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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 4  |  Page : 350-355  

Prevalence of anemia in antenatal women at first point-of-care visit to district combined hospital, Chakia, Uttar Pradesh, India


1 Department of Obstetrics and Gynecology, District Combined Hospital, Chandauli, India
2 Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission23-Jun-2019
Date of Decision21-Jul-2019
Date of Acceptance24-Jul-2019
Date of Web Publication20-Jul-2020

Correspondence Address:
Lavina Chaubey
43, Vaishnavi Vihar Colony, Susuwahi, Post Dafi, Varanasi - 221 011, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_179_19

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  Abstract 


Background: The WHO global database on anemia for 1993–2005, covering almost half of the world's population, estimated the prevalence of anemia worldwide at 25%. India is one of the countries with anemia as a serious public health concern. Nearly 50% of the pregnant women in India and 51% in Uttar Pradesh were shown to be anemic as per the National Family Health Survey-4 (2015/16). Objectives: This study was undertaken to determine (1) the prevalence of anemia in women attending the Antenatal Outpatient Department of District Combined Hospital, Chakia, Uttar Pradesh and (2) the association of sociodemographic variables with anemia. Materials and Methods: This was a retrospective cross-sectional study, wherein information regarding hemoglobin (Hb) levels and other variables of 631 antenatal women were taken from the records. Anemia was classified as per the WHO and Centers for Disease Control and Prevention (CDC) criteria for Hb levels. Results: The prevalence of anemia was 92% using the WHO criteria and 87.6% with CDC criteria. About 63.2% of women had moderate anemia (WHO), of which 59.3% were between age group of 22 and 30 years, 61.4% were second gravidas, 60.7% came in the second trimester, and 59.8% had ≥1 live birth. There was association with blood types as well. Conclusion: Early antenatal registration, diagnosis, and management of anemia are important due to high prevalence of moderate anemia in the study area.

Keywords: Anemia, Centers for Disease Control and Prevention Criteria, hemoglobin, pregnancy, prevalence, WHO criteria


How to cite this article:
Yadav U, Singh TB, Chaubey L. Prevalence of anemia in antenatal women at first point-of-care visit to district combined hospital, Chakia, Uttar Pradesh, India. Med J DY Patil Vidyapeeth 2020;13:350-5

How to cite this URL:
Yadav U, Singh TB, Chaubey L. Prevalence of anemia in antenatal women at first point-of-care visit to district combined hospital, Chakia, Uttar Pradesh, India. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Dec 1];13:350-5. Available from: https://www.mjdrdypv.org/text.asp?2020/13/4/350/290161




  Introduction Top


India is a country with anemia as a serious public health concern since nearly 50% of the pregnant women were shown to be anemic as per the National Family Health Survey (NHFS-4) (2015/16). In Uttar Pradesh (UP), the estimated prevalence is 51.0%.[1],[2] Reports from India from way back in 1981 indicated that a sizeable proportion of all maternal deaths (16%) were attributable to anemia.[3] A study from Lancet, 2002, showed that India contributed to 80% of maternal deaths in South Asia due to anemia.[4] The hemoglobin (Hb) levels used to diagnose anemia (g%) in pregnant women as per the WHO nutritional anemia “Tools for effective prevention and control, 2017”, were mild (10.0–10.9 g%), moderate (7.0–9.9 g%), and severe (<7.0 g%).[5] Iron deficiency was the major cause of anemia in 50% women of reproductive age group.[6] Other nutritional deficiencies, infectious diseases, and hemoglobinopathies are other important contributory causes to the high prevalence of anemia.[7]

The objectives of this study were to determine the magnitude of the problem of anemia in antenatal women attending District Combined Hospital (DCH), Chakia.

The primary outcomes studied were as follows:

  1. Prevalence of anemia in the study area
  2. Association of sociodemographic variables with anemia.


The secondary outcome studied was to look for any association of anemia with blood groups of the study participants for improving measures for prevention of anemia since blood of rare groups is not easily available in the community.


  Materials and Methods Top


Study design

This was a retrospective cross-sectional study.

Study subjects

For the study, the data of 631 antenatal women who registered between August 2017 and July 2018, at first point of care were taken from the antenatal register maintained in the DCH, Chakia. As the antenatal case enters the hospital, she gets registered as an outpatient department (OPD) case on payment of Rs 1/- and gets an OPD slip. All female patients are directed to the obstetrics and gynecology OPD. One qualified staff nurse records the blood pressure and weight of all patients and classifies them into obstetrical and gynecological cases by asking leading questions and sends them to the gynecology/obstetrics subsection for history, examination, and relevant investigations. At this point, patients with previous bad obstetric histories, current pregnancy complication, or associated comorbidities are not registered as hospital antenatal and directly referred to higher centers for intensive/specialized treatment. At the hospital, point-of-care testing services are available, so that reports of investigations are available within 60–90 min. Hb is done on fully automated machines by a dedicated trained laboratory technician who also does the blood grouping, documents the reports, and sends them back to the obstetric OPD. All patient data and investigation reports are recorded in the antenatal register by the staff nurse and checked for accuracy by the obstetrician. Subsequently, data are entered into the computer by a data entry operator in National Institute for Transforming India, Government of India Aayog format on UP Health Management Information System and uploaded to the state government by the end of every month.

Ethical aspects

Data were collected from the antenatal register of DCH, Chakia, UP, from August 2017 to July 2018, with permission of Chief Medical Superintendent (CMS/2018-19/466A dated 18.08.2018). All efforts were made to maintain confidentiality by analyzing the data in an anonymous unlinked manner.

Inclusion criteria

Women whose records were complete regarding Hb levels, blood group type, age, gravida, trimester at registration, number of live births, and number of abortions were included in the study.

Exclusion criteria

Women with incomplete records were excluded from the study.

The recorded data were checked and assessed with regard to the following variables and categorized as below:

  1. Hb (g%) categorized as per both the WHO and Centers for Disease Control and Prevention (CDC) classification


    1. WHO: mild (10.0–10.9 g%), moderate (7.0–9.9 g%), and severe (<7.0 g%).
    2. CDC: first and third trimesters: <11.0 g% and second trimester: <10.5 g%


  2. Age (years) data divided into: Group 1 = 18–21, Group 2 = 22–29, and Group 3 = 30–35
  3. Number of pregnancy events (gravida): Group 1 = primipara, Group 2 = 2nd gravida, Group 3 = 3rd gravida, and Group 4 is ≥ 4th gravida
  4. Trimester at registration: Group 1 ( first trimester) =0–12 completed weeks, Group 2 (second trimester) =13–27 completed weeks, and Group 3 (third trimester) =28–40 completed weeks
  5. Number of live births: Group 1 = no live birth and Group 2= ≥one live births
  6. Number of abortions: Group 1 = no abortion and Group 2= ≥one abortion.


Statistical analysis

The analysis was carried out using trial IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. IBM Corp., Armonk, NY, USA). The data are presented in mean ± standard deviation, number, and percentage. Chi-square test was used to find the significant association of sociodemographic variables with anemia. The level of significance of 5% at two-tailed test is considered as statistically significant.


  Results Top


[Table 1] shows that among 631 women who came for antenatal registration, nearly 92% (581/631) were anemic as per the WHO classification, and of these, 63.2% (367/581) had moderate anemia. Among the severe category, the lowest Hb recorded was 1.6 g%.
Table 1: Distribution of participants as per hemoglobin (g%) based on the WHO classification

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In [Table 2], the distribution of Hb g% as per the CDC classification shows that 88.9% (561/631) of women were anemic. Of the total second trimester registrations (68.2%), 89.5% of (385/430) women had moderate anemia.
Table 2: Distribution of participants as per hemoglobin (g%) based on centers for disease control classification

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[Table 3] shows that majority of women registered in the second trimester and that moderate anemia was dominant among all categories of variables, followed by mild anemia. However, the difference between various subgroups of the variables did not show any statistical significance.
Table 3: Distribution of participants as per demographic variables with hemoglobin (g%)

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[Table 4] shows the prevalence of blood group types in 319 study participants as 36.7% (117) having predominantly B+ and the least common being AB+ in 8.5% (27) pregnant women in Rh+ category. Moderate anemia was 66.7% (18) in AB+ women. When seen as per Indian cutoff for Hb, trimester wise, only 11.6% (37) of women had Hb ≥10.5 g%, and it was seen that anemia was more common in 25 of 27 women with AB+ blood group (92.6%), followed by 73 of 81 A+ women (90.1%).
Table 4: Distribution of blood groups in participants with hemoglobin (g%)

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  Discussion Top


The WHO Global Database on Anemia for 1993–2005, covering almost half the world's population, estimated the prevalence of anemia worldwide at 25%.[8] In countries with high development, it is estimated at 9%, whereas in countries with low development, the prevalence is 43%. Women of reproductive age are most at risk, with global anemia prevalence estimates of 42% in pregnant women. Africa and Asia account for more than 85% of the absolute anemia burden in high-risk groups, and India is the worst hit.[9] The definition of anemia recommended by the CDC is a Hb or hematocrit (Hct) value less than the fifth percentile of the distribution of Hb or Hct in a healthy reference population based on the stage of pregnancy. This classification, derived from an iron-supplemented population, lists the following levels as anemic: Hb (g/dl) levels below 11 g/dl in the first trimester, 10.5 g/dl in the second trimester, and 11 g/dl in the third trimester. This standard has been accepted in India also.[10],[11]

In this study, the prevalence of anemia as per the WHO criteria was found to be 92% and 87.6% on an average as per CDC criteria, in the study area of Chakia in UP.[5],[10],[11] This is way above the national prevalence of 50% in India and 51% in UP as per NHFS-4 (2015/16) and poses a serious health concern. In a similar study from Andaman and Nicobar in 2018, the prevalence of anemia among pregnant women was 50.9% (WHO classification) which is comparable with the national prevalence.[12] Furthermore, greater number of women who were anemic, registered in their second trimester, followed by the third trimester forming a large group, who have a short diagnosis to delivery interval. Among these, moderate anemia dominated, followed by mild anemia. In a prospective study done at Dr. B.R. Ambedkar Medical College and Hospital, Bengaluru, during October 2009–2011, it was found that moderate anemia was present in almost 53.0% cases followed by mild (29.5%) and severe (17.5%), respectively.[13] Although mild anemia is not associated with adverse pregnancy outcome, moderate anemia does carry a significant risk of postpartum hemorrhage and infection in the mother. As per literature, the relative risk of maternal mortality associated with moderate anemia was 1.35 and for severe anemia was 3.51.[14] Anemia during pregnancy has also been found to be associated with low birth weight, premature births, stillbirths, and maternal deaths due to several direct and indirect reasons.[15] Therefore, moderate-to-severe maternal anemia is a high risk, and it is important for all cases of anemia in the community to be identified early and treated to ensure adequate Hb levels as early as possible.

The study also revealed that out of 631 registered cases, most women who came for antenatal care were between the age group of 22 and 29 years, followed by those between 18 and 21 years. However, only 6.8% between 30 and 35 years registered and more than 50% of these had moderate anemia. A study from Hyderabad (2017) had similar results, where out of 486 cases, the predominant age group of women coming to the hospital was between 20 and 29 years, and 0.6% were above 40 years of age. In this study, the major group of women having anemia were between 35 and 39 years.[16] Literature wise, higher maternal age at childbirth is reported to be associated with a range of pregnancy complications including: fetal growth restriction, preeclampsia, placental abruption, preterm birth, and stillbirth, and importantly, these increased risks appeared to be independent of maternal comorbidities.[17] Coupled with moderate anemia, as in this study, the expected rate of complications is bound to be high and may predispose to poor obstetric outcome. Therefore, this group should be specifically targeted to come for early first-trimester registration and frequent follow-up.

With respect to gravida variable, it is seen that more number of women who registered were primiparas, and among these, second-trimester registrations were more common instead of first trimester. As per the Guideline for Antenatal Care and Skilled Attendence at Birth, Government of India, Maternal Health Division 2010, all pregnant females should be registered early in the first trimester and at least one checkup should be done before 12 completed weeks of pregnancy. These guidelines need to be ensured at the community level for better antenatal care.[18] Chandhiok et al. from the division of reproductive health and nutrition, Indian Council of Medical Research (ICMR), 2006, did a cross-sectional study of 7005 pregnant women from 28 districts in 14 states and found that 5344 women reported for antenatal care after 4 months of pregnancy. They also found that there was a statistically significant reduction in the proportion of women obtaining antenatal care services with increasing age, parity, and number of living children and concluded that there was a need for improving community awareness on maternal health, motivating women to utilize maternal care services.[19] Furthermore, as shown by two studies in 2014 and 2017, multigravidity is a major risk factor for anemia in pregnancy, and therefore, the need for early and constant antenatal surveillance cannot be underemphasized for these women.[20],[21]

Frequent live births lead to inadequate replenishment of iron stores coupled with increased demand during pregnancy and lactation, leading to anemia. On the other hand, there are many conditions associated with pregnancy that may lead to failure to achieve a live birth and recurrent such episodes may also lead to anemia, some such conditions being: miscarriages, ectopic pregnancies, and molar pregnancies because they are also associated with acute blood loss. Bleeding during the second and third trimesters may be due to causes such as placenta previa, abruption of placenta, vasa previa, and uterine rupture again leading to loss of the fetus. In this study, data were analyzed to find the difference between the two groups since both are associated with significant risk of anemia and if present, the severity of anemia that dominated. It was seen that the group with one or more live birth was marginally more anemic (94%) than the group with no live birth (91%) and moderate anemia was dominant in both. However, this difference was not statistically significant. In a study from a rural area of Haryana, 2016, it was found that in women having live births, 51.1% cases had severe anemia and 50% cases very severe anemia. Here, the prevalence of anemia was less but of greater severity although ICMR classification had been used to analyze data.[22]

Since anemia predisposes to infection which is one of the causes of abortion, the logical inference would be that study participants having higher prevalence of anemia, may also have more abortions. However, despite the high prevalence of anemia found in this study, 97% of women did not give history of prior abortions. In these women, most women had moderate anemia followed by mild anemia. In another study from 2015, it was shown that some degree of anemia had a protective effect against pregnancy loss by neutralizing the increased coagulability in the second half of pregnancy which is a normal maternal adaptation to the pregnant state.[23] This may be a possible explanation for low rate of abortions despite a high prevalence of anemia. However, this inference needs more corroboration.

As a secondary outcome of this study, it was found that among the rhesus factor positive (Rh+) groups, the most common blood types were 36.7% B+, followed by 27.9% O+ and 25.4% A+. Severe and moderate anemia was proportionately more with AB+ type, whereas blood groups A+, B+, and O+ had a predominance of mild anemia.. However, reason could not be assigned since the study looked at only the association and not possible causes. The associations between blood groups and anemia are still a new area of research and currently being further explored. In an article by Kumar and Kaushik, it was observed that O type individuals were comparatively resistant to anemia, whereas individuals having A, B, or AB blood types were relatively prone. Another article found that in pregnant study participants of sickle cell disease, those having B+ blood group were less susceptible to anemia. However, in both studies, the reasons for their findings were not stated.[24],[25] Furthermore, all Rh antigens can potentially play a role in autoimmune hemolytic anemias as well as hemolytic reactions due to immune activation following pregnancy or transfusion, but some Rh− null individuals experience chronic hemolytic anemias of nonimmune origin.[26] However, it would be prudent to wait for a larger study before drawing any definite conclusions except that caution must be exercised with Rh− anemic women due to low availability of these blood types. Early diagnosis and correction of anemia would be a way to obviate the hurdle of scarcity of blood of rare type, if needed, in adverse circumstances.


  Conclusion Top


The prevalence of anemia was found to be very high among the antenatal women coming for first point-of-care visit to DCH, Chakia, UP, that is, nearly 92% when using the WHO classification and on an average, 87.6%, when using the CDC recommendation based on the stage of pregnancy. This is way more than the prevalence of 50% in India and 51% in UP as per NFHS-4 (2015/16), and therefore, a serious health concern in the community under study.

Demographically, a greater number of women tended to register for the first time in their second trimester, and among these, more women were primiparas, between 22 and 29 years of age group. Moderate anemia, as per the WHO classification, was dominant among all categories under study, followed by mild anemia. Therefore, keeping in mind the high prevalence of anemia in this region, it is imperative to motivate all antenatal women to come forward for first trimester antenatal registration irrespectively, so that anemia may be diagnosed as early as possible and maternal and perinatal morbidity and mortality, consequent to anemia, may be avoided in the community.

However, the limitation of the study was that assessment for anemia was done using single Hb value only at first point-of-care visit and did not show the improvement with treatment instituted, if any, and how it influenced the fetal and maternal obstetric outcomes. Furthermore, it is too early to draw an inference regarding the association between blood groups and anemia. A larger study is needed to form any definite opinion.

Acknowledgment

The authors are indebted to the nursing staff of DCH, Chakia, for helping with data compilation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Government of India. Anemia Mukt Bharat. Intensified National Iron Plus Initiative (I-NIPI) National Health Mission. New Delhi: Ministry of Health and Family Welfare Nirman Bhavan; 2018.  Back to cited text no. 1
    
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Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ; Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet 2002;360:1347-60.  Back to cited text no. 4
    
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World Health Organization. Nutritional Anemia: Tools for Effective Prevention and Control. Geneva: World Health Organization; 2017. Available from: https://creativecommons.org/licenses/by-nc-sa/3.0/igo. [Last accessed on 2019 Jun 10].  Back to cited text no. 5
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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