TOPIC:

KNOLEGDE ON THE CAUSE AND

PREVENTION OF ANEMAI IN
PRGANANT WOMEN AT THE BUEA
REGIONAL HOSPITAL

PRESENTED BY: KPWAH CLOUDIA CHOU

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Table of Contents
CHAPTER ONE..............................................................................................................................1
BACKGROUND.........................................................................................................................1
INTRODUCTION.......................................................................................................................2
BACKGROUND.........................................................................................................................4
PROBLEM STATEMENT..........................................................................................................4
GENERAL OBJECTIVES..........................................................................................................5
SPECIFIC OBJECTIVES............................................................................................................5
RESEARCH QUESTIONS.........................................................................................................6
SIGNIFICANCE OF THE STUDY............................................................................................6
DEFINITION OF TERMS..........................................................................................................6
CHAPTER TWO.............................................................................................................................8
INTRODUCTION.......................................................................................................................8
Pathophysiology of Anemia........................................................................................................9
Physiological Changes during Pregnancy-Related To Anemia.................................................11
1. Iron Metabolism..................................................................................................................12
2. Iron Requirements during Pregnancy.................................................................................12
3. Folate during Pregnancy.....................................................................................................13
Definition of Anemia in Pregnancy...........................................................................................13
Etiology of Anemia....................................................................................................................13
8. Fibroid.........................................................................................................................17
9. Multiple Pregnancies...................................................................................................17
10. Infections.....................................................................................................................18
Signs of IDA..............................................................................................................................19
Risk Factors for Anemia in Pregnancy......................................................................................19
Risks of Anemia in Pregnancy..................................................................................................20
PREVENTION AND TREATMENT.......................................................................................20
Dietary Advice.......................................................................................................................20
Prophylaxis............................................................................................................................22
Folic Acid Supplementation..................................................................................................23
Dealing With Delivery of Women with Iron Deficiency Anemia.........................................23
Blood transfusion: indications and risks................................................................................23
CHAPTER 3: RESEARCH METHODOLOGY...........................................................................25
3.1 Study Design........................................................................................................................25
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3.2 Study Area.......................................................................................................................25
3.3 Study Period....................................................................................................................25
3.4 Target Population............................................................................................................25

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 CHAPTER ONE

BACKGROUND

Anemia is a major health public problem with about two billion people being
anemic worldwide. The global prevalence of anemia in pregnancy is estimated to
be approximately 41.8% varying from a low percentage of 5.7%in the united states
of America to a high percentage of 75% in Gambia. Some women are anemic even
before they become pregnant and others become progressively anemic during
pregnancy. Infections such as Helminths infestation and HIV have been implicated
in the high prevalence of anemia in Saharan Africa.

Anemia is an important risk factor in pregnancy and it is associated with an

increased incidence of both maternal and fetal morbidity and mortality. More than
3% of maternal mortality in Africa is directly attributable to anemia. Maternal
anemia also contributes to an increase in perinatal mortality, low birth weight,
stillbirth, and fetal wastage. Anemia in pregnancy reduces tolerance to blood loss
and leads to impaired function and cardiac failure. Anemia prevalence data
remains an important indicator in public health since anemia is related to morbidity
and mortality in the population groups usually considered to be the most
vulnerable, pregnant women and children under the age of five. Anemia prevalence
study is also useful to monitor the progress of reproductive health. Despite efforts
being made to reduce the burden of anemia, its prevalence is still high in
developing countries. Thus, the objective of this study is to determine knowledge
on the cause and prevention of anemia in pregnancy in Buea.

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INTRODUCTION
Anemia is defined as a state in which the quantity or the quality of circulating red
cells is reduced below the normal level.

Anemia is one of the topmost causes of death globally and has been of grave public
health worry for both developing and developed countries affecting people of
different age groups. However, it is more prevalent in pregnant women, young
children, and other women of reproductive age. Globally, anemia prevalence is
about 29% in non-pregnant women, 38% in pregnant women, and 43% in children
with the highest prevalence in South Asia and Central and West Africa. The
commonest cause of anemia is iron deficiency with evidence suggesting that up to
90% of maternal anemia is due to inadequate intake `of dietary iron.

However, worm infestations (hookworm and schistosomiasis), bleeding

hemorrhoids, and vitamin B6. The cry of a `baby immediately after birth gives joy
to the mother. This means that a healthy mother and child after delivery is the
outcome that the pregnant mother, her family, and the entire community expect.
However, anemia is associated with increased maternal and newborn health
problems` as well as death.

Ghana through the Ministry of Health has been at the forefront with interventions
and strategies to control anemia in pregnancy. These strategies include education
and awareness creation, nutrient (iron) supplementation, and control and
prevention of parasitic infections in pregnancy. Additionally, the use of
insecticide`-treated nets (ITNs) and intermittent preventive treatment (IPT) against
malaria, effective deworming, and provision of improved water, sanitation, and
hygiene services are also being implemented to prevent anemia among pregnant
women. These strategies are meant to address common preventable causes of
anemia such as iron deficiency, worm infestation, and malaria control in the
country. However, data available indicates that 44.6% of pregnant women in
Ghana are anemic. Because of this, the study examined pregnant women adherence
to Ghana's anemia prevention strategies beiB12 deficiencies, human
immunodeficiency virus (HIV) infection, and genetic disorders such as sickle cell
anemia are other factors that cause anemia in pregnancy

Anemia in pregnancy is defined by WHO as a hemoglobin concentration below

11g\dl. Iron deficiency anemia is the most common form of malnutrition in the
world and is the eighth leading cause of disease in girls and pregnant women in

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developing countries. The most common way of diagnosing anemia is by
measuring the hemoglobin concentration in the blood in an individual who presents
with signs and symptoms of anemia, which is controlled by a homeostatic
mechanism; it varies slightly among normal subjects. In a non-anemic population,
the distribution of hemoglobin concentrations in individuals of the same age and
sex is Gauss1an and symmetrical; in an anemic population, it is skewed to the left.
In 1959, the World Health Organization (WHO) (1) proposed levels of hemoglobin
concentrations for different groups of individuals that could be considered as the
lower limits of normality; subjects with values below these levels were considered
anemic. World Health Organization estimates that 58% of pregnant women in
developing countries are anemic. Although most ministries of health in developing
countries have policies to provide pregnant women with iron in a supplement form,
maternal anemia prevalence has not declined significantly, where large-scale programs have
been evaluated.

During the period 1991–98, the Mother Care Project and its partners conducted
qualitative research to determine the major barriers and facilitators of iron
supplementation programs for pregnant women in eight developing countries.
Research results were used to develop pilot program strategies and interventions to
reduce maternal anemia. Across-region results were examined and some
differences were found but the similarity in the way women view anemia and react
to taking iron tablets was more striking than differences encountered by region,
country, or ethnic group. While women frequently recognize symptoms of anemia,
they do not know the clinical term for anemia.

Half of women in all countries consider these symptoms to be a priority health

concern that requires action and half do not. Those women who visit prenatal
health services are often familiar with iron supplements, but commonly do not
know why they are prescribed. Contrary to the belief that women stop taking iron
tablets mainly due to negative side effects, only about one-third of women reported
that they experienced negative side effects in these studies.

During iron supplementation trials in five of the countries, only about one-tenth of
the women stopped taking the tablets due to side effects. The major barrier to
effective supplementation programs is inadequate supply. Additional barriers
include inadequate counseling and distribution of iron tablets, difficult access and
poor utilization of prenatal health care services, beliefs against consuming
medications during pregnancy, and in most countries, fears that taking too much
iron may cause too much blood or a big baby, making delivery more difficult.
Facilitators include women's recognition of improved physical wellbeing with the
alleviation of symptoms of anemia, particularly fatigue, and a better appetite.
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BACKGROUND.
Anemia among pregnant women is one of the most common public health
problems in developing countries. World health organization (WHO) estimate
shows nearly half of pregnant women were affected by anemia.

PROBLEM STATEMENT
Anemia is very dangerous to pregnancy both to mother and child, there's a
significant risk of premature delivery and miscarriage in anemic women, the fetus
is also at risk of low weight birth, and severe anemia is associated with increased
maternal mortalities [ Oats J, Abraham S 2005].

Anemia is prevalent in most places because of insufficient knowledge since most

women are partially educated or not educated on anemia and the effects of anemia
on pregnancy. Since they are not aware, or do not, have a clear understanding of it,
they turn to neglect it and those who suffer from it feel reluctant in taking their
complete medication. Those who take their medication stop consuming it once
they feel relieved. Lack of insufficient knowledge has caused them to neglect a
healthy eating habit and so anemia will set in. Proper knowledge on anemia will
help these women eat right and prevent anemia the best way they can.

In Nigeria, the prevalence of anemia among pregnant women is 55.1%. If the

prevalence of anemia among pregnant women is 40.0% or more, it is considered a
severe public health problem (McLean et al., 2008). Anemia is a major cause of
morbidity and mortality in pregnant women and increases the risks of fetal,
neonatal, and overall infant mortality (Akhtar and Hassan, 2012). In 2013, an
estimated 289,000 women died worldwide. Developing countries account for 99%
(286 000) of the global maternal deaths with the sub- Saharan Africa region alone
accounting for 62% (179 000). About 800 women a day are still dying from
complications in pregnancy and childbirth globally (WHOa, 2015). Anemia during
pregnancy contributes to 20% of all maternal deaths (WHOb, 2015). According to
the KDHS 2008-09, maternal deaths increased from 414/100,000 in 2003 to

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488/100,000 in 2008-09 far from meeting MDG target goals for maternal
mortality. From this information, it can be estimated that the high prevalence of
anemia among pregnant women in Nigeria is considered to be the main factor for
maternal death.

Anemia during pregnancy is also a major risk factor for low birth weight, preterm
birth, and intrauterine growth restriction (Banhidy F et al., 2011and Haggaz et al.,
2010). Deficiency in folic acid during pregnancy can result in serious neural tube
defect (Wolff et al., 2009), heart defects and cleft lips (Wilcox et al., 2007), limb
defects, and urinary tract anomalies (Goh and Koren, 2008).

Pregnant women attending antenatal clinics in Nigeria are routinely put on iron
supplementation throughout their pregnancy. However, the prevalence of anemia
among pregnant women is still high. Moreover, the available data concerning
prevalence and specific etiologic factors of anemia during pregnancy in Nigeria are
limited.

GENERAL OBJECTIVES
 Definition of anemia
 To bring out the global evidence of anemia and its implication
 To understand the causes of anemia
 To understand the symptoms of anemia
 Treatment of anemia
 To understand the current programming in anemia prevention

SPECIFIC OBJECTIVES
 To find out the knowledge of pregnant women on anemia
 To find out the knowledge on the cause of anemia
 To find out the knowledge on the prevention of anemia

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RESEARCH QUESTIONS
 What is anemia in pregnancy?
 Do you know the causes of anemia?
 Do you know how anemia can be prevented?

SIGNIFICANCE OF THE STUDY

This study will be beneficial to pregnant women and the society on the knowledge
of the cause and prevention of anemia in pregnant women.

DEFINITION OF TERMS
WHO: World Health Organisation

PREGNANCY: A condition of having a developing fetus in a woman's fetus which

lasts for about 280days [40weeks or 9months]

ANC: Antenatal Care

IPT: Intermittent Preventive Treatment

Hb: Hemoglobin

HIV: Human Immunodeficiency Virus

ITNs: Human Treated Nets

MCV: Mean Corpuscular Volume

MCHC: Mean Corpuscular Hemoglobin concentration

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IDA: Iron Deficiency Anemia

CBC: Complete Blood Count

HELLP: Hemolysis Elevated Liver Enzymes and Low Platelets

RBCs: Red Blood Cells

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 CHAPTER TWO

INTRODUCTION
Anemia describes a situation in which there is a reduction of hemoglobin
concentration in the blood of pregnant women to a level below 11g/dl. Anemia is
one of the most common nutritional deficiency diseases observed globally and
affects more than a quarter of the world's population (WHO/CDC, 2008). Globally,
anemia affects 1.62 billion people (25%), among which 56 million are pregnant
women (Balarajan, 2011; WHO/CDC, 2008). It is estimated that 41.8% of
pregnant women worldwide are anemic. At least half of this anemia burden is
assumed to be due to iron deficiency. Iron deficiency anemia (IDA) is the most
common nutritional disorder in the world affecting 2 billion people worldwide with
pregnant women particularly at risk (WHO guideline, 2012). In developing
countries, the prevalence of anemia during pregnancy is 60.0% and about 7.0% of
the women are severely anemic (Agan et al., 2010). In Africa 57.1% of pregnant
women are anemic (de Benoist et al., 2008). Sub-Saharan Africa is the most
affected region, with the prevalence of anemia estimated to be 17.2 million among
pregnant women. This constitutes approximately 30% of total global cases (WHO,
2008). In Nigeria, the prevalence of anemia among pregnant women is 55.1% and
among non-pregnant women is 46.4% (Ministry of Health, 2013). Anemia during
pregnancy is considered severe when hemoglobin concentration is less than 7.0
g/dl, moderate when the hemoglobin concentration is 7.0 to 9.9 g/dl, and mild
when hemoglobin concentration is 10.0 to 10.9 g/dl (Balarajan et al., 2011; Salhan
et al., 2012; Esmat et al., 2010). When the prevalence of anemia among pregnant
women is 40.0% or more, it is considered a severe public health problem (McLean
et al., 2008).

Anemia during pregnancy has a variety of causes and contributing factors. Iron
deficiency is the cause of 75% of anemia cases during pregnancy (Balarajan et al.,
2011; Haidar, 2010). Infectious diseases such as malaria, helminths infestations,
and HIV are implicated with a high prevalence of anemia in sub-Saharan Africa
(Ouédraogo et al., 2012 and Tolentino and Friedman, 2007). Loss of appetite and

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excessive vomiting in pregnancy and heavy menstrual flow before pregnancy are
also documented causes of anemia during pregnancy (Noronha et al., 2010). Socio-
economic conditions, abnormal demands like multiple pregnancies, teenage
pregnancies, maternal illiteracy, unemployment/underemployment, short
pregnancy intervals, age of gestation, primigravida and multigravida (Haniff et al.,
2007; Noronha et al., 2010), smoking, excessive alcohol consumption, are the main
contributing factors of anemia during pregnancy (Moosa and Zein, 2011; Esmat et
al. 2010).

Anemia during pregnancy is a major cause of morbidity and mortality in pregnant

women and infants in developing countries (Akhtar and Hassan, 2012). In 2013, an
estimated 289women died worldwide. Developing countries account for 99% (286
000) of the global maternal deaths with the sub- Saharan Africa region alone
accounting for 62% (179 000). About 800 women a day are still dying from
complications in pregnancy and childbirth globally (WHOa, 2015). Anemia
contributes to 20% of all maternal deaths (WHOb, 2015). Anemia in pregnancy
causes low birth weight (Banhidy et al., 2011), fetal impairment, and infant deaths
(Kalaivani, 2009). Iron deficiency anemia affects the development of the nation by
decreasing the cognitive and motor development of children and productivity of
adults (Balarajan et al., 2011; Vivek et al., 2012). Deficiency of folic acid during
pregnancy can result in developing neural tube defect that develops in embryos
during the first few weeks of pregnancy leading to malformations of the spine,
skull, and brain (Wolff et al., 2009).

Pathophysiology of Anemia
Iron deficiency anemia (IDA) is a condition characterized by a significant and
consistent lack of iron storage in the body due to a variety of intrinsic and extrinsic
factors. This type of anemia is microcytic and hypochromic, which means the
volume of RBCs, or mean corpuscular volume (MCV), is <80 fL, and the average
concentration of Hgb in a single RBC, or mean corpuscular hemoglobin (MCH), is
<27 pg. The lack of or decrease in iron storage is manifested by a lower than
normal Hgblevel, which denotes the amount of iron bound to heme in erythrocytes,
or RBCs.Hemoglobin (Hgb) is a large molecule on RBCs that is made up of heme,
the iron compound, and globin, a simple protein. A major function of Hgb, besides
maintaining acid-base balance, is its ability to attract oxygen to the iron it carries.
After receiving oxygen from the lungs, Hgb forms what is called oxyhemoglobin.
The presence of oxygen on this protein is what makes blood appear bright red.
Organs throughout the body receive oxygen as RBCs circulate to body tissues,
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transported oxygen is released from the Hgb, and the oxygen molecule diffuses
into capillaries. The globin section of Hgb then receives carbon dioxide from tissue
cells and removes it from the body by respiratory exhalation (Rome, 2014b). Iron
metabolism, which is the breakdown of stored iron in the body, is the necessary
process for the production of Hgb and synthesis of enzymes required for systemic
oxygenation and cellular energy (Bánhidy et al., 2011). The body's major source of
iron comes from the reticuloendothelial system, in which macrophages from the
liver and spleen phagocytize old or damaged RBCs (Rome, 2014b). Enzymes, such
as heme oxygenase-1 (HO-1), play a role in the breakdown of heme that is released
from phagocytized RBCs. This process is done to create a form of usable iron
throughout the body. The resulting iron, which is either stored or quickly utilized
by proteins, such astransferrin, is the form necessary for energy as well as
oxygenation of cells, tissues, and organ systems (Chung, Chen, & Paw, 2012;
Khalafallah & Dennis, 2012; Rome, 2014b). Transferrin is a carrier plasma protein
that is synthesized in the liver and known to be an acceptable indicator of iron
supply within the body (Rome, 2014b). Transferrin has a high affinity for iron and
is referred to as ferrotransferrin when attached to an iron molecule during transport
(Winter, Bazydlo, & Harris, 2014). Storage of iron occurs mostly in the spleen,
bone marrow, and cytoplasm of macrophages. This iron storage is noted as ferritin
or hemosiderin, a broken-down form of ferritin. The production of Hgbis slowed
when iron storage is not replaced in these reservoirs, resulting in ID and a
coinciding Hgb level (Rome, 2014b; Winter et al., 2014). However, very little iron
stays in circulation compared to that which is utilized intracellularly for
erythropoiesis, or the production of RBCs, as well as for other cellular functions
(Chung et al., 2012; Winter et al., 2014). Hepcidin, a hepatic hormone secreted into
the ferroportin plasma to regulate iron, is indirectly proportional to iron stores and
serum iron. To specify, when hepcidin levels are low in the plasma, iron is released
into the blood at a high rate. When levels of hepcidin are high, iron is kept
intracellularly and used for cellular energy and erythropoiesis (Khalafallah &
Dennis, 2012; Rome, 2014b). Hepcidin regulation is also known to be affected by
erythropoietic activity, oxygen tension within hepatocytes, transferrin saturation
(TS), inflammation, and the iron content of hepatocytes. These physiological
components directly alter iron storage and serum iron levels, which in turn affects
hepcidin (Winter et al., 2014). Overall, hepcidin works to maintain homeostasis as
it iron transporters, including ferroportin and DMT1 (Liu & Kaffes, 2012).
Intestinal enterocytes and hepatocytes are proteins that act as negative feedback
indicators for iron levels. These proteins maintain a sufficient serum iron level as
they detect the ever-changing iron level in the blood and other organ tissues. Iron
can be harmful to cells if not properly stored by proteins, such as ferritin, and used
for cellular function and energy (Kurniawan, 2011). Extrinsic sources of iron, or
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the iron that is ingested through food, drink, and supplements, alter one's serum
iron level, as these sources indirectly increase the total iron in circulation
(Khalafallah & Dennis, 2012; Winter et al., 2014). Iron is a micronutrient required
for oxygenation within the body and is a major component for energy production
on the cellular and systemic levels. Therefore, an individual's serum iron and iron
storage level not only affects cellular functions but the individual as a whole. This
is evident by the systemic signs and symptoms associated with iron depletion and
their negative impact on an individual's quality of life. Cognitive development has
also been found to be associated with one's iron supply.

The hemoglobin level for nonpregnant women is usually 3.5 g/dL. However, the
hemoglobin level during the second trimester of pregnancy averages 11.6 g/dL
because of the dilution of the mother's blood from increased plasma volume. This
is called physiologic anemia and is normal during pregnancy.

Iron cannot be adequately supplied in the daily diet during pregnancy. Substances
in the diet, such as milk, tea, and coffee, decrease the absorption of iron. During
pregnancy, additional iron is required for the increase in maternal RBCs and
transfer to the fetus for storage and production of RBCs. The fetus must store
enough iron to last 4 to 6 months after birth.

During the third trimester, if the woman's intake of iron is not sufficient, her
hemoglobin will not rise to a value of 12.5 g/dL and nutritional anemia may occur.
This will result in decreased transfer of iron to the fetus.

Hemoglobinopathies, such as thalassemia, sickle cell disease, and G-6-PD, lead to

anemia by causing hemolysis or increased destruction of RBCs.

Physiological Changes during Pregnancy-Related To

Anemia

During pregnancy, there is a considerable increase in plasma volume, which

increases by 40–45% above the level of no pregnant women. The blood volume
expands by 15% compared with non-pregnancy levels. The disproportionate
amount of blood creates physiological and dilution anemia during pregnancy [5, 6].
However, these changes are of great importance and may protect pregnant women
against supine hypotension, guard against the adverse effects of the expectant
blood loss during labor, and meet the demand for increased blood flow to the
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uterus and fetus [5, 7–9]. Despite this hemodilution, there is usually minimal
change in mean corpuscular volume (MCV) or mean corpuscular hemoglobin (Hb)
concentration (MCHC). The increase in iron demand during pregnancy is met by
increased iron absorption. The maternal plasma erythropoietin level increases
during pregnancy and reaches its peak in the third trimester [5, 7–9]. This
accelerates erythropoiesis, but hemoglobin concentration and hematocrit decrease.

1. Iron Metabolism
In adult men, there is usually little iron loss from the body. Because females lose
iron during menses, their iron needs are greater. Usually, only around 4% of the
ingested iron is absorbed in the upper part of the small intestine, mainly in the
ferrous state, while the majority is ingested in the ferric state. Many metal-binding
proteins bind not only to iron but other metals such as zinc and copper. After
crossing the intestinal cells, most of the absorbed iron is bound to apoferritin
forming ferritin. Usually, around 35% of the transferritin is saturated with iron.

2. Iron Requirements during Pregnancy

The daily requirement of iron is around 1.5 mg in non-pregnant women. This
requirement increases dramatically during pregnancy to reach 6–7 mg/day (total
1000 mg) with advanced gestational age. Pregnancy causes a twofold to threefold
increase in the requirement for iron and a 10- to 20-fold increase in folate
requirement. The increase in demand for iron is mainly due to fetal requirement,
placenta, blood volume, tissue accretion, and the intra-partum potential for blood
loss [5, 10]. This six-fold increase in need is quite difficult to meet with diet alone,
especially in situations of poverty. In many underdeveloped countries, pregnant
women may have depleted iron stores and/or iron-deficiency anemia and,
therefore, are at increased risk of becoming anemic during pregnancy and
developing the adverse consequences of iron deficiency and anemia. For this
reason, iron supplementation during pregnancy is very important to keep the
maternal hemoglobin within the normal range. It was previously thought that even
in the absence of sufficient iron supplementation, fetal hemoglobin production was
not impaired because the fetus obtains iron even if the mother suffers from severe
anemia. This is now an obsolete theory, and maternal anemia may lead to fetal
anemia and many other perinatal adverse effects.

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 3. Folate during Pregnancy

The normal level of folic acid is not sufficient to prevent megaloblastic changes in
bone marrow in about 25% of pregnant women. Moreover, folic acid deficiency is
more likely to occur in twin pregnancy, and women taking anti-convulsion and
sulfa-containing drugs. All pregnant women in developing countries should receive
daily supplementation of 60 mg iron and 40 mg folic acid. Folate level is affected
by sickle cell disease, malaria, and hemolytic anemia. The issue of folate
deficiency has received global attention due to its association with neural tube
defects.

Definition of Anemia in Pregnancy

The World Health Organization (WHO) defines anemia during pregnancy as a
hemoglobin concentration <11 g/dl. However, this cutoff value for hemoglobin
concentration is affected by many factors such as ethnicity, altitude, and smoking
[10]. Anemia in pregnancy is further classified as mild/moderate (Hb 7–10.9 g/dl)
and severe (Hb < 7 g/dl) [2]. The Centers for Disease Control and Prevention
(1990) defined anemia as hemoglobin <11 g/dl in the first and second trimesters
and <10.5 g/dl in the third trimester. This is based on the reduction in hemoglobin
level during pregnancy caused by the disproportion in volume expansion between
the plasma and erythrocytes. This disproportion is considerably greater during the
second trimester. Postpartum anemia is defined by the WHO as hemoglobin <10
g/dl [10].

Etiology of Anemia
There are several different factors responsible for anemia. The most common is
iron deficiency anemia (IDA), which is generally assumed to represent 50% of
cases [11]. Among the various risk factors for IDA nutritional or low iron intake
together with acute blood loss are the leading causes. During pregnancy, symptoms
such as nausea and vomiting together with other contributing factors may cause
maternal anemia; the other factors include the history of heavy menstruation, high
parity, short birth spacing, lack of antenatal nutritional education, and multiple
pregnancy. Malabsorption interferes with iron absorption and parasitic infestation

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such as hookworm may also lead to low hemoglobin levels. Iron absorption is
enhanced by ascorbic acid and inhibited by phytic acid and tannins present in tea,
coffee, and chocolate.

The second common leading cause of anemia in pregnancy is folic acid deficiency.
Other micronutrient deficiencies such as vitamin A, B12, and riboflavin, zinc, and
copper may also contribute to anemia. Malaria, hookworm infestation, infection,
and deficiency of several micronutrients are leading causes of anemia during
pregnancy. The relative contribution of each of these factors to anemia during
pregnancy varies greatly by geographical location. Iron deficiency in anemic
subjects in poor communities may be complicated by one or more additional
micronutrient deficiencies. The etiologic pattern of anemia during pregnancy is
often complex such that, for example, infection and nutritional deficiencies coexist.

1. Blood Loss
You can lose red blood cells through bleeding. This can happen slowly over a long
period of time, and you might not notice. Causes can include:

 Gastrointestinal conditions such

as ulcers, hemorrhoids, gastritis (inflammation of your stomach), and cancer
 Non-steroidal anti-inflammatory drugs (NSAIDs) such
as aspirin or ibuprofen, which can cause ulcers and gastritis
 A woman’s period, especially if you have a heavy menstruation (or heavy
period). This can be associated with fibroids.
 Post-trauma or post-surgery as well.

2. Decreased or Faulty Red Blood Cell Prod

With this type of anemia, your body may not create enough blood cells, or they
may not work the way they should. This can happen because there is something
wrong with your red blood cells or because you don’t have
enough minerals and vitamins for your red blood cells to form normally.
Conditions associated with these causes of anemia include:

 Bone marrow and stem cell problems

 Iron-deficiency anemia
 Sickle cell anemia
 Vitamin-deficiency anemia, specifically b12 or folate

3. Bone marrow and stem cell problems 

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This may keep your body from producing enough red blood cells. Some of the
stem cells in the marrow that is in the center of your bones will develop into red
blood cells. If there are not enough stem cells, if they do not work right, or if
they’re replaced by other cells such as cancer cells, you might get anemia. Anemia
caused by bone marrow or stem cell problems includes:

 Aplastic anemia happens when you don’t have enough stem cells or have
none at all. You might get aplastic anemia because of your genes or because
your bone marrow was injured by medications, radiation, chemotherapy, or
infection. Other malignancies that commonly effect the bone marrow
include multiple myeloma or leukemia. Sometimes, there’s no clear cause of
aplastic anemia.
 Lead poisoning. Lead is toxic to your bone marrow, causing you to have
fewer red blood cells. Lead poisoning can happen when adults come into
contact with lead at work, for example, or if children eat chips of lead paint.
You can also get it if your food comes into contact with some types of
pottery that aren’t glazed right.
 Thalassemia happens with a problem with hemoglobin formation (4 chains
aren't correctly formed). You make small red blood cells-though you can
make enough of them to be asymptomatic, or it can be severe. It’s passed
down in your genes and usually affects people of Mediterranean, African,
Middle Eastern, and Southeast Asian descent. This condition can range from
mild to life threatening; the most severe form is called Cooley's anemia.
4. Iron-deficiency
This happens because you do not have enough of the mineral iron in your body.
Your bone marrow needs iron to make hemoglobin, the part of the red blood cell
that takes oxygen to your organs. Iron-deficiency anemia can be caused by:

 A diet without enough iron, especially in infants, children, teens, vegans,

and vegetarians
 Certain drugs, foods, and caffeinated drinks
 Digestive conditions such as Crohn's disease, or if you’ve had part of
your stomach or small intestine removed
 Donating blood often
 Endurance training
 Pregnancy and breastfeeding using up iron in your body
 Your period

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  A common cause is chronic slow bleed, usually from a gastrointestinal
source.

5. Sickle cell
Sickle cell anemia is a disorder that, in the U.S., affects mainly African Americans
and Hispanic Americans. Your red blood cells, which are usually round, become
crescent-shaped because of a problem in your genes. Anemia results when the red
blood cells break down quickly, so oxygen does not get to your organs. The
crescent-shaped red blood cells can also get stuck in tiny blood vessels and cause
pain.

6. Vitamin-deficiency
Vitamin-deficiency anemia can happen when you are not getting enough vitamin
B12 and folate. You need these two vitamins to make red blood cells. This kind of
anemia can be caused by:

 Dietary deficiency: If you eat little or no meat, you might not get enough
vitamin B12. If you overcook vegetables or do not eat enough of them, you
might not get enough folate.
 Megaloblastic anemia: When you don’t get enough vitamin B12, folate, or
both
 Pernicious anemia: When your body doesn’t absorb enough vitamin B12

Other causes of vitamin deficiency include medications, alcohol abuse, and

intestinal diseases such as tropical sprue.

7. Destruction of Red Blood Cells

When red blood cells are fragile and cannot handle the stress of traveling through
your body, they may burst, causing what is called hemolytic anemia. You might
have this condition at birth, or it could come later. Sometimes, the causes of
hemolytic anemia are unclear, but they can include:

 An attack by your immune system, as with lupus. This can happen to

anyone, even a baby still in the womb or a newborn. That is called hemolytic
disease of the newborn.
 Conditions that can be passed down through your genes, such as sickle cell
anemia, thalassemia, and thrombotic thrombocytopenic purpura (TTP)

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  Enlarged spleen. This can, in rare cases, trap red blood cells and destroy
them too early.
 Something that puts strain on your body, such as infections, drugs, snake or
spider venom, or certain foods
 Toxins from advanced liver or kidney disease
 Vascular grafts, prosthetic heart valves, tumors, severe burns, being around
certain chemicals, severe hypertension, and clotting disorders

8. Fibroid

Fibroids are non-cancerous abnormal growth that grows in the uterus during a
woman's childbearing age. For women who are suffering from fibroids and heavy
menstrual bleeding, the loss of blood can also mean loss of hemoglobin, an iron-
rich protein found in red blood cells. When iron begins to deplete from the blood, it
can no longer carry oxygen. This is known as iron-deficiency anemia.

9. Multiple Pregnancies

During pregnancy, your body produces more blood to support the growth of your
baby. If you're not getting enough iron or certain other nutrients, your body might
not be able to produce the amount of red blood cells it needs to make this
additional blood.

It is normal to have mild anemia when you are pregnant. However, you may have
more severe anemia when pregnant with multiple babies since more Hb is required
to support the pregnancy.

10.Infections

Infections, for example, Parasitic infections, for example, Malaria, schistosomiasis,

and hookworms.

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The malaria parasites, entering the blood after an infective mosquito bite, infect red
blood cells. At the end of that infection cycle, red blood cell ruptures. This process
lowers the amount of red blood cells and can in a severe stage cause severe
anemia.

Schistosomiasis infection is associated with iron deficiency and undernutrition,

which can cause damaging effects on pregnancy and child growth. The growth and
development of the worms in the body and the passing of their eggs through the
host causing damage and blood loss cause these effects in nutrition.
Schistosomiasis is thought to cause iron-deficiency anemia through intestinal blood
loss and blood loss in the feces and urine. During infection, eggs of the schistomes
pass through the intestinal wall and into the gut causing damage and inflammation.
This causes blood and iron loss resulting in iron deficiency anemia.

Intestinal parasitic infections especially helminths increase anemia in pregnancy.

The results of this are low pregnancy weight and intrauterine growth retardation,
followed by low birth weight, with its associated greater risks of infection and
higher prenatal mortality rates. An estimated 44 million pregnant women have
hookworm infections, which can cause chronic loss of blood from the intestines
and predisposes the women to develop iron deficiency anemia.

Helicobacter pylori (H. pylori) infection affects approximately one-half of the

world population and it is more prevalent in developing countries. This
microorganism colonizes the stomach. Typically, it is acquired during childhood
and causes asymptomatic chronic infection. A small portion of H. pylori-infected
subjects develop peptic ulcers usually during late adulthood and may cause
bleeding further leading to anemia in pregnant women.

11.Bleeding from other sites

The bleeding can either be slow, long-term bleeding; leading to anemia .Bleeding
rectally due to hemorrhoids can lead to large amounts of blood being lost from the
body that may cause anemia though it occurs rarely.

Signs of IDA
An abdominal examination to rule out enlarged spleen and/or liver is mandatory in
approaching an anemic pregnant woman. A complete blood picture (include

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peripheral blood film) is the first step in tailoring the next investigations aimed at
determining the etiology

While mild cases of anemia may have no symptoms at all, moderate to severe
conditions may present with the following symptoms:

 Excessive fatigue or weakness

 Pale skin
 Shortness of breath, heart palpitations, or chest pain
 Lightheadedness
 Cold hands or feet

They may experience all or none of these symptoms if you have anemia during
your pregnancy.

Fortunately, blood tests to screen for anemia are usually routine during prenatal
care. You can expect to be tested early in your pregnancy, and usually once more
as you move closer to your due date.

A complete blood count (CBC) test is the most common tool used to diagnose
anemia, which is a group of tests that measure the size and number of blood cells
in a sample.

Risk Factors for Anemia in Pregnancy

All pregnant women are at risk for becoming anemic. That is because they need
more iron and folic acid than usual. However, the risk is higher if you:

 Are pregnant with multiples (more than one child)

 Have had two pregnancies close together
 Vomit a lot because of morning sickness
 Are a pregnant teenager
 Don't eat enough foods that are rich in iron
 Had anemia before you became pregnant

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Risks of Anemia in Pregnancy
Severe or untreated iron-deficiency anemia during pregnancy can increase your
risk of having:

 A preterm or low-birth-weight baby

 A blood transfusion (if you lose a significant amount of blood during
delivery)
 Postpartum depression
 A baby with anemia
 A child with developmental delays

 Untreated folate deficiency can increase your risk of having a:

 Preterm or low-birth-weight baby
 Baby with a serious birth defect of the spine or brain (neural tube defects)
 Untreated vitamin B12 deficiency can also raise your risk of having a baby
with neural tube defects.

PREVENTION AND TREATMENT

Dietary Advice

As physiological iron requirements are several times higher in pregnancy than they
are in nonpregnant women, the recommended daily intake of iron for the second
half of pregnancy is 30 mg with iron absorption increasing threefold. The amount
of iron absorbed depends upon the following factors: (1) amount of iron in the diet,
(2) its bioavailability, and (3) physiological requirements. Dietary heme iron is
found mainly in red meats, fish, and poultry. Heme iron absorption is twofold to
threefold greater than non-heme iron. Moreover, meat contains organic compounds
(including peptides), which promote the absorption of iron from other less
bioavailable non-heme iron sources. While heme iron is more readily absorbed
than non-heme iron, the latter still forms approximately 95% of dietary iron intake.
Ascorbic acid significantly increases iron absorption from non-heme sources, with
the magnitude of this effect concordant with the increase in quantity of vitamin C
in the meal. The bioavailability of non-heme iron is enhanced by germination and
fermentation of cereals and legumes, which results in a decrease in the phytate

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content, a food constituent that hinders iron absorption. Tannins in tea and coffee
hinder iron absorption on consumption with or shortly after a meal.

Nutritional education is the main objective of antenatal care to assist in the

prevention of anemia. In addition, family planning and control of birth spacing is
another preventive measure that should be considered by health-care providers.
The WHO jointly with the International Nutritional Anemia Consultative Group
and the United Nations Children's Fund recommends routine supplements of 60
mg iron per day and 400-μg folate per day to all pregnant women for at least 6
months. This guideline also recommends continuation until 3 months postpartum
in areas of high prevalence of anemia (>40%). The standard oral preparation,
Fefol, comprising 100 mg iron and 350-μg folate, is suitable for both prevention
and treatment. Parenteral iron does not provide rapid correction of hemoglobin
levels compared with oral form but is an option for those with poor compliance
and who cannot tolerate the oral formulation. It is also suitable in cases of
malabsorption. The maximum rise in hemoglobin achievable with either oral or
parenteral formulations is 0.8 g/dl/week. Blood transfusion is indicated in cases of
severe anemia (Hb% < 7 g/dl) and anemia in late pregnancy when delivery is due.

Referral to secondary care level should be considered if any of the following

situations exist:

 Significant symptoms and/or severe anemia (Hb < 70 g/l), or

 Advanced gestation (>34 weeks), or
 If there is no rise in Hb at 2 weeks.

In non-anemic women who are at increased risk of iron depletion such as those
with:

 Previous anemia,
 Multiple pregnancy,
 Consecutive pregnancies with <1 year's interval between
 Vegetarians
 Women at high risk of bleeding
 Pregnant teenagers
 Jehovah's witnesses.
 Parenteral iron therapy
 Indications for parenteral iron therapy
 absolute non-compliance with oral iron therapy
 intolerance to oral iron therapy

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  Proven malabsorption.

Parenteral iron therapy bypasses the natural gastrointestinal regulatory mechanisms

to supply no protein-bound iron to the red blood cells. It is characterized by fast
increases in Hb and better replenishment of iron stores compared with oral therapy,
particularly iron sucrose. However, issues concerning its safety are waiting to be
addressed.

Contraindications for parenteral iron use are as follows:

 History of anaphylaxis or reactions to parenteral iron therapy

 First trimester of pregnancy
 Active acute or chronic infection
 Chronic liver disease.

Appropriate setting and staff trained in management of anaphylaxis should be

available on contemplating usage of parenteral iron.

Prophylaxis

Efforts aimed at preventing iron deficiency and iron deficiency anemia among
pregnant women include iron supplementation, fortification of staple foods with
iron, increasing health and nutritional awareness, combating parasitic infections,
and improvement in sanitation [20]. The WHO proposed a prophylactic dose of
300 μg (0.3 mg) daily during pregnancy in 1968.

During pregnancy, women need iron supplementation to ensure they have

sufficient iron stores to prevent iron deficiency [21]. Hence, in most developing
countries, iron supplements are used extensively during pregnancy to prevent and
correct iron deficiency and anemia during gestation.

A dose of 60 mg of elemental iron was accepted as a standard supplemental dose in

1959, depending on estimates of iron needs during pregnancy [22]. Several experts
[23, 24] have since endorsed this. Gastrointestinal discomfort is a common
observation among women consuming large amounts of supplemental iron,
especially if taken on an empty stomach. Gastrointestinal side effects are
recognized as the critical adverse effect on which the tolerable upper limit of intake
for iron is determined. The use of high-dose iron supplements commonly leads to
gastrointestinal manifestations, such as constipation nausea, vomiting, and
diarrhea, with the frequency and severity being determined by the amount of
elemental iron released in the stomach.

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Folic Acid Supplementation

Following the publication of some studies supporting the periconceptional use of

folic acid in the prevention of neural tube defects, the supplemental dose was
increased to 400μg (0.4 mg) of folic acid daily in 1998. This dose was considered
to provide more folic acid than needed to produce an optimal hemoglobin response
in pregnant women. If supplementation is delayed until after the first trimester of
pregnancy, it will not contribute to preventing birth defects [25]. Interestingly, a
recent Cochrane review showed that supplement with folic acid, alone or in
combination with vitamins and minerals, prevents neural tube defects, but it does
not have a clear effect on other birth defects [26].

Likewise, it has been found that folic acid alone, or in combination with vitamin
and mineral supplements during pregnancy, improved iron status in women
without affecting perinatal anemia, perinatal mortality, or other infant outcomes
[27, 28].

Dealing With Delivery of Women with Iron Deficiency Anemia

With good practice, this situation should generally be avoided; nonetheless, there
are instances when women book late have recently arrived from abroad or have not
engaged with antenatal care. In such circumstances, it may be essential to take
active measures to minimize blood loss at parturition. Attention should be paid to
delivery in hospital, securing an intravenous access and blood group, and save and
consideration of active management of the third stage of labor to reduce
postpartum blood loss.

Blood transfusion: indications and risks

There are multiple potential hazards from blood transfusions but most arise from
clinical and laboratory errors. Moreover, specific risks for women of childbearing
age include the potential for transfusion-induced sensitization to red blood cell
antigens, creating a future risk of fetal hemolytic disease. Massive obstetric
hemorrhage is widely appreciated as an important cause of morbidity and mortality
and necessitates prompt use of blood and components as part of appropriate
management.

Both clinical assessment and hemoglobin concentration are of immense

significance postpartum to decide on the optimum method of iron replacement. In

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the absence of bleeding, the decision to transfuse blood should be made on an
informed individual basis.

Blood transfusion should be reserved for women with:

 continued bleeding or at risk of further bleeding,

 imminent cardiac compromise

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 CHAPTER 3: RESEARCH
METHODOLOGY

3.1 Study Design

The study adopted a descriptive cross-sectional research design. Data were
collected with a self-administered questionnaire that was developed through an
intensive literature search
3.2 Study Area
This study was conducted at the Regional Hospital Buea. it is about 2km away
from the mile 17 motor park. It is situated precisely between the delegations of
education and the army barracks, along the highway to the Bokwango
neighborhood.

The hospital is made up of many units/departments/centers including the

following: the medical unit (male and female), the surgical unit, the pediatrics unit,
the maternity unit, the HIV/AIDS unit, the Laboratory unit, the X-ray unit, the
hemodialysis center, the Tuberculosis center, the Diabetes center, the theater
department and the Outpatient department (OPD).

The choice of the study area was because it is the most popular hospital and the
number one choice of most pregnant women.

3.3 Study Period

This study was conducted from October 2017 to June 2018 at the Regional
Hospital Buea.

3.4 Target Population

The study population included pregnant women attending the ANC in the above
hospital. The antenatal unit of the hospital has four clinics days in a week with
about 12 women minimum attending in a week. The estimated number of pregnant
women in a month is about 48 the as gotten from the ANC register (2020).

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 3.5 SAMPLING METHOD

Simple random sampling technique was used to select the pregnant women that
participated in the study. A pre-test was carried out on 18 pregnant women at the
regional hospital Buea, with the Cronbach’s alpha result of reliability index of
0.78. Measurement error was eliminated to ensure the reliability of the instrument.
A total number of 47 questionnaires were distributed to pregnant women, 40
questionnaires were adequately filled and returned giving a response rate of 85.1%.

SAMPLE SIZE
The minimum sample size was determined using Cochran’s Formula
with a calculated sample size of 182 women after addition of a 10% non-response
rate as follows:

N
n¿ 1+ N (e) 2

Where;
N=Population size=48
e=Level of precision expected data 95% confidence level = 0.05
n=Required sample size.

48
n= 1+ 48(0.05)2

n=42
In addition, 10% attrition rate; 10% of 48 = 4.8
Total = 42+4.8= 46.8 approximately 47.

3.6 DATA COLLECTION TOOL

A structured self- administered questionnaire was used for data collection. The
questionnaires were shared to participants and consent was gotten, the researcher
was present to explain any worries from participants.

METHOD OF DATA COLLECTION

3.7 DATA MANAGEMENT AND ANALYSIS

3.7.1 DATA MANAGEMENT

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 The data was stored in two different computers and a USB flash drive. The
information obtained by means of the questionnaires were coded into a computer
using Microsoft Excel 2019 and back up done daily.

3.7.2 DATA ANALYSIS

Data analysis was performed with the Statistical Package of the Social Sciences
(SPSS version 22.0). Frequencies and percentages were calculated and results
presented in tables and figures.

3.7.3 ETHICAL CONSIDERATION

The purpose and nature of this study was explained to the participants. Every
participant was informed that participating in the research was voluntary. Verbal
consent was obtained from all participants. Confidentiality of both participant and
information was observed, the questionnaires were coded.

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