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  • Research article
  • Open Access
  • Open Peer Review

Magnitude and factors associated with anemia among pregnant women attending antenatal care in public health centers in central zone of Tigray region, northern Ethiopia: a cross sectional study

  • 1Email author,
  • 2,
  • 3 and
  • 1
BMC Pregnancy and Childbirth201818:433

https://doi.org/10.1186/s12884-018-2063-z

  • Received: 4 April 2018
  • Accepted: 17 October 2018
  • Published:
Open Peer Review reports

Abstract

Introduction

Anemia is defined as a low blood hemoglobin concentration (< 11 mg/dl). It is a global public health problem especially in pregnant women and is associated with higher risk for both maternal and perinatal mortality and morbidity. In developing countries, like Ethiopia where anemia is common, determining the magnitude and identifying factors that are associated with anemia is necessary to control it.

Methods

Facility based cross sectional study design were conducted among 638 pregnant women attending antenatal care in public health centers in central zone of Tigray region, Northern Ethiopia from November 1/2017 to January 30/2018 using stratified multi stage sampling method. The data was collected through interviewing the pregnant women face to face after getting informed consent using structured and pre-tested questionnaire. The data was coded and entered in to Epi-info 7 then exported to Stata 14 for cleaning and further analysis. Both Bivariable and multi variable logistic regression model was used in the data analysis.

Results

The overall magnitude of anemia (hemoglobin level < 11 mg/dl) were found that 16.88% (95% CI: 13.95%, 19.8%). Factors which were significantly associated with anemia in the multivariable analysis were: history of malaria attack 1 year prior to study period (AOR = 4.73, 95% CI: 2.64, 8.46), women who had history of excessive menstrual bleeding (AOR = 3.94, 95% CI: 2.11, 7.35), unplanned pregnancy (AOR = 2.5, 95% CI: 1.4, 4.42) and three times or less meal frequency (AOR = 1.89, 95% CI: 1.02, 3.5).

Conclusion

The magnitude of anemia among pregnant were found that 16.88%. Malaria attack, excessive menstrual bleeding, pregnancy planning and meal frequency were found that significantly associated with anemia in the multivariable analysis. Pregnant women are recommended to increase meal frequency. Health providers should give attention to pregnant women who had history of malaria attack, excessive menstrual bleeding and women whose pregnancy were not planned.

Keywords

  • Anemia
  • Pregnant women
  • Ethiopia

Introduction

Anemia is defined as a low blood hemoglobin concentration [1]. It is a global public health problem affecting people in all age groups with major consequences for human health as well as social and economic development [13]. Anemia is a common health problem in pregnant women which is wider in developing countries than developed countries. As a result, it is associated with higher risk of low birth weight and both maternal and perinatal mortality and morbidity [47].

In developing countries, pregnant women are prone to anemia due to low socioeconomic conditions. The poor nutritional intake, repeated infections, frequent pregnancies and low health-seeking behaviors are associated with anemia [5, 8].

Since anemia is more common in child bearing women especially during pregnancy in Ethiopia, national nutritional strategies are formulated to reduce as part of the health sector transformation plan [9]. In countries like Ethiopia where anemia due to nutritional deficiencies mainly related to iron deficiency are the major causes [10, 11], identifying factors that are associated with anemia is necessary to control it. So, this study is aimed at assessing the magnitude and factors associated with anemia in pregnant women attending antenatal care.

Methods

Study design

Facility based cross sectional study design was conducted.

Study area and period

The study was conducted in central zone of Tigray region, Northern Ethiopia from November 1/2017 to January 30/2018. Central zone of Tigray is one of the six zones found in Tigray region. According to the 2007 census, Central zone of Tigray has 12 districts with estimated population of 1,500,000. Out of these population 750,000 are females and 750,000 are males. Central zone of Tigray has 66 health facilities (one referral hospital, 3 general hospitals, 6 primary hospitals and 56 health centers). The antenatal care (ANC) coverage of zone administration is 90%.

Source population

All pregnant women who attend ANC in public health centers in central zone of Tigray region during the study period.

Study population

All pregnant women who attend ANC at randomly selected public health centers in central zone of Tigray region during the study period.

Inclusion and exclusion criteria

Inclusion criteria

Pregnant women who attend 1st ANC visit and above at the same health center. Hence hemoglobin level of pregnant women was taken from base line assessment during 1st ANC visit as routine activities before starting any intervention.

Exclusion criteria

Women who attend 1st ANC other than the selected health center.

Sample size determination

The sample size was calculated using single proportion formula using epinfo-7 from study conducted in north west Ethiopia where the proportion of women with anemia was 25.2% [12].

Therefore, the total sample size was calculated using the assumption of marginal error 0.05, and 95% confidence interval. Based on these assumptions, the sample size was estimated as 290. After multiplying by 2 for design effect and adding 10% of non-respondents, the final sample size was determined as 638 study subjects.

Sampling procedures

Stratified multi stage sampling method was used to select health centers found in the central zone of Tigray region. During the selection of health centers, we stratified them as rural and urban. Two health centers each were randomly selected from 3 randomly selected woreda and one health center from urban in the central zone were included in the study. Proportion to sample size allocation was used to allocate the number of pregnant women from each health facilities by taking 3 months case load pregnant women on ANC visit. Systematic random sampling technique was used to get the study units.

Data collection procedure and tools

The data was collected through interviewing the pregnant women face to face after getting informed consent using structured and pre-tested questionnaire. The questionnaire was originally developed in English and then translate into Tigrigna (local language). Later on it was translated back to English to ensure its consistency. Finally, it was prepared in Local language (Tigrigna language) to collect data. In addition to that chart review was conducted to extract hemoglobin level at ANC 1st visit and another necessary data from ANC longitudinal register. During data collection, two BSC Degree and 7 diploma holder in nursing were hired as supervisors and data collectors respectively.

Data analysis

The data was coded and entered in to Epi-info 7 then exported to Stata 14 for cleaning and further analysis. Both Bivariable and multi variable logistic regression model was used in the data analysis. The assumption of logistic regression model fitness was checked using Hosmer and Lemeshow goodness of fit test statistics. Variables with P-value < 0.05 in the Bivariable logistic regression analysis was considered for inclusion in the multivariable logistic regression analysis to control the effect of confounders.

Variables which were significantly associated with the outcome variable were declared when adjusted odds ratio (AOR) with 95% confidence interval was significant in the multivariable analysis at P-value< 0.05.

Data quality

Three days intensive training were given to data collectors and supervisors on the data collection tools and collection procedures by the principal investigator.

Daily supervision of data collectors were made at each health centers during the study period by the supervisors and principal investigator. The collected data were carefully checked for completeness and consistency. Any confusion on the data collection procedure and responses were handled timely.

Results

Socio-demographic and economic characteristics of study participants

A total of 634 pregnant women were interviewed with the response rate of 99%. The average mean age of study participants was 26.99 years with standard deviation (SD) of 5.99. The majority of age group belongs to 20–34 years which accounts 487(76.81%). Nearly all 609(96.06%) of study participants were with orthodox religion. Regarding to marital status, 13(2.05%) of study participants were not married whereas 552(87.07%) were married. Eighty five (13.41%) of participants were with housewife occupation and 277(43.69%) of the study participants were with primary educational level. Four hundred fifteen (65.46%) of the study participant’s household size were 1–4 and about a quarter of study participants 127(25.08%) were with second wealth quintile (Table 1).
Table 1

Socio-demographic and economic characteristics of pregnant women attending ANC in public health centers in central zone of Tigray region, northern Ethiopia, 2018

Variables

Frequency

Percentage

Age in years

 15–20

55

8.68

 20–34

487

76.81

 ≥35

92

14.51

 Mean = 26.99 (SD = 5.99)

  

Religion

 Orthodox

609

96.06

 Muslim

25

3.94

 Marital status

  

 Not married

13

2.05

 Married

552

87.07

 Divorced

20

3.15

 Separated

46

7.26

 Others

3

0.47

Occupation

 House wife

85

13.41

 Farmer

399

62.93

 Merchant

89

14.04

 Employee

43

6.78

 Others

18

2.84

Level of education

 No formal education

173

27.29

 Primary

277

43.69

 Secondary

126

19.87

 Diploma and above

58

9.15

Household size

 1–4

415

65.46

 5–7

181

28.55

 ≥8

38

5.99

Wealth quintile

 Lowest

127

20.03

 Second

159

25.08

 Middle

181

28.55

 Fourth

60

9.46

 Highest

107

16.88

Out of the total study participants, 175(27.6%) were nulliparous and 79(16.92%) had history of abortion. Fifty seven (12.42%) and 37(8.06%) of the study participants were with less than 2 years birth interval and had history of still birth respectively. Regarding to history of malaria attack 1 year prior to this study period, 112(17.67%) of the study subjects had history of malaria. Most of the participants 542(85.49%) and 582(91.8%) had no history of excessive menstrual bleeding and pregnancy related complications respectively. Only 132(20.82%) of study subjects were with planned pregnancy. Almost half 315(49.68%) of the participants were with MUAC less than 23 cm.

The magnitude of anemia (hemoglobin level < 11 mg/dl) were found that 16.88% (95% CI: 13.95%, 19.8%). The mean hemoglobin level of study participants were 12.3 (SD ± 1.33). Most of the pregnant women 489 (77.13%) who attend their first ANC were at the 3–6 months of gestational age (Table 2).
Table 2

Obstetric history characteristics of pregnant women attending ANC in public health centers in central zone of Tigray region, northern Ethiopia, 2018

Variables

Frequency

Percentage

Parity

 Nulliparous

175

27.60

 1–4

391

61.67

 ≥5

68

10.73

Ever had abortion

 No

388

83.08

 Yes

79

16.92

Birth interval

 < 2 years

57

12.42

 ≥2 years

402

87.58

Had ever still birth

 No

422

91.94

 Yes

37

8.06

Have got malaria in previous year

 No

522

82.33

 Yes

112

17.67

Had excessive menstrual bleeding

 No

542

85.49

 Yes

92

14.51

Had pregnancy related complication

 No

582

91.80

 Yes

52

8.20

Planned pregnancy

 No

132

20.82

 Yes

502

79.18

Nutritional status (MUAC)

 < 23 cm

315

49.68

 ≥23 cm

319

50.32

Hemoglobin level

 < 11 mg/dl

107

16.88

 ≥11 mg/dl

527

83.12

 Mean 12.38(SD ± 1.33)

  

HGB level by gestational age (Average HGB level)

 < 3 Months Mean = 12.2(SD ± 1.63)

19

3

 3–6 Months Mean = 12.22(SD ± 1.29)

489

77.13

 > 6 Months Mean = 12.13(SD ± 1.41)

126

19.87

The meal frequency of study participants with greater than three times per day were 252(39.75%). Majority 541(85.33%) of the total participants were reported that they consume food made from cereals and grains daily. Besides, 179(28.23%) of the total participants didn’t take tea or coffee. Concerning to fruit and green leafy vegetables intake, only 11(1.74%) and 40(6.31%) of the total study participants reported with daily intake respectively (Table 3).
Table 3

Dietary factors characteristics of pregnant women attending ANC in public health centers in central zone of Tigray region, northern Ethiopia, 2018

Variables

Frequency

Percentage

Meal frequency

 ≤3times per day

382

60.25

 >3times per day

252

39.75

Eating food made from cereals, grains

 Daily

541

85.33

 Weekly

84

13.25

 Monthly or above

9

1.42

Drinking tea or coffee

 No

179

28.23

 Before meal

73

11.51

 Within 1 h

249

39.27

 After 1 h

133

20.98

Fruit intake

 No

291

45.9

 Daily

11

1.74

 Weekly

266

41.96

 Monthly or above

66

10.41

Green leafy vegetables intake

 No

91

14.35

 Daily

40

6.31

 Weekly

463

73.03

 Monthly or above

40

6.31

Dairy products/ milk product intake

 No

297

46.85

 Daily

58

9.15

 Weekly

211

33.28

 Monthly or above

68

10.73

Meat intake

 No

100

15.77

 Daily

16

2.52

 Weekly

172

27.13

 Monthly or above

346

54.57

Egg intake

 No

132

20.82

 Daily

62

9.78

 Weekly

343

54.10

 Monthly or above

97

15.30

Socio-demographic factors like; age of women, religion, marital status, occupation, household size and wealth quintile were not significantly associated with the anemia in Bivariable analysis at P-value < 0.05. Similarly, parity of women, history of abortion, birth interval, history of still birth and nutritional status were not significantly associated with anemia in Bivariable analysis. Regarding to dietary intake, variables which were not significantly associated with anemia in Bivariable analysis at P-value < 0.05 were; eating food made from cereals and grains, drinking tea or coffee, fruit intake, green leafy vegetables intake, dairy products/ milk product intake, meat intake and egg intake.

Variables which were significantly associated with anemia in Bivariable analysis but remains insignificant in multivariable analysis were; women’s level of education, birth interval and had pregnancy related complication. However, history of malaria attack 1 year prior to study period, women who had history of excessive menstrual bleeding, planned pregnancy and meal frequency were significantly associated with anemia in the multivariable analysis. Women with history of malaria attack were significantly associated with anemia comparing to women who had no malaria attack (AOR = 4.73, 95% CI: 2.64, 8.46). Comparing to women who had no history of excessive menstrual bleeding, anemia was 3.94 times higher in women with history of excessive menstrual bleeding (AOR = 394, 95% CI: 2.11, 7.35). Similarly anemia was higher in pregnant women who had no pregnancy planning (AOR = 2.5, 95% CI: 1.4, 4.42) comparing to their counter parts. Meal frequency less than or equal to 3 times per day was also significantly associated with anemia (AOR = 1.89, 95% CI: 1.02, 3.5) (Table 4).
Table 4

Bivariable and multivariable analysis of factors associated with anemia among pregnant women attending ANC in public health centers of central zone of Tigray region, northern Ethiopia, 2018

Variables

Anemia

COR (95%, CI)

AOR (95%, CI)

Yes

No

Women’s level of education

 No formal education

39(36.45%)

134(25.43%)

1

1

 Primary

35(32.71%)

242(45.92%)

2.01(1.22, 3.33)*

1.53(0.81, 2.89)

 Secondary

20(18.69%)

106(20.11%)

1.54(0.89, 2.8)

0.98(0.43, 2.25)

 Diploma and above

13(12.15%)

45(8.54%)

1.01(0.49, 2.06)

0.52(0.17, 1.61)

Birth interval

 < 2 years

16(20.78%)

41(10.73%)

2.2(1.2, 4.13) *

0.57(0.27,1.2)

 ≥2 years

61(79.22%)

341(89.27%)

1

1

Malaria attack in last 1 year

 No

64(59.81%)

458(86.91%)

1

1

 Yes

43(40.19%)

69(13.09%)

4.46(2.8, 7.1) *

4.73(2.64, 8.46) *

Had excessive menstrual bleeding

 No

69(64.49%)

473(89.75%)

1

1

 Yes

38(35.51%)

54(10.25%)

4.82(2.0, 7.84) *

3.94(2.11,7.35) *

Had pregnancy related complication

 No

93(86.92%)

489(92.79%)

1

1

 Yes

14(13.08%)

38(7.21%)

1.94(1.01, 3.72) *

1.87(0.77, 4.54) *

Planned pregnancy

 No

38(35.51%)

94(17.84%)

2.54(1.61, 4.0)

2.5(1.4,4.42) *

 Yes

69(64.49%)

433(82.16%)

 

1

Meal frequency

 ≤3 times per day

74(69.16%)

308(58.44%)

1.6(1.02, 2.49)

1.89(1.02, 3.5) *

 >3times per day

33(30.84%)

219(41.56%)

1

1

COR Crude Odds Ratio, AOR Adjusted Odds Ratio

*p-Value < 0.05

Discussion

We conducted study aimed on determining magnitude of anemia and factors associated with it. Out of 634 pregnant women included in the study, 107 (16.88%) were found to be anemic with 95% CI of 13.95 to 19.8% which is lower that studies conducted in Woldia (39.1%) [13], Gode town (56.8%) [11], Butajira (27.6%) [5], Nekemt (52%) [14], Mizan Tepi (23.5%) [15], Dera (30.5%) [4] and North West Tigray (36.1%) [16], but similar with the study conducted in Mekelle (19.3%) [10]. Overall magnitude of anemia in pregnant women is currently decreasing due to multi-sectorial interventions like increasing health access and economy in the country through time but still it remains a public health problem.

In this finding, pregnant women who had history of malaria attack in the last 1 year prior to study period were found that significantly associated with anemia (AOR = 4.73, 95% CI: 2.64, 8.46). This finding is similar with the study conducted in North Western zone of Tigray [16], in Dera District, South Gondar Zone [4] and Sunyani Municipal Hospital, Ghana [17] among pregnant women which declared that malaria attack was significantly associated with anemia. This could be explained that parasitic infections especially malaria results destruction of red blood cells [2].

In this study pregnant women with history of excessive menstrual bleeding were 3.94 times more likely to be anemic than those who had normal menstrual bleeding. A study conducted in Mizan Tepi University Teaching Hospital, South West Ethiopia [15] were also reported that heavy menstrual bleeding was significantly associated with anemia. This may be due to low iron reserves following excess bleeding during menstruation period.

Planned pregnancy was found that significantly associated with anemia. Anemia was 2.5 times higher in pregnant women whose pregnancy was not planned (AOR = 2.5, 95% CI: 1.4, 4.42). Women with their planned pregnancy may prepare prior or early in pregnancy on nutritional intake.

Meal frequency with 3 times or less per day was associated with anemia (AOR = 1.89, 95% CI: 1.02, 3.5). This study is consistent with Studies conducted in Mekelle town [10] and in North West of Tigray [16]. This implies increased meal frequency during pregnancy needs to fulfill the nutrients demand of pregnant women.

Conclusion

The magnitude of anemia among pregnant were found that 16.88. Factors that were independently significant with anemia were; history of malaria attack, excessive menstrual bleeding, pregnancy which was not planned and three or less meal frequency per a day. It is recommended that pregnant women should increase meal frequency. Health providers should give attention to pregnant women who had history of malaria attack, excessive menstrual bleeding and women whose pregnancy were not planned to control malaria in pregnancy.

Abbreviations

ANC: 

Antenatal care

AOR: 

Adjusted odds ratio

CI: 

Confidence interval

CM: 

Centimeter

COR: 

Crude odds ratio

HGB: 

Hemoglobin

MUAC: 

Middle upper arm circumference

SD: 

Standard deviation

Declarations

Acknowledgments

We would like to thank Aksum University for financial support of this study. Our thanks goes to directors of public health centers for their cooperation. Finally, we would like to thank the study subjects, data collectors and supervisors for their voluntariness in participating this study.

Funding

This research has been funded through college of Health sciences, Aksum University.

Availability of data and materials

The data used during the current study is available from corresponding author.

Authors’ contributions

TG have contributed in the design, data analysis, write up and manuscript development. EB, SH contributed in data collection and analysis. GK contributed to editing and revising of the final manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The ethical clearance was approved by Institutional Review Board of College of Health Sciences, Aksum University. In addition to that, permission was obtained from administration and directors of all health facilities. Information about the purpose of the study was given to the participants then informed written consent from pregnant women were obtained before data collection. On behalf of the participants under the age of 16, written consent was obtained from the parents/legal guardians.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
Department of Reproductive Health, College of Health sciences, Aksum University, Aksum, Ethiopia
(2)
Department of Human Nutrition, College of Health sciences, Aksum University, Aksum, Ethiopia
(3)
Department of Epidemiology and Biostatistics, College of Health sciences, Aksum University, Aksum, Ethiopia

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Copyright

© The Author(s). 2018

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