EVELYN HONE COLLEGE OF APPLIED ARTS AND COMMERCE

SCHOOL OF APPLIED AND HEALTH SCIENCES

AN ANALYSIS OF COVID-19 RISK FACTORS AMONG PREGNANT WOMEN IN
ZAMBIA.

A CASE STUDY OF ZAMBIA.

NAMES STUDENTS ID

CLASS :
SUPERVISOR: DR.T.HAAKONDE

JUNE 2023

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Table of Contents
CHAPTER ONE..............................................................................................................................4

1.0 INTRODUCTION.................................................................................................................4

1.1 Background............................................................................................................................4

1.2 Problem statement..................................................................................................................6

1.3 Justification of the Study........................................................................................................6

Conceptual framework.................................................................................................................7

Conceptual framework.................................................................................................................7

1.4 Main Objective.......................................................................................................................7

1.4.1 Specific Objective.........................................................................................................7

1.5 Main research question..........................................................................................................7

Covid-19 risk factors among pregnant women............................................................................7

CHAPTER TWO.............................................................................................................................8

LITERATURE REVIEW............................................................................................................8

COVID-19 risk factors among the pregnant women……….…………………………………….8

2.1 Gestational diabetes………………….………………………………………………………8
2.2 Preeclampsia..........................................................................................................................8

2.3 Educational level……………………….………………………… ……………………10

CHAPTER THREE.......................................................................................................................15

METHODOLOGY........................................................................................................................15

3.1 Study Area............................................................................................................................15

3.2 Study design.........................................................................................................................15

3.3 Sample size and sampling....................................................................................................16

3.4 Inclusion and Exclusion criteria...........................................................................................16

3.5 Data collection tools and techniques....................................................................................16

3.6 Data Analysis.......................................................................................................................16

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 3.7 Ethical consideration............................................................................................................17

CHAPTER FOUR......................................................................................................................17

4.0 Budgeting and time plan .....................................................................................................18

4.1 Budgeting.............................................................................................................................18

4.2 Time plan………………………………………………………………………………..19

4.3 Budget justification..........................................................................................................21
4.4 Information dissemination..................................................................................................23

Refferences………………………………………………………………………………………25

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 CHAPTER ONE

1.0 INTRODUCTION
1.1 Background
The new coronavirus disease (COVID-19) caused by severe acute respiratory syndrome
coronavirus-2 (SARS-CoV-2) has continued to ravage the world (Wan, 2020). The first reports
of the novel pneumonia emerged from Wuhan, Hubei province in China (Kristian et al, 2020).
Black women seem more prone to SARS-CoV-2, along with Asian and other minority races.
Risk factors for severe COVID-19 in the pregnant population include maternal age above 35
years, comorbidities such as hypertension and diabetes, obesity, and gestational diabetes. It is
possible that comorbidities and COVID-19 share synergistic immunological and inflammatory
pathways (Allotey et al., 2020; Ellington et al., 2020; Knight et al., 2020; Narang et al., 2020).

In the extant literature, the main risk factors associated with severe COVID-19 in pregnant women
include increasing age, high body mass index, chronic hypertension, pre-eclampsia, and pre-
existing diabetes. Since the early days of the pandemic, there has been conflicting literature
regarding the risk of COVID-19 in pregnant women. While some studies done in China and
Senegal do not suggest an increased risk of severe disease among pregnant women compared to
the general population, another study in France suggested increased respiratory morbidity related to COVID-
19 infection. Further, in a multinational cohort study, COVID-19 in pregnancy was associated with
increased severe maternal morbidity and mortality compared to pregnant women without COVID-19,
which was more pronounced in low resource settings. Physiological and immunological changes in
pregnancy render women susceptible to respiratory infections. It has been shown that during
pregnancy, there is a shift from T helper cells 1 to T helper 2 cells, decreased number of
circulating natural killer cells, and overexpression of angiotensin-converting enzyme (ACE)
receptors. Essentially, these changes occur in the first and third trimesters of pregnancy, making
it difficult for pregnant women to fight viral infections. Symptomatic COVID-19 in pregnant
women is associated with adverse neonatal outcomes such as increased preterm births, stillbirths
and fetal distress compared to non-infected women.

There is a lack of data on the risk factors associated with COVID-19 infection
among pregnant women, especially in low-resource settings owing to the non-availability of

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universal screening programs. The few studies done on prevalence in such settings have
shown inconsistent results. There seem to be discrepancies with some high-income countries
showing lower prevalence compared to low-income countries. Therefore, there is an
urgent need to gather more evidence on the prevalence and risk factors of COVID-19 among
pregnant women to enhance their care.

Acute respiratory failure occurs in up to 8% of COVID-19 patients and is considered the

principal cause of death in COVID-19. The vulnerability of a pregnant woman lies in their
increased oxygen consumption, decreased functional residual capacity, and physiological
hyperventilation with compensated respiratory alkalosis, which can make the progress rapidly if
pneumonia occurs. Moreover, due to different anatomy and physiology of the pregnant woman,
and also the presence of a fetus, there are some special considerations in management of ARDS
in pregnant women. A dearth of information, especially during the first months of the COVID-19
pandemic, led to increased levels of anxiety among pregnant women as well as unnecessary
caesarean deliveries and elective terminations (Wu et al, 2020).

Zambia, like many countries, introduced strategies to curb the spread of COVID-19 diseases,
such as lockdown, routine hand washing, social distancing and routine screening for
any person presenting to a health facility regardless of the presenting symptoms. Therefore, all
pregnant women also underwent routine screening for COVID-19 when they presented for
antenatal care and delivery at designated health facilities.

Therefore, this study aims to analyze covid-19 risk factors among pregnant women in Zambia as
case study.

1.2 Problem statement

The new coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome
coronavirus-2 (SARS-CoV-2) continue to ravage the world (Wan, 2020). The first reports of the
novel pneumonia emerged from Wuhan, Hubei province in China (Kristian G 2020). This is the
third introduction of a very pathogenic and large-scale epidemic coronavirus into the human
population in this century since the severe acute respiratory syndrome coronavirus (SARS-CoV)
in 2002 and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012 (Guo, 2020).
Risk factors associated with severe COVID-19 in pregnant women include increasing age, high
body mass index, chronic hypertension, pre-eclampsia, and preexisting diabetes. Since the early

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days of the pandemic, there has been conflicting literature regarding the risk of COVID-19 in
pregnant women. While some studies done in China and Senegal do not suggest an increased risk
of severe disease among pregnant women compared to the general population.
Zambia, a country in the Centre of the Southern African Region only had its first two cases
reported on the 18th of March 2020 (WHO, 2020). Conditions that tend to compromise
immunity, and hence could lead to fatalities in COVID-19 include chronic lung disease or
moderate to severe asthma, serious heart conditions, cancer, severe obesity, diabetes, renal
failure, liver disease, pregnancy and poorly controlled HIV/AIDS (CDC, 2020a). In other
instances, cancer treatment, smoking, bone marrow or organ transplantation, and prolonged use
of corticosteroids and other immune weakening medications can compromise one’s immunity
(CDC, 2020b).

The prevalence of COVID-19 infection among pregnant women in Zambia was 36.9% and was
associated with increased gestational age and a lower level of education.

1.3 Justification of the Study

This study will provide information that will be a database on reducing various consequences
associated with COVID-19 on pregnant women in Zambia. The COVID-19 is new therefore
knowing the risk factors regarding the new pandemic will give us insight on how we should
manage and prevent maternal mortalities. This study will not only contribute to the growing
knowledge on the novel virus but will also serve as a basis of knowledge for future researchers

The findings from the study will also be used to inform the Ministry of health and other relevant
authorities. concerning areas that need improvement on awareness in order to reduce the risks of
Covid-19 among pregnant women.

Conceptual framework
The conceptual frame that will be used by the study is presented below

Conceptual framework
INDEPENDENT VARIABLES OF STUDYDEPENDENT VARIABLE

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 1.1 Conceptual Framework

sde
Economic Factors
Social Factors

Gestational Diabetes
Educational level

Lack of resources to access

quality health care services High population density

COVID-19 risk factors among pregnant

women

High exposure rates to suspected

carriers

Preeclampsia

Environmental Factors

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Source: (Author,2023)

1.4 Main Objective

To determine Covid-19 risks factors among pregnant women in Zambia.

1.4.1 Specific Objectives

1 To determine the association between Economic Factors for example Gestational Diabetes

and Covid-19 risks factors among Pregnant women

2. To establish the relationship between Environmental factor like Preeclampsia and Covid-
19 among pregnant women.

3. To establish the relationship between Social factor for example Educational level and
Covid-19 risks factors among women.

1.5 Main research question

What are the risks factors of COVID-19 among pregnant women in Zambia?

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 CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 COVID-19 risk factors among the pregnant women
Physiological changes in the immune and respiratory system may make pregnant women more
susceptible to COVID-19 infection (Dashraath et al, 2020). Associated with placental
immaturity, the early ACE2 expression can make the first trimester the most susceptible period
for SARS-CoV-2 infection (Pringle et al, 2011). A report by the US CDC demonstrated that the
prevalence of COVID-19 in pregnant women was 9.0% (8207/91412). COVID-19 affected
Pregnant women had a higher ICU admission rate than non-pregnant COVID-19 women (1.5%
vs 0.9%). 0.5% of pregnant women required mechanical ventilation compared with 0.3% of non-
pregnant women, with comparable mortality rates (Ellington et al, 2020). In Sweden, the risk of
being admitted to ICU was also higher in pregnant and immediately postpartum women with
laboratory-confirmed SARSCoV-2, compared to non-pregnant women of similar age (relative
risk: 5.39; 95% CI: 2089−10.08) (Collin et al, 2020) .Taken together, currently available data
showed a higher risk of ICU admission in pregnant women affected with COVID-19.

2.2 Gestational Diabetes

Gestational Diabetes are known risk factors for acquiring COVID-19 in pregnancy. However,
unlike prior studies, these two risk factors were handled here as continuous measures, and they
were also assessed in relation to acquiring COVID-19 well beyond pregnancy. In a novel
manner, gestational age at delivery was also assessed while avoiding any potential reverse
causation introduced when COVID-19 and timing of birth were assessed in the same pregnancy
because a severe infection may either precipitate or necessitate preterm birth.

In our study, gestational age was significantly associated with COVID-19 infection. The finding
is similar to other literature which showed that most women presented with the disease in the
third trimester of pregnancy. This could be probably due to the immunological changes that take
place as a woman approaches term to a pro inflammatory state.

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The risk of severe COVID-19 was higher when each measure was analyzed continuously and
even more so when combined together at conventional cut points. Recent data among middle-
aged non-pregnant adults demonstrated a higher risk of COVID-19-related Intensive Care Unity
admission, invasive mechanical ventilation, and mortality in the presence of the MetSyn . While
the current study could not formally assess all MetSyn criteria, maternal lipid profile, glucose
intolerance in pregnancy, and pre-pregnancy Body Mass Index have been shown to predict the
onset of MetSyn three months postpartum , as do a history of preterm delivery, gestational
Diabetes Mellitus, and Body Mass Index years after pregnancy .

These study findings align with a body of work that considers in-pregnancy measures like BMI,
glucose handling, and timing of delivery as a means to predict, and potentially modify, a
woman’s future health. To date, studies have largely focused on future cardiometabolic health,
but not new-onset infection. The current study further suggests that metabolic measures may
offer a future perspective on a woman’s vulnerability to COVID-19. Even so, it remains to be
determined whether these and other metabolic factors (for example blood pressure) influence her
susceptibility to other types of viral and bacterial infections, or whether metabolic modification
after birth can mitigate the onset of severe infectious illness.

In our study, gestational age was significantly associated with COVID-19 infection. The finding
is similar to other literature which showed that most women presented with the disease in the
third trimester of pregnancy. This could be probably due to the immunological changes that take
place as a woman approaches term to a pro inflammatory state.

Our study found that being married was a predisposing factor in the univariable analysis.
However, it was no longer significant after adjusting for confounders. A mixed-methods study
done in Lima found that pregnant women who were cohabiting had lower chances of having
COVID-19 when compared with other marital status. Most women included in this study were
married, so we could not detect the true effect. Furthermore, married women may be at risk of
infection from their partners, effectively increasing contact with others. This finding provides
preliminary evidence in our setting, but more studies on this association are needed.

2.3 Preeclampsia
Preeclampsia is a pregnancy condition, whose physiopathology is not fully understood, but it is
known to involve endothelial dysregulation, imbalance of angiogenic factors, coagulopathy, and

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placental injury. Its main clinical feature is hypertension after 20 weeks of gestation which is
accompanied by multiple organ damage such as renal injury, hepatic injury, and neurologic
symptoms.

In pregnancy, maternal immune response to SARS-CoV-2 infection triggers a systemic

inflammatory cascade marked by cytokine dysregulation, endothelial dysfunction, and
coagulopathy, causing multiple organ injuries which ensue clinical and laboratory features
similar to those seen in PE.

Multiple studies in the scientific literature report an increased incidence of PE and GH among
SARS-CoV-2-infected pregnant patients. The common theme of abnormal maternal circulation
shared between PE and the immune response to SARS-CoV-2 can be a possible explanation for
the increased incidence of HDP.

However, it is still not currently known whether this association is causal due to the lack of
specific biomarkers to distinguish the two conditions. A group of scholars [8] described PE-like
syndrome as the set of clinical and laboratory features secondary to SARS-CoV-2 infection that
resemble those of PE. Due to the similar presentation and lack of specific biomarkers, it is
possible that PE has been over reported among pregnant women infected by SARS-CoV-2.

2.4 Educational level

We sought to understand prevalence and characteristics of pregnant women diagnosed with
COVID-19 in Zambia. We found a prevalence of COVID-19 of 36.9% among pregnant women
presenting to the two health facilities. Women with a secondary level of education were less
likely to have COVID-19 infection than those with primary level of education, and a one week
increase in gestational age was associated with higher odds of COVID-19.

The prevalence of COVID-19 infection among pregnant women is variable in the extant
literature with most studies having been conducted in high-income countries. A hospital in
Houston, USA found a prevalence of 8.0%, another hospital in Connecticut, USA reported
prevalence of 3.9%, and 3.4% in Jammu and Kashmir, India. These findings are all much lower
than what we found, plausible explanation is that we conducted our study during the peak of
wave three of the COVID-19 pandemic which was the worst experienced by Zambia . Further,

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the two sites served as COVID-19 centres and catered for women from all levels of care from
both government and private facilities, and additionally referrals from other parts of the country.
Women with a positive COVID-19 test from any of the health centres were referred to WNH-
UTH or LMUTH for further assessment. Further, studies have shown that people of colour are at
an increased risk for COVID-19 infection, which could partly explain the high prevalence in this
setting.

We found that the level of education was significantly associated with COVID-19 infection. Is.
Pregnant women with secondary education were less likely to present with COVID-19 than
women with primary school education. This is similar to a study done in Europe which suggested
that people of lower education are economically disadvantaged in terms of housing and live in
overcrowded spaces, making it difficult to social distance thus increasing their risk of COVID-
19. Furthermore, pregnant women with low education may have access to knowledge on
infection prevention but have poor understanding and attitudes towards practicing preventive
measures.

COVID-19 during pregnancy is known to increase severe maternal morbidity and death,
particularly intubation and intensive care unit (ICU) admission. Our data provided additional
information about the increased risk of infection associated with preexisting comorbidities, such
as DM and high body mass, and the association with insulin dependent GDM. Women with these
conditions should be monitored carefully for COVID-19, glycemic control, and weight gain.

CHAPTER THREE
METHODOLOGY
3.1 Study Area

3.1.1: Study Location

The present study will be conducted in Zambia, which is located in Southern Africa between
latitudes 8° and 18° south and longitudes 22° and 34° east and covers a total area of 752,612
square kilometres.

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Figure 3.1.1: Map showing study location, Zambia (Source: Google Maps).

3.1.2: Study Population

The population of Zambia is said to about 19.47 million as of 2021 census statistics report and
the study population is estimated to 50 000 pregnant women ( CSO 2021).

3.2. Study Design

A descriptive cross-sectional research will be carried out among pregnant women seeking mother
and child health services in health care facilities across the country using both qualitative and
quantitative study method. These women will be reached through a developed data collection
technique.

3.3 Sample size and sampling

3.3.1: Sample Size

A desired sample approximately minimum of 300 volunteers from the pregnant women will be
enrolled in a study and responding to the research question using questionnaire and interview
guide.

3.3.2: Sampling Technique

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A systematic random sampling will be utilized so as to capture the relevant data in line with
research objectives.

3.4 Inclusion and Exclusion Criteria

3.4.1 inclusion criteria

In the current study, residents of Copperbelt province who have been residing in the area for a
continuous period of not less than 2years will be included in the study.

3.4.2 Exclusion criteria

Nonresident of Copperbelt and those residing in the area for less than 2years will be excluded
from the study.

3.5.1 Data Collection Tools

Both closed-ended and open-ended structured questionnaire and interview guide will be
developed in order to capture data aimed at answering the research question.

3.5.2 Data Collection Technique

An open-ended structured questionnaire and interview guide will be distributed among enrolled
study participants for the purpose of analysing the risk factors for covid-19 among pregnant
women in Zambia.

3.6 Data Management and Analysis

3.6.1: Data Management

Before the data analysis began, the data from the field will be thoroughly cleaned to ensure
validation. This will be done through critical checking of all questions to ensure that they will be
appropriately answered by the respondents. Prior to data collection, data collectors will be
trained in data collection and questionnaire administering techniques. Questionnaires will be
pretested to enhanced data quality.

3.6.2: Data Analysis

In analysing the qualitative aspect of the data obtained from the field data collection, a constant
comparative approach will be employed. This is done by critically reviewing all information

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from each informant. Descriptive statistics will be computed to summarize data using SPSS
version 25 software, where frequencies, percentages and means as well as statistical tests the chi-
square and t-test for each item of the data collection tools will be presented using graphs, tables
and charts after data analysis. Bivariable and multivariable logistic regression analysis will be
conducted to to analayse COVID-19 risk factors.

3.7 Ethical considerations

Ethical clearance from the Research and Ethical Committee of the Unversity of zambia was
sought and a written permission from Lusaka city council was obtained to start data collection.
Verbal consent will also be sought from the head of households. Anonymity, confidentiality and
privacy will be upheld during and after carrying out the research by not indicating names of
individuals who are owners of households that participated in the study.

CHAPTER FOUR

4.0 BUDGETING AND TIME PLAN

4.2 Budget

Table 4.1: showing a budget of the study

Budget Item Cost (ZMW) unit Amount (ZMW)

Stationary
Note books 25.00 25 625.00
Ream of paper 100.00 6 600.00
Scientific calculator 250.00 4 1000.00
Leveno Laptop 40,000.00 2 80,000.00
Printing 8,600.00 1 8,600.00
Stapples 30.00 5 150.00
Nataraj Pens 5.00 50 250.00
Tipp-ex pen 30.00 10 300.00
Binding materials 30.00 25 750.00
Sub-total A 92,302.00

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 Logistics

Phone recharge 800.00 30 24,000.00

credit

Transport 80,000.00 1 80,000.00

Lunch allowance 2. 500,00 30 75, 000.00

Sub-total B 179,000.00

Total 272,302.00

Contingency @ 15% 40, 845.30

Grand total 313, 147.30

4.2: Time Plan

Table 4.2: showing the time line of the study.

Serial Activity Time line responsibility

Numbe
r (S/n)
1 Proposal writing 1st to 4th week of February,2023 Principle
Investigator (PI)
2 Approvals 1st week of March,2023 PI
3 Site visitation and familiarization 2nd week of March, 2023.
4 Pilot study 3nd to 4th week of March,2023 PI

5 Training and orientation of 1st week of April, 2023. PI

research assistants
6 Data collection 2st to 4th week of April,2023 Research
assistants (RAS)
7 Data analysis 1st to 4th week of May ,2023 PI and statistician

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 8 Report writing 1st to 2nd week of June ,2023 PI

9 Dissemination of findings 3rd week of June,2023

PI

4.3 Budget Justification

Two reams of paper for printing the questionnaires and consent letters will be needed as it
contains 1000 sheets of paper. Equally 5 pens will be needed because that's the total number of
people conducting the research. More consent letters and questionnaires will be printed to cater
for any damages that will be incurred. Phone credit recharge will be necessary for the purpose of
communicating with the participants. In case of any emergency or unplanned circumstance, a
cost of K46.00 will be set aside as contingency.

4.4 INFORMATION DISSEMINATION

Upon completion of this study, the Principal investigator will ensure that a printed copy will be
given to the Copperbelt District Health Management Team. Another copy will be given to the
delegated supervisor Dr. Haakonde our lecture at Evelyn Hone College of Applied Art and
Commerce. Any other interested part in knowing the outcomes of this study, a copy of the
findings will be made available to them

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