Prevalence and Risk Factors of Anemia among Antenatal Mothers Registered at a District Hospital in North India: A Cross-sectional Record Based Study

Introduction

Anemia is one of the common diseases prevalent in all age groups affecting majority of population in India and globally, especially women, children and elderly, due to its multifactorial etiology including nutritional causes viz., deficiency of iron, vitamin B₁₂, folic acid and protein; blood loss due to hemorrhoids, ulcers, trauma, surgery, menstruation, delivery; drug related, especially anticancer drugs; genetic disorders like thalassemia, sickle cell anemia, etc. Thus anemia has multifactorial causation; however, iron deficiency is undoubtedly the most significant cause of nutritional anemia globally.¹

According to United Nations (U.N.) declaration in 1997, anemia is a major public health problem. Globally two million people suffer from anemia or iron deficiency.² World Health Organization (WHO) estimated the prevalence of anemia in pregnant women to be 14% in developed and 51% in developing countries, while it was estimated to be 65% -75% in India.³ Anemia in pregnancy accounts for 1/5th of maternal deaths globally and India alone has a major share of about 80% of the maternal deaths in South Asia.⁴ About 50% of maternal deaths occur in the first 24 hours following birth, mostly due to PPH (post-partum hemorrhage), of which anemia is one of the most important causes.⁵

Anemia is the most common disorder which contributes significantly to high maternal mortality besides various other adverse effects on the mother and her fetus like developmental anomalies, IUGR (intra-uterine growth retardation), abortions, preterm deliveries, low birth weight, and even intra-uterine, perinatal and neonatal deaths, besides various other associated maternal symptoms such as palpitations, tachycardia, breathlessness, pre-eclampsia, PPH, sepsis and increased cardiac output leading to cardiac stress which may inturn cause cardiac failure.⁶

Hb estimation is the most practical and cost-effective method of diagnosis of anemia. As per World Health Organization, anemia in pregnancy is categorized into three categories based on measurement of Hb concentration viz., (i) Mild – 10-10.9 gm% (ii) Moderate - 07-9.9 gm% and (iii) Severe – lower than 07 gm%.⁷

Iron deficiency is probably the most common nutritional deficiency in the world and it exists ubiquitously among all kinds of anemia during pregnancy due to high fetal demands for iron. Besides iron deficiency, other risk factors associated with anemia in pregnancy are malnutrition, unhealthy lifestyle, hemoglobinopathies, age (<20 years or > 35 years), twin or multiple pregnancies, repeated and closely-spaced pregnancies, smoking, alcohol abuse, history of menstrual disorders or past infections.^8,9

India became the first developing nation to take up National Nutritional Anemia Prophylaxis program (NNAP) to prevent anemia among pregnant women which was initiated in 1970 during the 4^th five- year plan with the aim of reducing prevalence of anemia to 25%.¹⁰ Supply of free iron pills, free investigations and treatment, conduct of regular Antenatal care (ANC) clinics under various schemes like Janani Surakhsha Yojna, Janani Sishu Surakhsha Karyakaram, Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) is being provided to pregnant mothers in India.

As per guidelines of Ministry of Health & Family Welfare, Government of India, a daily dose of 100 mg of elemental iron with 0.5 mg folic acid is recommended for 180 days during second and third trimesters and is adequately available in all government health institutions across India.¹⁰ Irrespective of the availability and affordability of low cost effective interventions for prevention and treatment of anemia among pregnant women, its prevalence is still high in India.³ With this background, the present study was conceptualized with the objective of studying the prevalence of anemia and its associated risk factors among pregnant women attending a secondary level health care center in North India.

Materials and Methods

A retrospective study of records maintained in Antenatal Care register at District Hospital Udhampur, in Udhampur district of the union territory of Jammu and Kashmir from 01/03/2018 to 28/02/2019 i.e., one year, was conducted to study the prevalence of anemia among registered pregnant females. Permission for collection of data was taken separately from the concerned hospital authority.

The relevant information for each registered case/ antenatal female from the antenatal register including age, order of pregnancy, last menstrual period, expected date of delivery, number of antenatal check-ups, tetanustoxoid immunization, iron-folic acid supplementation, weight and blood pressure measurement, hemoglobin estimation, date and type of delivery, pregnancy outcome and weight at birth was recorded. All the data was scrutinized and compiled in MS-Excel. The registered females were further grouped according to age, religion, immunization status, order of pregnancy etc. using percentages and proportions. The association of anemia with variables such as age of mother, order of pregnancy, tetanus toxoid immunization, iron folic acid intake, type of delivery, pregnancy outcome and birth weight was studied using Chi square test for trends in an open-source software Open Epi version 3.01.

Results

Mean age of antenatal females was 27.68±4.59 years (Range: 18 – 45 years). As observed in Table 1, maximum number of pregnant women were in the age group of 25 to 34 years (n=122), and least in the age group of >35 years (n=13). Majority were Hindus by religion (93.30%) and first- time mothers (62.57%). About 160 (89.38%) had taken either two doses of TT or Booster in the current pregnancy and were considered fully immunized, while 16 (8.94%) had taken only the first dose and only three (1.68%) were unimmunized. There were only 3.92% of pregnant women who had not taken IFA supplementation. A total of 97.21% (n=174) pregnant mothers were found to be anemic in the present study. About 141women (78.77%) delivered normally and one fifth (n=38) delivered through LSCS. No still births were reported. Four-fifths of registered females delivered neonates with normal birth weight (≥2.5 kg) whereas approximately 20% delivered neonates with low birth weight (<2.5 kg).

As seen in Table 2, 35 (19.55%) pregnant women were mildly anemic, 106 (59.22%) had moderate anemia and 33 (18.44%) were severely anemic. More than half of females in each age group were moderately anemic. Moderate anemia was highest in second order pregnancies (62.5%) while severe anemia was highest in third order pregnancies (26.32%). When association of anemia was compared between age groups <25 years and ≥25 years and between first order and ≥ 2nd order pregnancies using Chi square for trends, both the groups were comparable as there was no statistically significant difference between the two groups. However, regarding TT immunization, there was statistically significant difference (p=0.002) between females who had received first, second or booster dose during current pregnancy and those who were unimmunized. Among women who had taken IFA, only 17.44% were severely anemic as against 42.86% severely anemic women among those who did not take IFA; but these differences were not statistically significant. Similarly, percentage of severe anemia was higher among caesarean deliveries (28.95%) in comparison to normal deliveries (15.60%).

No still births were reported but there was statistically significant difference (p=0.017) between hemoglobin levels of women who delivered low birth weight babies and those who delivered normal weight babies.

Discussion

The present study revealed a very high prevalence of anemia i.e., 97.21% among pregnant mothers which is in accordance with the studies of Toteja GS et al. and Sharma JB et al. who reported the percentage of prevalence of anemia as 84.9% in 16 districts of 11 states of India and 96% in Delhi, respectively.^11,12 Faruk Ahmed reported the prevalence of anemia to be 49% among pregnant women in rural Bangladesh, whereas De Benoist et al. reported world-wide prevalence of anemia (1993-2005, WHO Global Database) as 41.8%.^13,14 Another national survey reported 47.5% of the pregnant mothers to be anemic, while another survey conducted in Ethiopia observed an overall prevalence of anemia as 21.3%; but these figures are much lower than the present study.^15,16

In the current study, percentages of mild, moderate and severe anemia were recorded as 19.55%, 59.22% and 18.44%, respectively. However, Toteja G.S. et al. and Sharma JB et al. reported lower percentage of severe anemia to the tune of 13.1% and 5.3%, respectively, while EN Nwizu et al. reported 12.7% and 4.3% of the women to be having mild and moderate anemia, respectively.^11,12,17

Regarding overall immunization coverage, the present study revealed that 98.32% of pregnant females received at least one dose of tetanus toxoid (T.T.) immunization. Banerjee reported that 80% of pregnant mothers were immunized for T.T., which is in concordance with the present study.¹⁸ Another study in Jammu region also reported that 86.7% of pregnant women were covered under TT immunisation.¹⁹ In contrast, a lower coverage for T.T. (42%) was recorded in Bihar by Yadav and Singh.²⁰ Regarding full immunization, the present study showed that 89.38% pregnant females were fully immunized which is in contrast to the findings of other studies conducted in Ethiopia and Delhi that reported 51.8% uptake of T.T among mothers who gave birth in the past 12 months and 54.6% among pregnant females, respectively.^21,22 Metgud et al, found that 70.77% pregnant females had received either two doses or one booster dose, whereas Singh and Yadav (2000) reported that 53% of pregnant women had taken either both the doses of T.T. immunization or a booster dose.^23,24 Similarly, Rafiq et al. observed in his study that only 50.9% of pregnant women were fully immunized in Srinagar.25 The present study also revealed that only 8.94% of pregnant mothers were partially immunized which is in contrast to a much higher percentage of 49.41% and 42.6% found by Rafiq et al. and Talwar et al., respectively in their studies.^22,25 Also 1.68% pregnant women were not immunized in this study whereas 10.8% was the observed proportion for the same by Agarwal OP et al. ²⁶

The current study also showed that 96.08% pregnant women had taken iron-folic acid tablets, whereas studies conducted by other authors reported that 59.68%, 52.6% and 32.62% had taken IFA supplementation, respectively.^19,23,25 However, a much lower coverage of only 5.8% was reported by Lal et al. in his study,²⁷ while another study in East Delhi reported that 27.2 percent antenatal females did not receive any iron/folic acid tablets.²⁶

The present study revealed that 100%, 95.9% and 100% mothers among all pregnant women were anemic corresponding to the age group of 18-24 years, 25-34 years and greater than 35 years, respectively. Alemayehu and Zewde observed in their cross-sectional study that 32.4%, 41.9% and 33.3% of pregnant mothers were anemic corresponding to the age range of 32-38 years, 39-45 years and >45 years, respectively.¹⁶

Regarding the pregnancy outcome, in the present study, 100% of live births were recorded and not even a single case of still birth was noted. This is in accordance with the study conducted by Manpreet Kaur et al. who also reported zero cases of still birth.²⁸

The present study revealed that 19.55% neonates were born with low birth weight in contrast to the findings of Rahman MM et al. who reported 12% low-birth-weight babies overall in low and middle-income countries and attributed it to maternal anemia.²⁹

Conclusion

It was concluded from the present study that anemia continues to be a major public health challenge and unrelenting measures should be taken to eradicate maternal anemia at individual and community levels, which include awareness of mothers regarding anemia, its causes and implications, nutritional supplementation, dietary intake of iron, proteins, locally available fruits and vegetables especially rich in iron, maximum compliance to prescribed iron supplements, antenatal visits, etc. This is achievable through frequent visits by the teams of ASHA, Anganwadi worker and ANM (Auxiliary Nursing Midwife) to the homes of pregnant mothers. Concerted efforts for thorough implementation of various national schemes and programs designed for antenatal females are the need of the hour so that the goal of ‘anemia mukt bharat’ is achieved.

Conflicts of Interests

Nil