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Maternal Anaemia and Morbidity in South-Western Nigeria

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Maternal Anaemia and Morbidity in South-Western Nigeria Maternal Anaemia and Morbidity in South-Western Nigeria by Oluwatoyin Oyindamola Ejidokun A thesis submitted for the degree of Doctor of Philosophy in the Faculty of Medicine University of London Centre for International Child Health Institute of Child Health University of London 30 Guilford Street London WCIN lEH January 1996 ProQuest Number: 10016785 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest. ProQuest 10016785 Published by ProQuest LLC(2016). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. Microform Edition © ProQuest LLC. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 This thesis is dedicated to my husband Omogbolahan Olaniyi Ishola, my parents, my in-laws, Late Alhaji M.B.O.IshoIa (RIP) and Mrs M. Ishola, my brothers and sisters. "Not by might nor by power, but by my Spirit", says the Lord Almighty. (Zechariah 4:6\ The Holy Bible, New International Version). ABSTRACT 489 pregnant Nigerian women aged 16 to 45 years randomly selected from antenatal clinics of a peri-urban slum and two rural coastal areas in South-western Nigeria were followed up throughout pregnancy. They were interviewed individually and in focus groups to enquire about their use of iron, folic acid and antimalarials, and their health status before their first antenatal clinic attendance. The prevalence of anaemia (Hb <110 g/1) and severe anaemia (Hb < 80 g/1) was 70.3% and 8.6% respectively. Among women who booked in the first, second and third trimesters, the prevalence of anaemia was 54.3%, 77.3% and 69.2% respectively. Although a high proportion of women claimed to consume iron (43.9%) and antimalarials (43.3%), there were no significant differences in haemoglobin (Hb) values between those who took these haematinics and those who did not. Rather fewer women (18.4%) took folic acid tablets. Of 441 blood films examined, malaria parasitaemia was present in 63 (14.3%), with a higher prevalence among rural women. Of these, 49 (77.8%) were P. malariae and 9 (14.3%) were P. falciparum. There was no association between malaria parasitaemia and anaemia. One (0.2%) of the women had Sickle Cell Anaemia (Hb SS), 18.9% had Hb AS and 6.5% were Hb AC. 25 (21.9%) of 114 stool samples examined for parasites were positive. Of these, 19 (76%) were due to Ascaris lumbricoides, 2 (8%) had Trichuris trichuria, 1 (4%) had Ancylostoma duodenale and 3 (12%) had multiple parasites. The prevalence of anaemia was similar in infected and uninfected subjects. The highest levels of serum ferritin, alpha-1-acid glycoprotein (AGP) and C-reactive protein (CRP) occurred in the most anaemic women. Presumably elevated ferritin here is a result of infection, making the assessment of iron status rather difficult. These subjects also had lower levels of serum retinol and there was a significant association between serum retinol and Hb values. The contributions of infection and vitamin A deficiency to anaemia of pregnancy are discussed. TABLE OF CONTENTS Abstract........................................................................................................................2 Table of contents ....................................................................................................... 3 List of figures ..........................................................................................................11 List of tables ............................................................................................................ 12 Acknowledgements ...................................................................................................18 CHAPTER 1-INTRODUCTION 1.1 Definition of anaemia ....................................................................................19 1.1.1 WHO definition of cut-off points ................................................. 19 1.1.2 Prevalence of anaem ia ........................................... 19 1.1.3 Pathophysiology and maternal effects of anaemia in pregnancy 23 1.1.4 Fetal effects of anaemia in pregnancy .......................................... 24 1.1.5 Aetiology of anaemia in pregnancy ...............................................25 1.2 Blood volume changes during normal pregnancy .....................................27 1.3 Iron .................................................................................................................28 1.3.1 Iron requirements ...........................................................................28 1.3.2 Dietary iron .......................................................................................30 1.3.3 Iron losses ......................................................................................... 32 1.3.3.1 Basal physiological iron lo sse s ................................ 32 1.3.3.2 Pathological iron loss .................................................32 1.3.4 Storage iron .................................................................................... 32 1.4 Folate ............................................................................................................ 33 1.4.1 Increased folate requirements.........................................................34 1.4.2 Diagnosis of folate deficiency.........................................................36 1.5 Vitamin A ..................................................................................................... 37 1.5.1 Sources of vitamin A .......................................................................37 1.5.2 Vitamin A requirements ..................................................................37 1.5.3 Absorption of vitamin A ................................................................38 1.5.4 Methods of assessment of vitamin A statu s ................................. 38 1.5.5 Bioavailahility of vitamin A ...........................................................39 1.5.6 Vitamin A and iron interrelationships ........................................ 40 3 1.6 M alaria ........................................................................................................... 43 1.7 Management of anaemia in pregnancy ......................................................46 1.7.1 Iron and folate supplementation ................................................... 46 1.7.2 Control of infections ...................................................................... 53 1.7.3 Dietary modification ......................................................................53 1.7.4 Food fortification ........................................ 54 1.8 Sickle cell disease ........................................................................................... 54 1.8.1 Pathophysiology ............................................................................... 55 1.9 Human Immunodeficiency Virus .................................................................. 56 1.10 Maternal health ..............................................................................................57 1.10.1 Maternal mortality ................................ 57 1.10.2 Maternal morbidity ......................................................................... 57 1.10.2.1 Existing sources of information on maternal health ..................................................58 1.10.2.2 The need to improve the quality of data 59 1.10.2.3 Techniques for measuring maternal health .... 59 1.11 Thesis Overview ..............................................................................................60 CHAPTER 2-STUDY COMMUNITY AND RESEARCH DESIGN 2.1 The Country; Nigeria .................................................................................... 61 2.1.1 Geography ......................................................................................... 61 2.1.2 Climate ..............................................................................................62 2.1.3 Agricultural production and food availability ............................ 62 2.1.4 Food consumption ........................................................................... 64 2.1.5 Nutritional status and health related factors ...............................66 2.1.6 Demography .....................................................................................68 2.1.6.1 Total population ..................................... ...............68 2.1.6.2 Population growth r a te ........................................ 69 2.1.6.3 Population density ................................... .............. 70 2.1.6.4 Urban population growth r a te ............................ 70 2.1.6.5 Ethnic groups .......................................... .............. 71 2.1.6.6 Age structure .......................................... .............. 71 2.1.7 Administration ...............................................................................72 2.1.8 Health ............................................................................................... 72 2.1.9 Access to services .............................................................................73 2.2 The study areas .............................................................................................74 2.2.1 Infrastructural facilities .................................................................74
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