incidence and factors of anemia among women attending...

Ribat UniversityThe National

Faculty of Nursing

of Anemia among Women and factors Incidence

Attending Delivery in River Nile State Sudan

fulfillment for the requirement of the award of M.Sc. researchA thesis submitted in

Ribat -degree in obstetric and gynecological nursing, faculty of nursing at AL

university

By:

Sulaiman rFaiza Abd Elrazig Elnazi Khartoum High nursing Collage 1985) -(diploma of nursing

Shendi University2004) -(B. Sc. Of nursing

Supervisor:

Abd Elrahman Khalid Abd Allah

PROF. ssociatedA -Md. Of Obstetrics and Gynecology Khartoum University 1996

Ribat University.-Faculty of Medicine At Al

(February 2015)

اىطـي بطـخ اشثــبعخ

ويخ ازشيغ

بيــــه السيــذات فــــي حالة الىالدة وعىامله حـــذوث فقـــر الـــــذم

بمستشفيات والية وهــــر الىيـــل، السىدانــــي ــــىي عـــــــــشط اسظــشـ ثـسـثـيــب اسعــــــــــــــــبــــــخ مذــــخ إيـــــفبء

اـــبخغزيش فــــــــي رــــــــشيغ اـغــــــبء وازـــــىيـــذدسخــــــخ

:خاطبج

عيب فبئضح عجذ اشاصق ازيش

1891 ويخ ازشيغ اعبي/ اخشطى -دثى ازشيغ اعبي

2002اعبي خبعخ شذي ازشيغثىبىسيىط

إشـــــــــــشاف:

د. عجذ اشز خبذ عجذ هللا

شبسن أــشاع اغــبء واــــزىيذأعـــزبر

خــــــــبعخ اــــــشثبط اـــىطـــــي

اطــــــــــتوــيخ

2011فجشايش

Dedication

To the soul of my darling father..

To my great mother, brothers and sisters..

To my lovely kids: Ahmed, Sara, Abdel Raziq, ElHaj and Khalid..

I dedicate this work with love and gratitude

Acknowledgements

Firstly, my thanks are due to God for bless and guidance for this work to

be established. I would like to express my deep appreciations and sincere

thanks to my advisor: Doctor. AbdelRahman Khalid, director of obstetric and

gynecology department, Faculty of Nursing, AlRibat University for keen

supervision, patient guidance and close follow for the present study. My

appreciations are due to my co-advisor, Dr. Hashim Gasim, Senior

obstitrition, ElShorta Hospital, Atbara for his close follow up. Also I would

like to thank Mr. AbdelBagi Sheikh Eldin for his great help in data analysis.

Special appreciations are extended to my colleagues in Shendi Teaching

Hospital, ElMc Nimir University Hospital, ElDamer Hospital, ElShorta

Hospital , Atbara Teaching Hospital and Berber Hospital for their technical

help and keen encouragement. Faithful appreciations are due to professor

AlBadri Mohamed ElAmin, President of ElSheikh AlBadri University and Dr.

Khalid Mohamed Taha, Director of Atbara Veterinary Research Laboratory

for their valuable help and keen care.

I would like to thank my children: Sara, Ahmed, Abdel Razig and ElHaj

for their efforts in printing this manuscript. Finally, I express my

appreciations to all women subjected to the study for their collaborative

behavior in filling the questionnaire.

Abstract

Introduction: Anemia is most common medical disorder in pregnancy and

post partum period. The term anemia describes condition in which

hemoglobin concentration less than 11 gm according to WHO estimation.

Folic acid and B12 play an important role in HB synthesis and can in

dependently affecting DNA synthesis .vitamin A and C also contributing to

the absorption and utilization of dietary iron. Blood loss during pregnancy

also consider to be a same causes of anemia with pregnancy and Post-

partum, ectopic pregnancy abortion.

Methods: This was a descriptive hospital based study conducted in six

governmental hospitals in River Nile State.

The study aimed to estimate the incidence and factors of anemia among women

attending delivery during the period from July 2013 to July 2014.

A total of 308 cases had been tested for hemoglobin estimation from whole

blood. Accompanied questionnaire was filled by the targeted cases seeking data

about age, social status, level of academic study and health status. Data

analyzed using Statistical Package for Social Studies (SPSS).

Result: The study revealed that 198 (64.3%) of the study population were

anemic, while 110 (35.7%) revealed normal ranges of hemoglobin

concentration. Pregnant women who use tonics and cared with ante-natal

medical follow up were significantly protected against anemia (P-value ˂ 0.05).

Accordingly, the study strongly recommends the use of tonics and regular

medical follow up for pregnant women. Also the investigator suggests the

addition of iron supplements to the bread of pregnants.

الذراسة ملخص

افبط . طجيخ في اس وفزشحأوجش اشبو ا فمش اذ

خشا عي زغت مبييظ هيئخ اظسخ اعبيخ. 11 يعي رشويض اذ أل فمش اذظطر

شهب عي اسغ اىوي وب ثو أ يعجب دوسا هبب في اهيىغىثي 12ـزغ افىيه و فبيزي ث

ذ في اغزاء.وعبدخ اسذي االزظبصفي ي )أ( و )ج(و فبيزيغبعذ

غجت فمش اذ في اىالدح وب ثعذهب , و أعجبة فمذ اس خبسج اذ ازي يفزمذ أثبء اس ي

.اخاإلخهبع ...... و اشز

ولذ هذفذ إي زذوس , اذساعخ عي وطف اغذ غزشفيبد اسىىيخ ثىاليخ هش اي اسرىضد

شذ , 3102 إي يىيى3102وعىا فمش اذ ثي اغيذاد في زبخ اىالدح في فزش يىيى

زبخ. 216عذد هيىغىثياذساعخ فسض عيبد اذ

ظبزت اسبالد سظش اىػع االخزبعي , اعزجيب اعزبسحر خالي اذساعخ ء

ر إخشاء رسي اجيببد ع طشيك ثشبح اسضخ , و اظسي سبالد ازعيي,اعش و اىػع

. اإلزظبئيخ عى االخزبعيخ

يذاد االئي ( ثسبخ طجيعيخ و اغ23.5) 001و اذ %( ثفمش 4242بئح اذساعخ إطبثخ ) وشفذ ز

وازي وبذ واليب في فزشح اس اذوسيخ يغزخذ زجىة اسذيذ وزغ افىيه ع ازبثعخ اطجيخ

فمش اذ.

ازبثعخ اطجيخ سىا زدت فمش اذ واعزعبي زجىة اسذيذ وزغ ثأهيخاذساعخ أوطذ

إػبفخ عظش اسذيذ خجض اسىا. الزشاذافىيه ع

Table of contents

Dedication…………………………………………………………..…I

Acknowledgements……………………………………………………II

Arabic abstract………………………………………………….…….III

English abstract………………………………………………………VI

Chapter one

1 Introduction

1.1 Justifications

1.2 Objectives

1.2.1 General objectives

1.2.2 Specific objectives

Chapter two

2.1 Literature review

List of Tables

1. Incidence of anemia among study population……………….24

2. Anemia incidence and Living area ………….………………25

3. Anemia incidence and age group…………………………….26

4. Anemia incidence and years of education …………………..27

5. Anemia incidence and work status……………………..........28

6. Anemia incidence and family members……………………...29

7. Anemia incidence and numbers of pregnancies……………..30

8. Anemia incidence and use of iron……………………….......31

9. Anemia incidence and visit to health facility………………..32

10. Anemia incidence and type of foods………………………..33

11. Anemia incidence and fatigue among the study population..34

12. Anemia incidence and poor appetite among the study

population………………………………………………...….35

13. Anemia incidence and repeated infection ………………..…36

Table of contents

Dedication…………………………………………………………..…I

Acknowledgements……………………………………………………II

Arabic abstract………………………………………………….…….III

English abstract………………………………………………………VI

Chapter one……………………………………………………....…….1

1 Introduction………………………………………………..….……..2

1.3 Justifications………………………………………….….….……..3

1.4 Objectives………………………………………………….………4

1.4.1 General objectives……………………………….…………..4

1.4.2 Specific objectives……………………………….…………..4

Chapter two………………………………………………..…………..5

2 Literature review……………………………………………………6

2. 1 Hematological changes during pregnancy……….….…………6

2.1.1 Blood volume…………………………………………………6

2.1.2 Hemoglobin concentration…………………………………...8

2.1.3 Iron metabolism………………………………………………8

2.2 Epidemiology of anemia………………………………….…….9

2.3 Grades of anemia………………………………………………11

2.4 the complex risk factors associated with anemia……………..12

2.4.1 Poor maternal nutrition and micronutrient deficiency…….....12

2.4.2 intestinal Heminths……………………………………………14

2.4.3 Obesity…………………………………………………...…...14

2.4.4 Low income……………………………………………….......15

2.5 Consequences of anemia……………………………………......16

2.6 Effect of anemia on mothers………...……………………..…...16

2.6.1 effect of anemia on maternal morbidity and mortality..….......16

2.6.2 Performance during delivery………………………………….18

2.6.3 Lactation performance………………………………………..18

2.6.4 Working capacity and general wellbeing……………………..19

2.6.5 Immunity status………………………………………….…....19

Chapter three…………………………………………………….….20

3 Methodology……………………………………………………..21

3.1 Research design………………………………………………......21

3.2 Study area…………………………………………………….…..21

3.3 Study population ………………………………………………...21

3.4 Sample …………………………………………………………...21

3.5 Data collection ………………………………………………..…21

3.6 Data analysis………………………………………………..……21

3.7 Pilot study……………………………………………..….……...22

3.8 Limitation of the study…………………………………..………22

Chapter four……………………………………………………..……...23

4 Results…………………………………………………………..…..23

Chapter five………………………………………………………….….37

5 Discussion and Findings……………………………….………...…37

Chapter six…………..………………………………………………..…47

6 Conclusion and Recommendations…………………………………47

6.1 Conclusion…………………………………………….………….48

6.2 Recommendations…………………………………….……....….48

References……………………………………………………..………..50

Appendix…………………………………………………….….………58

Chapter One

1- INTRODUCTION

Anemia is most common medical disorder in pregnancy and post partum

period. The term anemia describes condition in which hemoglobin

concentration less than 11 gm (WHO) or the number of red blood cells is

reduce below the normal values for age and sex. As a result of this decrease,

the oxygen carrying capacity of the blood is diminished a peripheral tissue.

(1)

Anemia is usually multi-factorial in origin in adequate diet in take is

considered one of the main factors contributing to anemia. Iron deficiency

account for approximatly97%of all anemia's during the reproductive age.

Iron is a key component of hemoglobin .so that if the body has low quantity

of iron it will affect the body oxygen delivery system. (2)

Folic acid and B12 play an important role in HB synthesis and can in

dependently affecting DNA synthesis .vitamin A and C also contributing to

the absorption and utilization of dietary iron.

Blood loss during pregnancy also consider to be a same causes of anemia

with pregnancy and Post-partum, ectopic pregnancy abortion as well as

vaginal and cervical lesion placenta previa and apruptio placenta are the

most common causes of blood loss at the lasts time of pregnancy in

developing countries. Parasites are play significant role in the etiology of

anemia .Hemorrhoids associated with pregnancy also can raised to chronic

blood loss as peptic ulcer disease and intrinsic bowel disease.(3)

Anemia directly and in directly contributes to 40% of maternal death in

the third world. Severe anemia can lead to cardiac failure in pregnancy

while lesser grade associated with decrease maternal well being and

contributes to maternal death due to hemorrhage and infection...Also the

physical activities or work may be difficult to perform because not enough

oxygen is available for using by the muscles. More over sensation of feeling

cold also a body temperature can not be regulated appropriately; the

immune systems compromised as well as, reflected in decreased wound

healing ability.(4)

Anemia can be the reason of mean impaired oxygen delivery to the fetus,

which have severe consequence and contribute to pre-natal mortality by

increasing both likely hood of intra uterine growth retardation, preterm

delivery and low birth weight more over and poor breast feeding.(5)

1.1 Justifications:

Hence, this study will be undertaken to shed light on the magnitude of low

hemoglobin level among women in the Rive Nile state which is considered a

common health problem facing females in their reproductive years, and

dramatically adversely affect her health later in life, her fertility, her

recovery from pregnancy and child birth, and the health of the outcome.

1.2 Objectives:

1.2.1. General objective:

To asses Incidence of Anemic among Women Attending Delivery In The

River Nile State.

1.2.2. Specific Objectives:

1- To Determine the Incidence of Anemia among Women Attending Delivery

in the River Nile State.

2- To Identify The Factors Affecting The Incidence of Anemia Among Those

Women.

Chapter Two

Literature Review

Chapter Two

2. Literature Review

2.1. Hematological Changes during Pregnancy:

Child birth appears to induce hemoglobin changes. These change are

found mainly in the following: - (1) blood volume; (2) hemoglobin

concentration and (3) Iron metabolism, (6)

2.1.1 Blood Volume:-

During pregnancy, the maternal blood volume increases markedly. The

blood volume expansion result from an increase on both plasma and

maternal circulation, the increase in the volume of erythrocytes averaging

450ml.Moderate Erythrocyte hyperplasia is present in the bone marrow,

and the reticulocyte count is elevated slightly during normal pregnancy.

This change is related to increase in maternal plasma erythropoietin level,

which peak early the third trimester and correspond to maximal

erythrocyte.(7)

In a sever studies of normal women ,by 12 menstrual weeks, the plasma

volume expands by approximately 15% while at or very near to averaged

about 40 to 45% above their non pregnant level. (5)

Pregnancy induced hypervolemia has several important functions (1) to

meet the demands of the enlarged uterus with its greatly hypertrophied

vascular system (2) to protect the mother and in turn the fetus against the

deleterious effects of impaired venous return in the supine and erect

positions and (3) to safeguard the mother against the adverse effects of

blood loss associated with parturition.(8)

After child birth, readjustment in the maternal blood volume is dramatic

and rapid .change in the blood volume after birth depends on several factors

such as blood loss during child birth and the amount of extra vascular water

(physiologic edema) mobilized and excreted .blood loss results in an

immediate but limited decrease in total blood volume .many women loss

approximately 500ml of blood during vaginal birth and the about twice this

much during cesarean birth. (9)

Pregnancy-induced hypervolemia allows most women to tolerate these

considerable blood losses during child birth. Therefore most of blood

volume increase during pregnancy is eliminated with in the first 2 weeks

after birth, with return to none pregnancy values by 6 months post

partum.(1)

More over postpartum physiologic changes protect the women from

excessive blood loss by elimination of utero-placental circulation reduces

the size of the maternal vascular bed by 10 to 15% loss of placental

endocrine function remove the stimulus for vasodilatation and mobilization

of extra vascular water stored during pregnancy increases blood volume.(5)

2.1.2 Hemoglobin concentration:-

Hemoglobin is the oxygen carrying compound contained in RBCs. The

amount of the hemoglobin per 100 millimeters of blood can be used as an

index of the oxygen-carrying capacity of the blood. Total hemoglobin

depends primarily on the number of the RBCs. The hemoglobin carries and

the extent on the amount of the hemoglobin in each RBCs. During normal

pregnancy hemoglobin and hematocrit concentration decrease .as the result

whole blood viscosity decrease .hemoglobin concentration at term average

12.5 g/dl thus hemoglobin concentration below 11 g/dl especially late in

pregnancy should be considered abnormal. (8)

After delivery the hemoglobin level typically fluctuate test other modest

degree and then rises to and usually exceeds the non pregnant level .the rate

and magnitude of increase early in the pauperism result from the amount of

hemoglobin added during pregnancy and the amount of blood loss at

delivery modified by a puerperal decrease in plasma volume. During the

first 72 hours after childbirth there is a greater loss of plasma volume than

in the number of blood cells. This results in an increase in hematocrit and

hemoglobin levels and decrease in blood cell destruction by seventeenth

day after birth. (5)

2.1.3 Iron Metabolism:-

The total iron content of normal iron women ranges from 2-2.5 about half

the amount found normally in men .More over, the iron store of normal

young women are only about 300mg.The hemoglobin contains about 70% of

the body iron, while storage iron account foremost of the remainder .Iron in

hemoglobin is responsible for distributing for oxygen throughout the body

and also assists enzymes in the use of oxygen by the cells. (5)

The total iron requirements of normal pregnancy is 1000 mg about 500

mg for maternal hemoglobin mass expansion 300 mg are actively

transferred to the fetus and placenta and about 200 mg are lost through

various normal routes of execration primarily the gastrointestinal tract.

these are obligatory losses and occur even the mother is iron deficient .the

average increase in the total volume circulatory erythrocytes(about 450 ml

during pregnancy when iron is available)uses the other 500 mg of iron

because 1 ml of normal erythrocytes contains 1.1 mg of iron. Therefore the

iron requirement becomes quite large during the second half of pregnancy

with averaging 6 to 7mg/day. (5)

In the absence of supplementation iron the hemoglobin concentration and

hematocrit fall appreciably as the maternal blood volume increase .if the

non anemic women are not given supplementation iron, serum iron and

ferreting concentration decline during the second half of pregnancy. Thus

amount of iron absorbed from diet together with that mobilized from stores

become insufficient to meet the maternal demands superimposed by

pregnancy. (10)

2.2. Epidemiology of anemia: -

Anemia remains the comment nutritional and most intractable problem

worldwide with its highest incidence among pregnant women, WHO

estimated that more than 2 billion people world wide, is anemic. It is

especially more common in developing countries because of poor nutrition

and high Incidence of parasitic infestation.(11)

National anemia surveys have been conducted in about 25 developing

countries. It was found that incidence of anemia among pregnant women in

developing countries average 56% with arrange of 35% to 100%among

various Region of the world .south Asia regional anemia incidence has been

estimated to be 75% among pregnant women . (12)

In African, anemia affects more than half of all pregnant women .according

to recent survey the center for disease control, the incidence of anemia in

low in come women , in the first trimester is approximately3.5% in white

women and 12.5 %in Africa associated with increase to (18.85% and38.1%

prospectively)by the third trimester. The human nutrition collaborative

Research support Program (NHCRSP) reported that incidence of anemia in

Sudan among pregnant, lactating and non-lactating and non-pregnant

women were.

Result of health population survey for the year 2000 in Sudan, revealed that

around 30% of pregnant women suffered from anemia and 40% of pregnant

women had mild anemia and 10% suffered from moderated anemia. (13)

The incidence of postpartum anemia was higher among those who had

anemia during pregnancy 49%, Inculding 48% of those who were 13 to14

weeks postpartum, compared to24% of women who had not suffered from

prenatal anemia. (3)

With distribution of different type of micronutrient deficiencies

contribute to anemia in different surveys, it was found that 98% of the

cases, the etiology of post partial anemia are iron deficiency of vitamin,

foliate and vitaminB12 were found in approximately 40%,30%and25%of

pregnant women of anemia.(5)

2.3. Grades of anemia: -

Anemia is Defined as low level of hemoglobin in red blood cells .Iron is

hemoglobin molecule fixes oxygen in the lung and relapses it’s the tissues

where oxygen generate energy for the body .According to who criteria

,anemia was defined as Hemoglobin (HB) of <11g/dl.so that any women

with hemoglobin 11g/dl or more is considered normal . Hemoglobin

between 9g/dl to 10.9g/dl is considered as mild anemia, between 7g/dl to

8.9g/dl moderate and hemoglobin less than 7g/dl is sever anemia (WHO

...).The center for disease control and prevention (.....) defined anemia as less

than 11 gm/dl in the first and third trimester less than 10.5g/ dl in the

secondtrimester.(14)

2.3.1. Severe anemia (hemoglobin<7 dl) is the public health problem if

incidence exceeds 2%. Its problem in most counties in Africa and south Asia

and some countries in East Asia and the pacific (e.g., Cambodia).(15)

2.3.2. Mild anemia developing over along period of time end to produce few

symptoms: e.g. fatigue, irritability, loss of sense of well being lack of interest

of life. 3.Moderat to sever Anemia that develop quickly will produce many

symptoms and signs these include pallor of skin and mucus membrane and

conjunctiva; tachycardia; dyspnea; headache; nausea and vomiting;

depression weight loss and edema; diaphoresis; paresthesia; a cold feeling

and burning sensation of tongue (glossies).(16)

With greater severity, anemia became debilitating as work capacity and

tolerance of physical execration are restricted. Finally, it can produce cardio

respiratory failure and death. Koilonychias, finger nail are thin, friable and

brittle, with distal half having a concave or spoon shape resulting from

impaired nail bed epithelial growth. It is considered path gnomonic of iron

deficiency. Also blue sclera with a definite bluish hue is a highly specific of

iron deficiency .The bluish ting results from thinning of the sclera, which

make the choroids visible. The thin sclera results from impairment of

collagen synthesis by iron deficiency.

2.4 The complex risk factors associated with anemia:-

Anemia is usually factorial in origin , and the following are the most

common risk factors associated with anemia:-

2.4.1 Poor maternal nutrition and micronutrient Deficiency:-

Poor nutrition status in pregnancy has adverse consequences that can

persist from one generation to the next; iron Defiance is common cause of

anemia in pregnant women. Iron Deficiency during lactation is mostly a

residual from pregnancy and delivery and can be partially alleviated

because of lactation amenorrhea .However once menstruation returns, if

lactation continues; iron requirements became higher to reach a median of

about 1.81 mg/day. Dietary iron absorption in the most populations of

Developing world may not be sufficient for fulfill these needs. (3)

Multiple micronutrient deficiency also contribute to anemia in pregnancy,

and deficiencies of vitamin A, foliate ,and vitamin B12 were found in

approximately 40%,30% and 25%, respectively of pregnant women with

anemia,.(17)

Also association between vitamin A deficiency and anemia has been

demonstrated in many nutritional surveys, and a number of intervention

studies. Vitamin A appear to protect against anemia through diverse

biologic mechanisms, including the enhancement of the growth and

differentiation of erythrocyte progenitor cells, modulation of immunity to

infectious diseases and mobilization of iron stores from tissues.(18)

Riboflavin deficiency is widespread in population consuming little milk or

products, and high incidence of biochemical deficiency has been observed in

studies from different parts of the developing world. Riboflavin deficiency

may impair iron mobilization, globing synthesis, and iron absorption and

mobilization. Vitamin C has and anti- oxidant properties and also facilitates

the absorption and mobilization of iron. Several studies suggest that vitamin

deficiency exacerbate anemia. (16)

An unusual behavior associated with anemia in pregnancy. Pica, which is

characterized by hunger and appetite for nonfood substances including ice,

clay, cornstarch and even dirt, creates health problem and decrease

minerals absorption. Excessive intake of antacids, oxalates and phosphates

competes with the absorption of sites of iron. Food with higher fiber and

diary product also decrease absorption of iron and then contribute to

Anemia. (19)

2.4.2 Intestinal Helminthes:-

Hook worm and other intestinal helminthes as schistosomiasis and in

some cases trichuriasis cause gastrointestinal blood loss, mal absorption,

and inhibition of appetite, there by exacerbating micro nutrition defensives

and maternal anemia .Several studies had shown that hook worms cause

severe anemia and magnetron in developing countries in tropics, with

estimated over billion infected worldwide. The parasite most commonly

associated with is hookworm followed by Ascaris (p<0.06). Infection of

pregnancy may cause decrease fetal growth and weight gain. (20)

2.4.3 Obesity:

Obesity is defined as body mass index (BMI) greater than 29.Several

studies suggest that higher pregnancy BMI substantially increases the risk

marker of postpartum anemia found that risk of postpartum anemia (21)

was similar for women with BMI values from 17 to 24 compared with

women with a BMI of 20.Adjusted relative risk increased as BMI increased

from 24 to 38. Women with aBMI0f 28 had 1,8 times the postpartum anemia

risk of women with a BMI of 20(955confidenece interval 1.8,2.5),and obese

women with a BMI of 36 had ~2.8 times the risk (95% confidence

interval1.7,4.7). (21)

In addition compared with non-obese women, obese women have greater

risk of postpartum hemorrhage, and cesarean delivery with adjusted OR

was 1.66(95%CL 1.51,1.82) The complication can result in blood losses

exceeding 1000 ml, the equivalent of 400 mg of iron . Base women also have

risk of delivering a macrocosmic infant (birth weight>4000g) which cause

higher delivery blood loss and lengthens the duration of lochia and then

contributes to Anemia. (22)

2.4.4 Low Income:

Recent suggested that anemia is common among low income women. The

incidence of iron deficiency anemia among women with poverty index

ratio<130%was substantially higher than those with a poverty index

ratio>130%.furthermore,compared with postpartum women who had

poverty index ratio>130%,their lower income counterparts were ~3 time as

likely to have anemia (%+_SEM: 22.2+_5.9 vs.6.3+_2.1)and iron deficiency

anemia (%+_SEM: 10.3+_ 3.3 vs.2.1+_1.3) incidence of anemia in poorest

compared to the richest quintile is to times higher in India and 1.4 times

higher in Sudan, Cambodia, LAC and ECA.(23)

Women of low socioeconomic status use multivitamin and mineral

supplements less often during pregnancy and have in adequate dietary than

women of higher socioeconomic status The difference is important because

red cells mass expansion among women who do not use iron prenatal iron

supplements is half that of women who are supplemented.(24)

Compared with higher in come women, women of low socioeconomic

status class frequently received in adequate or no pre natal or postpartum

care, which may prevent them from receiving risk assessment, education or

treatment for medical condition .Additionally inter pregnancy interval has

been shown to be shorter of women of low socioeconomic class. This in

adequate birth spacing may result in cycle in which iron status never

completely recovers. Moreover, low income women are not less likely to

initiate breast Feeding .Breast feeding may be protective against the

development of iron deficiency because it length amenorrhea, thereby

reducing bodily iron losses. (25)

2.5 Consequences of Anemia:-

Anemia is the one of most common risk factors in the area of obstetrics

and prenatal medicine. During pregnancy and in the pauperism, it is

associated with an increase incidence of both maternal and fetal morbidity

and mortality and morbidity .THE extend of which is dependent up on the

severity of Anemia and is resulting complications. (26)

2.6 Effect of Anemia on Mothers : -

2.6.1 Effect of Anemia on maternal morbidity and mortality:-

The major concern about the adverse effects of anemia on pregnant

women is the belief that this population is at greater risk of prenatal

morbidity and mortality .With sever anemia, most tissues of the body

become starved of oxygen, and the effect is the most marked on the heart

muscle which may fail together. (26)

The circulatory changes in sever anemia are due to oxygen lack in the

tissue caused by reduction in oxygen carrying capacity of the blood .these

change are rarely seen untie the hemoglobin concentration drops to 6.5 to

7mg/dl.the circulation is raised both heart and pulse rate rise, the skin and

mucus membranes, though pale, became warm suggesting arteriolar

dilatation .another effect of Arteriolar dilation is a decrease in peripheral

resistance, with a fall in diastolic blood pressure, since the systolic pressure

remains unchanged or slightly raised. The pulse pressure there for raises

and the pulse became water hammer in character. Vigorous pulsation of

large blood vessels of neck became visible and bruit is heard over them and

over other vessels. Renal hypoxia from reduced renal blood flow leads to

sodium retention and edema. Death from anemia is a result of heart failure,

shock, or infection that has taken advantage of impaired resistance to

diseases in the patient. Close to 500,00 maternal death ascribed to

childbirth or early post-partum occur every year, the vast majority taking

place in the developing world .Anemia is a major contributory or sole cause

in 20 -40% of such death In many regions anemia is a factor in maternal

mortality in selected developing countries ranges from 27 ( India) to 194

(Pakistan) death per100000 live births, Data show an associated between

higher risk of maternal mortality and severe anemia and an association

between hemoglobin concentrations at ,or close to ,delivery and subsequent

mortality . Maternal Death in the pauperism may be related to a poor ability

to withstand the adverse effects of excessive blood loss, an increase risk of

infection, and maternal fatigue .Since it reduces resistance to blood loss,

death may occur also from bleeding association with normal delivery .In

addition, Association of Anemia with adverse Maternal outcome such as

puerperal sepsis, ante partum hemorrhages, postpartum hemorrhages. (27)

2.6.2 Performance during Delivery:-

Delivery demands endurance and sever physical effort .physically fit

women perform better and have fewer complications during delivery when

contrasted with less fit women as in sever anemia. In sever anemia .cardiac

failure during labor is a major cause of death. WHO(1992),reported that

during child birth a healthy mother may tolerate a blood loss up to more

little .In an anemic mother .a loss of liter an 150 ml can be fatal. Anemic

Mother are poor Anesthetic and operative risk because Anemia lowers

resistance to infection and wounds may fail to heal promptly after surgery

,or may break down altogether.

2.6.3 Lactation Performance:-

Anemic mothers are less competent than their normal counterparts in the

process of lactation, and milk composition. Moreover, anemic mothers

reported a higher level of symptomatology associated with in sufficient milk

syndrome are not a only less likely to initiate breast feeding ,Also anemic

Mothers were not having enough milk ,baby nursing to often ,and baby not

gaining enough weight as the main reasons for discontinuing breast feeding

.

2.6.4 Working capacity and general wellbeing:-

The negative relationship between anemia and working capacity is well

established in both men and women. The impact of pregnancy it's residual

and iron deficiency anemia on the woman as a mother, as a worker and as a

person in general. In general anemia contribute to fatigue and is associated

with impaired aerobic capacity ,decrease voluntary activity ,and reduced

work capacity ,and then cause lower economic productivity . Anemia

interfaces with the patient `s usual activities she became accomplished usual

tasks at home, garden, or work return her from socialization with family or

friends.

2.6.5 Immunity status:-

Several anemic pregnant women have impaired cell mediated immunity

that is reversible with iron treatment .Also, iron storage are associated with

iron adverse changes in many component of the immune system ,including

resistance to the infection and delay wound healing ,resulting in prolonged

hospitalization .More over changes in the function of the immune system.(28)

Chapter three

Methodology

Chapter three 3. Methodology

3.1 Research design: This was a descriptive hospital based study

3.2 Study area:

Shendi teaching hospital, Eldamer hospital, Elshorta hospital, Elmakk Nimir

University hospital , Atbara teaching hospital and Barbar hospital.

3.3 Study population:

The population under study consists of all women attending delivery in the

period of the study.

3.4 Sample :

All women attending delivery in the period of the study (308).

3.5 Data collection:

Demographic data such as age, sex, education level, occupation, family

size, types of diet, chronic diseases, collected using direct interview after

taken consent.

In the interview, the researcher used the structured face to face

questionnaire. During the interview any vague information had been

simplified by the researcher to ensure exact and real answer by the

participants.

3.6. Data analysis:

Data of the questionnaire and results of blood tests were analyzed using

software program statistical package for social sciences (SPSS). Frequencies

and percentages were calculated and chi-square test was performed to

investigate the significance in the association of the different variables and

incidence of anemia. Correlations were considered significant if the

observed significance level (P-value was< 0.05).

3.7. Pilot study:

Pilot testing had been done prior to the beginning of data collection to

check validity of the questionnaire. Refining of questionnaire had been done

according to the result of the pilot study.

3.8 Limitation of the study: Budget was a limitation of this study.

Chapter four

Results

Chapter four

The Results

Out of 308 participants, 198 pregnant women were suffer from anemia

with a total incidence rate of (64.3%) while110 (35.7 %) of women have

normal hemoglobin based on WHO estimation.(Table 4.1 )

(Table 4.1 )Incidence of Anemia among study population: (N=308)

item frequencies %

Women with anemia 198 64.3

Women without anemia 110 35.7

TOTAL 308 100

Table (4.2) Anemia incidence and Living area : (N=308)

Variables Chi-

Square

Women

with anemia

Women

without

anemia

P-value

No % No %

Living

area

urban 2.141 116 59% 66 60% 0.710

rural 82 41% 44 40%

p-value (<0 .05 significant )

All participants are attending maternal health care centers and receiving

similar health services, however, a higher incidence rate of anemia was

found among urban inhabitance, 116 out of 182 (59%) compared to 82 out

of 126 (41%) among rural inhabitance [Table 4.2]. Differences in the

incidence rates were not significant (P = 0.71 at α = 0.05).

Table (4.3) (N=308) Anemia incidence and age group :

Variables Chi-

Square

Women

with anemia

Women

without

anemia

P-

value

No % No %

Age

(years)

24 - 29 4.617 72 37% 46 42% 0.32

30-34 80 40% 48 43%

35 > 46 23% 16 15%


table (4.3) shows Differences in the incidence rates among the various

age group were of no statistically significant values (P = 0.32 at α = 0.05).

Table (4.4)(N=308) Anemia incidence and years of education :

:Variables Chi-

Square

Women

with

anemia

Women

without

anemia

P-

value

No % No %

Years

of

education

6 and < 4.318 78 40% 37 36.6% .82

7-11 84 42% 45 40.9%

12 and > 36 18% 28 25.5%


Table (4.4) showed increased levels with increased years of education (≤

6, 40%; 7-11, 42% ) [Table 4.4]. Differences in incidence rates among the

various educational group were not statistically significant (P = 0.82 at α =

.05).

Table (4.5)(N=308) Anemia incidence and work status :

Variables Chi-

Square

Women

with

anemia

Women

without

anemia

P-

value

No % No %

Workin

g status

yes 3.638 46 .23% 42 38% .96

No 152 .77% 68 62%


Table (4.5) showed that incidence of anemia was much higher among non

working group (152 out of 22o: 77%) compared to working group (46 out of

88: 23%) [Table 4.5]. Differences in the incidence rates were not statistically

significant (P = 0.96 at α = 0.05).

Table (4.6)(N=308)Anemia incidence and family members

Variables Chi-

Square

Women

with

anemia

Women

without

anemia

P-value

No % No %

Family

members

3and< 1.741 147 74% 79 72% .94

4 - 6 43 21% 27 25%

7and> 8 4% 4 3%


Findings with respect to number of family members were also found as

with decreased number of family members an increased of the anemia

incidence rate was found (147 cases out of 226: 79%) less than 3members

compared with (51 controls out of 82 :25%) greater than 4 members (Table

4.6). Differences in incidence rates were not statistically significant (P = 0.94

at α = 0.05).

Table (4.7)(N=308)Anemia incidence and numbers of pregnancies

Variables Chi-

Square

Women

with anemia

Women

without anemia

P-value

No % No %

Number of

pregnancies

4and> 1.003 154 78% 86 78% .90

5and< 44 22% 14 22%


Participants with 5 or more pregnancies seems to show lower incidence

rates of anemia as (44 out of 58: 22% ) of anemic participants were with 5

or more pregnancies compared to (20 out of 87: 23%) for those with 4

pregnancies or less (Table 4.7). This is contradictory the expectation as

irons stores being depleted and exhausted due to frequent and close

intervals pregnancies and deliveries. Differences in incidence rates were not

statistically significant (P = 0.90 at α = 0.05).

Table (4.8)(N=308)Anemia incidence and use of iron

Variables Chi-

Square

Women

with

anemia

Women

without

anemia

P-value

No % No %

use of

iron

yes 15.295 43 22 102 92.8 0.00

No 155 78 8 7.2


Table (4.8), this is an expected observation as iron supplement is a major

treatment option. Dose differences of iron supplements seem to have effect

on incidence rates 0f anemia among the study population. Differences in

incidence rates were statistically significant (P = 0.00 at α = 0.05).

Table (4.9)(N=308)anemia incidence and visit to health facility

Variables Chi-

Square

Women

with

anemia

Women

without

anemia

P-value

No % No %

Number

of visits

Less than 4 2.361 129 66 76 69 0.04

4 and more 69 34 34 31


Table(4.9) This is clear from the findings among those participants at

more than 4 visits (34% suffering from anemia) compared to those

participants at less than 4 visits (66% suffering from anemia). It's clear that

the association between number of visits and incidence rates of anemia is

biggest . Differences in incidence rates were statistically significant (P = 0.04

at α = 0.05).

Table (4.10)(N=308)Anemia incidence and type of foods

: Variables Chi-

Square

Women with

anemia

Women

without

anemia

P-

value

No % No %

Red meat

and

chicken

Daily

5.939

75 38% 37 34% 0.204

Weekly 123 62% 73 66%

vegetables

Daily 4.658 91 46%

42 38% 0.79

Weekly 107 54% 68 62%

fruits Daily 7.129 93 47% 41 37% 0.129

Weekly 105 53% 69 63%


Table (4.10) we found that incidence showed increased levels with

increased type of food consumption. Differences in incidence rates among

the various food consumption type( red meat and chicken, vegetables, fruits

) were not statistically significant (P = 0.82 ,0.204,0.79,0,129) respectively .

Table (4.11)(N=308)Anemia incidence and fatigue among the study

population

Variables Chi-

Square

Women

with

anemia

Women

without

anemia

P-value

No % No %

fatigue Yes 9.922 119 60 46 42 0.007

No 79 40 64 58


table (4.11) Differences in incidence rates were statistically significant (P

= 0.007 at α = 0.05).

Table (4.12)(N=308)Anemia incidence and poor apitite among the study

population

Variables Chi-

Square

Women

with

anemia

Women

without

anemia

P-value

No % No %

poor

appetite

Yes 6.125 134 77 50 45 0.047

No 64 23 60 65


Table (4.12) shows the distribution of cases regarding to the poor

appetite among the study population .

Table (4.13)Anemia incidence and repeated infection (N=308)

Variables Chi-Square Women with

anemia

Women

without

anemia

P-value

No % No %

repeated

infection

Yes 3.726 110 55 50 45 0.155

No 88 45 60 55


As show in table (4.13) , incidence rate of anemia among women with

repeated infection were 110 (55%) compare with non repeated infection 88

(45%).

fiveChapter

Discussions and Findings

Chapter five

Discussions and Findings

Anemia is a major health problem that affects 25% to 50% of the population

of the world the prevalence of anemia in pregnancy shows a great variations in

different parts of the world. Studies from industrialized countries show that 45%

of pregnant women have a Hb less than 11 whereas the prevalence is generally

higher and the variation is greater in developing countries with 90% anemia (34)

.

Anemia in pregnancy is associated with increased rates of maternal and prenatal

mortality, premature delivery, low birth weight and other adverse outcomes

(35).The current study had been conducted among women attending delivery in

different six hospitals in the River Nile State, The main objective of the study

was to know the incidence of anemia regarding women attending delivery in the

different selected hospitals. The

findings indicated that, the study sample characterized by different demography.

Table (4-1) reflected that, such differences might be due to the fact that rural

communities with different eating habits and social beliefs as our data exclude

problems associated with compliance to iron supplements, knowledge, attitudes

and practices of pregnant women living in these areas.Table (4-2) showed age

from (24 - 29) in our study seems to show the highest incidence rate of anemia

(72out of 118; 37%, see Table 4.2). The finding of the present study is agreement

with findings reported in Karachi (36)

, in Iran (37)

. (17.9%) were with mild anemia

and in Tanzania (38)

.In Turkey (39)

, they have identified young age as a risk factor.

Women are at higher risk for developing anemic due to the fact that they must

meet their nutritional needs for their growth in addition to the nutritional needs

during pregnancy. It is also well known that iron needs are high in adolescent

girls because of the increased requirements for expansion of blood volume

associated with the adolescent growth spurt and the onset of menstruation.

Differences in incidence rates among the various age group were of no

statistically significant values (P = 0.32 at α = 0.05).

Table(4-3) Increased educational levels is expected to improve knowledge and

hence is expected to reflect more awareness regarding heath problems, however,

in the current study it was difficult to see any link between educational level and

incidence of anemia among the study population.

Table (4-4) showed With respect to the working status one also expect to see

higher incidence rates of anemia among the non working group of pregnant

women as they might be engaged in their work home and may not be able to pay

the required attention for their body needs of rest and nutrient. Our data in this

respect showed that incidence of anemia was much higher among non working

group (152 out of 22o: 77%) compared to working group (46 out of 88: 23%)

[Table 4-4]. Differences in incidence rates were not statistically significant (P =

0.96 at α = 0.05). The finding of the present study is lower than that finding,

reported in Turkey (39)

, found a high percentage (94%) of the pregnant women

were housewives this could be a possible reason for women having health

problem during their pregnancy (39)

.

Women of low socioeconomic status use multivitamin and mineral

supplements less often during pregnancy and have in adequate dietary than

women of higher socioeconomic status the difference is important because red

cells mass expansion among women who do not use iron prenatal iron

supplements is half that of women who are supplemente.(24).

The negative relationship between anemia and working capacity is well

established in both men and women. The impact of pregnancy it's residual and

iron deficiency anemia on the woman as a mother, as a worker and as a person in

general. In general anemia contribute to fatigue and is associated with impaired

aerobic capacity ,decrease voluntary activity ,and reduced work capacity ,and

then cause lower economic productivity . Anemia interfaces with the patient `s

usual activities she became accomplished usual tasks at home, garden, or work

return her from socialization with family or friends. (28)

Table (4-5) showed findings with respect to number of family members were

also found as with decreased number of family members an increased of the

anemia incidence rate was found (147 cases out of 226: 79%) less than 3

members compared with (51 controls out of 82 :25%) greater than 4 members

(Table 4.5). Differences in incidence rates were not statistically significant (P =

0.94 at α = 0.05). Compared with higher income women, women of low

socioeconomic status class frequently received in adequate or no prenatal or

postpartum care, which may prevent them from receiving risk assessment,

education or treatment for medical condition .Additionally inter pregnancy

interval has been shown to be shorter of women of low socioeconomic class.

This in adequate birth spacing may result in cycle in which iron status never

completely recovers. Moreover, low income women are not less likely to initiate

breast Feeding .Breast feeding may be protective against the development of iron

deficiency because it length amenorrhea, thereby reducing bodily iron losses. (25)

Table (4-6) showed participants with 5 or more pregnancies seems to show

lower incidence rates of anemia as (44 out of 58: 22% ) of anemic participants

were with 5 or more pregnancies compared to (20 out of 87: 23%) for those with

4 pregnancies or less (Table 4.6). the finding of the present study is was similar

with findings reported in India (28)

, and in Sudan (46)

, they found no significant

association between anemia and parity. But this result was disagrees to study in

Karachi (36)

in Iran (37)

, in Tanzania (40)

, in Turkey (39)

, in Saudi Arabia (41)

, in

Malaysia (42)

, and in Nigeria (43)

, identified increased parity 0-9 have also been

associated with more anemia this may be because underlying cause being

depleted iron stores (44, 45)

. Anemia was higher among pregnant women who had

more than 6 pregnancy, the same result were seen in Karachi (36)

, in Turkey (39)

,

& in Malaysia (42)

, reported increased gravidity was 1-10 have been associated

with more anemia this might be explained by underlying cause being depleted

iron stores (44, 45)

. Significant association was found between the last birth

intervals and anemia, pregnant who conceived within less than 24 months, were

at greater risk of having anemia when compared with normal group. This is

contradictory the expectation as irons stores being depleted and exhausted due to

frequent and close intervals pregnancies and deliveries. Differences in incidence

rates were not statistically significant (P = 0.90 at α = 0.05).

Table(4-7) A recommended strategy recommended by WHO to prevent iron

deficiency anemia in pregnant women is to provide universal supplementation of

iron (60mg per day) and folic acid (400μg/day) as soon as possible after

gestation starts-no later than the third month-and continuing for the rest of

pregnancy. however, in the current study, use of iron supplements seems to

affect the status of anemic patients as lower incidence rates among the study

population (current use; 78% compared to non use 22%; ). Anemia was high

among pregnant women who do not taking iron supplement. The same results

were seen in Iran (18)

, in Malaysia (42)

, in Pakistan (47)

, in Karachi (36)

; they found

anemia less common in ladies taking oral iron supplements compared with ladies

who were not taking oral iron supplements.

In the absence of supplementation iron the hemoglobin concentration and

hematocrit fall appreciably as the maternal blood volume increase .if the non

anemic women are not given supplementation iron, serum iron and ferreting

concentration decline during the second half of pregnancy. Thus amount of iron

absorbed from diet together with that mobilized from stores become insufficient

to meet the maternal demands s uperimposed by pregnancy. (10)

Most of women did not take their daily tablet of iron supplement regularly

and resisted it because of the perceived complications, such as; tables weakening

the blood of interfering with the digestive.

Liquid forms of iron that causes less gastrointestinal distress. However,

they can stain the teeth thus patients should be instructed to take this medication

through a straw, to rinse the mouth with water, and to practice good oral hygiene

after taking this medication. Finally, patients should be informed that iron salts

may color the stool dark green or black. (34)

Table(4-8) According to the WHO, a pregnant woman should pay at least 4-6

antenatal visits to a health facility in order for the visits to be effective. A clear

association between numbers of visits and incidence rates of anemia among

participants.

Table (4-9) Increased (red meat and chicken, vegetables, fruits ,et. )

consumption wear expected to improve family health and hence is expected to

reflect more awareness regarding heath problems, however, in the current study

it was difficult to see any link between type of food consumption and incidence

of anemia among the study population, and in contrast.

Food rich in vitamin C (e.g., citrus fruit, broccoli and capsicum) promote the

absorption of non-heme iron. A number of dietary factors inhibit non- heme

absorption, polyphones in tea and coffee phytates in wholegrain breads and

cereals, oxalic acid found in spinach and beer root and calcium especially

calcium supplements These inhibitors should not be taken with the main iron-

containing meal. (32)

The nurse should Instruct the patient to avoid foods that are gas forming,

because they cause abdominal distention, which may decrease the appetite and

also interfere with the respiratory efforts. The mother should be encouraged to

avoid hot, spicy, and acid fluids to decrease gastrointestinal irritation If the

mother is anorexic or a finicky eater, small, frequent meals may be better

tolerated. (28)

The nurse should advise pregnant women on the correct selection and

preparation of foods that are high in folic acid. Folic acid is found in leafy green

vegetable such as Brussels sprouts, broccoli and spinach but is destroyed easily

by prolonged boiling or steaming. Other sources include peanuts, chickpeas,

bananas and Chris fruits. It is also found in avocado pears, asparagus and

mushrooms. It is recommended that all women of childbearing age should eat

more folate-rich foods, eat food fortified with folic acid such as bread and

cereals. (33)

Table (4-10) Between incidence of anemia and fatigue among the study

population there was a statistically significant correlation. incidence of anemia

was higher in women with fatigue compared to women without fatigue.

The nurse should obtain the patient's medical history, and conduct a physical

examination. Because fatigue is one of the most common signs of anemia, the

nurse should assess the patient's level of physical activity, ability to perform the

usual activities of daily living, and sleep and rest pattern. Check vital signs and

observe for s

shortness of breath on exertion. Assess the patient's level of Knowledge about

the disorder, treatment, and care needed and instruct accordingly. Allow the

patient to ask questions and verbalize concerns. (31)

Table (4-11) showed the distribution of both cases and healths regarding to the

poor appetite among the study population . there are 134 (77%) of cases among

women had a poor appetite compare with 64 (23%) of cases among participants

had non poor appetite . Differences in incidence rates were statistically

significant (P = 0.047 at α = 0.05).

Table(4-12) showed incidence rate of anemia among women with repeated

infection were 110 (55%) compare with non repeated infection 88 (45%). in the

current study it was difficult to see any link between the repeated infection and

incidence of anemia among the study population, [Table 4.12].Differences in

incidence rates were not statistically significant (P = 0.155 at α = 0.05). The

infection is most common cause of death in anemic women that has taken

advantage of Impaired resistant to diseases in the patient. Maternal Death in the

puerperium may be related to a poor ability to with stand the adverse effects of

excessive blood loss, an increase risk of infection, and maternal fatigue . (27)

Chapter six

Conclusion & recommendations

Chapter six

6 Conclusion & recommendations

6.1 Conclusion:

Out of 308 pregnant women attended delivery rooms in the targeted

hospitals, a number of 198 (64.3%) were found to be anemic, while 110

(35.7%) were found to be within the normal ranges of hemoglobin

concentration. Pregnant women who use tonics and cared with ante-natal

medical follow up were significantly protected against anemia (P-value ˂ 0.05).

6.2 Recommendations:

Special attention should be taken towards the laboratories at hospitals

and clinics. Such laboratories should be well equipped with effective,

accurate and cheep means of haemoglobin determination to be reachable to

women during pregnancy and due delivery.

Strategically, all new mothers should be counseled by health care

providers about the risks of anemia throughout their pregnancy. Math

media should be used more effectively as a powerful way to disseminate

consistent knowledge to maximal numbers of target population about

anemia. Nurses should be implement a general health promotion and

prevention program about anemia to all women. This aspect of health

education should be given special importance in antenatal clinics and basic

health care settings were women come during and after pregnancy. Another

opportunity of this health education is places were family planning and

child health care services are provided. These considered efforts can lead to

better health of women and prevent anemia and morbid outcomes of

pregnancy.

On should counsel women about significant fatigue so the can do their

work and home environments in an attempt to achieve adequate rest.

References

References

1. Wong Dl., Perry SHE., Hockenberry MJ., LowDeranilk D. and Wilson D,:

Maternal Child Nursing Care. 3rd

ed., USA: Mosby Inc., Chapter 20(2006);

P.594.

2. Steketee RW.; Pregnancy, Nutrition and Parasitic Diseases. J Nutr 133 (Suppl

2): (2003): P.p. 1661S-1667S.

Van den Broek NR. And Letsky EA. And White SA.; Status in Pregnancy in

south Malawi. Am J Clin Ntur 72 (Suppl 1): (2004): P.p. 247S-256S.

3. Viteri F.; The Consequences of Iron Deficiency and Anemia in Pregnancy.

In:Allen LH, King J, Lonnerdal B.Nutrient Regulation during Pregnancy,

Lactation and Infant Growth. New York: Plenum Press. (2003).

4. Crown E., Murray-Kolls L. and Beard J.; Low Hemoglobin Level is a risk for

Post partum Depression. American Society for Nutritional Sciences. J. Nure

133(2009):; P.p. 4139-4142.

5. Cunningham FG., Leveno KJ., Bloom SL., Hauth JC., Glistrap L. and

Wenstrom KD.; Williams Obstetric. 22nd

ed., M Graw-Hill. New York, London;

(2005): P.p. 129-32 ch, 5, 1144-50 ch; 51.

6. Clapp JF., Little KD. And Widness JA.; Effect of Maternal Exercise Exercise

and Fetoplacental Growth Rate on Serum Erythropietin Concentration. AMJ.

Obstet Gynecol; (2009): 118: 1021.

7. Bernstein IM., Ziegler . and Bader GJ.; Plasma Volume Expansion in Early

Pregnancy. Obstet Gynecol; 97(2009): P.669.

8. Resnik R. The pueroerium In Greasy R.K., Restik R., and Lams J.D. (eds):

Maternal- fetal medicine: principles and practice, ed 5, Philadelphia, Saunders.

(2009).

9. Bowes W. and Katz V.; Postpartum care. In Gabbe S.G., Niebyl J.R., and

Simpson J.L. (eds): Obstetrics. Normal and Problem Pregnancies, 4th

ed., New

York, Churchill Livingstone. (2008).

10. Galloway R.; Anemia Prevention and Control What works? Part 1 / Part 2

USAID ,World Bank, PAHO/WHO, Micronutrient Initiatiative, FAO, and

UNICEF. (2009).

11. Dreyfuss ML., Stoltzfus RJ., Shrestha JB., Pradhan EK., LeClerq SC. And

Khatry SK..; Hookworms, Malaria and Vitamin A Deficiency Contribute to

Anemia and Iron Deficiency among Pregnant Women in the Plains of Nepal.

Joumal of Nutrition; 130 (10) (2006): P.2527-36.

12. Ministry of Health, International Population Council; Health Population

Survey, Sudan. (2007).

13. Bodnar LM., Scanlon KS., Freedman DS., Siga-riz AM. And Cogswell ME.;

High incidence of Postpartum Anemia among Low-income Women in the

United States. AM. J. Obestet. Gynecol; 185(2009): P.p. 438-443.

14. Galloway R.; Anemia Prevention and Control What works? Part 1 / Part 2

USAID ,World Bank, PAHO/WHO, Micronutrient Initiatiative, FAO, and

UNICEF. (2009).

15. Ross SD., Fahrbach K., Fram D., Sheye R., Connelly JE. And Glaspy J.; The

Effect of Anemia Treatment on selected Health- related Quality of life Domains:

A systematic Review. CLin. Ther; 25: (2003): P.p. 1786- 1805.

16. Grodner M., long S. and De young S.; Foundation and Clinical Applicatios of

Nutrition: Nursing Approach, 3rd

ed. Mosby, USA(2004):; P. 222-5, 316-17.

17. Semba RD. And Bloem MW.; The Anemia of Vitamin A deficiency:

Epidemiology and Pathogenesis. Eur J Clin Nutr; 56(2010):: P.p. 271-281.

18. Fishman SM., Christian P. and West KP.; The role of Vitamins in the

Prevention and Control of Anemia. Publie Health Nutr; 3(2005):: P.p. 125-150.

19. Torlesse H. and Hodegs M.; Albendazole Therapy and Reduced decline in

Haemoglobin Concentration during Pregnancy (sierra Leone). Trans R Soc Trop

Med Hyg; 95(2008): P.p. 195-201.

20. Bodnar IM., Seige-Riz AM., Arad L., Chantala K. and MC Donald T.;

Predictors of Pregnaacy and Postpartum Hemoglobin Concentrations in Low-

income Women. Public Health Nutr. 2003 Sep; 7, 60: (2010): P. 601-11.

21. Lao TT., Chan BCP., Leung WC. And Fong HOL.; Postpartum Anemia

Unrelated to Maternal to Maternal Prepregnancy BMI. Obesity Research; 12:

(2009): P.p. 1903-1904.

22. HWO; World Health Day. Safe Motherhood, Shandey. Sudan ,WHO, 7 April

(2003); P.p. 1-3.

23. Lestsky EA.; : The hematological system. In: Clinical Physiology in Obstetrics

(Hytten F., & Chamberlain G., (2010):

24. Bodnar LM., Cogsweel EM. And Scanlon SK.; Low Income Postpartum

Women Are at Risk of Iron Deficieny. American Society Nutritional Sciences,

27 April; P.p. 2298-2302.

25. Breymann C., Current Aspects of Diagnosis and Therapy of Iron Deficiency

Anemia in Pregnancy. Schweiz Rundsech Med Prax.Aug; 2; 90 (31-32) (2008):

P. 1283-91.

26. Allen LH.; Anemia and Iron Deficieny: Effects on Pregnancy Outcome

American Journal of Clinical Nutrition. May Vol. 71, No. 5, (2009): P.p. 1280S-

1284s.

27. Pehrsson PR., Moser-Veillon PB., Sims LS., Suitor CW. And Russek-Cohen

E.; (2009): Post partum Iron Status in non-lactating Participants and Non-

participants in the Special Supplemental Nutrition Program for Women, Infar

and Children. A. M. J. Clin Nutr; 73: P.p. 86-92.

28. Mattson SN., Urassa EN., Mari M., Ronquist G., Lindinark G. and Nystrom

L.; (2004): Core Curriculum for Merernal Newborn Nursing, 2nd

ed.,

Philadelpia, London: W.B. Saunders Company; P.p. 595-618.

29. Stanhope M. and Lancaster J.; (2006): Community Public Health Nursing, 5th

ed. Mosby: New York, Philadelphia; 517-2.

30. Taylor C., Lillis C. And Le Mone P.; (2004): Fundamental of Nursing. 3rd ed.,

London, Philadelphia; Lippincott Company; P.p. 1201-1202.

31. Smeltzer CS. And Bare GB.; (2004): Text Book of Medical Surgical Nursing.

10th ed., London, Philadelphia: Lippincott Williams & Wilkins; P.p. 630-635.

32. Rosdahl BC. and Kowalski TM.; (2003): Textbook of Basic Nursing. 8th ed.,

London, Philadelphia Lippincott Williams & Wilkins; P.p. 1091 – 1092, 1323 –

1324.

33. Anger Wk., Liang YX., Nell V., Kang SK., Coe D., Bazylewicz-Walczak B.,

Rohlman DS. And Sizemord OJ.;(2008): Lessons Learned15ـــــ years of the

WHO-NCTB: A review. Neurotoxicology; 21: P.p.837-846.

34. Low Dermilk DL., Perry ESH. and Boback MI.;: Maternity and Women's

Health Care. 9th ed. London, Philadelphia: Mosby Company; (2005), P.p.20-35.

Appendix

بسم هللا الرحمن الرحيم

ــــــــــــــــــــــــــــــــــــا نإستبيــــــــــ

84ـــ 79 78ـــــ 69 68ــــ 59 العمر :

المستوى التعليمى لألم :ـــ

أمى أساس ثانوى جامعى فوق الجامعى

المهنة :ـــ

معلمة أخرى ربة منزل موظفة عاملة

المستوى التعليمى لألب :ـــ

أمى أساس ثانوى جامعى فوق الجامعى

المهنة :ـــ

موظف أعمال حرة أخرى

عدد مرات الوالدة :ــــ

فما فوق 9 8ــــ6بكرية

السكن :ـــ

ينة قريةمد

عدد أفراد األسرة :ـــ

أكثر >ـــ : 9ـــ 7 6ــــ5

نوع الغذاء:ــــ

وميا أسبوعيا شهريا يتم تناول االلياف ي

يتم تناول اللحوم الحمراء +البيضاء يوميا أسبوعيا شهريا

يتم تناول الفواكه يوميا أسبوعيا شهريا

يوميا أسبوعيا شهريا يتم تناول البقوليات

األمراض المزمنة:ـــ

هل هناك اصابة بالمالريا أثناء الحمل نعم ال

هل هناك نزيف أثناء الحمل نعم ال

نعم ال هل هنالك نزيف بعد الوالدة

هل هناك تاريخ إجهاض اوجنين ميت او ناقص نعم ال

نعم ال هل هناك اصابة بالسكر

ض القلب نعم ال هل هناك اصابة بامرا

هل هناك اصابة بالضغط نعم ال

هل هناك اصابة باالزما نعم ال

نعم ال هل هناك اصابة بالبلهارسيا

هل هناك اصابةبالديدان نعم ال

المتابعة أثناء الحمل :ـــ

شهور كل شهر نعم ال;هل توجد متابعة فى

هوركل أسبوعين نعم الش>هل توجد متابعة فى

هل توجد متابعة فى الشهرالتاسع كل أسبوع نعم ال

تناول المقويات :ــــ

هل ال نعم هل تناولتى حديد

نعم ال تناولتى فوليد أسيد

نعم ال هل تناولتى أخرى

األنميا:ـــ

ال هل نعم هل شعرتى باعباء

يوجد فقدان شهية نعم ال هل أصيبتى

نعم ال بااللتهابات المتكررة

الفحوصات :ــــ

ال وجود شحوب فى العين نعم

ال نعم CBC فحص الدم الكامل

incidence and factors of anemia among women attending...

Documents