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India’s vast tribal belt, which ranges across its central heartland and up its eastern flank, is home to indigenous and animist communities, whose disparate mother tongues traditionally had no written form. Isolated and undeveloped, these regions have some of India’s highest incidence of malaria, as mosquitoes thrive in its dense forests. The tribal belt also has some of India’s highest rates of women dying during or after pregnancy and childbirth.
India’s public health establishment has not identified malaria as a contributory factor in the country’s estimated 44,000 maternal deaths each year. Nor does India have specific policies for routine testing and treatment of malaria in pregnant women, unless they report to doctors exhibiting classic malaria symptoms.
Public health professionals working in the tribal regions are convinced, however, that the disease is an underlying factor in a significant number of the maternal deaths they see. They believe India needs new approaches to identifying and treating pregnant women infected with the parasites in order to protect them and their unborn children.
“We usually find there are 20 to 30 per cent more maternal deaths in districts that have malaria compared with those that don’t,” says Prabir Chatterjee, a doctor at the state health resource centre in Chattisgarh, a tribal belt state. “My interpretation is that the 20 to 30 per cent may be due to malaria.”
In many African countries with a high incidence of malaria, pregnant women are routinely screened for malaria or given preventive treatment. In India, malaria has never been treated as a big problem for pregnant women, as the national incidence is relatively low.
Doctors working in the tribal areas say India needs different protocols for malaria hotspots. Specifically, they advocate that pregnant women be tested routinely for malaria during their prenatal check-ups using low-cost rapid diagnostic kits. Women found to be infected could receive treatment to ensure they do not develop a full-blown case of the disease. Many private hospitals follow such practices.
“Is malaria in pregnancy an issue? Yes,” says John Oommen, a doctor at Christian Hospital in the remote Bissamcuttak district of Orissa, another state in the tribal belt. “How big? Nobody knows. Are some things being done? Yes. Can we do more? Yes.”
Researchers from the London School of Hygiene and Tropical Medicine are conducting a long-term study in Jharkhand state, also in the tribal belt, to assess whether routine malaria screening would improve maternal health. The results are expected to tilt the debate on whether the cost of such an intervention would be worth it for India’s cash-strapped public health system. “We are at a crossroads,” says Suranjeen Pallipamula, a maternal mortality expert in Jharkhand. “We can’t really say it should be done. We are still waiting for evidence to see if it’s effective or efficient.”
Chattisgarh officials decided last year to require such testing as part of antenatal care in high-malaria districts. The scheme has yet to be implemented fully. In Jharkhand, some urge such screening on a pilot basis in areas with the highest burden of malaria. “We believe the malaria programme is definitely improving every day,” says Dr Pallipamula. “But unless you focus on pregnant women, you are not going to impact malaria in pregnancy.”
India’s malaria burden is debated hotly between the government and independent researchers. New Delhi estimates it has some 1m cases and a few hundred fatalities a year. Researchers who have studied mortality patterns say 125,000 to 277,000 malaria fatalities a year is a more “plausible range”.
India’s policy is only to count a malaria case or death if the disease is confirmed by blood-test at a government hospital. Critics believe this severely underestimates the true burden, as many ailing Indians seek private treatment, or never see a doctor.
What is clear is that malaria is disproportionately concentrated in the tribal belt and its poorly-educated indigenous communities which have limited public healthcare provision.
An analysis in the Indian Journal of Medical Research last year observed that districts with a tribal population of 30 per cent or more account for just 8 per cent of India’s total population. Yet these districts account for 46 per cent of India’s total malaria cases and malaria deaths.
For pregnant women and their unborn babies, malaria can have severe consequences ranging from low birth weight to miscarriage. It can leave women severely anaemic, raising risk of complications during labour and delivery, particularly the risk of severe, possibly lethal, post-partum bleeding.