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American Journal of  
Environment and Climate (AJEC)

Magnitude of  Anemia and its Associated Factors Among Pregnant 
Women in Jowhar District, Somalia

Sharmarke Burhan Taste1*, Nurezeman Gali1, Dessalegn Tamiru1

Volume 1 Issue 3, Year 2022
ISSN: 2832-403X (Online)

DOI: https://doi.org/10.54536/ajec.v1i3.832
https://journals.e-palli.com/home/index.php/ajec

Article Information ABSTRACT

Received: October 25, 2022
Accepted: December 22, 2022
Published: December 26, 2022

Globally, anemia affected 1.62 billion people; of  these, 56 million anemia cases were 
found in pregnant women. Anemia is a global public health problem that affects both 
developing and industrialized countries with major consequences of  social and economic 
burdens. This study set out to determine the prevalence of  anemia and its associated factors 
among pregnant women attending Antenatal Care at public hospitals in Jowhar district, 
South Somalia. A total of  376 study respondents were included in the study. Structured 
questionnaires and laboratory investigation was used to collect data. Data were analyzed using 
binary and multivariable logistic regression. The significance of  the association was declared 
at a p-value < 0.05. The overall prevalence of  anemia was 53.1%. Most of  the participants 
were mild anemic (36.53%). The mean hemoglobin concentration of  pregnant women was 
10.7 ± 2.0 g/dl. In second trimester of  pregnancy (AOR=0.32, 95%CI=0.12-0.83), taking 
meal less than two times per day (AOR=4.80, 95%CI=1.41-16.36), rare meat (AOR= 43.07, 
95%CI=2.56-73.50) and fruit (AOR= 6.01, 95%CI= 1.05-34.33) consumption and lack of  
iron folic supplementation (AOR= 10.06, 95%CI= 1.51-67.05) were significantly associated 
with anemia among pregnant women. Findings indicated that more than half  (53.1%) of  
the pregnant women were anemic, which is a severe public health problem according to 
WHO classifications. Therefore, the Federal Ministry of  Health and its counterpart in Hir-
Shabelle State should work together to tackle anemia through nutrition education and folic 
iron supplementation.

Keywords
Maternal Anemia, Pregnant 
Health, Jowhar District, South 
Somalia

1 Department of  Nutrition and Dietetics, Jimma University, Ethiopia
* Corresponding author’s e-mail:  dr.sharmab143@gmail.com

INTRODUCTION
Centers for Disease Control and Prevention (CDC) and 
the World Health Organization (WHO) defined anemia 
as a hemoglobin concentration of  less than 11 g/dL 
(WHO, 2011; Alemayehu et al., 2016). According to WHO 
classifications, anemia in a pregnant woman is categorized 
as severe, moderate, and mild if  the blood hemoglobin 
concentration is <7 g/dl, 7 to 9.9 g/dl, and 10.0 to 10.9 g/
dl, respectively (Mihiretie. et al. 2015; WHO, 2017). 
The World Health Organization classified the burden 
of  anemia as a problem of  public health based on its 
prevalence among the population in a particular area and 
anemia is considered as a public health problem if  its 
prevalence is 5% or greater (WHO, 2017; De Benoist B. et 
al. 1993). Although both males and females of  all ages can 
be affected by anemia, pregnant women and young children 
are the most vulnerable groups due to an increment of  iron 
requirement (Alemayehu, A. 2016; Fidler, 2017).  
According to WHO estimations, currently, the prevalence 
of  anemia among pregnant women is 41.8% and African 
pregnant women account for 61.3%. Studies showed that 
Sub-Saharan African countries are highly affected by 
anemia and the prevalence of  anemia among pregnant 
women is estimated at 17.2 million which is almost 30% 
of  all global cases (McLean, Erin, et al. 2009).  
Various studies have confirmed that anemia in pregnant 
women is still one of  the most serious unsolved public 
health issues in developing countries, owing to a variety 
of  socio-cultural challenges such as illiteracy, poverty, 
lack of  awareness, cultural and non-secular taboos, poor 

dietary habits and a high parasitic infestation (Karaoglu, 
Leyla, et al. 2010). Anemia is an indicator of  both poor 
nutrition and healthcare services (WHO, 2017). 
Anemia during pregnancy is liable for increased feto-
maternal morbidity and mortality and a high risk of  
LBW, which will continue into subsequent generations 
(Alemayehu, A. et al. 2017; WHO, 2017). Anemia 
contributes to 20% of  maternal mortality worldwide. 
Maternal anemia is related to a twofold and threefold 
increased risk for pre-term delivery and delivery of  an 
LBW infant, respectively. The economic loss because of  
anemia, specifically iron deficiency anemia, is estimated 
at approximately $2.32 per capita or 0.6 % of  Gross 
Domestic Product (GDP); this figure even rises to $16.78 
per capita or 4.05% of  GDP if  cognitive losses are 
considered. (Klemm R. et al 2010)
Appropriate diagnosis and treatment of  anemia are 
capable of  restoring personal health and raising national 
productivity levels by a maximum amount of  20% (Breda J. 
2020). Anemia in pregnancy has unfavorable implications 
for both the mother and the baby, including maternal 
morbidity and mortality, prenatal and postpartum child 
loss, and physical and cognitive loss. In the Jowhar district 
of  South Somalia, this study aimed to determine the 
prevalence of  anemia and its associated factors among 
pregnant women.

METHODOLOGY  
Study setting  
Facility-based cross-sectional study design was conducted 

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in Jowhar district, South Somalia from April 20 to June 01, 
2021.  Jowhar district was bordered by Jalalaqsi and Bulo-
Barde Districts to the North, Adale District to the West, 
and Bal’ad to the South. It has an estimated population of  
269,851. Jowhar district is located at a distance of  90 km 
from Mogadishu, the capital of  Somalia. In the Jowhar 
district, there are two public hospitals that offer a full 
range of  comprehensive health services. 

Source and Study Population  
All pregnant women attending antenatal care clinics at 
public hospitals in Jowhar district were considered as the 
source population, while selected pregnant women who 
were attending Antenatal care from April 20 to June 01, 
2021, were the study population.

Sample size and sampling procedure
Single proportion formula was used to calculate the sample 
size, and the following assumptions were considered: the 
prevalence of  anemia in the Jowhar district was 50% 
and 10% non-response. Then, 384 sample sizes were 
calculated. As the number of  pregnant women in the 
study area was 3200, the correction calculation was used, 
and the final sample size was 376. The sampling frame 
was prepared by using pregnant women’s registration 
forms from the hospitals. Simple random sampling was 
used to select the final respondents to give them an equal 
chance of  being selected for the study. 

Data collection procedures   
Pre-tested structured interviewer-administered 
questionnaires were used. The questionnaire was adapted 
from different literature, and it was initially prepared in 
English and then translated into Somalia language. The 
interview was conducted by trained BSc nurses, and the 
response of  each pregnant woman to every question was 
recorded on the questionnaire as per the pre-determined 
instructions.
Following the completion of  the interview of  each 
pregnant woman, they were requested to give blood and 
stool specimens for the hematological and parasitological 
examinations, respectively. The laboratory investigation 
was conducted after the necessary specimen was 
collected. A stool specimen examination was performed 
within 30 minutes. Two slides were prepared from each 
stool specimen using direct wet-mount and formol-ether 
concentration techniques. The slides were examined by 
two senior laboratory technicians using 10X and 40X 
microscopic objectives (Cheesbrough, M. 2005).
Thick and thin blood films were prepared by collecting 
blood from a finger prick and stained with Giemsa stains. 
The thick blood film provides enhanced sensitivity to the 
blood film technique and is used to detect low levels of  
parasitemia. The thin blood film was fixed with methanol 
and stained with diluted Giemsa-stain using buffered 
water at pH 7.2 to emphasize the parasite inclusions in 
the RBC (Trivedi ND, 2010).
Hemoglobin (Hgb) concentration was determined by 

Hemocue HB 201+ analyzer (HemoCue, Angelholm, 
Sweden). The blood sample was collected by finger 
pricking after rubbing the fingertip with sterile cotton 
(immersed in 70% alcohol), and pricking it with a sterile 
disposable lancet. A drop of  blood was allowed to enter 
the optical window of  the micro cuvette through capillary 
action. The microcuvette was placed into the cuvette 
holder for photometric determination of  hemoglobin 
level. Then, the concentration of  hemoglobin level was 
quantitatively determined in g/dl (Nkrumah B, 2014).
In this study, pregnant women were considered as anemic 
if  the Hb concentration was <11 g/dl. Then, anemia 
is defined as mild, moderate, and severe if  the Hb 
concentration is 10-10.9 g/dl, 7- 9.9 g/dl, and less than 7 
g/dl, respectively (2). 

Data quality control
The questionnaire was translated into Somali language and 
then back into English to detect any discrepancies. The 
HemoCue photometer (HemoCue201+) was calibrated 
before taking any sample. The precision of  HemoCue 
was repeatedly checked. Standard operating procedures 
(SOPs) were followed for all laboratory analyses.

Data processing and analysis
Data were coded, and entered into EpiData version 3.1, and 
then checked for completeness and consistency. The data 
was exported to SPSS version 26 for analysis. Descriptive 
analyses such as frequency and mean were performed to 
summarize the findings of  the data. The Kolmogorov-
Smirnov test was done to check the normality of  the 
data distribution. The relationship between anemia and 
independent variables were investigated through bivariate 
analysis. In bivariate analysis, variables with a P-value < 
0.20 were selected as candidates for multivariable logistic 
regression analysis to identify significantly associated 
variables with anemia and control confounding variables. 
Multivariable logistic regression analysis was performed 
by the entry method and model fitness was confirmed by 
the Hosmer-Lemeshow test. Frequency tables and charts, 
odds ratios, p-values, and 95% confidence intervals 
were used to present the results univariate, bivariate, 
and multivariable logistic regression analyses. For all 
statistical tests, a P-value<0.05 was considered statistically 
significant.

RESULTS
The mean age of  the respondents was 25.78 (±5.3) 
years, and 128 (34.1%) of  respondents were in the age 
group 21-25 years. The majority (320) of  the interviewed 
women were married (85.3%) and urban dwellers (251, 
66.9%). More than one-third (39.7%) of  respondents 
could not read and write. The majority of  respondents 
were housewives (218, 58.1%). One hundred sixty 
(42.7%) participants were in the second trimester. It was 
also found that 151 (40.3%) of  the respondents had a 
history of  bleeding during the current pregnancy (Table 
1). 

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Table 1: Socio-demographic and Obstetric characteristics of  pregnant women attending Antenatal Care in Jowhar 
district, South Somalia, 2021.  
Characteristics Categories Total Percent (%)
Age 16-20

21-25
26-30
31-35
≥36

76
128
121
32
18

20.3
34.1
32.3
8.5
4.8

Residence Urban Rural 251 
124

66.9 
33.1

Mothers’ Education Unable to read and write
Primary education  (1-8)
Secondary level and above

149
134
94

39.7
35.7
24.5

Marital status Married 
Unmarried 

320 
55

85.3
14.7

Trimester First trimester
Second trimester
Third trimester

124 
160 
91 

33.1
42.7
24.3

Gravidity <3
>3

365 
10 

97.3
2.7

Birth interval <24 months
>24 months

217 
158 

57.9
42.1

Blood loss during pregnancy Yes
No

151
224 

40.3
59.7

Prolonged menstruation Yes
No

91 
284 

24.3
75.7

History of  abortion Yes
No

114 
261

30.4
9.6

Mothers’ occupation House-wife
Employed
Student 
Servant 

218
67
22 
68

58.1
17.9
5.9
18.1

Income availability Yes 
No 

148 
227 

39.5
60.5

Almost half  (49.1%) of  the respondents ate meals thrice 
daily. More than half  of  the pregnant women (176, 
49.7%) took meat every other day. About one hundred 
sixty-six (48.8%) of  pregnant women ate vegetables every 
other day. Most respondents (184, 64.1%) said they drink 

tea after every meal, and 97 (45.1%) drink coffee after 
every meal. Most of  the respondents attended ANC 
greater than two times (67.7%). A large proportion of  
respondents (341, 90.9%) took iron supplements during 
their current pregnancy (Table 2). 

Table 2: Dietary practice and ANC service utilization characteristics of  pregnant women attending Antenatal Care 
in Jowhar district, South Somalia, 2021.  
Characteristics Categories Total Percent (%)
Meal frequency per a day More than three times 

Three times 
Less than two times 

99
184
92

26.4
49.1
24.5

Meat frequency per a day Everyday 
Every other day
Once a week
Once a month

81
176
77
20

22.9
49.7
21.8
5.6

Vegetables frequency  Everyday
Every other day
Once a week
Once a month

127
166
39
8

37.4
48.8.
11.5
2.4

Fruits eating Frequency Everyday
Every other day
Once a week 
Once a month

124
105
52
26

40.4
34.2
16.9
8.5

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Staple food Injera and broth
Maize and beans
Spaghetti
Rice

88
161
31
95

23.5
42.9
8.3
25.3

Frequency of  drinking tea After every meal
Once a day
Every other day
Occasionally

184
67
19
17

64.1
23.3
6.6
5.9

Frequency of  drinking coffee After every meal
Once a day
Every other day
Occasionally

97
57
28
33

45.1
26.5
13.0
15.3

Number of  ANC visit One
>Two

121
254

32.3
67.7

Iron/folate Yes 341 90.9
Supplementation No 34 9.1
The findings of  this study showed that the mean Hb 
concentration of  the study participants was 10.7 ± 2.0 g/
dl ranging from 6.5 g/dl to 15.6 g/dl. One hundred thirty-
seven (36.53%) had mild anemia (Hb<9.0-10.9g/dl and 

61(16.3%) had moderate anemia. The leading parasitic 
infection among pregnant women in the area was Giardia 
lamblia 171 (45.6%) followed by Entamoeba histolytica 
100 (26.7%). A large number of  (61.1%) participants had a 

Table 3: Magnitude of  anemia and other diseases among pregnant women attending Antenatal Care in Jowhar 
district, South Somalia, 2021 
Characteristics Categories Total Percent (%)
Anemic Not anemic

Mild anemia 
Moderate anemia 

176
137
61

46.93
36.53
16.3

Parasitic infection Giardia lamblia 
Trichuris trichiura
Ascaris lumbricoides
Strongyloides stercoralis
Entamoeba histolytica
Hookworm 
Hymenolepsis nane

171
9
72
3
100
17
3

45.6
2.4
19.2
0.8
26.7
4.5
0.8

Malaria species Plasmodium falciparum 
Plasmodium vivax 
Mixed (p.f+p.v)

129
97
17

53.1
39.9
7.0

known history of  malaria attacks in the last year (Table 3). 
Findings of  multivariate analysis showed being a second 
trimester (AOR=0.32, 95%CI=0.12-0.83), taking meals 
less than two times (AOR=4.80, 95%CI=1.41-16.36), 
poor meat (AOR=43.07, 95%CI=2.56-73.50) and  fruit 

consumption (AOR=6.01, 95%CI=1.05-34.33), lack of  
iron folate supplementation (AOR=10.06, 95%CI=1.51-
67.05) were significantly associated with maternal anemia 
(Table 4). 

Table 4: Multivariable logistic regression analysis of  factors associated with anemia among pregnant women attending 
antenatal care in Jowhar district, South-Somalia, 2021.
Characteristics Category Anemic Not 

anemic
COR(95% CI) AOR(95% CI) P

Occupational status House-wife
Employed 
Student 
Servant

101(46.3)
45(67.2)
17(77.3)
36(52.9)

117(53.7)
22(32.8)
5(22.7)
32(47.1)

0.77(0.45-1.32)
1.82(0.91-3.65)
3.02(1.0-9.13)
1

1
1.52(0.35-6.87)
8.89(0.94-83.74)
1

0.588
0.056

Marital status Married 
Unmarried 

156(49.7)
20(36.4)

164(51.3)
35(63.6)

1.67(0.92-3.01)
1

2.91 (0.86-9.87)
1

0.087

Educational status Unable to read & write
Primary level
Secondary and above

76(51.0)
58(43.3)
65(70.7)

73(49.0)
76(56.7)
27(29.3)

0.43(0.25-0.75)
0.32(0.18-0.56)
1

0.55(0.12-2.45)
0.35(0.09-1.30)
1

0.434
0.116

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Trimester First
Second
Third 

79(63.7)
66(41.3)
54(59.3)

45(36.3) 
94(58.8)
37(40.7)

1
0.40(0.245-0.65)
0.83(0.46-1.45)

1
0.32(0.12-0.83)
1.10(0.39=-3.08)

0.019
0.850

History of  intestinal 
parasites

Yes 
No

139(60.7)
90(39.3)

60(41.1)
86(58.9)

2.21 (1.45-3.38)
1

1.27(0.50-3.23)
1

0.617

Bleeding during 
pregnancy

Yes 
No 

64(42.4) 
135(60.3)

87(57.6) 
89(39.7)

2.06 (1.36-3.14) 
1

2.15(0.74-6.24) 
1

0.161

History of  abortion Yes 
No 

49(43.0) 
150(57.5)

65(57.0) 
111(42.5)

1.79(1.15-2.80) 
1

0.55(0.18-1.68) 1 0.291

Number of  meals 
per day

>3 times per day
Three times per day
<2 times per day

83(83.8)
90(48.9)
26(28.3)

16(16.2)
94(51.1)
66(71.7)

1
13.17(6.5,26.56)
2.43(1.42-4.16)

1
30.12(7.05, 28.6)
4.80(1.41-16.36)

0.000
0.012

Meat consumption Everyday 
Every other day
Once a week
Once a month 

31(38.3)
103(58.5)
40(51.9)
15(75.0)

50(61.7)
73(41.5)
37(48.1)
5(25.0)

1
2.28 (1.33-3.90)
1.74(0.93-3.28)
4.84(1.60-14.64)

1
3.27 (1.18-9.12)
1.80 (0.52-6.19)
43.07(2.56-73.5)

0.023
0.353
0.009

Vegetables 
consumption

Everyday 
Every other day
Once a week
Once a month

56(44.1)
100(60.2)
24(61.5)
5(62.5)

71(55.9)
66(39.8)
15(38.5)
3(37.5)

1
1.92(1.20-3.07)
2.03(0.97-4.23)
2.11 (0.48-9.22)

1
0.86(0.33-2.28)
0.41(0.07-2.39)
2.50(0.11-58.73)

0.767
0.320
0.569

Frequency of  eating 
fruits

Everyday 
Every other day
Once a week
Once a month

73(58.9)
49(46.7)
31(59.6)
21(80.8)

51(41.1)
56(53.3)
21(40.4)
5(19.2)

1
0.61(0.36-1.03)
1.03(0.53-1.99)
2.93(1.04-8.29)

1
0.58(0.22-1.54)
0.98 (0.32-3.03)
6.01(1.05-34.33)

0.276
0.977
0.044

Tea drinking after 
meal

After every meal
Once a day
Every other day
Occasionally 

73(39.7)
35(52.2)
10(52.6)
12(70.6)

111(60.3)
32(47.8)
9(47.4)
5(29.4)

1
1.66(0.95-2.92)
1.689(0.66-4.36)
3.65(1.23-10.79)

1
1.95(0.80-4.78)
0.71(0.13-3.81)
2.36(0.50-11.11)

0.143
0.694
0.277

Coffee  drinking 
after meal

After every meal
Once a day
Every other day
Occasionally 

61(62.9)
9(15.8)
19(67.9)
17(51.5)

36(37.1)
48(84.2)
9(32.1)
16(48.5)

1.59(0.72-3.54)
0.18(0.07-0.47)
1.99(0.69-5.66)
1

Iron/folate 
supplement

Yes 
No 

175(51.3)
24(70.6)

166(48.7)
10(29.4)

1
8.28(1.057-4.91)

1
10.1(1.51-67.05)

0.017

Previous delivery 
Place 

Health institution
Home 

152(56.3)
47(44.8)

118(43.7)
58(55.2)

1.59(1.01-2.50)
1

1.01(0.40-2.55)
1

0.978

DISCUSSION
The overall prevalence of  anemia among pregnant 
women during this study was 53.1%. This finding is 
much higher than the national prevalence of  anemia 
in pregnant women, which is 45.5% (WBG, 2016). 
However, this finding is lower compared to findings from 
Mogadishu (84.3%) (Bekele A, 2016) Ethiopia (62.7%), 
Algeria (76.5%) (Coutinho GG, 2005), India (74.8%) 
(Makhoul Z. et al. 2012), Eastern Sudan (62.6%) (Adam I. 
et al. 2005), Niger Delta and Nigeria (66.7%) (Isa A. et al 
2012).This discrepancy could be due to the sociocultural 
and time gap differences. 
Findings of  this indicated that pregnant women in the 
second trimester were more likely to be anemic compared 
to the women in the first trimester. This finding is 
supported by previous studies conducted in Ghana and 
India (Mockenhaupt FP. et al. 2000; Viveki RG. et al. 
2012). Furthermore, research conducted in Malaysia, 
Vietnam, and Nepal discovered that a higher gestational 
age is linked to a higher risk of  anemia. This could be 

1= Reference, COR=Crude Odds Ratio and AOR=Adjusted Odds Ratio

because of  increment of  demands and lowering mother’s 
blood’s iron binding capacity. 
The study also revealed that iron supplementation 
was significantly associated with anemia. Pregnant 
women who did not take iron supplements during their 
pregnancies had a higher risk of  having an anemic 
mother. Different studies from Ethiopia (Addis Alene K, 
2014; Gebre A, Mulugeta A, 2015), Uganda (Ononge S. 
et al, 2014), Nigeria (Nwizu EN. 2011), Vietnam (Aikawa 
R. et al 2005) and India (Banerjee B. et al. 2009) revealed 
similar findings. The results of  this study also showed that 
pregnant women who ate fewer than two meals per day 
were more anemic than those who ate more than three 
meals per day. This might be due to the fact that during 
pregnancy there is an increased energy and nutrient 
requirement. This finding is consistent with previous 
studies conducted in Southern Sudan and Kenya, which 
found that pregnant women who consumed ≥3 meals/
day were less anemic (Ndegwa SK. 2019; Fan FS, 2016; 
Ghose B. et al. 2016).

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Consumption of  meat was significantly associated 
with anemia among the pregnant women. Pregnant 
women who were rarely consuming meat were more 
highly exposed to anemia compared pregnant mothers 
who frequently consumed meat. Studies have also 
demonstrated that eating meat significantly reduces the 
risk of  developing anemia since meat and meat products 
are healthy dietary sources of  iron (Obse N. et al. 2013). 
This study also revealed that eating fruit was substantially 
linked to preventing anemia. Pregnant women who 
consumed fruits were less likely to develop anemia 
compared to their counterparts. Additionally, studies from 
Pakistan and Turkey revealed a link between eating fruit 
twice a week or more and a lower incidence of  anemia. 
Studies have also shown that eating fruits and green leafy 
vegetables promotes non-heme iron absorption. These 
kinds of  food provide nutrients such as ascorbic acid, 
which is required for non-heme iron absorption.

CONCLUSIONS
Findings of  this study showed that more than half  
(53.1%) of  the pregnant women were anemic in Jowhar 
district which significantly associated with second 
trimester, meal frequency, meat and fruit consumption 
and folic iron supplementations.  Therefore, the Minister 
of  Health of  the Federal Government of  Somalia should 
closely work with both government and non-government 
organizations to tackle the problem of  anemia among 
pregnant women by providing nutrition education and 
Iron folic supplementation.  

Limitation of  the study
This study has significant input in prevention of  anemia 
and to create awareness as there is no study specifically 
in Jowhar district as well as south Somalia.  However, it 
is difficult to say whether anemia came before or after 
the predisposing factors as the study design was cross-
sectional. Additionally, we were unable to examine 
morphology assessment of  RBCs, serum ferritin, folate, 
or cobalamin concentrations due to logistical restrictions, 
which would have helped us, suggesting the micronutrient 
responsible for severe anemia.  

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