Introduction
Anemia is presently a common
nutritional problem in the world and it is associated with potential
adverse effects such as reduced power of labor and reproductive disorders (1).
In this disorder, the volume of red blood cells and the serum levels of iron
decrease, and in case of failure to compensate this loss, the hemoglobin levels
also decrease and anemia occurs (2). Iron deficiency is the most common cause of anemia during
pregnancy. Increased risk of anemia during pregnancy is caused by the mother’s
increased need for iron, fetal and placental iron demand for growth, increased
red blood cell mass, and the mother's increased blood volume in the third trimester (3). This disorder during pregnancy is a
recognized risk factor for the mother and fetus. The most important fetal
complications include growth retardation, preterm birth, and intrauterine
death, and the main maternal outcomes include cardiovascular symptoms, loss of
immune function, weakness, fatigue, and reduced blood supply (4). However,
anemia is not a disease, but a symptom like fever, and it is very common during
pregnancy. Due to the lack of oxygen in the tissues, complications such as
fatigue, dizziness, weakness, and shortness of breath, which are symptoms of
anemia, occur (5).
According to the World Health
Organization (WHO), Iron Deficiency Anemia (IDA) in pregnant women refers to a
hemoglobin concentration of less than 11 g/dl in the first and third trimester
and a 5 g/dl reduction in the second trimester
(6). Women, from the first months of pregnancy and even much later, suffer from
iron deficiency accompanied with a reduction in red blood cell count. In a
normal pregnancy with a single fetus, the pregnant mother requires about a
thousand milligrams of iron. It seems that this total amount of iron extends
many women’s sources of iron. If the body cannot compensate this difference
through the digestive system, it results in IDA (7).
According to the results of
studies conducted in different regions, factors such as low education levels,
teenage pregnancy, multiple births, poor nutritional status, wrong food habits, history of parasitic diseases, irregular use or
non-use of iron, and abortion were effective on the incidence of IDA (8-10).
Anemia associated with iron
deficiency is a major problem in developing countries. It was estimated that
52% of pregnant women in developing countries were anemic, while this ratio in
developed countries was 23% (11). The WHO estimated that IDA constituted about
20% of the 515000 maternal deaths worldwide in 2005 (12). The numerous studies
carried out on the epidemiology of IDA among pregnant women of different
societies, including Iran, have reported contradictory results. A survey
conducted in 11 regions of Iran in 2001 on 4368 healthy pregnant women in their
5th-9th months of pregnancy estimated their iron status
(due to the need to evaluate the effect of iron supplementation), the results
of this study showed that the prevalence of IDA in pregnant women was 21.5%
(13). The prevalence of IDA in pregnant women in a study conducted in Shiraz,
Iran, in 2011 was estimated as 12.3% (12). According to a study conducted in
Thailand in 2009, the prevalence of IDA in the first and third trimesters was
1.3% and 41.7%, respectively (14).
Today, in Iran, in order to
prevent IDA, iron supplements in the form of pills and drops are distributed
among high-risk groups, such as pregnant women who are in their fourth month of
pregnancy until three months after delivery, through health systems and health
centers. This measure can improve iron deficiency relatively fast and it can be
used as an important strategy to solve this problem in groups of the population
which are more susceptible to iron deficiency (7). Low intake of iron
supplements were due to the unawareness of
pregnant mothers regarding their necessity, unpleasant taste, and side effects. The success of the
iron supplementation program requires strengthening the training of health
workers, providing maternal education, and producing higher quality supplements
(1).
To prevent future outcomes for
both the mother and fetus, research on the prevalence of IDA among pregnant
women has an important role in decision-making and political planning (11).
Since the completion of the international iron supplementation program, based
on the high prevalence of anemia, the WHO has recommended prevalence studies to
monitor health regeneration (15). The highest rate of childbirth complications
and maternal and fetal mortality in terms of socioeconomic status of women was
related to the lower classes of society, and multiple pregnancies (16). Anemia
in various regions, due to being affected by
climatic, social, economic, and cultural conditions, has different prevalence
and accurate statistics on the prevalence of anemia in pregnant women is not
available (8). There are also no records of the prevalence of IDA among
pregnant women in Bandar Lengeh, Iran. Therefore, in
this study, the prevalence of IDA and factors influencing it were studied among
pregnant women in Bandar Lengeh. It
was expected that the results of this study would provide useful
information for more favorable healthcare during pregnancy and improved
maternal health.
Material
and Methods
This was a cross-sectional study
conducted in 2015. The research environment included urban
healthcare centers covered
by the health network of Bandar Lengeh. This city is located in the
southern part of Iran, and its population is 116 thousand. The study population
included all pregnant women attending urban healthcare
centers who had completed their pregnancy.
The sample size was estimated
using formula (1) and considering the confidence level of (Z2) 95%,
sampling error of (d) 0.04, and prevalence of (p) 0.21 of IDA in pregnant women
based on previous studies (13).
(1)
Therefore, sample size was estimated as 398
individuals and with the possibility of sample loss it was determined as 420
individuals.
Bandar Lengeh had two urban
healthcare centers (Shahid Rajayi and Shahid Ghaderinezhad) and one health
clinic (Shahid Bahonar). The general population of pregnant women covered by
Shahid Rajayi Health Center was 333 individuals, Shahid Ghaderinezhad Health
Center was 335 individuals, and Shahid Bahonar Clinic was 158 individuals. For
sampling, each of the three centers were considered as a single cluster and the number of subjects
assigned to each center was selected proportional to the number of pregnant
women covered by each center, through systematic
approach, and from the list of pregnant women (register center of continuous
care of pregnant women in the centers).
The data were gathered using a
checklist containing demographic information such as age, education,
occupation, and ethnicity, and characteristics associated with pregnancy such
as pregnancy interval, planned or unplanned pregnancy, labor rank, history of
bleeding during pregnancy, history of preterm birth and low birth weight, the
number of health care services received, and information about blood hemoglobin
of the mother in the first and third trimester of pregnancy. Data were
extracted from the family health records. IDA in pregnant women according to
the WHO description is based on the hemoglobin parameter (6); therefore, in
this study, only the hemoglobin parameter was used to determine IDA in pregnant
women.
The inclusion criteria included
having health records in an urban healthcare center.
The exclusion criteria included having a recorded disease associated with
anemia such as thalassemia minor and sickle-cell
disease (SCD), multifetal pregnancies, receiving
or donating blood during pregnancy, and preterm birth (less than 37 weeks). In
this study, given that the family records were
examined, the confidentiality of the subjects
were considered and the individuals’ names were not mentioned on the
checklists.
After gathering the data, they
were entered into SPSS software (version 23, SPSS Inc., Chicago, IL, USA) and
statistical analysis was performed. Quantitative data were reported as mean ±
SD and qualitative data were reported as number (%). To evaluate the relationship
between quantitative data and IDA in pregnant women, chi-square and Fisher's
exact tests were used. To study the effect of anemia in the first and third
trimesters of pregnancy on the frequency of IDA in pregnant women, McNemar's
test was used. The significant level of the statistical tests was considered as
0.05.
Results
In total, 418 checklists were
completed. Frequency distribution of 418 pregnant
women based on age group was 21 patients (5%) of less than 18 years, 363
patients (86.8%) of 18-35 years, and 34 individuals (8.2%) of more than 35
years. In general, the mean age of pregnant women in this study was 27.17 ±
5.62 years (minimum 14 years and maximum 45 years). In addition, 5 patients
(1.2%) were illiterate, 99 patients (23.7%) had primary school education, 93
patients (22.2%) had secondary school education, 166 (39.7%) had high school
education, and 55 patients (13.2%) had university education. Moreover, 369
cases (88.3%) of pregnant women were of Persian ethnicity,
1 case (0.2%) was Turk, 1 case (0.2%) was Kurd, 31 patients (7.4%) were of Arab
ethnicity, and 16 cases (3.8%) were of other ethnicities. Furthermore, 400
(95.7%) pregnant women were housewives and 18 (4.3%) were employed. Pregnancy characteristics of
the studied women are presented in table 1. Overall, the prevalence of IDA in
pregnant women referred to health centers in Bandar Lengeh in the first and
third trimester of pregnancy was, respectively, 94 cases (22.5%) with interval
estimation of 95% (18.4%-26.5%) and 192 cases (45.9%) with interval estimation
of 95% (41.1%-50.6%).
Discussion
In connection with the overall
aim of the research to determine the prevalence of IDA in pregnant women
according to hemoglobin concentration of less than 11 g/dl and its affective
factors, it was found that the prevalence of IDA in pregnant women in the first
and third trimester was 22.5% (CI 95%: 18.4%-26.5%) and 45.9% (CI 95%:
41.1%-50.6%), respectively. This showed the increase in the prevalence of
anemia with increase in the age of pregnancy. In studies in Isfahan, Iran (17),
Thailand (14), Mexico (10), Spain (18, 19), Pakistan (20), and Kuwait (21), the
prevalence of anemia was reported higher in the third trimester. Therefore, the
highest prevalence of IDA was observed in the eighth and ninth months. The
possible cause of this phenomenon is the physiology of pregnancy; the maximum
iron uptake by the fetus takes place after the thirtieth week of pregnancy. The
dilution of the blood in the first and second trimester of pregnancy also
reduced hemoglobin concentration and negative iron balance, especially in the
third trimester of pregnancy (17). Therefore, mothers at the end stages of pregnancy are at greater risk of IDA, and
this indicates the importance of continuous use of iron supplements since the
early stages of pregnancy (14). Based on the results of a study conducted in
Semnan, Iran, the prevalence of IDA in the first trimester was reported as
60.1% and in the third trimester as 48.7% (22). This result was inconsistent
with the findings of the present study. This may be due to the differences in the
diagnostic parameters of IDA used. Diagnostic parameters that were used in this
study included hemoglobin, hematocrit, and ferritin,
while the diagnosis of IDA in the present study was based on the criteria
mentioned in the WHO definition, which was the concentration of blood
hemoglobin.
In general, various studies
indicated that the prevalence of IDA differed greatly among different countries
and even among different regions of a county and the range was between 12% and
43%. Iron deficiency and its related anemia in
pregnant Iranian women is a health problem and the extent of its prevalence is
different in the different regions of the country. The
results of various surveys in Iran also showed that the changes in the
prevalence of IDA in pregnant women ranged between 4.5% and more than 50% (13,
17). It seems that difference regarding
geographic regions, lifestyle, diet, socioeconomic status, and the prevalence
of infectious and parasitic diseases in different
parts of Iran were the main reasons for the wide range of results reported in
different studies (9).
The findings of this study showed
a lower incidence of IDA in the third trimester of pregnancy with the increase
in the number of pregnancies. This finding was similar to the results of a
study in Pakistan (23), but was inconsistent with the results of 11 regions of
Iran (13), Turkey (15), Isfahan, Iran (17), Semnan (22), Shiraz, Iran (24), and
America (25). It is evident that repeated
pregnancies cause the loss of iron in the mother's body, and in case of lack of
attention and timely treatment, will cause severe and chronic maternal anemia.
Its consequences range from physical weakness, lethargy, early fatigue, and
depressed mood for the mother. Thus, the mother’s repeated pregnancies will
have irreversible physical and mental consequences for the fetus and the
mother. Therefore, provision of special care, and training and advice to
observe a diverse and balanced diet along with iron supplementation is a
necessity for mothers with fifth or higher pregnancy (17). The findings of the
present study in this regard may be due to the mothers’ experience and increase
in their awareness about timely and adequate intake of iron supplements during
pregnancy caused by their repeated pregnancies.
A significant negative
correlation was observed between the prevalence of IDA and pregnant mother's
education level and occupation in this study. Anemia was reduced with increase
in the level of education and government employment. The results of other studies
also confirmed the findings of this study and showed that the higher level of
education and employment of the mother, and consequently,
the increase in the level of nutritional information greatly helped to reduce
the prevalence of anemia (12, 16, 17).
According to a survey conducted
in 11 regions of Iran in 2001, the coverage of the supplementation program among pregnant
Iranian women was estimated at about 84% and regular consumption of iron
supplements had a significant effect in reducing the risk of anemia in pregnant
women in Iran (13). Based on the findings of this study, although 97% of
pregnant women were taking iron supplements, almost half (46%) of them suffered
from IDA in the third trimester of pregnancy. This indicated the inadequacy of iron
supplementation approach alone in the fight against IDA. Therefore, one of the
causes of anemia and iron deficiency in pregnant women in Iran may be their
undesirable nutrition pattern and wrong food habits that lead to low iron intake and absorption (13).
Starting the pregnancy period with the absence of anemia or moderate
consumption of iron supplements reduced the risk of anemia in late pregnancy.
Although this action seemed adequate for the
prevention of IDA, its prevalence in a large percentage of women was unclear (18, 26).
It was concluded that the
improvement of the prevalence of IDA in pregnant women required appropriate
nutrition training techniques in Southern Iran. Further studies are necessary
to determine the appropriate nutritional advice through which the requirements
of pregnant women can be designed according to the characteristics of each
individual.
The limitation of this study was
that in order to determine the prevalence of IDA, it was limited only to
checking the blood hemoglobin concentration. Generally, in the healthcare
delivery system, the parameter of hemoglobin concentration is used to diagnose
anemia, because it is cheap and accessible as reference standard. Nevertheless,
for some women, measuring only the hemoglobin concentration to detect IDA is
not enough. Therefore, for the rapid and definitive diagnosis and timely
treatment of IDA, the use of a combination of multiple parameters in the
healthcare system is recommended. It is also recommended to use the potential
of pre-pregnancy care programs in the healthcare system for the diagnosis and
correction of anemia in women, so they can be prepared with a suitable physical
condition for the start of their pregnancy.
Conclusion
According to the results, IDA prevalence was undesirable, especially in the third
trimester of pregnancy. Since this eating disorder is a preventable condition
and pregnant women are a group at risk for anemia, considering
the expansion of pre-pregnancy care, increased awareness among mothers
regarding correct patterns of nutrition and
maintenance of a diverse and balanced diet, regular consumption of supplements,
contraception in older ages, and maintenance of appropriate intervals between
pregnancies seem necessary.
Acknowledgments
Our sincere appreciation goes to
the Health Research Deputy of the Health and Treatment Network of Bandar Lengeh
who allowed the conducting of this survey in the urban health centers, and the
staff of health centers in Bandar Lengeh who cooperated in data collection.
Conflict
of interests:
None declared.
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