CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Anaemia constitutes a major health challenge globally and has attracted attention towards

curtailing its prevalence. In the United Nation’s Millennium Development Goals (MDGs),

reducing child mortality and improve maternal health was a major goal (goals 4 and 5) for

attaining development for 2015. To correct this failure in African continent and their inability to

succeed in the MDGs, a new development strategy and plan was initiated known as the

Sustainable Development Goals (SDGs) on September 2015, by the General Assembly adopted

the 2030 Agenda for Sustainable Development that includes 17 Sustainable Development Goals

(SDGs) where ensuring good health and well-being, as goal three of the sustainable development

goals (SDGs) has been a fundamental objective in transforming the global world economy.

Shettima (2016) noted that Africa such as Nigeria plays a very important role in the attainment of

the SDGS due to the fact that the SDGs will only succeed, if they succeed in Africa. To this end,

there is a need to focus on Africa as a focal point at the planning, strategic, process and

implementation levels of development. A major factor to this SDGs attainment is the increase of

the level of awareness and the causes and prevention of anaemia in pregnancy.

Anemia could be refer to as a reduction in the concentration of hemoglobin, packed cell volume

or red blood cell count below that which is normal for the age and sex of an individual in a

population (Okafor, Mbah & Usanga, 2017). It occurs below the levels of hemoglobin of 11g/dl

for children aged six months to six years, 12g/dl for children aged between 6 and 14 years,

13g/dl for adult males, 12g/dl for non-pregnant adult females and 11g/dl for adult pregnant

females. For pregnant women, World Health Organization (2016) noted that, maternal anemia

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occurs at a Hemoglobin (Hb) level of <11g/dl, or Hematocrit (Hct) of <33% in all trimesters of

pregnancy and could be very dangerous to the life of the baby and the mother. According to

Okafor et al. (2017), it is one of the clinical problems in pregnancy that is usually caused by

increase demand imposed by the growing fetus and the most common symptom of malaria in

pregnancy and usually develops during the second trimester. Qureshi et al (2016) noted that it is

caused by nutritional deficiency and generally results when the iron demands needed by the body

are not met by iron absorption, regardless of the reason. There are several types of anaemia and

could include Iron deficiency anaemia; Thalassemia; A plastic anaemia; Hemolytic anaemia;

Sickle cell anaemia; Pernicious anaemia; Fanconi anaemia; among others.

Noting the different types of anaemia, it is important to investigate the awareness and causes of

anaemia among pregnant women and its prevention. Batool et al (2015); Balarajan et al (2016)

and Suryanarayana et al (2016) noted that there is poor awareness and knowledge of the

magnitude and consequences of anaemia burden and it is higher among developing countries

such as Nigeria. In addition, there is a lack of education and information about anaemia

prevention, and awareness of the causes (Balarajan et al., 2016).

Moreover, Adamu et al. (2017) noted that anemia has diverse health consequences which are

fatigue and congestive cardiac failure. Balarajan et al (2016) noted that consequences of anaemia

could include maternal and perinatal effect; cognitive development effect, work productivity

effect, among others. According to Mayo Foundation for Medical Education and Research

(MFMER) (2019), consequences of anaemia to pregnant women include severe fatigue,

pregnancy complications, heart problems, and finally death. In addition, there may also be an

increased blood loss at delivery which could put women at risk of postpartum hemorrhage,

greater risk of delivering premature and low-birth-weight babies who have an increased risk of

2
dying, etc.

1.2 Statement of Problem

Anaemia is a major cause of morbidity and mortality in pregnant women and increases the risks

of foetal, neonatal and overall infant mortality. In 2013, an estimated 289,000 women died

worldwide due to anaemia. Developing countries account for 99% (286 000) of the global

maternal deaths with sub- Saharan Africa region alone accounting for 62% (179 000). About 800

women a day are still dying from complications in pregnancy and childbirth globally (WHOa,

2015). Anaemia during pregnancy contributes to 20% of all maternal deaths (WHOb, 2015).

Anaemia during pregnancy is also a major risk factor for low birth weight, preterm birth and

intrauterine growth restriction. Deficiency in folic acid during pregnancy can result in serious

neural tube defect, heart defects and cleft lips, limb defects, and urinary tract anomalies.

Pregnant women attending antenatal clinic in Nnamdi Azikiwe University Teaching Hospital,

Nnewi are routinely put on iron supplementation throughout their pregnancy. However, the

prevalence of anaemia among pregnant women is still high.

Hence, the need to investigate the level of awareness and also the health implication of anaemia

among pregnant women.

1.3 Aim and Objectives of the Study

This study investigated the level of awareness of the causes and prevention of anaemia amongst

pregnant women attending antenatal clinic in Nnamdi Azikiwe University Teaching Hospital,

Nnewi.

The objectives are:

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i. To examine the level of awareness of the causes and prevention of anaemia amongst

pregnant women attending antenatal clinic in Nnamdi Azikiwe University Teaching Hospital,

Nnewi.

ii. To know the various health implication of anaemia amongst pregnant women attending

antenatal clinic in Nnamdi Azikiwe University Teaching Hospital, Nnewi.

iii. To examine knowledge of anaemia amongst pregnant women attending antenatal clinic in

Nnamdi Azikiwe University Teaching Hospital, Nnewi.

1.4 Research Questions

i. Are pregnant women attending antenatal clinic in Nnamdi Azikiwe University Teaching

Hospital, Nnewi aware of anaemia?

ii. What are the various health implication of anaemia among pregnant women attending

antenatal clinic in Nnamdi Azikiwe University Teaching Hospital, Nnewi?

iii. Are pregnant women attending antenatal clinic in Nnamdi Azikiwe University Teaching

Hospital, Nnewi knowledgeable about anaemia or not?

1.5 Research Hypotheses

Tested at 0.05 level of significance:

Ho1: There is no significant relationship between the level of awareness and the knowledge of

anaemia status amongst pregnant women in Nnamdi Azikiwe University Teaching Hospital,

Nnewi.

Ho2: There is no significant relationship between the level of awareness and the health ensuring

strategies undertaken to curtail anaemia during pregnancy amongst pregnant women in Nnamdi

4
Azikiwe University Teaching Hospital, Nnewi.

Ho3: There is no significant difference in the level of awareness with respect to the demographic

characteristics of pregnant women in Nnamdi Azikiwe University Teaching Hospital, Nnewi.

1.6 Significance of the Study

Although many scholars have written on the prevalence of anaemia in Nigeria, it is significant to

note however that micronutrient deficiencies lead to anaemia in pregnancy. Therefore this study

is basically for pregnant women, expectant mothers and women who are ready for marriage.

Hence the study hopefully is significant to the extent that the above specify persons should be

able; to know what causes anaemia, to understand the important, benefits of enough nutrients and

enhanced their nutrition, to understand the efficacy of micronutrients,to know some other factors

that could lead to anaemia in pregnancy, such as poor weight gain and to understand the double

jeopardy of anaemic condition at the end of the study.

The health workers will make use of this study in updating their knowledge about anaemia in

pregnancy, so as to be able to make proper assessment, diagnosis, planning and implementation

of modalities geared towards competent management of cases in order to reduce the incidence of

anaemia among pregnant women. Findings from this study will hopefully be useful in providing

appropriate preventive measures to reduce the maternal mortality of which anaemia is one of the

leading causes. It is believed that the proposition from this study will help the pregnant women

have more knowledge on what anaemia is all about. As a final point, it possibly would serve as a

work of reference to future researchers in that area.

1.7 Scope of the Study

The study is delimited to the pregnant women in Nnamdi Azikiwe University Teaching Hospital,

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Nnewi, Anambra State. The major concentration of our consideration is the question of what

causes anaemia in pregnancy. To do this effectively, a critical appraisal of the various variables

supporting the research work will be done pointing out their contributions to the cause of

anaemia in pregnancy. Since this research is aimed at determining the level of awareness on the

prevention of anaemia among pregnant women in Nnamdi Azikiwe University Teaching

Hospital, Nnewi, Anambra State, thoughtfulness will be paid to the several preventive measures

against the occurrence of anaemia in pregnancy.

1.8 Limitations to the Study

The challenges that posed a threat to this study include the following; fund to be able to assess

materials even online and equally type the work, collections and retrieval of documents from

health centers archives, and even those of hospitals and attitudes turned to be huge obstacles and

time constraints due to other academic pressure. However efforts were made to address these

problems or limitations.

1.9 Definition of Terms

Anaemia: A condition in which when the haemoglobin (Hb) level in the body is less than 11

gram per decilitre, which decreases oxygen-carrying capacity of red blood cells to tissues.

Antenatal clinic (ANC): Maternal and Child Health clinic which provides care for expectant

parents; the mother's and baby's health is monitored, maintained and optimized to ensure a

healthy pregnancy, safe delivery and post delivery period. Moreover the clinic provides

nutritional supplements (iron/folate) and dietary information throughout the pregnancy.

Febrile illness: A nonspecific term for an illness of sudden onset accompanied by fever

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Folic acid: water soluble B vitamin (B9) found mostly in leafy green vegetables like kale and

spinach, orange juice, and enriched grains. Folic acid plays an important role in the production of

red blood cells and helps fetal neural tube develop in the brain and spinal cord.

Haemoglobin (Hb): Iron-containing oxygen-transport metallo-protein in the red blood cells

which is composed of globin and heme that gives red blood cells their characteristic colour.

Iron: A micronutrient needed for the transport of oxygen in blood to various parts of the body.

Iron deficiency: A state of insufficient iron to maintain normal physiological functions of body

tissues.

Iron deficiency anaemia: An advanced stage of iron depletion defined as iron deficiency and

low haemoglobin resulting in the condition of anaemia.

Maternal death: The death of a woman while pregnant or within 42 days of termination of

pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or

aggravated by the pregnancy or its management but not from accidental or incidental causes.

Multigravida: A pregnant woman with one or more previous pregnancies.

Parity: the number of times that a woman has given birth to a fetus at a gestational age of 24

weeks or more, regardless of whether the child was born alive or was stillborn.

Pregnancy: The state of carrying a developing embryo or fetus within the female body for a

period of 280 days or 40 weeks.

Primagravidae: A woman who is pregnant for the first time.

Supplementation: Provision of specified dose of nutrient preparation which may be in the form

of tablet, capsule, oil solution or modified food for either treating an identified deficiency or

prevention of the occurrence of such a deficiency in an individual.

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 CHAPTER TWO

REVIEW OF RELATED LITERATURE

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This chapter discuss about the related literature based on the topic of the research work and

analyzing the conceptual, theoretical framework, empirical reviews and summary of the

literature reviewed.

2.0 Introduction

Anaemia during pregnancy is defined as a condition where there is less than 11g/dl of

haemoglobin (Hb) concentration in the blood of pregnant women, which decreases oxygen-

carrying capacity of the blood to the body tissues. The importance of good haemoglobin

concentration during pregnancy for both the woman and the growing foetus cannot be

overemphasized. Being a driving force for oxygen for the mother and foetus, a reduction below

acceptable levels can be detrimental to both (Alam et al., 2015). Anaemia affects 1.62 billion

(24.8%) people globally (WHO, 2015). Globally, almost half of all preschool children (47.4%)

and pregnant women (41.8%) and close to one-third of non-pregnant women (30.2%) are

anaemic (De Benoist et al., 2015). Anaemia affects more than 500 million women in developing

countries where 4 of every 10 pregnant women are anaemic (WHO, 2016). Although reports

exist about what is being done and what should be done globally to address prevention and

treatment of maternal anaemia, prevalence of anaemia and maternal mortality around the world

remains high (WHO, 2016). About half of this anaemia burden is a result of iron deficiency

anaemia (IDA). IDA is most prevalent among preschool children and pregnant women. Among

women, iron supplementation improves physical and cognitive performance, work productivity,

and well-being. Moreover iron supplementation during pregnancy improves maternal, neonatal,

infant, and even long-term child outcomes. Although dietary deficiency may be contributory, the

etiology of the vast majority of cases of iron deficiency anaemia in infancy and childhood is

9
maternal iron deficiency anaemia in pregnancy.

WHO has categorized and emphasized on the significant health consequences based on the

prevalence of the anaemia. If the prevalence of anaemia is 4.9% or less, it is considered as no

public health problem for that country. Prevalence of anaemia between 5.0% and 19.9%

indicates a mild public health problem. Moderate public health problem is been considered when

the prevalence is between 20.0% and 39.9%. If the prevalence is 40.0% or more, it is considered

as a severe public health problem (McLean et al., 2015).

2.1 Conceptual Framework

The conceptual framework used for this study is adopted and modified from UNICEF’s

conceptual framework on the determinants of malnutrition (UNICEF, 1998).This conceptual

framework demonstrates the relationship between independent variables (participant’s

demographic and socio-economic characteristics, obstetric history, ANC visits and taking of

iron and folic (IFA) supplementation, health condition of the current pregnancy, awareness on

causes and consequences of anaemia during pregnancy and the dietary habits and nutritional

status and dependent variables (anaemic state or non-anaemic state of the pregnant women).

Independent Outcome Dependent

variables variable Variables

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 Socio-demographic
characteristics Positive
outcome Change in
maternal,
feotal and
Socio-economic Anaemic neonatal
status morbidity
Negative and
Obstetric historyoutcome mortality
rates

Non-
Attendance for ANC anaemic
clinic and taking
IFAS

Healthconditionof the
current pregnancy

Awareness on causes and

consequences of
anaemia Confounding variables: Genetic
makeup of the women Geographical

Dietary habits and location

nutritional status

Figure 1.1: Conceptual framework on factors associated with anaemia in pregnancy

Source: Adopted from the state of the World’s children UNICEF, 1998.

2.1.1 Definition

The word anaemia connotes a deficiency in the number of red blood cells or in their

haemoglobin content, which can lead to a decrease in oxygen-carrying capacity of the blood,

causing unusual tiredness resulting in pallor, shortness of breath, and lack of energy. Anaemia

may be relative or absolute. Relative anaemia is that which occur in pregnancy.

Absolute anaemia involves a true decrease in red cell mass. The cells are manufactured in the

bone marrow and have a life expectation of approximately four months (120 days).

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To produce red blood cells, the body needs (among other things) iron, vitamin B12 and folic

acid. If there is a lack of one or more of these ingredients, anaemia will develop.

Red blood cells are the cells that circulate in the blood plasma giving the blood its red colour.

Through its pumping action, the heart propels blood around the body through arteries. The red

blood cells obtain oxygen in the lungs and carry it to all the cells of the body. The cells use the

oxygen to fuel combustion of sugar and fats, which produces the body’s energy. During this

process called oxidation, carbon dioxide is created as a waste product. It binds itself to the red

blood cells that have delivered their load of oxygen. The carbon dioxide is then transported via

the blood in the veins back to the lungs where it is exchanged for fresh oxygen by breathing.

The World Health Organization (WHO) recommendation is that anaemia in pregnancy is present

when the value of the total circulating haemoglobin (Hb) mass in the peripheral blood is 11g/dl

(PCV 33%) or less, however, in developing nations it is generally accepted that anaemia exists

when the Hb concentration is less than10g/dl or packed cell volume (PCV) is less than 30%

(Akin, 2015). Anaemia ranges from mild, moderate to severe and the WHO pegs the

haemoglobin level for each of these degree of anaemia in pregnancy at9.0-10.9g/dl as mild

anaemia; 7-8.9g/dl as moderate anaemia and <7.0g/dl as severe anaemia.

2.1.2 Epidemiology

Each year more than 500,000 women die from pregnancy-related causes, 99% of these are from

developing countries. Estimates of maternal mortality resulting from anaemia range from

34/100,000 live births in Nigeria to as high as 194/100,000 in Pakistan. Incombination with

obstetric haemorrhage, anaemia is estimated to be responsible for 17 – 46% of cases of maternal

death.

The incidence of anaemia in pregnancy would vary from place-to-place even within the same

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country depending on the socio-economic status and level of development.It is claimed that 5 –

50% of pregnant women in the tropics who attend antenatal clinics are anaemic as against the

prevalence rate of 2% in the developed world(Adamu et al., 2017).

It has been estimated that over half the pregnant women in the world have a haemoglobin level

indicative of anaemia. In industrialized countries, anaemia in pregnancy occurs in less than 20%

of women. This however, reaches the level of public health significance(>10%).Published rates

for developing countries range from 35% to 72% for Africa, 37% to 75% for Asia and 37% to

52% for Latin America. A retrospective study of normal pregnant women who registered with

the antenatal unit of the University of Nigeria Teaching Hospital (UNTH) Enugu between

January 1, 2005 and October 30, 2005 showed that 40.4% of the study population was anaemic

(Hb< 11g) at booking. The prevalence of anaemia at booking increased significantly with

increasing gestational age at booking.

Another study carried out in Gombe, North-eastern Nigeria showed a prevalence of anaemia in

pregnancy of 51.8%. The majority of these patients 67.4% were mildly anaemic; 30.5% were

moderately anaemic; while only 2.1% had severe anaemia.

In West Africa, anaemia in pregnancy results from multiple causes, including iron and folate

deficiency, malaria and hookworm infestation, infections such as HIV and haemoglobinopathies.

Pica has been identified as a risk factor for anaemia in pregnancy.27 This could be applicable to

this environment in which special clay of the kaolin group (called “nzu” in Igbo language) is

easily accessible in the open markets, and some pregnant women crave it. The situation is

particularly worse in southern Asia where¾ of the pregnant women are anaemic (see table 2.1).

Not only is anaemia common, it is often severe. From published reports available, it can be

estimated that 2-7% of pregnant women have Hb values <7.0g/dl, and probably 15 – 20% have

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values<8.0g/dl. It has been suggested that the prevalence of anaemia may depend on the season,

increasing relation to malaria transmission in the wet season or in relation to increased food

shortage at the end of the dry season.

In 1993, the World Bank ranked anaemia as the eighth leading cause of disease in girls and

young women of childbearing age in developing countries, though anaemia is assumed to be less

common in non-pregnant women.

Table 2.1: Estimated prevalence of mild, moderate and severe anaemia in pregnant women in

some continents (1998)

Continent Hb<7 g/dl 7-9.9 g/dl 10-10.9 g/dl No. of No. ofTotal (%)

Countries Subjects
Africa

Eastern 4 27 16 6 5687 47

Middle 5 2 21 3 4632 54

Northern 3 25 25 1 222 53

Southern 2 18 15 1 1936 35

Western 4 33 19 6 22131 56
Asia Eastern + 24 13 + + 37

S/Eastern + 39 19 + + 63

Southern 5 43 25 4 15811 75

Western 7 28 20 4 14347 50

2 4 3363

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 S/America

Caribbean 2 33 17 12 11058 52

Central 2 26 14 2 841 42

Southern 1 24 12 4 7261 37

Source: WHO data base: Safe Motherhood March –June 1993.

2.1.3 Causes Of Anaemia inPregnancy

Anaemia in pregnancy is a major public health problem in developing countries. In sub Saharan

Africa, such anaemia is generally accepted as resulting from nutritional deficiency, particularly

iron deficiency. Women often become anaemic during pregnancy because the demand for iron

and other vitamins is increased due to physiological burden of pregnancy. The inability to meet

the required levels of these substances either as a result of dietary deficiencies or infections gives

rise to anaemia. The mother must increase her production of red blood cells and, in addition, the

foetus and placenta need their own supply of iron, which can only be obtained from the mother.

In order to have enough red blood cells for the foetus, the body starts to produce more red blood

cells and plasma. It has been calculated that the blood volume increases approximately 50%

during pregnancy, although the plasma amount is disproportionately greater.1This causes a

dilution of the blood, making the haemoglobin concentration fall. This is a normal process, with

the haemoglobin concentration at its lowest between weeks 25 and 30 of gestation.

The pregnant woman may need additional iron supplementation, and a blood test called serum

ferritin is the best way of monitoring this.

Anaemia in pregnancy is often of multiple aetiologies. Iron and folate deficiency are by far the

most important aetiological factors. The increased demand for these substances is further

aggravated by multiple pregnancies, short birth intervals, parasitic and helminthic infections

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which is common amongst black women. Malaria parasites causing the destruction of the red

blood cells contribute significantly to the prevalence of anaemia in apopulation. AIDS should be

considered in the differential diagnosis of a patient with anaemia. Haemoglobinopathies such as

sickle cell disease contribute to the causation of anaemia in Africa.

2.1.4 Iron deficiency

Iron requirement is increased in pregnancy, due to the demand of the foetus and the increase in

blood volume, especially in the last trimester, with up to 80% of the requirement relating to the

third trimester. The total iron requirement during the whole pregnancy is about 1000mg (300mg

for the foetus, 50mg for the placenta, 450mg for the increase in the maternal red cell mass and

240mg for the continuing maternal basal iron losses).

Requirements during the first trimester are relatively small (about 0.8mg per day), but rise

considerably during the second and third trimesters to as high as 6.3mg per day. After delivery

and during lactation, iron requirements decrease to 1.31mg per day, which is less than the

requirement in menstruating women 2.3mg/day (Adamu et al., 2015).

Despite an increase in iron absorption in pregnancy, diet alone is unable to satisfy the increased

requirement. Therefore, the extra requirement for iron has to be met by the body’s iron stores.

However, many women in the developing world start pregnancy with a depleted iron store due to

diets low in iron, chronic blood loss from parasitic infections, and frequent and closely spaced

pregnancies, not giving the body enough time to replenish its depleted stores. It has been

estimated that in the absence of iron supplementation, it can take up to two years to return to pre-

pregnancy iron status. Iron stores in women of reproductive age are further depleted through

menstrual blood loss.

Iron deficiency is mainly nutritional in origin. There are two types of dietary iron-haem and non-

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haem. Haem iron is found in foods of animal origin such as meat, fish, poultry and its

bioavailability is high with absorption being 20-30%. It is absorbed about twenty three times

better than non-haem iron. Non-haem iron is found in food of plant origin, especially whole

grain cereals, tubers, vegetables and pulses. A small amount of haem iron in the diet will

improve absorption of non-haem iron and thus the diet composition is an important determinant

of the amount of iron actually absorbed. Its bioavailability is lower and is determined by the

presence of enhancing and inhibiting factors consumed in the same meal. Enhancers of non-

haem iron absorption include meat, poultry, fish and vitamin C. Meat, poultry and fish are

therefore of double value in that not only do they provide a rich source of bioavailable iron, but

also enhance the absorption of non-haem iron contained in the rest of the meal. The foods

consumed in most African homes have low meat, low vitamins and high carbohydrates and high

phytates which inhibit iron absorption. Phytates are present in wheat and other cereals, and even

a small amount can markedly reduce iron absorption. In developing countries where meat intake

is low, vitamin C is the most important enhancer of iron absorption. The addition of as little as

50mg of vitamin C to meal can double iron absorption. This amount of vitamin C can be

provided by an orange, 20g of pawpaw or mango, or 100g of raw cabbage. But invariably,

malnutrition or under-nutrition prevalent in many parts of the developing world are as a result of

socioeconomic deprivation and sometimes due to taboos and superstitious ways of preparing

certain foods for example, overcooking vegetables.

In addition to the diet derived from the food, the iron could be exogenous originating from the

soil or iron cooking vessels. This can considerably increase the iron content of a meal.

2.1.5 Folate Deficiency

Folates are heat labile, light sensitive, water-soluble vitamins which are essential for red blood

17
cell maturation. Folates are found in almost all foods, but more in liver, yeast extract, dark green

leafy vegetables, yam, sweet potatoes, egg yolk, fish, pulses, nuts and fruits such as banana,

plantain and mangoes. Fresh foods rich in folates are only available during the harvest period

which is seasonal, so the intake of folate is seasonal too. Some important staples in the

developing world such as rice, cassava, millet, sorghum and maize are poor sources of folate.

Folate deficiency produces an anaemia characterized by unusually large red blood cells

(megaloblastic anaemia). Because folates are heat labile, prolonged cooking and repeated

reheating of food, which is a common practice in the developing world can be an important

factor in the aetiology of folate deficiency anaemia. Folate requirement approximately doubles

during pregnancy, especially during the third trimester and puerperium (Vitamin B12 and Folate

Deficiency) and since body stores of folate are limited and dietary intake is likely to be

insufficient, anaemia often developed as a consequence. There is usually a steady fall in the level

of serum folate throughout pregnancy, especially in women from lower socioeconomic groups,

in multigravidae, smokers, and in women with twin pregnancies. Diseases associated with

haemolysis such as malaria or sickle cell disease also increase the requirement for folate. Thus

malaria and folate deficiency often coexist in pregnant women. Studies show that, anti-malarial

prophylaxis alone without folate supplement reduces the frequency of megaloblastic anaemia in

primigravidae by 50% while folate supplement completely abolishesit (Vitamin B12 and Folate

Deficiency).

Iron and folate deficiency, both of nutritional origins tend to coexist in the same subject. This

must be kept in mind as iron deficiency most times conceals the presence of coexisting

megaloblastic anaemia. There is evidence that folate supplement given to a mother around the

time of conception reduces the incidence of neural tube defects in infants born to these mothers.

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2.1.6 Malaria

In Sub-Saharan Africa the region of the world hardest hit by malaria, malaria infection is

estimated to cause 400,000 cases of severe maternal anaemiayearly. This is a major cause of

severe anaemia in pregnancy. In high transmission areas, women have gained a level of

immunity to malaria that wanes somewhat during pregnancy. It is a particular problem for

women in their first and second pregnancies and for women who are HIV- positive. Anaemia

associated with malaria is caused by haemolysis of the red blood cells, hypersplenism, (a

condition characterized by exaggeration of the inhibitory or destructive function of the spleen);

contribute to the anaemia in up to 25% of women who suffer from anaemia in pregnancy. Thus

protection against malaria through chemotherapy and other methods of malaria control can

immensely reduce maternal morbidity and mortality.

2.1.7 Hookworm

This is one of the principal causes of iron deficiency anaemia in developing countries. About ¼

of the world’s population has hookworm infection. It is prevalent throughoutthe tropics and

subtropics where there is contamination of the environment with faeces and it is mainly by skin

contact with such contaminated soil or vegetations.

The adult hookworms live in the small intestine, attached to the mucosa from which they suck

blood, causing chronic blood loss. Over a period of time even small hookworm loads may cause

sufficient blood loss to deplete body iron stores. If the store is already depleted, hookworm

infection can give rise to iron deficiency within a few weeks especially during pregnancy when

iron requirements are increased.

2.1.8 Sickle cell disease(SCD)

About 60million people worldwide carry the sickle cell trait, 50million of whom are in Africa.

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Persons with the sickle cell trait (heterozygote) have minimal clinical problems, but the

homozygotes have SCD, which causes chronic hemolytic anaemia. Over 100,000 infants are

born each year with SCD, most of them in Africa. Anaemia is a significant characteristic in

sickle cell disease (which is why the disease is commonly referred to as sickle cell anaemia).

Anaemia is usually severe and may be exacerbated by acute sequestration of sickled cells or

more commonly by the "aplastic crisis" which occurs when bone marrow haemopoesis is slowed

down during acute infections. Folic acid and iron deficiency are often associated with SCD

because the haemolytic process increases the requirement for these nutrients.

2.1.9 Human Immunodeficiency Virus(HIV)

HIV infection must be included in the causes of anaemia in pregnancy among African women

where seropositivity ranges from 6-24% in antenatal clinics.(Akin, 2015) When the anaemia is

associated with leucopenia and thrombocytopenia, the antenatal health worker should suspect

AIDS especially if she is not responding to treatment.

2.1.10 Vitamin A Deficiency

Vitamin A is a fat-soluble vitamin which is obtained from the diet as preformed vitamin A

(Retinal) and from some carotenoid pigments in food that can be cleared in the bodytogive

Retinol. Preformed vitamin A occurs naturally only in animals and the richest dietary sources are

liver, fish oils and dairy products. Between 25-35% of dietary vitamin A come from Carotenoids

mainly from plant foods such as carrots and dark leafy vegetables. Caretenoids can be converted

to vitamin A in the liver where vitamin A is stored. Absorption from plant sources is low. The

digestion and absorption of vitamin A are closely linked with lipid absorption and therefore low

dietary fat intake may interfere with vitamin Aabsorption.

Assessment of vitamin A status in pregnancy is commonly by measurement of serum retinol. In

20
pregnancy as a result of the physiological changes earlier described, serum retinol levels have

been shown to drop below non pregnancy concentration.30 Vitamin A is believed to be essential

for normal embryogenesis, haemopoesis, growth and epithelial differentiation. Basal requirement

in pregnancy is 370mcg/day. A diet void of vitamin A results in decreased

haemoglobinlevels.30A study carried out in Indonesia showed that antenatal supplementation

with both iron and vitamin A reduces the prevalence of anaemia (Vitamin B12 and Folate

Deficiency).

It has been suggested that vitamin A is required for the mobilization and utilization of iron for

haemoglobinsynthesis.32Currently WHO recommends routine vitamin A supplementation

during pregnancy or anytime during lactation in areas with endemic vitamin A deficiency.

Other causes of anaemia in pregnancy include:

Late ANC booking.

Loss of blood due to bleeding from hemorrhoids (piles) or stomach ulcers.

Urinary tract infections (UTI) of any aetiology and infections due to clostridium welchii

can also cause anaemia in pregnancy.

Anaemia is more common in women who have pregnancies close together. Birth spacing

favours iron nutrition among fertile-age women because each pregnancy has a high cost in

terms ofiron.

Multiple pregnancy (women carrying twins ortriplets).

Low socioeconomic status as a result of the low socio-economic conditions in most

developing countries coupled with deprivation due food taboos and superstitious beliefs,

many pregnant women avoid some food items. Most of the foods consumed in most African

homes are low in vitamins and high in carbohydrates and high phytate contents which reduce

21
 iron absorption. Most of the homes do not have means of food storage like refrigerators and

some of these foods are seasonal.

2.1.11 Clinical Features of Anaemia

2.1.11.1 Symptoms

The classical picture of tiredness, weakness and dizziness are present in only a small percentage

of patients with anaemia. Infact, it is common for patients with haemoglobin of less than 6.8g/dl

(PCV 18%) to walk into the clinic without any complaints. Over 80% of patients are picked

during routine estimation of haemoglobin level during visits to antenatal clinic. This fact reveals

the importance of routine haemoglobin estimation in pregnant women during each antenatal

visit.35In severe cases however, there may be classical symptoms of anaemic heart failure which

include dyspnoea and generalized oedema.

2.1.11.2 Signs

Through a careful general examination, the likely cause of the anaemia can be suspected. For

example, patients with sickle cell disease are generally slim, with long thin limbs. Another

feature is the prominence of the forehead (bossing). An important sign often missed in these

patients are scarification marks over the joints; particularly the elbow and knee joints

representing traditional treatment for chronic bone pains. Sometimes scarification marks are seen

over the splenic area.

The central sign for anaemia is pallor and the areas to examine for pallor are the mucous

membranes (conjunctiva, the tongue and the buccal mucosa), the palms and the nail beds.

Jaundice should be excluded as its presence may suggest a haemolytic cause. There may be

oedema of the limbs. In the chest, there may be basal crepitations which may be complicated by

heart failure. In patients with moderate to severe anaemia, a pan-systolic murmur (ejection or

22
haemic murmur) may be heard.

2.1.12 Effects Of Anaemia On Pregnancy Outcome

2.1.12.1 Effect of anaemia on maternal morbidity and mortality

The main function of haemoglobin is that of carrying oxygen to the tissues, other components of

the blood perform other important functions. The main effect of anaemia therefore, is a high

output cardiac failure. Iron deficiency has no direct effect on labour as such; however, a woman

who is anaemic when going into labour will tolerate badly any blood loss, an inevitable

occurrence at delivery. Normally, a mother can take blood loss of up to 1000 ml (one litre) in her

stride, but a markedly anaemic woman may find this to be a tall order and it could create a life-

and-death crisis. Severely anaemic women readily go into shock as a result of very small amount

of blood loss at delivery and mortality in such patients is in the range of 30 to 50%.The major

concern about the adverse effects of anaemia on pregnant women is the belief that this

population is at greater risk of perinatal mortality and morbidity. Maternal mortality from

anaemia in selected developing countries ranges from 27/100,000 live births in India, 34/100,000

live births in Nigeria to 194/100,000 live births in Pakistan.36Some data show an association

between a higher risk of maternal mortality and severe anaemia. Though such data were

predominantly retrospective observations of an association between maternal hemoglobin

concentrations at or close to delivery and subsequent mortality, there is little evidence of

increased risk associated with mild or moderate anemia.

Such data do not prove that maternal anaemia causes higher mortality because both the anaemia

and subsequent mortality could be caused by some other condition. For example, in a large

Indonesian study, the maternal mortality rate for women with a hemoglobin concentration<10g/L

was 70.0/10,000 deliveries compared with 19.7/10,000 deliveries for non anaemic women. In

23
another study, often cited as showing an association between maternal anaemia and subsequent

mortality, approximately one-third of the anaemic women had megaloblastic anaemia due to

folic acid deficiency and two-thirds had hookworm. The cut-off for anaemia was extremely low

(<65 g hemoglobin/L), and the authors stated that although anaemia may have contributed to

mortality, it was not the sole cause of death in many of the women.

It has been suggested that maternal deaths in the puerperium may be related to a poor ability to

withstand the adverse effects of excessive blood loss, an increased risk of infection and maternal

fatigue; however, these potential causes of mortality have not been evaluated systematically.

There is a dearth of information on the rates and severity of infection of anaemic pregnant

women or iron-deficient anaemic pregnant women. Iron deficiency was associated with lower

lymphocyte stimulation indices and iron supplementation improved lymphocyte stimulation in

severely anaemic pregnant Indian women. Additional studies on pregnant women are needed in

which appropriate measures of immune function are evaluated in response to iron

supplementation.

Pregnant women with sickle cell anaemia are classified as high-risk. Pregnancy adds stress to the

body and increases the chance of a sickle cell crisis. Sickle cell anaemia in pregnancy also

increases the risk of certain complications such as miscarriage, a type of high blood pressure

called Pregnancy-induced Hypertension, and premature birth. However, thanks to modern

medicine, pregnant women with sickle cell anaemia have a good chance of having a safe and

healthy pregnancy.

2.1.12.2 Effect of maternal anaemia on birth weight

In several studies, a U-shaped association was observed between maternal haemoglobin

concentrations and birth weight(Allen, 2009). Abnormally high haemoglobin concentrations

24
usually indicate poor plasma volume expansion, which is also a risk for low birth weight. Lower

birth weights in anaemic women have been reported in several studies. In a multivariate

regression analysis of data from 691 women in rural Nepal, adjusted decrements in neonatal

weight were associated with haemoglobin concentrations respectively. The odds for low birth

weight were increased across the range of anaemia, increasing with lower haemoglobin in an

approximately dose-related manner (1.69, 2.75,and 3.56 for haemoglobin concentrations of 90–

109, 70–89,and 110–119 g/L, respectively). Trials that included large numbers of iron-deficient

women showed that iron supplementation improved birth weight. Some investigators reported a

negative association between maternal serum ferritin and birth weight and a positive association

with preterm delivery. These findings probably indicate the presence of infection, which elevates

serum ferritin.

2.1.12.3 Effect of maternal anaemia on duration of gestation

There is a substantial amount of evidence showing that maternal iron deficiency anaemia early in

pregnancy can result in low birth weight subsequent to preterm delivery. Fetal morbidity in the

form of low birth weight (both preterm and intrauterine growth retardation) is said to be higher

especially in untreated anaemic pregnant women.

Agboola found placental hypertrophy and villous fibrosis in the placentae of anaemic mothers,

but the weights of infants born to these mothers were statistically within normal. It would appear

that the type and duration of the anaemia in these patients is what affects the placentae and the

birth weights of these babies rather than the anaemia per se.24 For example, Welsh women who

were first diagnosed with anaemia (haemoglobin<10.4g/L) at 13–24 weeks of gestation had a

1.18–1.75-foldhigher relative risk of preterm birth, low birth weight, and prenatal mortality.

After controlling for many other variables in a large Californian study, Klebanoff et al showed a

25
doubled risk of preterm delivery with anaemia during the second trimester but not during the

third trimester. Low haematocrit concentrations in the first half of pregnancy but higher

hematocrit concentrations in the third trimester were associated with a significantly increased

risk of preterm delivery. When numerous potentially confounding factors were taken into

consideration, analysis of data from low-income, predominantly young black women in the

United States showed a risk of premature delivery (<37weeks) and subsequently of having a low-

birth- weight infant that was 3 times higher in mothers with iron deficiency anaemia on entryto

care. There was no such increased risk for mothers who were anaemic but not iron deficient at

entry to care, or for those who had iron deficiency anaemia in the third trimester. Similar

relations were observed in women from rural Nepal, in whom anaemia with iron deficiency in

the first or second trimester was associated with a 1.87-foldhigher risk of preterm birth, but

anaemia alone was not. In an analysis of 3,728 deliveries in Singapore, 571 women who were

anaemic at the time of delivery had a higher incidence of preterm delivery than did those who

were not anaemic, but no other differences in either pregnancy complications or neonatal

outcomes were observed (Scholl, 2009). Thus, the results of several studies are consistent with

an association between maternal iron deficiency anaemia in early pregnancy and a greater risk of

preterm delivery. The apparent loss of this association in the third trimester is probably because a

higher haemoglobin concentration at this time may reflect poor plasma volume expansion and an

inability to discriminate between low haemoglobin caused by iron deficiency from that caused

by plasma volume expansion.

2.1.13 Diagnosis and Assessment of Anaemia

Ideally anaemia should be diagnosed when red cell mass (RBC mass) in the body decreases

below the expected normal for a healthy population, which is a mean of 25ml/kg for women and

26
28ml/kg for men. However, measurement of RBC mass is difficult and not easily available.

Hence a convenient and practical way to define anaemia is the measurement of Hb concentration

in blood. Anaemia is said to be present when Hb concentration falls below

13g/dlinmen,or<12g/dl in women. A lower threshold <11g/dl defines presence of anaemia in

small children.

This definition assumes a normal distribution of RBC mass and plasma-volume. Problems may

arise when this proportion is altered. For example, in normal pregnancy RBC mass increases by

about 25% whereas the expansion in plasma volume is much greater, thereby bringing the Hb

concentration down. And an Hb level of 11g/dlmay be a norm in pregnancy. One should be wary

of such spurious anaemia or masked anaemia situations. These are physiologicalvariations.

These days, electronic cell counters are widely available for estimating Hb concentration. These

instruments automatically measure a lot many more parameters, apart from Hb concentration.

Such parameters on RBC indices viz the MCV, MCH, MCHC, RDW, RBC count, haematocrit

and also the WBC and platelet counts are informative in patients with anaemia. Reticulocyte may

be measured automatically or manually.41Specific diagnosis in anaemia is a function of clinical

assessment and laboratory investigations. The two must be put together for a comprehensive

diagnosis:

27
 Clinical Laboratory
Assessmen Investigatio
t n
1/3r 1/3r
d d

Clinical +
Laboratory
1/3rd

Figure 2.1: Source of Data for diagnosis in anaemia

2.1.14 Investigations in a patient with anaemia

Complete blood count is the single most important investigation in anaemia. It should include

Hb, HCT, WBC, platelet count and RBC indices viz RBC count, MCV, MCH, and RDW.

Peripheral blood smears examination, to look for abnormalities in RBC, WBC, and platelets.

Reticulocyte count.

The above triad comprises the primary investigations in anaemia and can be performed on a

single EDTA blood sample.

Secondary investigations are guided by the results of the above tests in a given clinical context,

and may include one or more from the following:

1. Serum ferritin, vitamin B12, and RBC folate levels

2. Hb electrophoresis and quantitation (Hb A2, Hb Fetc)

3. Blood biochemistry for hepatic and renal functions

4. Bone-marrow aspiration

28
5. Trephine biopsy from bone marrow

6. Imaging studies may include X-ray chest/skull/ and other bones as warranted

7. Ultrasound abdomen, radio-isotope studies

8. RBC survival & kinetic studies (not available routinely).

Other specialized tests include Coombs test, osmotic fragility, Ham’s test, erythropoietin level,

immunocytochemistry, cytogenetics etc.

Another set of investigations may need to be undertaken to unravel the primary causative

disease. These would depend upon the clinical suspicion and the results of investigations as

listed above.

Thus, a patient with diagnosis of iron deficiency anaemia (commonest type of anaemia in clinical

practice) may warrant one or more of the following investigations:

1. Dietaryhistory

2. Stool for ova, cyst, and occult blood. If stool shows occult blood positive, do GI endoscopy or

Barium meal studies (Ba Meal and BaEnema)

3. Urine routine and for microscopic haematuria

4. Gynaecological assessment in women

5. Chest X-ray

6. Tests for bleeding disorders (PR, APTT, BTetc)

7. Tests of iron assimilation

Likewise, other types of anaemias may warrant a different set of investigations. Diagnosis in a

patient with anaemia can be approached from several angles. It is dictated by the available

clinical and laboratory information.

29
2.1.15 Management of Anaemia

The aim and goals of treatment should be to restore haemoglobin levels and Red cell indices to

normal, and to replenish iron stores, to prevent a further fall in haemoglobin level, relieve

symptoms related to anaemia thereby improving quality of life (QoL). If this cannot be achieved,

consideration should be given to further evaluation. Large variation in clinical scenarios requires

an array of actions. Initiation of treatmentdepends on symptoms (fatigue, headache, dyspnea, and

palpitations), aetiology and severity of anaemia, co-morbidity and potential adverse effects of

therapy.

2.1.15.1 Iron therapy

For iron deficiency without anaemia, different approaches to iron replacement should be

considered and discussed with the patient. If patients are likely to develop IDA, monitoring

frequency should be increased. Options for iron supplementation include:

Oral Iron

Treatment of an underlying cause should prevent further iron loss, but all patients should have

iron supplementation both to correct anaemia and replenish body stores. This is achieved most

simply and cheaply with ferrous sulphate 200 mg twice daily.42Lower doses may be as effective

and better tolerated and could be considered in patients not tolerating traditional doses. The main

factor in favour of oral iron is convenience, not efficacy. Oral iron may not be able to

compensate ongoing blood loss. Oral iron supplements can be used if absolute indications for IV

iron therapy are not met. If oral iron is used, response and tolerance should be monitored, and

treatment changed to IV iron if necessary. Side-effects are usually dose-related. The absorption

and efficacy are not greater when high doses are used. Not more than 100 mg elemental iron

daily should be prescribed. Other iron compounds (e.g. ferrous fumarate, ferrous gluconate) or

30
 formulations (iron suspensions) may also be better tolerated than ferrous sulphate.

Ascorbic acid (250–500 mg twice daily with the iron preparation) may enhance iron absorption.

It is recommended that oral iron is continued until three months after the iron deficiency has

been corrected so that stores are replenished.42 It is true that if iron is taken with food there is

some reduction in side effect related to GIT. However staple African diet consists of cereals and

cereals contain phytic acid. Phytate reduce iron absorption. Addition of vitamin C in medicine or

in the diet enhances iron absorption. So the timing of oral iron intake in relation to food should

be taken into consideration when managing the cases. If the predictable rise in haemoglobin does

not occur after oral iron therapy, one must find out the possible reasons. Some of the reasons are

as follows:

1. Incorrect diagnosis.

2. Mal-absorption syndrome

3. Presence of chronic infection

4. Loss of iron from the body

5. Lack of patients compliance

6. Ineffective release of iron from a particular preparation.

Parenteral iron

The defaulting rate with oral iron therapy in pregnant women is fairly high because of

gastrointestinal side effects like nausea, vomiting, diarrhoea and abdominal pain.

Sometimes pregnant women present with severe anaemia after 30-32 weeks of pregnancy and in

those cases time is an important factor to improve haemoglobin status. In such situations

parenteral iron therapy is indicated. Parenteral iron can be given by intramuscular or intravenous

route.

31
i. Intramuscular (IM)Iron

Sorbitol-citric acid complex (75mg) is used for intramuscular route only. On the other hand iron-

dextran can be used both by intramuscular and intravenous route. The maindrawback of

intramuscular iron is the pain and staining of the skin at injection site, myalgia, arthralgia and

injection abscess.

ii. Intravenous (IV)Iron

Clinical comparative trials show faster and prolonged response with IV iron (compared with

oral). IV iron is more effective, better tolerated and improves QoL to a greater extent than oral

iron. Absolute indications for I.V iron include:

– Severe anaemia (haemoglobin<10g/dl).

– Intolerance or inappropriate response to oral iron.

– Severe intestinal disease which reduces absorption of iron.

– Concomitant therapy with an erythropoietic agent.

– Patient preference.

– Where there is aversion for blood transfusion e.g. the Jehovah witness.

– When there is no blood available for transfusion.

I.V iron can be considered inappropriately interventional especially when iron dextran is used

with its risk of anaphylactic reactions.

Intravenous route should be reserved for those who do not wish to have frequent intramuscular

injections. Iron can be given intravenously at one shot as total dose infusion (TDI). Utmost

caution is needed for total dose iron therapy via intravenous route because of severe anaphylactic

reaction that may occur such as immediate vascular collapse, tachycardia, dyspnoea, cyanosis

vomiting, pyrexia etc. Therefore total dose of iron therapy by intravenous route should only be

32
given in a hospital setting where facilities are available to manage severe reaction after

irondextran.The total dose of infusion of iron (TDI) is calculated using the following formular:

TDI= (15- patient"s Hb) x body weight in Kg x3 =mg.

2.1.15.2 Management of severe anaemia in late pregnancy (after 32weeks)

These patients should ideally be managed in a hospital setting. They may or may not present

with heart failure. However they all need urgent admission and bed rest. They need complete rest

with sedation, oxygen. In case, of CCF patient should be given digitalis, diuretics and packed red

cells. Packed red cells are preferred choice for severe anaemia in later part of pregnancy. This

should be infused along with diuretics. Once the patient is stabilized total dose infusion of iron

Dextran may be considered.

Contraindications of parenteral iron therapy include Nephritis, cardio respiratory disease and

allergy.

Table 2.2: Dosing and infusion intervals of I.V iron based on the compound used

Chemical properties High MWLow MW ironIron gluconate Iron sucrose Ferric carboxy-
iron dextran dextran maltose
Complex stability High High Low Moderate High
Acute toxicity Low Low High Medium Low
Dosing
Test dose required. Yes 1000 Yes No Yes*/No 200–No
Max. dose(mg). 360 1000 62.5–125 500 1000
Max. infusion time(min). 100 360 60 30–210 15
Max.bolus dose (mg). 2 100 125 200 200
Max. injection time(min). 2 10 10 Fast push
Safety profile
Risk of anaphylaxis. Yes Yes No No No
Relative risk of serious High Moderate Low Lowest NA
adverse events.
Adapted from Table 5; MW= molecular weight; *only in Europe; NA = not available Gasche

33
 C et al. InflammBowel Dis 2015;13:1545–1553

Erythropoietic therapy

Erythropoietic agents are effective for treatment of anaemia from chronic diseases (ACD) and

may improve quality of life (QoL). This should be considered if haemoglobin is <10 g/dL or if

there is no response to IV iron therapy within 4 weeks.

Vitamin supplementation

Replacement of vitamin B12 or folic acid should be initiated if serum concentrations are below

normal.

Blood transfusion

Most patients have chronic bleeding and repeated blood transfusions are not appropriate.

Management should be directed at diagnosing and stopping bleeding. Indications for replacement

of blood after acute or chronic bleeding vary depending on the clinical situation, including rate of

bleeding. Indications for replacement of blood after acute or chronic bleeding vary depending on

the clinical situation, including rate of bleeding, haemodynamic state, haemoglobin, age and

concomitant disease. Blood transfusion is no substitute for treatment of IDA with IV iron,

possibly in combination with EPO. If transfusion is necessary, iron replacement therapy is still

required.

Indications for blood transfusion

1. Acute blood loss.

2. All cases of severe anaemia in pregnancy irrespective of gestationalage.

3. Where moderate anaemia coexists with serious diseases such as sepsis, renal failure,

haemoglobinopathies and eclampsia.

34
4. Anaemic patients seen for the first time during labour, or when they are aborting or during the

last four weeks of pregnancy, though their haemoglobin level may be around 6 or7g/dl.

5. In severe cases of anaemia, intravenous administration of 50mg of ethacrinic acid or 40mg of

frusemide is followed 5 or 10 minutes later by slow transfusion of packed cells. Transfusion of

whole blood may occasionally be required to correct thrombocytopenia.

2.1.16 Prevention of anaemia in pregnancy

It is advisable to build up iron store before a woman marries and becomes pregnant. This can be

achieved by:

1. Routine screening for anaemia for adolescent girls from schooldays

2. Encouraging iron rich foods

3. Fortification of widely consumed foods with iron

4. Providing iron supplementation from schooldays

5. Annual screening for those with risk factors

If all pregnant women receive routine iron and folic acid, it is possible to prevent nutritional

anaemia in pregnant women. National Nutritional Anaemia Prophylaxis Program recommends

60milligram elemental iron and 500 micrograms of folic acid daily for 100 days to all pregnant

women. However it is suggested that 100milligram of elemental iron and 1 milligram folic acid

are the optimum daily doses needed to prevent pregnancy anaemia. Higher dose is required in

women from developing countries as they start pregnancy with low or absent iron stores due to

poor nutrition and frequent infections like hook worm and malaria.

35
2.2 Theoretical Framework

In effect social cognitive models propose that determinants that shape human behavior are

imparted through socialization and may be disposed, vulnerable and susceptible to change. While

appraising the literature, two theories were found to offer a strong theoretical framework for this

research namely: the social cognitive theory (SCT) and the Health Belief Model (HBM).

Social cognitive theory

The Social Cognitive Theory stems from the Social Learning Theory and was suggested by

Alfred Bandura in 1986. The pregnant women knowledge, attitude, beliefs, care and control, role

model, willingness to change, were identified as malleable factors in order to influence the

dietary habits, and adherence to Iron Folic-Acid (IFA) supplements. The design of the

intervention is guided by the Social Cognitive Theory (SCT). According to the SCT, at least two

principal sources of self-efficacy; verbal persuasion and performance accomplishment are

intended to mediate the effect of this intervention. The education of pregnant women about

anemia, nutrition, and Iron Folic-Acid (IFA) supplementationcould foster the perception that

their actions can control anemia in them.

Health Belief Model

Health Belief Model was first developed in the 1950s by social psychologists Hochbaum,

Rosenstock and Kegels. The model uses constructs that represent perceived threats and net

benefits such as perceived susceptibility, perceived severity, perceived benefits, perceived

barriers, cues to action and self-efficacy. The model asserts that these constructs account for

aperson’s “readiness to act”. The most important role is figured in teaching and providing

pregnant women with information needed based on social and psychological behavioral changes

to maintain health during pregnancy mainly those related to nutritional aspects.  Using health

36
belief model during health education session nurses emphasize on behavioral changes to assist

pregnant women to change their eating habits and practices that contribute to nutritional deficit.

2.3 Empirical Review

The awareness of anaemia among pregnant women at their current ANC visit (62.9%) was

similar to the awareness of 69.1% reported by Ouma et al., 2007, among pregnant women in

Kisimu in Western Kenya, the awareness of 61.4% recorded by Kavle et al., 2008, among

pregnant women in Tanzania. Also similar awareness have been recorded by Al hassan, 2006

(61%) in Benin and Fiedler et al., 2014 (69%) in Mali and in Sudan (62.9%) by Adam et al.,

2005.

However, the awareness recorded was marginally higher than the awareness of 52.5% in Central

Sudan recorded by Bushra et al., 2010, the awareness of 41.5% among pregnant women, in

Easten Caprivi, Namibia (Thompson,1995), the awareness of 54.5% among pregnant women in

Oyu in Nigeria (Olatunbosun et al.,2014), the awareness of 47.4% among pregnant women

(Msuya et al., 2011), in the Moshi Municipality of Tanzania, and the awareness of 47% among

pregnant women (Ayoya et al.,2006), in Mali. The awareness for the current study is also

marginally higher than that ascertained in prior studies by Melku et al., 2014 with a recorded

awareness of 40% and Anlaakuu, 2015 in Sunyani with a recorded awareness of 41.5%,

Achampong et al., 2018 with a recorded awareness of 51% among pregnant women in Accra,

and another study in the Sankyere West district (Glover-Amengoet al., 2005) with a recorded

awareness of 57.1%.

It is also noteworthy to mention that the awareness recorded in this study is considerably higher

than the awareness of 26.8% reported by Alzaharani (2012) in Taif, Saudi Arabia, the awareness

37
of 23.2% among pregnant women (Buseri et al.,2008), in Niger Delta state in Nigeria and the

awareness of 33.8% in a related Sudan (Alzaharani, 2012). The awareness for the current study is

also considerably higher than that ascertained in prior studies by Khadija (2006) with recorded

awareness of 25.7% and Saweet al. (1992) with a awareness of 24.5% and Margwe(2015) with a

recorded awareness of 38.7%.

It is again important to note that the awareness recorded in this study is considerably lower than

the awareness of 90.5% among pregnant women in Taif, in Saudi Arabia (Baig-Ansari et al.,

2008), the awareness of 87.2% among pregnant women in Auranbagad in India (Lokare et al.,

2012), and the awareness of 72.6% among pregnant women (Dreyfuss et al., 2000), in Nepal.

The wide stream of disparities realized as can be seen when the study is compared to other

related studies perhaps could be attributed to differences in geographical locations, development

and socioeconomics including access to economic resources, health care and healthy foods for

consumption.

It is again noteworthy to mention that the awareness of anaemia at first ANC visit (93.9%) falls

considerably outside of that reported for pregnant women in Africa (57.1%), Ghana (65%) and

Northern Region (43%) in which the study was conducted (GHS, 2016). This is very worrying as

it indicates that many mothers go into pregnancies with anaemia which is a poor start could

result into developmental difficulties on the part of the growing foetus. Also since many prior

studies have reported that pregnant women report for their first visits at health facilities usually

in the second trimester, grave harm could have been caused to the foetus before the initiation of

corrective measures. Anaemia in pregnancy greatly increases the risk of delivery complications

including excessive blood loss that could result in maternal mortality. It also contributes to low

birth weight.

38
The disparity of anaemia ascertained between the first and current ANC visits could be attributed

to high reported compliance of intake of iron and folic acid supplements and the impressive

reported dietary diversity especially in respect of protein intake. As this is bound to cause a rise

in haemoglobin levels and consequently improve anaemia status. Overall, the high awareness

also insinuates that amidst interventions that have been put in to address anaemia in Ghana, its

alleviation still remains a challenge.

Padmavathi et al (2015) “Awareness of anemia in pregnancy among the caregivers of pregnant

women in Saveetha Medical College Hospital” Anemia is the most common nutritional

deficiency disorder in the world. WHO has estimated that prevalence of anemia in developed and

developing countries in pregnant women is 14 per cent in developed and 51 per cent in

developing countries and 65-75 per cent in India. Anemia is one of the important factor which

decides the outcome of pregnancy. Affects of anemia among pregnant women includes increased

risk of low birth-weight or prematurity, perinatal and neonatal mortality, increased risk of

maternal morbidity and mortality. Anaemia is estimated to contribute to more than 115,000

maternal deaths and 591,000 perinatal deaths globally per year(4). This study is focused on the

awareness of affects of anemia in pregnancy among the persons who are taking care of these

women at home(caregivers). Indian customs have food taboos and implementation of

supplemental iron during pregnancy experiences a kickback because of the common belief that

any drug in pregnancy can cause teratogenicity(malformed fetus). We have taken the help of a

questionnaire which targets the knowledge of anemia in various aspects like affects in

pregnancy, sources of food which can improve anemia, foods which can affect the absorption of

iron etc. among these caregivers. The aim is to find out the awareness of anemia in pregnancy

among the caregivers of pregnant women reporting to Saveetha Medical College and Hospital.

39
Among 300 participants, 70% were unaware of the symptoms of anemia, 100% were unaware of

the cardiac complications, postpartum hemorrhage, maternal mortality due to anemia in

pregnancy; however more than 70% were aware of the diet rich in iron and proteins which can

improve anemia 100% of the participants were unaware that iron tablets should not be taken with

tea or coffee or milk. No significant difference was found between the level of awareness and the

demographic variables like sex, age, income, literacy or caregiver’s relation with the patient.

Participants were totally unaware of the grave complications of anemia. It needs to be re-

emphasized that through media-radio, television (which contributed to the sources of health

information in 48.4% of the participants ) we can impart more knowledge to the general

population regarding the complications of anemia and need for regular follow up with their

doctor( who contributed to sources of health information in 46.3% of the participants) for

decreasing the maternal mortality in India. Distribution of pamphlets with information regarding

these aspects of anemia to the caregivers will definitely improve the knowledge of anemia

among these people.

Alemayehu et al , (2017) “Adherence to iron with folic acid supplementation and its associated

factors among pregnant women attending antenatal care follow up at Debre Tabor General

Hospital, Ethiopia, 2017” Nutritional anemia is a major public health problem throughout the

world, particularly in developing countries. Iron with folic acid supplementation (IFAS) is

recommended to mitigate anemia and its resulting complications during pregnancy. There has

been limited study on IFAS adherence of pregnant women in the study area. The aim of this

study was to assess adherence to IFAS and its associated factors among pregnant women

attending antenatal care service in Debre Tabor General Hospital, Ethiopia. An institution-based

cross-sectional study was conducted from January 9 to April 8, 2017, at Debre Tabor General

40
Hospital. A total of 262 study participants were included and selected by systematic random

sampling. The entire interviewed questionnaire was checked and entered into EpiData version

3.1 and then exported to SPSS version 20 for windows for analysis. IFAS adherence status was

defined as, if pregnant mothers took 65% or more of the IFAS which is equivalent to taking

IFAS at least 4 days a week during the 1-month period preceding the study. Regressions were

fitted to identify independent predictors of IFAS adherence. A P-value of less than 0.05 was used

to declare statistical significance. A total of 241 pregnant women were included (92% response

rate), of which 107 (44%) were adherent to IFAS. Only 39% received IFAS counseling, and 52%

had some knowledge of IFAS. Gravidity (AOR = 2.92 95% CI (1.61, 5.30)), gestational age at

first ANC visit (AOR= 3.67, 95% CI (1.94, 6.97)), pregnant women who got advice about IFAS

(AOR = 2.04, 95%CI (1.12, 3.75)), current anemia (AOR = 2.22, 95%CI (1.45, 4.29)), and had

knowledge about IFAS (AOR = 3.27, 95% CI (1.80, 5.95)) were statistically associated with

adherence to IFAS among pregnant women. Overall, IFAS adherence among pregnant women

was low. The associated factors with adherence of IFAS were counseling and knowledge, early

ANC attendance, pregnancy history, and current anemia diagnosis. IFAS counseling by health

workers was low but, when given, was associated with improved IFAS adherence. Health

workers and health extension workers should consistently counsel on IFAS benefits during ANC

visit, to improve IFAS adherence during the current and subsequent pregnancies.

Masreshaet al (2018) “Pregnant women’s knowledge, attitude and practice regarding the

prevention of iron deficiency anemia among Ethiopian pregnant women” Background: Despite

the fact that there are various methods for the treatment and prevention of maternal anemia, there

are still many pregnant women affected by anemia-related health problems and contributing

factors. The aim of the study was to assess the knowledge, attitude, and practice of pregnant

41
women with regard to the prevention of iron deficiency anemia (IDA) in public hospitals of

Harar, Eastern Ethiopia.

Methods: This cross-sectional study was done on 128 pregnant women, who referred to public

hospitals in Harar, Eastern Ethiopia for antenatal care. Sample selection was based on random

sampling. The anemia status of the pregnant women was determined by measuring their

hemoglobin and ferritin serum levels. The data was collected using a close-ended, semi-

structured questionnaire.

Results: According to the results, 68% of the participants had no IDA. Most of them had heard

about anemia and defined it. The majority of them knew the causes and the preventive methods

(58.6%). Most of them had a positive perception of the consumption of folic acid, family

planning, feeding on regular meals. Most of them (59.4%) took folic acid during pregnancy, and

56.3% fed on fiber-rich food.

Conclusion: This study found that around one-third of the pregnant women had IDA. So it is

vital to promote health education, involve private health institutions and husbands. Health

facilities and stakeholders should, therefore, work on increasing the awareness, positive

perception and skill necessary for the prevention of IDA.

Margaret et al (2019) “Preventive Measures of Anemia in Pregnancy Among Pregnant Women

Attending Antenatal Clinic in Ibadan, Nigeria” Anemia is a major cause of morbidity and

mortality among pregnant women in developing countries like Nigeria. The burden and

predisposing factors varies even within countries. It is one of the potential lethal complications

of pregnancy leading to large number of maternal and fetal death. However, it is preventable and

curable. The aim of this study was to find out the preventive measures and knowledge of anemia

in pregnancy among pregnant women attending antenatal clinic in Adeoyo Maternity Teaching

42
Hospital, Ibadan. The study utilized the use of non-experimental cross sectional type of

descriptive survey and a convenient sampling technique was used to select 384 participants. Data

were obtained using a self- administered questionnaires and analyzed using SPSS version 20.0, p

≥ 0.05 significant level. The results of the study unveiled majority 282 (73.4%) of the

respondents have adequate knowledge of anemia in pregnancy. Majority 242 (63%) of the

respondents adopt use of iron supplements and folic acid as a preventive measure against anemia

in pregnancy. However, a large percentage (79.9%) of them avoid eating culturally forbidden

foods rich in iron. Also, a good proportion 252 (62%) of the respondents have good perception

on anemia in pregnancy. The findings based on the hypothesis revealed a significant association

between respondents’ antenatal clinic attendance and knowledge of preventive measures of

anemia in pregnancy. It was concluded that pregnant women’s knowledge of preventive

measures against anemia in pregnancy is paramount to healthy life in pregnancy and good

pregnancy outcome.

2.4 Summary of Literature Reviewed

This chapter presented the relevant literature for this study. The first part looked at conceptual

literature. This is focused on concepts of anaemia, the causes and preventive measures. The

second part presented the theories based on the study. Third is the empirical literature which

were gotten from past research.

CHAPTER THREE

METHODOLOGY

43
3.1 Design of Study

Descriptive survey design was used to investigate the level of awareness and knowledge and the

health implications of anaemia among pregnant women.

3.2 Setting of Study

The study was conducted in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra

State, Nigeria.

3.3 Target Population

118 ante natal women was used for the study selected using a convenience sampling technique

3.4 Sample and Sampling Method

Simple random sampling method was used in the selection of 118 participants for the study

Thus, inclusion and exclusion criteria were used to select participants for the study. Each day

at the antenatal care clinic, pregnant women were screened using “pregnant women screening

questionnaire” to identify those who met the inclusion criteria. All qualified clients were

included in the study. Simple random sampling method was used in the selection of 100

participants for the study. The first participant was randomly selected among the first 68

people on the first day and then subsequent randomized selection till the 118 were met.

3.5 Validity of Instrument

Data was collected through a period of five weeks from February 2020 to March 2020 based on

44
their attendance in Nnamdi Azikiwe University Teaching Hospital, Nnewi. 70 % of the women

were illiterates so questions were interpreted to each woman in the local language by four

research assistant who were nurses. Researchers met the women interview was carried out in the

waiting area of the mosque and it took about 30 minutes for each one.

Tool and validity

One tool was developed by the researchers; a structured interviewing questionnaire which

consists of four major sections namely: the demographic characteristics of respondents, health

implications of anaemia and the strategies deployed to curtail them, and the level of awareness

and knowledge of anaemia among pregnant women and factors that causes anaemia in

pregnancy.

The content and construct validity of the research instruments was done to ensure that items in

the instrument meet the desired research objective, questions and hypotheses of the study. Also,

a reliability analysis was done using the Cronbach’s alpha and yielded coefficients of 0.71 for

health implications of anaemia;74 for the strategies deployed to curtail anaemia, 0.70 for the

level of awareness; 0.69 for the level of knowledge of anaemia; and 0.65 for genetic factors, 0.75

for maternal factors, 0.67 for nutritional, and 0.81 for infectious agents.

The predicting health behavior and social cognition was measured using adapted MacKian

(2003) health belief model. The range of behaviors examined was categorized into broad areas:

preventive health behaviors, sick role behaviors and clinic use; threat perception and behavioral

evaluation. The study used conceptual framework to support this study as presented in Figure 1

below.

3.6 Instrumentation of Research

The questionnaire has four major sections namely: the demographic characteristics of

45
respondents, health implications of anaemia and the strategies deployed to curtail them, and the

level of awareness and knowledge of anaemia among pregnant women and factors that causes

anaemia in pregnancy which is also divided into five sub sections: genetic factors, maternal

factors, nutritional, and infectious agents. In section two, three and four, the variables of this

study was captured in a likert scale.

Figure 1: Increase awareness and knowledge of Anaemia model

From the conceptual framework (increase awareness and knowledge of anaemia model), there

are four major variables: level of awareness, level of knowledge, health ensuring strategies to

curtail anaemia and the demographic characteristics of pregnant women. It is assumed that the

level of awareness could influence both the level of knowledge and also health ensuring

strategies to curtail anaemia. It is also assumed that there could be different levels of awareness

with respect to the socio-demographic characteristics of pregnant women hence, their use in this

46
study.

3.7 Data analysis

Data was collected and analyzed by computer program SPSS version 21. The quantitative

variables were presented in tables as numbers and percentage; and analyzed by ANOYA, p-value

< 0.05 was considered to be statistically significant and regression model to examine the

relationship between and among variables of interest in the study.

3.8 Ethical considerations

Ethical approval was obtained from the ethical committee of Ladoke Akintola University of

Technology, Ogbomosho and the Gynecology & Obstetric Department central hospital, Warri,

Delta state.

An informed oral consent was obtained from all participants who were willing to participate in

the study after explanation of the purpose of the study, the benefits, the nature, the process and

expected outcomes of the study. All rights, anonymity and confidentiality of the respondents

were respected and they have the right to withdraw from the study at any time regardless of the

cause.

CHAPTER FOUR

RESULTS, FINDINGS AND DISCUSSIONS

47
The result of this study is presented in three subsections of this section namely: demographic

characteristics; the responses to research questions and the hypotheses testing presentation.

Table 4.1: Demographic Characteristics of Respondents

Demographic Characteristics Frequency Percent

Age Below 20 Years 17 17.0
21-25 years 23 23.0
26-30 years 30 30.0
31-35 years 13 13.0
Above 35 years 13 13.0
Missing System 4 4.0
Total 100 100.0
Marital Status Single 14 14.0
Married 66 66.0
Separated 5 5.0
Widowed 2 2.0
Missing System 13 13.0
Total 100 100.0
Education level No formal education 6 6.0
Primary education 8 8.0
Secondary education 57 57.0
Tertiary education 26 26.0
Missing System 3 3.0
Total 100 100.0
Occupation Farming 10 10.0
Self entrepreneur 51 51.0
Civil servant 22 22.0
Medical practitioner 5 5.0
Student 7 7.0
Missing System 5 5.0
Total 100 100.0
Field Survey, 2020

Table 4.1 shows that respondents who are between the age brackets 26-30 years has the highest

percentage (30%) and those who are married has the highest percentage (66%).Secondary

education has the highest percentage (57%), while those who had no formal education has the

lowest percentage (6%). Self-entrepreneurs have the highest percentage (51%), while

48
respondents who are medical practitioners has the lowest percentage (5%). This implies that

pregnant women used for this study have moderate demographic characteristics.

Research Questions

Research Question one: Are pregnant women attending antenatal clinic in Nnamdi Azikiwe

University Teaching Hospital, Nnewi aware of anaemia?

Table 4.2: Level of Awareness of Anaemia among pregnant women

Awareness of Anaemia Frequency Percent

I am aware that anaemia affect pregnant women Disagree 4 4.0
Agree 90 90.0
Missing System 6 6.0
Total 100 100.0
Fatigue is a major symptom of anaemia Disagree 13 13.0
Agree 82 82.0
Missing System 5 5.0
Total 100 100.0
Weakness is a major symptom of anaemia Disagree 16 16.0
Agree 75 75.0
Missing 9 9.0
System
Total 100 100.0
Pale or yellowish skin is a major symptom of Disagree 13 13.0
anaemia Agree 84 84.0
Missing System 3 3.0
Total 100 100.0
Irregular heartbeats is a major symptom of anaemia Disagree 4 4.0
Agree 92 92.0
Missing System 4 4.0
Total 100 100.0
Shortness of breath is a major symptom of anaemia Disagree 14 14.0
Agree 83 83.0
Missing System 3 3.0
Total 100 100.0
Dizziness or lightheadedness is a major symptom ofDisagree 13 13.0
Agree 78 78.0

49
anaemia Missing System 9 9.0
Total 100 100.0
Chest pain is a major symptom of anaemia Disagree 13 13.0
Agree 84 84.0
Missing System 3 3.0
Total 100 100.0
Cold hands and feet is a major symptom of anaemia Disagree 15 15.0
Agree 82 82.0
Missing System 3 3.0
Total 100 100.0
Headache is a major symptom of anaemia Disagree 1 1.0
Agree 97 97.0
Missing System 2 2.0
Total 100 100.0
Field Survey, 2020

Table 4.2 shows that 90% are aware that anaemia affect pregnant women. 82% stated that fatigue

is a major symptom of anaemia; while 84% stated that pale or yellowish skin is a major symptom

of anaemia. Also 92% stated that irregular heartbeats is a major symptom of anaemia while 97%

stated that headache could also be one of the major symptoms of anaemia.

Research Question two: What are the causes of anaemia among pregnant women attending

antenatal in Nnamdi Azikiwe University Teaching Hospital, Nnewi knowledgeable?

Table 4.3: Level of Knowledge on the causes of Anaemia among pregnant women

Frequency Percent
Anaemia is a deadly challenge in pregnant women Disagree 6 6.0
Agree 93 93.0
Missing 1 1.0
System
Total 100 100.0
It can affect the health of the mother Disagree 10 10.0
Agree 87 87.0
Missing 3 3.0
System

50
 Total 100 100.0
It can also affect the health of the child in Disagree 11 11.0
pregnancy Agree 82 82.0
Missing 7 7.0
System
Total 100 100.0
Anaemia is a condition where the number of red Disagree 7 7.0
blood cells or the oxygen-carrying capacity in a Agree 88 88.0
Missing 5 5.0
pregnant woman is insufficient to meet the
System
physiologic needs Total 100 100.0
Maternal anemia occurs at a Hemoglobin (Hb) Disagree 6 6.0
Agree 90 90.0
level of <11g/dl, or Hematocrit (Hct) of <33% in Missing 4 4.0
all trimesters of pregnancy System
Total 100 100.0
Field Survey, 2020

Table 4.3 shows that 93% stated that anaemia is a deadly challenge in pregnant women that it

can affect the health of the mother and the child in pregnancy. In addition, 88% of the

respondents stated that anaemia refers to a condition where the number of red blood cells or the

oxygen-carrying capacity in a pregnant woman is insufficient to meet the physiologic needs and

maternal anemia is a condition that occurs at a Hemoglobin (Hb) level of <11g/dl, or Hematocrit

(Hct) of <33% in all trimesters of pregnancy.

51
Research Question three: What are the various health implication of anaemia among

pregnant women attending antenatal clinic in Nnamdi Azikiwe University Teaching

Hospital, Nnewi?

Table 4.4: Health Implication of Anaemia among pregnant women

Frequency Percent
Anaemia could affect the health of the foetus Disagree 14 14.0
Agree 86 86.0
Total 100 100.0
Anaemia could affect the health of the mother Disagree 16 16.0
Agree 83 83.0
Missing 1 1.0
System
Total 100 100.0
Anaemia could lead to low birth weight Disagree 22 22.0
Agree 73 73.0
Missing 5 5.0
System
Total 100 100.0
Anaemia could cause morbidity Disagree 17 17.0
Agree 82 82.0
Missing 1 1.0
System
Total 100 100.0
Anaemia could lead to heart failure among Disagree 8 8.0
pregnant women Agree 91 91.0
Missing 1 1.0
System
Total 100 100.0
Anaemia could lead to obstetric haemorrhage and Disagree 6 6.0
puerperal infection
Agree 93 93.0
Missing 1 1.0
System
Total 100 100.0

52
 Anaemia could cause postpartum depression Disagree 3 3.0
Agree 94 94.0
Missing 3 3.0
System
Total 100 100.0
Anaemia could affect child development Disagree 10 10.0
Agree 89 89.0
Missing 1 1.0
System
Total 100 100.0
It could also affect work productivity Disagree 10 10.0
Agree 87 87.0
Missing 3 3.0
System
Total 100 100.0
Field Survey, 2020

Table 4.4 shows 86% that anaemia could affect the health of the fetus and mother can also cause

low birth weight and morbidity. 91% stated that anaemia could lead to heart failure, obstetric

haemorrhage, puerperal infection and postpartum depression among pregnant women. 89%

stated that anaemia could affect child development while 87% stated that it could also affect

work productivity of the women.

Research Hypotheses

Ho1: There is no significant relationship between the level of awareness and the knowledge

of anaemia status among pregnant women in Nnamdi Azikiwe University Teaching

Hospital, Nnewi.

This subsection provides the regression analysis result to hypothesis one, and this is presented in

table 4.5. The adjusted R square is .49, which shows a 49% goodness of fit and implies that the

53
regression analysis could only explain the relationship between the variable of interest.

Table 4.5: Regression Analysis awareness on the causes and prevention of anaemia

Coefficients
Model Unstandardized Standardized t Sig.
Coefficients Coefficients

B Std. Error Beta

1 (Constant) 5.301 .972 5.457 .000

Awareness .316 .037 .704 8.533 .000

a. Dependent Variable: Knowledge

Table 5 shows that the relationship between awareness on the causes and prevention of anaemia

among pregnant women is significant (p<0.05). This implies that the null hypothesis which

stated that there is no significant relationship between awareness on the causes and prevention is

rejected (p<0.000). Hence, there is a significant relationship between awareness on the causes

and prevention of anaemia among pregnant women.

Ho2: There is no significant difference in the level of awareness with respect to the

demographic characteristics of pregnant women in Nnamdi Azikiwe University Teaching

Hospital, Nnewi.

Table 4.6: Analysis of Variance level of awareness of anaemia

Tests of Between-Subjects Effects

Dependent Variable: Awareness
Source Type III df Mean Square F Sig. Partial Eta

54
 Sum of Squared
Squares
Corrected 125.163a 4 31.291 1.071 .379 .072
Model
Intercept 1244.356 1 1244.356 42.610 .000 .437
Age 53.759 1 53.759 1.841 .180 .032
Marital status 31.719 1 31.719 1.086 .302 .019
Education 56.137 1 56.137 1.922 .171 .034
Occupation 6.884 1 6.884 .236 .629 .004
Error 1606.170 55 29.203
Total 40238.000 60
Corrected 1731.333 59
Total
a. R Squared = .072 (Adjusted R Squared = .005)

ANOVA result in table 6 shows that there is no significant difference in level of awareness of

anaemia among pregnant women with respect to their demographic characteristics such as age,

occupation, education level, etc. (p>0.05). This implies that the null hypothesis which stated that

there is no significant difference in level of awareness of anaemia among pregnant women is

accepted. (p>0.05). Hence, there is no significant difference in the level of awareness of anaemia

among pregnant women and social demographic variables.

Ho3: There is no significant relationship between the level of awareness and the health

ensuring strategies undertaken to curtail anaemia during pregnancy among pregnant

women in Nnamdi Azikiwe University Teaching Hospital, Nnewi.

This subsection provides the regression analysis result to hypothesis three presented in table 4.7

The adjusted R square is .39, which shows a 39% goodness of fit and implies that the regression

analysis could only explain the relationship between the variable of interest.

Table 4.7: Regression Analysis

55
 Coefficientsa

Model Unstandardized Standardized t Sig.

Coefficients Coefficients

B Std. Error Beta

1 (Constant) 14.066 1.055 13.329 .000

Awareness .028 .040 .081 .698 .488

a. Dependent Variable: strategies

The result in table 7 shows that the level of awareness and the health ensuring strategies

undertaken to curtail anaemia during pregnancy among the participants is not significant

(p>0.05). This implies that the null hypothesis which states that there is no significant

relationship between the level of awareness and the health ensuring strategies to curtail anaemia

during pregnancy among pregnant women is not accepted (p>0.05). Hence, there is no

significant relationship between the level of awareness and the health ensuring strategies

undertaken to curtail anaemia during pregnancy among pregnant women.

Discussion of Findings

The findings of this study revealed that the level of awareness on the causes and prevention of

anaemia are high among pregnant women in Nnamdi Azikiwe University Teaching Hospital,

Nnewi. Majority are aware that anaemia is a deadly challenge that affect the health of pregnant

women and their fetus.

56
The findings of this study is at variance with the study of Batool et al. (2010); and Suryanarayana

et al. (2016) that level of awareness on the causes of anaemia burden is poor in developing

countries such as Nigeria. The findings of this study support the works of Balarajan et al. (2011);

Yadav et al. (2014) and Osungbade and Oladunjoye (2012) that there is an increasing level of

awareness of causes of anaemia in Nigeria. However, this contrasts Batool et al. (2010) that the

level of awareness prevention of anaemia is low among pregnant women.

The findings of this study also revealed that the health implications of anaemia is higher on

pregnant women in Nnamdi Azikiwe University Teaching Hospital, Nnewi than in the fetus.

There was a significant relationship between awareness on the causes and prevention of anaemia

among pregnant women in Nnamdi Azikiwe University Teaching Hospital, Nnewi. There were

no significant relationship between awareness on the causes and prevention anaemia among

pregnant women and also between the level of awareness and the health ensuring strategies

undertaken to curtail anaemia during pregnancy among pregnant women in Nnamdi Azikiwe

University Teaching Hospital, Nnewi. Hence, there is need to increase the level of awareness of

anaemia among pregnant women in this region of Nigeria towards ensuring better health

ensuring strategies. This reinforces the study of Omiunu (2015) that the awareness of anaemia

among pregnant women is important to curtail its effect on the pregnant mother and fetus

towards the attainment of SDGs. The study findings buttresses Osungbade & Oladunjoye (2012)

and Omiunu (2015) that revealed that to there is the dire need to enhance the strategies to

improve the level of awareness on the causes and prevention among mothers and health workers.

This study finding supports Balarajan et al. (2011) that revealed lack of education and

information about anaemia prevention, and awareness of the benefits of appropriate intervention

measures among pregnant mothers in developing countries such as Nigeria. It also supports the

57
study of Okik (2012); Dattijo et al. (2016); Department of Health, Government of South

Australia (2019), that lack of awareness on the causes and prevention of aneamia can affect the

level of health consequences and the strategies deployed to curtail anaemia while it contrast the

study by Verma et al. (2004) that there is no significant relationship between knowledge of

anaemia and its prevalence.

CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.1 Summary

Awareness of anaemia within the survey group was high with many indicating having received

information on anaemia principally from health workers and to a less extent form the media. This

finding is in line with findings of Aruna, 2017. This also indicates that health workers within the

locale may have been up to the task since it is priority within the Ghana health service to

drastically reduce anaemia since its influence in maternal mortality and delivery complications

has been greatly suffered in the past.

58
5.2 Conclusion

In conclusion, the level of awareness on causes of anaemia are high among pregnant women in

Nnamdi Azikiwe University Teaching Hospital, Nnewi. There was a significant relationship

between awareness and knowledge of anaemia; no significant difference in the level of awareness

of anaemia among pregnant women and socio demographic variables in Nnamdi Azikiwe

University Teaching Hospital, Nnewi; and no significant relationship between the level of

awareness on the preventive strategies undertaken to curtail anaemia during pregnancy among

pregnant women in Nnamdi Azikiwe University Teaching Hospital, Nnewi.

In conclusion, there is need to increase the level of awareness of anaemia among pregnant women

in Warri, Nigeria towards ensuring better health ensuring strategies.

5.3 Recommendations

i. Anaemia has become a major health challenge among pregnant women, it is important that

the government and hospitals should help raise its level of awareness on the causes of anaemia by

organizing workshop to lecture pregnant women especially during pregnancy in various hospitals.

ii. Major drugs that could help to prevent anaemia among pregnant women should be provided

for free during pregnancy by governments and hospitals.

iii. Women should be subjected to constant free blood test due to a very low level of socio

economic development and high poverty rate in Nigeria to be able to cater for at least a higher

percentage, if not all pregnant women.

iv. It should also be mandated that pregnant women should know their blood level status before

59
registering for antenatal and also during the antenatal. This must be done in the third trimester to

ensure the life of the baby and that of the mother are save.

v. Government and hospitals should endeavor to also reduce the hospital bills, due to the fact

that many pregnant women could find other options of place of delivery such as homes and other

cheap avenue which could raise the probability of endangering the baby and the mother.

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