CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND

The health and well-being of pregnant women is influenced by numerous factors including

Socio-economic status. Pregnancy is a critical period characterized by increased nutritional

requirements to support the maternal health and fetal growth and development (Yip et al.,2000).

Lack of appropriate nutritional elements in the pregnant women's diet, a number of maternal

deficiencies can occur which includes low level of calcium, phosphates, vitamins and iron.

Studies have shown that, about 375 mg of iron is needed by the fetus and additional 600 mg is

needed by the maternal to form her own extra blood. Total iron store's in the body is about 4-5g

of which 72% is stored in form of hemoglobin (Tabessum et al., 1997). However anemia

according to the World Health Organization, is defined having a hemoglobin content below

11.0g/dl or a hematocrit concentration below 33% and is one of the most typical hematological

disordes of pregnancy (WHO, 1993). Anemia in pregnancy is more common than 50% in

improverished nations, especially in sub-saharan Africa including Nigeria (Meng et al., 2000).

Different researchers had over time showed a correlation between heamatological parameters

and socioeconomic status (Hackett et al., 2021). Individuals with lower socioeconomic status

may face challenges that can have negative impact on their red blood indices during pregnancy.

Socio-economic Status (SES) is recognized as a major contributor to health disparities in overall

disease rate morbidity, mortality and quality of life. SES refers to factors like income , education,

and job status , which can affects person's access to resources and health care (Baker & Gibson,

2014). Normal blood level which can serve as an indicator of physiological functioning represent
a critical socio-economic status (SES) because they can reveal common biological pathways

between health and SES (Kohler et al., 2013).

Socioeconomic disparities have been extensively studied in relation to a range of health

outcomes, including maternal and feta health. Such disparities may also extend to hematological

parameters which plays a vital role in maternal-fetal health red blood indicies, such as mean

corpuscular volume (MCV), mean corpuscular hemoglobin (MCH) mean corpuscular

hemoglobin concentration (MCHC) that are valuable in monitoring the effects of socioeconomic

status (Oyawoye & Ogunkunle, 2004). Socio-Economic Status (SES) measures family economic

and social position in relation to others, based on various variables used for social and economic

development (Zafer et al., 2015). Estimation made by National Health and Examination Survey

(NHANES) from 2011 - 2016 among women between the ages of 31 to 44 years, has shown that

more than 97% have inadequate vitamin D and 44% have inadequate Vitamin A and calcium

intake in their diet (Devarshi et al., 2021).

1.2 STATEMENT OF RESEARCH PROBLEM

Socioeconomic status is one of the most important factors associated with health and well-being

of pregnant women, which is defined by factors such as income, education and occupation (Lee

et al., 2016), When SES is low in pregnancy, there is a risk of adverse pregnancy outcome.

Previous studies have revealed that low SES is associated with pregnancy complications such as

abortion, preterm delivery, pre-eclampsia, eclampsia and gestational diabetes (BO, and

Stephansson O, et al.; 2001, 2002). Low SES is associated with abnormal increase in blood

volume and pressure and this was linked with the poor level of education on health management

(Leng et al., 2015). In Nigeria, SES has been said to have a significant relationship with blood
metabolism and it's component or parameters (Adedoyin et at., 2013). Although these studies

had showed significant relationship between socioeconomic status and blood related health

disorder in different parts of the world; there is however paucity of data not any study done or

established reference local values of Red blood cell indices in Kano state Nigeria.

1.3 JUSTIFICATION

Socioeconomic disparities have been widely recognized as significant contributors to health

disparities. Individuals from lower socioeconomic backgrounds often face greater challenge in

access to health care, nutrition and other resources, which can affect their health outcomes

including hematological parameters. Alterations in red blood cells indicies during pregnancy can

have significant implications for both maternal and fetal. Anemia or other hematological

abnormalities can increase the risk of complications such preterm birth, low birth weight,

maternal morbidity. By studying the impact of socioeconomic status on Red blood indicies, we

can identify women at higher risk and develop strategies to promote optimal hematological status

during pregnancy, ultimately improving maternal and fetal health outcomes.

1.4 AIM

The aim of this research is to assess the impact of socioeconomic status on Red blood cell

indices in pregnancy.

1.5 OBJECTIVES

• To determine the red blood cell indices in pregnancy

• To compare the red blood cell indices of pregnant women at different socio-economic

status
1.6 HYPOTHESIS

There are no significant alterations in the socioeconomic status of red blood cell indices of

pregnant woman.

CHAPTER TWO

LITRETURE REVIEW

2.1 SOCIOECONOMIC STATUS

The term socio-economic status refers to an individual’s position in a society which is

determined by wealth, occupation, and social class and is a measure of an individuals or groups

standing in the community. It usually relates to the income, occupation, educational attainment,

and wealth of either an individual or a group. These types of variables are summarized into a

single figure or socio-economic index. There is no general agreement on the definition of SES

and so different socio-economic indexes are built for different uses ( M.R. Sarsani et al., 2011).

According to (Sharan et at., 1986) SES is a mental construct, a degree of esteem or lack of

esteem which people in society display toward an individual. High SES , therefore, indicates a
high income , high status occupation and adequate living conditions, where as low SES refers to

poor income , low occupation, and inadequate living conditions. High SES is considered to

provide a healthy and enriched stimulating environment in which personality may develop

appropriately, where as people of low -income groups may develop feelings of insecuritieand

inferiority and an unhealthy attitude toward people and objects.

SES can be seen as a hypothetical construct and is measured using a combined parameters of

education, health, poverty, income and consumption. SES affects education, health seeking

behavior, feeding, income,life style amongst others ( Baker and Gibson et al., 2014 )

2.2 Hematological Profile

Hematological profile is measured world wide to estimate general health, because it is reliable

indicator and is a simple, fast and cost-effective test (Shen C et al., 2010). In addition, the

hematological profile is considered to be one of the factors that is affecting pregnancy and it

outcome ( Klebanoff et al., 1991 and Allen et al., 2000). During pregnancy there are some

changes that occur and can be observed in hematological indicies such as red blood cell (RBC)

count, hemoglobin(Hb) concentration, platelet (PLT) count, and white blood cell (WBC) count.

Some of these are decreased for example, RBC and PLT counts due to the results of

physiological hemodilution that occur in pregnancy (Cabaniss et al.,1987 and Kelton et

al.,1988).

2.2.1 Blood

Blood is a body fluid in the circulatory system of humans and other vertebreates that delivers

necessary substances such as nutrients and oxygen to the cells, and its transports metabolic waste

products away from those same cells ( Merriam-webster et al., 2017). Blood in the circulatory
system is also called the peripheral blood and the blood cells carries peripheral blood cells

(National cancer institute NCI 2022). Blood is composed of blood cells suspended in blood

plasma. Plasma which contains 55% of blood fluid, is mostly water (92% by volume), ( The

Franklin institute Inc 2009) and contains proteins, glucose, mineral ions, hormones, carbon

dioxide, and blood cells themselves. The blood cells are mainly red blood cells (RBCs or

erythrocytes), white blood cells (WBCs or leukocytes), and in mammals platelets (also called

thrombocytes), ( National Cancer Institute 2011) . The most abundant cells in the vertebrates

blood are the red blood cells ( Aryal et al., 2017 ). These contain hemoglobin, an iron-containing

protein, which facilitates oxygen transport by reversibly binding to this respiratory gas thereby

increasing its solubility in blood ( Cleveland Clinic 2022 ) In contrast, carbon dioxide is mostly

transported extracellular as bicarbonate ion transported in plasma.

Blood is circulated in the body through blood vessels by the pumping action of the heart. In

animals with lungs, arterial blood carries oxygen from inhaled air to the tissues of the body, and

venous blood carries carbon dioxide, a waste product of metabolism produced by cells, from the

tissues to the lungs to be exhaled. Blood is considered a specialized form of connective tissue

(Krause et al., 2005). Blood accounts for 7% of the human body weight ( Alberts B et al., 2012 )

with an average density of 1000 kg/m3, very close to pure water`s density of 1000 kg/m3

(Shmukler et al., 2004 ).

Hematological status involving red blood cells , white blood cell (Leukocytes), mean corpuscular

volume, mean corpuscular hemoglobin, corpuscular hemoglobin concentration are valuable in

monitoring toxicity level that may affect the blood and health status of individual and are useful

in the diagnosis and monitoring of many diseases as well as investigation of the extent damage of

blood (Oyawoye et al., 2004).

2.2.2 White Blood Cell

the total white blood cell (4000-11000)form part of bodys

immune system (Ganong et.; 2003). the major function of white blood cell and its differentials

are to fight infections ,form a defense to the body by phagocytosis against invasion by foreign

organisms and to produce, transport and distribute antibodies in immune responses. (Soetoan et

al., 2013).

2.2.3. Blood Platelets

There are about (200-500) thousands platelets in the human body. Platelets are associated with

blood clotting. Low platelets concentration suggest that the process pf clot-formation (blood

clothing) will be prolonged resulting in excessive loss of blood in the case of injury.

2.2.4. Red Blood Cell (RBC)

RBCs are the most common blood cells and principal carriers of oxygen of the body to the body

tissue from lung alveoli.their cytoplasm is rich in hemoglobin, an iron containing bio- molecule

that can bind oxygen and is responsible for the red color of the cells, in human beings, matured

red blood cells are flexible and oval biconcave.

2.2.2.1 Packed Cell Volume (PCV)

Packed cell volume (PCV), also know as hematocrit or erthrocyte volume fraction (EVF), is the

percentage of red blood cell in blood (Purves et al., 2003). According to (Issac et al., 2013)

Packed cell volume is involved in the transport of oxygen and absorbed nutrients. Increased

packed cell volume shows a better transportation and this results in an increased primary and

secondary polycythemia.
2.2.2.2 Variations in PCV

Increase in PCV

1. Polycythemia

2. Dehydration

3. Dengue shock syndrome

Decrease in PCV

1. Anemia

2. Cirrhosis

3. Pregnancy

4. Hemorrhage ( due to ectopic pregnancy)

2.2.2.3 Blood Indicies

Blood Indicies are the calculations derived from RBC count, hemoglobin content of blood and

PCV. ( K , prema Sembulingam., sixth edition section 2, Chapter 13).

2.2.2.4 Important of Blood Indicies

Blood Indicies help in diagnosis of the type of anemia.

2.2.2.5 Different Blood Indicies

1. Mean corpuscular volume (MCV).

MCV is the average volume of a single RBC and it is expressed in cubic microns (cu ).

2. Mean corpuscular hemoglobin (MCH).

MCH is the quantity or amount of hemoglobin present in one RBC. It is expressed in micro-

microgram or picogram.

3. Mean corpuscular hemoglobin concentration (MCHC).

MCHC is the concentration of hemoglobin in one RBC. It is the amount of hemoglobin

expressed in relation to the volume of one RBC.

2.3 Anemia

Anemia is the blood disorder, characterized by the reduction in RBC count, Hemoglobin content,

Packed cell volume(PCV).

2.2.1 Classification of Anemia

2.2.2 Morphological Classification

1. Normocytic Normochromic Anemia

Size (MCV) and color (MCHC) of RBCs are normal.But the number of RBC is less.

2. Macrocytic Normochromic Anemia

RBCs are larger in size with normal color.RBC count is less.

3. Microcytic Hypochromic Anemia

RBCs are smaller in size with less color.

2.2.3 Etiological Classification.

1. Hemorrhagic Anemia

Hemorrhage refers to excessive blood loss

2. Hemolytic Anemia

Hemolysis means destruction of RBCs.

3. Nutrition Deficiency Anemia

Anemia that occur due deficiency of a nutritive substances necessary for erthropoiesis is called

nutrition deficiency anemia.eg iron , protein , vitamins , ( C ,B12 , and folic acid.).

4. Aplastic Anemia

Aplastic anemia is due to the disorder of red bone marrow.Red bone marrow is reduced and

replace by fatty tissue.

5. Anemia of chronic diseases

It is characterized by short lifespan of RBCs, caused by disturbance in iron metabolism or

resistance to erthropoietin action.

2.2.4 Signs and significance of Anemia

• Skin and mucous membrane

Color of skin and mucous membrane becomes pale.

• Cardiovascular system
 There is an increase in heart rate ( tachycardia) and cardiac output.

• Respiration

There is an increase in the rate and force of respiration.

• Digestion

Anorexia, nausea, vomiting, abdominal discomfort and constipation are common.

• Metabolism

Basal metabolic rate increase in severe anemia.

• Kidney

Renal function is disturbed. Albuminuria is common.

• Reproductive system

In females, the menstrual cycle is disturbed.

• Neuromascular system

Common neuromascular sysptoms are increased sensitivity to cold, headache, lack of

concentration, restlessness, irritability, drowsiness, dizziness or vertigo and fainting.

2.4 PREGNANCY

pregancy is the time when one or offspring are developing inside womans body (Eunice

et al., 2013) A multiple pregnancy involves one or more offspring or fetus , child birth

occurs 40 weeks from the last menstrual cycle (Eunice et al., 2013) . developing
 offspring during first 8weeks is called embryo. symptoms of early pregnancy may

include missed period, tender breast, nausea and vomiting frequent urination as well as

hunger (Eunice et al.,2013).

Pregnancy is generally divided into three trimesters.

The first trimester is from week one through 12 and it include when sperm fertilize the

eggs (Eunice KS et al., 2013). After travelling through the fallopian tubes, the fertilized

eggs forms embryo. During this moments the posssibility of miss carriage is highest(John

H et al., 2012).

Around the middle of second trimester fetal movement may be heard (John H et

al.,2012). At 28 weeks more than 90 percent of the baby may survive . Outside the uterus

if high quality medical care is provided (John H etal.,2012).

2.4.1 PHYSIOLOGICAL COMPLICATIONS DURING PREGNANGY

some complications of pregnancy includes, (Eunice etal.,2013)

• Disorder og high blood pressure

• Gestational diabetes

• Iron deficiency anemia and

• Severe vomiting and nausea

2.4.2 PRENATAL CARE

Prenatal care improve the result of pregnancy.(Eunice et al., 2013). pretanal care may include

taking folic acid regular excercise, avoid taking non prescribe drugs and also alcohols, regular

excercise, blood test and regular physical examination.(Eunice et al., 2013).

In the ideal childbirth labor start on its own at women (ACOG et al., 2013). baby born before 37

weeks are preterm and at higher risk of health problems such as cerebral palsy.

2.4.3 GRAVID and PAROUS

Gravid is a Latin word describing heavy and pregnant women is described as gravida. Gravidity

is a term used to describe the number of times the woman becomes pregnant. The word parity is

also used to tell the number of times the woman take the pregnancy to a viable stage(0). Twins

and other multiple births is considered as one pregnancy and birth.

Null gravid is a woman tha has never been pregnant

A woman that became pregnant for the first time is called primigravida (Robinson et al.,1939).

Multigravida is for women that give birth multiple times (Merriam Webster 2012).

2.4.4 SIGNS AND SYMPTOMS OF PREGNANCY

The usual and normal symptoms of pregnancy do not prevent daily activities but in a condition

where there are some pregnancy-related problem can cause severe symptoms that are associated

with anemia.

Usual symptoms and discomfort of pregnancy

• Tiredness
 • Constipation

• Morning sickness

2.4.5 PHYSIOLOGICAL CHANGES OF BLOOD COMPONENT IN PREGNANT

WOMEN BLOOD VOLUME AND HEMOGLOBIN ALTERATION IN PREGNANCY

During pregnancy the blood plasma volume rise to about 40-50% and the Red blood cell volume

increase to about 20-30%, the changes occur usually in the second trimester near the 32 week

gestation (Mims et al., 2015) from the study conducted in southwest part of Nigeria on pregnant

and non-pregnant women there are differences in PCV , EBC, esinophil, monocyte, lymphocyte

and ESR (Osunnuag et al., 2011). Due to an increase in plasma volume which causes dilution the

hemocrit and hemoglobin volume decrease and these are measures of RBC. The erythropoietin

level increase to about 150% during pregnancy this is to stimulate red blood cells volume (Mims

et al., 2015). The effect of pregnancy on platelet count is somehow unclarified; usually no effect

is what some studies have shown while others showed drop in platelet count (Mims et al., 2015).

2.4.5.1 PLATELET AND WHOLE BLOOD CELLS

There is no certainly about the changes in platelet count, with some studies showing sight

increase while other found no changes (Mims et al., 2015). During labor there is increase in

WBC count occasional appearance of myelocyte .(Mims et al., 2015).

 CHAPTER THREE

MATERIALS AND METHODS

3.1 Materials

3.1.1 Laboratory Equipment

• Hematology Analyzer

• Centrifuge

• Microscope

• EDTA tubes for anticoagulation

• Needles, syringes, alcohol swabs ,and sample containers for collecting and storing blood

samples

3.1.2 Sample size

The study sample size will be 100 pregnant women attending MMSH and Abdullahi Muhammad

Wase Hospital.

3.1.3 Sample Population

The study population will be the pregnant women regardless of what trimester attending

MMSH and Muhammad Abdullahi Wase Hospital.

3.1.4 Sample Techniques

The sampling technique will be consecutive sampling, where every subject meeting the criteria

of inclusion is selected until the required sample size is achieved.

3.1.5 Inclusion Criteria

i include only pregnant patient

3.1.6 Exclusion Criteria

i non pregnant patient

ii patient with miscarriage

iii patient who refuse to give consent

3.1.7 Statistical Analysis

All data collected will be expressed as mean+SD.It will be analyze using student T-test.

3.1.8 Study Location

The study will be carried out at Murtala Muhammad Specialist Hospital, at Kofar Mata Road

700224 kano city and Muhammad Abdullahi Wase Nassarawa GRA kano city 700213,kano.

3.2 Methods

This section describe the methods and materials that are proposed to be used in this study. The section is
organized according to the following headings: study area, study design, study population, sample size
technique, inclusion and exclusion criteria, data collection and statistical analysis.

3.2.1 Data Collection

Procedure for Data Collection

  Dietary intake questionnaires
 Measurement of height
 Measurement of weight

3.2.1 Data Analysis

Obtained data will be enter and clean Microsoft Excel 2023. Analysis is going to be done using statistical
package for social sciences (SPSS, version20) Quantitative variable will be compared using paired
samples t-test ,while statistical associations between categorical variables will be done using chi-square
test test of association

3.2.2 Ethical Clearance and Approval

Ethical approval or clearance will be collected from Kano state ministry of health . Permission shall be
obtained from the management MMSH Kano and Abdullahi Muhammad WASE , consent shall also
obtain from the subjects . The study protocol will be fully explained to the study subjects. The study will
be conducted on 100 subjects.

3.2.3 Statistical Analysis

Data will be collected and will be expressed as Mean-+ SEM. It will be analyze using one way Analysis
of variance, ANOVA. This will followed by a tukey,spost-hoc test, to Compare the level of significant
differences high and low socio-economic status group using SPSS version 23.0 a values of p<0.05 will be
considered significant.