_____________________________________________________________________________________________________ # Dean; *Corresponding author: E-mail: kaleabtesfaye35@gmail.com; Asian Journal of Immunology 4(1): 190-214, 2021; Article no.AJI.78308 Predictors of Anemia among Pregnant Women Attending Antenatal Care at Public Hospitals of Sidama Region, Ethiopia, 2021 a Case Control Study Protocol Kaleab Tesfaye Tegegne a*, Abiyu Ayalew Assefa a, Andualem Zenebe a, Wosenyeleh Semeon Bagajjo b#, Berhanu Bifato a, Alelign Tadele Abebe c and Sintayehu Assefa d a Department of Public Health, Hawassa College of Health Science, Hawassa, Ethiopia. b Hawassa College of Health Science, Hawassa, Ethiopia. c Department of Medical Laboratory Technology, Hawassa College of Health Science, Hawassa, Ethiopia. d Department of Mid Wifery , Hawassa College of Health Science, Hawassa, Ethiopia. Article Information Open Peer Review History: This journal follows the Advanced Open Peer Review policy. Identity of the Reviewers, Editor(s) and additional Reviewers, peer review comments, different versions of the manuscript, comments of the editors, etc are available here: https://www.sdiarticle5.com/review-history/78308 Received 01 October 2021 Accepted 04 December 2021 Published 30 December 2021 ABSTRACT Background: Anemia is the main cause of morbidity and mortality among pregnant women in developing countries with maternal and fetal consequences, which leads to premature births, low birth weight, fetal cognitive impairment and death. Objective: To determine predictors of anemia among pregnant women attending ANC at public hospitals of Sidama region, Ethiopia, 2021. Methods and Materials: A facility based unmatched case-control study design will be conducted at public hospitals of Sidama region. A total of 6 Midwives, 6 laboratory technician and 6 supervisors will be involved in the data collection process. Cases will be recruited consecutively as they present to the hospitals and immediately four controls will be allocated for each case that came after selection of cases. The data will be entered into Epidata software and exported to SPSS software for windows version 23 for analysis. Descriptive statistics will be computed and both bivariable and multivariable logistic regression will be employed to identify predictors of anemia among pregnant women. The output will be presented using adjusted odds ratio (AOR) with the respective 95% confidence interval (CI). Budget and Work Plan: A total of 184,928 Ethiopian Birr will be required to carry out this study. The data collection will be conducted from June 25 to July 25, 2021. Study Protocol Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 191 Keywords: Anemia; predictors; pregnancy. 1. INTRODUCTION 1.1 Background Anemia implies a reduction in capacity of red blood cells to transport oxygen to tissues as a result of fewer circulating erythrocytes than normal or a decrease in the concentration of hemoglobin (Hgb). Anemia during pregnancy is defined as a hemoglobin concentration less than 11gram per deciliter (g/dl) and classified as mild (10.0–10.9g/dl), moderate (7.0–9.9g/dl) and severe <7g/ dl. Currently, World Health Organization (WHO) recognized that the hemoglobin value less than 11.0 g/dl at 1st and 3rd trimesters and less than 10.5 g/dl in the 2nd trimester is used to define anemia [1]. Anemia is highly dominant among pregnant adolescents due to the dual iron requirements, for their own growth and the growth of the fetus, and is less likely to access antenatal care [2]. In the world pregnant women who are affected by anemia are 56 million, out of those 17.2 million pregnant women are from Africa [3]. Globally Iron deficiency anemia (IDA) affecting about 32 million pregnancy women and is the most common cause of anemia among pregnant women [3,4] and 50 % of all the pregnant women who develop anemia live in middle and low-income countries [5]. The magnitude of anemia among pregnant women was found to be highest in developing countries, such as sub- Sahara Africa, South-East Asia were 57% and 48% respectively and lowest prevalence which is 24.1% reported among pregnant women in South America [6]. Prevalence of anemia among pregnant women in Africa was nearly half (46.3%) [7], 62.7% pregnant women are anemic in Ethiopia [3]. Pregnant women might be at risk of developing anemia due to low socioeconomic conditions. The poor nutritional intake, repeated infections, poor diet, poor antenatal care service, frequent pregnancies, low health-seeking behaviors and parasitic diseases, such as malaria and hookworm are associated with anemia [8-11]. Insufficient intake and poor bioavailability of iron- rich foods also have significant contribution for the onset of anemia during pregnancy [11]. Despite the efforts made by the government and other stakeholders, anemia during pregnancy is still a public health problem in the Ethiopia. 1.2 Statement of Problem In 2011, 38% (32.4 million) of pregnant women aged 15-49 years were anaemic globally [12]. Africa (61.3%) and Southeast Asia (52.5%) are regions with the highest rate of anemia during pregnancy in the world [13]. Anemia is still a public health problem in Ethiopia. According to the Central Statistical Agency of Ethiopia 2016 report [14], the prevalence of anemia among pregnant women was 29% which decreases with increasing women’s education and household wealth. The most common obstetric problems of anemia during pregnancy include; less exercise tolerability, puerperal infection, thromboembolic problems, postpartum hemorrhage, pregnancy- induced hypertension, placenta Previa and cardiac failure, abortion, prematurity, intrauterine fetal death, neonatal low birth weight, postnatal mortality and morbidity [15-17]. WHO intended to decrease anemia among reproductive-age women including pregnant women by 50% up to 2025 [18]. Ethiopian Ministry of Health also tried to mitigate the problem of anemia and its impact through the implementation of essential nutrition action [19]. Our study is important to develop strategies according to local conditions, taking into account the specific determinants of anaemia in the study area and among pregnant women. Furthermore, most of the previous cross-sectional studies conducted in Ethiopia recommended analytic study like case-control studies to be conducted [17,20-22]. In Sidama zone, previously one case control study was conducted from February to March 2011 to identify predictors of anemia among pregnant women in Hawassa and Yirgalem cities [23], but our study differs in several ways from the previous study. one we will used women Dietary Diversity Score and MUAC to assess nutritional status of pregnant women so this will help to identify nutritional factors associated with anemia and second we will do laboratory examination on peripheral morphology of red blood cells and this will give information on the type of anemia that a pregnant women Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 192 developed and third we include water sources and sanitation ,this help to test the association between safe water Sippy and anemia among pregnant women and fourth we include all public hospitals in Sidama region. A lot has been done to minimize the risk of anaemia, but the complication of anaemia is still a problem amongst pregnant women. The true predictors of anaemia were not well addressed in the study area. Therefore, this study will tried to investigate the stated information gaps among pregnant women so as to give evidence based action. 1.3 Significant of the Study Despite the efforts made by the government and other stakeholders, anemia during pregnancy is still a public health problem in Ethiopia. Research findings have revealed that determinants of anemia vary from place to place. This highlights the importance of determining the problem-based factors associated with anemia using a strong study design in order to obtain local data in the regions. In Sidama, to the best of current knowledge, no research exists that has used case control study design to identify predictors of anemia among pregnant woman. The finding of this study would help to guide the antenatal care service providers and other concerned stakeholders to work more towards alleviating the problem. Also it might be used as a base line data for other researchers who are interested on this area. 2. LITERATURE REVIEW 2.1 Factors Associated with Anemia Anemia during pregnancy has a variety of causes and contributing factors including socioeconomic conditions, abnormal demands like multiple pregnancies, teenage pregnancies, malnutrition, maternal illiteracy, unemployment, short pregnancy intervals, age of gestation, primigravida and multigravida, loss of appetite and excessive vomiting in pregnancy [24]. A study conducted in Canada revealed a strong significant association between intestinal parasitic infection and anemia in pregnant women [25]. A study conducted among Pregnant Women Receiving Antenatal Care (ANC) at Fatima Hospital in Jashore, Bangladesh showed that Monthly family income, family size, gestational age (third trimester), birth spacing < 2 years [AOR (95% CI), Excessive blood loss during previous surgery (Yes), Food group eaten 24 hours (1 – 4 groups), Breakfast regularly were predictors of anemia among pregnant women [26]. An analysis of recent national survey data to identify Determinants of anemia among women and children in Nepal and Pakistan elucidate that anemia was significantly higher among women from the poorest households in Pakistan, women lacking sanitation facilities in Nepal, and among undernourished women (BMI < 18.5 kg/m2) in both countries (Nepal and Pakistan) [27]. Furthermore, a research findings from study done in Yemen cited that low family monthly income, short pregnancy spacing, never consumed liver, and presence of health problems as a risk factors associated with anemia [28]. Across sectional study which was done at different gestational periods of 320 pregnant woman visiting antenatal care clinic at Kakamega county (Kenya) shows that, anemia was not significantly associated between age and anemia but there was significantly association between anemia and socio-economic status of the expectant mothers [29]. Prior studies in Ethiopia have reported significant associations between anemia in pregnancy and parasitic infections (e.g. schistosomiasis, hookworm infection), prior use of contraceptives, use of iron supplementation, birth spacing/ intervals, parity and gravidity, educational attainment, age, body weight, trimester of pregnancy and wealth status [21,30-36]. A cross sectional study which was done to assess prevalence of anemia and associated risk factors among pregnant women attending antenatal care in Azezo Health Center Gondar town, Northwest Ethiopia show that, anemia was significantly associated with age groups ranged from 26-34 years old and age groups greater than 34 years old. Rural residence was significantly associated with reduced anemic cases [37]. Institution based cross sectional study which was done to assess Prevalence of Anemia and its associated Factors among all Pregnant Women Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 193 Attending Antenatal Care (ANC) in Mizan Tepi University Teaching Hospital, South West Ethiopia revealed that, Anemia was significantly associated with history of malaria attack, and infections with hookworm, Ascaris lumbricoids, S. mansoni, Giardia intestinalis, and Entamoeba histolytica/dispar. However, iron supplement was protective of anemia [38]. A study on prevalence of anemia and associated factors among pregnant women in Ethiopia indicated that Undernutrition as seen in mid upper arm circumference (MUAC) being less than 23cm and food consumption score being poor and borderline category, were factors independently associated with anemia [39]. A result of study conducted at Jigjiga revealed that previous chronic diseases with, knowledge about anemia, excessive menstrual bleeding, history of malaria attack and history of abortion had significant association with anemia [40]. A community based cross- sectional study was conducted to assess Prevalence of anemia and associated factors among pregnant women in Southern Ethiopia revealed that household monthly income, level of food security, availability of latrine, frequency of meal per day, eating animal source of food at least once per week, history of malaria infection, and nutritional status; low socio economic class, trimester second and third, gravidity three to five and six and above, iron not supplemented, hookworm infection and low dietary diversity score showed statistically significant association (p<0.05) with anemia [41]. Fig. 1. Conceptual framework showing anemia and associated factors among pregnant women attending ANC in Sidama Region, 2021. Developed from different literatures reviewed [34-42] Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 194 Unmatched-Case Control Study conducted at Hawassa and Yirgalem cities found lower educational level, prolonged menstruation period 6-8 days before the index pregnancy, intestinal parasitic infection, gastritis with duodenal ulcer bleeding and not taking meat/organ meats as major predicting risk factors for occurrence of anemia among pregnant women [23]. A study conducted to Determinants of Anemia among Pregnant Women Attending Antenatal Clinic in Public Health Facilities at Durame Town also identified were parasitic infection, not taking additional diet during pregnancy, consuming tea/coffee immediately after food, not eating meat, previous heavy menstrual blood flow, and being housewife as a major determinant factors of anemia among pregnant women [42]. 3. OBJECTIVE To identify predictors of anemia among pregnant women attending ANC service at public hospitals of Sidama region, Ethiopia, 2021. 4. METHODOLOGY 4.1 Study Area The study will be conducted in public hospitals of Sidama region. It is located about 275 Kilometers away from Addis Ababa. It has 30 Districts, 1 city administration and 6 town administration with a total of 576 kebeles of which 524 of them are rural and 52 are urban. It is one of the highly populated areas in Ethiopia, having a total population of about 4 million people residing on 72100 hectare of land. Out of the total population 5.7% are urban and 94.3% rural residents [43]. Sidama is characterized by three agro-ecological zones: the dry midlands/lowlands (20%), the midlands (48%) and the highlands (32%). In Sidama region mixed agriculture (crop and livestock production) is practiced. Major crops grown include: enset, coffee, maize, wheat, teff, barley, haricot bean and khat. Enset is the main staple crop both in highlands and midlands while maize is so in the lowlands. There are two cropping seasons in Sidama Zone: belg and meher. Belg rains are mainly used for land preparation and planting of long cycle crops such as maize and sorghum and seed bed preparation for meher crops. The meher rains are used for planting of cereal crops like barley, teff, wheat and vegetable crops. Besides, meher rains are also responsible for the growth and development of perennial crops such as enset, coffee and khat. Food security is more precarious in the lowland areas of Aleta Wondo, Borecha, Darra, Bensa, Loka Abaya and Hawassa Zuria woredas mainly due to moisture stress and water logging in some pocket areas hampering agricultural production, less diversification of food sources and minimum use of improved farm inputs due to lack of cash and credit facilities to purchase the inputs. The Sidama region administration has a total of 4063 health professional of different disciplines and 524 Health Posts, 127 Health Centers, 1 general and 12 District hospital owned by government and additionally there are 21 private and 3 NGO clinics, 65 private rural drug venders. The overall potential health service coverage of the Zone by public health facilities are 90.3%. 4.2 Study Design and Period A facility based unmatched case-control study will be conducted 4.3 Source Population All pregnant women attending ANC service at public hospitals of Sidama region will be the source population. 4.4 Study Population All pregnant women attending ANC at public hospitals during study period and fulfilled the inclusion criteria will be the study population for this study. 4.5 Eligibility Criteria 4.5.1. Inclusion criteria  Pregnant woman who attending first ANC visit  Permanent resident pregnant woman (at least 6 months). 4.5.2 Exclusion criteria  Pregnant woman with severe illness and unable to speak and second and third visit. 4.6 Sample Size Determination Epinfo version 7 software will be applied to compute the sample size for cases and controls with an assumption of 95% confidence level, 80 % power of the study, 4:1 (r=4) ratio of non- anemic over anemic, the odds ratio = 2.5 from factors that has association with anemia from Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 195 Table 1. Sample size calculation for the study Factors AOR % of controls exposed Power Ratio of controls to cases CI Anemic Non Anemic Final sample size Source Intestinal Parasite(Yes/No) 2.9 11.6 80 1:4 95 62 248 310 (23) Previous heavy menstrual flow(Yes/No) 2.62 12.2 80 1:4 95 75 300 375 (42) Meat (Yes/No) 2.8 18.7 80 1:4 95 51 201 252 (23) Additional food(Yes/No) 2.5 9 80 1:4 95 105 419 524 (42) Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 196 Fig. 2. Schematic representation of sampling procedure recent study conducted in Durame and proportion of controls exposed 9.0% [42], the maximum sample size after adding the potential none response rate of 10% the total sample size became 576 (115 cases and 461 controls). The computation is depicted in the following table (Table 1). 4.7 Sampling Techniques From 18 public hospitals found in the region we randomly selected 6 hospitals. Enumeration of prior three month’s ANC register was conducted in order to know monthly flow of each hospital. Then, based on the number of ANC register, the sample size was allocated proportionally for all selected public hospitals in the region (Fig. 2). Cases will be recruited consecutively as they present to the hospitals and immediately four controls will be allocated for each case that came after selection of cases. 4.8 Study Variables Dependent variable for Objective one: Anemia. Independent variables:  Sociodemographic; clinical and reproductive; nutrition and lifestyle; and knowledge and health service related factors are independent variables. 4.9 Operational Definitions Anemia: Any hemoglobin level below 11g/dl in first and third trimesters and below 10.5gm/dl in the second trimester of gestation is considered as anemia [1]. Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 197 Nutritional Assessment: Nutritional assessment of woman will be done using anthropometry and dietary methods.  A Mid-upper arm circumference (MUAC) measurement of < 23cm and ≥23cm will be classified as malnutrition and normal nutritional status, respectively [43].  Dietary Diversity (DD) will be categorized as adequate (consumption of at least five of the ten food groups) and inadequate (consumption of less than five food groups) [44]. Knowledge about Anemia: We will used eight items composite score to measure the knowledge level of respondents regarding anemia which includes: general signs of anaemia, Iron-rich foods, foods that increase iron absorption, foods that decrease iron absorption, causes of anaemia, consequences of anaemia for pregnant women and infants and young children, and prevention of anaemia. The cumulative mean score of knowledge of participants about anemia will be estimated using mean score. Based on this, those who had scored less than the mean will be considered to have poor knowledge and those who had scored greater than or equal to the mean value will be considered as having good knowledge. 4.10 Data collection Procedure Data will be collected using a structured and pre- tested questionnaire, anthropometry and laboratory analysis of stool specimens. A total of 6 Midwives, 6 laboratory technician and 6 supervisors will be involved in the data collection process. 4.10.1 Questionnaires The questionnaire included information on sociodemographic; clinical and reproductive; nutrition and lifestyle; and knowledge and health service related factors will be collected using a structured and pre-tested questionnaire, anthropometry and laboratory analysis of stool and blood sample. The part of the questionnaire on Dietary Diversity (DD) was adopted from a standard tool [44]. 4.10.2 Anthropometric assessment 4.10.2.1 Anthropometric assessment of nutritional status Nutritional status of pregnant mother is measured using MUAC which is the only anthropometric measure for assessing nutritional status among pregnant women [43]. Mid-upper arm circumference (MUAC) of the mother will be measured using flexible non-stretchable standard tape measure as measure of nutritional status. 4.10.2.2Dietary methods of assessing nutritional status The DD was assessed using 24 hours recall method. Respondents will be asked whether they had taken any food from predefined 10 food groups on the preceding day. Accordingly, the level of Dietary Diversity Score (DDS) will be computed out of 10 [44]. 4.10.3 Fecal sample collection and laboratory analysis 4.10.3.1 Fecal sample collection Following the completion of questionnaire, a wide screw capped containers pre-labeled with names will be distributed to each respondent. Participant who will not able to provide sample on the first day were asked again on the following day. 4.10.3.2 Fecal sample laboratory analysis Initially, an adhesive cellophane tape with a glass slide and a fecal specimen container will be distributed to the pregnant women. Approximately 2mg fecal specimen in labeled plastic vials containing 10% formaldehyde for the preservation of helminth eggs, protozoan cysts, and trophozoites in the fecal specimens will be collected. The stool specimens will be examined for the presence of parasites, helminth eggs, and larvae and protozoan trophozoites or cysts using direct wet mount. 4.10.4 Blood sample collection and laboratory analysis Labeled venous or heparinized blood samples giving sequential numbers of the study participants will be used. Blood samples will be used for Hemoglobin determination (by using HemoCue) and RBCs morphology identification. Hemoglobin determination venous blood sample will be taken, filled to micro cuvette, wipe of excess blood from the outside of the micro cuvette tip, and then placed in the cuvette holder of the device for measuring hemoglobin concentration [45]. This Hgb determination will be done by selected hospitals as parts of routine ANC service. Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 198 4.11 Data Quality Control Three day intensive training will be given on how to perform MUAC measurement and on interviewing techniques using standard checklist and structured questionnaire. The checklist and questionnaires will be translated into a regional working language (Sidaamu Afoo). Supervision will be conducted. Double data eatery will be done and the questionnaire will be pretested on 5 % of total sample size at Leku Primary Hospital. During data collection, continuous supervision will be done by the supervisors and principal investigator. 4.12 Data Processing and Analysis The data will be entered into Epidata software and exported to SPSS software for windows version 23 for analysis. Descriptive statistics will be computed and both bivariable and multivariable logistic regression will be employed to identify predictors of anemia among pregnant women. 5. WORK PLAN AND BUDGET 5.1 Work Plan Table 2. Showing the work plan of the study in Sidama Region, 2021 Activity Apr May Jun Jul Aug Sep Oct Nov Dec Research proposal Preparation Final proposal submission and Defense Obtaining ethical Clearance Giving training Data collection and processing Result Writing Final paper Submission Defense and dissemination of result 5.2 Budget Table 3. Showing the stationary cost for the study in Sidama region, 2021 No Items Source of budget Unit Amount Unit price(birr) Total price(birr) 1 Pen HCHS Pieces 30 6 180 2 Pencils >> Pieces 50 3 150 3 Paper for Duplication >> Packet 30 300 9,000 4 Pencil sharpener >> Pieces 18 5 90 5 Pencil eraser >> Pieces 18 5 90 6 Notebook >> Pieces 22 20 440 Sub Total 9,950 Table 4. Showing the services cost for the study in Sidama region, 2021 No Items Source of budget Unit Amount Unit price(birr) Total price(birr) 1 Photo copying (including the pre-test) >> Pieces 634 8 5,072 2 Lab investigation for stool specimen specimen 10 10*634 6,340 Sub Total 11,412 Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 199 Table 5. Showing the training cost for the study in Sidama region, 2021 No Items Source of budget Unit Unit price(birr) Total price(birr) 1 12 Data collectors HCHS 12 339*12*1 4,068 2 6 Supervisors >> 6 6*339*1 2,034 3 Trainer(PIs) 4 4*339*1 1,356 Sub total 7,446 Table 6. Showing the Perdiem payment for the study in Sidama region, 2021 No Items Source of Budget Unit Unit price (birr) Total price(birr) 1 Data collector HCHS Per questionnaire 100*634 63,400 2 Supervisor >> 339 per day 339*6*30 61,020 Sub total 124,420 Table 7. Showing the total cost of the study in Sidama region, 2021 No Items/activities Source of Budget Unit Total price(birr) 1 Stationary HCHS Birr 9,950 2 Service (transportation etc) >> >> 11,412 3 Training >> >> 7,446 4 Perdiem for data collection and supervisors >> >> 124,420 Grand total 153,228 6. CONCLUSION The findings will be presented to the Hawassa College of Health Science community and submitted to Hawassa College of Health Science research and publication core process owner. The findings will also be communicated to local health planners and other relevant stake holders in the area to enable them take recommendations in to consideration during their planning process. It can also be communicated to health planners and managers at regional level through Hawassa College of Health Science website and library. Efforts will be made to publish in peer reviewed national and international journals. CONSENT Written permission will be obtained to undertake the study from the selected hospitals. Participation in the study will be based on voluntary base and the participants will be informed about the right to withdraw at any time from the study. Confidentiality will be assured by using anonymity. Pregnant women who had anemia (Hb<11g/dl) will be provided with Iron-folate tablets and those who were in the third trimester and infected with intestinal parasites will be dewormed. Written consent will be requested from every study participant included in the study during data collection time after explaining the objectives of the study. For this purpose, a one page consent letter was attached to the cover page of each questionnaire stating about the general objective of the study and issues of confidentiality which was discussed by the data collectors before proceeding with the interview. 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Prevalence and predictors of maternal anemia during pregnancy in Gondar, Northwest Ethiopia: an institutional based cross-sectional study. Anemia; 2014. 31. Kefyalew AA, Abdulahi MD. Prevalence of anemia and associated factors among pregnant women in an urban area of eastern Ethiopia. Anemia. 2014;561–7. 32. Desalegn S. Prevalence of anaemia in pregnancy in Jima town, southwestern Ethiopia. Ethiop Med J. 1993;31(4):251–8. 33. Abriha A, Yesuf ME, Wassie M. Prevalence and associated factors of anemia among pregnant women of Mekelle town: a cross sectional study. BMC Res Notes. 2014;7:888. 34. Bekele A, Tilahun M, Mekuria A. Prevalence of anemia and its associated factors among pregnant women attending antenatal Care in Health Institutions of Arba Minch town, Gamo Gofa Zone, Ethiopia: A crosssectional study. Anemia. 2016;2016:1073192. 35. Gedefaw L, Ayele A, Asres Y, Mossie A. Anemia and associated factors among pregnant women attending antenatal Care Clinic in Wolayita Sodo Town. Southern Ethiopia Ethiop J Health Sci. 2015;25(2):155–62. 36. Getachew M, Yewhalaw D, Tafess K, Getachew Y, Zeynudin A. Anaemia and associated risk factors among pregnant women in Gilgel gibe dam area, Southwest Ethiopia. Parasites Vectors. 2012;5: 296. 37. Alem M, Enawgaw B, Gelaw A, Kena T, Seid.M, Olkeba Y. Prevalence of anemia and associated risk factors among pregnant women attending antenatal care in Azezo Health Center Gondar town, Northwest Ethiopia. J Interdiscipl Histopathol. 2013;1(3):137-144. 38. Zekarias B, Meleko A, Hayder A, Nigatu A, Yetagessu T. Prevalence of anemia and its associated factors among pregnant women attending antenatal care (ANC) In Mizan-Tepi University Teaching Hospital, https://doi.org/10.4236/fns.2019.109076 https://doi.org/10.4236/fns.2019.109076 Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 202 South West Ethiopia. Health Sci J. 2017;11(5):529. 39. Walelign F, Gariba EB, Roba KT. Prevalence of anemia and associated factors among pregnant women in Ethiopia. Food Sci Nutri Res. 2018; 1(1). 40. Gebretsadik S, Negussie A, Abate M, Assefa L. Prevalence and associated risk factors of anemia among pregnant woman in rural part of Jigjiga, Eastern Ethiopa. Journal of pregnancy and child health. 2017;4(3). 41. Lebso M, Anato A, Loha E. Prevalence of anemia and associated factors among pregnant women in Southern Ethiopia: A community based cross-sectional study. PLoS ONE. 2017;12(12): e0188783. Available:https://doi.org/10.1371/ journal.pone.0188783 42. Weldekidan F, Mesfin Kote M., Meseret Girma M. Determinants of anemia among pregnant women attending antenatal clinic in public health facilities at Durame Town: Unmatched case control study. Anemia. 2018;Article ID 8938307:8. Available:https://doi.org/10.1155/2018/893 8307 43. Federal democratic Republic of Ethiopia, Ministry of Health. Training course on the management of acute malnutrition participant module First edition, September 2019 Addis Ababa, Ethiopia. 44. FAO and FHI 360. Minimum dietary diversity for women: a guide for measurement. Rome: FAO; 2016. 45. Cheesbrough M. District laboratory practice in tropical countries 2009, part 1. 2nd ed. Cambridge: Cambridge University Press; 2009. https://doi.org/10.1155/2018/8938307 https://doi.org/10.1155/2018/8938307 Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 203 Annex I: Information Sheet Good morning/good afternoon. My name is ______________I am here on the behalf of research team of Hawassa Health Science College. The team is conducting research on ‘Predictors of Anemia Among Pregnant Women Attending Antenatal Care at Public Hospitals of Sidama Region, Ethiopia, 2021’. You are selected by random sampling technique to participate in this study because you are currently taking ANC service at this hospital. Your participation will only be based on your willingness .You have the right to choose not to take part in this study. If you choose to take part, you have the right to stop at any time. If you are willing to participate or refuse or decide to withdraw later, you will not be subjected to any ill-treatment. If you agree to participate in the study, you will be interviewed about socio-demographic characteristics, knowledge and health service related factors, clinical and reproductive factors, and nutrition and lifestyle related factors. Your name will not be written on the questionnaire. No one will have access to the non-coded data except the principal investigator and the data will only be used for this study. Your willingness and honest answers are very important for the success of this study. We would like to appreciate your help in responding to these questions, and it will not take more than 30 minutes. Annex II. Informed Written Consent form I (the respondent), the undersigned, am told that the researchers are going to conduct study in Sidama region governmental hospitals to assess the risk factors of anemia and its effect on birth weight and s/he acquainted with me the first time s/he meets. I also informed that both the government and the Woreda health office to commence appropriate strategies to battle this problem would use the result of the study. I am, too, told that the research will benefit the community in general including me, the respondent, and that the research will not inflict any harm to me. Besides, I briefed that I will be interviewed for not more than 20 to 30 minutes. In addition, I let know that the investigators selected me randomly. Moreover, I am notified that my participation in the study is entirely voluntarily, and that I can quit from the study any time I want. Likewise, I am enlightened that I will not be subjected to any form of punishment following my failure to participate in the study. In the same way, I am explained that the information collected from me will not by any means be disclosed to any people other than those participating in the study unless obtained permission from me. Equally, I told that I could ask them questions I found difficult or any type otherwise. Are you willing to participate in the study? Yes _______ No____ Signature _________ Study area: - Sidama region Health Facility___________________ Name of the interviewer______________ Sig. _____ Date ________ Name of supervisor _____________Sign _______ Date_______ Questionnaire code ____________________ Annex III: Questionnaires I. Socio-demographic characteristics of pregnant women Code Variables Coding categories Skip 100 Age of respondent ___________ 101 Residence 1. Rural 2. Urban 102 Marital status 1. Never married 2. Married 3. Separated 4. Widowed Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 204 103 Religion 1. Protestant 2. Orthodox 3. Muslim 4. Other 104 Mothers Educational level 1. No formal education 2. Primary (1-8) 3. Secondary (8-12) 4. College and above 105 Husband Educational level 1. No formal education 2. Primary (1-8) 3. Secondary (8-12) 4. College and above 106 Occupation status 1. Government employee 2. Self employed 3. Housewife 4. Farmer 5. Other (Specify)_____________ 107 What is the source of the food for the family? 1. Buying from market 2. Farming(crops, animals) 3. Food aid/donation 4. other(specify) 108 Who has the primary responsibility of providing food for the house hold? 1. Father 2. Mother 3. Grandmother 4. Relatives 5. Other(specify) 109 Do you have a bank saving account? 1.Yes 2. No 110 Average monthly income of the family In birr________ 111 Family Size 112 What is the main source of drinking water for members of your house hold? 1. Purified water 2. Tap water 3. public tab/stand pipe 4. protected well 5. unprotected well 6. other specify 113 Did you take any action to make the water safer to drink? 1.Yes 2. No If no, skip to Q115 114 If yes, what do you usually do to make the water safer to drink? 1. Boiling 2. Chlorine-water 3. Sand 4. Guard/bishangari/aqua tab 5. Other(specify) 115 What kind of toilet your family members usually used? 1. flush to piped sewer system 2. flush to septic tank 3. ventilated improved pit latrine 4. pit latrine with slab 5. pit latrine without slab 6. no facility/ bush/field 7. other( specify) II. Clinical and reproductive related factors of pregnant women Code Variable Coding categories Skip 200 When did you see your last menstrual 1. ____/_____/___ Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 205 period? ( enter date, month & year) __E.C 2. I don’t know 201 Have you ever given a birth? 1. Yes 2. No 202 Parity 1. Para one 2. Para two 3. Para three or more 203 Gravidity _______________ 204 Gestational age 1. 1st trimester 2. 2nd trimester 3. 3rd trimester 205 What is the interval between current and previous pregnancy? 1. < 2 years 2. ≥ 2 years 206 Age at first pregnancy(years) 207 Age at first marriage (years) 208 Menstrual cycle 1. Regular 2. Irregular 209 Menstruation by no of pads 210 Duration of menstruation in days __________________ 211 Number of miscarriages (spontaneous abortion) __________________ 212 Number of stillbirths __________________ 213 Children <5 yrs death 215 1. 216 Gastritis 1. Yes 2. No 217 Duodenal bleeding(presence of hematemesis) 1. Yes 2. No 218 History of medication (Quinine, cephalosporin, penicillin, methyldopa, NSAIDs(Aspirin, Ibuprofen)) 1. Yes 2. No 219 History of induced abortion 1. Yes 2. No 220 Contraceptives use 1. Yes 2. No If no skip to 222 221 Types of contraceptive methods 1. Pills 2. Injectable 3. Implant 4. IUCD 5. Other 222 Intestinal parasite 1. Yes 2. No If no skip to224 223 List types of I/P 3. 224 Do you have any diagnosed chronic disease previously? 1. Yes 2. No 224 If yes, specify the name of diagnosed chronic disease? ----------------- 225 Did you infected with malaria in the last 3 months? 1. Yes 2. No 226 Diarrhea illness in past two week 1. Yes 2. No 227 Hemorrhoids 1. Yes 2. No 228 Gum bleeding 1. Yes 2. No 229 Presence of current blood loss 1. Yes Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 206 2. No STIs 1.Yes 2. No HIV status (by review records) 1.Positive 2. Negative III. Nutrition and lifestyle related factors of pregnant women Code Variable Coding categories Skip 300 MUAC in cm _____________ 301 What is your staple diet? 1. Teff 2. Enset based 3. Maize based 4. Roots 5. Others(speci fy) 302 Main meal frequency in a day 1.One times 2.Two times 3. Three times 303 Additional meal during pregnancy 1. Yes 2. No 304 Eat foods made from teff 1. Yes 2. No 305 Average weekly consumption of animal source foods like meat, chicken, milk, egg, cheese, fish? 1. 1-2 times 2. ≥3 times 3. I have not eaten 306 Eating condition during pregnancy 1. Increased 2. No change 3. Decreased 307 Substance use (Cigarate, alcohol, khat) 1. Yes 2. No 308 Drinking tea immediately after meal 1. Yes 2. No 310 Drinking coffee immediately after meal 1. Yes 2. No 312 Consistent use of bed net 1. Yes 2. No 313 Wearing shoes consistently 1. Yes 2. No IV. 24 hour Food Frequency Questionnaire Code Food groups Coding categories Consumed Yes = 1 No = 0 400 Grains, white roots and tubers, and plantains Maize, rice, wheat, sorghum, millet or any other grains or foods made from these (e.g. bread, porridge). 401 Pulses Mature beans or peas (fresh or dried seed), lentils or bean/pea products. 402 Nuts and seeds Beans, peas, lentils, nuts, seeds or foods made from these 403 Dairy Milk, cheese, yoghurt or other milk products 404 Meat, poultry and fish Fresh or dried fish, Beef, goat, chicken 405 Eggs Eggs from poultry 406 Dark green leafy vegetables Cassava leaves, kale, spinach etc. 407 Other vitamin A-rich fruits and Mangos, apricots Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 207 vegetables 408 Other vegetables Tomato, onion etc. 409 Other fruits Other fruits, including wild fruits V. Knowledge and health service related factors Code Variable Coding categories Skip 500 Have you heard about anaemia? 1.Yes 2. No 501 If Yes: Can you tell me how you can recognize someone who has anaemia? (at least two) - Less energy/weakness - Paleness/pallor - Spoon nails/bent nails (koilonychia) - More likely to become sick (less immunity to infections) - Other - Don’t know 1.Yes 2. No 502 What are the health risks for infants and young children of a lack of iron in the diet? (at least one) - Delay of mental and physical development - Other - Don’t know 1.Yes 2. No 503 What are the health risks for pregnant women of a lack of iron in the diet? (at least one) - Risk of dying during or after pregnancy - Difficult delivery - Other - Don’t know 1.Yes 2. No 504 What causes anaemia? (at least two) - Lack of iron in the diet/eat too little, not much - Sickness/infection (malaria, hookworm infection, other infection such as HIV/AIDS) - Heavy bleeding during menstruation - Other - Don’t know 505 How can anaemia be prevented? (at least two) - Eat/feed iron-rich foods/having a diet rich in iron - Eat/give vitamin-C-rich foods during or right after meals - Take/give iron supplements if prescribed - Treat other causes of anaemia (diseases and infections) - seek health-care assistance - Other - Don’t know 506 Can you list examples of foods rich in iron? (at least two) - Organ meat (Liver, Kidney, Heart etc.) - Flesh meat (Beef, Pork, Lamb, Goat, Rabbit, Dog, Chicken, Duck, etc.) - Fish and seafood (fresh fish, Dried fish, Canned fish etc.) Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 208 506 When taken during meals, certain foods help the body absorb and use iron. What are those foods? (at least one) - Vitamin-C-rich foods, such as fresh citrus fruits (orange, lemons, etc.) - Other - Don’t know 507 Some drinks decrease iron absorption when taken with meals. Which ones? (at least one) - Coffee - Tea - Other - Don’t know 508 Nutrition education in pregnancy 1. Yes 2. No 509 One-way walking distance from nearby health facility 1. 0-30 minutes 2. 0-30 minutes 510 At what gestational age did you start your first ANC visit 1. Weeks________ 2. I don’t know 511 Did you get any iron supplement in this pregnancy? 1. Yes 2. No 512 If yes, how many days did you take? 1. No. Of days_______ 2. I don’t know 513 Did you take any anti helminthic drugs previously? 1. Yes 2. No 513 Home delivery (previous) 1.Yes 2. No VI. Data related with laboratory analysis Type of investigation Result Stool examination HGB determination Perpheral morphology Annex IV: Keere Galtini/Keere Hossini Ani ______________kowe leelomohu hawaasi fayyimate koleejje xiinxallote gaamo riqiweeti.tini gaamo xiinxallo asitanni noohu 2013M.D sidaamu qoqowi giddo heedhanno hospitaalera ilate albise buuxirate daanno amuuwi mundeete xe’ne abbanore buuxateeti. Ati hedeweelchote tenne xiinxallora beeqancho ikakki ati xaa yannara tenne tenne hospitaalera ilate albiidi buuxo aana nootahuraati.beeqokki umikki fajjonni calaati.Tenne xiinxallora dawaro aa giwate wo’ma dandoo noohe.dawaro aate sumuu yiitarono aye yannarano agurate qoosokki agarantinote. dawaro aate sumuu yiitaro woyi giwittaro woyi agure fulate sumuu yiitarono owaante adhate ledo xaadannokkita xawinseemmo. Tenne xiinxallora dawaro aate sumuu yiitaro heeshokki gari daafira,fayyimatenna xaadonorira noohe egenora,kilinikaalenna sirote daafiranna saga’latenna hee’nanni gari daafira afuu xa’mo xa’mineemohe. Su’mikki xa’mote woraqati aana diboreesamanno. Jawiidi hajajaancho aguranna Ayeeno ikkiro uyinoonni kodde hunara dandoo dinosi qoleno dawarootta dawaro tenne xiinxallora calla horonsi’nannite. Ate sumuu yaakkinna halaalancho dawarokki tenne xiiinxallo gumulate lowo horo noosete. Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 209 Tenne xa’muwa qolate asoota kaa’lora wodaninni galatoofantanni 30 daqiiqi aleenni keeshishannokitano qummi asineemmo Annex V: Sumuu Yaa Xawisate Forme Ani (dawaro eemati) woroonni malaatisa’yanni kuni xiinxallo assanohu Sidaamu Qoqowi giddo mangitete hospitaalera mundeete xe’ne abannorenna godowi qaaqi lophpho aana abanno qarrira xa’maera umi yannara xaadeenaeeti.mangitenna woradu fayimate biiro tenne xiixalote guma adhite soorote horonsidhara sumuu yitinotano xawiseenaeti.tini xiixallo aneno ikko wole dagooma horo uyitanote yee hedeemahuraati.qoleno dawaro aa’yanni ane aano daanno qarri nooikihuraati.konnira 20-30 daqiiqa sainokki yanna giddo isi/ise ledo hasaawate wo’naaleemma. Qoleno xa’mituerino hedeweelcho doortinoetano roorimankanni dawareemahuno umi’ya fajjoni ikkinota xawisa hasireemma hasirumma yannara dawara agurammara woyi hasaawa uurisamara wo’ma fajjo nooeta xawisaniiti.xiinxallote xa’mo dawara hooga’yanni qorochishanoehu nooekita afa’ya lede xawisaniiti.qoleno anewiini afi’nooni dawaro ane fajjo nookiha wolehu reqecci assa dandiinanikkita yaano xiixallo asitanno bissa gobaani wolu afara dandaanokitano xawinseenaeeti.taaloteno duushitinoekki xa’mo heedhuro xa’me dawara afira dandeematano afeeti. Dawarate maaye yaatta? Eewa………………….Dee’ni…………….Malaate…………… Xiinxallote darga.Sidaamu Qoqowo Fayyimate mine…………………………. Xa’amanohu su’ma………………………….Malaate……………………Barra……………… Loosisannohu su’ma……………………….Malaate……………………Barra……………… Xa’mote woraqati koodde……………………….. Ledote hasattora aliidi xinxaalaano afirate Su’ma Abiyu Ayaalew Bilbilu kiiro;-+251912417806 e-mail - Su’ma Alelinyi Taadele Bilbilu kiiro;-+251913440394 e-mail - Su’ma Qaleaabi Tesifaaye Bilbilu kiiro;-+251911066932 e-mail - Su’ma Sintaayehu Aseffa Bilbilu kiiro;-+251911392734 e-mail - Annex VI: Xa’mote Woraqata I godowii noo ama daafo addi addi xa’mo Koodde Variable Koodete dana Agure sa’a 100 Dirose ………………………… 101 Teesose 1. Baadiyye 2. Quchumaho 102 Adhamate gara 1. Adhantinoikite 2. Adhantinote 3. Tirtinote/babaxitinote 4. Adhinohu reenosete 103 Ama’nose 1. Ortodokisete 2. Kaatolikete 3. Protestaantete 4. Musiliimete 104 Amase rosu deerra ……………………… 105 Galtese rosu deerra …………………….. 106 Loosise dana 1. Umise looso 2. Minu amaati 3. Mangitete looso 4. Wolu heeriro xawisi….. Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 210 107 Maatese sagale afidhanowa? 1. Dikkote hidhite 2. Gatiiidi jajinni 3. Sagalete kaa’lonni 4. Wolu nooro xawisi…… 108 Maaatete sagale abate umiidi qeechchi noohu ayeerati? 1. Annaho 2. Amate 3. Ahaahete 4. Fiixaho 5. Wolu nooro xawisi……………. 109 Baankete suuqo noohe? 1. Ee nooe 2. Dinoe 110 Mereerima maatese eo ……………………. 111 Maatese kiiro? 112 Waa afidhannowa 1. Xalala waa 2. Wolu heeriro xawisi….. 3. Gosa hinkii’li.tanoha 4. Qorowantino bue 5. Qorowantinoikki bue 6. Wolu nooro xawisi…… 113 Waa xalala assate asatari nooni? 1. Ee no 2. Dino 114 Nooha ikkiro maa assa? 1. Waa gafe aga 2. Kiloorine leda 3. Shaafunni xinbiiwa 4. Wayi agaraancho/bishangarwora 5. Wolu nooro xawisi…… 115 Hiito shumate mine horonsiratta? 1. Waa duneena tuubotenni harannoha 2. Sepric taanke eannoha 3. Aleenni ayere eesanoha/VIP/ 4. Tuanchu noo shumate bale/pit with slab 5. Tuanchu nooikki shumate bale/ pit without slab 6. Xawoho/mulla bayichcho/ ofolla 7. Wolu nooro xawisi…… II godowii noo ama fayyimasenna sirote kifile daafo addi addi xa’mo Koodde Variable Koodete dana Agure sa’a 200 Qaccete aganu mundee mamoote laoo? 1. ………/…………/……….. 2. Di afoomma 201 Ilte egenootta 1. Ee 2. Diegenoomma 202 Iltinohu ino kiiro (me’e iltino) 1. Mitto iltino 2. Lame iltino 3. Sasenna sau ale 203 Godobino kiiro (me’e higge godobino) ………. 204 Godowa noohu diro(GA) 1. 1 st trimester 2. 2 nd trimester Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 211 3. 3 rd trimester 205 Godowaminohu albidiihuwinni noo xeertinynye 1. <2 diro 2. >2 diro 206 Umiseha Meikki dirisenni godobino 207 Meikki dirisenni adhantino 208 Aganunni du’nantanno mundee 1. garunni daganno 2. garimalete 209 Du’nantanno mundee batinynye (saanete bikkiniro) …………………. 210 Du’nantanni keeshitanno barra ……………… 211 Umose kayisinosero kiiro (abortion) …………………….. 212 Godowa bae ilamohu kiiro (still birth) 213 5 diri woro reyinose qaaqi nooro 214 Luuxichchu xisso 1. ee noose 2. dinose 215 Mundee tufa 1. ee noose 2. dinose 216 Egemitanno/horonsidhanno xagichchi Quinine,pencillin,methyldopa,NSA IDs(asprin,ibuprofen) 1. ee noose 2. dinose 217 Mannu kaa’lonni leelitino Umu kao (induced abortion) 1. ee noose 2. dinose 218 Ila gargadha 1. Ee gargadhitanno 2. Digargadhitanno Gargadhitano kkiro 220 sai 219 Hiikoye gargaraancho horonsidhanno Egeminanniha/pills/ Marfenniha/injectable/ Cigilete waamaniha/implant/ Sirote kifile giddo woranniha/IUCD/ Wolu nooro xawisi/other/ 220 Heleete da’muulchchi/parasite/ 1. ee no 2. dinose Nooikkiro kiiro 222 sai 221 Heleete da’muulichi nooro danasi xawisi? 3. 222 Albaanni Wole keeshitino xidanna/chronic disease/ 1. ee no 2. dinose 223 Nooha ikkiro su’mansa xawisi …………. 224 Sai sasu again giddo Shekeerete xiwani nooheni? 1. ee no 2. dino 225 Sau 2 lamalara Godowa gobara qola/deeishsha 1. ee no 2. dinose 226 Qunxushote xiwani/hemmoroids/ 1. ee no 2. dino 227 Egireggu mundaa 1. ee no 2. dinose 228 Xaa mundeete anje 1. ee no 2. dinose 229 Siimu xaadinni sa’anno xisso 1. ee no Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 212 2. dino 230 HIV buuxo 1. Positive 2. Negative III saga’litannonna heeshose gade daafira addi addi xa’mo Koodde Variable Koodete dana Agure sa’a 300 Giwoodu bikko (MUAC)(cm) ………………….. 301 Wo’mu woti sagalese 1. Gaashshete qixaabinote 2. Weesete qixaabinote 3. Badalate qixaabinote 4. Umanni rumuddate 5. Wolu heeriro xawisi………… 302 Barrunni me’e higge saga’litanno 1. mitte higge 2. lame higge 3. sase higge 303 Godowi yannara ledote sagale no? 1. Ee no 2. Dino 304 Gaashshe gumi karsinni loosantino sagale ittanno 1. Ee itanno 2. Dittanno 305 Lamalatenni saadate karso me’e hige itannoro 1. 1-2 hige 2. Sauna sasu ale 3. Horo ditanno 306 Godowii noo yannara saga’litanno gari 1. lexayi lexay haranoho 2. soorro dinooho 3. ajayi ajay harannoho 307 Wole ledonire adha (alkoole,sigaara caate 1. Ee no 2. Dino 308 Hurbaatu gedeno mulenni shae aga 1. Ee no 2. Dino 309 Hurbaatu gedeno mulenni buna aga 1. Ee no 2. Dino 310 Agobere wo’ma wote horonsira 1. Ee no 2. Dino 311 Koatte wo’ma wote wodha 1. Ee 2. Dee’ni IV 24 saate itanno sagale deerra xa’mo Koodde Sagalete dana Koodete dana Ittanoro=1 Itaakiro=0 400 Gummate sagale Badala,ruuze,bashanqa,hayixe, loonsoonire 401 Pulses Baaqela ,atara, nuugetenni loonsonire 402 Saadannire Ado,buuro,burbuxxo 403 Maala lukkotenna asu maala Freshe meu maala 404 Quuphphe Lukkotenni 405 Haanja muro Boye ,spinachete daro 406 Vit A noosere Mango 407 Wole muro Timatime,shunkurta 408 Wole gumma Dubbu afi’nanni gumma V Afasenna keeranchimate afanshi ledo xaadanno xa’mo Koodde Variabile Koodete dana Agure sa’a 500 Mundeete xe’ne abanorira egenno 1. Ee noose Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 213 noose? 2. Dinose 501 Ee yituro afatare kula dandaatae  Wolqate anje  Ille wajira  Wolu herirono  Diafoomma 1. Ee noose 2. Dinose 502 Keeranchimate qarri maati mundeete xe’ne qaaqu aana abitannori (ajanna 1)  Aimirote qarra  Wole  Diafoomma 1. Ee affino 2. Diaffino 503 Godowii noo ama aana abanno qarri(ajanna 1)  Reyo  Ilate qarama  Wolere  Diafoomma 1. Ee affino 2. Diaffino 504 Mundeete xe;ne abbanori(ajanna 2)  Sagalete Irene hooga  Xisso (shekeere,hookworm)  Mundeete du;nama  Wolere  Diafoomma 1. Ee affino 2. Diaffino 505 Mundeete xe;ne hiito gargadhinayi(ajanna 2)  Irone noo sagale itatenni  Vit c sagale itatenni  Irone xagichcho adhatenni  Wole xisso akamatenni  Wolere  Diafoomma 1. Ee affino 2. Diaffino 506 Ironr gidose noo sagale kulatae (ajanna 1)  Bisu maala(afale,mule)  Duumo maala  Asu maala 1. Ee affino 2. Diaffino 507 Saga’lineemo sagale bisinke iron gudanoti hiitet (ajanna 1)  Vit c noo sagale  Wolere  Diafoomma 1. Ee affino 2. Diaffino 508 Bisinke ironete adho qanasanno sagale  Shae  Buna  wolere  Diafoomma 1. Ee affino 2. Diaffino Tegegne et al.; AJI4(1): 190-214, 2021; Article no.AJI.78308 214 509 Godowii noo ama saga’litano rosichchi 1. Ee noose 2. Dinose 510 Keeranchimate mine minisenni noo xeertinynye 1. 30 daqiiqi ale 2. 30 daqiiqi woro 511 Meikki trimesteraati umi buuxo asirittahu(ANC)? 1. Lamala ………………. 2. Diafoomma 512 Godowi yannara Ironete adhite egenootta 1. Ee 2. Degenoomma 513 Ee yituro me’e higge 1. Barru kiiro…………. 2. Diafoomma 514 Godowi damuula garagat-rtanno xagga adha 1. Ee 2. Degenoomma 515 Alba mine ilte egenoota 1. Ee 2. Degenoomma VI Labratorete xaadanno data Types of investigation Result Stool examination HGB determination Peripheral morphology _________________________________________________________________________________ © 2021 Tegegne et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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