INTRODUCTION
According to the
world health organization (WHO), anemia in pregnancy is defined as hemoglobin
concentration (Hb) of < 11 g/dl, or haematocrit
level (PCV) < 33%. [1] Anemia is a very common pregnancy complication, and
it is a global health challenge. However, most of the burden is in countries
with poor resource setting; the World Health
Organization estimated the prevalence as 53.8%
to 90.2% in developing countries, and 8.3% to 23% in developed countries. [2]
Data
from Indian Demographic and
Health Survey (2019–2021) reported a prevalence of 50.0%. [3] However, a study in Rural
Medical Center in West Bengal (in India) reported a very high rate of 90.0%, [4]
In Tanzania, a study at Mkuranga District Hospital also
reported a high prevalence of 80.0%. [5] In Katsina State, Nigeria,
a multi
center study reported a rate
of 44.0%. [6]. Much lower rates were reported in some centers; at Hiwot Fana
Specialized University Hospital in Ethiopia it was 25.3%, [7] and a study at Itojo Hospital, South Western Uganda had a rate of 7.4%. [8]
Several
factors have been proven to be associated with anemia in pregnancy globally. A
multi-center study in China and South Korea identified the risk factors as living
in rural area (OR = 1.207), multiple gestation (OR
= 1.478), ≥ 3 gravidity (OR = 1.195), and low educational level (OR =
1.203). [9]
In
Nairobi Kenya, a study at Pumwani Maternity Hospital identified the predictors
of anemia in pregnancy as: non compliant with intake of hematinics
(AOR = 2.04; 95% CI = 1.14 - 3.64; P =
0.016), advanced maternal age (AOR = 2.71; 95% CI = 1.25 - 5.88; P = 0.012), and
unemployment (AOR = 1.91; 95% CI = 1.03 - 3.53; P = 0.039) [10]
Another
study at University of Peradeniya Teaching Hospital
in Sri Lanka reported the significantly associated factors as low monthly
family income, low weekly consumption of
red meat (OR 8.994; 95% CI, 5.74 - 14.09, p < 0.05) and high weekly tea
intake (OR 0.21795% CI 0.144 - 0.327, p < 0.05). [11]
In Sub-Saharan Africa, parasitic infections that
cause anemia in pregnancy are very common; Iron deficiency anemia is frequently
caused by Malaria, and hook worm infections. [[12]. Previous studies on antenatal women in Nigeria
reported high rates of malaria infestation; 76.0% in Yola,
[13] 53% at Enugu, [12] and 23.5%
at Ahmadu Bello University, Zaria. [14]
Hookworm
infestation in antenatal women is relatively common in developing countries,
especially in farmers. A study on pregnant women with anemia in a rural
community at Enugu in South East Nigeria reported a rate of 27%. [12] Another
study (a meta-analysis) on hookworm infestation reported a global prevalence
that range from 1% to 78%, and that pregnant women with hookworm infection
were more likely to have anemia, odds ratio = 2.55 [2.20, 2.96], P < 0.001) [15]
Other common causes of anemia in West Africa
are pregnancy complications such as antepatum hemorrhage,
from abruptio placenta and placenta praevia. [16] Excessive bleeding after delivery (post
partum hemorrhage) is even more common, especially from uterine atony, and
genital tract trauma during delivery. [17, 18]
The factors associated with anemia in
pregnancy has been widely studied, and there are many publications on this
subject matter globally (including Nigeria), but none in this environment. Hence
the need for this study, as the results is expected to enhance the management
of our antenatal women.
Objectives:
This
study intends to elucidate the determinants of anemia at booking, at 36 weeks
and after delivery, among women who received antenatal care. It would also
determine the socio-demographic characteristics of the women.
METHODOLOGY
Study
site and subjects
The study was carried out at the antenatal
clinic, antenatal and labour wards, in the department of obstetrics and gynaecology,
NDUTH, Yenagoa, Southern Nigeria. The subjects were pregnant women who booked
for ANC, and delivered vaginally in NDUTH.
Study
design
This
was a retrospective analytic cross-sectional study. It was carried out from
January 2018 to December 2022.
Inclusion criteria
Included in this study were pregnant women
who booked for ANC, and delivered vaginally during the study period.
Exclusion criteria
Excluded were unbooked
patients, women who booked for ANC in NDUTH, but delivered elsewhere, and women
whose hemoglobin or haematocrit levels were not well documented in their case
notes.
Also excluded were women who delivered by
caesarean section, and booked patients whose pregnancies terminated before the
period of fetal viability, which in Nigeria is 28 weeks gestation in Nigeria. [19]
NDUTH
policy on screening for anemia in pregnancy
The hospital policy is to screen all pregnant
women at the booking visit, at 36 weeks, and within 24 – 48 hours after
delivery. Blood samples are collected from the patients and sent to the
hospital hematology laboratory for full blood count, which includes hemoglobin
(Hb), and haematocrit or
packed cell volume (PCV).
Diagnosis
of anemia in pregnancy
The diagnosis of anemia in pregnancy was
based on the WHO criteria, as shown below. Patients with Hb
< 11g/dl or PCV < 33.0% were considered anemic.
The
chances of having postpartum anemia was 3 times higher in women who were anemic
at 36 weeks gestation, odds ratio = 3.85[0.87, 17.03], p = 0.05.
It is also 4 times higher in women who had
uterine atony immediately after delivery, odds ratio = 4.05 [1.71, 9.35], p =
0.0005, and 6 times higher when delivery is complicated with cervical
laceration, odds ratio = 6.00[1.15, 31.41], p = 0.01.
Other significant factor are placenta praevia
p = 0.04, and assisted vaginal breech delivery p = 0.04.
DISCUSSION
Anemia
in pregnancy is one of the most common pregnancy complications experienced globally,[1]
and its impact is more pronounced in poor resource settings, especially in sub-
Saharan Africa, where nutrition is poor, [20] malaria is endemic, [14] and
there is poor utilization of obstetrics services.
It is therefore not suppressing that the
75.4% rate of anemia we got in this study was quite high. However, it did not
deviate widely from what was obtained in other developing countries; 90% from a
study in India, [4] 80.0% in Tanzania, [21] 62.5% in Bangladesh, [22] and 65.2% in Obudu in
Nigeria. [23]
Fortunately, the high rates in developing countries stated
above are not absolute; very low rates have actually been recorded in some
centers in the developing world, some of which are comparable to the 8.3% to 23.0% reported for developed countries by WHO. [2]
7.4% was reported in South West Uganda, [8] 8.19% at Peradeniya in Sri Lanka, [11] 18.0% at Kilimanjaro Christian Medical Centre in
Tanzania, [24] and 24.5% in Kano, Nigeria. [25]
Regarding
the severity of anemia, the high rate of anemia (we got in this study) does not
seem to pose many problems, as majority of the cases in NDUTH were mild. This
is further supported by the fact that our rate of severe anemia was extremely
low; 2.8% at booking, 0.6% at 36 weeks, and 1.1% post partum.
However, in many centers globally, moderate
anemia was more common. At West Bengal in India, majority (60.5%) of the women
has moderate anemia. [4] Similar results were reported from studies in
Bangladesh, [22], and Eswatini. [26] On the contrary, a very formidable pattern was
reported at Harari region in Ethiopia, were severe
anemia was more common (11.8%), followed by moderate anemia (8.13%), and mild
was least (6.10%). [7] The reason why moderate to severe anemia were more
common was not clear. However, it could be due to late booking for ANC, poor
intake of hematinics, and living in a malaria endemic
region.
Regarding maternal age and
anemia, our study has established the fact that teenage pregnancy is strongly
associated with anemia in pregnancy. Nigeria is one of the countries globally
with the highest number of teenage mothers, especially in Northern Nigeria,
where early marriage is a cultural and religious practice. [27, 28] According to the Nigerian
National Demographic Health Survey (2008 – 2018), the prevalence of teenage
motherhood increased from 50.9% in 2008 to 55.2% in 2018. [28]
Teenage pregnancy as a risk
factor for anemia has also been verified from studies in other parts of the
world; a study at Rural Medical College-Hospital in India
reported that 68.4%
of pregnant teenagers were anemic. [29] A study at Ashanti Region in Ghana (on pregnant teenagers)
revealed that 57.1% of the patients had anemia. [30] In Northwestern
Malaysia, the prevalence was 53.1%. [31]
The reason why pregnant
teenagers are vulnerable to anemia is because of inexperience, and lack of
knowledge on pregnancy and antenatal care. In addition, they are not competent
to take decisions on issues related to their health. As a result, they are
likely to book late for ANC, and they are also unlikely to take hematinics as prescribed. [28,
29] In Malaysia, it was reported that teenagers who booked late for ANC
were 16 times more likely to develop anemia, (AOR 16.33; 95% CI: 6.51, 40.99).
[31]
In this study, we observed
that rural dwellers were more prone to malaria in pregnancy. In Nigeria, there
is significant rural urban drift, because our rural areas are underdeveloped,
with very low living standards, and absence of jobs. Majority of our rural dwellers
depend on small scale crude farming and fishing for survival. It is therefore
not surprising that they significantly had more anemia than the urban dwellers.
This is most probably from poor nutrition, and hookworm infestation.
The relationship between
rural dwelling and anemia in pregnancy was also established in other centers.
At West
Bengal in India, a very high rate of 90.0% was reported, [4] A multi-center
study in China and South Korea reported that pregnant women living in rural
area significantly has more anemia than those living in urban areas, (OR = 1.207). In contrary, a study at Eswatini (in southern part of Africa) reported that anemia
in pregnancy was more common in urban dwellers, odds ratio = 1.8 [1.19–2.72]. [26]
The reason for this disparity is not very clear. However, it’s very possible
that their rural area where the study was done is developed.
With respect to pregnancy
complications that predispose to anemia, prominent among our significant
findings (in NDUTH) were: malaria, and multiple gestation. Malaria causes
anemia because the malaria parasite (especially plasmodium falciparum) causes
hemolysis, and destruction of the red blood cells. [32]
Nigeria is in the heart of
the malaria belt in Africa, according to WHO, this region carries 94% of all malaria
cases and 95% of deaths. [33] Four African countries accounted for more than half of
all malaria deaths globally: Nigeria (26.8%), the Democratic Republic of the
Congo (12.3%), Uganda (5.1%) and Mozambique (4.2%). [34] As a result, WHO
recommended that pregnant women living in this region should use insecticide
treated nets, insect repellants, and intermittent preventive therapy for malaria prevention. [1]
Malaria as a cause of anemia
in pregnancy in Nigeria has been proven by various studies; a study in Yola reported that as much as 76.0% of ANC women diagnosed
with anemia in pregnancy had malaria. [13] Another study at Ikot Ekpene
reported that the prevalence of malaria among ANC women diagnosed with anemia
was over 50%. [35]
A very common cause of
anemia in pregnancy (vindicated by our study) is multiple gestation. Similar
results have also been published in other centers; a study in a tertiary hospital
in China reported the prevalence of anemia among women with twin as 42.6%. [36]
At Ohio State University (Wexner Medical Center) in
the US, the prevalence was 21%. [37] The cause of anemia in women with multiple
gestation is increased demand for iron by the growing fetuses; Iron is a very
important precursor for hemoglobin biosynthesis. [38]
Regarding postpartum anemia,
the significant factors obtained in this study, such as placenta praevia and
genital tract lacerations are obvious causes of blood loss, [17, 39] and requires little explanation.
CONCLUSION
The prevalence of anemia in pregnancy in NDUTH is
unacceptably high; however it could be mitigated via advocacy. Especially
against late booking for ANC, teenage pregnancy, and malaria prevention; by use
of insecticide treated nets, insect repellants, and intermittent preventive
therapy (as recommended by WHO).
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