Project – Assessment of Malaria Prevention Practices and Their Effect on Malaria Incidence among Pregnant Women: A Study of Selected Primary Health Centres in Ikorodu LGA, Lagos State.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Malaria remains one of the most important public health challenges in malaria-endemic countries, particularly in sub-Saharan Africa. It is caused by Plasmodium parasites and transmitted predominantly through the bites of infected female Anopheles mosquitoes. Although malaria affects the general population, pregnant women constitute one of the groups at increased risk of malaria infection and its complications because pregnancy alters immune responses and increases susceptibility to disease. Malaria infection during pregnancy can result in maternal anaemia, severe illness, placental parasitaemia and maternal death, while adverse consequences for the fetus include miscarriage, stillbirth, premature delivery and low birth weight (World Health Organization [WHO], 2023). The continued burden of malaria therefore makes prevention during pregnancy an important component of maternal and reproductive health programmes.

The global burden of malaria remains substantial despite decades of prevention and control efforts. According to the WHO, an estimated 263 million malaria cases and 597,000 malaria-related deaths occurred globally in 2023, with the African Region accounting for approximately 94% of global malaria cases. Nigeria continues to carry the largest estimated malaria burden globally, accounting for about 26% of malaria cases in 2023. This high burden is particularly important for maternal health because pregnant women living in malaria-transmission areas are continuously exposed to infection and may experience repeated episodes throughout pregnancy (WHO, 2024). The persistence of such a high malaria burden demonstrates that availability of malaria-control interventions alone may not be sufficient; appropriate access, acceptance and consistent utilization of preventive practices are equally important.

In Nigeria, malaria prevention during pregnancy is incorporated into antenatal and primary healthcare services. Major preventive practices include sleeping under long-lasting insecticidal nets (LLINs), receiving intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP), attending antenatal care, receiving appropriate health education, and seeking prompt diagnosis and treatment when malaria symptoms occur. The WHO recommends that pregnant women in malaria-endemic areas receive IPTp-SP beginning as early as possible in the second trimester, with doses administered at least one month apart and the objective of receiving at least three doses. LLIN use is also recommended because sleeping under an insecticide-treated net provides personal protection against malaria-transmitting mosquitoes during pregnancy (WHO, 2023, 2025).

However, national evidence indicates that implementation of malaria prevention practices among pregnant women in Nigeria remains incomplete. Findings from the Nigeria Malaria Indicator Survey 2021 showed that only 50% of pregnant women aged 15–49 years slept under an insecticide-treated net on the night preceding the survey, while only 31% of women who had a live birth in the preceding two years reported receiving three or more doses of sulfadoxine-pyrimethamine during their most recent pregnancy. Although these figures represent important progress, they also indicate that a considerable proportion of pregnant women remain inadequately protected. The gap between recommended malaria-prevention practices and actual utilization is important because effective malaria prevention requires consistent and appropriate use rather than simple awareness or ownership of preventive commodities (National Malaria Elimination Programme [NMEP] & National Population Commission [NPC], 2022).

Evidence from Nigerian studies further demonstrates that possession or awareness of malaria-prevention commodities does not necessarily translate into appropriate preventive behaviour. Ankomah et al. (2012), using data from 2,348 pregnant women in Nigeria, found that although knowledge that ITNs prevent malaria was an important predictor of ownership and use, actual utilization remained considerably lower than ownership. Similarly, Awosan et al. (2015) reported that only 19.2% of pregnant women in their Nigerian study were actually using an ITN despite relatively high awareness and household ownership. These findings suggest that factors such as knowledge, perceived usefulness, comfort, ability to hang the net, environmental conditions, accessibility and socioeconomic circumstances may influence whether pregnant women consistently adopt recommended prevention practices (Ankomah et al., 2012; Awosan et al., 2015).

The relationship between malaria prevention practices and malaria occurrence among pregnant women has also been demonstrated in empirical research. Uneke et al. (2017), in a study involving pregnant women in southeastern Nigeria, found that malaria parasitaemia was lower among women who used both IPT and ITNs compared with women who used neither intervention. Similarly, a study conducted among pregnant women in Lagos found an overall malaria prevalence of 8.4% and observed differences in malaria infection according to the malaria-control measures adopted by participants; women who had received more than one dose of IPT had lower infection rates than those who had not received IPT. These findings provide evidence that preventive practices can influence malaria infection during pregnancy, although the level of protection may depend on the consistency and combination of interventions used (Uneke et al., 2017; Falade et al., 2011).

Primary Health Centres (PHCs) provide an important platform for implementing malaria-prevention interventions among pregnant women because they serve as points of contact for antenatal care, health education, preventive medication, screening, diagnosis and referral. The WHO emphasizes antenatal care as an important platform for delivering IPTp and other interventions for malaria prevention in pregnancy. Nevertheless, evidence from Nigeria shows that gaps may persist even among women who attend antenatal clinics. For example, a study in Enugu State found that although 41% of women reported sleeping under ITNs during pregnancy, only 15.4% did so every night as recommended, while uptake of recommended IPTp doses was also incomplete. Such findings make it necessary to assess not only whether pregnant women attend PHCs but also the extent to which the preventive services and practices promoted through these facilities are actually adopted and whether they are associated with malaria incidence among pregnant women (WHO, 2022; Nnadi et al., 2013).

Ikorodu Local Government Area of Lagos State provides an important setting for examining this issue because malaria prevention among pregnant women is influenced by the interaction between individual behaviour, antenatal-care utilization and the availability of preventive services at primary healthcare level. Although previous research has examined malaria prevention among pregnant women in Nigeria and Lagos State, evidence specifically examining the relationship between prevention practices and malaria incidence among pregnant women attending selected PHCs in Ikorodu LGA remains limited. A localized assessment can therefore provide evidence on the actual use of ITNs, uptake of IPTp-SP, antenatal-care practices, environmental and personal preventive measures, and malaria occurrence among pregnant women. Such evidence is relevant to strengthening health education, improving adherence to preventive interventions and supporting the implementation of malaria-control strategies at the primary healthcare level. This is consistent with Nigeria’s malaria-control objectives of improving access to and utilization of vector-control interventions and ensuring access to appropriate malaria chemoprevention, diagnosis and treatment (NMEP, 2021; WHO, 2024).

1.2 Statement of the Problem

Malaria in pregnancy remains a significant maternal and public health concern in Nigeria despite the availability of effective preventive interventions. Pregnant women are biologically more vulnerable to malaria, and infection may contribute to maternal anaemia, severe disease and adverse pregnancy outcomes. Nigeria’s position as the country with the largest estimated malaria burden globally further emphasizes the importance of protecting vulnerable populations, including pregnant women. The continued occurrence of malaria among pregnant women raises questions about whether recommended preventive interventions are being adequately accessed and consistently practiced at the community and primary healthcare levels (WHO, 2024).

A major concern is the gap between the recommended standards of malaria prevention and actual utilization among pregnant women. The Nigeria Malaria Indicator Survey 2021 reported that only half of pregnant women slept under an ITN the night before the survey, while less than one-third of women with recent live births reported receiving at least three doses of SP during their most recent pregnancy. Similarly, previous Nigerian studies have reported substantial gaps in consistent ITN use and IPTp uptake. These findings suggest that awareness and availability of preventive measures do not automatically guarantee appropriate utilization, thereby creating an important public health challenge for malaria control during pregnancy (NMEP & NPC, 2022; Ankomah et al., 2012; Nnadi et al., 2013).

Another problem is that malaria prevention practices may differ considerably according to individual, household and healthcare-related factors. Some pregnant women may own ITNs but fail to use them regularly, while others may attend antenatal care without receiving or completing the recommended number of IPTp doses. Evidence from Nigeria indicates that knowledge of malaria prevention, education, urban-rural location, confidence in using mosquito nets and antenatal-care attendance can influence preventive behaviour. Consequently, simply recording whether a pregnant woman has attended a PHC may not adequately explain her actual exposure to malaria-prevention practices or her risk of malaria infection (Awosan et al., 2015; Nnewi population-based study, 2019).

The specific situation among pregnant women attending selected PHCs in Ikorodu LGA therefore requires empirical investigation. While studies have examined malaria prevention among pregnant women in different parts of Nigeria, including Lagos, differences in location, healthcare access, population characteristics, environmental conditions and health-seeking behaviour mean that findings from other areas cannot automatically be generalized to pregnant women attending PHCs in Ikorodu. There is consequently a need to assess the malaria-prevention practices adopted by pregnant women in selected PHCs in Ikorodu LGA and determine whether these practices are associated with malaria incidence. The findings may provide useful evidence for improving antenatal health education, strengthening adherence to IPTp and ITN use, and guiding local malaria-control interventions.

1.3 Purpose of the Study

The main purpose of this study is to assess malaria prevention practices and their effect on malaria incidence among pregnant women attending selected Primary Health Centres in Ikorodu Local Government Area, Lagos State.

Specifically, the study seeks to:

1. assess the malaria prevention practices adopted by pregnant women attending selected PHCs in Ikorodu LGA;
2. determine the level of utilization of insecticide-treated/long-lasting insecticidal nets among pregnant women attending selected PHCs;
3. assess the uptake of intermittent preventive treatment with sulfadoxine-pyrimethamine among the pregnant women;
4. determine the incidence of malaria among pregnant women attending the selected PHCs;

1.4 Research Questions

The following research questions will guide the study:

1. What malaria prevention practices are adopted by pregnant women attending selected PHCs in Ikorodu LGA?
2. To what extent do pregnant women attending selected PHCs utilize insecticide-treated/long-lasting insecticidal nets?
3. What is the level of uptake of intermittent preventive treatment with sulfadoxine-pyrimethamine among pregnant women attending selected PHCs?
4. What is the incidence of malaria 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 significant relationship between malaria prevention practices and malaria incidence among pregnant women attending selected Primary Health Centres in Ikorodu Local Government Area, Lagos State.

1.6 Significance of the Study

The study will be significant to pregnant women because it will provide information on practical measures for reducing exposure to malaria during pregnancy. Findings may improve awareness of the importance of consistent ITN use, appropriate uptake of IPTp-SP, regular antenatal attendance and prompt care-seeking when malaria symptoms occur.

The study will also be useful to healthcare workers, particularly nurses, midwives, community health officers and other PHC personnel. The findings may help healthcare workers identify weaknesses in malaria-prevention counselling and strengthen antenatal health education and follow-up of pregnant women who miss recommended preventive interventions.

The study may benefit Lagos State malaria-control authorities and the National Malaria Elimination Programme by providing local evidence on malaria-prevention practices among pregnant women. Such evidence can support programme planning, health education, distribution of preventive commodities and strengthening of malaria interventions at primary healthcare level.

The findings will also be useful to primary healthcare administrators in Ikorodu LGA by identifying possible gaps in the delivery and utilization of malaria-prevention services. The information may assist PHCs in improving antenatal-care processes, monitoring IPTp uptake, promoting consistent ITN use and strengthening malaria screening and referral.

Finally, the study will contribute to academic and research knowledge on malaria prevention among pregnant women in Nigeria. It may serve as a reference for future researchers investigating malaria, maternal health, preventive health practices and the effectiveness of primary healthcare interventions in Lagos State and other malaria-endemic settings.

1.7 Scope of the Study

The study will focus on the assessment of malaria prevention practices and their effect on malaria incidence among pregnant women attending selected Primary Health Centres in Ikorodu Local Government Area, Lagos State.

The study will specifically examine preventive practices such as the use of insecticide-treated/long-lasting insecticidal nets, uptake of intermittent preventive treatment with sulfadoxine-pyrimethamine, antenatal-care attendance, environmental mosquito-control practices, malaria-related health education and prompt utilization of healthcare services when malaria symptoms occur.

The study population will comprise pregnant women attending selected PHCs in Ikorodu LGA. The study will assess their malaria-prevention practices and determine whether variations in such practices are associated with malaria incidence among the respondents.

The geographical scope is limited to Ikorodu Local Government Area of Lagos State, and therefore findings will be interpreted primarily within the context of the selected PHCs and their population rather than generalized automatically to all pregnant women in Lagos State or Nigeria.

1.8 Operational Definition of Terms

Assessment: The systematic process of examining and measuring malaria prevention practices and malaria incidence among pregnant women in the selected PHCs.

Insecticide-Treated Net (ITN): A mosquito net treated with insecticide to provide personal protection against mosquitoes that transmit malaria.

Long-Lasting Insecticidal Net (LLIN): An insecticidal mosquito net designed to maintain its insecticidal effectiveness for an extended period and used as a major malaria-prevention intervention.

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

Malaria Incidence: The occurrence of new malaria infections or malaria episodes among the pregnant women studied during the specified study period.

Malaria Prevention Practices: The behaviours and interventions adopted by pregnant women to reduce their risk of malaria, including ITN/LLIN use, IPTp-SP uptake, environmental mosquito-control measures, antenatal attendance and prompt healthcare-seeking.

Pregnant Women: Women who are carrying a developing fetus and who are attending the selected PHCs for antenatal or other maternal healthcare services.

Intermittent Preventive Treatment in Pregnancy (IPTp): The administration of recommended antimalarial medicine to pregnant women at predetermined intervals during pregnancy, regardless of whether the woman has malaria symptoms or a confirmed malaria infection.

Primary Health Centre (PHC): A primary-level healthcare facility providing basic preventive, promotive, diagnostic, treatment and maternal healthcare services to members of a community.

Antenatal Care (ANC): Healthcare and monitoring services provided to women during pregnancy to promote maternal and fetal wellbeing and identify and manage pregnancy-related risks.

Project – Assessment of Malaria Prevention Practices and Their Effect on Malaria Incidence among Pregnant Women: A Study of Selected Primary Health Centres in Ikorodu LGA, Lagos State.