International Journal of Food Sciences and Nutrition,

September 2011; 62(6): 585592

Risk factors associated with anemia and iron deficiency among Kuwaiti
pregnant women
FARUK AHMED1 & MONA A. AL-SUMAIE2
Department of Family Sciences, College for Women, Kuwait University, Safat, Kuwait, and 2Community Nutrition Promotion
Department, Food and Nutrition Administration, Ministry of Health, Kuwait

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Abstract
A cross-sectional study was carried out to indentify the risk factors of anemia and iron deficiency in Kuwaiti pregnant women.
Pregnant women (n 465) aged 18 47 years, of 4 39 weeks at gestation were recruited during antenatal visits from six health
facilities in Kuwait. Socio-demographic, pregnancy-related and dietary information were collected. Hemoglobin, serum ferritin
and serum C-reactive protein concentrations were determined. Logistic regression analysis revealed that iron deficiency and not
taking iron-folate tablets or taking them occasionally were the two most important risk factors associated with anemia. Pregnant
women with higher gestational age, short birth spacing (# 2 years), not taking iron-folate tablets or taking them occasionally, not
consuming fruit juice, and consuming brown bread, tea and/or coffee were significant risk factors associated with iron deficiency.
In conclusion, various factors including dietary habits appeared to be associated with poor iron status, which is the most
important risk factor for anemia among Kuwaiti pregnant women.

Keywords: Anemia, iron deficiency, iron-deficiency anemia, risk factors, pregnant women, Kuwait

Introduction
Anemia is recognized as the worlds most widespread
nutritional disorder, affecting 1.6 billion people that
constitute about 25% of the global population (WHO
2008). Iron deficiency (ID) is considered to be the
main cause of anemia, especially among young
children and pregnant women, who are at increased
risk due to their increased requirement (Allen and
Casterline-Sabel 2001). Deficiency of other nutrients
such as vitamins A, C, B2, B12 and folic acid may also
cause anemia (Fishman et al. 2000). Other identified
non-nutritional causes of anemia include malaria
(Stoltzfus et al. 1996, Dreyfuss et al. 2000), hookworm infestation (Stoltzfus et al. 1996), chronic
infection and inflammation (Jansson et al. 1986), and
hemoglobinopathies such as thalassemia (Linpinsarn
et al. 1996).
Anemia has been reported to contribute significantly to maternal morbidity (Harrison 1988) and
mortality (Brabin et al. 2001). Iron-deficiency anemia
(IDA) in pregnancy poses serious risks to the
offspring, including preterm delivery and subsequent

low birth weight and possibly poor neonatal health

(Scholl and Hediger 1994, Allen 2000). ID in
pregnancy is also a risk factor for infant IDA (Kilbride
et al. 1999) that, if left uncorrected, can be associated
with adverse behavioral and cognitive development
(Allen 2000). Further evidence relates ID during
pregnancy with poor fetal growth and increased risks
later in life of chronic diseases, such as heart disease,
hypertension and maturity-onset diabetes (Hales and
Barker 2001).
Over the past few decades, several studies have
shown that anemia is a significant public health
problem in Kuwait. However, most of these studies
were conducted in preschool children, adolescents and
in non-pregnant women (Jackson et al. 1999, Jackson
and Al-Mousa 2000, Ministry of Health 2005). Only a
few studies in the early 1990s have reported anemia
in pregnant women as the focal group. For example,
Dawood et al. (1990) conducted a survey among
pregnant women aged between 14 and 45 years living
in Kuwait and reported a prevalence of 36.8% for

Correspondence: Dr Faruk Ahmed, Associate Professor, Department of Family Sciences, College for Women, Kuwait University, Safat, Kuwait.
Tel: 965 2498 3164. Fax: 965 2251 3929. E-mail: fahmed_001@yahoo.com.au
ISSN 0963-7486 print/ISSN 1465-3478 online q 2011 Informa UK, Ltd.
DOI: 10.3109/09637486.2011.566848

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586 F. Ahmed & M. A. AL-Sumaie

anemia. ID has often been claimed to be the
predominant cause of anemia in this population, but
mostly based on low hemoglobin levels, which is not
necessarily indicative of ID alone. To date, very few
studies have assessed the iron status using appropriate
indicators and examined the contribution of ID as a
risk factor for anemia in a Kuwaiti population (Jackson
et al. 1999, Jackson and Al-Mousa 2000). Furthermore, the etiologic factors responsible for anemia
among pregnant women are multiple and often
complex. For example, beside poor diet and nutrition,
frequent labor, multi-parity, close birth spacing and
infection were identified as the risk factors for anemia
in pregnant women (Bondevik et al. 2000, Musaiger
2002, Al-Suleiman et al. 2004, Rasheed et al. 2008).
To date, no systematic studies have been carried out to
explore the risk factors of anemia or ID in Kuwaiti
pregnant women. To design an effective intervention
program that can target the underlying causes and
prevent or treat anemia in this population group, it is
of paramount importance to identify the potential risk
factors for anemia and ID. Therefore, the present
study was designed to identify the potential risk factors
associated with anemia and ID among Kuwaiti
pregnant women.

Subjects and methods

Subjects
A total of 465 pregnant women, aged 1847 years, of
439 weeks at gestation were recruited during their
regular antenatal visit from six health facilities, one from
each of the six governorates (administrative division),
in Kuwait. Each subject was asked to give written
consent to her participation, before being accepted into
the study. The subjects with diabetes mellitus, edema
and albumin urea were excluded from the study. The
study was approved by the ethical committee of the
Faculty of Medicine, Kuwait University, Kuwait and
the Ministry of Health, Kuwait. The study was
conducted during JanuaryMarch 2009.

Sample size
The sample size was calculated based on two variables:
the prevalence of anemia and ID. On the basis of
an average prevalence (30%) of anemia among
pregnant women in the previous studies and with an
estimated 95% confidence interval of 25 35%, 323
subjects would be required to achieve a valid estimate
of prevalence. Since there were no data on the
prevalence of ID in this population, using 50%
prevalence of ID would increase the sample size to
385 subjects. We considered the larger (n 385) of
the above two estimates of sample size and, after
including a 20% allowance for any unforeseen errors in
data collection, the study required 462 women.

Data collection
At enrolment, socio-demographic information (age,
education and employment status) and pregnancy
history (parity and birth space from last pregnancy)
were obtained by trained interviewers. The gestational
age of the participants was estimated by counting the
weeks from the date of the participants last menstrual
period to the date of interview. Trained interviewers
administered a food frequency questionnaire (FFQ)
that emphasized food items that are rich sources of
iron, and foods that are known to enhance (rich in
vitamin C) or inhibit (high fiber, phytates and tannins)
dietary iron absorption, and consisted of 33 food items
commonly consumed by the study population. The
FFQ was adopted from a previously developed semiquantitative FFQ used to measure dietary pattern in
the United Arab Emirates and Kuwait (Dehghan et al.
2005). Information was also collected on the intake of
iron-folate tablets.
Biochemical measures
A sample of 5.0 ml venous blood was drawn from each
of the participants and an aliquot was placed in an
ethylenediamine tetraacetic acid (EDTA)-containing
tube with the remainder centrifuged for collection of
serum. The EDTA-treated aliquot was used for
measurement of hemoglobin (Hb). Appropriate
aliquots of serum were taken in separate tubes for
measurement of serum ferritin (SF) and serum Creactive protein (CRP). The Hb concentration was
measured by spectrophotometric method using
CELL-DYN 4000 Analyzer (Abbott Diagnostics,
Santaclara, CA, USA). The SF concentration was
determined by electrochemiluminescence immunoassay using cobase immunoassay analyzer (Roche
Diagnostics GmbH, Mannheim, Germany). The
sensitivity of the SF assay was 0.50 mg/l. For SF
assay, 433 samples were available with some samples
lost during analysis. Serum CRP concentrations were
measured using Beckman Coulter Image Immunochemistry system (Beckman Coulter UK Ltd, High
Wycombe, UK). Serum CRP was used as a marker of
acute inflammation/infection, since SF concentrations
become elevated in the presence of infection or
inflammation (Witte 1991, Thompson et al. 1992).
Statistical analysis
For each variable, normality of the distribution of data
was checked by the Kolmogorov Smirnov goodnessof-fit test. The Hb data were normally distributed;
thus data were presented as the mean ^ standard
deviation (SD). SF concentrations were skewed
towards higher values; thus medians were used as the
measure of central tendency. Where necessary, SF data
were normalized using natural log transformation.
For presentation, the values were back-transformed

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Iron deficiency among Kuwaiti pregnant women

to original units. Anemia was defined as Hb
concentration , 110.0 g/l (WHO 2001). The cut-off
point for defining ID using SF in pregnancy is not
well established as this can be affected by hemodilution. Two studies conducted in the developing
countries have used SF concentration , 10 mg/l to
classify ID in pregnant women (Dreyfuss et al. 2000,
Jiang et al. 2005). Therefore, we also used SF
concentration , 10.0 mg/l to define ID. The chisquare test was performed to detect the differences
between the prevalence of anemia and ID and
gestational age.
To assess the relationship of various socio-demographic, pregnancy-related factors and frequency of
intake of selected food items with Hb and SF
concentrations, the data were divided into groups,
either on the basis of prior logical categories or to
produce sizable number of subjects in each group. The
means and differences between groups were assessed
using analysis of variance followed by post-hoc Tukey test
where appropriate. Pearsons correlation test was also
used to assess the association of Hb and SF with various
factors. Multiple logistic regression (backward stepwise) analysis was carried out and odds ratios (ORs)
were used to identify the risk factors associated with
anemia and ID. Sets of variables that were significantly
associated with either anemia (anemia model) or ID (ID
model) in the bivariate analysis were entered into the
models. Statistical significance was defined as P # 0.05.
The data were analyzed using SPSS for Windows
(version 17; SPSS Inc., Chicago, IL, USA).

Results
The majority (60%) of the women were aged between
20 and 29 years (Table I). More than two-thirds of the
women (70.5%) completed at least secondary school
level. Nearly one-half (49.5%) of the women were
working and only 4.7% were students. About 22% of
the women were in their first pregnancy. Eight-five
percent of the women were either in the second or
third trimester. About 40% of the women had a birthspace # 2 years from last pregnancy. Sixty percent of
the women took iron-folate tablets regularly, and
17.6% had some forms of inflammation/infection,
judged by high serum CRP concentration
(CRP . 20.0 mg/l).
The overall prevalence of anemia (Hb , 110.0 g/l)
and ID (SF , 10.0 mg/l) were 24.1% and 41.3%,
respectively. The prevalence of anemia and ID
increased with the progress of pregnancy, but the
difference was significant only for ID (Table II).
Of all anemic pregnant women, 64% were found to
have IDA (Hb , 110.0 g/l and SF , 10.0 mg/l).
Furthermore, 34% of the women also had ID without
anemia. Anemic pregnant women had significantly
(P 0.001) lower SF concentrations than the women
who were not anemic (data not shown).

587

Table I. Characteristics of the study participants (n 465).

Variable
Age (year)
1819
2029
3039
4047
Level of education
Primary or less
Intermediary
Secondary
Diploma or above
Occupation
Housewife
Working
Student
Gestational period
First trimester
Second trimester
Third trimester
Parity
0
1 2
$3
Birth-interval (year)
#2
.2
Taking iron-folate tablets
Regularly
Never/occasionally
Serum C-reactive protein
Normal (#20.0 mg/l)
High (.20.0 mg/l)

12
279
157
17

2.6
60.0
33.7
3.7

18
119
89
239

3.9
25.6
19.1
51.4

230
213
22

45.8
49.5
4.7

69
229
167

14.8
49.2
36.0

100
93
272

21.5
20.0
58.5

184
281

39.6
60.4

281
184

60.4
39.6

383
82

82.4
17.6

A large majority of the pregnant women did not

consume beef (62.4%), goat or lamb (45.2%), fish
(54.6%), liver (87.3%) and white bread (74%) at all
during the week preceding the interview (Table III). On
the other hand, about 64% of the women had brown
bread, 29% had chicken, 52% had green leafy vegetables
(GLV), 36% had fruits, 27.5% had fruit juice, 46.5%
had coffee and 54% had tea at least once per day.
Compared with the pregnant women of their first
trimester, Hb and SF concentrations were significantly
(P 0.001) lower in pregnant women of the second
and third trimesters (Table IV). The less educated
women (primary or intermediary level) had significantly lower Hb (P 0.02) and SF concentrations
(P 0.004) than higher educated women (secondary
school certificate or above). The women who were
pregnant for the first time had significantly higher SF
concentration than the women with parity 3 or above
(P 0.015). The women with a birth-space $ 2 years
from the last pregnancy had significantly higher SF
concentrations than the women with a birth-space
# 2 years (P 0.012). The women who consumed
iron-folate tablets regularly had significantly higher
concentrations of Hb (P 0.008) and SF (P 0.001)
than those who either did not take iron-folate tablets at
all or took them occasionally.
The pregnant women who consumed brown bread
at least once a day had significantly lower SF

588 F. Ahmed & M. A. AL-Sumaie

Table II. Hemoglobin and serum ferritin concentrations, and prevalence of anemia and iron deficiency among the Kuwaiti pregnant women
by gestational period.
Percentile
Mean SD

Variable

Median

Prevalence (%)
25th

Hemoglobin (g/l)
First trimester (n 69)
Second trimester (n 229)
Third trimester (n 167)
Total (n 465)
Serum ferritin (mg/l)
First trimester (n 63)
Second trimester (n 209)
Third trimester (n 161)
Total (n 433)

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75th

121.4 13.8
117.0 10.3
114.9 10.4
116.9 11.1
22.6
11.1
9.8
11.1

10.5
7.2
6.7
7.2

36.1
18.1
15.4
18.9

Anemiaa
18.8
22.3
28.7
24.1
Iron deficiencyb
20.6
39.2
52.2
41.3

Defined using a cut-off point , 110.0 g/l for hemoglobin; b Defined using a cut-off point , 10.0 mg/l for serum ferritin.

concentration than those who consumed brown bread

less than once a day (Table V). The women who
consumed fruit juice at least once a week had
significantly higher SF concentration compared
with those who did not consume fruit juice at all.
The women who consumed tea or coffee at least once
a week had significantly lower SF concentration than
those who never had tea or coffee.
The Hb concentration of the pregnant women
was positively correlated with their education level
(r 0.133; P 0.004), SF concentration (r 0.245;
P 0.001) and frequency of intake of fish (r 0.095;
P 0.04), but was negatively correlated with gestational period (r 0.19; P 0.001) and frequency
of intake of dry seeds (r 0.094; P 0.04), GLV
(r 0.101; P 0.029) and tea (r 0.115;
P 0.013). Statistically significant positive correlations
were also observed between SF concentrations and
education level (r 0.145; P 0.002), frequency of
intake of iron-fortified white bread containing
60 ppm H-reduced iron (r 0.119; P 0.014), nuts
(r 0.116; P 0.016) and fruit juice (r 0.158;
P 0.001), while there were negative correlations with
parity (r 0.133; P 0.006), gestational period

(r 0.257; P 0.001) and frequency of consumption

of brown bread (r 0.173; P 0.001), tea
(r 0.117; P 0.01) and coffee (r 0.112;
P 0.01).
When the education level of the pregnant women,
gestational period, birth spacing, iron status, markers
of inflammation/infection (serum CRP), consumption
of iron-folate tablets, and frequency of intakes of white
bread, fish, GLV, dry seeds (mainly sunflower,
watermelon and pumpkin seeds) and tea were
included in the multiple logistic regression model for
anemia, poor iron status and not consuming ironfolate tablets at all or taking them occasionally were
found to be the most important predictors for anemia
in these women (Table VI).
Logistic regression was also performed for ID
(SF , 10.0 mg/l) as the dependent variable (Table VI).
Higher gestational age, birth spacing #2 years from
the last pregnancy, not consuming iron-folate tablets
or taking them occasionally, not consuming fruit juice
at all, and consumption of brown bread at least once a
day and consumption of tea/coffee at least once a week
were found to be significantly important predictors of
ID in these women.

Table III. Distribution of the Kuwaiti pregnant women by frequency of intake of selected food items (n 465).
Food item

Never

12/week

3 4/week

5 6 week

$7/week

White bread
Brown bread
Goat/lamb
Beef
Chicken
Liver
Fish
GLV
Fruit
Dates
Fruit juice
Dried beans
Nuts
Seeds
Tea
Coffee

346 (74.4)
50 (10.8)
210 (45.2)
290 (62.4)
92 (19.8)
405 (87.3)
254 (54.6)
51 (11.0)
63 (13.5)
124 (26.7)
151 (32.5)
267 (57.5)
313 (67.4)
259 (55.8)
136 (29.2)
160 (34.4)

37 (8.0)
59 (12.7)
160 (34.4)
124 (26.6)
103 (22.2)
53 (11.4)
189 (40.7)
77 (16.6)
115 (24.7)
99 (21.4)
128 (27.6)
147 (31.5)
83 (17.8)
126 (27.2)
47 (10.2)
46 (9.9)

17 (3.7)
52 (11.2)
0 (0.0)
0 (0.0)
122 (26.2)
5 (1.1)
0 (0.0)
62 (13.3)
86 (18.5)
43 (9.2)
55 (11.8)
23 (4.9)
12 (2.6)
19 (4.1)
29 (6.2)
35 (7.5)

3 (0.6)
7 (1.5)
79 (17.0)
38 (8.2)
12 (2.6)
0 (0.0)
20 (4.3)
33 (7.1)
33 (7.1)
5 (1.1)
3 (0.6)
5 (1.1)
2 (0.4)
0 (0.0)
2 (0.4)
8 (1.7)

62 (13.3)
297 (63.8)
16 (3.4)
13 (2.8)
136 (29.2)
1 (0.2)
2 (0.4)
242 (52.0)
168 (36.2)
193 (41.6)
127 (27.5)
23 (5.0)
55 (11.8)
60 (12.9)
251 (54.0)
216 (46.5)

Data presented as n (%).

Iron deficiency among Kuwaiti pregnant women

589

Table IV. Hemoglobin and serum ferritin concentrations by selected sociodemographic, pregnancy and health-related factors of the pregnant
women in Kuwait.

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Variable
Age
18 29 years
30 47 years
Education
, Secondary School Certificate
$ Secondary School Certificate
Occupation
Student
Working
Housewife
Gestational period
First trimester
Second trimester
Third trimester
Parity
0
12
$3
Birth-interval
# 2 years
. 2 years
Taking iron-folate tablets
Regularly
Never/Occationally
Serum C-reactive protein
Normal (#20.0 mg/l)
High (.20.0 mg/l)

Hemoglobin (g/l)

P value

Serum ferritin (mg/l)

P valuea

117.1 ^ 11.0 (291)

116.5 ^ 11.2 (174)

0.54

15.3 ^ 11.4 (272)

14.5 ^ 11.5 (161)

0.71

115.0 ^ 11.4 (137)

117.6 ^ 10.9 (328)

0.02

13.0 ^ 10.5 (133)

15.9 ^ 11.7 (300)

0.004

115.3 ^ 16.3 (22)

118.1 ^ 10.5 (213)
115.9 ^ 11.0 (230)

0.105

19.4 ^ 15.3 (21)AB

15.6 ^ 10.0 (199)A
14.0 ^ 12.1 (213)B

0.007

121.4 ^ 13.8 (69)A

117.0 ^ 10.3 (229)B
114.9 ^ 10.4 (167)B

0.001

23.9 ^ 14.5 (63)A

14.1 ^ 9.9 (209)B
12.6 ^ 10.2 (161)B

0.001

117.4 ^ 11.1 (100)

118.6 ^ 11.3 (93)
116.1 ^ 11.0 (272)

0.14

16.6 ^ 10.2 (92)A

16.0 ^ 11.7 (87)AB
14.1 ^ 11.7 (254)B

0.015

116.0 ^ 11.4 (184)

117.4 ^ 10.9 (281)

0.54

14.1 ^ 12.4 (174)

15.6 ^ 10.6 (259)

0.012

118.0 ^ 10.7 (281)

115.2 ^ 11.5 (184)

0.008

16.5 ^ 12.3 (255)

12.8 ^ 9.6 (178)

0.001

117.1 ^ 11.4 (383)

116.0 ^ 9.6 (82)

0.39

14.9 ^ 11.5 (352)

15.3 ^ 11.3 (81)

0.65

Data presented as mean ^ SD (n). P value is based on one-way analysis of variance followed by Tukeys test. a Based on natural log of serum
ferritin values. For each variable means in the same column with superscript without a common letter differ, p , 0.05.

Discussion
The present study reports on the potential risk factors
associated with anemia and ID among Kuwaiti
pregnant women. By and large, these women are well
educated and enjoy a high level of economic affluence
from the oil revenues. In spite of this, nearly onequarter (24%) was found to be anemic. In contrast, an
earlier study reported 37% anemia in pregnant women
in Kuwait (Dawood et al. 1990). One possibility is that
over a period of 20 years the prevalence of anemia has
decreased due to the healthcare effort made for
controlling the problem. In the present study, none of
the women had severe anemia, a finding similar to that
observed among pregnant women in Saudi Arabia
(Rasheed et al. 2008). Nonetheless, according to
WHO classification, anemia in this population still
remains a moderate problem of public health
significance (WHO 2001).
The majority of previous studies have drawn the
inference that IDA is highly prevalent among pregnant
women in Kuwait and other Arab-Gulf Countries,
mostly based on low Hb levels (Dawood et al. 1990,
Ministry of Health 2005, Musaiger 2002). The
limitation of using the Hb level as an indicator for
ID is that it lacks specificity (Garbey et al. 1969).
The present study was the first to evaluate the extent of
ID in pregnancy in Kuwait using the SF concentration. Using a cut-off point , 10.0 mg/l for SF, we

found that 41.3% of the pregnant women had ID

irrespective of their anemia status. On the basis of
combined cut-off point for Hb and SF concentration
(Hb , 110.0 g/L and SF , 10.0 mg/L), 64% of all
anemic women were suffering from IDA, indicating a
significant public health problem. Although SF is
considered to be the most sensitive indicator of iron
status, several studies have shown a marked elevation
of SF during subclinical infection or inflammation
(Witte 1991, Thompson et al. 1992), and clearly
defined cut-off points for diagnosing ID in pregnancy
in the presence of coexisting infection have been
lacking (Cook et al. 1992). In the present study, 17.6%
of the women had inflammation or infection judged
by high serum CRP levels (. 20.0 mg/l). During
pregnancy, the upper normal limit for serum CRP
level is considered to be 20.0 mg/l (Nielsen et al.
1990). Recently, there has been a suggestion that the
effect of inflammation on SF can be removed by
multiplying the individual SF concentrations of
subjects with inflammation by a correction factor of
0.82 (Thurnham 2008). After adjusting the SF
concentrations in the women with inflammation in
the present study, 45% of the women were found to
have ID and 66.7% of the anemic women had IDA.
Thus nearly one-third of the anemia in this population
could not be accounted for by ID.
In the present study, 20% of the anemic women
had high serum CRP concentration, indicating the

590 F. Ahmed & M. A. AL-Sumaie

Table V. Hemoglobin and serum ferritin concentrations by frequency of intake of selected food items in the pregnant women in Kuwait.

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Food item
White bread
Never
$ 1 times/week
Brown bread
06 times/week
$ 7 times/week
Beef
Never
$ 1 times/week
Liver
Never
$ 1time/week
GLV
06 time/week
$ 7 times/week
Nuts
Never
$ 1 time/week
Fruit
06 time/week
$ 7 times/week
Fruit juice
Never
$ 1 time/week
Tea
Never
$ 1 time/week
Coffee
Never
$ 1 time/week

Hemoglobin (g/l)

P value

Serum ferritin (mg/l)

P valuea

116.3 ^ 11.4 (346)

118.6 ^ 10.1 (119)

0.054

14.4 ^ 11.4 (323)

16.7 ^ 11.4 (110)

0.057

117.5 ^ 11.7 (168)

116.5 ^ 10.7 (297)

0.36

17.6 ^ 11.6 (155)

13.5 ^ 11.1 (278)

0.001

117.0 ^ 11.2 (290)

116.7 ^ 11.0 (175)

0.76

14.9 ^ 11.6 (271)

15.2 ^ 11.0 (162)

0.77

116.8 ^ 11.2 (405)

117.4 ^ 10.3 (60)

0.71

14.8 ^ 11.4 (376)

16.2 ^ 11.6 (57)

0.22

116.3 ^ 10.6 (223)

117.4 ^ 11.5 (242)

0.32

14.2 ^ 10.8 (208)

15.7 ^ 11.9 (225)

0.26

116.7 ^ 10.8 (313)

117.7 ^ 11.8 (152)

0.62

14.0 ^ 10.8 (295)

17.1 ^ 12.4 (138)

0.009

116.7 ^ 11.2 (297)

117.2 ^ 11.0 (168)

0.66

15.2 ^ 11.6 (281)

14.7 ^ 11.1 (152)

0.98

116.9 ^ 10.4 (151)

116.9 ^ 11.5 (314)

0.99

13.0 ^ 11.4 (140)

15.9 ^ 11.3 (293)

0.002

117.9 ^ 10.9 (136)

116.4 ^ 11.2 (329)

0.18

17.3 ^ 13.4 (123)

14.1 ^ 10.4 (310)

0.006

117.6 ^ 11.1 (160)

116.5 ^ 11.1 (305)

0.30

17.2 ^ 13.1 (145)

13.9 ^ 10.3 (288)

0.003

Data presented as mean ^ SD (n). P value is based on one-way analysis of variance. a Based on natural log of serum ferritin values.

presence of acute inflammation or infection. As acute

inflammation has often been found to be associated
with anemia (Abshire and Reeves 1983, Jansson et al.
1986), we also explored the effect of inflammation/
infection by comparing the Hb levels between those
women without any inflammation and those with
inflammation using a cut-off point . 20 mg/l for
serum CRP. We did not find any significant differences

in Hb levels between the two groups. One explanation

for this finding could be due to small number of
women with inflammation.
As mentioned earlier malaria (Stoltzfus et al. 1996,
Dreyfuss et al. 2000), hookworm infestation (Stoltzfus
et al. 1996), and hemoglobinopathies (Linpinsarn et al.
1996) can also cause anemia. Malaria and hookworm
infections are not endemic in Kuwait due to improved

Table VI. Odds ratio and 95% CI for risk factors associated with anemia and iron deficiency among Kuwaiti pregnant women using multiple
regression analysis.

Anemiaa
Iron status (SF . 10.0 mg/l)
Iron-folate tablet (Taking regularly)
Birth spacing (.2 year)
Iron deficiencyb
Gestational period (first trimester)
Second trimester
Third trimester
Birth spacing (.2 years)
Iron-folate tablet (Taking regularly)
Brown bread (#6 times/week)
Fruit juice ($1 times /week)
Tea/coffee (never consumed)
Tea/coffee 1 6 times/week
Tea/coffee .7 times/week

Odds ratio

95% CI

P value

2.71
1.80
1.62

(1.664.42)
(1.142.84)
(0.952.75)

0.001
0.024
0.078

1.00
2.08
3.66
1.83
1.64
2.27
1.68
1.00
2.21
2.62

(1.034.20)
(1.787.55)
(1.202.80)
(1.082.49)
(1.443.57)
(1.082.60)
(1.283.79)
(1.245.52)

0.0001
0.042
0.001
0.005
0.02
0.001
0.02
0.009
0.011
0.004

Parentheses indicate reference category. a Defined using a cut-off point , 110.0 g/l for hemoglobin. b Defined using a cut-off point , 10.0 mg/l
for serum ferritin.

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Iron deficiency among Kuwaiti pregnant women

sanitation and high ambient temperatures that exist
during much of the year (Hira et al. 1988, Iqbal et al.
1999). However, studies have shown that a-thalassemia is common in the Kuwaiti population (Diejomaoh
et al. 2000). In the present study we do not have any
information on hemoglobinopathies, and this merits
further investigations.
We also explored the relationship of various sociodemographic, pregnancy-related and dietary factors
with Hb and SF concentrations in this population.
Bivariate analysis revealed that Hb concentrations
decreased significantly with the increased gestational
age. Women with higher education levels and those
who took iron tablets regularly had significantly higher
Hb levels. Others have also reported similar findings
(Aikawa et al. 2006, Rasheed et al. 2008, Habib et al.
2009). When multiple logistic regression analysis was
carried out to identify the potential risk factors
associated with anemia, we found that the pregnant
women with poor iron status (SF , 10.0 mg/l) were
2.71 times more likely to develop anemia than women
with adequate iron status. The women who did not
take iron-folate tablets at all or took them occasionally
were significantly 1.8 times more likely to be anemic
than women who took them regularly. Close birth
spacing (# 2 years) also appeared to be an important
risk factor (OR 1.62; 95% confidence interval [CI]
0.95 2.75) for anemia in this population, although
it did not reach the level of statistical significance.
Our analysis also found that SF concentrations
decreased significantly with the increased gestational
age. This could be due to numerous physiological and
metabolic changes, such as hemodilution combined
with significantly higher requirements of iron and
other nutrients. The women with parity 3 or more, and
women a birth-space # 2 years from the last pregnancy had significantly lower SF concentration.
Frequent pregnancy can lead to the deterioration in
iron status, especially in the presence of inadequate
iron intake or poor bioavailability (Viteri 1994).
The women who took iron-folate tablets regularly
had significantly higher SF concentrations, indicating
that iron supplementation can improve iron status in
this population.
Furthermore, the women who consumed white
bread at least once a week had higher SF concentrations (P , 0.06) than the women who did not
consume white bread at all. In Kuwait, all forms of
white beard are fortified with iron and folate, and thus
the results indicate some benefit of fortification. The
women who had fruit juice at least once a week had
significantly higher SF concentration. Fruit juice is
high in vitamin C, and the bioavailability of iron is
enhanced by vitamin C (Shah et al. 2003). On the
other hand, the women who consumed brown bread
regularly ($ 1 time/day) and those who had tea or
coffee at least once a week had significantly lower SF
concentration. In Kuwait, brown bread is not fortified
with iron. Further, brown bread is high in fiber and

591

phytic acids, and tea and coffee contains polyphenolic

compounds, all of which are known to inhibit
inorganic iron absorption from a plant-based diet
(Hercberg and Galan 1992, Bothwell 1995). This may
have important implications for this population since a
significant proportion of these women consume whole
grains, dry beans, legumes and GLV, a major source of
non-heme iron.
Since iron status was found to be the main predictor
of anemia in this population, we also identified the risk
factors for developing ID using multiple regression
analysis and found that higher gestational period, and
close birth spacing (# 2 years) are the predominant
pregnancy-related risk factors associated with ID.
Furthermore, compared with the women in their first
trimester, the risk of ID was 2.08 and 3.66 times
higher for women in their second and third trimesters,
respectively. The women who did not take iron-folate
tablets at all or took them occasionally were also at
higher risk of developing ID. Consumption of fruit
juice at least once week appeared to be protective from
developing ID. On the other hand, consumption of
brown bread and consuming tea or coffee appeared to
be significant predictors for developing ID. The risk of
ID was also increased with the increase in consumption of tea or coffee; the OR was 2.2 for women who
had tea or coffee atleast once a week and was 2.6 for
those who had at least once a day.
The present study included Kuwaiti pregnant
women who attended government maternity clinics,
and only those who gave permission for their
participation. Therefore, the weakness of this study
is that the participants were not selected to be
representative of the general population. However,
this study reports a strong association between anemia
and poor iron status, and it is likely for most pregnant
women in this population that the situation is no
better, on the whole, than that reported here.
In conclusion, ID is highly prevalent among Kuwaiti
pregnant women. Gestational age, close birth spacing
since last pregnancy, not taking iron-folate supplements at all or taking it occasionally, and poor dietary
habits appeared to be significantly associated with
poor iron status, which is the most important risk
factor for anemia in this population. The findings of
the present study may have important implications
for the iron supplementation program. Our data
reinforce the needs for a comprehensive intervention
strategy to improve the iron status and thereby reduce
anemia in this population.
Declarations of interest: The authors express
sincere thanks to Dr Samira Al-Mehanna, Dr Hadeya
Al-Shatti, Dr Sameera El-Baghly, Dr Abubakr Hegazi
and Dr Fareeda Taleb of the participating maternity
clinics, Ministry of Health, Kuwait for helping with
pregnancy-related data collection. They also thank Ms
Prasanna Prakash and the participating dieticians of
the Food and Nutrition Administration, Ministry of

592 F. Ahmed & M. A. AL-Sumaie

Health, Kuwait for helping with dietary data collection
and data entry and cleaning. Special thanks to
Professor Carol Ghazzi for her valuable comments
and advice. None of the authors have any conflicts of
interest. The study was funded by Kuwait University,
Kuwait (project number: WF01/08).

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