The health of pregnant women in rural Tanzania with specific emphasis on anaemia and the impact of socially marketed insecticide treated bednets

Anaemia in pregnancy is one of the main maternal health problems globally,
affecting over 50% of pregnant women in sub-Saharan Africa. Although not
always shown to have a causal link, severe anaemia contributes to maternal
morbidity and mortality and to poor pregnancy outcomes and infant survival. The
work encompassed in this thesis describes fertility and health in pregnancy with a
specific emphasis on anaemia. In addition, the applicability of ITNs for the
prevention of malaria and anaemia in pregnancy is examined in more detail. In Part II of the thesis, achieved fertility and the family building preferences of
women are described. A high fertility setting is described in which there is also a
high incidence of late pregnancy loss, which increases the exposure of women to
poor maternal health outcomes. There were indications of an increasing desire
for fertility regulation methods, especially amongst teenagers. This was
evidenced principally by high levels of unmet need amongst teenagers for family
planning methods, and through focus group discussions which highlighted
induced abortion as a pressing concern for the health of young women. In Part III of the thesis the magnitude of anaemia as a health problem in
pregnancy is discussed. In Kilombero over three-quarters of pregnant women
were anaemic, 11% severely so, which defines the area as high risk. Multiple
risk factors for anaemia were present and there was a sharp seasonal peak. In
this study malaria and iron deficiency were both important contributors.
Unmarried women, both primigravidae and multigravidae, were at increased risk
of being severely anaemic suggesting that socio-economic vulnerability also
plays an important role. The relevance of pregnancy anaemia as a public health
issue was underlined by our findings that, independent of other factors, anaemia
in pregnancy was associated with a three-fold increase in infant mortality risk. In Part IV the impact of socially-marketed insecticide treated nets on pregnancy
and child morbidity was reported. Social marketing proved to be a highly
successful tool for delivering ITNs with a rapid increase in uptake of the product.
At the time of these impact surveys 61% of under two year olds and 53% of
pregnant women were ITN users. This was the first evaluation of the impact of
ITNs on morbidity under programme conditions. ITN use was associated with a
reduction of 38% of all cases of severe anaemia in pregnancy and 63% of all
cases in children under two years of age. It is recommended that ITNs be
promoted at every level for use by pregnant women and children. Women in the Kilombero Valley have a high life-time risk of dying due to
pregnancy related causes, typical of the sub-Saharan Region as a whole. They
are exposed to the three biggest contributors to ill health: poverty, malnutrition
and infectious disease, especially malaria. Approaches for tackling these
problems using complimentary strategies are discussed. However, due to the
multi-level benefits of ITN use in pregnancy – through protection of the pregnant
woman, her growing foetus, and subsequently impacting on infant health -
insecticide-treated bednets, together with improved campaigns for highlighting
the needs of pregnant women, are indicated as the principal way forward to
better health.