Abstract

Background: Anemia among pregnant women is one of the most common public health problems in developing countries. World health organization (WHO) estimates shows nearly half of pregnant women were affected by anemia. It significantly increases fetal and maternal mortality and morbidity due to maternal vulnerability for infection and hemorrhage. Identify determinant factors of anemia among pregnant women in “Prevalence and determinants of anemia in third trimester. It is one of the most common preventable causes of maternal morbidities ranging from 22.6% to 54.0%. However, the prevalence and determinants that contribute to the occurrence of anemia were not extensively studied. Aim of the study: To evaluate the anemia and its determinants among pregnant women attending ANC at MCH in makkah city September 2019. To increase awareness of anemia during pregnancy and its adverse effects on the maternal and fetal outcomes. Method: Cross-sectional study conducted MCH in one of the most important cities in Saudi Arabia, which is Makkah. Sample population was pregnant women attending ANC in MCH in makkah city. Our total participants were (310) pregnant women. Results: The following variables were significantly associated with anemia: Age were (OR=0.333), Nationality status were (OR=1.830), Occupational status were (OR=0.649), Gestational age were (OR=0.580), History of drinking tea immediately after main meals (OR=0.557), Eating green vegetables were (OR=1.525), Eating animal products were (OR=1.651), Gravidity were (OR=2.192). Conclusion: Anemia is still a significant problem facing pregnant women and jeopardizing their outcomes. Diet during pregnancy, consuming tea/coffee immediately after food, meat consumption, previous heavy menstrual blood flow, and occupational status of women were significant factors associated with anemia among pregnant women so, it is recommended to increase the efforts toward the health education of women in childbearing age.

1. Introduction

Anemia refers to a condition in which the hemoglobin content of the blood is lower than normal for a person´s age, gender and environment, resulting in the oxygen carrying capacity of the blood being reduced ^{1, 2}.

Anemia in pregnancy state could be a major drawback worldwide. Because of the lack of data concerning the magnitude of anemia and the necessity to boost the standard of care ³ , the target of this study is to extend awareness the prevalence of anemia among pregnant women antenatal clinic at Maternity and Children Hospital in Makkah as well as to work out the association between anemia in pregnancy state and certain socio-demographic factors. During pregnancy state, more of changes occur within the body to accommodate the feto-placental system. Among these changes in the hematological system are physiologic anemia, neutrophilia, thrombocytopenia, exaggerated coagulant factors and decreased fibrinolysis. ⁴

The mean minimum acceptable hemoglobin level all through being pregnant through WHO criteria is taken to be 11 g/dL ⁵.

In addition, WHO divides anemia in being pregnant into: mild anemia (hemoglobin 10-10.9 g/dL), moderate anemia (hemoglobin7.0-9.9 g/dL) and severe anemia (hemoglobin <7 g/dL) ⁶

Estimates from the World Health Organization record that 35% to 75% of pregnant women in developing countries, and 18% in developed countries are anemic ². The greatest burden of anemia is born through Asia and Africa where it is estimated that 60% and 52% of pregnant women, respectively, are anemic and between 1% and 5% are severely anemic (hemoglobin <7 g/dl) and is related with ladies of age less than 20years, 1/3 trimester of pregnancy, rural residents, and multiparous women ^{6, 7}.

Anemia is observed as an indicator of both poor nutrition and poor health. It impairs health and well-being in women and increases the risk of maternal and neonatal adverse outcomes. During pregnancy, anemia is responsible for a lot of complications in women. Some of those associated problems are less exercise tolerability, puerperal infection, thromboembolic problems, postpartum hemorrhage, pregnancy induced hypertension, placenta previa, cardiac failure, low birth weight, preterm delivery, and prenatal death ⁸. In the early pregnancy up to 12 week of gestation, the plasma volume extent will increase by 15 %. ^{1, 2, 3, 4, 5, 6, 7, 8} It continues to become bigger until 30 to 34 weeks, after which there is solely a modest rise. At the end of pregnancy, the common expansion is about 1100 to 1600 mL and to a plasma extent of 4700 to 5200 mL, 30 to 50 % above the non-pregnant ladies level. ⁹

Anemia occurs at all stages of the life cycle but its risk is higher in state of pregnancy due to an increased iron requirement, physiological demand, and loss of blood and due to infections ^{10, 11}. Anemia in being pregnant is one of the most frequent preventable causes of maternal morbidity and bad prenatal result ¹².

Globally anemia affected 1.62 billion people, of these, 56 million anemia cases were found in pregnant women ¹³. The primary care medical doctor who is the backbone of the health care system and additionally the first contact factor for a patient plays a crucial role in the identification and administration of anemia. Even in the public sector, majority of the antenatal cases are handled at the degree of primary health care. ¹⁴

Also anemia is estimated to contribute to more than 115000 maternal deaths and 591000 prenatal deaths globally per year ¹⁵. Although organic risk factors such as dietary deficiency, parasitic infestations, and chronic illnesses are accepted risk factors, it is essential for the doctor to apprehend the ecological or structural hazard elements that may be of regional interest. These consist of socio-demographic characteristics, obstetric variables, intellectual health, and dietary popularity mirrored with the aid of the body mass index (BMI). These elements are now not amenable to clinical administration with iron supplementation but can be comprehensively addressed at the degree of primary care. ¹⁶

Even if anemia is a global public health problem affecting both developing and developed countries with major consequences for human health as well as social and economic development, its burden is more significant in developing countries ¹⁷. Various studies confirmed that until recent time, anemia in pregnant women remains one of the most unresolved public health problems in developing countries because of various socio-cultural problems like poverty, lack of awareness, poor dietary habits, and high prevalence of parasitic infestation ¹⁸.

For instance, current estimates from the World Health organization (WHO) put prevalence of anemia at 41.8% among pregnant women, with the highest prevalence rate (61.3%) found among pregnant women in Africa and 52.5% among South East Asia. In Saudi Arabia, the prevalence of anemia among pregnant women was 20.4% according to the study about prevalence of anemia among pregnant women registered for ANC at AL-Wazarat Health Center in Riyadh during the period of January till December 2012. ¹⁹

Also, there was some other study done in Saudi Arabia about occurrence of anemia amongst pregnant female attending sixty nine essential fitness care centers in Asir in the course of august 2012 which determined that incidence was 31.9%. ²⁰

1. It is a global health problem that can have worse impact on maternal and fetal outcome.

2. The researcher has an interest in subject of anemia among pregnant women as he had similar experience with his wife when she was pregnant.

3. Up to researcher’s knowledge, few similar studies have been conducted in MCH in Makkah city.

To evaluate anemia and its determinants among pregnant women. So that increasing awareness of anemia during pregnancy and its adverse effect on the maternal and fetal outcome.

1. To estimate the prevalence of anemia among pregnant women attending ANC at MCH in Makkah city during September 2019.

2. To identify the determinants of anemia among pregnant women attending ANC at MCH in Makkah city during September 2019

2. Methodology

The study has been carried out in MCH in one of the most important cities in Saudi Arabia, which is Makkah. It is the holy city for all Muslims, and is located in the western region in an area called Makkah region.

All Pregnant women attending to the ANC in MCH in Makkah city throughout the period of the study and accept to participate in the study.

Cross-sectional, analytic study.

● All pregnant women attending ANC for regular follow up during the study period.

● All nationalities

● All age groups

● Pregnant women known case of thalassemia or sickle cell disease or any other previously known cause of anemia.

According to MCH administration registries, average numbers of pregnant women attending antenatal clinic at MCH in Makkah city in one month is 1600. By using (https://www.raosoft.com/samplesize.html), the recommended sample is 310 to detect the prevalence of anemia at 95% confidence level, 5% estimation error and study response rate 50%. Then to compensate for the nonresponses and not completed questionnaires, 10% was added to the sample. Therefore, the final sample size had been 341.

There are four antenatal clinics daily( two in the morning and two in the afternoon ), one antenatal clinic in the morning and one antenatal clinic in the afternoon had been chosen by simple random technique and within each clinic the pregnant women sample had been chosen using simple random sampling technique by using random number generator (https://www.random.org). Each pregnant woman was organized in visiting daily paper and coded by number.

The researcher prepared a questionnaire which was validated by two family medicine consultants. An interview that was carried out between the researcher and each participant at ANC in MCH in Makkah city at September 2019, after which the researcher checked the medical record of the participant to determine her level of Hb or she was sent to hospital laboratory to measure her Hb level if it is the first visit as MCH protocol.

The questionnaire designed in English and consists of two main sections:

The first section is concerned with personal general information about the participants (age, nationality, job title, educational level).

The second section is concerned with anemia status and determinants of anemia.

● The researcher has visit the MCH in Makkah city.

● The researcher has given the official acceptance paper from health affairs to the manager of the hospital.

● The researcher has filled the questionnaires through the interview with pregnant women attending ANC who met the inclusion criteria after taking their verbal consent.

After obtaining necessary approvals, the researcher and one trained nurse used an appointment list of pregnant women assigned to the ANC clinic. From the list, the selected to make interviews with each participant in the waiting area near the clinic. They 1^st explained the objectives of the research in an easy language to the participants and gained their consents before sitting, interviewing them and filling up the questionnaires. If one participant didn’t show up for any reason, she will be replaced by the next one on the list. This process was continued until the involved participants were covered totally.

A) Dependent: Anemia status.

B) Independent:

● Age.

● Marital status.

● Nationality.

● Educational status.

● Occupational status.

● Gestational period.

● Parity.

● Multiple pregnancies.

● Iron intake.

The statistical package for social sciences (SPSS) software version 23 had been used for data entry and analysis. The necessary statistical tests had been used with a significance of P-value <0.05.

A pilot study has been conducted at Hera General Hospital in Makkah city with 10% of the sample size whose results has be excluded from the final research. The aim of the pilot study has be to test for the comprehensibility of the questionnaire as has as to estimate the time needed to fill in the questionnaire and feasibility of the methods.

● Permission from the Makkah joint program of family and community medicine has been obtained.

● Permission from the Directorate of Health Affairs of the Holy Capital has been obtained (IRB committee).

● Permission from the MCH has been obtained.

● Permission from the participants has been taken.

● All information has been kept confidential and results has been submitted to the department as feedback.

● There may be significantly high prevalence of anemia among pregnant women attending ANC in MCH in Makkah city.

● To know the risk factors associated with anemia among pregnant women as it may lead to worse impact on maternal and fetal outcome.

● Time limitations.

● Difficult to determine whether the outcome followed exposure in time or exposure resulted from the outcome due to cross sectional study.

Self-funded.

3. Results

Table 1 shows the socio-demographic details of 310 informed and consented pregnant women who came for their antenatal follow up and were enrolled in this study.

Regarding the age majority of the study groups were in the age range of (20-35) years were (77.1%) while participant women the age >35 were (20.3%).

Regarding the nationality many of the respondents were Saudi Nationality (73.9%) while non-Saudi were (26.1%).

Regarding the education status, all the respondents had educational degree status (310).

Regarding the occupational status, the majority of participant were housewives (73.2) while employees were (26.8%)

Table 2 shows the Gravidity in our study was (85.2%) and (14.8%) for multigravida and Primigravida, respectively.

Table 3 showing the highest prevalence was in the third trimester (75.2%) while in the second trimester was (19.7 %) and first trimester was (5.2%).

Table 4 showing a higher prevalence in single pregnancy (99.7%) than Multiple (0.3 %).

Table 5 showing the majority of the respondents were using iron supplements (64.2%) while the respondents who are not using were (35.8%).

Table 6 shows that majority of the respondents were not drinking tea after meal (73.9%) while the respondents who had the habit of drinking tea immediately after meals were (26.1%).

Table 7 shows the majority of the respondents had the habit of eating green vegetables (28.1%) while the respondents (25.5 %), (23.5%), and (22.9%) had the habit of eating green vegetables every other day, very rare and weekly, respectively.

Table 8 shows the majority of the respondents had the habit of eating animal products daily (59.7%) while the respondents eating animal products every other day, and weekly, respectively were (30.0%) and (10.3%).

Table 9 shows the prevalence of anemia in this study reflecting that majority of the respondents were Non-anemic (58.1%) while the anemic respondents were (41.9%).

Table 10 shows a statistically significant association between anemic status and age groups (P-value <0.001). Those women between 20 and 35 years old were having the highest prevalence of anemia followed by those over 35 years and young ladies under 20 years old.

Table 11 shows no statistically significant association between anemic status and nationality (P-value 0.018). About (66.9%, 33.1%) of the Saudi, Non-Saudi were anemic respectively.

Table 12 shows a statistically significant association between anemic status and occupational status (P-value <0.001). About (80.8%) of the women who were housewives were anemic. While only (19.2%) of employees were anemic.

Table 13 shows no statistically significant association between anemic status and gravidity status were P-value <0.038. The prevalence of anemia in this study was (90%, 10.0%) in multigravida and Primigravida, respectively.

Table 14 shows a statistically significant association between anemic status and gestational age were P-value<0.001. The prevalence of anemic in this study were (62.3%,34.6%,3.1% ) Third trimester, Second trimester and First trimester, respectively.

Table 15 shows no statistically significant association between anemic status and Using any sort of iron supplement were P-value <0.286. The prevalence of anemia in this study in those who used sort of iron supplement (60.8%), while those who did not used sort of iron supplement (39.2%).

Table 16 shows a statistically significant association between anemic status and drinking tea immediately after main meals were P-value <0.001. The prevalence of anemia in this study in those who were not drinking tea immediately after main meals was (63.8%), while those who were drinking tea immediately after main meals was (39.2%).

Table 17 shows a statistically significant association between anemic status and eating green vegetables were P-value <0.001. The prevalence of anemia among the respondents who were eating green vegetables (very rare, every other day, daily, and weekly) was (34.6%, 26.2%, 25.4%,13.8%), respectively.

Table 18 shows a statistically significant association between anemic status and eating animal products were P-value <0.002. The prevalence of anemia in the respondents who were eating animal products (daily, every other day, and weekly) was (50.0%, 40.8%, and 9.2%).

The multiple logistic regression between Anemic and Non-anemic patients was performed for each dependent variable and (Age, Nationality, Occupational status, Gravidity, Gestational age, Drink tea immediately after main meals, Eating green vegetables and Eating animal products) in our study. Variables having a p-value of less than 0.25 were transferred to multiple logistic regression. The results of multiple logistic regressions with backward method after checking of model fitness test by Hosmer-Lemeshow as well as omnibus tests with which non-significant and significant test result were tested, respectively. ²¹

The odds of developing anemia stats among women Age showed a statistical significance P-value 0.001 while the B, S.E. and Wald were (-1.099, 0.327,11.328), respectively. The Odd ratio was (OR=0.333) and confidence interval (lower and upper were 95% CI 0.176 - 0.632).

The odds of developing anemia stats among women nationality showed a statistical significance P-value 0.047 while the B, S.E. and Wald were (0.604, 0.304, 3.959)), respectively. The Odd ratio was (OR=1.830) and confidence interval (lower and upper were 95% CI 1.009 - 3.318).

The odds of developing anemia among women occupational status showed a non-statistical significance P-value 0.151 while the B, S.E. and Wald were (-0.432, 0.301, 2.058), respectively. The Odd ratio was (OR=0.649) and confidence interval respectively were (lower and upper were 95% CI 0.360– 1.171).

The odds of developing anemia among women Gravidity showed a statistical significance P-value 0.047 while the B, S.E. and Wald were (0.785, 0.395, 3.959), respectively. The odd ratio was (OR=2.192) and confidence interval (lower and upper were 95% CI 1.012– 4.751).

The odds of developing anemia among women Gestational age showed a statistical significance P-value 0.024 while the B, S.E. and Wald were (-0.544, 0.241, 5.109), respectively. The odd ratio was (OR=0.580) and confidence interval (lower and upper were 95% CI 0.362– 0.930).

The odds of developing anemia among women drinking tea immediately after main meals showed a statistical significance P-value 0.044 while the B, S.E. and Wald were (-0.585, 0.290, 4.063), respectively. The odd ratio was (OR=0.557) and confidence interval (lower and upper were 95% CI 0.316– 0.984).

The odds of developing anemia among women eating green vegetables showed a statistical significance P-value 0.002 while the B, S.E. and Wald were (0.422, 0.135, 9.817), respectively. The odd ratio was (OR=1.525) and confidence interval (lower and upper were 95% CI 1.171– 1.986).

The odds of developing anemia among women eating animal products showed a statistical significance P-value 0.025 while the B, S.E. and Wald were (0.502, 0224, 5.029), respectively. The odd ratio was (OR=1.651) and confidence interval (lower and upper were 95% CI 1.065– 2.560).

Also the odds of developing anemia stats among women Constant showed a statistical significance P-value 0.451 while the B, S.E. and Wald were (1.040, 1.381, 0.568), respectively. The odd ratio was (OR=2.831)

4. Discussion

In this study we estimated the prevalence of anemia among pregnant women and its association with certain risk factors such as socio-demographic factors (Age, Nationality, Occupational status), obstetrical and antenatal risk factors, (Gravidity, Gestational age), life style (Drinking tea immediately after main meals, Eating green vegetables and Eating animal products).

The overall prevalence of anemia was found to be 41.9% in our study, which reflects the burden of anemia among a group of pregnant women availing of antenatal care at a public-sector hospital. (See Table 9) Samuel et al. in a similar study, which was done at an urban public health facility in Bangalore, observed an almost similar prevalence rate of 30.3%. ²² As compared with other study findings done in an urban setup in South India, our study findings are higher than the prevalence rate of 23.16% observed in Vellore ²³ but lower than the prevalence rate of 50.1% that was found. ²⁴

In Saudi Arabia, Earlier in 1994, the prevalence of anemia was 31.9% in the Southern region, ²⁵ compared to higher prevalence of 41.3% in Eastern region in 2008. ²⁶ The higher prevalence in the eastern region can be attributed to the endemicity of sickle cell. Also our study finding is higher than prevalence found in some Gulf countries like Kuwait 36.8% ²⁷ and Oman 43.6% (comparable). ²⁸

Other Asian countries showed higher prevalence of pregnancy anemia, like in Malaysia 34.6% ²⁹ and Vietnam 43.2%. ³⁰ Lager studies done in India ³¹ and Bangladesh ³² reported higher prevalence of anemia of 84.9% and 50% respectively, reflecting a poor state of the nutritional health among pregnant women in these developing countries.

In our study, socio-demographic factors appear to be significantly associated with anemia particular in age group 20-35 were the percentage was (86.9%) (See Table 10).

Low socio-economic status are known to be associated with anemia as revealed in other research findings ^{33, 34}. Balarajan et al. ³¹ also in their analysis of epidemiology of anemia in low and middle-income countries noted a skew in the distribution of anemia in lower income groups. There was a statistically significant difference in the prevalence among housewives versus employee women where housewives (80.8%) had anemia while the employee who had anemia were (19.2%) (See Table 12) in contrast to the result findings from a study which was done by Baig-Ansari et al. An example to that was the prevalence ³⁵ in the United States found to be 22% indicating an improved economic status of the community and good nutritional support to pregnant women in those counties. ³⁶

We could not confirm the existence of association between obstetric variables such as gravidity with anemia in our study however, it showed that primigravida women (10%) are less likely than of multigravida women to develop anemia during pregnancy (90.0%) (See Table 13) which could be a consequence of depletion of iron reserves owing to repeated pregnancies. ³⁷

Nevertheless, similar to our study findings, Singh et al. ³⁸ did not find any such association with gravidity, whereas Suryanarayana et al. ³⁹ could not establish any linkage with parity.

In our study, we found that the advancing gestational age is significantly increasing the risk for anemia in the third trimester (62.3%) while second trimesters (34.6%) (See Table 14). This is similar to the findings in the other study conducted in Saudi Arabia. ^{25, 40} Compared to the first trimester, more cases of anemia found in the second and third trimesters are possibly attributed to the hemodilution and plasma expansion that occur physiologically with advancing gestational age. ⁴¹

The development of anemia among pregnant mothers who were not drinking tea immediately after food was greater than the mothers who consumed tea immediately after food during their pregnancy while non-anemic pregnant women who did not drink tea immediately after food were (81.1%) (See Table 16). This result is in agreement with a study done in Egypt and Ethiopia, which showed significant association between anemia and consumption of tea ⁴² and this could be attributed to the effect on iron absorption which leads to inadequate dietary iron intake in the pregnant women.

A statistically significant association between anemic status and eating animal products was observed in our study P-value <0.002. The prevalence of anemia in this study the respondents had eat animal products daily compared to those who ate every other day had the likelihood of developing anemia. (See Table 18) This result is consistent with other studies done in Ethiopia ^{43, 44}. This significant association might be due to the reason that meat is an important source of hemeiron. According to this study odds of getting anemia in pregnant mothers among women Age show had a statistical significant were P-value 0.001 (AOR=2.49, 95% CI: 1.22- 5.08).

The result in The multiple logistic regression showed that the odds of getting anemia in pregnant mothers were higher among mothers whose birth interval was less in years (OR=2.192% , 95% CI: 1.012-4.751).

According to this study odds of getting anemia in pregnant mothers among women Nationality show had a statistical significant were P-value 0.047 (AOR=1.830, 95% CI 1.009 - 3.318). Similar finding has also been documented in a study conducted at Jimma hospital ⁴⁵.

Similarly, pregnant mothers who were gestational age show had a statistical significant were P-value 0.024 were (OR=0.580, 95% CI 0.362– 0.930) (See Table 19). This table to assess different dietary risk factors associated with anemia. Green leafy vegetables, taking fruit after meal and drinking tea did not show significant association with anemia on multivariate logistic regression, which may be due to no difference in eating habit among the study participants.

5. Conclusion

This study identified factors important that determine anemia among pregnant women in the study area. Among the studied factors, drinking tea immediately after food intake, not eating meat, not taking additional diet during current pregnancy, average monthly income, taking iron supplementation irregularly and being housewife are the factors which was associated with anemia during pregnancy. It is recommended that community based early identification of determinants of anemia and appropriate interventions have paramount importance in fighting anemia to help mothers enjoy their pregnancy. Strengthening health education and counseling on diversifying dietary intake. Regions with higher anemia prevalence among pregnant women should be given due attention. Further studies should be conducted to better understand the determinant factors in these regions. A community based study with large sample size and more strong study design should be conducted.

References