Prevention of Malaria in Pregnancy in Malaw
Acta Universitatis Tamperensis, No. 1560
By Annika Launiala
Tampere University Press
Distributed by Coronet Books
$77.50 Paper Original
Malaria in pregnancy is a multidimensional public health problem that has severe adverse consequences for the pregnant woman and her unborn baby. Pregnant women are at risk of delivering babies with low birth weight (below 2500g), and malaria increases the risk of maternal anaemia that may lead to maternal death. In sub-Saharan Africa alone there are approximately 25-30 million pregnant women at risk of the disease. To date, medical anthropology research on malaria in pregnancy has been scarce. Little is known about the factors that affect pregnant women’s and their extended family members’ motivation and agency to seek treatment and preventive services from the antenatal clinic (ANC) which serves as a platform for implementation of the current malaria prevention strategies, namely intermittent preventive treatment and insecticide treated nets. Yet it is acknowledged that prevention programmes depend largely on pregnant women’s participation and adherence with services. This applied medical anthropology research was planned to provide comprehensive understanding of factors affecting prevention of malaria in pregnancy from the perspective of pregnant women and their extended family members, as well as to provide insights into the interwoven factors at local, national and global level that affect planning and implementation of tailored and context specific malaria prevention programmes. The research plan is based on a three year experience (1998-2001) of working in malaria prevention in Malawi.
This study was conducted among the Yao in Lungwena and its surrounding villages in rural Malawi. The main fieldwork was carried out in 2002 and a complementing focused data collection in 2006. The study employed an ethnographic approach and multiple methods in order to comprehensively illustrate what happens when the local reality of a pregnant Yao woman encounter the globally agreed priorities and policies transformed into national malaria prevention programmes implemented in a rural antenatal clinic setting. The main methods used are focus group discussions (FGDs) and in-depth interviews (IDI) with pregnant women, women of reproductive age, female elders and men covering multiple themes ranging from pregnancy and delivery issues to malaria in pregnancy and its prevention. As part of the interviews, different kinds of ranking and classification exercises were conducted regarding pharmaceuticals, obstetric complications and illnesses. A total of 16 FGDs and 64 IDIs were conducted mainly in the communities. At the Lungwena ANC, observations were carried out in order to understand what kind of health education and services pregnant women receive and how malaria prevention activities are implemented in practice. In addition, the study in-cluded data from a knowledge, attitudes and practices (KAP) survey, totaling 248 interviews and from the three year work experience with national level programme planning and management of community based malaria prevention programmes in Malawi.
The main findings from this study show that prevention of malaria in pregnancy needs to be extended beyond the pregnant women. Men as husbands, and female elders, have specific roles and responsibilities to maintain the well-being of the pregnant women in the community. The emphasis of prevention programmes aiming to replace cultural misconceptions with appropriate public health information is also problematic because it often fails to recognise that local understanding of malaria is formulated in encounters among community members, health workers and the like, and these syncretic explanatory models of malaria are diverse among community members. There is no one kind of local understanding of malaria in pregnancy. In addition, the findings explain why malaria in pregnancy is not perceived as a major danger among the Yao women suggesting that the local risk concept differs from the public health risk definition. Examining malaria in the context of pregnancy and perceived vulnerabilities shows that pregnant women are exposed to multiple dangers ranging from witchcraft, extra-marital relationships, multiple illnesses to everyday worries in a resource poor setting. Malaria is only one of the many dangers emerging in the local community context.
To conclude, this study clearly demonstrates that an ethnographic approach and multi-method design provide important knowledge and novel insights into understanding malaria in pregnancy that cannot be found utilising a simplistic KAP survey alone. Malaria in pregnancy is a complex problem, and its prevention at the ANC is affected by multiple interwoven factors ranging from socio-cultural factors to economic and structural factors, many of which are beyond the agency of the pregnant women, men and female elders. The current emphasis on health education fails to address the everyday constraints and needs of pregnant women. Programmes should place more emphasis on pregnancy and efforts to achieve positive pregnancy outcome than prevention of a single disease during pregnancy. Based on the findings several recommendations for improving prevention programmes are made.
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