Malaria in Pregnancy--A Case Study

I promised I'd post more about my project on malaria in pregnancy, so here is a case study I did of one women who came to Kiboga Hospital with malaria. Even if a woman has grown up in a malaria endemic region like Uganda, when she becomes pregnant the malarial parasites can hide in the placenta and cause severe disease. Severe anemia is the most common complication, which can lead to peripartum and postpartum hemorrhage, and malaria-induced anemia causes the most maternal deaths at Kiboga Hospital. Additionally the parasites in the placenta lead to miscarriages, still births, premature births, and low birth weights, and these infants that are born are at a much increased risk for contracting other diseases and dying in their first few years of life. Here is Juliet's story:
------------------

When I first met Juliet during Monday morning rounds on the maternity ward she seemed like many other women in a similar condition: glad that she no longer felt ill, and very eager to leave the hospital. I learned that Juliet was 24 years old and six months pregnant with her third child, and had been admitted with severe malaria over the weekend. She had recovered well after several doses of IV quinine and was hoping to be discharged that day. I asked the doctor to ask her the questions I’ve been using to survey all pregnant women admitted with malaria, and among other things we learned that she doesn’t sleep under a bed net, did not have malaria in her previous pregnancies or as a child, and had recently emigrated from Rwanda. Her case piqued my interest.

Since Juliet was told she need to wait for another blood smear before she could be discharged I asked the doctor to introduce me and my project and ask if I could come back and chat with her while she waited. She looked surprised and embarrassed as he translated, but shyly looked at me through her long lashes and agreed to the interview. When I found her later (with a nurse who could translate her tricky Rwandan dialect) I noticed that while she still seemed shy she had retied her hair into a beautiful scarf and had changed into a nicer dress; it seemed she was looking forward to the interview as well. Juliet was very quiet and succinct with the male doctor earlier, but once the nurse and I started talking with her she talked very animatedly and used her hands to mime out what she was describing so I could follow along.

I soon learned that Juliet was born and raised in Rwanda. She grew up in a village with her family where they raised cattle and relied on subsistence farming for food. She attended school for five years before school fees became too expensive for her family, so she dropped out and helped her family with “digging” instead. When Juliet was 18 years old she married a cattle farmer, and now she has two daughters ages six and three.

A few months ago a newly pregnant Juliet moved with her husband and her younger daughter to Kiboga District in Uganda to be near her husband’s family, who are cattle farmers in the town of Kiboga. Their oldest daughter is still in Rwanda; she is staying with Juliet’s mother and attending a new, free school mzungus have started in her old village. Juliet’s family is renting a room in a house shared with two other families that is located on the highway about 4 miles outside of Kiboga. Their family is quite poor, and while they eat three meals a day they cannot afford much else.

When Juliet was two months pregnant she fell ill quite suddenly. Juliet said she was shivering uncontrollably, her abdomen felt extremely hot on the inside, she was dizzy, and she had a horrible headache. She was scared and didn’t know what was wrong with her but when she went to Kiboga Hospital for treatment she learned that she had malaria. She had heard of malaria in Rwanda, and knew that people in her village had gotten it before, but neither she nor anyone in her family had ever had it. After getting several doses of IV medication she was discharged with oral medications to take, but since they made her nauseous and caused vomiting she stopped after taking only a few.

This past weekend Juliet, who is now six months pregnant, was digging in her family’s rented land when she started shivering and developed severe joint pain. She decided to stop digging and instead squatted down to begin collecting nuts, but she quickly lost all her energy and returned to the house. She was still shivering and achy and suspected she had malaria again, and so walked the four miles to the hospital for treatment.

I asked Juliet if she knew what malaria is, or what causes it. She is still unsure of what the disease entails since she has had different experiences with it, and had no guesses as to what could cause it. The nurse asked her if she had ever heard of a fever disease caused by mosquitoes, and while Juliet said she hadn’t her face lit up and she explained that she’d had lots of mosquito bites since moving to Kiboga, and asked if they were related to her sicknesses. She used to sleep under a mosquito net in Rwanda but her family cannot afford to buy them here, so she’s been bitten many times at night. She has been attending antenatal classes at the hospital, but doesn’t think they’ve ever mentioned malaria (although she has trouble understanding rapid Lugandan) and she was not given a free bed net. She knows she has been given lots of pills to swallow at antenatal, and thinks she may have received 3 pills to prevent malaria, but she was very unsure.

At the end of our chat I took time to talk with Juliet about malaria and what causes it and explain that her whole family is at risk because they’ve never been exposed to it before. I also explained that malaria can be harmful to her pregnancy, and told her to specifically ask for a bed net at her next antenatal appointment. Finally the nurse and I tried to convince her to complete her oral quinine treatment this time, and made sure she was prescribed an anti-nausea medication to take with it at home.

Juliet thanked us for helping her and her family, and I thanked her for sharing her story with me. As I walked out of the ward I looked back towards her bed to find her still watching me. She broke out in a huge grin—the first one I’d seen from her all day—and waved goodbye to me with both her arms. I waved enthusiastically back and felt lighthearted knowing we had both helped each other that day.