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Este trabalho observacional teve como objetivo investigar os fatores associados com o desenvolvimento da malária ao longo da gestação e as implicações da infecção por Plasmodium no momento do parto e da malária clínica ao longo da gestação para o crescimento fetal e para o nível de hemoglobina materna no parto, em uma região de alta endemicidade para a doença, onde há cocirculação de P. falciparum e P. vivax, na Amazônia Brasileira. Ao todo 1.180 gestantes participaram das análises de fatores associados ao desenvolvimento de malária gestacional e 1.140 - as gestantes que tiveram filhos nascidos vivos não gêmeos - participaram das análises da associação entre ocorrência de malária gestacional e os desfechos gestacionais abordados neste estudo. A prevalência de malária clínica antenatal, diagnosticada por microscopia de gota espessa, foi de 8,0%, sendo 74,6% dos casos notificados como P. vivax; a prevalência de infecção por Plasmodium no momento do parto, diagnosticada por qPCR, foi de 7,5% - ao todo 12,5% das gestantes que participaram deste estudo tiveram malária clínica antenatal ou infecção por Plasmodium no parto. A grande maioria (89,9%) das infecções por Plasmodium no parto foram assintomáticas. Morar em área rural foi o principal fator associado à malária gestacional na população deste estudo. No que se refere ao impacto da malária para os desfechos de crescimento fetal e nível de hemoglobina no parto, observou-se que malária antenatal provocou redução média de 0,36 (intervalo de confiança [IC] 95%, - 0,57 - -0,14 p = <0,01) no escore z de peso ao nascer, de 0,31 (IC 95%, - 0,54 - -0,08, p = 0,01) no escore z de comprimento ao nascer, e de 0,34 g/100 mL (IC 95%, -0,62 - -0,05 p = 0,02) na concentração de hemoglobina no momento do parto. Foi observado que um único caso de malária vivax antenatal foi suficiente para afetar negativamente o crescimento fetal e a concentração de hemoglobina materna. Quando foram analisados somente os casos de malária vivax repetidas, o efeito negativo foi ainda mais pronunciado. Entre as 637 amostras de cordão umbilical que tiveram diagnóstico molecular feito, 4 (0,6%) foram positivas para P. vivax e 2 (0,3%) para P. falciparum, totalizando uma prevalência de 0,9% de malária congênita na população de estudo. Apenas um dos casos de malária congênita apresentou sintomas. Foram observadas falhas de notificação no banco de dados do sistema de Informação Epidemiológica (SIVEP Malária), e há indicação de falhas no tratamento de malária na gestação no Brasil. Os resultados deste estudo confirmam que a malária vivax na gestação pode ter implicações graves para a saúde materno-fetal. No âmbito local os resultados deste estudo evidenciam a malária na gestação como problema de saúde pública nas regiões endêmicas do Brasil. / The main objectives of this observational study were to investigate the associations between malaria in pregnancy (MiP) and sociodemographic and biological variables of mothers and estimate its impact on birth weight and length and maternal hemoglobin in 1,180 women from Juruá Valley, the main malaria hotspot in Brazil. Antenatal malaria episodes, 74.6% of them due to Plasmodium vivax, were microscopically diagnosed in 8.0% of the women and were associated with an average reduction in birth weight z-scores of 0.36 (95% confidence interval [CI] -0.57 - -0.14 p = <0.01) and in birth length z-scores of 0.31 (CI 95%, - 0.54 - -0.08, p = 0.01), compared with malaria-free pregnancies. Affected mothers had a mean decrease in hemoglobin concentration at delivery of 0.34 g/100 mL (CI 95%, -0.62 - -0.05 p = 0.02). Although repeated antenatal vivax infections were associated with poorer birth outcomes, even a single vivax malaria episode was associated with a significant reduction in birth weight and length and maternal hemoglobin. Overall, 7.5% women had the parasites DNA found in peripheral blood at delivery. Most (83.1%) of these 89 perinatal infections were due to P. vivax and only 7.9% of them progressed to symptomatic disease after delivery. P. vivax and P. falciparum DNA was found in 0.6% and 0.3% of 637 cord blood samples examined, respectively, but only one newborn developed clinical neonatal malaria. Living in rural areas was the main factor associated with gestational malaria in the study population. Moreover, we found further evidence that health-care providers often fail to comply with the countrys malaria treatment guidelines for pregnant women in Brazil. We retrospectively found that Primaquine was prescribed for more than half of the antenatal P. vivax infections diagnosed during the study, not only in the first trimester (when the pregnancy status might be unknown) but also in infections correctly reported as MiP. Our results further challenge the notion that vivax malaria is relatively benign during pregnancy and call for better strategies for its prevention.

A malária é uma doença parasitária grave e quando ocorre durante a gravidez é uma das principais causas de mortalidade materno-infantil, podendo apresentar como consequências anemia materna, aborto, nascimento prematuro, restrição do crescimento intrauterino e baixo peso ao nascer (BPN). A infecção por Plasmodium (P.) falciparum é reconhecida como um determinante importante de consequências sérias durante a gravidez e efeitos adversos semelhantes também foram relatados em infecções por P. vivax. A despeito de sua alta prevalência e a sua possível associação com importantes complicações durante a gravidez, os efeitos da malária para gestantes e seus conceptos ainda não estão totalmente compreendidos. Este trabalho propõe estudar as consequências da malária gestacional e sua associação com a restrição do crescimento intrauterino e baixo peso ao nascer em uma área endêmica no extremo oeste da Amazônia brasileira. Foi realizado um estudo retrospectivo e prospectivo composto por gestantes da região do Vale do Alto Juruá (Acre, Brasil), no qual foram avaliadas as consequências e a extensão do efeito da malária sobre o recém-nascido através da coleta de dados epidemiológicos e material biológico. Neste estudo, foi observado um aumento no número de partos prematuros e BPN entre os recém-nascidos das gestantes infectadas por P. vivax quando comparadas com o grupo não infectado. Em relação à infecção por P. falciparum durante a gravidez, observamos que a doença representou um fator de risco para o nascimento de neonatos com perímetro cefálico reduzido, assim como uma maior probabilidade de ocorrência de casos de microcefalia e nascimentos prematuros. Além disso, todos esses efeitos adversos estavam ligados à malária placentária, caracterizada principalmente por um aumento de agregados nucleares sinciciais e infiltrados inflamatórios, bem como um forte desequilíbrio dos fatores angiogênicos e diminuição dos níveis de leptina. Muitos estudos, realizados principalmente na África, destacam os efeitos deletérios da malária por P. falciparum no contexto materno-fetal, mas pouco se sabe sobre a malária gestacional nas áreas endêmicas da América, onde predominam as infecções por P. vivax. Nossos resultados sugerem que infecções por esta espécie estão longe de serem benignas em razão da alta incidência de lesões placentárias, baixo peso ao nascer, abortos e partos prematuro em nossa casuística. Além disso, este estudo também mostrou que a malária gestacional por P. falciparum aumentou a probabilidade de partos prematuros e a ocorrência da redução do perímetro cefálico nos recém-nascidos, o que está associado à malária placentária. Assim, o conhecimento do impacto da infecção sobre a placenta e no desenvolvimento fetal poderá trazer uma importante contribuição para o entendimento da malária gestacional, além de possibilitar o desenvolvimento de ações específicas na rotina de cuidado pré-natal. / Malaria is a severe parasitic disease that, when occurs during pregnancy, it is one of the main cause of maternal-fetal mortality leading also to maternal anemia, abortion, preterm birth, intrauterine growth restriction and low birth weight. Infections by Plasmodium (P.) falciparum are known to be detrimentally involved in poor pregnancy outcomes, effects that were also described during P. vivax infections. Despite its significant prevalence and possible association to severe complications during pregnancy, the impact of malaria in pregnant women and their children are not clearly understood. Current study aims to evaluate the consequences of malaria in pregnancy and correspondent association with intrauterine growth restriction and low birth weight in an endemic area located in the furthest west region of the Brazilian Amazon. A retrospective and prospective study was performed, accounting with pregnant women living in the region of Vale do Alto Juruá (Acre, Brazil) in which the consequences and extension of malaria effects on the newborns was evaluated through the analysis of epidemiological data and biological material. In this study, we observed an increase in the number of preterm deliveries and low birth weight among children born from pregnant women infected with P. vivax when compared to non-infected pregnant women. Regarding P. falciparum infection during pregnancy, we have noticed that this is a risk factor for newborns with reduced head circumference, also increasing the probability of occurring cases of microcephaly and preterm birth. Besides, every deleterious effect was associated with placental malaria, which is mainly characterized by an increase in the syncytial nuclear aggregates and inflammatory infiltrates, as well as by an imbalance in placental angiogenic factors and a reduction in leptin levels. Several studies mainly developed in Africa, highlight the negative effects of P. falciparum malaria in the maternal-fetal context yet, little is known about malaria in pregnancy that occurs in the endemic areas of the America where infections caused by P. vivax are predominate. Our results suggest that infections promoted by this parasite species are far from being benign as it was depicted in our cohort, which has shown high incidence of placental lesions, low birth weight, abortion and preterm delivery. Moreover, the present study has shown that malaria in pregnancy caused by P. falciparum increased the probability of preterm delivery and reduction of head circumference in newborns, which is associated to placental malaria. Therefore, knowing the impact of infection in the placenta and fetal development may bring an important contribution to the understanding of malaria in pregnancy, allowing the development of specific action that can be implemented in the routine of antenatal cares.

Malaria in pregnancy remains a public health challenge in Nigeria despite the fund appropriation for malaria control. The health challenges of malaria in pregnancy vary with populations and there is limited knowledge on the impact of the socioeconomic status and health-seeking behavior on malaria in pregnancy in Nigeria. The objective of this cross-sectional quantitative survey was to examine whether socioeconomic status and health-seeking behavior predict malaria in pregnancy in Nigeria using the social cognitive theoretical model. The data from a 2015 Nigeria Malaria Indicator Survey was used in this study. Data were analyzed using chi-square, binary, and multivariate logistics regression analyses. The study demonstrated that socioeconomic status (wealth index/income [Poorest: OR 2.709, 95% CI 1.869-3.928, p 0.000; Poorer: OR 1.791, 95% CI 1.256-2.555, p 0.00] and no education: OR 2.868, 95% CI 1.761-4.671, p 0.000) made significant contributions in predicting malaria in pregnancy. The research results also showed that socioeconomic status is a predictor of health-seeking behavior (wealth index/income [Poorest: OR 0.414, 95% CI 0.244-0.705, p 0.001], no education: OR 0.329, 95% CI 0.174-0.622, p 0.001 and primary education: OR 0.348, 95% CI 0.191-0.636, p 0.001). Additionally, the study findings showed that malaria in pregnancy determined the choice of formal health-seeking behavior by pregnant women (malaria in pregnancy: OR 0.551, 95% CI 0.469-0.648, p 0.000). The results of this research might guide Nigeria's Ministry of Health to develop approaches on women empowerment that would focus on socioeconomic status and health-seeking behavior of women such as programs to improve women's education and income generation.

No abstract available. / Thesis (M.N.)-University of KwaZulu-Natal, Durban, 2012.

This study examines the impact of a health education film, Chumo, in Dar es Salaam on knowledge about malaria in pregnancy. Specifically, the study examines the meanings that the selected audiences make after watching the film. Drawing on the tradition of ‘reception studies’, the data for this study was generated through focus group discussions. These discussions were preceded by thematic analysis of the film and its script. An analysis of the audiences’ responses reveals that Chumo, mostly, successfully conveyed new knowledge about malaria in pregnancy, and reinforced existing knowledge bases about the disease. The audiences were able to ‘decipher’ most of the preferred meanings (of the producers) with regard to the disease, particularly in relation to the transmission of the disease and its prevention in pregnant woman. For example, the analysis indicates that both women and men become more aware of the importance of attending antenatal care sessions at local clinics (hereafter ANC). An interesting finding is that men, mostly, expressed a reluctance to attend ANC with their wives because they fear having to undergo HIV/AIDS testing. Men also expressed the sentiment that attending ANC is a women’s responsibility. The discussion groups also raised issues about the use of insecticide-treated nets - some people believe that using them will affect their health because of the chemicals used to treat the nets. From the reception analysis, various other meanings and themes, relating to the choice of storylines and gender stereotypes used in the story, were raised in discussion. The study attempted to assess whether the storyline was advantageous in conveying the core educational messages, or if some elements of the storyline either ‘got in the way’ or reinforced gender roles in ways that may or may not be helpful in terms of combatting malaria in pregnancy. The study also found that Chumo stimulated interpersonal communication, which may trigger behaviour change. It can be demonstrated, at least for the participants in these focus groups, that the film motivated positive attitudes towards behaviour change, i.e. created at least some intention to change. However, interpersonal communication and attitude to change are not, of course, actual change of behaviour: these elements only indicate the possibility of behaviour change in the future. Further study needs to be undertaken to explore whether the actual change took place and whether the change is a result of the exposure to Chumo.

Text in English / Malaria is endemic throughout Uganda and the leading cause of morbidity and mortality. Malaria causes complications in 80.0% of all pregnancies in Uganda. This study attempted to identify factors that influence pregnant women’s utilisation of anti-malaria services in the Buikwe district of Uganda. These factors were contextualised within the Social Learning Theory’s major concepts. The target populations comprised pregnant women attending antenatal clinics (phase 1) and midwives providing antenatal services (phase 2) at 16 clinics in the Buikwe district of Uganda during the data collection phase of the study. Structured interviews were conducted with a sample of 400 randomly selected pregnant women and with the accessible population of 40 midwives. Pregnant women, who had progressed beyond primary school level education, were more likely to take intermittent preventive treatment (IPT) drugs and to use long lasting insecticide treated nets (LLINs) to prevent malaria. Pregnant women were more likely to implement malaria-preventive actions if they lived within five kilometres of clinics, were satisfied with available health services, were knowledgeable about the malaria preventive measures and had used IPT during previous pregnancies. Pregnant women who implemented one malaria-preventive action were likely to implement other actions as well (Pearson’s correlation coefficient was 0.65; p<0.05). Midwives’ provision of malaria-preventive services to pregnant women were influenced by the availability of IPT drugs, accessibility of safe drinking water, frequency of giving health education to pregnant women, cooperation with village health teams, malaria-related in-service training, midwives’ education level and experience. Although 97.9% of the pregnant women had taken IPT and 84.2% of those who had received LLINs, utilised these nets, malaria prevention during pregnancy could be improved. All pregnant women should attend antenatal clinics at least four times during each pregnancy, commencing during the first trimester of pregnancy to receive adequate health education and prenatal services, including IPT and LLINs. All midwives should receive malaria-related in-service training. Regular audits of midwives’ records should identify and address strengths and weaknesses related to the prevention and management of malaria during pregnancy. Such actions could enhance the prevention and management of malaria, estimated to affect 80% of pregnant women in Uganda. / Health Studies / D. Litt. et Phil. (Health Studies)