View/Download PDF
Original Article
ARTICLE IN PRESS
doi:
10.25259/IJMS_5_2020
CROSSMARK LOGO Buy Reprints
PDF

Prevalence and associated factors of anemia among pregnant women in Sana’a, Yemen

Department of Community Medicine, MAHSA University, Saujana Putra Campus, Jenjarom, Selangor, Malaysia
Corresponding author: Meram Azzani, Department of Community Medicine, MAHSA University, Saujana Putra Campus, Jenjarom 42610, Selangor, Malaysia.dr_memeazzani@yahoo.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
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, doi: 10.25259/IJMS_5_2020

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].

Table 1:: Sociodemographic characteristics of the study participants (n=384).
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.

Table 2:: The obstetric history of the study participants (n=384).
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.

Table 3:: ANC attendance, iron and folic acid supplementation, and reported health problems among the study participant (n=384).
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].

Table 4:: Prevalence of anemia among pregnant women in this study (n=384).
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.

Table 5:: Dietary habits of the study participants (n=384).
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].

Table 6:: Factors associated with anemia in pregnant women in second and third trimesters using univariate and multivariate logistic regression analyses.
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.

References

  1. , , , . Worldwide prevalence of anaemia 1993-2005: WHO Global Database on Anaemia. Geneva: World Health Organization; .
  2. , , , , , . Prevalence of anemia and its socio-demographic determinants in pregnant women at a tertiary care hospital in Jaipur, Rajasthan. J Evol Med Dent Sci. 2015;4:7195-206
    [CrossRef] [Google Scholar]
  3. , , , , , , et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013. A systematic analysis for the global burden of disease study 2013. Lancet. 2014;384:980-1004
    [CrossRef] [Google Scholar]
  4. , , . Assessment of anemia, IDA and ID among pregnants in Qatar: Cross sectional survey. SM J Public Health Epidemiol. 2016;2:1035
    [Google Scholar]
  5. The Global Prevalence of Anaemia in 2011. Geneva: World Health Organization; .
  6. , , , , . Epidemiology of iron-deficiency anemia among pregnant women in menoufia governorate, Egypt and Taiz Governorate, Yemen: A comparative study. Menoufia Med J. 2016;29:1005-11
    [Google Scholar]
  7. , , , , . Prevalence and associated factors of anemia among pregnant women residing at high altitude in Yemen. Am J Health Res. 2017;5:93-8
    [CrossRef] [Google Scholar]
  8. Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity. Vitamin and Mineral Nutrition Information System. Geneva: World health organization; .
  9. , . Prevalence and socio-demographic factors associated with anaemia in pregnancy in a primary health centre in Rivers State, Nigeria. Afr J Prim Health Care Fam Med. 2012;4:328
    [CrossRef] [Google Scholar]
  10. , , , . Prevalence of anaemia amongst pregnant women and its socio-demographic associates in a rural area of Delhi. Indian J Community Med. 2002;27:157-60
    [Google Scholar]
  11. , , , , , , et al. Knowledge and practice about cervical cancer and Pap smear testing among patients at Kenyatta national hospital, Nairobi, Kenya. Int J Gynecol Cancer. 2003;13:827-33
    [CrossRef] [PubMed] [Google Scholar]
  12. , , , , . Prevalence of UTI among pregnant women and its complications in newborns. Indian J Pharm Pract. 2017;10:45-9
    [CrossRef] [Google Scholar]
  13. , , , . Anaemia in pregnancy: A public health problem in Enugu, Southeast Nigeria. J Obstet Gynaecol. 2013;33:451-4
    [CrossRef] [PubMed] [Google Scholar]
  14. , , , , , , et al. Prevalence and risk factors of anemia among pregnant women attending a high-volume tertiary care center for delivery. J Turk Ger Gynecol Assoc. 2015;16:231-6
    [CrossRef] [PubMed] [Google Scholar]
Show Sections