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PrevalenceandPredictorsofMaternalAnemiaduringPregnancyinGondar,NorthwestEthiopia:AnInstitutionalBasedCrossSectionalStudy

Anemia.20142014:108593.

PMCID:PMC3942101

Publishedonline2014Jan20.doi:10.1155/2014/108593

PrevalenceandPredictorsofMaternalAnemiaduringPregnancyinGondar,
NorthwestEthiopia:AnInstitutionalBasedCrossSectionalStudy
MulugetaMelku, 1,*ZelalemAddis, 2MeseretAlem, 3andBamlakuEnawgaw4
1
DepartmentofHematology,SchoolofBiomedicalandLaboratorySciences,CollegeofMedicineandHealthSciences,UniversityofGondar,P.O.Box
196,6200Gondar,Ethiopia
2
DepartmentofMedicalMicrobiology,SchoolofBiomedicalandLaboratorySciences,CollegeofMedicineandHealthSciences,UniversityofGondar,
6200Gondar,Ethiopia
3
DepartmentofImmunologyandMolecularBiology,SchoolofBiomedicalandLaboratorySciences,CollegeofMedicineandHealthSciences,University
ofGondar,6200Gondar,Ethiopia
4
DepartmentofHematology,SchoolofBiomedicalandLaboratorySciences,CollegeofMedicineandHealthSciences,UniversityofGondar,6200
Gondar,Ethiopia
*MulugetaMelku:Email:mulugeta.melku@gmail.com
AcademicEditor:AurelioMaggio
Received2013Aug14Revised2013Nov25Accepted2013Dec10.
Copyright2014MulugetaMelkuetal.
ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,distribution,andreproduction
inanymedium,providedtheoriginalworkisproperlycited.

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract

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Background.Anaemiaisaglobalpublichealthproblemwhichhasaneminenceimpactonpregnantmother.The
aimofthisstudywastoassesstheprevalenceandpredictorsofmaternalanemia.Method.Acrosssectionalstudy
wasconductedfromMarch1toApril30,2012,on302pregnantwomenwhoattendedantenatalcareatGondar
UniversityHospital.Interviewbasedquestionnaire,clinicalhistory,andlaboratorytestswereusedtoobtaindata.
Bivariateandmultivariatelogisticregressionwasusedtoidentifypredictors.Result.Theprevalenceofanemiawas
16.6%.Majorityweremildtype(64%)andmorphologicallynormocyticnormochromic(76%)anemia.Anemia
washighatthirdtrimester(18.9%).Lowfamilyincome(AOR[95%CI]=3.1[1.19,8.33]),largefamilysize
(AOR[95%CI]=4.14[4.13,10.52]),hookworminfection(AOR[95%CI]=2.72[1.04,7.25]),andHIV
infection(AOR[95%CI]=5.75[2.40,13.69])wereindependentpredictorsofanemia.Conclusion.The
prevalenceofanemiawashighmildtypeandnormocyticnormochromicanemiawasdominant.Lowincome,
largefamilysize,hookworminfection,andHIVinfectionwereassociatedwithanemia.Hence,effortsshouldbe
madeforearlydiagnosisandmanagementofHIVandhookworminfectionwithspecialemphasisonthosehaving
lowincomeandlargefamilysize.
1.Background

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Anaemiaisaglobalpublichealthproblemaffectingbothdevelopinganddevelopedcountrieswithmajor
consequencesforhumanhealthaswellassocialandeconomicdevelopmentwhichresultsinalossofbillionsof
dollarsannually[13].Accordingtothe2008WorldHealthOrganization(WHO)report,anaemiaaffected1.62
billion(24.8%)peopleglobally[2].Ithadanestimatedglobalprevalenceof42%inpregnantwomenandisamajor
causeofmaternalmortality[4,5].InAfrica,57.1%ofthepregnantwomenwereanemic.Moreover,anemiain
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pregnantwomenisaseverepublichealthprobleminEthiopia62.7%ofpregnantwomenwereanemic[2].
Althoughtheprevalencevarieswidelyindifferentsettingsandaccuratedataareoftenlacking,inresourcelimited
areasterriblysignificantproportionsofwomenofchildbearingageparticularlypregnantareanaemic[3].
Geographically,thoselivinginAsiaandAfricaareatthegreatestrisk[1].
Theeffectofanemiaduringpregnancyonmaternalandneonatalliferangesfromvaryingdegreesofmorbidityto
mortality.Asmanystudieselucidated,severeanemia(Hg<7g/L)duringpregnancyhasbeenassociatedwith
majormaternalandfetalcomplications.Itincreasestheriskofpretermdelivery[6,7],lowbirthweight[69],
intrauterinefetaldeath[7],neonataldeath[10],maternalmortality[11],andinfantmortality[12].
Anemiaismultifactorialinetiologythediseaseisthoughttobemainlycausedbyirondeficiencyindeveloping
countries.InsubSaharanAfricawhereirondeficiencyiscommon,theprevalenceofanemiahasoftenbeenused
asaproxyforirondeficiencyanemia(IDA)[3].Othermicronutrientdeficiency(vitaminsAandB12,riboflavin,
andfolicacid)hasalsobeenacauseofanemiaduringpregnancy[13].Likewise,Infectiousdiseasessuchas
malaria,helminthesinfestations,andHIVarealsoimplicatedwithhighprevalenceofanemiainsubSaharanAfrica
[14,15].Therewasalsoaconsiderablevariationintheprevalenceofpregnancyanemiabecauseofthedifferences
insocioeconomicconditions,lifestyles,andhealthseekingbehaviorsofdifferentpopulationacrossdifferent
countriesandculturesandobstetricsandgynecologicalrelatedconditionofpregnantmothers[1641].
Sinceanaemiaduringpregnancyhasadeleteriousconsequences,WHOadoptedreducingmaternalmortalityasone
ofthethreehealthrelatedmillenniumdevelopmentgoalssothatinternationalcommunityiscommittingwithinthis
frameworktoreducematernalmortalitybythreequarterattheendof2015[42].Anemiaprevalencedataremains
animportantindicatorofpublichealthsinceanemiaisrelatedtomorbidityandmortalityinthepopulationgroups
usuallyconsideredtobethemostvulnerablelikepregnantwomen.Atagloballevel,anemiaprevalenceisauseful
indicatortoassesstheimpactofwidespreadorhighlyeffectiveinterventionsandtotracktheprogressmade
towardsthegoalofreducinganemiaduringpregnancy[43].Anemiaprevalencestudyisalsousefultomonitorthe
progressofreproductivehealth[2].Despitetheeffortsmadetoreducetheburden,itsprevalencehasnotbeen
studiedyetcomprehensivelyindevelopingcountries.Thus,theobjectiveofthisstudywastodeterminethe
prevalenceandpredictorsofanemiaamongpregnantwomenwhoattendedANCinGondarUniversityHospital.
2.Methods

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2.1.StudyPopulation,SampleSize,andSamplingProcedure

Thestudypopulationwaspregnantmothersattendingantenatalcare(ANC)atGondarUniversityTeaching
Hospital.ThehospitalisfoundinGondartownunderAmhararegionalstateofEthiopiawhichislocatedat750
KmfarfromAddisAbaba,thecapitalcityofEthiopia,totheNorthwestpartofthecountry.Thetownissituatedat
analtitudeof2100to2870metersabovethesealevel.Accordingtothe2007Ethiopiancensusreport,Gondarhas
atotalpopulationof206and987andmorethanhalf(108,902)ofthemarefemales[44].
Asinglepopulationproportionformula,[n=(Z/2)2p(1p)/d2],wasusedtoestimatethesamplesize.However,
duetothelackofpreviousstudiesabouttheprevalenceofanemiaduringpregnancyinthisparticulararea,50%
prevalencewasusedforcalculation.ByreviewingtherecordsofdailyflowofpregnantwomenforANC
utilization,about1410pregnantwomenwereestimatedtovisitANCclinicduringthestudyperiod.Sincethe
populationduringthestudyperiodwasbelow10,000,thesamplecorrectionformulawasapplied.Then,atotalof
302pregnantwomenwhoattendedANCservicewereselectedusingsystematicrandomsamplingtechniquefrom
theirsequenceofANCvisitintheperiodbetweenMarchandApril,2012,fortwomonths.
2.2.DataCollection

Afacetofaceinterviewusingstructuredpretestedquestionnairewasemployedtoobtaindataabout
sociodemographic,obstetric,andgynecological,dietaryintake,andmedicalconditionsofpregnantmothers.Asfor
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thecurrentpregnancy,intakeofhaematinics,gestationalage,antepartumhemorrhage,anddietaryintakewere
documented.Bloodpressure,weight,andheightweremeasuredandbodymassindex(BMI)wascalculatedas
(weight(kg)/height(m2)).WomenwerethencategorizedintofourgroupsaccordingtotheirBMIasfollows:
underweight(BMI20kg/m2),normal(20kg/m2BMI24.9kg/m2),overweight(BMIof25kg/m2BMI
29.9kg/m2),andobese(BMI30kg/m2)[23].Atotalof6mLvenousbloodsamplewasobtainedfromeach
participant.Ofthis,3mLofitwasdrawnintoethylenediaminetetraaceticacidtubeforcompletebloodcount
whereastheremaining3mLwasdrawntoplanetubeforserologicaltests.Participantswerealsorequestedtogive
freshstoolsampleforparasitologicalexaminationofintestinalparasitosis.
2.3.LaboratoryAnalysis

Completebloodcountincludingredbloodcellcount,hemoglobinconcentration(Hgb),meancellvolume(MCV),
meancellhemoglobin(MCH),andmeancellhemoglobinconcentration(MCHC),plateletcount,andwhiteblood
cellcountwerecarriedoutusingSYXMEXKX21haematologyanalyzer(SysmexCorporationKobe,Japan).A
thinandthickbloodfilmhadbeenpreparedandstainedwithGiemsastainforthedetectionandspeciationof
Plasmodiumparasitespecies.Stoolwetmountwaspreparedusingsalineand/oriodineandexamined
microscopicallyforidentificationofintestinalhelminthesandprotozoaparasitosis.Allstoolsampleswere
processedwithin30minutesofcollection.Serumand/orplasmasamplesweretestedforHIVfollowingthecurrent
HIV1/2testingalgorismusingKHB(ShanghaiKehuabioengineeringCo.,LTD.,China),Statpack(Chembio
DiagnosticSystems,Inc.,Newyork,USA),andUnigold(TrinityBiotechPlc,Bray,Ireland).Syphilisreactivity
wasalsotestedusingRPRtest(HumanGmbHWiesbaden,Germany)asperthemanufacturer'sinstructionand
recommendation.
2.4.AssessmentofAnemia

Hgbcutoffvalueadjustedtosealevelaltitudewasusedtodefineanemiaonthebasisofgestationalageandto
classifythedegreeofseverityusingWHOcriteria.TheHgbvaluelessthan11.0g/dLatfirstandthirdtrimesters
andlessthan10.5g/dLatsecondtrimesterwasusedtodefineanemia.Basedontheseverity,womenwithHgb
valueof(10g/dLHgb<11g/dL)atfirstandthirdtrimestersand(10g/dLHgb<10.5g/dL)atsecondtrimester
wereclassifiedasmildanemic.PregnantwomenwhohadaHgbvalueof(7g/dLHgb<10g/dL)and(Hgb<7
g/dL)werecategorizedasmoderateandsevereanemic,respectively,regardlessoftheirgestationalage[45].
ManufacturerreferenceswereusedtodefinethenormalrangesforMCV(80.0100.0fl),MCH(27.033.5pg),
andMCHC(32.036.0g/dL).
2.5.DataProcessingandAnalysis

DatawereenteredtoEPIinfoversion3.5.3andthentransferredtoSPSSversion20statisticalpackageforanalysis.
DescriptiveandsummarystatisticswerecarriedoutusingpercentagesandmeanSDandwerepresentedintables
andgraphs.Binarylogisticregressionanalysiswasconductedtoevaluatethedifferenceinanemiaprevalence
acrosstherelevantvariables.Oddsratio,Chisquare,and95%CIforoddsratiowerecomputedtoassessthe
strengthofassociationandstatisticalsignificanceinbivariateanalysis.IndependentvariableshavingPlessthanor
equalto0.2inunivariateanalysiswereincludedinmultivariateanalysistocontrolconfoundersinregression
models.VariableshavingPvaluelessthan0.05inmultivariatebinarylogisticregressionmodelwereconsideredto
bestatisticallysignificant.
2.6.EthicalClearance

ThestudywasapprovedbyinstitutionalreviewboardofUniversityofGondar.Thepurposeandimportanceofthe
studywereexplainedtoeachstudyparticipants.Writtenconsentwasobtainedfromeachwoman.Toensure
confidentialityofparticipants,information,anonymoustypingwasusedwherebythenameoftheparticipantsand
anyparticipants'identifierwerenotwrittenonthequestionnaire,and,alsoduringtheinterviewtokeeptheprivacy,
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theywereinterviewedalone.ResultswerecommunicatedwithcliniciansworkinginANCunitforappropriate
management.
3.Result

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3.1.CharacteristicsoftheStudyParticipants

Atotalof302pregnantwomenwithamean(SD)ageof26.475.24yearswereincludedinthestudy.The
majority242(80.1%),284(94%),250(82.8%),and194(64.2%)wereurbandwellers,married,hadattended
primaryschoolandabove,andhousewivesbyoccupation,respectively.Theaveragemonthlyincomeofthe
participantswas1860EthiopianBirr(EB)and147(48.7%)werelivingwiththreetofourfamilymembers(Table1
).
Table1
Sociodemographiccharacteristicsofpregnantwomenandprevalenceof
anemiabysociodemographiccharacteristics(n=302).
Concerningobstetricalhistory,57.3%weremultigravida,ofwhom52.7%hadaninterpregnancyintervalofmore
thanorequalto24monthsand23.7%experiencedabortion.Nearly70%ofthestudyparticipantswereatthird
trimester.Assessmentofmedicalconditionoftheparticipantrevealedthat72.5%hadanormalBMI,95.4%hadno
historyofchronicdiseases,and4.6%hadhistoryofprevioussurgery.Laboratoryinvestigationshowedthat10.3%
and26.5%oftheparticipantswerereactiveforHIVandinfectedwithoneormorethanoneintestinalparasites,
respectively.A.lumbricoides(34.1%),hookworm(25.3%),andE.histolytica/dispar(17.2%)werethepredominant
parasitesfound(Table2).
Table2
Theprevalenceofanemiaaccordingtotheobstetricsandmedicalfactors(n
=302).
Thedietaryhabitandnutritionalassessmentrevealed19.8%didnottakeanimalproductsintheircurrent
pregnancy,and42.4%hadahabitofeatinggreenvegetablesonmonthlyandabovebasis.About80.1%hada
habitofdrinkingcoffeeandteaaftermeal(datanotshown).Intheircurrentpregnancy,44.7%,41.4%,and7.3%
tookironsulfate,folicacid,andmultivitamintablesasnutritionalsupplement,respectively(Table3).
Table3
Prevalenceofanemiainrelationtodietaryhabit,ANCfollowup,and
nutrientsupplementationattheircurrentpregnancyperiod(n=302).
3.2.PrevalenceandPredictorsofAnemia

ThemeanHgblevelofpregnantwomenwas11.961.37g/dL(range:5.8517.05g/dL)andtheoverall
prevalenceofmaternalanemiawas16.6%(n=50).Oftheanemicwomen,6%,30%,and64%wereseverely,
moderately,andmildlyanemic,respectively(Figure1).
Figure1
Percentageofanemiabyseverityamonganemicpregnantwomen(n=50).

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Basedonredbloodcellmorphologicclassificationofanemia,ofthetotalanemicpregnantmothers,76%had
normocyticnormochromicanemiaand14%hadmicrocytichypochromictypeofanemia(Table4).
Table4
Distributionofmorphologictypeanemiaamongstudyparticipants.

Highprevalenceofanemiawasobservedinthosepregnantwomenwhowerelivingwithmorethanfourfamily
members(36.4%),illiterate(25.7%),andwhosemonthlyfamilyincome<1000EB(22%)(Table1).Inaddition,
highprevalencerateofanemiawasfoundamongmotherswhowereHIVseropositive(38.7%),infectedwith
hookworm(34.8%),underweighted(30%),withmorethanfourgravidae(32.3%),havingchronicdisease(27.3%),
andat3rdtrimester(18.9%)(Table2).
Theprevalenceofanemiaamongthosewhohadahabitofeatinganimalproductsintheirfoodstuff,nothavinga
habitofeatingvegetable,andwhotaketea/coffeeaftermealwas17.8%,22.4%,and15.3%,respectively.About
18.6%and17.5%pregnantwomenwhodidnottakeironsulphateandfolateasnutritionaltherapy,respectively,
wereanemic(Table3).
Inbivariateanalysisilliteracy,lowmonthlyfamilyincome,largefamilysize,underweight,gravidity,hookworm
infection,andHIVseropositivityweresignificantlyassociatedwithmaternalanemia.Butinmultivariatelogistic
regressionanalysiscontrollingthepossiblecofounders,onlylowmonthlyfamilyincome(AOR=3.15,95%CI:
1.19,8.33),largefamilysize(AOR=4.13,95%CI:1.62,10.52),hookworminfection(AOR=5.75,95%CI:
2.40,13.69),andHIVseropositivity(AOR=2.72,95%CI:1.014,7.25)remainedbeingindependentpredictorsof
pregnancyanemia(Table5).
Table5
Multivariatebinarylogisticregressionanalysisofpregnancyanemiawith
predictorvariables(n=302).
4.Discussion

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Theoverallprevalenceofanemiawas16.6%(95%CI(12.6,20.6)).Thisprevalencewascomparabletostudies
conductedinTrinidadandTobago(15.3%)[16],Thailand(20.1%)[17],Zurich(18.5%)[45],Hawassa(15.3%)
[39],andGondartown(22%)[46].
TheprevalenceisconsiderablylowerthanpreviousstudyreportsfromMalaysia(35%),Jordan(34.7%),Vietnam
(43.2%),SoutheasternNigeria(76.9%),EasternSudan(62.6%),andJimma,Ethiopia(38.2%)[22,23,25,35,38,
41].Thepossiblereasonforthedifferencemayberesultedfromgeographicalvariationoffactorsacrossdifferent
areas.Inaddition,lowerprevalencecanbeattributedtogradualimprovementoflifestyleandlivingstandardsand
healthseekingbehaviorbytheeffortofgovernmenttoachievetheMillenniumdevelopmentgoalaimedtoreduce
thematernalmortalitybythreequarterbyyear2015.Insupportofthisargument,theprevalenceofanemiain
womenofage1549yearshaddecreasedfrom27%in2005to17%bytheyear2011inEthiopia[47].
Inthisstudy,mildanemiawascommonfollowedbymoderateanemia.ThisisconsistentwithreportsfromAfrica
andelsewhereintheworld[23,25,29,31,39].Thisstudytriedtodemonstratethecommonmorphological
characteristicofanemiaamongpregnantmothers.Ofthetotalanemicpregnantwomen,76%hadnormocytic
normochromicanemiafollowedbymicrocytichypochromictypewhichisinagreementwithareportfromTurkey
[18]andAzezo,Gondartown[46].
Thisstudydemonstratedthatmotherswhohavelowmonthlyfamilyincomewerethreetimesmorelikelytobe
anemicascomparedtothosewithhighmonthlyfamilyincome.Thisisinagreementwithsomestudies[24,29]and
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contradictedtootherreports[22,23,40,41].Accordingtothe2007Ethiopiancentralstatisticalagencyhousehold
incomeconsumptionandexpendituresurvey,morethan57%ofthetotalexpenditureisspentonfood[48].
Moreover,inthisstudy,80%ofstudyparticipantswerefromurbanareasuggestingthattheyarefoodnetbuyers.
Asincomeislow,theexpenditureforfoodbecomeslow.Besides,duetofoodpriceinflation,thepurchasing
powerofincomeislow.So,lowincomegroupsdidnotgetadequatenutritionandtherebylowfamilyincome
groupswereatriskofanemia.
Accordingtotheresultsofourstudy,pregnantmotherswhohadbeenlivingwithinafamilyofmorethanfour
membersweremorelikelytobeanemiccomparedtothoselivingwith2familymembers.Nevertheless,inJordan
[23],therewasnosignificantdifferenceofanemiaprevalencebetweengroupsofpregnantmotherslivingwith
varyingfamilysizes.ThisdifferencemaybeattributedasinJordancasethestudywasundertakeninruraldistrict
wheretherewasnotgreatvariationinfamilysizeandincome.But,inthisstudy,80%ofpregnantwomenwerein
urbanareashavingvaryingincomelevelsand20%inruralareaswithvaryingfamilysize.
ThisstudyalsoshowedthattheproportionofanemiaamongpregnantwomenwhohadbeeninfectedwithHIV
wassignificantlyhighercomparedtothosenoninfectedthatissixtimesathigherrisk.Thisisinlinewithprevious
studies[29,3133,35].ThisincreasedprevalenceofanemiaamongHIVseropositivepregnantwomenmaybe
explainedbythefactthatHIVinfectionisassociatedwithlowerserumfolate,vitaminB12,andferritinin
pregnancy[31].Inaddition,AnemiainHIV/AIDSpatientsmayarisefromanumberofcauses,including
deregulationofthehostimmunesystemleadingtodestructionorinhibitionofhematopoieticcells[49].
Inourstudy,hookwormhasincreasedtheriskofbeinganemicandthisfindingwasconsistentwithotherstudies
[26,41,46].Thisisbecauseadulthookwormparasitesattachandinjureupperintestinalmucosaandalsoingest
blood.Thisbringsaboutgastrointestinalbloodlossandinducesdepletionofiron,folicacid,andvitaminB12that
ultimatelyanemia[13,50].
Eventhoughitwasnotstatisticallysignificantinmultivariatelogisticregression(butsignificantinbivariate
analysis),multigravidaandgrandgravidahadhighoddsforanemiaascomparedtoprimigravidae.Likewise,
studiesinMalaysia[22],BurkinaFaso[29],Sudan[38],andJimma[41]reportedthatgraviditydidnothave
statisticallysignificantcontributionfordifferenceinanemiaprevalence.Despitethis,astudyfromTrinidadand
Tiago,multigravidahadsignificantlyincreasedlikelihoodofbeinganemicthanprimigravidae[16].Thedisparity
maybeasaresultofsociodemographiccharacteristicdifferencebetweenstudyparticipants.Inthisstudy,
participantswhoweremultigravidahadthefollowingcharacteristics.90%hadnormalandaboveBMI,78%were
urbanresidents,and50%ofthemhadmiddleandhighmonthlyfamilyincome.Thesesituationsmayreducethe
riskofanemiainmultigravidapregnantmothersparticipatedinthisstudy.
Inthisstudy,supplementationofironsulphate,folicacid,andmultivitaminduringthecurrentpregnancyperioddid
notsignificantlyreducetheprevalenceofanemiaascomparedtothosewhodidnottakethesesupplementations.
Thefindingwasincontradictionwithotherstudies[1921,25,26,28].Thepossiblereasonmaybethat,inanemic
pregnantwomen,thesenutritionalsupplementsweremorelikelytobeprescribedasaninterventionfor
managementofanemiaintheirpreviousANCvisit.Thisneedsafurtherstudytoexplicitlyexplainhowmuch
effectivethecurrentWHOnutritionalsupplementationrecommendationprogramisbeingimplementedfor
preventionandcontrolofanaemiainpregnantwomen[51].
4.1.LimitationsoftheStudy

Oneofthelimitationofthisstudyisthenatureofthestudydesignitsself,beingasacrosssectionalstudydesign,it
doesnotshowwhichprecededanemiaorriskfactors.Duetoconstraintoftimeandresource,stoolconcentration
techniqueandparasitedensitywerenotdonesowecouldnotassesstheimpactofparasiteloadontheseverityof
anemia.Inadditiontothis,thelowsensitivityofwetmounttodetectparasiteinpatientwithlowparasiteloadmay
underestimatetheprevalenceofintestinalparasiteandalteroddsratio.Theotherlimitationisthatthisstudywas
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conductedattertiarycarehospitallocatedatGondartownandmajorityofthestudyparticipantswereurban
residents.Butmanyofthepregnantwomeninthatdistrictwerelivinginruralareaswhereaccesstoantenatal
facilitiesislimited,sotheprevalenceofanemiawouldhavebeenevenmoreifthestudywasdoneinthegeneral
population.
5.Conclusion

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Inconclusion,theprevalenceofanemiaamongpregnantwomenwashighespeciallyatthirdtrimester.Mildtypeof
anemiawasthecommonestone.Morphologically,thepredominanttypeofanemiawasnormocyticnormochromic,
followedbymicrocytichypochromicanemia.Lowfamilyincome,highfamilysize,hookworminfection,and
livingwithHIV/AIDSwerethemainpredictorsofmaternalanemia.Toreducetheprevalence,thereisaneedto
strengthenhealthcareseekingbehaviorofwomentoensureearlydiagnosisandmanagementofHIV,hookworm,
anemia,andothermedicalconditions.Thereisalsoaneedtoencouragefamilyplanning,anddesignpoliciesand
strategiespertinenttoreductionofanemiainlowincomegroups.Alargecommunitybasedstudyneedstobedone
todeterminetheprevalenceandpredictorsofanemiainthegeneralpopulationofpregnantwomen.Besides,further
studiesusingmicronutrientassaytechniqueswhicharesensitiveforthedetectionoflatentanemiabeforethe
changeofRBCmorphologyandindicestakesplacehavetobeconducted.
Acknowledgments

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Theauthorsthankallmidwivesandlaboratorystaffswhoheartfullyparticipatedduringdatacollectionand
laboratoryanalysisactivities.Theauthorsarealsogratefultothankpregnantwomenfortheirvoluntary
participationinourstudy.Lastly,theywouldliketothanktheUniversityofGondarandGondarUniversity
Hospitalforfinancialandlogisticssupports.
ConflictofInterests

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Theauthorsdeclarethatthereisnoconflictofinterestsregardingthepublicationofthispaper.
Authors'Contribution

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MulugetaMelkuparticipatedindesigningthestudy,performedthedatacollectionandstatisticalanalysis,andwas
aleadauthorofthepaper.ZelalemAddis,MeseretAlem,andBamlakuEnawgawparticipatedindesigningthe
studyandhelpedindraftingthepaper.Allauthorsreadandapprovedthefinalpaper.
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