PREVALENCE OF ANEMIA AND ITS ASSOCIATED FACTORS AMONG PREGNANT WOMEN ATTENDING ANTENATAL CENTER IN SHARJAH, UAE

PREVALENCE OF ANEMIA AND ITS ASSOCIATED FACTORS AMONG PREGNANT WOMEN ATTENDING ANTENATAL CENTER IN SHARJAH, UAE

Moyad J. Shahwan ^*, Nageeb A. Hassan and Nada M. Sada

College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates.

ABSTRACT: Anemia during pregnancy is a common complication which can involve a mother’s health, baby’s health, or both. Socioeconomic status is affecting the prevalence of maternal anemia, which is varied substantially across regions and countries. Although, the prevalence of maternal anemia in UAE has not yet been well documented nationwide. Therefore, knowledge of the prevalence and determinants of low hemoglobin (Hb) levels will improve the health of pregnant women and upcoming generations. This study aimed to assess the prevalence of anemia and associated factors among pregnant women in UAE, Sharjah. The present study showed that the overall prevalence of anemia (Hb < 11 g/dl), was estimated to be 28.0%. The majority (16%) had mild anemia. There was no statistically significant difference between the anemic and nonanemic groups regarding socioeconomic and obstetric factors. Since, anemia among pregnant women is considered a moderate public health problem based on the World Health Organization classification of anemia. We recommend further studies to represent the whole nation and to assess the geographic location differences.

Anemia, Pregnant women, Maternal, Hemoglobin

INTRODUCTION: Prenatal care is essential preventive healthcare, which decreases the risk of pregnancy complications. Pregnancy complications are health problems which can involve a mother’s health, baby’s health, or both. One of the most common maternal health conditions a woman may experience during pregnancy is Anemia. However, anemia is defined as a hemoglobin (Hb) level of less than 11 g/dL, or hematocrit less than 33%, at any point during pregnancy ¹. According to the Centers for Disease Control and Prevention CDC, anemia is defined as hemoglobin and hematocrit lower than 11% and 33% in the first trimester, 10.5% and 32% in the second trimester, and 11% and 33% in the third trimester.

Many parameters can be changed due to the regular physiologic adjustment during pregnancy such as hemoglobin, hematocrit, reticulocytes, plasma ferritin, and unsaturated iron binding capacity. Therefore, diagnosing true anemia and determining the cause of anemia is challenging. Anyhow, in investigating iron status in women in the Middle East, most studies have used decreased serum hemoglobin to indicate anemia, decreased serum/plasma ferritin with normal hemoglobin levels to indicate iron deficiency or depleted iron stores, and decreased plasma ferritin together with decreased hemoglobin levels to indicate iron deficiency anemia IDA ².

Iron deficiency anemia is the most predominant cause of anemia during pregnancy ³. Approximately 50% of anemia’s due to iron deficiencies ⁴, and the remaining cases of anemia due to micronutrient deficiencies (e.g. folate, riboflavin, vitamins A and B12), acute and chronic infections (e.g. malaria, cancer, tuberculosis and HIV), and inherited or acquired disorders that affect haemoglobin synthesis, red blood cell production or red blood cell survival (e.g. haemoglobinopathies) ⁵.

Besides there are many other risk factors associated with maternal anemia that contribute to adverse fetal outcomes such as unhealthy lifestyle, age (<20 years or >35 years old), twin or multiple pregnancies, smoking or alcohol use and history of menstrual disorders ⁶. Anemia resulting from iron deficiency associated with low birth weight and increased risk of maternal and perinatal mortality ⁷.

In developing regions, 3.0 million deaths in 2013 were due to maternal and neonatal mortality, which was considered a significant contributor to overall global mortality ¹. Also, the Global overall prevalence for low birth weight infants due to Iron deficiency anemia is 15.5% - 20% ¹. In the UAE, the rates of low birth weight infants are widespread because of the high prevalence of Iron Deficiency Anemia in pregnancy ⁸. Moreover, maternal anemia may cause vaginal bleeding during the first trimester and high risk of preterm delivery ⁹. Therefore, anemia during pregnancy has shown to cause quite substantial consequences.

The Eastern Mediterranean Region had the third highest anemia burden for pregnant women, accounting for 3.9 million (95% CI: 3.3-4.6) women with anemia in 2011. A cross-sectional study was conducted on 6539 pregnant women from KSA by Mahfouz et al.and the overall prevalence of anemia was found to be 31.9% ¹⁰. In Egypt, Rezk et al. reported a prevalence of IDA at 51.3% in pregnant women ¹¹. In another survey of 270 pregnant Egyptian women, Ibrahim et al. found that 75% were mildly anemic (Hb 9-11 g/dL) and 23.2% were moderately anemic (Hb 7-9 g/dL) ¹².

Of those diagnosed with anemia, only 35.7% compiled with recommendations to supplement with folic acid plus iron. According to the Egypt Demographic and Health Survey reports, the increased use of iron supplements caused a marked reduction in IDA among pregnant women.

UAE is a pro-natal society, and there are high numbers of grand multiparous mothers among the obstetric population ¹³. Therefore, a high rate of anemia would be expected among pregnant women in the UAE. Although the prevalence of maternal anemia in UAE has not yet been well documented nationwide, limited data indicate that the prevalence of this burden among pregnant women ³. Therefore, knowledge of the prevalence and determinants of low hemoglobin levels will improve the health of pregnant women and upcoming generations. This study aims to assess the prevalence and associated factors of anemia among pregnant women in UAE, Sharjah.

METHODS:

Study Setting and Design: A retrospective Cross-sectional descriptive study was conducted in the antenatal center, Sharjah, UAE, with the duration of the study being six months. The data was collected from consecutive check-up examination records of apparently pregnant women in different age groups.

According to the World Health Organization (WHO), the degree of anemia was determined as mild (Hb = 10- 10.9 g/dl), moderate (Hb = 7- 9.9 g/dl) and severe anemia (Hb < 7 g/dl) ¹⁴.

The study included all pregnant women who attended the antenatal center, in the period from 1 January 2018 till the end of June 2018. All the participants are from Arab nationality, and their ages range from 17 to 45 years.

All Arab Pregnant women in the first trimester who came for the antenatal center during the study period were included in the study. Pregnant women with no history of thalassemia or any genetic diseases were included. Pregnant women in the second and third trimester were excluded. Pregnant women with previous abortion were also excluded. Cases of dysfunctional uterine bleeding and any other diagnosed diseases, especially hemoglobinopathies, renal and liver disease, were excluded.

Data Collection: Relevant sociodemographic data, medical (obstetric) history, details of the delivery, and laboratory data were obtained from the medical records of the patients including: age, occupation, type of previous deliveries, number of living children, last birth interval, RBC: Red Blood Cell count, Hb: hemoglobin, HCT: Hematocrit, MCV: Mean corpuscular volume MCH: Mean corpuscular hemoglobin, MCHC: Mean corpuscular hemoglobin concentration.

Ethical Principles: The study was conducted only after getting the approval and Permission from the main office in the antenatal center, Sharjah to gain access to previous medical records. The relevant data were collected from the Medical records department based on the ICD-10 definition of anemia in pregnancy from all the records of pregnant women during 1^st Jan 2018 - 30^th June 2018.

Statistical Analysis: The data management and analysis were initiated by presenting data in the Excel and were transferred into the Statistical Package for Social Science (SPSS) statistics software for further analysis. The data were presented by tables, graphs, and charts. Data were summarized using mean and standard deviation values for anemia and associated factors, number and percentage for categorical variables.

Chi-square test was done for associations. A t-test was done to compare mean values. A p-value<0.05 was considered significant.

FIG. 1: DISTRIBUTION OF PARTICIPANTS ACCORDING TO AGE

FIG. 2: DISTRIBUTION OF PARTICIPANTS ACCORDING TO THE OCCUPATION

FIG. 3:  DISTRIBUTION OF PARTICIPANTS ACCORDING TO THE TYPE OF DELIVERY

FIG. 4: DISTRIBUTION OF PARTICIPANTS ACCORDING TO THE BIRTH INTERVAL

FIG. 5: DISTRIBUTION OF PARTICIPANTS ACCORDING TO THE DEGREE OF ANEMIA

FIG. 6: DISTRIBUTION OF ANEMIA ON THE BASES OF AGE

RESULTS:

Socio-demographic Characteristics of the Participants: As shown in Table 1, A total of 100 representative health clinic attendees participated in the study. The mean ± SD age of the participants was 29 ± 4. The majority, 79(79.0%), of the participants, were within the age range of 25-34. Out of the 100 participants, 13(13.0%) and 8(8%) were in the age group of 16-24 years and 35 or above years, respectively. Most of the participants were housewives (72.0%), and about 28.0% of them were employees.

TABLE 1: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF PREGNANT WOMEN IN THE ANTENATAL CENTER, SHARJAH (No. = 100)

TABLE 2: OBSTETRIC CHARACTERISTICS OF PREGNANT WOMEN (No. = 100)

Obstetric Characteristics of the Participants: Sixty-seven (67.0%) of the antenatal center attendees had a previous history of pregnancy. From those who had the previous history of birth, 50(74.6%) and 17(25.4%) had a history of normal and cesarean deliveries, respectively. Also, from those who had the previous history of birth, the majority, 54(80%), had 1-2 living children, 12(17.9%) had less than four children, and one attendee had five or more at the time of the study. Moreover, from those who had a history of birth, 22(32.8%) and 45(67.2%) had a birth interval of fewer than two years and more than two years between the last and the current pregnancy, respectively. Only 6(6.0%) of the participants had two or more cesarean deliveries.

Prevalence and Severity of Anemia: Prevalence and degree of anemia among pregnant women are shown in Table 3. Among the 100 study participants, the overall prevalence of anemia (Hb < 11 g/dl), was estimated to be 28.0%. The mean Hb concentration was 11.5 ± 1.2 g/dl with a range of 9 to 13.9g/dl. The degree of anemia among pregnant women was estimated based on the classification of WHO for the severity and degree of anemia in pregnancy: mild anemia (Hb = 10- 10.9 g/dl), moderate anemia (Hb = 7- 9.9 g/dl), and severe anemia (Hb< 7 g/dl). The result of this study indicated 16% mild anemia, 12% moderate anemia, and 0% severe anemia among pregnant women.

TABLE 3: PREVALENCE AND DEGREE OF ANEMIA AMONG PREGNANT WOMEN

Factors Associated with Anemia Among Pregnant Women: Anemic and non-anemic pregnant women were categorized into three age groups 16-24 years, 25-34, and more than 35 years. Out of 28 anemic women, four were in 1^st, and third groups and 24 were in the 2^nd group. While out of 72 non-anemic pregnant women 11 were in the 1stgroup, 55 in the 2^nd group and 6 in the 3^rd group. It was seen that the prevalence of anemia is higher in the 25-34 years age group as compared to other age groups Table 4. There was no statistically significant difference between the anemic and non-anemic groups regarding maternal age and occupation.

Anemia status in pregnant women was shown in Table 5 according to the obstetric factors, which include: type of delivery, number of births, the interval of last birth, and number of cesarean surgeries. There was no statistically significant difference between the anemic and non-anemic groups regarding obstetric characteristics.

RBC: Red Blood Cell count, Hb: Hemoglobin, HCT: Hematocrit, MCV: Mean corpuscular volume, MCH: Mean corpuscular hemoglobin, MCHC: Mean corpuscular hemoglobin concentration

Patients were distributed based on complete blood count (CBC) parameters. Out of 100 patients, MCV was low (microcytic) in 31 women, normal (normocytic) in 68 and high (macrocytic) in one woman. The majority, 87 women, had normal MCHC, 12 women had high MCHC, and one had low MCHC at the time of the study. Moreover, 3 and five women had low and high MCH, respectively. While 92 had normal MCH (normochromic). HCT was low in 75 women, and it was average in 2 women and high in 23. R.B.C was low in 90 women, and it was normal in 10 women.

Out of 28 anemic women, the majority had normocytic (55%) and normochromic (92%) anemia. However, there is no statistically significant difference between anemic and non-anemic groups regarding CBC parameters.

TABLE 4: CROSS TABULATION BETWEEN THE SOCIO-DEMOGRAPHIC CHARACTERISTICS AND LEVEL OF Hb (N=100)

TABLE 5: CROSS TABULATION BETWEEN THE OBSTETRIC CHARACTERISTICS AND LEVEL OF Hb (N = 100)

P: level of significance; *Significant association (P < 0.05)

TABLE 6: DISTRIBUTION OF PATIENTS ON THE BASIS OF CBC PARAMETERS

TABLE 7: CROSS TABULATION BETWEEN THE CBC PARAMETERS AND LEVEL OF Hb

DISCUSSION: The present study was conducted to assess the prevalence of anemia and its associated risk factors among pregnant women attending the antenatal center in Sharjah. According to WHO, the prevalence of anemia is high among pregnant woman with high rates of prevalence (35 to 75%) in many developing countries ¹⁴.

In the present study based on the blood picture of 100 pregnant women, the overall prevalence of anemia is 28%. This prevalence is considered a moderate public health problem ¹⁴. Our findings are close to the results reported from neighboring countries which specified that prevalence of anemia among pregnant women in Qatar 28%, Syrian Arab Republic 30%, Jordan 27%, Lebanon 27%, Libya 28%, United Arab Emirates 26%, Sri Lanka 26% and Iran, Islamic Rep 26% ^{14, 15}.

On the other hand, the prevalence of anemia in the present study was lower than that reported in India (87-100%), Boditi (61.6%), Gode town, Eastern Ethiopia (56.8%), Tanzania (58.2%), Yemen (58.09%), Sudan (57.745), Guinea-Bissau (57.7%), Senegal (57.58%), Vanuatu (57.3%), Cambodia (57.1%), and Angola (57.07%) ^{15, 16}. This difference could be resulting from the geographical variation of factors across different areas, food consumption, and due to the time gap between the current study and other studies.

The present study specifies that out of all pregnant women involved in this study, 16% had mild anemia, and 12% had moderate anemia, and no one had severe anemia. Majority of women had mild anemia followed by moderate anemia. These findings are also comparable with the results from other studies ^{17, 18}.

In the current study, the mean age of pregnant women was 29 ± 4 years. A study from Karachi has informed a similar mean age of the pregnant women as 28 ± 5.20 years ¹⁹. The anemic and non-anemic pregnant women further divided based on age into three groups’ (16-24, 25-34, and more than 35 years).

In the present study, there was no statistically significant difference between the anemic and non-anemic groups regarding maternal age. This is inconsistent with a result of a case-control study conducted by Zama et al., ^20, which found that no statistically significant difference between the anemic group and the non-anemic group regarding maternal age.

The majority of pregnant women were housewives (72%) while the employees were (28%). In the current study, there is no statistically significant difference between the anemic group and the non-anemic group regarding occupation. This is in contrast to a result of a study conducted by Hala M et al., which found that the risk of anemia was higher among housewives as compared with employees ²¹. This difference may be due to the small sample size in the present study compared to other studies.

Moving onto the obstetric history of the patient, our study depicted that the majority of cases of anemia underwent normal deliveries. When associating anemia with the type of previous deliveries of the patient, it was concluded that no statistical y significant difference between the anemic and non-anemic group regarding the type of delivery.

From those who have previous deliveries (67), most of the participants had (1-2) previous births or living children (54), birth interval more than 2 years (45) and one or less cesarean surgery (94%). However, investigating the possible risk factors associated with anemia among the participants revealed that no statistically significant difference between the anemic and non-anemic group regarding a number of births, birth interval and number of cesarean surgeries.

On the contrary to our results, a study conducted among pregnant women in Sokoto, Nigeria specified that anemia was highly prevalent in women with multiple previous births. It also stated a number of living children as being one of the potential etiological factors of anemia in pregnancy ²². Another study revealed that the risk of getting anemia increase as the number of births increase ²³. Also, a cross-sectional study revealed that pregnant women having birth interval less than two years were at higher risk of becoming anemic as compared to those with a birth interval for more than two years ¹⁷. These differences are according to the small sample size and the setting (one medical center) of the current study.

Moreover, a study conducted in Yemen showed that pregnant women who underwent two or more cesarean surgeries were found to have an increased risk of anemia during pregnancy ²⁴. Another study revealed that cesarean sections are accompanied by the risk of suffering serious complications, including hemorrhage, infection, and rupture of the uterus ²⁵.

Patients were distributed based on CBC parameters. Majority of participants have a normal size of red blood cell (normal MCV) and normal size of hemoglobin concentration in the red blood cell (normal MCH, MCHC). Also, from those who had anemia, the majority had normochromic, normocytic anemia. It is shown in Table 6 that there is no statistically significant difference between the anemic and non-anemic groups regarding CBC parameters or red blood cell indices.

CONCLUSION: The overall prevalence of anemia among women attending the antenatal center in Sharjah was 28%, so anemia is considered a moderate public health problem. Sociodemographic factors (age, occupation), obstetric factors (a type of delivery, number of births, birth interval, number of cesarean surgeries), and CBC parameters were not significantly associated with anemia. We recommend further studies to represent the whole nation and to assess the geographic location differences.

ACKNOWLEDGEMENT: The authors gratefully acknowledge Dr. Ammar Jairoun proofreading of the manuscript and comments.

COMPETING INTEREST: The authors declare no conflict of interest.

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    How to cite this article:

    Shahwan MJ, Hassan NA and Sada NM: Prevalence of anemia and its associated factors among pregnant women attending antenatal center in Sharjah, UAE. Int J Pharm Sci & Res 2019; 10(11): 5002-09. doi: 10.13040/IJPSR.0975-8232.10(11).5002-09.

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