 Kurdistan Journal of Applied Research (KJAR) | Print-ISSN: 2411-7684 – Electronic-ISSN: 2411-7706 | kjar.spu.edu.iq Volume 2 | Issue 2 | july 2017 | DOI: 10.24017/science.2017.2.7 Prevalence and severity of anemia among pregnant women in primary health centers/Erbil City Rushna Ghazi Abdulwahid Surgical Specialty Hospital/Cardiac Center Erbil DOH Erbil Iraq rushnamahamad@yahoo.com Hamdia Mirkhan Ahmed Head of Midwifery Department College of Nursing Hawler Medical University hamdia.mirkhan@nur.hmu.edu.krd Abstract: Anemia in pregnancy is a major public health problem, especially in developing countries. Nutritional anemia is the most common type of anemia worldwide and mainly includes iron, folic acid, vitamin B12 and vitamin C deficiencies. Iron deficiency contributes to half of the burden of anemia globally. The objectives of this study were to find out the prevalence and severity of anemia among pregnant women. A descriptive study was conducted on 600 pregnant women, during the period October 2015 to November 2016 at four primary health care centers in Erbil city. Data gathered through interview with study sample and filling questionnaire format and reviewing their antenatal records. Blood hemoglobin level was measured to assess the severity of anemia. Chi-square test and regression were used to analyze the data. Prevalence of anemia was 46.2%, and 67.1% of the anemic women had mild anemia. There was a significant association of severity of anemia with wife education and occupation, smoking, the number of abortions and cesarean section, ante partum hemorrhage, taking tablets of iron and folic acid per month. The study concluded that prevalence of anemia considered high in Erbil city, the highest percentage had mild anemia. Keywords: Prevalence, anemia, pregnancy INTRODUCTION Anemia in pregnancy is a major public health problem, especially in developing countries. It affects 41.8% of pregnant women globally [1]. Anemia in pregnancy is defined by the World Health Organization (WHO) as a hemoglobin concentration below 11 g/dL [2,3]. According to WHO definition, the prevalence of anemia in pregnancy varies between 15% and 67% worldwide, with one of the highest (30-65%) in sub-Saharan countries, and the lowest (15- 25%) in developed countries. This rates seem too high even in high resource countries where under nutrition is almost absent [4]. Anemia during pregnancy is considered severe when hemoglobin concentration is less than 7.0 g/dL, moderate when hemoglobin falls between 7.0–9.9 g/dL and mild from 10.0-11 g/dL [5]. The cause of anemia in pregnancy is multi-factorial. Iron, folate, vitamin B12 and vitamin A deficiencies as well as intestinal parasitic infections, malaria, chronic illness have all been shown to be the main causes of anemia among pregnant women [1]. Nutritional anemia is the most common type of anemia worldwide and mainly includes iron, folic acid, vitamin B12 and vitamin C deficiencies. Iron deficiency contributes for half of the burden of anemia globally. Iron deficiency affects 1.3 to 2.2 billion persons out of those 50% are women of reproductive age. In Ethiopia nearly 17% of women with age 15–49 are anemic of these 22% are pregnant women [6]. Anemia in pregnant women has severe consequences on health, social, and economic development. Anemic pregnant women will be at risk of low physical activity, increased maternal morbidity and mortality, especially those with severe anemia. In addition, both pregnant women and their neonates encounter negative consequence including fetal anemia, low birth weight (LBW), preterm delivery, intrauterine growth restriction and perinatal mortality [1]. Anemia in pregnancy is associated with adverse consequences both for the mother and the fetus. Studies have shown that the adverse consequences of maternal anemia may affect not only the neonate and infant but also increase the risk of non-communicable diseases when the child grows into an adult and the risk of low birth weight in the next generation [7]. Low maternal hemoglobin levels are associated with increased risk of preterm delivery, low birth weight babies, APGAR score <5 at 1 min and intrauterine fetal demise [8]. The study aimed to find out the prevalence and severity of anemia among pregnant women and its relationship with some demographic and obstetric variables. METHODS AND MATERIALS A cross- sectional study was conducted among pregnant women who attended antenatal care in primary health care centers (PHCCs) / Erbil city, during the period October/ 1 st / 2015 to November/ 13 / 2016. Four primary health care centers from totally 19, were randomly selected according to geographic area Brayati from north, Kurdistan from south, Malafande from east, and Mahamad bajalan from west. A purposive sampling of 600 pregnant women was included in the study. Sample size was estimated using the general formula for targeted population size, allowed error 5%, prevalence (ratio of the studied phenomenon in the population in similar study) and using the 95% confidence interval. The sample size of each primary health care center was according to their ratio in the targeted population. Mothers who had the following criteria were included: pregnant woman who were in 1 st, 2 nd ,3 rd trimester of pregnancy and those who accept to participate in the study. Woman’s with history of chronic hypertension, diabetes, thyroid, cardiac diseases and systematic lupus erythematosis, hemoglobinopathies such as thalassemia and those who hah early & late vaginal bleeding or ante partum hemorrhage (abruptio placenta and placenta previa) and hemorrhoid were excluded. Prior to data collection the official permission was obtained from College of Nursing, Erbil General Directorate of Health, and primary health care centers for carrying out the study in Erbil City. Face to face interview method and reviewing antenatal card was used for data collection and filling a designed questionnaire after taking permission & explanation the objectives of the study to the mother’s. Blood hemoglobin level was measured to assess severity of anemia. Severity of anemia is determined according to Alene & Dohe as the following: Mild (hemoglobin level between 10.0- 11 gm/dl), Moderate (hemoglobin level between 7.0- 9.9 gm/dl), Sever (hemoglobin level less than 7 gm/dl)[5]. Approval of the Ethical Committee from the College of Nursing, in addition to approval of General directorate of primary health care center was secured, mothers consent verbally was taking to participate in the study. Data were entered into a computer using the Statistical Package for Science Services (SPSS version 23). Frequency, percentage and chi-square test was used for interpretation of data. RESULTS The highest percentage 57.3% of the study sample aged between 25-36 years old, while the lowest percentage 8% aged between 37-48 years old. Regarding residency, all participants of the study sample were living in urban area. In the present study the prevalence of anemia during pregnancy was 46.2%, regarding severity of anemia the highest percentage 67.1% of the study sample had mild anemia, while the lowest percentage 32.9% of the study sample had moderate anemia, and there was no cases for severe anemia (Table1). The results also indicated that there was a highly statistically significant association between severity of anemia with wife education & smoking (p < 0.001), and significant association with husband education and wife occupation, while there was no significant association with other variables (Table 2). A significant association between severities of anemia with number of SC was found in the present study, while there was no significant association between severity of anemia with other variables (Table 3). Table 4 shows that there was a significant association between severity of anemia with number of taking tabs/month of iron & folic acid, while there was no significant association between other obstetrical characteristics during current pregnancy. Logistic regression analysis revealed that, lower professional job, taking <30 tabs of iron & folic acid per month, public clinic attending for antenatal care were indicated as risks for anemia. On the other hand, high professional job and birth spacing <2 years were indicated no risks for anemia (p> 0.05 OR= 3.062, 1.433, 1.039, respectively)(Table 5). Table 1- Prevalence and severity of anemia among study sample Prevalence F % Anemic 277 46.2 Non-anemic 323 53.8 Total 600 100 Severity of anemia Moderate 91 32.9 Mild 186 67.1 Total 277 100 DISCUSSION WHO global database on anemia estimated the classification of anemia as a significance problem of public health if the prevalence of anemia be ≥40.0 [9]. The result of the present study shows the prevalence of anemia among pregnant women 46.2%. So according WHO classification it indicates as severe public problem. This results are similar to the results of other studies done in Bali, Indonesia in 2002 which was 46.2%, in northern Tanzania was 47.4% in 2011, and 48.2% in South-East Asia and 44.2% in Eastern Mediterranean by WHO 2005, in South Eastern Nigeria in 2007 was 40.4%, in Kakamega County, Kenya was 40% in 2014[3]. Prevalence of anemia during pregancy in the present study was higher than the results of other studies done in Wolayita Sodo Town, Southern Ethiopia in 2015 was 39.94%, in Makkah, Saudi Arabia was 39% in 2012, in Southeast Ethiopia was 27.9% in 2014, in Europe was 25.1% and in Americas 24.1% by WHO , in Nablus, Palestine was 21.7% in 2007, in Mekelle town was 19.7% in 2014, in the lower North Of Thailand was 17.5% in 2012, in Kerman, Iran was 4.7% in 2010. While the prevalence of anemia in the present study was lower than the results of other studies done in Korangi Industrial Area was 54.3% in 2010, inBaghdad was 55.4% in 2012, in an urban area of Eastern Ethiopia was 56.8% in 2014, in Africa was 57.1% by WHO , in eastern Sudan was 62.6% in 2005,in ruralpopulation of Kolar district of India was 64% in 2015, in a Malaria- Endemic Area in Benin was 68.3% in 2012, in an urban area of Pakistan was 90.5% in 2008 [3]. Regarding severity of anemia 67.1% had mild anemia and 32.9% had moderate anemia and there was no detecting for severe anemia in the present study. Kefiyalew et at, found that 55%, 32.5%, 12.5 of study sample had mild, moderate and severe anemia respectively, which was consistent to the results of the present study [10]. Dim & Onah reported 90.7% had mild anemia, 9.3% had moderate anemia and no cases of severe anemia was detected on their studies which was consistent to the results of the present study [2]. Gedefaw et al, found in their study that 30.34% of the study sample had mild anemia, 60% had moderate anemia and 9.66% had severe anemia which was in contrast to results of the present study [1]. Naz & Begum found these rates regarding severity of anemia in their study: 23.18% mild anemia, 37.7% moderate anemia, 27.27% severe anemia and 11.8% very severe anemia which were in contrast to the results of the present study [11]. Table 3- Association of severity of anemia with obstetrical history of the study sample (n= 277) Variables Moderate Mild P-value Chi-square test F % F % Gravidity Primigravida Multigravida 37 54 36.3 30.9 65 121 63.7 69.1 0.559 Parity Nulliparous Primiparous Multiparous Grand multipara 44 21 13 13 31.9 34.4 29.5 38.2 94 40 31 21 68.1 65.6 70.5 61.8 0.890 Number of CS None 1-3 4-6 70 19 2 30.3 43.2 100 161 25 0 69.7 56.9 0 0.032 Birth spacing / Years n=185 < 2 => 2 30 37 30.9 42.0 67 51 69.1 58.0 0.066 Table 2- Association of severity of anemia with socio-demographic characteristics (N= 277) Variables Moderate Mild P-value Chi-square test F % F % Age group/years 13-24 25-36 37-48 35 46 10 36.5 29.3 41.7 61 111 14 63.5 70.7 58.3 0.315 Wife Education Illiterate Read and write only Primary school Intermediate school Secondary school Institute, college, and above 20 0 8 15 18 30 54.1 0.0 16.7 39.5 46.2 30.3 17 16 40 23 21 69 45.9 100.0 83.3 60.5 53.8 69.7 < 0.001 Husband Education Illiterate Read and write only Primary school Intermediate school Secondary school Institute, college, and above 12 2 10 15 12 40 46.2 66.7 17.2 26.3 33.3 41.2 14 1 48 42 24 57 53.8 33.3 82.8 73.7 66.7 58.8 0.014 Wife Occupation High professional job Lower professional job Unskilled workers 0 12 79 0.0 26.1 35.7 10 34 142 100.0 73.9 64.3 0.035 Husband Occupation High professional job Lower professional job Unskilled workers 2 38 51 14.3 31.1 36.2 12 84 90 85.7 68.9 63.8 0.217 Economic status level Low economic status < 90 Middle economic status 90-120 High economic status 121-150 42 29 20 30.9 36.7 32.3 94 50 42 69.1 63.3 67.7 0.676 Smoking Passive None 19 72 20.2 39.3 75 111 79.8 60.7 0.001 Table 4- Association of severity of anemia with current obstetrical characteristics of the study sample (N= 277) Variables Moderate Mild P-value Chi-square test F % F % Trimester First trimester Second trimester Third trimester 5 51 35 50.0 32.3 32.1 5 107 74 50.0 67.7 67.9 0.501 Iron, folic acid, fero folic supplementation Yes No 91 0 32.4 37.5 0 186 67.6 62.5 0.612 Number of iron and folic acid tablet taking/month < 30 ≥ 30 None 82 9 67 29.5 57.7 37.5 171 15 160 70.5 42.3 62.5 0.013 First visiting and registering in ANC units First trimester Second trimester Third trimester 15 9 11 32.4 33.2 25.0 11 15 23 67.6 66.8 75.0 0.887 Anemia before pregnancy Yes No 78 2 55.6 32.1 157 6 44.4 67.9 0.140 Hb level checking before pregnancy Yes No 5 86 29.4 35.4 4 182 70.6 64.6 0.290 Iron and folic acid supplementation before pregnancy Yes No 35 56 37.5 32.4 84 102 62.5 67.6 0.612 Frequency of ANC 1-3 4-6 9 82 34.9 22.9 15 171 65.1 77.1 0.107 Places of attending ANC Public clinic Private & public clinic 21 70 29.2 34.1 51 135 70.8 65.9 0.439 Table 5- Logistic regression analysis of the factors associated with anemia Variables P- value Odd’s Ratio 95% CI of OR Wife Occupation High professional job Lower professional job Unskilled workers (reference category) 0.270 0.041 3.062 0.543 0.419 - 22.377 0.302 –0.976 Birth spacing / Years < 2 ≥ 2 (reference category) 0.118 1.433 0.913 – 2.249 Number of iron and folic acid tablet taking/month < 30 ≥ 30 (reference category) < 0.001 0.147 0.054 – 0.400 Places of attending ANC Public clinic Private & public clinic (reference category) 0.037 0.611 0.385 – 0.970 The results of the present study showed that there was a highly significant association of severity of anemia with wife education and smoking, these results agreed with results of Mirzaie et al, who found that there was a highly significant association of prevalence of anemia with maternal education and smoking [12]. Aikawa et al, mentioned that there was a highly significant association of Hb levels with maternal education which was consistent to the results of present study [13]. Khapre et al, results agreed with results of the present study regarding education which indicated that there was a significant relation of severity of anemia with maternal education [14]. There was no significant association of age group with severity of anemia in the present study, which was consistent to the results of Siteti et al, & Mirzaie et al, who found that there was no significant association of severity of anemia with maternal age [12,15]. A study done by Morsy & Alhady, who conducted descriptive study among 400 pregnant women to determine the prevalence of anemia and the influence of some factors associated with anemia during pregnancy in Egypt, they mentioned that maternal age has strongly associated with anemia level, which is disagreed with the results of present study [16]. Rajamouli et al, conducted a cross-sectional study on pregnant women, attending the maternity clinic of rural health training centre and teaching hospital of Chalmeda Anand Rao institute of medical sciences Karimnagar Telangana, India,to study the prevalence of anemia in rural pregnant women and the factors associated with anemia, they found that there was a significant association of severity of anemia with wife occupation which was consistent to the results of present study [17]. Studies of Khapre et al, also agreed with the present study regarding wife occupation who found that there was a significant association of severity of anemia with maternal occupation [14]. Soh et al, conducted a cross-sectional study in urban areas in Malaysia to determinethe Hb levels of antenatal mothers and their association with various socio- economic characteristics, they found that there was a high significant association between Hb level with economic status, which was in contrast to the results of present study, while it was agreed with that in which wife occupation have significant association with Hb levels and maternal occupation [18]. The present study show that there was no significant association of severity of anemia with iron, folic acid, fero folic supplementation in current pregnancy, which was in contrast to results of a study done by Mirzaie et al, and Aikawa et al, who mentioned that there was a significant association of Hb levels with iron supplementation [12,13]. While results of Lelissa et al, agreed with the results of present study regarding iron & folic acid supplementation, who mentioned that there was no significant association of severity of anemia with iron and folic acid supplementation [19]. Viveki et al, and Lelissa et al, mentioned on their results that there was no significant association of severity of anemia with trimester of pregnancy, which was consistent to the results of present study [20]. Regarding birth spacing <2 years in the present study there was no indicated for risks of anemia, which was in contrast to results of Abdelhafez and El-Soadaa who mentioned that women with short inter pregnancy periods were at more risk of developing anemia during pregnancy [21], while it was consistent to results of Abu-Hasira who found that decreased birth spacing didn’t show such association [22]. 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