Cited by 148Malaria Research and ControlPregnancy and preeclampsia studiesHemoglobinopathies and Related Disorders

Adverse Pregnancy Outcomes in an Area Where Multidrug‐Resistant Plasmodium vivax and Plasmodium falciparum Infections Are Endemic

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Poespoprodjo, Jeanne Rini, Fobia, Wendy, Kenangalem, Enny, Lampah, Daniel A., Warikar, Noah, Seal, Andrew, McGready, Rose, Sugiarto, Paulus +3 more·2008·Clinical Infectious Diseases

Abstract

BACKGROUND: Plasmodium falciparum infection exerts a considerable burden on pregnant women, but less is known about the adverse consequences of Plasmodium vivax infection. METHODS: In Papua, Indonesia, where multiple drug resistance to both species has emerged, we conducted a cross-sectional hospital-based study to quantify the risks and consequences of maternal malaria. RESULTS: From April 2004 through December 2006, 3046 pregnant women were enrolled in the study. The prevalence of parasitemia at delivery was 16.8% (432 of 2570 women had infections), with 152 (35.2%) of these 432 infections being associated with fever. The majority of infections were attributable to P. falciparum (250 [57.9%]); 146 (33.8%) of the infections were attributable to P. vivax, and 36 (8.3%) were coinfections with both species. At delivery, P. falciparum infection was associated with severe anemia (hemoglobin concentration, <7 g/dL; odds ratio [OR], 2.8; 95% confidence interval [95% CI], 2.0-4.0) and a 192 g (95% CI, 119-265) reduction in mean birth weight (P<.001). P. vivax infection was associated with an increased risk of moderate anemia (hemoglobin concentration, 7-11 g/dL; OR, 1.8; 95% CI, 1.2-2.9; P=.01) and a 108 g (95% CI, 17.5-199) reduction in mean birth weight (P<.019). Parasitemia was associated with preterm delivery (OR, 1.5; 95% CI, 1.1-2.0; P=.02) and stillbirth (OR, 2.3; 95% CI, 1.3-4.1; P=.007) but was not associated with these outcomes after controlling for the presence of fever and severe anemia, suggesting that malaria increases the risk of preterm delivery and stillbirth through fever and contribution to severe anemia rather than through parasitemia per se. CONCLUSIONS: These observations highlight the need for novel, safe, and effective treatment and prevention strategies against both multidrug-resistant P. falciparum and multidrug-resistant P. vivax infections in pregnant women in areas of mixed endemicity.

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  • Younger women, particularly adolescents, are at higher risk of malaria infection than older women, independent of parity.

    “It is well established that younger women (primigravidae and multigravidae), particularly adolescents, are at higher risk of malaria infection than older women,18–20 and this is independent of parity.20–22”

    From Malaria in pregnancy. (2013) · cites this paper as [18]

    The Results section, “Risk Factors for Maternal Malaria” (page unavailable), identifies primigravidity—not younger age—as independently associated with parasitemia. The Discussion likewise says first-time mothers were more susceptible than multigravid women. The paper does not establish higher risk among adolescents or an age-related risk independent of parity. (LLM, conf=0.78)

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  • In unstable transmission settings, malaria can cause maternal anaemia, more in primigravidae than multigravidae and for falciparum infections more than for vivax infections.

    “Where malaria transmission is unstable, malaria can cause maternal anaemia,18,35,39–40 more in primigravidae than in multigravidae and for falciparum infections more than for vivax infections.18,35”

    From Malaria in pregnancy. (2013) · cites this paper as [18]

    The Results (Maternal Anemia; page unavailable) support a stronger association with anemia for falciparum than vivax infection. But they report severe anemia was more prevalent in multigravid than primigravid women (10.5% versus 7.6%), the opposite of the claimed parity comparison; the Discussion also says multigravid women were more anemic. (LLM, conf=0.90)

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  • Severe cases of malaria in pregnancy may progress to life-threatening complications such as severe malaria in both the mother and the fetus.

    “Severe cases may progress to life-threatening complications such as severe malaria both the mother and the fetus [40, 43, 84].”

    From Current update on malaria in pregnancy: a systematic review (2025) · cites this paper as [84]

    The Results (Maternal Malaria) report women meeting criteria for severe malaria and two deaths involving P. falciparum infection with multiorgan failure. The Results (Pregnancy Outcomes) and Discussion report stillbirth and other adverse fetal outcomes, but do not describe severe malaria in the fetus or establish that severe cases progressed to it. (LLM, conf=0.86)

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  • In unstable transmission settings, preterm deliveries, still births and neonatal deaths have been associated with malaria.

    “In unstable transmission settings, preterm deliveries, still births and neonatal deaths have been associated with malaria.18”

    From Malaria in pregnancy. (2013) · cites this paper as [18]

    The Results (Pregnancy Outcomes; page not provided) associate maternal malaria with preterm delivery and P. falciparum parasitemia with stillbirth and early neonatal death, although the latter associations were no longer statistically significant after adjustment for fever and severe anemia. The Methods (Study site; page not provided) describe transmission in the Papua study area but do not establish that it was an unstable-transmission setting, so that qualifier is not verified by this source. (LLM, conf=0.78)

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  • Fever, anaemia, and high levels of TNF alpha or interleukin 10 have been identified as important risk factors for malaria-related preterm delivery.

    “It is unclear what the mechanism at the basis of malaria-related preterm delivery is, though fever, anaemia, and high levels of TNF alpha or interleukin 10 have been identified as important risk factors.18,83–84”

    From Malaria in pregnancy. (2013) · cites this paper as [18]

    The Discussion identifies concomitant fever and severe anemia as major determinants of prematurity associated with maternal malaria, and the Results report their associations with preterm delivery. The paper does not identify elevated TNF alpha or interleukin 10 as risk factors; searches for those cytokines returned no supporting passage. Page numbers were not available in our copy. (LLM, conf=0.87)

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  1. [1]Wickramasuriya GAW Clinical features of malaria in pregnancy: malaria and ankylostomiasis in the pregnant women 1937 Oxford University Press London

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Authors
Poespoprodjo, J. R., Fobia, W., Kenangalem, E., Lampah, D. A., Warikar, N., Seal, A., McGready, R., Sugiarto, P., Tjitra, E., Anstey, N. M., & Price, R. N.
Affiliations
  • Menzies School of Health Research (AU)
  • University College London (GB)
  • Churchill Hospital (GB)
  • Kementerian Kesehatan Republik Indonesia (ID)
  • Charles Darwin University (AU)
Venue
Clinical Infectious Diseases
Published
2008-05
Volume
46
Issue
9
Pages
1374-1381
ISSN
  • 1058-4838 (ISSN-L)
  • 1537-6591
OpenAlex
W2154959709
Cited by
148
References
32
Citations by year
2026: 3 · 2025: 3 · 2024: 3 · 2023: 4 · 2022: 6 · 2021: 5 · 2020: 7 · 2019: 12 · 2018: 11 · 2017: 5 · 2016: 11 · 2015: 12 · 2014: 12 · 2013: 10 · 2012: 18
FWCI
8.57
Type
journal article
Language
en
Open access
Locations
  • Clinical Infectious Diseases (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • UCL Discovery (University College London) (submittedVersion)
Funders
  • Wellcome Trust (074637, 071614)
  • Menzies School of Health Research
  • International Center for Responsible Gaming
  • Mahidol University
  • Medical Research Council
  • National Health and Medical Research Council (283321)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Malaria Research and Control
  • Health Sciences › Medicine › Obstetrics and Gynecology › Pregnancy and preeclampsia studies
  • Health Sciences › Medicine › Genetics › Hemoglobinopathies and Related Disorders
Keywords
maternal malaria, Plasmodium vivax, Plasmodium falciparum, multidrug resistance, adverse pregnancy outcomes, severe anemia, birth weight, preterm birth, stillbirth, fever, co-infection, Papua, malaria in pregnancy, hemoglobin levels, malaria prevention
MeSH terms
Adult, Animals, Antimalarials, Cross-Sectional Studies, Female, Humans, Indonesia, Piperazines, Plasmodium falciparum, Plasmodium vivax, Pregnancy, Pregnancy Outcome, Surveys and Questionnaires, Quinolines, Pregnancy Complications, Parasitic, Malaria, Falciparum, Malaria, Vivax, Drug Resistance, Multiple, Parasitemia, Endemic Diseases, Artemisinins

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