MATERNAL ANAEMIA AND PERINATAL OUTCOME IN PLATEAU STATE SPECIALIST HOSPITAL, JOS, NORTH CENTRAL NIGERIA.

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MATERNAL ANAEMIA AND PERINATAL OUTCOME IN PLATEAU STATE SPECIALIST HOSPITAL, JOS, NORTH CENTRAL NIGERIA.  

SUMMARY

The study was carried out to determine whether there was any relationship between maternal anaemia and adverse perinatal outcome in Plateau state specialist hospital, Jos.

Anaemia in pregnancy is a common problem in the developing countries. It is widely considered a risk factor for adverse perinatal outcome. About 20% of maternal mortality in Africa is thought to be attributable to maternal anaemia.

This was a cohort study where the women were enrolled during their routine antenatal care booking in the hospital and followed till discharged after delivery from the hospital. Only women who met the inclusion criteria during enrolment and gave a written informed consent to participate in the study were recruited. During recruitment, socio-demographic data, past medical history, history of index pregnancy and physical examination findings were collected in a predesigned questionnaire. Capillary blood sample was tested for haemoglobin concentration at enrolment and at delivery. Gestational age at birth, perinatal deaths, Apgar score at 1 and 5 minutes, birth weight and maternal mortality and morbidities were also recorded.

Most of the women 142(72.4%) had mild anaemia while 54(27.6%) had moderate anaemia at booking. There was no case of severe anaemia at recruitment. Only 106(54.08%) of them remained anaemic during delivery with 2(1.0%) developing severe anaemia from abruptio placenta. The prevalence of anaemia in the study was 23.76%.

Thirty-four (17.3%) of the women had preterm delivery, 32(16.2%) and 8(4.1%) had Apgar score less than 7 at 1 and 5 minute respectively. Twenty (10.2%) had birth weights less than

2.5kg while 7(3.5%) had IUFD and 4(2.0%) died during the early neonatal period. There was no maternal mortality recorded in this study. Maternal morbidities observed included 9 cases of PPH, 5 cases of PIH, 2 cases of eclampsia and a case of placenta praevia.

Health care providers need to be aware of the potential dangers of anaemia in pregnancy both to the mother and her unborn baby with the sole aim of reducing this unacceptably high prevalence of anaemia if the goal of reducing maternal and infant morbidity and mortality is to be achieved. Educating women on the need for early commencement of antenatal care and delivery in the hospital will help reduce the prevalence of anaemia and the adverse perinatal outcome often observed.

TABLE OF CONTENTS Declaration………………………………………………………………………….i

Acknowledgement………………………………………………………………....ii

Dedication…………………………………………………………………………iii

Certification……………………………………………………………………….iv Table of contents………………………………………………………………….v

List of tables and figures……………………………………………………….....vi

Abbreviations……………………………………………………………………..vii

Summary………………………………………………………………………..… 1

CHAPTER ONE

1.1     Introduction………………………………………………………….………3

1.2     Statement of the problem……………………………………………. .. …..11

1.3     Aim and objectives………………………………………………………… 12

1.4     Relevance of the study………………………………………………… ...    13

 

CHAPTER TWO

2.1 Definition of anaemia…………………………………………………………….14

2.2 Classification of anaemia…………………………………………………………14

2.3 Erythropoiesis……………………………………………………………………16

2.4 Determinants of anaemia in pregnancy…………………………………………18

2.4.1 Biological risk factors………………………………………………………….19

2.4.1.1 Physiological changes in pregnancy…………………………………….........19

2.4.1.2 Parity………………………………………………………………………….20

2.4.1.3 Maternal age…………………………………………………………………..22

2.4.1.4 Nutritional deficiency…………………………………………………………22

2.4.1.4.1 Iron deficiency………………………………………………………………23

2.4.1.4.2 Folic acid deficiency………………………………………………………...26

2.4.1.4.3 Vitamin B12 deficiency…………………………………………………..…30

2.4.1.4.4 Vitamin A deficiency ……………………………………………………….31

2.4.1.5 Infections……………………………………………………………………...34

2.4.1.5.1 Malaria………………………………………………………………………34

2.4.1.5.2 Intestinal helminthes………………………………………………………...36

2.4.1.5.3 Urinary tract infection………………………………………………………38

2.4.1.5.4 HIV infection……………………………………………………………….39

2.4.1.5.5 Anaemia of chronic inflammation…………………………………………..41

2.4.2 Behavioural determinants……………………………………………………….43

2.4.2.1 Dietary patterns………………………………………………………………43

2.4.2.2 Health seeking behaviour……………………………………………………..43

2.4.3 Socio-cultural and environmental factors………………………………………44

2.5 Effects of anaemia on pregnancy…………………………………………………46

2.5.1 Anaemia in pregnancy and maternal morbidity and mortality………………....46

2.5.2 Maternal anaemia and preterm delivery………………………………………..48

2.5.3 Maternal anaemia and low birth weight………………………………………...51

2.5.4 Maternal anaemia and Apgar score…………………………………………….54

 

2.5.5 Maternal anaemia and stillbirths………………………………………………..55

2.6 Diagnosis of anaemia……………………………………………………………...56

2.7 Treatment of anaemia………………………………………………………….......57

2.8 Prevention of anaemia……………………………………………………………..59

CHAPTER THREE

3.0 Materials and method……………………………………………………………….63

3.1 Study area………………………………………………………………………..….63

3.2 Study population…………………………………………………………………….64

3.3 Sample size………………………………………………………………………….64

3.4 Sampling method……………………………………………………………….……65

3.5 Selection criteria…......................................................................................................66

3.5.1 Inclusion criteria…………………………………………………………………...66

3.5.2 Exclusion criteria…………………………………………………………………..66

3.6 Data collection……………………………………………………………………….66

3.7 Materials…………………………………………………………..…………………68

3.7.1 Mission(R) Haemoglobin testing system……………………………………………68

3.8 Sample collection…………………………………………….………………………69

3.8.1 Gestational age…………………………………………….………………………70

3.8.2 Birth weight………………………………………………………………………70

3.8.3 Apgar score………………………………………………………………………..70

3.9 Method of data analysis………………………………………………………….….71

CHAPTER FOUR

4.0 Results………………………………………………………………………………72

4.1 Socio-demographic characteristics of the respondents……………………………..72

4.2 History of index pregnancy………………………………………………………….77

4.2.1 Parity………………………………………………………………………………77

4.3 Obstetrics history…………………………………………………………………….78

4.4 Past medical history………………………………………………………………….78

4.5 Physical examination………………………………………………………………..78

4.6 Haemoglobin concentration of respondents…………………………………………80

CHAPTER FIVE

5.1 Discussion……………………………………………………………………………89

5.2 Conclusion………………………………………………………………………….100

5.3 Recommendation………………………………………………………………....102

References………………………………………………………………………………104

 

   CHAPTER ONE

1.1   INTRODUCTION

Anaemia is generally defined by the value of haemoglobin (Hb). It is present when the haemoglobin value is below the reference value for the age, sex and place of residence of the individual1,2. Anaemia in pregnancy is regarded as a major public health problem especially in the developing countries with the most vulnerable group being women and children. The world health organization estimates that more than half of pregnant women in the world have haemoglobin concentration indicative of anaemia2,3. During pregnancy, the physiological changes that take place entails that the normal values are lower1.

Anaemia in pregnancy as defined by the world health organization (WHO), is a haemoglobin concentration below 11g/dl3-5.

Anaemia in pregnancy is classified as mild, moderate or severe. The WHO gave haemoglobin values of 10.0 – 10.9g/dl for mild, 7.0 – 9.9g/dl for moderate and less than 7.0g/dl for severe anaemia in pregnancy3,4. The mean minimum haemoglobin concentration in pregnancy by the WHO criteria is taken to be 11.0g/dl in the first half of pregnancy and 10.5g/dl in the second half of pregnancy6.

The normal physiological changes in pregnancy leads to an expansion of plasma volume by 4655% while the red cell volume expands by only 18-25%6,7. The increase in plasma volume begins as early as the 6th week and peaks at about 30-34 weeks before stabilizing. The increase in plasma volume is greater in patients with multiple pregnancies and larger babies whereas intrauterine growth restricted babies are associated with less than normal increase in plasma volume7. The differential increase in plasma volume and the red cell volume leads to a dilutional decrease in haemoglobin concentration called physiological anaemia of pregnancy8,9.  Anaemia as an important public health problem has women and children as its most vulnerable group10,11. The WHO estimates that more than half of the pregnant women in the world have haemoglobin concentration indicative of anaemia3,4.  The burden, unfortunately, is carried by the developing countries where anaemia is thought to be one of the most common problems affecting pregnant women3,4,11. It is estimated that 15% of pregnant women in the developed countries are anaemic whereas 35-75% of pregnant women in the developing countries has haemoglobin concentration indicative of anaemia3. The disparity in the prevalence of anaemia between the developed and developing countries may be because of differences in for example, socio-economic conditions, and lifestyle and health-seeking behaviors across different cultures12.

Pathological anaemia of pregnancy is multi-factorial but largely due to iron deficiency (ID)13. Folate deficiency is a minor component contributing to anaemia and it may be masked by a coexisting ID8. Multi-parity, poor socioeconomic and educational status, is the principal reason for the high prevalence of anaemia in the developing countries8. In a study reviewing the determinants of anaemia in Malawi, Munasinghe S et al, grouped the determinants of anaemia into biological risk factors, behavioral, socio-cultural and environmental determinats11. The biological risk factors include physiological haematologic changes in pregnancy, maternal age, gravidity, nutritional deficiencies and infections11. Behavioral determinants mainly involve dietary pattern and health seeking behavior of the woman. The literacy level and socioeconomic status of the woman, the perception of the society of the problems of anaemia during pregnancy and cultural food taboos are other determinants of anaemia during pregnancy11. Munasinghe however did not consider the possibilities of recurrent antepartum haemorrhage as a cause of anaemia in pregnancy1. Some authors have reported that anaemia is more common in adolescent but that observation seems to be the result of the fact that adolescents are more often primigravidae and not from the young age of the women per se11. A univariate analysis of the study conducted in two hospitals in Malawi showed an increased risk of anaemia for women under the age of 20 but when the data was corrected for gravidity and gestational age at booking, the increased risk with age no longer existed11. In Ghana, Glover- Amengor et al reported a young age to be significantly associated with low haemoglobin concentration and the highest prevalence of maternal anaemia10.

Gravidity is one of the most important determinant of maternal response to pregnancy even though the biological mechanisms through which gravidity is associated with anaemia is unclear11,14. A study carried out in Blantyre and Namitambo in Malawi, showed that, adjusted for age and gestational age, primipara were at an increased risk of anaemia and severe anaemia when compared to grand multipara in both rural and urban settings11. While some studies found that increasing parity was associated with an increase in the risk of anaemia in pregnancy, other studies reported no evidence of such an association. Another group actually reported a reduction in the risk of anaemia in pregnancy15. Yahaya MA et al in a study in Oman, found that high parity pregnancies carry about three times higher risk of developing anaemia in pregnancy in a dose response fashion over increasing levels of parity15.

Another important biological determinant of anaemia during pregnancy is infection. Infections contribute to iron deficiency especially in developing countries where they are more prevalent11. Infections causing chronic blood loss such as hookworm infestations and schistosomiasis increase the iron requirement of the patient11. Viral and bacterial infections may also interfere with food intake, absorption, storage and use of many other nutrients including iron. Repeated episodes of infections thus, may contribute to the development of ID and anaemia11.  Parasitic infestations known to cause anaemia include malaria, hookworm and schistosomiasis10,14.

Malaria is the most important of the parasitic diseases of human beings especially in sub-Saharan Africa where about 90% of all the deaths due to malaria occur16. Caused by the Plasmodium species (P. malariae, P. ovale, P. vivax and P. falciparum), malaria is an important cause of

maternal anaemia14,17. The susceptibility of pregnant women to malaria has been attributed to a reduction of both cellular and humoral immune response to the malaria parasite that had been acquired through life11. The association between malaria in pregnancy and maternal anaemia has been reported in several studies. Troyle-Blomberg et al in Cameroon reported that the prevalence of anaemia at first booking clinic was 68.9% and in the group of anaemic women, the mean haemoglobin concentration of malaria parasite positive women was significantly lower than that of the malaria negative women18. Similar studies in rural northern Tanzania, southern Tanzania and Uganda reported a strong association between malaria parasitaemia and maternal anaemia1820. The anaemia following malaria parasitaemia may not only be from haemolysis but also from folate deficiency and hypersplenism16. The accelerated rate of haemopoiesis needed to keep abreast with the red blood cells destruction increases the folic acid requirements, which may not be satisfied during pregnancy owing to the competing demands of the developing foetus16. There is evidence that malaria can induce ID by several mechanisms; possibly through immobilizing iron in haemozin complexes and loss of urinary iron, as well as reducing intestinal iron absorption during the acute illness even though these mechanisms is poorly understood11.

Anaemia in pregnancy is thought to contribute significantly to maternal morbidity and mortality,

foetal well being and perinatal morbidity and mortality2-4. However, the literature is conflicting about the association between anaemia and perinatal outcome. While some studies have demonstrated a strong association between low Hb concentration before delivery and adverse outcomes such as preterm delivery, low birth weight (LBW), intrauterine growth restriction (IUGR), small –for- gestational age and anaemia, other studies found no associations21.

Maternal mortality due to anaemia is reported to be about 20% across Africa and is said to occur through three main mechanism22. Firstly, anaemia makes women more susceptible to deaths from haemorrhage by lowering their haematological reserves for blood loss especially at birth22. Ujah IAO et al while studying the factors contributing to maternal mortality over a seven year period in Jos, North central Nigeria, noted that anaemia was responsible for 14.6% of the indirect causes of maternal death23.  It has also been documented that nearly 600,000 women die each year as a result of complications of pregnancy and child birth22. Most of these deaths occur in developing countries where the risk of women dying in pregnancy and child birth is 50-100 times greater than of women in the developed world22. A detailed compilation of reports on the causes of maternal deaths attributable to anaemia was published by the WHO in which 62 reports from 33 countries provided the proportion of maternal deaths attributable to anaemia24. In that report, anaemia was listed as a direct cause of death in 26% of cases and as an indirect cause in the remainder24.

A decrease in physical working capacity, impaired immune function and cardiac failure has been noted to be the main maternal morbidities associated with maternal anaemia1,25.

Prematurity is a leading cause of perinatal morbidity and mortality26. Preterm delivery refers to the delivery of the foetus before the 37th week of gestation. The incidence of preterm birth is dependent on many factors and varies from one country to another and from institution to institution26. Maternal anaemia has been documented by many authors to be a risk factor for preterm birth while others claimed there is no such associations27.  Levy et al in a study in Israel reported that, maternal anaemia influences birth weight and preterm delivery but not associated with adverse perinatal outcome in that population28. The premature delivery per se is said to occur as a result of folate deficiency1. A research was conducted to understand how anaemia may predispose to preterm labour3. It was found that anaemia could predispose to preterm labour directly or indirectly due to increased risk of infection. The direct effect is related to increased synthesis of corticotrophin-releasing hormone (CRH) as a result of tissue hypoxia which causes maternal and foetal stress, thus constituting a risk factor for preterm labour, pregnancy induced hypertension and premature rupture of membranes3. Allen LH in a review of articles in California reported several studies linking anaemia with preterm delivery and LBW4. In that review, Welsh pregnant anaemic women had a 1.18 – 1.75 fold higher relative risk of preterm birth, LBW and perinatal mortality. After controlling for many other variables in a large Californian study, Klebanoff et al showed a double risk of preterm delivery with anaemia during the second trimester but not during the third trimester29. Hussein LK et al in another study in Dar es Salaam, Tanzania, found that the risk of preterm delivery increased significantly with severity of anaemia21. There was no association between severity of anaemia and Apgar score, still births and early neonatal deaths in that study. They therefore concluded that, the risk of preterm delivery and LBW were significantly and independently increased relative to the severity of maternal anaemia found on admission for delivery21.

Anaemia in pregnancy has also been reported to affect the foetal weight. A foetal birth weight below 2500g is regarded as low birth weight25,30.  A fall in maternal haemoglobin below 8.0g/dl has been reported to cause a significant fall in birth weight due to increase in prematurity and

IUGR31. Philip JS et al in a study on maternal Hb concentration and birth weight reported that, the minimum incidence of LBW (2.5Kg) and of preterm labour (<37 completed weeks) occurred in association with Hb concentration of 9.5 – 10.5g/dl; values commonly considered representative of anaemia30. Rizvi et al in another study in Karachi, found that maternal Hb level was independently associated with LBW after adjusting for the effects of other variables32. The study further observed that, the odds of delivering a LBW baby decreased with increase in maternal Hb and that mothers who do not take iron supplements during pregnancy had increased odds of having a LBW baby32. The weight of an infant at birth can be seen as an important indicator of maternal health and nutrition prior to and during pregnancy. The prevalence of LBW in Pakistan and other South Asian countries is put at 12 -25%33. A similar prevalence of 12.7% was reported in Jos, north central Nigeria34. Tukur et al in Jos however reported the prevalence of LBW among pregnant women infected with malaria to be 4% as opposed to 14.1% and 29.7% in Burkina Faso and Mali respectively12.

The Apgar score (American paediatrics gross assessment record) is a useful tool in assessing the cardio-respiratory and neurological response of a new born infant35. These scores are conventionally determined at 1 and 5 minutes. The cardio-respiratory and neurological response is often depressed as a result of numerous causes at birth. A low or depressed Apgar score signifies a problem that needs explanation and management. A low Apgar score has been described as an adverse perinatal outcome of anaemia in pregnancy by different authors.  Apgar score of <7 in 1 and 5 minute was reported in 2% and 1% of pregnant anaemic mothers at delivery respectively in Iran25. Lone et al in Karachi, Pakistan reported that pregnant anaemic mothers had a 1.8 times higher risk of giving birth to babies with Apgar score <7 in 1 and 5 minutes11. Jaleel R and associates, while studying severe anaemia and adverse pregnancy outcome,  found 11% of babies with Apgar score <7 among women who were severely anaemic36. There were little or no studies linking anaemia and Apgar score in Nigeria.

Still birth is defined as the death of a foetus after the age of viability (24-28weeks gestation) and before delivery. The causes of still birth are not known37. Stephansson et al37 in a study in Sweden found a higher Hb concentration >14.6g/dl to be responsible for increased risk of still birth, but anaemia (Hb concentration <11.0g/dl) was not significantly associated with the risk of still birth in a multivariate analysis (OR- 1.2; 95% CI, O.5-2.7). Kalaivani K in a study on prevalence and consequences of anaemia in pregnancy in New Delhi, India reported that a fall in maternal Hb below 11.0g/dl is associated with a significant rise in perinatal mortality rate31. He further observed that, a fall in maternal Hb below 8.0g/dl has a 2-3 fold increase in perinatal mortality rate and 8-10 fold increase perinatal mortality with a fall in maternal Hb below

5.0g/dl31. He however added that, coexisting obstetrics problems such as multiple pregnancies, pregnancy induced hypertension and antepartum haemorrhage contribute, at least in part, to the adverse obstetric outcome reported among anaemic women.

 

1.2        STATEMENT OF THE PROBLEM

Anaemia in pregnancy and its impact on perinatal outcome has been studied by different authors especially in Asia. The literature on this subject in Nigeria and other African countries is however scanty. A review of the literature on anaemia in pregnancy revealed a high prevalence of anaemia in developing countries compared to the developed countries. The prevalence has also been observed to vary from place to place even within the same region, thus suggesting localized factors determining the prevalence of the disease. A review of some articles in Nigeria showed the prevalence of anaemia in pregnancy to range between 20.9% to 76.5%1,12,38,39. Glover-Amengor et al10 in Sekyere West district of Ghana, reported a prevalence of 57.1% using a Hb concentration of <10g/dl instead of the WHO cut off of <11.0g/dl. The prevalence in Malawi11, Democratic republic of Congo40, Dar es Salaam21 and Grey-town, South Africa41 are reported to be72%, 72%, 68% and 39.9% respectively. Guatnam et al42 in a study conducted in two villages in Delhi, India found a prevalence of 96.5% while Elhassan et al43 in a similar study in Medina Hospital Sudan reported a prevalence of 67%. The researcher also observed that anaemia during pregnancy in Plateau State Specialist Hospital is not uncommon and a number of these women often present with adverse perinatal outcome such as preterm delivery, LBW, low Apgar score and/ or still births for which no definite cause is documented. These observations and the great variability in the prevalence of anaemia in pregnancy across the world and in particular the sparse literature on the subject in our community prompted the study.

     1.3.        AIM AND OBJECTIVES

                                               AIM

To determine the relationship between maternal anaemia and perinatal outcome in Plateau State Specialist Hospital with a view to recommend measures of reducing its burden.

                                           

OBJECTIVES

  1. To determine the prevalence of anaemia in the study population.
  2. To determine whether there is a relationship between maternal anaemia and; Preterm delivery
  3. Low birth weight
  4. Low Apgar score
  5. Still birth.

 

 

1.4.   RELIVANCE OF THE STUDY.

  The relationship between maternal anaemia and perinatal outcome has been studied   extensively in certain regions of the world. However, the extent to which maternal anaemia affects maternal and neonatal health is still uncertain. Some studies have demonstrated a strong association between low Hb concentration before delivery and adverse outcomes whereas others have found no such significant associations.

The study will aim at adding to the pool of knowledge existing on this subject and if possible assist to erase the areas of uncertainty. The knowledge acquired from the study will also enhance specific targeted interventions and holistic management of the problem hence leading to a reduction of this unacceptably high prevalence of anaemia among pregnant women.                

 

MATERNAL ANAEMIA AND PERINATAL OUTCOME IN PLATEAU STATE SPECIALIST HOSPITAL, JOS, NORTH CENTRAL NIGERIA.  

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