Prevalence of anaemia among pregnant women in Derna city, Libya

INTRODUCTION

Anemia is considered a major public health problem; playing an important contributor to mortality and morbidity among pregnant women globally, especially in developing countries.¹

Physiologically, during pregnancy there is an increase of iron and folate requirements, therefore the possibility of decreased iron and folate is high if there is not supplementation.² Early detection and effective management of anaemia in pregnancy would add to planning appropriate strategies aimed at reducing the burden of maternal morbidity and mortality. Anemia in pregnancy is associated with a reduced oxygen delivery to the fetus, subsequently causing intrauterine growth retardation, stillbirth, low birth weight, neonatal deaths, preterm birth, and consequent impaired growth and cognition of the child.^3,4

Furthermore, infants of anemic women are born with reduced iron stores and are at risk of anemia during infancy and increased risk of infant morbidity and mortality thereafter.^5,6 In developing countries, the main cause of anaemia during pregnancy is nutritional deficiencies of iron, folate, and vitamin B12 and also parasitic diseases, such as malaria and hookworm.^6,7 Women with sever anemia have lower ability of enduring moderate blood loss during labor, which makes them at higher risk of requiring blood transfusion.⁸ Furthermore, the mother with severe anemia may have increased the risks of cardiac failure or death from peripartum hemorrhage.² Therefore, reduction of anemia during pregnancy is therefore a key component of safe motherhood and childhood.⁹

In 2011 the World Health Organization (WHO) estimates the prevalence of anaemia in pregnant women worldwide as 38.2% (95% CI: 33.5-42.6) and in South-East Asia, Eastern Mediterranean and African Regions range from 38.9% to 48.7%.¹ In addition, African and Asian Regions appear to be the main affected regions worldwide, accounting for 46.3 % in Africa and 48.7% in South-East Asia. Followed by 25.8% in Europe and 24.9% in America Regions.¹

A number of studies on the epidemiology of anaemia in Africa; have shown different prevalence figures of anaemia. For example, in Nigeria 54.5%, in Ethiopia 56.8% and in Kenya 57%.^10-12

In addition, there has been few research on the epidemiology of anaemia in pregnancy in Arab countries, range from 25% in Kuwait to 40% in Saudi Arabia.¹ It appears that almost third of pregnant women in several Arab countries suffer from anemia, in Egypt 30% of pregnant women are affected, 31% in Iraq, Morocco 32% Qatar 28 %, Saudi Arabia 40%, Tunisia 29% and United Arab Emirates 26%.¹

Limited data are available in Libya, especially in different cities and regions, WHO in 2011 estimated that 28% of pregnant women in Libya suffer from anemia; a figure lower than previously estimated in 2005(34%).¹ So, the purpose of this study is to estimate the prevalence of anemia in pregnant women with its associated factors in Derna city in Libya.

METHODS

A cross-sectional face-to-face interview was used to gathered data from 01 June 2015 to 30 December 2015. The number of pregnant women required to be screen from study population was calculated according to Raosoft software.

The assumptions were: there is 95% power at the 5% significant level to find a 40 % prevalence of anemia, considering that there was no known study on the prevalence of anaemia amongst pregnant women in a primary health centre conducted in Libya. It was therefore calculated that a minimum sample size of 575 pregnant women would provide an estimate of prevalence with 4% error. However, this minimum sample size was increased to 595 participants to improve the precision of the study.

Patients’ selection

All pregnant women attending the antenatal clinic in the primary health centre were enrolled in the study. The role of antenatal clinic in Libya that the pregnant women should attend the clinical at least 3 times during the pregnancy period for clinical examination and ask for routine medical tests each trimester which including the haemoglobin level.

Procedure

Data was collected from pregnant women by questionnaires administered by the physician. Their names were not required on the questionnaire and each subject was assured that the information given was only for scientific purposes and would be kept confidential. Information on the questionnaire included socio-demographic characteristics such as age, occupation and educational status. Haemoglobin level was obtained from the last result reordered in patients file.

Anaemia in this study is defined by using the WHO criteria of haemoglobin values of less than 11g/dL.¹³

• • Mild anaemia 9.0-10.9g/Dl
• • Moderate anaemia 7.0-8.9g/dL
• • severe anaemia <7.0 g/dL

Statistical analysis

Data analysis was performed using SPSS software version 20. Descriptive statistics, including percentage, mean, range, and standard deviations, were calculated for all variables. Proportions were compared using Chi-square tests and P-value less than 0.05 was considered statistically significant. Logistic regression analysis was performed to estimate the association between the potential risk factors and anaemia among pregnant women.

RESULTS

Five hundred and ninety five (595) pregnant women were included in the study. The ages of the pregnant women ranged from 15 to 48 years with a mean age of 30.3±6.2 years. Most of pregnant women had completed a secondary-level education (59.8%) and (73.6%) were from the middle socio-economic class (Table1). The mean Hgb level of pregnant women was 10.63±1.43 g/dL (range: 6.00-14.00 g/dL) and the overall prevalence of anaemia among pregnant women was found to be 54.6% (95% CI, 51.45%-57.75%).

The prevalence of mild, moderate, severe anaemia were observed as 44.5%, 7.6%, and 2.5%, respectively. Thus the prevalence of mild anaemia was high in comparison to the other degrees of anaemia. Anaemia was observed to be more prevalent in pregnant women within age between 15-20 and 36-40 years. While age ≥41 had 1.58 times (OR=1.58; 95% CI=0.58-4.31; P=0.37) more likely to be anaemic than other age group. The association between age and anaemia in pregnancy was, however, not statistically significant (χ² = 4.082, p = 0.54) (Table 1).

The mean ages of anaemic and non-anaemic pregnant women were similar, 30.37 and 30.22 years respectively. The prevalence of anaemia was highest amongst pregnant women with a primary-level education (62.2%) (OR=1.57; 95% CI= 0.78-3.15; P=0.20). This relationship between the prevalence of anaemia and the level of education of pregnant women was not statistically significant (χ2 = 4.76, p = 0.190) (Table 1).

Anaemia was also found to be more prevalent amongst housewife (54.5%) followed by employed (55.70%) and businesswomen (55.00%) than students, but this relationship was not statistically significant (χ² = 1.92, p = 0.587). However, students had 1.88 times (OR=1.88; 95% CI= 0.70-5.00; p=0.20) more likely to be anaemic than other groups (Table 1). The family monthly income for anaemic and non-anaemic women was similar (χ² = 0.66, p = 0.72). However, the middle income had 1.12 times (OR=1.12; 95% CI=0.63-1.96; P=0.71) more likely to be anaemic (Table 1). Concerning obstetrical history, 74.1% were multigravida, 55.6% of the study women were parity from 0-1. The prevalence of anaemia was found more in multigravida (56.5%) with 1.33 times more likely to be anaemic than primigravidae (OR=1.33; 95% CI=0.92-1.92; P=0.13) and in women with more than 2 parity (Table 2).

Overall mean gestational age was 20.86±10.43 weeks ranged from 12 weeks to 43 weeks. The majority was in the third trimester (35.0%). Anaemia was found to be more prevalent in women during the third trimester (59.6%) (Table 2). The anaemic condition among different age groups shows to have no significance as the moderate and severe anaemic condition seem to have almost the similar values with little variation but mild anaemia was higher in all age groups (Table 3).

However, among the gestation age, there was no different between the distribution of anaemia in sever and moderate anaemia in gestational age while the heights percentage in mild anaemia in third trimester (49.8%) (Table 4).

DISCUSSION

This data was gathered from pregnant women from Derna City/ Libya. Libya is classified as a developing country with an HDI of 0.784 and Libya estimate of prevalence was higher and lower than other studies estimated.¹⁴ There is a consensus in the literature that anaemia is a common problem in pregnant women in most of developing countries.

The preliminary estimate of prevalence of anaemia in Derna was 54.6% (95% CI, 51.45%-57.75%) using WHO criteria, anaemia in pregnant women is when the haemoglobin concentration in the blood less than 11.0 g/dl. Furthermore, anaemia considered as a severe public health problem among pregnant women when the prevalence is 40.0% and more by WHO.¹ The prevalence of anaemia is high in this study, however, 44.5% had mild anaemia which Hb level ranged from (9-10 g/dl), 7.6% had moderate anaemia (Hb 7.0-8.9 g/dl) and 2.5% had severe anaemia (Hb<7.0 g/dl). This was lower than what found in pregnant women in Gondar, were (64%) mild type and (52.73%) and (60%) in India.^15-17

The prevalence estimate of anaemia in Derna / Libya was higher to the overall prevalence of anaemia among pregnant women in the world which was 38.2% and a slight similar to the overall prevalence among pregnant women in Africa, 44.6%.¹ Nevertheless, Derna’s estimate is within a range of the prevalence in some Africa countries for example in Nigeria was 54.5%¹⁰, Ethiopia was 56.8%, Kenya was 57%.^11,12 And lower compared with what was obtained in similar studies conducted in Nigeria (62.6%) and (62.2%) in Egypt.^18,19 And lower in women attended to antenatal clinic at hospital of Potro Novo-Cape Verde, Benin 38.8% and in other two studies in Nigeria 23.2% and 29%, 16.6% in Northwest Ethiopia.^15,20-22

Interestingly, this finding is higher to the overall prevalence found among pregnant women than other studies in the Middle East and North Africa, 40.08 % in Algeria, 26.2% in Bahraini, 27.1% in East Anatolian Province, Turkey, Jordan (34.7%) and (39%) in Makkah, Saudi Arabia.^23-27 There are many reasons to explain this variation. These variations in the prevalence may be due to different methodology and sampling techniques used, nutritional habits and characteristics of the target population.

The mean age group of pregnant women was 30.3±6.2 (15-48) years. Severe anaemic condition is seen among the pregnant women with age group between 36-40 years representing 6.5% followed by 2.5% severity among the age group 26-30. Pregnant women aged 41 years and above were about 1.58 times more likely to be anaemic compared to those aged 15-20 years. This was similar to other studies.^5,28 The age of the pregnant women was not significantly associated with anaemia. This is similar to other study.²³

No significant association was found between anaemia and educational levels. This is in accordance with Jordan and Nigeria study.^18,26 However, the prevalence of anaemia in this study was higher amongst pregnant women with primary education this is similar to findings in a study by Taner et al in Turkey, in Bahrain by Merza et al, in India by Lokare et al and in Nigeria by Ndukwu and Dienye.^5,18,24,28 The lower level of anaemia among women with primary education might due to the less awareness regarding to anaemia and consequences of anaemia.

Most of the women were employed 291 (48.9%). 162 (55.7%) of them were suffering from anaemia. This is in accordance with India study.²⁹ However, students were 1.88 times more likely to had anaemia than others. This may be because of the lower sample size of this group. Socio-economic status is known as one of the important factors of anaemia. Interestingly, in this study was not significant different between socio-economic classes and anaemia which similar to other study.^26,30 This appears to be at variance with other studies in which it is expected to be more in the lesser socio-economic class more prevalent.^5,18

The results in our study showed that 62% of pregnancies with parity more than 4 have anemia than other parity. This similar to other studies.^24,26-28 Pregnant women with Multipara were 1.33 times more likely to had anaemia than primigravidae but not statically significant. This is was similar to other study.³¹ The lower level of anaemia among women with Multipara might be due to the greater menstrual losses. Multiparity may induce anemia by reducing maternal iron reserves at every pregnancy and by causing blood loss at each delivery.

In present study, anaemia was found to be more prevalent among pregnant women in third trimester (59.6%). This is in accordance to some other studies; in Egypt, Jordan and Saudi Arabia.^{15, 18,25,29} This could be attributed to the increased requirements of micronutrients during the last trimester. Present study has some limitations; the data were collected from one urban city in Libya. This means that the results cannot be generalized to a rural population. Also, the absence of stratified sampling technique could introduce some bias in the study.

Literature discovered that tea reduces iron absorption but does not affect iron status in the body.³² So, the diet of the pregnant women should be investigated. As, most of Libyan population drink tea after the meal which unhealthy habits. Low intake of red meat was associated with anaemia, however, Libyan eat red meat at least 3 times a week. Biochemical tests included measurement of serum iron, ferritin, and total iron binding capacity (TIBC) should be used to classify the types of anaemia.

CONCLUSION

The prevalence of anaemia among pregnant women in Libya is comparable to that considered as a severe public by WHO suggesting those anaemia among pregnant women is public health problem in Libya. So, awareness regarding balanced diet, regular antenatal checkups, regular intake of iron and folic acid tablet, it is highly recommended.

ACKNOWLEDGEMENTS

The authors are grateful for all study participants who took part in the study for their time. We also acknowledge the antenatal clinic in the primary health centre for providing all necessary assistance to carry out the present study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The ministry of health in Derna city and faculty of medical technology approved the study

REFERENCES

1. 1. WHO .The global prevalence of anaemia in 2011. Geneva: World Health Organization; 2015. Available at: http://www.who.int/nutrition/publications/micronutrients/global_prevalence_anaemia_2011/e n/. Accessed on 9^th June 2015.
2. 2. Martí-Carvajal A, Peña-Martí G, Comunian G, Muñoz S. Prevalence of anemia during pregnancy: Results of Valencia (Venezuela) anemia during pregnancy study. Arch Latinoam Nutr. 2002;52(1):5-11.
3. 3. Levy A, Fraser D, Katz M, Mazor M, Sheiner E. Maternal anemia during pregnancy is an independent risk factor for low birth weight and prterm delivery. Eur J Obstet Gynecol Reprod Biol. 2005;122:182-6.
4. 4. Xiong X, Buekens P, Alxander S, Demianczuk N, Wollast E. Anemia during pregnancy and birth outcome: a meta-analysis. Am J Perinatol. 2000;17(3):137-46.
5. 5. Lokare PO, Karanjekar VD, Gattani PL, Kulkarni AP. A study of prevalence of anemia and sociodemographic factors associated with anemia among pregnant women in Aurangabad city, India. Ann Nigerian Med. 2012;6(1):30-4.
6. 6. Balarajan Y, Ramakrishnan U, Ozaltin E, Shankar AH, Subramanian SV. Anaemia in low-income and middle-income countries. The Lancet. 2011;378(9809):2123-5.
7. 7. Haidar J. Prevalence of anaemia, deficiencies of iron and folic acid and their determinants in ethiopian women. J Health Popul Nutr. 2010;28(4):359-68.
8. 8. Candio F, Hofmeyr GJ. Treatments for iron-deficiency anaemia in pregnancy: RHL commentary. The WHO Reproductive Health Library; Geneva: World Health Organization.
9. 9. Daily PJ, Wylie BJ. Iron deficiency during pregnancy: blessing or curse? J Infect Dis. 2008;198:157-8.
10. 10. Olatunbosun OA, Abasiattai AM, Bassey EA, James RS, Ibanga G. Morgan A. Prevalence of Anaemia among Pregnant Women at Booking in the University of Uyo Teaching Hospital, Uyo, Nigeria. BioMed Res. 2014. Article ID: 849080.
11. 11. Alene KA, Dohe AM. Prevalence of Anaemia and Associated Factors among Pregnant Women in an Urban Area of Eastern Ethiopia. Anemia. 2014. Article ID: 561567.
12. 12. Okube TO, Mirie W, Odhiambo E, Sabina W, Habtu M. Prevalence and factors associated with anaemia among pregnant women attending antenatal clinic in the second and third trimesters at Pumwani Maternity Hospital, Kenya. OJOG. 2016;6:16-27.
13. 13. World Health Organization. Micronutrient deficiencies: Iron deficiency anaemia 2008. Available at: http://www.who.int/nutrition/topics/ida/en/. Accessed on 01^st June 2015.
14. 14. United Nations Development Programme: Human Development Report 2009. New York United Nations Development Programme 2009. Available at: http://hdr.undp.org/en/media/HDR_2009_EN_Complete.pdf. Accessed on 4 February 2016.
15. 15. Melku M, Addis Z, Alem M, Enawgaw B. Prevalence and predictors of maternal anemia during pregnancy in Gondar, Northwest Ethiopia: An Institutional Based Cross-Sectional Study. Anemia 2014. Article ID 10859. Available at: http://dx.doi.org/10.1155/2014/108593.
16. 16. Vemulapalli B, Rao KK. Prevalence of anemia among pregnant women of rural community in Vizianagram, North Coastal Andhra Pradesh, India. AJMS. 2014;5(2):21-5.
17. 17. Cheema HK, Bajwa BS, Kaur K, Joshi H. Prevalence and possible risk factors of anaemia in different trimesters of pregnancy. IJCMR. 2016;3(4):1194-7.
18. 18. Ndukwu GU, Dienye PO. Prevalence and socio-demographic factors associated with anaemia in pregnancy in a primary health center in Rivers State, Nigeria. Afr J Prm Health Care Fam Med. 2012;4(1).
19. 19. Ibrahim ZM, Abd El-Hamid S, Mikhail H, Khattab MS. Assessment of Adherence to Iron and Folic Acid Supplementation and Prevalence of Anaemia in Pregnant Women. Med J Cairo Univ. 2011;79(2):115-21.
20. 20. Ouedraogo S, Koura GK, Accrombessi MM, Bodeau-Livinec F, Massougbodji A, Cot M. Maternal anemia at first antenatal visit: prevalence and risk factors in a malaria-endemic area in Benin. Am J Trop Med Hyg. 2012;87(3):418-24.
21. 21. Buseri FI, Uko EK, Jeremiah ZA, Usanga EA. Prevalence and risk factors of anaemia among pregnant women in Nigeria. Open J Hematol. 2008;2:14-9.
22. 22. Aluka C, Amadi AN, Kamanu CI, Fejyi-Waboso PA. Anaemia in pregnancy in Abia State University Teaching Hospital Aba. J Med Invest Pract. 2001;2:58-61.
23. 23. Demmouche A, Khelil S, Moulessehoul S. Anemia among pregnant women in the Sidi Bel Abbes Region (West Algeria): An Epidemiologic Study. J Blood Disord Transfus. 2011;2(3).
24. 24. Merza R, Alekri R, Alekri S, Alsaleh A, Alnasir F. The prevalence and factors associated with iron deficiency anemia in anemic pregnant women. Bahrain Medical Bulletin. 2014;36(3).
25. 25. Karaoglu L, Pehlivan E, Egri M, Deprem C, Gunes G, Genc MF, Temel I. Prevalence of nutritional anemia in pregnancy in an east Anatolian province, Turkey. BMC Public Health. 2010:10(329).
26. 26. Al-Mehaisen L, LKhader Y, Al-Kuran O, Abu Issa F, Amarin Z. Maternal anemia in rural Jordan: room for improvement. Anemia 2011. Article ID 381812.
27. 27. Abdelhafez AM, El-Soadaa SS. Prevalence and risk factors of anemia among a sample of pregnant females attending primary health care centers in Makkah, Saudi Arabia. Pak J Nutr. 2012;11(12):1113-20.
28. 28. Taner CF, Ekin A, Solmaz U, Gezer C, Çetin B, Keleşoğlu M, Erpala MB, Özeren M. Prevalence and risk factors of anemia among pregnant women attending a high-volume tertiary care center for delivery. J Turk Ger Gynecol Assoc. 2015;16:231-6.
29. 29. Rai N, Nandeshwar S, Rai P. A study on magnitude of anaemia and its socio-demographic correlates among pregnant women in Sagar city of Bundelkhand Region, Madhya Pradesh, India. Int J Community Med Public Health. 2016;3(1):128-32.
30. 30. Haniff J, Das A, Lim OT, Mohamaf ZM. Anemia in pregnancy in Malaysia: a cross-sectional survey. Asia Pac J Clin Nutr. 2007;16(3):527-36.
31. 31. Tolentino K, Friedman JF. An update on anemia in less developed countries. Am J Trop Med Hyg. 2007;77(1):44-51.
32. 32. Mennen L, Hirvonen T, Arnault N, Bertrais S, Galan P, Hercberg S. Consumption of black, green and herbal tea and iron status in Frenchadults. Eur J Clin Nutr. 2007;61(10):1174-9.