Materials & Methods
BACKGROUND: Almost half of the pregnant mothers globally, present haematological values indicative of anaemia, and knowing the current situation in Porto Novo province is necessary to highlight antenatal healthcare providers towards early detection and prompt management of anaemia in pregnancy.
AIMS AND OBJECTIVES: to study the prevalence of anaemia, types and causes of anaemia in pregnant mothers of Porto Novo Province.
KEY WORDS: Anaemia, Pregnancy, Public Health, Porto Novo, Cape verde.
LIMITATIONS OF THE STUDY: Abdominal Ultrasonography, Serum Ferritin, Zinc Protoporphyrin, Folate and B12 levels and Stool examination were not done due to high costs of reagent. Follow up procedures of the pregnancy to see the maternal and fetal outcome especially during labour, partum and post partum and the parity of each pregnant mother were not done.
A total of 160 blood samples were collected into EDTA tubes between 1- January to 31-march 2011, at the Antenatal Clinic of Hospital of Porto Novo during the first visit of the pregnant women to the reproductive section and Using Sysmex KX-21-N by Sysmex corporation, Japan. The haematological parameters of Haemoglobin (Hb), Haematocrit (HCT), Mean Cell Volume (MCV) and Red Cell Distribution Width in coefficient variation (RDW-CV) were determined in all the samples; the trimester stages of each pregnancy were noted. Out of the 160 pregnant women blood samples analyzed, 62(38.8%) were anaemic, and the majority 71% were mildly anaemic cases, whereas 29% were moderately anaemic and no severe anaemic cases were recorded. Iron deficiency anaemia was 8.1% whereas 91.9% showed mixed anaemia indicating Normocytic- Normochromic. Anaemia was higher (53.2%) in pregnant women in the second trimester. CONCLUSION: The administration of iron with folic acid (folicferro), vitaminB12 and food aid program should be re-inforced for all pregnant women.
KEYWORDS: Anaemia, Pregnancy, Prevalence, Public Health, Porto Novo.
Anaemia is a global public health problem affecting both developing and developed countries with major consequences for human health as well as social and economic development. It occurs at all stages of life cycle, but is more prevalent in pregnant women and young children. It occurs when the concentration of haemoglobin falls below what is normal for a person´s age, gender and environment, resulting in the oxygen carrying capacity of the blood being reduced.
Anaemia is often classified as mild degree (Hb 9.0 – 11.0g/dl), moderate (Hb 7.0 – 9.0g/dl), severe (Hb 4.0 – 7.0 g/dl), and very severe Hb less than 4.0 g/dl. It can also be classified based on the Haematocrit (PCV) %. A common etiological classification of anaemia identifies 3 major causative groups of anaemia; Nutritional, marrow disease and haemolytic disease. Nutritional anaemias are by far the most common type of anaemia worldwide and mainly include iron, folate and vitaminB12 deficiencies.
The World Health Organization (WHO) estimated that in developing countries, prevalence rates in pregnant women are commonly in the range of 40 to 60 percent. Around half of those with anemia, are suffering from iron deficiency anaemia, that is having deficient body iron stores but without frank anaemia; the latter are therefore considered to be at risk of iron deficiency anaemia. Folate deficiencies and other causes account for the major proportion of the remaining anaemia.
Anaemia can affect psychological and physical behavior. Even very mild forms influence the sense of well being, lessen resistance to fatigue, aggravate other disorders and affect work capacity. For pregnant women anaemia can result in severe morbidity and mortality and reduces the resistance to blood loss with the result that death may be possible from the blood loss associated with delivery. The so called physiological anaemia occurs when there is disproportionate increase of plasma volume during pregnancy, leading to apparent reduction of Red blood cells, haemoglobin and Haematocrit values.
During pregnancy, growth of the fetus and of the placenta and the larger amount of circulating blood in the expectant mother, lead to an increase in the demand for nutrients, especially iron and folic acid. The majority of women in the developing countries start pregnancy with depleted body stores of these nutrients and this means that their extra requirement is even higher than usual.
The total iron needed during the whole of pregnancy is estimated at about 1000mg -Bruno de Benoist et al(1992). The daily requirements for iron as well as folate are six times greater for a woman in the last trimester of pregnancy than for a non pregnant woman. This need cannot be met by diet alone, but is derived from at least partly from maternal reserves. In a well nourished woman, about half the total requirement of iron may come from iron stores. When these reserves are already low due to malnutrition, and /or frequent pregnancies, anaemia results. It has been estimated that even when food intake is adequate, it may take two years to replenish body iron stores after a pregnancy.
The early stages of anaemia in pregnancy are often symptomless. However, as the Hb concentration falls, oxygen supply to vital organs declines and the expectant mother begins to complain of general weakness, tiredness and headaches. Pallor of the skin and of the mucous membrane, as well as the nail beds and tongue may not become noticeable until Hb drops to about 7.0g/dl. With a further fall in Hb concentration to 4.0g/dl, most tissues of the body become starved of oxygen and the effect is most marked on the heart muscles, which may fail altogether. Death from anaemia is the result of heart failure, shock or infection that has taken advantage of impaired resistance to disease in the patient.
While less severe anaemia may not be a direct cause of maternal death, it can contribute towards death from other causes, particularly haemorrage. Anaemic mothers do not tolerate blood loss to the same degree as healthy women. During childbirth, a healthy mother may tolerate a blood loss of up to a litre. However, in an anaemic mother, the story is different; a loss of as little as 150ml can be fatal. Anaemic mothers are poor anaesthetic and operative risks because anaemia lowers resistance to infection and wounds may fail to heal promptly after surgery or may break down altogether.
The WHO has estimated that the prevalence of anaemia in developed and developing countries in pregnant women is 14 percent in developed countries and 51 percent in developing countries. For example in India, anaemia was estimated at 65 to 75 percent (WHO 2004).
Ezzati M. et al (2002) reported that half of the global maternal deaths due to anaemia occur in South Asian countries; India contributes to about 80 percent of the maternal deaths due to anaemia in the region of South Asian. It is obvious that Indians’ contribution both to the prevalence of anaemia in pregnancy and maternal deaths due to anaemia is higher than warranted by the size of its population.
Dr. Kalaivani (2009) said that factors responsible for high prevalence of anaemia in India have shown to be iron deficiency as the major cause of anaemia followed by folate deficiency and in recent years, B12 deficiency has also been highlighted. Particularly, in India the prevalence is high because of; low dietary intake, poor iron and folic acid intake, poor bioavailability of iron in phytate and fibre rich Indian diet and chronic blood loss due to infection such as malaria and hookworm infestation.
Mah-e-munir Awan et al (2004) reported 96 percent of pregnant populations of Multan area in Pakistan were anaemic. Microcytic hypochromic anaemia resulting from iron deficiency is the most frequent form of anaemia 76 percent Sifakis et al (2000), followed by folate deficiency 20 percent reported Seshadri et al (2001) and combined iron and folate deficiency 20 percent stated Chenoufi et al (2001) on findings of 200 cases and he concluded by saying that several factors are implicated on high prevalence of anaemia in the pregnant population. Poor dietary status reflected by low socio- economic status makes micronutrient deficiency clinical and subclinical, relatively more common.
Breast feeding (88 percent) is also an important stress on the nutritional status of the mother. All these factors deplete the micronutrient stores of the mother, to the extent that she becomes anaemic even in the first trimester in the next pregnancy and this brings a more severe outcome for both the mother and the child reported by Bondevik &Abel et al (2001).
Yuan Xing et al (2009) on Tibet pregnant population concluded that averages of 63 percent of Tibet mothers were anaemic and that the gestational age, ethnicity, residence and low income of Tibetans amounted significantly to the Hb level and the occurrence of anaemia in pregnant Tibetans.
Ma AG and Chen XC et al (2004) reported 41.58% in pregnant people of Qingdao province of China were anaemic and the subjects with iron deficiency anaemia had much higher rates of vitamin C, folate and B12 deficiencies than those in the non anaemic subjects and especially in the deficient rates of ascorbic acid and folate in the anaemia group. Moreover, they observed that the decreasing trends of Hb concentrations were accompanied by the decreases of serum levels of vitamin A, ascorbic acid, folate and B12 and concluded that multiple vitamin deficiencies may be associated with anaemia in pregnant mothers in the last trimester.
However, the work of Karaoglu et al (2010) on pregnant women of East Anatolian province of Turkey registered a percentage of 27.1% of anaemic pregnant women, having four or more children and being in the third trimester. Their finding also was associated with PICA (soil eating habits of pregnant women). Most of the anaemia recorded was normocytic- normochromic indicating mixed anaemia. In Turkey, for pregnant women, anaemia was a moderate public health problem, co-existing of iron, folate and B12 deficiencies was observed.
However, anaemia and iron deficiency in the mother are not associated with significant degree of anaemia in the children during neonatal period. Nevertheless, iron stores in these neonates are compromised, iron content in the breast milk of anaemic mother is also compromised and because of these factors, substantial proportion of infants become anaemic by six months, Kilbridge et al (1999) on the study of anaemia among pregnant Jordan population. Thus maternal iron deficiency and anaemia render the offspring vulnerable for developing iron deficiency and anaemia right from infancy.
The work of Jahan & Hossain (1996) said that anaemia of 59 percent were recorded among pregnant mothers in Bangladesh, although despite high prevalence registered, severe cases were absent and iron deficiency increased at lower Hb level. Dreyfuss et al (2000) reported 73 percent of pregnant Nepalese were anaemic with 7 percent being severe anaemic cases while Atukorala et al (1994) studied Sri lanka pregnant women and recorded 65 percent.
Dr. Rita marahatta (2007) reported the prevalence of anaemia of 42.6 percent in pregnant women of Kathmandu Nepal and the birthweight, Apgar score at the time of birth, occurrence of preterm delivery and intra uterine fetal death (IUFD) were more common in anaemic group than in non-anaemic group. Maternal anaemia in pregnancy continued to be considered a risk factor for poor pregnancy outcome and can result in complications that threaten the life of both mother and fetus. However, current knowledge indicates that iron deficiency in pregnancy is a risk factor for preterm delivery followed by low birthweight and possible inferior neonatal health. Although, the extent to which maternal anaemia affects maternal and neonatal health is still uncertain. Some studies have demonstrated a strong association between low haemoglobin before delivery and adverse outcomes while others have not found a significant association.
Thomsen et al (1993) stressed that during pregnancy, the needs of the growing fetus and placenta as well as the increasing maternal blood volume and red cell mass, impose such a demand on maternal iron stores that iron supplementation at daily doses between 18 and 100mg from 16 weeks gestation onwards could not completely prevent the depletion of maternal iron stores at term.
Kurki et al (1992) conducted a research to understand how anaemia predisposes to preterm labour either directly or indirectly due to increase risk of infection, direct effect is due to hypoxia induced by anaemia which induces synthesis of corticotrophin releasing hormone(CRH) associated with stress predispose to preterm labour and even pregnancy induced hypertension.
Goldenberg et al (1996) reported that increase level of CRH in mother stimulates increase production of cortisol in fetus which in turn inhibits the longitudinal growth of the fetus. Another indirect mechanism is iron deficiency leads to oxidative damage to erythrocytes in the fetoplacental unit which stimulates production of CRH both invivo and invitro.
Dr. Roy et al (1992) said that association of anaemia with adverse maternal outcome such as puerperal sepsis, antepartum haemorrhage, postpartum haemorrhage and maternal mortality is no longer debatable and that is why early diagnosis and treatment of anaemia is of utmost importance in pregnant women.
According to Olukoya & Abidoye (1991) on Lagos antenatal screening in Nigeria argued that Hookworm infestation, malaria and HIV infections have contributed immensely with severe anaemic cases seen among pregnant Nigerians in Lagos province.
The experience of Desalegn et al (1993) on Ethiopian pregnant mothers confirmed the prevalence of 41.9 percent and the rates were 56.8 percent for rural areas and 35.9 percent in the urban areas of Ethiopia. However, the rate of anaemia were higher among illiterate pregnant Ethiopians and those who did not practice family planning of any sort and in the third trimester with increased parity concluded Desalegn and co- workers.
The technical knowledge of Msolla & Kinabo (1997) on Tanzania pregnant women revealed that 95 percent of Tanzania pregnant subjects were anaemic and all these women were suffering from iron, folate and vitaminB12 deficiencies. This suggests that all subjects had a combination of Microcytic and megaloblastic anaemia. The results shown that there were positive correlations between Hemoglobin concentration and weight of the infants at birth. This observation suggests also that anaemia had a significant influence on the birth weight of the infant. Furthermore, this could be an indication of poor food security in general and major causes of anaemia were identified as being poor dietary intake of iron rich foods and probably poor utilization due to diseases like malaria. All the women tested on Tanzania study had basic knowledge on anaemia but despite these knowledge and awareness, the women were still anaemic.
Marti-carvajal et al (1996) tested 630 blood samples of pregnant mothers of Valencia area in Venezuela and reported 34.44 percent of mothers with anaemia. This work was contrasted with that of Meda et al (1996) on Burkina Faso in West Africa were pregnant mothers presented 66 percent of anaemia and also Singh & Fong (1998) stated 81 percent of pregnant mothers in Singapore presented with anaemia. Ogbeide et al (1994) argued that anaemia during pregnancy is an indicator of the precarious nutritional status of any Nation and it remains as a worldwide public health problem and therefore recommends a regular review of factors which may contribute to the prevalence of the maternal anaemia. Independently of its impact on fetal health, maternal anaemia increases the risk of maternal morbidity. Therefore, it is very important to prevent and to treat maternal anemia.
The work of Omoniyi Adebisi & Gregory Strayhorn (2005) reported anaemia in pregnancy among United States based on race, and the blacks revealed 20.4 per 1000, while the whites showed 10.6 per 1000. Teenage pregnant women had the highest prevalence in all races; while mothers aged 35 and 39 had the lowest prevalence. However, the higher the mother´s attained level of formal education, the lower the observed prevalence of anaemia. Omoniyi et al also stated that increased in parity, unmarried status, multiple pregnancy and non-metropolitan residence were all associated with the higher incidence of anaemia among pregnant women, but the risk factors for anaemia in pregnancy were similar in both whites and blacks, though lack of formal education had stronger impact in blacks than whites. They concluded by saying that black race were significantly associated with higher risk of anaemia in pregnancy than whites, therefore race is an important determining risk factor of anaemia in pregnancy.