Antenatal care positive responses to pregnant women in preventing and controlling malaria in pregnancy:the sub-Saharan African perspective

Margaret Tete Telay Doe ·Ousman Bajinka ·Amadou Barrow

Abstract Background The response to antenatal care (ANC) for maternal and off spring outcomes,especially in pregnant women has been thoroughly studied.However,despite the number of interventional studies on the treatment of sulfadoxine-pyrimethamine combination (IPTp-SP) uptake,the point in point cases of the positive responses of ANC in improving health conditions of pregnant women are not found in the literature.Data sources This review collected ANC responses to the positive health outcomes for pregnant women with malaria,the challenges faced regarding IPTp-SP uptake during ANC visits and the role of ANC in preventing and controlling malaria in sub-Saharan Africa.It elucidated ANC and uptake of optimal intermittent preventive IPTp-SP and further described ANC as a tool for heterogeneity for malaria prevention.Results ANC is seen as a microscope to malaria in pregnacy,maternal iron deficiency and anemia checkpoints,ANC and malaria treatment strategies,and ANC and the use of insecticide treated nets (ITN).The review further discussed ANC attendance influencing factors,limitations to ANC implications and the prospects in ANC visits on preventing malaria in pregnancy.Conclusions A declining trend of malaria transmission in Africa has been observed in recent years.However,the burden of malaria in pregnancy remains a health concern.The rate of SP resistance,low uptake of IPTp-SP,low LLINs distribution,late gestational ANC visits and low turnaround for optimal ANC visits for first time mothers’ aggrevated the malaria-endemic settings among pregnant women in sub-Saharan Africa.

Keywords Malaria ·Pregnant women ·ANC visits ·Pregnancy outcome ·IPTp-SP uptake

Introduction

One of the historical human life-threatening diseases called malaria is still within the population of the tropical inhabitants.In sub-Saharan Africa,8%—14% of low birth weight and 20% of stillbirths are due to malaria in pregnancy [1],and millions of women are exposed to malaria in pregnancy[2].Factors that promote the spread of malaria among pregnant women attending ANC is the lack of absolute awareness as to the modes of transmission and prevention of malaria[3,4].Malaria is caused by a parasite type carried by a mosquito called

Plasmodium parasite

,and it is transmitted through bites [3].The antibodies developed from exposure to

Plasmodium

parasite infection-causing malaria infection makes both the pregnant woman and the fetus-susceptible or suppressed immunity [5].Nucleotide polymorphism (SNP)rs2910164 G ＞ C is strongly correlated with increased odds for

P.falciparum

infection.This is more prominent during the first pregnancy when pregnant women who lack suffi-cient acquired immune responses against pregnancy-specific strains of P.falciparum and long-duration infections,which includes pregnant women with acquired preconception [6,7].Although the decline in antibodies leads to reduced malaria exposure,the transfer of antibodies to the fetus in utero could not be prevented by IPTp-SP treatment for pregnant women [5].

Attaining healthcare might be expensive;however,ANC across sub-Saharan Africa is more or less free and easily accessible to the women population.ANC provides important data in the surveillance of infectious disease in the community level [8,9].It is apparent that to achieve an effective prevention of malaria in pregnancy,interventions like uninterrupted ANC visits,IPTp-SP and the use of ITNs are imperative [10].WHO revision to the policy on monthly administration that coincides with the first ANC and delivery for IPTp with SP has proven positive neonatal outcomes[11].WHO and other health organizations recommended ANC as the best way to address malaria,and tuberculosis(TB) and human immunodeficiency syndrome (HIV) among the pregnant women who form a high-risk group [11].The role of ANC implementation and evidence during pregnancy in sub-Saharan Africa has addressed the incidence of TB,Malaria and HIV infection.The ANC registrants unlike the non-registrants are not observing the circle of distribution of free long-lasting insecticidal nets (LLINs) and mass distribution of LLINs during ANC visits has proven the community acceptance of the proper use of ITNs [12,13].

With regard to malaria,ANC-based surveillance gives insight to the routine measure of the burden of malaria in pregnancy and adds improvements to pregnancy outcomes [8].In addition to preventing anemia in pregnancy,ANC visit as a vital public health intervention could alleviate the burden of the prevalence of intestinal helminths[14].A study on ANC visits in Kenya on malaria found that the majority with asymptomatic malaria in pregnancy are younger age and anemia in pregnancy was associated with gestational age parasitemia [15].In addition to malaria severity as outcomes,anemia is also strongly associated with acute undernutrition in rural Sierra Leone [16].A study that linked household and health facility survey data about sub-Saharan African ANC quality of service provision revealed that there are gaps existing in population-level coverage of quality ANC interventions [17].This review collected ANC responses to the positive health outcomes for pregnant women with malaria,the challenges faced regarding IPTp-SP uptake during ANC visits and the role of ANC in preventing and controlling malaria in Subsaharan Africa.Using the search terms on PubMed "Antenatal Care AND Malaria AND sub-Saharan Africa" within the last 10 years.The following PRISMA flow diagram summarized how we reach our final number of articles that give analysis of our review (Fig.1).

Fig.1 PRISMA flow diagram summarizing the study selection process of included studies

ANC and uptake of optimal IPTp-SP

In Ivory Coast,the uptake of IPTp-SP drugs was higher when compared with TT immunization and was found to be significantly associated with ANC visits [18].The number of ANC visits was predicted to be associated with low uptake of optimal SP doses for pregnant women in a study conducted in Malawi [10].Inadequate participation in pregnant women during ANC visits is retarding the sub-optimal uptakes as per malaria preventions.However,women who were recruited to be tested for malaria and hemoglobin tests as part of their pregnancy outcomes in Ghana were found with no beneficial effects [19].Consequently,ANC general malaria screening and healthy pregnancy outcomes remain.

ANC as a tool for heterogeneity for malaria prevention

Trends in malaria and geographic distribution induced factors and details on malaria intervention coverage are crucial for resource allocation in eliminating malaria in the community.ANC is gaining much ground as to serving a pragmatic sentinel population in the research scheme of malaria surveillance [8].For instance,in Tanzania,it was found that ANC for pregnant women is a pragmatic sentinel population when assessing the trends and heterogeneity of malaria prevention.While the study could not correlate a direct association between malaria test-positivity from ANC with other population subgroups as a predictive analysis,it is prudent for the involvement of community-level measurements to give evidence-based epidemiology [20].In continuous tracking of malaria,routine screening made accessible to the population of pregnant women is imperative.For instance,the positive rate detected among afebrile individuals in a study conducted in Tanzania does not only prepare the outpatient clinics for febrile illness but also general health monitoring of pregnant women is a routine surveillance hotspot [21].

ANC as a microscope for malaria in pregnancy

With ANC visits,the chances of missing asymptomatic malaria among pregnant women have improved.For instance,one of the negative risk factors for negative birth outcomes is anemia existing in asymptomatic malaria cases that were detected in the first ANC visits from a study conducted in Tanzania.In addition,the study found a strong association between younger maternal ages,primigravida,low BMI with low hemoglobin concentration.In Ghana,a great number of malaria associated with anemia infections were observed under microscope to have less than 1000 parasite count per microliter of blood smear [22].For this response,asymptomatic malaria could be detected with screening intervention of malaria and anemia during the early ANC visits [23].Outside the peak of the rainy season in Monrovia,the detection rate of

Plasmodium falciparum

infections during the first ANC visit is one in every 8 pregnancies [24].A study on pregnant women with malaria during their first ANC visit in Kisumu,Kenya found that the transfer of Kaposi sarcoma-associated herpesvirus(KSHV) seroprevalence antibodies across the placenta is not affected by malaria during pregnancy [25].Almost half of the

P.falciparum

infections detected in the first trimester may occur pre-pregnancy.Thus,there is a need to protect young women from malaria infection,as well during the pre-pregnancy period [26].

ANC and maternal iron deficiency and anemia

In malaria-endemic regions,prenatal maternal iron deficiency in pregnancy is a health concern.However,this deficiency could be detected early in pregnancy during ANC visits and enable interventions to prevent infant motor development and cognition [23].Anemia in pregnant women is caused by iron deficiency or major public health diseases.Moreover,it was found that malaria and HIV predispose anemia more than iron deficiency in Southwest Nigeria.In a bid to detect these conditions among pregnant women,in addition to being dewormed for helminths and given IPTp for malaria,for women with HCT values less than 33%require complementary routine malaria screening during ANC visits are required [27].

ANC and malaria treatment strategies

A treatment option with artemether-lumefantrine (AL) on community scheduled malaria screening and treatment(CSST) was investigated to determine maternal and infant health outcome with IPTp-SP combination.Although there were some conflicting outcomes among study countries,IPTp-SP could lower the risk of placental malaria and improve birth weight and reduce the rate of anemia [28].The pfmdr1 N86 wild-type allele was found to be common in coverage of IPTp-SP and AL treatment was conducted in Burkina Faso [29].ANC attendees in Sunyani Municipal Hospital in Ghana were found to have an increased risk of anemia due to malaria in pregnancy in addition to the consumption of fish/snails and the gestational age at the first ANC visit [30].Single screening and treatment (SST) strategy during the first ANC visits has detected asymptomatic cases that would have been missed in a study conducted in Tanzania.In addition to the emerging resistance to sulfadoxine-pyrimethamine (SP),the contradictory IPTp in the first trimester should be taken care of [31].

The efficacy in the treatment of sexually transmitted infection (STIs) and reproductive tract infections is optimal at the early stage of disease development.These infections are studied to be occurring as co-infection with malaria in pregnancy and poses adverse birth outcomes.However,when the screening of this co-infection is incorporated into ANC visits,it will reduce not only the symptoms but also an effective treatment for a lifetime is ensured [32].In Togo,it was established that ANC visits did not only reduce the burden of malaria in pregnancy but also improved contraception use that is helping to curb unplanned pregnancies and sick children are also taken care of during ANC visits [33].

ANC and the use of ITN

ITN uptake and ANC were found to be far less than the expected 90% in the Jimma Zone of Ethiopia [34],and less impressive in Uganda.However,ANC and radio advertisements have proven effective for mass ITN campaigns and increased the availability of ITN in households in Nigeria[35,36]

ANC attendance influencing Factors

Structural barriers in the health system,which include infrastructure,human resources,funding and distribution [11].Out-of-stock supply chains of both SP and ITNs may be part of the barriers to ANC targeted accomplishment [37].The disparities in the delivery of malaria service and the readiness for various health facilities across Tanzania alone are bringing a series of setbacks.Western Kenya region is also found to receive adequate LLINs,however,inefficiencies in the allocation in line with the government of Kenya is another challenging issue [38].The malaria program policymakers have a lot to do in curbing these disparities and standardizing the service deliveries for malaria intervention programs [39].Health care providers imposed informal regulations,the perception of poor quality of ANC by the women folk,fear of HIV testing and to some extent distance[40].

The adoption system including leadership,limited buy-in from implementers and governance [11,41].With WHO's service availability and readiness assessment (SARA) framework,the capacity of most of the health systems in Africa might not be able to support service delivery.For instance in Tanzania,the capacity and skills existing among the healthcare workers were found to be unmatched by the level of guidelines put forward by WHO [42].Access to health insurance was a factor that determines IPTp coverage during ANC visits in the Greater Accra region of Ghana [43],and the number of ANC visits influenced low IPTp-SP uptake access in Ghana [44],and awareness was found to be the most possible reason in Ghana [45].

Patient-centered barriers which deal with the personal burdens,the stigmatization attached and the fear are major factors influencing ANC implications [11].ANC attendance is influenced by the level of perception by the women's folks and their husbands including close relatives [46].While many would argue that education status,age of the mother and exposure to radio messages as key determinants;the uptake of IPTp-SP during pregnancy is an emerging determinant as some women are misinformed about the intervention [47,48].Furthermore,other associating factors for women with uptake IPTp-SP are frequency of ANC visits,gestational age during the first ANC visit and the general readiness of health facilities in providing malaria-related services [49].In Mali,it was the age of the pregnant women (less than 20 years) who were found not to undertake the recommended 3 doses of IPTp-SP.This 3 dose intervention strategy was not significantly associated with wealth status,education or residence [50].In South Africa,at least 4 visits of ANC happen to women delivering during garden seasons and very low during the rainy season [51].In southwest Nigeria,the most common factors responsible for low ANC utilization for pregnant women are stock out of IPTp-SP drugs and late bookings for ANC visits [52].At a more general view for Nigeria,late initiation of IPTp after the second trimester was detected using a demographic health record system [53] (Table 1).

Limitations to ANC implications

From the study to assess the satisfaction drawn by the clients with regard to preventive services delivered at ANC on pregnancy-related malaria in Nigeria,at least half of the respondents were satisfied.However,the remaining were dissatisfied with their interpersonal relationship with healthcare givers and the cost involved in assessing care.These issues maybe solved once there are incentives put forward for good client satisfaction ratings on staff,continuous supply of long-lasting ITNs and intermittent preventive treatment for malaria with the subsidized cost of malaria-related commodities [54,55].

As part of the factors detected in the Mount area of Cameroon,SP resistance efficacy studies are necessary.Moreover,it warrants an emergency intervention with respect to resistance against the observable prophylactic benefits [56].Since the prevalence of the SP resistance marker dhps K540E exceeds WHO limits (50%),the implementation of that intermittent preventive treatment for infants (IPTi) with SP is not advisable in North and South Kivu,DRC [57].Another SP-resistant strain is the presence of quintuple mutants in Burkina Faso.While this is scary for the inefficacy of IPTp-SP in the near future,drug combinations to tackle malaria in pregnancy are required [58].

In a bid to shed some light on the effect of providing four-of-care tests for ANC on nurse utilization,maternal and child health services was modeled using discrete-event simulation (DES) modeling.This model found that for the first and second ANC visits,there is enough time for WHO’s required ANC activities to be offered,even using integrated testing.This study could ascertain the sufficient number of staff at the healthcare department,despite the delivering four point-of-care tests as a burden to improve ANC [59].

Prospects in ANC visits on preventing malaria in pregnancy

ANC visits can improve health facilities and communitybased preconception and conception care interventions.However,good dietary habit counseling such as eating protein and iron-rich food sources and a balanced diet are crucial in preventing anemia.Establishing a standard diet habits among local settings in sub-Saharan Africa and an effective engagement of community leaders will add weight to advocating the devoid of food cultural prohibitions and taboos that negatively affect pregnant women [60].The perception of pregnant women for any interventions in healthcare centers should be made clear and restore confidence by skilled personnel at the ANC.Once professionalism is established between the healthcare giver and the clients,smooth service delivery can be achieved [59].

In addition to healthcare providers in the interpretation of ANC policy for pregnant women in combating malaria,district and regional heads should also participate in communicating with the local people in their own tune [61].Effective communication between experts and clients can give a greater appreciation as to clinical interventions [48,62].From the East-Central Ugandan perspective,in addition to improving institutional delivery,the involvement of religious leaders and improving household wealth are key determiners of the uptake of optimal doses of IPTp-SP.While lower-level health centers should be strengthened with IPTp-SP activities,incorporating this activity into the ANC visits will add weight to the intervention.While in Bamenda Health District in Cameroon,the awareness around IPTp is not enough,the routine training for health is inadequate as well.Once pregnant women are better informed regarding IPTp uptake,this will boost their morals in accepting this intervention and hence reduce the burden of malaria in pregnant women and consequently improve the health outcome of both the mother and the baby [63,64].A paradigm shift in health education should be centered on convincing eligible women about the safety of IPTp [65].

Pregnant women in the Conakry and Kindia regions of Guinea who could receive short message services (SMSs)to remind women of upcoming ANC visits were found to be 48 times more likely to attend all the visits and are 12 times more likely to receive SP doses during pregnancy [66].With digital databases accessible from distance and ANC visits,pregnancy and newborn diagnosis assessment (PANDA)mHealth system in Madagascar has improved.It is crucial for healthcare providers to consider the digitization of the ANC service delivery at the grass root level of technology through SMSs and gradually scale up to telemedicine [67].

Among the end-users especially in the rural communities,there is always an appropriateness,acceptability and feasibility of integrating available point-of-care tests (POCTs)into ANC services.Thus,future scale-up efforts are needed to address the challenges in general healthcare settings including management decisions [68].To adjuvant,the ANC coverage,community delivery of IPTp has proven increased IPTp dose delivery.Prompt reimbursement of funds,private health facilities,and medical supplies to a public and regular supply of programme drugs should be a priority for the Ministry of Health to reduce malaria in pregnancy [68,69].

Recommendation for ANC uptake in SSA context

Governments and development partners/agencies involved in maternal and child health implementation should develop specific ANC programmes that target different age groups across SSA countries.Information on MCH programmes,especially ANC services should be packaged in a way that suits the best maternal women to promote their utilization of services.Therefore,MCH programmes including ANC intervention strategies and policy decisions should focus on both rural and urban reproductive-age women throughout Africa.

Various stakeholders in the health sectors are strongly encouraged to improve accessibility,efficiency,affordability,and awareness about skilled pregnancy care.Despite the fact that nations and NGOs place a strong emphasis on ANC contacts as part of healthy maternal policies and initiatives.

To address a long-term change towards improving the utilization of ANC services among women in Africa,governments must focus on improving women's socioeconomic status and access to high-quality ANC services.Women's health-care behavior will be significantly influenced by promoting education for girls.Reinforcing the media-specific campaign by emphasizing the benefits of having adequate ANC contacts would help to expand its reach.

Conclusions

There have been tremendous efforts towards mitigating the mortality rate due to malaria in pregnancy.Moreover,ANC as the means to advocate,teach and restore confidence regarding pregnancy-related intervention is prominent.This review might exhaust the all cases of ANC positive response for pregnancy;however,IPTp-SP uptake and the point in point cases of the positive responses of ANC in improving the health conditions of pregnant women are collected.ANC responses to positive health outcomes for pregnant women with malaria,the challenges faced regarding IPTp-SP uptake during ANC visits and the role of ANC in preventing and controlling malaria in sub-Saharan Africa.Although there has been a decline in malaria transmission in Africa,the burden of malaria in pregnancy still remains a health concern for the inhabitants.The rate of SP resistance,low uptake of IPTp-SP,low LLINs distribution and low ANC visits and turnaround for optimal ANC visits for first-time mothers’aggravates the malaria-endemic settings in sub-Saharan Africa.

Author contributions

MTTD and OB wrote the paper,and AB proofread the manuscript.

Funding

The publication fee will be reimbursed by Central South University.

Availability of data and material

Not applicable.

Declarations

Ethics approval

Not applicable.

Conflict of interest

The authors declare no competing interest.