CHAPTER ONE

1.0 INTRODUCTION
This chapter will consist of the background of the study, problem statement, general and
specific objectives, research questions, significant of the study, scope of the study and finally
the conceptual framework of the study

1.1 BACKGROUD OF THE STUDY

PE Malaria is derived from the Latin word malaria which means “bad air”. The disease is
caused by four types of plasmodium, namely, P/ falciparum, p\ vivax, P/ malarias, and p\
ovale (Nevill， 1990) and is transmitted by female mosquitoes of the genus Anopheles
namely A gamble, A.fmies/us, A. meles A. arabiemis（Coimbra198). Malaria is among
the most prevalence to infectious diseases affecting more than 40%oftheworld’s
population and kills more than 100 million people per year. According to（Osuntokun，
1985: malaria occurs in the area between latitude 62°N and 40°S mainly in the tropical
and subtropical zones where the climate provides optimal conditions for the survival of
mosquitoes and a minimum temperature of 17 C belowwhich the plasmodium cannot
develop

Globally: Approximately 40% of the world population is at risk of malaria whilst about 500
million people become severely ill with malaria Korenrompet al.，2005）. Globally, a child dies
of malaria every 30 seconds and more than one million people die of malaria annually and
these are mostly infants, young children and pregnant women in (Rugemalia2006) About 90%
of these deaths occur in sub Saharan Africa and nearly 25% of all childhood Mortality in
WHO.2000Moreover, approximately 50 million women living in malaria- endemic countries
throughout the world become pregnant in each year. It is worth noting that, malaria worsens
during pregnancy and together with anemia is responsible for 10, 000 maternal deaths and 200,
000infant deaths per yes(Murphyet al.，2001the risk of severe

malaria is increased in pregnant women co-infected with HIV

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Africa bears: 90% of the world’s burden of malaria. Pregnant women and children in Africa are
particularly vulnerable to the adverse consequences of malaria caused by the most lethal
parasite, Plasmodium falciparum. The African Region of the World Health Organization (WHO),
experiences the majority of the global burden of malaria-associated maternal illness and low
birth weight
Pregnant women in malaria-endemic areas donot always receive then necessary prevention
and treatment they need, and this contributes to the extremely high numbers of maternal and
infant deaths caused by malaria Thus, in each year, approximately25 million African women
become pregnant in malaria-endemic areas （Snow，1999 Specifically In Sub-Saharan Africa:
up to 500 million are susceptible to malaria infection out of which an estimated one million,
mainly children, die every year (Nevill，1990). In East Africa, the endemicity of malaria is found
in the humid low-lying areas of the coastal plains and the lake shores of Victoria and Tanganyika
（Prothero， 1961)

In Somalia In 2008 the Health management information system (HMIS) reported 45,826
uncomplicated malaria cases (both confirmed and unconfirmed) and 4.456severe malaria cases
.As HMI
Shas not been rolled out to all health facilities this is probably an underestimate of the actual
burden of disease (WHO.2008estimated that there were 608,831 cases of uncomplicated
malaria (lowest predicted: 311,038- highest predicted: 1,981,438) and 3,491 malaria deaths.
However, based on a modelled approach undertaken by Snow et al (2007) using
epidemiological data approximately 770,000 (IQR, 464,000 – 1,700,000) clinical attacks of P.f.
are estimated to occur per year. The burden of disease is predicted tf P.f. are estimated to
occur per year. The burden of disease is predicted to vary considerably across the country
depending upon the transmission pattern sand human population density .In addition
approximately 4,500 deaths each year are estimated to occur as a direct result from P.
falciparum infectio

1.2 PROBLEM STATEMENT

malaria in pregnancy include maternal anaemia, low birth weight, prematurity and
increased perinatal mortality.
low birth weight. restricted growth of the baby in the womb. stillbirth. miscarriage. death
of the mothere Of the estimated 50 million pregnancies that occur each year globally,
approximately 25 million is thought to occur in developing countries.

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 The pregnant women and children are thought to be the most vulnerable to malaria. Whereas
several initiatives have been implemented over the years to control malaria in pregnancy, none
of these has succeeded in its entirety. Without any intervention, malaria would cause10, 000 of
these women and200, 000 of their infants death a as result of malaria infection and severe
malarial anemia. Developing countries (or rather tropical countries) are thought to bear the
global brunt of malaria in pregnancies in addition to the unfinished business of HIV/AIDS and
other communicable disease like Tuberculosis. Pregnant women are twice as likely to become
infecte
with P. falciparum malaria as non-pregnant women living under the same conditions

(Lindsayet al.，2000). It is estimated that over 30 million women living in malaria pandemic
parts of Africa become pregnant every year. In Ghana, a study has put the overall prevalence of
malaria parasitaemia during pregnancy as 47%. Also, National Malaria Control Program (NMCP)
has it that the risks associated with malaria in pregnancy include; low birth weight threatened
abortion, miscarriage, prematurity (NMCP)
2012). Therefore there is no research conducted about the effects of malaria on pregnant
women in Mogadishu specially Hodon district

1.3 PURPOSE OF THE STUDY

The aim of this study is to assess the effects of malaria infection among the pregnancy women
in Hodan district.

1.4 OBJECTIVE OF THE STUDY

Research objective can be classified in to general objective and specific objective.

1.4.1General objectives
The main objective of this study is to assess the effect of malaria among pregnant women in
Hodan district .

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1.4.2 Specific objectives :-
1. To determine the socio-economic effect of malaria among pregnant women in Hodan
district Mogadishu Somalia
2. To find out the mental effect of malaria among pregnant women in Hodan district
Mogadishu Somalia
3. To determine the prevention and management of malaria among pregnant women in
Hodan district Mogadishu Somali

1.5 RESEACH QUESTIONS

1. What are the socio economic effects of malaria infection the pregnant women among
people in Hodan district?
2. How does Malaria effect the mental of health of pregnant women among in Hodan district?
3. What is the preventionin and management of malaria infection pregnant women among in
people in Hodan distric?

1.6 significaant of study

Malaria is found in many region of the world ,in sub Saharan Africe .it is a leading cause of
death illness and poor growth and dlopment among young children .it is estimated thate a
children it is estimated thate a child dies of malaria every 30 secony in this area malaria is
particulary dangerous for pregnans

1.7 SCOPE OF THE STUDY

This research will be carried out on the impact of malaria on pregnant women. The study will
cover the economic, mental and prevalence impact of malaria on pregnant women 1.7.1
Content scope Pregnant women who lives in Hodon district, Mogadishu-Somalia.

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1.7.1 Time scope
The study was conducted from APril to June 2021 in Hodan District Mogadishu Somalia

1.7.2 Geographical scope

Study will be conduct in Hodan District Mogadishu Soma

1.8. DEFINATION KEY TERM

1. Malaria infection: during pregnancy is a significant public
with substantial risk for the pregnant women her fetus and the new born child?

2. Pregnancy assocated: malaria causes low birth weight and maternal anemia?
3. Mother infected: with malaria during pregnancy can pass more of their own cell to their
baby and change the infant s risk of later inf

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1.8 CONCEPUTIAL FRAME WORK

DV IV

SOCIO ECONOMIC EFEECT

• Marital status & costal health card

• Decreased productivity due to

brain damage from Cerebral
malaria

MALARIA
MENTAL EFFECT

PREVENTION

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 CHAPTER TWO:
LITERATURE REVIEW
2.1 Introduction
Pregnant women are vulnerable to the effects of malaria. They are more likely than
nonpregnant women to become infected with P. falciparum malaria and, once infected, there is
a tendency toward increased severity of disease （Pariseet al.，1998） caused in part by the
transient depression of cell-mediated immunity that occurs during pregnancy （Griffithet al.，
2007）. The effects of malaria on pregnant women differ with various factors, such as the
woman’s level of immunity, her gravidity, the trimester of pregnancy, and the presence or
absence of co–morbidity （BouyouAkotetet al.，2003）. The effects of malaria in pregnancy
also are affected by the status of malaria in the community. The main factors, which influence
the epidemiology of falciparum malaria and malaria of other Plasmodium species, are the
intensity of transmission and immune response of the infected person （Cheesbrough，198）.
Malaria transmission in an area may be stable or unstable. Immunity is maintained through
continued exposure to malaria parasite(s). In stable transmission areas, most malaria infections
are asymptomatic （Sirimaet al.，2006）. In areas of unstable, nonendemic transmission,
adult women who have no significant level of immunity are more likely to be symptomatic
when parasitaemic, and are at greater risk of developing severe disease and of death （WHO，
2005）.Lower parity, especially first and second pregnancies, and younger age increase the
susceptibility to malaria （Mutabingwaet al.，2005）.

2 .2 Prevalence of malaria
Morbidness in the pregnant women in the sub–Saharan region of Africa is most common, for in
pregnancy, there is a synergistic change in both the physiological and humoral immunity level
which render these women vulnerable to diseases of any kind (especially malaria which is
endemic) （Kakkilaya，2002）. Ghana is a malaria hyper endemic country, and pregnant
women are especially vulnerable to malaria, which can adversely affect the outcome of
pregnancy.

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The placenta may be heavily infected with malaria parasites in pregnancy, and this may result in
adverse effects on the fetus （Menendezet al.，2007）. Malaria endemicity and parity are two
of the factors that can influence the effects of malaria on a mother and her baby （Brabin，

Primigravidae are more susceptible than multigravidae and have higher incidence of placental
malaria （Adebamiet al.，2007）. In malaria-endemic regions, even the babies of
asymptomatic pregnant women may show intrauterine foetal growth retardation and low
birthweight （Adebamiet al.，2007）. The evidence for malaria infection in pregnancy can be
obtained from either the density of peripheral parasitaemia during pregnancy or placental
infection at the time of delivery （Brabin，1983）. Parasite densities in placental infectionsare
sometimes difficult to assess with accuracy because there seems to be no correlation between
parasite density in peripheral blood and in the placenta in pregnant women with well-
developed immunity in malaria-holoendemic regions （Brabin，1983）. Thus, the placenta
may contain large
numbers of infected red blood cells (as many as 65%), whereas the peripheral blood is free
parasites （Brabin，198 IMPLICATION FOR BIRTHWEIGH

Malaria is a complex parasitic disease that continues to be a global health challenge. Pregnant
women are more susceptible to malaria and have greater risks of developing severe disease
with birth complications. Malaria in pregnancy causes considerable morbidity and mortality in
pregnant women and newborns in sub-Saharan Africa （Guyattet al.，2001）. The symptoms
and complications of malaria during pregnancy differ by the intensity of malaria transmission of
the setting (stable/unstable) and thus the level of immunity the pregnant woman has obtained.
Stable transmission predominates in Africa, south of the Sahara and consequently this region
bears the greatest burden of malaria infections during pregnancy. In these areas of high or
moderate (stable) malaria transmission, the ill health effects are particularly apparent in the
first and second malaria-exposed pregnancies （WHO，2008）. Despite the higher prevalence
of parasitaemia and higher parasite density compared to non-pregnant women, falciparum
malaria infection in pregnant women in these areas is usually asymptomatic. Maternal
immunity reduces the risk for severe illness. Thus, clinical malaria is not a prominent feature of
the infection during pregnancy and in settings of stable transmission, maternal mortality due
solely to malaria is uncommon. In these settings, the major detrimental effect of infection is
low birthweight (LBW) and maternal anaemia （Guyattet al.，2004）.

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 In areas with stable malaria transmission (where prevalence during pregnancy ranges from
10%-65%) malaria during pregnancy contributes to approximately 2%-15% of maternal anaemia
and 8%- 14% of LBW. Malaria contributes to an estimated 8%-36% of prematurity and to
additional 13%-70% of intrauterine growth retardation (IUGR) depending on level of malaria
risk （Shulmanet al.，2002）.

Maternal malaria infection accounts for almost 30% of all causes of LBW that can be prevented
during pregnancy （Steketee，2003）. Maternal malaria infection is estimated to account for
3%-8% of all infant deaths （Shulmanet al.，2002）.

Plasmodium falciparum malaria can run a very turbulent course in pregnancy, particularly in the
first and second pregnancies. These complications are more common and severe in hyper-
endemic areas for falciparum malaria. Physiological changes of pregnancy contribute to the
aggravation of malariinfection. There is a generalized immunosuppression in pregnancy with
reduction in gamma globulin synthesis and inhibition of the recticulo-endothelial system,
resulting in decrease in the levels of antimalarial antibodies and loss of acquired immunity to
malaria （Kakkilaya，2002）. This makes the pregnant woman more prone to malaria
infection, and, parasitaemia tends to be much higher （Kakkilaya，20）

Changes in the hormonal milieu, increase in the body fluid volume, decrease in haemoglobin
level and other changes add to the severity of infection. Also, placenta is the preferred site of
sequestration and development of malaria parasites. Intervillous spaces are filled with parasites
and macrophages, interfering with oxygen and nutrient transport to the foetus leading to LBW
and other complications of the new born （Kakkilaya，2002）. Malaria in pregnancy puts the
foetus into great danger. High grades of fever, placental insufficiency, hypoglycaemia, anaemia
and other complications can adversely affect the foetus. Also transplacental spread of the
infection can result in congenital malaria in the foetus

（Kakkilaya，2002）. Pregnant women in sub–Saharan Africa are at risk of severe sequelae

and delivering LBW babies (approximately 95% of all LBW newborns in the world occur in low-
income countries) as a result of malaria

infection （Steketee，2003）. However, in areas with high P. falciparum malaria transmission,

women may have acquired substantial immunity against the malaria parasites and that, in their
first and second pregnancies they are most at risk of malaria associated anaemia and LBW

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（Guyattet al.，2004）. Severe falciparum malaria in full term pregnancy carries very high
mortality. Maternal distress may go unrecognised in these patients and, therefore, careful
monitoring of maternal and foetal parameters is of great importance. Falciparum malaria
induces uterine contractions, resulting in premature labour. Thus, the frequency and intensity
of contractions appear to be related to the height of the fever. There is, therefore, the need to
monitor the uterine contractions and foetal heart rate which may reveal asymptomatic labour,
foetal tachycardia and bradycardia indicating foetal distress （Kakkilaya，2002

2.2.1 RISKS FOR LOW BIRTH WEIGHT BABIES

Pregnancy–associated malaria is characterized by placental malaria and the sequestration of
malaria parasites. Placental malaria is defined as the accumulation of Plasmodium– infected
erythrocytes in the intervillous spaces in the placenta, causing histological changes including
leukocyte-induced damage to the trophoblastic basement membrane. （Uneke，2007a）. The
P. falciparum parasites in pregnant women have substantial adverse effects on pregnancy
outcome (causing both prematurity and IUGR) and, are thus, the pathogenesis of LBW and
infant mortality （Ismailet al.，2). Pregnancy itself is immunosuppressive, and the developing
placenta provides a niche for new parasite strains to sequester and avoid elimination （
Rogersonet al.，1999）. Examination of placental blood films for infected erythrocytes is often
much more difficult and error prone than examination of peripheral blood because of tissue
debris, large numbers of white blood cells, and multiple stages of the parasites found in
placental tissues （Singeret al.，2004）. When a pregnant woman is infected with the malaria
parasite, the infected erythrocytes bind to specific receptors in the placenta, especially
chondroitin sulphate A, and interfere with oxygen and nutrient transport across the placenta.
Antiadhesion immunoglobulin G antibodies against chondroitin sulphate A–binding parasites
are associated with protection from maternal malaria that develops only over successive
pregnancies

（Dorman，2000）. These infected erythrocytes congregate in the maternal placental vascular

space, where the parasites replicate. Malaria-infected placentas are frequently observed to
carry antibodies, cytokines, and macrophages, which are indicative of an active immune
response （Ismailet al.，2000）. This immune response may stimulate early labour, thoughthe
precise effect of malariaparasitized placentas on prematurity is not clear. The IUGR effect
appears to relate to nutrient transport to the foetus.

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 First, a high density of parasites and chronic parasite infection in the placental blood and the
associated cellular immune response may result in consumption of glucose and oxygen that
would have gone to the foetus. Second, histopathological studies of infected placentas have
found thickening of the cytotrophoblastic membranes, which may interfere with nutrient
transport （Ismailet al.，2000）. However, the details of these biological processes remain
uncertain given that they can be studied only after the placenta has been delivered. Malaria-
associated maternal anaemia may also contribute independently to IUGR （Ismailet al.，2000
）. most likely through a reduction in oxygen transport to the foetus

Low birthweight is the single greatest risk factor for neonatal and infant mortality （McCor198
In Africa, malaria is responsible for a significant number of the cases of preventable LBW

（Pariseet al.，1998）. The effects on neonatal mortality are even more marked, with a LBW
baby being nine times more likely to die in the first month of life than a normal-weight baby

（Aitken，199). The risks for mortality increase steadily as the birthweight decreases to below
the LBW threshold. Low birthweight can be due to prematurity or IUGR. Identifying LBW cases
caused by prematurity can be difficult, as many African women are not certain of their
gestational age; as a result, very few studies report separately data on LBWs for preterm infants
and those for infants with IUGR （Guyattet al.，2004）. Low birthweight is also a well-
documented risk factor for poor neurosensory, cognitive, and behavioural development, as well
as for limited school performance and academic achievement

（Tayloret al.，2000）. However, the most vulnerable group appears to be those infants born
prematurely, who will be two to four times more likely to experience failure in school than
infants of normal birthweight and will need specialist support or educational services

（Guyattet al.，2004）

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2.2.2 Malaria- related Anaemia in pregnancy
In malaria endemic communities, pregnant women and children are more vulnerable to
malaria infection. Its effects in pregnancy include chronic anaemia, acute severe anaemia,
miscarriage/forced abortion and pre-term delivery in the mother, and in the foetus and
newborn; low birthweight, congenital malaria, stillbirth, perinatal and neonatal deaths （
Shulmanet al.，2002）. In Sub-Saharan Africa, the major detrimental effect of malaria infection
is low birthweight (LBW) and maternal anaemia （Kayentaoet al.，2005）. In Africa, anaemia
remains a major health problem. It is highly prevalent in Ghana and the fourth leading reason
for admissions in many hospitals （Agyei，2005）. It has been described as the second leading
cause of death. The main causes of anaemia can be attributed to poor diet that has low iron
bio-availability (extent to which a nutrient is absorbed into the blood stream), low absorption
enhancers, inhibitors, excessive blood loss, breakdown of the red blood cells and increase in the
requirements of essential elements during the growth of the foetus

Malaria, other fever cases, parasitic worm infestations and genetic disorders have also been
identified as other causes of anaemia （Agyei，2005）. Studies on P. falciparum–related
anaemia in pregnant women （Guyattet al.，200） suggest that about 400,000 pregnant
women develop moderate or severe anaemia each year in Sub-Saharan Africa as a result of
malaria infection. In Ghana, it has been estimated that 64.5% of pregnant women are anaemic
whilst 59% lactating women are anaemic （Agyei，2005）

2 .2.3 Maternal mortality

Malaria in pregnancy is a major public healM Mth problem in tropical and subtropical regions of
the world. In Africa, millions of women living in malaria-endemic areas become pregnant each
year and most live in areas of relatively stable malaria transmission （Tagboret al.，2008）.
Each year more than 500 000 women die during pregnancy or childbirth （WHO，2005） and
more than 4 million babies die in the first 28 days of life, accounting for 38% of mortality in
children aged less than five worldwide （Adamet al.，2005）. Of every 1000 children born in
Africa and South East Asia, 44 and 38 respectively, die in the neonatal period, compared with
four in high income countries

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In sub-Saharan Africa, the rate of maternal mortality is 2.5 times more than those in Asia, which
are in turn more than 20 times those in developed countries （WHO，2005）. Effective
interventions to reduce maternal and neonatal deaths exist （Darmstadtet al.，2005）, but
they are not available to people living in the poorest parts of the world （WHO，2005）. In
stable transmission areas, few malaria infections in healthy adults result in fever, and the same
is true for semi-immune pregnant women. Although it is commonly assumed that most
parasitaemic pregnant women are asymptomatic. （Tagbor，2005） In his studies on
treatment of malaria in pregnancy suggested that pregnant women were more likely to
complain of symptoms compatible with malaria if they were parasitaemic than if they were not,
despite the absence of a recent history of fever. In Africa, 5–10% of pregnant women may
develop severe anaemia (defined as haemoglobin
The relative contribution of IUGR or preterm delivery in causing LBW varies by the level of
malaria endemicity as well as other factors, such as access to prompt treatment and spread of
HIV.
In areas of high malaria transmission where women are exposed to a greater frequency of
antenatal infections and may have acquired immunity to prevent most febrile episodes that
cause preterm delivery, IUGR is likely to be the predominant cause of malaria –associated LBW
（Brabin Bet al.，2001）.

Malaria in pregnancy in these settings may be responsible for up to 70% of IUGR, whereas its
contribution to preterm delivery, although still substantial, is relatively lower at up to 36%

（Steketeeet al.，2001）

2.2. 4 Diagnose of the Malaria in pregnancy

Malaria parasites can b e identified by examining under the microscope a drop of the
patient's blood, spread out as a “blood smear” on a microscope slide. Prior to
examination, the specimen
is stained (most often with the Giemsa stain) to give the parasites a distinctive
appearane

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 The gold standard for the diagnosis of malaria involves microscopy with visualization
of Giemsa-stained parasites in a blood sample. Species determination is made based
on morphological characteristics of the four species of human malaria parasites and the
infected red blood cells.

2.2.5 Treatment of malaria in pregnancy

Medications that can be used for the treatment of malaria in pregnancy include
chloroquine, quinine, atovaquone-proguanil, clindamycin, mefloquine (avoid in first
trimester), sulfadoxine-pyrimethamine (avoid in first trimester) and the artemisinins (see
below). Briand et al compared the efficacy and safety of sulfadoxine-pyrimethamine to
mefloquine for ermittent preventive treatment during pregnancy. In their study, 1601
women of all gravidities received either sulfadoxine-pyrimethamine (1500 mg of
sulfadoxine and 75 mg of pyrimethamine) or mefloquine (15 mg/kg) in a single dose
twice during pregnancy. There was a small advantage for mefloquine in terms of
efficacy, although the incidence of side effects was higher with mefloquine than with
sulfadoxine-pyrimethamine.
During the first trimester of pregnancy, mefloquine or quinine plus clindamycin should
be used as treatment; however, when neither of these options is available, artemether-
lumefantrine should be considered. Malaria infection in pregnancy is a major cause of
maternal death, maternal anemia, and adverse pregnancy outcome (spontaneous
abortion, preterm delivery, growth restriction/low birth weight, stillbirth, congenital
infection, neonatal mortality) in geographic areas where malaria infection occurs
commonly in pregnant ...
mbination therapy
The World Health Organization (WHO) now recommends that all women in the second
or third trimester of pregnancy who have
uncomplicated P. falciparum malaria should be treated th artemisinin-based
combination therapy.

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2.3 Socio -economic effect of malaria among pregnant women
The low social status of women in developing countries limits their access to economic
resources and basic education and thus their ability to make decisions related to their health
and nutrition. Some women are denied access to care when it is needed either because of
cultural practices of seclusion or because decision-making is the responsibility of other family
members. Lack of access to, and use of essential obstetric services including malaria
prophylaxis, are crucial factors that contribute to high maternal mortality （Adamet al.，200）
Lack of decision-making power and of alternative opportunities consigns many women to a life
of repeated childbearing. Excessive physical work coupled with poor diet also contributes to
poor maternal outcomes. Worldwide, nearly 600 000 women between the ages of 15 and 49
die every year as a result of complications arising from pregnancy and childbirth （Kulmala，
2000） . The tragedy is that these women die not from disease but during the normal,
lifeenhancing process of procreation. Most of these deaths could be avoided if preventive
measures were taken and adequate care was available. For every woman who dies, many more
suffer from serious conditions that can affect them for the rest of their lives. Maternal mortality
is an indicator of disparity and inequity between men and women andits extent is a sign of
women's place in society and their access to social, health, nutrition services and to economic
opportunities
Poverty, ignorance and malnutrition do contribute to the enormous burden of malaria in
pregnancy. Maternal and perinatal morbidity and mortality are high, especially in neglected
situations. The main burden results from infection with P. falciparum （Sanderset al.，2005）
The poor health and nutrition of women and the lack of care that contribute to their death in
pregnancy and childbirth also compromise the health and survival of the infants and children
they leave behind. It is estimated that nearly two-thirds of the 8 million infant deaths that occur
each year result largely from poor maternal health and hygiene, inadequate care, inefficient
management of delivery, and lack of essential care of the newborn （Kulmala，2000）

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. Again, malaria as a quintessential disease of poverty has long been seen as a consequence of
poverty, but today there is strong evidence that malaria actually helps to create poverty and
sustains underdevelopment. Reducing the burden of malaria is, therefore, an extremely cost–
effective way of promoting development and reducing poverty. Around half a billion cases of
malaria each year result in well over one million deaths, and over ninety percent of all these
deaths occur in sub–Saharan Africa （Alnwick，2000）

（WHO，2000） reported that many African countries lacked the infrastructures and
resources necessary to mount sustainable campaigns against malaria and as a result few
benefited from historical effort to eradicate malaria. In Africa, not only does malaria result in
lost life and lost productivity due to the disease and premature death, butmalaria hampers

children’s schooling and social development through both absenteeism and permanent
neurological and other damage associated with severe episodes of the disease
. Although we have moderately effective ways to prevent and treat malaria, stemming the
disease is very challenging, for biological as well as other sociological reasons. Not only does
Plasmodium continue to develop drug resistance, but nations (those in Africa) with political
unrest do strive to distribute drugs to prevent or treat malaria. Figure 8 below shows the
estimated burden of malaria and poverty in the world..

2.3.1 Marital status costs of healthcare

Marital status is the legally defined marital state. There are several types of marital
status: single, married, widowed, divorced, separated and, in certain cases, registered
partnership
Never married persons are persons who never got married in concordance with valid
regulations. Married persons are those who got married before a competent body in
concordance with valid regulations

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Widowed persons are persons whose marriage ceased to exist by death of one of
spouses or by declaring a missing spouse dead respectfully. Divorced persons are
those whose marriage was terminated.
the literature in this areas is based on the cost of illness methodology that separates malaria cost
into direct costs of medical care and supplies (including costs of treatment, transport, special
foods etc) and the indirect costs associated with wages lost by the infected person and any other
family members who abandon their work to take care of the sick family member （Malaney，
2003） . At the household level, direct costs represent the resources that could have been used
for other types of consumption or investment had malaria not occurred. Indirect costs of malaria
are measured as an estimate of time lost multiplied by a wage rate
Severa! studies have applied the cost of illness (COI) approach to estimate the cost burden of
malaria. The main studies of this type are by （Ettlinget al.，1991）, （Mills，1993） , （
Asenso-Okyereet al.，1997）, （Goodmanet al.，2000） and （Attanayakeet al.，2000） .
（Ettlinget al.，1994） estimated household expenditure on malaria treatment to be between
US dollars 0.41 and US dollars 3.88 per person per month, which is equivalent to US dollars 1.
79 and US dollars 25 per household per month. These expenditures tend to be highly skewed.
For example, in Malawi, expenditure on malaria prevention and treatment was found to be
highly regressive, accounting for a larger proportion of income among the poor households.
Poor households in endemic areas spent about 19 to 28% of their cash income treating
episodes of malaria as opposed to only 2% among the high income households. Although the
poor in general spend less on treatment than other income groups this pattern of spending
makes up a higher proportion of monthly or annual income for poor people than for those on
higher incomes. （Worrallet al.，2004） Points out that such high cost burdens for the poor
are likely to deplete household assets or trigger coping strategies,
which further deepen the economic burden on the poor households. This view is shared by

（Najeraet al.，1996） who note that the cost of prevention, treatment, and loss of
productivity resulting from malaria-related morbidity and mortality accounts for a larger
proportion of the annual income of poor agricultural households. In Ghana, （ Asenso-
Okyereet al.，1997)

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 estimated the average expenditure at US dollars 8.7 per m,alaria episode. In Ethiopia, （ML，
1999） showed that households spent US dollars 0.8 and US dollars 1.6 per malaria episode,
which was equivalent to a loss of 12- 26 days of work, accounting for up to 5-8% of household
income. In Nigeria, Obima et al., (2004) showed that households spent on average US dollars
1.84 per month on malaria treatment while expenditure on other illnesses amounted to US
dollars 2.60 per month. The cost of days lost from malaria illness was higher at US dollars 1.28
per month compared with that of other illnesses, which was US dollars 1.08. The combined
financial cost of treating malaria and that of other diseases accounted for 7.03% of the monthly
average household income, with the treatment of malaria illness accounting for 2.91 % of the
household income. Overall, cost of malaria treatment and prevention accounted for 45.9% of
the total household health care spending or US dollars 3.11 per month while other illness
episodes including HIV/AIDS contributed 54.1 % with a mean of US dollars 3.7 per episode.
Similar studies
undertaken in Sri Lanka, Zimbabwe, and Zambia provide further evidence of the cost burden of
malaria. These studies show that on average, households spent close to 25% of their income on
malaria prevention and control. In Sri Lanka, for example, （Jowettet al.，2002） found that
on average households lost approximately 1.8 working days due to malaria illness, which is
equivalent to US dollars 15.5 per malaria episode per household
. If we consider other malaria-related expenditures apart from medical expenditure, then the
economic burden would perhaps be much higher than is reported by most studies. Given that
an episode of malaria lasts for about seven days, it means that each malaria affected household
will have to spend an additional proportion of their income on food, which adds a considerable
burden on the household, particularly if more than one member of the family is Sick.
Another work relevant to our study is that by Ruiz and Roeger (n.d) who carried out an indepth
analysis of the socioeconomic impact of malaria in three communities ofColombia and Ecuador.
In Colombia, theaverage cost per case of malaria stood at US dollars 17.30.
Indirect costs accounting for the largest component of the costs (US dollars 15.80) with the
direct costs accounting for only US dollars 1.50 of the total computed cost

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The loss was equivalent to a 5.6 days work. In Ecuador, the average cost per case of malaria was
estirnated at US dollars 10.40 with indirect costs estimated at US dollars 5.90 and direct costs
US dollars 4.50. The loss was equivalent to 21 % of monthly wage earnings. The authors
concluded that the major economic effect of malaria was in the reduction ofhousehold labour
(indirect costs).
Few studies have employed the willingness to pay approach in estirnating the economic losses
associated with malaria morbidity (see for example （Masiyeet al.，2005）, （Whittingtonet
al.，2003） . （Masiyeet al.，2005） estimated the economic benefits that can be derived
from an irnproved treatment programme. The economic benefit of an irnproved malaria
treatment programme was estirnated at US dollars 77 million per annum, representing a 1.8%
of the country' s GDP. The authors concluded that treatment of malaria generates enormous
economic benefits to society. （Whittingtonet al.，2003） uses the willingness to pay
approach to evaluate adults' perceived magnitude of economic benefits of avoiding malaria.
The study estimated the probability of an individual's willingness to pay for a hypothetical
vaccine for a specified set of price and wealth levels. They estimated a multivariate regression
function using a probit model based on a random utility framework, which assumes that
respondents' aim at maximising their utility when they make decisions whether to pay for a
vaccine at a specified price in order to avoid malaria. The average willingness to pay to avoid an
illness was estirnated at US dollars 14. This implies that the economic benefits to families and
individuals from malaria control activities are large.
The marginal effects of wealth on willingness to pay for a vaccine were large and significant at
low price levels but negative for medium and high prices. There are two explanations for this
finding. One explanation for the finding is that malaria vaccine is a normal good so that
increased income increases. its demand and therefore the willingness to pay for it. The other
explanation, which is also in line with economic theory, is that, increased wealth makes the
individual pricesensitive since he bas other ways of protecting himself from malaria, rather than
through the vaccine.

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2.3. 2 Decreased productivety due to brain damage from cerebral
malaria:

. In an attempt to address past Most of the studies that have examined the impacts of malaria
on productivity have applied production models of various types （Audibert，1986）, （
Wang'ombeet al.，1993）, （Laxminarayanet al.，2003）. The main work under this category
is by （Audibert，1986） who estimated the relationship between health status and
agricultural non-wage
peasant production in Cameroon. Output of rice per acre was modelled as a function of a range
of explanatory variables, including prevalence of malaria and schistosomiasis among household
members. Other key explanatory variables included family size, number of years of experience
in specific crop farming, size of the working population (measured by the total number of
people effectively working in the farm and number of adults working in the farms ), and a
seasonal dummy variable to capture the effects of climatic changes on rice growing. Other
covariates included the surface area of cultivated land, fertility of cultivated soil, the number of
millet fields and the duration of transplanting for the rice farmers. Contrary to expectations, tlie
coefficient on malaria (measured by the levels of parasitaemia) was not statistically significant
in the rice output equation but the schistosomiasis prevalence was found to have statistically
significant effect.
It is possible that the use of malaria prevalence during the dry season without also considering
the effect of the disease during the rain season when the prevalence would have been higher
may have been responsible for the unexpected results. Secondly, and most importantly, malaria
is potentially endogenous to farm output and the author' s failure to address the endogeneity
problem could also have contributed to the unexpected resultsestimation failures,

（Audibertet al.，1998） applied a stochastic frontier production model to assess the effect of
malaria on farm efficiency. Technical efficiency ( defined as the maximum output achieved from
available inputs) was mode lied as a function of malaria and other covariates.

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 Prevalence of malaria among adults with a parasitemia density greater than or equal to 500
parasites per micro litre of blood was used as a proxy for malaria. Similar to previous estimation
results,
the coefficient on prevalence of parasitaemia did not have a statistically significant effect on
technical efficiency. However, when parasitaemia with a density greater than 500 was included
in the model, the coefficient was found to be statistically significant.Leightonetal,199)

provide further evidence on the impact of malaria on annual crop production due to malaria
morbidity. The authors examined the short-run economic impact of malaria in Kenya and
Nigeria, based on field data. Specifically, the study focused on the annual malaria-related
production loss at the national, sectoral, and household levels, as well as for urban and rural
populations and for men and women. They also investigated the effect of malaria on labour
productivity for the individuals who resumed work during a malaria episode. High variations in
productivity loss were noted between rural and urban areas, between social economic groups
and across sectors.
The burden of health expenditures was unevenly distributed among rural and urban
populations, with households at lower socioeconomic levels spending greater shares of their
income than better-off households. The findings further revealed that the loss in income was
higher among women than men. The loss in the agricultural sector were 58% compared to 7%
in the industrial sector in Kenya while in Nigeria the losses in agricultural and industrial sectors
were 50% and 10% respectively.
Few studies have examined the effects of malaria on agricultural land use patterns (see for
example （Wang'ombeet al.，1993） ; （Laxminarayanet al.，2003） （Wang'ombeet al.，
1993） examined the effect of malaria on agricultural land use patterns and household income
in irrigation and non-irrigation areas in Kenya. The study used two production functions to
measure the effect of malaria on cassava production and total household income. In the first
equation they examined the effect of malaria on cassava production while controlling for
household size and other household characteristics over a period of three months.
In the second specification, they examined the impact of family size,malaria and the level
ofhousehold education on annual total household income. They too, like （Audibert，1986）
Found that malaria did not have a statistically significant effect on cassava production nor on
the acreage cultivated. There are two possible explanations for the findings.

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 First, intra-household labour substitution including household hiring of labour to substitute the
sick family member may have attenuated the effects of malaria episode on income or cassava
production at the time of the illness. Second, no effort was made to control for endogeneity of
malaria variable in the production equations estimated. （Laxminarayanet al.，2003）
estimated the impact of malaria risk on agricultural production and crop choice.
They specified a reduced form equation of crop supply function. All individual crops were
grouped into three categories: rice, food and industrial crops. The explanatory variables
included prices for each category of food,
agricultural land for annual crops, labour endowment in male equivalent, %age of crop land
under irrigation, age and years of schooling of household head, province specific malaria risk,
agricultural wages, price of fertilisers, distance to the nearest hospital and pharmacy and
indicator terms for regions. The dependent variable in the year specific models was the amount
of crops harvested. The main findings of the study were that the risk of malaria had a significant
negative effect on production of many agricultural crops such as rice, corn and vegetables.
Specifically, a 1 % increase in the four-week malaria risk resulted in a 0.34% reduction in rice
output, and a 0.25% increase in food supply. Malaria did not however, have a significant effect
on the production of annual industrial crops. Based on the findings, the authors concluded that
the risk of malaria places an enormous economic burden on agricultural production, regardless
of whether or not a number of the household actively suffers a malaria episode. The second
conclusion was that farmers who anticipate malaria attack may adapt coping strategies e.g.
choice of crop, selecting less risk crops to minimise risk associated with illness.

Pandey (2001) and （Liu Qunhuaet al.，2004） concur with the findings by Laxminarayan and
Moeltner. Both studies found that the decline in malaria incidence not only improved the
health status of the population but also the productivity of farmers.
. Pandey (2001) for example, found that crop output for households with malaria was lower,
regardless ofwhether or nota household member suffered an episode of malaria.

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Pandey's study is useful from the policy point of view because it shows the mechanism through
which malaria affects farm output. One important mechanism is through the reduction in
labour suppl y of households or lower productivity of workers and increased expenditure on
medical care. Increased expenditure on malaria treatment and prevention implies that less
expenditure on farm inputs such as fertilizers, which may affect farm output. The effect was
however, found to be minimal among high-income households because they can better afford
anti-malaria measures and treatment when necessary. A similar study by （Coleet al.，2005）
supports earlier findings that poor health ( due to disease illness) has a strong negative impact
on total factor productivity.（Laxminarayan，2004） arrived at similar conclusions as Utzinger
and others. Using data from Viet Nam, he showed that reduction in the incidence of malaria
due to increased govemment investment in malaria control and treatment
significantly improved income for all households living in malaria endemic areas. To test this
hypothesis, he estimated the impact of changes in malaria incidence on changes in household
living standards over a six year period. The results showed that a 10% decrease in malaria cases
resulted to a decrease of 0.63% in health care expenditures. This was equivalent to US dollars
0.16 benefit to each household for every 10% reduction in malaria. Simulation results further
showed that if malaria cases were reduced by 60% nationwide, the reductions would translate
to an annual economic benefit of approximately US dollars 14 million (or a 1.8% increase in
annual household consumption).

2.4 The Effect of Malaria on mental Development

lt is well established that malaria can impair cognitive development, performance and
behaviour, and thus reduce learning ability at school and productivity at work （Lucas，2005）
. Several studies have found that malaria in pregnancy is associated with anaemia, epileptic
convulsions and growth retardation during the first three years of life.
. Using malaria eradication campaigns in the malaria periphery as quasiexperiments he
demonstrated the effect of malaria on lifetime human capital accumulation in three countries:
Paraguay, Sri Lanka and Trinidad.

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. Education -zzz(measured as years of completed schooling, ability to read a newspaper or
reading a newspaper with difficulty) was specified as a function of malaria (proxied by pre-
eradication and eradication_period), place of residence indicators (city, town, and country-side)
and location. Estimates_ obtained using Tobit and probit models in the three countries showed
a negative and significant effect of the malaria rate on educational achievement. Extending the
analysis to 13 African countries with the highest malaria endemicity, the predicted gains in
years of completed education ranged between 0.11 years in Zimbabwe and 0.56 years in
Uganda. The gains in education
correspond to an increase in the per capita GDP of US dollars 16 (1.2%) and US dollars 77
(7.5%) in Zimbabwe and Uganda, respectively. Overall, the results showed that a reduction of
malaria incidence rate by 10% would result to an increase in the years of completed education
of 0.074 and 0.119 years

2.5 Preventing of malaria

Prevention measures. Prevention of malaria is currently based on two complementary
methods: chemoprophylaxis and protection against mosquito bites.

1. Stay somewhere that has effective air conditioning and screening on doors and
windows. ...
2. If you're not sleeping in an air-conditioned room, sleep under an intact mosquito
net that's been treated with insecticide.
3. Use insect repellent on your skin and in sleeping environments

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 2.6 Summary
Malaria infection in pregnancy is a major cause of maternal death, maternal anemia,
and adverse pregnancy outcome (spontaneous abortion, preterm delivery, growth
restriction/low birth weight, stillbirth, congenital infection, neonatal mortality) in
geographic areas where malaria infection occurs commonly in pregnant ...
The disease, caused by mosquito-borne parasites, is present in 102 countries and is
responsible for over 100 million clinical cases and 1 to 2 million deaths each year. Over
the past two decades, efforts to control malaria have met with less and less success.

Malaria is a mosquito-borne infectious disease that affects humans and other

animals. Malaria causes symptoms that typically include fever, tiredness, vomiting, and
headaches. In severe cases, it can cause yellow skin, seizures, coma, or death.
Pharmacologic treatment in pregnancy
Medications that can be used for the treatment of malaria in pregnancy include
chloroquine, quimisininsnine, atovaquone-proguanil, clindamycin, mefloquine,
sulfadoxine-pyrimethamine (avoid in first trimester) and the arte

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 CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Introduction In this chapter,
we focus on to represent research methodology which is reference of detailed procedure to be
followed to realize and achieve the research objectives and also this procedure and research
questions. The chapter contains research design, research population, sample size and sampling
techniques, research instruments used for the data collection, validity and reliability of the
study, data gathering procedure of the study, data analysis and ethical consideration and
limitations that certainly limit the reliability of the study.

3.2 Research design

This study will conduct through descriptive survey research design especially a cross sectional
survey design using a quantitative approach. According to the ( Oso & Onen, 2008) Survey
research design was used to investigate population by selecting samples to analyze and
discover occurrences, and also describes and explains events as they are, as they were or as
they will be. The purpose of this design will to provide numeric descriptions of some part of the
population. A survey may focus on factual information about individuals or it might aim to
collect the opinions of the survey takers. The researchers of this study select this tool, because
of it suitability in several ways such as rapid data collection, ability to understand a population
from part of it and good for extensive research

3.3 Population
The population of Hodan district is estimated 97,213 as mentioned in population estimation
Survey conducted in 2021 by the ministry of planning,

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3.4 Sample Size
We use international sample size calculator to get the sample size from the population

Determine sample size

Confidence level:
Confidence interval:
Popu lation:
The percentage of pregnant women in
hodan during the research were 18%,
95% 99% thus the sample size became the
following Sample size
needed@percentage of pregnant
5 women = 383*18% = 69
97213

Sample size needed

383

3.5 Sampling techniques

This study will use to practice the probability especially sample random techniques. Sample
random technique used to select samples without bias from the target/accessible population.
Sample random mean is the best method to collect reliable questionnaire

3.6 Data collection method

3.6.1 Research instrument
This study used questionnaire as main tool and instruments for collecting data. The selection of
this tool has been guided by the nature of the data to be collected and the time available as
well as the objectives of the study

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3.6.2 Research procedure
In this procedure, data collected from 69 women from th villages at hodon district namely
Zeebiyaano , Banaadir ,Zoobo Km4 ,Taleex ,Tarboonka ,Albarako ,. The distributions of the
respondents were 1 fromZoobiyon d village, 10 Banaadir village 15 from Halzzz village and 9
from Hawotako village. The data was collected by hand and the researchers were responsible
the collection of data. The researchesr was their duty to cooperate with the respondents to fill
the questionnaires appropriately. The researchers take the responsibility of the data collection
in that place for the time needed

3.7 Validity and Reliability of the Instrument

Validity refers to the extent to which data collection method accurately measures what it was
intended to measure or to the extent to which research findings are about what they are
claimed to be about (ibid). According to Oso & Onen (2008) validity refers to the extent to
which research results can be accurately interpreted and generalized to other populations. It's
the extent to which research instrument measure what they are intended to measure. Joppe
(2000) defines reliability as: "The extent to which results are consistent over time and an
accurate representation of the total population under study is referred to as reliability and if
the results of a study can be reproduced under a similar methodology, then the research
instrument is considered to be reliable". So that validity and reliability are very important for
this research to be accurate. Therefore, the researchers of this study are going to use adapted
questionnaire which has already been tested by other researchers, in order to enhance and
ensure that the instrument’s validity and reliability, the researchers will use pilot test.

3.8 Data analysis

As we know, there are two broad techniques used when every person wants to carry out a
research which are quantitative methods and qualitative methods, therefore as we use to
analyze the data through quantitative research. Data was collected through closed end
questioners. SPSS software version 20 will be used in the data analysis in order to find the
impact of malaria on pregnant women.

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3.9 ETHICAL CONSIDERATIONS
In this study, the researchers regarded the ethical issues through the research project by
keeping the privacy, confidentiality and anonymity of respondents. To maintain ethical issue,
the researchers requested from hospital’s administration a permission to distribute
questionnaire to their employees and also told them that the information will be used only for
academic purpose and the research will be kept the solitude, confidentiality and secrecy of
respondents. The researchers promised that this research will be conducted in a fully ethical
manner and all copyrights will be reserved.

3.10 Limitations of the Study

First, the major expected limitations of this study are the following, the study will use only one
method of data collection which is modified Questionnaire which may bring different results if
used another technique. Second, the study uses a small sample size which may limit conformity
of the result. The third, language barrier is also another obstacle which does not allow the
respondents easily fill the questionnaire because some of the respondents are not good in
understanding English language, therefore we as the research team facilitated and interpreted
into Somali language, The fourth constraint was time and budget constraints faced by the
researchers during the research project

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