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ORIGINAL ARTICLE
Year : 2015  |  Volume : 18  |  Issue : 4  |  Page : 182-187

Predictors of anemia in pregnancy among pregnant women accessing antenatal care in a poor resource setting in South Eastern Nigeria


1 Department of Obstetrics and Gynaecology, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria
2 Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
3 Department of Pathology, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria

Date of Web Publication16-Feb-2016

Correspondence Address:
R C Onoh
Department of Obstetrics and Gynaecology, Federal Teaching Hospital, PMB 102, Abakaliki, Ebonyi State
Nigeria
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DOI: 10.4103/1118-8561.176588

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  Abstract 

Background: Anemia in pregnancy affects about half of pregnant women and constitutes a serious health problem. Objectives: The aim was to determine the prevalence of anemia in pregnancy, as well as its pattern and determinants. Materials and Methods: This was a prospective cross-sectional study conducted at antenatal booking clinic of Federal Teaching Hospital Abakaliki from February to July 2012. Hemoglobin <11 g/dl was regarded as anemia. Estimation of hemoglobin concentration, HIV infection, blood group, genotype and blood film for malaria parasite and erythrocyte morphology were done. Stool analysis was also done. Results: Prevalence of anemia in pregnancy was 58%. Anemia in pregnancy was a common finding among primigravida 82 (66.1%), social Class II 14 (56.0%), social Class III 98 (53.6%), social Class IV 45 (61.6%), social Class V 117 (65.4%), antenatal booking at 14–27 weeks 211 (70.3%), and antenatal booking at ≥28 weeks 47 (74.6%). The significant predictors of anemia in pregnancy include HIV in pregnancy (odds ratio [OR] =4.88 [1.09–21.84]), P = 0.04, obstetric hemorrhage (OR = 2.97 [1.27–6.97]), P = 0.01, malaria parasitemia (OR = 4.28 [2.28–8.03]), P < 0.001, primigravidity (OR = 0.04 [1.03–2.41]), P = 0.04, and helminthiasis (P < 0.001). Conclusion: Anemia is still a common finding in pregnancy, and important contributing factors include malaria parasitemia, helminthic infestation and HIV in pregnancy.

Keywords: Anemia, antenatal care, poor resource setting, predictors, pregnancy


How to cite this article:
Onoh R C, Lawani O L, Ezeonu P O, Nkwo P O, Onoh T, Ajah L O. Predictors of anemia in pregnancy among pregnant women accessing antenatal care in a poor resource setting in South Eastern Nigeria. Sahel Med J 2015;18:182-7

How to cite this URL:
Onoh R C, Lawani O L, Ezeonu P O, Nkwo P O, Onoh T, Ajah L O. Predictors of anemia in pregnancy among pregnant women accessing antenatal care in a poor resource setting in South Eastern Nigeria. Sahel Med J [serial online] 2015 [cited 2019 Sep 23];18:182-7. Available from: http://www.smjonline.org/text.asp?2015/18/4/182/176588


  Introduction Top


Anemia in pregnancy constitutes an important reproductive and global health problems.[1],[2] It is a significant cause of maternal as well as perinatal morbidity and mortality, especially in developing countries.[3],[4],[5] It is responsible for about 20% maternal deaths in Africa and 11% maternal deaths in Nigeria.[3] It has been postulated that it contributes to most maternal deaths through obstetrics hemorrhage.[5]

Anemia in pregnancy affects about half of all pregnant women worldwide.[2],[3],[6] The World Health Organization (WHO) estimates the prevalence of anemia among pregnant women to vary from 53.8% to 90.2% in developing countries, and 8.3–23% in developed countries.[3] The wide variations in the prevalence rates are because of differences in etiological factors, socio-demographic characteristics, lifestyles, and health seeking behavior across different cultures.[4],[7],[8] Common etiological factors of anemia in pregnancy include poor nutrition, deficiencies of iron and other micronutrients, malaria, hookworm infestation, HIV infections and hemoglobinopathies.[6],[7],[8],[9],[10],[11] Pregnancy as an entity may increase the burden of anemia because of changes in the immune system associated with pregnancy, dilution effect of the pregnancy and increased susceptibility to some of the etiological factors such as malaria and helminthiasis.[10],[11] During pregnancy, there is increase susceptibility to malaria parasitemia, impaired micronutrient absorption by helminthic (hookworm) infestation in endemic areas as well as increased demand of both macro and micronutrients.[6],[7] Anemia in pregnancy could lead to increased risk of preterm delivery, low birth weight, prolonged labor and postpartum hemorrhage [12] Though anemia in pregnancy is common in developing countries, prospective study on this topic are limited in Abakaliki. This study determines the prevalence, pattern, risk and etiological factors of anemia in pregnancy at Federal Teaching Hospital Abakaliki.


  Materials and Methods Top


This study was carried out at Federal Teaching Hospital Abakaliki in Ebonyi State, Nigeria.

The study was prospective and cross sectional in design. It involved consecutively recruited pregnant women at the antenatal booking clinic at Federal Teaching Hospital, Abakaliki, Ebonyi State, Southeast of Nigeria from February to July 2012.

Ethical approval for the study was obtained from the hospital Ethics and Research Committee and written consent was obtained. Those who were not sure of their last menstrual period but have obstetric ultrasound were included. The pretested questionnaires administered to the consented pregnant woman contained information on the socio-demographic characteristics, index pregnancy and complications in the previous pregnancy. Social class was adopted as a combination of the occupation of the husband and the educational status of the pregnant woman.[13]

Blood samples were collected from the pregnant women using ethylenediaminetetraacetic acid bottle and hematological investigations were carried out to determine hemoglobin concentration, blood group, genotype and HIV screening. Blood film for malaria parasite and morphology of the erythrocytes were also done. Malaria parasitemia was determined by the microscopic examination of Giemsa–stained thick and thin blood films. Hemoglobin concentration of <11.0 g/dl constituted anemia using the WHO criteria. Sterile containers were given to these pregnant women to collect stool on the morning of the next booking clinic day. Submitted samples were analyzed for intestinal worms (trophozoites and cysts of intestinal protozoa, ova and larvae of intestinal helminths) using standard methods on the same day of submission. Data was analyzed using the Epi-info software package version 3.5.1 2008 (CDC, Atlanta, USA). Bivariate analysis was done to differentiate the variables into those that are related to anemia and those not related to anemia. Multivariate analysis was done using logistic regression to determine the associations of the variable with anemia while controlling the cofounding variables. Chi-square and Fisher's exact test in variables <5 were used to determine the level of significance. Level of significance was set at P < 0.05.


  Results Top


A total of 498 (90.6%) pregnant women were analyzed out of 550 recruited for the study. Forty-nine (8.9%) pregnant women did not return their stool samples for stool analysis while 3 (0.6) refused blood sample collection for hematological investigation.

The prevalence of anemia in pregnancy was 58% (mild 54.4% and moderate anemia 3.6%) [Figure 1].
Figure 1: Types of anemia in pregnancy based on hemoglobin level concentration

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Mean hemoglobin concentration was 10.9 ± 2.7 g/dl with a range of 8–14 g/dl. The mean parity, body mass index and gestational age at booking were 2.02 ± 1.65 (0–7), 23.46 ± 7.05 kg/m 2 ( 19.7–39 kg/m 2) and 17.08 ± 4.09 weeks (and 4–38 weeks), respectively. The mean age of respondents was 28.04 ± 4.7 years (range: 17–42 years). Anemia in pregnancy was common among pregnant women within the age bracket of 17–19 years 9 (90%), 20–24 years 62 (54.9%), 25–29 years 107 (59.8%), 30–34 years 87 (57.2%), and 35–39 years 23 (56.1%). Anemia in pregnancy was a common finding in married women 288 (58.2%), women with body mass index of 18–24.9 kg/m 2 124 (58.1%), 25–29.9 kg/m 2 145 (59.4%), 30–34.5 kg/m 2 19 (54.3%), women of all parties and all occupational types in this study. Anemia in pregnancy was also a common finding among primigravida 82 (66.1%), social Class II 14 (56.0%), social Class III 98 (53.6%), social Class IV 45 (61.6%), social Class V 117 (65.4%), antenatal booking at 14–27 weeks 211 (70.3%) and antenatal booking at ≥28 weeks 47 (74.6%). The above findings were illustrated in [Table 1].
Table 1: Socio-demographic characteristics and anemia in pregnancy

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There is a significant association between anemia in pregnancy and parity, social class and gestational age at booking. Anemia in pregnancy is more likely to occur in primigravida with odds ratio (OR) of 1.58 (1.03–2.41).

Anemia in pregnancy is a significant occurrence that cut across all the social class [Table 2].
Table 2: Logistic regression indicating association between sociodemographic characteristics and anemia in pregnancy

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Anemia in pregnancy is a significant occurrence in all trimesters with higher OR in the 2nd and 3rd trimester-OR of 1.63 and 2.34 respectively [Table 2].

HIV in pregnancy and obstetrics hemorrhage in the previous pregnancy were significantly associated with anemia in pregnancy, P < 0.05 [Table 3]. Women with HIV infection were 4.88 times more likely to be anemic in pregnancy than those without HIV infection, while women with prior history of obstetrics hemorrhage were 2.97 times more likely to present with anemia in pregnancy in subsequent pregnancy [Table 3].
Table 3: Logistic regression of risk factors to anemia in pregnancy in index and prior pregnancy

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[Table 4] shows the comparison of inter-pregnancy interval and anemia in pregnancy. Anemia in pregnancy was common among pregnant women whose inter pregnancy intervals were <1 year 34 (75.6%), 1–2 years 167 (58.6%), and 3–4 years 23 (56.1%) though not statistically significance (χ2 = 6.54, P = 0.07).
Table 4: Inter pregnancy interval and anemia in pregnancy

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Comparison of outcome of stool analysis and anemia in pregnancy was illustrated in [Table 5]. Helminthic infestations occurred in 69 (13.9%) of pregnant women and it was significantly associated with anemia in pregnancy (χ2 = 13.45, P < 0.001) 54 (18.7%). Pregnant women with anemia in pregnancy had more helminthic infestations 54 (78.2%) than those without anemia in pregnancy 15 (21.8%). Hookworm infestation, Ascaris lumbriocoides and Trichuris trichuria were more common among pregnant women with anemia in pregnancy than those without anemia in pregnancy with value of 27 (93.1%) versus 2 (6.9%), 22 (71.0) versus 9 (29.0%), 3 (60.0%) versus 2 (40.0%) respectively. Type of helminthic infestation was significantly associated with anemia in pregnancy (χ2 = 8.34, P = 0.02).
Table 5: Comparison of outcome of stool analysis and anemia in pregnancy

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Participants with malaria parasitemia had four times higher risk of having anemia in pregnancy than those without malaria parasitemia (OR = 4.28 [2.28–8.03]), P < 0.001.

Women with anemia in pregnancy were 5.36 times more likely to have microcytic hypochromic anemia and 2.51 times to have macrocytic hypochromic anemia in pregnancy [Table 6].
Table 6: Logistic regression showing outcome of blood film and its association with anemia in pregnancy

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  Discussion Top


This study shows that anemia in pregnancy constitutes a serious health problem in Abakaliki, Southeast, Nigeria. The prevalence was higher than the 40.8% seen in Enugu, Southeast, Nigeria,[9] 41.9% in Jamitown Southeast Ethiopia,[10] 35.3% in surulere Lagos, Southwest, Nigeria,[1] 51.8% in Gombe Northeast Nigeria,[2] 20.7% in Benin city Southsouth Nigeria.[11] Possible explanations for the high prevalence rate of anemia in pregnancy in this study could be because most of the inhabitants of the state are of low socio economic status, with majority residing in the rural areas where there is poverty, ignorance and illiteracy among women within the reproductive age.[13] Pregnant women with the above attributes are at risk of developing anemia in pregnancy. This prevalence was, however, lower than the findings in Abeokuta, Nigeria with prevalence of 76.5%.[12]

Mild anemia was the dominant degree of anemia seen in this study, and this is in keeping with the other findings in Nigeria.[1],[2],[9],[11],[12],[14] There was no case of severe anemia seen in this study, and this was in consonant with the findings in Enugu, Southeast Nigeria [9] and Ibadan, South west, Nigeria.[14] However, severe anemia was seen in Benin, Abeokuta and Shagamu with prevalence of 2.8%, 1.7% and 0.7%, respectively.[11],[12],[15] Severe anemia in these studies was seen in pregnant women with sickle cell anemia and in chronically ill patients or in the immune-compromised.[11],[12]

Anemia was very common among teen pregnancies (17–19 years) in this study. This may be because teenage pregnancy is usually unintended, unplanned, outside wedlock in our setting with associated inadequate nutrition, poor health seeking behavior and poor antenatal care uptake. Similar findings were noted in Benin and Abeokuta in Nigeria as well as in Indian.[11],[12],[16] Studies done in Enugu Nigeria and in Trinidad and Tobago showed that maternal age had no relationship with anemia in pregnancy at booking.[9],[17]

Primigravida, low socioeconomic class and late antenatal booking were significantly associated with anemia in pregnancy in this study. This is similar to the findings in Enugu Nigeria,[9] Abeokuta, Nigeria,[12] Benin, Nigeria,[11] Lagos in Nigeria [1] and Ghana [18] where anemia was found to increase with late antenatal booking but at variant with Trinidad and Tobago where increased parity is associated with anemia in pregnancy.[17] Primigravida have more chances of having worse morbidity and even maternal mortality following anemia in pregnancy. This is because their anemia tends to be severe following complicated malaria.[12]

Anemia in pregnancy was very common among pregnant women with inter pregnancy interval <1 year and this is similar to findings at Greytown South Africa [19] and in surulere Lagos, Southwest, Nigeria.[1] This is because short inter pregnancy interval impedes full recovery from the stress of labor and delivery and it occurs commonly following the unmet needs of contraception. The use of anovulatory contraceptive method reduces iron loss by almost half.[20] Adequate birth spacing favors iron nutrition and store among fertile aged women because each pregnancy has a high cost in iron depletion.[20]

Malaria, hookworm infestation and human immunodeficiency virus were significant causes of anemia in pregnancy in this study, and the findings are similar to other report on anemia in pregnancy.[4],[6],[7],[10],[18],[20],[21],[22] HIV infection in pregnancy increases prevalence of anemia by its association with lower serum folate and serum ferritin in pregnancy.[6] This relationship between HIV infection and anemia in pregnancy agrees with our findings as microcytic and macrocytic anemia were significant type of anemia among women with anemia in pregnancy in our study. Hookworm infestation interferes with iron absorption during pregnancy and results in microcytic type of anemia in pregnancy as was seen in this study.[6] The hookworm also sucks blood, which may cause bleeding within the gastrointestinal tract causing chronic anemia in pregnancy.[6] Malaria causing anemia in pregnancy may be due to sequestration of malaria parasite within the placenta thus avoiding splenic clearance.[18],[23],[24] Damage in the placental wall results in inflammatory response syndrome. This causes thickening of the placental wall and a reduction in the transfer of nutrients to the fetus causing intrauterine growth restriction.[18],[23],[24]

Microcytic and macrocytic anemia were common findings in this study. A combination of iron and folate deficiency anemia in pregnancy is common among low socioeconomic group consuming mostly cereal based diet aggravated by prolonged cooking and food reheating of liquid preparations.[20] Low socioeconomic class in this study were significantly associated with anemia in pregnancy and may justify the above association. Low socioeconomic class are also at risk of HIV infection, malaria and helminthic infestations as well as other etiological factors of anemia in pregnancy.[1],[2],[12],[15]

Anemia in pregnancy is still a common finding in pregnancy. It is associated with low socioeconomic status, late antenatal booking, primigravidity, prior obstetrics hemorrhage, malaria parasitemia, helminthic infestation and HIV in pregnancy.


  Recommendation Top


Health education on the need for preconceptional care and early antenatal care as well as ways of preventing anemia prior to conception should be explained to women of reproductive age group.

Stool analysis and blood film should be included in the routine tests during antenatal care in developing countries, especially in areas at risk of helminthiasis and malaria parasitemia. Anti-helminthics should be given as prophylaxis to pregnant women in low resource setting after quickening or during preconceptional care.

 
  References Top

1.
Anorlu RI, Oluwole AA, Abudu OO. Sociodemographic factors in anaemia in pregnancy at booking in Lagos, Nigeria. J Obstet Gynaecol 2006;26:773-6.  Back to cited text no. 1
    
2.
Bukar M, Audu BM, Yahaya UR, Melah GS. Anaemia in pregnancy at booking in Gombe, North-eastern Nigeria. J Obstet Gynaecol 2008;28:775-8.  Back to cited text no. 2
    
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Bruno B, Mclean E, Egli I, Cogswell M. World prevalence of anemia 1993-2005. WHO global database on anemia. Geneva: World Health Organisation, WHO/WH/155; 2008.  Back to cited text no. 3
    
4.
Candio F, Hofmeyr GJ. Treatment of iron-deficiency anemia in pregnancy: RHL commentary. The WHO Reproductive Health Library. Geneva: World Health Organisation. Available at https://www.aps.who.int/rhl/pregnancy_childbirth/medical/anemia/cfcom/en/. [Last reviewed on 2007 Nov 23, Last accessed on 2015 Mar 14].  Back to cited text no. 4
    
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Lee AI, Okam MM. Anemia in pregnancy. Hematol Oncol Clin North Am 2011;25:241-59, vii.  Back to cited text no. 6
    
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Bondevik GT, Eskeland B, Ulvik RJ, Ulstein M, Lie RT, Schneede J, et al. Anaemia in pregnancy: Possible causes and risk factors in Nepali women. Eur J Clin Nutr 2000;54:3-8.  Back to cited text no. 7
    
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Desalegn S. Prevalence of anaemia in pregnancy in Jima town, southwestern Ethiopia. Ethiop Med J 1993;31:251-8.  Back to cited text no. 10
    
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Uche-Nwachi EO, Odekunle A, Jacinto S, Burnett M, Clapperton M, David Y, et al. Anaemia in pregnancy: Associations with parity, abortions and child spacing in primary healthcare clinic attendees in Trinidad and Tobago. Afr Health Sci 2010;10:66-70.  Back to cited text no. 17
    
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Monjuru Hogue AK, Kader SB, Hogue E, Mugero C. Prevalence of anemia in pregnancy at Greytown South Africa. Trop J Obstet Gynaecol 2006;23:3-7.  Back to cited text no. 19
    
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Viteri FE. The consequences of iron deficiency and anaemia in pregnancy on maternal health, the foetus and the infant. SCN News 1994;11:14-8.  Back to cited text no. 20
    
21.
Friis H, Gomo E, Koestel P, Ndhlovu P, Nyazema N, Krarup H, et al. HIV and other predictors of serum folate, serum ferritin, and hemoglobin in pregnancy: A cross-sectional study in Zimbabwe. Am J Clin Nutr 2001;73:1066-73.  Back to cited text no. 21
    
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van den Broek N. The aetiology of anaemia in pregnancy in West Africa. Trop Doct 1996;26:5-7.  Back to cited text no. 22
    
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24.
Phillips RE, Pasvol G. Anaemia of Plasmodium falciparum malaria. Baillieres Clin Haematol 1992;5:315-30.  Back to cited text no. 24
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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