Malaria in pregnancy: the social sciences' contribution
Programmes designed to reach out to pregnant women who either have malaria or are at risk of contracting it could benefit greatly from the input of social science studies, say researchers. The article, which is published in the journal Public Library of Science Medicine, is an outcome of a study on new approaches to improve coverage and compliance of antimalarial treatment for pregnant women in rural Africa, which was carried out in the framework of the EU-funded PREMA-EU (Malaria and Anaemia in Pregnancy) project. According to the World Health Organisation, every year 30 million women living in Africa's malaria-endemic areas become pregnant. Pregnancy reduces a woman's immunity to malaria, making her more likely to become infected. Meanwhile the unborn children of women with malaria are at greater risk of spontaneous abortion, stillbirth, premature delivery and low birth weight. Up to 200,000 newborn deaths a year are thought to be due to malaria in pregnancy. The WHO has guidelines on preventing and treating malaria in pregnant women. These focus on sleeping under insecticide-treated nets, intermittent treatment of all pregnant women with an antimalarial drug, and the effective treatment of pregnant women showing symptoms of malaria. The WHO notes that this package could be delivered by antenatal clinics. However, few clinics currently offer these services, and not all pregnant women attend antenatal clinics. In their article, the researchers argue that studies from the social sciences could help healthcare providers understand the social and economic factors which drive pregnant women to either seek out or avoid malaria prevention or treatment services, and antenatal services in general. They propose two models, one focusing on malaria prevention, the other on treatment, in which they identify the key gaps in our knowledge in this important field. On treatment, the authors point out that 'prompt and effective treatment depends on illness recognition. However, malaria-related symptoms can be easily confused with pregnancy-related symptoms.' So far there are no studies on how women differentiate between malaria and pregnancy symptoms, or even how many women are aware that pregnancy makes them more susceptible to malaria. Further research is also needed to understand the perceived benefits and risks of treatment for the mother, the foetus and the newborn child. 'It is important to know whether socially the mother or the foetus is prioritised since the benefits for one might imply risks for the other,' the researchers note. Another important factor is the question of who controls the behaviour of the pregnant women, and the researchers cite the example of a family in which the woman realises she is ill but resources such as money for transport are controlled by the husbands. 'In this way, participation may be strongly influenced by others than those directly targeted,' the researchers write. On access to treatment centres, the authors point out that: 'rural women may need to work and live on fields situated far away from the health centres and, during the rainy season, roads may be inaccessible, hindering access to health centres. The perception of time lost travelling to and from the health centre or waiting at the health centre clearly influences treatment seeking in relation to the work situation of the women, with regard to child care and intra-domestic labour substitution.' Other non-medical costs associated with malaria treatment include transportation costs, costs for accompanying relatives and food for the patient. Many of the factors affecting access to malaria treatment also apply to access to malaria prevention measures, which could be delivered via antenatal clinics. For example, 'It is worth emphasising that even when antenatal clinics are free of charge, direct non-medical and indirect costs, especially those for transport, are still considerable and might hinder access,' say the researchers. Other factors which could deter women from attending antenatal clinics at all include social values and perception of pregnancy. For example, adolescents or unmarried women may prefer to avoid revealing their pregnancy by attending an antenatal clinic, fearing the gossip that would result from their pregnancy becoming known. Women may also be put off if they perceive health personnel to be rude, if they do not speak the same language, or if they fear being examined by a male nurse or doctor. 'Reality shows that the implementation of 'simple' tools, like IPT [intermittent preventive treatment], is not so simple because community reactions are not taken into account,' the researchers conclude. 'With this article, we hope to create awareness among researchers of such complex interactions and the need of involving social sciences even for apparently 'straightforward' interventions.' The researchers hope that by studying the factors influencing the behaviour of pregnant women in these rural communities, they can contribute to the target, agreed at the Abuja Malaria Summit in 2000, of ensuring that at least 60% of pregnant women are protected against malaria infection and its consequences.