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PATTERN OF ANAEMIA AMONG PREGNANT WOMEN ATTENDING ANTENATAL CLINIC OF FAITH MEDIPLEX, BENIN CITY
SUMMARY
This study was conducted in order to find out the pattern and prevalence of anaemia in pregnancy among pregnant women attending antenatal clinic in Faith Mediplex, Benin City.
Background: Anaemia in pregnancy is a common problem in most developing countries and a major cause of morbidity and mortality especially in malaria endemic areas. A deliberate desire to know the current situation and pattern of this condition in our environment prompted this study. This knowledge will motivate the antenatal care givers towards early detection and prompt management of anaemia in pregnancy
Objective: The objective was to establish the characteristics of antenatal attendees in Faith Mediplex, Benin City who have anaemia. The study will also determine the relationship between gestational anaemia and some aetiological factors in order to make practical recommendations that will improve the management of this condition.
Study Design: The study was a descriptive, cross- sectional study and the sampling method was convenient (non-probability) sampling
Method: This study was conducted among 400 pregnant women at booking in antenatal clinic of Faith Mediplex, Benin City from August to Novermber 2010. A questionnaire was used to obtain sociodemographic data of each respondent. Physical examination was done measuring weight, height, blood pressure, and symphysio-fundal height. Blood was collected for haemoglobin concentration estimation, genotype, malaria parasite, HIV test and peripheral smear. Analysis of data was done using statistical package for social sciences. Version 16.0 (SPSS 16.0)
Results: The prevalence of anaemia in pregnancy was 58.0% (Hb < 11 gm/dl) among antenatal patient in Faith Mediplex, Benin City. There was association between gestational anaemia and socioeconomic status, gestational age and malaria which were statistically significant. Multiple logistic regression analysis revealed only malaria as a good predictor of anaemia in pregnancy. There were no specific trends between anaemia in pregnancy and maternal age, parity and trimester at booking, HIV and haemoglobinopathy. Peripheral smear showed that majority of the respondents (69:2%, N=155) had microcytic, hypochromic anaemia which is a qualitative marker for iron deficiency anaemia. With reference to degree of anaemia, half of the pregnant women had mild anaemia while 7.1% were of severe variety.
Conclusion / Recommendations: Prevalence of anaemia in pregnancy was very high among pregnant women attending antenatal clinic in Faith Mediplex, Benin City. Majorityhad microcytic hypochromic anaemia indicative of iron deficiency anaemia. Most of the women with gestational anaemia are of mild degree while good number had severe variety. Gestational anaemia had statistically significant relationship with socio-economic status, gestational age at booking and malaria. Logistic regression analysis showed that only malaria was found to be a good predictor of gestational anaemia. A robust public health education to encourage preconception counselling, early prenatal booking with iron supplement, educational and economic empowerment for all women, and promoting preventive measures against malaria (chemoprophylaxis [IPTp] and use of insecticide treated bednets at home) were strongly recommended. All these will ensure considerable reduction in gravid anaemia and safe motherhood.
Keywords: Anaemia, Pregnant women, Antenatal care, Prevalence, Pattern.
TABLE OF CONTENTS
CONTENT PAGE
COVER PAGE ........................................................................................................................................ i DECLARATION .................................................................................................................................... ii ATTESTATION .................................................................................................................................... iii CERTIFICATION ................................................................................................................................. iv DEDICATION ........................................................................................................................................ v ACKNOWLEDGMENTS ..................................................................................................................... vi TABLE OF CONTENTS ...................................................................................................................... vii LIST OF TABLES ................................................................................................................................. ix LIST OF FIGURES ................................................................................................................................ x LIST OF ABBREVIATIONS ................................................................................................................ xi SUMMARY .......................................................................................................................................... xii CHAPTER ONE ..................................................................................................................................... 1
1.0 Introduction ............................................................................................................................ 1
1.1 Statement of the Problem ....................................................................................................... 3
1.2 Relevance to Family Medicine ............................................................................................... 4
1.3 General Objective ................................................................................................................... 5 1.3.1 Specific Objectives ................................................................................................................. 5 CHAPTER TWO .................................................................................................................................... 6
2.0 Literature Review ................................................................................................................... 6
2.1 Definition and Classification of Anaemia in Pregnancy ........................................................ 6
2.2 Epidemiology.......................................................................................................................... 8
2.3 Prevalence of Anaemia in Nigeria .......................................................................................... 9
2.4 Aetiology of Anaemia in Pregnancy ..................................................................................... 14
2.4.1 Nutritional Deficiencies ........................................................................................................ 14 2.4.1.1 Iron Deficiency and Anaemia in Pregnancy ......................................................................... 14
2.4.1.2 Folate Deficiency and Anaemia in Pregnancy ...................................................................... 17
2.4.1.3 Vitamin B12 Deficiency and Anaemia in Pregnancy ............................................................ 18
2.4.1.4 Vitamin A Deficiency and Anaemia in Pregnancy……………………………………………………………..19
2.4.2 Infections/Infestations .......................................................................................................... 20 2.4.2.1 Malaria and Anaemia in Pregnancy ...................................................................................... 20
2.4.2.2 HIV/AIDS and Anaemia in Pregnancy................................................................................. 23 2.4.2.3 Hookworm Infestation and Anaemia in Pregnancy .............................................................. 24
2.4.3 Haemoglobinopathy and Anaemia in Pregnancy ................................................................. 25
2.5 Clinical Presentation ............................................................................................................. 27
2.6 Laboratory Diagnosis ........................................................................................................... 27
2.7 Complications ....................................................................................................................... 29 2.8 Management ......................................................................................................................... 31 CHAPTER THREE .............................................................................................................................. 34 3.0 Materials and Methods ......................................................................................................... 34
3.1 Background of the study site ................................................................................................ 34
3.2 Ethical Considerations .......................................................................................................... 35
3.3 Study Design ........................................................................................................................ 35
3.4 Study Population................................................................................................................... 36
3.4.1 Inclusion Criteria .................................................................................................................. 36
3.4.2 Exclusion Criteria……………………………………………………………………………………………………………….36
3.4.3 Determination of Sample Size .............................................................................................. 36
3.5 Administration of Questionnaire .......................................................................................... 37
3.5.1 Scoring System for Section A .............................................................................................. 38
3.6 Physical Examination ........................................................................................................... 38
3.7 Laboratory Analysis ............................................................................................................. 39
3.7.1 Sample Collection................................................................................................................. 39 3.7.2 Sample Processing ................................................................................................................ 40
3.7.3 Sample Testing ..................................................................................................................... 42 3.8 Data Analysis ........................................................................................................................ 46 CHAPTER FOUR ................................................................................................................................. 50
4.0 Results .................................................................................................................................. 50 4.1 Socio-demographic Characteristics of the Patients .............................................................. 50
4.2 Test of Significance .............................................................................................................. 58 4.3 Prevalence of Anaemia ......................................................................................................... 62 CHAPTER FIVE .................................................................................................................................. 67
5.0 Discussion ............................................................................................................................. 67
5.1 Demographic Characteristics of the Patients. ....................................................................... 67
5.1.1 Age Group ............................................................................................................................ 67
5.1.2 Marital Status. ....................................................................................................................... 68
5.1.3. Socioeconomic status ........................................................................................................... 68
5.2 Prevalence of Anaemia…………………………………………………………………………………………………… 68
5.2.1. Age and Prevalence of Anaemia........................................................................................... 69
5.2.2. Anaemia and Gestational Age .............................................................................................. 70
5.2.3 Anaemia and Gravidity. ........................................................................................................ 71
5.2.4. Socioeconomic Status and Anaemia in Pregnancy ............................................................... 71
5.2.5 Parity and Anaemia in Pregnancy......................................................................................... 72 5.2.6 Malaria and Anaemia in Pregnancy ...................................................................................... 73
5.2.7 Human Immunodeficiency virus (HIV) and Anaemia in Pregnancy ................................... 73
5.2.8 Distribution by Peripheral Smear ......................................................................................... 74 5.2.9 Distribution by Haemoglobin Genotype ............................................................................... 75
5.3 Relevance of the study to Family Medicine ......................................................................... 76
CHAPTER SIX ..................................................................................................................................... 78
6.0 Conclusion and Recommendations....................................................................................... 78
6.1 Conclusion ............................................................................................................................ 78
6.2 Limitations of the study ........................................................................................................ 78
6.3. Recommendations ................................................................................................................ 79 6.4 Further research needs .......................................................................................................... 80 REFERENCES ..................................................................................................................................... 81
APPENDIXES ...................................................................................................................................... 90 Questionnaire ........................................................................................................................................ 90
Consent form…………………………………………………………………………………………………………………………………..92
Approval letter for Dissertation……………………………………………………………………………………………………….93
Letter for Ethical Approval……………………………………………………………………………………………………………….94
CHAPTER ONE 1.0 Introduction
Anaemia in pregnancy is a major health problem in the world. It contributes immensely to high prevalence of maternal and perinatal mortality, premature delivery, low birth weight, and other adverse outcomes1. In developing countries, the prevalence rate of anaemia among pregnant women is estimated to be in the range of 35% - 72% for Africa, 37%-75% for Asia and 37% - 52% for America2. Fifty-six percent of pregnant women in West African subregion are expected to have anaemia3.
Anaemia even when mild is associated with reduced productivity at work. During pregnancy, severe anaemia may result in circulatory changes that are associated with increased risk of heart failure. During labour, women with severe anaemia are less able to tolerate even moderate blood loss. Consequently they are at a higher risk of requiring blood transfusion and blood related infections like Human Immunodeficiency Virus, Hepatitis B virus etc. Furthermore, severe gestational anaemia is an important direct and indirect cause of maternal death 1. This also affect the foetus leading to intrauterine growth restriction, still birth and low birth weight4,5.
Estimation of maternal mortality resulting from anaemia range from 34 per 100,000 live births in Nigeria to as high as 194 per 100,000 live births in Pakistan2,6. The high mortality ratio in developing countries was found to be related primarily to differences in available obstetric care for women living in areas with inadequate antenatal and delivery care facilities. This is one the cardinal issue being addressed by the Millennium Development Goal (MDG) programme geared towards reduction of maternal and infant mortality rate by fifty percent in 20157.
In 1983, World Bank ranked anaemia as the eighth leading cause of disease in girls and women in developing countries8. Consequent upon this, some developing nations have worked out short and long term development programme towards improving the well being of girl child and quality of life in women. Anaemia in pregnancy, according to World Health Organisation (WHO), is defined as a pregnant woman with haemoglobin concentration below 11 gramme per decilitre (g/dl) at normal sea level. This presupposes that a different definition will be applied to pregnant women living in high altitude. Anaemia is further classified into mild anaemia (Hb =
- – 10.9 g/dl), moderate anaemia (Hb =7.0-9.9 g/dl) and severe anaemia (Hb less than 7g/dl). This is an arbitrary classification since its application varies from one region of the world to another and from developed to developing nations.
It is however very useful to have an internationally agreed cut-off points especially for the purpose of being able to compare outcome of studies conducted at different locations of the world. For the purpose of this study a WHO definition was adapted. The use of haemoglobin concentration for diagnosis of anaemia in pregnancy is preferred to packed cell volume (PCV). This is due to physiological changes in pregnancy resulting in expansion of red cell mass (1825%) and plasma volume (46-55%)9. This observation has made haematocrit to be unreliable in the diagnosis of gestational anaemia.
The pattern of anaemia in pregnancy refers to a broad picture of anaemia with reference to presentation, classification and associated factors. The most cost effective and beneficial screening method for anaemia in pregnancy depends on the local pattern. A study designed to establish the link between these variables with a view to producing a predictive value will help in initiation of health intervention. For instance, the presence of established factors associated with a class of anaemia will prompt an early intervention.
The predisposing factors have been identified to include nutritional deficiencies like iron, folate, vitamin B12, vitamin A, malarial infestation, human immunodeficiency virus, haemoglobinopathy, grandmultiparity, low socioeconomic status, late prenatal booking and inadequate child spacing5,6,.
Anaemia in pregnancy is a common health problem seen by Primary Care Physicians. The pattern of this condition varies from developed to developing countries. The reasons for variation can be attributed to many factors which include nutritional status, cultural practices, religious belief, socioeconomic factors and level of health awareness among the population.
The multifactorial aetiology of maternal anaemia demand for an assessment of the pattern which will give a broad and vivid picture of this condition. The clear perspective will guide in elucidating the scope of this health challenge plaguing the pregnant women in our environment. There are a few studies on the pattern of anaemia in pregnancy in Nigeria. Some of the studies available were carried out in tertiary healthcare centres. This then supports the need for such a study in secondary non-governmental, faith-based hospital like ours. Such studies will lead to formulation of a balanced policy that will be transformed into effective and sustainable intervention and control programmes for our pregnant women. A study of aetiological pattern of anaemia in pregnancy will bring to light the most common factors associated with maternal anaemia in our area. This will also underscore the need for further research with a view to establish a clear casual relationship.
1.1 Statement of the Problem
The present study will therefore attempt to answer the following questions:
- What is the most common class of anaemia among our pregnant women?
- Which are the common associated factors of anaemia?
Finally, the implications of the findings in Family medicine towards meeting the enormous challenges to the health of our pregnant women are discussed.
1.2 Relevance to Family Medicine
It is pertinent to note here that most women in reproductive age group visit primary and secondary health care centres. Consequently, most ante-natal needs are managed in primary and secondary health care centres. Family Physicians who are mostly at this level of health care are better placed to identify some of the risk factors of anaemia during routine clinical care. An early detection and prompt commencement of corrective measures will help to reduce the prevalence of anaemia in pregnancy.
Furthermore, an astute frontline Doctor is better equipped to offer prenatal counselling to the women in reproductive age group. This is very apt in view of the fact that most women only visit the Gynaecologist/Obstetrician when they are already pregnant. The high cost of consultation and limited number of Specialist Obstetrician vis-à-vis the pregnant women put the
Primary Care Doctor in a position to manage most of the pregnant women.
This study will attempt to identify the local pattern of anaemia which will help the Family Physician to make better assessment and recognise the factors that can predispose to anaemia in pregnancy. This will lead to giving early corrective measures and subsequent prevention of anaemia and its adverse effect to the foetus and mother.
1.3 General Objective
To determine the pattern of anaemia among pregnant women booking at ante-natal clinic of Faith Mediplex, Benin city in order to make recommendations for early diagnosis, prompt management and prevention of this condition.
1.3.1 Specific Objectives
- To determine the prevalence of anaemia among pregnant women at booking in ante-natal clinic of Faith Mediplex, Benin City.
- To assess the pattern of anaemia among pregnant women booking at ante-natal clinic in
Faith Mediplex, Benin City
To evaluate factors associated with anaemia in pregnancy.
PATTERN OF ANAEMIA AMONG PREGNANT WOMEN ATTENDING ANTENATAL CLINIC OF FAITH MEDIPLEX, BENIN CITY
