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Tusimin et al., J Preg Child Health 2016, 3:5
DOI: 10.4172/2376-127X.1000291
ISSN: 2376-127X

Research Article OMICS International

The Impact of Severity of Antenatal Anaemia on Maternal and Perinatal

Outcome in Hospital Serdang, Malaysia
Maiza Tusimin1*, Aishah Yazit2, Nur Syaza Zainulddin2, VS Selvavaani KN Vaiappuri2 and Sabariah Md Noor2
1Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
2Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
*Corresponding author: Maiza Tusimin, Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia; Tel:
60125129464; E-mail: maiza@upm.edu.my
Received date: October 22, 2016; Accepted date: October 28, 2016; Published date: October 31, 2016
Copyright: © 2016 Tusimin M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution and reproduction in any medium, provided the original author and source are credited.

Abstract

Introduction: Anaemia in pregnancy is one of the most common public health issues in developing countries,
affecting approximately 60% of pregnant woman worldwide. Severity of antenatal anaemia had been robustly linked
with complications in maternal and perinatal outcome.

Objective: This study aimed to analyze the relationship of antenatal anaemia with maternal and perinatal
outcome among parturient delivering in Hospital Serdang.

Materials and method: This retrospective cross-sectional study was conducted in a tertiary public hospital in
Serdang, Selangor. 473 anaemic mothers were recruited from the electronic medical database by clinical notes and
cross-referencing to the datasets of relevant test. All subjects received antenatal oral iron supplementation.

Results: Multiparous mother contributed to majority of the anemia cases in pregnancy (60.5%). Out of 473
anaemic mother suffering from Iron Deficiency Anemia (IDA), 61.3% (n=290) mothers had mild anaemia, 38.5%
(n=182), and 0.2% (n=1) mothers had moderate and severe anaemia respectively. A significant association was
demonstrated between severity of anaemia with postpartum haemorrhage and small for gestational age. On
contrary, severity of maternal anaemia was non-significantly associated with placenta abnormalities, preeclampsia
and sepsis.

Conclusion: Anaemia amongst pregnant women especially multipara imposed a spectrum of health problems to
both, mother and child. Prevention is not insurmountable; hence active intervention by all level of health care
provider is imperative in order to decrease poor maternal and perinatal outcome.

Keywords: Anaemia; Maternal outcomes; Perinatal outcome
Introduction
Anaemia is a widespread public health problem amongst pregnant
women worldwide [1-3]. About half of all anaemic women live in the
Indian subcontinent, where 88% of them developed anaemia during
pregnancy [4]. Recent World Health Organization (WHO) data shows
that Africa has the highest frequency (57.1%) of anaemia in the world
[5]. WHO defines cut-offs value for anaemic pregnant women as
haemoglobin (Hb) concentration of less than 11 g/dl and a
haematocrit of less than 0.332 at sea level [3]. The severity of anaemia
in pregnancy is based on the level of Hb, i.e., mild anaemia (between
10-10.9 g/dl), moderate (7.0-9.9 g/dl) and severe of less than 7.0 g/dl
[3]. Maternal anaemia is commonly considered as a risk factor for poor
pregnancy outcome [6] and has been associated with a multitude of
problem on both woman and neonate [7]. Ghimire and Ghimire have
found that severe anaemia significantly increases the risk of neonatal
complication which includes pre-term delivery, low birth weight and
small for gestational age [8]. Similarly, moderate anaemia have been
linked with increased weakness, lack of energy, fatigue and poor work
performance among the pregnant women and severe anaemia has been
associated with poor maternal and fetal outcome [9]. Anemia in
pregnancy also contributes to haemorrhage and infection especially
amongst the severely anemic women causing cardiac failure and
subsequently leading to maternal death [10]. In 2015, Brabin et al.
disclosed that severe anaemia (OR 3.51, 95% CI: 2.05–6.00) has strong
association with maternal mortality [11]. In addition, Ali et al. found
that higher prevalence of preeclampsia have been demonstrated among
the pregnant women with severe anaemia [12].
Women with Hb between 8.0 and 9.9 g/dl [13] had significantly
higher risk for low birth weight, preterm birth and small for gestational
age than women with Hb between 10.0 and 11.9 g/dl [1]. A recent
study by Farrukh revealed that anaemia in pregnancy is associated
with significantly large placental weight and a high fetoplacental ratio
[14]. Moreover, previous meta-analysis studies have showed that
maternal anaemia during early pregnancy is associated with increase
in preterm birth and low birth weight [15]. In Malaysia, Haniff et al.
revealed the prevalence of anaemia was 35% and mostly of the milder
type and more prevalent in the Indian and Malays ethnicity [16]. This
study revealed that at a cut-off point of 11 g/dL, grand multiparas
(n=45%) and mothers in third trimester of pregnancy (n=43%) were
mostly affected by anaemia. Additionally, gestational age and ethnicity
were the main factors that were positively correlated with anaemia.
Despite the immense effort made by the Malaysian government to

J Preg Child Health, an open access journal Volume 3 • Issue 5 • 1000291

ISSN:2376-127X
Citation: Tusimin M, Yazit A, Zainulddin NS, Vaiappuri VSSKN, Md Noor S (2016) The Impact of Severity of Antenatal Anaemia on Maternal and
Perinatal Outcome in Hospital Serdang, Malaysia. J Preg Child Health 3: 291. doi:10.4172/2376-127X.1000291

Page 2 of 6

reduce the health and economic burden of anaemia in pregnancy, it
prevalence and impact on maternal health have not been explored
comprehensively in our country.
Materials and Methods
Ethics
Ethics approval (reference NMRR-15-557-25505) was granted by
the National Medical Research Register Ministry of Health, Malaysia
(NMRR), Clinical Research Centre Serdang, Malaysia (CRC) and The
University Research Ethics Committee, Universiti Putra Malaysia
(JKEUPM).
Study population
This is a cross-sectional retrospective study conducted from January
to June 2015 in Hospital Serdang, Selangor. Hospital Serdang is a
government-funded multi-specialty hospital located in the district of
Sepang, in the state of Selangor, Malaysia and serving approximately
570,000 populations. The hospital provides tertiary antenatal care,
receiving referrals from other clinics and private hospitals and for
women who live close to the hospital facility, as well as serving as
teaching hospital for medical student from Faculty of Medicine and
Health Sciences, Universiti Putra Malaysia.
Study criteria
Sample size was calculated using standard errors associated with
confidence intervals (1.96) and standard errors associated with power
(0.842). Universal sampling was used during sample selection. Eligible
pregnant women were identified via electronic medical database by
clinical notes and cross-referencing to the datasets of test results
included full blood count (FBC), ferritin level, date of investigation
and information about gestational age, such as estimated date of
delivery, gestational age at the time of blood testing or follow-up and
date of last menstrual period. Results were de-identified, but results for
each individual woman remained linked and only mothers with
singleton pregnancy diagnosed with Iron Deficiency Anemia (IDA)
were included in the study. Exclusion criteria include patients with
other chronic illnesses, e.g. chronic kidney disease, malignancy,
thalassemia or other causes of anemia in pregnancy and previous
blood transfusion at least three month prior to study recruitment. Hb
level was used to classify severity of anaemia. The cut-off point of Hb
level in pregnant women as defined by World Health Organization
(WHO) are mild anaemia, Hb level between 10.0-10.9 g/dl; moderate
anemia, Hb level between 7.0-9.9 g/dl; and severe anemia, Hb level less
than 7.0 g/dl [3]. All subjects received antenatal oral iron and folic acid
supplementation (ferrous fumarate 200 mg daily, folic acid 5 mg od) as
per hospital antenatal care protocol.
Maternal and Perinatal Outcome: The maternal outcomes explored
in this study were postpartum haemorrhage, placenta abnormality,
preeclampsia and sepsis. Postpartum haemorrhage was defined as
blood loss of more than 500 ml following vaginal delivery and 1000 ml
following a cesarean section delivery. Abnormal placenta implantation
(placenta previa), abnormal placental invasion (placenta accrete/
increta/percreta) and premature placental separation (placenta
abruptio) were described as placenta abnormality. NICE guideline
2015 defined Preeclampsia as new onset of hypertension and either
proteinuria or end-organ dysfunction after 20 weeks of gestation in a
previously normotensive women.
Preterm birth, low birth weight, small for gestational age and
intrauterine growth restriction were the perinatal outcomes that were
studied in this research. World Health Organization (WHO) defines
preterm birth as babies born alive before 37 completed weeks’ gestation
and low birth weight (LBW) is defined as baby’s birth weight of less
than 2500 g. Small for gestational age (SGA) is defined as infant born
with a birth weight less than the 10th centile for that appropriate
gestational age. Intrauterine growth restriction (IUGR) refers to the
foetus that has not achieved the expected in utero growth potential due
to genetic or environmental factors.
Results
Total number of patients who have fulfilled the inclusion and
exclusion criteria was 473, giving the prevalence rate of maternal
anemia secondary to IDA during the study period of 14.3%. The
highest numbers of anaemic mothers by ethnicity were Malays
(85.4%). Multiparous mother contributed to majority of the anemia
cases in pregnancy (67%). The mean gestational age at delivery was
37.67+2.68 (Table 1).
Variables Frequency n (%)
Maternal age 29.62+5.12
Ethnicity
Malay 404 (85.4)
Chinese 21 (4.4)
India 18 (3.8)
Others 30 (6.3)
Gravidity
1 131 (27.7)
2-4 289 (61.1)
>5 53 (11.2)

A total of 473 anaemic mothers diagnosed with IDA were recruited Parity
in this study. The prevalence of maternal anemia secondary to IDA
during the study period was 14.3%. Data was analyzed using IBM SPSS 1 155 (32.8)
Statistics version 21.0. Descriptive analysis was used to describe the 2-3 228 (48.2)
distribution of socio-demographic, antenatal profile and severity of
anaemia. The association between categorical variable which includes >4 90 (18.8)
severity of anaemia and outcomes in mothers and newborns were
Gestational age at delivery (week) 37.67+2.68
analyzed using Chi square test and Fisher’s exact test. All statistical
tests were evaluated at the 0.05 significance level.
Table 1: Demographic and clinical characteristics (n=473).

J Preg Child Health, an open access journal Volume 3 • Issue 5 • 1000291

ISSN:2376-127X
Citation: Tusimin M, Yazit A, Zainulddin NS, Vaiappuri VSSKN, Md Noor S (2016) The Impact of Severity of Antenatal Anaemia on Maternal and
Perinatal Outcome in Hospital Serdang, Malaysia. J Preg Child Health 3: 291. doi:10.4172/2376-127X.1000291

Page 3 of 6

Out of 473 anaemic mother suffering from IDA, 61.3% (n=290)
mothers had mild anaemia, 38.5% (n=182), and 0.2% (n=1) mothers
had moderate and severe anaemia, respectively. Further analysis
showed 23.9% (n=113) of anaemic women suffered from placenta
abnormality (placenta previa, placenta abruptio) and 10.8% (n=51) was
complicated with postpartum haemorrhage. 7.2% (n=34) and 2.5%
(n=12) of these anaemic mothers had preeclampsia and antenatal
infection respectively. A significant numbers of mothers with IDA
experienced preterm birth (15.6%); and 14.6% of the parturient gave
birth to LBW newborn. Meanwhile, 5.9% (n=28) and 2.7% (n=13)
new-borns were complicated with SGA and IUGR respectively (Table
2).

Frequency (n) Percentage (%)

Severity

Mild 290 61.3

Moderate 182 38.5

Severe 1 0.2

Total 473 100

Maternal outcome

Postpartum Haemorrhage 51 10.8

Placenta abnormality 113 23.9

Preeclampsia 34 7.2

Infection (sepsis) 12 2.5

No significant complication 263 55.6

Perinatal outcome

Preterm birth 74 15.6

Small for gestational age 28 5.9

Low birth weight 69 14.6

Intrauterine growth restriction 13 2.7

No significant complication 289 61.2

Table 2: Severity of anaemia with maternal and perinatal outcome. slightly increased in moderate to severe anaemic mothers, i.e., placenta
abnormality of 25.7% (n=47), postpartum haemorrhage of 15.3%
Interestingly, this study revealed four morbidity associated with
(n=28), preeclampsia of 7.1% (n=13), and sepsis of 4.4% (n=8). A
mild maternal anemia namely placenta abnormality (23.9%, n=66),
statistically significant association was revealed between postpartum
postpartum haemorrhage (7.9%, n=23), preeclampsia (7.2%, n=21)
haemorrhage and severity of maternal anaemia (p=0.012) (Table 3).
and infection (1.4%, n=4). These maternal related complications were

Mild Moderate & Severe X2 p-value

n (%) n (%)

Postpartum haemorrhage 23 (7.9) 28 (15.3) 6.334 0.012a

Placenta abnormality 66 (22.8) 47 (25.7) 0.528 0.468a

Preeclampsia 21 (7.2) 13 (7.1) 0.003 0.955a

Infection (sepsis) 4 (1.4) 8 (4.4) N/A 0.068b

Table 3: Severity of anaemia with maternal adverse outcomes.

The study demonstrated a significant association between severity of SGA as compared to 3.4% in mother who had only mild anaemia in
maternal anaemia and SGA (p=0.004). 9.8% of the babies delivered by pregnancy (Table 4).
mother who suffered from moderate to severe anaemia were born as

J Preg Child Health, an open access journal Volume 3 • Issue 5 • 1000291

ISSN:2376-127X
Citation: Tusimin M, Yazit A, Zainulddin NS, Vaiappuri VSSKN, Md Noor S (2016) The Impact of Severity of Antenatal Anaemia on Maternal and
Perinatal Outcome in Hospital Serdang, Malaysia. J Preg Child Health 3: 291. doi:10.4172/2376-127X.1000291
Mild
n (%)
Preterm birth 38 (13.1)
Small for gestational age 10 (3.4)
Low birth weight 35 (12.1)
Intrauterine growth restriction 7 (2.4)
Table 4: Severity of anaemia with perinatal adverse outcomes.
Discussion
Anaemia complicating pregnancy is a known menace to both
mother and fetus. It is not only a global pandemic but also instigates a
multitude of complications such as maternal infection, prematurity,
IUGR and low birth weight [17]. Nutritional Iron Deficiency Anaemia
IDA is the commonest cause of anaemia during pregnancy and hence
our study population involved all pregnant mothers suffering from
IDA. In the present study, the prevalence of maternal anemia
secondary to IDA during the study period was 14.3%. A local study in
South-ease of Peninsular Malaysia reported that 35% of Malaysian
mothers were inflicted by anemia in pregnancy and mostly of the mild
type and more prevalent in the Indian and Malays communities [16].
This difference may possibly attributed by the difference geographical
distribution whereby our study was conducted in urban area and the
later was undertaken in rural district region. All patients in this study
received oral iron supplementation of ferrous fumarate 200 mg daily
along with folic acid 5 mg daily as per the government antenatal care
protocol. These prescriptions are freely available in all our health care
centers and prescribed to all pregnant women as early as 14 weeks
period of gestation. Nonetheless, patient’s compliance towards iron
supplementation was uncertain as the data were retrieved from the
electronic medical database. In the present study, maternal anemia was
detected at late second trimester and early third trimester. Majority
(85.4%) of the anaemic mother were of Malay ethnicity which is the
predominant race in Malaysia, followed by Chinese (4.4%) and Indian
(3.8%). 61.3% (290/473) of the mothers suffered from mild anaemia,
38.5% (182/473) had moderate anaemia and 0.2% (1/473) had severe
anaemia. These findings are comparable with other Asian country.
Baig-Ansari found that 0.7% mothers were severely anaemic in an
urban setting in Pakistan [18]. Likewise, Bentley and Griffiths has
discovered that 2.2% pregnant women suffered from severe anaemia in
Andhra Pardesh [19] whereas 4% of severely anemic mother were
reported in Vietnam [5].
Maternal Outcome
Postpartum haemorrhage (PPH) is recognized as one of the leading
cause of maternal mortality worldwide. WHO defined PPH as an
estimated blood loss of greater than 500 mL in vaginal deliveries and
greater than 1000 mL in cesarean deliveries [17]. Severe anemia may
impair myometrial contractility resulting from impaired oxygen-
carrying capacity leading to enzyme and cellular dysfunction. WHO
statistical data shows that 25% of maternal deaths occur due to PPH
[20]. The result obtained from this study demonstrated that PPH was
seen in 7.9% cases of mild anaemia and 15.3% in cases of moderate to
severe anaemia. In addition, PPH were significantly associated with the
J Preg Child Health, an open access journal
ISSN:2376-127X
Page 4 of 6
Moderate and Severe X2 p-value
n (%)
36 (19.7) 3.668 0.055a
18 (9.8) 8.22 0.004a
34 (18.6) 3.817 0.051a
6 (3.3) 0.314 0.575a
varying degree of severity of anaemia. Frass in her observational
studies explained that relationship between PPH and severe anaemia
accounting for about 90% in most studies [21]. Pregnant women with
moderate-to-severe anaemia had a significantly greater total blood loss
of an average 91 mL [21] as compared to non-anaemic women
(p<0.01). Kavle found that blood loss at delivery was slightly elevated
in mild anaemic women as compared to non-anaemic women [22]. He
also observed strong association between the severity of anaemia with
blood loss at delivery and in the postpartum period [22].
The susceptibility of women with severe anaemia to preeclampsia
has been linked to deficiency of micronutrients and antioxidants. The
reduction in serum levels of calcium, magnesium and zinc during
pregnancy have been linked to the development of preeclampsia [23].
The present study revealed a non-significant association between
severities of maternal anaemia with preeclampsia. Nonetheless, we
believe a larger population group would yield an otherwise significant
association as in a study conducted by Ali et al. where they revealed
that women suffered from antenatal anaemia had 3.6 times higher risk
of preeclampsia as compared to non-anaemic mothers [12]. They
proved that the greater the severity of maternal anemia, the greater the
risk of preeclampsia (OR 1.6 (0.8-3.4), P 0.1). Similarly, Uzan
discovered that the risk of preeclampsia was 2 to 5 fold higher in
pregnant women with anaemia [24].
Numerous studies have attempted to explore the association of
severity of maternal anemia and placental abnormality. Bencaiova and
Breymann reported frequency of placenta abnormality in association
with maternal anemia in Zurich was 3.6% [1]. Conversely, our study
revealed 23.9% of the mothers with IDA suffered from placental
abnormality where majority of these patients were diagnosed with
placenta previa. Interestingly, this group of patients had never
experienced antepartum haemorrhage throughout pregnancy.
Severe anaemia in pregnancy requires urgent medical treatment and
Hb<4 g/dL is an emergency carrying a risk of congestive cardiac,
failure, sepsis and death. Jaleel and Khan observed a high frequency of
caesarean section or episiotomy wound infection in severely anaemic
pregnant women as compared with non-anaemic pregnant women
[25]. Rukuni et al. had showed that anaemic mothers were more
susceptible to postpartum infection and sepsis (adjusted OR 1.89, 95%
CI 1.39–2.57) [26]. These results differ from our findings in which the
association of severity of anaemia with sepsis was not statistically
significant.
Perinatal Outcome
Maternal anaemia causes a substantial reduction in oxygen carrying
capacity and hence impairment of oxygen delivery to placenta and
Volume 3 • Issue 5 • 1000291
Citation: Tusimin M, Yazit A, Zainulddin NS, Vaiappuri VSSKN, Md Noor S (2016) The Impact of Severity of Antenatal Anaemia on Maternal and
Perinatal Outcome in Hospital Serdang, Malaysia. J Preg Child Health 3: 291. doi:10.4172/2376-127X.1000291
fetus. This later resulted in a significant impact to perinatal health
particularly SGA and IUGR. SGA has been found to have significant
association with severity of anaemia as compared to preterm birth and
LBW [27]. On contrary, study on Finnish women has revealed no
correlation between maternal anaemia in the first trimester with SGA
[28]. This is could be due to the population involved in the later study
are known to have low prevalence of severe anaemia in pregnancy. Yi et
al. [27] had demonstrated an association between SGA and severity of
anaemia in large retrospective cohort study among anaemic Korean
women. Study conducted in University Hospital of Zurich, Swiss found
that pregnant women with an Hb level between 8.0 and 9.9 g/dl having
significantly higher risk for SGA [1] compare with pregnant women
with Hb level between 10.0 and 11.9 g/dl.
Several studies have reported that maternal anaemia during
pregnancy is associated with low birth weight (LBW). WHO defines
LBW as baby weight of less than 2500 g. According to Ali et al. [12],
women with mild/moderate anaemia having 2.5 times higher of LBW
as compared to women with no anaemia (95% CI: 1.1-5.7). Women
with severe anaemia having 8.0 times higher risk of LBW (95% CI:
3.8-16.0). Kidanto [29] found that risk of low birth weight and preterm
delivery were significantly increased with severity of maternal
anaemia. Furthermore, Sangeeta have found that the risk of preterm
delivery increases with severity of anaemia [30]. They also found that
IUGR had a statistically significant association with severity of
anaemia [30]. Similarly, Kalaivani in her study also reported that
prematurity delivery rate and IUGR escalates when maternal Hb levels
were below 8.0 g/dl [31]. In contrary, the present study revealed only
5.9% of the fetus born as LBW and 15.6% cases of premature delivery.
These two outcomes were not statistically significantly associated with
severity of maternal anaemia.
Study Limitation and Recommendation
A larger cohort study would be ideal in order to generate a more
significant clinical exposure and outcome for which an effective
interventional program could be designed to improve the overall
outcome of maternal anaemia. Researchers recommend future studies
with larger sample size, supported by a grant and longer study period
and inclusion of dietary intake among antenatal mothers as potential
confounder.
Conclusion
Anaemia amongst pregnant women imposed a significant spectrum
of health problems to both, mother and child. Prevention is not
unsurmountable; hence active intervention by all level of health care
provider is imperative in order to decrease poor maternal and
perinatal outcome and hence the overall economic burden.
Acknowledgement
We gratefully acknowledge the Director of Hospital Serdang and all
the members of the Department of Obstetrics and Gynaecology, for
their assistance in the study. In addition, we thank all lecturers who
have assisted us to complete this study. This work was supported by the
Faculty of Medicine and Health Sciences, University Putra Malaysia.
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Perinatal Outcome in Hospital Serdang, Malaysia. J Preg Child Health 3: 291. doi:10.4172/2376-127X.1000291

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ISSN:2376-127X