Table of Contents

DECLARATION.......................................................................................................................................................iii
Approval...................................................................................................................................................................... iv
DEDICATION...........................................................................................................................................................v
CKNOWLEDGEMENT.....................................................................................................................................................vi
CHAPTER ONE............................................................................................................................................................1
PROBLEM AND ITS SCOPE........................................................................................................................................1
1.1 Background.....................................................................................................................................................1
1.2 Problem statement.........................................................................................................................................3
1.3 Purpose of the Study.....................................................................................................................................4
1.4 Objectives of the study......................................................................................................................................4
1.4.1 general objective..............................................................................................................................................4
1.4.2 Specific objectives.........................................................................................................................................4
1.5 Research questions.............................................................................................................................................4
1.6 Scope of the study.............................................................................................................................................5
1.6.1 Geographical scope.........................................................................................................................................5
1.6.2 Time Scope:.....................................................................................................................................................5
1.7 Significance of the study..................................................................................................................................5
1.8 Conceptual frame work.......................................................................................................................................5
1.9 Operational definitions of key terms.................................................................................................................6
CHAPTER TWO REVIEW OF RELATED LITERATURE............................................................................................8
2.0 Introduction..........................................................................................................................................................8
2.1 Concepts, ideas, opinions of experts and previous authors..........................................................................8
2.2 Prevalence of anaemia during pregnancy......................................................................................................11
2.3 Consequences and burden of anaemia in pregnancy...................................................................................12
2.4 Types Of Anemia During Pregnancy...............................................................................................................13
2.5 Factors associated with anaemia in pregnancy............................................................................................15
2.6 Diagnosis of anemia in pregnancy..................................................................................................................19
2.7 Prevention and treatment of anaemia...........................................................................................................19
CHAPTER THREE......................................................................................................................................................23
RESEARCH METHODOLOGY....................................................................................................................................23
3.0 Introduction........................................................................................................................................................23

i
3.1 Research design.................................................................................................................................................23
3.2 Target population..............................................................................................................................................23
3.3 Sample size........................................................................................................................................................23
3.4 Sampling technique..........................................................................................................................................24
3.5 Research instrument.........................................................................................................................................24
3.6 Validity and reliability of the test.....................................................................................................................24
3.6.1. Validity............................................................................................................................................................24
3.6.2. Reliability.......................................................................................................................................................25
3.7 Data collection procedure..............................................................................................................................25
3.7.1. Primary Data..................................................................................................................................................25
3.7.2. Secondary Data.............................................................................................................................................25
3.8 Data analysis.....................................................................................................................................................26
3.9 Ethical consideration.........................................................................................................................................26
3.10 Limitation of the study....................................................................................................................................26
Table 1: Budget breakdown....................................................................................................................................27
Table: 2 Work plan.................................................................................................................................................28
REFERENCE..............................................................................................................................................................29

ii
 New Generation University Collage

Deparment of buplic health

factors contributing maternal anaemia among the pregnant women

The factors contributing maternal anaemia among the pregnant women of MCH in Hargeisa,
Somaliland.

Submited by Hoodo

Thesis Submitted in Partial Fulfillment for the Requirement of the Bachelor Degree

In public health

Supervisor by: magca superviserka

march, 2019

iii
DECLARATION
I’m Hoodo do declare hereby that this Thesis titled “The factors contributing maternal aneamia
among the pregnant women of Sahardiid MCH in Hargeisa, Somaliland” is entirely my own original
work, except where acknowledged, and that has not been submitted before any other university or
institution of higher learning for the award of Bachelor of public health.

Signed……………………………. Date………………………..

HOODO

iv
Approval

This Thesis titled “The factors contributing maternal anaemia among the pregnant women of MCH
in Hargeisa, Somaliland” was prepared under my supervision and had been submitted for
examination by my approval as a candidate’s supervisor.

Signed……………………………. Date………………………..

Supervisor:- magaca super

DEDICATION
This work is dedicated to our beloved parent my dear mother magaca mamada who give us a
continuous support during our study in bachelor degree of public health besides we dedicated to
our dear brothers and sisters.
v
CKNOWLEDGEMENT

All praise is due to Allah who made possible for me to complete this thesis, and gave me the
strength, love and sense of direction during the course of this study and the completion of my
academic pursuit, for his help and guidance throughout the research process

Second, i would gratitude to my dearest family in particular my beloved mother WWWWWW for
the long encouragement, motivation and support to us. Indeed we can’t conclude their praise
worthy in phrases, my brother WWWWW and my sister WWWW also
vi
I would like to thank anyone who helped me my academic financially, morally and technically
especially my dear brother WWWW my sister WWWWWW and also Mr WWWWWW who enabled
me carry out this study successfully.

for his help and guidance throughout the research process, without his careful supervision and
expertise, would not have been completed; he has been a valuable guide and has helped me to
mature this study Thank you Mr WWWW and supervisor WWWW and for your positive attitude.

I would like to express our appreciation to our lecturers about their dynamic way for delivers
lessons and their great encouragement to sustain our education.
Our acknowledgement also goes to all the managerial persons and office staffs of New Generation
University Collage for their co-operations. My special gratitude goes to my friend’s specially
wwwww.
Not forgotten, my appreciation to dean of public health wwww for his encouragement, motivation
and support throughout our field in thesis.

Allah bless you for his paradise.

vii
 CHAPTER ONE

PROBLEM AND ITS SCOPE

1.1 Background

Anaemia describes a situation in which there is a reduction of haemoglobin concentration in the

blood of pregnant women to a level below 11g/dl. Anaemia is one of the most common nutritional
deficiency diseases observed globally and affects more than a quarter of the world’s population.

Maternal anemia is defined as a hemoglobin concentration of less than 110 g/L (less than 11 g/dL)
in venous blood.

Anaemia during pregnancy has a variety of causes and contributing factors including
socioeconomic conditions, abnormal demands like multiple pregnancies, teenage pregnancies,
malnutrition, maternal illiteracy, unemployment, short pregnancy intervals, age of gestation,
primigravida and multigravida, loss of appetite and excessive vomiting in pregnancy (Haniff et al.,
2007; Noronha et al., 2010).

Low socio-economic condition is main factor associated with anaemia in pregnancy. Multiparty may
induce anaemia by reducing maternal iron reserves at every pregnancy and by causing blood loss
at each delivery. Multigravida women are more at risk to develop anemia than primigravidae.
Increasing number of pregnancies and deliveries are positively associated with the risk of
developing anaemia. Single pregnant women are more prone to develop anaemia than married
women. Tea consumption is also associated with anaemia by reducing iron absorption capacity
(Baig-Ansari., et al 2008).

Infectious diseases such as malaria, helminthes infestations and HIV are implicated with high
prevalence of anaemia in sub-Saharan Africa. Febrile illness in the index pregnancy is significantly
associated with anaemia Infection causes gastrointestinal blood loss resulting in depletion of the
iron stores and consequently impaired erythropoiesis. (Nwizu et al., 2011).

1
Other factors which put pregnant women at a higher risk of acquiring anaemia are: folate and
vitamin B12 deficiencies, acute or chronic blood loss (gastrointestinal bleeding/heavy periods),
smoking, excessive alcohol consumption, poor sanitation, Eating soil during pregnancy is also
another risk factor for development of anaemia (Leyla et al., 2010).

Globally, anaemia affects 1.62 billion people (25%), among which 56 million are pregnant women
(WHO/CDC, 2008).

It is estimated that 41.8% of pregnant women worldwide are anaemic. At least half of this
anaemia burden is assumed to be due to iron deficiency. Iron deficiency anaemia (IDA) is the most
common nutritional disorder in the world affecting 2 billion people worldwide with pregnant women
particularly at risk (WHO guideline, 2012).

In developing countries, the prevalence of anaemia during pregnancy is 60.0% and about 7.0% of
the women are severely anaemic In Africa 57.1% of pregnant women are anaemic (de Benoist et
al., 2008).Sub-Saharan Africa is the most affected region, with prevalence of anaemia estimated to
be 17.2 million among pregnant women. This constitutes to approximately 30% of total global
cases (WHO,2008).

In Kenya the prevalence of anaemia among pregnant women is 55.1% and among nonpregnant
women is 46.4%. Anaemia during pregnancy is considered severe when haemoglobin
concentration is less than 7.0 g/dl, moderate when the haemoglobin concentration is 7.0 to 9.9
g/dl, and mild when haemoglobin concentration is 10.0 to 10.9 g/dl (Balarajan et al., 2011; Salhan
et al., 2012; Esmat et al., 2010).

A recent national study has shown that Somali women are suffering from shocking levels
of anemia. Anemia in Somalia is caused by a range of factors including frequent exposure
to diseases which are often untreated, and the consumption of predominantly cereal based
diets, which are missing key vitamins and minerals.
There is also quality of life issues associated with maternal anemia that are comparable to
those seen in individuals with serious chronic diseases, such as difficulty in concentration,
cognition, disturbed mother–infant interactions, and depression, as providers we seem to
have a problem with pregnancy associated anemia as we do not consider it to be an
abnormality until it becomes quite severe.

2
1.2 Problem statement

Anemia in pregnancy is a common problem in most developing countries and a major cause of
morbidity and mortality especially in malaria endemic areas. In pregnancy, anemia has a significant
impact on the health of the fetus as well as that of the mother. 20% of maternal deaths in Africa
have been attributed to anemia.

Maternal aneamia in a pregnancy women is immense problem which exists all over the world
developed and developing countries but it is deferent, the developed countries made an action
to decreased the maternal death causes aneamia according to developing countries but still there
is a problem and now we recognized that the maternal mortality rate is less then as
before.

Low socio-economic condition is main factor associated with anaemia in pregnancy.Multiparity may
induce anaemia by reducing maternal iron reserves at every pregnancy and by causing blood loss
at each delivery.

We are aware of the maternal death will be a problem to the population development, because
About 800 women die from pregnancy- or childbirth-related complications around the world every
day, equivalent to 33 an hour,so we must aware a reduction of haemoglobin concentration in the
blood of pregnant women to a level below 11g/dl, and food intake of pregnancy women.

In Somaliland anemia among pregnant women has been reported for the last decay every ¼ (one
of four) women who become pregnant gets anemia or at risk of the factors which predispose to
have an anemia. Ministry of Somaliland had just implemented an integration health care system
which composes different kinds of health care including primary health care for all the regions,
nutritional supplementation feeding program which is based on selective approach, health
education and promotion, practicing of proper sanitation and Deforming in order to destroy and
make preventive barriers for the risk factors.

3
Recently small studies demonstrated causal – relationship between severe anemia and uterine a
tony which is the main cause of PPH accounting for about 90% in most studies In the case of
Hargeisa 26% of rural women in Somaliland are anemic while others are at risk to develop anemia.
11% of urban women in Hagias particularly those who live in slummy areas are anemic because of
poor socio-economic level the aim of this study was to assess the prevalence and predictors of
maternal anemia. FSNAU. (2010).

1.3 Purpose of the Study

To determine factors and prevalence of maternal aneamia among pregnanancy women attending
at Sahardiid MCH at Ibrahim kodbur, Hargeisa, Somaliland.

1.4 Objectives of the study

1.4.1 general objective

To assess factors and prevalence of maternal aneamia among pregnanancy women attending at
Sahardiid MCH at Ibrahim kodbur, Hargeisa, Somaliland.

1.4.2 Specific objectives

1. To determine the factors and prevalence of anemia among pregnant women receiving antenatal
care.

2. To find out the common complications of maternal anemia.

1.5 Research questions

1. What is the factors and prevalence of contributing maternal anemia among pregnant women
attending at Sahardiid MCH at Ibrahim kodbur, Hargeisa, Somaliland ?

2. What are the factors associated with Anaemia among pregnant women attending at Sahardiid
MCH at Ibrahim kobo, Hagias, Somaliland?
4
1.6 Scope of the study

1.6.1 Geographical scope

The study will done at sahardiid MCH.Sahardiid MCH is locate Jig jiga yar village in ibrahim kood
bur district hargeisa, capital. estimated roughly around 10000 and 20000 households, in distance
of around 16sqkms and it locate northwest of Hargeisa, it is the corner village next to Hero-Awr
village., Hargeisa, Somaliland. The MCH provides services 450 mothers of low social economic
community.

1.6.2 Time Scope:

The study will used on the time between March- 2019- May -2019.

1.7 Significance of the study

The rationale behind this research proposal is to identify the factors and prevalence of anemia in
pregnant women and also will help to find out the magnitude of maternal anemia. It will
also serve as a future reference for researchers. This study will also be beneficial to the MOH to
know more about the magnitude of this problem. The study’s goal is designed to help mothers for
the improvement of their health to overcome this problem.

The finding of this study will return a benefit to the society considering that preventing of maternal
anemia plays an important role of the overall health. Thus, mothers that apply the recommended
approach of this study will be able to improve their health for better. Moreover, this research will
provide recommendations on how to prevent maternal anemia. This study will provide brief
description to the most common type of anemia which affect pregnant mothers in order to focus it,
rather seeking the cause. This study also gives attention to non-pregnant women and make them
aware during their pregnancy.

1.8 Conceptual frame work

The conceptual framework used for this study is adopted and modified from UNICEF’s
conceptual framework on the determinants of malnutrition (UNICEF, 1998).This conceptual
framework demonstrates the relationship between independent variables (participant’s
demographic and socio-economic characteristics, obstetric history, ANC visits and taking of
5
iron and folic (IFA) supplementation, health condition of the current pregnancy, awareness on
causes and consequences of anaemia during pregnancy and the dietary habits and nutritional
status and dependent variables (anaemic state or non-anaemic state of the pregnant women).

Fig1: Conceptual framework of the study (IFA, iron–folic acid; ANC, antenatal care and
how associate,
Adherence towards IFA supplementation
programme recommendation

Womens’ knowledge
of pregnancy- related
Health service utilization risk
Family support
hunband’s and Frenquency of ANC visits
other family’s
invilvement
during pregnancy

Acess to help sevice

Womens’ exposure to
health and nutrition
Socioeconomic/demography Women’s edecational
information
level Pregancy older maternal pregnancy house hold
wealth. Nutritional status of pregnancy women

1.9 Operational definitions of key terms

Anaemia: A condition in which when the haemoglobin (Hb) level in the body is less than 11
gram per decilitre, which decreases oxygen-carrying capacity of red blood cells to tissues.

Antenatal clinic (ANC): Maternal and Child Health clinic which provides care for expectant
parents; the mother's and baby's health is monitored, maintained and optimized to ensure a
6
healthy pregnancy, safe delivery and post delivery period. Moreover the clinic provides
nutritional supplements (iron/folate) and dietary information throughout the pregnancy.

Haemoglobin (Hb): Iron-containing oxygen-transport metallo-protein in the red blood cells

which is composed of globin and heme that gives red blood cells their characteristic colour.

Iron: A micronutrient needed for the transport of oxygen in blood to various parts of the body.

Maternal death: The death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management but not from accidental or incidental causes.

Pregnancy: The state of carrying a developing embryo or fetus within the female body for a
period of 280 days or 40 weeks.

7
 CHAPTER TWO REVIEW OF RELATED LITERATURE

2.0 Introduction

This chapter deals with the review of literature on the studies that have been done on the area
under study. the aim of this study is to determine the factors and prevalence contributing of
maternal anemia among pregnant women receiving antenatal care, also to find out common
complication of anemia in pregnant mothers.

2.1 Concepts, ideas, opinions of experts and previous authors.

Anemia in pregnancy is a decrease in the total red blood cells (RBCs) or hemoglobin in the blood
during pregnancy or in the period following pregnancy. It involves a reduction in the oxygen
carrying capacity of the blood. Anemia is an extremely common condition in pregnancy and
postpartum world-wide, conferring a number of health risks to mother and child.

Anaemia during pregnancy is defined as a condition where there is less than 11g/dl of
haemoglobin (Hb) concentration in the blood of pregnant women, which decreases oxygen
carrying capacity of the blood to the body tissues.

Anemia is a global public health problem affecting both developing and developed countries with
major consequences for human health as well as social and economic development. It occurs at all
stages of the life cycle, but is more prevalent in pregnant women. (26)

Anemia in pregnancy is one of the most common and widespread public health problems affecting
24.8% of the population today especially in the developing countries it is also an important
contributor to maternal mortality/morbidity, anemia is the most frequent maternal complication of
pregnancy. (25)

Globoly WH0 (1992) report showed prevalence in pregnant women across the world as 50%
with55-60% in developing countries. reported prevalence of iron deficiency anemia to be 34% in
Chinese pregnant mothers. Singh K et al 53 from their correctional study in Singapore reported
that iron deficiency is the most common cause of anemia in pregnancy responsible for
81.3%cases. Faruk Ahmed (2000) reported that among the rural population of Bangladesh

8
prevalence of anemia was 49% in pregnant women. WH0 in 2001 estimated prevalence of 52 % in
pregnant females. (29)

Anemia is one of the most common nutritional deficiency diseases observed globally. Although
nutritional anemia affects members of both sexes and all age groups, the problem is more
prevalent among women and contributes to maternal morbidity and mortality,
as well as to low birth weight [1].

In 1993, the World Bank rated anemia as the eighth leading cause of disease in young girls and
women in the developing world. According to World Health Organization- World health Statistics
2005, the average prevalence of anemia in the world is 41.8%. Many studies show that anemia in
pregnancy is globally common but Africa and Asia bear the greatest burden.

It has been estimated that nutritional anemia affects almost two-thirds of pregnant women in
developing countries. However, many of these women were already anemic at the time of
conception, with an estimated prevalence of anemia of almost 50% among non pregnant women
in developing countries [1].

In Pakistan, the prevalence of anemia among ever-married women aged 15 to 44is reported to be
26% in urban areas and 47% in rural areas [2].

The prevalence of anemia among pregnant women living in urban areas is similar, ranging
from29% [3] to 50% among pregnant women attending antenatal clinics in a large private, tertiary
hospital inKarachi [4, 5

during pregnancy for both the woman and the growing foetus cannot be overemphasized. Being a
driving force for oxygen for the mother and foetus, a reduction below acceptable levels can be
detrimental to both. Anaemia affects 1.62 billion(24.8%) people globally (WHO, 2008).

Globally, almost half of all preschool children (47.4%)and pregnant women (41.8%) and close to
one-third of non-pregnant women (30.2%) are anaemic (De Benoist et al., 2008; Badham et al.,
2007).

Anaemia affects more than 500 million women in developing countries where 4 of every 10
pregnant women are anaemic (USAID.

9
Although reports exist about what is being done and what should be done globally to address
prevention and treatment of maternal anaemia, prevalence of anaemia and maternal mortality
around the world remains high (USAID, 2011).

About half of this anaemia burden is a result of iron deficiency anaemia (IDA). IDA is most
prevalent among preschool children and pregnant women. Among women, iron supplementation
improves physical and cognitive performance, work productivity, and well-being. Moreover iron
supplementation during pregnancy improve maternal, neonatal, infant, and even long-term child
outcomes (Sant-RaynPasricha et al., 2013).

Although dietary deficiency may be contributory, the etiology of the vast majority of cases of iron
deficiency anaemia in infancy and childhood is maternal iron deficiency anaemia in pregnancy.
WHO has categorized and emphasized on the significant health consequences based on the
prevalence of the anaemia. If the prevalence of anaemia is 4.9% or less, it is considered as no
public health problem for that country. Prevalence of anaemia between 5.0% and 19.9%indicates
a mild public health problem. Moderate public health problem is been considered when the
prevalence is between 20.0% and 39.9%. If the prevalence is 40.0% or more, it is considered as a
severe public health problem (McLean et al., 2008).

In Africa and South East Asia, the prevalence is estimated at 57.1% and 48.2% respectively. This
is twice as common as in America and Europe where prevalence is estimated at 24.1% and 25.1%
respectively. Sub Saharan Africa bears the major burden of disease. Prevalence of anemia in
pregnancy in Nigeria is between 30-40%. [5,26] In Ethiopia, overall prevalence of anemia was
found to be 41.9%with urban areas having a prevalence of 35.9% compared to the rural
population at 56.8%.[6].

In1996, a study carried out on selected countries in South Eastern Africa showed a prevalence of
58%, 76%, 75.6% and 74.4% in Mozambique, Rural Zaire, Coastal Kenya and Tanzania
respectively. [4]
In Malawi, between July 1997 and June 1998, a study done on the urban population on women
attending antenatal clinic at St. Elizabeth Hospital in Blantyre, 57.1% were found to be anemic.[3]
In Kenya, a study on prevalence conducted in Kakamega put prevalence of anemia in pregnancy at
25.7%. [22] Another one conducted in Kericho District had prevalence of anemia in pregnancy at
24.5% [23].
10
According to The Global Micronutrient survey done in May to October 1999,prevalence of moderate
anemia in pregnancy was 54% in Kenya, while almost 70% of pregnant women in Kenya were
moderately anemic. This is despite routine supplementation with iron for all pregnant women
attending antenatal clinics. A prospective study on severe anemia in pregnancy was done in
Kisumu District and it studied prevalence and risk factors. Of the respondents who developed
obstetric complications, 22% were found to be anemic. Poor pregnancy care, illness during
pregnancy, socioeconomic conditions of the mother and the sanitary conditions of the household
among other things also significantly increased prevalence of anemia in their subjects.[9]A study
done in Kilifi District, 10% of women booked for antenatal care had severe anemia (Hb<7g/dl)
with 76% having Hb ,11g/dl and the main causes for the anemia were reported as iron deficiency
often exacerbated by hookworm infestation, malaria, folate deficiency and HIV infection. [31]

2.2 Prevalence of anaemia during pregnancy

Anaemia affects 24.8% of the world’s population (WHO, 2008). Worldwide, the prevalence of
anaemia during pregnancy has been estimated at 41.8%, corresponding to 56.4 million
women(McLean et al., 2006). Prevalence of anaemia among pregnant women is around 24.1% in
the Americas, 48.2% in South East Asia, 25.1% in Europe, 44.2% in East Mediterranean, 30.7% in
West Pacific and highest in Africa at 57.1% (de Benoist et al., 2008).

Studies in Africa have shown a high prevalence of anaemia in pregnancy ranging from a low of
41% to a high of 83%in different settings (Haggaz,2009).

Sub-Saharan Africa is the most affected region, with anaemia prevalence estimated to be 17.2
million pregnant women, which corresponds to approximately 30% of total global cases (WHO,
2008).A cross-sectional study conducted in northern Tanzania revealed that the prevalence of
anaemia among pregnant women was 47.4% (Sia et al., 2013).

A study which was conducted in the University of Uyo Teaching Hospital, Uyo, Nigeria revealed
that the prevalence of anaemia among pregnant women was 54.5% and majority (61.0%) of the
anaemic women had mildan aemia, 38.5% had moderate anaemia, while 0.5% had severe
anaemia (Olujimi et al., 2014).

11
A study which was conducted in 2014 to determine the prevalence of anaemia in pregnancy in an
urban area of eastern Ethiopia found that 56.8% of pregnant women were anaemic. 1.2% of them
were severely anaemic, 26.7% were moderately anaemic, and 28.9% were mildly anaemic
(Kefyalew and Abdulahi, 2014).

In Kiboga district, Uganda, the prevalence of anaemia among pregnant women was 63.1% (Mbule
et al., 2013). A cross-sectional study which was conducted in Egypt revealed that the prevalence of
anaemia among pregnant women was 62.2% (Zakia etal., 2011).

In Kenya the most recent micronutrient survey in the country indicated that the prevalence of
anaemia among pregnant women is 55.1% (MOH, 2013). A study which was conducted in
Kakamega County, Kenya revealed the prevalence of anaemia among pregnant women was 40%
(Mulambalah et al., 2014).

Unpublished report which was conducted at Mbagathi District Hospital, Nairobi revealed that the
prevalence of anaemia among pregnant women attending antenatal clinic was36.2% (Carolyne
Wanjiru,2013). A prospective study conducted on severe anaemia during pregnancy in Kisumu
District of Kenya; showed that out of59% women who experienced obstetric related complications,
22% were suffering from severeanaemia.

2.3 Consequences and burden of anaemia in pregnancy

Anaemia has significant adverse health consequences, as well as adverse impacts on social
andeconomic development (WHOc, 2015). It is one of the most intractable public health problems
in developing countries and the commonest complication in pregnancy in sub-Saharan
Africa(Buseri et al., 2008).

In developing countries, anaemia in pregnancy is a major cause of maternal and foetal morbidity
and mortality (Akhtar and Hassan, 2012).It is estimated that anaemia causes more than 115,000
maternal and 591,000 prenatal deaths globally per year. Anaemia during pregnancy contributes to
20% of all maternal deaths .Anaemia increases risk of maternal morbidity and mortality, abortion,
poor intrauterine growth, preterm birth and low birth weight. These effects in turn result in higher
perinatal morbidity and mortality and higher infant mortality rate (Bodeau et al., 2011).

12
Anaemia in pregnancy causes low birth weight, fetal impairment and infant death. It also causes
preterm birth, low APGAR score, intrauterine growth restriction. Deficiency in folic acid during
pregnancy can result in a serious neural tube defect (severe abnormalities of the central nervous
system) that develop in embryos during the first few weeks of pregnancy leading to malformations
of the spine, skull, and brain, heart defects and cleft lips(Wilcox et al., 2007), limb defects, and
urinary tract anomalies (Goh and Koren, 2008).

When the pregnant women are anaemic, the odds for fetal growth restriction and low birth weight
are tripled. The odds for preterm delivery are more than doubled. Even a moderate hemorrhage in
an anaemic pregnant woman can be fatal A basic principle of fetal/neonatal iron biology is that
iron is prioritized to red blood cells at the expense of other tissues, including brain. When iron
supply does not meet iron demand, the fetal brain may be at risk even if the infant is not anaemic.
Anaemia adversely affects cognitive performance, behavior and physical growth of infants,
preschool and school-aged children. Anaemia depresses the immune status and increases the
morbidity from infections in all age groups. (Olujimi et al., 2014).

The high prevalence of anaemia among pregnant women in Kenya has significant adverse health
effects, as well as adverse impacts on social and economic development which requires aggressive
attention to identify the specific etiologic factors so as to come up with appropriate strategies that
will ensure its reduction.

2.4 Types Of Anemia During Pregnancy

There are over 400 different types of anemia, but some are more prevalent in pregnancy. The
most commonly experienced types of anemia during pregnancy are:

Iron-deficiency anemia: This is the leading cause of anemia in the United States, and
consequently, the most common type of anemia during pregnancy. Approximately 15% to 25% of
all pregnancies experience iron deficiency. Iron is a mineral found in the red blood cells and is used
to carry oxygen from the lungs to the rest of the body, as well as helps the muscles store and use
oxygen. When too little iron is produced, the body can become fatigued and have a lowered
resistance to infection. Learn more about how to treat iron deficiency naturally during your
pregnancy.

13
Folate-deficiency anemia: Folate refers to Folic Acid, which is a water-soluble vitamin that can
help prevent neural tube defects during pregnancy. Folic Acid is a common supplement taken by
pregnant women, but it can also be found in fortified foods such as cereals, leafy vegetables,
bananas, melons, and legumes. A diet lacking folic acid can lead to a reduced number of red blood
cells in the body, therefore leading to a deficiency.

Vitamin B12 deficiency anemia: Vitamin B-12 is also a necessary vitamin for the body to have
to help with the production of red blood cells. Although some women may consume enough B-12
in their diet, it is possible their body cannot process the vitamin, and this causes them to have the
deficiency.Symptoms Of Anemia During Pregnancy.

Symptoms of anemia during pregnancy can be mild at first and often go unnoticed. However, as it
progresses, the symptoms will worsen. It is also important to note that some symptoms can be
due to a different cause other than anemia, so talking with your doctor is important.

symptoms of anemia are: Weakness or fatigue,Dizziness,Shortness of breathRapid or irregular

heartbeatPainPale skin, lips, and nailsCold hands and feetTrouble concentrating.

Maternal Changes during Pregnancy

During pregnancy, there is an increase in both red cell mass and plasma volume to accommodate
the needs of the growing uterus and fetus. The circulating plasma volume increases linearly to
reach a plateau in the 8th or 9th month of pregnancy. The increment is about 1000 ml, which
corresponds to 45% of the circulating plasma volume in non-pregnancy. The plasma volume
decreases rapidly after delivery and is then restored to the non-pregnancy level at about 3
puerperal weeks. However, plasma volume increases more than the red cell mass leading to a fall
in the concentration of hemoglobin in the blood, despite the increase in the total number of red
cells. This drop in hemoglobin concentration decreases the blood viscosity and it is thought this
enhances the placental perfusion providing a better maternal-fetal gas and nutrient exchange
[16].
Physiological hemo dilution of pregnancy and at what level of hemoglobin, women and babies
would get benefit from iron treatment. Some studies suggest that the physiological decrease in
hemoglobin is associated with improved outcomes for the baby. An adult woman has about
2,000 mg iron in the body, 60–70% of which is present in erythrocytes, with the rest stored in the
liver, spleen, and bone marrow. When a woman becomes pregnant, the demand for iron
14
increases. Specifically, about 1,000 mg more is required, comprising 300 mg for the fetus and
placenta, 500 mg for increased maternal hemoglobin, and 200 mg that compensates for
excretion. Therefore, an additional 50% of the amount of iron present in the non-pregnant state
should be ingested during pregnancy [17].

2.5 Factors associated with anaemia in pregnancy

The etiology of anemia during pregnancy among women in developing countries is multi factorial
and varies by geographic region [6]. The primary cause of anemia during pregnancy worldwide is
iron deficiency secondary to chronic inadequate dietary intake and menstruation, heightened by
the physiologic demands of the fetus and maternal blood volume expansion during pregnancy
[6,7].

Genetic causes and poor hygiene that may lead to infections and infestations are other
contributing factors [8].With limited resources available to address public health problems,
knowledge of the local etiological factors responsible for anemia is crucial in order to design
appropriate prevention and treatment strategies.

Most of the published studies from Pakistan have been conducted on women seeking care in
clinical or hospital settings and thus may not give a true picture of anemiaand its causes in a
population-based sample. The aim of our study was to report the prevalence of anemia and the
dietary and socioeconomic factors associated with anemia in a cohort of pregnant women living in
an urban community setting in a developing country.

Anaemia during pregnancy has a variety of causes and contributing factors including
socioeconomic conditions, abnormal demands like multiple pregnancies, teenage pregnancies,
malnutrition, maternal illiteracy, unemployment, short pregnancy intervals, age of gestation,
primigravida and multigravida, loss of appetite and excessive vomiting in pregnancy (Haniff etal.,
2007; Noronha et al., 2010).

Low socio-economic condition is main factor associated with anaemia in pregnancy. Multi parity
may induce anaemia by reducing maternal iron reserves at every pregnancy and by causing blood
loss at each delivery. Multigravida women are more at risk to develop anaemia than primigravidae.

15
Increasing number of pregnancies and deliveries are positively associated with the risk of
developing anemia(Leyla et al., 2010).

Single pregnant women are more prone to develop anaemia than married women (Nwizu et al.,
2011).Tea consumption is also associated with anaemia by reducing iron absorption capacity (Baig-
Ansari., et al 2008).

Iron deficiency is one of the most prevalent nutritional deficiencies in the world and is reported by
the World Health Organization (WHO) to affect four to five billion people. WHO estimates that
people suffer from anemia Approximately50% of all anemia is estimated to bedue to iron
deficiency, a condition of deteriorating iron reserves in the body caused by low dietary in take of
iron, poor absorption of dietary iron, or blood loss (for example, from hookworm, repeated
childbirth or heavy menstruation) which leads to loss of iron.

Iron deficiency anemia(IDA) is the most severe form of iron deficiency, and results when the
body’s iron supply cannot support production of hemoglobin in adequate amounts to maintain
normal functioning of the body. Anemia from other causes(and therefore, not iron deficiency
anemia), results from malaria or from genetic disorders, among other causes. Other micronutrient
deficiencies (e.g.,vitamins A, B6 and B12, riboflavin, and folic acid) are also known to cause
anemia.

Anemia and iron deficiency remain at epidemic levels among women and children in many nations.
Given the availability of proven interventions to prevent and treat anemia caused by a variety of
determinants, the persistent high prevalence represent a lack of political will and failure of the
public health sector. New estimates of the numbers of maternal and prenatal deaths associated
with iron deficiency anemia underscore the urgent need to refocus resources and public health
priorities to more effectivelyackle the problem.

Anemia prevalence is highest among pregnant women, infants, and young children due to the high
iron demands of growth and pregnancy. On average,45% of pregnant women and 49% of children
under five years of age are anemic in developing regions.

Iron deficiency affects more people than any other condition, constituting a public health condition
of epidemic proportions. More subtle in its manifestations than, for example, protein-energy

16
malnutrition, iron deficiency exerts its heaviest overall toll in terms of ill-health, premature death
and lost earnings.[19,21]

Iron deficiency and anemia reduce the work capacity of individuals and entire populations, bringing
serious economic consequences and obstacles to national development. There is documented loss
of cognitive function. [27,28]
Other micronutrients like Vitamin B-12, Folic acid and Zinc deficiencies have also been associated
with anemia in pregnancy[7,10,15] leading to a combination of both microcytic and megaloblastic
anemia. Soil transmitted helminthes also contribute to anemia in pregnancy leading to secondary
iron deficiency anemia.

Hookworm and Trichuris infection in the second trimester significantly increases risk of pregnant
women developing anemia in the third trimester of pregnancy. Those with moderate infection with
trichuris were found to be at a higher risk of developing anemia and the highest risk was in women
who had co-infection with hookworms.[11, 16].

In Kwan Zulu Natal province in South Africa, urinary schist so mass caused anemia as they cause
iron deficiency and chronic Hemorrhage. Similarly HIV infection increased the risk of anemia
twofold. This is due to poor nutritional intake, malabsorption syndromes and bone marrow
suppression from the disease. Some of the antiretroviral drugs like Zidovudine cause bone marrow
suppression and thus increase the risk of anemia. Those who tested positive had higher rates of
anemia than those who tested negative.[29]

The consequences of anemia include: Increased maternal and perinatal mortality, Increased
numbers of preterm birth and/or low birth weight, Impaired cognitive development in children, and
Reduced adult work productivity.

Recent WHO analysis of causes of maternal death showed that hemorrhage is the major
contributor to maternal deaths in developing countries. In a separate analysis, iron deficiency
anemia (IDA) was an underlying risk factor for maternal and perinatal mortality and morbidity, and
was estimated to be associated with115,000 of the 510,000 maternal deaths(22%) and 591,000 of
the2,464,000 perinatal deaths (24%)occurring annually around the world.

Infectious diseases such as malaria, helminthes infestations and HIV are implicated with high
prevalence of anaemia in sub-Saharan Africa (Ouédraogo et al., 2012 and Tolentino andFriedman,
17
2007). Febrile illness in the index pregnancy is significantly associated with anemia (Nowise et al.,
2011).

Infection causes gastrointestinal blood loss resulting in depletion of the iron stores and
consequently impaired erythropoietin. Other factors which put pregnant women at a higher risk of
acquiring anemia are: folate and vitamin B12 deficiencies, acute or chronic blood loss
(gastrointestinal bleeding/heavy periods), smoking, excessive alcohol consumption, poorsanitation.
Eating soil during pregnancy is also another risk factor for development of anemia (Leyla et al.,
2010).

Physiological adaptation in pregnancy leads to physiological anemia of pregnancy. This is because

the plasma volume expansion is greater than red blood cell (RBC) mass increase which causes
haemodilution. It has been estimated that the daily iron requirements of a 55-kg pregnant woman
increases from approximately 0.8 mg in the first trimester to 4–5 mg during the second trimester
and more than 6 mg in the third trimester. Pregnant women need iron to cover their basic losses,
increased RBC mass and demand from feto placental unit. This requirement is not met by food
alone in developing countries therefore oral iron supplementation is justified(Olujimi et al., 2014).

Previous studies have found several factors associated with the use of antenatal IF A supplements.
These are: the age of the woman, her educational status, her working status, the socio-economic
status of her family, her parity, the number of IFA supplements received, her use of ANC services,
her place of residence and her partner’s occupation. A study has shown that education beyond
high school is positively associated with adherence to IFA.

Knowledge of anemia and its prevention has also been identified as an important factor for taking
iron/folate supplements (Lacerete et al., 2011).

The causes and contributing factors of anemia during pregnancy are multiple and varied depending
on geographical location, socio-demographic and economic characteristic, obstetric history, cultural
and health conditions and health seeking behaviours. Hence it is important to identify the specific
etiologic factors in specific environment or community.

Therefore, this study aims at identifying specific factors associated with anemia among pregnant
women who attended ANC at Pumwani Maternity Hospital, Nairobi.

18
2.6 Diagnosis of anemia in pregnancy

In measuring the status of anemia in the population, haemoglobin (Hb) concentration is the most
reliable indicator as opposed to clinical assessments. A haemoglobin (Hb) level less than 11g/dl or
hematocrit less than 33% can be considered for diagnosis of anemia in pregnancy.

Anaemia in pregnancy is divided into mild anemia (Hb 10.0 – 10.9 g/dl), moderate anemia (Hb7.0
– 9.9 g/dl) and severe anemia (Hb less than 7.0 g/dl) (WHO, 2000). An accepted standard of
practice is that all women have at least one Hb measurement during pregnancy. This is usually
carried out by automated (Coulter) counter.

However, in developing countries, a portable Hb photo meter(HemoCue) has been widely used as
a simple and accurate alternative. Hb is measured with a finger-prick sample of whole blood drawn
up directly into a disposable micro cuvette by capillary action and inserted into a HemoCue photo
meter. The HemoCue has been found to have a sensitivity of between 80% and 97% and
specificity between79% and 99% depending on the cut-off points for Hb used.

2.7 Prevention and treatment of anaemia

A key component of a safe motherhood initiative is to reduce maternal mortality by half through
the eradication of anaemia during pregnancy (Hogue et al., 2007).Control of anaemia among
pregnant women is done through micronutrient supplementation of iron and folic acid during the
ANC attendance. Correction of iron deficiency in pregnancy involves appropriate diet and oral iron
supplementation. WHO recommends that all pregnant women in areas where anaemia is prevalent
should receive supplements of iron and folic acid (WHO, 2008).

In spite of the WHO recommendations, the use of IFAS among pregnant women is still low in
Kenya. The KDHS(2008-09) showed that 54% of women reported taking iron tablets or syrup for
less than 60 days during the pregnancy (MoH, Republic of Kenya, 2013). Daily oral iron (60 mg)
and folic acid(400 µg) should be commenced as soon as a woman becomes pregnant, and
continued up to 6months' postpartum.

Most countries in Sub-Saharan Africa, including Kenya, have a national policy to prevent and treat
anaemia in pregnancy. This includes the provision of haematinics (ferrous sulphate andfolic acid)
19
to all pregnant women. In Kenya, routine iron supplementation is the current cornerstone of
efforts to reduce iron-deficiency anaemia during pregnancy (KNBS and ICFMacro, 2010).

According to the Kenya national guidelines (MOH, 2008), all pregnant women
should receive free iron and folic acid supplements through the essential drug kit of the Ministry of
Public Health and Sanitation. National recommendations are for women to begin supplementation
during the first month of pregnancy with 60 mg of iron sulphate and 400 μg offolic acid daily
(MOPHS, 2008).

Pregnant women need iron to cover their basic losses, increased RBC mass and demand from feto
placental unit. It is recommended to take iron with orange juice to enhance its absorption.
Parenteral iron can be administered intramuscular (IM) or intravenous (IV). Studies have shown
that low or moderate dose of iron/folate supplementation in early pregnancy has a positive
affection foetal growth in women with both adequate and deficient iron status (Rodriguez-Bernal,
Rebagliato and Ballester, 2012).

Patients with mild anaemia (haemoglobin level, 9.0–10.5 g/dl)should receive oral iron at 160 to
200 mg of elemental iron daily, with an expected increase in haemoglobin levels of 1 g/dl after 14
days of therapy (Breymann et al., 2010). Compared to oral iron, parenteral iron demonstrates
faster haematologic recovery, likely because of variations in13oral iron tolerability, absorption, and
compliance (Reveiz et al., 2007; Milman, 2006).

Severe anaemia in pregnancy (Hb less than 7 g/dL) requires urgent medical treatment and Hb less
than 4g/dl is an emergency carrying a risk of congestive cardiac failure, sepsis and death. Folate
deficiency is seen in 5% cases of anaemia in pregnancy. A dose of 5 mg oral folic acid daily is
recommended for correction of anaemia. In cases of vitamin B12 deficiency, 250 µgcynacobalamin
administered parent rally every week is recommended for anaemia treatment. Incases of severe
anaemia near term – daily vitamin B12 in a dose of 100 µg should bead ministered for a week.

A community based trial from China found a 47% reduction in neonatal mortality in women who
received IFA supplements compared with those who took folic acid alone (Zeng et al., 2008).

Therefore, to reduce the risk of maternal anaemia, iron deficiency and poor pregnancy outcomes,
the WHO guidelines recommend a standard daily oral dose of 60 mg iron and 400 μg folic acid
supplements throughout pregnancy, to begin as early as possible as apart of antenatal care (ANC)
20
programs.Pre-pregnancy counseling, dietary advice and therapy are very important for ensuring
best pregnancy outcomes.

It is recommended that full blood count should be checked at the booking visit in pregnancy and
repeated at 28 weeks to screen for anaemia. In high risk mothers and multiple pregnancies, an
additional haemoglobin check should be performed near term. Dietary advice should be given to all
mothers to improve intake and absorption of iron from food(Olujimi et al., 2014).

Rich sources of iron include heme iron (in meat, poultry, fish and eggyolk), dry fruits, dark green
leafy vegetables (spinach, beans, legumes, lentils) and iron fortified cereals. Certain foods which
may inhibit iron absorption should not be taken with iron rich foods. These include poly phenols (in
certain vegetables, coffee) and tannins (in tea). Weekly iron(60 mg) and folic acid (2.8 mg) should
be given to all menstruating women including adolescents, periodically, in communities where IDA
is considered a problem (Goonewardene etal., 2012).

Besides increased intake, treatment of underlying conditions and deworming(antihelminthic

therapy) are important preventive measures. These vitamins play an important role in
embryogenesis and hence any relative deficiencies may result in congenital abnormalities. Finding
the underlying cause is crucial to the management of these deficiencies. From a neonatal
perspective, delayed clamping of the umbilical cord at delivery (by 1–2 min) is important step in
prevention of neonatal anaemia (Olujimi et al., 2014).

2.8 Theoretical perspectives

Theoretically, programs and interventions targeting diseases should be evaluated with respect to
goals determined a priori, during the planning stages. Certain designs are recommended in order
to better evaluate the impact of interventions.13 

However, if the frequency of the event prior to the implementation of the program is known,
simply conducting a post-implementation survey allows one to evaluate its effectiveness.

In the case of anemia among pregnant women, prior studies are scarce, geographically localized,
and based on small, restricted samples.6 Thus, the inexistence of solid data on anemia prior to the
implementation of flour fortification prevented us from carrying out a simple post-implementation

21
survey to evaluate the results of the fortification strategy. The evaluation of repeated cross-
sectional panels used as a baseline the levels found prior to implementation.

Interventions such as food fortification yield results in the long term. However, experience shows
that positive effects are larger and occur faster the greater the physiological need for the effects of
the intervention.23 

The choice of pregnant women to assess the effect of fortification is therefore justified, since this
is the group which has the highest demand for iron. Moreover, the study could only be carried out
because the Brazilian health care system ensures prenatal care to all pregnant women within
public services, and includes Hb testing as one of the recommendations for the first prenatal care
visit. However, hematological alterations associated with pregnancy complicate the evaluation of
anemia in this period,20 and therefore Hb levels were measured according to gestational age and
compared with Brazilian and international curves.

In the present study, data were obtained from medical records. This can be regarded as a
limitation given the quality of this information, which is not always standardized. However, use of
secondary data allowed for an assessment of a large number of cases (12,119 pregnant women
attending public health care facilities). Thus, it was possible to carry out a baseline survey of
anemia in pregnant women and to determine its evolution at least one year after the effective
implementation of flour fortification.

A bibliographical survey of studies published since the 1970's found that most studies of anemia
prevalence in pregnant women in Brazil were carried out in the state of São Paulo, and that their
results classify prevalence of anemia as moderate to severe. 6 This suggests that the problem may
be even greater in states that are less developed and have less access to health care services. The
results of the present study, when analyzed by region, confirm this possibility.

In addition to the social, economic, and cultural differences between the Brazilian regions, there
are also differences in the quality of prenatal care. While only 1.4% of mothers in the South and
Southeast do not have access to prenatal care, over half of them having seven or more visits, in
the North, 6.4% of births occur without prenatal care, and only 28% of women have seven or
more visits

22
 CHAPTER THREE

RESEARCH METHODOLOGY

3.0 Introduction

This chapter details the methods of data collection, analysis and presentation that well be using in
this study. It focuses on Research Design, Target Population, Sample Size, Sampling procedure,
Methods of Data collection, Validity and Reliability, Data Gathering Procedure, Data analysis
techniques and Limitation used in the study.

3.1 Research design

This study design will descriptive/ cross-sectional study to assess the factors and prevalence of
maternal anemia in pregnant women attending Sahardiid MCH, Ibrahim kod bur, Hargeisa city,
Somaliland.

3.2 Target population

The study population will be all pregnant mothers who were randomly selected from Sahardiid
MCH especially those who will be attended antenatal care in Sahardiid MCH.

3.3 Sample size

the number of people of the study contact at the course of primary data collection at Sahardiid
MCH, Ibrahim kod bur, Hargeisa city, Somaliland,was used By solvent’s formula,Sample size
formula (Using Slovene’s Sample selection formula, 2001) = N/1+N (e2)

Slovene’s formula:
N
n= 2
1+ N (e)
Where n=sample ¿ N =target population ;∧e=0.05 level of significance

50
¿ 2
1+50 (0.05)

23
 50
n=
1+50(0.0025)

50
n=
1+(0.125)

50
n=
1.125

n=¿44

3.4 Sampling technique

This study will employ probability simple random sampling to select the key of respondents and
the researcher will use simple random sampling. The main reason used is to collect reliable
information. It preferred for this study because it saves time and money. the research is targeting
maternal aneamia in a prignancy women at Sahardiid MCH.

3.5 Research instrument

Questionnaire will suitable instrument to obtain information needed can easily described in
writing. Since the sample size is fairly large and there is questionnaire will considered ideal for
collecting such data, because it is suitable for collecting a lot of information over short period of
time.

3.6 Validity and reliability of the test

3.6.1. Validity

Validity is the extent to which a concept, conclusion or measurement is well-founded

and corresponds accurately to the real world. The word "valid" is derived from the
Latin valid us, meaning strong. To identify the validity of data collection instrument (questioner) is
used this formula which is the relevant question is divided by the total questions and the outcome
will have the above optimal.
V=RQ/TQ.

24
Where
V= Validity

RQ= relevant questions

TQ= total number of questions

3.6.2. Reliability

Reliability of the study contains the total number of questionnaire difference divide
by total number of questionnaire, and will be test and retest procedure.

3.7 Data collection procedure

After the research questioner is approved the researcher will distribute the questioner with
attached a letter of introduction from the respondents. After receiving the questioners back, the
researcher will analyze the collected data using by the SPSS data analyzing package.

3.7.1. Primary Data

Primary data consists of a collection of original primary data collected by the researcher. It is often
undertaken after the researcher has gained some insight into the issue by reviewing secondary
research or by analyzing previously collected primary data. The primary data of this study will
obtaining information from maternal aneamia in a prognancy women at Sahardiid MCH Hargiesa
Somaliland.

3.7.2. Secondary Data

Secondary data refers to data that was collect by someone other than the user. Common sources
of secondary data include information from collecting by government departments, organizational
records research articles and data that will be originally collecting for other research purposes.
Secondary data of this study will get from these following: if there is previous data which was
Done at Sahardiid MCH.

25
3.8 Data analysis

The purpose of study will to assess factors and prevalence of maternal anemia in prignancy
women at Sahardiid MCH, the Data was processed by using SPSS v20 and the result is analyzed by
using graphics,tables and charts. Numerical data was encoded by using bars, pie charts with
percentages, which visually communicate a quantitative message.

3.9 Ethical consideration

The researchers undertook to observe all relevant ethical and legal considerations that were
applicable to scientific research. And also got consent from the principle of Sahardiid MCH before
the study, also Permission to carry out was obtained from NEW GENERATION COLLAGE
UNIVERSITY department of health science. Data is then collected respecting the rights of the MCH
and avoiding by writing names on study tool.

3.10 Limitation of the study

One of the limitations of this study is the nature of the study design, being as a cross-sectional
study design, it does not show which preceded anaemia or the risk factors. Second, due to
constraint of resource (money), it was not possible to classify the types of anaemia based on red
blood cell morphology. Morphologic classification would give us clear picture on the types of
anaemia and therefore we could determine the magnitude of iron deficiency anaemia
simultaneously.

Third, as the current study was conducted entirely within one hospital and all the participants were
from differences of geographic location were not assesse. Therefore, generalizability to other
hospitals and rural areas in the country may not be possible.

26
 Table 1: Budget breakdown

NO D e s c r i p t i o n Q u a n t i t y Unit cost in s/shilling Total cost in s/shilling

1 Stationary material
1 . P a 1 p a c k 2 5 , 0 0 0 s h 2 5 , 0 0 0 s h
p e r 1 2 1 , 5 0 0 s h / p e n 1 8 , 0 0 0 s h
2 . 2 1000sh/pencil 2 , 0 0 0 s h
P e n
3 . P e
n c i l
2 Internet and costs
4. I n t e r n e 2 4 h r s 5 , 0 0 0 s h / h r s 5 , 0 0 0 s h
t
1 2 0 , 0 0 0 s h 1 2 0 , 0 0 0 s h
5 . T e l e p h o n e
c o s t

3 P e r s o n a l c o s t

6. Printing of first darft of the 10 pages 2 0 0 s h / p a g e 2 0 0 0 s h

proposal
T h e t h e s i s
10 page 2 0 0 s h / p a g e 2 0 0 0 s h
7. Printing of second darft of the
proposal 9 0 , 0 0 0
T h e t h e s i s 6 days 1 5 , 0 0 0

8 . Tra v ellin g
cos t s
4 T o t a l 2 6 4 , 0 0 0 S H

27
Table: 2 Work plan

Activity Duration in days Responsibility

Preparation and drafting 9-27 march 2019 Researcher

chapter
one through chapter
three
Data collection 27 – march 30 - 2019 Researcher

Data organization 1-5 april 2019 Researcher

&cleaning
Data entry 6-10 april 2019 Researcher
Data analysis 11-15 april 2019 Researcher

Writing and conclusion 16-17 april 2019 Researcher

28
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