Prospective study on prevalence of anemia of pregnant women and its outcome: A community based study

Abstract

Background
Anemia is one of the most common nutritional deficiency disorders affecting the pregnant women in the developing countries. Anemia during pregnancy is commonly associated with poor pregnancy outcome and can result in complications that threaten the life of both mother and fetus.

Objective
The objective of the study was to estimate the prevalence of anemia among pregnant women and to determine its association with maternal and fetal outcomes.

Settings and Design
This study design was a prospective, observational, community-based study.

Subjects and Methods
Four hundred and forty-six pregnant women were included in the study from three primary health centers in Kolar district by multistage sampling technique and were followed up till 1 week after delivery.

Statistical Analysis
The data were analyzed using SPSS version 22; correlation coefficient, Chi-square test, and logistic regression were used.

Results
There was a significant overall improvement in the hemoglobin levels of pregnant during the follow-up (10.3–10.72 gm%). About 35.6% of the women had maternal or fetal morbidity. Anemia was one of the main pregnancy-related complications (62.3%), other complications include difficult labor (3%), postpartum hemorrhage, and preeclampsia 1.6% each abortions/stillbirths (3.5%). The fetal complications include low birth weight (25.5%) followed by premature delivery (0.2%) and birth asphyxia (0.5%).

Conclusions
A high prevalence of anemia in pregnant women apparently increases the maternal and fetal risks. To improve maternal and fetal outcome, it is recommended that the primary health care has to be strengthened, prevention, early diagnosis, and treatment of anemia in pregnancy to be given priority.

Full text

Official Publication of the Academy of Family Physicians of India
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Introduction
Anemia is one of the most common nutritional deciency
disorders affecting the pregnant women; the prevalence in
developed countries is 14%, in developing countries 51%, and
in India, it varies from 65% to 75%.[1,2]
Anemia is the second most common cause of maternal death
in India and contributing to about 80% of the maternal deaths
caused by anemia in South East Asia.[2,3‑5] Anemia is also an
established risk factor for intrauterine growth retardation, leading
on to poor neonatal health and perinatal death.[6‑10]
The prospective observational study is undertaken to estimate the
prevalence and to study maternal and early neonatal morbidity
and mortality associated with anemia in a pregnant woman.
Subjects and Methods
A prospective observational study was conducted in three primary
health centers (PHCs) of Kolar Taluk during March 2013‑January
2015. A sample size of 446 pregnant women was estimated
based on the prevalence of anemia of 59% among pregnant
Prospective study on prevalence of anemia of pregnant
women and its outcome:A community based study
Ravishankar Suryanarayana1, Muninarayana Chandrappa1,
Anil Navale Santhuram1, S. Prathima2, S. R. Sheela3
Departments of 1Community Medicine, 2Pathology and 3Obstetrics and Gynaecology, Sri Devaraj Urs Medical College, Kolar,
Karnataka, India
Abs tr Ac t
Background: Anemia is one of the most common nutritional deficiency disorders affecting the pregnant women in the developing
countries. Anemia during pregnancy is commonly associated with poor pregnancy outcome and can result in complications that
threaten the life of both mother and fetus. Objective: The objective of the study was to estimate the prevalence of anemia among
pregnant women and to determine its association with maternal and fetal outcomes. Settings and Design: This study design was
a prospective, observational, community‑based study. Subjects and Methods: Four hundred and forty‑six pregnant women were
included in the study from three primary health centers in Kolar district by multistage sampling technique and were followed up
till 1 week after delivery. Statistical Analysis: The data were analyzed using SPSS version 22; correlation coefficient, Chi‑square
test, and logistic regression were used. Results: There was a significant overall improvement in the hemoglobin levels of pregnant
during the follow‑up (10.3–10.72 gm%). About 35.6% of the women had maternal or fetal morbidity. Anemia was one of the main
pregnancy‑related complications (62.3%), other complications include difficult labor (3%), postpartum hemorrhage, and preeclampsia
1.6% each abortions/stillbirths (3.5%). The fetal complications include low birth weight (25.5%) followed by premature delivery (0.2%)
and birth asphyxia (0.5%). Conclusions: A high prevalence of anemia in pregnant women apparently increases the maternal and fetal
risks. To improve maternal and fetal outcome, it is recommended that the primary health care has to be strengthened, prevention,
early diagnosis, and treatment of anemia in pregnancy to be given priority.
Keywords: Fetal morbidity, maternal morbidity, prevalence
Original Article
Access this article online
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Website:
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DOI:
10.4103/jfmpc.jfmpc_33_17
Address for correspondence: Mr. Ravishankar Suryanarayana,
Department of Community Medicine, Sri Devaraj Urs Medical
College, Kolar ‑ 563 101, Karnataka, India.
E‑mail: suryasankya@gmail.com
How to cite this article: Suryanarayana R, Chandrappa M, Santhuram AN,
Prathima S, Sheela SR. Prospective study on prevalence of anemia of
pregnant women and its outcome: A community based study. J Family
Med Prim Care 2017;6:739-43.
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Suryanarayana, et al.: Anemia in pregnancy and its outcome
Journal of Family Medicine and Primary Care 740 Volume 6 : Issue 4 : October-December 2017
women (National Family Health Survey [NFHS]‑3 survey) with
95% condence level and with an absolute precision of 5%,
including a dropout rate of 20%.
Multistage sampling technique was adopted to select the pregnant
woman. Randomly selected three PHCs and the Accredited
Social Health Activists (ASHA) workers of these PHC were
trained and motivated to bring all the sampled antenatal care
cases to the antenatal clinic at the PHC on xed days. The
pregnant woman was examined by the OBG consultant, and
postgraduates and the data were collected. Pretested and a
semi‑structured questionnaire was used to collect the data; the
woman were followed up every month with the help of ASHA
worker until 1 week after delivery. The hemoglobin (HB) of the
pregnant women was measured at the rst visit and repeated
at every 3rd month.
The HB measurements of the pregnant woman were measured
using HemoCue analyzer (HemoCue Hb 301). Anemia was
classified based on the WHO criteria; HB concentration
of <11 g/dl was considered as anemia. HB concentration of
10–10.9 g/dl, 7–9.9 g/dl, and <7 g/ dl was considered as mild,
moderate, and severe anemia, respectively.
The pregnant women were counseled about their HB level and
importance of consumption of the iron and folic acid tablets,
locally available iron‑rich foods and regular antenatal checkups, etc.
The data were analyzed using IBM SPSS Statistics V22.0 (IBM
United States). The quantitative measures are presented by mean
and standard deviation and qualitative variables by proportions.
Chi‑square test, correlation coefcient, and logistic regression
were used for testing signicance. P ≤ 0.05 was considered
statistically signicant.
Results
A total of 446 pregnant women were enrolled for the study and
were followed up until 1st week after delivery. Out of 446 women
enrolled, 427 women completed the follow‑up with an attrition rate
of 9.5%. Mean age of pregnant women was 22.4 years. Most of
the women were Hindus, belonging to schedule cast (SC)/schedule
tribes (ST) (57.4%) and below poverty line (89%).
The prevalence of anemia was 62.3% in pregnant women, and
it was observed that anemia was common in the age group of
21–30 years (66.1%), SC/ST (61.6%), and OBC (30.8%). There
was a signicant association of anemia status with educational
status and gravida. The prevalence of anemia increased
with the duration of pregnancy, but it was not statistically
signicant. Anemia is more common in the women with birth
interval <1 year (40.2%) [Table 1].
During the follow–up, there was a signicant improvement in
the HB levels from a mean of 10.3‑10.72 g%. The number of
women having various grades of anemia reduced and the number
of women with normal HB increased during the follow‑up this
was statistically signicant [Table 2].
Nearly 35.6% of the pregnant women encountered maternal and
fetal morbidity. Majority of the fetal and maternal complications
were observed in anemic women. Out of 15 participants who
underwent lower segment cesarean section (LSCS) and 60% were
anemic. Similarly, 80% of participants who had abortions, 40% of
obstructed labor, 86% of postpartum hemorrhage (PPH), 71.4%
of preeclampsia, and all the women with prolonged labor were
anemic. Around 25% of women delivered low birth babies, 57%
of low birth weight (LBW) babies, 69% of abortions/stillbirths,
and all the newborn with birth asphyxia occurred in mothers
who were anemic [Table 3].
No significant positive correlation between birth weight
and follow‑up Hb of pregnant women was observed in this
study (r = 0.041, P = 0.406).
Table 1: Prevalence of anemia according to the
sociodemographic status of the study participants
Particulars Normal Anaemia
χ
2
P
Age
<20 48 (29.8) 88 (33.0) 0.533 0.766
21‑30 112 (69.6) 176 (66.1)
31‑40 1 (0.06) 2 (0.09)
Education status
Illiterates 40 (24.8) 103 (38.7) 16.13 0.003*
Primary education 06 (3.7) 20 (2.9)
Secondary education/
SSLC/others
43 (26.7) 67 (25.2)
Higher secondary/PUC 58 (36.0) 64 (24.1)
Degree/PG 14 (8.8) 12 (9.1)
Caste
General 9 (5.6) 10 (3.7) 5.428 0.143
Other backward classes 64 (39.7) 82 (30.8)
Scheduled caste/scheduled
tribes
81 (50.3) 164 (61.6)
Others 7 (4.4) 10 (3.9)
Type of family
Extended 13 (8.1) 27 (10.1) 0.643 0.725
Joint 95 (59.0) 149 (56.0)
Nuclear 53 (32.9) 90 (33.9)
Gravida
Primi 74 (45.9) 81 (30.4) 30.62 0.001*
Second 82 (50.9) 127 (47.7)
Multigravida 5 (3.2) 58 (21.9)
Duration of pregnancy
(weeks)
<12 28 (17.4) 38 (14.3) 5.07 0.079
13‑24 77 (47.8) 106 (39.8)
25 weeks and above 56 (34.8) 122 (45.9)
Birth interval (year)
<1 71 (44.1) 107 (40.2) 1.52 0.468
1‑2 47 (29.2) 73 (27.4)
3 years and above 43 (26.7) 86 (32.4)

Suryanarayana, et al.: Anemia in pregnancy and its outcome
Journal of Family Medicine and Primary Care 741 Volume 6 : Issue 4 : October-December 2017
No significant positive correlation was observed between
birth weight and follow‑up Hb of pregnant women
(r = 0.041, P = 0.406).
Independent factors contributing to the risk of anemia was
evaluated by logistic regression model. It was observed that literacy
status (OR = 0.576) and bad obstetric history (OR = 15.07) were
the important and independent risk factors for anemia among
pregnant women [Table 4].
Discussion
Indian Council of Medical Research surveys showed that
over 70% of pregnant women in the country were anemic.[2]
Similar prevalence rate of anemia (63%) in pregnant women
was observed in the present study. In contrast, very high
prevalence was observed by Viveki et al., Totega, Agarwal
et al., and Gautam et al. (82.9%, 84.9%, 84%, and 96.5%,
respectively).[4,7,11,12] However, lower prevalence was reported
from Nepal (42.5%) and Haryana (51%) and NFHS‑2 and
3 (49.7%).[1,2,4]
Severe anemia among the participants in the present study was
low (2.3%) which was similar to study by Kapil and Sareen (1.6%)
and NHFS‑2 (2.5%).[13] Whereas other studies reported higher
prevalence; Totega (13.1%), Agarwal et al. (9.2%), Vivek
et al. (7%), and Gautam et al. (22.8%).[4,7,11,12] In a study by Bhargavi
Vemulapalli et Al., 40.97% had a moderate degree of anemia
and 6.28% of the population had a severe degree of anemia.[14]
The high prevalence of anemia can be attributed to low dietary
intake of iron and folic acid, deprived bioavailability of iron or
chronic blood loss due to infections.[2]
Table 2: Comparison of anemia status between baseline
and at the end of the study
Hemoglobin
levels (g%)
Baseline
n
(%) At full‑term
n
(%)
χ
2
P
<7 12 (2.8) 10 (2.3) 8.01 0.046*
7.1‑9.9 75 (17.6) 55 (12.9)
10‑10.9 179 (41.9) 163 (38.2)
>11 161 (37.7) 199 (46.6)
Total 427 (100) 427 (100)
*p value signicant at 5% level of signicance
Table 3: Distribution of pregnant women according to
complications and anemia status
Complications during delivery Normal Anemic Total
Anemia status 161 (34.7) 266 (62.3) 427
LBW 47 (43) 62 (57) 109
LSCS 6 (40) 9 (60) 15
Abortions and still births 3 (20) 12 (80) 15
Obstructed labor 6 (60) 4 (40) 10
PPH 1 (14) 6 (86) 7
Preeclampsia 2 (28.6) 5 (71.4) 7
Prolonged labor 0 2 (100) 2
Birth asphyxia 0 2 (100) 2
Premature delivery 1 (100) 0 1
LBW: Low birth weight; PPH: Postpartum hemorrhage; LSCS: Lower segment cesarean section
Table 4: Logistic regression analysis of risk factors in anemia and outcome
Predictors No anemia Anemia Unadjusted odds Adjusted odds (95% CI)
P
Age (year)
<30 169 249 0.339 1.008 (0.021‑7.723) 0.974
>30 06 03
Gestational age (weeks)
<20 81 115 0.769 1.160 (0.606‑1.494) 0.305
>20 92 139
Gravida
<3 171 242 4.239 1.556 (0.552‑47.152) 0.056
>3 02 12
Para
<3 172 252 1.365 1.115 (0.123‑27.012) 0.730
>3 01 02
Birth interval (year)
<3 153 217 1.304 1.007 (0.400‑1.730) 0.982
>3 20 37
Literacy status
Illiterate 53 115 0.525 0.576 (0.389‑0.982) 0.050*
Literate 121 138
Birth weight
2.5 kg 43 67 0.935 0.941 (0.529‑1.481) 0.796
>2.5 kg 129 188
Bad obstetric history
Yes 161 121 16.08 15.071 (7.612‑29.120) 0.001*
No 11 133
CI: Condence interval, *p value signicant at 5% level of signicance

Suryanarayana, et al.: Anemia in pregnancy and its outcome
Journal of Family Medicine and Primary Care 742 Volume 6 : Issue 4 : October-December 2017
Maternal anemia is considered as risk factor for poor pregnancy
outcomes, and it threatens the life of fetus. Available data from
India indicate that maternal morbidity rates are higher in anemic
women.[2,9,15] In the present study, about 35.6% of the women
had maternal and fetal morbidity, LSCS, abortions, obstructed
labor, PPH, preeclampsia, prolonged labor, LBW, and birth
asphyxia were commonly seen among anemic pregnant women.
There is a substantial amount of evidence showing that maternal
iron deciency anemia early in pregnancy can result in LBW
subsequent to preterm delivery.[10] In the present study, around
25% of women delivered low birth babies; the majority of
them (57%) were among women with anemia.
A study by Sangeetha in Bangalore reported highest (63%)
prevalence of LBW among pregnant women, whereas Marahatta
observed least (16.6%).[1,6] The other fetal complications among
pregnant women in the present study include premature
delivery (0.2%) and birth asphyxia (0.5%).
Studies in India demonstrated that the high proportion of
maternal deaths are due to anemia in pregnant women,[8] whereas
in the present study, there were no maternal deaths and no
preterm delivery, whereas Marahatta in Nepal reported 3%
preterm deliveries in anemic women.[1]
In the present study, gravida, education of pregnant women, and
bad obstetric history were signicantly associated with anemia.
A study by Chowdhury et al. in Bangladesh also found that
education of women was signicantly associated with anemia
in pregnancy,[16] whereas in a study by Singh et al. observed an
insignicant association between anemia and gravida.[17]
Anemia seems to be higher among women with parity more than
three in the present study, but it was not statistically signicant.
In a similar study conducted by Obse et al. in Ethiopia parity > 5
has a signicant association with anemia.[18]
It was observed in the present study that, among pregnant women
with birth interval more than 3 years, anemia was high with an
odds ratio 2, in a similar study conducted by Alemayehu Bekele
in Ethiopia birth interval was signicantly associated with anemia
with an odds ratio of 3.[19]
There was a signicant statistical association between anemia
and complications during pregnancy in the present study, which
is similar to the study conducted by Nair et al.[20]
Conclusions
High prevalence of anemia in pregnant women (63%) indicates
that anemia continues to be a major public health problem in
rural areas of India. Anemia in pregnancy increases the maternal
and fetal risks. Gravida status, female literacy, and bad obstetric
history were important risk factors contributing for anemia in
pregnant women.
To improve maternal and fetal outcome, it is recommended that
the primary health care has to be strengthened and high priority
has to be given to aspects such as prevention, early diagnosis,
and treatment of anemia in pregnancy.
Health education on reproductive health, monitoring the
consumption of iron folic acid tablets, early diagnosis of high‑risk
pregnancy, and appropriate management and strengthening of
their healthcare‑seeking behavior are important health‑care
measures to be undertaken at the community level. Furthermore,
it is time for the realization that health system should focus on
various factors that contribute to the occurrence of anemia and
include them as important indicators in the National Health
Policy.
Acknowledgment
Dr. Mahesh V, Assistant Professor, Department of Community
Medicine, Interns and Accredited Social Health Activists workers
for their support in collection of data.
Financial support and sponsorship
This study was nancially supported by SDUAHER.
Conflicts of interest
There are no conicts of interest.
References
1. Marahatta R. Study of anaemia in pregnancy and its outcome
in Nepal medical college teaching hospital, Kathmandu,
Nepal. Nepal Med Coll J 2007;9:270‑4.
2. Kalaivani K. Prevalence and consequences of anaemia in
pregnancy. Indian J Med Res 2009;130:627‑33.
3. Mbule MA, Byaruhanga YB, Kabahenda M, Lubowa A.
Determinants of anaemia among pregnant women in rural
Uganda. Rural Remote Health 2013;13:2259.
4. Viveki RG, Halappanavar AB, Viveki PR, Halki SB, Maled VS.
Prevalence of anaemia and its epidemiological determinants
in pregnant women. Al Ameen J Med Sci 2012;5:216‑23.
5. Ahmad N. The prevalence of anaemia and associated factors
in rural Indian community. Australas Med J 2010;1:276‑80.
6. Sangeetha VB, Pushpalatha S. Severe maternal anemia and
neonatal outcome. Sch J Appl Med Sci 2014;2:303‑9.
7. Gautam VP, Bansal Y, Taneja DK, Saha R, Shah B, Marg Z,
et al. Prevalence of anaemia amongst pregnant women and
its socio‑demographic associates in a rural area of Delhi.
IJCM 2002;27:157‑60.
8. Iyengar K. Early postpartum maternal morbidity among
rural women of Rajasthan, India: A community‑based study.
J Health Popul Nutr 2012;30:213‑25.
9. Ivan EA, Mangaiarkkarasi A.. Evaluation of anaemia in
booked antenatal mothers during the last trimester. J Clin
Diagn Res. 2013;7:2487–90.
10. Allen LH. Anaemia and iron deficiency: Effects on pregnancy
outcome. Am J Clin Nutr 2000;7:1280‑4.
11. Agarwal KN, Agarwal DK, Sharma A, Sharma K, Prasad K,
Kalita MC, et al. Prevalence of anaemia in pregnant &

Suryanarayana, et al.: Anemia in pregnancy and its outcome
Journal of Family Medicine and Primary Care 743 Volume 6 : Issue 4 : October-December 2017
lactating women in India. Indian J Med Res 2006;124:173‑84.
12. Totega GS. Prevalence of anaemia among pregnant women
and adolescent girls in 16 districts of India. Food Nut Bull
2006;27:311‑5.
13. Kapil U, Sareen N. Prevalence of anemia amongst overweight
and obese children in NCT of Delhi. IJCH 2014;26:295‑7.
14. Vemulapalli B, Rao KK. Prevalence of anaemia among
pregnant women of rural community in Vizianagaram, North
Coastal Andhra Pradesh, India. Asian J Med Sci 2013;5:21‑5.
15. Singh R, Chauhan R, Nandan D, Singh H, Gupata SC, Bhatnagar M.
Morbidity profile of women during pregnancy: A hospital
record based study in Western UP. IJCH 2012;24:342‑6.
16. Chowdhury HA, Ahmed KR, Jebunessa F, Akter J, Hossain S,
Shahjahan M. Factors associated with maternal anaemia
among pregnant women in Dhaka city. BMC Women Health
2015;15:77.
17. Singh R, Singh AK, Gupta SC, Singh HK. Correlates of
anaemia in pregnant women. Indian J Community Health
2015;27:351‑5.
18. Obse N, Mossie A, Gobena T. Magnitude of anaemia and
associated risk factors among pregnant women attending
antenatal care in Shalla Woreda, West Arsi Zone, Oromia
Region, Ethiopia. Ethiop J Health Sci 2013;23:165‑73.
19. Bekele A, Tilahun M, Mekuria A. Prevalence of anemia and
its associated factors among pregnant women attending
antenatal care in health institutions of Arba Minch town,
Gamo Gofa Zone, Ethiopia: A Cross‑sectional study. Anemia
2016;2016:1073192.
20. Nair M, Choudhury MK, Choudhury SS, Kakoty SD,
Sarma UC, Webster P, et al. Association between maternal
anaemia and pregnancy outcomes: A cohort study in Assam,
India. BMJ Glob Health 2016;1:e000026.