The Rate and Risk Factors for Anemia Among Pregnant Mothers in Jerteh

edic ty M ine ni & u H Nik Rosmawati et al., J Community Med Health Educ 2012, 2:5 m e a m l o t h

C DOI: 10.4172/2161-0711.1000150

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ISSN: 2161-0711 Research Article Open Access The Rate and Risk Factors for Anemia among Pregnant Mothers in Jerteh Terengganu, Malaysia NH Nik Rosmawati1*, S Mohd Nazri2 and I Mohd Ismail3 1Environmental Health Unit, Department of Community Medicine, School of Medical Science, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia 2Occupational Health unit, Department of Community Medicine, School of Medical Science, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia 3Health System Management Unit, Department of Community Medicine, School of Medical Science, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia

Abstract Background: Antenatal mothers with anemia are high risk to varieties of health implications as well as to their off springs. Many studies show a high mortality and morbidity related to anemia in pregnancy. Methods: This cross-sectional study was designed to determine factors associated with anemia amongst forty seven antenatal mothers attending Antenatal Clinic at Klinik Kesihatan Kuala Besut, Terengganu in November 2009. Systematic random sampling was applied and information gathered based on patients’ medical records and through face-to-face interviewed by using a structured questionnaire. Results: The mean age of respondents was 28.3 year-old. More than half of mothers were multigravidas. Of 47 respondents, 57.4% (95% CI: 43.0, 72.0) was anemic. The proportion of anemia was high for grand multigravidas mother (66.7%), those at third trimester of pregnancy (70.4%), did antenatal booking at first trimester (65.4%), poor haematinic compliance (76.5%), not taking any medication (60.5%), those with no co-morbid illnesses (60.0%), mothers with high education level (71.4%) and those with satisfactory monthly income (61.5%). The proportion of anemia was 58.3% and 57.1% for mothers with last child birth spacing of two years or less and more than two years accordingly. There was a significant association of haematinic compliance with the anemia (OR: 4.571; 95% CI: 1.068, 19.573). Conclusions: Antenatal mothers in this area have a substantial proportion of anemia despite of freely and routinely prescription of haematinic at primary health care centers. Poor haematinic compliance was a significant risk factor. Health education programs regarding haematinic compliance and adequate intake of iron rich diet during pregnancy need to be strengthened to curb this problem.

Keywords: Anemia; Risk factors; Pregnancy; Rate So far, only a few studies (6.7%; 8 out of 120 published and unpublished data) [9], has been done throughout Malaysia concerning Introduction this problem. Due to a significant risk for health of the mother as well Anemia in pregnancy constitutes a major public health problem as the fetus therefore, it is importance to carry out a study to determine in developing countries and a high morbidity and morbidity among the prevalence and factors associated with anemia amongst the most antenatal mothers [1-3]. The average mortality attributed by anemia in vulnerable group, antenatal mothers attending Antenatal Clinic at Asia is estimated as 7.26% [4]. Most of anemias in pregnancy are due to primary health care. Then, the magnitude of the problem and its iron deficiency [2]. It has been known contributes a risk to the fetus for epidemiology can be established. On top of that, this problem is easily preterm delivery, subsequent low birth weight, and inferior neonatal preventable and treatable. health [3,5]. Operational definitions Anemia amongst antenatal mothers is a worldwide health problem. The Hb thresholds used to define anemia in this study was based Its prevalence in Africa was 57.1 % (95 % CI 52.8–61.3), South-East Asia on WHO definition. Anemia is refer to the Hb concentration of less was 48.2 % (95 % CI 43.9–52), Europe was 25.1 % (95 % CI 8.6–31.6), than 11 g/dL and non-anemia is refer to Hb concentration of 11 g/dL Western Pacific was 30.7 (95% CI 18.6–3) and 41.8% (95 % CI 39.9– or more [2]. The level of educational status of respondents was grouped 43.8) worldwide for the year 1993 to 2005 affecting 56 million pregnant women [2]. In Malaysia, the prevalence was 35% and mostly of the mild into low (refer to those with no education and those with education up type and more prevalent in the Indian and Malays communities [6]. to primary school), intermediate (refer to those with secondary school) and high (refer to those with tertiary education). Respondents who World Health Organization (WHO) has categorized and followed the haematinics prescription by health staffs were considered emphasized on the significant health consequences based on the as good haematinics compliance. prevalence of the anemia. If the prevalence of anemia is 4.9% or less, it is considered as no public health problem for that country. The prevalence of anemia between 5.0% and 19.9% indicates a mild public *Corresponding author: NH Nik Rosmawati, Environmental Health Unit, health problem. Moderate public health problem is been considered Department of Community Medicine, School of Medical Science, Health when the prevalence is between 20.0% and 39.9%. If the prevalence is Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia, 40.0% or more, it is considered as severe public health problem [2]. E-mail: [email protected] Many studies explained the status of anemia in antenatal mothers Received May 03, 2012; Accepted May 24, 2012; Published May 26, 2012 was depend on the socioeconomic level [1,7], illiteracy, extremes of Citation: Nik Rosmawati NH, Mohd Nazri S, Mohd Ismail I (2012) The Rate and mother’s age, primigravida or grandgravida, short pregnancy intervals Risk Factors for Anemia among Pregnant Mothers in Jerteh Terengganu, Malaysia. J Community Med Health Educ 2:150. doi:10.4172/2161-0711.1000150 [7,8] and age of gestation [6,8]. In measuring the status of anemia in the population, hemoglobin (Hb) concentration is the most reliable Copyright: © 2012 Nik Rosmawati NH, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which indicator as opposed to clinical measures. Furthermore, it is cheaper permits unrestricted use, distribution, and reproduction in any medium, provided and relatively easy to perform [2]. the original author and source are credited.

J Community Med Health Educ Volume 2 • Issue 5 • 1000150 ISSN: 2161-0711 JCMHE, an open access journal Citation: Nik Rosmawati NH, Mohd Nazri S, Mohd Ismail I (2012) The Rate and Risk Factors for Anemia among Pregnant Mothers in Jerteh Terengganu, Malaysia. J Community Med Health Educ 2:150. doi:10.4172/2161-0711.1000150

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Monthly income was categorized into 3 levels. Poor income refer medication, those with no co-morbid illnesses, mothers with high to those with income less than RM 720 (based on the poverty line index education level and satisfactory monthly income. The proportion of for West Malaysia in 9th Malaysia), satisfactory constituted of those anemia was 58.3% and 57.1% for mothers with last child birth spacing with monthly income RM 720 to RM 1999 and good for those between of two years or less and more than two years accordingly. Simple logistic RM 2000.00 and RM 4000. Respondents with known medical illnesses regression revealed no significant different for the socio-demography (including hypertension, diabetes, thallessemia, kidney, systemic lupus and studied factors with the rate of anemia amongst antenatal mothers erythematous, others) are classified as having co-morbidities. as illustrated in Table 2. Patients and Method Table 3 shows the result of multiple logistic regressions. There was a significant association of haematinic compliance with the anemia Study design and selection of participants among the respondents with the OR of 4.571 and 95% CI between A cross-sectional study was conducted in November 2009 at Klinik 1.068 and 19.573. Kesihatan Kuala Besut Terengganu, located about 60 km from Kota Discussion Bharu, a city of Kelantan or 150 km from Kuala Terengganu, a city of Terengganu. A Systematic random sampling was applied to antenatal An overall prevalence rate of anemia in pregnancy mothers in this mothers attending the clinic within study period (29th October to study was 57.4% (95% CI: 43.0, 72.0). This level is substantially high 26th November 2009) and excluding those with mental handicaps or compared to previous study done in Kelantan where the prevalence was in severe health conditions. The total numbers of antenatal mothers 47.5% [8]. The prevalence of anemia in Malaysia was 35% which is much involved in this study was 47 respondents and the response rate was lower than this study [6]. Other countries did show a lower prevalence 100%. of anemia such as 41.3% in Saudi Arabia [3], 48.2% in South-East Asia [2] and 41.8% worldwide [2]. However, the prevalence of anemia in Research instruments developing countries such as Nigeria was higher, 76.5% [1]. The rate Data collection was carried out by using a structured study of anemia for pregnant mothers in this study is approaching to WHO questionnaire. The questionnaire consisted of socio-demography estimation for developing countries and far behind from economically information (including age, education level and monthly income) developed countries such as in Europe, where their prevalence was and elicited risk factors (including parity, spacing with last child 25.1% [2]. This high figure is surprising considering the routine birth, haematinics compliance, time of antenatal booking, taking practice at all primary health care centers to provide pregnant women other medications and the presence of co morbidity problems. This with prophylactic elemental iron. This reflects a poor nutritional health questionnaire was constructed through series of discussions with of antenatal mothers in this country. experts and underwent face validity. Due to limited time, validity and Anemic state of mothers may predispose themselves as well as reliability test was not done. The hemoglobin level was based on the their off springs to several unwanted health outcomes such as preterm current available results tested using the hemoglobinometer analysis deliveries, low birth weight and prenatal mortality conditions [3]. of the blood samples drawn from either capillary or venous blood. All these information was gathered through face-to-face interviewed Variable Frequency Percentage 95 % CI and from patients’ medical records. The average time taken for each Anaemia, Yes 27 57.4 43.0, interview session was fifteen minutes. No 20 42.6 72.0 Gravida, Primigravidas 14 29.8 Statistical analysis Multigravidas (2-5) 27 57.4 Grand multigravidas (>5) 6 12.8 Data gathered were input into SPSS version 12.0 and analyzed Gestational age, First trimester 5 10.6 using same software. Continuous variables were described as mean Second trimester 13 27.7 and standard deviation whereas, categorical variables were expressed Third trimester 27 57.4 Last child birth, 2 years or less 12 25.5 by frequency and percentage. Simple logistic regression and multiple More than 2 years 35 74.5 logistic regressions were used to determine the significant factors Antenatal booking, 26 55.3 associated with hemoglobin levels. A p-value of less than 0.05 was First trimester 20 42.6 judged to be statistically significant. Second trimester Haematinic compliance, 30 63.8 Yes Results 17 36.2 No Of 47 respondents, 57.4% was anemic (95% CI: 43.0, 72.0). The Taking other medication, 9 19.1 Yes mean age of respondents was 28.3 year-old. More than half of the 38 80.1 mothers were multigravidas and the least was grandmultigravidas. No Nearly three-quarter had more than 2 years last child birth spacing Monthly income, Poor 21 44.7 Satisfactory 13 27.7 and more than half were at third trimester, did antenatal booking at Good 13 27.7 first trimester of pregnancy and good haematinics compliance. More Co morbid illnesses, 37 78.7 NO than 80% of respondents did not take any other medications during 10 21.3 pregnancy. Majority of antenatal mothers have no co-morbidity Yes illnesses and their level of education were at intermediate level. About Education level, Low 8 17.0 Intermediate 32 68.1 46% of mothers had poor monthly income as shown in Table 1. High 7 14.9 ‡ The rate of anemia was high for grandmultigravidas mother, Age (years) 28.3 (6.48) those at the third trimester of pregnancy, did antenatal booking at ‡ Mean (sd) first trimester, poor haematinic compliance, and did not taking any Table 1: Descriptive profile among antenatal mothers (n= 47).

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Crude OR It is correspond with a study done in Saudi Arabian in which teenage Variables % of anemia P-value (95% CI) pregnant females were not at a higher risk of anemia than older women Gravida, Primigravidas 50.0 1 if good prenatal care was provided [10]. This study also revealed no Multigravidas (2-5) 59.3 1.455 0.572 Grand multigravidas (>5) 66.7 2.000 0.496 significant associations between socio-demography, number of Gestational age, First trimester 60.0 1 gravida, year of spacing with last child birth, time of antenatal booking, Second trimester 30.8 0.296 0.266 the presence of co-morbidities, and taking other medications during Third trimester 70.4 1.583 0.648 pregnancy. Last child birth, 2 years or less 58.3 1 More than 2 years 57.1 0.952 0.943 After multivariate analysis using multiple logistic regressions, the Antenatal booking, only significant risk factor was haematinic compliance with the OR of First trimester 65.4 1 Second trimester 45.0 0.433 0.170 4.571 (95% CI: 1.068, 19.573). Meaning that, pregnant mothers with Haematinic compliance, poor haematinics compliance were 4.6 times probability to be anemic Yes 46.7 1 compared to pregnant mothers with good hameatinic compliance. It is No 76.5 3.714 0.053 expected to have the high rate of anemia at the third trimester when the Taking other medication, mothers are not well complied with the haematinic prescription and Yes 44.4 1 No 60.5 1.917 0.385 yet the baby is on growing and the demand for the iron as well as other Monthly income, Poor 57.1 1 minerals are high. Satisfactory 61.5 1.200 0.800 Good 53.8 0.875 0.851 It is interesting if future study can explore why pregnant mothers Co morbid illnesses, are poor compliance to the oral haematinics though these pills are NO 56.8 1 freely available and given at the primary health care centers. Perhaps Yes 60.0 1.143 0.854 the major barrier would be lack of motivation and misconceptions Education level, Low 62.5 1 Intermediate 53.1 0.680 0.635 on the benefits of haematinics. A study done in Saudi Arabian among High 71.4 1.500 0.715 pregnant mothers who are poor haematinics compliance found that, the Age (years) 1.018 0.700 reasons given by mothers for irregular intake of iron supplementation Table 2: Distribution of anemia and associated factors using simple logistic included forgetfulness (52.9%), unnecessary (17.6%) and harmful for regression (n=47). their fetus (5.9%) [3]. Another big across-region qualitative study on the women’s perception on the iron deficiency anemia revealed that Variables B Adjusted OR (95% CI) P-value poor haematinics compliance were contributed by their beliefs that Haematinic compliance, 1 against consuming medications during pregnancy, taking regular Yes 1.520 4.571 (1.068, 19.573) 0.041 No haematinics may cause too much blood or a big baby therefore making Table 3: Factors associated with anemia using multiple logistic regression (n=47). delivery more difficult, experiencing on the negative side effects and the commonest reason was they did not know why they were prescribed These health implications are resulted from the impairment of oxygen on that [11]. delivery to placenta and fetus [1]. Apart from that, low hemoglobin level of the mothers has been proved to cause an increase in maternal There are several limitations attached to this study including a very mortality rate. It has been estimated as 7.26 % of maternal mortality short study period as well as no grant available to fund it. Furthermore, is attributed by all-cause anemia both direct and indirect cause [4]. In since this study is part of the student projects, the number of researchers fact, African study showed a high maternal death attributed by anemia involved is many. Thus, the results of the study may be influenced by which was 20% [1]. Case fatality rate for anemia in pregnancy was inter-rater reliability bias. reported between 1% to more than 50% [4]. Te effect of anemia not only take place during pregnancy, but could be extended up to post- Recommendation partum period and even newly delivered baby may suffer problem of A high rate of anemia in pregnant mothers need to be tackled reduced iron stores up to first year of life [5]. seriously by the health care workers especially at the primary health The highest rate of anemia in this study was at the third trimester care centers because of possible health implication to the mothers (70.4%) even though the difference is statistically not significant. A and babies. Though adequate supplies of iron medication were freely study done in Saudi Arabian shown the significant high prevalence of available in all health care centers, there are still many reasons that anemia during the third trimester [3]. Low hemoglobin level at third prevent mothers from taking it regularly. Therefore, it is important to trimester is in fact not solely depend on the haematinic intake but address on the haematinic compliance by giving adequate counseling probably due to physiological expansion of maternal plasma volume. and education to mothers or perhaps with the involvement of their partners. Hopefully, mothers furthermore could be advised on the Grand multigravidas mother also has the high rate of anemic importance of taking good iron supplementation especially in the (66.7%) during pregnancy compared to primigravida and multigravida second and third trimesters of their gestation. Apart from that, their mothers, but the differences ware statistically not significant. A survey among pregnant women in Nigeria found that the primigravida has dietary sources need to be ensured to contain a high iron contents. A higher prevalence of anemia (69.7%) (P< 0.05) [1]. However, this study done in Indonesia did recommend on the addition of vitamin A current study did not support that finding. The reason would be a small as an oral supplement to improve the hemoglobin concentration [12]. sample size in which only six respondents (12.8%) of grandmultigravida Future studies with larger sample size, supported by a grant and mothers were included in the study and therefore they did not represent longer study period would be more meaningful. Researchers also the true prevalence in this population. suggest for future study to include type of food intake among antenatal Age was also found to be not a risk factor for anemia in this study. mothers as potential confounder.

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Conclusion 4. Brabin BJ, Hakimi M, Pelletier D (2001) An analysis of anemia and pregnancy- related maternal mortality. J Nutr 131: 604S-614S.

Our study showed there was a substantial proportion of anemia 5. Allen LH (2000) Anemia and iron deficiency: effects on pregnancy outcome. in this population. Despite of freely and routinely prescription of Am J Clin Nutr 71: 1280S-1284S. haematinic at primary health care centers, more than half of pregnant 6. Haniff J, Das A, Onn LT, Sun CW, Nordin NM, et al. (2007) Anemia in pregnancy women were anemic. Poor compliance on haematinic intake by in Malaysia: a cross-sectional survey. Asia Pac J Clin Nutr 16: 527-536. mothers was significantly associated with anemia by the OR of 4.571 7. Noronha JA, Bhaduri A, Vinod Bhat H, Kamath A (2010) Maternal risk factors (95% CI: 1.068, 19.573). This information is really valuable to initiate and anaemia in pregnancy: A prospective retrospective cohort study. J Obstet a further exploration to find the root cause of the high rate of anemia Gynaecol 30: 132-136. among pregnant mothers in our community. 8. Ahmad Z, Jaafar R, Mohd Hassan MH, Othman MS, Hashim A (1997) Anaemia Acknowledgement during pregnancy in rural Kelantan. Mal J Nutr 3: 83-90. 9. Ming KE, Lieng TC, Jenn NC, Jaafar S (2008) Bibliography of Primary Care The author wishes to thank to all staffs at Kuala Besut Health Clinic and All Research in Malaysia. Kuala Lumpur: University of Malaya, Malaysia. members in group 5 final year medical students 2009/2010 batch for completing the investigative assignment project during their Preventive Medicine Posting. 10. Mahfouz AA, el-Said MM, al-Erian RA, Hamid AM (1995) Teenage pregnancy: are teenagers a high risk group? Eur J Obstet Gynecol Reprod Biol 59: 17-20. References 11. Galloway R, Dusch E, Elder L, Achadi E, Grajeda R, et al. (2002) Women’s 1. Idowu OA, Mafiana CF, Dapo S (2005) Anaemia in pregnancy: a survey of perceptions of iron deficiency and anemia prevention and control in eight pregnant women in Abeokuta, Nigeria. Afr Health Sci 5: 295-299. developing countries. Soc Sci Med 55: 529-544. 2. McLean E, Cogswell M, Egli I, Wojdyla D, Benoist Bd (2008)Worldwide 12. Muslimatun S, Schmidt MK, Schultink W, West CE, Hautvast JA, et al. (2001) prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information Weekly supplementation with iron and vitamin A during pregnancy increases System, 1993–2005. Public Health Nutrition 12: 444–454. hemoglobin concentration but decreases serum ferritin concentration in 3. Rasheed P, Koura MR, Al-Dabal BK, Makki SM (2008) Anemia in pregnancy: Indonesian pregnant women. J Nutr 131: 85-90. A study among attendees of primary health care centers. Ann Saudi Med 28: 449-452.

J Community Med Health Educ Volume 2 • Issue 5 • 1000150 ISSN: 2161-0711 JCMHE, an open access journal