Anemia in pregnancy remains a major problem in nearly all developing and many industrialized
countries. The World Health Organization estimates that 58% of pregnant females in
developing countries are anemic.1 In the Arab Gulf countries, maternal anemia, especially
iron deficiency anemia has been considered as of the important public health problems
with a prevalence ranging from 22.6% to 54.0%.2 High parity with iron deficiency was
found to be an important risk factor for maternal mortality at King Fahad University
Hospital, Al-Khobar, Saudi Arabia, during the 20 year-period from 1983 to 2002.3 Several
studies have reported the risks of pregnancy anemia on the mother and her offspring.
In a review of those studies, Scholl and Hediger suggested that anemia during early
pregnancy increases the likelihood of poor outcomes such as preterm deliveries, low
birth weight and perinatal mortality.4 A higher risk of urinary tract infection, pyelonephritis
and pre-eclampsia has been reported in observational studies on iron-deficient women
who are not necessarily anemic.5 There is lack of recently published data on maternal
anemia from the urban area of Al-Khobar (Eastern province). This study was therefore
conducted to determine a) the magnitude of anemia among pregnant women attending primary
health care centers (PHCCs) of Al-Khobar and b) the association of pregnancy anemia
with certain socio-demographic, biological and dietary factors.
METHODS
Nine PHCCs in three centers serving 22.7%, 14.9% and 12.9% (total 50.5%) of the registered
population of Al-Khobar were selected for this cross-sectional, descriptive study.
All Saudi and non-Saudi pregnant females who visited the centers during a 1-year period
(March 2006 to February 2007) were included.
Data were collected from antenatal records and questionnaires that were interview-administered
for all consecutive pregnant women who visited the three PHCCs during a 2-week period
in February 2007. The latter group comprised a subsample of 80 mothers. Information
collected from antenatal records included socio-demographic and biological data: age,
nationality, gravida, inter-pregnancy interval, trimester of pregnancy when last hemoglobin
was tested, history of sickle-cell trait/disease and level of hemoglobin last recorded.
The non-cyanide hemoglobin analysis method was used and results read by a spectrophotometer
(Symex KX-21, Germany). A hemoglobin level of <11g/dL was considered anemia. Criteria
for mild, moderate and severe anemia were hemoglobin levels of >10–10.9 g/dL, 7–10
g/dL and <7 g/dL, respectively.6 Data from the questionnaire included additional information
from the sub-sample: educational level, history of polymenorrhea or menorrhagia prior
to the index pregnancy, intake of non-nutritious substances (pica), tea consumption
soon after meals, regularity of iron supplementation and intake of iron-containing
foods during the second and third trimester of pregnancy. A semi-quantitative food
frequency questionnaire (FFQ) was used for mothers to determine their dietary intake
of iron. The FFQ was a checklist of 15 food items, each containing at least 3% of
the recommended dietary allowance of iron.7 A score was assigned for each food item.
The total score for each mother was calculated according to the number and frequency
of food servings she consumed per week. Data processing involved a check for accuracy
and completeness of data followed by statistical analysis with the help of the SPSS
version 11 program. Univariate analysis of data was done by the χ2 and t tests as
appropriate. A P value of ≤.05 was considered as significant.
RESULTS
During the study period, 498 women attended the three PHCCs for antenatal care. Despite
a protocol of routine hemoglobin estimation at each trimester during antenatal check-up,
data was missing in 34 (6.8%) records and hence information for 464 women was included
in the analysis. Three hundred fifty-three (76%) of the women were Saudi. The mean
and standard deviation was 26.7±5.4 years for age and 23.2±10.0 weeks for gestational
age, and gravida was 3.7±2.7. Forty of 80 women (50%) in the subsample had completed
a secondary education or higher.
Figure 1 shows that 192 (41.3%) of 464 pregnant women attending PHC facilities for
antenatal care were anemic. Mild, moderate and sever anemia was present in 117 (25.2%),
73 (15.7%) and 2 (0.4%) women, respectively. Thirteen of 192 anemic cases (6.7%) had
sickle cell trait/disease. Table 1 shows that although more Saudi women were anemic
than non-Saudis, this was not statistically significant (P>.05). Anemia was highest
among women in their third trimester of pregnancy (P<.01)
The mean frequency score for food items rich in iron was higher in non-anemic (44.2)
than anemic women (38.3), but the difference was statistically insignificant (P>.05).
Insignificant differences by mean age, gravida and last inter-pregnancy interval were
found between anemic and non-anemic pregnant women. Nineteen out of 54 pregnant women
(35%) in their second and third trimesters of the sub-sample were non/irregular takers
of iron supplementation and anemia was more common among them (57.9%) than in regular
takers (14.3%) (P<.05) (Table 2). Reasons given by mothers for no/irregular intake
of iron supplementation included “forgetfulness” (52.9%), “unnecessary” (17.6%) or
“harmful” for the fetus (5.9%). No relationship was observed between anemia and tea
consumption immediately after main meals. Of the 80 pregnant women in the subsample,
9 (11.3%) mothers were indulging in pica. There was no statistical association of
anemia to pica. Only 6 mothers (7.5%) reported a history of polymenorrhea/menorrhagia
prior to pregnancy, hence correlation analysis of this variable with anemia was not
done.
DISCUSSION
A prevalence rate of 41.3% for anemia in pregnancy in the current study is substantially
high and is a reflection of the nutritional health of predominantly Saudi Arabian
pregnant women attending PHCCs. This high figure is surprising considering the routine
practice at PHCCs to provide pregnant women with prophylactic elemental iron of 60
mg/day and up to 180 mg/day in cases of anemia. Though adequate supplies of iron medication
were freely available in all health centers we visited, more than one-third of the
second and third trimester pregnant women of our study sub-sample were non/irregular
takers of iron supplementation. Major barriers to consuming medication were lack of
motivation and misconceptions. Perhaps this was a result of inadequate counseling
by the health care providers. Mothers need to be educated that dietary sources do
not meet the daily requirement of iron during pregnancy7 and iron supplementation
is important especially in the second and third trimesters of the gestational period.
Other studies have also reported an increased risk of anemia in mothers who were non/irregular
takers of iron pills.8,9
The magnitude of anemia (41.3%) in the study population is slightly higher than that
reported in an earlier study (1994) on pregnant women of the Southwestern region of
Saudi Arabia (31.9%),10 but is similar to findings of small-scale studies conducted
in the neighboring countries of Kuwait (36.8%),11 Oman (43.6%)12 and Bahrain (49.6%)13
as well as those from other Afro-Asian countries such as Mali (47%),14 rural Vietnam
(43.2%)9 and Malaysia (34.6%).15 Large-scale studies from India16 and rural Bangladesh17
have reported a higher anemia prevalence of 84.9% and 50% respectively, indicating
a poorer state of nutritional health among mothers in these developing countries.
On the other hand, studies from economically developed countries have shown a lower
frequency of pregnancy anemia such as those from the USA (22%)18 and Belgium (31%).19
It was encouraging to note that most of the maternal anemia cases in the current study
were of the mild/moderate and not severe type, which is similar to findings from Malaysia,15
rural Vietnam9 and Indonesia.8 Severe anemia is more prevalent in countries where
infections such as malaria or diarrhea are common.14,20
The prevalence of sickle cell trait/disease (6.7%) in the current study is close to
that reported by the National Premarital Screening Program (4.46%) in 2007 for Saudi
Arabia.21 As the disease is more pronounced in the eastern region of Saudi Arabia,21
all PHCCs routinely monitor the sickle cell status of pregnant women; this protocol
should continue in order to provide better care for this high-risk group. Age was
not a risk factor for anemia in our study. Mahfouz et al found that Saudi teenage
pregnant females were not at a higher risk of anemia than older women if good prenatal
care was provided.22 Unlike some studies,10,12 we did not observe any variation in
anemia by gravida and last pregnancy interval. However, advancing gestational age
significantly increased the risk of anemia, which is similar to the findings of other
studies.8–10,19 Compared to the first trimester, a lower hemoglobin level in the second
and third trimesters is partly artifactual and is due to a physiological expansion
of maternal plasma volume, making it more or less difficult to separate out women
who are truly anemic. If iron intake is not adequate during this period to meet the
increased demands of the mother and the growing fetus, further reductions in hemoglobin
occur due to iron deficiency.
Our study showed that anemic women had a lower mean food frequency score for iron-intake
than those who were not anemic. The results were, however, not significant. This finding
is consistent with the literature.23 Some of the reasons include imprecise estimation
of iron-intake by checklists and variations in iron absorption related to enhancers/inhibitors
in food. Further, the levels of iron stores in the body may outweigh any effect of
iron-intake on anemia in relatively well-nourished populations.23 Accurate laboratory
data versus dietary intake remain the best tools to determine the iron status of individuals.
Compulsive intake of nonnutritive substances such as earth, clay, chalk, soap and
ice by 11.3% of the sub-sampled women compares with published data on pica prevalence
(8%–65%).24 Though pica has frequently been associated with anemia or iron deficiency
in pregnancy, we did not see this relationship in our study.
In conclusion, our study showed that a sizable proportion of pregnant women were found
to be anemic. Non/irregular intake of iron medication by mothers was significantly
associated with anemia. Health education programs at the PHCCs should address the
importance of compliance for iron supplementation along with adequate intake of iron-rich
dietary sources during pregnancy and for 3 months postpartum as per recommendations
of the WHO for countries with a high prevalence (≥40%) of pregnancy anemia.25