The prevalence of anemia and its association with the dietary habits

among pregnant women of Rahim Yar Khan.

Submitted By

Batch D, 4th Year MBBS Session (2018-2019)

Department of Community Medicine

Sheikh Zayed Medical College, Rahim Yar Khan

Name of Student: ________________________________
Class Roll number: ______________________________
University Roll number: __________________________
Signature of Student: _____________________________
Signature of Supervisor:___________________________

Supervisor

Dr. Samina Waseem, Associate Professor

DEPARTMENT OF COMMUNITY MEDICINE

SHEIKH ZAYED MEDICAL COLLEGE, RAHIM YAR KHAN
BATCH D, 4thYEAR MBBS (2018-2019)

Name Roll Name Roll

Number Number
M. Zarak Khan Niazi 111 Hammad karim 552

Amama Zainab 474 Asif Javaid 553

Manahil Qamar 475 Muhammad Hassaan Ali 554

Sobia Ehsan 476 Fawad Arshad 556

Mahnoor 477 Adeel Shamshad 557

Arfa Arshad 478 Nabeel Nouman 558

Sumaya 479 Shahzad Rahim 559

Rohma Baloch 480 Ali Rehman 561

Fareha Rasheed 481 Hamza Amjad 562
Shazia Wazir Khan 482 Muhammad Bilal 563
Irum Akram 483
Nabiha Afzal 484

Sajida Batool 485

Ayesha Choudhary 489

Uzma Iqbal 491

Muhammad Amjad 550

Muhammad waqas 551

TABLE OF CONTENTS
Sr. No Contents Page Number
1 Abstract 7

2 Introduction 9

3 Objectives 26

4 Methodology 28

5 Results 31

6 Discussion 41

7 Conclusion 44

8 Suggestions 46

9 References 48
 ABSTRACT
Background: Anemia during pregnancy is a significant concern. In developing countries, the
cause of anemia during pregnancy is multifactorial and includes nutritional deficiencies of iron,
folate, and vitamin B12 and also parasitic diseases, such as malaria and hookworm.The
development of anemia is associated with increased risk of preterm births and low birth-weight
infants.The prevalence of anemia among ever-married women aged 15 to 44 is reported to be
26% in urban areas and 47% in rural areas. Objective: To determine the prevalence of anemia
and its association with the dietary habits among the pregnant women visiting the OPD of Sheikh
Zayed Hospital Rahim Yar Khan.Study Design:Cross sectional Study Place: OPD of
Gynecological department of SHEIKH ZAYED HOSPITAL RAHIM YAR KHAN. Duration of
study: From 18th of March to 18th of April 2019.Subjects and Methods: A questionnaire based
study was done on 115 pregnant women choosen on the basis of convenient sampling to test the
prevalence of anemia and its association with the dietary habits of pregnant women using self-
designed questionnaire.The women of age group between 18 – 36 years were interviewed and
data was collected regarding intake of milk,meat,fruits and vegetables,their frequency of intake
per week and regarding intake of iron supplements and folic acid.Physical appearance of
pregnant women was also noted. Hb levels were recorded from report.According to WHO
criteria of Hb level the subjects were as mild,moderate,severe and non-anemic(normal:11-
12.99g/dl,mild anemia:9-10.99 g/dl,moderate 7-8.9g/dl severe:<7g/dl).

.Results: Out of 115 women 67(58.3%) were educated and 48(41.7%) were illiterate, 105(91.3)
were housewives and 10(8.7%) were working women. According to the Hb score, 30(26.1%)
were found to be non-anemic and 85(73.9%) were anemic. According to the severity scale
taken, 43(37.4%) were found to be mildly anemic (Hb 9-10.9mg/dl),35(30.4%) were moderately
anemic (Hb range 7-8.9 mg/dl) and 7(6.1%) were found to be severely anemic (Hb<7mg/dl).
Conclusion: We found that three out of four pregnant women is anemic and dietary intake
during pregnancy was associated with anemia. Therefore, the role of adequate diet and optimal
pre-pregnancy needs to be emphasized in the women of child bearing age.
Key words:Anemia, Pregnant Women, dietary habits, Hospital
 INTRODUCTION
Anemia, defined as a decreased concentration of blood hemoglobin, is one of the most common
nutritional deficiency diseases observed globally and affects more than a quarter of the world’s
population 1,2.Anaemia is a global public health problem affecting both developing and
developed countries with major consequences for human health as well as social and economic
development. It occurs at all stages of the life cycle, but is more prevalent in pregnant women
and young children.

In 2002, iron deficiency anemia (IDA) was considered to be among the most important
contributing factors to global disease burden3. Inadequate iron intake can lead to varying degrees
of deficiency such as low iron stores, early iron deficiency and iron Deficiency anemia. Whole
grain cereals, meats, fish and poultry are the major contributors to iron intake, but the iron from
plant sources is less bio-available. The form in which iron is consumed will affect dietary intake
requirements as not all dietary iron is equally available to the body. The factors that determine
the proportion of iron absorbed from food are complex.

Iron is a universal co-factor for mitochondrial energy generation and supports the growth and
differentiation of all cell types4.The human body has evolved to conserve
iron in several ways, including the recycling of iron after the breakdown of red cells and the
retention of iron in the absence of an excretory mechanism. However, since excess levels of iron
can be toxic, its absorption is limited to 1 to 2 mg daily, and most of the iron required (about 25
mg per day) is provided through recycling by macrophages that phagocytose erythrocytes. The
latter two mechanisms are controlled by the hormone hepcidin, which maintains total-body iron
within normal ranges, avoiding both iron deficiency and excess5. The requirements for absorbed
iron increase gradually through gestation from 0.8 mg/day in the first trimester to 7.5 mg/day in
the third trimester. The average requirement in the entire gestation period is ∼4.4 mg/day. The
absorbed iron is predominantly used to:
1. Expand the woman’s erythrocyte mass.
2. Fulfill the foetus’s iron requirements.
3. Compensate for iron losses (i.e. blood losses) at delivery.
The newborns’ body iron content depends to a large extent on their birth weight. At a low birth
weight of ∼2,500 g, the iron content of the newborn is ∼200 mg and at a “normal” birth weight
of ∼3,500 g, the iron content is ∼270 mg.Total iron requirements in normal pregnancy have been
estimated to ∼1,240 mg . A considerable amount of iron is recycled to the body iron reserves,
when the mother’s erythrocyte mass postpartum declines to the prepregnancy level. Due to
menostasia, the woman “saves” median ∼160 mg iron during pregnancy. The net iron loss,
which is related to pregnancy itself, is ∼630 mg.
Iron deficiency refers to the reduction of iron stores that precedes overt iron deficiency anemia or
persists without progression. Iron-deficiency anemia is a more severe condition in which low
levels of iron are associated with anemia and the presence of microcytic hypochromic red cells6,7.
During pregnancy there is a significant increase in the amount of iron required to increase the red
cell mass, expand the plasma volume and to allow for the growth of the fetal-placental unit and
this impose such a demand on maternal iron stores that iron supplementation at daily doses
between 18 and 100 mg from 16 weeks gestation onwards could not completely prevent the
depletion of maternal iron stores at term8.The frequency of iron deficiency begins to rise again,
mainly in female individuals, during adolescence, when menstrual iron losses are superimposed
with needs for rapid growth. Because a 1 mL loss of blood translates into
a 0∙5 mg loss of iron, heavy menstrual blood loss (>80 mL per month in about 10% of women)
sharply increases the risk for iron deficiency.9Other risk factors for iron deficiency in young
women are high parity, use of an intrauterine device, and vegetarian diets 10. Anemia during
pregnancy is a significant concern.
During pregnancy, the fetal demand for iron increases maternal daily iron requirements around
10-fold, increasing from 6 mg/day to 22 mg/day in first and third trimesters of pregnancy,
respectively. This increased demand for ironis covered mostly from maternal iron stores, which
makes pregnant women at higher risk of developing iron deficiency and IDA11,12. Anemia during
pregnancy is considered severe when hemoglobin concentration is less than 7.0 g/dL, moderate
when hemoglobin falls between 7.0–9.9 g/dL, and mild from 10.0-11 g/dL26,27. The
haemoglobin concentration is still widely used as a pseudomarker for iron deficiency, mainly due
to the simplicity and low cost of the analysis. However, haemoglobin is not suitable to assess
iron status— especially not in pregnancy. There exists a broad overlap between the distribution
of haemoglobin in subjects with and without iron deficiency. Mobilizable body iron reserves can
be estimated by the serum ferritin concentration, which, in healthy subjects, is a good biomarker
for iron status28,29. In non-pregnant women, a serum ferritin concentration of 1 μg/l
corresponds to approximately 7–8 mg of mobilizable iron. Serum ferritin of 30 μg/l indicates
iron reserves of 210–240 mg. Serum ferritin of 15–30 μg/l indicates small iron reserves; a level
of <15 μg/l indicates body iron depletion and values <12 μg/l are associated with iron deficiency.
In developing countries, the cause of anemia during pregnancy is multifactorial and includes
nutritional deficiencies of iron, folate, and vitamin B12 and also parasitic diseases,such as
malaria and hookworm.

Folic acid deficiency causes a megaloblastic type of anemia that is second in occurrence as a
cause for nutritional deficiency anemia of pregnancy after iron deficiency anemia. Folates and
especially their derivative formyl FH4 are necessary for
appropriate DNA synthesis and amino acid production. Insufficient levels of folic
acid may lead to the manifestations noted in megaloblastic anemia. Folic acid must
be provided in the diet: common sources are green vegetables, fruits (lemons, melons), and
meats (liver, kidney)13. Additionally, the higher levels of estrogen and progesterone
during pregnancy seem to have an inhibitory effect on folate absorption The symptoms of folic
acid deficiency are those of general anemia plus roughness of the skin
and glossitis. The erythrocyte precursors are morphologically larger (“macrocytic”),
and an abnormal nuclear–cytoplasmic appearance as well as normochromic and
macrocytic findings are diagnostic criteria for megaloblastic anemia. MCH and
MCHC are usually normal, whereas the large MCV is helpful in differentiation of
this anemia from physiologic changes of pregnancy or iron-deficiency anemia. For
MCV, the presence of increased serum iron and transferrin saturation are also helpful.
Neutropenia and thrombocytopenia are the results of abnormal maturation in
granulocytes and thrombocytes. A low serum level (<3 g/l) may occur early in folic
acid deficiency.

The majority of folic acid deficiencies during pregnancy appear in the third trimester. Severe
folic acid deficiency in experimental animals has been linked to an increased appearance of
pregnancy abnormalities such as prematurity, fetal death, hypertension, placental abruption, or
fetal malformations14.

Except for folic acid, vitamin B12 deficiency is clinically important because of its role in the
metabolism of folate through the production of active FH4. When serum B12 levels are
depressed during pregnancy, it may lead to a type of megaloblastic anemia which exists in
common with folic acid– related anemia in 98% of megaloblastic anemias at pregnancy15.Other
B complex vitamin–related anemias are almost never seen in pregnancy. Though rare, vitamin
B6 (pyridoxine) deficiency is noted during pregnancy by a decrease to about 75% of
normal levels.A relationship between this deficiency and hypochromic microcytic
anemia has been reported. Another hypochromic-type anemia has been noted in
80% of pregnant women with ascorbic acid (vitamin C) deficiency (scurvy). The interaction of
ascorbic acid and iron metabolism is regarded as the etiologic reason for
this anemia. Of the fat-soluble vitamins (A, D, E, K), vitamin A deficiency has
been shown by some investigators to produce an anemia similar to iron-deficiency
anemia16.

The relative contribution of each of these factors to anemia during pregnancy variesgreatly by
geographical location, season, and dietary practice. In Sub-Saharan Africa, iron and folate
deficiencies are the most common causes of anemia in pregnant women 17 .Anemia has a variety
of converging contributing factors including nutritional, genetic, and infectious disease factors;
however, iron deficiency is the cause of 75% of anemia cases 18,19,20.Genetic causes and poor
hygiene that may lead to infections and infestations are other contributing factors in the
development of IDA among the pregnant women.

Nutritional iron deficiency arises when physiological requirements cannot be met by iron
absorption from diet. Dietary iron bioavailability is low in populations consuming monotonous
plant-based diets with little meat.21 In meat, 30–70% of iron is haem iron, of which 15–35% is
absorbed. However, in plant-based diets in developing countries most dietary iron is non-haem
iron, and its absorption is often less than 10%. 22,23 The absorption of non-haem iron is increased
by meat and ascorbic acid, but inhibited by phytates, polyphenols, and calcium. 24 Because iron
ispresent in many foods, and its intake is directly related to energy intake, 25 the risk of deficiency
is highest when iron requirements are greater than energy needs.
 A mixed pattern of anemias has been associated with protein deficiency in pregnancy. The
increasing needs of the mother and the demands from the fetus increase protein requirements
26
from about g in the nonpregnant state. Protein deficiency is not uncommon in a great part of
the world, and anemia associated with kwashiorkor is a characteristic normochromic and
hormocytic anemia that is associated with decreased erythropoiesis and reduced iron intake.

In a study on nutritional habits of pregnant women in Saudi Arabia, factors most frequently
correlated to anaemia were infrequent intake of meat and juices, menorrhagia, intake of antacids,
and non-steroidal anti-inflammatory drugs . Another study found that 13.2% of women
experienced some form of pica . Most craved food items by Saudi women were milk, salty and
sour foods, sweets and dates. On the other hand, spicy foods and beverages were most
avoided items27.

Evidence suggests that calcium does not have any significant long-term effect on iron
absorption. In addition, milk and milk products have not been found to affect iron absorption . As
the bioavailability of nutrients can sometimes be affected due to interactions, concerns have been
raised about the potential for calcium to influence iron absorption. While short-term studies
suggest that calcium may interfere with iron absorption, long-term calcium and milk product
intake has not been linked to any adverse effect on iron status.Furthermore, some studies have
investigated whether milk product consumption may impact iron absorption. In a randomized
crossover trial over 4 days, the consumption of a glass of milk with 3 main meals, or the
consumption of calcium-fortified foods providing an equivalent amount of calcium, did not
inhibit nonheme-iron absorption48. In another study, it was found that the addition of milk or
yogurt to a plant-based diet did not affect iron bioavailability28.
In conclusion, the consumption of milk products does not appear detrimental to iron absorption
and bioavailability. During pregnancy, reported dietary consumption of meat and milk was also
associated with less anemia and, as in prepregnancy, with a significant increase in mean
hemoglobin concentrations in those who consumed greater amounts of red meat. Also, as was the
case for milk consumption prior to pregnancy, the greater the quantity of milk consumed during
pregnancy, the lower the mean hemoglobin concentration. Consumption
of fruits and eggs more than twice a week during pregnancy was associated with significantly
higher hemoglobin levels.
Consumption of nonfood items, especially clay and dirt were strongly associated with anemia, as
well as with lower mean hemoglobin concentrations. Intake of iron supplements was associated
with an increasing prevalence of anemia and lower hemoglobin concentrations.51

The development of anemia is associated with increased risk of preterm births and low birth-
weight infants29.Anemia impairs health and well-being in women and is associated with adverse
reproductive outcomes30-31.

The reported prevalence of IDA in Pakistani women is between 30-60%.Pakistan has a high
maternal (276per 100,000 live births) and perinatal mortality (75 per 1000 pregnancies)18 and
both are associated with acute blood loss in situations of chronic IDA32.In Pakistan, the
prevalence of anemia among ever-married women aged 15 to 44 is reported to be 26% in urban
areas and 47% in rural areas10.The prevalence of anemia among pregnant women living in urban
areas is similar, ranging from 29% to 50% among pregnant women attending antenatal clinics in
33,34
a large private, tertiary hospital in Karachi .Annually it is estimated that 22% of maternal
deaths and 24% of perinatal deaths around the world are attributed to IDA 35.In pregnant women
of low-income areas in the USA, the frequency of iron deficiency anaemia in the first, second,
and third trimesters is 2%, 8%, and 27%, respectively36

When a woman enters pregnancy with a large iron deficit and is subjected to the added demands
for iron during pregnancy, it may be too late to address the problem of anemia during
pregnancy.With limited resources available to address public health problems, knowledge of the
local etiological factors responsible for anemia is crucial in order to design appropriate
prevention and treatment strategies. Most of the published studies from Pakistan have been
conducted on women seeking care in clinical or hospital settings and thus may not give a true
picture of anemia and its causes in a population-based sample. The current study was carried out
on the pregnant women attending the outpatientdepartment(OPD) and wards of Sheikh Zayed
hospital Rahim YarKhan.
 Objectives:
The objectives of this study were to:

1. Assess the prevalence of anemia among the pregnant women visiting OPD of Sheikh Zayed
Hospital Rahim Yar Khan
2. Know association with the dietary habits among the pregnant women of sheikh Zayed
hospital R.Y.Khan.
 METHODOLOGY:

Study design: This was a cross-sectional study.

Study setting: This was conducted among the pregnant women visiting the OPD of
gynecological department of Sheikh Zayed Hospital Rahim Yar Khan.

Study subjects: Women having pregnancies of either first, second or third trimester.

Sample size: A total of 115 pregnant women were included in the study.

Sampling technique: Convenient sampling technique was used.

Duration of study: From 18th of March to 18th of April 2019.

Inclusion criteria: The study included the women:

 Age group between 18-36 years.

 Who were willing to participate in the study
 With normal appearance.

Exclusion criteria: Women having previous history of trauma, any surgery, worm infestation,
bleeding disorder, abnormal vaginal bleeding, cancer of uterus or cervix, diabetes mellitus and
other chronic disorders.

Data collection: Women were briefed about the purpose of research and assured of
confidentiality. Informed verbal consent was taken. Participants were interviewed regarding
demographic, socio economic characteristic and previous pregnancy history. Data was collected
regarding intake of milk, meat, fruits and vegetables, their frequency per week and regarding
intake of iron supplements and folic acid. Physical appearance of pregnant women was also
noted. Hb levels were also recorded from report. According to WHO criteria of Hb level the
subjects were labeled as mild, moderate, severe and non-anemic(normal:11-12.99g/dl, mild
anemia:9-10.99 g/dl, moderate 7-8.9g/dl severe:<7g/dl).41The data was analyzed by using
computer software SPSS16.0.
RESULTS:
This study was conducted to know the prevalence of anemia among pregnant mothers visiting
tertiary care hospital. Results were as following:
Table no.1: Descriptive statistics of educational status.

status
Frequency Percent

Educated 67 58.3

Illiterate
48 41.7

Total
115 100.0

Table 1 shows that out of 115 pregnant women, 67(58.3%) were educated .
Table no.2: Occupation wise distribution of the pregnant women.

status Frequency Percent

Housewife
105 91.3

working women
10 8.7

Total
115 100.0

Table 2 shows that out of 115 pregnant women, 105(91%) of women were housewives and
10(8%) were working class.
Table no.3: Physical appearance wise distribution of women.

Anemic appearance Frequency Percent

Yes
80 69.6

No
35 30.4

Total
115 100.0

table 3 shows that 70% women were clinically anemic.

Figure 1

Figure no. 1: Pi chart showing the distribution of sample taken in different anemic categories.
Table no.4: Descriptive statistics of anemic pregnant women among different
severity group.

Status
Frequency Percent

mild anemic
43 37.4

moderate anemic
35 30.4

severe anemic
7 6.1

non anemic
30 26.1

Total
115 100.0

Table 4 reveals that 30(26.1%) pregnant women were non anemic, 43(37.4%) , 35(30.4%),
7(6.1%) were mildly, moderately and severely anemic respectively.

Figure no. 2: Graph showing severity of anemia among the pregnant women.
Table no.5: Descriptive statistics of Anemia association among group taking iron supplements.
 Iron Supplements
status
Yes No Total

mild anemic 35 8 43

moderate anemic 26 9 35

severe anemic 3 4 7

non anemic 27 3 30

Total 91 24 115

Table 5 shows that 91(79.1%) pregnant women were taking iron supplements and out of these
64(70.32%) were anemic, 24(20.9%) not taking iron supplements 21(87.5%) were anemic.
Table no.6: descriptive statistics of anemia association among group of pregnant women taking folic
acid.

Folic acid intake

Status
Yes no Total

mild anemic 34 9 43

moderate anemic 21 14 35

severe anemic 3 4 7

non anemic 26 4 30

Total 84 31 115

Table 6 shows that 84(73.04%) were taking folic acid supplements and out of these taking folic
acid 58(83.69%) were anemic, 31(26.9%) not taking iron supplements 27(87.1%) were anemic.
Table no. 7:Distribution of anemia association among group taking meat 2 times a week.

Meat intake
Status
Yes No Total

mild anemic 22 21 43

moderate anemic 24 11 35

severe anemic 3 4 7

Non anemic 22 8 30

Total 71 44 115

Table 7 shows that 71(61.7%) pregnant women were taking meat twice a week and out of these
49(69.01%) were anemic, 44(38.3%) not taking iron supplements 36(81.81%) were anemic.
Table no. 8: Descriptive statistics of Association of anemia with green vegetables and fruit intake
among pregnant women twice weekly.

Green vegetables and fruits intake

Status
Yes No Total

mild anemic 43 0 43

moderate anemic 35 0 35

severe anemic 6 1 7

non anemic 30 0 30

Total 114 1 115

Table 8 shows that 114(99%) pregnant women were taking fruits and green vegetables and out of
these 64(70.32%) were anemic, 24(20.9%) not taking iron supplements 21(87.5%) were a
Table no.9: Association of vitamin B12 intake with anemia among pregnant women.

VitaminB12Supplements intake
Status
Yes no Total

mild anemic 29 14 43

moderate anemic 17 18 35

severe anemic 3 4 7

non anemic 22 8 30

Total 71 44 115

Table 9 shows that 71(61.7%) pregnant women 59(83.09%) were anemic and 44(38.3%) not
taking vitamin B supplements 36(81.81%) were anemic.
Table no. 10: Association of pica intake with anemia among pregnant women

status Pica intake

Yes no Total

mild anemic 3 40 43

moderate anemic 6 28 35

severe anemic 1 6 7

non anemic 8 22 30

Total 18 96 115

Table 10 reveals that 18(15.65%) pregnant women taking pica 10(55.55%) were anemic and out
of 96(83.45%) not taking pica 74(77.08%) were anemic.

DISCUSSION:
Present study has assessed the pregnant females of Sheikh Zayed Hosptial Rahim Yar Khan for
anemia by using self- designed questionnaire. One hundred and fifteen (115) pregnant women
were asked questions related to dietary habits and their current physical status to fill the
questionnaires. Out of 115 women 67(58.3%) were educated and 48(41.7%) were illiterate,
105(91.3) were housewives and 10(8.7%) were working women. Physical appearance of anemia
was found in 105(91.3%)of pregnant women and it was absent in 35(30.7%). According to the
Hb score, 30(26.1%) were found to be non-anemic and 85(73.9%) were rendered anemic.
According to the severity scale taken from the WHO criteria of anemia severity, 43(37.4%) were
found to be mildly anemic (Hb 9-10.9mg/dl),35(30.4%) were moderately anemic (Hb range 7-
8.9 mg/dl) and 7(6.1%) were found to be severely anemic (Hb<7mg/dl).

The prevalence of anemia among pregnant women reported in our study was in the average
range reported for several other developing countries .The prevalence of anemia among pregnant
women of other countries ranged from 35% to 81%37-38. World Health Organization (WHO) data
show that iron deficiency anemia in pregnancy is a significant problem throughout the world
with a prevalence ranging from an average of 14% of pregnant women in industrialized countries
to an average of 56% in developing countries. But our result is significantly higher than the
criteria mentioned above. This may be attributed to the low socio-economic status and lack of
resources. Among 115 pregnant women studied it was found that 44(38%) women were not
taking the meat due to lack of resources or poverty and 36(81.8%) were anemic. Similarly same
results were seen among those who were not taking vitamin B12 supplements .Another
associated factor that is iron intake was studied and results showed that out of 24(20%) pregnant
women not taking the iron supplements 21(87%) were anemic

. Another studies conducted in Saudi Arabia, about 66% of women consumed 1 to 3 portions of
meat (chicken, fish or lamb) per week. Fifty five percent consumed milk from 4 to 7 times per
week. The consumption of fruits and vegetables was all more than 3 times per week. The
proportion of women who experienced cravings (increase desire or appetite for a specific food
item) was 35.5% (CI 0.27- 0.45, OR 0.55). The percentage of women with cravings and type of
food items commonly craved for. Meat and milk were the most craved food items among the
studied population by 31% each.Craving for other food items like, dirt and pica was experienced
by 18%39.Our study was almost comparable with this study as 61% of women consumed 1 to 3
portions of meat per week. 53% consumed milk every day. 99% consumed fruits and vegetables
3 times daily on weekly basis. In our study, pica intake was almost 16%.

Our study is in accordance with Saudi Arabia because of similar dietary habits, culture, religion
and climatic conditions. Part of the fact that some of the results are higher in pakistan is due to
the lack of resources and high poverty ratio. Other independent variables which are not
significant factors in this study but found to be significant by other studies reviewed include age
of the mother, age at pregnancy, age at marriage, number of deliveries, number of children,
family size, educational status of the mother, and occupation of the mother 40,41.

There are a lot of indications that severe maternal anemia in pregnancy is associated with poor
pregnancy outcome and that the cause of this association has yet to
be elucidated. Moreover, what effects the maternal anemia has on the fetus are not
well defined; however, several reports in the literature associate the reduction in hemoglobin
level with prematurity, spontaneous abortions, low birth weight, and fetal
deaths. Some authors believe that even a mild reduction in Hb level (8–11 mg/dl) may
produce a predisposition to these conditions; in contrast, other authors support a direct
relationship between anemia and fetal distress only when the maternal Hb levels
arelessthan6mg/dl.
It is important to know what effect the iron status of the mother has on the iron
status of the fetus for definitive and correct conclusions about management. There
are controversial opinions about this: some investigators found that levels of maternal iron exert
little effect on that of the neonate at birth 42. On the other hand, studies
of cord blood serum iron levels have shown a direct relationship between maternal
and fetal iron levels. Additionally, when serum ferritin is used as an indicator of
iron status, it was found that babies born to mothers who did not take iron supplements during
pregnancy had reduced iron stores at birth62. Most authors agree that
only severe anemia may have direct adverse effects on the fetus and neonate and that
a mild to moderate maternal iron deficiency does not appear to cause a significant
effect on fetal hemoglobin concentration.
There are several reports that correlate the anemia during pregnancy with prematurity and low-
birthweight infants, indicating a direct relationship between low birth
weight and low maternal Hb level.In a large epidemiologic study, it was shown
that the risk of a preterm delivery was increased by 20% in pregnancies with Hb levels between
10 and 11 mg/dl and by 60% in pregnancies with Hb levels between 9 and
10 mg/dl. In our study, 37% of women were mildly anemic thus they are more prone to all these
complications during their peri natal and post natal period than other women having normal
range of hemoglobin that is above 12mg/dl. Below 9 mg/dl, the risk was more than doubled,
tripled, and so on for each
fall of 1 mg/dl.63 In the same study, no correlation was found between maternal Hb
levels and growth retardation. In another large epidemiologic study, perinatal mortality was
found to be tripled when the maternal Hb levels fell below 8 gr/dl in comparison with Hb levels
above 11 mg/dl.22 In addition, Garn et al.23 demonstrated an
association between low maternal Hb levels and poor pregnancy outcomes such as
prematurity, low birth weight, fetal death, and other medical abnormalities with increasing
complication rates when there were lower maternal Hb concentrations.
Nevertheless, all these reports are strong indications of an adverse effect of maternal
anemia on fetal growth and pregnancy outcome. Nevertheless, it would be better, at
least in cases of mild to moderate maternal anemia, to characterize these simply as
possible risk factors rather than as an adequate evaluation indicating an obvious adverse impact
on the fetus. Moreover, it is important to stress that low maternal Hb
levels are often associated with other pathologic conditions, so it is difficult to be
sure whether maternal anemia per se causes or even contributes directly to the increased
mortality and morbidity rates. In other words, low Hb levels are often a secondary phenomenon
caused by antecedent infections or chronic illnesses that in turn
may lead to severe complications during pregnancy that do not fundamentally depend on the
hematologic profile of the pregnant woman.
In univariate analysis, consumption of fruit was associated with a decreased risk of anemia.
Given the fact that a large percentage of the iron in these diets is from non haeme sources, the
decreased risk may be attributed to the presence of vitamin C, which is known to enhance the
absorption of non heme iron.43

Iron supplementation alone during pregnancy may be inadequate to prevent anemia in a large

proportion of women who enter pregnancy with little or no iron stores. Furthermore, reported

compliance rates for iron supplements during pregnancy are low 44,45.Another study suggests that

Interms of dietary practices, it is interesting to note that the consumption of red meat more than

twice weekly tended to be protective, and tea consumption had a negative effect. Given the

socioeconomic status of the majority of Pakistani women, it may not be possible to increase the

intake of heme iron substantially, but nutrition education to include red meat even as part

of a mixed vegetable or legume dish could reduce the prevalence of anemia by not only

increasing the intake of iron but also enhancing the intake of nonheme iron, especially from

wheat flour, which is the staple food in this area. Second, all women whose intake of iron is not

optimal should be educated regarding the detrimental effect of milk on iron absorption. In

addition, pregnant women should be counseled regarding the detrimental effect of pica,

especially the intake of clay and dirt, on iron absorption.46,47

WHO recommends that in vulnerable populations, supplemental iron should be given to

adolescents and women for 2 to 4 months per year to ensure that women have reasonable iron
stores when they enter pregnancy48.

LIMITATIONS
 Our study had some of the limitations. We were unable to account for other known factors
associated with anemia such as helminth infections, genetic disorders, and vitamin A deficiency.
Although helminthic infection contributes to the prevalence of anemia 49, it may not be an
important factor in this area because of its low prevalence in Pakistan 50. The high prevalence of
iron deficiency in the developing world has substantial health and economic costs. However,
more data are needed on the functional consequences of iron deficiency; for example,
the effect of iron status on immune function and cognition in pregnant women and infants needs
to be clarified. Continuing rapid advances in understanding the molecular mechanisms of iron
absorption and metabolism might enable development of new strategies to combat iron
deficiency.

SUGGESTIONS:

The main strategies for correcting anemia in pregnant women exist, alone or in combination:

1.Education combined with dietary modification or diversification.

2.To improve iron intake and bioavailability.

3.Iron supplementation (provision of iron, usually in higher doses, without food) . Iron
supplementation can be targeted to high-risk groups (eg, pregnant women), and can be cost
effective.51 Iron should be provided with meals, although food reduces absorption of medicinal
iron by about two-thirds52 Alternatively, oral iron supplements can be supplied every few days;
this regimen might increase fractional iron absorption.53

4.Fortification of foods. Fortification is probably the most practical, sustainable, and cost-
effective long-term solution to control iron deficiency at the national level. 54,55 Although dietary
modification and diversification is the most sustainable approach, change of dietary practices and
preferences is difficult, and foods that provide highly bioavailable iron (such as meat) expensive.

CONCLUSION
 The study showed that three out of four pregnant women was anemic. Majority of them
belonged to low socio economic group and did not have enough to consume a healthy diet. Some
of them were anemic due to consumption of food having low nutritive value or reluctancy
towards meat and related products that are required for hemoglobin formation. Few of them
showed anemic status only because of multi parity. There was also a group of anemic pregnant
women who had little or no knowledge about the dietary requirements. It was also seen that age,
pica intake and occupation had little or no influence on anemic status of majority of pregnant
women.

The cause of anemia need further research in particular, a focus on less commonly studied
factors may be required to develop adequate interventions. However in the meantime, it is
recommended that all women of child bearing age in Pakistan should receive basic nutritional
education regarding food sources of iron and how the food choices would affect iron absorption.
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