Adverse fetal and neonatal outcomes and associated factors among malaria infected parturient at Wallaga University Comprehensive Specialized Hospital, Western Ethiopia

Abstract

Background

Malaria during pregnancy remains a major public health challenge, significantly contributing to poor fetal and neonatal outcomes. This study aimed to determine the prevalence and associated factors of adverse fetal and neonatal outcomes among malaria-infected parturient at Wallaga University Comprehensive Specialized Hospital, Western Ethiopia.

Methods

An institution-based retrospective cross-sectional study was conducted using medical records of 271 malaria-infected parturient from March 10, 2024, to March 9, 2025. Data were extracted using a standardized checklist, entered into Microsoft Excel, and analyzed using SPSS version 27. Multivariable logistic regression was employed to identify independent predictors, with statistical significance set at p < 0.05.

Results

The prevalence of adverse fetal and neonatal outcomes was 37.27% (95% CI: 32.0%–42.9%), with low birth weight being the most common complication. Independent predictors included residing in rural area (AOR = 4.97; 95% Cl, 1.92–12.90), being primigravida (AOR = 5.41; 95% Cl, 1.95–15.05), having moderate anemia (AOR = 3.25; 95% Cl, 1.46–7.25), having severe anemia (AOR = 4.89; 95% Cl, 1.95–12.29) and having four or fewer antenatal care contacts (AOR = 5.70; 95% Cl, 2.56–12.72).

Conclusion

Nearly four in ten study participants experienced adverse fetal and neonatal outcomes. The risk is highest for participants from rural areas, experiencing their first pregnancy, struggling with moderate to severe anemia, or failing to complete at least five antenatal care contacts. Therefore, targeted interventions should prioritize anemia prevention and management, specialized monitoring for primigravidas, and rural outreach to ensure women complete at least five antenatal care contacts.

Introduction

Malaria is a vector-borne tropical and sub-tropical disease which is caused by Plasmodium parasites and transmitted through the bite of female Anopheles mosquitoes [1]. There are five known species of the genus plasmodium to cause malaria among humans, which include Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, Plasmodium ovale, and Plasmodium knowlesi [2, 3], among which Plasmodium falciparum is the deadliest human malaria and the most prevalent in sub-Saharan Africa [1, 4].

Pregnant mothers are highly susceptible to malaria infestation, and they are more likely to experience severe manifestations as compared to non-pregnant women [5]. The 2021 report from the World Health Organization (WHO) indicated that up to 32% of pregnant women in African countries suffer from malaria infection [1]. This heightened vulnerability might be attributable to genetics and socio-demographic factors [6, 7], pregnancy-related hormonal, immunological and nutritional changes (8). Although the clinical manifestations of malaria may vary across individuals, fever of irregular type, sense of chillness, shivering, headaches, muscle pains, nausea, vomiting, fatigue, and dizziness are among the most common [9, 10].

Pregnancy-associated malaria (PAM) imposes adverse consequences on the fetus and newborns [11, 12]. Additionally, the parasites tend to attach themselves to placental intervillous spaces [13, 14], which contributes to placental insufficiency [15–18]. Consequently, this may induce intrauterine growth restriction (IUGR), low birth weight (LBW), stillbirth, preterm birth, and infant anemia [19–21]. This makes PAM a significant contributor to infant mortality, being responsible for approximately 200,000 annual infant deaths [22].

Studies conducted in Sub-Saharan African countries showed that pregnant mothers are affected by malaria, with a prevalence range of 7.7% to 41.6% [23–26]. Additionally, findings from studies conducted among pregnant women in different parts of Ethiopia reveal malaria prevalence ranging from 16.3% to 28.3% [27–29]. However, there is a dearth of evidence indicating the adverse fetal outcomes of malaria among pregnant women in general, and there was no study conducted particularly in Ethiopia, to the best of the investigators’ search. Therefore, this study aimed to provide information regarding the overall outcome of malaria among parturient who visited Wallaga University Comprehensive Specialized Hospital (WUCSH).

Materials and methods

Study area

The study was conducted at Wallaga University Comprehensive Specialized Hospital (WUCSH), a major teaching and referral institution located in Nekemte, Western Ethiopia, approximately 331 km from Addis Ababa. The hospital serves a catchment population of over five million people, providing specialized services including adult and neonatal intensive care and dialysis. Within its 250-bed capacity, the Department of Obstetrics and Gynecology operates a 44-bed maternity and postpartum ward. This department provides comprehensive maternal health services—ranging from preconception to postpartum care—and is staffed by eight senior obstetricians (including three subspecialists), 15 residents, and 35 midwives. According to the Hospital Management Information System (HMIS), the facility manages an average of 3,355 births annually.

Study period

From March 10, 2025 to April 9, 2025.

Study design

An institution-based retrospective cross-sectional study was employed to assess the prevalence and associated factors of adverse fetal outcomes among malaria-infected parturient.

Study population

Medical records of parturient diagnosed with malaria using blood film at Wallaga University Comprehensive Specialized Hospital during the study period.

Inclusion and exclusion criteria

Inclusion criteria

All medical records of parturient diagnosed with malaria using blood film at Wallaga University Comprehensive Specialized Hospital during the study period were eligible for inclusion in the study.

Exclusion criteria

Medical records that were significantly incomplete or missing critical variables required for the analysis (such as maternal outcomes, birth weight, or laboratory confirmation) were excluded from the final study population.

Sample size determination

The sample size for this study was estimated using a single population proportion formula, assuming a 95% confidence level and a 5% margin of error. Based on a previous study in Nigeria [30], the proportion of malaria-related Low Birth Weight (LBW) was established at 19.7% (p = 0.197). Applying these parameters, the minimum required sample size was calculated to be 243. To account for a potential 10% rate of incomplete or missing medical records, the final sample size was adjusted to 268. However, to maximize the representativeness of the data and enhance the study’s statistical power, all eligible medical charts recorded within the one-year study period were reviewed.

Sampling procedure

A consecutive sampling technique was employed to include all eligible records. Medical Record Numbers (MRNs) were identified from the admission registers and delivery logbooks of the Labor Ward, Operation Theatre, and Maternity Ward. All admissions and deliveries recorded between March 10, 2024, and March 9, 2025, were retrieved. The required clinical data were then systematically extracted from these records into Microsoft Excel for processing.

Study variables

Dependent variables

Adverse fetal and neonatal outcomes.

Independent variables

Socio-demographic characteristics (age, residence), clinical factors (gravidity, parity, co-morbid medical illness, previous adverse fetal outcomes, maternal nutritional status, type of treatment, type of malaria species, gestational age at malaria diagnosis, hemoglobin level at diagnosis, malaria prevention method, onset of labor, mode of delivery.

Operational definitions

Maternal anemia refers to Hemoglobin concentration less than 11.0 g/dL in the third trimester and postpartum period.

Preterm delivery is defined as babies born alive before 37 completed weeks of estimated gestational age.

Stillbirth is defined as a death of a fetus occurring at or greater than 28 weeks gestation or a birth weight ≥ 1000 g.

Low birth weight has been defined as the weight at birth of a baby which is less than 2500 g.

Low fifth-minute APGAR score is 5th minutes APGAR score of < 7.

Small for Gestational Age: Birth weight below the 10th percentile for gestational age.

Adverse fetal and neonatal outcomes: Cases with one or more of either stillbirth, preterm birth, low birth weight, small for gestational age; low 5th-minute APGAR score, Neonatal Intensive Care Unit (NICU) admission.

Incomplete medical record: A record without birth weight, without APGAR score, and without newborn evaluation.

Comorbid medical condition: The presence of one or more non-malaria illnesses such as diabetes mellitus, asthma, or chronic hypertension) occurring in the same patient.

NICU admission: refers to any newborn with a recorded medical chart who is formally admitted to the NICU for the management of medical conditions requiring advanced care.

Data collection procedure

Data were collected using a checklist. Relevant information was extracted from the medical records of pregnant women diagnosed with malaria. Data collectors reviewed the charts and recorded the required variables accordingly. After completion of data collection, all medical records were returned to the card room properly. The extraction process was supervised daily to ensure all variables were captured accurately.

Data collection procedure

Data were collected using a checklist developed from different literature [6–42]. This checklist includes socio-demographic characteristics, obstetric and clinical factors of study participants, and adverse fetal outcomes. Data collection was conducted by three trained BSc midwives, while one General Practitioner supervised the overall data collection process.

Data quality control

Training was given to data collectors and the supervisor by the investigators for one day. The training included discussion on the objectives of the study, the contents of the checklist, procedures, data collection techniques, and ethical issues. Every day after data collection, questionnaires were reviewed and checked for completeness by the supervisor. A pilot study was conducted on 10% (27) samples at Nekemte comprehensive specialized Hospital two weeks before actual data collection to check for checklist reliability. Modifications were taken accordingly. Double data entry was done by two data clerks to minimize errors during data entry. Inconsistencies were checked, and appropriate corrections taken.

Data processing and analysis

The collected data were coded and entered into Microsoft Excel and sent to SPSS version 27 for analysis. Bivariate analysis was employed to identify the explanatory variables having an association with the outcome variable, and independent factors with p-value < 0.25 were qualified for the final model. In a multi-variable logistic regression model, the presence and strength of association were measured by adjusted odds ratio (95% CI). A p-value < 0.05 was considered statistically significant for all the independent variables in the final model. Model fitness was checked by using the Hosmer and Lemeshow test, and the assumption was fulfilled (as the p-value was > 0.05). Multicollinearity was checked for the overall model by the variance inflation factor (VIF), and VIFs were < 5 for all independent variables.

Results

Socio-demographic and obstetrics characteristics of study participants

Of the 3,594 total deliveries recorded during the one-year study period, 279 (7.76%) parturient were identified as having malaria infection. After the exclusion of eight incomplete medical records, 271 cases were included in the final analysis. The study population had a mean age of 22.85 years (± 4.54 SD), with more than half of the participants (56.8%) falling within the 20–28 years. Notably, all study participants (100%) were married, and the overwhelming majority (81.9%) were rural residents.

The obstetric profile of the study participants showed that 46.90% were primigravida, followed by multigravida (36.50%) and grand-multigravida (16.60%) women. Regarding past obstetric history, the vast majority (90.4%) had no history of previous adverse pregnancy outcomes. Analysis of healthcare utilization revealed a significant gap in prenatal care, as only 27.30% of participants met the threshold of five or more Antenatal Care (ANC) contacts, while the majority (72.70%) had four or fewer visits and 2.20% received no ANC at all. Furthermore, 55.70% of the participants were diagnosed with malaria at a gestational age of 37 weeks or later, while 44.30% were diagnosed prematurely, highlighting the risk of infection throughout all stages of pregnancy (Table 1).

Table 1.

Socio-demographic and obstetric characteristics of malaria infected parturient at Wallaga University Comprehensive Specialized Hospital, 2025

Variable	Category	Frequency	Percent
Age category in years	< 20	80	29.5
	20–28	154	56.8
	≥ 29	37	13.7
Residence	Urban	49	18.1
	Rural	222	81.9
Gravida	Primigravida	127	46.9
	Multigravida (II-IV)	99	36.5
	Grand -multigravida (≥ V)	45	16.6
Previous adverse outcome	No	245	90.4
	Yes	26	9.6
ANC contact	No	6	2.2
	1–4	197	72.7
	≥ 5	74	27.3
GA at time of malaria diagnosis	≥ 37 weeks	151	55.7
	< 37 weeks	120	44.3

The clinical profile of study participants

The clinical profile of the 271 malaria-infected parturient highlights significant health challenges. The majority of participants (94.50%) had no pre-existing co-morbid medical conditions. A substantial proportion suffered from varying degrees of anemia. Specifically, 43.20% of the women were anemic, with 15.10% experiencing severe anemia (< 7.0 g/dL). In terms of malaria prevention, a striking 81.9% of the participants reported not using insecticide-treated nets (ITNs). The majority of infections (71.20%) were caused by Plasmodium falciparum, the species most commonly associated with severe maternal and fetal complications, while Plasmodium vivax accounted for the remaining 28.80%. Regarding clinical management, nearly half (45.80%) of the patients were treated with Artemether-Lumefantrine, while 34.30% received Artesunate and 19.9% were managed with a combination of both drugs (Table 2).

Table 2.

The clinical profile of malaria infected parturient at Wallaga University Comprehensive Specialized Hospital, 2025

Variable	Category	Frequency	Percent
Co-morbid medical condition	Absent	256	94.5
	Present	15	5.5
Hemoglobin status	Normal (≥ 11 g/dl)	154	56.8
	Mild anemia(10.0–10.9 g/dl)	30	11.1
	Moderate anemia(7.0–9,9 g/dl)	46	17.0
	Severe anemia(< 7.0 g/dL)	41	15.1
Use of insecticide treated net	No	222	81.9
	Yes	49	18.1
Malaria species	Plasmodium Falciparum	193	71.2
	Plasmodium Vivax	78	28.8
Type of drug given	Artesunate	93	34.3
	Artemether-Lumefantrine	124	45.8
	Artesunate & Artemether-Lumefantrine	54	19.9

Adverse fetal and neonatal outcomes among study participants

Among the 271 malaria-infected parturient, the overall prevalence of adverse fetal and neonatal outcomes was 37.27% (95% CI: 32.0%–42.90%). The distribution of these complications shows that low birth weight (LBW) (22.50%) was the most frequent adverse outcome. This was followed by preterm birth (18.50%) and stillbirth (15.10%). The figure also shows low Apgar scores at five minutes to be 10.8%. Many neonates (12.90%) were admitted to the Neonatal Intensive Care Unit (NICU) (Fig. 1).

Fig. 1.

Adverse fetal and neonatal outcomes of malaria-infected parturients at Wallaga University Comprehensive Specialized Hospital, 2025

Factors associated with adverse fetal and neonatal outcomes among study participants

In this study, multivariable analysis of malaria-infected parturient at Wallaga University Comprehensive Specialized Hospital indicates that rural residence, lower gravidity, fewer than five ANC visits, and moderate-to-severe anemia are significant independent predictors of adverse fetal and neonatal outcomes.

Participants residing in rural areas exhibited nearly five times higher odds of experiencing adverse outcomes compared to their urban counterparts (AOR = 4.97; 95% CI: 1.92–12.90). Parity also showed a significant trend, with primigravida women facing the highest odds (AOR = 5.41; 95% CI: 1.95–15.05) and multigravida women facing a 3.8-fold increase in odds (AOR = 3.82; 95% CI: 1.34–10.85) compared to grand-multigravidas. Low ANC attendance (≤ 4 contacts) was associated with a 5.7-fold increase in odds (AOR = 5.70; 95% CI: 2.56–12.72). Finally, maternal anemia was a strong predictor, as the odds of complications were 3.25 times higher for those with moderate anemia (AOR = 3.25; 95% CI: 1.46–7.25) and 4.89 times higher for those with severe anemia (AOR = 4.89; 95% CI: 1.95–12.29) compared to women with normal hemoglobin levels (Table 3).

Table 3.

Multi-variable logistic regression analysis of factors associated with Adverse fetal and neonatal outcomes among malaria infected parturient at Wallaga University Comprehensive Specialized Hospital, 2025

Variable	Category	AFO		AOR (95% C.I.)	p-value
		Yes	No
Residence	Rural	128	94	4.97 (1.92, 12.90)	0.00
	Urban	42	7	1
Gravidity	Primigravida	69	58	5.41 (1.95, 15.05)	0.00
	Multigravida	65	34	3.82 (1.34, 10.85)	0.01
	Grand –multigravida	36	9	1	0.01
Previous adverse fetal outcome	Yes	12	14	2.37 (0.82, 6.83)	0.11
	No	158	87	1
ANC contact	≤4	108	89	5.70 (2.56, 12.72)	0.00
	≥ 5	62	12	1
GA at time of malaria diagnosis	≤ 37wks	61	59	1.70 (0.88, 3.25)	0.11
	≥37wks	109	42	1
Co-morbid medical condition	Present	5	10	3.58 (0.93, 13.78)	0.06
	Absent	165	91	1
Hemoglobin status	Mild anemia(10.0–10.9 g/dl)	19	11	1.25 (0.48, 3.31)	0.65
	Moderate anemia(7.0–9,9 g/dl)	21	25	3.25 (1.46, 7.25)	0.00
	Severe anemia(< 7.0 g/dL)	13	28	4.89 (1.95, 12.29)	0.00
	Normal(≥ 11 g/dl)	117	37	1	0.00
Use of insecticide treated net	No	133	89	2.01(0.82, 4.91)	0.13
	Yes	37	12	1
Type of malaria treatment given	Artesunate	54	39	1.99 (0.96, 4.14)	0.07
	Artesunate & Artemether-Lumefantrine	31	23	1.60 (0.67, 3.81)	0.29
	Artemether-Lumefantrine	85	39	1	.

Discussion

This study aimed to determine the prevalence and identify factors associated with adverse fetal outcomes among malaria-infected parturient at Wallaga University Comprehensive Specialized Hospital. The study found that 37.27% of newborns experienced at least one adverse fetal and neonatal outcome. This finding is consistent with studies conducted in Tanzania (32%) [31], the Amhara region (33.1%) [32], and Awi Zone, Ethiopia (41.1%) [33].

However, the finding is lower than the studies conducted in the Somali region of Ethiopia, 51.9.0% [34] and Nigeria, 52.6% [35]. The possible explanations for this variation might be the differences in socio-cultural, study setups, inclusion criteria, and study population. Conversely, our finding is higher than those reported in Guinea (14.0%) [36], Colombia (12.8%) [37], and India (29.26%) [38]. Such discrepancies likely arise from differences in study design, healthcare infrastructure, and regional malaria endemicity.

Rural residents had approximately five times higher odds of experiencing adverse fetal and neonatal outcomes as compared to urban residents (95% CI: 1.92–12.90, p < 0.001). This is consistent with findings from China [39], Brazil [, Canada [41], Wag Himra Zone [42], and Arba Minch [43]. The possible explanation for this association is that rural resident mothers have lower socioeconomic status, limited access to healthcare, and are less likely to have awareness of the warning signs and potential complications related to pregnancy [44].

Primigravida (95% CI: 1.95–15.05, p < 0.001) and multigravida (95% CI: 1.34–10.85, p < 0.001) samples have higher odds of experiencing adverse fetal and neonatal outcomes when compared to grand-multigravidas. The finding is consistent with a study conducted in Tanzania [45], Gambia [46] and a systematic review of studies in Sub-Saharan Africa [19]. This is largely explained by the lack of acquired immunity in first-time or early-parity pregnancies. With subsequent pregnancies, women gradually develop variant-specific immune responses that reduce parasitemia and improve the inflammatory response, offering a protective effect to the fetus [47, 48].

Women with anemia had about three- to five-fold odds of facing adverse fetal and neonatal outcomes when compared to non-anemic ones [(95% CI: 1.46–7.25, p < 0.001) in moderate anemia and (95% CI: 1.95–12.29, p < 0.001) in severe anemia]. Similar associations were found in Bangladesh [49] and Canada [50]. Anemia reduces the blood’s oxygen-carrying capacity, hindering the delivery of essential nutrients to the placenta. This can induce hypoxia and oxidative stress, increasing the risk of preterm birth, low birth weight, and premature rupture of membranes [51, 52]. Therefore, the use of insecticide-treated bed nets and chemoprophylaxis against malaria deserves better given due attention in malaria-prone areas.

Women with four or fewer ANC contacts had nearly six-fold higher odds of experiencing adverse fetal and neonatal outcomes compared to their respective counterparts (95% CI: 2.56–12.72, p < 0.001). This was in line with the studies conducted in Wag Himra Zone [42] and Southern Ethiopia [53]. ANC serves as a critical window for the early identification and management of complications [54]. Therefore, the stakeholders in the study area should better strengthen access to ANC using health extension workers and improve community awareness on the importance of ANC.

Limitations

This study provides valuable preliminary findings; however, it has limitations. As a retrospective chart review, the selection of variables was restricted to available recorded data, and certain clinical details may have been missing. Additionally, the cross-sectional nature of the study precludes the establishment of definitive causal relationships between the identified factors and fetal outcomes.

Conclusion

Nearly four in ten study participants experienced adverse fetal and neonatal outcomes. The risk is highest for participants from rural areas, experiencing their first pregnancy, struggling with moderate to severe anemia, or failing to complete at least five antenatal care contacts. Therefore, targeted interventions should prioritize anemia prevention and management, specialized monitoring for primigravidas, and rural outreach to ensure women complete at least five antenatal care contacts.

Abbreviations

AICU

Adult Intensive Care Unit

ANC

Antenatal Care

APGAR

Appearance, pulse

HMIS

Management Information System

IUFD

Intrauterine Fetal Death

IUGR

Intrauterine growth restriction

ITNs

Insecticide-treated nets

LBW

Low Birth Weight

MRNs

Medical Record Numbers

NICU

Neonatal Intensive Care Unit

PAM

Pregnancy-associated malaria

WHO

World Health Organization

and WUCSH

Wallaga University Comprehensive Specialized Hospital

Author contributions

DA, TT & GT were involved in manuscript preparation. DA prepared Tables 1, 2 and 3; fig. 1. All authors reviewed the manuscript.

Funding

No funding source.

Data availability

The data sets used and analyzed during the current study are available from the corresponding author on formal request.

Declarations

Ethical approval and consent to participate

Ethical clearance was obtained from the Research Ethics Committee of Wallaga University (Ref. No: REC/031/2025). Then, a support letter was written to the different units in the hospital. Privacy was maintained by using anonymous identifiers; no personal names or addresses were recorded. All methods were performed per the relevant guidelines and regulations.

Consent for publication

Not applicable.

Informed consent

Due to the retrospective nature of the chart review, a waiver of informed consent was granted.

Competing interests

The authors declare no competing interests.