The study used available data from Ghana's DHIMS 2 databases for the Savannah region to describe regional trends of MiP test positivity rate from 2018 to 2022. The MiP test positivity rate generally declined from 60.4–51.4% with an average positivity rate of 54.5% over the study period. This decline is in line with the trend observed nationally, though there were disparities among the three ecological zones (Osarfo, Ampofo, & Tagbor, 2022). According to Ampofo and co-authors the national MiP test positivity rate declined from 54.0–34.3% between 2014 and 2021(Ampofo et al., 2022). The Savannah ecological belt had the least decline of 43% compared with 53% and 74% in the forest and coastal ecological belts respectively (Osarfo et al., 2022).
The declining trend in the MiP test positivity rate nationally and in the Savannah region, might indicate the possibility of some positive interventional effects on malaria in pregnancy such as the use of SP for IPTp and the use of ITNs. This effect is however moderate in the Savannah region compared with that observed nationally. This moderate decline in the MiP cases in the Savannah region might be because the region is a high malaria-prevalent region with marked seasonal variation and hence periconceptional infection might be a key factor that accounts for the slow decline in MiP cases in the Savannah region (Awine, Malm, Peprah, & Silal, 2018; Berry et al., 2018; Osarfo et al., 2022). It is further said that, due to its characteristic seasonal malaria transmission pattern, the hot weather in the Savannah belt may discourage consistent bed net utilisation (Aberese-Ako, Magnussen, Ampofo, & Tagbor, 2019; Ampofo et al., 2022). This, therefore, indicates that the reduction of malaria among pregnant women in the Savannah region requires more than just the use of SP and ITNs, and calls for in-depth analysis of these interventions and also new approaches by the health authorities and all other stakeholders. A chemoprevention similar to the seasonal malaria chemoprevention done for children under – 5 years could be considered in women of reproductive age in the Savannah region as a starting point.
There was a surge in the MiP test positivity rate in the Savannah region in 2020. This increased trend in malaria cases was observed globally in 2020 and is attributed to the Covid 19 pandemic that hit the world starting in Wuhan China in 2019. The WHO in 2021, stated that there were about 14 million more malaria cases, and 69000 more deaths in 2020 compared to 2019 attributable to disruptions of service provision in malaria prevention, diagnosis and treatment during the pandemic (WHO, 2021). According to Hussein and his colleagues, the pandemic disrupted malaria prevention interventions in pregnancy such as the distribution of insecticide-treated nets (ITNs), indoor residual spraying, as well as malaria chemoprevention during the lockdown and therefore called for an urgent need for rapid and effective responses to avoid malaria outbreaks (M. I. H. Hussein, Albashir, Elawad, & Homeida, 2020). In Sub-Saharan Africa, Heuschen and his group reported that many researchers provided potential explanations for COVID‑19 effects on the malaria burden; these ranged from relevant diagnostical and clinical aspects to reduced access to health care services, impaired availability of curative and preventive commodities and medications, and effects on malaria prevention campaigns (A. K. Heuschen et al., 2021). Evidence in Ghana showed that there was a reduction in the proportion of pregnant women who received IPTp between 2019 and 2020 due to COVID-19 effects (NMEP, 2022). In the northern region of Ghana, it was found that when the lockdown was implemented, pregnant women experienced reduced access to intermittent preventive malaria treatment and insecticide-treated nets, resulting in subsequent higher malaria morbidity in 2020 (A.-K. Heuschen et al., 2021). This study gives some evidence that the declining global burden of malaria reflects positively among pregnant women in the Savannah region of Ghana, though the decline is slow.
All the age groups of pregnant women were infected by malaria; with the majority within the 20–34 years age group. This agrees with the findings of many studies of malaria among pregnant women, which found the majority of MiP cases to be between 25–34 years (Dosoo et al., 2020; Fondjo et al., 2020; Mwin et al., 2021). This observation may be because women at this age are at their prime for reproduction and represent the majority of pregnant women.
This study however revealed that pregnant women aged < 20 years were more susceptible to malaria in pregnancy as they presented with the highest MiP test positivity rate. This agrees with previous observations by other researchers in Ghana (Osarfo et al., 2022). It was observed that adolescent girls in sub-Saharan Africa (SSA) are more prone to experience clinical malaria episodes during pregnancy and have peripheral malaria and placental infection at delivery than adult women (Pons-Duran et al., 2022). Young pregnant women and women of low gravidity are said to lack immunity to plasmodium-infected erythrocytes that sequester in the placenta and thus are susceptible to placental malaria (PM), leading to severe adverse outcome s(Ampofo et al., 2022; Doritchamou et al., 2019; Osarfo et al., 2022). Preventing MiP in this category of pregnant women will not only reduce the burden of MiP but prevent pre-eclampsia, as it's linked to placental malaria (Obiri et al., 2020). A more effective IPTp drug such as dihydroartemisinin-piperaquine (IPTp-DHA-PPQ) could be considered in this category of pregnant women as it was associated with a lower incidence of malaria infection during pregnancy and at delivery compared to IPTp-SP (Desai et al., 2016).
Further analysis of the distribution of MiP by districts show Districts in the Savannah region with high MiP test positivity rates had slow decline in the MiP rate and is driven mainly by 3 districts. These Districts are Bole, Sawla-Tuna-Kalba, and North Gonja. The West Gonja District had the lowest MiP test positivity rate. The Bole District alone accounted for over two-thirds of malaria in pregnancy burden in the region over the study period. Bole and the Sawla-Tuna-Kalba are districts sharing boundaries with the Ivory Coast and the Burkina Faso and communities nearby do cross into these districts to access healthcare when they are ill. This could account for the increased MiP in these districts. Again, the Bole district has some illegal small-scale mining sites, popularly known as galamsey in Ghanaian local Parlance with many people from other parts of the country coming into the district with their families. The Sawla-Tuna-Kalba and the North Gonja districts have the Mole National Park which has wildlife located within them. This wildlife could also serve as a reservoir for malaria parasites and vectors for transmission.
Even though the West Gonja district shares boundaries with these Districts and also has a portion of the Mole National Park located in it, it had the lowest MiP test positivity rate. The Black and White Volta rivers and their tributaries also pass through these Districts and may serve as breeding sites for mosquitoes. High MiP test positivity rate and malaria incidence correlate poorly and these districts with high MiP test positivity rate might not have high malaria in pregnancy incidence (Boyce et al., 2016; Okiring et al., 2021). A study in the Democratic Republic of Congo which evaluated trends in reported malaria cases between 2005 and 2014, attributed the sharp increase in confirmed cases after 2010 to the introduction and scale-up in mRDTs rather than a true increase in the incidence of malaria (Lechthaler et al., 2019).
Strengths and Limitations of the Study
The study has some strengths including being the first that looked at the MiP test positivity rate in the Savannah region. The findings could thus form the basis for other future studies. Furthermore, the findings are based on actual data captured in the DHIMS 2 that is retrospectively analysed but not based on the perception, opinion, and recall ability of respondents. This eliminated the potential effect of recall bias. Malaria test positivity is not affected by RDT stock-out or interruption of microscopy services because the denominator does not include suspected cases that are not tested especially since the average testing rate was above 90%. The data sample in the analysis was large (census of all MiP-positive cases over the study period in the DHIMS 2), and hence the findings are representative of the region.
Despite these strengths, this study has some limitations. MiP test positivity rate correlates poorly with malaria incidence rate and hence Savannah region cannot be said to have high MiP incidence because the positivity rate is high and vice versa. Again, the MiP test positivity rate does capture pregnant women who are asymptomatic of malaria but have parasites. Again, the study relied on secondary data in the DHIMS 2. Therefore, the accuracy and quality of the data captured in the DHIMS 2 cannot be fully accounted for. Thus, any data capture errors could not have been addressed adequately. DHIMS 2 data is an aggregated one and analysis at the individual women’s level couldn’t be done.