Open Access

Research
Anaemia in pregnant adolescent girls with malaria and practicing pica

1,& 1 1 1 1
Freda Dzifa Intiful , Edwin Kwame Wiredu , George Awuku Asare , Matilda Asante , David Nana Adjei

1
School of Biomedical and Allied Health Sciences, University of Ghana, Ghana

&
Corresponding author: Freda Dzifa Intiful, Department of Nutrition and Dietetics, School of Biomedical and Allied Health Sciences, University of
Ghana, Ghana

Key words: Pregnant, adolescent, anaemia, pica, malaria, Ghana

Received: 09/03/2016 - Accepted: 27/04/2016 - Published: 27/05/2016

Abstract
Introduction: Pregnancy during the adolescent period is challenging mainly because of the nutritional demands of both the adolescent and
pregnancy period. The risk for anaemia increases especially in developing countries such as Ghana where malaria is endemic and the practice of
pica is common. In this study, we sought to determine the prevalence of anaemia, pica practice and malaria infection among pregnant adolescent
girls and assess the extent to which these factors are associated. Methods: Two hundred and sixty five (265) pregnant adolescent girls were
recruited from three hospitals in Accra. Haemoglobin levels, malaria infection and the practice of pica were assessed. Pearson’s Chi squared tests
were used to determine associations and logistic regression analysis was used to determine the odds of being anaemic. Significance was set at
p≤0.05. Results: Anaemia prevalence was 76% with severity ranging from mild (47.8%) to severe (0.8%). About 27.5% were moderately
anaemic. Pica was practiced in only 9.1% of the girls. Malaria infection was prevalent in 17.7% of the girls. The logistic regression analysis
indicated that pregnant girls with malaria infection were 3.56 times more likely to be anaemic when compared to those without malaria. Also, those
who practiced pica were 1.23 times more likely to be anaemic when compared to those who did not practice pica. Conclusion: Anaemia is very
prevalent in pregnant adolescent girls and is a public health problem. Drastic measures should be taken to reduce the high prevalence.

Pan African Medical Journal. 2016; 24:96 doi:10.11604/pamj.2016.24.96.9282

This article is available online at: http://www.panafrican-med-journal.com/content/article/24/96/full/

© Freda Dzifa Intiful et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.

Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com)

Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net)

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Introduction Polyclinic, James Town Maternity Home (Ussher fort Polyclinic) and
the La Polyclinics. A total of 265 pregnant adolescent girls were
recruited for the study. All pregnant girls who reported for the first
The adolescent period is characterized by intense growth physically,
time for ante-natal clinic were approached and invited to be part of
psychosocially and cognitively. The intensity of this growth period
the study. Those who consented and were apparently healthy were
necessitates the increase in nutritional needs. During this period
recruited. Pregnant girls who had cases of haemoglobinopathies
there is a high demand for iron, especially in the adolescent girl
were excluded from the study. Ethics approval for the research was
because of the onset of mensuration. Iron deficiency is a major
obtained from the Ethics and Protocol Review Committee of the
cause of anaemia. The risk for anaemia increases when the
School of Biomedical and Allied Health Sciences of the University of
adolescent girl becomes pregnant. There are several factors that
Ghana, College of Health Sciences. Permission was also sought from
interact and contribute negatively to the outcome of pregnancy in
the Greater Accra Health Directorate and the health facilities where
the adolescent girl. The presence of anaemia, practice of pica and
the study was undertaken.
malaria has all been implicated. The presence of these conditions in
pregnant adolescent girls can pose greater challenge because of the
Data collection
obvious burden of the pregnancy on the rapidly growing mother
which additionally has to cater for another developing foetus.
Semi-structured questionnaires were used to obtain information
Anaemia affects about 38% of pregnant women globally. The
regarding patient’s background including ages, level of education,
prevalence is about 44.6% in Africa and 56% in Ghana [1]. The
marital status and practice of pica obtained. Five (5) ml of blood
World Health Organization(WHO) considers this prevalence to be
was drawn into an EDTA tube. Full blood count was performed to
unacceptable and of severe public health significance [1]. Anaemia
determine haemoglobin levels. Cut-off values for the determination
in pregnancy is of great concern as it is associated with
of anaemia in pregnancy were set based on World Health
complications such as low birth weight, preterm delivery,
Organization (WHO) criteria [12]. The following categories for
spontaneous abortions and ultimately death [2, 3].There is also an
anaemia were used: Hb<7g/dl –Severe, Hb 7.0-9.9- Moderate, Hb
established relationship between pica and anaemia [4, 5]. Pica is a
10-10.9- Mild, and Hb > 11 - Normal. A rapid test kit method,
condition involving the consumption of non-food substances. This
Coretests® One Step Malaria Pf/Pv Ag Test kit(Core Technology:
practice has been found to be common among pregnant women
Beijing, China)was used to determine the presence of malaria
even though it can also be seen among all categories of people
infection according to manufacturer’s instructions. Data were
including children. Several studies have linked the practice of pica to
entered and analysed using SPSS version 17 and summarized using
negative health outcomes such as micronutrient deficiencies
means and percentages. Pearson’s Chi squared tests were used to
particularly iron, zinc and calcium [6].
determine associations and logistic regression analysis was used to
determine the odds of being anaemic. The level of significance was
Malaria is an endemic infectious disease and a common public
set at p=0.05 with a confidence interval of 95%.
health problem in Ghana, affecting pregnant women. It is globally
ranked as the second most common cause of deaths related to
infectious disease after tuberculosis [7]. According to Takem and
D’Alessandro [8] the presence of malaria infection in pregnant Results
women is higher than in non- pregnant women probably resulting
from the several changes that occurs during the period of The background characteristics of the girls are summarized in Table
pregnancy; including hormonal and immunologic factors making 1. The mean age of the girls was 17.88; (SD=1.08) years. The 18
pregnant women more susceptible. In a recent review, malaria year olds formed the majority (37.7%) of the girls; followed by the
infection among pregnant women across West and Central Africa 19 year olds (33.2%) with the 15 year olds (4.2%) being the least
was reported to be about 35.1% (95%CI: 28.2–41.9) [9]. There are represented. More of the girls (63%) were in their second trimester
severe consequences of malaria infection in pregnancy. These with only 8.7% in their third trimester. The highest level of
include anaemia, miscarriage, maternal mortality, low birth weight education attained by the girls was senior high school level (2.6%).
and still birth [7]. The WHO estimates that malaria infection Majority of them had junior high school (36.2%) and primary
accounts for more than 10,000 and 100, 000 maternal and neonatal (33.6%) education as the highest educational level attained. About
deaths respectively [10]. In Ghana, adolescent pregnancy accounts 27.5% of them had no form of education. Almost half of the girls
for about 14% of all pregnancies. Maternal and infant mortality are (47.5%) were unemployment. The main form of employment was
still very high. Maternal mortality currently stands at 319 per 100, petty trading (33.6%). About 89% of the girls were single with only
000 live births and infant mortality 43 per 1,000 live births [11]. 3.8% indicating they were married. The rest (6.8%) were co-
Therefore there is the need to ensure that all categories of mothers habiting with their partners. Table 2 describes the prevalence of
receive optimum care to help reduce maternal and child mortality as anaemia, malaria infection and pica practice among the pregnant
the nation strives to meet the target set by the Sustainable girls. The mean haemoglobin concentration was 10.32 (SD=1.32)
Development Goals. The aim of this study was to determine the g/dl. Anaemia based on haemoglobin status was very high among
prevalence of anaemia, pica practice and malaria infection among the girls. About 76% of the girls were anaemic. Anaemia severity
pregnant adolescent girls and assess the extent to which these ranged from mild (47.8%) to severe (0.8%). Moderate anaemia was
factors are related. 27.5%. Anaemia was more prevalent among those in the second
trimester (79.4%) compared to those in the first (72%) and third
(69.5%) trimesters. The evaluation of the practice of pica indicated
Methods that about 9% of the girls practiced some form of pica. Pica was
more prevalent in the third trimester (30.4%) compared to the other
trimesters. Malaria parasites were identified in 17.7% of the girls.
The study was a cross sectional study carried out among pregnant
The association between anaemia, malaria infection and pica
adolescent girls between the ages of 15-19 years. The girls were
practices are presented in Table 3, Table 4. Pearson’s Chi-square
attending ante-natal clinics for the first time at three hospital
tests showed statistically significant association between anaemia
facilities in the Greater Accra Region of Ghana namely the Mamprobi 2
and malaria infection (χ 13.91, p=0.003, df =3) and anaemia and

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 2
pica practices (χ 13.26, p=0.004, df=3). Majority (51.3%) of those malaria infection across the year. The highest incidence usually
who had malaria were moderately anaemic (Table 3). About 46% of occurring after the rains therefore the incidence could be affected
those practicing pica were mild to moderately anaemic (Table 4). by the period the data were obtained. It is also important to note
The percentage of girls who practiced pica and were anaemic and that the girls in this study may not be on any prophylactic treatment
those with malaria infection and anaemic are presented in Table 5. that is usually given to pregnant girls when they go for antenatal
Most of the girls (83.3%) practicing pica were anaemic whiles clinic because they were recruited in the study when they had just
46.2% of those with malaria infection were also anaemic. A logistic reported at the antenatal clinics for the first time. It is therefore
regression analysis was performed to predict the likelihood of possible that the continuous education on malaria in the media
anaemia (Table 6). The results indicated that the girls infected with could have informed them in protecting themselves against the
malaria infection were 3.56 times more likely to be anaemic as infection. Consistent with other findings, this study reported
compared to those who were not infected. Also, those who significant association between anaemia and pica practices and also
practiced pica were 1.23 times likely to be anaemic compared to anaemia and malaria infection. When a logistic regression was
those who did not practice pica. When the model was adjusted for performed, those infected were more than three times likely to be
age, trimester and education level, the odds of being anaemic anaemic. The likelihood slightly increased when the model was
slightly increased for both girls infected with malaria infection and further adjusted by age, trimester and education level. This is
those practicing pica. consistent with other findings where malaria infection has been
linked to the presence of anaemia in pregnant women [24, 27]. Due
to the adverse effects of malaria infection in pregnancy,
Discussion recommendations have been made to use insecticide treated
mosquito nets and prophylactic drugs such as sulfadoxine
Anaemia in pregnancy is an obstetric risk which needs to be treated pyrimethamine. The use of these measures have brought reductions
to prevent complications. The present study reports a disturbingly in anaemia and low birth weight delivery in pregnant women [28,
high (76.2%) prevalence of anaemia among pregnant girls. This is 29]. There were some limitations to this study. The design of the
higher than the national prevalence of 56% in pregnant women in study was cross sectional and therefore causality could not be
Ghana and other reported studies in Kenya (61%), India (63%) and assumed. Other factors that may also contribute to the prevalence
Nigeria (40.4%) [1, 13-15].The presence of anaemia among of anaemia such as iron deficiency, folate deficiency and worm
pregnant women is not a new phenomenon but the severity of the infestation were not considered in this paper.
prevalence among this population of adolescent girls is alarming.
This high prevalence can be explained not only by the physiologic
demands during pregnancy and the adolescent period but other Conclusion
factors including low dietary intakes of nutrients such as iron can
result in deficiencies and worm infestations. As a matter of policy, In conclusion, this study has demonstrated that anaemia prevalence
pregnant women attending antenatal care in Ghana are mandatorily in adolescent pregnant girls is high. Pregnant girls who were
supplemented with haematinics to reduce the incidence of anaemia. anaemic were more likely to be practicing pica and infected with
The girls in this present study were recruited on the first day of malaria. This report should further strengthen the need to
attending antenatal clinic and therefore it is more likely that a large investigate pica practices in pregnant adolescent girls during
number of them would not be on any supplements that would help antenatal clinics and also step up measures to prevent malaria
curb the anaemia situation. Pica is one of the factors that has been infections.
identified as a risk to developing anaemia in pregnancy [16].
Contrary to other studies this present study found a low (9%) What is known about this topic
practice of pica among the girls. This finding was intriguing when
compared to other studies. The prevalence was relatively lower than • Prevalence of anaemia in all pregnant women in Ghana;
47% reported elsewhere in Ghana, 44%, 46% and 74% reported in • Malaria infection among women who are pregnant in
Mexico, US and Kenya respectively [17-20]. Even though Ghana.
participants in this study may not have received any education from
health professionals at the time of participating in the study, it is What this study adds
possible they might have heard of the dangers of consuming these
substances from some other sources such as the media and this • Prevalence of anaemia in pregnant adolescent girls in
could have contributed to their low practice of pica. Majority of the Ghana;
girls practicing pica (83.3%) were found to be anaemic. When a • The prevalence of the practice of pica among pregnant
logistic regression was performed, they were 1.23 times more likely adolescent girls;
to be anaemic. The relationship between pica and anaemia has • The contribution of malaria and pica in anaemia among
been documented in other studies [5, 21]. Therefore, in spite of the pregnant adolescent girls.
low prevalence reported in this study, it is still prudent to educate
pregnant women and adolescents against practicing pica because of
its reported link to anaemia in pregnancy and incidence of lead
poisoning [22].
Competing interests

Malaria infection was present in about 17.7% of the girls. In similar The authors declare no competing interest.
studies Uddenfeldt et al [23] and Glover-Amengor et al [24]
reported 41% and 35% among their study participants. Ofori etal
[25] also reported 19.7% malaria infection among pregnant women Authors’ contributions
at the time of enrolment into the study whiles Tay et al [26]
reported 12.6%. The disparities in the prevalence could be Concept and design of study: FDI, EKW, GAA. Data collection: FDI,
explained with an assertion by Ofori et al [25]. According to Ofori et GAA. Data analysis, statistics and interpretation: FDI, DNA, EKW,
al, there is a considerable level of variation in the incidence of
Page number not for citation purposes 3
GAA, MA. Development of manuscript: FDI, EKW, GAA, MA, DNA. All 9. Chico RM, Mayaud P, Ariti C, Mabey D, Ronsmans C,
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To the University of Ghana Office of Research Innovation and
of malaria in pregnancy in malaria-endemic areas. The
Development (ORID) for funding this research and to all the
American journal of tropical medicine and hygiene. 2001;64(1
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dataworldbankorg/indicator/SPDYNIMRTIN/countries Accessed:
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Table 1: background information of pregnant adolescent girls
nd rd
Variable 1st Trimester 2 Trimester 3 trimester Total
N (%) N (%) N (%) N (%)
Age (years)
Mean ±SD
(17.88±1.08)
15 6 (2.3) 4 (1.5) 1 (0.4) 11 (4.2)
16 1 (0.4) 19 (7.2) 0 (0.0) 20 (7.5)
17 15 (5.7) 24 (9.1) 7 (2.6) 46 (17.4)
18 27 (10.2) 66 (24.9) 7 (2.6) 100 (37.7)
19 26 (9.8) 54 (20.4) 8 (3.0) 88 (33.2)
Total 75 (28.3) 167 (63.0) 23 (8.7) 265 (100)
Educational level
No education 19 (7.2) 48 (18.1) 6 (2.3) 73 (27.5)
Primary 26 (9.8) 56 (21.1) 7 (2.6) 89 (33.6)
Junior secondary 29 (10.9) 57 (21.5) 10 (3.8) 96 (36.2)
Senior secondary 1 (0.4) 6 (2.3) 0 (0.0) 7 (2.6)
Total 75 (28.3) 167 (63.0) 23 (8.7) 265 (100)
Occupation
Unemployed 39 (14.7) 75 (28.3) 12 (4.5) 126 (47.5)
Artisan 3 (1.1) 11 (4.2) 3 (1.1) 17 (6.4)
Trader 25 (9.5) 58 (21.9) 6 (2.3) 89 (33.6)
Other 8 (3.0) 23 (8.7) 2 (0.8) 33 (12.5)
Total 75 (28.3) 167 (63.0) 23 (8.7) 265 (100)
Marital status
Married 6 (2.3) 2 (0.8) 2 (0.8) 10 (3.8)
Single 65 (24.5) 155 (58.5) 17 (6.4) 237 (89.4)
Co habitation 4 (1.5) 10 (3.8) 4 (1.5) 18 (6.8)
Total 75 (28.3) 167 (63) 23 (8.7) 265 (100)
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5
Table 2: anaemia prevalence, pica practice and malaria infection among pregnant adolescent girls
st nd rd
Variables 1 trimester 2 trimester 3 trimester Total
(N=75) (N=167) (N=23) (N= 265)
n (%) n (%) n (%) n(%)
Haemoglobin
status (g/dl)
(Mean ±SD)
Normal
12 (16.0) 35 (20.96) 7 (30.4) 63 (23.8)
(11.97±0.80)
Mild anaemia
37 (49.3) 80 (47.9) 10 (43.5) 127 (47.8)
(10.40±0.23)
Moderate anaemia
17 (22.7) 50 (30.30) 6 (26.1) 73 (27.5)
(8.88±0.78)
Severe anaemia
0 (0.0) 2 (1.2) 0 (0.0) 2 (0.8)
(5.40±0.28)
Total
75 (100.0) 167 (100.0) 23 (100.0) 265 (100.0)
(10.32±1.32)
Pica practice
Yes 4 (5.3) 13 (7.8) 7 (30.4) 24 (9.1)
No 71 (94.7) 154 (92.2) 16 (69.60) 241 (90.9)
Total 75 (100.0) 167 (100.0) 23 (100.0) 265 (100)
Malaria infection (N=66) (N=136) (N=18) (N=220)
Yes 6 (9.1) 29 (21.3) 4 (22.2) 39 (17.7)
No 60 (90.9) 107 (78.7) 14 (77.8) 181 (82.3)
Total 66 (30.0) 136 (61.8) 18 (8.2) 220 (100)

Table 3: association between malaria infection and anaemia (N=220)

Malaria status Normal Mild Moderate Severe
Total
haemoglobin anaemia anaemia Anaemia
N (%)
n (%) n (%) n (%) n (%)
Infected 6 (15.4) 12 (30.8) 20 (51.3) 1 (2.6) 39 (100)
Not Infected 48 (26.5) 89 (49.2) 43 (23.8) 1 (0.6) 181 (100)
2
χ (3, N=220)=13.91, p=0.003

Table 4: association between anaemia and pica practice

Pica practice Normal Mild Moderate Severe
Total
haemoglobin anaemia anaemia anaemia
N (%)
n (%) n (%) n (%) n (%)
Yes 13 (54.2) 7 (29.2) 4 (16.7) 0 (0.0) 24 (100)
No 50 (20.7) 120 (49.8) 69 (28.6) 2 (0.8) 241 (100)
2
χ (3, N=265)=13.26, p=0.004

Table 5: percentage of pregnant girls practicing pica and with malaria infection
Haemoglobin status Pica (N=24) Malaria infection (N=39)
n(%) n(%)
Normal 4 (16.7) 21 (53.8)
Anaemic 20 (83.3) 18 (46.2)
Total 24 (100.0) 39 (100.0)
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Table 6: the odds of being anaemic among pregnant adolescent girls
Factor Unadjusted Adjusted
Odds ratio 95% CI p-value Odds ratio 95% CI p-value
Pica Practice
Yes 1.23 0.39-3.92 0.727 1.30 0.39-4.4 0.618
No 1.00 (Reference) 1.00 (Reference)
Malaria
infection
Infected 3.56 1.73-7.34 0.001* 3.62 1.72-7.56 .001*
Not infected 1.00
(Reference) 1.00 (Reference)
*Significance p<0.05
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