Lack of Awareness on Prevention of Anaemia in Pregnancy Among Pregnant Women in Rural Area
Objectives of the study
The general objective of this is to assess the lack of awareness on prevention of anaemia in pregnancy among pregnant women in rural area. Specifically, the study seeks to;
- Determine the factors that predispose to anaemia in pregnancy amongst pregnant women attending antenatal care in Elele community.
- Assess the strategies used by the pregnant women for the prevention and management of anaemia in Elele community
- Determine the challenges encountered in the management of Anaemia among pregnant women in Elele community.
Concept of Anaemia
Anemia is a frequent companion to pregnancy due to the relatively larger plasma volume expansion compared to red blood cells. Proper transport of oxygen from the maternal blood to fetal circulation is essential during childbirth to give birth to a viable baby and also saludable. Maternal morbidity is also affected by the degree of anemia that occurs during pregnancy. Therefore, anemia may precede conception, which is often aggravated by pregnancy, and occupational accidents may sustain it (Lawson J. and Steward D., 2014). Therefore, it is an important public health issue that requires the most attention, as pregnancy and childbirth around the world are daily events and, in particular, we need to lower our high maternal mortality rate.
The word anemia connotes a deficiency in the number of red blood cells or hemoglobin content that results in a diminished ability to transport oxygen from the blood, causing unusual fatigue that generates pallor, respiratory distress and lack of energy. Anemia can be relative or absolute. Relative anemia occurs during pregnancy (Bolton F., Street M. and Pace A., 2013). Absolute anemia implies a true decrease in the mass of red blood cells. The cells are produced in the bone marrow and have a life expectancy of approximately four months (120 days) (Bolton et al., 2013). The body needs iron, vitamin B12 and folic acid to produce red blood cells. Absence of one or more of these ingredients causes anemia.
Red blood cells are the circulating cells in the blood plasma, which give the blood its red color. Through its pumping action, the heart drives blood through the arteries through the body. Red cells absorb oxygen into the lungs and transport it to all body cells. The cells use oxygen to drive the burning of sugars and fats that produce the body’s energy. In this process called oxidation, carbon dioxide is produced as a waste product. It binds to red blood cells that have released their oxygen load. Carbon dioxide is then transported back to the lungs by the blood in the veins, where it is exchanged by breathing for fresh oxygen (Bolton et al., 2013).
The recommendation of the World Health Organization (WHO) is that anemia occurs in pregnancy when the value of the mass of hemoglobin (Hb) circulating in the peripheral blood circulating 11 g/dl (PCV 33%) or less but in developing countries it is generally accepted That anemia is present when the concentration of Hb is less than 10 g/dl or hematocrit (PCV) less than 30% (Akin Agboola 2013). Anemia ranges from mild to severe to moderate and WHO estimates hemoglobin levels for each of these degrees of anemia in pregnancy to be between 9.0 and 10.9 g/dl as mild anemia; 7-8.9 g/dl as moderate anemia and <7.0 g/dl as severe anemia (WHO, 2012).
Every year more than 500,000 women die from pregnancy-related causes, 99% of them from developing countries. Estimates of maternal mortality from anemia range from 34 / 100,000 live births in Nigeria to 194 / 100,000 in Pakistan. Anemia is estimated to account for 17 to 46% of maternal deaths when combined with obstetric hemorrhage. The incidence of anemia in pregnancy varies from place to place, even within a country depending on socioeconomic status and level of development (Nynke van des Broeka 2013). It is between 5 and 50% of pregnant women in the tropics participating in prenatal clinics anemic compared to the prevalence rate of 2% in the developed world (Tropical Journal, 2013) claims that.
It is estimated that more than half of pregnant women in the world have hemoglobin levels indicative of anemia. In industrialized countries, anemia occurs in pregnancy in less than 20% of women. However, this is important for public health (> 10%). The quotas published for developing countries vary between 35% and 72% for Africa, between 37% and 75% for Asia, and between 37% and 52% for Latin America. A retrospective study of normal pregnant women were registered in the prenatal unit of the University Hospital of the University of Nigeria (UNTH) Enugu showed that 40.4% of the study population was isemica (Hb <11 g) in reserve. The prevalence of anemia in the reserve increased significantly with increasing gestational age in the reserve (Cyril D. and Hycinth O., 2017). Another study conducted in Gombe in northeastern Nigeria found a 51.8% prevalence of pregnancy anemia. The majority of these patients 67.4% were mildly anemic; 30.5% were moderately anemic; while only 2.1% had severe anemia (Bukar M., Audu B., Yahaya U. and Melah G., 2012).
In West Africa, anemia in pregnancy is due to several causes, such as iron and folic acid deficiency, malaria and hookworm infestations, infections such as HIV and hemoglobinopathies. Pica has been identified as a risk factor for anemia in pregnancy (Adam I., Ichamis A. and Elbashir M., 2012). This could be applicable to this environment where one can easily access the special group kaolin clay in open markets (called “NZU” in Igbo language) and wish some pregnant women. Anemia is not only common, it is often severe. Published reports available, it is estimated that between 2 and 7% of pregnant women Hb has <7.0 g/dl, and probably between 15 and 20% has values <8.0 g/dl. It is suggested that the prevalence of anemia may depend on the season, increase the link with the transmission of malaria in the rainy season, or increase food shortages associated with end-dry season. In 1993, the World Bank ranked anemia as the eighth leading cause of the disease among girls and young women of age in developing childbearing, although it is believed that anemia is less common in non-pregnant women (Nynke van des Broeka 2013).
Causes of Anaemia in Pregnancy
Anemia in pregnancy is a major public health problem in developing countries. In sub-Saharan Africa, such anemia is widely recognized as a result of a lack of nutrients, especially iron deficiency (WHO, 2012). Women often become anemic during pregnancy as the need for iron and other vitamins increases due to the physiological burden of pregnancy. The inability to achieve the required levels of these substances due to malnutrition or infection leads to anemia. The mother has to increase her production of red blood cells and additionally the fetus and the placenta need their own supply of iron, which can only be obtained from the mother.
To have enough red blood cells for the fetus, the body begins to produce more red blood cells and plasma. It is estimated that the blood volume increases about 50% during pregnancy, although the amount of plasma is proportional older (Viteri, 2014). This causes a dilution of the blood that causes the hemoglobin to decrease. This is a normal process, with hemoglobin concentration at the lowest level between weeks 25 and 30 gestación (Bolton F., Street M., & Pace A., 2013). The pregnant woman supplements need additional iron, and the best way to control this is a blood test called serum ferritin.
Anemia in pregnancy is often of multiple causes. Iron and folic acid deficiency are by far the most important etiological factors. The increased demand for these substances is exacerbated by multiple pregnancies, short birth rates, parasitic infections and helminth, which are common among black women. Malaria parasites, which cause the destruction of red blood cells, contribute significantly to the prevalence of anemia in a population. Hemoglobinopathies such as sickle cell disease contribute to the cause of anemia in Africa. The causes are explained below;
Iron deficiency: iron needs increase during pregnancy because the fetus demand and increased blood volume, especially in the last quarter, with up to 80% of the requirements for the third quarter. The total iron requirement during pregnancy is about 1000 mg (300 mg for the fetus, 50 mg for the placenta, 450 mg for an increased maternal red cell mass, and 240 mg for the continuous maternal loss of iron basal) (Hodges, 2012). Requirements during the first trimester are relatively small (about 0.8 mg per day), but significantly increase to 6.3 mg per day in the second and third trimesters. After childbirth and during breastfeeding, iron use decreases 1.31 mg/day, which is 0.24 for menstruating women (2.3 mg/day). Despite the increase in iron intake being less than the requirement, pregnancy, diet alone can do not cover increased demand. Therefore, the extra iron needs to be covered by the iron reserves of the body. Many women in developing countries start pregnancy with a reserve of depleted iron because of diets low in iron, but loss of chronic blood due to parasitic infections and frequent and tight pregnancies, without giving the body enough time to replenish your depleted reserves. It was estimated that in the absence of iron supplements, it can take up to two years to get back to the pre-pregnancy state of iron. The iron reserves in women of childbearing age continue to decline due to the loss of menstrual blood (Hodges, 2012).
Descriptive cross-sectional design will be used to assess the management of anemia among pregnant women attending antenatal care in Elele community, Emohua L.G.A, Rivers state. This design examines the characteristics, behaviours, attitude and intentions of a group (typically only a subset) to answer a series of questions. In this study, descriptive cross-sectional design is considered appropriate.
Area of study
Search Results Featured snippet from the web The Ishimbam or Elele clan cluster is located at the northern part of Ikwerre land, in Ikwerre and Emohua Local Government Areas. Most of these communities believe in one ancestor called “Ochichi” whose descendants founded most of the clans. Elele is believed to have been founded by “Ele”, Ochichi’s first son.
The target population for this study will comprise of pregnant women attending antenatal care in Elele community, Emohua L.G.A, Rivers state, who will also be involved as participants in the data collection process for analysis. Data collated form the records unit of the Hospital showed an average of 500 pregnancy cases for a period of 6 months (September, 2018 to March, 2019). For the purpose of this study, the inclusion criterion is stated as follows;
DATA ANALYSIS AND INTERPRETATION
In this research study, 220 pregnant women attending antenatal care in Elele community, Emohua L.G.A, Rivers state were studied. All the questionnaires were correctly filled, retrieved and used in the research. Response rate therefore for this research was 100% for the questionnaire. The results of the analysis are presented below.
DISCUSSION OF FINDINGS, CONCLUSION AND RECOMMENDATIONS
In this chapter, the researcher discussed the result from the data analysis and relating interpretation to literature review in order to sharpen the focus of discussion using the research question.
Discussion of Findings
Research Question One: What are the factors that predispose to anaemia in pregnancy amongst pregnant women attending antenatal care in Elele community?
The socio-demographic characteristics of the study population revealed that out of the 220 respondents, 169 of them were in the age range of 20-29 years while those that were 40years old and above were the least (0.3%). The minimum age of the respondents was 18years while the maximum age was 46years. The mean age of the respondents was 26.8years. About half of the women were self-employed, 26.8% were fulltime housewives, 13.5% were unemployed, and 4.9% were company workers, while 4.4% were Civil Servants. More than three-quarter of the respondents had one form of formal education or the other, while only a meager 2.2% had no any form of education at all. This certainly must have affected their level of awareness and health-seeking behavior hence, the least prevalence of anaemia among those with tertiary education.
The knowledge about anaemia and its causes, in this study is low (21.2%), majority of the respondents said they had never heard of anaemia. This is in line with a similar study conducted in Raichur, India where knowledge about anaemia in pregnancy is very low (6.48%) (Vijaynath et al, 2010). Most women who have heard of anaemia were not able to correctly identify the causes. A major hurdle is the fact that anaemia is not perceived a major health problem by many even by sufferers who ascribed its consequences to general fatigue. Even where the problem is recognized, there may be a reluctance to invest necessary funds owing to skepticism regarding the effectiveness of interventions for controlling it. Evidence of the independent effect of iron status on function would therefore, help in advocacy. The predisposing factors recognized to be responsible for anaemia in pregnant women were parity (14.2%), adoption/miscarriage previously (28.1%), blood transfusion (23%), and being a sickle cell anaemia patient (28.3%). This was in contrast to a study by Monif (2014) who revealed that women who had malaria during pregnancy were almost five times more likely to be anaemic. Similarly other studies have found almost the same association, which suggest that women who were anaemic during pregnancy were 3 times more likely to be anaemic (Monif et al., 2014; WHO 2016). This can be controlled by providing pregnant women with insecticide- treated bed nets (ITN) and intermittent preventive treatment (IPT) with anti -malarial medication.
The results of this study also showed that the prevalence of anaemia was higher in the multiparous women than the primiparous women (number of times given birth). This is in line with a similar study which showed that high parity pregnancies carry about three times higher risk of developing anaemia in pregnancy than low parity pregnancies, and that the risk of anaemia in pregnancy increases in a dose-response fashion over increasing levels of parity (WHO, 2012). This may be explained by the increased susceptibility to hemorrhage in women having high parity. High parity is among the factors with etiologic potential in causing anaemia in Pregnancy. The WHO defines high parity as five or more pregnancies with gestation periods of ≥ 20 weeks, and low parity as less than 5 pregnancies with gestation periods of ≥ 20 weeks (WHO, 2012). Compared to the non-pregnant state, every pregnancy carries an increased risk of hemorrhage before, during, and after delivery. Therefore, higher parity exposes women more frequently to periods of hemorrhage risk.
Research Question Two: What are the strategies used by the pregnant women for the prevention and management of anaemia in Elele community?
The highest strategy was that regular medical checkup is necessary during pregnancy (70.4%), adequate treatment is necessary to eradicate hook worm infestation and malaria to prevent anaemia (67.3%), and fasting or missing the meals must be avoided during pregnancy (65.3%). It was strongly kicked against the statement that pregnant women should eat last after consumption of all family members whatever is left over, shown by the response of 10.2% of the respondents.
The prevalence of anaemia amongst women attending ANC in Elele community, Rivers state in this study was found to be 56.4%.This falls within the range 35%-75% from previous reports from a study by Chukwubelu and Obi (2014). It is however higher than 29.1% reported from similar studies conducted in Sagamu, 8.8% reported from Enugu and 29.79% from Lagos (Chukudebelu & Obi, 2014; Ojo, 2015; Olodeoku, 2011). The high prevalence of anaemia found among women in this study could be attributed to low educational status, low nutritional and socio-economic status commonly found among residents of urban slums. According to the World Health Organization, a severe public health problem exists if the prevalence of anaemia is equal or greater than 40% in any group (De Benoist et al, 2012). This is therefore, an indication that anaemia during pregnancy is a major problem in Nigeria.
In other studies, pregnant women who were not eating balanced diet properly at least one time per week compared to those who ate two times had the likelihood of developing anemia. This result is consistent with other studies done in Ethiopia (Argaw, 2015; Bekele, et al, 2016). This significant association might be due to the reason that meat is an important source of heme iron. However, consuming substances like tea immediately after food has a negative association with anemia during pregnancy. The odds of developing anemia among pregnant mothers who were consuming tea/coffee immediately after food were 3.6 times greater than the odds of mothers who did not consume tea/coffee immediately after food during their current pregnancy. This result is in agreement with a study done in Egypt and Ethiopia, which showed significant association between anemia and consumption of tea (Ashiry, 2014). This could be drinking tea/coffee after food intake may affect iron absorption which leads to inadequate dietary iron intake in the pregnant women.
Research Question Three: What are the challenges encountered in the management of Anaemia among pregnant women in Elele community?
The challenges to effective management and prevention of anaemia among pregnant women were analyzed in table 4.4 above. The results indicated that the major challenge was finances with a response rate of 84.1%, followed by time constraint (62.3%), lack of support from family/friends (59.3%), and accessibility to ANC services (56.9%). These factors impede the effective adherence and practice of the pregnant women towards anaemia prevention and management. Anemia in pregnancy is related to different socio-demographic factors which in turn have certain limitations and constraints (Jufar, 2013; Karaoglu, 2010). Studies have shown a higher prevalence of anemia in young pregnant mothers, large family size and large number of children ever borne. In different studies, age, family size, parity and economical status were found to be significantly associated with anemia during pregnancy (Jufar, 2013; Karaoglu, 2010) which were consistent with our current study.
In conclusion, the overall prevalence of anemia indicated that it is a moderate public health problem. Intervention strategies should focus on associated factors of anemia among pregnant women. Increase awareness for family planning methods might have a contribution for reducing risk of anemia. Economic and nutritional empowerment should be considered. Large scale longitudinal studies should be done to identify specific etiologies and root causes of anemia among pregnant women by assessing micronutrients (serum iron and folate).
Implications of findings to Nursing
This study has implication for nursing arising form the results and findings. The study indicated that knowledge about anaemia and its causes, in this study is low implying a wide gap in the health education and information space. Health services and facilities should be made accessible for the pregnant women during antenatal care and for mothers during postnatal care to ensure that health linkages are strengthened between these two parties involved (the health beneficiaries and the health agents). This will ensure better health outcomes and safer pregnancies for women. High level of knowledge on anaemia, its causes and management strategies should be disseminated and adequately discussed through awareness programmes, training sessions, workshops and sensitization campaigns which will be anchored by health workers, health educators and other healthcare professionals during their antenatal visit to hospital.
The purpose of the study was to determine the lack of awareness on prevention of anaemia in pregnancy among pregnant women in Elele community, Emohua L.G.A, Rivers state. To achieve the purpose of the study, objectives and research questions were formulated. Related literature pertinent to the study was reviewed under conceptual review, theoretical review, and empirical headings.
From the findings, the knowledge about anaemia and its causes, in this study is low (21.2%), majority of the respondents said they had never heard of anaemia. Most pregnant women in Elele community have been exposed to secondary education but unfortunately, were not well informed with the condition of anemia in pregnancy. The predisposing factors recognized to be responsible for anemia in pregnant women were parity (14.2%), adoption/miscarriage previously (28.1%), blood transfusion (23%), and being a sickle cell anaemia patient (28.3%). Increasing access to health information and quality services will greatly affect health seeking behavior and utilization of health services.
The prevalence of anaemia was high (56.4%) among the pregnant women in this study. Assessment of anaemia during pregnancy is important, because it directly or indirectly contributes to the high Maternal and perinatal morbidity and mortality seen in Nigeria. It also affords one the opportunity to institute interventions to prevent complications especially when carried out at booking. Therefore, there is a need to identify the risk factors for anaemia. Among other findings, the study showed that the lack of knowledge of anaemia was almost universal. Additional finding shows a strong correlation between parity and prevalence of anaemia, that the higher the parity, the greater the prevalence of anaemia (“pregnancy too many”).
Measures to improve and demonstrate maternal and child health (MCH) effectiveness through built-in evaluation procedures should thus go hand-in-hand with a drive to increase awareness of the need for iron supplements. Such an increased awareness will lead to an increased demand. Ultimately, adherence with iron therapy at the user level is affected by interactions between policy, service system and user factors. As already mentioned, lack of awareness of the prevalence, health impact and economic cost of anaemia, and the efficacy of iron supplementation at all three levels (health policy makers, health care providers and among vulnerable groups within communities) are all significant problems.
Based on the findings, the following recommendations were made;
- There is need for public enlightenment campaigns to sensitize the public on what anaemia is, its causes, risk factors and complications. Strategies should also be put in place to increase awareness on anaemia. These should include dissemination of information via antenatal and under-five clinics, public radio, and community development meetings conducted by extension workers.
- Health education and promotion, especially to encourage all pregnant women to book early for antenatal care and to take appropriate intervention measures. Information, Education and Communication (IEC) efforts should be directed towards increasing levels of awareness and commitment at all levels.
- All pregnant women should be intermittently screened for the presence of anaemia during the antenatal care visit, instead of just at booking which is the practice in most health facilities.
Limitations of the Study
The constraints faced by the researcher include time constraint as the researcher had to combine this study with other academic activities and preparations, inadequate material of the study, stress and financial constraints. Also, this work was limited to Elele community, Emohua L.G.A and pregnant women attending antenatal care; this implies that a general inference cannot be made for other women and mothers on issues related to motherhood practices.
Suggestions for Further Studies
Based on the research findings, the researcher suggests the following areas for further studies. There is need for more research to analyze the role of risk factors and perception in management of anemia among pregnant women and mothers as a whole.
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