PREVALENCE OF ANEMIA AND ASSOCIATED FACTORS

AMONG PREGNANT WOMEN AT SOS AND DE

MARTINO HOSPITALS IN MOGADISHU-SOMALIA
Author name :

Maria abdullahi abdirahman

Faculty of Nursing

Plasma University
Table of Contents

1. CHAPTER ONE.........................................................................................................1
INTRODUCTION..........................................................................................................1

1.0 overview

1.1 Research Background............................................................................................1

1.2 Problem Statement................................................................................................6

1.3 purpose of Study.....................................................................................................7

1.4 Research Objectives.................................................................................................8

1.4.1Main Objectives.......................................................................................................

1.4.2Specific Objectives.................................................................................................

1.5 Research Questions..................................................................................................8

1.6 Scope of study ............................................................................................................

1.7 significance ..............................................................................................................8

1.8 conceptual framework…………………………………………………………………………………………9

2. CHAPTER TWO (Related Literature Review)

2.0 Overview

2.1 Objective 1 Restated as a title

2.2 Objective 2 Restated as a title

2.3 Objective 3 Restated as a title

2.4 Objective 4 Restated as a title

2.5 Summary 2.6 Conclusion

3 CHAPTER THREE (Methodology) 3.0 Overview

3.1 Research design

3.2 Target population

3.3 Sample

3.4 Sampling technique

3.5 Research instruments/Data Collection

3.6 Data analysis

3.7 Validity and reliability

3.8 Limitations

3.9 Ethical consideration

 CHAPTER ONE

INTRODUCTION

0.1 Overview
This chapter researchers will focus on research background, problem statement, research
objectives, researcher questions, and significance of study and definitions of key terms.

1.1 Research Background

One of the most common health issues among pregnant refugees worldwide is
anemia. Anemia in pregnant women is multifaceted and has negative effects on both
the maternal and the infant health. Anemia is a state in which the number and size of
red blood cells (RBCs) or the hemoglobin (Hb) concentration below the recognized
standard reference ranges; as a consequence reduces oxygen-carrying capacity to
fulfill the body's physiological requirements. Age, gender, and pregnant status all
affect it differently. For instance, hemoglobin (Hb) levels less than 11 g/dL are
considered anemia during pregnancy. (Aklilu Alemayehu 1. G., 2016).

Globally. The most recent World Health Organization recommendations, gestational anemia is
defined as hemoglobin levels of 110 g/L in the first and third trimesters and 105 g/L in the
second trimester (WHO). (Chang-Fa Sun1, 2021). Anemia in pregnant women can have
multiple causes. Dietary deficiencies notably those of iron and folate deficiencies, intestinal
infections (parasites), malaria, and long-term illnesses. There are some key obstetric and
reproductive health-related factors that cause anemia in pregnancy including gestational age,
parity, subsequent birth interval, history of excessive menstruation, and bleeding during
pregnancy. (Aklilu Alemayehu 1. G., 2016). Anemia is linked to premature birth, low birth
weight, and infant mortality, and it accounts 20% of global maternal deaths. (Abera Abay1 H.
W., 2017). One of the main factors contributing to mortality in refuges is anemia. Anemia
was the cause of 55% of all maternal deaths reported in the Kenyan refugee camp of Daddab
in 2008. Additionally, anemia's harmful effects on infants' physical and cognitive
development remain long after they are born. (Aklilu Alemayehu 1. G., 2016).

Anemia is a significant problem for public health in developing nations where almost
60% of pregnant women are anemic. In the world, anemia affects 1.62 billion (24.8%)
individuals, according to a WHO report from 2008. It is a leading cause of maternal
death, with an estimated global prevalence of 42% among pregnant women.
(Tabassum Zehra*1, 2014). 75% of all types of anemia in pregnancy are caused by
iron deficiency, which is the most prevalent dietary deficiency in the world.
Prevalence of anemia during pregnancy is greater than 20% in more than 80% of the
world's nations. Because of the variations in social structures, style of life, and health-
seeking practices between countries, anemia in pregnancy occurs at varying rates.
Prevalence rates for anemia in pregnancy extend from 35 to 60%. Are reported to be
below 20% in developed nations. Anemia can afflict pregnant women anywhere in the globe
(the global prevalence of anemia in pregnancy is estimated to be around 41.8%). The USA
has the lowest estimated prevalence of anemia at 5.7%, whereas Gambia and India have the
highest at 75% and 65-75%, respectively. (Gian Carlo Di Renzo1, 2015). Physiologic anemia
in pregnancy: In a healthy woman, the plasma volume begins to rise about week six of
pregnancy. The physiologic decrease in the Hb concentration during pregnancy is caused by
this increase, which is disproportionally bigger than the equivalent alterations on the red cell
mass. As a result, despite the drop in Hb level, there is a considerable decrease in
arteriovenous oxygen extraction at the heart and a significant rise in the pregnant woman's
capacity to carry oxygen. At term, the plasma volume increases by approximately 1,250 ml,
or 48% more than in the non-pregnant state.

This is the result of a quick surge at first, then a gradual climb after the 30th week of
pregnancy. Numerous studies show a direct relationship between the newborn's weight and
the rise in plasma volume. 1, 5–8 it appears that the rise in plasma volume is a sign of the
fetus's normal growth and one of the signs of a healthy pregnancy. The red cell mass similarly
rises, however more slowly than the plasma volume. At term, the overall gain is roughly 18%,
or 250 ml. The red cell mass, however, may increase to 400 ml after stimulation with iron
supplements—a total increase of around 30% compared with the non-pregnant state.
Increased red cell mass is associated with fetal growth, though presumably to a smaller extent
than increased plasma volume. (PHARMAKIDES, 2006). Criteria are-RBC 3.2
million/cumm As well as Hemoglobin 10 gm. And the RBC morphology on peripheral smear
is normal i.e. normocytic normochromic. PCV 30%.

Causes of anemia in pregnancy, It can be difficult to diagnose real anemia and

pinpoint the cause of anemia because of the typical physiological changes that occur
during pregnancy that impact the hematocrit and some other indices, including
hemoglobin, reticulocytes, plasma ferritin, and unsaturated iron-binding capacity. The
most prevalent anemia are megaloblastic anemia and iron-deficiency anemia. These
anemia’s are more prevalent in women who do not take prenatal iron and folate
supplements and who have poor diets. Hemolytic anemia and aplastic anemia are two
additional, less frequent forms of acquired anemia during pregnancy. Additionally,
anemia’s such thalassemia and sickle cell disease might affect the mother's and fetus's
health. Nutritional deficits are the most common cause of true or absolute anemia, as
was previously mentioned. The clinical presentation may be worsened by
accompanying infections, general poor nutrition, or inherited diseases such
hemoglobinopathies. Frequently, these deficits are numerous. However, inadequate
intake, inadequate absorption, increased losses, increased needs, and inefficient use of
hemopoietic elements constitute the main causes of nutritional anemia. A lack of iron
is the cause of about 75% of all anemia identified during pregnancy. Characteristic of
hypochromic, microcytic erythrocytes on the peripheral blood smear indicate a
significant iron shortage. It is important to take into account additional, although
uncommon, causes of hypochromic anemia, such as hemoglobinopathies,
inflammatory processes, chemical toxicity, malignancy, and pyridoxine-responsive
anemia. The megaloblastic anemia of pregnancy caused by folic acid insufficiency
and, by vitamin B12 deficiency, make up the majority of the remaining cases of
anemia in pregnancy other than the iron-deficiency variety. In humans, anemia
brought on by a lack of other vitamins or minerals is uncommon. (PHARMAKIDES,
2006).

Maternal effects of anemia. Of course, both the mother and the fetus suffer negative
repercussions from severe anemia. Additionally, there is proof that less severe anemia
is linked to unsuccessful pregnancies. Women with a hemoglobin level more than 6
gr/dl are less likely to experience severe maternal problems that are directly connected
to anemia.

Even lower Hb levels, meanwhile, can cause serious morbidity in pregnant women,
including infections, longer hospital admissions, and other general health issues. This
clinical state may be accompanied by a variety of symptoms and indications, to
varying degrees. Headache, tiredness, lethargy, paresthesia, and the clinical symptoms
of tachycardia, tachypnea, pallor, glossitis, and cheilitis are the most frequent of these.
There may be substantial life-threatening complications as a result of high-output
congestive heart failure and poor oxygenation of tissues, including heart muscle, in
more severe cases, especially in pregnant women with hemoglobin levels less than 6
gr/dl. Due to nutritional deficiency anemia, such diseases are uncommon, at least in
developed nations, or when the pregnant lady takes iron supplements. However,
pregnancy issues include placenta previa or abruptio placenta, surgical delivery, and
postpartum bleeding may show as severe iron deficiency anemia or hemorrhagic
anemia. If these problems are not addressed with iron supplements or blood
transfusions, serious consequences may result. (PHARMAKIDES, 2006).

Effects of anemia on the fetus. There are many signs that indicate severe maternal
anemia during pregnancy is connected to a poor pregnancy outcome, yet the reason
for this connection is still unknown. However, various reports in the literature link the
drop in hemoglobin level to prematurity, spontaneous abortions, low birth weight, and
fetal death. The effects of maternal anemia on the fetus are not fully understood.
While some authors accept a direct link between anemia and fetal distress only when
the maternal Hb levels are less than 6 gr/dl, other authors support the idea that even a
slight fall in Hb level (8–11 gr/dl) may develop a predisposition to these disorders.
For precise and accurate management decisions, it is crucial to understand how the
mother's iron status affects the fetus' iron status. There are differing views on this;
some researchers discovered that the amount of iron in the mother has minimal impact
on the iron status of the newborn at delivery. However, research on the iron levels in
cord blood serum has revealed a direct link between maternal and fetal iron levels.
Additionally, it was discovered that kids delivered to moms who did not take iron
supplements throughout pregnancy had lower iron levels at birth when serum ferritin
was utilized as a marker of iron status. The majority of scientists concur that a mild to
moderate maternal iron shortage does not appear to have a substantial impact on the
fetal hemoglobin content and that only severe anemia may have direct negative
consequences on the fetus and neonate. According to numerous publications, low
birth weight and low maternal hemoglobin levels are directly related to anemia during
pregnancy, which has been linked to prematurity and low birth weight newborns.
Pregnancies with Hb levels between 10 and 11 gr/dl and pregnancies with Hb levels
between 9 and 10 gr/dl had a 20% and a 60% greater risk of preterm delivery,
respectively, according to a major epidemiologic investigation. The danger increased
by more than doubling, tripling, and so on for each drop of 1 gr/dl below 9 gr/dl.
Growth retardation and maternal Hb levels did not correlate in the same study.

In a different large epidemiologic investigation, it was discovered that maternal

hemoglobin levels below 8 g/dl were associated with a threefold increase in perinatal
death when compared to values above 11 g/dl. Additionally, Garn et al. showed a link
between low maternal Hb levels and poor pregnancy outcomes, including preterm,
low birth weight, fetal death, and other medical anomalies, with higher complication
rates when maternal Hb concentrations were lower. Nevertheless, all of these
publications provide compelling evidence that maternal anemia has a negative impact
on fetal growth and pregnancy outcomes. However, it would be preferable to refer to
these merely as potential risk factors rather than as an adequate appraisal
demonstrating an obvious negative influence on the unborn, at least in cases of mild
to moderate maternal anemia. (PHARMAKIDES, 2006).

Over 1.6 billion people worldwide suffer from anemia, which is a serious public
health issue. Anaemia has been linked to higher rates of maternal and newborn
mortality, poor neurodevelopment in children, and diminished cognitive and physical
function later in life. India has one of the highest rates of anemia in the world, where
it causes significant mortality, disability, and lost productivity. In India, anemia is
thought to affect 63% of lactating women, 59% of pregnant women, 56% of women
of reproductive age, and 70% of children under the age of five. (Julia L. Finkelstein1,
2019). A study was done in southern India revealed that 30% of pregnant women
were anemic with Hb level <11 gm/dl. 48% of that 30% were iron deficient with
serum ferritin < 15.0 μg/l and 23% had iron deficiency anemia at their first prenatal
visit. (Julia L. Finkelstein1, 2019). Another study in Venezuela, 630 Venezuelan
pregnant women in their third trimester at labor from the Valencia; the prevalence of
anemia was 34.44% (severe: 1.8%, moderate: 15.2%, and mild: 83%).

Iron deficiency anemia (IDA) was present in 39.2% (95%CI= 32.7 to 45.7),
prevalence of folate deficiency anemia (FDA) was 11.98% (95%CI = 7.6% to 16.3%).
Combined anemia (IDA and FDA) occurred in 11.52% (95%CI= 7.27% to 15.7%).
(Arturo Martí-Carvaja l, 2002). A study that was done in Faisalabad district, Pakistan
showed that the overall prevalence of anemia in pregnant women was 75%. (Anam
Anjum, 2015). Another study in Bali, Indonesia; showed that the prevalence of iron
deficiency anemia among pregnant women was 46.2%; most of the cases of anemia
were mild. (Ketut Suega1, 2002).

One-quarter of the world's population suffers from anemia, making it a challenge for
public health.

In Africa anemia in pregnant women is a significant mainland problem. World Health

Organization (WHO) data on anemia from 1993 to 2005 indicated that 19.3 million
(55.8%) of African pregnant women were anemic. Among African refugees, the
prevalence of anemia ranged from 15.2% in Togo to 84.4% in Ethiopia. (Aklilu
Alemayehu 1. G., 2016). A study that was conducted among pregnant women in East
Africa revealed that the prevalence of anemia was 41.82% (95% CI: 40.78, 42.87)
with a large difference between specific countries which ranged from 23.36% in
Rwanda to 57.10% in Tanzania. (Alemneh Mekuriaw LiyewID1*, 2021). Another
study in Ethiopia showed that the prevalence of anemia among pregnant women was
31.8% [95% CI: 28.9, 35.5]. (Abera Abay1 H. W., 2017). A study in south-western
Nigeria studied 500 pregnant women, at the time of prenatal booking, 138 (27.6%) of
the 500 enrolled women were discovered to be anemic. Primigravidae (33.9%) had a
higher rate of anemia than multigravidae (25.3%) did. (Okunade K.S*, Anaemia
among pregnant women at the booking clinic of a teaching hospital in south-western
Nigeria, 2014). Pregnant women attending to the antenatal clinic participated in a
cross-sectional study at Mbagathi County Hospital in Nairobi County, Kenya, the
findings at Mbagathi County Hospital in Nairobi County, Kenya, showed a substantial
correlation between helminthic infection and anemia, with a frequency of anemia
among pregnant women of 40.7%. (Ndegwa, Anemia & Its Associated Factors
Among Pregnant Women Attending Antenatal Clinic At Mbagathi County Hospital,
Nairobi County, Kenya, 2019).

According to the World Bank's collection of development indicators, the prevalence

of anemia among pregnant women (%) in Somalia was reported at 48.7% in 2019.
(World Bank Data..2019).
Pregnant women in internally displaced camps
In Somalia were the subject of an anemia study, which indicated that the prevalence
of anemia among pregnant women was overall in 44.4%. (Ramla Hussein Ahmed1,
2021). Between April 20 and June 1, 2021, the Jowhar district in South Somalia
undertook a facility-based cross-sectional study design; 53.1% of pregnant women
overall had anemia during the course of this study. (Sharmarke Burhan Taste1*,
2022).

1.2 Problem Statement

Anemia is a significant public health problem among pregnant women in Somalia.

Anemia during pregnancy is characterized by a low level of hemoglobin in the blood
and is associated with several adverse outcomes, such as maternal morbidity and
mortality, preterm delivery, and low birth weight. Despite efforts to address the
problem, anemia remains highly prevalent among pregnant women in Somalia. In
2019, the prevalence of anemia among pregnant women rose to 48.7%, compared to
the previous recorded prevalence of 47%. This indicates a slight but notable increase
in the occurrence of anemia among pregnant women in Somalia.
Limited studies have been conducted on the prevalence of anemia and associated
factors among pregnant women in Somalia. The goal of our study is to determine the
effects of inadequate prenatal care, diseases during pregnancy, and the mother's
socioeconomic situation on the development of anemia during pregnancy. Antenatal
mothers in Somalia have very poor health seeking behavior, along with poor lifestyle
and inaccessible health facilities in the country, since the country has high malarial
endemic areas, this may also contribute to severity of anaemia in pregnancy. The high
endemicity of malaria in the country combined with the harsh weather, poverty,
negative cultural practices and poor health seeking behaviour seems to be augment the
cause of anemia in pregnancy in the country, therefore the study intends to uncover
the risk factors that contribute to the cause of anemia in pregnancy in SOS hospital
and De Martino hospital.

1.3 Purpose of the study

The finding of the study will surving as guidance for the health authorities, NGO, and the
international community operating in Somalia.

1.4 Research Objectives

1.4.1 Main Objectives

The primary objective of this study is to determine the prevalence of anemia among
pregnant women in SOS and De Martino hospitals in Mogadishu-Somalia and
identify the associated factors contributing to this health issue.

1.4.2 Specific Objectives

1. To identify the socio-demographic factors associated with anaemia among

pregnant women at SOS hospital and De Martino hospital.
2. To determine the pregnancy related factors associated with anaemia among
pregnant women at SOS hospital and De Martino hospital.
3. To identify the effect of dietary factors on the prevalence of anaemia among
pregnant women at SOS hospital and De Martino hospital.
 1.5 Research Questions

1. What are the socio demographic factors associated with anaemia among
pregnant women in SOS hospital and De Martino hospital?
2. What are the pregnant related factors associated with anaemia among pregnant
women in SOS hospital and De Martino hospital?
3. What dietary factors are associated with anaemia among pregnant women in
SOS hospital and De Martino hospital?

1.6 Significance of the Study

The study addressed health, socio-economic, and environmental issues that affected
antenatal mothers in SOS Hospital and De Martino Hospital. The outcome of this
study will be used by the government, non-governmental organizations, and the
community. The study will provide important information that guides anemia
interventions in Maternal Child Health (MCH) clinics in Somalia and private
institutions. The study will contribute knowledge and awareness of anemia among
pregnant women. The study information will also be important to design appropriate
nutritional interventions and make policies that would reduce the morbidity and
mortality due to anemia among pregnant women.
1.7 Conceptual Framework
Independent variable (I.V) Dependent variable (D.V)

Socio-demographic
factors:
1. Maternal age
2. Maternal occupation
3. Maternal education

Obstetric factors:
Anemia in pregnancy
1. Pregnant trimesters
2. Parity
3. Birth intervals
4. ANC visits

Dietary factors:
1. Frequency of eating/day
2. Eating meat
3. Consumption of tea after
meals
1.8 Definition of important terms / Glossary

Anaemia, condition in which when the hemoglobin (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 nutritional supplements (iron/folate) and dietary
information throughout the pregnancy.

Appearance, Pulse, Grimace, Activity, Respiration (APGAR) score: A numerical

expression of an infant’s condition, usually determined at 60 seconds after birth,
based on heart rate, respiratory effort, muscle tone, reflex irritability and color.

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.

Gravidity: the number of times that a woman has been pregnant.

Haemoglobin (Hb): Iron-containing oxygen-transport metallo-protein in the red

blood cells which is composed of globin and heme that gives red blood cells their
characteristic colour.

Iron: A micronutrient needed for the formation of hemoglobin which transports

oxygen in blood to various parts of the body.

Iron deficiency: A state of insufficient iron to maintain normal physiological

functions of body tissues.

Iron deficiency anaemia: An advanced stage of iron depletion defined as iron

deficiency and low haemoglobin resulting in the condition of anaemia.

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.

Multigravida: A pregnant woman with one or more previous pregnancies.

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 period of 280 days or 40 weeks.

Primigravidae: A woman who is pregnant for the first time.

Supplementation: Provision of specified dose of nutrient preparation which may be

in the form of tablet, capsule, oil solution or modified food for either treating an
identified deficiency or prevention of the occurrence of such a deficiency in an
individual.

First Trimester of pregnancy: (0 to 13 Weeks of gestational age) Second Trimester

of pregnancy, (14 to 26 Weeks of gestational age). Third Trimester of pregnancy (27
to 40 Weeks of gestational age) Illiterate, inability to read or write. Primary, primary
education level, Secondary and secondary education level.
 CHAPTER TWO

LITERARTURE REVIEW

2.0 Introduction

This chapter presents literature review that related to this research study, and the basic
objective of the study that includes; the socio-demographic factors associated with
anemia among pregnant women at SOS hospital and De Martino hospital as well as
the pregnant related factors associated with anemia among pregnant women in SOS hospital
and De Martino hospital and the effect of dietary factors on the prevalence of anemia
among pregnant women at SOS hospital and De Martino hospital.

2.1 Concepts, Opinions, or Ideas about Anaemia

Significant negative health effects of anemia might also have negative
social and economic development effects. (WHO, 2015). It is the most
prevalent pregnancy complication in sub- Saharan Africa and one of the
most difficult public health issues in developing nations. (F.I. Buseri1,
2008). Pregnancy-related anemia is one of the leading causes of maternal
and fetal morbidity and mortality in underdeveloped nations. (Hassan2,
2012). Anemia is thought to contribute to more than 115,000 maternal and
591,000 perinatal deaths worldwide each year. (Sudha Salhan, 2012).
Anaemia during pregnancy contributes to 20% of all maternal deaths
(WHO, 2015). The risks of maternal morbidity and death, abortion,
inadequate intrauterine growth, preterm delivery, and low birth weight are
all increased by anemia. These consequences lead to increased prenatal
morbidity and death as well as increased newborn mortality rates.
(Florence Bodeau-Livinec, 2011).

Anaemia in pregnancy causes low birth weight. (Ferenc Ba´nhidy Ph.D. a,

2011). fetal impairment and infant deaths. (Kalaivani, 2009). A study
which was a comprehensive review and meta-analysis of all available data
on hemoglobin concentration and pregnancy outcomes worldwide,
demonstrating the significant impact maternal anemia has on pregnant
outcomes. The findings indicated a strong association between maternal
anemia during the first trimester of pregnancy and LBW, PTB, and SGA,
indicating that maternal anemia during the first trimester increases the risk
of these outcomes. Additionally, it was established that there is no
connection between LBW and PTB and maternal anemia in the second and
third trimesters. (Shoboo Rahmati1, 2016). A major neural tube defect
(severe abnormalities of the central nervous system) that develops in
embryos during the first few weeks of pregnancy can result from folic acid
deficiency during pregnancy and cause anomalies of the spine, skull, and
brain. (Wolff et al., 2009). The chances of fetal development restriction
and poor birth weight are double in anemic pregnant mothers. Preterm
birth has a more than doubling of odds. In an anemic pregnant lady, even a
mild bleed can be fatal. (Olujimi A. Olatunbosun, 2014).
Micronutrient supplementation of iron and folic acid is done while the
ANC is present to control anemia in pregnant women. A proper diet and
oral iron supplements are used to treat iron deficiency in pregnancy.
WHO advises all expectant mothers to take iron and folic acid
supplements in areas where anemia is common. (WHO, 2008). Most
countries in Sub-Saharan Africa, including Kenya, have a national policy
to prevent and treat anaemia in pregnancy. This includes the provision of
hematinic (ferrous sulphate and folic acid) to all pregnant women. In
Kenya, routine iron supplementation is the current cornerstone of efforts to
reduce iron- deficiency anemia during pregnancy (KNBS and ICF Macro,
2010). According to the Kenya national guidelines (MOH, 2008), all
pregnant women should receive free iron and folic acid supplements
through the essential drug kit of the Ministry of Public Health and
Sanitation. National recommendations are for women to begin
supplementation during the first month of pregnancy waith 60 mg of iron
sulphate and 400 μg of folic acid daily (MOPHS, 2008). Studies have
demonstrated that both women with sufficient and deficient iron status can
benefit from low or moderate doses of iron/folate supplementation in the
early stages of pregnancy. (CL Rodriguez-Bernal1, 2012).
Patients with mild anemia (hemoglobin level, 9.0–10.5 g/dl) should take
160–200 mg of elemental iron orally every day. After 14 days of
treatment, it is estimated that their hemoglobin levels would have
increased by 1 g/dl. (Surbek, 2010). Compared to oral iron, parenteral iron
demonstrates faster haematologic recovery, likely because of variations in
oral iron tolerability, absorption, and compliance. (Reveiz L, 2007,
Milman, 2006). Severe anaemia in pregnancy (Hb less than 7 g/dL)
requires urgent medical treatment and Hb less than 4 g/dl is an emergency
carrying a risk of congestive cardiac failure, sepsis and death. Folate
deficiency is seen in 5% cases of anaemia in pregnancy. A dose of 5 mg
oral folic acid daily is recommended for correction of anaemia. In cases of
vitamin B12 deficiency, 250 μg cynacobalamin administered parenterally
every week is recommended for anaemia treatment. In cases of severe
anaemia near term – daily vitamin B12 in a dose of 100 μg should be
administered for a week. A community-based trial from China found a
47% reduction in neonatal mortality in women who received IFA
supplements compared with those who took folic acid alone (Zeng et al.,
2008). Therefore, to reduce the risk of maternal anaemia, iron deficiency
and poor pregnancy outcomes, the WHO guidelines recommend standard
daily. oral dose of 60 mg iron and 400 μg folic acid supplements
throughout pregnancy, to begin as early as possible as a part of antenatal
care (ANC) programs. Pre-pregnancy counseling, dietary advice and
therapy are very important for ensuring best pregnancy outcomes.
It is recommended that full blood count should be checked at the booking
visit in pregnancy and repeated at 28 weeks to screen for anaemia. In high
risk mothers and multiple pregnancies, an additional hemoglobin check
should be performed near term. Dietary advice should be given to all
mothers to improve intake and absorption of iron from food (Olujimi et al.,
2014). Rich sources of iron include heme iron (in meat, poultry, fish and
egg yolk), dry fruits, dark green leafy vegetables (spinach, beans, legumes,
lentils) and iron fortified cereals. Certain foods which may inhibit iron
absorption should not be taken with iron rich foods. These include
polyphenols (in certain vegetables, coffee) and tannins (in tea). Weekly
iron (60 mg) and folic acid (2.8 mg) should be given to all menstruating
women including adolescents, periodically, in communities where IDA is
considered a problem (Goonewardene et al., 2012). Besides increased
intake, treatment of underlying conditions and deworming (antihelminthic
therapy) are important preventive measures. These vitamins play an
important role in embryogenesis and hence any relative deficiencies may
result in congenital abnormalities. Finding the underlying cause is crucial
to the management of these deficiencies. From a neonatal perspective,
delayed clamping of the umbilical cord at delivery (by 1–2 min) is
important step in prevention of neonatal anaemia. (Olujimi A.
Olatunbosun, 2014).

2.3 Theoretical / Conceptual/Applications Perspectives

The conceptual framework determinants of malnutrition (UNICEF,
1998).This conceptual framework demonstrates the relationship between
independent variables (participant’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) this study is adopted
and modified from ( UNICEF’s conceptual framework on the determinants
of malnutrition (UNICEF, 1998).

2.3 Factors associated with anaemia in pregnancy

2.3.1 Socio-demographic factors
Anemia in pregnant women can be significantly influenced by
sociodemographic characteristics such maternal age, educational
attainment, and occupation.

2.3.2 Maternal age

When assessing if a pregnant woman has anemia, maternal age can be a
significant factor. According to a 2016 study done in South Sudan and
Ethiopia, women between the ages of 25 and 34 had the highest likelihood
of having anemia. This could be a result of the age group's
2.4 Theoretical / Conceptual/Applications Perspectives
The conceptual framework determinants of malnutrition (UNICEF,
1998).This conceptual framework demonstrates the relationship between
independent variables (participant’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) this study is adopted
and modified from ( UNICEF’s conceptual framework on the determinants
of malnutrition (UNICEF, 1998).

2.5 Factors associated with anaemia in pregnancy

2.5.1 Socio-demographic factors
Anemia in pregnant women can be significantly influenced by
sociodemographic characteristics such maternal age, educational
attainment, and occupation.

2.5.1.1 Maternal age

When assessing if a pregnant woman has anemia, maternal age can be a
significant factor. According to a 2016 study done in South Sudan and
Ethiopia, women between the ages of 25 and 34 had the highest likelihood
of having anemia. This could be a result of the age group's, high
reproductive rate. According to the study, women aged 30-39 years had a
1.3–1.6 times higher risk of anemia than those aged 15–19 years. (Aklilu
Alemayehu 1. L., 2016).Another study conducted in Ethiopia in 2017
revealed that anemia was substantially correlated with the mother's age;
anemia was less likely to occur in women aged 25–29 and 30-34 compared
to those under 20 years old. Other research, including those in Ethiopia,
Uganda, Ghana, Thailand, and Turkey, also showed similar results.
Anemia was found to be the most prevalent nutritional issue in teen
pregnancies in a previous study in the same field. Adolescence (10–19
years) is undoubtedly a time of significant growth and development, which
causes it to demand more iron (2.2 mg/day) than preadolescence (6–9
years) did (0.7– 0.9 mg/day). Unfortunately, an adolescent girl's
vulnerability to anemia increases if she gets pregnant since the mother and
the fetus will compete for nutrients to maintain their rapid growth. (Abera
Abay1 H. W., 2017)
2.5.1.1 Maternal educational status
The prevalence of anemia was positively impacted by maternal education. According to one
study, maternal education may have decreased anemia risk by increasing knowledge of and
adherence to healthy eating before and during pregnancy. (Okunade K.S*, 2014). Another
cross-sectional study conducted in South Sudanese refugee camps in 2018 revealed that
anemia among pregnant women was caused, in part, by a lack of education. According to
previous data, pregnant women who couldn't read or write had a higher risk of developing
anemia than those who completed secondary school or higher. This might be because
pregnant women with secondary education and higher were more aware of the importance of
a healthy diet. (Romedan Delil1, 2018).

According to a different study, women with a secondary or higher level of education were
less likely to be anemic than their colleagues, with the majority of women (89%) reporting an
inter pregnancy. Numerous studies have shown that education lowers the risk of anemia.
Pregnant women with higher levels of education have better incomes and consume nutrient-
rich foods, preventing nutritional anemia. Additional positive outcomes for mothers and
children have been linked to secondary and higher education, including higher rates of
exclusive breastfeeding, attendance at the recommended four or more prenatal visits, use of
skilled labor assistance, and seeking medical attention for children who have malaria or
pneumonia. (Grace Stephen, 2018).
2.5.1.2 Maternal occupation status
Pregnant women's employment status was substantially correlated with the development of
anemia. Pregnant women whose husbands were daily workers were more susceptible to
anemia than women whose husbands were government employees, according to a 2018 study
conducted in refugee camps in western Ethiopia and South Sudan. This might be because
merchants and other employees had more economic status than day laborers did. It also
implies that women in low socioeconomic status are likely to have less formal education and
frequently face financial difficulties, making it difficult for them to get and afford wholesome
food. Hence, they are more likely to suffer from the adverse effects of poor/inadequate
nutrition, chronic infections and worm infestations. (Romedan Delil1, 2018).
2.5.2 Obstetric Factors
Obstetric characteristics of a pregnant woman play an important role in determining
hemoglobin status through increasing requirement for iron or depletion of its storage.
2.3.1.1 Pregnant trimesters
According to a study, pregnant women who were anemic in the third trimester were 3.12
times more likely to be so than those who were anemic in the first trimester. This may be due
to the third trimester's increasing dietary requirements for the fast growing fetus. (Aklilu
Alemayehu 1. L., 2016). Another study conducted in Nairobi County, Kenya's Mbagathi
County Hospital revealed that anaemia was more common among pregnant women in the
second and third trimesters. Due to the fact that many prenatal moms started their hospital
visits during the second and third trimesters, the risk of acquiring anaemia was noticeably
higher during those times. According to the same study, the prevalence of anemia was 42.2%
at its maximum in the third trimester, which also happens to be when hems-dilution is at its
highest, suggesting that this may have made the anemia worse. (Ndegwa, Anemia & Its
Associated Factors Among Pregnant Women Attending Antenatal Clinic At Mbagathi
County Hospital, Nairobi County, Kenya, 2019). Another study found that as the pregnancy
progresses through the trimesters, the risk of anemia rises. The hemoglobin concentration
starts to drop during the first trimester of pregnancy, reaches its lowest point during the
second trimester, and then starts to climb again during the third trimester. This may help to
explain why there were fewer cases of anemia.

In the current study's third trimester of pregnancy. Additionally, the majority of

pregnant women begin antenatal care in the second trimester of their pregnancies, and
iron-folate supplements are also administered, which reduces the mother's nutritional
iron depletion. (Abera Abay1 H. W., 2017).
2.3.1.2 Parity
According to a study conducted in the Mekelle District, moms with a parity history of five or
more had a higher risk of developing anemia than those with a history of parity of less than
two. This can be explained by the fact that high parity in women is frequently associated with
increased hemorrhage susceptibility and maternal nutritional depletion syndrome. When a
pregnancy is healthy, hormonal changes create a rise in plasma volume, which lowers the
quantity of hemoglobin but does not fall below a specified threshold (e.g., 11.0 g/dl) (Terefe
Derso1*, 2017).
According to other studies, multiparty may cause anemia by decreasing the mother iron stores
throughout each pregnancy and by resulting in blood loss with each delivery. However, there
was no statistically significant relationship found in this study between anemia and parity.
There are two possible explanations for this. First, more than 79% of the multiparous women
in this study have just one to three children, and more than 80% of those women had births
separated by more than three years. Therefore, there would be less bleeding after each
delivery. Second, most multiparous women had been taking iron or iron folate supplements
compared to prim parous women. (Kefiyalew J1 *, 2018). According to a study, the
likelihood of anemia is seen to increase as parity increases.
This is in line with the notion that several pregnancies deplete the
mother's nutritional reserves. According to a prior study, women who had
one to two, three to five, or more previous deliveries were 1.47, 1.51, and
1.86 times more likely to develop anemia than nulliparous women. But
several other studies came to conflicting conclusions. (Samson
Gebremedhin*1, 2014). Another study conducted in Pakistan in 2017
examined the relationship between parity and the prevalence of anemia in
pregnant women. It was discovered that the women with the previous two
(02) live children had the highest anemia prevalence rates. In the study,
the frequency was 38.3% . Previous research has indicated that parity 2 to
4 is when anaemia in pregnant women is most prevalent. (Sarah Khalid,
2018).
2.3.1.3 Birth intervals

According to a 2018 study on the relationship between birth intervals and anemia, the gap
between pregnancies is considered to be a significant and controllable risk factor for
unfavorable birth outcomes. It has a tremendous potential to safeguard mothers' health and
enhance the results of subsequent pregnancies. With increased risk for maternal and neonatal
death, this continues to be a significant concern for women in developing nations. Women
who have a short interpregnancy interval typically don't have enough time to heal and prepare
for the following pregnancy. It is thought that the biological link between a short
interpregnancy interval and poor maternal and newborn outcomes results from the mother's
lack of time to recover from the nutritional strain and stress of her previous pregnancy. Short
IPI has a bigger effect on young women since the fetus may compete with an immature
adolescent who is still growing for nutrition. Short-interval pregnant women are more likely
to experience uterine rupture or scar dehiscence, failure trial of scar, abruptio placenta,
placenta previa, prenatal infections, and antenatal infections. The health benefits of spacing
pregnancies out optimally are larger for both the mother and the kid, and it also gives the
mother a chance to recuperate from pregnancy, labor, and lactation. When there is more time
between births, the next pregnancy and baby are more likely to be born when they are fully
developed. (T Noor, 2018). The likelihood of unfavorable obstetric outcomes increases with a
shorter interpregnancy period. Preterm births, low birth weight babies, stillbirths, and early
neonatal deaths are all linked to short birth intervals. The current study also discovered that
compared to women who had more than two years between pregnancies, pregnant women
with short pregnancy intervals were more than twice as likely to experience anemia during
the current pregnancy. This could be explained by how breastfeeding and the frequent, brief
intervals between pregnancies affect the mother's overall physiologic condition. The woman
won't have sufficient time to recover from the lack of nourishment. (Getachew Mullu
Kassa1*, 2017). In the current study, women with shorter pregnancy intervals had a higher
risk of anemia, which is consistent with data from a prior study. The mother's ability to
recover from the consequences of prior pregnancies is delayed by the short time between
pregnancies, increasing the likelihood that she will develop maternal depletion syndrome.
Since the mother's iron reserves are further depleted since the foetal demand is satisfied first,
anemia develops. It has been demonstrated that it takes nearly two years for the exhausted
maternal iron stores at the end of one pregnancy to be replaced. (E.N. Nwizu, 2011).
 2.3.1.4 Antenatal care visits
According to a study, the increased prevalence may also be related to a
delayed start to antenatal care. Due to the delay in diagnosis, the chance to
treat the deficit early in pregnancy with iron supplements and food
counseling is lost. (Ndegwa, Anemia & Its Associated Factors Among
Pregnant Women Attending Antenatal Clinic At Mbagathi County
Hospital, Nairobi County, Kenya, 2019). Another study found that the
prevalence of anemia was lower in women who attended ANC four or
more times (17.4%) than in those who only attended once (35.3%), and it
was also lower in women who reported taking iron supplements during
their most recent pregnancies (20.2%) than in those who did not (29.5%).
(Grace Stephen, 2018).

2.3.2 Dietary factors

Compared to pregnant women who ate a large variety of foods, those who
consumed a limited variety of foods were more likely to be anemic. This
might be because a woman's life cycle's most nutritionally demanding time
is during pregnancy. Their iron level dropped as a result. To meet the
typical physiological demands of both the mother and the fetus, it is
advised that pregnant women consume a more varied diet than those who
follow a monotonous diet. (Romedan Delil1, 2018).

2.3.2.1 Consumption of meat

If there is a greater need for a certain micronutrient while also
having a limited supply, nutritional anaemia will develop.
Anaemia during pregnancy can be more likely to occur if the
required micronutrients are not consumed in sufficient amounts or
are consumed improperly. In this study, pregnant women who had
meat no more than once per week had a 2-fold increased risk of
anemia compared to those who consumed it more frequently. This
could be as a result of the best supply of heme iron being meat.
(Aklilu Alemayehu 1. L., 2016). Another study found a strong
correlation between lower meat consumption in the previous week
and a higher risk of prenatal anemia. Heme-iron is abundant in
meat and has a better bioavailability than non-heme-iron, which is
mostly found in plant-based food sources. Heme-iron also
improves the absorbability of non-hem iron. (Abera Abay1 H. W.,
2017). According to a recent study conducted in Kenya in 2019,
pregnant women who had a meal frequency of less than or equal
to two times per day had a higher prevalence of anemia than
pregnant women who had a meal frequency of three or more
times per day. This is the case because, compared to pregnant
women who ate three or more times a day, those who ate less
frequently—less than or equal to two times a day—had a higher
risk of developing anemia. (Ndegwa, 2019).

2.3.2.2 Consumption of tea immediately after meal

Increased tea consumption lowers the absorption of iron,

according to a study. In this study, drinking tea was a significant
predictor of maternal hemoglobin. Contrarily, sources of ascorbic
acid and foods high in vitamin A, such as citrus fruits, which
improve the absorption of iron, were infrequently ingested.
(Kefiyalew J1 *, 2018). As documented in various research, the
frequency of consuming meat and vegetables revealed statistically
significant association with anemia. Researchers discovered that
study participants who drank tea after meals were 7.8 times more
anemic than those who drank tea only once or never a day. The
production of insoluble iron tannate complexes was thought to be
the cause of tea's influence on the absorption of non-heme iron.
(Niguse Obse1, 2013).
 CHAPTER THREE

METHODOLOGY

2.4 Study Design

The study design will be a cross-sectional study to identify the prevalence
and risk factors of anemia among pregnant women attending the antenatal
care unit in SOS hospital and De Martino hospital.

2.5 Study area

The study area will be taken at SOS hospital and De Martino

hospital. The SOS Children's Village had opened in Mogadishu in
1985 and the hospital was used for maternity, pediatric, and other
humanitarian services. In the hospital, almost 400 women gave
birth each month. De Martino hospital is a very big referral
hospital in its own name and as a building, after a long time, the
hospital now works for the Somali people. Currently the hospital
is run and managed by the Somali Ministry of Health, the hospital
employs a wide range of staff including doctors, nurses,
laboratories, anesthesiologists, hygiene ists, Cleaners, porters,
guide, IT, HR logistic and others. More than 400 patients come to
the hospital for every morning, including children, women
(pregnant or not pregnant), and adults who become hospitalized
and outpatient. These regions were picked since they were simple
to find appropriate samples with the necessary qualities.

2.6 Study population

The target population will be all pregnant women attending SOS hospital and De
Martino hospital.
2.7 Inclusion criteria

1. Pregnant women will be eligible to participate in this study

if they are at least 18 years healthy, and carrying a single
fetus.
2. Pregnant women who are mentally and physically capable
of being interviewed will also be eligible to participate.
3. Pregnant mothers who will attend SOS hospital and De
Martino with Hb of less than 11mg/dl and voluntarily
accept to participate in the study and verbally consent will
be included in the study.
2.8 Exclusion criteria

1. Pregnant women with mental illness and severely ill patients will be excluded from
our study
2. Pregnant woman who will attend SOS hospital and De Martino but decline to
participate in the study will be excluded from our study.
3. Pregnant women who are taking therapeutic iron/folic acid supplements will also be
excluded from our study.
4. Pregnant women will be excluded if they have any known medical complications,
including HIV infection, hepatitis B, or syphilis.

2.9 Sampling technique

Our sampling technique will be non-probability convenient sampling technique.

2.10 Sample size determination

The sample size will be calculated using Kish Leslie formula, using the prevalence of
anaemia in pregnant women. Kish Leslie formula was invented by Hungarian-American
statistician and survey methodologist Leslie Kish (born László Kiss, July 27, 1910 – October
7, 2000).

n = z2p (1-p)/e2
n = Sample Size

Z = Standard normal deviation, set at 1.96, to corresponding to the 95% confidence interval.

P = Prevalence of anaemia pregnancy women in of 48.7%

e = Significant error which is 5% (i.e., 0.05)

1-P = Expressed proportion of pregnant women.
 z2p (1 − p)/e2

(𝟏.𝟗𝟔)𝟐 ×𝟎.487×(𝟏−𝟎.487)÷(𝟎.𝟎𝟓)𝟐 = 384

384 of respondents.

2.11 Data Collection Instrument

A semi-structured questionnaire will be developed and administered. It will be filled by

researchers while interviewing the study participants who fulfilled eligibility criteria.
Structured interviews will be conducted at the baseline clinic visit to collect information on
sociodemographic characteristics, including maternal age, educational level, socioeconomic
status, and obstetric history and dietary consumption.

2.12 Data Collection procedure

A standard clean venipuncture technique will be used to collect 4ml of blood from each
participant from the antecubital or dorsal vein, of which will be drawn into a dipotassium
EDTA anticoagulant tube. The hemoglobin will be analyzed using a CBC machine. Every
subject’s sample and her questionnaire will be labeled with a unique identification number.

2.13 Data Analysis and processing

The collected data will be coded and entered in SPSS- Version 27 for analysis. Descriptive
analysis such as mean, standard deviation, frequency, and percentages will be performed to
summarize the socio-demographic, obstetric, and nutrition-related data. Bivariate chi-square
analysis will be used to determine the significance of the associations between the variables.
Multivariable logistic regression analysis will be performed using the backward stepwise
regression method to control potential confounding variables. Finally, the strength of
association will be measured by adjusting odds ratios with a 95% confidence interval (CI) for
exposure variables and the outcome variable (Anemia). A p-value< 0.05 will be regarded
statistically significant in all conditions of the analysis.
2.14 Ethical Considerations

Approval will be obtained from the dean of the faculty of Medicine and
Health science. The dean of the faculty will be briefed and assured of strict
confidentiality. Participants will be requested to give verbal consent after
receiving verbal explanations in Somali, supplemented with an information
sheet. It will be made clear to the participants that participation will be
voluntary and those who refuse to give information will not suffer any
consequences. They will also be assured that their names will not appear on
any documentation to ensure anonymity.

2.15 Limitation of the Study

1. Firstly, the study will be done only in SOS hospital and De Martino
hospital in Mogadishu- Somalia; therefore, the findings from this
study cannot be generalized to all pregnant women in Somalia.
2. Secondly, the study will not include Malaria and HIV tests or even
stool examinations for parasitic tests which may be a possible
explanation for some findings. Even the history of fever for malaria
and loose stool for GI parasites will not be taken.
3. Thirdly, no physical examination will be done in the study.
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(Florence Bodeau-Livinec, 2011) (Ferenc Ba´nhidy Ph.D. a, 2011)

(Kalaivani, 2009) (Shoboo Rahmati1, 2016) (Wolff et al., 2009).

(Olujimi A. Olatunbosun, 2014) (CL Rodriguez-Bernal1, 2012).

(Surbek, 2010) (Olujimi A. Olatunbosun, 2014)

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(Romedan Delil1, 2018 (Terefe Derso1*, 2017)

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