Socio-demographic and obstetric factors associated with anaemia Socio-demographic and obstetric factors associated with anaemia

among pregnant women in Sokoto, North Western Nigeriaamong pregnant women in Sokoto, North Western Nigeria

Prof. Erhabor OsaroProf. Erhabor Osaro

Faculty of Medical Laboratory Science, Department of Haematology and Faculty of Medical Laboratory Science, Department of Haematology and

Transfusion Medicine Usmanu Danfodiyo University, Sokoto, NigeriaTransfusion Medicine Usmanu Danfodiyo University, Sokoto, Nigeria

Statement of the problemStatement of the problem

• Each year > 0.5 M women die from pregnancy-related causes including anaemia.Each year > 0.5 M women die from pregnancy-related causes including anaemia.

• Anaemia is a problem of global public health importance & is the 8th leading cause Anaemia is a problem of global public health importance & is the 8th leading cause

of disease in girls and women in SSA.of disease in girls and women in SSA.

• Anaemia result in Anaemia result in 20% of maternal deaths in SSA.20% of maternal deaths in SSA.

• Maternal mortality resulting from anaemia affect 34/100,000 live births in Nigeria.Maternal mortality resulting from anaemia affect 34/100,000 live births in Nigeria.

• In pregnancy, anaemia has a significant impact on the health of the foetus & In pregnancy, anaemia has a significant impact on the health of the foetus &

mother. mother.

• Foetuses are at risk of preterm deliveries, low birth weights, morbidity and perinatal Foetuses are at risk of preterm deliveries, low birth weights, morbidity and perinatal

mortality due to the impairment of oxygen delivery to placenta and foetus.mortality due to the impairment of oxygen delivery to placenta and foetus.

• Women in SSA patronise traditional birth attendants (TBA).Women in SSA patronise traditional birth attendants (TBA).

• Unbooking and late antenatal booking exist in Nigeria ( 9.9% booked in the 1Unbooking and late antenatal booking exist in Nigeria ( 9.9% booked in the 1stst

trimester).trimester).

Study DesignStudy Design

• This study was a prospective observational study

aimed at investigating the prevalence of anaemia

among pregnant women attending antenatal care in

Sokoto, North Western Nigeria.

Materials and MethodMaterials and Method

• This study involved 403 consecutively-recruited pregnant This study involved 403 consecutively-recruited pregnant

women attending ANC in Sokoto, Nigeria. women attending ANC in Sokoto, Nigeria.

• Qualitative data was collected using questionnaire. Qualitative data was collected using questionnaire.

• 3mls of blood was collected into EDTA anticoagulated 3mls of blood was collected into EDTA anticoagulated

blood tubes. blood tubes.

• PCV and HB was determined using the SWELAB 3 part-PCV and HB was determined using the SWELAB 3 part-

differential Haematology analyzer (Medonic of Sweden). differential Haematology analyzer (Medonic of Sweden).

Statistical AnalysisStatistical Analysis

• Data was analyzed using SPSS statistical software version 17.0. Data was analyzed using SPSS statistical software version 17.0.

• Data were expressed as percentages and means. Data were expressed as percentages and means.

• The proportion of women with anaemia was compared against The proportion of women with anaemia was compared against

socio-demographic, economic and obstetrics variables using chi socio-demographic, economic and obstetrics variables using chi

square statistical test. square statistical test.

• Multivariate logistic regressions were employed for variables Multivariate logistic regressions were employed for variables

associated with anaemia. associated with anaemia.

• A p-value of ≤ 0.05 was considered significant in all statistical A p-value of ≤ 0.05 was considered significant in all statistical

analysis.analysis.

Inclusion and exclusion criteriaInclusion and exclusion criteria

• Inclusion criteria included; age (≥ 18 years), history of Inclusion criteria included; age (≥ 18 years), history of

pregnancy, willingness to offer verbal informed consent to pregnancy, willingness to offer verbal informed consent to

partake in the study.partake in the study.

• Exclusion Criteria; Non-pregnant women, pregnant non- Exclusion Criteria; Non-pregnant women, pregnant non-

consenting women and pregnant women on haematinics, consenting women and pregnant women on haematinics,

long-term medication and those with history of pregnancy long-term medication and those with history of pregnancy

induced hypertension (PIH), pre-eclampsia and bleeding induced hypertension (PIH), pre-eclampsia and bleeding

disorders were excluded from this study.disorders were excluded from this study.

ResultsResults

• Subjects included 403 pregnant women aged 18-44 years with mean age of Subjects included 403 pregnant women aged 18-44 years with mean age of

32.32 ± 10.60 years.32.32 ± 10.60 years.

• Mean PCV & HB levels were significantly lower among pregnant subjects Mean PCV & HB levels were significantly lower among pregnant subjects

compared to non – pregnant controls (p=0.001). compared to non – pregnant controls (p=0.001).

• Out of the 403 women, 228 (56.6%) had HB levels <10g/dl (anaemic) while 175 Out of the 403 women, 228 (56.6%) had HB levels <10g/dl (anaemic) while 175

(43.4%) were non- anaemic. (43.4%) were non- anaemic.

• Anaemia was marginally higher among pregnant subjects in the 15-19 years Anaemia was marginally higher among pregnant subjects in the 15-19 years

age group.age group.

• Anaemia was significantly lower among highly educated subjects compared to Anaemia was significantly lower among highly educated subjects compared to

less educated subjects. less educated subjects.

• Anaemia was marginally higher among less-remunerated subjects. Anaemia was marginally higher among less-remunerated subjects.

ResultsResults

• Anaemia was significantly higher among pregnant women in polygamous Anaemia was significantly higher among pregnant women in polygamous

compared to monogamous relationships. compared to monogamous relationships.

• Anaemia was more prevalent among teenage pregnant subjects (< 18 years Anaemia was more prevalent among teenage pregnant subjects (< 18 years

of age).of age).

• Anaemia was higher among multigravidae compared to primgravidaeAnaemia was higher among multigravidae compared to primgravidae

• Anaemia was more prevalent among pregnant subjects with < 24 months Anaemia was more prevalent among pregnant subjects with < 24 months

inter pregnancy intervals compared to those >24 months.inter pregnancy intervals compared to those >24 months.

• Anaemia was higher among grand multiparous Anaemia was higher among grand multiparous women compared to women compared to

primiparous subjects.primiparous subjects.

• There was no significant difference in the prevalence of anaemia based on There was no significant difference in the prevalence of anaemia based on

religious affiliationreligious affiliation..

Table 1: Prevalence of anaemia based on age and Table 1: Prevalence of anaemia based on age and educational statuseducational status

VariableVariable N (%)N (%) AnaemicAnaemic

N (%)N (%)

Non-Non-

AnaemicAnaemic

N (%)N (%)

Mean (SD)Mean (SD)

HBHB

Mean (SD)Mean (SD)

PCVPCV

p-valuep-value

Age groups (years)Age groups (years)

15-1915-19 17 (4.2)17 (4.2) 6 (35.3)6 (35.3) 11 (64.7)11 (64.7) 10.2 (0.8)10.2 (0.8) 30.7 (2.1)30.7 (2.1) 0.155 0.155

20-2420-24 120 (29.9)120 (29.9) 66 (55.0)66 (55.0) 54 (45.0)54 (45.0) 9.7 (1.3)9.7 (1.3) 29.3 (3.5)29.3 (3.5)

25-2925-29 162 (40.4)162 (40.4) 89 (54.9)89 (54.9) 73 (45.1)73 (45.1) 9.9 (1.3)9.9 (1.3) 30.0 (3.6)30.0 (3.6)

30-3430-34 74 (18.4)74 (18.4) 45 (60.8)45 (60.8) 29 (39.2)29 (39.2) 9.7(0.9)9.7(0.9) 29.4 (2.6)29.4 (2.6)

35-3935-39 24 (6.0)24 (6.0) 18 (75.0)18 (75.0) 6 (25.0)6 (25.0) 9.5 (1.4)9.5 (1.4) 28.9 (4.1)28.9 (4.1)

40-4440-44 6 (1.5)6 (1.5) 4 (66.7)4 (66.7) 2 (33.3)2 (33.3) 9.6 (0.1)9.6 (0.1) 29.0 (0.2)29.0 (0.2)

Educational LevelEducational Level

TertiaryTertiary 33 (8.2)33 (8.2) 12 (36.4)12 (36.4) 21 (63.6)21 (63.6) 10.0 (1.2)10.0 (1.2) 30.4 (3.2)30.4 (3.2) 0.034*0.034*

SecondarySecondary 133 (33.0)133 (33.0) 79 (59.4)79 (59.4) 54 (40.6)54 (40.6) 9.8 (1.2)9.8 (1.2) 29.7 (3.3)29.7 (3.3)

PrimaryPrimary 140 (35.0)140 (35.0) 68 (48.6)68 (48.6) 72 (51.4)72 (51.4) 9.5 (1.5)9.5 (1.5) 28.9 (4.5)28.9 (4.5)

Non-formalNon-formal 97 (24.0)97 (24.0) 60 (61.9)60 (61.9) 37 (38.1)37 (38.1) 9.4 (1.2)9.4 (1.2) 28.5 (4.5)28.5 (4.5)

Table 2: Prevalence of anaemia based on incomeTable 2: Prevalence of anaemia based on income

IncomeIncome N (%)N (%) AnaemicAnaemic

N (%)N (%)

Non-Non-

AnaemicAnaemic

N (%)N (%)

Mean (SD)Mean (SD)

HBHB

Mean (SD)Mean (SD)

PCVPCV

p-valuep-value

< 10,000< 10,000 66 (17.0)66 (17.0) 34 (51.5)34 (51.5) 32 (48.5)32 (48.5) 9.9 (1.3)9.9 (1.3) 29.8 (3.7)29.8 (3.7) 0.6780.678

11,000-11,000-

20,00020,000

83 (21.0)83 (21.0) 49 (59.0)49 (59.0) 34 (41.0)34 (41.0) 9.7 (1.3)9.7 (1.3) 29.4 (3.4)29.4 (3.4)

21,000-21,000-

30,00030,000

16 (4.0)16 (4.0) 7 (43.8)7 (43.8) 9 (56.3)9 (56.3) 9.7 (1.5)9.7 (1.5) 28.8 (5.2)28.8 (5.2)

31,000-31,000-

50,00050,000

90 (23.0)90 (23.0) 39 (43.3)39 (43.3) 51 (56.7)51 (56.7) 9.9 (1.1)9.9 (1.1) 30.1 (3.1)30.1 (3.1)

> 500,000> 500,000 148 (36.7)148 (36.7) 63 (42.6)63 (42.6) 85 (57.4)85 (57.4) 9.7 (1.1)9.7 (1.1) 29.4 (3.1)29.4 (3.1)

Table 2: Prevalence of anaemia based on type of marriage type, religious Table 2: Prevalence of anaemia based on type of marriage type, religious affiliations & age at time of marriageaffiliations & age at time of marriage

VariableVariable N (%)N (%) AnaemicAnaemic

N (%)N (%)

Non-Non-

AnaemicAnaemic

N (%)N (%)

Mean (SD)Mean (SD)

HBHB

Mean (SD)Mean (SD)

PCVPCV

p-valuep-value

Type of marriageType of marriage

MonogamousMonogamous 284 (70.0)284 (70.0) 106 (41.7)106 (41.7) 148 (58.3)148 (58.3) 9.8 (1.3)9.8 (1.3) 29.6 (3.4)29.6 (3.4) 0.01*0.01*

PolygamousPolygamous 119 (30.0)119 (30.0) 80 (53.7)80 (53.7) 69 (46.3)69 (46.3) 98 (1.2)98 (1.2) 29.6 (3.4)29.6 (3.4)

Religious AffiliationsReligious Affiliations

ChristianChristian 55 (14.0)55 (14.0) 34 (61.8)34 (61.8) 21 (38.2)21 (38.2) 10.0 (1.3)10.0 (1.3) 30.7 (4.0)30.7 (4.0) 0.8360.836

MuslimMuslim 348 (86.0)348 (86.0) 194 (55.8)194 (55.8) 154 (44.2)154 (44.2) 9.8 (1.2)9.8 (1.2) 29.5 (3.4)29.5 (3.4)

Age at time of marriage (Years)Age at time of marriage (Years)

< 18< 18 78 (19.4)78 (19.4) 45 (57.7)45 (57.7) 33 (42.3)33 (42.3) 9.7 (1.1)9.7 (1.1) 29.4 (3.4)29.4 (3.4) 0.4640.464

> 18> 18 325 (80.6)325 (80.6) 183 (56.3)183 (56.3) 142 (43.7)142 (43.7) 9.8 (1.2)9.8 (1.2) 29.7 (3.4)29.7 (3.4)

Table 1: Major Triad responsible for anaemia in SSA Table 1: Major Triad responsible for anaemia in SSA

DiscussionDiscussion

• Our study is in agreement with advocacy (SOGON, 2004) that HB & PCV & indices of Our study is in agreement with advocacy (SOGON, 2004) that HB & PCV & indices of

anaemia is vital in evaluating the risk of anaemia and interventionanaemia is vital in evaluating the risk of anaemia and intervention

• Our observed anaemia prevalence (56.6%) is consistent with a previous report which Our observed anaemia prevalence (56.6%) is consistent with a previous report which

indicated that the anaemia is a significant challenge in pregnant women (Ayoya et al., 2011). indicated that the anaemia is a significant challenge in pregnant women (Ayoya et al., 2011).

• Our observed prevalence is however lower than;Our observed prevalence is however lower than;

70% reported in Lagos (Anorlu et al., 2001)70% reported in Lagos (Anorlu et al., 2001)

67.4% in Enugu (Iloabachie and Meniru, 1990)67.4% in Enugu (Iloabachie and Meniru, 1990)

76.5% in Ibadan (Idowu et al., 2005)76.5% in Ibadan (Idowu et al., 2005)

59.6% in Calabar (Agan et al 2010)59.6% in Calabar (Agan et al 2010)

62.2% in Ile Ife (Komolafe et al., 2005)62.2% in Ile Ife (Komolafe et al., 2005)

66.0% in Burkina Faso (Meda et al., 1999)66.0% in Burkina Faso (Meda et al., 1999)

53.9% in Southwest Ethiopia (Gatachew et al., 2012). 53.9% in Southwest Ethiopia (Gatachew et al., 2012).

DiscussionDiscussion

Our observed prevalence is higher than;Our observed prevalence is higher than;

• 30.4% prevalence observed in Ethiopia (Jemal et al., 2010)30.4% prevalence observed in Ethiopia (Jemal et al., 2010)

• 15.3% in Trinidad and Tobago (Uche - Nwaichi et al., 2010)15.3% in Trinidad and Tobago (Uche - Nwaichi et al., 2010)

• 38.8% in Port – Novo Cape Verde (Okeke, 2011)38.8% in Port – Novo Cape Verde (Okeke, 2011)

• 27.4% in Thailand (Tippawan, 2011)27.4% in Thailand (Tippawan, 2011)

• 42.2% in Oman (Yahya et al., 2011)42.2% in Oman (Yahya et al., 2011)

• 40.8% in Western Algeria (Demmouche et al.,2011)40.8% in Western Algeria (Demmouche et al.,2011)

• 51.8% observed in Gombe State (Bukar et al., 2008)51.8% observed in Gombe State (Bukar et al., 2008)

• 40.4% in Enugu (Dim and Onah, 2007)40.4% in Enugu (Dim and Onah, 2007)

• 30% in Ibadan (Olubukola et al., 2011)30% in Ibadan (Olubukola et al., 2011)

• 17% in Kano (Nwizu et al., 2011)17% in Kano (Nwizu et al., 2011)

• 50% in Brazil (Ferreira et al.,2008) 50% in Brazil (Ferreira et al.,2008)

• 46.2% in Benin City (Bankole et al., 2012). 46.2% in Benin City (Bankole et al., 2012).

DiscussionDiscussion

Our observed prevalence was higher for several reasons;Our observed prevalence was higher for several reasons;

• Our study used HB cutoff value of 10g/dl compared to other which Our study used HB cutoff value of 10g/dl compared to other which

used the WHO HB cutoff value of 11.0g/dl. used the WHO HB cutoff value of 11.0g/dl.

• Haemoglobin cutoff of 11.0g/dl derived from the West continues to Haemoglobin cutoff of 11.0g/dl derived from the West continues to

be used erroneously as diagnostic for anaemia among Africans. be used erroneously as diagnostic for anaemia among Africans.

• It may be appropriate to have a separate criteria for all Africans to It may be appropriate to have a separate criteria for all Africans to

accommodate the subset with lower haemoglobin.accommodate the subset with lower haemoglobin.

• Previous report found that race-specific anaemia criteria of 10 g/l Previous report found that race-specific anaemia criteria of 10 g/l

yielded a comparable sensitivity and specificity among Africans.yielded a comparable sensitivity and specificity among Africans.

DiscussionDiscussion

The prevalence of anaemia was higher among grand The prevalence of anaemia was higher among grand

multiparous multiparous women compared to multiparous woman and women compared to multiparous woman and

primiparous subjects.primiparous subjects.

• Previous report indicates that grand multipara are a high risk Previous report indicates that grand multipara are a high risk

obstetric patients.obstetric patients.

• Improving the socio-economic standard of women and Improving the socio-economic standard of women and

increased awareness on the importance of family planning increased awareness on the importance of family planning

can reduce the incidence and complications of can reduce the incidence and complications of

grandmultiparity (Ikeako et al., 2011). grandmultiparity (Ikeako et al., 2011).

DiscussionDiscussion

Anaemia was higher among less educated, poor remunerated Anaemia was higher among less educated, poor remunerated

pregnant women in polygamous relationships. pregnant women in polygamous relationships.

• Several factors contribute to the high rates of maternal Several factors contribute to the high rates of maternal

anaemia in Nigeria widespread nutritional deficiencies; high anaemia in Nigeria widespread nutritional deficiencies; high

incidence of infectious diseases; low access to and poor incidence of infectious diseases; low access to and poor

quality of health services; low literacy rates; ineffective quality of health services; low literacy rates; ineffective

design, implementation and evaluation of anaemia control design, implementation and evaluation of anaemia control

programmes and poverty (Ayoya et al., 2012). programmes and poverty (Ayoya et al., 2012).

DiscussionDiscussion

• Previous report (Zahira, 2012) indicates that a significant relationship exist between Previous report (Zahira, 2012) indicates that a significant relationship exist between

low socio-economic status and anaemia among pregnant women.low socio-economic status and anaemia among pregnant women.

• Highly educated people have a greater access to finance & information & are more Highly educated people have a greater access to finance & information & are more

likely to make more evidenced –based & informed decisions concerning their likely to make more evidenced –based & informed decisions concerning their

nutrition, health & well-being (Rao et al., 2011). nutrition, health & well-being (Rao et al., 2011).

• Previous report indicates a high prevalence of micronutrient deficiencies (folic acid, Previous report indicates a high prevalence of micronutrient deficiencies (folic acid,

zinc, iron, copper, and magnesium) amongst pregnant women of low zinc, iron, copper, and magnesium) amongst pregnant women of low

socioeconomic status (Pathak et al., 2004).socioeconomic status (Pathak et al., 2004).

• Women in polygamous relationships are prone to less care, lessWomen in polygamous relationships are prone to less care, less empowered, are empowered, are

often victims of often victims of domestic violence & abuse. domestic violence & abuse.

• Men in polygamous relationships are less likely to invest time & resources in the Men in polygamous relationships are less likely to invest time & resources in the

care & support for their pregnant wives (care & support for their pregnant wives (Al-Krenawi, 2012, Al-Krenawi, 2012, Upadhyay et al., 2012). Upadhyay et al., 2012).

DiscussionDiscussion

The reasons for the high prevalence of anaemia in this study and developing The reasons for the high prevalence of anaemia in this study and developing

countries are multi-factorial and includes; countries are multi-factorial and includes;

•Iron deficiencyIron deficiency

•Other micronutrient deficiencyOther micronutrient deficiency

•Excessive blood lossExcessive blood loss

•HaemogobinopathiesHaemogobinopathies

•Malaria & other parasitic infections (hookworm and schistosomiasis infestation).Malaria & other parasitic infections (hookworm and schistosomiasis infestation).

•HIV-infection HIV-infection

•MalnutritionMalnutrition

•Multiparity and inadequate child spacingMultiparity and inadequate child spacing

•Low socioeconomic status (Agan et al., 2010, Bankole et al., 2012).Low socioeconomic status (Agan et al., 2010, Bankole et al., 2012).

DiscussionDiscussion

• Prevalence of anaemia was higher among pregnant women in Prevalence of anaemia was higher among pregnant women in

the 15-19 age group and among women who got married at < 18 the 15-19 age group and among women who got married at < 18

years compared to those who got married at > 18 years. years compared to those who got married at > 18 years.

• Adolescent pregnancy is an increasing challenge particularly in Adolescent pregnancy is an increasing challenge particularly in

Northern Nigeria and most developing countries (Ogele et al., Northern Nigeria and most developing countries (Ogele et al.,

2011). 2011).

• Previous report indicates that age of the pregnant women plays Previous report indicates that age of the pregnant women plays

a significant role in the prevalence of anaemia (Gibbs et al., 2012 a significant role in the prevalence of anaemia (Gibbs et al., 2012

and Olubukola et al., 2011).and Olubukola et al., 2011).

Conclusion and recommendationConclusion and recommendation

This present shows a high prevalence of anaemia among pregnant women in Sokoto, This present shows a high prevalence of anaemia among pregnant women in Sokoto,

Nigeria. Nigeria.

• We advocate for targeted iron supplementation for pregnant women. We advocate for targeted iron supplementation for pregnant women.

• Routine haemoglobin and haematocrit should be included in antenatal care protocol of Routine haemoglobin and haematocrit should be included in antenatal care protocol of

pregnant women. pregnant women.

• We recommend the implementation of WHO recommendation of provision of We recommend the implementation of WHO recommendation of provision of

antihelminthic therapy (third trimester) to control hookworm and other helminthic antihelminthic therapy (third trimester) to control hookworm and other helminthic

infections.infections.

• There is also the need for the promotion of insecticide-treated bed nets. There is also the need for the promotion of insecticide-treated bed nets.

• Provision of intermittent preventive treatment (IPTp) to protect pregnant women. Provision of intermittent preventive treatment (IPTp) to protect pregnant women.

• Mass media campaigns & peer outreach education are required to educate women on Mass media campaigns & peer outreach education are required to educate women on

the advantages of early ANC booking & compliance with prescribed medications. the advantages of early ANC booking & compliance with prescribed medications.

AcknowledgementAcknowledgement

• My sincere thanks goes to the My sincere thanks goes to the management of OMICS group (USA), management of OMICS group (USA),

UDUS and UDUTH for their sponsorship to make attendance to this UDUS and UDUTH for their sponsorship to make attendance to this

conference a reality.conference a reality.

• We are grateful to the subjects and staff of the Haematology We are grateful to the subjects and staff of the Haematology

Department of UDUTH and UDUS for their collaboration.Department of UDUTH and UDUS for their collaboration.

• I acknowledge my co-authors;I acknowledge my co-authors; Dr. Ahmed Y, Dr. John RT , Mr Dr. Ahmed Y, Dr. John RT , Mr Isaac Isaac

IZ; Mr IsahIZ; Mr Isah BA and Miss BA and Miss Ukatu S (Translated)Ukatu S (Translated)..

ReferencesReferences

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QuestionQuestion

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