Malaria in Pregnancy: Prevalence and Associated Factors at First Antenatal Care Visit in Nakivale Refugee Settlement, Uganda

Background Malaria remains a leading cause of illness and death in Uganda, disproportionately affecting children under five and pregnant women. In the aftermath of COVID-19, malaria incidence has risen globally, and Uganda ranks among the countries with the heaviest burden, recording the third-highest number of cases and deaths worldwide and the highest prevalence in East and Southern Africa. Pregnant women in refugee settlements face heightened vulnerability due to limited resources, poor living conditions, and reduced access to healthcare. However, little was previously known about malaria prevalence and risk factors in refugee settings such as Nakivale refugee settlement in southwestern Uganda. Methods This study aimed to determine the prevalence of malaria infection and associated factors among pregnant women attending their first antenatal care (ANC) visit in Nakivale and Rubondo Health Centre IIIs. A cross-sectional survey was conducted among 374 pregnant women. Data were collected through interviewer-administered questionnaires, key informant interviews, and laboratory testing of capillary blood for Plasmodium infection by microscopy. Quantitative data were analyzed using STATA 15.0 with modified Poisson regression to identify associated factors, while qualitative data underwent thematic analysis in Atlas.ti. Results The study found that malaria prevalence among the pregnant women was 19.3% (72/374), more than double the 8.9% reported for Western Uganda overall. Nearly half of the participants (46.8%) demonstrated low knowledge of malaria prevention. Risk factors significantly associated with malaria infection included low knowledge of malaria prevention (APR = 1.89, 95% CI: 1.15–3.09), living ≥ 5 km from the nearest health facility (APR = 1.78, 95% CI: 1.18–2.62), and non-use of insecticide-treated nets (ITNs) (APR = 1.76, 95% CI: 1.23–2.52). Protective factors were secondary or higher education (APR = 0.53, 95% CI: 0.33–0.83), perception of high malaria risk (APR = 0.53, 95% CI: 0.36–0.78), being in the second trimester (APR = 0.64, 95% CI: 0.46–0.89), and receipt of indoor residual spraying (IRS) within the last year (APR = 0.16, 95% CI: 0.08–0.33). Conclusion In conclusion, malaria prevalence in Nakivale refugee settlement is alarmingly high among pregnant women. Low knowledge and limited access to preventive measures contribute to increased risk, while education, awareness, and preventive interventions such as ITN use and IRS reduce vulnerability. Strengthening health education, improving access to malaria prevention tools, and targeting interventions to high-risk groups are critical to lowering the malaria burden in refugee populations.