RISK FACTORS FOR ANAEMIA IN PREGNANCY IN THE RURAL AND URBAN OBSTETRIC POPULATIONS IN ANAMBRA NORTH SENATORIAL ZONE OF ANAMBRA STATE.

SUMMARY

Anaemia still constitutes a major cause of maternal morbidity and mortality in developing countries.¹ This is a challenge especially in an effort to realize the Millennium Development Goal —five (MDG 5)

The study was on the risk factors for anaemia in a rural health centre (Umunya) and an urban health centre (Court Road, Onitsha) in Anambra North senatorial zone of Anambra state, Nigeria.  It was a comparative study of the risk factors in two different socio demographic areas but operating with similar health set-up. From existing literatures on anaemia in pregnancy, definition, causes, diagnosis, the various risk factors were highlighted. The consequences and prevention were noted.

A total of four hundred and sixty-six (466) pregnant women at first booking were enrolled in the study. This was made up of two hundred and thirty nine (239) from the Comprehensive Health Centre Umunya, a rural location and two hundred and twenty-seven (227) from the Basic Health Centre. Court Road, Onitsha an urban clinic. This was a response rate of 92.1%. Statistical Package for Social Sciences, (SPSS) version 17 was used for statistical analysis. Prevalence of anaemia was 130(28%) in the whole study population. It was observed that mild anaemia was 65(13.95%), moderate anaemia was 64(13.73%) and severe anaemia was only 1(0.21%). However, in the study locations, among rural respondents the prevalence of anaemia was mild anaemia: 57(12.23%), moderate anaemia: 63(13.52%) and severe anaemia of 1(0.21%). In the urban respondents, mild anaemia was 8(1.72%), moderate anaemia was 1(0.21%) and severe anaemia was 0.0% Pearson Chi-Square test for level of anaemia in the two locations showed that there was statistical significant relationship in the prevalence of anaemia in the rural and urban locations, (p<0.05). In the rural respondents, mean heamoglobin,(HB) level was 10.11gm/dl whereas in the urban respondents, mean haemoglobin level was l2.23gm/dl.

The major risk factors identified were age of the patient at booking, hookworm infestation, malaria, lower social class, parity, gravidity, occupation of the respondents and educational status.

Better health planning and provision of more resources to the disadvantaged areas were advocated. Also there should be more health promotion, nutrient supplementation especially iron and folic acid as well as preventive health care.

TABLE OF CONTENTS

TITLE PAGE                                                                                          i

ACKNOWLEDGEMENT                                                                        ii

DEDICATION                                                                                        iii

CERTIFICATIONS                                                                                 iv-v

DECLARATION                                                                                     vi

TABLE OF CONTENTS                                                                         vii

LIST OF FIGURES                                                                           viii

APPENDIX VI                 MAP OF ANAMBRA                                   143

APPENDIX VII       QUESTIONNAIRE SCORE SAMPLE                144-147

CHAPTER ONE

                                                  INTRODUCTION

1.1 BACKGROUND OF THE PROBLEM:

Anaemia in pregnancy constitutes a major public health problem especially in developing countries.¹ Anaemia is characterized by a reduction in the concentration of haemoglobin in the blood.^1,2 It may be physiologic or pathologic. Physiologic anaemia of pregnancy results from dilution because the plasma volume expands more than erythrocyte volume. The haematocrit in pregnancy normally drops several points below its pre pregnancy level. In pathologic anaemia of pregnancy, the oxygen carrying capacity of the blood is deficient because of disordered erythrocyte production or excessive loss of erythrocytes through destruction or bleeding.

The World Health Organization defined anaemia in pregnancy as the mean minimum acceptable haemoglobin level during pregnancy;haemoglobin, Hb of 11gm/dl.³ This was further categorized as mild anaemia, Hb of (9 – 10.9)gm/dl; moderate Hb(7–8.9)gm/dl and severe anaemia Hb< 7gm/dl.⁴ In healthy pregnant women living at sea level, the range was l1-l2 gm/dl.⁴ This classification is however arbitrary.⁴ Lower values are found in developing countries where majority of women go through pregnancy with lower haemoglobin levels without any effects on both mother and child.    In Nigeria, the working definition of anaemia by health workers is haemoglobin

value <10gm/dl.⁵Anaemia can also be classified based on the haematocrit(PCV) value.⁵ The WHO ranked anaemia as the 8th leading cause of death in girls and women in the developing world.³In developing countries, the prevalence rate of anaemia in pregnant women ranged between 40% and 60% and the main cause was iron deficiency. Iron deficiency is often nutritional in origin resulting mostly from the consumption of plant based foods.³From vegetables and plants iron is obtained as non-haem iron as against haem iron from meat. Haem iron is absorbed 2-3x better than non-haem iron.³ In the Food and Agriculture Organization (FAO) Corporate Document Repository (chap 13)^3, titled “Human vitamin and mineral requirements, the roles of iron in human metabolism” were well elaborated. It noted two kinds of dietary irons: haem iron and non haem iron.³In the human diet, the primary source of haem iron is the haemoglobin from consumption of meat, poultry and fish. Sources of non-haem iron are cereals, roots, pulses, legumes, fruits and vegetables. The document noted that absorption of iron from meat sources was about 25% but could be up to 40% during deficiency of iron. Non-haem iron was observed as the main form of dietary iron. Its absorption is influenced by the individual iron status and several factors in the diet.³ Mostly plant diets have poor iron bioavailability.³ The document further noted that the enhancing factors for iron absorption are ascorbic acid and derivatives as citrus fruits, potatoes and some vegetables; others are meat, fish and other sea-foods. However, inhibiting factors are phytates and other inositol phosphates (bran products, cereal oats, rye, cocoa, nuts, and soya beans). Others are phenolic compounds such as coffee, tea, cocoa, spices, certain vegetables and most red wines.⁶In developing countries, infections can contribute to iron deficiency. The impact of diet on anaemia is attributed partly to inadequate dietary intake of iron and partly found to be secondary to malaria parasitaemia.⁷

Folate is another important factor in the formation of blood haemoglobin and its deficiency can lead to megaloblastic anaemia. Folate is a heat labile, light sensitive water soluble vitamin essential for red blood cell maturation. It is present in some natural foods such as dark green vegetables, yams, sweet potatoes, bananas, nuts, liver, eggyolk, and fish.^8,9 Unfortunately, many important and widely consumed food materials in Africa such as cassava, millet, sorghum and maize are poor sources of folic acid.⁸ The common practice of rewarming of “soup” does destroy the folic acid contained in the vegetable component of the soup. The heat labile folate when destroyed causes its deficiency.

Vanderjagt et al noted that folic acid fortification of food in several countries has been proved to reduce the incidence of neural tube defect⁷. The recommended daily intake of folic acid should be increased from 400 micrograms per day in the non-pregnant to 800 micrograms per day during pregnancy as there is a highest demand in late third trimester and in multiple pregnancies. ^8,10

Deficiency of folic acid causes megaloblastic anaemia. Folic acid and serum vit B₁₂ concentrations fall during pregnancy.^6,11 The megaloblastic anaemia which develops is due to prolonged vitaminB₁₂ and folate deficiency. The recommended intake of vitamin B₁₂ in the non-pregnant is 2.0 microgram per day but in pregnancy it is 3.0 microgram per day. Any diet with animal products will be able to supply this but strict vegetarians may have a deficient intake of vitamin B₁₂ and their diet need to be supplemented during pregnancy.^6,9 In a study in India, Patha et al observed that there was iron, folate and vitamin B₁₂ deficiency in pregnancy. The study was on iron, folate and vitamin B₁₂ stores among pregnant women in a rural area of Haryana state, India. They concluded that apart from iron and folate; vitamin B₁₂ deficiencies may play an important role in causing anaemia in pregnancy.¹² Similarly in Gombe, Northern Nigeria; Vanderjagt et al observed that themost common deficiency relating to anaemia was iron. Secondly that vitamin B₁₂ status may be a risk factor for neural tube defects and pre-eclampsia. Food assistance or supplementation was suggested. Also the author in a related study in Jos North central Nigeria advised for the addition of vitaminB₁₂ supplements to the existing regimen of folate and iron supplements currently provided to pregnant women in Nigeria.¹³This is to avert adverse maternal and foetal outcome from its deficiency.

Vitamin A plays an important role in haematopoiesis.⁹ Recently it has been suggested that vitamin A supplementation, particularly in women with low or borderline serum retinol concentration, may improve mobilization of iron stores. In most studies in subSaharan Africa, vitamin deficiencies including vitamin A are not a major issue as risk factor for anaemia in pregnancy.¹⁴However, in a study done by Van den Broek et al in South Malawi, 23% of the study population were iron deficient, 32% were deficient of both iron and one of the other macronutrient; 26% were deficient of other micronutrient only and that was mostly vitamin A.⁹So the importance of vitamin A deficiency as a risk factor for anaemia was highlighted.

1.2    Effects of malaria and hookworm on anaemia in pregnancy:

Malaria due to Plasmodium falciparum may cause severe anaemia in pregnancy. In sub- Sahara Africa, 23 million pregnant women are exposed to malaria infection annually. Women in their first and second pregnancies living in endemic areas are at a higher risk of acquiring malaria than non-pregnant women or multigravida, due to reduction of an

appropriate immune response to malaria.^14,15,16

Desai et al in their review on Infectious Disease in The Lancet similarly observed that

25million pregnant women are at risk of Plasmodium falciparum infestation every year in sub-Sahara Africa.¹⁶ The review was on epidemiology and burden of malaria in pregnancy. It stated that one in every four women had evidence of placental infection at the time of delivery. They posited that P. falciparum infection during pregnancy in Africa rarely result in fever and so remain undetected and untreated. The review explained that meta-analysis of the intervention trials suggested that successful prevention of malaria will reduce severe maternal anaemia by 38%, low birth weight by 43% and perinatal mortality by 27% among primigravidae.¹⁶ Though still poorly understood, malaria can induce iron deficiency by several mechanisms: by immobilizing iron in haemazion complexes, loss of urinary iron and reduced intestinal iron absorption during the acute illness period.¹⁴

By far the most important cause of pathological blood and iron loss in the tropics is hookworm infestation.^11,15Hookworm infestation has long been recognized among the major causes of anaemia in poor communities.¹⁵ Understanding the benefits of the management of hookworm infection in pregnancy has lagged behind the other major causes of maternal anaemia.⁷ It is acquired mainly by skin contact with contaminated soil or vegetation.¹⁷ In people whose dietary iron intake is low and whose blood iron stores are already depleted, hookworm infection can presumably give rise to iron deficiency anaemia in just few weeks especially during pregnancy when iron requirements are increased.^17,18

In the differential diagnosis of anaemia in pregnancy, Human Immunodeficiency Virus infection must now be included considering the high prevalence in developing countries. If anaemia is associated with leucopenia and thrombocytopaenia, the antenatal health worker should be alerted to the possibility of Acquired Immune Deficiency Syndrome.

Transmission of Human Immunodeficiency Virus infection by blood transfusion is possible in resource poor countries; where there is high prevalence of Human

Immunodeficiency Virus positivity among donors and where the ability to screen for Human Immunodeficiency Virus is sub-optimal.¹²

Behavioural risk factors mainly involve dietary pattern, health seeking behaviours and cultural risk factors. Pregnancy is recognized as a special event in a woman’s life by most societies and often dietary restrictions imposed on women. These may include food taboos which are culturally defined and may adversely affect the health of women during pregnancy. A woman’s health decision making is influenced by her own perception of pregnancy and her health status. The health perception reflects her cultural background, status and woman’s role within the family and community.¹⁹In some societies, pregnant women are expected to carry out their daily activities as in nonpregnant state. So some pregnant women may not differentiate signs of malaria from those of pregnancy. Also pregnancy complications may make women not attend antenatal clinics. The husband may limit her mobility and autonomy or even finances in seeking for treatment. Also poor education may increase the risk of anaemia in

pregnant women. ^20,21

There are some socio-cultural factors that expose pregnant women to risks of anaemia. In some settings only young children sleep under bed nets. In polygamous families, the favorite wife may receive better care and protection.^21,22,23  Lack of income may hamper a pregnant woman accessing a bed-netor antenatal care. ^21,24 All these increased the risk of malaria and anaemia in pregnancy.

Anaemia is a global public health problem affecting both developing and developed countries with major consequences on human health as well as social and economic development. Iron deficiency anaemia accounts for half of the cases of anaemia in pregnancy; they may have deficient body iron stores without frank anaemia. Folate deficiency and other causes account for the major proportion of the remaining anaemia.²⁵The unacceptably high level of anaemia in developing countries could be an underestimate. The reason is that data from rural areas is still lacking. Also the actual prevalence rates for many individual countries are not known and there are few community based studies.²¹From these findings, the present study became imperative to help reduce the global problem of anaemia.

1.3   Effects of anaemia on the pregnant woman and the foetus

The growth of the foetus and placental blood circulation in pregnancy lead to increased demand for nutrients. Most common ones are iron and folic acid. In the developing countries, the extra requirements of these nutrients are even higher than usual as

majority of these pregnant women start pregnancy with depleted stores.^13,14

During pregnancy the total iron needed is estimated at about l000mg .^13,14 The daily requirements of iron and folate are six times greater for a woman in the last trimester of pregnancy than a non-pregnant woman.^13,14 Diet alone cannot supply this need but is derived at least partially from maternal reserves. In a well-nourished woman about half the total requirement of iron may come from iron stores. Anaemia results in the presence of already low reserves from malnutrition and or frequent pregnancies. Even when food intake is adequate, it is estimated that it takes about two years to replenish body iron stores after a pregnancy.^4,13 In pregnancy, the early stages of anaemia are often symptomless. Symptoms start as the haemoglobin concentration falls and oxygen supply to vital organs declines. The expectant mother then starts to complain of generalized weakness, tiredness and headaches. Pallor of the skin, mucous membrane, nail beds, and tongue may not be noticeable until haemoglobin drops to about

7.Ogm/dl.^13,18 With further drop in Hb concentration to about 4.Ogm/dl most body tissues become starved of oxygenand the effect is most marked on the heart muscles, which may even fail. Death from anaemia may result from heart failure, shock, or infection. The infection is a consequence of impaired resistance to disease in the

patient.^13,18 Women with mild anaemia in pregnancy have decreased work capacity. If their work involves manual labour, they may be unable to earn a livelihood. Those with chronic mild anaemia may go through pregnancy and labour without any adverse consequences since they are well compensated.^26,27,28 Available data from India and elsewhere showed that women with haemoglobin below 8gm/dl tend to have higher maternal morbidity²⁸. Premature birth, lower birth weight and perinatal mortality are higher in moderate anaemia. These women may not be able to bear even small blood loss through pregnancy.²⁹ Antepartum and postpartum hemorrhage, pregnancy induced hypertension and sepsis can lead to substantial proportion of maternal deaths in women with moderate anaemia. There is diminished resistance to infection especially during puerperium. Staphylococcal infections are common and latent tuberculosis may be overwhelming.³⁰ Puerperal sepsis is more common in anaemic women and minor infections of the urinary tract may prove fatal.³¹

In a review article a decline in the immune status of pregnant women was noted. The review showed that there was a fall in T and B-cell count with fall in haemoglobin levels

below 11gm/dl. However the humoral immunity as assessed by response to immunogens including tetanus toxoid remains unchanged.²⁸It was also observed that different types of de-compensation occur with varying degrees of anaemia. The studies suggested that with maternal haemoglobin below 11gm/dl, peri-natal mortality rate significantly rises.^29,30 Further, report showed that when maternal haemoglobin levels fall below 8.0gm/dl, there will be an increase in prematurity rate and intrauterine growth restriction leading to increased low birth weight in infant.^29,30A fall in maternal haemoglobin below 11.0gm/dl is associated with a significant rise in perinatal mortality rate. It was further observed that there was usually a 2 to 3 fold increase in perinatal mortality rate when maternal haemoglobin levels fall below 8.0gm/dl and 8 to 10 fold increase when maternal haemoglobin levels fall below 5gm/dl. Also it was noted in that report, that maternal anaemia in pregnancy, will result in substantial proportion of the infants becoming anaemic by six months of extra uterine life.^31,32 The reason adduced was that as neonates these newborns have low iron stores and also their anaemic mothers have low iron content in breast milk.²²

Viteri cited studies in industrialized world which found higher rates of foetal deaths and abnormalities, premature deaths, and low birth weight among newborns of anaemic mother.²⁹ He further corroborated this in a study in Nigeria where low birth weight (<2000g) reduced from 50% to 7% and perinatal mortality dropped from 38% to 4% by successful treatment of anaemia with iron and folic acid.²⁹

Less severe anaemia in pregnancy may contribute to maternal death from other causes especially haemorrhage. Anaemic mothers do not tolerate blood loss as healthy mothers. A healthy mother during delivery can tolerate up to one litre of blood loss whereas a loss of as little as 200mls can be fatal in an anaemic mother.²⁹

There are several risk factors for anaemia in pregnancy, and they include physiological factors e.g. (a) Changes in pregnancy, age, ethnicity, and gravidity (b) nutritional factors which include iron and folate deficiencies, vitamin B₁₂ and vitamin A deficiencies (c) infections- malaria, hookworm and lately Acquired Immune deficiency Syndrome (d) behavioral factors/health seeking behaviour. (e) Socio-cultural, environmental and seasonality factor.⁸ Other risk factors were vitamin B₁₂ deficiency, poor dietary intake, poor intake of both iron and folate, poor bioavailability of iron from the stable diet and chronic blood loss due to infection such as malaria and hookworm.^33,35Breast feeding is also an important stress factor on the nutritional status of the mother. These factors reduce the micro-nutrient stores of the mother. She becomes anaemic resulting in a more severe outcome for both the mother and the child.³³

1.4   Estimation of anaemia in pregnancy

The World Health Organization, (WHO) introduced the Haemoglobin colour scale estimation.TaIiquist scale is a type. It can be used to do simple test for haemoglobin estimation in poor resource areas.

Abia in a study on maternal anaemia in pregnant women found the Sahli’s

haemoglobinometer to be very useful in rural, low resource settings³⁴.

Reduction of the prevalence of anaemia in pregnancy is a key component of safe motherhood. This work on the risk factors for anaemia in pregnancy in urban and rural areas in Anambra North Senatorial zone of Anambra state  is hoped to improve the quality of antenatal care in developing countries.

1.5   STATEMENT OF THE PROBLEM AND PROBLEM ANALYSIS

The problem of anaemia in pregnancy is not yet fully appreciated especially as it is influenced by socio-economic status in many localities³⁵. The risk factors in urban and rural communities are expected to vary.^26,35 This is in view of the different socioeconomic status and background of the women. So what are these different and varying risk factors and their influence on anaemia in pregnancy? These includes: standard of living, cultural practices, and access tohealth information. Others are health care facilities available, age, malaria and hookworm infestations, gravidity and parity. The impacts of these factors differ in urban and rural communities. So anaemia may vary with different determinants and problems in both rural and urban obstetric populations. Information available showed that a comparative study of the risk factors for anaemia in pregnancy in these communities and relating it to their socio-economic status has not been done in the area of study.  Therefore this study is necessary to throw more light on these problems. The study will highlight thekey risk factors, and those more at risk in the study population, thus ensuring better care during subsequent antenatal

clinic visits.

The knowledge derived from this study will help in identifying the target population with the highest risk of anaemia in pregnancy. Also it will provide basis for health planning towards the reduction and if possible elimination of anaemia in pregnancy.

1.6        RELEVANCE OR JUSTIFICATION FOR THE STUDY

The maternal mortality rate in Nigeria is high requiring far-reaching policy measures to tackle it. Anaemia is a leading cause of maternal mortality in Nigeria and is often much more pronounced amongst the low socio-economic group.⁵ Anaemia is often easily preventable hence the importance of the study to reduce the problem. Cultural practices and standards of living differ from community to community; as a result, anaemia in pregnancy may present with different features in different communities. Therefore it is desirable to carry out the study of anaemia in various zones of the country. Most of the published data on anaemia in pregnancy and its risk factors are from other parts of the country while no such comparative study has been done in Anambra North senatorial zone of Anambra State. This study will therefore highlight the magnitude of anaemia and its determinants in both the rural and urban obstetric populations in the area and our environment. It is hoped that this study would encourage early screening for anaemia and preventive measures to reduce the incidence.

Finally, this study is expected to rekindle the interest of doctors, the general populace and policy makers on the various risk factors for anaemia in pregnancy in the rural and urban environments. The differences if any would be noted and various approaches at reducing themworked out. This will lead to a healthy outcome for both mother and child.

1.7     AIM AND OBJECTIVES.

AIM.To determine the risk factors for anaemia in pregnancy and compare these in urban and rural pregnant women.

OBJECTIVES

1. To determine the socio-demographic characteristics of the obstetricpopulation at the

Comprehensive Health Centre (NAUTH, Annex) Umunya and the PHC Basic Health Centre, Onitsha.

2. To determine the mean haemoglobin levels of pregnant women at first booking.
3. To establish the risk factors for anaemia in pregnancy separately in urban and rural obstetric populations and relate them to their socio economic status.

RISK FACTORS FOR ANAEMIA IN PREGNANCY IN THE RURAL AND URBAN OBSTETRIC POPULATIONS IN ANAMBRA NORTH SENATORIAL ZONE OF ANAMBRA STATE.