The Prevalence of Anemia Among Pregnant Women at Booking in Enugu, South Eastern Nigeria

Cyril C. Dim, MBBS (Nig); Hyacinth E. Onah, MBBS (Nig), MPA, FMCOG, FWACS, FICS

Disclosures
In This Article

Discussion

The prevalence of anemia in pregnancy of 40.4% in this study was consistent with data observed in other studies in developing countries.[7,8,11] The prevalence was greater than 8.8% but less than 67.4% observed in the same center in 1979[13] and 1990,[6] respectively. The very low incidence of anemia in the 1979 study might have been due to the use of a hemoglobin concentration of 10 g/dL as the definition of anemia in pregnancy. Although this study established a marked reduction in the prevalence of anemia in pregnancy when compared with the 1990 review, which used the same criterion, the explanation is difficult and cannot be easily attributed to an improvement in the health status of women of reproductive age group in the locality. Expectedly, most of the anemic patients (90.7%) in this study were of the mild variety, whereas 9.8% were moderately anemic. Incidentally, as in other recent studies from southeastern Nigeria[10,11] and Ibadan, Western Nigeria,[12] no case of severe anemia was noted, unlike in Shagamu, Western Nigeria,[14] where 0.7% of the anemic pregnant women were severely anemic. Also, in Southern Malawi, 3.6% of anemic pregnant women were of the severe variety ( Hb < 7.0 g/dL).

In West Africa, anemia in pregnancy results from multiple causes, including iron and folate deficiency; malaria and hookworm infestation; infections, such as HIV; and hemoglobinopathies.[15,16] Pica has been identified as a risk factor for anemia in pregnancy.[17] This could be applicable to this environment in which a special type of clay of the kaolinite group (called "nzu" in Igbo language) is easily accessible in the open markets, and some pregnant women crave it. Further studies are required to explain this craving and its effect on patients' nutrition and anemia in pregnancy.

Iron deficiency is believed to be the most common cause of anemia in pregnancy;[3] therefore, anaemia in a normal pregnant woman in this environment is usually attributed to iron deficiency, and successful treatment is often achieved with iron and folic acid without further investigations. This may explain why patients' case notes reviewed in this study could not give further information on the investigations done to identify the specific causes of the anemia. Available basic investigations that should have been carried out in these patients include blood-film microscopy for red blood cell morphology and ring form of Plasmodium falciparum and stool analysis for helminths, especially hookworm. Furthermore, with the mean gestational age at booking of 22 weeks in this study, physiologic hemodilution in pregnancy[18] may explain the increased prevalence of mild anemia.

As in a previous study from the center,[6] maternal age and parity had no statistical relationship with the prevalence of anemia at booking. Both studies observed that anemia at booking increased with gestational age, which is consistent with findings in similar studies[7,8] but variant with a related study in Zimbabwe,[19] which found that gestational age and season were not significant predictors of hemoglobin concentration. With the current HIV/AIDS epidemic in Nigeria,[20] unlike in 1990 when the previous review was done, this study has gone further to identify a significant statistical relationship between HIV infection and a high prevalence of anemia in pregnancy. This increased prevalence of anemia among pregnant women living with HIV/AIDS may be explained by the finding that HIV infection is associated with lower serum folate and serum ferritin in pregnancy.[19]

This study was limited by its retrospective nature and reliance on case notes with the attendant documentation inadequacies. Therefore, we could not study the specific causes of anemia in pregnancy in this environment. A prospective study with emphasis on the etiology of anemia in pregnancy is recommended.

We conclude that the prevalence of anemia at booking is still high in Enugu. The results suggested that anemia predates the pregnancy in the majority of cases. Hence, preconception care, including iron and folic acid supplementation, is advocated to reduce this problem. During pregnancy, efforts should be geared toward the early detection and treatment of anemia before delivery. Also, medical staff managing pregnant women should endeavor to investigate anemic pregnant women further in order to identify the etiology whenever possible, despite commencing the usual treatment with iron and folate. All of these efforts would help to ensure safe motherhood and achieve the relevant targets of the Millennium Development Goals.

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