
(Rassi et al., 2016). There was varying knowledge and among the health workers regarding the
current IPTp guidelines, specifically the timing of administration. One third of the health
workers had training on IPTp, while another one third had not been formally trained specifically
on IPTp but received training on malaria. The final one third of health workers reported that they
never had any training at all (Rassi et al., 2016). The guideline inconsistencies differ from WHO
recommendations and likely contribute to missed opportunities for pregnant women to receive
optimum malaria preventive treatment in Uganda (Rassi et al., 2016).
Priorities need to be addressed to ensure that guidelines are consistent and health workers
need to be professional and respectful towards all women utilizing ANC services (Rassi et al.,
2016). Whether women are accompanied by their partners or attend ANC alone and regardless of
how they are dressed, health workers must ensure all pregnant women have equal access to
services. Health workers must be trained and mentored in a traditional classroom setting to gain
knowledge and understanding of preventive treatment against malaria during pregnancy as well
as who is eligible.
A quantitative study in Uganda was undertaken to determine the factors associated with
IPTp use among pregnant women. The study collected data from pregnant women regarding
their knowledge and attitude towards IPTp. Research revealed important factors regarding
womens knowledge about the purpose of seeking ANC services and proper use of SP for IPTp.
Some women were knowledgeable about the purpose and correct use of the IPTp SP tablets,
while others werent (Mumumuza, et al., 2016). The majority of women in this study understood

MALARIA PREVENTION PRACTICES AND BARRIERS

that they are at an increased risk for malaria during pregnancy; however they were not aware of
the risks to the fetus. Women who had more than five pregnancies were found less likely to
attend ANC because they didnt perceive it as being important.
The women who demonstrated an understanding of receiving the recommended two
doses of IPTp during pregnancy and reported having access to free clean water at ANC visits
were found to be more than three times likely to receive the recommended doses (Mumumuza, et
al., 2016). The results of the study suggest that these factors are associated with an increased
uptake of IPTp SP treatment among pregnant women in Uganda. The study findings suggest that
promoting health education campaigns need to improve in regards to IPTp utilization among
pregnant women in Uganda.
Another study was undertaken in Uganda in peri-urban areas to determine pregnant
womens perceptions and practices in utilizing IPTp as well as barriers. The study included the
use of a survey and interviews. It also explored interventions in order to increase IPTp uptake
among pregnant women. Interviews were conducted with women who had given birth within the
previous year and revealed that most of the women understood that malaria disease is dangerous
during pregnancy, although many reported not attending ANC for different reasons. Most women
stated that their main reason for not attending ANC was because they didnt feel sick, and
therefore, did not think that SP treatment was necessary (Mbonye, et al., 2016). Other women
reported that ANC services were too far away and had experienced long wait times. Some
women did not attend ANC if their partner felt that it was unnecessary. Most women were
knowledgeable about the dangers of malaria during pregnancy; however they were unaware that
it can cause stillbirths and abortions (Mybonye, et al., 2016).

MALARIA PREVENTION PRACTICES AND BARRIERS

The study found that few women who attended the recommended four ANC visits
received at least three doses of IPTp as current policy states. Other women were simply unaware
of the benefits of SP during pregnancy. The study findings suggest that increasing access to
malaria prevention by increasing public awareness will help to strengthen health seeking
behaviors among pregnant women and improve the quality of health services (Mybonye, et al.,
2016). Implementing policies to promote health that explain the benefits of SP and the
importance of attending ANC will help to educate women in Uganda about the importance of
IPTp during pregnancy (Mybonye, et al., 2016).
Conclusion
The research in this paper revealed many barriers that pregnant women in Uganda
encounter. Women reported being treated poorly or refused care by health workers if they
werent dressed accordingly or accompanied by their partner. Many women in Uganda are
simply unaware of the risk factors of malaria to themselves and/or their fetus. They are also
lacking proper education regarding the importance of IPTp and SP as well as seeking ANC
services. Although women attend ANC, several of them reported that they arent given the
recommended three doses of SP during pregnancy. Health worker knowledge is lacking in
regards to who is eligible for SP and who isnt. The guidelines where some of these studies took
place conflict with the WHO guidelines. All of these barriers, combined with conflicting
guidelines and lack of training among health workers creates a large gap in IPTp utilization.
Malaria is a heavy burden that is present throughout most of Uganda and there does not seem to
be a straightforward solution to this problem. However, increasing access to ANC services,
providing ongoing training to health workers and promoting public awareness seems to have
promising potential to increase the uptake of IPTp among pregnant women in Uganda.

MALARIA PREVENTION PRACTICES AND BARRIERS

10

References
Centers for Disease Control and Prevention. (2015). Intermittent preventive treatment of malaria
for pregnant women. www.cdc.gov Retrieved from
https://www.cdc.gov/malaria/malaria_worldwide/reduction/iptp.html
Centers for Disease Control and Prevention. (2016). Malaria. www.cdc.gov Retrieved from
https://www.cdc.gov/malaria/about/faqs.html
Mbonye, A. K., Mohamud, S. M., & Bagonza, J. (2016). Perceptions and practices for preventing
malaria in pregnancy in a peri-urban setting in south-western Uganda. Malaria Journal,
15,1-5. doi:10.1186/s12936-016-1246-1
Ministry of Health, Uganda. (2016). National malaria control program. http://health.go.ug/
Retrieved from http://health.go.ug/programs/national-malaria-control-program
Muhumuza, E., Namuhani, N., Balugaba, B. E., Namata, J., & Kiracho, E. E. (2016). Factors
associated with use of malaria control interventions by pregnant women in Buwunga
subcounty, Bugiri district. Malaria Journal, 15, 1-8. doi:10.1186/s12936-016-1407-2
Musoke, D., Karani, G., Ndejjo, R., Okui, P., & Musoke, M. B. (2016). Experiences of
households using integrated malaria prevention in two rural communities in Wakiso
district, Uganda: a qualitative study. Malaria Journal, 13, 1-9. doi:10.1186/s12936-0161369-4

MALARIA PREVENTION PRACTICES AND BARRIERS

Odongo, C. O., Bisaso, R. K., Byamugisha, J., & Obua, C. (2014). Intermittent use of
sulphadoxine-pyrimethamine for malaria prevention: a cross-sectional study of
knowledge and practices among Ugandan women attending an urban antenatal clinic.
Malaria Journal, 13(1), 399-406. doi:10.1186/1475-2875-13-399
Rassi, C., Graham, K., Mufubenga, P., King, R., Meier, J., & Gudoi, S. S. (2016). Assessing
supply-side barriers to uptake of intermittent preventive treatment for malaria in
pregnancy: a qualitative study and document and record review in two regions of
Uganda. Malaria Journal, 15, 1-16. doi:10.1186/s12936-016-1405-4
TRAVAX, Health Protection Scotland. Retrieved from
http://www.malariamaps.hps.scot.nhs.uk/images/malariamaps/uganda/uganda.gif
World Health Organization. (2016a). Malaria in pregnant women. www.who.int Retrieved from
http://www.who.int/malaria/areas/high_risk_groups/pregnancy/en/
World Health Organization. (2016b). World malaria report 2015. www.who.int Retrieved from
http://apps.who.int/iris/bitstream/10665/200018/1/9789241565158_eng.pdf?ua=1

11