CHAPTER ONE

1.0 Introduction

Anemia refers to a condition in which the hemoglobin content of the blood

is lower than normal for a person´s age, gender and environment, resulting

in the oxygen carrying capacity of the blood being reduced. Maternal anemia

during pregnancy, defined by the World Health Organization as hemoglobin

(Hb) concentration <110 g/L (1), bodes poorly to the mother and the fetus,

The adverse effects depend upon the severity and duration of anemia and the

stage of gestation (Kalaivani et al 2019).

Anaemia during pregnancy is a major public health problem throughout the

world, particularly the developing countries. Despite the fact that most of the

anaemia’s seen in pregnancy is largely preventable and easily treatable if

detected in time, anaemia still continues to be a common cause of mortality

and morbidity in Nigeria. Diminished intake and increased demands of iron,

disturbed metabolism, prepregnant health status and excess iron demands as

in multiple pregnancies, women with rapidly recurring pregnancies, blood

loss during labour, heavy menstrual blood flow, inflammation and infectious

diseases are important factors which lead to development of anaemia during

pregnancy (Tolentino and Friedman 2009)

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Anaemia is directly responsible for 20% maternal death and is an associated

cause in another 20% [1]. Current knowledge indicates that iron deficiency

anaemia in pregnancy is a risk factor for preterm delivery and subsequent

low birth weight and possibly for inferior neonatal health. In World Health

Organization / World Bank rankings, iron deficiency anaemia is the third

leading cause of disability-adjusted life years lost for females aged 15- 44

years(Dutta 2004). Anemia is a silent disease with a slow progression and a

few physical symptoms, which may cause the patient not to be able to feel

the condition until they are in an advanced state of the illness (WHO). A

person with anemia is considered to have lower than normal hemoglobin

levels in the bloodstream, followed by a decrease in the oxygen-carrying

capacity of red blood cells to the tissues (Alem et al., 2013).

Numerous underlying factors can cause anemia in pregnant women,

including social, demographic, economic, nutritional, and health factors

(Abriha et al., 2014). Iron deficiency is the most important cause of anemia

in pregnant mothers. The mother’s body requires iron to increase blood flow

and the growth of tissues in her body and meet the fetus's physiological

needs in the first months of life (Abdelrahim et al., 2009; Adam et al.,

2005a; Ayoya et al., 2006; Bushra et al., 2010; Getahun et al., 2017;

Gopalan, 1996; Kagu et al., 2007a; Maternal hemoglobin concentration &

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 birth weight, 2000; Mohamed et al., 2011; Muhangi et al., 2007; Taylor &

Lind, 1979; United Nations Children’s Fund, United Nations University,

WHO. Iron-deficiency anemia: assessment, prevention, & control. A guide

for programme managers). Maternal iron demand during this period

increases from 1 to 2.5 mg per day in early pregnancy to 6.5 mg per day in

the third trimester (Dewey & Chaparro, 2007; Maternal hemoglobin

concentration & birth weight, 2000; Taylor & Lind, 2017). Anemia can also

develop during chronic diseases such as tuberculosis, malaria, HIV, and

diabetes, and genetic factors may also increase susceptibility to anemia

(Abou Zahr & Royston, 1991; Marchant et al., 2002). It should be noted that

the contribution of each of these factors in the development of anemia in

pregnant women varies according to social, economic, lifestyle, and health-

seeking behaviors in different geographical areas and under the influence of

specific cultures of different.

1.2 Statement of problem

Anaemia during pregnancy is a major public health problem throughout the

world, particularly the developing countries. Despite the fact that most of the

anaemia’s seen in pregnancy is largely preventable and easily treatable if

detected in time, anaemia still continues to be a common cause of mortality

3
 and morbidity in Nigeria.This has inspired the purpose behind this study to

evaluate the rate of occurrence of anemia in pregnant women.

1.1 Aims and Objectives

Aim

To determine the frequency of occurance anemia in pregnancy among

women attending antenatal care at wuntin dada primary health care, Bauchi

Bauchi state.

Objectives

 To prepare questionnaire which will be used to collect data from

patient

 To collect blood sample to analyze in the laboratory for Packed cell

volume which will be used to determine anemia

 To compute and analyze result using statistical tool like excel.

1.4 Scope of the Study

The work will be limit to the collection of blood sample for PCV test and

administration of questionnaire to collect socio-demographic data from the

respond, the work is also limited to be conducted within three month.

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 CAPTER TWO

LITERATURE REVIEW

2.1 Concept of Anaemia:

The term anacmia refers to the reduction in the oxygen canying capacity of the

blood due to fever circulatino red blood cells then normal or a reduction in the

concentration in the production or an increased loss of enterocytes. Anaemia is said

to occur when the hemoglobin content of blood is below the normal range expected

for the age and sex of the individual, provided that the presence of pregnancy, the

state of hydration of the individual and the attitude have been taken in to account

while several authorities and expells accepts the lower limits of normal

hemoglobin concentration as 120/dl in women and 14g/dl in men, WHO accepts up

to llgm present as the normal hemoglobin level of 100/(11 to tolerate

pregnancylabour and delive1Y vel)' well and with aood outcome. The centre for

disease control U.S.A defined an anaemia as a hemoolobin (Hgb) or hematocrit

(Hct) value less that the fifth percentile of the distribution of Hob or Hct in a

healthy

reference population.

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2.2 Classification of Anaemia:

1. Kinetic - Red cells normally remain fairly constant in number suggesting that

cell production is equal to cell distribution. Consequently ID cell number decline

this must be due to either:- (i) A decreases in the production Of red cells. (ii) An

increases in the destruction, loss of pooling or destruction of red blood cells.

2. Morphological Anaemia - The size and hemoolobin content of led cell in

characteristic and diagnostic guide. This is red cell nunlber are decreased in

relation to hemoolobin content and red cell mass. then the red cell will be lar«er

than normal (Macrocytic Anaemia) if hemoglobin and red cells mass are decreased

in relation to the number of red cclls, the red cells will be smaller than normal and

contain less henloglobin (Microcytic Hypochromic Anaemia) if red size in

unchanoed the anaemia is termed (nonnocytic) ad if the hemoglobin concentration

of each cell is normal the additional term normochromic is applied (woolf 1998).

3. Relative anaemia:- is characterize by a normal total red cells mass such as a

hematologic disorder but lilther as disturbance the regulation of the plasma volume

(Thomas etal, 1997).

Absolute anaemia:- absolute anaemia are characterized by decreased red cell mass.

The clarification of the absolute anaemia is difficult, since it raises take in to

account kinetic, initially all anaemia caused by increased destmction of red cells.

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The differentiate is t a great extent based on the reticulocyte count subsequent

diaonostic break down can be based on either morphologic or path physiologic

criteria (Thomas etal 1977).

4. Anaemia - Anaemia is the most of common nutritional deficiency disorder in

the mild. Causes are deficiency of nutritional substance and it is need for

erithropoiesislike the metals, protein and vit anaemia (Iron, folate, vit B 12, vit B6,

vit C and copper) such as IDA, megaloblastic anaemia so important types (WHO,

1997) megalonblastic anaemia resulting from nutrional causes is usually due to

folate deficiency (Woolf 1998).

2.3. Diagnostic Method and Investigation of Anaemia

A full blood count and film should be taken. HB HCT and RBCs are reduced.

2.3.1 Complete blood count (CBC) — The complete count (CBC) gives important

information about the kind and numbers of cells in the bold. ACCBC helps the

physician to check any synlptoms, such as weakness, fatique or bruisin« and also

help to diaonose condition such as anaemia, infection and may hit (Gruber, 1998)

A complete blood count assess all components of the blood (red blood cell, white

blood cells and platlates). An abnormally high or low count indicate the presence

of various discasc (Grubcr,1998) A complete blood count may be done as part of a

regular physical examination. A blood count can give valuable information about
7
the general state of health (Gruber, 1998) The complete blood count (CBC)

include.

2.3.2 Hemoolobin (HB):- The hemoglobin mote cute fills up the red blood cell it

carries oxygen, carbon dioxide and gives the red blood color the hemoolobin test

me assures the amount of Hb in the blood a oood test measured of the blood

viability (Albeits and Brucem 2005). Hemoglobin is composed of globin and the

iron containing hemoalobin found protoporphyrin (Besa et, 1992).

2.3.3 Hematocrit (HCT):- Pack cell volume (PC4) This test measures the amount

of the space (volume) red blood cells take up in the blood. The volume is

given as percentage of red cells in two (2) major test that show if anaemia or

phycythemia is a present (Albeits and Bruce, 2005).

23.4 Red Blood Cell Count (RBC):- Red blood cells cal-ry oxygen fronl the lung to

the rest of the body they also carry carbon dioxide back to the lung so it can be

exhaled if the RBC count is low (Anaemia) the body nnay not transport oxygen it

needs if the cOunt is too high (polycythemia) there is a chance that red blood cells

will clillnp together and block tiny blood vessels (capillaries) this also make it hard

for the red blood cells to carry oxygen (Alberts and Bruces, 2005).

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Red Blood Cell Indices (Absolute Value):- ther am thne 3 IVd blood cell indices

nran corpuscular volume (MC V) ruean corpuscular henloglobin (N (CH) and

mean eolTuseular hetnoglobin concentration (IX ICRC).

Blood Cell Count (WBC, Leucocyte):-white blood cell protect frolil

the body. white blood cells are bioger than red blood cells but fewer in nulliber. a

person has become infected the number of white blood cells rises vety quieklv and

Bntce, 2005).

2.3.7 Types of white Blood Cell wBC) Diffexntiate:- There are luajor types of

white blood cell are neutrophils. Iyphocytes, moncyte, esinophil and

bashiles immature neutmphil called band neutmphil being also part of this test eac

cells plays a different mle in protecting the body. the number of each type of

WBCS cell important information about the immune system.

Too many or too few of the different types of WBCS can help in diagnosis of the

infection allergic or toxic reaction to medicine or chemical and Inanvcondition.

such as anaemia (Albeit, Bruce 2005).

23.8 Platelets (Thrombocyte) Account:- platelets ale the sruallest type of the blood

cells, they are important in bloodino occur the platelets stuell, clump together and

form a sticky plug that help to stop the bleedincy if theie are two few platelets

uncontrolled bleeding may be a problem, if thete an too many platelets there's a

9
chance of blood clot forming in a blood vessel. Also platelets may be involved in

hardening of the alleries (Athensclemsis) (Albers and Bluce, 2005).

Of volume of pits mean platelets volurne used along with pits count to diagnose

some types of diseases (Abert and Bruce 2005).

2.3.10Platelets Distribution Withed (PDW):- Platelets distribution withed can be

also be measure which shows if the platelets are all the same or different sizes

(Albeits and Bluces 2005)

2.4 Antiology:

The causes of anaemia in the causes of anaemia in pregnancy are often multi-

factional in developing countries, the major causes of anaemia in pregnancy are

nutritional deficiencies, infections hemon-haoe and hemoolobin an this anaemia is

also stem in some chronic medical disorder like renal and hepatic diseases

(Ezeechi Oliver and Kalejaiye Olufunto 2006).

2.4.1 Nutrition:- In many regions of the world nutritional deficiency is the major

cause of anaemia in pregnancy the World Health Oraanization (estimates that

about half of all pregnant women globally suffer from nutrition all anaemia is

mainly due iron and folate deficiency in diet. Diseases that cause poor dietary'

intake or mal absomtion of these nutrients will also in nutritional anaemia. Iron

deficiency is commonest cause of nutritional anaemia in both developing and

10
industrialized countries and is usually as a result of poor diet. Source of iron

include meat (lives in particular) vegetables and daily products the demand for iron

increases in pregnancy as it is required by mother and fetus for growth and

development in developing countries the already deflated iron stores as a result of

poor diet, too early too many and too frequent pregnancy are unable to cope with

æquirement of along Of iron required during a normal pregnancy the resultant

effect is iron deficiency anaemia. Hook worm intestation is another cause of iron

deficiency anaemia in the topics. The folic acid requirement is also increased two

fold in pregnancy.

2.42 Normal body storms can only last for 3-4 months' folate deficiency in

pregnancy often develops as a result of poor dietary intake which is often the case

in developing countries as well as excess utilization sources of folatc

include liver, egg, yolk and leafy green vegetables. Folate deficiency results in

ineffective erythropoiesis folate deficiency can be further exacerbated in pregnant

woman with hemoglobin apathies as well as in those residing in areas of high

malaria endemicity as increased hemolysis lead to high red cell tum over and

increased folate deman. Vitamin B 12 is rare during pregnancy as the requirement

is as low as 2-5 and liver stores last for as long as 2 years (Ezechhi Oliver and

Kaliiaiie Olunfunto 2006).

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2.4.3 Infections - Pregnant women are mane prone to infections as a result of

depressed immunity. Anaemia due to infections usually as a result of

products from the infecting organism coursing health, fever, red cell destruction

and reduced red cell production. Bacteria, infection used to be a leading cause of

anaemia, however in Trojans and developing countries malaria and more recently

HIV/AIDs re leading contributors to anaemia in pregnancy (Ezechi Oliver and

Kala Jaiye Olunpunto 2006)

2.4.4 Malaria - Malaria infection is a leading cause of anaemia in the tropic both in

pregnant individual malaria induced anaemia is more profound in profound in

pregnancy as the susceptibility to malaria is greater in the prim gravid. Anaemia

resulting from malaria infection is caused by the destruction of infected and un-

infected red blood cells as well as bone malTow suppression. Red blood cell

infected with the malaria parasite also accumulate and sequester in the placenta.

Macrophages and cytokines (e.g tumer necrosis factor and inter Liukin). Enhance

red cell destruction, micronutrient deficiencies, infections with HIV, look wornl

infestation or other chronic inflammat013' stater with worsen anaemia these

persons (Ezechi Oliver and Kalejaiye Olunfanto, 2006).

24.5 HIV/AIDs - Anaemia is most common hematoloaical complication of the

human deficiency virus (HIV) infection and may be consequent upon the

12
effects of the virus itself or treatment with various dill(ys. The mechanism of

decreased red blood cell production, increased red cell destruction and infective

protluction of red blood cells. The etiology of HIV associated anaemia is multi-

factorial and include the infiltration of the bone marrow by the vims by tumor or

infection. Bone marrow suppression by the virus itself the use of all suppressive

drugs like Zidovodine or drugs the prevent the utilization of folate like

contrimoxole. Other eti010ffies include decreased of erythropoietin, red cell

destnction as a result of all to anti bodies to red blood cells and nutritional

deficiencies could occur as a result of reduced intake due to difficult in swallowing

as a result of oropharyngeal through mal-absorption or increased catabolism or as a

result of ill heater and associated fever from various infection. A part from iron and

folate deficiency, other repolled vitamin deficiencies in HIV infection include

vitamin B 12, vitamin Bb, and vitamin A (Ezechi Oliver and Kalajaiye Olunfanto,

2006).

Hemoglobin apathies are inherited disorders

2.4.6 Hemoglobin Opathies affecting hemoglobin structure (Sickle cell disorder) or

synthetic (Thalassemia) they are usually seen in individuals from Africa, the

middle east, the mediterran ean, Asia and the far east. The hemoglobin apathies,

that cause anaemia in pregnancy are sickle disorders I-IBSS, HBSC Thalassemia.

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Hemoglobin apathies cause a chronic hemolytic In sickle cell disorders, the

abnormal hemoglobin sickle in hypoxic state, predisposing the structurally damage

cells to early destruction hence concurrent infections will worsen anaelllia (Ezechi

Oliver and Kalajanyc

24.7 Haemorrhaoe - Acute blood loss as a result of ectopic pregnancy, ante partum

hemon-hage and abortions are common causes of anaemia in

pregnancy. Chronic loss from worm infestations, gastro-intestinal user and

hemolytic result in depletion of and infective elythropoiesis.

2.4.8 Red Cell Plasma - This is a cause of anaemia in pregnancy and results from a

selective failure of erythropoiesis. In most cases, the cause is unknown. The

indentified causes of pure red aplasia include autoimmune disease (e.g SLE) chugs

and infection with parvo Villis B19 (Ezechi Oliver and Kalaianye Olufunto, 2006).

2.5 Epidemiology:

Anaemia is a global public health problem of affecting both developed and

developing countries, being name prevalent in children under five (5) years and

pregnant women. The alobal estimate indicates that 293.1 million of pregnant

women approximately 43% are anaemia world guide and 28.5% of these wolnen

are found in Sub-Sahara Africa. The prevalence of sever anaemia (hemoblobin

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c5g/dl) in a number of hospital base studies ranges from 8% to 29% and was

associated with a case facility rate of 9-18% (8). In west Africa, a study involving

3 countries including Nigeria, Ghana and Mali the prevalence of mild anaelllia was

24.3% moderate anaemia was 64.3% and severe anaemia was 10.6 in a study done

in Nigeria, anaemia was found to be an important public health problem where

70.5% Of women attending antenatal care were found to be anaemic. In a study

done Uganda, anaemia was found to be severe public health problem among

Pregnant women living around Lake Albert and Lake Victoria. The prevalence was

68.9% and 27.3% respectively. A community basic study in Tanzania, involving

pregnant conducted in Kilomborc, Rufiji and Uganda, thc prevalence of moderate

and severe anaelllia was 87% witli hemoglobin lg/dl, 390/0 and 30/0 with

hemoglobin 45g/(ll. In Magu Mwanza thc prcvalcnce of anacmia in pregnant

wonlen was found be 62.6% (Agarwal KN, Agarwal DK 200.3).

2.6 Deterrninants of Anaernia:

The determinants of anaemia look similar with littlc variation according to

geographical region. In Nigeria, a study done at Kaduna showed anaemia was

positively associated with malaria, malnutrition, nutritional deficiency, HIV

15
infection and low socio econolllic status. Similar result was obtained from studies

done in Kenya, Ghana, Burkina, Fago and Mali. In additional to those factors, a

Brazilian study rcvcalcd that a short duration of breast feeding was associated with

anacmia. Heliminthes and schist some infection were additional factors in Burkina

Fago, Mali and Ghana (Agarwal KN, Agaprval Dk 2()()3).

2.7 Clinical Diagnosis of Anacmia:

Because of its low cost and feasibility, WHO, has included evaluation of palmar

pallor as the initial tool to dctcct anacmia in its algorithm management of matcmal

morbidity. Studies to look at specificity and sensitivity of palmar pallor to detect

anaemia were done in Lagos, post Harcourt and Kano. These studies found that

palmar palor was neither sensitivc nor specificity of 90.8%. the sensitivity/

specificity was better in severe anaemia, 48% and 99% respectively. WHO advice

this should be used in primary care setting where hemoglobin astilnation can not

easily be obtain (Bcrymann C2002).

2.8 Laboratory Diagnosis of Anaemia:

Hemoglobin and hematocrit have been used to detected anaemia. These parameters

may be affected by factors such as method and equipment used for its

determination hemoglobin cannot be derived from the hematocrit value with an

16
acceptable accuracy using the role of diving by three because the relationship

between hemoglobin and hematocrit changes with age during the first year of life.

Therefore, fold conversion from hematocrit (o hemoglobin under estimated, the

prevalence of anaemia detemnining hemotoglobin seems to be the more sensitive

ways to deftemine mild and modrate anaemia.

2.9 Prevention of Anaemia

Studies have been done to find sustainable efforts to prevent anaemia. Prevention

and treatment malaria has been shown to prevent anaemia. In studies conducted in

areas of intense malaria transmission in Nigeria. In addition, irons supplementation

iron deficiency pregnant women or low weight causes a reduction in anaemia at in

pregnancy. HIV infection has been associated with increased risk Of anaemia

among pregnant women. The use of heall to eligible HIV infected women during

pregnancy could prevent maternal to child transmission of HIV.

This could reduce the burden of anaemia in children in population in which HIV

seroprevelence is high, instestinal helminthiasis has associated with increased risk

Of anaemia, routing used of anthelminthic drugs at childhood and by pregnant

Women has reduced the prevalence of intestina helminthiasis (Ezechi Oliver and

Kalejaiye Olunfunto, 2006).

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2.10 Management of Anaemia

The public health impact of anaemia is probably highest in malaria endelnic areas

were iron deficiency also tends to be common clinical trials have been done

to compare different anaemia treatment. In General Hospital Bauchi the used of

ferrous sulphate and anti malarial extended for three marks and improving

compliance have benefited for anaemic pregnant women in malaria endemic area

has there is significantly increasing in packed cell volume (PC V). In addition the

supplementation of low does micro-nutrient including polyvison which contain

vitamin A, D, E , B I, B2, niacin B6 with either iron or prophylaxis SP contribute

to significant hemoglobin improvement. In Tafawa Balewa local government

pregnant women with complicated malaria who were transfused according to

WHO cuidelines at discharoe the mean hemoglobin was low similar to non

transfused children and most of them remained moderate to severely anaemic.

Transfusion does not influence hicher increase in hemoglobin concentration. At

General Hospital Bauchi the recommended management of mild and moderate

anaemia include oral hematinic. In patients with severe anaemic apart from blood

transfusion, oral hematinic are also recommended (Ezechi Oliver and Kalajaiye

Olunfunto, 2006).

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2.11 Case Fatility Rate Associated with Anaemia

Anaemia is one of the causes of mortality in pregnant women attending antenatal

care at hospital in Sub-Sahara Africa. Even where blood transfusion in available

there is a significant cases feltility rate of 6-8% studies have been done to 100k at

case fertility rate due to severe anaemic. In Nigeria, the case feltility rate was

found to be 13.6% among pregnant women and the variable associated with

mortality where malnutrition, tachycardia, coma and absent of blood transfusion.

In Bauchi within the national health management and information system the case

fertility rate was reported to be 17.8%. in pregnant attending antenatal care. It is

the second cause of death after malaria, and the pattern of women death attribute to

anaemia charges with malaria transmission. In areas in which malaria transmission

is high (holoendemic), the anaemia attributable death increased.

2.12 Consequences of Anaemia in Pregnancy

2.12.1 Fetal - The fetal consequences of anaemia in pregnancy are well established

and defend not only on the severity of anaemia but also on the duration of the

anaemic state. A fall in maternal hemoglobin below 11.0g/dl is associated with a

significant rise in parental mortality rate. The rate of perinatal mortality tipples at

maternal hemoglobin level below 8.0g/dl and increase by tenfold when anaemia is

very severe. Similar finding are also been noted for both infant birth weight and
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preterm delivery rate. The significant fall in bilth weioht as a result of increase in

preterm rate and intrauterine growth restriction has been repolted with maternal

hemoglobin level below 8.0g/dl (Ezchi Oliver and Kalajaiye Olufunto, 2006).

2.12.2Matemal - The present of severity and duration of anaemia effect maternal as

well fetal well beincr. Women whose mean livelihood involved manual labour may

find it difficult to earn a living as tolerance and capacity for

exercise is reduced. This worse if the unset of anaemia is acute, adequate

compensatory mechanism enable the woman to go through pregnancy and labour

without any adverse consequences (Ezchi Oliver and Kalajaiye Olufunto, 2006).

Where anaemia is moderate, there is substaintial reduction in work capacity and he

may be unable to cope with household chores and child care. Women with

moderate anaemia tend to experience higher rate of morbidity during pregnancy as

COmpared to those with mild anaemia. Evidence has shown that a large percentage

Of maternal death due to antepaltum hemoglobin (APH), free eclampsia and

infection occur in women with moderate anaemia. The maternal outcome in severe

anaemia defend on level of decomposition if not recognize early and corrected, the

heart is unable to compensate for the severity of anaemia and eventual circulatory

failure occurs leading to pulmonary edema and death. The women are unable to

tolerate third staoe of labour and blood loses associated with delivew, when the
20
anaemia is very severe there is a space rise in maternal death. (Ezchi Oliver and

Kalajaiye Olufunto, 2006).

2,13 Pregnancy and the Changes in Pregnancy: pregnancy is most important

physiological stace for human kind since as it assures continuous of the species,

pregnancy produce major physical alteration in the mother, support fetus as its

develop the capacity of in depended. existence and introduce a new organism in

the placenta that provide the link between the fetus and her mother (Hy/ten, 1985)

2.3.1 Anatomical Changes -As pregnancy progresses, the female reproductive

organ become increasingly vascular and engorged with blood, the hence

vascularity increases vaginal sensitivity and sexual intensity. Prodded by rising

level of extrogen and progesterone, the breast enlarge and enuoroedwith blood and

areola darkness. The decree of uterine enlargement during pregnancy is

remarkable, the uterus fills most of the pelvic cavity by 16weeks.

As pregnancy continues the utens pulse hioher in to the abdominal cativity

excelling pressure and both abdominal and pelvics organs. (Marieb and Hoelin,

2003). 2.13.2Physocioloøical Chances During Preanancy

Hemoglogical Changes:- Total blood volume increases by 40% above non

Pregnant level volume rises from 6weeks gestation and stabilizers by 32- 34weeks

21
red blood cell(RBC) marks increase early in the second trimester to 20-35% above

non pregnant level by term (San-is etal, 2009).

The disprotionated rise in plasma volume compared with the RBC mass result in

hemodilution and decrease hemoglobin and hematocrit count. There is

physociological fall Hb and abnormal Hb €10.5g/dl requires investigation, if non

stores are adequate the H TC rises from the second to third trimester (Sarris etal,

2009). The plasma volume rises and RBC mass are number of

RBC increases, the result is fall in hematocrit, this declaim in HTC is called

(physociological Anaemia) or (Dilutional Anaemia), of pregnancy. Through

anaemia represents a fold in the oxygen transport capacity of blood relative to the

normal physociological stage, which during pregnancy oxygen carrying capacity is

hicher than the non pregnant stage. (RILCONEN etal, 1994). The plasma volume

at time is about 1200ml, which translation in to an nearly 80%. The rate blood cell

mass increases by term ranges between 250 and 400mls. H TC declaim in second

to trimester, but rises slowly thereafter, the most equipment means of approachi1W

the problem is to assign llg/dl at the lower limit of normal Hb values during

pregnancy. Interestingly high Hb value during pregnancy are not felicitous findinff

Unexplained value above 13ff/dl are associated with poor fetal outcome, including

22
intrauterine growth retardation, low billh weiaht and preterm birth not surprisingly,

a rise in serulu erythrocyte values appear to be a key factorin rate red cell mass

expansion during pregnancy. Crythropoetin level rise to 50% above base line by

the second trimester. Amane robost rise in serum erythropoietin level occurs in

women who are iron deficient . in normal pregnancy, the means corpuscular

volume (MC V) typically rises by approximately 4fl. A fall in red cell MCV is the

earliest sign of iron deficiencies later the mean corpuscular hemoglobin (MC V)

fall and finally anaemia result (Milman etal, 2000).

c. The WBC count increase and may peak of over 20mg per ml in stressful

condition, the neutrophil count begins to increase in the second month of

pregnancy and plateaus in the second and third trimester, at which time the total

WBC count ranges from 9000 to 5000 cell/micro l. there is no change in the

absolute lymphocyte count (Rilconen etal, 1994).

The Platelets - Typically fall by approximately 10% in an uncomplicated

pregnancy, in approximately 7% of women, this is more severe and canresult in

thrombocytopenia (PHS cont 440-109). In over 75% of cases, this is mild and

unknown cases of pregnancy approximately 21% of cases are secondary to a

hypeftensive disorder will 4% are associated with immune thrombocytopenic

purpura (ITP). No treatment is required and the infant is not affected. A pregnant

23
women will also become hypercoauulabe leading to increased risk for developing

blood clots and embolisms, due to increase liver production of coafflllation factors

mainly brinogen and factor vill (Riikonen etal, 1994).

Pregnancy alters the balance within the coagulation system to favor clotting which

assured to be in preparation for controlling bleeding at time of delivery.

Concentration from clotting factors such as (vii, ix and x increase), as does

fibrinogen with levels increasing by up 50%. Fibrinolytic activity isdecreased, with

a fall in concentration of endogenous fibrinolytic such as anti thrombin and

proteins. The test of coagulation, activated partial thromboplastia time (APPTT),

prothrombin time (P T), and thrombin time (IT), remain normal. This

hypercoagulable state is exacerbated by the compressive effect of the gravid

utersus on the iliac vessels causing venous stasis in the lower limbs. This is more

marked on the left as the left iliac vein is compressed by the iliac and the avarian

afteries. This predisposition for

clothing result in the increased risk of venous thrombosis associated with

pregnancy (SalTis, etal, 2009).

Hormonal changes and endocrine changes:- Pregnant women experience

adjustment in their endocrine system level of progestin and estrooen rise

continually throughout pregnancy, suppressing the hypothalamic axis and

24
subsequently the menstrual cycle. Estrogen is mainly produced by the placenta and

is associated with the fetus well-being. Women also experience increased human

chiclrionlic gandotropin (BHCG)(Koller etal, 1979).

parathyroid hormone is increased which leads to increases of calcium uptake in the

gut and re-absorption by the kidney. Adrenal hormones such as coltisol and

aldosterone also increase. Human placental lactogen (hpl) is produced by the

placenta and stimulate lipolysis and fatty acid metabolism by women, conserving

blood clucose for use by the fetus, it can also decrease maternal tissue sensitivity to

insulin resulting gestational diabetes

(Koller etal,1979). There is a relative maternal iodine deficiency, this

caused by 2-fold increases in renal loss (GFR re-absorption). And active transport

of iodine in to the thyroid is increased by 3-fold. Increased thyroid binding globin

(TBG) hepatic synthesis leads to an increase in total thyroxin (T4) and tri-

iodothyronine (T 3) first trimester increased HCG lead to decreased TSH and

increased T4, second and third trimesters T4 decrease, third trimester TSH

increases (San-is etal, 2009).

Cardiovascular chances The women are sole provider of nourishment for the

embryo and later, the fetus and so her plasma and blood volume slowly increase by

40-5-% over the course of the pregnancy to accommodate the change. The increase

25
in healt rate (15 beat/min morethan usually). Cardiac Output increases by 50%,

mostly during first trimester (Koller etal, 1997).

This helps proper the greater circulatory volume around the body. The uterus press

and pelvic blood vessels, which may impair venous retum from the lower limbs,

resulting in varicose veins and legs Oedima (Marieb ad Hoehn, 20013)

Renal changes - The kidney produces more urine during pregnancy because of the

mother's increased metabolic rate and the additional burden of

disposing of fetal metabolic wets. The glomendar filtration rate (GFR) commonly

increase by 80%. Then the decreased blood urea nitrogen (BUN) and creatinine

and Glucose urea (due to saturated tubular redosignotion may be seen (Koller etal,

1979). Urinary stasis predeceases to utl and pyelonephritis, mild glycosunnia

and/or protein-uria can occur in normal pregnancy, semm albumin decreases,

serum cholesterol increases, and totalbody water increases by 6-81 and plasma

osmolality falls (Sarris etal, 2009). Gastrointestinal chances - During pregnancies

women can experiences nusea and vomiting (morning sickness), which may be due

to elevated BHCG and should resolve by 14-15weeks. Additionally, there is

prolonged gastric time, decrease gastrosophageal sphincter tone, which can lead to

acid reflux, and decreased colonic motality. Which lead to increase water

26
absorption and

constipation (Koller etal, 1979).

v. Respiratory system changes - Tidal volume increase markedly during

pregnancy while respiratory rate is relatively in charged and residual volume

decline. The increase in tidal volume is due to mothers oreater need for oxygen

during pregnancy and the fact that progesterone enhances thesensitivity of the

medullar respiratory center to carbon dioxide (Maries and Ultoehn, 20013). All

physiological changes are maximal late in the second trimester and then start to

retun to pregnancy level (Sarris etal, 2009).

Anemia During Pregnancy:

More than half of the pregnant women in the world have hemoglobin levels of

anaemia. Knowledoe of the current situation of the condition in our environment is

necessary. This knowledge will motivate antenatal caregivers early detection and

prompt management of anaemia in pregnancy (Cyril and Hyacinth, 2005). The

demand of the developing fetus placed the folate. Disease, celtain hemolytic

anaemia (Wiltrobe etal, 1942). physiological Anaelllia or Dilutional Anaemia of

Pregnancy - The plasma volume increases dispropoftionately to red cell mass. A

reduction in the

hematocrit and hemoglobin concentration usually stabilizer at 0.33L/L and llg/dl

27
respectively, severe as useful pulpose by enhancing placental perfusion, there by

facilitating oxygen and nutrient delivery to the fetus. An

additional benefit is that fewer red cells are lost with the hemorrhageaccompanying

placental separation (Wiltrobe etal, 1942).

B.Wien the hemoglobin concentration is less than 10.4g/dl a true reduction in red

cell mass is like by present ; however, because of variation in the magnitude of the

hydremic, a fixed dividing line between the normal and abnormal is difficult to

place in pregnancy. Red cells remain nor-mochromic and normocytic unless

deficiency of iron of folate supervenes (Wiltrobe etal, 1942).

Multiple factors lead to nutritional anaemia in pregnancy. Developing Contries life

style, low socioeconomic condition illiteracy and lack of knowledge of good

dietary habits. Anaemia during pregnancy is associated with increase maternal

morbidity and mortality and contributes to 20% of the maternal mortality in Africa.

Folate deficiency account for 95% of megabastic anaemia in pregnancy. Iron

deficiency anaemia (IDA) is a major health problem during pregnancy (WHO,

1997).

CHAPTER THREE

3.0 Materials and Methods.

28
3.1 Study Area

The study area was carried out at Wunti Dada Primary Health Care in

Bauchi, Bauchi state which is located in the northern part of Nigeria with

coordinates of Latitude 100 18’ 37.15’’ N and Longitude 90 50’ 37.97’’ E

and it covers 45,837 square kilometers. The state is bordered by Kano and

Jigawa to the North, Yobe and Gombe to the east and Kaduna to the west

and Plateau to the south.

3.2 Study Population

Among the 1000 pregnant women attending antenatal care at the wunti dada

primary health care in Bauchi state the sample size was carved out via the

use of socio-demographic, dietary and other characteristics.

3.3 Sample Size and sampling techniques

The required sample size for this study was calculated using formula for

single population proportion based on the prevalence rate of 62.7% reported

from the previous study and using the 95% confidence interval and 5%

marginal error. By adding 10% for none response the final sample size will

be 100 patients.

3.4 Collection of Samples

A structured and interviewer administered questionnaire was used to collect

data on the socio-demographic variables, dietary habit, and obstetric factors.

29
 Data was collected by midwives of the hospital. Venous blood was collected

to determine haemoglobin concentration after an informed consent is

obtained from the study subjects.

3.5 Data analysis

Data were entered and analyzed with the aid of Microsoft office, Anemia

was one of the main pregnancy - related complications include difficult

labour,other complications include low birth weight.

CHAPTER FOUR

4.0 Results
Socio-demographic characteristics of study subjects
30
 Total of 100 informed and consented pregnant women who came for their

antenatal follow up were enrolled in this study and all were urban dwellers.

The mean age of the attendants was 28.8 years old (range from 15-46).

Majority of the study groups were in the age range of 25-31 years. Many of

the respondents were married (96.6%). One hundred ninety two (48.6%) of

the respondents were housewife and 27 (6.8%) were merchants. Forty

percent of the respondents had educational status of 9-12 grade and 122

(30.9%) had diploma/degree. One hundred twenty seven of the respondents

did not know their income and 125(31.6%) had an average income. Two

hundred fifteen (54.4%) respondents had family size of greater than four

(Table 1).

Table 1: Socio demographic characteristics of pregnant women attending antenatal

care at wuntin dada PHC.

31
Variables Anemic Non-anemic Total
Age <15 18 82 100
16 – 25 62 38
26 – 35 45 55
36 – 45 30 70
>46 78 22
Marital status Single 0 100
Married 82 18
Widowed 86 14
Divorced 56 44
Occupation House wife 83 17
Civil servant 50 50
Merchant 61 39
Others 90 10
Education Primary 20 80
Secondary 82 18
Tertiary 46 54

Prevalence and severity of anemia

The overall prevalence of anemia using a cut off level of hemoglobin <11 g/dl

(<33% haematocrit) was 21.3% (64/100). The mean haematocrit value was 0.36

(36%), ranging from 19-45%. Out of all anemic pregnant women about 80.95%

(68/84) were mildly anemic, 17.86% (15/84) were moderately anemic and 1.19%

(1/84) were severely anemic.

32
Table 2: Distribution of anemia among pregnant women with Obstetric and other

variables attending antenatal care at wuntin dada PHC.

Variable Anemic Non-anemic Total

Trimester <13 weeks 84 16 100
13 -24 weeks 70 30
> 24 weeks 80 20
Blood loss Yes 85 15
No 82 15
Malaria Yes 76 25
No 24 75
Transfusion Yes 2 18
No 98 82

Table 3: Distribution of anemia with dietary habit among pregnant mother

attending antenatal care at Wuntin Dada PHC.

Eating Habit Anemic Non-anemic Total

Frequency of No 0 0 100
eating animal Once Daily 40 15 100
food Once weekly 15 8 100
Once monthly 10 12 100
Frequency of No 0 0
eating green Once Daily 17 40
leafy vegetable Once weekly 18 8
Once monthly 8 9
Taking fruit Yes 15 85
after meal No 68 32
Taking Yes 72 28
tea/coffee No 67 33

Anemia and socio-demographic characteristics

About 41.9%, 33.3%, 32.4% of the pregnant women who were in the age range of

39-45, >45 and 32-38 years were anemic respectively. Forty percent of anemic

33
pregnant women were divorced and 21.3% were married. Forty five percent (45%)

and 31.6% of anemic pregnant women were illiterate and had family size of greater

than four respectively (Table 2).

Obstetrics and other characteristics and anemia

Two hundred sixty two (66.3%) of the respondents were multigravidae and one

hundred thirty five (34.2%) were multiparous. About 40.3% of the respondents had

birth interval of greater than two years and 42.5% of the multiparous pregnant

women delivered their children at health institutions. Two hundred forty one (61%)

of them had no history of excess blood loss/abortion in their previous pregnancy

and 49.1% of the responded that they use contraceptives. 10.4% of the

multigravidae did not follow ANC in their previous pregnancy. Small number of

the respondents, 2.5% and 1.5% had history of blood transfusion and malarial

infection in the last one year respectively.

The prevalence of anemia in this study was 17.29% and 23.37% for primigravida

and multigravida respectively. The prevalence of anemia in multipara was more

24.44% (33/78) than primipara 22.22% (26/84) and in those who were nulliparous

25/143 (17.48%). Anemia was also found to increase as the gestational age

increases, showing the highest prevalence in the third trimester 35.48% (33/93)

than second 21.64% (29/89) and first trimester 13.09% (22/91). Women with birth

interval of less than two years had shown more prevalence of anemia

34
(32/93(34.4%)) than those with an interval of greater than or equal to two years

29/59 (18.23%) and women with no history of delivery 23/43(16.08%). Place of

delivery also showed difference in prevalence of anemia (28.9% in the pregnant

women who delivered at home and 22.02% in women who delivered at health

institution).Contraceptive users showed lower prevalence of anemia (18.04%)

compared to none users (24.37%) (Table 2).

Dietary habits and anemia

Out of 100 respondents (36.96%) had the habit of eating meat and animal products

once per week, (25.82%) once in a month, (21%) every other day and 11 once in a

year. One hundred thirty three (33.67%) of the respondents had the habit of eating

green leafy vegetables. (32.15%), (22.78%), and (9.36%) had the habit of eating

green leafy vegetables every other day, once per week and once in a month

respectively. Two hundred eighty eight (72.9%) of the study subjects had the habit

of drinking coffee/tea immediately after meal and two hundred sixty three

(66.58%) had the habit of eating fruits after meal. Multiple logistic regressions did

not show statistically significant association between anemia and any of the dietary

habits (Table 3).

CHAPTER FIVE
5.0 Discussion

35
The prevalence of anemia in this study population using a cut off level of Hb

<11 g/dl (<33% haematocrit) was 21.3% (84/395). This result is almost

consistent with across sectional study carried out in Gonder (23%) and in the

University of Port Harcourt Teaching Hospital, Port Harcourt in Nigeria

which had shown a prevalence rate of 23.2%. In contrast to this study, a

study conducted at Health Promotion Hospital Nakhonsawan, in Thailand

showed a prevalence rate of 14.1% [14].This may be due to a

differeKenyance in socio-economic and educational status between the study

populations in the two study areas. The result of the present study is much

lower than that of Jima (57%), Assendabo (62.7%), Peru (50%), Western

Maharashtra, India (92.38%), highlands of Tibet (China) (70%) and most of

the pregnant women of developing countries (35-75%). Other similar studies

conducted in east Anatonian province; Turkey, the highlands of Tanzania

and in rural areas of had shown prevalence of 27.1%, 28% and 33%

respectively. This discrepancy might be because of the strengthened health

educations given at health institutions during ANC follow up and that there

was time difference and this study is done only in the urban women.

Additionally, it could be due to the variation of the method where sahli’s

method was used in previous studies conducted in Jimma and Assendabo. In

comparison to the standard method (Fluid based system hematology

36
analyzer) used in this study, the Sahli’s technique was reported to be much

less satisfactory under operational circumstances, chiefly because of dilution

problems involved in the use of ordinary manual pipettes and subjective bias

during visual comparison. Out of all anemic pregnant mothers, 80.95% of

them had mild anemia, 17.86% had moderate anemia and 1.19% had severe

anemia according to WHO classification for degree of anemia. In contrast to

this study, a study conducted in Kenya and in Jimma had shown moderate

anemia in 68% and 74.3% respectively. This inconsistency may be because

of the strengthened health education given on risk factors and prevention of

anemia and interventions given at health institutions during ANC follow up

in an attempt to reduce the prevalence and severity of anemia among

pregnant mothers. In addition, it might because of time and place difference

between the present study and the study conducted in Kenya and in Jima.

Anemia in pregnancy is related to different socio-demographic factors. In

different studies, age, educational status, economic position have been found

to be significantly associated with anemia during pregnancy. This study has

assessed socio-demographic variables associated with anemia but only age

15-46 yrs and educational status had shown statistically significant

association with anemia which indicates the higher prevalence of anemia in

illiterates, large family size and aged pregnant mothers. This high prevalence

37
of anemia in these study participants might be due to inadequate knowledge

on factors causing anemia and on how to prevent the risk factors. Similar

study conducted on prevalence and risk factors of anemia in rural areas of

India and in Jimma showed a statistical significant association between

education and anemia and in Turkey, between anemia and large family size

which are consistent with this study.

Obstetric factors are known determinants of anemia. In the present study,

anemia was 2.04 times more prevalent at third trimester. The 26.2%

prevalence of anemia at the first trimester increased to 39.28% at the third

trimester. There was also a statistically significant association between

anemia and history of blood loss, ANC and contraception.

One of the major contributory factors for anemia in developing countries is

consumption of plant based food containing insufficient iron, especially

insufficient available hem iron from meat. Meat is a good source of high

quality protein, iron and zinc and of all the B-vitamins except folic acid. Iron

absorption is enhanced when consumed with foods high in vitamin C such as

orange juice but substances in coffee and tea inhibit iron absorption. This

study has tried to assess different dietary risk factors associated with anemia.

Eating animal food, green leafy vegetables, taking fruit after meal and

drinking tea/coffee did not show significant association with anemia on

38
 multivariate logistic regression which may be due to no difference in eating

habit among the study participants. This study is done only at single

institution; hence, further studies have to be conducted in different hospitals

of Addis Ababa to have findings representing the whole population.

Additionally, further laboratory studies have to be conducted to identify the

specific causes of anemia in the pregnant mothers so as to guide the health

care givers to work alleviating the existing problems.

5.2 Conclusion

The overall prevalence of anemia in this study using a cut off level of

haemoglobin <11 g/dl (<33% haematocrit) was 21.3% and the majority of

them were of the mild type (haemoglobin: 10-10.9 g/dl).Though the

prevalence of anemia in this study is lower than prevalence of anemia in

previous studies conducted in other areas of Ethiopia, it still remains higher.

The present study has shown a statistically significant association between

anemia and age, gestational age, gravidity, parity, antenatal care, birth

interval, blood loss, family size and educational status (illiterates).This

emphasizes the need for continuing strengthening of interventions on factors

associated with anemia.

REFERENCES

39
Miean E. Conges. M. Agli 1. Wojdyla D. Debendit B. (1993) worldwide

prevalence of anaemia: WHO Vitamin and Mineral nutrition Information System:

1993 — 2005 Public Health Nutrition 2008, 12 (14): 44 — 54. Allen

LH, (1993) Anaemia and Iron deficiency effects on pregnancy outcome. AMJ

Clinic nutria. , 71: 1285 Stoltsfus R.J. iron deficiency (2008) global reference and

consequences food nutntlon. Bull 2003; 24 99- 103

Untro J. Cross R. Schultire W. Sidiqoetama D. (1998). The association between

BNII and hemotoglobin and work productivity amonc Indonesia 133 female

factors workers European J. clinic nutrition 52, 131 — World

Health Organization (1992). The prevalence of anaemia in women is a tabulation

of available infonnation Geneva Switzerland: WHO Inch MSM/922 \

Nbuke RB, Letsky (2000). EA: Etiology of anaemia in pregnancy in South Malawi

AMJ Clinic, nutrition 72; 247 - 256 World Health Organization WHO

40
 (1993). Prevention and management of severe anaemia in pregnancy; repolt of

technical working group Geneva Switzerland: WHO 1993; WHO/FNE/MSM/93.5

Demaye EM; Tagman A. (1998). Prevalence of anaemia in the world. WHO

quality; 38: 302 — 16 Venden brock NR, progrian SI, Mahango CJ, et'al (2000).

Anaemia in pregnancy in Southelll Malawi prevalence and risk factors. BIOG.

2000; (07: 435 - 437).

41