EFFECTS OF NON-COMPLIANCE TO LLIN AND IPT IN PREGNANCY ON MATERNAL AND NEONATAL MALARIA, AGE AND BIRTH WEIGHTS OF NEONATES AT UYO

Pregnant mothers and children under 5 years are most vulnerable to Plasmodium falciparum malaria in Nigeria. Non-compliance to LLIN and IPT, and resultant maternal and cord blood malaria on neonatal age and birth weights were studied in Uyo, Nigeria between September and October 2013. Peripheral and cord blood from 106 consenting pregnant women were examined for malaria parasites; and their usage of LLIN and IPT ascertained. Ages and weights of resulting neonates were recorded at birth. Results showed that maternal and neonatal malaria infection rates (IR) were 54.7% (Mean± SD=49.23±26.41) and 45.3% (Mean± SD=40.6±20.6), with indications that maternal immunity increases with parity. Generally 29.2% and 39.6% of all neonates were respectively delivered pre-term and underweight. About 53.8% and 51.9% of the women were non-compliant to LLIN and IPT, respectively; and 91.4% of LLIN non-compliant as well as 94.8% of IPT non-compliant were infected with malaria. We inferred that use of LLIN and IPT would have offered the women protection against malaria. Heat generation, fear of toxic reactions, and difficulty in settingup LLIN as well as ‘not sick’, fear of abortion, and doubtful efficacy of IPT were among the reasons given by pregnant women for non-compliance. Sustained health education on the use of LLIN and IPT will help to reduce malaria infection and its consequences in Uyo.


INTRODUCTION
Malaria remains one of the most important diseases of the tropics after several years of concerted effort to combat it [1]. According to [2], hundreds of millions of people are affected and pregnant women are more susceptible together with their little children. It was stated by [3] that malaria is associated with 11.0% of all maternal deaths and 70.5% of morbidity in pregnancy. Also, pregnant women are at greater risk of malaria infection and of symptomatic malaria than nonpregnant adults [4]. Maternal falciparum malaria infection [1], [5], [6], [7], [8] as well as neonatal malaria infection [9], [10] have been reported from different parts of Nigeria. In areas of stable malaria transmission, where adult women have considerable acquired immunity, Plasmodium falciparum infection during pregnancy is non-symptomatic but could lead to maternal anemia, placental and cord blood malaria and low birth weight [11], [12]. Neonatal malaria that was thought to be uncommon in indigenous populations has now been reported in both endemic and non-endemic areas [13]. Factors responsible for the significant increase in maternal and neonatal malaria may include the quality of antenatal care services [14] and increased resistance of P. falciparum to anti-malaria drugs [15]. The present study investigated the effects of non-compliance to LLIN and IPT in pregnancy on maternal and neonatal malaria, age and birth weights of neonates at Uyo Nigeria.

MATERIALS AND METHODS
The study was carried out at a School of Nursing Teaching Hospital Uyo, the capital city of Akwa Ibom State Nigeria. The 227-bed hospital has 17 bed spaces at the labour ward. Uyo (7 0 47' -8 0 03'N; 4 0 53' -5 0 07'East) has in 1991 a population of 118,250. Mean annual temperature of 27 0 C, relative humidity of 70% -80%, mean annual rainfall of 2484 mm, and the modified rainforest zone (called oil palm bush) of the area make it suitable for the breeding of mosquito vectors of human malaria parasites. The area also has two distinct seasons -dry season (November to March) and rainy season (April to October). Daily, average of 7pregnant women were presented at the hospital Labour Unit, and 4 of them were systematically selected for the study which lasted for 26 days cutting across September and October 2013. At the end, a total of 120 pregnant women were studied. The Ethics and Research Committee of the Department of Parasitology and Entomology, Nnamdi Azikiwe University approved the study while School of Nursing Teaching Hospital Management Committee Uyo permitted the use of hospital facilities. Informed consents of the participants were obtained after the purpose of the research was thoroughly explained to them by the researchers and Nurses on duty. Salient demographics of each pregnant woman were retrieved from hospital antenatal folders. Information on Usage of LLIN and IPT was obtained from the subjects. Records on antenatal folders showed that all of them received free LLIN and IPT drugs at antenatal visits. Oral interview revealed reasons for non-use of LLIN and IPT by some of them. A total of 106 peripheral blood samples of the mothers and corresponding cord blood samples were examined for Plasmodium falciparum. Examination of neonates and cord blood sample collections were done in the labour ward by duty-nurses at delivery who recorded neonatal birth weights to the nearest 0.05kg. Normal birth weight (NBW) was between 2.5kg and 4.0kg, under birth weight (UBW) as less than 2.5kg, Full term delivery was between 37 and 42 weeks gestation while Pre-term delivery was before 37 weeks of gestation. One µl of cord blood was taken from the umbilical vein (about 15cm from its place of attachment to the placenta) after cleaning the cord with 70% alcohol to avoid mixing the cord blood with the maternal blood. The cord was clamped before blood sample was taken to prevent contamination of cord blood from placenta. Peripheral blood sample were drawn from the mother using 5ml syringe, and all collected samples were transferred to separately labeled EDTA anti-coagulant sample bottles which were immediately taken to the hospital laboratory for parasitological examinations for Plasmodium species of parasites using thick and thin blood films -Giemsa staining techniques. Descriptive statistics were computed for all relevant data, using totals, percentages averages and mean and standard deviation from the mean where applicable. Variables were analyzed in MS Excel with histograms displaying error bars with either standard error or 5% values.

RESULTS AND DISCUSSIONS
Plasmodium falciparum was the only malaria parasite species encountered in the study. Table 1 shows the status of pregnant women and neonates infected with Plasmodium falciparum malaria. The trends shown in Figure 1 indicated that women in their 1 st parity were more susceptible to malaria infection than those in 2 nd and 3 rd parities. There was significant difference in malaria infection rates among neonates delivered by mothers with different parity (χ 2 cal =29.1; χ 2 crit. =5.991; df=2, P<0.05).  [16], 35% for Calabar [17] but was not up to 54.2% reported by [18] at Ile Ife. Interestingly, [15] reported that increase in neonatal malaria may be attributed to increased resistance of P. falciparum to anti-malaria drugs which resulted in increase in maternal parasitaemia but we also think that other factors such as non-compliance to LLIN and IPT which we investigated are important. High prevalence of maternal malaria in Uyo could be attributed to sanitation problem, flooding and consequent stagnant water that are suitable breeding sites for malaria vectors [19], [20], [21], [22] and the non-usage of LLIN and IPTs during antenatal period by some mothers [3], [23] as well as poor knowledge, attitude and practice regarding malaria which is widespread in Nigeria [24].
The delivery statuses of infected neonates by parity of all pregnant women are shown in Table 2. Majority of the neonates were delivered full term while 29.25% were pre-term. There was significant difference between the mean birth weights of Full term neonates (NBW= 3.03±0.09kg.) and pre-term neonates (UBW= 2.23±0.057kg). We also observed that 60.4% of infected neonates from infected mothers had NBW while the remaining 39.6% had UBW. Moreover [6] had stated that primigravid mothers and their neonates are more susceptible to P. falciparum infection. In this study, parity influenced the prevalence of cord blood malaria parasitaemia. It was found out that cord blood malaria was higher among neonates delivered by primigravid mothers than among their secondigravid and multigravid counterparts in Table 2.  [12] that women in their first pregnancy are most vulnerable to malaria infection. Table 3. The mean UBW of malaria infected neonates from infected mothers was 2.20±0.005kg while mean NBW of malaria infected neonates from infected mothers was 2.53±0.005kg. The significant gap between the two means indicated a strong association between maternal malaria and neonatal birth weight in agreement with [4] and [11] that maternal malaria account for almost 30% of all causes of LBW that may be prevented during pregnancy. In this study 27.58% of mothers that were P. falciparum positive gave birth to NBW neonates, while 39.62% infected mothers had LBW neonates. Importantly, [1] has explained that sequestration or localization of malaria parasite within placenta of pregnant mother may jeopardize materno-foetal relationship, thus affecting the supply of nutrients to fetus and this may cause neonatal LBW. However, [6] had a contrary view when they noticed that all infants encountered with LBW also had negative cord blood malariaso this phenomenon requires further investigation.   Tables 4 and 5 respectively.    Tables 4 and 5 respectively were infected with malaria, but up to 91.4% and 94.8% of non-compliances to LLIN and IPT contracted malaria which adversely affected neonatal delivery terms and birth weights. Table 6 summarized the reasons for non-compliances to LLIN and IPT by pregnant women.  Figure 3 is the highlight of important aspects of maternal malaria in respect of LLIN and IPT usage by pregnant mothers studied.

CONCLUSION
Falciparum malaria still constitutes a public health problem in Uyo, where the prevalence of maternal and neonatal malaria was high, with associated neonatal pre-term birth and low birth weight. KAP regarding LLIN and IPT among pregnant women is poor so sustained health education on the use of LLIN and IPT will increase compliances and help to reduce maternal malaria and its consequences in Uyo.