Journal of Clinical Sciences

ORIGINAL RESEARCH REPORT
Year
: 2022  |  Volume : 19  |  Issue : 4  |  Page : 123--129

Anemia in pregnancy: Prevalence among clients attending antenatal clinics in Chikun LGA, Kaduna, Nigeria


Bilkisu Nwankwo1, Sarah Joseph2, Nafisat Ohunene Usman1, Adegboyega Moses Oyefabi1,  
1 Department of Community Medicine, Kaduna State University, Kaduna, Kaduna State, Nigeria
2 Department of Internal Medicine, Barau Dikko Teaching Hospital, Kaduna, Kaduna State, Nigeria

Correspondence Address:
Dr. Bilkisu Nwankwo
Department of Community Medicine, College of Medicine, Kaduna State University, Kaduna, Kaduna State
Nigeria

Abstract

Background: Despite concerted global efforts to reduce the burden of maternal anemia, it remains a major public health issue. Over 40% of pregnant women worldwide are anemic; low- and middle-income countries (especially those in sub-Saharan Africa) make a disproportionately higher contribution to the global burden. The condition can lead to undesirable outcomes for the mother and child. This study was conducted to determine the prevalence of anemia in pregnancy among women attending antenatal clinics in Chikun LGA, Kaduna. Methods: This study was conducted among 145 women attending antenatal clinics in Chikun LGA. Data were collected using a pretested, semi-structured interviewer-administered questionnaire. Hemoglobin (Hb) level was determined and anemia was defined using the World Health Organization-recommended cutoff of <11 g/dl. The results were presented in frequency tables. Data were analyzed using IBM SPSS Statistics version 26. Statistical significance was set at P < 0.05. Results: Fifty-five (37.9%) of the respondents were between the ages of 25 and 29 years. The mean age of the respondents was 28.61 ± 5.5 years. The majority, 107 (73.8%), had a household size of 2–4. Only 16 (11.0%) respondents were aware of anemia. Pregnant women were identified by half (50.0%) of the respondents as being more at risk of anemia. Only a quarter (25.0%) of respondents had good knowledge of anemia. Over two-fifth (42.8%) of the respondents were anemic. There was a statistically significant relationship between household size and anemia in respondents. Conclusion: A large proportion of the respondents were anemic; this underscores the need to strengthen the nutritional counseling and routine hematinics given during the antenatal period. Social drivers should also be addressed in terms of favorable public policies.



How to cite this article:
Nwankwo B, Joseph S, Usman NO, Oyefabi AM. Anemia in pregnancy: Prevalence among clients attending antenatal clinics in Chikun LGA, Kaduna, Nigeria.J Clin Sci 2022;19:123-129


How to cite this URL:
Nwankwo B, Joseph S, Usman NO, Oyefabi AM. Anemia in pregnancy: Prevalence among clients attending antenatal clinics in Chikun LGA, Kaduna, Nigeria. J Clin Sci [serial online] 2022 [cited 2022 Nov 30 ];19:123-129
Available from: https://www.jcsjournal.org/text.asp?2022/19/4/123/360620


Full Text



 Introduction



Despite concerted global efforts to reduce the burden of maternal anemia, it remains a major public health issue. Over 40% of pregnant women worldwide are anemic; low- and middle-income countries (especially those in sub-Saharan Africa) make a disproportionately higher contribution to the global burden.[1] The prevalence of anemia in pregnancy is highest in Africa (44.6%), followed by Asia (39.3%), and the lowest prevalence is in North America (17.0%).[2] In Nigeria, the prevalence is 61.1%, but the prevalence varies according to region.[3] Anemia in pregnancy occurs when the hemoglobin (Hb) concentration is <11 g/dl.[4] There are several causes of anemia in pregnancy ranging from poor micronutrient intake, excess blood loss, and infective causes. Research shows that nutritional deficiencies (such as iron deficiency) are the most common cause.[5] In pregnancy, the condition can lead to undesirable outcomes for the mother (postpartum hemorrhage, infections, spontaneous abortion, and mortality) and child (intrauterine growth restriction, low birth weight, and perinatal mortality).[6] Research has shown that iron-deficiency anemia in pregnancy could affect the developing fetal brain leading to abnormal brain structure, poor cognition, autism, poor memory, and schizophrenia.[7] Folic acid deficiency is linked to Neural Tube Defects (NTD).[6] The effects of this condition reach far beyond the direct medical outcomes; it could cause or worsen economic hardships, and greatly impact on the psychological and emotional well-being of the patient's family.[8] Against this backdrop, the World Health Organization (WHO) recommends that pregnant women are routinely screened during antenatal care (ANC) visits and given daily iron and folate supplementation.[9]

A complex interrelationship of sociocultural, economic, environmental, and personal factors has led to the higher prevalence of maternal anemia in developing countries. Due to the dynamic nature of these factors as well as the emergence of new public health challenges, the control of this condition remains an uphill task.[10] As a result of the link between anemia and morbidity and mortality (especially in vulnerable groups). Its prevalence has been found to be an indicator of the health of a population.[11] Anemia in pregnancy is associated with higher rates of preterm deliveries, small for gestational age babies, low birth weight, perinatal deaths, and maternal mortality.[11],[12] A study using WHO multicounty survey data showed that severe anemia during pregnancy or postpartum doubled the risk of maternal mortality.[13] Unremarkable progress has been made toward achieving the Sustainable Development Goal (SDG) of halving the prevalence of anemia in women of reproductive age by 2030.[14]

Nigeria is the most populous nation in Africa with about 40% of the population living below the poverty line.[15] Women (especially those in rural areas) are routinely disenfranchised and lack financial and decision-making autonomy.[16] As a corollary, they are not in control of dietary diversity in the household or food allocation.[17] Northern Nigeria has poor maternal and child health indices as well as poor uptake of many evidence-based life-saving resources.[18],[19] Malnutrition in women of reproductive age and children aged <5 years is more prevalent in this region than in the southern parts of the country. However, there is a paucity of information on anemia in pregnancy in this region. Assessing the prevalence of anemia in pregnancy and its determinants is required for effective prevention strategies which will go a long way in attaining the SDG target of reducing anemia in women of reproductive age by half by 2030.[20] Therefore, this study was conducted to determine the prevalence of anemia in pregnancy among clients of primary health facilities in Chikun LGA, in Kaduna State.

 Methods



Chikun LGA is located in the southern part of Kaduna state. It shares boundaries in the south with Kachia, in the east with Kajuru, in the south-east with Kaduna south, in the north-east with Igabi,in the north-west with Birnin Gwari and in the west with Niger state. The area has an estimated population of 372,272 from the 2006 National Population Census which consists of 187,433 males and 184,839 females and a projected population of 502,500 in 2016. The LGA has 12 wards.[21] The major ethnic group is Gbagyi, however, the area is ethnically diverse and has tribes from all over the country. Islam and Christianity are the most widely practiced religions in the area. There are six secondary health facilities, of which three are privately owned; there are also 121 primary health facilities; 52 are government owned, while 69 are privately owned. Of the 52, 12 are PHCs while the remaining 40 are health posts. Each of the 12 wards has one PHC.[22] Four wards were excluded from this study due to difficulty in accessing them as a result of insecurity. Antenatal booking clinics are held on Tuesdays, while antenatal follow-up clinics are run on Wednesdays in all public PHCs.

Study design

The study was a descriptive cross-sectional study.

Study population

Pregnant women attending antenatal care (ANC) clinics in Chikun LGA were enrolled in the study.

Inclusion criteria

Pregnant women attending antenatal booking clinic in primary health-care centers in Chikun LGA were included in the study.

Exclusion criteria

The exclusion criteria of this study were as follows:

Pregnant women who presented to the booking clinic very ill/with complicationsPregnant women who were recently transfused or had received blood transfusions in the index pregnancyPregnant women who had hemoglobinopathies, had early pregnancy bleeding or antepartum hemorrhage, and were already receiving treatment for anemia in pregnancy before their booking visit.

Sample size determination

The sample size was determined using the formula:[23]

n = z2pqd2

where:

n = minimum sample size required.

z = standard normal deviate at 95% confidence level.

z = 1.96

P = prevalence of anemia from a previous study 90.5% (0.905)[24]

q = complementary probability of prevalence of anemia which is 1 − P = 0.095

d = degree of accuracy desired at 95% confidence interval, =0.05

n = 1.962 × 0.905 × 0.095/0.052

n = 132.1

nonresponse rate 10%=13.2

n = 132.1 + 13.2 = 145.3

n = 145.

Sampling technique

A multistage sampling technique was employed.

Stage 1

Four PHCs out of eight were selected using simple random sampling (Narayi, Sabon Tasha, Nassarawa, and Yelwa). Average antenatal visits/month were obtained from the records in the PHCs. Using the probability proportional to size approach, the sample size for each of the facilities was determined.

Formula: Sample size x stratum size/population size

Sample size = 145

Stratum size = average number of women who attend booking clinic/month in a selected PHC

Population size = average number of women attending booking clinic/month in four selected PHCs (88)

Narayi: 145 × 16/88 = 26.3, ≅ 26 women

Sabon Tasha: 145 × 44/88 = 72.5, ≅ 73 women

Yelwa: 145 × 8/88 = 13.1, ≅ 13 women

Nassarawa: 145 × 20/88 = 32.9, ≅ 33 women

Therefore, 26, 73, 13, and 33 women were recruited into the study from Narayi, Sabon Tasha, Yelwa, and Nassarawa PHCs, respectively.

Stage 2

A systematic sampling technique was used to select women who met the inclusion criteria. Using the average monthly attendance (88) at the PHCs as the sampling frame and the sample size for each facility obtained above, the sampling interval of three was obtained for Narayi and Nassarawa, while one and seven were obtained for Yelwa and Sabon-Tasha respectively. The first respondent was randomly selected. Subsequently, the sampling interval was added to the preceding respondent until the required sample size was achieved.

Data collection

A pretested, semi-structured, interviewer-administered questionnaire was used to collect the data. The questionnaire was developed after reviewing previous studies.[4],[11],[19]

The questionnaire had four sections:

Section A obtained sociodemographic information of the respondents. Some questions asked here include age, marital status, educational level, income level, religion, tribe, occupation, and household sizeSection B assessed obstetric and past medical historySection C obtained information on history of current pregnancySection D assessed respondents' knowledge on anemia.

The questionnaire was pretested in PHC Kabala Doki which was a similar community to the study area. Seven women were recruited in the pretest (that is 5% of the sample size). Adjustments were made based on observations made during the pretest.

Venous blood was collected from the respondents using disposable syringes into ethylenediaminetetraacetic acid (EDTA) bottles. Capillary tubes were filled three-quarter way with blood from the EDTA bottles. The capillary tubes, labeled with the names of the participants, were sealed at one end with a flame and spined in the hematocrit machine. The packed cell volume (PCV) was read using an hematocrit reader.

Data analysis

Collected data were cleaned and analyzed using the Statistical Package for the Social Sciences (SPSS) version 26 (Armonk, NY: IBM Corp.) and presented in frequency tables. Variables were tabulated using frequencies and percentages. Chi-square and Fisher's exact tests were used to test for associations.

Measurement of indicators

Knowledge

Knowledge of the study participants about anemia was assessed using 28 questions covering areas such as causes, symptoms, complications, and prevention. Each correct answer was given a score of 1, while a wrong answer was given a score of 0. Responses of “don't know” and incorrect responses were considered the respondent being unaware of the subject, while correct responses were considered being aware of the subject. Participants who had a total score of 0–8 were considered to have low knowledge, those with a total score of 9–18 were considered to have fair knowledge, while those having a total score of 19–28 were considered to have high knowledge of anemia.

Prevalence

This study used the WHO classification of anemia in pregnancy. The PCV was converted to g/dL. It is defined as the Hb <11 g/dL while mild, moderate, and severe anemia were based on Hb measurements of 10.0–10.9 g/dL, 7.0–9.9 g/dL, and <7.0 g/dL, respectively.[25] These criteria were used in this study.

Ethical consideration

Ethical approval was obtained from the Ethical Committee of Barau Dikko Teaching Hospital, Kaduna (NHREC/30/11/21A). Permission was sought and obtained from the heads of the PHCs. Information about the study was provided to each participant, and the anonymity, confidentiality of their responses, and voluntary participation were emphasized, following which informed consent was obtained from each participant.

 Results



[Table 1] shows that 55 (37.9%) of the respondents were between the ages of 25 and 29 years. The mean age of the respondents was 28.6 ± 5.5 years; majority, 107 (73.8), had a household size of 2–4, and 112 (77.2%) of them had an average household monthly income of over ₦50,000. [Table 2] shows that over half, 81 (55.9%), of the respondents had parity between 1 and 4 and a little above a third, 56 (38.6%), had their last childbirth more than 3 years ago. The gestational age of majority of the respondents, 122 (84.1%), was 4–6 months while almost two-thirds, 89 (61.4%), were on hematinics. Only 16 (11%) respondents were aware of anemia [Table 3]. Half of the respondents (50%) had health workers as their source of information. Less than half (43.8%) defined anemia correctly, while half (50%) identified pregnant women as being more at risk of anemia. Only a quarter (25.0%) of respondents had good knowledge of anemia. Almost half (42.8%) of the respondents were anemic, 23.5% were mildly anemic, while 19.3% were moderately anemic [Table 4]. There was a statistically significant relationship between household size and anemia in respondents [Table 5].{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}

 Discussion



ANC is an evidence-based public health intervention aimed at improving health outcomes in pregnancy.[19] Over three-quarters of the respondents in this study booked for ANC between 4 and 6 months. Comparative findings were obtained from a study in Cross River State where 79.8% of the respondents booked for ANC between 4 and 6 months.[26] The findings from this study were similar to studies carried out in Ibadan and Zaria where the median gestational age at booking was 4 months and 5 months, respectively.[24],[25],[27],[28] This similarity could be attributed to the fact that there has been widespread information about the importance of ANC as well as the fact that the health centers are accessible to the clients in these regions. However, booking is still later than recommended likely due to lack of awareness of the ideal timing for booking. The recommendation by the WHO is that pregnant women should book for ANC ≤12 weeks while subsequent contacts should take place at 20, 26, 30, 34, 36, 38, and 40 weeks' gestation.[29] Antenatal care is the entry point for a woman to access a wide range of services during pregnancy. Early initiation of ANC and the increase to eight visits is associated with improved maternal and fetal health outcomes.[30]

Almost two-thirds of the respondents were taking hematinics. This finding was lower than that in a study carried out in Jos and Ibadan where 89.3% and 97%, respectively, were taking hematinics.[31],[32] The disparity could be attributed to the fact that the respondents in the other studies were recruited during routine ANC visits, but the respondents in this study were recruited during booking when hematinics had not been prescribed. Those who were on the drugs prior to booking were likely multiparous women who knew the drugs to take. Prophylactic hematinics are crucial to the health of the mother and child due to the higher physiological requirement for iron and folic acid.[33]

Only about a quarter of the respondents had good knowledge of anemia. This finding differs from those in studies carried out in Uganda and India where 45.1% and 45.4%, respectively, had good knowledge of anemia.[34],[35] The disparity could be attributed to the widespread awareness campaigns about anemia in pregnancy in those countries.[34],[35] Knowledge of anemia, especially during the pregnancy period, could lead to improved uptake of hematinics which will aid in the prevention of anemia.[4] Adequate health knowledge has been found to be a key predictor of adopting desired health behavior.[36]

Over 40% of the respondents had between mild and moderate anemia. This finding is lower than that obtained from a study carried out in Uyo, where 54.5% of the respondents were anemic.[37] This difference could be due to the fact that only about a third of the respondents had a febrille illness in this index pregnancy while the prevalence of febrille illness in the Uyo study was almost half.[37] Febrile illness could be seen as proxy for malaria which is the most common febrile illness in the country (a known cause of anemia in pregnancy). Febrile illness could negatively affect the mother and her unborn child, causing abortion, preterm labor, stillbirth, and maternal mortality.[38] Anemia in pregnancy could also lead to a host of problems for both the mother and her child. The negative pregnancy outcomes could have far-reaching effects; extending beyond the pregnant woman to her family and society at large.[5]

There was a statistically significant relationship between size of the respondent's household and presence of anemia. This is similar to studies in Uganda and Ethiopia where large household size was found to be a predictor of anemia.[34],[39] This relationship exists due to the high level of poverty in sub-Saharan Africa, leading to household food insecurity.[40] Limited resources are expected to cater to large families. When the household meal is shared, the head of the household (typically male) is given preference over women and children.[41] This practice pervades this region due to the fact that women are denied agency over themselves. As such, decisions involving them and their needs are taken by male members of the household. This puts them at a disadvantage and perpetuates the cycle of vulnerability.[42]

 Conclusion



The study found that over 40% of the respondents were anemic and this was associated with family size. About a third of them had a febrile illness during the pregnancy. These findings underscore the importance ANC where the respondents will be treated for the underlying cause and giving prophylactic agents to prevent future occurrences. Health-care workers should organize outreach to enlighten the communities they serve on anemia in pregnancy and the negative health outcomes that could possibly be associated with it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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