PPrreevvaalleennccee ooff AAnneemmiiaa aammoonngg PPrreeggnnaanntt WWoommeenn AAtttteennddiinngg AAnntteennaattaall CCaarree aatt SSeellaamm HHeeaalltthh CCeenntteerr,, AAddddiiss AAbbaabbaa,, EEtthhiiooppiiaa BByy RRaahheell FFaassssiill AA TThheessiiss SSuubbmmiitttteedd ttoo tthhee DDeeppaarrttmmeenntt ooff ZZoooollooggiiccaall SScciieenncceess iinn PPaarrttiiaall FFuullffiillllmmeenntt ooff tthhee RReeqquuiirreemmeennttss ffoorr aa MMaasstteerr ooff SScciieennccee DDeeggrreeee iinn BBiioollooggyy AAddvviissoorr:: HHaasssseenn MMaammoo ((PPhhDD)) AAddddiiss AAbbaabbaa EEtthhiiooppiiaa SSeepptteemmbbeerr,, 22001166 TTaabbllee ooff ccoonntteennttss Content Page Table of contents ii Acknowledgments iv Abbreviations v List of Tables vi List of Annexes vii Abstract viii 1. Introduction 1 1.1 Types and determinants of anemia 1 1.1.1 Micronutrient deficiency 2 1.1.2 Infections and chronic illnesses 3 1.2 The impact of maternal anemia 4 1.3 Anemia treatment and prevention 6 2. Objectives 8 2.1 General objective 8 2.2 Specific objectives 8 3. Materials and Methods 9 3.1 Study area 9 3.2 Study design and population 9 3.3 Sample size 9 3.4. Haemoglobin measurement and anemia determination 10 3.5 Data quality control 10 3.6 Data analysis 10 3.7 Ethical considerations 10 4. Results 15 4.1 Study population 11 4.2 Anemia and related variables 11 5. Discussion 15 6. Conclusion and Recommendation 18 7. References 19 ii 8. Annexes.....................................................................................................................................23 9. Declaration.................................................................................................................................31 10. Statement of supervisor(s).......................................................................................................32 iii AAcckknnoowwlleeddggmmeennttss I would like to express my deepest gratitude to my advisor, Dr Hassen Mamo, for his useful comments and engagement through the whole study period. He spent much of his time in supporting me how to collect literature, data and write-up the Thesis. I would like to thank health professionals Ato Andualem and Ato Tinsae at Selam Health Center of Gulelle Sub-city, Addis Ababa, who supported me to communicate with the study participants and collect the data. I am grateful to the study participants who took off their time and willingly filled out the lengthy questionnaire and for their overall participation. I would like to extend my gratitude to my dear colleagues who kindly supported and encouraged me throughout the study. Finally, the Ethiopian Federal Ministry of Education and Addis Ababa University (Department of Zoological Sciences) are acknowledged for the financial and academic supports respectively. iv AAbbbbrreevviiaattiioonnss AACA Addis Ababa City Administration AOR Adjusted Odd Ratio CDC centers for disease control and prevention CI confidence interval COR Crude Odd Ratio CSA central statistical agency EDTA ethylenediaminetetraacetic acid Hb haemoglobin Hct haematocrit IPG inter-pregnancy gap IPIs intestinal parasitic infections IDA iron deficiency anemia MDG millennium development goal P prevalence RBC red blood cells SPSS statistical package for social sciences SHC Selam health center UNDP united nations development programme WFP world food programme WHO world health organization v LLiisstt ooff TTaabblleess Table Page Table 1 Hb and haematocrit (Hct) levels……...............................................................................1 Table 2 Anemia of pregnant women at Selam Health Center,Addis Ababa, December 2015-February 2016…………………….............................................................. 12 Table 3 Smoking and alcohol drinking habits of anemic and non-anemic pregnant women at Selam Health Center, Addis Ababa, December 2015-February 2016 (N = 480)…........13 Table 4 Maternal characteristics of anemic and non-anemic pregnant women at Selam Health Center, Addis Ababa, December 2015-February 2016 (N = 480)…………….....13 Table 5 Univariate and multivariate logistic regression analysis results of socio demographic and other variables in relation to anemia among pregnant women in Selam Health Center, Addis Ababa, December 2015 to February 2016 (N = 480)…………………….14 vi LLiisstt ooff AAnnnneexxeess Annex Page Annex I: Informed consent form………………………………………………………………..22 Appendix II: Informed consent form (Amharic version)……………………………………….23 Annex III: Questionnaire ……………...…………………..…………………………………...24 Annex IV: Questionnaire (Amharic version)…………………………………………………..25 Annex V: Pictures related to the study……...…………...…………………………………….27 Annex VI: Ethical clearance……….…………………………………………………………29 vii AAbbssttrraacctt Anemia is a widespread health problem among pregnant women causing maternal/infant morbidity and mortality mainly in low-income countries. Understanding of the magnitude of anemia and related socio-demographic variables in a specific setting would help scale-up preventive and therapeutic measures in a locality. The aim of this study was, therefore, to estimate the prevalence of anemia among pregnant women attending antenatal care at Selam Health Center, northwest Addis Ababa. The study was conducted from December 2015 to February 2016. Questionnaire and face-to-face interview methods were used to gather pertinent data on socio-demography, clinical history and maternal characteristics of the participants. Venous blood was drawn to measure haemoglobin (Hb) and define anemia (Hb<11.0g/dl). The overall prevalence of anemia was 16.3% (n=480). Majority of the participants (52%) have mild anemia (10-10.9gm/dl).Those with human immunodeficiency virus(OR=3.67,95%CI:1.7-7.90,P value=0.001), or with intestinal parasitic infection (OR=3.46, 95% CI:1.67-7.20,Pvalue=0.001) or having lower inter-pregnancy gap (OR=7.312,95%CI:3.041-17.587,Pvalue=0.001) were significant predictors of anemia .The prevalence of anemia in this study was lower than reports from some other parts of Ethiopia, due to early antenatal care follow up and better health care awareness among the participants, the figure is sizeable and in need of attention. Keywords: anemia, haemoglobin, pregnancy, prevalence, Selam health center, antenatal viii 11.. IInnttrroodduuccttiioonn Anemia is a condition in which the number or size of red blood cells (RBC) and thus haemoglobin (Hb) concentration fall below the required level resulting in impaired capacity to transport oxygen (WHO 2015). It is characterized by symptoms like feeling of fatigue, tiredness, skin paleness, irregular heartbeat, and shortness of breath among others. The disorder is diagnosed by measuring the blood Hb level which is easy and inexpensive. The World Health Organization (WHO) defines anemia based on age, sex and level of pregnancy with separate cutoff values for each (Table 1). Table 1: Haemoglobin (Hb) and haematocrit (Hct) levels Age or gender group Hb(gm/l) Hct(l/l) Children 6-59 months 110 0.33 Children 5-11 years 115 0.34 Children 12-14 years 120 0.36 Non-pregnant women (>15 years) 120 0.36 Pregnant women 110 0.33 Men (>15 years) 130 0.39 Source: WHO 2001 11..11 TTyyppeess aanndd ddeetteerrmmiinnaannttss ooff aanneemmiiaa There are different types of anemia based on different criteria. Most of the literatures show that anemia can be grouped into three major classes based on the specific cause. These are anemia caused because of blood loss, decreased or faulty RBC, and destruction of RBC. Blood loss can be rapid or chronic. Rapid blood loss may be due to surgery, child birth, ruptured blood vessels, etc. Chronic blood loss can happen as a result of a number of factors like cancer, gastrointestinal bleeding and heavy menstrual bleeding (www.m.webmd.com) Anemia of decreased or faulty RBC may be caused by malnutrition or lack of micronutrients that are essential to make the RBC. The World Food Programme (WFP) defined malnutrition as ''a 1 state in which the physical functions of an individual is impaired to the point where he or she can no longer maintain adequate bodily performance processes such as growth, pregnancy, lactation, physical work and resisting and recovering from diseases and multiple micronutrient deficiencies'' (CDC and WFP 2005). Further, the WHO states that ''nutritional deficiencies during some critical periods in our life can result death and disease and have long term consequence on cognitive and social abilities, school performance, and work productivity. In addition to this it can affect the whole life cycle and pass to generations.'' (WHO 2014). Anemia is, therefore, as one type of nutritional deficiency that affects a country's economy because it results in less productive individuals in both sexes that can’t contribute to the growth and development of a country. Typically RBCs have life span of 120 days in the bloodstream but they can be destroyed beforehand resulting in anemia. Both non-infectious diseases (like hemolytic anemia, sickle cell disease) as well as infectious diseases can cause early destruction of the RBC. In general anemia results because the loss exceeds the production of new RBC. (https://www.nim.nih.gov./medlineplus/medlineplus.html). Anemia is a major global public health concern. The highest proportions of individuals affected are from sub-Saharan Africa and Southeast Asia (WHO 2015). It affects all age- and sex-groups with highest prevalence, 43%, 38%, occurring among under 5 children and pregnant women respectively (WHO 2015). This shows that although anemia attacks every part of the global population, children and pregnant women are the most vulnerable groups. 11..11..11 MMiiccrroonnuuttrriieenntt ddeeffiicciieennccyy Micronutrient deficiency is a condition that occurs when essential vitamins and/or minerals are not present in adequate amount in the diet. Anemia, night blindness, goiter are the most common micronutrient deficiencies (CDC and WFP 2005). Although anemia has a multi-factorial etiology, iron deficiency is its most common cause (WHO 2015). Iron is essential for many biochemical processes including electron transfer reactions, gene regulation, regulation of cell growth and differentiation, and oxygen transport .oxygen is bound to haemoglobin within the red blood cells or as facilitator of oxygen diffusion in tissue. 2