|Year : 2019 | Volume
| Issue : 1 | Page : 59-62
Prevalence of anemia among pregnant women attending ante-natal clinic in a tertiary health-care facility: A study in an area under insurgency in Northeastern Nigeria
Hadiza Tikau Idi1, Sani Awwalu2, Usman Abjah3, Aliyu Ahmadu Babadoko2, Aisha Indo Mamman2, Aliyu Dahiru Waziri2, Adamu Abdullahi Atterwahmie4
1 Department of Haematology, Federal Medical Centre, Nguru, Yobe State, Nigeria
2 Department of Haematology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
3 Department of Haematology, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
4 Department of Obstetrics and Gynaecology, Federal Medical Centre, Nguru, Yobe State, Nigeria
|Date of Web Publication||14-May-2019|
Dr. Hadiza Tikau Idi
Department of Haematology, Federal Medical Centre, Nguru, Yobe State
Source of Support: None, Conflict of Interest: None
Context: Anemia in pregnancy is a very common event in the developing world. Pregnancy is associated with high nutritional demands which may culminate in third-trimester anemia. Most studies conducted on the prevalence of anemia in North Eastern Nigeria were before the onset of the current insecurity. Aims: The aim of this study is to determine the prevalence of anemia among women in the third trimester of pregnancy attending Antenatal Clinic in the Federal Medical Centre, Nguru, Yobe State, Nigeria. Settings and Design: A cross-sectional descriptive study involving 200 women in the third trimester of pregnancy. Subjects and Methods: Semi-structured questionnaires were utilized to collate age, parity, and date of last child birth (LCB). Hematocrit levels were determined using an automated hematology analyzer. Hematocrit levels were stratified according to the World Health Organisation's classification as follows: <21.0%-severe, 21.0%–29.9%-moderate, 30.0%–32.9%-mild anemia, and ≧33.0%-not anemic. Data were analyzed using SPSS version 20.0. Continuous variables were summarized using means and standard deviations. Chi-square and Pearson correlation analyses were conducted to determine relationships. A value of P ≤ 0.05 was considered statistically significant. Results: The mean age, parity, LCB, and hematocrit of the study participants were 26.35 ± 6.17 years, 3.72 ± 2.75, 2.03 ± 1.62 years, and 32.64 ± 7.06%, respectively. The overall prevalence of anemia (hematocrit <33%) was 46.5% with mild, moderate, and severe anemia present in 40 (20%), 39 (19.5%), and 14 (7.0%), respectively. The Pearson correlation analysis between parity and hematocrit levels was weak, negative, and statistically significant (r = −0.144, P = 0.042). Chi-square analysis revealed a significant relationship between parity and anemia (χ2 = 13.166 (df, 6), P = 0.039). Conclusion: The prevalence of the third-trimester anemia in Northeastern Nigeria is of severe public health significance and is associated with parity.
Keywords: Anemia, insurgency, Northeastern Nigeria, pregnancy
|How to cite this article:|
Idi HT, Awwalu S, Abjah U, Babadoko AA, Mamman AI, Waziri AD, Atterwahmie AA. Prevalence of anemia among pregnant women attending ante-natal clinic in a tertiary health-care facility: A study in an area under insurgency in Northeastern Nigeria. Ann Trop Pathol 2019;10:59-62
|How to cite this URL:|
Idi HT, Awwalu S, Abjah U, Babadoko AA, Mamman AI, Waziri AD, Atterwahmie AA. Prevalence of anemia among pregnant women attending ante-natal clinic in a tertiary health-care facility: A study in an area under insurgency in Northeastern Nigeria. Ann Trop Pathol [serial online] 2019 [cited 2020 Feb 24];10:59-62. Available from: http://www.atpjournal.org/text.asp?2019/10/1/59/258175
| Introduction|| |
Africa has the highest prevalence of anemia in pregnant women in the world. Anemia is more pronounced during the third trimester because of increased fetal demand (300 mg), increase in maternal red blood cell mass (450 mg), placental (90 mg), and maternal basal iron loss (230 mg). The WHO defines anemia in this group as a hematocrit of <33%. The WHO has stratified prevalence of anemia into different categories of public health significance as follows; <4.9%-normal, 5.0%–19.9%-mild, 20.0%–39.9%-moderate, and ≥40%-severe.
Anemia in pregnancy may mostly be due to physiological changes in pregnancy as characterized by increased demand for iron and folic acid alongside marked increase in plasma volume without a corresponding increase in red cell mass. However, this does not preclude other causes or intercurrent illnesses as etiological factors.
Insurgency is a violent attempt to oppose a country's government carried out by citizens of that country. Thus, it results in many adverse effects such as poverty, malnutrition as well as maternal, and pediatric anemia among vulnerable groups. Insurgencies may lead to displacement of people from their places of abode. This may lead to limited access to food which may result in malnutrition. One of the presentations of malnutrition is anemia. Even in the absence of insurgency, anemia in pregnancy is a global health problem affecting more than half of all pregnant women worldwide. The high prevalence of anemia has been associated with low socioeconomic status. Maternal anemia may be compounded by vomiting, decreased intake as well as nonintake of nutritional supplements during pregnancy. Other factors include frequent pregnancies associated with short intervals leading to maternal depletion in which successive pregnancies result in worsening iron depletion and birth outcomes.
In settings of security challenges, mothers will not get what they want or require to eat due to none availability. Heads of households are unable to provide nutritionally enriched food to their pregnant spouses due to unemployment while those that are employed are unable to leave their houses due to insecurity. In addition, farmers may be displaced from their settlements and as such cannot farm due to the lack of access to their farms. Furthermore, mothers may be anorexic due to great psychological stress common during strife. Nutritional supplementation for mothers with iron and folic acid is the practice in all clinics in almost all countries as recommended by the WHO. However, some mothers attend antenatal clinics (ANCs) for the first time in the third trimester whereas others have reduced or absent compliance due to the side effects of these drugs.
Most studies conducted on the prevalence of anemia in the North East of Nigeria were before the onset of the current insecurity. Therefore, this study was to determine the current prevalence of third-trimester anemia in a tertiary hospital (Federal Medical Center (FMC) Nguru, Yobe State) situated in a conflict zone and the direct impact of such conflicts on the previous prevalence.
| Subjects and Methods|| |
This was a cross-sectional descriptive study involving 200 women in the third trimester of pregnancy, over a 5-month period (August to December 2015). It was conducted in the ANC of the FMC Nguru, Yobe State, Nigeria. Participants were enrolled during the ANC visits using a convenience sampling technique. Following the acquisition of institutional ethical committee approval and informed consents from the participants, semi-structured questionnaires were utilized to collate data on age, parity and date of last childbirth (LCB). Only women in the third trimester with singleton pregnancies were enrolled in the study. The third trimester was defined as estimated gestational ages between 29 and 40 weeks based on ultrasound scan.
Participants were stratified into three groups based on parity; primip-1, multipara 2–4, and grand multi 5 and above. Those with a history of either cough of >3 weeks' duration, HIV positivity, the presence of sugar in the urine, history of diabetes or hemoglobin SS were excluded from the study. Blood film was done to rule out those with leukemia and toxic granulation and also for morphological classification. Hematocrit levels were analyzed using Mindray Shenzhen automated hematology model 3200 analyzer. Hematocrit levels were stratified according to the WHO classification as follows: <21.0%-severe, 21.0%–29.9%-moderate, 30.0%–32.9%-mild, and ≥33.0%-not anemic.
Data were analyzed using SPSS version 20.0, 2011 Armonk, NY, IBM Corp. Continuous variables were summarized using means and standard deviations. Chi-square and Pearson correlation analyses were conducted to determine relationships. In addition, 95% Confidence Intervals (CIs), the coefficient of determination (r2) and Cramer's V were computed. Level of significance was set at P≤0.05.
FMC Nguru, Yobe State is in Northeastern Nigeria. It is located at latitude 12.8°N and longitude 10.5°N, respectively. Yobe State shares boundaries with Jigawa and Bauchi States to the South-West, Borno State to the East and the Niger Republic to the North. The hospital is a Tertiary Health Centre, providing services to all local governments in the State and the Southern part of Niger republic. Yobe, Borno, Adamawa, Bauchi States were affected by the insurgency leading to displacement, loss of lives, and properties.
| Results|| |
The mean age, parity, LCB, and hematocrit of the study participants were 26.35 ± 6.17 years (95% CI 25.35, 27.08 years), 4.0 ± 3.0 (95% CI 3.0, 4.0), 2.03 ± 1.62 years (95% CI 1.81, 2.26 years), and 32.64 ± 7.06% (25% CI 31.28%, 33.45%), respectively [Table 1]. Most 125 (62.5%) (95% CI 55.3%, 70.6%) were booked for ANC in the third trimester whereas the remaining 75 (37.5%) booked in the second trimester. While the overall prevalence of anemia was 93 (46.5%) (95% CI 40.4%, 52.6%); mild, moderate and severe anemia were present in 40 (20.0%), 39 (19.5%), and 14 (7.0%), respectively. More grand multipara had severe anemia compared to primipara and multipara [Figure 1]. Majority of the women had normocytic normochromic anemia 130 (65.0%), 50 (25.0%) had microcytic hypochromic anemia, 10 (5.0%) had macrocytic anemia and the remaining 20 (10.0%) had dimorphic blood picture on film. 136 (68.0%) have normal mean corpuscular volume (MCV), 50 (25.0%) have low MCV and remaining 14 (7.0%) had a high MCV. The Pearson correlation analysis between parity and hematocrit levels was weak, negative, and statistically significant (r = −0.144, P = 0.042; r2 = 0.021). Pearson correlation analysis between LCB (n = 88) and hematocrit levels was weak, positive, and not statistically significant (r = 0.064, P = 0.556; r2 = 0.004). Chi-square analyses revealed a significant relationship between parity (primip-1, multipara 2–4, and grand multi ≥5) and hematocrit (<21.0%-severe, 21.0%–29.9%-moderate, 30.0%–32.9%-mild, and ≥ 33.0%-not anemic) (χ2 = 13.166 [df = 6], P = 0.039, Cramer's V = 0.181). More grand multipara had severe anemia compared to primipara and multipara; 7 (9.9%) versus 1 (1.7%) versus 6 (8.5%), respectively [Figure 1].
| Discussion|| |
The WHO has stratified prevalence of anemia into different categories of public health significance as follows; ≤4.9%-normal, 5.0%–19.9%-mild, 20.0%–39.9%-moderate and ≥40%-severe. The overall prevalence of anemia in this study is very high and consistent with the WHO stage of severe public health significance. Our findings although higher than those of Koyuncu et al. in Turkey are lower than those of El-Ashim et al. in Egypt in third-trimester pregnant women. In addition, the finding of a higher proportion of severe anemia in this study compared to an earlier study by Kagu et al. in the same region may be connected to the general insecurity which destroys the land, water, biological and social resources for food production. Other possible contributory factors may be low literacy levels and general lack of reproductive health awareness.
Food insecurity is one of the factors that can contribute to the high prevalence of anemia among pregnant women. Food availability is reduced because of the destruction of food stores and this leads to severe food shortages, mass starvation with nutrient deprivation as a result of the elimination of a single growing season., This is in addition to socioeconomic and demographic factors which have been linked to mild and moderate anemia. Interestingly, Kagu et al. (2007) reported higher figures compared to our findings in women attending their first antenatal in the same area before the present insurgency. This suggests that other factors apart from the insurgency may be responsible. It is also important to note that their sample size was larger and their study was done when the environment was peaceful and clinic attendance possibly higher. In addition, it is possible that the women were not eating well as a result of hyperemesis and also were yet to commence any nutritional supplements. The burden of anemia in our study although similar to that reported in Mali by Ayoyu et al. is lower than that reported by ElZahaf et al. in Libya. These are areas that have also faced insurgencies.
The mean PCV from our study was similar to the findings of Babadoko et al. (2014) in a previous retrospective study among the same population. However, they did not stratify their study participants based on the severity of anemia as we have done. Hence, the prevalence and magnitude of anemia cannot be established from their study. Severe anemia among pregnant women is associated with a myriad of complications which include maternal cardiovascular diseases, reduced physical and mental performance, lack of immunity, and unavoidable fatigue. Intrauterine growth retardation and fetal death may also complicate such pregnancies. Anemic mothers may not be able to withstand the rigors of labor and as such prolonged labor and its attendant consequences may result. Although early diagnosis and treatment are key in reducing maternal morbidity and mortality we believe that a bottom-up approach and tackling socioeconomic factors contributing to maternal anemia will be more appropriate.
The association between parity and anemia in this study is expected. This is because repeated conception without adequate spacing will lead to maternal depletion syndrome. This may be because such mothers with short inter-pregnancy intervals may not have had sufficient time to replace nutrients used in the previous pregnancy.
| Conclusion|| |
The high overall prevalence of third-trimester anemia in Northeastern Nigeria is of severe public health significance and is associated with parity. The limitation of this study is its hospital-based nature. This is because a widespread study is not feasible due to the current security situation in this region. We recommend further studies to determine the cause(s) of this high prevalence as the majority showed a microcytic or macrocytic picture on blood film.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bothwell TH. Iron requirements in pregnancy and strategies to meet them. Am J Clin Nutr 2000;72:257S-64S.
WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2011 (WHO/NMH/NHD/MNM/11.1). Available from http://www.who.int/vmnis/indicators/haemoglobin.pdf
. [Last accessed on 2017 Apr 01].
Lee AI, Okam MM. Anemia in pregnancy. Hematol Oncol Clin North Am 2011;25:241-59, vii.
Reveiz L, Gyte GML, Cuervo LG, Casasbuenas A. Treatments for iron-deficiency anaemia in pregnancy. Cochrane Databaseof Systematic Reviews 2011;10: Art. No.: CD003094. DOI: 10.1002/14651858.CD003094.pub3.
Kalaivani K. Prevalence and amp; consequences of anaemia in pregnancy. Indian J Med Res 2009;130:627-33.
] [Full text]
World Health Organization. Iron and Folate Supplementatation Intergrated Management of Pregnancy and Childbirth (IMPAC) in Standards for Maternal and Neonatal Care Developed by the Department of Making Pregnancy Safer. World Health Organization; 2006. p. 1-6. [Last accessed on 2018 Apr 04].
Koyuncu K, Turgay B, Şükür YE, Yıldırım B, Ateş C, Söylemez F, et al.
Third trimester anemia extends the length of hospital stay after delivery. Turk J Obstet Gynecol 2017;14:166-9.
El-Ashim A, El-Ghazali S, Habu I. Prevalence and determinants of anaemia in third trimester pregnancy in Fayoum Governorate Egypt. Acta Med Mediterr 2014;30:1045-51.
Kagu MB, Kawuwa MB, Gadzama GB. Anaemia in pregnancy: A cross-sectional study of pregnant women in a Sahelian tertiary hospital in Northeastern Nigeria. J Obstet Gynaecol 2007;27:676-9.
Cropper WP, Harvod MA. Food availability after nuclear war. In: Harwell MA, Hutchinson TC, editors. Environmental Consequences of Nuclear War 11 Ecological and Agricultural effects. 2nd
ed.: John Wiley and Sons Ltd. Chichester, New York, Brisbane, Toronto and Singapore; 1985. p. 359.96.
Bentley ME, Griffith PL. The burden of anaemia among women in India. Eur J Clin Nutr 2003;57:52-60.
Ayoyu MA, Spiekermann-Brouwer GM, Traorĕ A, Stolzfus RJ, Garza C. Determinants of anaemia among pregnant women in Mali. Food Nutr Bull 2006;27:3-11.
ElZahaf RA, Omar M. Prevalence of anaemia among pregnant women in Derna city Libya. Int J Community Med Public Health 2016;3:1915-20.
Babadoko AA, Takai IU, Kawuwa MB. Distribution of ABO, Rh D blood groups and haemoglobin phenotypes among antenatal clinic attendees in federal medical centre Nguru, Nigeria. Bor Med J 2014;11:86-91.
King JC. The risk of maternal nutritional depletion and poor outcomes increases in early or closely spaced pregnancies. J Nutr 2003;133:1732S-6S.