Prevalence of Anemia and Associated Factor Among Pregnant Women Attending Ante Natal Care in Arba Minch Public Health Institutions, South Ethiopia

Anemia 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 the life cycle, but is more prevalent in pregnant women. The highest prevalence of anemia among pregnant women in the developing world is due to its multi-factorial causes. Anemia leads to complication that will affect both the mother and the growing fetus. Objectives of the study was to determine the prevalence of anemia and associated factor among pregnant women that attends antenatal care at Arba Minch public health institutions, 2019. Institutional based cross sectional study was conducted on 374 pregnant women attending ANC at Arba Minch public health institutions. Systematic random sampling was used to recruit pregnant women. Semistructured questionnaire used for assessment of socio-demographic and socioeconomic factor. Venous blood was collected from pregnant women and Hemoglobin was estimated using CBC machine analyzer. Blood film for Hemoparasite as well as morphological types of anemia was assessed. Stool sample was taken for examination of intestinal parasites by using wet mount direct microscopy and formol ether concentration. Binary logistic regressions were done to determine association of variables by using SPSS version 21. Results of the study shows that, the prevalence of anemia was found to be 28.8% among pregnant women. Mild, moderate and severe anemia was 75.7%, 23.3% and 1% among anemic women respectively. Multivariate logistic regressions shows, monthly income [AOR=3.37, 95%: 9.35-10.09, P< 0.000], fruit consumption [AOR=6.9, 95%: 1.36-4.9, P<0.000], blood loss [AOR=3.66, 95%CI: 1.56-8.7, P<0.000] and being infected with malaria [AOR=6.10, 95%CI: 2.25-16.43, P<0.000] were independently associated with anemia. Morphologically, 75.5% of anemic pregnant women had Normocytic Normochromic, 23.3% had Microcytic hypochromic, and only 1% had Macrocytic normochromic. It is concluded that, the prevalence of anemia among pregnant women was moderate public health significances which is independently associated with low monthly income, habit of fruit consumption, blood loss and being infected with malaria parasites. It is recommended that creating awareness of the pregnant women on feeding iron rich foods like fruit, liver, poultry, cereals and green vegetables and giving health education on how to prevent malaria.


Introduction
Anemia is defined as a state or condition in which the reduction of hemoglobin concentration, hematocrit or in RBC mass for the same age, sex and geographical locations, resulting in lower quantities of oxygen available to support the body's activities. Which decrease the oxygen caring capacity of RBC to tissues [1]. It can be occur at all stage of life cycle, but it is more prevalent in pregnant women, because the hematological system undergoes changes in order to meet the needs of developing fetus and placenta.
Anemia in pregnancy can be classified in to two; one is physiological, which is due to increase in plasma volume / pseudo anemia/, in addition with marked demand of extra iron during pregnancy. The other is pathological, it can be due to deficiency of micronutrient (iron, folic acid vitamin B 12 ) or due to infection (hemoparasite and intestinal parasites) or it can be due to hemoglobin pathies and by other causes [2][3][4].
Anemia due to deficiency of micro nutrients (iron deficiency) is the common cause of anemia in pregnancy. In pregnancy the rate of erythropoiesis increase's, so during erythropoiesis there are factors needed to be fulfilled such as iron for synthesis of Heme/part of Hgb/, in pregnancy an extra of 1000mg of iron needed, other nutrients such as vitamin B 12 for synthesis of RNA, folic acid (vitamin 9) for later stages of DNA synthesis, also trace elements such as Zinc for protein metabolism &nucleic acid metabolism and others can be needed for erythropoiesis. If there is micronutrient deficiency or poor nutrition it will leads to anemia [5].
Also parasitic infection mostly Malaria & Hookworm can be associated with anemia in pregnancy, in which they cause reduction of RBC, as in malaria once the sporozoite form enter human host it will go to liver, it will multiplies &exit into the blood stream in the merozoite form, the merozoite then invades erythrocytes which leads to phagocytosis of infected blood cells by the spleen or sequestrated in spleen. In normal adults infected blood cells sequestrated in spleen but in pregnant women it will also sequestrated in placenta. In case of plasmodium falciparum also there is direct lyses of RBC so it will decrease the number of RBC, which can leads to anemia [6].
Hook worm infection cause anemia in pregnancy, after the entry to human host it will go to small intestine or if it' ingested it will directly go to small intestine which result blood loss by laceration or enzymatic damage to the intestinal mucosa leading to blood loss, others helminthes such as Tricuristricuria cause blood loss also Ascaris lumbricoid associated with reduced vitamin absorption, decreased appetite will co-releate with anemia in pregnancy [7]. The most common way or primary method for the diagnosis of anemia is measuring or determining hemoglobin concentration. As WHO classify in terms of hemoglobin concentration in which (10-10.9) g/dl considered as mildly anemic,(7.9-9.9) g/dl as moderately anemic and (<7.0) g/dl considered as severely anemic [8].
Anemia is a global public health problem affecting both developing and developed countries with major consequences for health as well as social & economic development but it is more common in developing countries like countries in Africa and Asia as they have poor nutritional status and high prevalence of intestinal parasite [2].
The global Prevalence of anemia as WHO declared in 2011 was 38. 2% (Hgb concentration <11.4 g/dl) or nearly 32.4 million in pregnant women that are in age of 15-49 years, also it declares the prevalence of severe anemia in pregnant women with hemoglobin level (<7g/dl) is 0.9% or 0.8 million (800,000) [9,10]. There is an established relationship between anemia and maternal mortality, IDA anemia alone was estimated to be an underlying factor for 22% of maternal deaths [11].
Anemia can be taken as indicator of both poor nutrition as well as poor health status because among the causes of anemia in pregnancy deficiency of micronutrient takes major role in its occurrence prevalence. In developing countries there is poor socioeconomic status and also high prevalence of intestinal parasite and hemoparasite that leads to its occurrence. The most dramatic health effect of anemia is increased risk of maternal and child mortality due to severe anemia [12].
Severe anemia (Hgb<7g/dl) during pregnancy has been associated with major maternal and fetal complication or death, Such as increase pre term delivery, neonatal and maternal death, inferior neonatal health [13][14][15].
Prevalence of anemia is high in developing countries as compared to developed countries, mostly the greatest burden of anemia come from Asia and Africa, especially in south Asia like India, a high prevalence of anemia in pregnancy was observed which is 96.5%, of which 22.8% had mild, 50.9 per cent had moderate and 22.8% had severe anemia in a study conducted in Delhi [16]. Generally in Asia the prevalence of anemia in pregnancy is 60% and in Africa is 52%. Also in sub Saharan Africa it is estimated that 20% of maternal deaths are associated with anemia [17].
In our country Ethiopia the prevalence of mild anemia (Hgb<12) is 23% and the prevalence of severe anemia (Hgb<7g/dl) is 1.1%, although the prevalence at the national level is considered to be mild, some regions in the lowlands exhibited extremely high prevalence of anemia. For instance in Somalia region nearly 50% of women were anemic in 2011, in Afar 40.4% &in dire-dawa33% [10].
Many researchers have been conducted to show anemia its associated factors among pregnant women in the world. But it remains the main public health problem, especially in developing countries. The etiology of anemia in Ethiopia is not well established and the information available is limited in representativeness of the whole country. Even if various researchers came up with different conclusions despite the problem being among the ten top morbidities reported by most health institutions in the country [18,19] Hence, this study was conducted to determine the prevalence of anemia and associated factor among pregnant women attending antenatal care center in Arba-Minch public health facilities. Information from the study might be used for policy maker for developing health intervention programmes designed to control and prevent anemia.

Study Area and Study Design
The study was conducted in Arba Minch Public health facilities. Arba-Minch town is located in Gamo Gofa zone Southern Nation Nationality and peoples region (SNNPR) about 500 KM south of Addis Ababa, at the elevation of 1285m above sea level [33]. The total population of the town is about 103,965 people; by using conversion factor for 2014/15 of SNNPR pregnant women in the town it is expected to be 4296 [34].
Institutional based cross sectional study was conducted.

Study Period
The study was conducted January 21 to April 21/2019.

Source Population/Study Population
All pregnant women attend antenatal care unit during study period.

Inclusion Criteria
Pregnant women that were resident in study area and that attend antenatal care unit in Arba Minch Public health institutions.

Exclusion Criteria
Those pregnant women who were seriously sick and unable to give data.

Sample Size Determination
The Sample size of 374 was determined using single population proportion formula. Level of confidence taken was 95%, 5% margin of error, P is 32.8% which is from the study conducted previously on anemia and associated factors in pregnant women attending ANC in health institution of Arba Minch town in 2016 [31]. Ten percent non-response rate was added to the sample size as a contingency.

Sampling Strategies
All pregnant women who attend for antenatal care follow up and who meet the inclusion criteria were included in our study. Participants were included only once on their first visit during the study period by using systematic random sampling after proportional allocation done for AMH and two health centers which, 200 and 174 respectively. The interval 'K' is calculated based on the data obtained from the previous two month on logbook by the formula N/n. From the previous two month data before data collection N=400 from the logbook, which K=400/200~2 for AMH and 250/174~2 for health centers. We recruited the pregnant women every 2 interval until sample was fulfilled.

Dependent Variable
Anemia.

Independent Variable
Age, Diet, income, occupation, educational level, residence, blood loss during current pregnancy, spacing number of child, gestational period, parasitic infection, abortion, iron and folate supplementation, gravidity, usage of contraceptives before pregnancy.

Operational Definition
Anemic pregnant women: -pregnant women that have Hgb concentration less than 11g/dl. Non anemic pregnant women:-pregnant women that have Hgb concentration greater than 11g/dl.
Mild anemia: -when the Hgb concentration of pregnant women is b/n 10-10.9 g/dl.
Moderate anemia: -when the Hgb concentration of pregnant women is b/n 7.0 to 9.9 g/dl.
Severe anemia:-when the Hgb concentration of pregnant women is less than 7 g/dl.
Normocytic Norm chromic: -when RBCs have normal size or RBCs similar to the nucleus of size of small lymphocyte and Red cell with a small central pallor (about 1/3 of the cell diameter).
Microcytic Hypo chromic:-erythrocytes having small size or smaller than nucleus of small lymphocyte and with a more pronounced central pallor (i.e. greater than 1/3 the diameter of the cell).
Macrocytic norm chromic: -erythrocytes that have large size than nucleus small lymphocyte and with normal central pallor.

Socio-demographic and Socioeconomic Data
A semi structured questionnaire was used to obtain data on demographic and socio economic variables also other relevant possible associated factors.

Laboratory Data
i. Blood Specimen for Hemoglobin Determination Three ml (3 ml) of venous blood was collected in EDTA tube and transferred to CBC automated hematology analyzer for Hgb determination.
ii. Blood Specimen for Morphology Study The blood specimen was placed on slide and thin smear was prepared and stain with Wright stain and examined by senior technologist.
iii. Blood Specimen for Hemoparasite Examination The blood specimen was placed on slide, thick and thin film was prepared and stain with Giemsa then it was examined by expertise.
iv. Stools Specimen for Intestinal Parasite Stools specimen was collected and examined for identification of intestinal parasite, by using direct wet mount and formol ether concentration technique.
v. Data Quality Management Training was given for data collectors before data collection. The questionnaire was developed in English and then was translated into local language (Amharic language) again it was translated to English for similarity check. Blood sample was collected and placed on proper anticoagulant such as EDTA and analyzed within a hour. For automated hematology analyzer background count and precision of the result was performed daily. Blood Smear with bullet shape prepared on clean microscopic slide for morphology and hemoparasite examination. Quality of stain was maintained by proper preparation of stain and staining in proper time.
Stool sample was collected with proper instruction in clean, dry material and wet mount was prepared on clean microscopic slide and examined within one hour, and negative result was rechecked by another investigator. Every laboratory procedure was performed according with standard operating procedure (SOP).

Data Processing and Analysis
Data was edited, cleaned, using SPSS version 20. Dependent variable frequencies, percentage, mean, range was calculated. Binary logistic regression analysis was used to determine association of anemia and with independent variables. Odds ratios (OR) and 95% confidence intervals (CI) was estimated and variables whose level statistically significant (P<0.25) on Bivariate analysis was entered jointly into a multivariate logistic regression. P-value less than 0.05 were considered as statistically significant. Data was presented in different tools such as by cross tabulation.

Ethical Consideration
Prior to data collection, written permission letter was taken from Arba Minch University college of medicine and health science, ethical Review Committee and legal permission from Arba Minch Hospital and health centers in order to conduct the study. Written informed consent was taken from each participant, and the purpose of the study properly described by the data collector's. During the course of the study the information of the participant was kept confidential and optimal amount of sample was taken. To insure confidentiality the name of the patient was not written on the questionnaire rather it was coded.

Characteristics of Study Participants
In this study 312 pregnant women attending antenatal care were participated with 83% of response rate. The mean age of the participants was 24.8. Around 100 (32.1%) of respondent were in age group of 26-23 years and about 3 (1%) were in age group of >36years. Majority of the women interviewed were married 303 (97.1%) and urban dwellers 213 (68.3%). About 134 (42.9%) of the participant had primary school level and 109 (34.9%) had secondary school level and above. Regarding occupational status, majority of the respondent were house wives 123 (39.4%) which was shown in (Table 1).

Dietary Habits of Pregnant Women
Out of the 312 participants 129 (41.3%) had the habit of eating animal and animal products once per month, 92 (29.5%) had the habit of eating fruits 2-4 per week and 157 (50.3%) had the habit of eating green vegetables daily. Almost half (47.8%) of the participant drink milk after meal and 252 (80.8%) drink tea immediately after meal ( Table 2).

Factors Associated with Anemia
Since our dependent variables is dichotomous logestic regression was used to assess the predictors of anemia. First bivariate analysis was carried out in order to analyze the crudes odds ratio. After bivariate analysis those variable whose crude odds ratio less than 0.25 was candidate for multivariate analysis. So, after bivariate analysis, variables like monthly income, mother educational level, consumption of fruit, consumptions of green vegetables, blood loose during the previous delivery, gestational age, iron and folate usage and malaria are entered together for multivariate analysis and the results shown in (Table 6). After multivariate analysis using multiple logistic regressions, factors like Educational level, consumption of green vegetables, gestational age and iron/folate usage were changed to non significant showing no effect on anemia. But monthly income, fruit consumption, blood loss and malaria infection remained independently associated with anemia.
Pregnant women that have monthly income <650 is 3 times more likely hood of anemic than pregnant women that have monthly income >1300 with AOR of 3.07 (95%CI: 9.35, 10.09) and also those pregnant women that didn't consume fruit nearly 4 times more likely hood of anemic than the pregnant women that consume fruit daily with AOR of 3.9 (95%CI: 1.36, 6.94). The likely hood of being anemic were 3.6 times higher among pregnant women that have a previous history of blood loss during delivery than with no history of blood loss (AOR=3.66, 95% CI: 1.56-8.7) and pregnant women that have malaria infection, 6 times more likely to develop anemia than those who have not infected with AOR of 6.10 (95%CI: 2.26-16.43).

Discussions
The result of the study shows that the overall prevalence of anemia among pregnant women was 28.8%. According to WHO cutoff points to rank the public health significance of anemia in a population, it is moderate public health significance in the area [12]. However, other studies revealed the prevalence anemia among pregnant women is higher such as in india, Nepal, Kenya it was 82%, 42%, 40% respectively [22,23,25]. The variation is due to differences in income, differences in diet and lifestyle that may affect anemia levels. In some parts of our country the prevalence of anemia in pregnant women such as in Nekemte is high relative to our study which is 52% (Mihiret H. et al 2011), the variation is due to socio economic and Sociodemographic factors [29].
The prevalence of anemia in our study site is higher than those similar studies reported from different areas like, Gonder Azezo which is 21% (Meseret A. et al.). [26] The higher the prevalence could be the low socioeconomic status, lower nutritional status and a parasitic infestation of the study area than those reported from elsewhere. But it was relatively consistence with similar study carried out in Harerge which is 27.1% (Kefyalew F et al). [28] Regarding anemia status by severity, High proportions of anemia were mild (55.5%) followed by moderate (43.3%) and sever anemic 1% which was consistence with similar study conducted in Sidama Region, Ethiopia by Samson G. et al. [27] Our study tried to demonstrate the common morphological characteristic of anemia among pregnant mother. Out of the total anemic pregnant women, 75.7% had Normochromic normocytic, 23.3% had Microcytic hypochromic and only1% had macrocytic normochromic. This finding is deviated from studies conducted in India [22], Normocytic normochromic blood picture were the most common morphological types of anemia found in this study, which are characteristic of anemia due to blood loss or other obstetrical issues. Our morphological study result agreed with studies conducted in Gonder [26], the high percent of Normocytic Normochromic anemia suggested that majority of them were might be in the early stages of iron deficiency anemia.

Conclusions
The result of the study shows that prevalence of anemia among pregnant women that attend ANC in Arba Minch Public health facilities was 28.8%. It is moderate public health significance among pregnant women according to WHO level of public health significance. The majority of the anemia was mild (55.5%) and moderate anemic 43.3%. only 1% was severe anemia.
The anemia observed is associated with multiple factors such as socioeconomic factors like family income, dietry habit in consumption of fruit, heavy blood loss in previous pregnancy, and malaria infection.
Morphologically, majority were Normocytic normochromic (75.7%), and Microcytic hypochromic anemic is (23.3%) Based on the result obtained from this study the following recommendations were forwarded. 1) Awareness should be created for pregnant women on utilization of easily available and affordable iron rich diet such as fruits, green vegetables and others. 2) Giving HID utilization of ITN and other malaria prevention mechanisms. 3) Another further study should be done to identify the causes of anemia by evaluation of iron indicators like serum ferritin, serum transferrin etc.