Factors associated with malaria in pregnancy among women attending ANC Clinic in Kwadaso Municipality, Ghana: a health facility based cross-sectional study

Abstract

Background

Globally, malaria remains a critical public health challenge, particularly in sub-Saharan Africa. Pregnant mothers are at a relatively higher risk of severe malaria than their non-pregnant counterparts due to natural immune suppression. In Ghana, the prevalence of malaria during pregnancy poses significant risks to maternal and fetal health. The primary aim of this study was to determine the factors associated with malaria in pregnancy among women attending ANC clinics in the Kwadaso Municipal, Ghana.

Method

This study employed a cross-sectional design to gather quantitative data from 405 pregnant women using a multistage sampling method. Data were collected through structured questionnaires administered. Descriptive and inferential statistics, including frequency tables, percentages, and regression analysis using Stata 17, were utilized for data analysis.

Results

Out of the 405 participants, 201 (49.6%) tested positive for malaria, while the knowledge level of malaria among pregnant women was 16.5%. Bivariate logistic regression was conducted to determine the factors influencing malaria among pregnant women. The results showed that pregnant women aged 17 to 25 years are 5.41 times more likely to have high malaria prevalence compared to 40 to 51 age group (cOR = 5.41, 95% CI [2.20–6.83], p = 0.015). Pregnant women who do not use insecticide-treated bed nets regularly users are 10.3 times more likely to have high malaria compared to users (cOR = 10.3, 95% CI [4.05–11.02], p < 0.001). Multivarite logistic regression also showed that Women earning between 100 to 500 cedis are 7.0 times more likely to have malaria compared to those earning 3000 cedis or more (aOR = 7.0, 95% CI [3.23–8.74], p = 0.003). Women who do not regularly use insecticide-treated bed nets are 15.0 times more likely to experience high malaria prevalence compared to those who do use them (aOR = 15.0, 95% CI [7.03–16.09], p < 0.001), Lack of mosquito nets significantly increases the likelihood of 9.53 times high malaria prevalence (aOR = 9.53, 95% CI [4.07–10.95], p = 0.003). Pregnant women with Junior High School (JHS) education are 3.50 times more likely to have high malaria compared to those with no formal education (aOR = 3.50, 95% CI [1.32–4.78], p = 0.002).

Conclusion

This study highlights the significant burden of malaria among pregnant women in Kwadaso Municipal. Factors such as age, education levels, and socioeconomic status were identified as key determinants of malaria diagnosis. Additionally, environmental and preventive factors, including insufficient use of insecticide-treated bed nets and proximity to stagnant water, contributed to the likelihood of malaria. The study suggests that the Ghana Health Service and Ministry of Health should improve access to insecticide-treated bed nets, enhance malaria awareness, and integrate regular malaria screening into antenatal care.

Introduction

Background

In regions with limited access to healthcare and resources, a persistent global health challenge is the prevalence of diseases such as malaria [1]. As a complex illness with highly variable epidemiology and clinical presentations, it remains one of the leading causes of death worldwide [2]. Traditionally, diagnosis has primarily focused on signs and symptoms [2], leading to presumptive treatment of the disease. This practice has resulted in the misuse of anti-malarial drugs, inefficient resource use, and unnecessary suffering, especially when fever is accompanied by other illnesses [3]. Pregnant women and children under five are particularly vulnerable to this parasitic infection [3], with this group experiencing high morbidity and mortality rates that pose a significant public health concern [4]. In Africa, where 90% of malaria deaths occur, a child succumbs to the disease every minute [5]. Pregnant women face a heightened risk of severe infection due to natural immune suppression during pregnancy [5]. This condition is a major public health issue in tropical and subtropical regions [3], where it leads to serious complications such as maternal anemia, miscarriage, stillbirth, premature birth, and low birth weight, all contributing to increased maternal and infant mortality and morbidity [1]. Infections in the placenta during pregnancy are closely linked to maternal anemia [4].

According to the World Health Organization, in 2013, approximately 528,000 deaths were attributed to malaria globally, with about 78% of these deaths occurring in sub-Saharan Africa [5]. Many public healthcare facilities were found to lack essential diagnostic tools like microscopes, limiting effective diagnosis [6]. In 2022, nearly half of the global population was at risk of malaria [7]. While sub-Saharan Africa bears the heaviest burden, other regions—including South-East Asia, the Eastern Mediterranean, Western Pacific, and the Americas—also report significant numbers of cases and deaths [7]. An estimated 249 million cases of malaria occurred in 2022, with 608,000 deaths, of which the African Region accounted for 94% of cases and 95% of deaths [7]. Vulnerable groups, particularly pregnant women and children under five, represented nearly 80% of all malaria deaths in the WHO African Region that year [7].

Globally, the prevalence of malaria has shown a gradual decline over the years, but it continues to be a major public health challenge [8]. According to the World Health Organization, in 2020, there were approximately 241 million cases of malaria reported [9], most malaria cases and deaths indeed occurred in sub-Saharan Africa, accounting for about 95% of all malaria cases and deaths, which aligns with your assertion that sub-Saharan Africa bears the brunt of the burden [10]. In endemic areas, the burden of malaria on pregnant women is exacerbated by factors such as limited access to antenatal care, inadequate use of preventive measures like insecticide-treated bed nets, and challenges in accessing appropriate antimalarial treatments [11]. In combating the spread of malaria, insecticide-treated bed nets (ITNs) have emerged as a crucial intervention [12]. ITNs are recommended for use by the World Health Organization (WHO) and have been implemented in both developed and developing countries [13]. These efforts are integral to achieving the Sustainable Development Goals (SDGs) target of ending malaria epidemics by 2030 [14]; and [12]. However, despite these initiatives, challenges persist in ensuring universal access and consistent utilization of ITNs, especially among caregivers with children under five years old [15]. In developed countries, ITNs are primarily used by travellers to malaria-endemic areas to prevent malaria transmission [15].

In developing countries, ITNs are distributed through mass distribution campaigns and are primarily used by children under five years and pregnant women [16]. These nets act as a physical barrier, effectively preventing mosquito bites during sleep and subsequently reducing the risk of malaria transmission [17]. Their effectiveness in reducing malaria cases, particularly among vulnerable populations such as children under five, has been well-documented in numerous studies and public health initiatives [18].

However, several contextual factors intricately influence ITN utilization among caregivers with children under five [19] Socio-economic disparities, varying cultural beliefs, geographical accessibility to healthcare facilities, educational backgrounds, and past exposure to health interventions significantly impact the adoption and sustained use of ITNs within communities [20]. Emerging challenges such as resistance to insecticides, issues related to ITN durability, and behavioural factors affecting sustained utilization highlight the need for updated and context-specific data [20]. In Ghana, malaria continues to be a major public health concern, with an estimated 5.5 million cases and 16,000 deaths reported in 2019 [21]. In response, insecticide-treated nets (ITNs) have been introduced as part of the country’s national malaria prevention strategy [22]. According to the 2019 Ghana Malaria Indicator Survey, 74% of households owned at least one ITN [23].

Although significant progress has been made in malaria control, malaria in pregnancy remains a major public health concern in sub-Saharan Africa, including Ghana. While national studies highlight the burden of malaria, they often overlook localized factors, such as socio-demographic and healthcare-related influences, that may vary across municipalities. Despite ongoing interventions, such as the use of insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp), malaria remains a leading cause of morbidity and mortality among pregnant women in Ghana. In the Kwadaso Municipality, there is limited data on the factors influencing malaria in pregnancy, which hinders the development of targeted interventions to address this critical public health issue. While the World Health Organization (WHO) recommends IPTp and ITNs as key preventive strategies, their adherence and effectiveness can vary significantly due to differences in local healthcare systems, education levels, and cultural practices. However, data on these contextual factors in Kwadaso Municipality is sparse, creating a significant gap in understanding how to tailor interventions effectively. This study seeks to fill this gap by identifying the specific socio-demographic, behavioral, and healthcare-related factors associated with malaria in pregnancy among women attending ANC clinics in the region. Therefore, this study sought to determine factors associated with malaria in pregnancy among women Attending ANC Clinic in Kwadaso Municipality Hospital of Ghana.

Materials and methods

Study design and data source

To carry out the study, a facility-based cross-sectional study design was used. In population-based research like this one, cross-sectional study designs were suitable. Cross-sectional designs, when compared to other study designs, were cheaper and offered an objective way to quantify phenomena over a relatively short period of time without the requirement for participant follow-up. Despite the above advantages, cross-sectional studies were liable to biases such as nonresponse bias and recall bias.

Study site description

The study was conducted in Kwadaso Municipal. Kwadaso Municipal has a population of approximately 251,215, where the growing population puts pressure on healthcare facilities. The district is equipped with 20 health facilities but faces a high malaria incidence. The municipality has operational health facilities, which include district hospital, health centres, and Community-Based Health Planning and Services (CHPS) compounds. To combat malaria, preventive measures such as the distribution of insecticide-treated nets (ITNs), intermittent preventive treatment in pregnancy (IPTp), and public health education campaigns are actively implemented. These interventions have shown moderate success in reducing malaria prevalence; however, gaps in adherence to preventive measures and challenges in healthcare access contribute to the persistently high malaria incidence in the munciplaity.

Study population

The target population consisted of pregnant women attending antenatal clinics at municipal hospitals. The study population included pregnant women attending ANC within the Kwadaso Municipality. The choice this population was necessitated by the fact that, pregnant women are at higher risk of having malaria.

Sampling strategy

A multi-stage sampling approach was used to study the factors associated with malaria in pregnancy among women attending ANC clinics. First, five sub-districts were randomly selected within the municipality based on malaria prevalence, using data from the 2022 Ghana Demographic and Health Survey (GDHS), the 2019 Malaria Indicator Survey (MIS), and the District Health Directorate. In each selected sub-district, one general government hospital, three health centers, and one Community-Based Health Planning and Services (CHPS) compound were randomly chosen from a list of operational facilities. Pregnant women attending ANC at each facility were systematically selected from the daily attendance list. The sampling interval (e.g., every 5 th person) was calculated based on the average daily attendance and the target sample size for each facility. A random starting point was used to ensure unbiased selection. For example, if the target sample was 10 participants and the attendance list had 50 entries, every 5 th woman was selected. This systematic sampling ensured diverse representation across different settings with varying malaria prevalence. The study involved both higher-level (hospitals) and lower-level (health centers, CHPS compounds) health facilities. This methodology provided a comprehensive approach to understanding malaria in pregnancy across various sub-districts in the municipality.

Sample size determination

The sample size of the study was determined using Cochran's (1977) formula.

The formula utilized will be:

$$n=\frac{{z}^{2}\times p(1-p)}{{d}^{2}}$$

where:

n = Sample size.

Z = The z-score that corresponds with a 95% confidence level, typically 1.96.

P = Estimated prevalence of malaria among pregnant women, based on the study by [24], which found the self-reported prevalence of at least one episode of malaria to be 76.7% (95% CI [74.1–79.3%]).

d = Margin of error set at 4.12% (0.0412).

$$\begin{array}{c}n=\frac{1.96^2\times0.176\times\left(1-0.176\right)}{1-0.176}\\=384\\384\end{array}$$

To account for potential non-response and incomplete data, we added 10% to the minimum sample size, bringing the final sample size to 405 pregnant women.

Data collection methods and instruments

The study used structured, self-administered questionnaires to collect data. The data collection instrument was adapted from the literature and modified to suit the specific objectives of the study. The questionnaire was structured into four components. The first component contained only closed-ended questions, designed to assess respondents’ socio-demographic characteristics such as age, sex, and educational background, while the second and third components were based on the study's objectives. Interviewers, trained in both questionnaire administration and ethical considerations, were recruited from peers. The two-day training session equipped them with a thorough understanding of the questionnaire and ensured adherence to ethical protocols during data collection. The study was conducted from June 2024 to August 2024, covering a period of three months. The study employed a mixed approach, some questionnaires were self-administered, while others were interviewer-administered depending on the participant’s literacy level and preference.

Ethics approval and consent to participate

This study was approved by the University of Health and Allied Sciences Research Ethics Committee (UHAS-REC) under reference number UHAS-REC B.10 [086]23–24. Prior to data collection, permission was obtained from the Kwadaso Health Directorate to conduct the research. Informed consent was obtained from all participants before their involvement in the study. For participants aged under 18 years, written informed consent was obtained from their parents or legal guardians, as well as verbal assent from the minors themselves to ensure their understanding and willingness to participate. This dual consent process was reviewed and approved by UHAS-REC to adhere to ethical standards for research involving minors.

For participants aged 18 years and above, informed consent was provided either through written signatures or thumbprints. Additionally, verbal consent was sought to ensure full comprehension for participants who required further explanation or clarification. Confidentiality was maintained by using pseudonyms, and data was securely stored in an encrypted, password-protected database. Access to the data was restricted to the Principal Investigator and the research supervisor.

Study variables

Outcome variables

Prevalence of Malaria in Pregnancy

These variable measures the proportion of pregnant women attending ANC clinics diagnosed with malaria. Malaria cases among pregnant women were identified based on test results from approved healthcare centers. In addition to participant-reported malaria episodes, the study cross-referenced diagnoses with documented records in ANC booklets. The frequency of malaria diagnoses was obtained from two sources: participant self-reporting and cross-referencing with documented records in ANC booklets. Malaria diagnoses were based on test results from approved healthcare centers, CHPS and government hospital. The data collectors reviewed patient records from ANC booklets to verify self-reported malaria episodes. Ethics approval for this study covered the use of both participant-reported data and the review of ANC records.

Knowledge of malaria

This variable evaluates the level of awareness among pregnant women regarding malaria transmission, prevention, and treatment.

Explanatory variables

The explanatory variables included socio-demographic factors (such as age, gender, education level, income, and marital status), knowledge-related, Health-Related Factors, Environmental and Geographic Factors, Behavioural Factors and access factors served as explanatory variables influencing these outcomes.

Statistical Analysis

Data gathered from participants were input into the Kobo Collect application and subsequently exported to STATA v17.0 for analysis. To ensure data quality, a double-checking process was implemented to correct any discrepancies that arose during data entry. Descriptive statistics were utilized to analyse all numerical data. To determine associations between variables, p values less than 0.05 from Chi-square tests and logistic regression were considered statistically significant at a 95 percent confidence interval. The results were presented in tables and figures.

Result

Socio Demographic Characteristic

Table 1 presents the socio- demographic of participants. The mean age is 29 years (SD = 1.80), with 238 (58.7%) in the 26 to 39-year age group out of 405 participants. In terms of religion, 200 (49.3%) are Christian, while 166 (40.9%) practice Islam. Ethnic distribution shows that 380 (93.8%) are Akan, follow by Ewe 11 (2.7%) and Ga/Dangme 9(2.2%). Educational levels vary with 83 (20.4%) have no formal education, 61 (15.0%) completed JHS, 61 (15.0%) completed Primary education, 116 (28.6%) have SHS/SSS/O Level/A Level, and 84 (20.7%) have tertiary education. Out of the 405 pregnant women 299(73.8%) are married, while 17 (4.2%) are divorced or separated, 72 (17.7%) are never married, and 17 (4.2%) are widowed and 389 (96.1%) have valid health insurance. For income, 120 (36.8%) earn 3000 cedis or more, 79 (24.2%) earn between 1100 to 2500 cedis, 100 (30.6%) earn between 100 to 500 cedis, and 27 (8.2%) earn between 600 to 1000 cedis.

Table 1 Socio- Demographic of Characteristics

Proportion of Pregnant women Diagnosed with Malaria

Table 2 provides an overview of malaria Proportion of Pregnant Women Diagnosed with Malaria during pregnancy among the 405 individuals surveyed. Of the participants, 204 (50.4%) were not diagnosed with malaria during their pregnancy, while 201 (49.6%) were diagnosed. Regarding the number of times diagnosed with malaria, 9 (5.1%) were diagnosed more than three times, 94 (53.1%) were diagnosed once, and 74 (41.8%) were diagnosed twice. In terms of insecticide-treated bed net use, 330 (81.5%) regularly use them, whereas 75 (18.5%) do not. For Intermittent Preventive Treatment in pregnancy (IPTp), 268 (66.2%) of participants reported receiving at least one dose of IPTp-SP, while 137 (33.8%) had not received any dose.

Table 2 Proportion of pregnant women diagnosed with Malaria

Proportion of Pregnant Women Diagnosed with Malaria

Figure 1 presents the proportion of pregnant women diagnosed with malaria. Out of the 405 participants, 201 (49.6%) tested positive for malaria (classified as'malaria positive'), while 204 (50.4%) did not have a recorded malaria diagnosis (classified as'malaria negative').

Fig. 1

Proportion of Pregnant Women Diagnosed with Malaria

Knowledge Level of Malaria

Table 3 shows the knowledge level of malaria among the 405 participants. Most individuals, 388 (95.8%), have heard of malaria before, while 17 (4.2%) have not. Regarding malaria transmission and causation, 351 (86.7%) correctly identified mosquito bites as the primary mode of transmission. However, malaria is caused by the Plasmodium parasite, which is transmitted through the bite of an infected female Anopheles mosquito. Meanwhile, 29 (7.2%) incorrectly believed malaria is caused by contaminated water, and 25 (6.2%) thought it was airborne. For symptoms, 351 (86.7%) are aware of them, whereas 54 (13.3%) are not. In terms of prevention during pregnancy, 297 (73.3%) know that insecticide-treated bed nets are effective, 63 (15.6%) recognize intermittent preventive treatment, and 45 (11.1%) are aware of antimalarial medication. The primary sources of information about malaria are healthcare providers with 352 (86.9%), followed by family and friends 37 (9.1%), and media 16 (4.0%).

Table 3 Knowledge Level of Malaria

Overall, Knowledge Level of Malaria

The overall knowledge level of malaria among pregnant women was assessed using a composite score derived from responses to the following questions:'Heard of malaria before'and'Symptoms of malaria,'with answers coded as'Yes'or'No.'To determine whether a participant had'Low'or'High'knowledge, their responses were summed to create a composite score. Participants were then classified based on the percentile rank of their scores. Those with composite scores below the 25 th percentile were classified as having'Low'knowledge, while those with scores at or above the 75 th percentile were classified as having'High'knowledge.

Figure 2 shows that, out of the 405 participants, 338 (83.5%) were categorized as having'High'knowledge, and 67 (16.5%) were categorized as having'Low'knowledge."

Fig. 2

Overall, Knowledge Level of Malaria

Factors Associated with Malaria among Pregnant Women

Table 4 shows that 289 participants (71.3%) regularly use insecticide-treated bed nets while sleeping. Risk factors for malaria identified by participants included lack of mosquito nets 190 participants (46.9%), standing water around residences 162 participants (40.0%), and poor drainage 53 participants (13.0%). Regarding malaria prevention measures, 253 participants (62.4%) reported eliminating standing water around their homes, 79 (19.5%) consistently used mosquito repellents, and 73 (18.0%) sought early treatment when feeling unwell.

Table 4 Factors Associated with Malaria among Pregnant Women

Bivariate Logistic Regression of Factors Associated with Malaria

Table 5 shows bivariate logistic regression was conducted to determine the factors influencing associated with malaria. The results indicate that women aged 26 to 39 years are 0.82 times less likely to have high malaria prevalence compared to those aged 40 to 51 years (cOR = 0.82, 95% CI [0.52–0.97], p < 0.001). Women aged 17 to 25 years are 5.41 times more likely to have high malaria prevalence compared to the reference group (cOR = 5.41, 95% CI [2.20–6.83], p = 0.015). Women practicing Christianity are 0.23 times less likely to have high malaria prevalence compared to those practicing African Traditional religion (cOR = 0.23, 95% CI [0.01–0.31], p = 0.009). Conversely, women of the Islam faith are 3.05 times more likely to have high malaria prevalence compared to those of African Traditional religion (cOR = 3.05, 95% CI [1.50–4.8], p = 0.039). In terms of educational level, women with a primary education are 3.13 times more likely to have high malaria prevalence compared to those with no formal education (cOR = 3.13, 95% CI [1.1–2.31], p = 0.009). Marital status reveals that never married women are 2.63 times more likely to have high malaria prevalence compared to divorced or separated women (cOR = 2.63, 95% CI [1.21–3.84], p = 0.406).

Table 5 Bivariate logistic regression of factors associated with Malaria

The analysis also indicates that women without valid health insurance are 42% less likely to have high malaria prevalence compared to those with health insurance (cOR = 0.58, 95% CI [0.61–0.073], p = 0.002). In terms of income, women earning between 600 to 1000 cedis are 3.89 times more likely to have high malaria prevalence compared to those earning 100 to 500 cedis (cOR = 1.38, 95% CI [1.38–4.08], p = 0.017). Pregnant women who do not use insecticide-treated bed nets regularly users are 10.3 times more likely to have high malaria compared to users (cOR = 10.3, 95% CI [4.05–11.02], p < 0.001). Additionally, women lacking mosquito nets are 7.03 times more likely to have high malaria prevalence compared to those with adequate access (cOR = 7.03, 95% CI [4.10–9.55], p < 0.001. Women who clean stagnant water around the house have a lower likelihood of high malaria prevalence (cOR = 0.01, 95% CI [0.09–0.53], p = 0.000).

Multivariable Logistic Regression of Factors Associated with Malaria

Table 6 shows that women aged 26 to 39 years are 2.01 times more likely to have high malaria prevalence compared to those aged 40 to 51 years (aOR = 2.01, 95% CI [1.12–3.60], p = 0.018). Women aged 17 to 25 years show a significant increase in likelihood, being 9.26 times more likely to have high malaria prevalence compared to the 40 to 51 age group (aOR = 9.26, 95% CI [3.52–12.05], p < 0.001). Pregnant women practicing Christianity have 2.14 times higher odds of high malaria compared to African Traditional religion (aOR = 2.14, 95% CI [1.2–3.6], p = 0.006). Pregnant women practicing Islam are also 6.41 times more likely to have malaria prevalence compared to those in the African Traditional religion (aOR = 6.41, 95% CI [2.13–7.61], p < 0.001). Pregnant women with Junior High School (JHS) education are 3.50 times more likely to have high malaria prevalence compared to those with no formal education (aOR = 3.50, 95% CI [1.32–4.78], p = 0.002). Those with Primary education are similarly at increased risk (aOR = 5.41, 95% CI [2.22–6.76], p = 0.004), indicating that lower education levels are associated with higher malaria prevalence. Conversely, women with Tertiary education are 50% less likely to have high malaria prevalence (aOR = 0.50, 95% CI [0.32–0.78], p = 0.002), suggesting that higher educational attainment may confer some protective benefits. Married women are 83% less likely to have high malaria prevalence compared to those who are divorced/separated (aOR = 0.17, 95% CI [0.03–0.98], p = 0.048).

Table 6 Multivariable logistic regression of factors associated with malaria diagnosis

Moreover, women without valid health insurance are 1.30 times more likely to have high malaria prevalence compared to those with insurance (aOR = 1.30, 95% CI [1.15–4.59], p < 0.001). Women earning between 100 to 500 cedis are 7.0 times more likely to have malaria prevalence compared to those earning 3000 cedis or more (aOR = 7.0, 95% CI [3.23–8.74], p = 0.003). Women who do not regularly use insecticide-treated bed nets are 15.0 times more likely to experience high malaria prevalence compared to those who do use them (aOR = 15.0, 95% CI [7.03–16.09], p < 0.001), Lack of mosquito nets significantly increases the likelihood of 9.53 times high malaria prevalence (aOR = 9.53, 95% CI [4.07–10.95], p = 0.003), Living near stagnant water is also a significant risk factor, with an aOR of 4.03 (95% CI [2.07–5.01], p < 0.001), suggesting that environmental factors contribute to malaria risk. Consistent use of mosquito repellents is associated with lower odds of high malaria prevalence (aOR = 0.34, 95% CI [0.39–0.73], p = 0.000) while seeking early treatment when feeling unwell is significantly protective against high malaria prevalence (aOR = 0.30, 95% CI [0.15–0.59], p < 0.001).

Discussion

This study was a cross-sectional quantitative study which sought to determine study malaria prevalence among pregnant women attending the Antenatal Care (ANC) clinic in Kwadaso Municipality, Ghana, provides valuable insights into the factors influencing malaria risk during pregnancy. This discussion synthesizes the findings, emphasizing the implications for public health and future research.

The study found that 49.6% of the 405 surveyed pregnant women were diagnosed with malaria. This prevalence is consistent with other studies in sub-Saharan Africa, where malaria rates among pregnant women often range from 30% to over 50% [25]. The high prevalence underscores the need for effective preventive measures, particularly in areas where malaria is endemic. This study contradicts with [26], which reported a prevalence of 8.70% in Ibadan, Nigeria, while [27] shows a much higher rate of 65.6% in Akure South Local Government, Nigeria [27]; [28]. Afolabi et al. [27] indicates a prevalence of 48% among pregnant women in six health care centers [27]. Interestingly, the prevalence rates vary significantly based on factors such as geographical location, HIV status, and trimester of pregnancy. For instance, [29] notes that the prevalence of malaria among HIV-positive pregnant women ranges between 31–61%, while for non-HIV infected pregnant women, it stands between 10–36% [29] [30] reports a much lower prevalence of 47.6 per mile in Pesawaran, Lampung Province, Indonesia [30]. The study revealed that while 95.8% of participants had heard of malaria, only 66.2% received Intermittent Preventive Treatment (IPTp) during pregnancy. This gap between awareness and action is echoed in another research. The findings suggest that knowledge alone is insufficient; there must be targeted interventions to enhance access to and adherence to preventive treatments. Several studies reported varying levels of IPTp-SP uptake among pregnant women. In [31] 87% of participants received SP in different doses, knowledge about IPTp was associated with increased uptake in some studies. [32] reported that knowledge about IPTp was significantly associated with higher uptake (p < 0.001). Similarly, [33] found that maternal knowledge of IPTp-SP benefits and optimal dosage were predictors of optimal uptake. Interestingly, [34] focused on healthcare workers’ knowledge, finding that while 62.2% were aware of current WHO IPTp-SP recommendations, only 39.1% had correct knowledge of it. This suggests potential gaps in provider knowledge that could impact patient education and IPTp-SP administration.

The overall knowledge level regarding malaria was high among participants, with 83.5% categorized as having a high level of knowledge. This finding contrasts with a study conducted by [35], where only 60% of pregnant women demonstrated adequate knowledge about malaria prevention. The difference may reflect variations in educational outreach and health education programs across different regions. Nevertheless, the study highlights the importance of continuous education to bridge the gap between knowledge and practice. The study found that younger women (17–25 years) were significantly more likely to have high malaria prevalence compared to older age groups. This finding aligns with existing literature indicating that younger mothers are at increased risk due to lower health-seeking behaviors and knowledge about malaria prevention.

Several papers reported higher malaria prevalence in younger women. [36] found that women aged 17–20 years had the highest prevalence (88.4%), followed by those aged 21–25 years (79.1%), while women over 25 years had the lowest prevalence (67.7%). Similarly, [28] reported that women aged ≤ 25 years had the highest malaria prevalence rate of 55.8%. [37] also noted higher odds of malaria prevalence in younger age groups compared to those over 54 years old. Interestingly, [38] found that adolescents (10–19 years) had a higher prevalence of sexually transmitted infections, with 12% testing HIV positive and 10% syphilis positive, compared to older age groups. This suggests that younger women may be at higher risk for multiple infectious diseases, not just malaria. Additionally, educational attainment emerged as a critical factor; women with primary education were more likely to contract malaria than those with no formal education. where lower educational levels were linked to higher malaria prevalence among pregnant women Conversely, women with tertiary education were less likely to have high malaria prevalence, suggesting that higher educational attainment may confer protective benefits against malaria. This observation is supported by research indicating that education enhances health literacy and access to preventive resources. The association between socioeconomic status and malaria prevalence is another critical finding. The study indicated that women without health insurance faced higher risks of malaria. This finding resonates with literature from various African countries, where economic barriers significantly hinder access to healthcare services and preventive measures Low socioeconomic status was found to be strongly associated with increased malaria risk and transmission. In KwaZulu-Natal, South Africa, factors like lack of toilet facilities, no formal education, and lack of electricity supply were significant predictors of malaria disease [39]. Similarly, in Cameroon, there was a significant association between malaria and malnutrition, with malnutrition being strongly linked to malaria status [40]

Interestingly, the strength of this association varied across different regions. A multi-country assessment in Sub-Saharan Africa revealed strong socioeconomic inequalities in malaria prevalence both between and within countries, with Eastern African countries showing higher inequality relative to wealth index compared to other regions [41]. In Uganda, children from the highest wealth quintile had significantly lower odds of malaria infection compared to poorer households [42]. The use of insecticide-treated bed nets (ITNs) was emphasized in the study, showing that non-users were significantly more likely to experience high malaria prevalence. This finding is consistent with numerous studies across Africa demonstrating that ITN usage is one of the most effective strategies for reducing malaria transmission among pregnant women. Furthermore, the emphasis on environmental factors such as living near stagnant water aligns with other research indicating that environmental modifications can significantly reduce mosquito breeding sites. Behavioural factors also play a role; for example, the study noted that women who clean stagnant water around their homes had a lower likelihood of high malaria prevalence. In fact, the studies consistently show that the presence of stagnant water near homes is associated with increased malaria risk. [3] reports that children living in households with stagnant water in the compound had significantly higher odds of malaria (AOR = 6.7, 95% CI: 3.6–12.6). [43] found that the presence of stagnant water around homes was statistically significantly associated with malaria-helminth coinfection in children (p < 0.05). [44] states that patients living in areas with stagnant water were more likely to be infected with malaria parasites (AOR = 16.191, 95% CI: 9.137, 28.692) compared to those living away from stagnant water. While the studies do not specifically mention cleaning stagnant water as a preventive behaviour, they consistently recommend drainage of stagnant water as a potential intervention to reduce malaria prevalence. This suggests that removing stagnant water, rather than just cleaning it, may be more effective in reducing malaria risk.

Conclusion

This study highlights the significant burden of malaria among pregnant women in Kwadaso Municipal. Factors such as age, education levels, and socioeconomic status were identified as key determinants of malaria diagnosis. Additionally, environmental and preventive factors, including insufficient use of insecticide-treated bed nets and proximity to stagnant water, contributed to the likelihood of malaria. The study suggests that the Ghana Health Service and Ministry of Health should improve access to insecticide-treated bed nets, enhance malaria awareness, and integrate regular malaria screening into antenatal care.

Strength and limitation of the study

This study has notable strengths, including a relatively large sample size of 405 participants and the identification of key risk factors such as maternal age, education level, and ITN usage, which contribute valuable insights to malaria prevention efforts among pregnant women. Additionally, the study provides relevant data to inform public health strategies in similar settings.

However, several limitations must be acknowledged. The cross-sectional study design limits the ability to establish causal relationships between the identified risk factors and malaria outcomes. The reliance on self-reported data, especially concerning ITN use and health behaviors, introduces the potential for recall or social desirability bias. Moreover, the findings may not be generalizable to other populations or regions, as the study was conducted in a single hospital setting within a specific geographic area.