Original article: Factors associated with maternal anaemia

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Bangladesh Journal of Medical Science Vol. 17 No. 04 October’18

Original article:Factors associated with maternal anaemia among pregnant women in rural India

Singal N1, Setia G2, Taneja BK3, Singal KK4

Abstract:Background: AnaemiainpregnancyisoneofthemostimportantandcommonpublichealthproblemnotonlyinIndiabutalsoinmostoftheSouthEastAsiancountries.Anaemiaisthemostcommonnutritionaldeficiencydisorderintheworld.Thereispredominanceofirondeficiencyanaemia (nutritional anaemia). In pregnancy, it is one of the leading causes responsible formaternalandperinatalmorbidityandmortality.Objective:TofindouttheriskfactorsassociatedwithanaemiainpregnantwomenatMMIMSRduringthestudyperiodwithspecialreferenceto the severity of the disease. Methods:ThestudywasconductedinDepartmentofObstetricsandGynaecology,MMIMSR,Mullana,Ambala.Thestudywascarriedoutbetweentheperiodofoctober2012toSeptember2014.Atotalof200casesofmoderateandsevereanaemiawereincludedin thestudyonthebasisofsimplerandomsamplingmethodand200casesofnonanaemicsubjectswereincludedtoserveascontrolsfor theanaemicgroup,duringthestudyperiod.Hbgm/dlwas takenascriteria fordecidinganaemiacasesandalso toclassify themaccording to the severity.Caseswere classified according toWHOcriteria.Results: Out of 200casesofanaemia,70%weremoderatelyanaemic(Hb7–9.9gm/dl)and30%wereseverlyanaemic(Hb<7gm/dl).Microcytichypochromictypeofanaemia(82.5%)wasmoreprevalentsuggesting nutritional inadequacies as cause of anaemia.Conclusion: In the present studymaternalilliteracy,lowSES,inadequateantenatalcare,closebirthspacing,poornutritionwereallriskfactorsforanaemiainpregnancyMicrocytichypochromictypeofanaemia(82.5%)wasmoreprevalentsuggestingnutritionalinadequaciesascauseofanaemia..Keywords: Pregnancy;Microcytichypochromic;irondeficiency;Anemia.

Correspondence to: GeetanjaliSetia,Ex.Resident,DepartmentofObs.&Gynae,M.M.InsttituteofMedicalSciences&Resarch,Mullana(Ambala),India.E-mail:[email protected]

1. NeerjaSingal,AssociateProfessor,DepartmentofObs.&Gynae*.2. GeetanjaliSetia,Ex.Resident,,DepartmentofObs.&Gynae#.3. BalKrishanTaneja,Ex.Professor,DepartmentofObs.&Gynae#.4. KiranKumarSingal,Professor,DepartmentofMedicine*

M.M.MedicalCollege&Hospital,Kumarhatti,Solan(H.P.)India M.M.InsttituteofMedicalSciences&Resarch,Mullana(Ambala),India.

IntroductionPregnancy is special: let’s make it safePregnancyisauniqueexperienceineverywoman’slife.Thethoughtofagrowingfoetusinthemother’swomb, indeed is nature’s way of expressing theattributes ofmotherhood.Anaemia in pregnancy isoneofthemostimportantandcommonpublichealthproblemsnot only in India but also inmost of theSouthEastAsian countries.About 16% to 40%ofmaternal deaths occur due to anaemia. Anaemia also increases maternal morbidity significantly.Pregnancy increases the requirements of various

nutrientsespeciallyironandfolateandthereforeputsa stress which will either precipitate or aggravateanaemia in pregnancy. Haemodilution occuring inpregnancyisalsoamainfactortoaggravateanaemia.Mostofthepregnantpatientspresentingtooutpatientdepartment have iron deficiency anaemia.Most ofthe population in India lives in rural areas whereproperhealthcareservicesarenotavailabletothem.Alongwith physiological causes, social causes arealso responsible foranaemiaduringpregnancy likeearlyageatmarriage,teenagepregnancy,illspacingbetweentwopregnanciesandpoorsupplementation

Bangladesh Journal of Medical Science Vol. 17 No. 04 October’18. Page : 583-592DOI: http://dx.doi.org/10.3329/bjms.v17i4.38320

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FactorsassociatedwithmaternalanaemiaamongpregnantwomeninruralIndia

ofiron,malnutrition,endemicdiseaseslikemalariaand worm infestations. Standards laid by WHOsuggest haemoglobin below 11 gm/dl as anaemia.According to standards laid down, incidence ofanaemia during pregnancy in India ranges from65% to 75%.1 The prevalence of anaemia all overtheworld is51%andisashighas87.5%amongstpregnant women in India.2 Anaemia continues to take a heavy toll of maternal lives in India fromdirectaswellasindirectdeaths,fromcardiacfailure,haemorrhage, infections, pre-eclampsia, puerperalsepsis. According to the FOGSI – WHO study(1997),anaemiaisresponsiblefor64.4%ofmaternaldeaths in India.3 The Indian Council MedicalResearch(ICMR)’sdataalsoshows84.2%anaemiaprevalence in rural pregnant women, of which13.1%wereseverelyanaemic.4 In India, the National Nutritional Anaemia prophylaxis programme waslaunched in 1972 and has been in operation sincethen.Theprogrammehasbeenreinforcedforthelastthreedecades,yettheprevalenceofanaemiaremainsalarmingly high. Anaemia, the most preventablecause of maternal mortality, should be eradicated from the female population in the coming yearsthatwillensurebettermaternalandperinatalhealth,happy family and a healthy nation. Multifacetedapproach is needed to correct anaemia in pregnantwomen. Aims and ObjectiveAimTofindouttheriskfactorsassociatedwithanaemiain pregnant women with special reference to theseverity of the disease.ObjectiveAnaemiainpregnancyisoneofthemostimportantandcommonpublichealthproblemnotonlyinIndiabut also in most of the South East Asian countries. Anaemiaisthemostcommonnutritionaldeficiencydisorder in the world. WHO has estimated thatprevalence of anaemia in pregnant women is 14percentindevelopedand51percentindevelopingcountries and 65-75 percent in India.1 About one third of the global population (over 2 billion) areanaemic.2India contributes to about 80 per cent ofmaternaldeathsduetoanaemiainSouthAsia.LowSES,inadequateantenatalcare,closebirthspacing,poor nutrition were all risk factors for anaemiain pregnancy. The high prevalence of anaemia isrecognized to be contributory to maternal mortality, under nutrition of the foetus and infant mortality.Material and MethodThepresentstudywasconducted inDepartmentof

Obstetrics and Gynaecology, MMIMSR, Mullana, Ambala. The study was carried out between theperiod of October 2012 to September 2014. Theobjectives of the study were to find out the riskfactorsassociatedwithanaemiainpregnantwomenofatMMIMSRduringthestudyperiodwithspecialreference to the severity of the disease.•Atotalof200casesofmoderateandsevereanaemiawere included in the study on the basis of simplerandom sampling method and 200 cases of nonanaemicsubjectswereincludedtoserveascontrolsfortheanaemicgroup,duringthestudyperiod.•Hbgm/dlwastakenascriteriafordecidinganaemiacases and also to classify them according to the severity.CaseswereclassifiedaccordingtoWHOcriteria5

Inclusion criteria

Antenatal women with moderate anaemia (Hb-7-9.9gm/dl)Antenatalwomenwithsevereanaemia(Hb<7gm/dl).Antenatalwomenwithmoderateandsevereanaemiaotherwisehavingnoothermedicalproblem.Exclusion criteria Antenatalwomenwithnoanaemia(Hb≥11gm/dl)Antenatal women with mild anaemia (Hb-10-10.9gm/dl)Antenatalcaseswithotherassociateddiseaseswereexcluded.Cases of bad obstetric history for any other reason.MethodsAll study subjectswere studied in full detailswithreference to age, literacy, socio economic status, diet, detailed obstetric and menstrual history. Present pregnancydetailsregardingthenumberofantenatalvisits, ill health, chronic infection or infestation any timeduringpregnancywerestudied.Womenwereinvestigatedfor:-- Completehaemogram.- UrineRoutineExaminationandMicroscopy:- StoolRoutineExaminationandMicroscopy:

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SingalN,SetiaG,TanejaBK,SingalKK

- Peripheral Blood Smear for evidence malarialparasite.

- Serumironandserumtotalironbindingcapacitytoknowtheironstores.

- SerumIron/Folate/HaemoglobinElectrophoresis(whenrequired)

- AnyOtherInvestigationsasandwhenrequired.OnlyHbwasdoneinthecontrolgroup.Allthestudysubjectswerefolloweduptilltheyweredischargedfromthehospital.Presentpregnancydetails–parity,intervalbetweenconception,numberofANCvisits,andanyassociatedmedicaldisorderwerestudied.

Statistical methods employed

1. TheMeananditisdefinedastheaverageof N values.

Mean=∑Nvalues N where∑=summationofall

N values

2. Chi-Square(χ2)Test

χ2= ∑(Oi Ei)2 Ei

WhereOiisObservedfrequencyandEiisExpectedfrequencywith n-1 degrees of freedom The completed questionnaires of patients werecompiled and enetered intoMicrosoftExcelwhichwere then analysed using SPSSVersion 2.1 or 21.Proportionswerecalculatedfordifferentparametersandχ2testwasthenusedtoassesstheassociationofthesefactorswithanaemiainpregnantwomen.

3. SignificantFigures

HighlySignificant(HS)(pvalue:p≤0.01)Significant(S)(pvalue:0.01<p

<0.05)NonSignificant(NS)(pvalue:p≥0.05)4.ContingencyCoefficient,CC=χ2 N+χ2

Whereχ2=Chi-SquareandN=NumberofpatientsResultsThestudy subjects were divided into two groups.200cases of moderate and severe anaemia200nonanaemic controls

Table-1: Distribution of study subjects according to age

Age (years)

Cases Controls

N=200 % N=200 %

≤19Yrs. 31 15.5 28 14

20-29Yrs. 158 79 164 82

> 30 Yrs. 11 5.5 8 4

Total 200 100 200 100

CC=0.061, P=0.691 (NS)

Majority of study subjects belonged to the age group of 20-29 years – 79% in casesand82% in controls.

15.5% of women in cases and 14% of women in controls were belonging to the teenage age groupof < 19 Years.

5.5% of cases and 4% of controls were elderly mothers with age > 30 years.

Table – 2: Distribution of study subjects according to socio economic status

SESCases Controls

N=200 % N=200 %

Lower 138 69 36 18

Middle 59 29.5 130 65

Upper 3 1.5 34 17

Total 200 100 200 100

CC=0.599; P<0.001(HS)All the cases were categorized as per modifiedKuppuswamy’ssocioeconomicclassification.69%ofthecasesasagainstonly18%ofthecontrolsbelonged to low socio economic group, indicatingthat low socio economic status is a risk factor foranaemiainpregnancy.

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Table – 3: Distribution of study subjects as per educational statusEducational Status

Cases Controls

N=200 % N=200 %

Illiterate 126 63 50 25

School Level 66 33 104 52

Graduate 8 4 46 23

Total 200 100 200 100

CC=0.504;P<0.001(HS)

Majority of anaemic women were illiterateaccountingto63%asagainstonly25%inthecontrolgroup. 52% in the controls and 33% in cases hadschool level education.Table – 4: Distribution of study subjects as booked and unbooked

CategoryCases Controls

N=200 % N=200 %

Booked 84 42 186 93

Unbooked 116 58 14 7

Total 200 100 200 100

CC=0.611;P<0.001(HS)

It was observed that 58% of the anaemic patientswere unbooked as against only 7% in the controlgroup. Hence anaemia is more common in theunbookedcases.Table – 5: Distribution of cases according to the severity of anaemia

Severity of anaemia

No. of cases (N=200)

%

Moderate 140 70

Severe 60 30

Total 200 100

It is observed that out of 200 anaemia cases 70%were moderately anaemic and 30% were severelyanaemic.Table – 6: Distribution of study subjects according to parity

ParityCases Controls

Moderate Severe N = 200 % N=200 %

Primi 52 24 76 38 112 56

Multi 88 36 124 62 88 44

Total 140 60 200 100 200 100CC=0.247,P<0.001(HS)

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38%ofanaemicpatientswereprimigravidaasagainst56% in the controls. 62% of anaemic cases weremultigravidaeasagainstonly44%inthecontrols.Hence anaemia is more common in multigravidaeprobably because of decreased birth spacing andmultiplepregnancies.

Table – 7:Birth spacing interval in multiparous patients

Birth Spacing Interval

Cases Controls

N* = 124 % N = 88 %

<2Yrs. 88 71 26 29.5

>2Yrs. 36 29 62 70.5

Total 124 100 88 100

CC=0.472;P<0.001(HS)N*-TotalNumberofMultigravidaePatients

71%of the caseshadbirth spacing intervalof≤2yearswhileitwasonly29.5%inthecontrolgroup.

70.5%ofthepatientsinthecontrolgrouphadbirthspacingintervalofmorethan2years.Thus, anaemia is more common in multigravidaewithdecreasedbirthspacing.

Table – 8: Symptom analysis of anaemic cases and control group

Symptoms Cases Controls

N = 200 % N = 200 %Asymptomatic 30 15 194 97

Weakness /Fatiguability

150 75 0 0

Dyspnoea /Palpitations

74 37 0 0

Pedal Edema 40 20 6 3

LossofAppetite 56 28 0 0

Malaria 3 1.5 0 0

Visualblackouts 3 1.5 0 0

Fever 3 1.5 0 0

UTI 3 1.5 0 0

TB 3 1.5 0 0p<0.001(HS)85%of anaemicwomen had symptoms suggestiveofanaemia.Thecommonsymptomswereweakness/fatiguabilityin75%,dyspnoea/palpitationsin37%andpedaledemain20%ofanaemiccases.97% of the control group were asymptomaticand only 3% had pedal edema due to associatedgestationalhypertension.

Table – 9: Distribution of study subjects according to menstrual history

Menstrual history

Cases Controls

N=200 % N=200 %

Normal 161 80.5 190 95

Increasedflow 39 19.5 10 5

Total 200 100 200 100CC=0.299; P<0.001 (HS)

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19.5% of anaemic cases had increased menstrualflowascomparedtoonly5%inthecontrolgroup.Table – 10: Haematinic intake in the study subjects in the present pregnancy

H a e m a t i n i c intake

Cases Controls

N = 200 % N = 200 %

Nil 58 29 0 0

Notadequate 53 26.5 0 0

Adequate 89 44.5 200 100

Total 200 100 200 100CC=0.659; P<0.001 (HS)

Ironintakewasconsideredtobeadequateifthewomenhadhaematinicintakefromthebeginningof second trimester.

29%ofanaemiccaseshadnohaematinicintakeand26.5%hadinadequateironsupplementation.

Only 44.5 % of anaemic cases had adequatehaematinicintakeasagainst100%inthecontrolgroup.

Table – 11: Table showing nutritional status of study subjects as per BMI

BMI (Kg/m2)Cases Controls

N = 200 % N = 200 %Underweight 42 21 8 4

Normal 156 78 186 93Overweight 2 1 6 3

Total 200 100 200 100CC=0.349; P<0.001(HS)

Thenutritional statuswasanalysedon thebasisofbody mass index (BMI). BMI of the women wascalculated by using the formula.BMI (inkg/m2) =Weight (inkg)Height2

(m)Women were divided into 4 categories

dependingontheBMI.< 19 Kg/m2=Underweight20–24Kg/m2=Normal>25Kg/m2=Overweight

21%oftheanaemicpatientswereunderweightasagainstonly4%inthecontrolgroup.

93%ofthecontrolshadnormalBMIasagainstonly78%inthecases.

Table – 12: Relationship of grade of anaemia with different mean blood parametersBlood parameters

(Mean value)Moderate(N = 140)

Severe(N = 60)

PCV (%) 27.0 19.2

MCV (fl) 76.0 61.8

MCH (pg) 22.37 17.91

MCHC (%) 27.4 25.1

S. Iron (mg/dl) 59.74 60.15

S.TIBC (mg/dl) 447.44 477.20

ThistableshowsthatmeanPCVwas27.0%inthemoderate anaemic group and 19.2% in theseverelyanaemicgroup.

The meanMCV was 76.0fl in the moderatelyanaemic and 61.8fl in the severely anaemicgroup.

ThemeanMCHwas22.37pginthemoderatelyanaemic and 17.91pg in the severely anaemicgroup.

ThemeanMCHCwas27.4%inthemoderately

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anaemic and 25.1% in the severely anaemicgroup.

ThisshowsthatMCV,MCHandMCHCareallreducedinirondeficiencyanaemia,whichisthecommonesttypeofanaemiainpregnancy.

The mean S. Iron was 59.74 mg/dl in themoderately anaemic and 60.15 mg/dl in theseverelyanaemicgroup.

The mean S. TIBC was 447.44 mg/dl in themoderately anaemic and 477.20 mg/dl in theseverelyanaemicgroup.

This shows that as the iron stores decrease in irondeficiencyanaemia,serumtotalironbindingcapacityincreases.

Table – 13: Type of anaemia in cases based on peripheral smearType of blood picture Frequency %

Microcytichypochromic 165 82.5

Dimorphic 35 17.5

Total 200 100Maximum cases had microcytic hypochromic

anaemiaaccountingfor82.5%ofcases.Dimorphic anaemiawaspresent in thebalance

17.5%ofthecases.

Table – 14: Table showing the results of stool examination in the anaemic casesStool examination Frequency %

Normal 143 71.5

Hookworm ova seen 42 21

Round worm ova seen 15 7.5

Total 200 100

Out of 200 cases of anaemia, 21% had positivestoolexaminationforhookwormovaand7.5%hadpositivestoolexaminationforroundwormova.DiscussionMajority of study subjects in the present studybelongedtotheagegroupof20-29years,79%incasesand82%inthecontrolsgroup(tableno-1).This iscomparabletothestudyconductedbyKhandaitDWetal (2001)23; inwhich70%of thecasesbelongedto20-29yearsagegroup. Some other studies also concluded similar results7,9.LowSESisariskfactorfor anaemia, poor nutrition being the main cause.In the present study 69% of the anaemic women(table no-2) belonged to low SES. These findingsare comparablewith study conducted byMalhotraP et al (2004)7, inwhichprevalenceof anaemia inwomen from low socioeconomic statuswas63.2%as compared to 38.5% in higher socio-economicalstatuswomen.StudiesconductedbySanhaHetal9, LokarePOetal11, Judith A et al18andHashimNetal13,NdukwuGU14alsoconcludedthatanaemiawasmore prevalent in women belonging to low socioeconomic class. This suggests a close relationshipbetweenlowSESandpregnancyanaemiaprobablybecauseofpoornutritionandinadequatehealthcare.In the present study it was observed that anaemiais more common among the illiterate mothers, the prevalencebeing63%asagainst25%inthecontrolgroup (table no-3). Only 33% of anaemic women

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had school education as compared to 52% in thecontrolgroup.ThisiscomparablewithstudiesdonebyNazHetal16 and Malhotra P et al14 and Khandait WD29.NazHetalconcludedthat55.6%ofanaemicwomenwere illiterate. MalhotraPetalconcludedthat prevalence of anaemia was 51.3% amongstilliteratewomenascomparedto43.5%prevalenceineducatedwomen.LokarePOetal21,HashimNetal23 alsofoundthatilliteracywassignificantlyassociatedwithhighprevalenceofanaemiaduringpregnancy.Regular antenatal checkups and adequate antenatalcare is the cornerstone for safe motherhood. 58%of the cases in the present study were unbooked(table no-4) as against only 7% in the controlgroup. This is comparable to study byAgarwal R30 inwhich 51.82%were unbooked. Study byNazH et al16 also concluded that that 67% cases wereunbooked in their study. In the present study 70%of subjects had moderate anaemia and 30% hadsevere anaemia (tableno-5).This is comparable tothe study conducted byAwasthi et al (2001)32, in which 71.5% subjects had moderate anaemia and28.5%hadsevereanaemia.Intheirstudy,HyderSMet al28concludedthat80%ofwomenhadmoderateanaemia. Rizwan F28, Toteja GS17 also concluded thatmajority ofwomen in the study hadmoderateanaemia.SimilarresultswereconcludedbyGautamV et al15.Anaemiainpregnancyismorecommoninwomenofhighparityduetofrequentpregnancyandinadequate spacing. In the present study, anaemiawasmorecommoninmultigravidaeaccountingfor62%ofcases(tableno-6)comparedtoonly44%inthecontrolgroup.TheseobservationsarecomparabletothestudyconductedbyAwasthiAetal32,inwhich65.5%subjectsweremultigravidaeand34.5%wereprimigravida.StudybyNazHetal16 also concluded that 61.5% of multigravide women had anemia.Studies conducted by Judith A et al18,HashimNetal13, Al-Farsi YM23alsofoundthatanaemiawasmoreprevalent inmiltigravidae.Close birth spacing hadanimpactonthehaemoglobinstatusofwomen.71%ofwomenintheanaemicgrouphadbirthspacing≤2years(tableno-7)ascomparedtoonly29.5%inthecontrolgroup.ThisiscomparabletostudyconductedbyKhandaitWDetal29,inwhich55.9%subjectshadbirthspacing>2years.SanhaHetal17 also found that anaemiawasmore prevalent inmultigravidaewithbirthintervaloflessthan36months.KozukiNetal34 studied that birth intervals shorter than 18 months are significantlyassociatedwithSGA,pretermbirthanddeathinthefirstyearoflife.Lackofaccesstofamilyplanninginterventionsthuscontributestotheburden

of adverse birth outcomes and infant mortality. Okwu GN et al22 examined pregnant women withbirthspacingoflessthanoneyearandlessthanoneandahalfyearshadsignificantlylowermeanHbandhigherprevalenceofanemia.Similarly,NwizuENetal12,LazovićNetal33 also found that short intervals between pregnancieswere significant predictors ofanaemia in pregnancy. In the present study, 85%of anaemic women had symptoms suggestive ofanaemia.ThecommonsymptomswereWeakness /Fatiguebilityin75%,Dyspnoea/Palpitationsin37%,LossofAppetite in28%andPedalEdema in20%cases.Malaria,fever,UTI,TBandvisualblackoutswerepresentin1.5%cases.(tableno-8).SharmaJB12 studiedthatanaemicpatientscomplainofweakness,exhaustion and lassitude, indigestion and loss of appetite. Palpitation, dyspnoea, giddiness, edemaand rarely anasarca and even congestive cardiac failure can occur in severe cases. Amengor GM et al24 studied that presence of malaria parasites inperipheralbloodconstitutedasignificantriskforlowHb.29%ofanaemiccaseshadnohaematinicintakeand 26.5% had inadequate iron supplementation.Only 44.5 % of anaemic cases had adequatehaematinic intake (tableno-10)asagainst100%inthe control group. Studies by Nik Rosmawati NHet al25 and Ivan EA et al26concludedthatinadequatehaematinicwasasignificantriskfactorforanaemia.21%oftheanaemicpatientswereunderweight(tableno-11)asagainstonly4%inthecontrolgroup.JudithA et al18 also concluded that lowBMI contributedsignificantlytothehigherprevalenceofanaemiainpregnancy.AdamI etal20 concluded that attention to maternal nutrition should be given to preventmaternalanaemiaandforimprovementofperinataloutcome.Inthepresentstudy,(tableno-12)themeanPCV,MCV,MCH,MCHCandS.IronandS.TIBCarecomparablethat tothatstudiedbyAgarwalV.31 InthepresentstudymeanPCVwas27%inmoderateanaemiaand19.2%insevereanaemia.InthestudyconductedbyAgarwalV,meanPCVwas21.6%inmoderateand14.9%insevereanaemia.

Blood parameters (Mean value)

Moderate(N = 140)

Severe(N = 60)

PCV(%) 27.0 19.2MCV(fl) 76.0 61.8MCH(pg) 22.37 17.91MCHC(%) 27.4 25.1S.Iron(mg/dl) 59.74 60.15

S.TIBC(mg/dl) 447.44 477.20

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InthepresentstudymeanMCVwas76flinmoderateand61.8flinsevereanaemia.MeanMCVwas83.5flinmoderate and 75.3fl in severe anaemia in studyby Agarwal V. In the present study mean MCHwas 22.37pg in moderate and 17.91pg in severeanaemia.MeanMCHwas 26.2pg inmoderate and22.6 pg in severe anaemia in study conducted byAgarwalV. In the present studymeanMCHCwas27.4% in moderate and 25.1% in severe anaemia.ThisiscomparabletostudybyAgarwalV,inwhichmeanMCHCwas26.4%inmoderateand24.4%insevereanaemia.InthepresentstudymeanS.Ironwas59.74mg/dlinmoderateand60.15mg/dlinsevereanaemia.InthestudyconductedbyAgarwalV,meanS.Ironwas 54.2mg/dl inmoderate and 28.19mg/dl in severe anaemia. In the present study, meanS.TIBCwas447.44mg/dl inmoderate and477.20mg/dlinsevereanaemia(tableno-12).Inthestudyby Agarwal V, mean S.TIBC was 320.62 mg/dlin moderate and 419.34 mg/dl in severe anaemia. Thus,ironstoresdecreaseinirondeficiencyanaemiaand serum total iron binding capacity increases.Peripheralsmearexaminationtellsusaboutthetypeofanaemiaandisimportantinthemanagement.Thepresent study correlates with study conducted byAwastietal.32 In thepresentstudymajority,82.5%of subjects had microcytic hypochromic anaemia(tableno-13)ascomparedto17.5%subjectshavingdimorphic anaemia.This is comparable to studyconductedbyAwasthietal, inwhich22%subjectshaddimorphicanaemiaand66.57%hadmicrocytichypochromicanaemia.AwanMMetal19 also found that76%of thecaseshadmicrocytichypochromic

anaemia. Similarly, in the study conducted by Rao P Srinivasa et al18, it was concluded that, anaemiain 1st trimester of pregnancy was endemic andmicrocytic,hypochromicanaemiaismostcommon.Wormscompetewithmaternalnutritionandarealsoresponsible for loss of blood and thus can causeanaemia. In the present study, 21% of cases werepositiveforhookwormovaand7.5%werepositiveforroundworminstoolexamination(tableno-14).Thus,28.5%caseswerepositiveforworminfestationsin the present study.Amengor GM et al24 studied that hookworm infestation was strongly associatedwith lowHb.GetachewMet al27 concluded from their study that, therewas a significant correlationbetween increasing hookworm parasite load anddecreasing haematocrit values. Thus Plasmodiummalaria and soil transmitted helminth infections were significantly associated with anaemia. Thus,Antenatal care should promote de-worming andeducationonpersonalhygiene.Inthepresentstudymaternal illiteracy, low SES, inadequate antenatalcare,closesbirthspacing,poornutritionwereallriskfactorsforanaemiainpregnancy.Among various causes of anaemia, 90% werenutritional in origin.Conclusion.In the present study maternal illiteracy, low SES,inadequate antenatal care, close birth spacing,poor nutrition were all risk factors for anaemia inpregnancy.Microcytichypochromictypeofanaemia(82.5%)wasmore prevalent suggesting nutritionalinadequaciesascauseofanaemia

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References:1. DeMayerEM,TegmanA.Prevalenceofanaemiainthe

World.WorldHealthOrganQlty .1998;38:302-16.2. ShrivastavaA, Prabha T, Sabuhi Q, Das V.Anaemia

in pregnancy –A novel regime of intramuscular irontherapy.J Obstet Gynaecol India.2005;55(3):237-40.

3. Bhat R . Maternal mortality in India – FOGSI-WHOstudy. J Obstet Gynaecol India.1997;47(3):207-14.

4. Dasgupta J,MittalR,SaxenaNC.,SaxenaBN,SoodS.K. Evaluation of the National Nutritional Anaemia Prophylaxis Programme.An ICMRTaskForce Study:IndianCouncilofMedicalResearch,NewDelhi;1989.

5. WHO- Haemoglobin concentrations for the diagnosisof anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2011 (WHO/NMH/NHD/MNM/11.1)

6. Sharma JB. Nutritional anemia during pregnancy innonindustrializedcountries.InStudJ(ed).ProgressinObstetric and gynaecology. 15 th ed. Edinburg: Churchill Livingstone;2003.103-22.

7. Malhotra P, Kumari S. Prevalence of Anaemia in Adult Rural Population of North India. J Assoc Physicians India.2004Jan; 52:18-20.

8. NazH,BegumB.Prevalenceandassociatedriskfactorsof anaemia in pregnantwomen in a teaching hospital,Korangi Industrial Area. Pak J Surg.2013;29(2):131-3

9. SanhaH, Tenesa S, Bansal K. Prevalence of anaemiaamongst pregnant women and its sociodemographicassociates in rural areas of Delhi. Indian J Community Med.2004;XXVII(4):345-8

10. Judith A, Noronha, Bhaduri A and Bhat V. Prevalence of anaemia among pregnant women: Acommunitybased study in Udupi district. Health and Population-PerspectivesandIssues.2008;31(1):31-40

11. Lokare PO,KaranjekarVD,Gattani PL,KulkarniAP.Astudyofprevalenceofanemiaandsociodemographicfactorsassociatedwithanemiaamongpregnantwomenin Aurangabad city, India. Ann Nigerian Med. 2012;6:30-4

12. NwizuEN, IliyasuZ, IbrahimSAandGaladanciHS .Socio-DemographicandMaternalFactorsinAnaemiainPregnancyatBookinginKano,NorthernNigeria.Afr J Reprod Health.2011;1(4):33-41.

13. Hashim N, Farooqi M, Naqvi S, Jaffery h f.Anemia;Moderatetosevereduringpregnancy.Professional Med J.2014;21(2):247-52

14. Ndukwu GU, Dienye PO. Prevalence and socio-demographic factors associated with anaemia inpregnancy in a primary health centre in Rivers State,Nigeria. Afr J Prm Health Care Fam Med. 2012;4(1),7pages.

15. GautamV,BansaYl,TanejaDK,ShahR.Prevalenceof anaemia amongst pregnant women and its socio-demographicassociatesinruralareaofDelhi.Indian J Community Med.2002Oct-Dec;XXVII(4):157-60

16. RizwanF.Prevalenceofanaemiainpregnantwomenanditseffectsonmaternalandfetalmorbidityandmortality. Pak J Med Sci.2010Jan-Mar; 26(1):92-5.

17. TotejaGS,SinghP,DhillonBS,SaxenaBN.Prevalenceof anemia among pregnant women and adolescentgirls in 16 districts of India. Food Nutr Bull. 2006

Dec;27(4):311-518. RaoPSrinivasa ,SrikanthS.PrevalenceofAnemiain

theFirstTrimesterofPregnancyinRuralPopulationofKrishna District in Andhra Pradesh. Sch J App Med Sci. 2013;1(5):570-4

19. AwanMM,AkbarMA,KhanMI.Astudyofanemiainpregnantwomenofrailwaycolony,Multan.Pak J Med Res.Jan-Mar2004;43(1):11-4

20. Adam I, Babiker S,MohmmedAA, SalihMM, PrinsMH,ZakiZM.Lowbodymassindex,anaemiaandpoorperinataloutcomeinaruralhospitalineasternSudan.J Trop Pediatr.2008Jun;54(3):202-4.

21. Lazović N, Pocekovac P. The importance of timeintervals between childbirth and anemia in pregnancy. Srp Arh Celok Lek1996Nov-Dec;124(11-12):307-10.

22. Okwu GN; Ukoha AI. Studies on the predisposingfactors of iron deficiency anaemia among pregnantwomeninaNigeriancommunity.Pak J Nutr.2008Jan-Feb; 7(1):151-6.

23. Al-FarsiYM,BrooksDR,WerlerMM,CabralHJ,Al-Shafei MA,Wallenburg HC. Effect of high parity onoccurrenceofanemiainpregnancy:acohortstudy.BMC Pregnancy Childbirth.2011;11:7.

24. Amengor GM, OwusuW B. Determinants of anemiain pregnancy in Sekyere West Ghana. Ghana Med Journal.2005sep;39(3):102-7

25. NikRosmawatiNH,MohdNazriSM,MohdIsmailMI.TheRateandRiskFactorsforAnemiaamongPregnantMothers inJertehTerengganu,Malaysia.J Community Med Health Educ.2012; 2(5):150

26. IvanEA,MangaiarkkarasiA.Evaluation of anemia inbooked antenatal mothers during the last trimester. J Clin Diagn Res.2013Nov; 7(11):2487-90

27. GetachewM,YewhalawD,TafessK,GetachewYandZeynudinA.Anaemiaandassociatedriskfactorsamongpregnant women in Gilgel Gibe dam area,SouthwestEthiopia.Parasites&Vectors.2012;5:296

28. Hyder SM, Persson LA, Chowdhury M, LönnerdalBO,EkströmEC.Anaemia and irondeficiencyduringpregnancy in rural Bangladesh. Public Health Nutr . 2004Dec;7(8):1065-70.

29. KhandaitDW,AmbadikarNN, Zodpey PS et al. Riskfactors for anemia in Pregnancy. J Obstet Gynaecol India.2001Jan-Feb;51 (1):42-4.

30. AgarwalR. AMulticentricstudyofAnaemia :Astepin conquering anaemia.Obs and Gynae Today. 2003 ;8(11):620-23.

31. AgarwalV. Evaluation of effect of IM injectable iron(225 mg/day) in anaemic pregnant patients. Obs and Gynae Today.2005;10(5):270-73.

32. AwasthiA,ThakurR.DaveA,GoyalV.Maternalandperinatal outcome in cases of moderate and severeanaemia. J Obstet Gynecol India.2001;57(6):62-65

33. Lazović N, Pocekovac P. The importance of timeintervals between childbirth and anemia in pregnancy. Srp Arh Celok Lek1996Nov-Dec;124(11-12):307-10.

34. KozukiN, LeeACC, SilveiraMF ,VictoraCG ,AdairL, JeanHumphrey J, et al. The associationsofbirth intervals with small-for-gestational-age, preterm,and neonatal and infant mortality: a meta-analysis. BMC Public Health.2013;13(Suppl3):S3

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Original article: Factors associated with maternal anaemia