On top of the deleterious effects of the feeble healthcare system that had existed in Africa’s most populous country pre-pandemic, the Covid situation continues to hamper logistics for Malaria supplies, treatment and prevention. This leaves Nigerian pregnant women worse off in the ongoing global health crisis. AKANIMO KUFRE, THE NEW DIPLOMAT’S A/IBOM|C/RIVER CORRESPONDENT digs in in this telling report.
Mrs. Magdalene Effiong, a pregnant woman in Nigeria’s Niger Delta region was rushed to a nearby Health Centre on the outskirts of Uyo, Akwa Ibom’s State capital earlier this year. She had suffered heavy bleeding and needed urgent medical attention during the peak of the Covid-19 lockdown in May.
The health center immediately referred her to the University of Uyo Teaching Hospital (UUTH) where medical teams saved her life, narrowly, but were unable to save her baby. Her loss was the result of malaria complications.
In Nigeria, the National strategy for malaria prevention and control, adopted in 2014, includes ambitious goals to control malaria in pregnancy by the end of 2020, such as the scale-up of Intermittent preventive treatment in pregnancy (IPTp) and use of Long Lasting Insecticidal Nets (LLINs) by pregnant women. But as curtains draw on 2020 marking the end of the suppossed milestone set for the strategy, these goals are far from being met.
‘Targeting pregnancy since 2004’
Nigeria launched its first strategy to prevent Malaria in Pregnancy (MiP) in 2004. It was a core component of the country’s elimination program, with targets reiterated in subsequent malaria control efforts, including the 2014-2020 strategic plan.
The national strategy states that pregnant women should receive an LLIN at their first antenatal care (ANC) visit and intermittent preventive treatment (IPTp) from 13 weeks into their pregnancy.
IPTp involves giving pregnant women a full course of antimalarial treatment with sulfadoxine-pyrimethamine whether they are infected with malaria or not, which means giving them three doses of the drug at least one month apart to reduce the risk of various complications, including anemia and low birth weight.
But today, millions of pregnant women in Nigeria remain unprotected, contributing to significant numbers of preventable maternal and neonatal illness and death. According to 2018 WHO Malaria Indicators, only 21.4% of pregnant women received complete IPTp treatment and only 40% of the population as a whole slept under an LLIN that year.
Recent data from the National Demographic Health Survey (NDHS) shows there has been a sharp decline in the distribution of Long Lasting Insecticide treated Nets (LLIN) provided to pregnant women on their first antenatal visit, from about 70% in 2017 to just 10% as of August 2020.
Nowhere is this struggle more evident than in Akwa Ibom state, where just 25.9% of pregnant women were using nets in 2018 and 17% received three complete doses of IPTp, according to 2018 NDHS data.
‘Supply Shortages — then Covid-19’
Health workers in Akwa Ibom claim most of the failure in drug and net distribution is due to strikes in previous years and poor availability of malaria commodities at health facilities long before Covid-19 arrived in the state.
Covid-19 nevertheless led to a decline in services for pregnant women during the peak of the pandemic as hospitals and clinics stressed shortages in malaria commodity supplies.
“Malaria is endemic here, meaning Malaria is on the ground 24/7, its always there. Covid-19 now came and hampered the logistics and modalities of treatment and malaria prevention,” said. Dr. Idorenyin Udoh, Obstetrician and Gynaecologist at UUTH.
Dr. Udoh added that because of Covid-19 there is going to be a significant decline in the utilization of LLINs, which will affect exposure to mosquito bites and cause an increase or upsurge of people coming down with malaria.
But when pregnant women succumb to malaria, it can “increase complications, like problems with miscarriages, preterm labour, and low weight birth,” he said.
At the Methodist General Hospital in Ituk Mbang, Akwa Ibom State, a nurse at the antenatal clinic who wished to remain anonymous due to fear of victimisation said that attendance in early January to March 2020 was up to 50 pregnant women per day, but the number dropped to 25 or 30 from April to May, due to government restrictions on visits to hospitals and the fear of getting Covid-19 infection.
But for the women that did go, supplies were limited and eventually out of stock.
“Before Covid-19 pregnant women who did attend were supplied LLIN on their first booking and pregnant women who tested positive for malaria were given treatment. But IPTp drugs were out of supply,” the nurse told The New Diplomat.
By August, LLINs were also reported out of stock and it was confirmed that some nets were later discovered stored away for so long that they had deteriorated. “A lot of the nets got bad and they were disposed.”
Mrs. Favour Nsisong, a 29-year-old pregnant mother residing in Uyo, said, “I am aware of the dangers malaria in pregnancy so I use LLIN”, but said she was not given a net on her first antenatal visit.
Another pregnant woman, Mrs. Blessing Ekeudeme, 27, said the net she is using was given in 2017, when she had her first baby.
State Malaria Control Program Coordinator, Dr. John Orok believes some of these challenges can be overcome with revised national guidelines on malaria control in pregnancy to all service delivery points in the state, the training of health staff and promotion of early and comprehensive antenatal care attendance as soon as a woman thinks she is pregnant.
‘Substantial progress, but not enough’
The National Malaria Elimination Program (NMEP) Coordinator, Dr. Audu Bala Mohammed, is happy with the progress made in malaria control nationwide. He believes the National Malaria Strategic Plan has scored a pass mark despite not meeting its 2020 targets.
“When you look at reduction in malaria prevalence, we came down from 27% to 23% between 2015 to 2018,” Dr. Mohammed said. He added that, “by 2025 we hope to cut 23% by halve, meaning we can eliminate malaria by 2030.”
The WHO Country Representative, Dr. Lynda Ozor is also content with Nigeria’s progress so far, but has concerns around malaria control during pregnancy, particularly prevention measures.
“The 2018 malaria indicator survey shows that only 17% of pregnant women received the recommended three or more doses of intermittent preventive therapy in pregnancy,” she said. But “pregnant women who come down with symptoms of malaria are tested and if positive, treated with antimalarial drugs according to the National treatment guidelines.”
Some of the factors hindering IPTp uptake among pregnant women include low antenatal care attendance rates, restrictions that prevent non-pharmacy workers from dispensing sulfadoxine-pyrimethamine, missed opportunities during visits, and poor availability or stock outs of drugs.
Also limiting efforts is the budget allocated to healthcare in malaria endemic regions.
In Nigeria, the private sector makes up about 33% of all health facilities and includes not-for-profit and for-profit organizations, while the public health care system makes up 67% of all healthcare facilities which are managed by federal, state and local government areas (LGA) or the National Primary Health Care Development Agency.
Local government areas, covering most rural areas, have the greatest population and malaria transmission rates, but receive the lowest financial allocation to operate the vast numbers of primary health care facilities located there. For such reasons Nigerians, including pregnant women, often pay out of pocket at every visit to the clinic for treatment.
“Each time I come here (antenatal clinic) I’m given a few tablets and asked to pay N500 or at times N1000, this sometimes discourage my visit to clinic especially if I don’t have money,” Mrs. Nsisong said.
Dr. Ozor believes that in order to achieve better results, health systems must be strengthened.
Then only can Nigeria can ensure malaria prevention and treatment services will be accessible to everyone who needs them, including pregnant women in Nigeria.
This story was produced by The New Diplomat. It was written as part of Reporting Malaria, a media skills development programme run by the Thomson Reuters Foundation. The content is the sole responsibility of the author and the publisher.