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INTRODUCTION
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 were the two major goals (which are goals
4 and 5) for attaining development for 2015. To correct the recorded failures 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. The General Assembly adopted the 2030 Agenda for attaining Sustainable
Development that includes 17 Sustainable Development Goals (SDGs). And among the listed
goals, ensuring good health and wellbeing was the number three of the goals sustainable
development goals (SDGs) has been a fundamental objective in transforming the global world
economy and access to good health. 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 be a
success, if only they succeed in Africa. To this end, there is a need to focus on Africa as a focal
point at the planning strategic, processes and implementations. Several studies had highlighted
that the major factor to this SDGs attainment in the increase of the level of awareness and
Anemia could be refer to as a reduction in the concentration of hemoglobin, packed cell volume
or red blood cell count below the normal range for the age and sex of an individual in a
population (Okafor, Mbah &Usanga, 2012). 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,
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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 (2011) noted that, maternal anemia
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. (2012), 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 which usually develops during the second trimester. Qureshi, Rafique, Mahmood,
Amin and Zaka (2011) 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
reasons. There are several types of anaemia which include: Iron deficiency anaemia,
Thalassemia, A plastic anaemia, Hemolytic anaemia, Sickle cell anaemia, Pernicious anaemia,
Apart from the different types of anaemia, it is important to investigate the knowledge and and
awareness among pregnant women; its health conseques and implication of anaemia among
pregnant women, the knowledge and awareness will help to prevent complications. Batool,
Zafar, Maann and Ali (2010); Balarajan, Ramakrishnan, Ozattin, Shankar, and Subramanian
(2011); Suryanarayana, Santhuram, Chandrappa, Shivajirao and Rangappa (2016) noted that
there is poor awareness and knowledge of the magnitude and consequences of anaemia burden
and it is higher among developing countries including Nigeria. In addition, there is a lack of
education and information about anaemia prevention, and awareness of the causes (Balarajan et
al., 2011).
Moreover, Adamu et al. (2017) noted that anemia has diverse health consequences which are
fatigue and congestive cardiac failure. Balarajan et al (2011) noted that consequences of anaemia
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include maternal and perinatal effects which are; cognitive developmental effects, poor work
productivity effects, amongst others. According to Mayo Foundation for Medical Education and
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
dying, etc.
These consequences could be the major reason why the sustainable development goals (SDGS)
included the enhancement of health challenges and well-being in transforming the global world
economy, hence, the need for this study toward the attainment of the sustainable development
goals in Nigeria.
Anaemia is a major cause of morbidity and mortality in pregnant women and increases the risks
of foetal, neonatal and overall infant mortality (Akhtar & Hassan, 2012). 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 (WHO, 2015). Anaemia during pregnancy contributes to 20% of all maternal
Anaemia during pregnancy is also a major risk factor for low birth weight, preterm birth and
intrauterine growth restriction (Banhidy F et al., 2011 & Haggaz et al., 2010). Deficiency in folic
acid during pregnancy can result to serious neural tube defects, heart defects, cleft lips, limb
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defects, and urinary tract anomalies (Goh & Koren, 2008; Wolff et al., 2009 & Wilcox et al.,
2007).
Despite the fact that pregnant women attending antenatal clinic in General Hospital Onitsha are
routinely put on iron supplementation throughout their pregnancy, but still the prevalence of
According to Okik (2012); Dattijo, Daru & Umar(2016); Department of Health, Government of
South Australia (2019), the lack of awareness and knowledge of aneamia can affect the level of
health consequences and the strategies deployed to curtail anaemia. Hence there is the need to
investigate the level of awareness and also the health implications of anaemia among the
The purpose of this study is to investigate the level of awareness of the causes and prevention of
anaemia among pregnant women attending antenatal clinic in Onitsha General Hospital, Onitsha
i. To examine the level of knowledge of anaemia among pregnant women attending antenatal
ii. To examine the level of awareness of the causes and prevention of anaemia among pregnant
iii. To know the various health implications of anaemia among pregnant women attending
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1.5 Research Questions
i. What is the level of knowledge of anaemia among pregnant women attending antenatal clinic
ii. What are the level of awareness of causes and prevention of anaemia among pregnant women
iii. What are the various health implications of anaemia among pregnant women attending
Ho1: There is no significant relationship between the level of awareness and knowledge of
anaemia in pregnancy.
Ho2: 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 General
Hospital, Onitsha.
Ho3: There is no significant difference in the level of awareness with respect to the demographic
The study is delimited to the pregnant women in General Hospital, Onitsha, 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
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research is aimed at determining the level of awareness on the prevention of anaemia among
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 pressures. However efforts were made to address these
problems or limitations.
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, and understand the importance and benefits of enough
nutrients. These facts will enhanced their nutrition, understand the efficacy of micronutrients,
and know some other factors that could lead to anaemia in pregnancy, poor weight gain and the
The health workers will make use of this study in updating their knowledge level on anaemia in
of modalities geared towards competent management of cases in order to reduce the incidence of
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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
As a final point it would possibly serve as a work of reference to future researchers in the area.
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
Febrile illness: A nonspecific term for an illness of sudden onset accompanied by fever
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.
which is composed of globin and heam 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.
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Iron deficiency anaemia: An advanced stage of iron depletion defined as iron deficiency and
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.
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
Supplementation: Provision of specified dose of nutrients preparation which may be in the form
of tablet, capsule, oil solution or modified food for either treating an identified deficiency or
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CHAPTER TWO
In this chapter, an extensive literature reviews were carried out to find other author’s studies and
This chapter was further divided into the following sub-sections namely: Conceptual review,
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.
Anaemiamay be relative or absolute. Relative anaemia is that which occur in pregnancy (Bolton
et al., 2009).
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).(Bolton et al.,
2009).
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 carbohydrate and fats, which produces the body’s energy. During
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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, 2008). 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 during pregnancy was 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 (Agan et al., 2010). Anaemia affects 1.62 billion
(24.8%) people globally (WHO, 2008). 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., 2008; Badham et al., 2007). Anaemia affects more than 500 million
women in developing countries where 4 of every 10 pregnant women are anaemic (USAID,
2011). 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
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mortality around the world remains high (USAID, 2011). 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
pregnancy improves maternal, neonatal, infant, and even long-term child outcomes (Sant-Rayn
Although dietary deficiency may be contributory, the etiology of the vast majority of cases of
iron deficiency anaemia in infancy and childhood is maternal iron deficiency anaemia in
pregnancy.
WHO has categorized and emphasized on the significant health consequences based on the
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
Each year more than 500,000 women die from pregnancy-related causes, 99% of these were
from developing countries. Estimates of maternal mortality resulting from anaemia range from
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
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
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
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
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
Table 2.1: Estimated prevalence of mild, moderate and severe anaemia in pregnant women in
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
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%
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.(Bolton et al.,
2009).
The pregnant woman may need additional iron supplementation, and a blood test called serum
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
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aggravated by multiple pregnancies, short birth intervals, parasitic and helminthic infections
which is common amongst black women. Malaria parasites causing the destruction of the red
blood cells contribute significantly to the prevalence of anaemia in a population. AIDS should be
a. 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
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
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Iron deficiency is mainly nutritional in origin. There are two types of dietary iron-haem and non-
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 bio available 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
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.
b. Folate Deficiency
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Folates are heat labile, light sensitive, water-soluble vitamins which are essential for red blood
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 andfolate 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
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time of conception reduces the incidence of neural tube defects in infants born to these mothers
(www.cdc.gov/malaria/pregnancy.htm).
c. 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 anaemia yearly. 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
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
d. 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 throughout the tropics and
subtropics where there is contamination of the environment with faeces and it is mainly by skin
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
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e. Sickle Cell Disease (SCD)
About 60million people worldwide carry the sickle cell trait, 50million of whom are in Africa.
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 “a plastic 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.
HIV infection must be included in the causes of anaemia in pregnancy among African women
where sero-positivity ranges from 6-24% in antenatal clinics.(Akin, 2008) When the anaemia is
associated with leucopenia and thrombocytopenia, the antenatal health worker should suspect
g. 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 body to give
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
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dietary fat intake may interfere with vitamin A absorption.
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
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
during pregnancy or anytime during lactation in areas with endemic vitamin A deficiency.
Urinary tract infections (UTI) of any aetiology and infections due to clostridium welchii
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 of iron.
developing countries coupled with deprivation due food taboos and superstitious beliefs,
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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
iron absorption. Most of the homes do not have means of food storage like refrigerators and
a. 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.
In severe cases however, there may be classical symptoms of anaemic heart failure which
b. 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
The central sign for anaemia is pallor and the areas to examine for pallor are the mucous
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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
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
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concentrations at or close to delivery and subsequent mortality, there is little evidence of
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
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
severely anaemic pregnant Indian women. Additional studies on pregnant women are needed in
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
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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.
concentrations and birth weight (Allen, 2009). Abnormally high haemoglobin concentrations
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.
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
Agboola found placental hypertrophy and villous fibrosis in the placentae of anaemic mothers,
24
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, Welshwomen 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
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
25
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
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
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.
(www.delhimedicalcouncil.nic.in/anaemia_website2005_pdf.).
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 physiological variations.
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
26
assessment and laboratory investigations. The two must be put together for a comprehensive
diagnosis:
Clinical Assessment
Laboratory Investigation
1/3rd 1/3rd
Clinical + Laboratory
1/3rd
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
Secondary investigations are guided by the results of the above tests in a given clinical context,
27
3. Blood biochemistry for hepatic and renal functions
4. Bone-marrow aspiration
6. Imaging studies may include X-ray chest/skull/ and other bones as warranted
Other specialized tests include Coombs test, osmotic fragility, Ham’s test, erythropoietin level,
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
1. Dietary history
2. Stool for ova, cyst, and occult blood. If stool shows occult blood positive, do GI endoscopy or
5. Chest X-ray
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
28
clinical and laboratory information.
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
and palpitations), aetiology and severity of anaemia, co-morbidity and potential adverse effects
of therapy.
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
a. 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
Lower 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
29
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 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
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
b. 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
30
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.
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 main drawback of
intramuscular iron is the pain and staining of the skin at injection site, myalgia, arthralgia and
injection abscess.
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
e. Patient preference.
f. Where there is aversion for blood transfusion e.g. the Jehovah witness.
I.V iron can be considered inappropriately interventional especially when iron dextran is used
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
31
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
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:
(www.delhimedicalcouncil.nic.in/anemiainpregnancy.pdf)
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
Contraindications of parenteral iron therapy include Nephritis, cardio respiratory disease and
allergy.
32
Table 2.2: Dosing and infusion intervals of I.V iron based on the compound used
adverse events.
Adapted from Table 5; MW= molecular weight; *only in Europe; NA = not available Gasche
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
Vitamin supplementation
Replacement of vitamin B12 or folic acid should be initiated if serum concentrations are below
normal.
Blood transfusion
33
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.
3. Where moderate anaemia coexists with serious diseases such as sepsis, renal failure,
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.
It is advisable to build up iron store before a woman marries and becomes pregnant. This can be
achieved by:
34
2. Encouraging iron rich foods
If all pregnant women receive routine iron and folic acid, it is possible to prevent nutritional
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
Conceptual Framework
The conceptual framework used for this study was adopted and modified from UNICEF’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).
Non-
Attendance for ANC clinic and taking anaemic
IFAS
Social Cognitive Model and Health Belief Model were used to back up this study. In effect of
these models propose that determinants that shape human behavior are impacted through
socialization and maybe disposed, vulnerable and suspectible to change. While appraising the
literature, two theories were found to offer a strong theoretical framework for this research work.
36
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, control, role
model, and 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 was guided by the Social Cognitive Theory (SCT). According to the SCT, at least
two principal sources of self-efficacy; verbal persuasion and performance accomplishment were
intended to mediate the effect of this intervention. The education of pregnant women about
anemia, nutrition, and Iron Folic-Acid (IFA) supplementation could foster the perception that
their actions can control anemia in them. In effect, social cognitive models propose that
determinants that shape human behavior are imparted through socialization and may be disposed,
Health Belief Model was first developed in the 1950s by social psychologists Hochbaum,
Rosenstock and Kegels. The model used constructs that represented perceived threats and net
barriers, cues to action and self-efficacy. The model asserts that these constructs account for a
person’s “readiness to act”. The most important role was 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
belief model during health education session nurses emphasize on behavioral changes to assist
pregnant women to change their eating habits and practices that contributed to nutritional deficit.
37
In a study carried out by Adam, (2008) on the prevalence of anaemia among pregnant women
attending ante-natal unit of the University of Nigeria Teaching Hospital (UNTH) Enugu between
January 1, 2005 to October 30, 2005. Two hundred (200) respondents were used for the study. A
researcher self developed questionnaire was used to elicit information from the respondents.
Data collected were analyzed using SPSS Version 22.0. Findings revealed that 40.4% of the
study population was anaemic at bookery. There is prevalence of anaemia at booking increased
significantly with increasing gestation age at bookery. Multiple factors were identified as the
causes, such factors include: iron and folate deficiency, malaria and hookworm infestation,
infections such as HIV and haemoglobinopathies. More health education from the health workers
was recommended, so as to prevent the causes of anaemia from the pregnant women.
In another study conducted by Allen (2009) on effects of anaemia in pregnancy among pregnant
women attending ante-natal clinic in Jos University Teaching Hospital, Plateau State. A total of
200 pregnant women were used for the study. A researcher self developed questionnaire was
used to elicit information from the respondents. Data collected and analyzed using SPSS Version
20.0. Results revealed that high output cardiac failure (30%) was the major effect of anaemia in
pregnancy. In addition, other effects identified were pre-mature labour, abortion, pre-natal
morbidity and mortality and high maternal mortality. It was recommended that adequate
In a study conducted by Bolton et al, (2009) in Gombe, North Eastern Nigeria on the prevalence
of anaemia in pregnancy among the pregnant women. A total of 100 pregnant mothers were used
for the study. A researcher self developed questionnaire was used to elicit information from the
respondents. Data collected were analyzed using SPSS Version 20.0. Results revealed that
majority of the pregnant women (67.4%) were mildly anaemic, 30.5% were moderately anaemic.
38
While only 2.1% had severe anaemia. Pica was identified as a risk factor for anaemia in
pregnancy. 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
recorded among the pregnant mothers. Malaria, hookworm infestation, HIV infection, iron and
Globally anaemia affects more than 500million women in developing countries where 4 of every
Although exist about what is being done and what should be done globally to address prevention
In theoretical framework, social cognitive model and health belief model were used to back up
the study. These theorists figured the most important roles of the health workers which is
teaching and providing pregnant women with information needed based on social and
psychological and behavioural changes mainly those related nutritional aspects to maintain
health during pregnancy and prevent anaemia. Using health believe model during health
education, session nurses emphasize on behavioural changes to assist pregnant women to change
In Empirical review;- previous studies conducted by different authors were reviewed. Findings
39
Therefore it’s the intention of the researcher to breach the gap of the knowledge and causes of
anaemia among the women at the rural communities which other studies failed to address.
CHAPTER THREE
RESEARCH METHODOLOGY
Descriptive survey design was used to investigate the level of awareness and knowledge and the
40
3.2 Area of Study
The study was conducted in General Hospital Onitsha, Onitsha North LGA, Anambra State,
Nigeria.
200 women attending ante-natal clinic General Hospital Onitsha were used for the study. They
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.
A reliability analysis was done using the Cronbach’s alpha which 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.
41
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.
Ethical approval was obtained from the ethical committee of National Open University of
In addition 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
Data was collected through a period of five weeks from February 2020 to March 2020 based on
their attendance in General Hospital, Onitsha. 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 clinic and it
42
A researcher developed questionnaire was used to collect data. The questionnaire has four major
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 was 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.
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
43
study.
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 ANOVA, p-value
< 0.05 was considered to be statistically significant and regression model to examine the
CHAPTER FOUR
The results of this study were presented in three subsections of this section namely: demographic
44
Demographic Characteristics Frequency Percent
Age Below 20 Years 34 17.0
21-25 years 46 23.0
26-30 years 60 30.0
31-35 years 26 13.0
Above 35 years 26 13.0
Missing System 8 4.0
Total 200 100.0%
Marital Status Single 28 14.0
Married 132 66.0
Separated 10 5.0
Widowed 4 2.0
MissingSystem 26 13.0
Total 200 100.0%
Education level No formal education 12 6.0
Primary education 16 8.0
Secondary education 114 57.0
Tertiary education 52 26.0
Missing System 6 3.0
Total 200 100.0%
Occupation Farming 20 10.0
Self entrepreneur 102 51.0
Civil servant 44 22.0
Medical practitioner 10 5.0
Student 14 7.0
Missing System 10 5.0
Total 200 100.0%
Field Survey, 2020
Table 4.1 showed that respondents who were between the age brackets 26-30 years had the
highest percentage (30%) and those who were married had the highest percentage
(66%).Secondary education had the highest percentage (57%), while those who had no formal
education had the lowest percentage (6%). Self-entrepreneurs had the highest percentage (51%),
while respondents who were medical practitioners had the lowest percentage (5%). This implies
that pregnant women used for this study had moderate demographic characteristics.
45
Research Questions
Research Question one: Are pregnant women attending antenatal clinic in Onitsha General
46
Total 200 100.0%
Cold hands and feet is a major symptom of anaemia Disagree 30 15.0
Agree 164 82.0
Missing System 6 3.0
Total 200 100.0%
Headache is a major symptom of anaemia Disagree 2 1.0
Agree 194 97.0
Missing System 4 2.0
Total 200 100.0%
Field Survey, 2020
Table 4.2 showed that 90% were aware that anaemia affects pregnant women. 82% stated that
fatigue was a major symptom of anaemia; while 84% stated that pale or yellowish skin was a
major symptom of anaemia. Also 92% stated that irregular heartbeats was 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
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 12 6.0
Agree 186 93.0
Missing System 2 1.0
47
Total 200 100.0%
Anaemia is a condition where the number of red Disagree 14 7.0
blood cells or the oxygen-carrying capacity in a Agree 166 88.0
Missing System 10 5.0
pregnant woman is insufficient to meet
thephysiologic needs Total 200 100.0%
Maternal anemia occurs at a Hemoglobin (Hb) Disagree 12 6.0
Agree 180 90.0
level of <11g/dl, or Hematocrit (Hct) of <33% in Missing System 8 4.0
all trimesters of pregnancy
Total 200 100.0%
Field Survey, 2020
Table 4.3 showed that 93% stated that anaemia was 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 was insufficient to meet the physiologic needs
and maternal anemia is a condition that occurs at a Hemoglobin (Hb) level of <11g/dl, or
48
Research Question three: What are the various health implications of anaemia among
Frequency Percent
Anaemia could affect the health of the foetus Disagree 28 14.0
Agree 172 86.0
Total 200 100.0%
Anaemia could affect the health of the mother Disagree 32 16.0
Agree 166 83.0
Missing System 2 1.0
49
Anaemia could affect child development Disagree 20 10.0
Agree 178 89.0
Missing System 2 1.0
Table 4.4 showed 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
Research Hypotheses
Ho1: There is no significant relationship between the level of awareness and the knowledge
This subsection provides the regression analysis result to hypothesis one, and this was presented
in table 4.5. The adjusted R square is .49, which shows a 49% goodness of fit and implies that
the 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
50
1 (Constant) 5.301 .972 5.457 .000
Table 4.5 showed that the relationship between awareness on the causes and prevention of
anaemia among pregnant women was significant (p<0.05). This implies that the null hypothesis
which stated that there is no significant relationship between awareness on the causes and
Ho2: There is no significant difference in the level of awareness with respect to the
51
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 4.6 showed 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
accepted. (p>0.05). Hence, there is no significant difference in the level of awareness of anaemia
Ho3: There is no significant relationship between the level of awareness and the health
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 ofinterest.
Coefficientsa
52
Model Unstandardized Standardized t Sig.
Coefficients Coefficients
The result in table 4.7 showed 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
53
CHAPTER FIVE
The findings of this study revealed that the level of awareness on the causes and prevention of
anaemia was high among pregnant women in Onitsha General Hospital, Onitsha. Majority were
aware that anaemia is a deadly challenge that affects the health of pregnant women and their
fetus.
The findings of this study is at variance with the study of Batool et al. (2010); and Suryanarayana
54
et al. (2016) which stated that the 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 was higher on
pregnant women in Onitsha General Hospital, Onitsha than in the fetus. There was a significant
relationship between awareness on the causes and prevention of anaemia among pregnant
women in Onitsha General Hospital, Onitsha. There were no significant relationships 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 Onitsha General Hospital, Onitsha. 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
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
study of Okik (2012); Dattijo et al. (2016); Department of Health, Government of South
55
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
5.2 Summary
Awareness of anaemia within the surveyed 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 indicated 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
5.3 Conclusion
In conclusion, the level of awareness on causes of anaemia was high among pregnant women in
Onitsha General Hospital, Onitsha. There was a significant relationship between awareness and
pregnant women and socio demographic variables in Onitsha General Hospital, Onitsha; and no
significant relationship between the level of awareness on the preventive strategies undertaken to
curtail anaemia during pregnancy among pregnant women in Onitsha General Hospital, Onitsha.
In conclusion, there is need to increase the level of awareness of anaemia among pregnant women
56
5.4 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
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
iv. It should also be mandated that pregnant women should know their blood level status before
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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APPENDIX
LETTER OF RESPONDENT
Department of Nursing Science,
Faculty of Health Science,
National Open University of Nigeria,
Awka Study Centre,
Abagana,
30th March, 2020.
Dear Respondent,
REQUEST TO COMPLETE QUESTIONNAIRE
65
I am a final year student of Department of Nursing Science, Faculty of Health Science, National
Open University of Nigeria, Awka Study Centre. I am conducting a research on “LEVEL OF
AWARENESS OF THE CAUSES AND PREVENTION OF ANAEMIA AMONG
PREGNANT MOTHERS IN GENERAL HOSPITAL, ONITSHA ANAMBRA STATE,
NIGERIA”, in partial fulfillment of the award of B. Sc in Nursing Science.
Attached to this letter is a questionnaire aimed at gathering some vital information to assist me
complete the research work. Kindly respond to the statements/questions as freely as possible in
the space provided. All information given will be treated with utmost confidentiality and will be
used solely for the research.
Thanks in anticipation of your co-operation.
Yours faithfully
……………………………
Aruma Jacinta Ifeyinwa
SECTION A
Section A: Bio-data (socio-demographic variables).
You are required to fill or tick [√] only one option as it applies to you in all sections below.
66
SECTION A:
1. Age
Below 20 Years [ ]
21-25 years [ ]
26-30 years [ ]
31-35 years [ ]
Above 35 years [ ]
2. Marital Status
Single [ ]
Married [ ]
Separated [ ]
Widowed [ ]
3. Education level
No Formal education [ ]
Primary education [ ]
Secondary education [ ]
Tertiary education [ ]
4. Occupation
Farming [ ]
Self entrepreneur [ ]
Civil servant [ ]
Medical practitioner [ ]
Student [ ]
SECTION B
LEVEL OF AWARENESS OF THE CAUSES AND PREVENTION OF ANAEMIA
AMONG PREGNANT MOTHERS IN GENERAL HOSPITAL, ONITSHA ANAMBRA
STATE, NIGERIA
COMPONENT
67
Instruction: In order to answer the attitudinal questions below, A is Agree; D means Disagree and
M is Missing system. You are expected to respond as it best represents your opinion on these
questions. Please tick as they apply to you. √
TABLE 1
Level of Awareness of Anaemia among pregnant women
ITEMS A D M
1 I am aware that anaemia affect pregnant women
2 Fatigue is a major symptom of anaemia
3 Weakness is a major symptom of anaemia
TABLE 2
Level of Knowledge on the causes of Anaemia among pregnant women
ITEMS A D M
1 Anaemia is a deadly challenge in pregnant women
2 It can affect the health of the mother
3 It can also affect the health of the child in pregnancy
4 Anaemia is a condition where the number of red blood cells or the
oxygen-carrying capacity in a pregnant woman is insufficient to meet
thephysiologic needs
5 Maternal anemia occurs at a Hemoglobin (Hb) level of <11g/dl, or
68
Hematocrit (Hct) of <33% in all trimesters of pregnancy
TABLE 3
Health Implication of Anaemia among pregnant women
ITEMS A D M
1 Anaemia could affect the health of the foetus
2 Anaemia could affect the health of the mother
3 Anaemia could lead to low birth weight
4 Anaemia could cause morbidity
69