Studies on prevalence of malaria and its adverse fetal outcomes in Federal Medical Centre (FMC), Owerri, IMO State, Nigeria

Despite a massive increase in private and public efforts over the last years, malaria remains one of the most salient global health concerns. The study adopted cross sectional and descriptive survey design to assess the prevalence of maternal malaria and its adverse fetal outcomes in Federal Medical Centre (FMC), Owerri, Imo State, Nigeria from September, 2020 to March, 2021. The study population were 814 consented pregnant women in their reproductive ages (16 - 55years) who attended ante natal clinic or delivered of their babies at FMCO during the time of study. Data collection involved administration of closed ended questionnaire to illicit information on biographic data. Clinical assessments/examinations (laboratory investigations) of maternal peripheral blood, and fetal birth weight were utilized. Shortly before child birth maternal peripheral blood was obtained from each participant into sterile container for laboratory analysis. Statistical analysis of generated data was carried out using descriptive analysis and of percentages and presented using tables. Statistical comparisons and test of significance between positive and negative groups were calculated using the non-parametric Chi-square test. Differences were considered significant at P< 0.05. The study revealed that 65.6% had malaria during pregnancy. Malaria prevalence is significantly associated with maternal age bracket ( x2= 16.27; P < 0.05), gravidity (x2 = 14.9; P < 0.05) and level of education (x2= 24.69; P < 0.05). There is significant relationship between maternal malaria and perinatal mortality (x2 = 23.14; P < 0.05). There is significant effect of maternal malaria on perinatal mortality based on maternal age (x2= 40.11; P < 0.05) and gravidity (x2= 48.67; P < 0.05). An overall prevalence of preterm deliveries were 19.7%. There is significant relationship between maternal malaria and preterm delivery (x2 = 27.58; P < 0.05). There is significant effect of maternal malaria on preterm delivery based on maternal age (x2 = 49.2; P < 0.05) and gravidity (x2= 56.94; P < 0.05). An overall prevalence of low birth weight were 23.6%. There is significant relationship between maternal malaria and fetal birth weight (x2 = 34.06; P < 0.05). There is significant effect of maternal malaria on fetal birth weight based on maternal age (x2 = 53.82; P < 0.05) and gravidity (x2= 65.94; P < 0.05). The study suggests effective therapy since perinatal mortality due to maternal malaria was recorded in this study. Preterm deliveries and low fetal birth weight based on gravidity and maternal age groups associated with maternal malaria as identified is a call for program managers to make haste and implement new strategies for malaria control.


Introduction
In malaria endemic areas, pregnant women are the highest risk group for malaria infection and to develop a severe form of the disease that results in mortality. Thus, increasing the use of antimalaria interventions that target pregnant women which can address the social, cultural, and economic factors that heighten susceptibility has the potential to control the disease in most of the susceptible and underserved groups [1].
Infection of malaria during pregnancy is common, which can result in fetus low birth weight, stillbirth, and decrement in intrauterine fetal growth. Besides, malaria infection has the greatest impact on the survival of mothers. The factor behind the high burden of malaria during pregnancy could be the increased body surface and specifi c odor secretions during pregnancy which may expose them to increased mosquito bites [1,2]. Malaria infection during pregnancy is a major public health concern in tropical and subtropical countries with signifi cant risk for the pregnant woman and her fetus. According to the estimated yearly report, the number of pregnant women who were at risk of malaria was about 25 million [4]. The rate of malaria infection is higher in pregnant women because of their decreased immunity. Mainly pregnant women living in areas of low or unstable malaria transmission have little or no immunity to malaria and are at higher risk of developing the severe disease as a result of malaria infection than nonpregnant adults living in the same area. Pregnant women with malaria have an increased risk of abortion, stillbirth, premature delivery, and low-birthweight infants [5,6]. Moreover, in unstable malaria transmission areas, pregnant mothers' death may be due to complications of severe malaria (hypoglycaemia, cerebral malaria, and pulmonary edema) or indirectly from malaria-related severe anemia [5].
In order to prevent malaria in pregnancy, current WHO guidelines recommend a multi-pronged approach including both preventive and curative measures [5]. According to Nigeria Malaria Fact Sheet (2011), only 11.8% of pregnant women slept under an ITN, and only 6.5% of pregnant women had taken the recommended two doses of SP during pregnancy [7]. Accordingly, the prevalence of malaria in pregnancy remains high, with recent estimates suggesting prevalence rates of close to 50% in the second and third trimesters. Plasmodium falciparum infections of the placenta remain a major medical challenge among pregnant women in sub-Saharan Africa. A number of factors infl uence the prevalence of placental malaria in pregnant women, including maternal age, gravidity, use of prophylaxis, nutrition, host genetics, and level of antiparasite immunity, as well as parasite genetics and transmission rates [8].
Twelve years after the fi rst Abuja declaration, Nigeria failed to halve the malaria burden in 2010. In the next 2 years leading up to the Millennium Development Goals' (MDG) deadline, Nigeria is still recording high prevalence (98.4%) of malaria (Ako-Nai and Adesiyan, 2012), hence it is doubtful if Nigeria could halt malaria by 2020 and begin to reverse the incidence.
The failure to consider community's knowledge, attitudes and practices (KAP) about malaria has contributed to the inability of programs to achieve sustainable control (Tyagi, Roy and Malhotra, 2013). People's behavior may increase malaria risk, but to change such behavior is not easy. Indeed, there are many reasons why particular behaviors exist and they often are tied to considerable benefi ts in areas quite distinct from health.
Thus, it is not usually the case that "these people don't know any better", but rather that their native logic and rationality make sense within the realities and limitations of their local circumstances [9].
Despite a massive increase in private and public efforts over the last years, malaria remains one of the most salient global health concerns. Approximately one in four women show evidence of placental infection at the time of delivery, with a large fraction of infection remaining undetected and untreated [10]. The health consequences of malaria infection during pregnancy are large: malaria-induced low birthweight is estimated to account for up to 360,000 infant deaths every year [11]; overall, 11.4% of neonatal deaths and 5.7% of infant deaths in malaria-endemic areas of Africa are estimated to be caused by malaria in pregnancy [12,13].
Recent data from Imo State indicate that total loss due to malaria in pregnancy within a six month period was estimated at 5.8 million naira, suggesting that the burden of malaria in pregnant women is high [14]. It has also been suggested that anaemia might be associated with low birth weight [15]. However low birth weight might be due to malaria-induced pathological lesions that occur in the placenta leading to intrauterine growth retardation [16]. This may occur following placental malaria parasitisation which is common in Plasmodium falciparum infection in pregnant women who live in malaria endemic countries [15]. Placental malaria poses a great challenge in malaria control strategies in that it may occur in asymptomatic parasitaemic as well as aparasitaemic pregnant women [17]. Studies have shown that parasitized erythrocytes tend to sequester in the placental capillaries leading to hypoxia, infl ammatory reactions and chronic intervellitis [18]. Therefore, while the placenta of infected pregnant women may be full of parasitised erythrocytes, with parasite densities sometimes in excess of 50% of the total placental erythrocyte count, the peripheral blood may remain free of parasites [19]. Consequently, interventions directed towards symptomatic parasitaemic pregnant women may leave out those who are equally at risk of anaemia and low birth weight. Information on epidemiology and socio-economic consequences of malaria in pregnant women in Imo State has been documented [12].
However, there are no recent studies and therefore this study was set to assess the prevalence of malaria and its adverse fetal outcomes in Federal Medical Centre (FMC), Owerri, Imo State, Nigeria. The publication of this research will alert the pregnant women, community, voluntary and government agencies on the cases of malaria during pregnancy with its resultant effect on the fetus and the infant. The result of this research will arouse the interest of the government and voluntary agencies (WHO) towards providing necessary materials, manpower, infrastructure needed to combat malaria in our society.The data collected on this research will serve to awaken doctors, nurses, environmental health workers and other health workers to great danger posed by malaria to the public thereby motivating them towards sensitizing the general public on preventive/ control measures of malaria. Furthermore, the result of this research would motivate environmental health workers for further research on how to combat mosquito in the environment so as to reduce its transmission of Plasmodium to individuals and the general populace. Perhaps solution of malaria controls lies -in primary care physicians such as family physician or community health workers working in the rural communities.
The result of this study will increase their current knowledge for health education and promotion on malaria at the fi rst contact either in the health facilities or in the patient's family house upon home visit. The fi ndings of this research would also motivate the pregnant women to adopt positive attitude and good practice to control malaria during pregnancy so as to reduce its effect on their unborn babies. It will equally help them to understand causes, signs and symptoms, transmission and consequences of malaria during pregnancy which in turn would help them adopt preventive/control measures of malaria. The study would serve as a reference point to future research on malaria and will also help to add to the required literature on malaria in pregnancy. The fi ndings of this research will go a long way in motivating curriculum planners towards enforcing the teaching of effects of malaria on the unborn child and also control measures to combat malaria during pregnancy in various levels of educational institution. Finally, the result of the study would motivate government and non-governmental agencies towards organizing conferences, seminars and workshops on roll back malaria strategies so as to benefi t the masses.
This study is limited to the assessment of the effects of malaria in pregnancy among pregnant women in Federal Medical Centre, Owerri (FMCO), Imo State, Nigeria. It is also limited to modifying variables like, knowledge, attitudes and practices of pregnant women in FMCO. The study is further delimited to independent variables of gravidity and maternal age groups of the pregnant women who visited the hospital to receive ante natal care or delivered their babies and, also gave their consent to participate in the study. The study was limited to the period the study took place: September 202 to March 2021. The study would be useful to mothers especially the pregnant ones, nurses, doctors, environmental health personnel, health educators/counselors, curriculum planners, hospital management, and health workers as well as those concerned with the prevention and control of malaria like World Health Organization (WHO).

Research methodology
Research design: The study adopted cross sectional and descriptive survey design. Eligible women were approached for recruitment and those who consented were followed from their ante natal visit till they delivered of their babies. Stratifi ed sampling technique was used together with simple random sampling. The women were grouped into weeks of antenatal visits and each week simple random sampling was used for those that came for antenatal visit to ensure equal chance of participation. Each morning, consenting women who met the study criteria was assigned numbers serially as they reported at the antenatal clinic. A client was picked at random from the fi rst three eligible attendants. Every third eligible attendant from the one picked was given questionnaire to fi ll. Any woman who had fi lled questionnaire had her antenatal folder/card marked 'BIO' to avoid repeat recruitment during any subsequent clinic attendance. The copies of the questionnaire were administered to them before they receive health counseling.

Study area
The study was carried out at Obstetrics unit (ANC, Labour ward) of Federal Medical Centre, Owerri, Imo State, Nigeria, from September, 2020 to March, 2021. Federal Medical Centre Owerri (FMCO) lies in the south east of Nigeria. It is a federal government owned tertiary hospital situated in Owerri municipal. Owerri is the capital of Imo State in Nigeria. FMCO is located along Orlu road. It lies on a land perimeter of 359 kilometers. At maximum, the hospital can be transformed to accommodate between 500 -850 inpatients at one time. It has several wards, three laboratories, two radiology laboratories and one support services and departments. FMCO is an apex health institution where complicated medical conditions are managed or treated. It also functions as a training ground for intern physicians, physiotherapists, pharmacists, and nurses who are trained on the job. It ideally offers specialized health care for inpatients and outpatients on referral from primary and secondary facilities. Its offers services related to cancer management, neurosurgery, cardiac surgery, plastic surgery, burns repair, palliative care, advanced obstetrics, neonatology, gynaecology and paediatric services. It serves an teaming population of about 127,213 persons in Owerri municipal alone, and about 1,407,000 persons from outside Owerri municipal (FMCO Records Unit, 2019). The hospital has a total staff strength of 1,674. FMCO takes an estimated 280 births per a month. This makes FMCO a suitable place to carry out this study on prevalence of malaria and its adverse effects on the woman and the fetus.

Population
The study population were consented pregnant women in their reproductive ages (16 -55years) who attended ante natal clinic or delivered of their babies at FMCO during the time of study; September 2020 to March 2021. This was made up of two thousand nine hundred and forty six (2,946) women. The study subjects for specimen collection and laboratory studies were nine hundred and eighty two (982) women. Of these, 168 (representing 17.1%) were not included in the analysis: 96 subjects were lost from maternal death and change of location/ hospital; 23 slides were not read because they were not properly prepared; while 49 women lost interest and so backed out. The remaining 814 (82.9%) subjects were used in the analysis.

Sample size selection
The researcher used Taro Yamane formula for sample selection (n = N ÷ 1 + N (0.05) 2 , n stands for sample size, N stands for the total population, 1 is constant, 0.05 stands for level of signifi cance [20]. Therefore, Inclusion criteria: Pregnant women who fulfi lled the following study inclusion criteria were enrolled into the study: (1) attended and concluded their antenatal clinic at FMCO, (2) received standard malaria preventive treatment in pregnancy, (3) had no known underlying chronic illness, (4) those who gave their consent Exclusion criteria: Women who were excluded included: (1) women who did not receive standard malaria preventive treatment in pregnancy, (2) those who did not conclude their ante natal visit or were not regular for ante natal at the hospital (3) those who came to receive other health care needs in the hospital, (4) mothers with multiple gestation, sickle cell disease, retroviral disease, and with any chronic ailment, (5) those who did not consent.

Validity of the instrument
Validity of the questionnaire, malaria determination, and birth weight were assured by the researcher's supervisor, some other senior lecturers from Department of Nursing Science of Imo State University, Owerri, Nigeria.

Reliability of the instrument
The reliability of the instrument was assured by testrunning the validated instrument, using 20 participants/ pregnant women at Imo State Specialist Hospital, Owerri in a pilot study, whereby administration of questionnaires, fetal weight, and laboratory investigations were carried out as described by Amal, et al. [21]; Aguilar, Machevo and Mayor [22]; Uneke [23]; Bulmer, et al. [24].

Questionnaire collection and administration process:
The questionnaire only cover demographic characteristics of respondents e.g. age, gravidity, level of education, marital and occupational status. After receiving clearance from ethical committee of the hospital, the study was conducted using a paper questionnaire. A one-day training workshop was held for the six research assistants/data collectors (2 staff nurse midwife and 1 senior nursing offi cer each at the labour ward and antenatal clinic of the hospital) to orient them about the purpose of the study, the survey questionnaire and how to handle respondents. The researcher and/ senior nursing offi cer checked the copies of fi lled questionnaire at the end of each day for completeness. During ante natal visits/shortly before or immediately after child birth the questionnaire was used to obtain socio-demographic information from the participants.
Detailed explanations of the content of the questionnaire was given to the participants by the researcher and/or the research assistants. Those participants who cannot read or understand were assisted.
Sample collection: Shortly before child birth maternal peripheral blood was obtained from each participant into sterile EDTA container for laboratory analysis [22,23]. The specimen were labeled and then sent to hematology laboratory where thick and thin fi lms were prepared.

Sample processing/Examination of samples
Assessment of neonatal anthropometric parameters: Birth weights of babies were measured with a standard weighing scale [21] and categorized into two groups namely low birth weight babies defi ned as newborn babies weighing less than 2.5 kg (5.5 lbs) and normal newborn babies weighing 2.5 kg or more [25].

Peripheral blood microscopy:
In hematology laboratory, thick smear of the blood specimen (maternal peripheral blood) were prepared on glass slides. The slides were allowed to dry and then stained with 3% Giemsa stain for 30minutes, rinsed with water and allowed to dry. The slides were then viewed under a microscope using oil immersion at x 100 magnifi cation for presence of parasite [26]. Staining of slides and parasite counting were done by a medical laboratory scientist working in the hematology laboratory [27]. per single thick fi lm fi eld), and ++++ (more than 10 parasites per single thick fi lm fi eld). Two hundred high power fi elds examined before a slide were considered negative [23].

Data analysis
Statistical analysis of generated data was carried out using descriptive analysis and of percentages and presented using tables. Statistical comparisons and test of signifi cance between positive and negative groups were calculated using the nonparametric Chi-square test. Differences were considered signifi cant at P< 0.05.

Ethical clearance
The study protocol was reviewed and approved by the Ethical Clearance Committee of Federal Medical Centre, Owerri.
Verbal consent was received from each participant before data collection. Respondents receive a detailed description of the research, confi dentiality provisions and the fact that their participation will be voluntary and they could withdraw at Citation: Iwuchukwu       There is signifi cant relationship between malaria and perinatal mortality among pregnant women in FMC, Owerri (x 2 = 23.14; P < 0.05).    Figure 5 shows overall prevalence of perinatal mortality based on maternal age, out of 157 pregnant women that are within the age brackets of 16 -25 years, 10.2% and 18.5% had stillbirths and miscarriage respectively. Also 504 respondents under age brackets of 26 -35 years, 6.4% and 10.3% had stillbirth and miscarriage respectively. Those under the age groups of 36 -45 years, 6.15 and 18.9% had stillbirth and miscarriage respectively whereas those that are under the age groups of 46 -55 years, 20.0% and 40.0% had stillbirth and miscarriage respectively. There is signifi cant relationship between perinatal mortality and maternal age groups among pregnant women in FMC, Owerri(x 2 = 20.15; P < 0.05). Table 3 shows the effect of malaria on prenatal mortality based on maternal age, out of 45 pregnant women within the age brackets of 16 -25 years had perinatal mortality and 31.1% and 26.7% of them that had malaria had stillbirth and miscarriage respectively. Also pregnant women with age brackets of 26-35 years who had malaria, 31.0% and 52.4% had stillbirth and miscarriage respectively. A total of 37 women within age brackets of 36-45 years had perinatal mortality and 5.4% and 29.7% of them that had malaria had stillbirth and miscarriage respectively. Out of 3 women that are within age brackets of 46 -55 years had perinatal mortality but 66.7% of those that had malaria had miscarriage and 33.3% of those that do not have malaria had stillbirth. There is a signifi cant effect of malaria on perinatal mortality based on maternal age among pregnant women in FMC, Owerri (x 2 = 40.11; P < 0.05). Table   4 shows overall prevalence of perinatal mortality based on gravidity, out of 251 primigravida women, 8.0% and 15.9% had stillbirths and miscarriage respectively. Also 401 multigravida women, 4.2% and 8.0% had stillbirth and miscarriage respectively. Those that are grand multigravida, 10.9 and 22.7% had stillbirth and miscarriage respectively whereas those that are great grand multigravida, 18.6% and 27.9% had stillbirth and miscarriage respectively. There is signifi cant relationship between perinatal mortality and gravidity among pregnant women in FMC, Owerri (x 2 = 49.22; P < 0.05). Table 5 shows the effect of malaria on perinatal mortality based on gravidity, out of 60 primigravida women that had perinatal mortality 30.0% and 28.3% of them that had malaria had stillbirth and miscarriage respectively. Also multigravida women who had malaria, 31.6% and 26.5% had stillbirth and    x 2 =23.14; P<0.05

Prevalence of malaria among pregnant women in Federal Medical Centre, Owerri, Imo State, Nigeria
The study revealed that 534 (     In areas where malaria is highly endemic, a protective semiimmunity against Plasmodium falciparum is acquired during the fi rst 10 to 15 years of life, and the majority of malaria-related morbidity and mortality occur in young children. However, in contrast with low malaria prevalence in adults, pregnant women in endemic areas are highly susceptible to malaria, and both the frequency and the severity of disease are higher in pregnant women (Meeusen, et al. 2010). In pregnancy, there is a transient depression of cell-mediated immunity that allows fetal allograft retention but also interferes with resistance to various infectious diseases. Furthermore, cellular immune responses to Plasmodium falciparum antigens are depressed in pregnant women [30].

Effect of Malaria on perinatal mortality among pregnant women in Federal Medical Centre, Owerri, Imo State, Nigeria
A total of 169 (20.8%) of the women had perinatal mortality, 58 (7.1%) had stillbirth and 111(13.7%) had miscarriage. This shows that a total of 645 (79.2%) had life babies. There is also signifi cant relationship between malaria and perinatal mortality among pregnant women in FMC, Owerri (x 2 = 23.14; P < 0.05). The fi nding of this study correlates with the fi nding of [17] whose fi nding revealed malaria as a cause of perinatal death (including stillbirth) in Africa.
The study further revealed that perinatal mortalities were high among great grand multigravida (18.6%) and women with age bracket of 46 -55 years (20.0%). Further analysis also revealed that there is signifi cant effect of malaria on perinatal mortality based on gravidity (x 2 = 48.67; P < 0.05) and maternal age (x 2 = 40.11; P < 0.05). This fi nding is in line with a study in Zaire, Nigeriawhich found out that maternal peripheral infection signifi cantly increased the risk of perinatal death [31]. Fetal mortality is estimated at 15% for P. vivax and around 30% for P. falciparum. Malaria is signifi cantly associated with gravidity and age of the women [32]. According to Seal, Mukhopadhay and Ganguly (2010) common problems for the fetus whose mother are malaria positive include, spontaneous abortion, stillbirth, premature delivery, intrauterine growth restriction, low birth weight, intrauterine fetal death etc. Maternal infection can also be associated with missed abortion, preterm labour, intrauterine growth restriction and intrauterine fetal death [33].

Effect of malaria on preterm delivery among pregnant women in Federal Medical Centre, Owerri, Imo State, Nigeria
The study revealed an overall prevalence or preterm delivery of 19.7%. There is also a signifi cant relationship between malaria and preterm delivery among pregnant women in Federal Medical Centre, Owerri, Imo State, Nigeria (x 2 = 27.58; P < 0.05). Malaria presents a signifi cant impact on the neonates, being associated with increased risk of spontaneous abortion, stillbirth, premature delivery, fetal death, Low Birth Weight (LBW) and fetal/child development retardation in malaria-endemic countries [10,34]. Malaria is also signifi cantly associated with preterm delivery and intra uterine growth retardation [14].
The fi nding further revealed that maternal age of 46-55 and great grand multiparous women experience preterm deliveries of 50.0% and 34.8% more than others respectively. Also there is signifi cant effect of malaria on preterm delivery based on maternal age (x 2 = 49.2; P < 0.05) and gravidity (x 2 = 56.94; P < 0.05). The fi nding of this study correlates with that of De Beaudrap, Turyakira and White [31] which revealed a signifi cant association between the risk of pre-term delivery and the occurrence of a malaria infection among the study group. Malaria in pregnancy not only affects the mother but also has a dangerous sequel for the developing fetus, resulting in premature delivery or intrauterine growth retardation [19].

Effect of malaria on fetal birth weight among pregnant women in Federal Medical Centre, Owerri, Imo State, Nigeria
The study revealed that 23.6% of pregnant women in FMC, Owerri had low birth weight babies. Furthermore, malaria signifi cantly affects birth weight among pregnant women in FMC, Owerri (x 2 = 34.06; P < 0.05). This fi nding correlates with a study of Bardaji, Sigaugue and Menendez [35] who found out that low birth weight, prematurity and risk of dying during infancy was increased among infants born to women with acute peripheral and placental malaria infection. Malaria during pregnancy can result in low birth weight (LBW), an important risk factor for infant mortality [13].
The study further revealed that there is a signifi cant effect of malaria on birth weight based on maternal age (x 2 = 53.82; P < 0.05) and gravidity (x 2 = 65.94; P < 0.05).
Malaria infection during pregnancy can have adverse effects on both mother and fetus, including maternal anemia, fetal loss, premature delivery, intrauterine growth retardation, and delivery of low birth-weight infants (<2500 g or <5.5 pounds), a risk factor for death. The risk is also associated with maternal age and gravidity [33]. Malaria infection during pregnancy has been said to cause infant mortality indirectly through its contribution to low birth weight and premature delivery, and it has been estimated that it would be responsible for 75,000-200,000 infant deaths in the sub-Saharan region [16,36,37]. On the other hand, a study in Zaire found that maternal peripheral infection signifi cantly increased the risk of low birth weight and perinatal death [31].
In contrast to this study, some studies have examined this association. Two studies conducted in Sudan and Uganda, respectively, found that peripheral malaria infection during pregnancy was not associated with low birth weight and increased infant mortality [38,39]. Similarly, another study in Kenya found that peripheral and placental malaria was not associated with post neonatal mortality in both HIV-positive and HIV-negative mothers [40]. The contrast might be from area of study, sample size, time of study and method of data analysis .

Summary of fi ndings
The present work was able to establish: 1. An overall prevalence of low birth weight were 23.6%.
3. All pregnant women within age brackets of 46 -55 years who had malaria had low birth weight babies. 4. Also great grand multigravidae women who had malaria have higher low birth weight babies (21.8%) than other gravidities 5. There is signifi cant effect of malaria on fetal birth weight based on maternal age (x 2 = 53.82; P < 0.05) and gravidity (x 2 = 65.94; P < 0.05)

Conclusion
This study assessed the prevalence of malaria and its adverse fetal outcomes in Federal Medical Centre (FMC), Owerri, Imo State, Nigeria. The prevalence of malaria among pregnant women was found to be relatively high. Also malaria prevalence among the pregnant women were signifi cantly associated with gravidity, gender and level of education.
The study further revealed a signifi cant effect of malaria on perinatal mortality, preterm delivery and birth weight based on gender and gravidity.

Recommendations
1. Malaria is largely a major public health concern with its resultant effect seen in this study population. The study suggests that any meaningful control measures in pregnancy should start as early as possible to curb the menace of miscarriages and still birth.
2. This study indicated that peripheral malaria is still high among the study population and calls for the intensifi ed efforts in malaria control in pregnancy.
3. The study suggests effective therapy since perinatal mortality due to malaria was recorded in this study 4. Preterm deliveries and low fetal birth weight based on gravidity and maternal age groups associated with malaria as identifi ed is a call for program managers to make haste and implement new strategies for malaria control. For example, use of rapid diagnostic tests to screen women for malaria at the fi rst or each antenatal visit and treatment of positive women with artemisinin combination therapies.