Project – Assessment of Risk Factors and Preventive Practices Associated with Malaria among Pregnant Women Attending Selected Primary Healthcare Centres in Jos North Local Government Area, Plateau State

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Malaria remains one of the most important public health problems globally, particularly in sub-Saharan Africa. It is a mosquito-borne infectious disease caused by Plasmodium parasites and transmitted mainly through the bites of infected female Anopheles mosquitoes. Although malaria is preventable and treatable, it continues to impose a considerable burden on health systems, households and vulnerable populations. The World Health Organization (WHO) estimated that there were approximately 282 million malaria cases and 610,000 malaria deaths globally in 2024, with the WHO African Region accounting for about 95% of both cases and deaths. Pregnant women are among the population groups at increased risk of severe consequences from malaria infection (World Health Organization [WHO], 2025).

The burden of malaria is particularly significant in countries where transmission is intense and persistent. Nigeria is one of the countries most heavily affected by malaria globally. The disease remains endemic across much of the country and continues to contribute substantially to morbidity, healthcare utilization and socioeconomic losses. The Nigerian government has therefore maintained malaria control and elimination as an important public health priority through national malaria policies and strategic plans. The National Malaria Strategic Plan (NMSP) 2021–2025 emphasized universal access to malaria prevention, diagnosis and treatment, while identifying pregnant women and children as important vulnerable populations requiring targeted interventions (Federal Ministry of Health [FMoH], 2021).

The Nigerian Malaria Indicator Survey (NMIS) provides nationally representative information on malaria-related indicators and remains an important source for assessing malaria control interventions in the country. The 2021 NMIS was implemented by the National Malaria Elimination Programme (NMEP), in collaboration with the National Population Commission and National Bureau of Statistics, with technical assistance from ICF. The survey assessed malaria-related indicators including household ownership and use of insecticide-treated nets and malaria prevention during pregnancy (National Malaria Elimination Programme [NMEP], National Population Commission [NPC], & National Bureau of Statistics [NBS], 2022).

Pregnancy represents a particularly important period for malaria prevention because physiological and immunological changes associated with pregnancy can increase susceptibility to malaria infection. WHO explains that malaria during pregnancy can increase the risk of maternal illness, anaemia, severe malaria and maternal death. It may also adversely affect pregnancy outcomes, including spontaneous abortion, stillbirth, premature delivery and low birth weight (WHO, 2023).

The relationship between pregnancy and malaria has been well established in the scientific literature. Steketee et al. (2001) reported that malaria during pregnancy may result in maternal anaemia, placental accumulation of parasites, low birth weight, intrauterine growth restriction, prematurity and increased infant mortality. Similarly, Desai et al. (2007) noted that malaria during pregnancy constitutes a substantial burden in sub-Saharan Africa, where millions of pregnant women are exposed to Plasmodium falciparum infection annually. The consequences are not limited to the mother but can extend to the fetus and newborn.

The biological vulnerability of pregnant women makes malaria prevention an essential component of antenatal care. Malaria parasites can accumulate in the placenta, thereby interfering with nutrient and oxygen exchange between the mother and fetus. Such placental infection has been associated with adverse fetal and neonatal outcomes. In areas of high transmission, the cumulative effects of repeated infection can contribute to maternal anaemia and poor pregnancy outcomes (Steketee et al., 2001; Desai et al., 2007).

The public health importance of malaria in pregnancy has led to the development of specific preventive interventions. WHO recommends an integrated package of interventions for malaria prevention and control during pregnancy. These include the use of insecticide-treated nets (ITNs), appropriate diagnosis and treatment of malaria, and intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) in areas of moderate-to-high malaria transmission in Africa (WHO, 2023).

Insecticide-treated nets are among the most important malaria prevention tools available to pregnant women. Sleeping under an insecticide-treated net reduces exposure to malaria vectors and provides both personal and community-level protection. However, ownership of a net does not necessarily translate into consistent utilization. Factors such as heat, discomfort, perceived mosquito density, condition of the net, sleeping arrangements, availability of suitable sleeping spaces and individual perceptions about malaria can affect actual use. Studies in Nigeria have demonstrated that demographic and socioeconomic characteristics can influence ITN ownership and utilization among women and pregnant women (Ankomah et al., 2012; Auta, 2012).

Similarly, Eleazar et al. (2022) examined factors affecting ITN use among pregnant women in Enugu, southeastern Nigeria, and highlighted the continuing importance of appropriate utilization of insecticide-treated nets as part of malaria prevention during pregnancy. The existence of preventive commodities alone may therefore be insufficient if pregnant women do not consistently use them or if barriers prevent them from accessing them.

Another important preventive strategy is intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine. IPTp-SP involves administering preventive doses of sulfadoxine-pyrimethamine to eligible pregnant women during pregnancy, irrespective of whether they have symptoms of malaria at the time of administration. WHO recommends that, in malaria-endemic areas of Africa, IPTp-SP should begin in the second trimester, with doses administered at intervals of at least one month and the objective of ensuring that women receive at least three doses during pregnancy (WHO, 2023).

Evidence supports the value of IPTp in reducing malaria-related adverse pregnancy outcomes. WHO notes that IPTp-SP is associated with reduced maternal parasitaemia, reduced low birth weight and increased mean birth weight. Nevertheless, coverage remains inadequate in many malaria-endemic settings. WHO’s 2024 field guide on community deployment of IPTp-SP reported that a substantial proportion of pregnant women still do not benefit from this protective intervention, demonstrating the continuing gap between policy recommendations and actual coverage (WHO, 2024).

The effectiveness of combining different preventive measures has also been demonstrated in Nigeria. A study among pregnant women in southeastern Nigeria found malaria parasitaemia to be considerably higher among women who used neither IPTp nor ITNs than among women who used preventive interventions. The study reported parasitaemia of 71.1% among women who used neither intervention compared with 45.6% among those who used both IPTp and ITNs, suggesting the potential value of combining preventive approaches (Onwujekwe et al., 2017).

Despite the availability of effective preventive strategies, malaria continues to affect pregnant women in Nigeria. Several factors may contribute to continued exposure and infection. These include poor or inconsistent use of ITNs, inadequate uptake of IPTp, delayed antenatal care attendance, inadequate knowledge of malaria prevention, socioeconomic limitations, environmental conditions that favour mosquito breeding, overcrowded or poorly screened housing, frequent outdoor exposure during evening or night hours, and limited access to appropriate health services. The interaction between these factors makes malaria prevention a multidimensional public health issue rather than simply a matter of providing antimalarial medicines.

Environmental and behavioural conditions can also influence malaria risk. Poor drainage, stagnant water, accumulation of refuse, inadequate environmental sanitation and housing conditions may create favourable breeding environments for mosquitoes. Pregnant women who live or spend considerable time in environments with high mosquito exposure may therefore face increased risk. Personal behaviour, such as sleeping without an ITN, spending evenings outdoors and failure to seek appropriate care when symptoms occur, can further increase exposure.

Health-seeking behaviour is another important component of malaria control. Prompt diagnosis and effective treatment can prevent uncomplicated malaria from progressing to severe disease and death. WHO emphasizes that the primary objective of malaria treatment is rapid and complete elimination of parasites from the bloodstream, thereby preventing progression to severe disease and reducing the likelihood of transmission (WHO, 2025).

Antenatal care provides an important platform for delivering malaria prevention services to pregnant women. During antenatal visits, women can receive health education, malaria screening where indicated, ITNs, IPTp-SP and other maternal health services. Regular ANC attendance can therefore provide opportunities for healthcare workers to identify malaria risk factors and promote appropriate preventive practices. However, the effectiveness of ANC-based malaria prevention depends on timely attendance, continuity of care, availability of commodities and adherence to recommended preventive measures.

The problem is particularly relevant to Jos North Local Government Area of Plateau State. Jos North is an urban and semi-urban local government area containing a substantial population and a network of primary healthcare facilities that provide antenatal and other maternal health services. Pregnant women attending these facilities constitute an important population for examining malaria risk and prevention because their experiences can provide information on access to preventive services, utilization of malaria control measures and behavioural practices.

Importantly, there is already evidence specifically demonstrating the relevance of malaria prevention among pregnant women in Jos North. A recent study conducted among 1,000 pregnant women attending antenatal care at five primary healthcare facilities in Jos North LGA examined the cost-effectiveness of IPTp-SP and ITN interventions. The study population consisted of pregnant women receiving ANC between 13 and 36 weeks of gestation, demonstrating that malaria prevention among pregnant women in Jos North is an important and locally relevant research issue (2025 study).

The Jos North evidence is particularly valuable because it demonstrates that preventive interventions are already being implemented through primary healthcare services in the area. However, the existence of such interventions does not automatically mean that every pregnant woman has adequate knowledge, access, adherence or consistent practice. It is therefore important to assess the risk factors that continue to expose pregnant women to malaria and to determine the preventive practices adopted by women attending selected primary healthcare centres.

The assessment of malaria risk factors should include both individual and environmental factors. Individual factors may include age, parity, gestational age, educational level, occupation, previous malaria experience, knowledge of malaria transmission and history of malaria during the current pregnancy. Health-service factors may include timing and frequency of ANC attendance, access to IPTp-SP and counselling received from healthcare workers. Environmental factors may include housing conditions, stagnant water around the home, drainage conditions, mosquito density and other circumstances that facilitate mosquito exposure.

Preventive practices, on the other hand, include regular sleeping under an ITN, acceptance and appropriate use of IPTp-SP, early attendance at antenatal care, prompt testing when malaria symptoms occur, environmental sanitation and avoidance of mosquito bites. Assessing these practices can reveal whether pregnant women are translating knowledge and access to services into actual preventive behaviour.

The importance of this assessment is further strengthened by the continuing global malaria burden. The WHO World Malaria Report 2025 indicates that malaria remains far from elimination targets despite substantial progress since 2000, with drug resistance posing an emerging challenge to malaria control. This reinforces the need to maximize preventive interventions and reduce avoidable infections, especially among vulnerable groups such as pregnant women (WHO, 2025).

Consequently, assessing malaria risk factors and preventive practices among pregnant women attending selected primary healthcare centres in Jos North LGA is important for generating locally relevant evidence. Such evidence can assist healthcare providers, public health practitioners, local government authorities and malaria-control programmes in identifying behavioural, environmental and health-service factors that require attention. It can also contribute to strengthening antenatal malaria education and improving utilization of proven preventive interventions among pregnant women.

1.2 Statement of the Problem

Malaria in pregnancy remains an important public health concern despite the availability of effective preventive and treatment interventions. Pregnant women are biologically more vulnerable to malaria and may experience serious consequences such as anaemia, severe illness and adverse pregnancy outcomes. Their unborn children may also be affected through low birth weight, prematurity, fetal growth restriction and other complications associated with maternal malaria (Steketee et al., 2001; Desai et al., 2007).

The continued burden of malaria presents a significant challenge to malaria-control efforts in Nigeria. Nigeria remains one of the countries carrying a substantial share of the global malaria burden, and national malaria policies have therefore emphasized preventive measures such as ITNs and IPTp-SP. However, the existence of national policies and malaria-control interventions has not eliminated malaria among pregnant women. The continued occurrence of malaria suggests that important gaps may remain in access, coverage, utilization and adherence to preventive measures (FMoH, 2021; WHO, 2025).

One major concern is the inconsistent use of insecticide-treated nets. Although ITNs are widely promoted as an effective malaria prevention method, possession of a net does not necessarily guarantee that it is used every night. Pregnant women may fail to use ITNs because of discomfort, heat, damaged nets, inadequate sleeping arrangements, perceptions of low mosquito density or other personal and environmental factors. Nigerian studies have shown that utilization of ITNs is influenced by demographic and behavioural factors (Ankomah et al., 2012; Auta, 2012).

Another concern is inadequate uptake of intermittent preventive treatment during pregnancy. Although WHO recommends IPTp-SP for pregnant women in malaria-endemic areas of Africa, a considerable proportion of pregnant women globally still do not receive the recommended protective intervention (WHO, 2024). In Nigeria, failure to receive adequate IPTp may be associated with late commencement of antenatal care, irregular ANC attendance, inadequate counselling, limited availability of medication, fear of adverse effects, misconceptions about preventive antimalarial medication and other socioeconomic or health-system factors.

Poor knowledge and misconceptions may also affect malaria preventive behaviour. Some pregnant women may recognize malaria as a common illness but have inadequate knowledge of how it is transmitted, the importance of consistent ITN use or the preventive purpose of IPTp-SP. Others may associate malaria prevention mainly with treatment after symptoms develop rather than with preventive behaviour before infection occurs. Such gaps can reduce compliance with recommended malaria prevention practices.

Environmental exposure represents another important problem. Conditions such as stagnant water, poor drainage, inadequate environmental sanitation and mosquito-friendly surroundings may increase exposure to malaria vectors. Where environmental risk factors coexist with inconsistent use of preventive measures, pregnant women may remain vulnerable to infection even when malaria-control commodities are available.

The problem is particularly significant in Jos North LGA because primary healthcare centres provide important antenatal services to pregnant women in the area. Although malaria prevention interventions are incorporated into ANC services, the actual extent to which pregnant women consistently practice recommended preventive measures and the specific risk factors that continue to expose them to malaria require further assessment.

Evidence from a study involving 1,000 pregnant women attending five PHCs in Jos North demonstrated the relevance of ITNs and IPTp-SP to malaria prevention in the local setting. The study compared women receiving IPTp-SP alone with women using both IPTp-SP and ITNs, indicating that these interventions are already part of malaria prevention services in the area. Nevertheless, a broader assessment focusing specifically on the combination of risk factors and preventive practices among pregnant women attending selected PHCs is necessary to identify the factors that may continue to undermine malaria prevention.

Furthermore, malaria prevention cannot be evaluated solely by determining whether women have received an ITN or IPTp. It is necessary to examine whether women use the ITNs consistently, whether they receive preventive treatment at appropriate intervals, whether they attend ANC early and regularly, whether they understand malaria transmission and whether environmental and behavioural conditions increase their exposure to mosquitoes.

If these factors remain inadequately understood, malaria-control programmes may continue to provide interventions without adequately addressing the reasons why some pregnant women remain at risk. This can lead to inefficient use of resources and missed opportunities to prevent maternal and fetal complications.

The problem, therefore, is not simply the existence of malaria among pregnant women but the persistence of modifiable risk factors and gaps in preventive practices despite the availability of evidence-based malaria prevention strategies. There is a need for local empirical evidence showing the specific risk factors experienced by pregnant women in Jos North and the extent to which they practice recommended malaria prevention measures.

It is against this background that this study seeks to assess the risk factors and preventive practices associated with malaria among pregnant women attending selected primary healthcare centres in Jos North Local Government Area, Plateau State. The findings are expected to provide evidence that can guide health education, antenatal counselling, malaria-control interventions and public health planning in the study area.

1.3 Purpose of the Study

The general purpose of this study is to assess the risk factors and preventive practices associated with malaria among pregnant women attending selected primary healthcare centres in Jos North Local Government Area, Plateau State.

Specifically, the study seeks to:

1. assess the level of knowledge of malaria transmission, symptoms, complications and prevention among pregnant women attending selected primary healthcare centres in Jos North LGA;
2. identify the major individual, behavioural, environmental and health-service-related risk factors associated with malaria among pregnant women in the study area;
3. determine the extent to which pregnant women attending the selected PHCs use insecticide-treated nets as a malaria preventive measure;
4. assess the uptake of intermittent preventive treatment with sulfadoxine-pyrimethamine among pregnant women attending the selected PHCs.

1.4 Research Questions

The following research questions will guide the study:

1. What is the level of knowledge of malaria transmission, symptoms, complications and prevention among pregnant women attending selected primary healthcare centres in Jos North LGA?
2. What are the major individual, behavioural, environmental and health-service-related risk factors associated with malaria among pregnant women in the study area?
3. To what extent do pregnant women attending selected PHCs use insecticide-treated nets for malaria prevention?
4. What is the level of uptake of intermittent preventive treatment with sulfadoxine-pyrimethamine among pregnant women attending the selected PHCs?

1.5 Research Hypothesis

The following null hypothesis will be tested at 0.05 level of significance:

H₀: There is no statistically significant relationship between selected malaria risk factors and preventive practices among pregnant women attending selected primary healthcare centres in Jos North Local Government Area, Plateau State.

1.6 Significance of the Study

The study will be significant to several groups.

Pregnant women: The findings may help pregnant women understand the importance of consistent malaria prevention during pregnancy. Information concerning ITN use, IPTp-SP, environmental sanitation and early healthcare utilization may encourage women to adopt appropriate preventive behaviours.

Healthcare providers: Nurses, midwives, community health officers and other healthcare workers in the selected PHCs may benefit from the findings by identifying common misconceptions, behavioural barriers and risk factors among pregnant women. The findings may assist healthcare workers in strengthening malaria-related health education during ANC visits.

Primary healthcare centres: The study may provide evidence that can help PHCs improve the delivery of malaria preventive services. The findings may assist facilities in identifying gaps in IPTp provision, ITN utilization counselling and malaria education.

Plateau State Ministry of Health and Local Government Health Authorities: The findings may provide locally relevant evidence for planning malaria-control activities and maternal health interventions. The information may be useful in targeting health education and preventive services to specific groups of pregnant women who demonstrate greater exposure or poorer preventive practices.

Malaria control programmes: Findings from the study may contribute to understanding why recommended malaria interventions may not always translate into consistent preventive behaviour. This may support efforts to strengthen implementation of malaria-control strategies at the community and primary healthcare levels.

Public health practitioners: The study may provide information on the interaction between environmental, behavioural and health-service factors in malaria prevention during pregnancy. This can support more comprehensive approaches to malaria control.

Researchers and students: The study may serve as a reference for future research on malaria in pregnancy, maternal health, preventive health behaviour and malaria-control interventions in Plateau State and other parts of Nigeria.

1.7 Scope of the Study

The study will focus on the assessment of risk factors and preventive practices associated with malaria among pregnant women attending selected primary healthcare centres in Jos North Local Government Area of Plateau State.

The study will specifically examine:

• knowledge of malaria;
• perceived and experienced malaria risk factors;
• environmental and behavioural exposure;
• use of insecticide-treated nets;
• uptake of IPTp-SP;
• antenatal care attendance;
• malaria preventive health-seeking behaviour;
• environmental sanitation practices; and
• other relevant malaria prevention practices.

The study population will comprise pregnant women attending antenatal care services at selected primary healthcare centres in Jos North LGA.

The study will not focus on malaria among children, men, non-pregnant women or patients attending tertiary healthcare facilities except where such information is necessary for contextual discussion.

1.8 Operational Definition of Terms

Assessment: The systematic process of collecting and analysing information to determine the level, pattern or condition of a particular phenomenon.

Malaria: A mosquito-borne infectious disease caused by Plasmodium parasites and transmitted primarily through infected female Anopheles mosquitoes.

Pregnant women: Women who are currently carrying a fetus and who attend antenatal care services at the selected healthcare facilities during the study period.

Malaria in pregnancy: Malaria infection occurring during pregnancy, whether symptomatic or diagnosed through appropriate clinical or laboratory procedures.

Risk factors: Individual, behavioural, environmental, socioeconomic or health-service-related conditions that may increase a pregnant woman’s likelihood of being exposed to or developing malaria.

Preventive practices: Actions undertaken by pregnant women to reduce their likelihood of contracting malaria, including ITN use, IPTp-SP uptake, environmental sanitation, avoidance of mosquito bites and appropriate healthcare-seeking behaviour.

Insecticide-treated net (ITN): A mosquito net treated with insecticide and used as a physical and chemical barrier against malaria-transmitting mosquitoes.

Intermittent preventive treatment in pregnancy (IPTp-SP): The administration of sulfadoxine-pyrimethamine to eligible pregnant women at recommended intervals during pregnancy to prevent malaria and its associated complications.

Antenatal care (ANC): Healthcare and monitoring services provided to a woman during pregnancy to promote the health of the mother and fetus and identify and manage pregnancy-related risks.

Primary Healthcare Centre (PHC): A first-level healthcare facility that provides basic preventive, promotive, curative and maternal health services to individuals and communities.

Jos North Local Government Area: A local government area in Plateau State, Nigeria, within which the selected primary healthcare centres for the study are located.

Project – Assessment of Risk Factors and Preventive Practices Associated with Malaria among Pregnant Women Attending Selected Primary Healthcare Centres in Jos North Local Government Area, Plateau State