Prevalence of Anemia and Assessment of Some Hematological Parameters among Pregnant Women who attended the Antenatal Care Clinic in Jibla University Hospital, Ibb-Yemen, 2023

Introduction: The prevalence of anemia was estimated to be two-thirds among pregnant women in developing countries, and contributes to low birth weight and child and maternal mortality. So, it is important to determine the prevalence of anemia and the related risk factors in any community to manage this problem. 

Objective: To prevalence of anemia and evaluate some of hematological changes during pregnancy.

Method: Community-based cross-sectional study was designed to gather data and blood samples for some hematological investigations from pregnant women, who attended the antenatal care clinic during the routine visits at Jibla University Hospital, Ibb governorate, Yemen, from November, 2022 to March, 2023. 

Result: 154 of pregnant women were recruited in this study. The prevalence of anemia was found to be 16.2% among the pregnant women, and the mean ± SD of hemoglobin level of all the pregnant women was 12.26 ±1.38g/dl. Also, there was non-statistically significant difference between the anemia and socio-demographic information, except the level of education, in which anemia was higher among pregnant women group who had high school and illiterate (21.8% and 20.4%), than other group who had basic level of education with (P=0.05). Also, there are non-statistically difference between anemia and reproductive history. However, there is statistically significant variations in some hematological parameters throughout the three trimesters among pregnant women; for RBCs count, MCV and MCHC with (P= 0.002, 0.049, and 0.044, respectively).

Conclusion: The prevalence of anemia was mild among pregnant women who attended the antenatal care clinic in Jibla University Hospital. Anemia was statistically significantly associated with education level of pregnant women. However, a statistically significant variation is found between some hematological parameters (RBCs, MCV and MCHC) and stages of pregnancy (trimesters).

The prevalence of anemia was two-thirds among pregnant women in developing countries, and contributes to birth with low weight and child and maternal mortality [36]. Yemen is considered as one of developed countries in the globe, and high poorest country in the Middle East Region with high uneducated females, and food security [13]. The Arabic spring events of 2011, war and siege had wasted impact on poor people as women and children in Yemen [29]. According to UNFPA, Yemen reported 2019 revealed that the maternal mortality ration was estimated in 385/100000 [7]. 

Anemia is a condition distinguished by a decline in the number or size of red blood cells and hemoglobin concentration which are inadequate to meet the body’s physiologic needs. Anemia is result in impaired capacity to transport oxygen (Tsai et al., 2019). In other term anemia is a reduction in hemoglobin (Hb) or hematocrit (HCT) or red blood cells (RBCs) count. It is a presentation of an underlying condition and can be subdivided into macrocytic, microcytic, or normocytic. Patients who suffer from anemia typically present with vague symptoms such as lethargy, weakness, and tiredness. Severe anemia may present with syncope, shortness of breath, and reduced exercise tolerance (Turner et al., 2022).

There are different contributing factors for anemia such as genetic, nutritional, and infectious diseases (Kumar et al., 2022). According to many studies, anemia amid young women can be attributed to some significant factors, i.e. the age of the respondent, marital status, educational level, nutritional status, wealth status, sources of drinking water and type of toilet facility (Tura et al., 2020). Also, low socioeconomic status, illiteracy, early age of marriage associated with increase in susceptibility to infectious diseases like hookworm infestations may serve to be the underlying factors related to the prevalence of anemia during pregnancy (Sinha et al., 2021).According to anemia in maternal stage; the defined anemia as hemoglobin level is less than 11 g/dl in pregnancy women and based on hemoglobin concentration anemia is divided into three levels, in terms of severity; severe anemia (hemoglobin level 7-4.5 g/dl), moderate anemia (hemoglobin level, 7-8.9 g/dl), and mild anemia (hemoglobin level, 9-10.9 g/dl) (Gudeta et al., 2019). The classified public health significance of anemia in community based on prevalence into: Normal (≤ 4.9%), mild (5.0-19.9%), moderate (20.0-39.9%), and severe (≥ 40%) (Idi et al., 2019). The prevalence of anemia in maternal was estimated as 41.8% in global, and 54% in Middle East Countries (Yang et al., 2018). Yet, it was accounted for 40% in Yemen (Stevens et al., 2022).

Maternal anemia has consequences with risk of mortality and bring different problems including experience of general weakness, fetal anemia, low birth weight, preterm delivery, increased risk of postpartum hemorrhage, intrauterine growth restriction, perinatal mortality stillbirth, deficiency of the capacity of the blood to transport oxygen around the body, poor work capacity, low tolerance to infections, shortness of breath, low physical activities, and mental functioning (Garzon et al.,2020, Frayne and Pinchon, 2019). Pregnant women are susceptible to iron deficiency anemia because of the increase in iron demands, up to additional 1000 mg (Garzon et al.,2020). Creating awareness amid pregnant mothers can help prevent them from anemia specially during their prenatal visit, iron supplementation, regular deworming, consistent use of insecticide treated bed net, nutritional counseling, food fortification, iron and folic acid supplementations and by treating the underlying causes and complications (Balcha et al., 2023).

Determination of the common spread of anemia in the different areas of any given governorate is of a great importance because of the wide variation of the socio-economic factors and the educational level, and the availability of the public health care and diagnostic facilities in each region. In Jibla district, a relatively high female education level and health care service may deduce the prevalence of anemia among the pregnant women. 

To prevalence of anemia and evaluate some of hematological changes during pregnancy among pregnant women who are attended the antenatal care clinic at Jibla University Hospital. 

Specific objectives of the Study

• To find out the prevalence of anemia among pregnant women.
• To evaluate some hematological changes in the pregnant women in stages of pregnancy (three trimesters). 
• To investigate the associated risk factors of anemia those are related to socio-demographic factors in the pregnant women. 
• Determinants associate risk factors of anemia related to reproductive history of pregnant women

Study design

A community based cross-sectional study was designed to gather data from pregnant women who attend the antenatal care clinic appointment during the routine visits in Jibla University Hospital, Ibb governorate, Yemen.

Target population

 All pregnant women who attend the antenatal care clinic during routine visit and eligible and meet the inclusion criteria.

Inclusion criteria

• Pregnant women who attend the routine antenatal care clinic.
• Pregnant women who agree to participate in the study.

Pregnant women who are free from severe or chronic systemic diseases that may affect the study such as chronic anemia, liver, renal, cardiovascular, and endocrinal diseases, etc.

Exclusion criteria

• Participants with an incomplete history.
• Participants who are not surely pregnant.

Participants who use medications that may affect the study such as hematinic drugs, medicines that may cause bone marrow suppression, drugs that may interfere with Iron metabolism or hemoglobin formation such as antacids, H2 receptors inhibitors, proton pump inhibitors (PPI), anti-folate, etc.

Sampling and sample size

Eligible pregnant women were recruited during their visit to out obstetrics clinic at antenatal care appointment. Quota sample was used to recruit 154 pregnant women who consented to participate in this study and completed the interview and the laboratory tests.

Data Collection and Period

Data was collected face to face from pregnant women by co-researchers, and laboratory results were obtained after completed routine assessment by obstetrics specialists during the period from November, 2022 to March, 2023.

Study Techniques

Researcher and co-researchers reviewed many of previous studies before designing the questionnaire of the current study. Thus, the questionnaire and laboratory investigations were used to collect data. Questionnaire investigations were adapted from other relevant studies of literature and amended to be appropriate to the local context. At first, preparation of questionnaire was designed in English language. Then, it was translated into Arabic language by expert English lecturers from Jibla University. After that, it was retranslated back into English to check the consistency.

The questionnaire consisted of three sections; first part included the socio-demographic information about the pregnant women such as age, residence, income, educational level, and family size, khat chewing and smoking habits. Second part included the reproductive history; such as last delivered place, number of gravidities, number of parities, number of abortions, and inter pregnancy interval. Third part included the laboratory results such as anemia parameters: hemoglobin (Hb), hematocrit (HCT), red blood cells (RBCs), mean cell volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), and red cell distribution width (RDW). White blood cells (WBCs) were also measured to study their changes during the pregnancy. A total of 2.5 ml of whole blood was collected into an EDTA vacutainer, and analyzed immediately in an automated blood counter (Sysmex XS 500i, Japan). Pregnant women with blood hemoglobin concentration level less than 11 g/dl were considered as anemic, while pregnant women with blood hemoglobin concentration greater than 11 g/dl were considered as non-anemic according to the guidelines of WHO, (2001).

Ethics approval

After reviewed and approved questionnaire by the Research ethics committee of Jibla University for Medical and Health sciences, the permission was also granted from hospital manager to collect data from the pregnant women. After explaining the study purpose and procedures, verbal consents were obtained from all participants and they informed that participation is voluntary.

Data analysis 

Statistical Package for Social Science (SPSS) version 23 was used to analyze data in this study. Chi-squire test was used to find out the relationship between anemia and associated risk factors related to socio-demographic characteristics and reproductive history characteristics. One way ANOVA was used to compare the hematological parameters in pregnant women of the three stages of pregnancy, and LSD was used as a post-hoc test. P-value ≤ 5 was taken as significant. 

Out of 154 pregnant women; 55 % of them were pregnant during the third trimester, and 39% were during the second trimester and only 6% were during first trimester, see figure (1). The table 1 shows the socio-demographic characteristics of pregnant women. It is cleared that mean ± standard deviation of age the study population is 26.9 ± 6.5 years with a range of age from 15 to 44 years. Around two fifths (38.3%) of pregnant women are aged over 30 years, followed by an age group between 21-29 years (35.1%), and an age group who is less than 20 years (26.6%). About three fifths (59.7%) of pregnant women were resident in rural regions. More than one third (35.7%) of the pregnant women have completed secondary school, compared to 31.8% of them who are illiterate. Moreover, more than half (57.1%) of pregnant women reported that the monthly income of their families is less than 50 USD, compared to 9.8% of them who had over 100 USD. Also, table 1 showed that more than three fifths (64.9%) of the pregnant women have a family consisted of more than 5 persons, compared to 35.1% of them who have 2-4 individuals in their families. Majority (83.8%) of the pregnant women are non-smokers, and more than half (55.8%) are used to chew Khat on daily basis.

Table 1: Socio-demographic Characteristics of Pregnant Women who Attended Antenatal Care Clinic at Jiba University Hospital, Ibb-Yemen, 2023 (n=154).

Abbreviations: USD, United States Dollar

Table 2: Reproductive History of the Pregnant Women who Attended Antenatal Care Clinic at Jibla University Hospital, Ibb-Yemen, 2023 (n=154).

Table 2 shows the reproductive history of the pregnant women. It is cleared that more than one half (57.8%) of pregnant women said that the last delivery was in the hospitals, compared to 24% of them who had last delivery at home. More than half (51.9%) of pregnant women had 2-5 previous gravidities, compared to 11.7% of them who had primary gravidity. Regarding to the parity, less than half (48.7%) of pregnant women have experienced with 2-5 times of parities, compared to 9.1% of them who had 6 or over parities. Concerning the abortion, it is obvious that slightly less than two thirds (65.6%) of pregnant women had no previous exposure to abortion, compared to 9.7% of them who had exposed to abortion for three times and over. For the inter pregnancy interval, more than two fifths (41.6%) of pregnant women had less than 2 years, compared to 40.2% of them who had over 2 years for inter pregnancy interval.

Figure 1: Shows the Percentage of pregnant women. It was cleared that 55% of them was during the third trimester, followed up with 39% were during the second trimester, and 6% were during first trimester.

Figure 2: Shows the prevalence of anemia among the pregnant women. It was obvious that 83.8% of pregnant women were none anemia, compared with 16.2% of them was suffering from anemia.   

Figure 3: Shows the prevalence of anemia in the 3 stages of pregnancy among pregnant women. It was cleared that the prevalence of anemia increases with the progression of pregnancy in which the prevalence in the 1st, 2nd and 3rd trimesters is (11.1%, 15.0% and 18.6%, respectively).

Table 3: Hematological Parameters Outcomes among Pregnant Women who Attended the Antenatal Care Clinic at Jibla University Hospital, Ibb-Yemen 2023 (n=154).

Abbreviations: Hb, hemoglobin; HCT, hematocrit; RBCs, red blood cells; MCV, mean cell volume; MCH, mean corpuscular hemoglobin; MCHC, mean corpuscular hemoglobin concentration; RDW, red cell distribution width; WBCs, white blood cells.

Table (3) shows the hematological parameters results among pregnant women. It is revealed that mean ± SD of Hb, HCT, RBC, MCV, MCH, MCHC, RDW and WBC were 12.28±1.38 g/dL, 37.42±4.00 %, 4.28±0.49 x 106 /μL, 86.89±8.95 fL, 28.72±3.15 pg, 32.71±1.11 g/dL, 14.13±3.19 %, 7.31±2.18 x 103 /μL, respectively. All these results are full within the reference values, except that the mean level of MCHC which is less than the lower limit of the reference value (33-37 g/dL).

Table 4: Distribution of Some Hematological Parameters in three Stage of Pregnancy among Pregnant Women who Attended Antenatal Care Clinic at Jibla University Hospital, Ibb-Yemen 2023 (n=154).

*P less than or equal to 0.05, **P less than or equal to 0.01, a: significantly > 2nd and 3rd trimester, b: significantly > 2nd trimester, c: significantly < 2nd> 3rd trimester.

Table (4): shows some hematological parameters in the three stages of pregnancy among pregnant women. The hematological parameters showed that there were a statistically significant differences in the three trimesters of pregnancy regarding some hematological parameters results; RBCs count with (P = 0.002), MCV with (P = 0.049) and in the MCHC with (P = 0.044). Furthermore, RBC count was significantly higher in the pregnant women who are in the 1st trimester as compared to those who are in the 2nd and the 3rd trimesters (mean ± SD = 4.72 ± 0.53, 4.15 ± 0.42, and 4.31 ± 0.50, respectively). MCV was significantly lower in the pregnant women who are in the 1st trimester as compared to those who are in the 2nd and the 3rd trimesters (mean ± SD = 80.47 ± 11.31, 88.20 ± 7.82 and 86.63 ± 9.21, respectively). On the other hand, there were no significant differences between the three stages of pregnancy (trimesters) regarding to the results of the other hematological parameters (Hb, HCT, MCH, RDW and WBCs).

Table 5: Relationship between anemia and associated risk factors regarding the socio-demographic characteristics among pregnant women who attended Antenatal Care Clinic at Jibla University Hospital, Ibb-Yemen, 2023, (n=154).

*P less than or equal to 0.05 is significant

Table 5 shows the relationship between anemia and associated risk factors regarding the socio-demographic characteristics among pregnant women. It is showed that there was a statistically significant difference between anemia and level of education of the pregnant women with (P = 0.05). It was noted that anemia is accounted for 21.8% of pregnant women who have secondary school, compared to 6% of them who had basic level of education. Also, table 5 showed that there were no statistically significant differences between anemia and other socio-demographic characteristics including the age, residence, family size, smoking, chewing Khat and monthly income. But it was cleared that anemia was accounted for 18.6% of the pregnant women group who their age is over 30 years compared to 13.1% in the group who their ages are between 21-29 years. About one fifth (19.3%) of the pregnant women group who live in urban areas suffer from anemia compared to 14.1% in the group who live in rural areas. Moreover, anemia was accounted for 18% among pregnant women who have a family consisted of 5 and over individuals compared with 13% in group who their family size is consisted of 2-4 individuals. Furthermore, the anemia was estimated to be found in 16.5% of the pregnant women who are Khat chewers compared with 15.9% among group who are non-Khat chewers.

Table 6: Relation between Anemia and Associated Risk Factors of Reproductive History among Pregnant Women who Attended Antenatal Care Clinic in Jibla University Hospital Ibb-Yemen, 2023, (n=154).

Table 6 shows the relationship between anemia and associated risk factors of reproductive history among the pregnant women. It was obvious that there are no statistically significant differences between the anemia and history of reproduction among pregnant women. But, table (6) showed that one quarter (25%) of pregnant women who had once gravidity suffered from anemia compared with 12.9% of the group who had their first pregnancy. More than one quarter (26.7%) of pregnant women group who had more than 5 parities were suffering from anemia compared with 12.3% of the group who had 2-5 parities. Also, table 6 revealed that more than one quarter (26.7%) of pregnant women who had three and over of abortions were suffering from anemia, compared with 10% of the group who had two abortions. Finally, regarding the inter pregnancy interval; more than one fifth (21.7%) of pregnant women who had less than 2 years inter pregnancy interval were suffering from anemia compared with 12.7% of those who had more than 2 years. 

During pregnancy, an observable modification of physiological functions of the pregnant woman's body occurs. Certainly, a significant increase of the metabolic needs and modifications of the hormonal homeostasis arise during the pregnancy (Bakrim et al., 2018). Anemia is a main cause to increase the mortality and morbidity among maternal and child in low-income countries (Victora et al., 2021). Many risk factors are associated with anemia among pregnant women including the socio-demographic status, economic status, dietary practice, obstetric factors, reproductive health, parasitic infestation, and other health-related factors (Dejene h et al., 2022). The current study revealed that mean age of the participants is 26.9 years with a standard deviation of ±6.5 and the range of age is from 15-44 years. This result agrees with another study conducted in Yemen (Gonaid et al., 2022). About one third 35.7% of pregnant women had attended secondary school, while 31.8% were illiterate. These results were supported from other study carried out in Yemen (Al-Maktari et al., 2021). Around the half (51.9%) of our study participants have gravidity for 2-5 times, and more than two fifty (41.6%) of them had internal pregnancy interval less than 2 years. These results are higher than the results of another study conducted in Yemen (Al-Aini et al., 2020). This difference between the two studies could be attributed to that current study is carried out with pregnant women who reside in sub-governorate areas. 

Anemia in pregnant woman is defined when the rate of haemoglobin concentration is less than 11 g/dL and the haematocrit (HCT) is less than 33% in the first and third stages of the pregnancy, while in the second trimester; haemoglobin concentration is less than 10.5 g/dL, and haematocrit less than 32% (Obeagu et al., 2021). However, the prevalence of anemia in pregnancy had estimated at 29% and reaches around 50% in low- and middle-income countries including Middle East region (Yang et al., 2018). In this study, the prevalence of anemia in pregnancy was estimated to be (16.23%). This finding is disagreed with other studies that were carried out in Yemen; in which one study showed that the prevalence of anemia reached to 55% among pregnant women in Al-hodiedah governorate (Gonaid et al., 2022), and another study carried out in Yemen by Akabat et al., (2017) who revealed that the prevalence of anemia among Yemeni pregnant women is 26.56%. Furthermore, a systematic review study conducted in Malaysia by Abd Rahman et al., (2022), recorded a higher anemia rate among pregnant women (19.3 to 57.4%) than that found in our study. The difference between the current study and the other studies could be attributed to that the current study was conducted in one health facility and did not include a displacement people, as well as the genetic, demographic and lifestyle variations.

Regarding socio-demographic characteristics of pregnant women, there is none statistically significant association between anemia and socio-demographic characteristics, except the education level. It was cleared that anemia is accounted to 21.8% of pregnant women who have secondary school, compared to 6% in those who had the basic level of education with (P≤0.05). This result was in similar line with other study carried out in Iraq, Kirkuk city (Ali Khalaf et al., 2020). Conversely, there was no a statistically significant relationship between anemia and other socio-demographic characteristics such as women age, residence, monthly income, and family size. These results are agreed with other study carried out recently in Saudi Arabia (Alreshidi et al., 2021). Interestingly, anemia in the present study was increased in pregnant women group who their age is over 30 years (18.6%) compared to 13.1% in the group who their ages are between 21-29 years. This result is in closed-line with other study carried out in Yemen, which reported that prevalence of anemia was high among pregnant women who their age is over 35 years, and who their age is less than 24 years (Serbesa et al., 2018). Additionally, prevalence of anemia was higher among the pregnant women who reside in the urban areas (19.3%). This result was supported by other study carried out in Dhaka, Bangladesh (Azhar et al., 2021).

Usually, the prevalence of anemia is high among pregnant women during the third trimester because of the hemodilution, poor nutrition and increase demand to iron and other vitamins (Ifeanyi et al., 2018). In this study, anemia prevalence showed that prevalence of anemia is high in pregnant women group during the third trimester (18.6%). This result is somewhat in line with other study carried out in Bangladesh; which revealed that the prevalence of anemia was the highest during the third trimester of pregnancy (Azhar et al., 2021).

There was a non-statistically significant difference between anemia and any one of the associated risk factors regarding reproductive history among pregnant women including gravidity, parity, number of abortion and inter-pregnancy interval. But, the prevalence of anemia was higher among the pregnant women who had once gravidity (25%). This result was supported by a systematic review and meta-analysis which was carried out in Iran (Faghir-Gangi et al., 2023). Moreover, the prevalence of anemia was higher among pregnant women who have more than 5 parities (26.7%) and who had once parity (21.9%). Also, the prevalence of anemia was high among pregnant women group had inter pregnant interval less than 2 years, with rate of 21.7%. These results are in the same line with other study (Azhar et al., 2021).

The objective of our study also included the evaluation of some hematological changes in the pregnant women. It was noted that mean levels of some hematological parameters (Hb, HCT, RBCs, MCV, MCH, RDW, and WBCs) are located within the normal reference values among pregnant women, except MCHC which was lower than the reference values (33-37 g/dL), with mean ± SD = (32.71±1.11). These results were supported from other study carried out on the Iraqi women (Thanoon et al., 2020). Also, the lower mean of MCHC in current study was close to other result recorded from pregnant women in Saudi Arabia (mean ± SD = 32.02±4.91 g/dL). (Hana et al., 2018). In addition, MCHC in the present study was a statistically significantly different in the three stage of pregnancy with (P = 0.044), in which MCHC was higher in the pregnant women during the 1st trimester compared to those who are in the 2nd and the 3rd trimesters. This result was agreed with a cohort study carried out in china (Lei et al., 2021). 

Furthermore, there was a statistically significant difference between RBCs and stage of trimesters with (P = 0.002). RBCs were higher in the first trimester than the other trimesters, and it was increased in the 3rd trimester compared with the 2nd trimester. These results were in same line with other study carried out on the pregnant women in Saudi Arabia (Hana et al., 2018). 

Additionally, this study reported that there was a none-statistically significant difference in MCH value during the three trimesters of pregnancy, but it was higher in the second trimester than the other trimesters. This result was in similar with a study carried out on Sudanese women with normal pregnancy (Rayis et al., 2017).

Moreover, there was a statistically significant difference between the three stage of pregnancy related to MCV, as it was observed that MCV was lower in the 1st trimester, compared to the 2nd and the 3rd trimesters. Likewise, a similar finding was showed from study carried out in Peru (Figueroa-Mujica et al., 2022). 

Finally, there was a non-statistically significant difference between the three stages of pregnancy regarding the WBCs count. This result was supported from other study carried out in Antenatal Care at Sabratha Teaching Hospital, in Northwest, Libya (Gebere et al., 2021). 

This study was implemented in one health facility. Another limitation is that other hematological parameters related to the nutrition such as ferritin, folic acid and vitamin B12 were not included in the laboratory tests. It is recommended to conduct other studies involving those tests.

This study revealed that the prevalence of anemia is mild among pregnant women who attended antenatal care clinic at Jibla University Hospital. Anemia is statistically significantly associated with education level of pregnant women. Moreover, a statistically significant variation is found between some hematological parameters (RBCs, MCV and MCHC) during the stages of pregnancy (trimesters). Researchers recommend implementing a maternal health nutrition education and other interventions to potentially reduce the prevalence of anemia during pregnancy.

• Future studies must be performed with large sample size in addition to many risk fctors should be included like parasitic infection, BMI, regularity of mensturation and nutrients supplementation. 
• Performing future study included further parameters to detect type of anemia like,blood film report, iron, ferritin and other diagnostic tests to detect anemia. 
• Implement a health promotion campaign about maternal health nutrition to improve the diversifying food intake and support pregnant women by iron supplementation.
•  It is more important to encourage women who attend the ANC to understand the risk of anemia in pregnancy and how prevent anemia. 
• Health staff should be introduced advises about using the family planning methods and to enhance maternal health nutrition education intervention, which is highly recommended to potentially reduce the prevalence of anemia during pregnancy.