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Prevalence and associated factors of anemia among pregnant women in Sana’a, Yemen
*Corresponding author: Meram Azzani, Department of Community Medicine, MAHSA University, Saujana Putra Campus, Jenjarom 42610, Selangor, Malaysia.dr_memeazzani@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: Al-Aini S, Senan CP, Azzani M. Prevalence and associated factors of anemia among pregnant women in Sana’a, Yemen. Indian J Med Sci 2020;72(3):185-90.
Abstract
Objectives:
According to the World Health Organization estimates, approximately half of the pregnant women suffer from anemia worldwide. Anemia prevalence during pregnancy ranges from 18% in developed countries to 75% in South Asia. This study aimed at determining the prevalence and associated factors of anemia among pregnant women in the second and third trimesters in Sho’ub District of Sana’a City, Yemen.
Material and Methods:
A cross-sectional study was conducted on 384 pregnant women aged between 15 and 49 years. Convenience sampling method was used to select the study participants. Information on the participants’ sociodemographic characteristics and nutritional and health status was collected using a structured questionnaire through face-to-face interview with participants. The hemoglobin level measurements were assessed using the Sysmex analyzer. Both descriptive and inferential analyses were utilized.
Results:
The prevalence of anemia among study participants was 25%; of which 70.83% had mild anemia, 28.13% had moderate anemia, and only 1.04% had severe anemia. Risk factors associated with anemia were low family monthly income (odds ratio [OR] = 0.357, 95% confidence interval [CI] = 0.215–0.590; p =0.001), short pregnancy spacing (OR = 3.106, 95% CI = 1.375–7.016; p = 0.06), never consumed liver (OR = 3.004; 95% CI = 1.528-5.790; p =0.001), and presence of health problems (OR = 2.260; 95% CI = 1.342–3.806; p = 0.002).
Conclusion:
Findings of the study revealed a high prevalence rate of anemia (25%) among pregnant women in Sana’a, Yemen, with low socioeconomic status, short pregnancy intervals, and having other health problems were the associated factors of anemia among the women studied. The findings suggest the need for implementing effective preventive strategies, especially advocacy and monitoring of the iron and folic acid supplementation.
Keywords
Anemia
Prevalence
Associated factors
Pregnant women
Second and third trimester
Yemen
INTRODUCTION
According to the World Health Organization (WHO), globally anemia affects 1.62 billion people which corresponds to 24.8% of the population worldwide.[1] The highest proportion of affected is in developing countries, particularly in Africa (47.5–67.6%), while the greatest number affected is in South Asia where 315 million people suffer from anemia.[1]
Anemia in pregnancy is an important public health problem worldwide. The WHO estimates that more than half of pregnant women in the world have a low hemoglobin level (<11.0 g/dl), the prevalence may, however, be as high as 61% in developing countries.[2]
Anemia accounted for 8.8% of the total disability from all conditions in 2010. Anemia prevalence over this time period decreased from 40.2% (35.8–46.0%) in 1990 to 32.9% (28.9–38.5%) in 2010.[3]
In the Eastern Mediterranean Region during the past four decades, remarkable changes have been noted in social, economic, health, and lifestyle patterns.
In Bahrain, a study was carried out on 366 pregnant women from five antenatal care health centers and the results showed that 26.2% of the women were anemic, of which 19.79% had iron deficiency anemia.[4] Besides, the study identified a lower educational level and close birth space (≤2 years) as the main risk factors of anemia among those women. Another study from Qatar found that the prevalence of anemia among pregnant women was 27.1%, of which 74.5% were mildly anemic and 25.5% were moderately anemic.[4]
Yemen is one of the poorest countries in the Middle East which has been devastated by civil wars. Anemia is one of the serious health problems among pregnant women, with a prevalence of 36% according to the World Bank.[5] Moreover, the previous studies have shown that the prevalence of anemia among pregnant women in Yemen varies between 26.5% and 81%.[6,7]
The Yemeni Civil War is an ongoing conflict that began in 2015. As consequences of war, there is a high prevalence of malnutrition, destruction of 50% of health facilities, and millions of people are lacking basic healthcare and many people are forced to flee from their homes. There is no updated information about the prevalence of anemia among Yemeni pregnant women since the ongoing civil war started in March 2015, especially in Sana’a City, the capital of Yemen. Consequently, the present study aims to determine the prevalence and risk factors of anemia among pregnant women in the second and third trimesters attending Safe Motherhood Specialized Hospital in Sho’ub District of Sana’a City, Yemen.
MATERIAL AND METHODS
A cross-sectional study was carried out at Safe Motherhood Specialized Hospital in Sho’ub District, Yemen. Based on anemia prevalence of 48.8% among pregnant women, the required sample size was calculated to be 383 pregnant women at 95% confidence interval (CI), and 5% desired precision. We included pregnant women aged between 15 and 49 years in their second and third trimesters. We excluded pregnant women who had chronic diseases causing to anemia such as cardiac, renal and lung diseases, and hemoglobinopathies. In addition, women who have recently had a blood transfusion during 3 months of the current pregnancy and pregnant women in their first trimester were also excluded from the study. This survey was conducted from January 28, 2018, to February 28, 2018.
Data collection
A structured questionnaire was developed in the English language based on a previously published questionnaire. Translation of questionnaire to Arabic language was performed. Forward and backward translation was achieved. Face validity was conducted before the beginning of the study on 30 pregnant women to ensure the clarity, comprehension, and simplicity of the study tool. A face-to-face interview was done by medical practitioners who were trained on how to administer the questionnaire for the purpose of this study. The questionnaire includes questions on the participant’s sociodemographic characteristics, medical history, iron and folic acid supplementation, and dietary habits.
Hemoglobin concentration was measured using Sysmex instrument. Hb concentration was recorded as g/dL; women with Hb levels between 10 and 11 g/dL were considered as mildly anemic, those with Hb levels between 7 and 9.9 g/dL were considered as moderately anemic, and those with Hb levels lower than 7 g/dL were considered as severely anemic.[8]
Statistical analysis
Data were analyzed using the SPSS Version 19 software (IBM Corporation, New York, NY, USA). Both descriptive and inferential analyses were utilized. Univariate analysis was used to examine the association between anemia and potential associated factors. Moreover, binary logistic regression analysis was utilized to identify factors independently associated with anemia. Adjusted odds ratio and 95% CI were computed. P < 0.05 was considered statistically significant.
Ethical consideration
This study was approved by the Ethics Committee of the MAHSA University, Selangor, Malaysia. All participants were informed about the objectives and protocol of this study before their informed consent was obtained.
RESULTS
A total of 460 pregnant women were invited to participate in this study. However, the 384 women with complete questionnaire data were included in this study, with a response rate of 83%.
Sociodemographic characteristics of the study participants
About half (51.6%) of the pregnant women were between 25 and 34 years of age. Most of the pregnant women (93.5%) were from the capital (Sana’a City) and more than three-quarters of pregnant women (83.1%) were housewives. In addition, 35.4% of the study population had a secondary school level of education and 29.2% of them had college and university level of education. With regard to family monthly income, 59.9% of the respondents were of middle income and 39.8% were of low income [Table 1].
| Variables | Frequency, n(%) |
|---|---|
| Age in years | |
| 15–24 | 161 (41.9) |
| 25–34 | 198 (51.6) |
| 35–44 | 25 (6.5) |
| Residence | |
| Sana’a | 359 (93.5) |
| Other areas | 25 (6.5) |
| Occupation | |
| Housewife | 319 (83.1) |
| Student | 28 (7.3) |
| Government or private employed | 37 (9.6) |
| Level of education | |
| No formal education | 28 (7.3) |
| Primary | 108 (28.1) |
| Secondary | 136 (35.4) |
| Graduate and postgraduate | 112 (29.2) |
| Income status (in Yemeni Rial) | |
| Low (<YER 50,000) | 153 (39.8) |
| Middle ( YER 50,000–200,000) | 230 (59.9) |
| High (>YER 200,000) | 1 (0.3) |
All values are number (%). YER, Yemen Rial; (US$1=YER500)
The obstetric and health history of the study participants
Table 2 shows the obstetric history of the study participants. The mean gestational age was 28 weeks (SD ± 0.500). The majority of the participants 203 (52.9%) were in the second trimester of pregnancy and 181 (47.1%) were in the third trimester of pregnancy. The women who had more than 5 children were 25 (6.5%). However, 125 women (32.6%) were primigravida, 63 women (16.4%) were multigravida, and 171 women (44.5%) had one or two children. In regard to birth spacing, 37.02% of the women had 3–4 years birth spacing.
| Variables | Frequency, n(%) |
|---|---|
| Gestational age (trimester) | |
| Second trimester | 203 (52.9) |
| Third trimester | 181 (47.1) |
| Number of children | |
| Primigravida | 122 (32.6) |
| 1–2 children | 171 (44.5) |
| 3–4 children | 66 (16.4) |
| ≥5 children | 25 (6.5) |
| Spacing between pregnancies | |
| 1–2 years | 88 (33.6) |
| 3–4 years | 97 (37.02) |
| ≥5 years | 77 (29.38) |
Table 3 shows the antenatal clinic visits and iron and folic acid supplementation during the current pregnancy. The majority (85.9%) of the women had an iron and folic acid supplementation during the current pregnancy. All the participants had missed appointment during 3 months of the current pregnancy. Regarding the health conditions of the women during the current pregnancy, 133 women (34.6%) had reported health problems such as weakness, fatigue, dizziness, urinary tract infections (UTI), contractions, and constipation.
| Variables | Frequency n(%) |
|---|---|
| Iron/folic acid supplementation | |
| Yes | 330 (85.9) |
| No | 54 (14.1) |
| Missed appointment for ANC visits | |
| 1 time | 93 (24.2) |
| 2–3 times | 158 (41.1) |
| ≥4 times | 133 (34.6) |
| Reported health problems during the current pregnancy | |
| Yes | 133 (34.6) |
| No | 251 (65.4) |
ANC: Antenatal clinic
Prevalence of anemia
The study revealed that the overall prevalence of anemia among pregnant women at Safe Motherhood Specialized Hospital in Sho’ub District was 25.0% (96/384), of which 70.80% of them had mild anemia, 28.2% had moderate anemia, and only 1.04% of them had severe anemia [Table 4].
| Variables | Frequency, n(%) |
|---|---|
| Anemic status | |
| Yes | 96 (25.0) |
| No | 288 (75.0) |
| Severity of anemia | |
| Mild anemia (Hb 10–11.0 g/dl) | 68 (70.83) |
| Moderate anemia (Hb 7–9.9 g/dl) | 27 (28.13) |
| Severe anemia (Hb <7 g/dl) | 1 (1.04) |
Dietary habits among the study participants
Table 5 shows the dietary habits of study participants, where 42.7% (164/384) of the pregnant women eat meat once per week and 44.8% (172/384) had the habit of eating fruit once a week. More than half (55.2%; 212/384) and one-third (33.6%; 129/384) of the study subjects had the habit of eating vegetables and drinking milk, respectively, daily. About three-quarters (72.7%) and a half (57.8%) of the women had the habit of drinking tea and/or coffee and consuming cereals, respectively, daily. Interestingly, over half (55.7%) of the women declared that they never ate liver.
| Variables | n(%) |
|---|---|
| Ate cereal | |
| Daily | 222 (57.8) |
| Once a week | 101 (26.3) |
| Twice a week | 24 (6.3) |
| Once a month | 7 (1.8) |
| Never | 30 (7.8) |
| Ate red meat | |
| Daily | 24 (6.3) |
| Once a week | 164 (42.7) |
| Twice a week | 52 (13.5) |
| Once a month | 69 (18.0) |
| Never | 75 (19.5) |
| Ate liver | |
| Daily | 21 (5.5) |
| Once a week | 23 (6.0) |
| Twice a week | 9 (2.3) |
| Once a month | 117 (30.5) |
| Never | 214 (55.7) |
| Ate vegetable | |
| Daily | 212 (55.2) |
| Once a week | 117 (30.5) |
| Twice a week | 37 (9.6) |
| Once a month | 6 (1.6) |
| Never | 12 (3.1) |
| Ate fruit | |
| Daily | 132 (34.4) |
| Once a week | 172 (44.8) |
| Twice a week | 57 (14.8) |
| Once a month | 13 (3.4) |
| Never | 10 (2.6) |
| Drinking milk | |
| Daily | 129 (33.6) |
| Once a week | 123 (32.0) |
| Twice a week | 37 (9.6) |
| Once a month | 48 (12.5) |
| Never | 47 (12.2) |
| Drinking tea or coffee with meals | |
| Daily | 279 (72.7) |
| Once a week | 58 (15.1) |
| Twice a week | 20 (5.2) |
| Once a month | 4 (1.0) |
| Never | 23 (6.0) |
The predictors of anemia in the studied pregnant women were evaluated individually using univariate logistic regression. Those factors that were significantly associated with anemia in the univariate model were included in the final multiple regression model.
Four factors were found to be significant in the univariate analysis which were included in the final logit model, namely, low family monthly income, a spacing between pregnancies, eating liver, and presence of health problems [Table 6].
| Variables | Crude OR (95%CI) | P-value | Adjusted OR (95% CI) | P-value |
|---|---|---|---|---|
| Family monthly income+ | ||||
| Low income | Ref** | |||
| Middle income | 0.390 (0.232–0.655) | <0.001* | 0.357 (0.215–0.590) | <0.001* |
| Spacing between pregnancy | ||||
| 1–2 years | 2.792 (1.258–6.197) | 0.012* | 3.106 (1.375–7.016) | 0.006* |
| 3–4 years | 1.585 (0.711–3.532) | 0.036* | 2.634 (1.140–7.016) | 0.023* |
| ≥5 years | Ref** | |||
| Health problems | ||||
| No | Ref** | |||
| Yes | 2.532 (1.576–4.067) | 0.001* | 2.260 (1.342–3.806) | 0.002* |
| Ate liver | ||||
| Daily | Ref** | |||
| Once a week | 1.083 (0.263–0.745) | 0.829 | 0.662 (0.377–1.162) | 0.151 |
| Twice a week | 1.156 (632–2.113) | 0.639 | 0.747 (0.375–1.488) | 0.407 |
| Once a month | 0.401 (0.164–0.982) | 0.045 | 1.285 (0.601–2.745) | 0.518 |
| Never | 2.944 (1.506–5.755) | 0.002* | 3.004 (1.528–5.790) | 0.001* |
*Significant at P<0.05. **Ref: Reference. Other factors were not statistically significant, therefore, we did not include them in the table. +High income was excluded as only a single woman had reported a high household income. OD: Odds ratio, CI: Confidence interval
Middle-income women were less likely to be anemic than those who had low income (OR = 0.357, 95% CI = 0.215–0.590; P < 0.01). Moreover, women who had a short space between pregnancies (1 and 2 years) were more likely to be anemic than those who had more than 5 years interval between deliveries (OR = 3.106, 95% CI = 1.375–7.016; P = 0.06). In addition, the relationship between health problems (weakness, fatigue, dizziness, UTI, contractions, and constipation) and anemia was found statistically significant where women having health problems were 2 times more likely to be anemic (OR = 2.260; 95% CI = 1.342–3.806; P = 0.002) compare to those without health problems. Furthermore, women who never eat liver were 3 times more probably to be anemic than who had consumed liver weekly or once a month (OR = 3.004; 95% CI = 1.528–5.790; P = 0.001) [Table 6].
DISCUSSION
Anemia in pregnancy is one of public health problems globally, particularly in developing countries. It has significant health, social, and economic consequences. Despite decades of efforts to improve the health status of pregnant women, women in developing countries are still suffering the effects of anemia during pregnancy.
The present study found that the overall prevalence of anemia among the study participants was 25.0%. This prevalence is lower than that reported in a survey conducted in Yemen by the WHO in 2011 which found that 36% of pregnant women were anemic.[5] This WHO estimation for Yemen was obtained from community-based surveys.
However, women with low monthly income were found to be significantly more susceptible to anemia than those of middle-income household monthly income. Ndukwu and Dienye[9] revealed an inverse association between the prevalence of anemia and socioeconomic status which was similar to our observation. Moreover, the severity of anemia was also detected to be contrariwise related to household income.[10] This is not unexpected considering the fact that women who had financial hardship might undergo the deleterious effects of poor nutrition and might have no access to health services.
In this study, a significant association between the presence of health problems and anemia was found. The highest prevalence of anemia was among pregnant women who had a health problem during pregnancy. A previous study at the maternity unit of Kenyatta National Hospital in Nairobi, Kenya, found that the prevalence of preterm birth was significantly associated with pregnancy who had UTI.[11] A similar finding was reported in India at Maternity Hospital, Bhimavaram, where the highest incidence of UTI was seen in pregnant women.[12]
In addition, there is a significant association between the prevalence of anemia and short spacing between pregnancies (1–2 years or 3–4 years). This finding is in line with a study conducted previously in Qatar where they found women with interpregnancy space of more than 3 years had a higher prevalence of anemia compared to others.[4]
In the present study, women who never consumed liver were 3 times more likely to be anemic as compared to those who consumed liver. However, the association between other dietary habits and the prevalence of anemia was not statistically significant. For instance, drinking of tea and/or coffee was identified as a significant predictor of anemia among pregnant women, however, our findings showed no similar association.
The findings of this study showed that there was no significant association between the nulliparous and grand multiparous grouping and maternal anemia. This is similar to a study done by Ezugwu et al.[13] In contrast, Taner et al.[14] found that pregnancies with parity more than 3 were 2 times more likely to be anemic than those with parity <3. However, low percentage of grand multiparous women (6.8%) in our study participants might have influenced the involvement of parity to statistically insignificant levels.
Low educational level of pregnant woman was not a significant factor of anemia in this study. In contrast, Taner et al.[14] found that women with low educational were detected to be significantly more at risk to anemia than others.
Limitations
This study was conducted in urban area, further investigation is needed to assess the prevalence of anemia in rural areas that have inadequate health-care facilities and might be much affected by the war. In addition, the cross-sectional study design is not possible to infer causal relationship.
CONCLUSION
This study revealed that anemia is still a significant problem among Yemeni pregnant women, where a quarter of the studied pregnant women in the second and third trimesters were found to be anemic.
The study revealed that anemia during pregnancy is significantly associated with some factors, including income statues, a short spacing between pregnancy, and present of health problem during pregnancy. Based on the findings of this study, identification of these risk factors is a valuable consideration to reduce the anemia prevalence during and after delivery. This study recommends that socioeconomic factors, which may lead to limited access to healthy food and antenatal care, contribute to most of the anemia cases and, therefore, should be recognized as the main determinants for anemia in pregnant women. It is a time for the realization that health system should focus on various factors that contribute to the occurrence of anemia and include them as important indicators in the National Health Policy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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