BACKGROUND: Malaria adversely affects pregnant women and their fetuses or neonates. Estimates of the malaria burden in pregnant women based on health facilities often do not present a true picture of the problem due to the low proportion of women delivering at these facilities in malaria-endemic regions. METHODS: Data for this study were obtained from the Healthy Beginning Initiative using community-based sampling. Self-identified pregnant women between the ages of 17-45 years were recruited from churches in Enugu State, Nigeria. Malaria parasitaemia was classified as high and low based on the malaria plus system. RESULTS: Of the 2069 pregnant women for whom malaria parasitaemia levels were recorded, over 99 % tested positive for malaria parasitaemia, 62 % showed low parasitaemia and 38 % high parasitaemia. After controlling for confounding variables, odds for high parasitaemia were lower among those who had more people in the household (for every one person increase in a household, OR = 0.94, 95 % CI 0.89-0.99). CONCLUSION: Results of this study are consistent with hospital-based estimates of malaria during pregnancy in southeastern Nigeria. Based on the high prevalence of malaria parasitaemia in this sample, education on best practices to prevent malaria during pregnancy, and resources in support of these practices are urgently needed.

In early pregnancy prolonged exposure to stress is known to have profound adverse effects on reproduction and is associated with suppressed progesterone secretion and consequent disturbance of the pregnancy-protective cytokine milieu, thus threatening early pregnancy maintenance. Maternal neuroendocrine responses to stress in early pregnancy are poorly understood. Therefore, we designed experiments to (1) study the hypothalamo-pituitary-adrenal (HPA) axis responses to stress in early pregnant mice, to discover whether and how responses change and (2) to determine the effect of stress in early gestation on pregnancy hormones, with a particular focus on the secretion and regulation of prolactin. To establish the effects of stress in early pregnancy (day 5.5) two different ethologically relevant stressors were used: lipopolysaccharide (LPS) or 24h fast stress, to mimic situations that may potentially arise during pregnancy in women: infection or hunger. HPA axis secretory responses to immune stress in early-mid pregnancy were robust and comparable to that in virgins. Vasopressin rather than the usual CRH neurone responses play a key role in maintaining this. However, the mode of action of glucocorticoids in mediating pregnancy complications is not yet established. Prolactin, and its hypothalamic control mechanisms, is a key candidate to mediate brain-to-body responses to stress. Prolactin has important roles in progesterone secretion, pregnancy establishment and immune regulation. We hypothesised that stress would negatively affect prolactin and its neuroendocrine control systems. Prolactin is mainly under the inhibitory control of dopamine, released predominantly from the tuberoinfundibular dopamine (TIDA) neurones. Prolactin also negatively feeds back on itself via prolactin receptors on the TIDA neurones and janus kinase (JAK)2/signal transducer and activator of transcription (STAT)5 signalling. Both immune and fasting stressors strongly inhibited basal prolactin secretion in early pregnancy, accompanied by a mild increase in activation of TIDA as shown by elevated Fos expression, compared to virgins. In addition, pregnancy attenuated LPS-induced recruitment of parvocellular paraventricular nucleus neurones and increased activation of brainstem noradrenergic nuclei which could potentially contribute to altered control of the dopamine-prolactin system. Following either immune or fast stress in early pregnancy ovine prolactin was able to drive enhanced expression of phosphorylated (p)STAT5. However, stress alone did not alter pSTAT5 implying it is not exclusively responsible for the stress-reduced prolactin observed in early pregnancy and another stress-induced stimulus must be activating TIDA neurones in these mice. LPS did not alter dopamine activity the median eminence (DOPAC: dopamine ratio) suggesting dopamine does not underlie stress-reduced prolactin secretion and other mechanisms must be considered. Direct effects of LPS, or its associated cytokines, on pituitary lactotrophs to inhibit prolactin secretion is a possible candidate. To investigate the effect of proinflammatory cytokines on the prolactin system in early pregnancy, d5.5 mice were administered TNF-alpha (a) or interleukin (IL)-6. Both cytokines increased TIDA activation, however, only TNF-a decreased plasma prolactin and progesterone, suggesting additional TNF-alpha action at the pituitary. As prolactin is anxiolytic we further proposed that stress would have a more profound effect on elevated plus maze performance in pregnant mice. However, early pregnant mice were generally more anxious vs. virgins regardless of LPS treatment. Taken together data show that stress in early pregnancy reduces prolactin and progesterone secretion, contributing to pregnancy complications/failure, but the neuroendocrine stress-related mechanism behind this suppression is yet to be determined.

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published_or_final_version / Physiology / Doctoral / Doctor of Philosophy

published_or_final_version / abstract / Obstetrics and Gynaecology / Master / Master of Philosophy

published_or_final_version / Public Health / Master / Master of Public Health

published_or_final_version / Obstetrics and Gynaecology / Master / Master of Medical Sciences

Unintended pregnancy is a significant public policy issue in the United States, yet current understanding of the measurement and meaning of women’s pregnancy intentions is incomplete. The aim of this dissertation is to provide new theoretical insight into women’s childbearing intentions and feelings about pregnancy, particularly when these two measures appear to be incongruent (i.e. women report feeling happy about pregnancy, but at the same time report wanting no more children). Incongruence is particularly common among Hispanic women, and current literature tends to view such women as ambivalent, assuming that they lack a clear and strong desire to avoid conception. Ambivalence, in turn, has been linked to less effective contraceptive use. Using a mixed-methods approach, this dissertation examines the hypothesis that incongruent intentions and feelings are not necessarily a reflection of ambivalence but rather two distinct concepts: women may be quite resolute about avoiding future pregnancies, yet for various reasons still express happiness at the prospect of a pregnancy. In Chapter 1, we examine prospectively measured happiness and intentions among a cohort of Latina pill-users at the U.S.-Mexico border, providing evidence that feelings of happiness about pregnancy may co-exist with effective use of contraception and with plans to continue method use long-term to prevent conception. In Chapter 2, we investigate the relationship between happiness and contraceptive desires, demonstrating that women with incongruent intentions and feelings often desire highly effective or permanent methods that they do not have the ability to access. Finally, in Chapter 3, we explore the concepts of happiness and intentions and the factors underlying each from women’s own perspectives through in-depth interviews, and provide a range of explanations for why happiness about pregnancy may be expressed even when another child would be a significant financial or emotional burden. Findings strongly suggest that automatically classifying women with incongruent intentions and feelings as ambivalent may lead to inaccurate measurement of unintended pregnancy, hinder understanding of the difficulties these women face in obtaining effective contraception, and limit the ability to devise strategies to prevent unintended pregnancy and address disparities across racial and ethnic groups. / text

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