title: Towards a strategy for malaria in pregnancy in Afghanistan: analysis of clinical realities and women's perceptions of malaria and anaemia.
abstract: BACKGROUND
  Afghanistan has some of the worst maternal and infant mortality indicators in the world and malaria is a significant public health concern. Study objectives were to assess prevalence of malaria and anaemia, related knowledge and practices, and malaria prevention barriers among pregnant women in eastern Afghanistan.
  
  
  METHODS
  Three studies were conducted: (1) a clinical survey of maternal malaria, maternal anaemia, and neonatal birthweight in a rural district hospital delivery-ward; (2) a case-control study of malaria risk among reproductive-age women attending primary-level clinics; and (3) community surveys of malaria and anaemia prevalence, socioeconomic status, malaria knowledge and reported behaviour among pregnant women.
  
  
  RESULTS
  Among 517 delivery-ward participants (1), one malaria case (prevalence 1.9/1000), 179 anaemia cases (prevalence 346/1000), and 59 low-birthweight deliveries (prevalence 107/1000) were detected. Anaemia was not associated with age, gravidity, intestinal parasite prevalence, or low-birthweight at delivery. Among 141 malaria cases and 1010 controls (2), no association was found between malaria infection and pregnancy (AOR 0.89; 95 % CI 0.57-1.39), parity (AOR 0.95; 95 % CI 0.85-1.05), age (AOR 1.02; 95 % CI 1.00-1.04), or anaemia (AOR 1.00; 95 % CI 0.65-1.54). Those reporting insecticide-treated net usage had 40 % reduced odds of malaria infection (AOR 0.60; 95 % CI 0.40-0.91). Among 530 community survey participants (3), malaria and anaemia prevalence were 3.9/1000 and 277/1000 respectively, with 34/1000 experiencing severe anaemia. Despite most women having no formal education, malaria knowledge was high. Most expressed reluctance to take malaria preventive medication during pregnancy, deeming it potentially unsafe.
  
  
  CONCLUSIONS
  Given the low malaria risk and reported avoidance of medication during pregnancy, intermittent preventive treatment is hard to justify or implement. Preventive strategy should instead focus on long-lasting insecticidal nets for all pregnant women.
authors.affiliation: London School of Hygiene and Tropical Medicine (LSHTM), London, UK. natasha.howard@lshtm.ac.uk.
authors.forename: Natasha
authors.initials: N
authors.lastname: Howard
authors.affiliation: HealthNet-TPO (HNTPO), Kabul, Afghanistan. sayedenayat@gmail.com.
authors.forename: Sayed
authors.initials: S
authors.lastname: Enayatullah
authors.affiliation: Health Protection and Research Organization (HPRO), Kabul, Afghanistan. nader.mohammad@googlemail.com.
authors.forename: Nader
authors.initials: N
authors.lastname: Mohammad
authors.affiliation: Health Protection and Research Organization (HPRO), Kabul, Afghanistan. drmayan2006@gmail.com.
authors.forename: Ismail
authors.initials: I
authors.lastname: Mayan
authors.affiliation: Care International, Kabul, Afghanistan. zohrashamszai@yahoo.com.
authors.forename: Zohra
authors.initials: Z
authors.lastname: Shamszai
authors.affiliation: London School of Hygiene and Tropical Medicine (LSHTM), London, UK. mark.rowland@lshtm.ac.uk.|HealthNet-TPO (HNTPO), Kabul, Afghanistan. mark.rowland@lshtm.ac.uk.
authors.forename: Mark
authors.initials: M
authors.lastname: Rowland
authors.affiliation: HealthNet-TPO (HNTPO), Kabul, Afghanistan. toby.leslie@lshtm.ac.uk.|Health Protection and Research Organization (HPRO), Kabul, Afghanistan. toby.leslie@lshtm.ac.uk.
authors.forename: Toby
authors.initials: T
authors.lastname: Leslie
mesh_terms: D000293:Adolescent; D000328:Adult; D000346:Afghanistan / Q000453:epidemiology; D000740:Anemia / Q000453:epidemiology* / Q000517:prevention & control; D016022:Case-Control Studies; D018562:Disease Transmission, Infectious / Q000517:prevention & control; D062665:Epidemiological Monitoring; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006767:Hospitals, District; D006801:Humans; D007231:Infant, Newborn; D008288:Malaria / Q000150:complications* / Q000453:epidemiology* / Q000517:prevention & control; D008875:Middle Aged; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology* / Q000517:prevention & control; D015995:Prevalence; D012307:Risk Factors; D012424:Rural Population; D055815:Young Adult