Size and morbidity in Malawian twins.

OBJECTIVE: Twins in developing countries may be disadvantaged due to their small size at birth, compromised nutrition and high infection risk. Although twinning is common in Africa, there are few longitudinal studies of growth and morbidity in this high-risk group. The aim of the present paper was to describe growth and morbidity of Malawian twins compared to singletons. METHODS: Morbidity episodes were recorded at 4 weekly intervals and at extra visits made to health centres for illness. Weight, length, head and arm circumference were recorded at birth and weight, length and MUAC at 4 weekly intervals to 52 weeks of age. RESULTS: Twins showed reduced fetal growth compared to singletons, with increasing fall-off in percentiles from 33 weeks gestation. Infant growth percentiles for twins were below those for singletons at all ages, but showed no fall-off from singleton percentile values. There were no differences in morbidity incidence during infancy between twins and singletons. CONCLUSION: Malawian twins showed no catch-up growth during infancy, their smaller size was not associated with higher morbidity incidence compared to singletons.

Adverse birth outcomes in a malarious area.

To determine factors associated with fetal growth, preterm delivery and stillbirth in an area of high malaria transmission in Southern Malawi, a cross-sectional study of pregnant women attending and delivering at two study hospitals was undertaken. A total of 243 (17.3%) babies were preterm and 54 (3.7%) stillborn. Intra-uterine growth retardation (IUGR) occurred in 285 (20.3%), of whom 109 (38.2%) were low birthweight and 26 (9.1%) preterm. Factors associated with IUGR were maternal short stature [adjusted odds ratio (AOR) 1.6, 95% confidence interval (CI) 1.0-2.5]; primigravidae (AOR 1.9, 95% CI 1.4-2.7); placental or peripheral malaria at delivery (AOR 1.4, 95% CI 1.0-1.9) and maternal anaemia at recruitment (Hb<8 g/dl) (AOR 1.9, 95% CI 1.3-2.7). Increasing parasite density in the placenta was associated with both IUGR (P=0.008) and prematurity (P=0.02). Factors associated with disproportionate fetal growth were maternal malnutrition [mid-upper arm circumference (MUAC)<23 cm, AOR 1.9, 95% CI 1.0-3.7] and primigravidae (AOR 1.8, 95% CI 1.0-3.1). Preterm delivery and stillbirth were associated with <5 antenatal care visits (AOR 2.2, 95% CI 1.3-3.7 and AOR 3.1, 95% CI 1.4-7.0 respectively) and stillbirth with a positive Venereal Disease Research Laboratory (VDRL) test (AOR 4.7, 95% CI 1.5-14.8). Interventions to reduce poor pregnancy outcomes must reduce the burden of malaria in pregnancy, improve antenatal care and maternal malnutrition.

Breast and complementary feeding practices in relation to morbidity and growth in Malawian infants.

OBJECTIVES: The objective of this study was to compare growth, morbidity incidence and risk factors for undernutrition between infants receiving complementary feeding early, before 3 months of age, with those receiving complementary foods after 3 months in a poor rural Malawian community. METHODS: A cohort of babies was enrolled at birth for follow-up to 12 months of age. Weight, length, morbidity and feeding patterns were recorded at 4 weekly intervals from birth to 52 weeks. RESULTS: Mean age at introduction of water was 2.5 months (range 0-11.8), complementary foods 3.4 months (range, 1.0-10.7) and solids 4.5 months (range 1.2-13.8). Over 40% of infants had received complementary foods by 2 months and 65% by 3 months. The proportion of exclusively breast-fed infants, which included those receiving supplemental water, was 13% at 4 months, 6.3% at 5 months and 1.5% at 6 months. Infants with early complementary feeding had lower weight for age at 3 and 6 months (P<0.05), and at 9 months (P=0.07) and at 2 months they were approximately 200 g lighter. Early complementary feeding was significantly associated with increased risk for respiratory infection (P<0.05), and marginally increased risk for eye infection and episodes of malaria. Maternal illiteracy was associated with early complementary feeding (OR=2.1, 95% CI 1.3, 3.2), while later complementary feeding was associated with reduced infant morbidity and improved growth. CONCLUSION: Breast-feeding promotion programmes should target illiterate women. Greater emphasis is required to improve complementary feeding practices.

Anthropometry of Malawian live births between 35 and 41 weeks of gestation.

The aim of this analysis was to construct cross-sectional gestational age specific percentile curves for birthweight, length, head and mid-arm circumference for Malawian babies, and to compare these percentiles with reference values for babies born to women with normal pregnancies, from a developed country. A cross-sectional study which enrolled pregnant women attending two study hospitals between March 1993 and July 1994 was undertaken. Data on maternal socio-economic status, newborn anthropometry, previous obstetric history and current pregnancy were collected. Smoothed percentile values were derived using the LMS method. Malawian reference percentiles were constructed for fetal growth from 35 weeks' gestation for singleton births. Mean birthweight, length and head circumference were lower at all gestational ages for Malawian compared with Swedish newborns. Fetal growth per completed gestational week was higher by 60 g in weight, 0.5 cm in length and 0.2 cm in head circumference in Swedish compared with Malawian babies. Growth restriction was present from 35 to 41 weeks' gestation. The pattern for the 10th percentile suggested that this was occurring from well before 35 weeks' gestation in a proportion of babies.

Catch-up growth in Malawian babies, a longitudinal study of normal and low birthweight babies born in a malarious endemic area.

INTRODUCTION: Infant growth has not been studied in developing countries in relation to maternal factors related to malaria in pregnancy and maternal illiteracy. OBJECTIVE: To describe growth patterns in infants with low and normal birthweight and determine maternal risk factors for infant undernutrition. METHODS: Babies born in a rural district of southern Malawi were recruited. An infant cohort was selected on the basis of low or normal birthweight. Weight and length were recorded at birth and at 4-weekly intervals until at 52 weeks after birth. Maternal characteristics at first antenatal attendance and delivery were obtained. Odds ratios in univariate analysis were adjusted for birthweight. Factors included in the multivariate regression included maternal illiteracy, season of birth, maternal iron deficiency and number of infant illness episodes. RESULTS: Low birthweight infants were shorter and lighter throughout infancy than either normal birthweight or international reference values. At 12 months, placental or peripheral malaria at delivery (adjusted odds 1.8; 1.0, 3.1), number of infant illness episodes (AOR = 2.1; 1.2, 3.6) and maternal illiteracy (AOR = 2.7; 1.5, 4.9) were independently associated with low weight for age. Maternal short stature (AOR = 1.8; 1.1. 3.2), male sex (AOR = 2.4; 1.4, 4.1), number of infant illness episodes (AOR = 2.6; 1.5, 4.4), and birth in the rainy season (2.1; 1.2, 3.7) were independently associated with stunting. Placental or peripheral malaria at delivery (AOR = 2.2; 1.1, 4.4) and number of illness episodes (AOR = 2.2; 1.1, 4.5) were independently associated with thinness. CONCLUSION: Malaria during pregnancy and maternal illiteracy are important maternal characteristics associated with infant undernutrition. Innovative health/literacy strategies are required to address malaria control in pregnancy in order to reduce the magnitude of its effects on infant undernutrition.

Anthropometry of fetal growth in rural Malawi in relation to maternal malaria and HIV status.

OBJECTIVE: To describe fetal growth centiles in relation to maternal malaria and HIV status, using cross sectional measurements at birth. DESIGN: A cross sectional study of pregnant women and their babies. Data on maternal socioeconomic status and current pregnancy, including HIV status and newborn anthropometry, were collected. Malaria parasitaemia was assessed in maternal peripheral and placental blood, fetal haemoglobin was measured in cord blood, and maternal HIV status was determined. SETTING: Two district hospitals in rural southern Malawi, between March 1993 and July 1994. OUTCOME VARIABLES: Newborn weight, length, Rohrer's ponderal index. RESULTS: Maternal HIV (adjusted odds ratio (AOR) 1.76 (95% confidence interval 1.04 to 2.98)) and first pregnancy (AOR 1.83 (1.10 to 3.05)) were independently associated with low weight for age. Placental or peripheral parasitaemia at delivery (AOR 1.73 (1.02 to 2.88)) and primigravidae (AOR 2.13 (1.27 to 3.59)) were independently associated with low length for age. Maternal malaria at delivery and primiparity were associated with reduced newborn weight and length but not with disproportionate growth. Maternal HIV infection was associated only with reduced birth weight. The malaria and parity effect occurred throughout gestational weeks 30-40, but the HIV effect primarily after 38 weeks gestation. CONCLUSION: Fetal growth retardation in weight and length commonly occurs in this highly malarious area and is present from 30 weeks gestation. A maternal HIV effect on fetal weight occurred after 38 weeks gestation.

The sick placenta-the role of malaria.

The human placenta is an ideal site for the accumulation of Plasmodium falciparum malaria parasites, and as a consequence serious health problems arise for the mother and her baby. The pathogenesis of placental malaria is only partially understood, but it is clear that it leads to a distinct epidemiological pattern of malaria during pregnancy. The objectives of this review are: (1) To review recent data on the epidemiology of malaria in pregnancy, with emphasis on placental malaria; (2) to describe the pathological changes and immunological factors related to placental malaria; and (3) to discuss briefly the functional consequences of this infection for the mother and her baby. The review attempts to bring together local events at the maternal-fetal interface which encompass immunological and pathological processes which relate to the epidemiological pattern of malaria in pregnancy in areas of both high and low malaria transmission. An integrated understanding of the epidemiological, immunological and pathological processes must be achieved in order to understand how to control malaria in pregnancy. The yearly exposure of at least 50 million pregnancies to malaria infection makes it the commonest and most recurrent parasitic infection directly affecting the placenta. These statistics and our limited understanding of its pathogenesis suggest the research priorities on this subject.

Haematological profiles of the people of rural southern Malawi: an overview.

An integrative review of the results of two published and two unpublished studies of anaemia in children, adolescent females, pregnant women and adults living in southern Malawi is presented. Anaemia was universally present in all age-groups, with the higher prevalences in infants (100%) and adolescent primigravidae (93.8%). Nutritional deficits of iron and vitamin A were major contributory factors but chronic malarial haemolysis also significantly contributed to the anaemia. Among boys, anaemia was more common among those with glucose-6-phosphate-dehydrogenase (G6PD) deficiency than in those without this deficiency (P<0.002). This enzymopathy, which occurred in 23.5% [95% confidence interval (CI)=16.7%-30.1%] of the male and 30% (CI=17.3%-42.7%) of the female infants examined, was also associated with neonatal jaundice. The overall prevalences of the-alpha(3.7)/alphaalpha and -alpha(3.7)/-alpha(3.7) thalassaemia genotypes were estimated at 41.0% (CI=28.3%-53.7%) and 8.7% (CI=1.5%-15.9%), respectively. Haemoglobin AS was present in 18.1% (CI=12.8%-23.4%) of the infants and haemoglobin SS in 2.5% (CI=1.4%-3.6%). As the prevalence of infection with Plasmodium falciparum was significantly higher in infants with haemoglobin AS than in those with AA (21.4% v. 6.7%; P<0.001), an increased risk of early-onset moderate parasitaemias in young infants probably stimulates the development of immunity, protecting older heterozygotes from severe malarial infection. Innovative community approaches are required to break the cycle of ill health that anaemia supports in those living in rural areas of southern Malawi. Interventions in adolescent girls could be of particular importance, as they could break the cycle in both pregnant women and their infants.

Risk factors for fetal anaemia in a malarious area of Malawi.

The prevalence of infants born with low cord haemoglobin (fetal anaemia) is high in areas where malaria and iron deficiency anaemia in pregnancy are common. The objective of the present study was to determine risk factors for fetal anaemia in an area of high malaria transmission in southern Malawi. A case control study was undertaken with fetal anaemia defined as cord haemoglobin (Hb) < 12.5 g/dl. Between March 1993 and July 1994, pregnant women attending the study hospitals for the first time in that pregnancy were enrolled. Data on socio-economic status, anthropometry, previous obstetric history and current pregnancy were collected. Malaria parasitaemia, Hb levels and iron status were measured in maternal blood at recruitment and delivery and in umbilical venous blood. Fetal anaemia occurred in 23.4% of babies. Mean (SD) cord Hb was 13.6 g/dl (1.83). Factors associated with fetal anaemia were: birth in the rainy season [adjusted odds ratio (AOR) 2.33, 95% CI 1.73-3.14], pre-term delivery (AOR 1.60, 1.03-2.49), infant Hb < 14 g/dl at 24 hours (AOR 2.35, 1.20-4.59), maternal Hb at delivery < 8 g/dl (AOR 1.61, 1.10-2.42) or <11 g/dl (AOR 1.60, 1.10-2.31). A higher prevalence of fetal anaemia occurred with increasing peripheral Plasmodium falciparum parasite density (p=0.03) and geometric mean placental parasite densities were higher in babies with fetal anaemia than in those without (3331 vs 2152 parasites/microl, p=0.07). Interventions should aim to reduce fetal anaemia by improving malaria and anaemia control in pregnancy and by addressing the determinants of pre-term delivery.

Changes in haemoglobin levels in infants in Malawi: effect of low birth weight and fetal anaemia.

OBJECTIVES: To examine the effect of low birth weight (LBW) and fetal anaemia (FA) on haemoglobin (Hb) patterns in infancy. To study the additional contribution of other risk factors known at birth. To examine the effect of iron supplementation during infancy on Hb levels. METHODS: A stratified cohort of infants in Malawi (83 with LBW (< 2500 g), 111 with FA (cord Hb < 125 g/l), 31 with both LBW and FA, and 176 controls) was followed during infancy. Hb levels were measured at about 2, 4, 6, 9, and 12 months of age. Repeated measures models were used to describe the changes in Hb levels over time. RESULTS: The mean Hb concentration in the control group was 95.5 g/l (95% confidence interval (CI) 92.5 to 98.5) at 2 months, 86.9 g/l (95% CI 84.4 to 89.4) at 9 months, and 898 g/l (95% CI 874 to 92.2) at 12 months. Differences between LBW infants and controls increased over time (difference at 12 months: 5.5 g/l (95% CI 1.3 to 9.7)). Infants with FA had borderline significantly lower Hb at 2 months (p = 0.07), but at 6 months their levels were similar to those of controls. The LBW infants and those with FA had the lowest Hb levels (difference from controls at 12 months 7.9 g/l). Parity, placental and maternal malaria at delivery, and sex significantly affected Hb levels after adjustment for LBW and FA. After iron supplementation, Hb significantly increased. CONCLUSIONS: Antimalarial control and iron supplementation throughout pregnancy should be increased to reduce the incidence of infant anaemia and improve child development and survival.

An analysis of intra-uterine growth retardation in rural Malawi.

OBJECTIVE: (1) To describe the sex-specific, birth weight distribution by gestational age of babies born in a malaria endemic, rural area with high maternal HIV prevalence; (2) to assess the contribution of maternal health, nutritional status and obstetric history on intra-uterine growth retardation (IUGR) and prematurity. METHODS: Information was collected on all women attending antenatal services in two hospitals in Chikwawa District, Malawi, and at delivery if at the hospital facilities. Newborns were weighed and gestational age was assessed through post-natal examination (modified Ballard). Sex-specific growth curves were calculated using the LMS method and compared with international reference curves. RESULTS: A total of 1423 live-born singleton babies were enrolled; 14.9% had a birth weight <2500 g, 17.3% were premature (<37 weeks) and 20.3% had IUGR. A fall-off in Malawian growth percentile values occurred between 34 and 37 weeks gestation. Significantly associated with increased IUGR risk were primiparity relative risk (RR) 1.9; 95% CI 1.4--2.6), short maternal stature (RR 1.6; 95% CI 1.0--2.4), anaemia (Hb<8 g/dl) at first antenatal visit (RR 1.6; 95% CI 1.2--2.2) and malaria at delivery (RR 1.4; 95% CI 1.0--1.9). Prematurity risk was associated with primiparity (RR 1.7; 95% CI 1.3--2.4), number of antenatal visits (RR 2.2; 95% CI 1.6--2.9) and arm circumference <23 cm (RR 1.9; 95% CI 1.4--2.5). HIV infection was not associated with IUGR or prematurity. CONCLUSION: The birth-weight-for-gestational-age, sex-specific growth curves should facilitate improved growth monitoring of newborns in African areas where low birth weight and IUGR are common. The prevention of IUGR requires improved malaria control, possibly until late in pregnancy, and reduction of anaemia.

An analysis of the determinants of anaemia in pregnant women in rural Malawi--a basis for action.

Haematological data are presented on 4104 pregnant women attending the antenatal-care facilities of two hospitals in a rural area in southern Malawi. In this area, malaria transmission is perennial and there is a high prevalence of HIV infection. The local women are exposed to drought and food shortages but experience high fertility rates. Mean (S.D.) haemoglobin (Hb) concentration was significantly lower in the primigravidae [8.7 (1.60 g/dl] than in the secundigravidae [9.1 (1.5) g/dl; P < 0.0001] or multigravidae [9.2 (1.5) g/dl; P < 0.0001]. Primigravidae also experienced significantly more iron deficiency and malaria than secundi- or multi-gravidae. For all parity groups, the lowest mean Hb levels were observed between 26-30 weeks' gestation. In primigravidae peak prevalence of malaria occurred between 16-20 weeks' gestation (38.6%) and peak prevalence of moderately severe anaemia (< 8 g Hb/dl) between 26-30 weeks' (35.7%). Multigravidae showed little variation in the prevalence of anaemia, iron deficiency and malaria with gestational age. Peak prevalences of malaria were observed in April, in the post-rainy season, with values of 51.4%, 56.0% and 25.3% for primi-, secundi- and multi-gravidae, respectively. Peak prevalences of iron deficiency occurred between April and May and those of moderately severe anaemia between May and June. Mean Hb was lower in adolescent primigravidae than in any other group of pregnant women [8.6 (1.5) g/dl], including the non-adolescent primigravidae [8.9 (1.6) g/dl; P = 0.008]. Other factors significantly associated with increased risk of moderately severe anaemia in primigravidae were illiteracy and poor nutritional status (i.e. body mass index < 18.5 kg/m2 and mid-upper-arm circumference < 23 cm). After forward, step-wise, regression analysis of relative risk (RR) factors and their 95% confidence intervals (CI), variables associated with an increased risk for moderately severe anaemia were iron deficiency (RR = 4.2; CI = 3.0-6.0) and malaria parasitaemia (RR = 1.9; CI = 1.3-2.7) in primigravidae, iron deficiency (RR = 4.1; CI = 2.7-6.3) and mid-upper-arm-circumference < 23 cm (RR = 1.8; CI = 1.1-3.0) in secundigravidae, and iron deficiency in multigravidae (RR = 3.1; CI = 4.3-6.9).

Increased prevalence of malaria in HIV-infected pregnant women and its implications for malaria control.

OBJECTIVES: To examine in pregnant women the relationship between HIV infection and malaria prevalence and to determine, in relation to HIV infection, the effectiveness of sulphadoxine-pyrimethamine in clearing P. falciparum infection. METHOD: Descriptive cross-sectional analysis of P. falciparum prevalence in pregnant women at first antenatal visit and of women at delivery who had received two sulphadoxine-pyrimethamine treatments for malaria. HIV status was assessed in 621 women who attended for antenatal care and for delivery at two rural hospitals in southern Malawi in 1993-94. Information was collected on maternal age, parity and gestational age. Prevalence of P. falciparum was measured at first antenatal visit and delivery. Women were given two routine treatment doses of sulphadoxine-pyrimethamine (SP), at first antenatal visit and between 28 and 34 weeks gestation, conforming to Malawi government policy on antimalarial control during pregnancy. RESULTS: Prevalence of HIV infection was 25.6% and all infections were HIV type-1. In primigravidae malaria prevalence at recruitment was 56.3% in HIV-infected and 36.5% in HIV-uninfected women (P=0.04). The corresponding figures for multigravidae were 23.8% and 11.0%, respectively (P<0.01). HIV-infected primigravidae had increased malaria prevalence at all gestational ages. Peak parasite prevalence occurred earlier in gestation in HIV-infected primigravidae (16-19 weeks if HIV-infected; 20-23 weeks if HIV-uninfected). The relative risk for parasitaemia in HIV-infected compared to HIV-uninfected women was significantly increased in three of five parity groups, including the two highest ones (parity>3), indicating parity-specific immunity to malaria was impaired. Malaria prevalence at delivery remained high in HIV-infected women despite prior routine treatment with sulphadoxine-pyrimethamine in pregnancy There was no significant difference in parasite prevalence at delivery between women who did or did not use sulphadoxine-pyrimethamine. CONCLUSIONS: HIV infection is associated with a significant increase in malaria prevalence in pregnant women of all parities with the effect apparent from early in gestation. Two treatment doses of sulphadoxine-pyrimethamine were inadequate to clear parasitaemia in many women by the time of delivery and this occurred independently of HIV status and despite high sensitivity to SP in this area. There is a need to undertake longitudinal studies to determine the incidence of P. falciparum infection in HIV-infected and uninfected pregnant women and to reassess the frequency and timing of sulphadoxine-pyrimethamine treatment doses in these women. Late pregnancy re-infections with P. falciparum probably explain the high parasite prevalence at delivery following sulphadoxine-pyrimethamine treatment at 28-34 weeks gestation.

Malaria in pregnancy and its consequences for the infant in rural Malawi.

Maternal malaria and anaemia, pregnancy and infant outcomes are reviewed among a cohort of mothers and their babies living in Chikwawa district, southern Malawi. Overall, 4104 women were screened at first antenatal visit and 1523 at delivery. Factors independently associated with moderately severe anaemia (MSA; < 8 g haemoglobin/dl) in primigravidae were malaria (relative risk = 1.9; 95% confidence interval = 1.6-2.3) and iron deficiency (relative risk = 4.2; 95% confidence interval = 3.5-5.0). Only iron deficiency was associated with MSA in multigravidae. After controlling for antimalarial use, parasitaemia was observed in 56.3% of the HIV-infected primigravidae and 36.5% of the non-infected (P = 0.04). The corresponding figures for multigravidae were 23.8% and 11.0%, respectively (P = 0.002). Over 33% of the infants born alive to primigravidae were of low birthweight (LBW; < 2500 g), and 23.3% of all newborns had foetal anaemia (< 12.5 g haemoglobin/dl cord blood). LBW was significantly associated in primigravidae with pre-term delivery, placental malaria and frequency of treatment with sulfadoxine-pyrimethamine (SP), and in multigravidae with pre-term delivery, adolescence, short stature and MSA. LBW was significantly reduced with a second SP treatment in primigravidae, and with iron-folate supplementation in multigravidae. Mean haemoglobin concentrations were significantly lower in the infant who had been LBW babies than in the others, and significantly associated with parity, peripheral parasitaemia at delivery and placental malaria. At 1 year post-delivery, life status was known for 364 (80.7%) of the 451 infants enrolled in the follow-up study. Independent risk factors for post-neonatal mortality were maternal HIV infection, LBW, and iron deficiency at delivery. This study identifies priorities for improving the health of pregnant women and their babies in this rural area of Malawi.

An evaluation of the effects of intermittent sulfadoxine-pyrimethamine treatment in pregnancy on parasite clearance and risk of low birthweight in rural Malawi.

The prevalence of infection with malarial parasites and the incidence of anaemia and delivery of infants with low birthweight (LBW) were investigated in 575 Malawian mothers who received one, two or three doses of sulfadoxine-pyrimethamine (SP) during pregnancy. All the subjects were enrolled at their first antenatal visit and all delivered at hospital. The prevalence of Plasmodium falciparum infection at first antenatal visit was 35.3% in primigravidae and 13.6% in multigravidae (P < 0.001). Mean haemoglobin concentration was significantly lower in primigravidae than in multigravidae (8.8 v. 9.5 g/dl; P < 0.001). Of the 233 women tested for HIV infection, 18.8% of the primigravidae and 23.7% of the multigravidae were seropositive. At delivery, there was no significant difference in parasite prevalence in peripheral or placental blood between women who had received one or two antenatal doses of SP. The multigravidae who had received two doses of SP had higher mean haemoglobin concentrations than those who had received just one (P = 0.009) [this difference was not seen in the primigravidae (P = 0.92)]. However, linear regression analysis indicated that the haematinic supplements given to the subjects contributed more to this increase in haemoglobin concentration than the SP. The mean birthweights were higher, and incidence of LBW lower in babies born to primi-and multi-gravidae who had received two or three doses of SP treatment than those seen in babies born to women who had had just one dose (P < 0.03 for each). The odds ratio for LBW in primigravidae compared with multigravidae decreased from 3.2 to 1.0 as the number of SP doses increased from one to three. The benefit of three doses (compared with none) was equivalent to the population-attributable risk of LBW in primigravidae being reduced from 34.6% to 0%. Subjects who were seropositive for HIV were twice as likely to give birth to LBW babies as the other subjects. The use of SP was not associated with maternal side-effects or perinatal complications. The present results indicate that multiple doses of SP taken during pregnancy will lead to a highly significant reduction in the incidence of LBW in infants born to primigravidae, even if the women have HIV infections. This reduction is observable even when parasite prevalence at delivery is high because of re-infections in late pregnancy; reduction in parasite prevalence earlier in pregnancy, as the result of SP treatment, leads to improved foetal growth.

PIP: The effect of antimalarial treatment followed by chemoprophylaxis during pregnancy on low birth weight (LBW) and anemia was investigated in a study conducted in Chikwawa District Hospital, Malawi, in 1993-94. The 575 women from this malaria-endemic community who were enrolled at their first prenatal visit and delivered at the Chikwawa Hospital were included in the data analysis; 24.3% were primigravidae. At enrollment, the prevalence of Plasmodium falciparum infection was 35.3% in primigravidae and 13.6% in multigravidae. At delivery, there was no significant difference in parasite prevalence between women who had received 1 or 2 antenatal doses of sulfadoxine-pyrimethamine (SP). Multigravidae--but not primigravidae--who received 2 SP doses had higher mean hemoglobin levels than those who received just 1 dose; however, linear regression analysis indicated that hematinic supplements contributed more to this increase than SP. The mean birth weights of infants born to primi- and multigravidae who received 2 or more doses of SP were significantly higher than those of infants whose mothers received only 1 dose. The odds ratio for LBW in primigravidae compared with multigravidae decreased from 3.2 to 1.0 as the number of SP doses increased from 1 to 3. The benefit of 3 doses compared with no treatment was equivalent to the population-attributable risk of LBW in primigravidae being reduced from 34.6% to 0. HIV-positive women (18.8% of primigravidae and 23.7% of multigravidae) were twice as likely to have LBW infants than HIV-negative women. The reduction in LBW deliveries was significant even when parasite prevalence at delivery was high as a result of reinfection in late pregnancy.

Improving antenatal care for pregnant adolescents in southern Malawi.

BACKGROUND: This paper considers why antenatal care (ANC) programs for adolescents may need to be improved in areas where a high proportion of first pregnancies are to young girls. DESIGN: Descriptive data on the characteristics of 615 adolescents (aged 10-19 years) who attended for a first antenatal care visit at two rural hospitals in southern Malawi are given. For the 41.5% who came for a supervised delivery, details of their pregnancy care and delivery outcome are provided. The Chi-square test is used for determining significant differences between age and parity groups and logistic regression for an analysis of low birthweight. RESULTS: Fifty-two percent of girls were nulliparous, 24.5% were < or =16 years and 73.3% were illiterate. Prevalence of anemia, malaria and HIV infection was high. Girls who were nulliparous, illiterate, made early antenatal care visits or gave a history of stillbirth or abortion were less likely to attend for delivery. Few primiparae required an assisted vaginal delivery or cesarean section but primiparae had more adverse birth outcomes. Forty percent of primiparae <17 years gave birth to low birthweight babies as did 28.3% of multiparae. In a logistic regression (all adolescents) low birthweight was correlated with literacy (p=0.03) and number of antenatal care visits (p=0.01). CONCLUSIONS: Pregnancy morbidity and adverse birth outcomes were common in spite of antenatal care attendance. This partly reflects poor management of malaria during pregnancy. In areas like Malawi, where childbearing starts early, girls in their first pregnancy need good quality care and careful monitoring if problems are not to be perpetuated to a second pregnancy. Many girls start pregnancy with HIV and schistosomal infections which indicates the need for programs before girls become pregnant.

PIP: A descriptive study of 615 girls 10-19 years of age attending their first prenatal visit at 2 rural hospitals in southern Malawi revealed a need to improve the quality of antenatal care for this high-risk group. 52% of teens were nulliparous and 73.3% were illiterate. Most nulliparae first attended for antenatal care at 20-23 weeks of gestation, while multiparae tended to report at 24-27 weeks. The mean number of antenatal visits was high: 5.3. 26.6% of pregnant adolescents were HIV-infected, 34.4% had malaria, and 92.6% were anemic. Details of pregnancy outcome were available only for the 251 girls (41.5%) who presented for supervised delivery. Girls who were nulliparous, illiterate, made early antenatal care visits, or gave a history of stillbirth or abortion were less likely to attend for delivery. 40% of primiparae under 17 years of age and 28.3% of multiparae had a low-birth-weight infant. Logistic regression analysis indicated that low birth weight was significantly inversely associated with literacy and number of antenatal care visits. The prevalence of peripheral parasitemia was as high at delivery as at first antenatal visit, indicating that malaria control during pregnancy was not performed or was not effective. These findings indicate that, when adolescent pregnancy begins at an early age, girls in their first and second pregnancies require intensive monitoring. On the other hand, in settings such as Malawi, where many young girls are anemic and HIV-infected when they become pregnant and have infections such as schistosomiasis that cannot be treated during pregnancy, programs must be initiated to improve the health status and literacy of young girls before they reach childbearing age.

Seroprevalence of hepatitis B and C and HIV in Malawian pregnant women.

OBJECTIVES: to describe the seroprevalence of hepatitis B (HBV) and C (HCV) infection in HIV-positive and HIV-negative pregnant women from rural Malawi. METHODS: descriptive study using serum samples collected between 1993-1995 in the Shire valley in rural Malawi. Fifty HIV-positive and 100 HIV-negative samples were selected randomly from 153 HIV-positive and 443 HIV-negative women delivering in the hospital. RESULTS: evidence of HBV and HCV infection was found in 71.7 and 16.5% of women, respectively. Chronic carriage of HBV (HBsAg positive) is high (13%) and in agreement with prevalences reported from highly endemic areas. Exposure to HBV and HCV probably occurred well before adulthood as the prevalence of anti-HBc antibody was high in young mothers <20 years of age (22/27; 81%). CONCLUSION: HBV and HCV infections are highly endemic in rural Malawi. There was no statistical evidence to suggest that HIV positivity was associated with an increased prevalence of HBV or HCV markers. Infection with HBV or HCV was not statistically associated.

Parasitological and haematological responses to treatment of Plasmodium falciparum malaria with sulphadoxine-pyrimethamine in southern Malawi.

In 1993, Malawi introduced sulphadoxine-pyrimethamine (SP) for the treatment of uncomplicated, Plasmodium falciparum malaria and became the first country in Africa to abandon chloroquine for first-time therapy. This decision produced an urgent need to monitor local P. falciparum for resistance to SP and to establish both clinical and parasitological criteria for drug failure. The parasitological and haematological responses to treatment of malaria in southern Malawi with SP have now been investigated. Children, aged 6-59 months, who attended health-care facilities with uncomplicated infections of P. falciparum alone were enrolled in the study. Each received standard treatment with SP and paracetamol and was followed-up on days 3, 7, 14, 21 and 28 post-treatment. Haemoglobin (Hb) was measured on days 0, 14 and 28. Zinc erythroprotoporphyrin (ZP) was estimated once during follow-up, as an indicator of iron status. Of 107 children enrolled, 84 children (78.5%) were followed for 14 days or until clinical failure. The parasitological success rate amongst the latter was 90.5% (76/84). One child showed poor parasite clearance (with a parasitaemia at day 3 > 25% of that at day 0), one had a low level of persistent parasitemia, and six were parasitaemic on day 14 after being parasite free on day 7. A 14-day follow-up increased the detection of parasitological failure by 7.2%. Haematological recovery on day 14 was not significantly different for parasitological successes or failures. The geometric mean parasite density (GMPD) was significantly lower in children classified as iron deficient (ZP > or = 3.0 micrograms/g Hb) and these children were significantly more likely to be severely anaemic (Hb < 8 g/dl) at day 0. Parasitological responses and haemoglobin levels 28 days after SP treatment were independent of ZP levels. These results show that, 2 years after the introduction of SP in Malawi for the treatment of uncomplicated, P. falciparum malaria, the drug combination remains effective in 90.5% of cases. Iron status did not affect parasitological recovery. Although iron-deficient children were at greater risk of severe anaemia they did not show significantly reduced recovery from malarial anaemia.

Gestational age assessment by nurses in a developing country using the Ballard method, external criteria only.

The aim of this study was to evaluate postnatal examination of the newborn by nurses in a developing country, using a modified Ballard method, scoring for the six external criteria only (Ballard-ext). Applicability of gestational age estimates with the Ballard-ext. was assessed by calculating its agreement with gestational age derived from the last menstrual period (LMP), fundal height and the Dubowitz method. The smallest difference in gestational age and the most narrow limits of agreement were found between the Ballard-ext. and the Dubowitz method. No reliable gestational age could be obtained from LMP or fundal height. At low gestational ages, Ballard-ext. tended to give lower gestational ages compared with the Dubowitz method. At an average gestational age of more than 251 days, Ballard-ext. gave higher values compared with Dubowitz. Both Ballard-ext. and the Dubowitz method identified 48% of low birthweight babies as growth-retarded (gestational age > or = 37 weeks). No significant difference in gestational age assessment of newborns between nurses was observed. The Ballard method, scoring for external criteria alone, compared favourably with the Dubowitz method. The test is simple to perform and can be reliably used routinely by nurses.

PIP: It is important to know gestational age in order to identify high-risk babies, especially in developing countries and malarious areas in which malnutrition and malaria in pregnancy often cause fetal growth retardation and/or pre-term delivery. The risk of low birth weight attributable to malaria in first pregnancies in malarious areas has been estimated to be as high as 40%. While gestational age is usually estimated from the last menstrual period (LMP), that method may yield inaccurate results due to errors in dates due to cycle variation and irregular menses. Manual assessment from uterine height is also inaccurate. A study was conducted to evaluate postnatal clinical assessment of gestational age by nurses in Malawi, a developing country, using a modified Ballard method, scoring for 6 external criteria only. Results were compared with other methods of gestational age assessment. No reliable gestational age could be obtained from LMP or fundal height approaches. However, at low gestational ages, the Ballard external criteria (BE) approach tended to give lower gestational ages than the Dubowitz score method. At an average gestational age of more than 251 days, BE gave higher values than did the Dubowitz method. Both BE and the Dubowitz method identified 48% of low-birth-weight babies as growth-retarded (gestational age of 37 weeks or longer). No significant difference in gestational age assessment of newborns between nurses was observed. The Ballard method, scoring for external criteria alone, compared favorably with the Dubowitz method and can be reliably and routinely used by nurses.

A comparison of amodiaquine and chloroquine in the treatment therapy of falciparum malaria in Kenya.

During June to August 1989, 158 symptomatic outpatients with P. falciparum malaria were randomly treated with either amodiaquine or chloroquine 25 mg/kg, divided over three days. Amodiaquine (Camoquin, Parke-Davis) was significantly more effective in terms of the rate of parasite clearance, 2.4 versus 3.1 days; parasite clearance day 7; 87% versus 41%; and clinical amelioration, 98% versus 68%. Moreover, this study demonstrates the lack of therapeutic toxicity of amodiaquine. Globally, tolerance was better with amodiaquine than with chloroquine; in particular, cutaneous side effects were less frequent with amodiaquine. There was no evidence of granulocyte or gross hepatic toxicity. These results suggest that WHO recommendations concerning amodiaquine should be questioned. In view of its low cost, demonstrated efficacy and lack of proven therapeutic toxicity, amodiaquine should be considered as a viable replacement for chloroquine in areas with high levels of clinical chloroquine failure.