Malaria and Anaemia: Prevalence, Risk Factors and Impact of Preventive Methods among Pregnant Women in the Akatsi South District, Ghana: A Hospital-Based Cross-Sectional Study

Background: Anemia and malaria infection during pregnancy are major public health problems in tropical and subtropical regions throughout the world. This study therefore aimed to ascertain the prevalence and risk factors of malaria and anaemia as well as the impact of preventive methods among pregnant women at the Akatsi South District Hospital. Subjects and Methods: A hospital based cross-sectional study using simple random sampling technique was conducted among 200 pregnant women receiving antenatal care and laboratory services at the Akatsi District Hospital from May 2016 to July 2016. A semi-structured

questionnaire was administered to obtain participant's malaria preventive methods in addition to demographic and gestational details including age, level of education, occupation, gravidity, parity, and gestational period. Participant's hemoglobin and malaria status was assessed using one milliliter (1 ml) whole blood collected into an Ethylenediamine tetraacetic acid (EDTA) tube using sterile syringe and needle. Ordinary one-way ANOVA was used to determine statistical variations among continuous variables whereas chi-square and Fisher's exact test where appropriate were used to assess statistical associations between categorical variables. P-values of < 0.05 was considered significant. Results: Of the 200 participants, majority (52.0%) were aged 20-29 years. The preponderance (67.0%) had their basic education level, were married (76.0%), lived in the urban communities (58.5%) and worked in the formal sector (44.5%). Prevalence of anaemia, malaria and malaria/anaemia comorbidities was 65.5%, 11.0% and 10.5% respectively. Significantly

Plain English Summary
Malaria and anaemia have remained a major public health problem in Ghana for decades despite the considerable health interventions by the Ghana government and relevant concerned institutions. This study therefore determined the prevalence of malaria and anaemia, its associated risk factors and the impact of preventive methods among pregnant women in the Akatsi South District of Ghana (ASD-G). A total of 200 pregnant women receiving antenatal care and laboratory services at the ASD-G were recruited. A fit-for-purpose questionnaire was used to capture the participant's demographic, gestational and malaria prevention methodology details. Blood samples were collected from the pregnant women and their hemoglobin levels and malaria status determined. Majority of the 200 pregnant women (52.0%) studied were between 20-29 years, had their basic education (67.0%), were married (76.0%), lived in the urban communities (58.5%) and worked in the formal sector (44.5%). The proportion of pregnant women with anaemia, malaria and the combination of malaria/anaemia was 65.5%, 11.0% and 10.5% respectively. The likelihood of malaria infection during first (0-13 weeks) and second (14-26 weeks) trimester was very high. Pregnant women who were not on IPT program and do

INTRODUCTION
Malaria for decades has been identified as a devastating public health problem particularly in pregnant women in the tropics [1] . The condition which is caused by parasites of the genus Plasmodium and transmitted by the female anopheles mosquitoes, was according to the World Health Organization (WHO) in the year 2008 estimated to infect 243 million people out of which 863,000 deaths were recorded with majority occurring among children under five years [2] . It has been indicated that of the 91 countries reporting indigenous malaria cases globally, approximately 80% of the total cases occur in the Sub-Saharan African countries; a region where about 25 million pregnant women are estimated to live at risk of P. falciparum malaria infection [3] . Significant burden includes 75,000-200,000 low birth weight (LBW) weight babies annually as a result of a combination of preterm delivery (PTD) and fetal growth restriction (FGR) [4] . For the unborn child, maternal malaria increases the risk of spontaneous abortion, still birth, premature delivery and low birth weight [5] . Based on the few studies available, it was estimated that pregnancy-associated malaria accounted for 3-8% of infant deaths [6] . Most devastating and life-threatening side effect of malaria in pregnancy is the development of anemia. Defined by WHO as hemoglobin concentration <11.0 g/dl [7] , anaemia for so many years has been a major public health problem in developing countries [8] . Prevalence of anaemia among pregnant women in developing countries averages 56%, ranging between 35% and 100% among different regions of the world [9] . Anemia is an associated cause of increased morbidity and mortality in women and children, poor birth outcomes, declined work productivity in adults, and impaired cognitive and behavioral development in children [10] . Prevalence of anemia according to findings is highest among pregnant women in Sub-Saharan Africa (SSA) (57%), followed by pregnant women in Southeast Asia (48%), and lowest (24.1%) in South America [7] . It has been indicated that each year, approximately 25 million pregnant women in sub-Saharan Africa live at risk of P.
falciparum infection which as has been judged to infect an estimated 216 million people and taken the lives of about 445,000 people globally [3] . It is for this reason that preventive mechanisms vis-à-vis the use of IPTs, use of ITNs and mosquito sprays and repellents etc. were developed in response to fighting against the infection. Not much studies have assessed the impact of the use of those preventive methods on the occurrence of malaria among the population especially the high-risk groups such as the pregnant women in the Akatsi South district of Ghana. Again, despite the fact that several programs exist, especially on malaria control that target pregnant women as a means of reducing anaemia in pregnancy, the rather high prevalence of anaemia recorded by these studies calls for investigation into other factors that may contribute to anaemia aside micronutrient deficiency and intestinal helminth infections. In view of the above, this study aimed to ascertain the prevalence and risk factors of malaria and anaemia among pregnant women of child-bearing age at the Akatsi South District Hospital. (http://www.raosoft.com/samplesize.html) with a 5% margin of error, 95% confidence interval, 2500 (Average annual antenatal attendance) population size and 85% response rate (obtained from a prior pilot study), 200 pregnant women were recruited for this study. Pregnant women who were registered with the facility but were not residents of the Akatsi South District were excluded from the study. Non-consenting pregnant women were also excluded from the study.

Study Design/Eligibility Criteria
Participation of the respondents was voluntary.

Data Collection
A semi-structured questionnaire was administered to the pregnant women to obtain their demographic and gestational details including age, level of education, occupation, gravidity, parity, and gestational period as well as information on malaria preventive measures they employed such as use of ITN, IPT, use of insecticide sprays, mosquito coils, mosquito repellents and creams.
About one milliliter (1 ml) whole blood was collected from each pregnant woman from the median cubital vein of the antecubital fossa of the arm into an EDTA tube using syringe and needle following standard blood collection protocols. Samples were collected at the onset of the rains, between May and July 2016 which marks the period of the malaria transmission season.
Participant's haemoglobin concentration was determined using the fully automated Sysmex XS-800i hematology analyzer (https://www.sysmex-europe.com/n/products/products-detail/xs-800i.html; Europe). Thick blood film was prepared using 6 ul of whole blood, stained using Giemsa stain and analyzed microscopically for malaria parasites. All the tests above were carried out following standard quality-controlled procedures. Malaria diagnosis was established by the presence of malaria parasites in the blood upon microscopy while anaemia was defined by hemoglobin concentration less than 11.0 g/dL [11] .

Data Handling and Management
Data collected from the questionnaires and results from the laboratory investigations were checked for consistency, correctness and completeness and then entered into Microsoft Excel 2016 using fit-for-purpose excel form so as to avoid as much as possible entry errors. Data were then exported into Statistical Package for Social Sciences (SPSS) for windows (version 21.0) for statistical analysis. Data were presented as frequencies and percentages in parenthesis for categorical data and mean ± Standard Deviation (SD) for continues data. Ordinary one-way ANOVA was used to determine statistical variations among continuous variables whereas chisquare and Fisher's exact test where appropriate were used to assess statistical associations between categorical variables. P-values of < 0.05 was considered significant.

Ethical Consideration
Ethical clearance for the study was obtained from the Committee on Human Research,

Publications and Ethics (CHRPE) of the School of Medical Sciences (SMS), Kwame Nkrumah
University of Science and Technology, Kumasi. Permission to undertake the study at the Akatsi South District Hospital was sought and granted by the Hospital Management and the Head of the laboratory before data collection. In addition, written consent was obtained from all participants who agreed to partake in the study after they were thoroughly informed and sensitized about the study.

RESULTS
This study recruited 200 pregnant women. Of these, 13.5% were below 20 years while 52.0% and 34.5% were aged 20-29% and 30 years and above respectively. Majority of the pregnant women (67.0%) were only able to make it up to their basic education level, were married (76.0%), lived in the urban communities (58.5%) and worked in the formal sector (44.5%).
Gravidity and parity status saw the preponderance of the pregnant women in the multigravidae (71.0%) and Primi-Multiparous (62.0%) whereas near half of the pregnant women were in the second trimester of gestation (Table 1). However, among participants diagnosed of malaria and a combination of malaria and anaemia, mean hemoglobin did not vary significantly among the various age groups ( Table 2). repellents surprisingly wasn't a factor to depend upon to prevent malaria or anaemia or a combination of these two conditions among the gravid women studied. Greater proportions of the pregnant women who employed all three malaria preventive methods reported negative for malaria and had normal haemoglobin levels. The use of mosquito repellent was not significantly associated with malaria, anaemia and comorbidity of the two conditions. Also, the use of all three malaria preventive methods was not significantly associated with the occurrence of anaemia among the pregnant women.   (Table 4).

DISCUSSION
This study assessed the prevalence of malaria and anaemia and the associated risk factors contributing to the development of these conditions as well as the impact of malaria preventive methods on malaria and anaemia prevalence among pregnant women receiving antenatal care services from the Akatsi South District Hospital in the Volta region of Ghana. The general demographic characteristics of our study participants compares well with other studies carried out among similar population [12,13] . This study recorded a malaria prevalence of 11.0% (22/200) among the pregnant women. Compared to akin population in Gabon [1,14] , this prevalence is quite low but understandable to some extent due to the vast year interval between these two studies since quite a lot of strategies and interventions might have been put in place into curbing malaria infections among the studied groups. Some of these interventions includes the introduction of IPT and the government of Ghana Ministry of Health periodic free sharing of ITN to help prevent mosquito bites and thereby preventing malaria and malaria related deaths.
Overall, 11.0%, 63.5% and 10.5% prevalence rates of malaria, anaemia and comorbidities of malaria and anaemia respectively was documented in this study. Prevalence rates of all three conditions was highest among participants aged 20-29 years. The occurrence of these conditions was not significantly associated with age (p>0.05). Variations in the hemoglobin concentrations of the study participants was however significant (0.001) only among the three categories of ages (i.e., <20, 20-29 and ≥30) diagnosed of anaemia. In Southeast Nigeria [15] and Gabon [14] , a malaria prevalence rate of 54.0% and 71% respectively higher than recorded in this study was documented. A rather lower 10.2% malaria prevalence [3] than recorded in this study was revealed among West Ethiopian pregnant women. The discrepancies in the malaria infection rate could be to some extent, due to the varied endemicity of the individual communities in these countries. Meanwhile, based on analytical evidence which will be demonstrated subsequently in this study, authors believe that the malaria preventive methods employed by the study participants contributed significantly to the reduced malaria prevalence observed in this study.
Prevalence rate of anaemia on the other hand was significantly high among the pregnant women studied. When classified as a problem of public health significance, the prevalence of anaemia in our study is a severe public health problem (≥40.0) [8] . According to Camila and colleagues, anaemia prevalence of 46.0% was recorded among pregnant women in 2016 [10] . It has been indicated that in Sub-Saharan Africa, prevalence of anaemia is highest among pregnant women (57.0%) [7] . In Ghana, similar studies among related population saw a prevalence rate of 42.7% in Northern Ghana [13] , 57.1% in Sekyere West district [16] and 66.4% in Dangme East district [17] .
The prevalence of anaemia as recorded in this study is even higher than the world prevalence of 32.9% recorded in 2010 [18] . This is a very significant information that should raise significant public eyebrows to the situation. Obviously, owing to the fact that Ghana is a malaria endemic country, malaria could be a contributing factor to the high anaemia prevalence recorded in this study. However, comorbid malaria and anaemia recorded a prevalence of 10.5%. This then suggest that malaria related anaemia in this study is 10.5% reasoning therefore that chunk of the participants have anaemia as a consequence of other factors aside malaria such as the dominant iron deficiency; a cause for significant public attention.
Malaria has been judged to infect an estimated 216 million people and taken the lives of about 445,000 people globally. It has been indicated that each year, approximately 25 million pregnant women in sub-Saharan Africa live at risk of P. falciparum infection [3] . It is for this reason that Stephen and co who indicated that protection from malaria in pregnancy includes the use of ITNs and administration of effective antimalarials through antenatal clinics, most especially IPTs [4] .
These findings therefore suggest that the judicious use of the ITN and ITPs most especially promises to reduce the prevalence of malaria and for that matter malaria related deaths significantly in the foreseeable future.  [3,12,13] .

CONCLUSION
The prevalence rates of malaria and anaemia among the pregnant women studied is high per findings from this study. Though not assessed in this study, the data suggest that majority of the maternal anaemia cases were non malaria related. The factors significantly associated with malaria parasitemia include; gestational period, ITN, and IPT usage. On the other hand, ITN, IPT and malaria parasites were significant factors associated with anaemia.

Declarations Ethical Approval and Consent to Participate
Ethical clearance for the study was obtained from the Committee on Human Research,

Publications and Ethics (CHRPE) of the School of Medical Sciences (SMS), Kwame Nkrumah
University of Science and Technology, Kumasi. Permission to undertake the study at the Akatsi South District Hospital was sought and granted by the Hospital Management and the Head of the laboratory before data collection. In addition, written consent was obtained from all participants who agreed to partake in the study after they were thoroughly informed and sensitized about the study.

Consent for publication
Not applicable.