Journal of Applied Economics and Business Studies, Volume.4, Issue 3 (2020) 113-136 https://doi.org/10.34260/jaebs.435 113 Journal of Applied Economics and Business Studies (JAEBS) Journal homepage: https://pepri.edu.pk/jaebs ISSN (Print): 2523-2614 ISSN (Online) 2663-693X A Study of Socioeconomic Determinants of Anemia among Expecting Mothers in Khyber Pakhtunkhwa Pakistan Faiza Nawaz1, Muska Mukhtar2 & Atta ur Rahman*3 1Research Scholar at Institute of Management Sciences Peshawar, Pakistan 2Lecturer, Institute of Management Sciences Peshawar, Pakistan 3Associate Professor, Institute of Management Sciences Peshawar, Pakistan ABSTRACT One of the instrumental factors contributing towards the GDP of any country is human capital and for a progressive human capital, the main resource is physical and mental health. Females constitute approximately 48% of population of Pakistan, out of which a great number suffer from nutritional deficiency anemia at their reproductive age, which results in an unhealthy child. This study is designed to find the socioeconomic factors that lead to anemia among expecting women. The research design for this study is case control where data was collected from two groups; control group (non- anemic pregnant women) and case group (anemic pregnant women) registered in the Basic Health Unit (BHU) from different areas of Peshawar. Collected data was analyzed using binary logistic regression. Findings revealed that monthly income of household, independent members or number of employed members of the family, gap between children, non-staple food consumption and supplements continuity have significant inverse relationship with anemia, indicating that increase in mentioned variables will decrease the prevalence of anemia in pregnant women of rural areas. The study concluded that anemia being a common grievance amongst pregnant women is mostly caused by low level of monthly income, family size with lower number of employed members, low frequency of non-staple food consumption per week, lack of continuity of iron supplements and poor health seeking behavior. Awareness regarding attainment Keywords Socioeconomic, Anemia, Logistic regression * attaurrahman@imsciences.edu.pk Journal of Applied Economics and Business Studies, Volume.4, Issue 3 (2020) 113-136 https://doi.org/10.34260/jaebs.435 114 of education irrespective of gender, government focus on health promotion interventions and more job opportunities can improve health conditions and socioeconomic status of women in Khyber Pakhtunkhwa. 1. Introduction The word ‘Anemia’ is derived from two Greek words ‘an’ means ‘without’ and ‘haima’ means ‘blood’. It was called ‘anaimia’ meaning without blood till late 18th century. However, in the early 19th century via modern Latin it came to be called as ‘anemia.’ Red blood cells (also called erythrocytes or RBC’s) contains a special protein called ‘hemoglobin’ which helps to carry oxygen from the lungs to the rest of the body and then returns carbon dioxide from the body to the lungs so that it can be exhaled. When the level of hemoglobin decreases, it results in anemia. In other words, anemia diminishes the capacity of the blood to carry oxygen to different organs of human body due to which an individual faces pallor and weariness, (American Society of Hematology, 2017; World Health Organization, 1992). There are more than 400 types of anemia, which are divided into three groups. The first group of anemia indicates symptoms of blood loss. Chronic blood loss anemia is most often the result of chronic gastrointestinal bleeding. It is due to conditions such as ulcers, hemorrhoids, gastritis (inflammation of the stomach) and cancer. Similarly, another cause of blood loss is use of non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen, which can cause ulcers and gastritis. Menstruation is another potential cause of this issue, especially if menstrual bleeding is excessive. Next group is of patients whose red blood cells may be faulty or decreased due to abnormal red blood cells or a lack of minerals and vitamins needed for red blood cells to work properly. Conditions associated with these causes of anemia include the sickle cell anemia, iron-deficiency anemia, vitamin deficiency, bone marrow and stem cell problems, and other health conditions. The third group comprises of people suffering from hemolytic anemia. These inherited conditions include sickle cell anemia and thalassemia. It may also result from stressors such as infections, drugs, snake or spider venom, or certain foods. Moreover, the toxins from advanced liver or kidney disease and inappropriate attack by the immune system (called hemolytic disease of the newborn when it occurs in the fetus of a pregnant woman) are also some of the prominent characteristics identified in the patients of this group. Other symptoms may include vascular grafts, prosthetic Journal of Applied Economics and Business Studies, Volume.4, Issue 3 (2020) 113-136 https://doi.org/10.34260/jaebs.435 115 heart values, tumors, severe burns, exposure to certain chemicals, severe hypertension and clotting disorders. Amongst the aforementioned three groups of anemia, iron deficiency anemia (IDA) from the second group is extremely common in individuals and is the most prevalent cause of anemia worldwide. There are various causes of IDA, but it occurs mostly due to lack of the mineral iron in the body due to insufficient nutrition intake (NHANES, 2012). It is affecting 50% of females at reproductive age globally and two-third of pregnant women of developing countries (World Health Organization, 2007, 2014; Mehta, 2015). Almost 50% of Pakistani females at their reproductive age are suffering from anemia amongst which 21% of the anemic females are aged between 9-29 years and similar conditions are faced by the females of Punjab, a province of Pakistan (Mazhar, 2015; Akhtar. 2013). Results of the studies conducted in our neighboring country, India, on prevalence of anemia among females, has similar outcomes (Jawarkar, Lokare & Kizhatil, 2015). The factors that are considered as the determinants of anemia are age, social class, stress, menstrual blood loss, and dietary deficiencies. Helminthic infection is another factor caused by different species of parasitic worms, mostly soil transmitted infections. Anemia is mostly detected in the underweight females having body mass index (BMI) less than 18.5 kg/m2. Hence, it shows that the nutritional status has significant relationship with anemia in the young females (Jawed et al., 2017). Micronutrients are very important for human body because human being need them to have strong mental and physical health, to fight with numerous diseases and produce strong and healthy children. In most cases, deficiency of micronutrient such as iron is caused by inadequate access to food and high burden of disease. Moreover, improvement in the dietary intake and quality of food also plays a significant role in developing healthy human body. Minerals and vitamins are required for body tissues and plays a vital role in human body growth and development (Khan, 2015). Multiple reasons and factors play a significant role in causing anemia. The existence of anemia in human body varies according to socioeconomic status, dietary deficiencies, different infectious diseases, cultural taboos, multiple pregnancies and genetic hemoglobin (Ahmad et al., 2010). As there are multiple antecedents of anemia, nevertheless, common type of anemia is iron deficiency, which is nutritional deficiency disorder. Although, nutritional deficiency anemia affect members of both sexes and all age groups however, the problem among women is more dominant. Moreover, according to estimation nutritional deficiency anemia affects almost two-third of pregnant women in developing countries. The prevalence of anemia among pregnant women therefore Journal of Applied Economics and Business Studies, Volume.4, Issue 3 (2020) 113-136 https://doi.org/10.34260/jaebs.435 116 results in maternal morbidity and mortality, low birthrate and even neonatal death. (Dharmalingam et al., 2010; World Health Organization, 1992) Anemia is most prevalent public health problem and it is indicated mostly in poor nutrition and health. Moreover, anemia is widespread in young females and pregnant women due to nutritional deficiency, poor health facilities, lack of awareness and education (World Health Organization, 2016). Furthermore, in developing countries, poor pregnancy outcomes are mostly due to improper intake of iron rich food and supplements, which mostly occurs due to lower socioeconomic status and lack of awareness regarding basic nutritional requirement especially during pregnancy (United Nation Standing Committee on Nutrition UNSCN, 2004). Past studies have indicated that improper nutritional intake is one of the main causes of IDA and few studies had found it widely prevalent in low and middle-income countries. Therefore, income status of the household is very important factor for availing the facility of iron rich food and supplements during pregnancy (United Nation International Children’s Emergency Fund/World Health Organization, 1999). Low income reduces the iron intake and increase in the prices of meat and fresh fruits make them less affordable (Bhargava et al., 2000). There is significant impact of low socioeconomic status on iron intake status as low household income (0.05, hence logistic regression model of this study is good fit. Table 3.4: Results of binary logistic regression analysis Variables B (Coefficient) S.E. Wald Df Sig. Exp(B) Odd Ratio 95% C.I.forExp(B) Lower Upper Age of Respondent -.367 .172 4.581 1 .132 .693 .495 .970 Res Edu ref: illiterate 3.516 4 .475 Primary -.203 .729 1.752 1 .186 .381 .091 1.590 Secondary -2.140 1.303 2.550 1 .110 .325 .008 1.628 Journal of Applied Economics and Business Studies, Volume.4, Issue 3 (2020) 113-136 https://doi.org/10.34260/jaebs.435 127 College -2.476 1.632 .475 1 .491 .117 .013 7.952 Higher -3.069 3.761 1.657 1 .401 .487 .001 1.014 Spouse Edu ref: illiterate 13.287 4 .010*** Primary -2.273 .866 6.890 1 .009*** .541 .019 1.562 Secondary -2.937 .923 .475 1 .125 .426 .164 6.114 College -3.854 .915 .870 1 .351 .399 .071 2.560 Higher -9.159 1.600 3.899 1 .048*** .103 .024 1.406 Family Size .534 .126 12.657 1 .000*** 1.564 1.222 2.000 Total Children 1.244 .351 6.609 1 .010*** 2.468 1.239 4.913 Gap between Children -2.141 .716 2.851 1 .009*** .350 .023 13.627 Emp. Family Members -1.201 .123 2.659 1 .012*** .223 .060 1.557 Unemp. family members .249 .125 3.944 1 .035*** 1.780 .610 1.997 Monthly income 5000-15000 13.110 5 .022*** 15000-25000 -1.384 .995 11.565 1 .001*** .352 .005 .895 25000-35000 -3.016 .925 4.155 1 .042*** .144 .025 .930 35000-45000 -3.117 1.446 4.644 1 .031*** .085 .003 .754 45000-55000 -3.700 1.683 4.835 1 .028*** .052 .021 .669 55000-above -9.192 5.828 7.241 1 .032*** .034 .001 .475 Non-staple food ref: none 10.847 3 .013*** Daily -23.193 6.129 4.461 1 .024*** .213 .905 2.604 Twice per week -21.893 5.457 4.162 1 .035*** .459 .121 7.205 Once per week -20.180 5.132 2.438 1 .016*** .741 .061 4.350 Supp. Continuity ref: No -2.493 .879 8.055 1 .005*** .083 .015 .462 Constant 1.657 2.057 .649 1 .421 .191 *= Significant at 0.10 (10% Significance level and 90% Confidence Interval) **= Significant at 0.05 (5% Significance level and 95% Confidence Interval) ***=Significant at 0.01 (1% Significance level and 99% Confidence Interval) The results reveal that age of respondent has positive but insignificant relation with anemia whereas, total children, family size and dependent members has positive and significant relation with anemia. Moreover, education of spouse, gap between children, independent members, monthly income, non-staple food consumption per week and supplement continuity has negative and significant while respondent education have negative but insignificant relation with dependent variable anemia. Variables such as age of respondent, family size, total children, gap between children, independent members and dependent members are not categorical. On the contrary, education of respondent, education of spouse, monthly income, non-staple food and supplement intake are categorical. Following is the interpretation of the results of above table. Journal of Applied Economics and Business Studies, Volume.4, Issue 3 (2020) 113-136 https://doi.org/10.34260/jaebs.435 128 The log odd results showed that an additional year of age of respondent reduces the odd of being anemic by 0.307 times. While the log odd results of family size and total children exhibits that with every single increase in number of member odds of becoming anemic increases by 0.564 and 1.468 times respectively. In terms of gap between children odd ratio result shows that with every increased year as a gap between children odd of level of anemia among pregnant mothers decreases by 0.650 times. Similarly odds of prevalence of anemia among pregnant mothers decreases by 0.777 times with every increase in the number of member being independent (employed member) whereas the odds of prevalence of anemia among pregnant mothers increases by 0.780 times with every increase in the number of member being dependent (unemployed member). According the above results of the table, respondents having education level up-to primary, secondary, college and higher level had 0.381,0.325,0.117 and 0.487 times the odds, respectively, of becoming anemic as compare to the respondents who were in the illiterate category. Similarly, respondents whose spouse having education up to primary, secondary, college and higher level, had 0.541, 0.426, 0.399 and 0.103 times the odds, respectively, as the spouse of the respondents who were illiterate to get anemic. The respondents who were in 15000-25000, 25000-35000, 35000-45000, 45000-55000 and 55000-above income group had 0.352, 0.144, 0.085, 0.052, 0.021 and 0.001 times the odds, respectively, as compare to those respondents who were in 5000-15000 income group to expose to anemia. Considering the effect of intake of non-staple food, respondents, having status of non-staple food intake on daily basis, twice per week and once per week had 0.213, 0.459 and 0.741 times odds, respectively, as to those who fall in category of none to face anemia. Whereas, the respondents who use to keep continuity in consuming supplements had 0.083 times odds as compare to those who do not consume supplements on continuity basis to become anemic. 4. Discussion The results based on the sample size used in the analysis in terms of anemic and non-anemic pregnant women’s non-staple food consumption per week and supplements continuity shows that lack of intake of iron rich food can strongly affect the level of hemoglobin, which in case of decrease can result in anemia in pregnant women. Hence, prolonged negative iron balance due to insufficient dietary intake during pregnancy contributes in prevalence of anemia (World Health Organization, 2014). It is also evident from the literature that the use of iron rich food and multivitamins sprinkle are Journal of Applied Economics and Business Studies, Volume.4, Issue 3 (2020) 113-136 https://doi.org/10.34260/jaebs.435 129 very effective during pregnancy and they can be easily added to the routine diet (Hardling et al., 2017; Milman, 2011). According to the results, frequency of non-staple food consumption per week is zero among 85% anemic expecting females and just 15% anemic pregnant women consume non-staple food like beef, eggs, fruits and milk, once per week. On the contrary, 73% non-anemic respondents consume non-staple food twice per week. Similarly, 12% anemic mothers keep continuity in supplements intake while 88% do not, while on the other side 73% non-anemic keep continuity in the intake of iron supplements. There can be many reasons behind poor status of iron rich nutritional intake but during the survey from sample size for current study examined that socio- economic status, which plays a vital role as improvement in monthly earnings, can increase the power of affording the non-staple food and iron supplements. As one of the most important factor that determines the food choices a person can make is the purchasing power, which means that how much one can spend on buying food (Marmot, 1984). Similarly, Jones et al., (1992) found that the children of the rich and middle class family had low prevalence of anemia as compared to those children who belongs to poor house hold because the children from rich and middle class family had better nutritional status. The results of socio-economic variables in terms of dependent, independent members and monthly income shows that non-anemic population size has greater number of independent members and higher monthly incomes as compared to anemic population size of the study. Therefore, it can be stated that if the number of earning members from a family size increases, it will help in raising the monthly earnings and can even overcome the burden of bigger family size. Low income can result in various outcomes in the form of cutting down the purchase of quality food and availing health care services, which can be an antecedent for prevalence of anemia during pregnancy (Kramer, 1987). Similarly, Habte et al., (2013) concluded that if the households with higher family size have more than one employed person that boosts the economic support at house hold level and can improves food availability which can help in decreasing the level of anemia in pregnant females. Further, the study at hand indicated significant results regarding family planning in terms of total number of children and gap between children. It revealed that the respondents with greater number of children are mostly anemic i.e. 13%, 9%, 3% and 1% have 8, 9, 10 and 11 children respectively. On the contrary, the percentage of non- anemic respondents having the aforementioned number of children is zero. Similarly, the gap between children is also a serious issue as the results shows that only 19% and 3% anemic respondents keep 1.5 to 2 years gap between their children respectively where 77% have one-year gap between their children. However, the Journal of Applied Economics and Business Studies, Volume.4, Issue 3 (2020) 113-136 https://doi.org/10.34260/jaebs.435 130 minimum gap, which the non-anemic respondents keep in their children, starts from 2 years. Therefore, it is clear from the findings that family planning can play an important role in improving the condition of anemia as a major health problem especially among pregnant women. Results reveal that 7% and 2% non-anemic mothers also have 5 to 7 children respectively but there is at least two years gap between their children. Hence, it indicated that if a family has up to 5 to 7 children, it can be less harmful for mother’s health if there is at least two years of gap between children along with proper intake of non-staple food and supplements continuity. Results are related with the of the study of Khaskheli et al., (2016), which concluded that approximately two-year gap between children can decrease the number of anemic mothers. Findings of this study corroborate with Ansari et al., (2008) and Harding et al., (2017) which concluded that the increase in the size of family and number of children increases the chances of prevalence of anemia in pregnant women. Independent variables like education level of respondent, which is insignificant whereas, education level of spouse has significant relation, but both have a negative and inverse relation with anemia. The descriptive analysis show that 81% of anemic pregnant women are illiterate while just 13% have primary, 5% have secondary and just 1% has college and higher level of education. On the contrary, 63% spouses of the respondents are illiterate where 11% has secondary, 16% have college and just 3% have higher education. The condition of non-anemic respondents and their spouses are different in terms of education level. The results indicate that 51% non-anemic respondents are illiterate while 37% has primary, 6% has secondary, 5% has college and 1% has higher education level. Moreover, the results for spouses of the expecting women shows that only 11% spouses are illiterate while 20% has primary, 37% has secondary, 24% has college and 9% has higher education level. Hence, the results show that education level is greater among non-anemic expecting women and in their spouses as compared to the anemic respondents and their spouses. However, during data collection it was observed that attainment of education for females and up to some level for males is not considered as priority due to poverty and other priorities, which mostly include necessities of daily life. Better socio-economic status can improve nutritional status along with the provision of academic opportunities for females (Feinstein et al., 2006). Therefore, improvement in socio-economic status can improve the living standard of the expecting mothers in terms of good education, which can improve awareness regarding healthy life style and family planning. Moreover, it can develop practice of Journal of Applied Economics and Business Studies, Volume.4, Issue 3 (2020) 113-136 https://doi.org/10.34260/jaebs.435 131 healthy nutrition in terms of intake of iron rich food and supplements, which can decrease the prevalence of anemia in expecting women up to certain level. 5. Conclusion The study at hand analyzed the impact of demographic conditions, family planning decisions, socioeconomic status, non-staple food consumption and supplements intake on anemia in the pregnant women of three rural areas of Peshawar, KPK. The study explored that anemia is a common disease undergone by most of the pregnant women. Its most common cause is low level of monthly income, large family size with lower number of independent members while higher number of dependent members, low frequency of non-staple food consumption per week, lack of continuity of iron supplements and poor health seeking behavior. Additionally family planning decision like keeping gap between children has also negative and significant relation with anemia. 6. Policy Recommendations The study at hand based on its findings and suggestions from the respondents indicate the following policy recommendations: 1. Awareness regarding attainment of education irrespective of gender should be developed in these rural areas along with improvement in the quality of education in schools. Since respondent education has negative relation with anemia, it indicates that increase in level of education of mothers will decrease the chances of anemia in them. Similarly, it is evident from the significant results and negative relationship that increase in education of respondents’ spouse will help in decreasing the percentage of anemic females. 2. The health facilities conditions at Basic Health Units (BHU) in the rural areas needs to develop in terms of basic health facilities. There shall be proper screening facilities available for anemia along with maintaining proper stock of supplements for expecting mothers. During the visit to BHUs of all three rural areas, it was observed that there is no facility for screening of anemia and ambulance for emergency condition. Moreover, the BHUs received enough stock of supplements for whole month but during the first week administration used to come up with an excuse that they are out of stock resulting in discontinuity of supplements intake. Hence, the results indicated a significant relation of continuity of supplements intake status with anemia. Journal of Applied Economics and Business Studies, Volume.4, Issue 3 (2020) 113-136 https://doi.org/10.34260/jaebs.435 132 3. Steps for awareness regarding importance of family planning should be taken as the results of the study suggests that increase in the gap between children can mitigate the condition of anemia. 4. Expecting mothers should be provided with free food vouchers by the government in order to facilitate quality food intake. 5. In order to improve the socioeconomic status of the households, more job opportunities should be provided as increase in monthly income and number of employed members of family has significant relation with anemia. Moreover, it indicates that if government works on improving the employment status it will improve the income status of households, which can leads towards adopting healthy life style. References Akhtar, S., Ahmed, A., Ahmad, A., Ali, Z., Riaz, M., & Ismail, T. (2013). 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