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Research Article | DOI: https://doi.org/10.31579/2693-4779/245
1Yemeni Board for Medical and Health Specialties, Ministry of Health and Population, Republic of Yemen.
2Departement of Basic Sciences, Faculty of Dentistry, Sana’a University, Republic of Yemen.
3 Medical Microbiology and Clinical Immunology Department, Faculty of Medicine and Health Sciences, Sana’a University, Republic of Yemen.
4Department of Medical Laboratories, College of Medicine and Health Sciences, Hadhramout University, Al-Mukalla, Republic of Yemen.
5National center of Central Public health Laboratories, Ministry of Health and Population.
6 Medical Microbiology and Clinical Immunology Department, Faculty of Health Sciences, Thamar University, Republic of Yemen.
*Corresponding Author: Hassan A. Al-Shamahy, Hatay 1-Faculty of Medicine and Heath Sciences, Sana'a University.
Citation: Al-Jarrmozi SAA, Amel A. Almagrami, Al-Moyed KA, Al-Shamahy HA, Al-Haddad AM, et al, (2024), Prevalence and Risk Factors for Anemia During Pregnancy in Sana'a City, Clinical Research and Clinical Trials, 11(4); DOI:10.31579/2693-4779/245
Copyright: © 2024, Hassan Abdulwahab Al-Shamahy. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 09 November 2024 | Accepted: 29 November 2024 | Published: 24 December 2024
Keywords: anemia; pregnancy; risk factors; hemoglobin; Sana'a; Yemen
Background: A common issue during pregnancy is anemia, which is defined as a decline in the blood's ability to carry oxygen, mainly as a result of lower hemoglobin levels. There are two possible types of declines: absolute and relative. It is well known that the most prevalent nutritional condition is iron deficiency.
Objective: In order to ascertain the prevalence of anemia and related risk factors among pregnant women in Sana'a, Yemen, a cross-sectional study was conducted.
Subjects and methods: Two hundred pregnant women between the ages of 17 and 40 years participated in this study. Calculations were made for socio-demographic, menstrual history, and haematological characteristics. Platelet counts were ascertained along with anemia proxies such as hemoglobin (HB), hematocrit (HCT), mean corpuscular volume (MCV), packed cell volume (PCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC).
Results: The mean hemoglobin level among our pregnant females was 12.8 mg/dL, with 26% diagnosed with anemia (<11.9 mg/dL). Notably, 38% of patients exhibited PCV levels below the norm, while none in >46 PCV (above the normal level). The average RBC count stood at 4.5 cells x 106/μl, ranging from 3.6 to 5.9 cells x 106/μl, with none falling below the normal range for adult females. The mean MCV was 81.3 fl, with 34% displaying microcytic anemia (<80 fl). Additionally, the mean MCH was 28.3 p/cell, with 22% experiencing iron deficiency anemia and 8% showing elevated counts (>31 p/cell) suggestive of anemia due to low folic acid or vitamin B12 levels. The mean MCHC was 34.6 g/dl, with 18% having levels exceeding 36 g/dl, indicating anemia. Age played a significant role, with anemia being notably associated with those under 19 years, exhibiting an odds ratio of 2.8. Other significant associations included illiteracy (OR = 2.3, p =0.01), being in the third trimester (OR=2.1, p=0.04), multigravida (OR=2.2, p=0.05), having a menstrual cycle longer than 5 days (OR=7.5, p <0.0001), and experiencing bleeding during pregnancy (OR=5.6, p<0.0001).
Conclusion: The prevalence of anemia during pregnancy among Yemeni pregnant women was moderate, but at a significant rate. Multigravidy and the third trimester were associated risk factors with a higher incidence of anemia during pregnancy. Other risk factors were women younger than 19 years, a longer menstrual cycle >5 days, bleeding during pregnancy, and a low level of education.
Pregnancy-related anemia is a common issue that is defined as a loss in the blood's ability to carry oxygen, mainly as a result of lower hemoglobin levels. There are two possible types of declines: absolute and relative. As most pregnancies result in a higher increase in plasma volume than red blood cell mass, it is commonly known that this causes "physiologic anemia." For decades, these physiological alterations have been described by a phenomenon known as "plethora gravidarum." The question of whether this "hydremia" is normal or indicative of a medical issue is still up for debate [1-3].
There is no published data regarding the prevalence of anemia among pregnant women in Yemen's various regions, nor is the prevalence of anemia among them known. Pregnant women's anemia rates can differ according to their socioeconomic level, access to healthcare, and eating habits, among other things. Pregnancy-related anemia is still a major public health concern in Arabic nations 2.
In pregnancy, anemia is defined as having a hematocrit of less than 33% or a hemoglobin level of less than 11 g/dL at any one time, according to the World Health Organization (WHO) 1. Pregnancy-related anemia is defined by the US Centers for Disease Control and Prevention as hemoglobin levels below 11 g/dL, hematocrit levels below 33% in the first or third trimester, or hemoglobin levels below 10.5 g/dL and hematocrit levels below 32% in the second trimester 3. The risk of anemia rises with each stage of pregnancy. By CDC standards, 8 percent of American low-income pregnant women are anemic in the first trimester, 12 percent in the second, and 34 percent in the third [4].
The US Department of Health and Human Services (DHHS) states that a key predictor of reproductive health is the prevalence of third-trimester anemia. Black Americans had the highest prevalence rate (48.5%), followed by Asians, Native Hawaiians and other Pacific Islanders (29%), Whites (27.5%), American Indians and Alaska Natives (33.9%), Hispanics and Latinas (30.1%), and Hispanics and Latinas [4,5]. Physicians D:\ARTICLES\CRCT\Next articles from 167\CRCT-24-RA-245have long understood that the reason why 10% to 70% of pregnant women reported in studies conducted in the early 20th century had hemoglobin levels below 7 g/dL was not due to hydremia alone. Due to the frequent discovery of hypochromia, microcytosis, and anisocytosis in blood smears of pregnant women with anemia and the repair of such anomalies following the administration of iron supplements, the 1950s established a substantial role for iron deficiency in pregnancy anemia [6]. Since then, the iron shortage has been acknowledged as the most prevalent cause of anemia in pregnancy around the world. This anemia typically manifests in the third trimester, when the iron is most maximally collected to support erythropoiesis in the developing baby [7].
The size and quantity of hemoglobin in each red blood cell can also be used to categorize anemia. It is known as microcytic anemia if the cells are small, macrocytic anemia if they are large, and normocytic anemia if the cells are normal in size. A hemoglobin level of less than 130 to 140 g/L (13 to 14 g/dL) for men and less than 120 to 130 g/L (12 to 13 g/dL) for women is the basis for diagnosing anemia 8,9. The reason must then be determined by additional testing [8,10].
This cross-sectional study was aimed to study the prevalence and associated risk factors of anemia in pregnancy among Yemeni women. Our results are anticipated to provide specific guidance for future studies and what needs to be addressed to fill in knowledge gaps at this time.
Study design
This cross-sectional active laboratory study was carried out in maternal clinics in Sana'a, Yemen from December 2023 until end of February 2024.
Sample size
A sample size of 200 was calculated using the following parameters: confidence level = 95%, margin of error = 6.22%, and frequency of anemia among pregnant women = 28% [Ref-1].
Data collection
Individual data were collected in a pre-designed questionnaire, including demographic data, pregnancy data, risk factors of anemia, clinical data, and laboratory results.
Statistical analysis
By using Epi Info statistical program version 6 (CDC, Atlanta, USA), the analysis of the data was performed. Expressing the quantitative data as mean values, or standard deviation (SD), when the data was normally distributed. Expressing the qualitative data as percentages. Also risk factors were calculated by 2X2 tables to get odds ratio, confidence interval, chi square and p value to determine the associated risk factors of anemia among our pregnant women.
Ethical consideration
Ethical authorization for the study was obtained from the Research Review Committee of the Faculty of Medicine and Health Sciences. All participants received an explanation of the study's goals and informed consent was taken from all participants before sampling.
Fields And Laboratory Works
From December 2023 until end of February 2024, a cross-sectional study centered in selected maternity clinics in the tertiary hospitals in Sana’a city was carried out, enrolling 200 pregnant females. Direct interviewing and review of medical records were used to gather socio-demographic and clinical data. Each participant provided a venous blood sample to determine blood markers including such as hemoglobin (HB), packed cell volume (PCV), red blood cells (RBCs) count, hematocrit (HCT), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC).ub
The mean age of our patients was 25.6 years with SD equal to 5.9 years and ages ranged from 17-40 years. Most of pregnant women were in the age group of 20-30 years (60%), followed by the group of >30 years (28%), while <19>Age groups (years) Number (%) Less than 19 36 (18) 20-25 60 (30) 26-30 60 (30 ) >30 44 (22) Total 200 (100) Mean age 25.6 years SD 5.9 years Median 26 years Mode 18 years Min-Max 17-40 years
Table 1: Age distribution of pregnant women included in the study in Sana’a city, tested for anemia
The mean hemoglobin level of our pregnant females was 12.8 mg/dL, the standard deviation level was 1.5 mg/dL and the level ranged from 9.0 to 15.6 mg/dL. Anemia (<11>Hb (mg/dL) Number (%) Less than 11.9 52 (26) 12-14 104 (52 ) ≥14.1 44 ( 22) Total 250 (100) Mean 12.8 SD 1.5 Median 13 Mode 11.9 Min-Max 9.0-15.6
The normal Hb level in adult females is 11.9 to 15 mg/dl.
Table 2: Hemoglobin level in pregnant women included in the study in Sana'a city, who were tested for anemia
Table 3 displays the PCV levels of pregnant women. Among the patients, 38% exhibited PCV levels below the normal range, 62
Anemia raises the risk of both maternal and newborn morbidity and mortality, as well as physical and psychological co-morbidity in mothers [11]. Yemen has the greatest prevalence of anemia among pregnant women (26%), according to the current study's data, however there is a considerable range in Yemen. Pregnancy-related anemia is more prevalent than one may realize; this broad range in prevalence may be caused by cultural diversity in socioeconomic conditions, lifestyle, and health-seeking practices. According to a recent systematic review and meta-analysis, the prevalence of anemia during pregnancy was found to be 36.8% (95% CI: 31.5%-42.4%) worldwide, with Africa having the greatest prevalence (41.7%) [12,13].
The current investigation found that multigravida and the third trimester were risk factors for an increased incidence of anemia in pregnancy. This finding was comparable to the risk factor in four studies 14-16, which found that multigravida/multiparous >3 was a risk factor in four studies 14-16]19], and nulliparous [17,18] was one of the risk factors to increase the incidence of anemia in pregnancy. This could occur from a pregnant woman's iron levels being depleted by several pregnancies [20]. A Malaysian study 21 found that the percentage of anemia was higher in grand multigravida women (66.7%). According to Okafor et al. and Isah et al., multiparity is a significant risk factor associated with iron deficiency anemia [22,23]. Pregnancy requires up a lot of iron, therefore having too many pregnancies too close apart will lead to an iron deficiency [24]. Pregnant women have a three to four times higher need for iron than non-pregnant women do [25].
Although iron can be mobilized from the maternal stores to meet this requirement, women are generally seen to have low iron stores, possibly due to the monthly blood loss during menstruation [26]. Once these reserves are depleted, the mother will develop an iron shortage [27]. A reduction in the rate at which hemoglobin is produced as a result of an iron deficit can lead to iron deficiency anemia [28]. Reducing the total number of pregnancies and increasing the time between pregnancies can help control iron deficiency
anemia in women. By reducing a woman's need for iron through family planning and child spacing, iron deficiency anemia's consequences and iron depletion can be avoided.
Other risk variables included in the current study included low educational attainment, bleeding during pregnancy, longer menstrual cycles than five days, and women under the age of 19. These findings are in line with the risk factors for anemia among pregnant women that have been reported in other studies, which include women under the age of 25 17, low income 14, a menstrual cycle longer than five days 14, bleeding during pregnancy 14, infrequent meat consumption 14, low level of education [29], and decreased consumption of iron-rich foods [30]. Low socioeconomic characteristics have also been associated with the incidence of iron deficiency anemia during pregnancy [31]. Anemia is a measure of socioeconomic hardship since it is inversely connected with household socioeconomic level, especially in emerging countries [32].
In Malaysia, the prevalence of anemia during pregnancy varied from 19.3% to 57.4%, with iron deficiency anemia specifically ranging from 20.8% to 21.2!. This level of anemia in pregnant women is similar to rates seen in countries with lower economic statuses. For instance, in Ethiopia, the pooled prevalence of anemia among expectant mothers was 31.66, while in Sudan it stood at 53.0% [33]. In contrast, in Iran, a similarly developing nation, the prevalence of anemia among pregnant women was notably lower at 13.6% [34].
The study that is mentioned indicates that anemia is still a major issue for Yemeni pregnant mothers. Prenatal or antenatal anemia screening should be customized for each pregnant lady 19,35. Two studies suggest that during pregnancy and for three months after delivery, health education programs at Primary Health Care Centers should address the need of adhering to iron supplementation guidelines and consuming an appropriate amount of iron-rich dietary sources 30, [36].
As part of the normal prenatal care for all pregnant women, the government and nongovernmental organizations ought to prioritize providing iron and folic acid supplements. In order to avoid repeated pregnancies, long-acting family planning methods must be used in all Yemeni locations where anemia is more common. Health extension providers ought to encourage community-based awareness initiatives and prenatal checkups. To fully understand the causes of anemia in pregnant women, further research must be done across the nation.
Among Yemeni pregnant women, anemia during pregnancy was significantly more common. Pregnancy-related anemia was found to be associated with risk variables such as multigravidity and the third trimester. Women under the age of 19, a menstrual cycle longer than five days, bleeding during pregnancy, and poor levels of education were additional risk factors.
For their collaboration and support, we thank and appreciate all the medical staff at maternal clinics in Sana'a, Yemen.
This work does not include any conflicts of interest.
Salwa’a Ahmed Ali Al-Jarrmozi, the first author of the study, under the supervision of Dr. Hassan A. Al-Shamahy. The other authors contributed to data analysis, writing, review, and final approval of the work.
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