EASTERN AFRICA INTERNATIONAL UNIVERSITY COLLEGE

DEPARTMENT BACHELOR SCIENCE

Anemia associated factors among Pregnant Women Attending

Public Health Facilities in degahbur ,werada, somali region ,
Ethiopia

SUBMITTED TO EASTERN AFRICA INTERNATIONAL UNIVERSITY COLLEGE

SCHOOL OF MEDICINE
DEPARTMENT OF BACHELOR OF SCIENCE
Prepared by

STUDENTS NAME ID\NO

1. KHAALID ABDI MAHAD 0106/12
2. FADXI DEEQ HASSEN
3. HAMSE BASHIIR
4. SUMAYA MAHAMED
5. HIBO AHMED ABDI
6. NIMCO IMAACIL AHMED

UGBAAD XUSEN ABDI

ADVISOR NAME ;- KHAALID ABDI MAHAD

i
 JUN 2022

DAGAH BOUR, SOMALI REGION

Declaration
We will undersign declare that this thesis is our original work and that it will presented for a
degree in any other institution and that all source of material used for the thesis will be duly
acknowledge.

Students Name Signature Date

1.

KHAALID ABDI MAHAD

FADXI DEEQ HASSEN
HAMSE BASHIIR
SUMAYA MAHAMED
HIBO AHMED ABDI
NIMCO IMAACIL AHMED

UGBAAD XUSEN ABDI

2.

MR KHAALID ABDI MAHAD

 JUN2022

DAGAH BOUR SOMALI REGION

ACKNOWLEDGEMENT
First, we would like to express our profound gratitude to our God/Allah who keep us alive and
protected us all the risk ways and throughout our entire life since the childhood.

Secondly, we would like to express our profound gratitude to our respectable advisor, Mr.
MAHAD ABDI for his excellence guidance, and constant encouragement throughout the research
working time. His emphasized and well define comments helped us in preparing and scan all
parts of this research within the time-frame.

3rdly, our sincerely thanks go to eastern Africa university College of health science, and
Department of human nutrition for overall heeds that has been given since first year.

Fourthly, we will give much appreciation thanks to our dear classmates and we appreciate
ourselves we group members for our much encouraging and participation during all length of
times process. Our best wishes to all who helps directly or indirectly in ensuring a better thesis
write-up. our deep appreciation and thanks goes to all our friends and all our parents for their
well dedicated support during data collection time and the data analysis, without their help, this
will not be possible.
Finally, this may be a good opportunity to acknowledge all members of our family, relatives and
friends for all their encouragement and support throughout our study and also we would like to
thanks degahbur general Hospital workers for their full information to relate our study.

ABREVIA
TIONS AND ACRONYMS

ANC Antenatal Care

CDC Centre of Disease Control

EDHS Ethiopia Demographic Health Service

HIV Human Immune Virus

HB Hemoglobin

IDA Iron Deficiency Anemia

IUGR Intra-Uterine Growth Restrict

LBW Low Birth Weight

RBC Red Blood Cells

SGA Small Gestational Age

TB Tuberculosis

WHO World Health Organization

Abstract
Background: prevalence of anemia deficiency is a major public health problem in Somali region.
Most of the studies in Somali region will do clinical goiter without assessing the subclinical anemia
deficiency. Therefore, there will need to assess the prevalence and associated factors of anemia
deficiency among pregnant women in degahbur general hospital
Objectives: To asses’ prevalence of anemia deficiency and associated factors in in degahbur
general hospital

Methods: we will select by simple random sampling technique, to conduct in degah bur January
2022 Data will be collected using a pre-tested structured and semi-structured questionnaire
prepared by reviewing the previous similar studies. The questionnaire will be translated in to
Somali and back to English to ensure its consistency. We will also use standard audiometric
titration method. .
Result: Of the total 345 sampled mother Pairs takers who had mother 15–49 months, 345 of them
participated in the study with a response rate of 66.7%. More than half of participants 173 (65.2%)
living in the urban kebele of degahbur town. Of the respondents of the study, 237 (93.7%) Muslim
religious followers and 100% will be Somali in the ethnic group. Almost 105 (41.5%) of the study
participants live in a household that has seven and above household members. The majority of 209
(82.6%) of the respondents will be housewives; married 215 (85%) and illiterate 186 (73.5
Conclusion: prevalence of anemia deficiency will be a public health problem in the study area.
This indicates the need for further strengthening of the existing salt iodization program in order to
avail homogenously and adequately

Keywords: anemia; pregnancy; hemoglobin; nutrition; public health problem.

Table of Contents

ACKNOWLEDGEMENT.........................................................................................................3
ABREVIATIONS.......................................................................................................................4
ChAPTER ONE .........................................................................................…...8
1. INTRODUCTION..................................................................................................................8
1.1. Background of the Study....................................................................................................8
1.2. Statement of the Problem...................................................................................................9
1.3. Objectives of the study......................................................................................................10
1.3.1. General Objective..........................................................................................................10
1.3.2. Specific objectives..........................................................................................................10
CHAPTER TWO.....................................................................................................................11
2. LITERATURE REVIEW...................................................................................................11
2.1 Anemia in Pregnancy.........................................................................................................11
2.1.1 Epidemiology of Anemia in Pregnancy.........................................................................11
2.2 Etiology of Anemia Among Pregnancy Mother..............................................................12
2.3 Risk Factors of Anemia in Pregnancy..............................................................................12
2.4 Prevalence of Anemia in Different countries...................................................................12
2.5 Consequences of Anemia in Pregnancy...........................................................................13
2.5.1 Consequences of Anemia on Maternal Health.............................................................13
2.5.2 Consequences of prenatal Anemia ...............................................................................14
CHAPTER THREE.................................................................................................................15
3 Methodology..........................................................................................................................15
3.1. Study Area.........................................................................................................................15
3.2. Study designs.....................................................................................................................15
3.3. Study Period......................................................................................................................15
3.4. Source of population.........................................................................................................15
3.5 Study Population................................................................................................................16
3.6 Inclusion and Exclusion Criteria......................................................................................16
3.6.1Inclusion criteria..............................................................................................................16
3.6.2. Exclusion Criteria..........................................................................................................16
3.7. Sample size and sampling technique...............................................................................16
3.8. Sampling Technique.........................................................................................................16
3.9. Variables............................................................................................................................17
3.9.1. Dependent Variable.......................................................................................................17
3.9.2. Independent variables...................................................................................................17
3.10. Data collection.................................................................................................................17
3.10.1. Structured interview tool............................................................................................17
3.10.2. Hemoglobin estimation................................................................................................17
3.10.3. Anthropometric measurements..................................................................................17
3.10.4. Data quality control measures....................................................................................17
3.10.4. Statistical analyze.........................................................................................................18
3.10.5 Ethical consideration....................................................................................................18
3.8. TIME BUDGET................................................................................................................19
3.8.1 Work plan........................................................................................................................19
3.5.2. COST BREAK DOWN..................................................................................................19
References.................................................................................................................................21
Annex-I......................................................................................................................................24
 CHAPTER ONE

1. INTRODUCTION

1.1. Background of the Study

Anemia is defined by a reduced level of either circulating red blood cells (RBCs) or
hemoglobin (Hb) for an individual’s age and sex, which consequently impairs tissue
oxygenation.1 It is a major cause of morbidity and mortality; affecting 1.62 billion
people, of which 56 million are pregnant women.1

According to World Health Organization, WHO anemia in pregnancy (also known as

gestational anemia) is defined by hemoglobin (Hb) concentration of less than 11.0g/dL.2
Numerous studies indicate a high burden of anemia among pregnant women; for
example, it was reported at 66.2% in Sudan, 25.2% in Northwest Ethiopia, 90.5% in
Hyderabad-Pakistan, 84.5% from 16 districts of 11 states of India, 40.4% in Southeastern
Nigeria, and 22.0% in Kampala, Uganda.3–8

Anemia is presented in three clinical forms; as mild when Hb levels are between 10 and
11 g/dL, moderate for Hb between 7.0 and 9.9g/dL and severe for Hb levels below
7.0g/dL.9,10 The implication is more pronounced as Hb levels reduces with eventual
life-threatening consequences, such as preterm delivery, low birth weight babies,
APGAR (Appearance, Pulse, Grimace, Activity, Respiration) score less than five at 1
min, intrauterine growth retardation and to the family, it has far-reaching health
consequences and social–economic prospects.11–15 To the fetus, anemia during
pregnancy affects cognitive and physical development, and may aggravate death.16

The causes of anemia are varied; and, it results from a single, or/and a complex interaction of
factors; such as genetic defects, nutrient deficiency, parasitic and chronic infections, blood loss,
as well as drug myelosuppression.17–21 Understanding the prevalence, associated factors and
their complex interaction may ease the interventions to lessen the case burden of anemia. This

1
Globally, Anemia is one of the public health concerns, which affects 1.62% million (56%)
pregnant women around the world. Particularly, common in South East Asia (48.7%)
WHO,2061: Tadesse 2017 Worldwide, it has been reported that nearly 510,000 maternal deaths
occur per year associated with childbirth or early post-partum. Approximately 20% of maternal
death is caused by anemia; with majority of deaths occurred in developing countries (Crawley J.et
al, 2020).

The reason of anemia during pregnancy in developing countries includes nutritional deficiencies
of iron, folate, and vitamin B12 and parasitic diseases, such as malaria and hookworm. The
relative contribution of each of these factors to anemia varies greatly by geographical location,
season, and dietary practices (Getahun.2020). Despite the efforts made by the government and
other stakeholders, anemia during pregnancy is still a public health problem in Ethiopia
particularly Somali region (a region known for food insecurity thus high rate of anemia).

2
1.2. Statement of the Problem

Anemia is global public health problem affecting people of different age groups. However, it is
more prominent in pregnant women, young children, and other reproductive age (E. McLean, et
al, et al., (2020)

According to the 2008 World Health Organization (WHO) report, anemia affected 1.62 billion
(24.8%) people globally. It had an estimated global prevalence of 56% in pregnant women and is
a major cause of maternal mortality (UNICEF WHO. (, 2020)

Ethiopia is among countries where there is a high level of anemia among women of reproductive
age (15-49years) and pregnant women. Seventeen percent of Ethiopian women age 15-49 are
anemic, with thirteen percent having mild anemia, three percent having moderate anemia, and
one percent having severe anemia (CSA,2020). A higher proportion of pregnant women are
anemic (22%) than women who are breast feeding (19%) and women who are neither pregnant
nor breastfeeding (15%) (K. M. Sullivan, (2020).

There is an increased iron requirement during pregnancy due to greater expansion in plasma
volume that results in a decrease in hemoglobin (Hgb) level to 11g/dl (CSA,2020).. Therefore,
any Hgb level below 11g/dl in pregnancy is considered as anemia (CSA,2020). Anemia could be
classified as mild, moderate, and severe. The Hgb levels for each class of anemia in pregnancy
are 10.0–10.9g/d1 (mild), 7–9.9g/dl (moderate), and <7g/dl (severe) (Shulman., (2020).

The availability of local information on the magnitude has a major role in the management and
control of anemia in pregnancy. Even though the global and national prevalence of anemia
among pregnant women were identified, it is not well determined in the study area. Therefore,
this study intended to provide information about prevalence of anemia among pregnant mothers
who have ANC follow up in Sultan Sheikh Hassan Yabare Referral Hospital 2020 GC.

3
1.3. Objectives of the study

1.3.1. General Objective

 To assess anemia prevalence among pregnant women who attend antenatal care at in
degahbur general hospital, in degahbur town, Somali region January 2022 GC

1.3.2. Specific objectives

 to assess anemia prevalence among pregnant women who attend antenatal care at
degahbur general hospital, in degahbur town, Somali region January 2022 GC

4
CHAPTER TWO

2. LITERATURE REVIEW

2.1 Anemia in Pregnancy

2.1.1 Epidemiology of Anemia in Pregnancy

Anemia in pregnancy is defined as Hb concentration less than 110 g/L at sea-level throughout
pregnancy by the WHO. The CDC considers the same cut-off of 110g/L for pregnant women in
the first and third trimesters of pregnancy and a cut-off of 105 g/L for pregnant women in their
second trimester. The global definition of anemia during pregnancy remains subjective as some
studies, especially in Asia, use a Hb cut-off of 100 g/L to diagnose anemia in pregnancy.66,67
Anemia in pregnancy is a serious public health problem worldwide. Recent global estimates
reveal that anemia accounts for more than 68 million YLD Considering the WHO criteria for
classifying anemia as a public health problem, anemia in pregnancy is a ubiquitous public health
problem worldwide. Even though anemia in pregnancy is a public health problem in almost
every country, less developed countries are the most affected bearing most of the burden of
anemia.

According to DE Benoist et al., over 40% of pregnant women worldwide are estimated to be
anemic whiles a recent publication of the global prevalence of anemia in 2011 by the WHO
reports a global anemia prevalence of 38.2 among pregnant women. However, South-East Asia
and Africa bear most of the burden of anemia in pregnancy with prevalence of 48.7% and 46.3%,
respectively in comparison with the 24.9% and 25.8% in the Americas and Europe, respectively.
Although a recent systematic analysis of Hb data revealed a slight decline in global prevalence of
anemia, the disparity in the prevalence of anemia in pregnancy between developed and less
developed countries still persisted.68 Narrowing down on the anemia prevalence among
pregnant women in some rural regions in less developed countries reveals even higher
proportions of affected pregnant women.14,69,70 At the individual and population level, anemia
is associated with socioeconomic determinants such as education, wealth and cultural practices.
Characterization of anemia by socioeconomic status is also evident in pregnant women among
whom other factors such as gravidity, duration between successive pregnancies, and early
pregnancy onset further increases the risk of anemia,

5
2.2 Etiology of Anemia Among Pregnancy Mother
There are several different factors responsible for anemia. The most common is iron deficiency
anemia (IDA), which is generally assumed to represent 50% of cases. Among the various risk
factors for IDA nutritional or low iron intake together with acute blood loss are the leading
causes. During pregnancy, symptoms such as nausea and vomiting together with other
contributing factors may cause maternal anemia; the other factors include history of heavy
menstruation, high parity, short birth spacing, lack of antenatal nutritional education, and
multiple pregnancy.

Malabsorption interferes with iron absorption and parasitic infestation such as hookworm may
also lead to low hemoglobin levels. Iron absorption is enhanced by ascorbic acid and inhibited by
phytic acid and tannins present in tea, coffee, and chocolate. The second common leading cause
of anemia in pregnancy is folic acid deficiency. Other micronutrient deficiency such as vitamin
A, B12, and riboflavin, zinc, and copper may also contribute to anemia. Malaria, hookworm
infestation, infection, and deficiency of a number of micronutrients are leading causes of anemia
during pregnancy. The relative contribution of each of these factors to anemia during pregnancy
varies greatly by geographical location. Iron deficiency in anemic subjects in poor communities
may be complicated by one or more additional micronutrient deficiencies. The etiologic pattern
of anemia during pregnancy is often complex such that, for example, infection and nutritional
deficiencies coexist.

2.3 Risk Factors of Anemia in Pregnancy

The etiology of anemia in pregnancy is multifactorial and the factors responsible rarely act in
isolation. In most situations, the risk factors of anemia co-exist. Apart from physiologic anemia
during pregnancy, reduced Hb concentration is an indication of impaired erythropoiesis or
increased hemolysis or both. In either of these scenarios, genetics, infectious or parasitic diseases
and nutrient deficiencies could be responsible.

2.4 Prevalence of Anemia in Different countries

Iron deficiency is the most widespread nutritional deficiency in the world and it accounts for
75% of all types of anemia in pregnancy. In more than 80% of countries in the world, the

6
prevalence of anemia in pregnancy is >20%. The prevalence of anemia in pregnancy varies
considerably because of the differences in social conditions, lifestyles and health seeking
behaviors across different cultures. Anemia can affect pregnant women all over in the world (the
global prevalence in pregnancy is estimated to be approximately 41.8%) with rates of prevalence
that range from 35 to 60% for Africa, Asia and Latin America and it is reported to be <20% in
industrialized countries. The lowest estimated prevalence of anemia is of 5.7% in the USA and
the highest is of 75% in Gambia and 65–75% in India.

2.5 Consequences of Anemia in Pregnancy

Although anemia is common during pregnancy, depending on its severity, complications may
develop that could negatively impact on the health of the pregnant woman and the growing fetus.
Anemia or low Hb concentrations during pregnancy could have an impact on the weight of
neonates and the gestational age at delivery. These consequences are more pronounced in women
with severe anemia (Hb< 70 g/L), in which case it could lead to maternal or neonatal mortality.
The consequences of anemia in pregnant women on maternal health, pregnancy outcomes and
child health are detailed in the subheadings that follow.

2.5.1 Consequences of Anemia on Maternal Health

Due to the impaired oxygen supply to tissues, arising from reduced Hb concentration in anemic
pregnant women, fatigue, dizziness, increased rate of heartbeat, and loss of concentration are
some of the mild symptoms expressed. Apart from these morbid situations, anemia in pregnancy
has also been associated with maternal mortality. Using national data from 44 countries, a strong
correlation was found between the prevalence of anemia in women and maternal mortality ratios.
Five years after the publication of the aforementioned study, another study in Ghana also
reported increased risk of maternal deaths among anemic women compared with non-anemic
women. A recent iron report from the Child Health Epidemiology Reference Group revealed a
29% reduction in maternal mortality for a 10g/L increase in Hb concentration late in pregnancy.
It is however worthy of note that except for severe anemia, anemia in pregnancy may not be
directly responsible for the increased maternal mortality. Other causes of anemia that could have
such detrimental consequences on maternal health, such as HIV, could contribute to maternal
death.

7
2.5.2 Consequences of prenatal Anemia on Fetal Development and Birth Outcomes

Researchers have investigated the impact of anemia in pregnancy on birth outcomes for over half
a century. In 1962, Klein published a paper in the American Journal of Obstetric Gynecology to
report the findings of his study concerning preterm birth and prenatal anemia (Hb<10 g/L). In
this paper, Klein observed that the incidence of preterm deliveries was higher in anemic pregnant
women compared to non-anemic pregnant women thus, 12.6% versus 7.2%, respectively. Since
his publication, numerous studies have been conducted to investigate the impact of anemia on
other birth outcomes including intrauterine growth restrictions (IUGR), small-for gestational age
(SGA), birth weight, still births and perinatal deaths. IUGR also called fetal growth restriction
refers to the failure of the fetus to achieve proper growth. Accurately, IUGR is diagnosed using
fetal characteristics such as fetal abdominal circumference, head circumference, biparietal
diameter, femur length provided by ultrasound scan to compute fetal weight. When the estimated
weight of the fetus is below the 10th percentile for its gestational age, it is diagnosed to be
growth-restricted. SGA is defined as the birth weight below the 10th percentile for the
gestational age of the neonate. LBW is also defined as birth weight less than 2500 g whiles
preterm birth describes neonates born before the 37week of gestation.

8
CHAPTER THREE

3 Methodology

3.1. Study Area

The study will be conducted in degahbur Somali region, eastern Ethiopia. Degahbur is almost
160KM away from the capital city of the Somali region jijiga and it has an elevation of 1,550
meters above the sea level. The town mostly dominated by the mixed and the annual rainfall of
degahbur is 200-400mm and the area receive this rainfall with the temperature of 31 o as an
average annually the maximum and minimum temperature range 35oand 20o respectively.

3.2. Study designs

An institutional-based cross-sectional study will be conducted among pregnant women aged between
15- up to 49 years.

3.3. Study Period

 January 16/ 2022----February 15/2022 GC

3.4. Source of population

The source of population will be all pregnant women who visited the degahbur general Hospital for
ANC service at specified time frame.

3.5 Study Population

Study population will randomly be selected pregnant mother who visited the hospital for ANC service

3.6 Inclusion and Exclusion Criteria

3.6.1Inclusion criteria
 All ANC Visit regardless of gestational age will be included

3.6.2. Exclusion Criteria

 Pregnant mother who are very ill
 Those who not voluntary to participate

9
3.7. Sample size and sampling technique
Single population proportion formula (equation is indicated below) will be used to determine
sample size by considering anemia prevalence as 66 % (EDHS, 2016). By using the 95% CI
and 5% marginal error (d)
2
( 1 . 96 )  p (1  p )
N  2 
( 0 . 05)

(3.8416) x 0.66 (1-0.66) = 344.82 = 345 sample size

(0.0025)
3.8. Sampling Technique
Simple Random Sampling technique will employ to select study participants. Therefore, 345
study participants will be selected by using Simple random sampling. To get the initial study
participant lottery method will be used If the selected study participant will not fulfill the
inclusion criteria, the next individual will been including.

3.9. Variables

3.9.1. Dependent Variable

 Prevalence Anemia (Hemoglobin)

3.9.2. Independent variables

 Socio demographic characteristics (Place of residence, Maternal Age, Religion, Marital
status of the mother, Educational level of the Mather, Maternal occupation, and family
monthly income

 Maternal and obstetrics characteristics (Maternal Hemoglobin MUAC, Parity, Birth

interval, History of abortion).

10
3.10. Data collection

3.10.1. Structured interview tool

A semi-structured questionnaire will be administered to collect data. The tool will be prepared
prior to the study. Subsequently, the questionnaire will be coded before data collection to make it
easy for entry into the computer.

3.10.2. Hemoglobin estimation

First ANC follow up hemoglobin status was recorded form index card of the mother and The
degree for severity of anemia in pregnancy was classified into three as per WHO criteria
(Benoist,2008): Mild anemia, 10.0–10.9 g/dl, Moderate anemia, 7.0–9.9 g/dl, Severe anemia:

3.10.4. Data quality control measures

To ensure the quality of data, the questionnaire will pretest in 5% of the sample size in a hospital
other than the selected ones, but similar to the study participant.

3.10.4. Statistical analyze

Statistical analysis will be conduct using SPSS software version 16. Tables, graphs, means and
frequencies will be used to present descriptive result.

3.10.5 Ethical consideration

Ethical clearance for the proposal will be obtained from Food science and Nutrition Department
Committee. The aim, purpose, benefits and method of the study will clearly explain to the
respondents. All of the study groups will be informed that their response will be kept secret.
Finally, the interview will be done in a way that it will not violate their privacy and
confidentiality of information. Thus, the name and address of the interviewees will not be
recorded in the questionnaire. The respondents will be informed that they have the right to be
involved or not to be involved in the study

11
Table1: Socio-economic and demographic characteristics of pregnant Mother who visited the
hospital for ANC service

Variables n(%)
Age in Year
15-24 17(21.2%)

25-35 56(70.0%)

36-49 7(8.8%)

Place of residence
Rural 19 (23.8%)
Urban 61 (76.2%)
Mother level of Education
Primary 27(33.8%)

Secondary 21(26.2%0
17(21.2%)
Diploma
10(12.5%
Degree 5(6.2%)
Master
Mother Occupation
House wife
Civil Servant 41(51.2%)
Private Worker 4(5.0%)
Trade 7(8.8%)
Professional 7(8.8%)
17(21.25%)
Students
1.(1.2%

12
Marital Status

Married 69(86.2%)

Single 2(2.5%)

Separated 4(5%)

Widowed 5 (6.2%)

Religion 62(77.5%)
Muslim 8(10.0%)
Orthdox
Christian 7(8.8%)
Other 3(3.8%)

Ethnicity
56(70%)
Somali
9(11.2%)
Oromo
11(13.8%)
Amhara
3(3.8%)
Tigray
1(1.2%)
Others

Family Size
<5 people 44(55%)
>5 people 36(45%)

4.1.2. Anemia prevalence

The hemoglobin concentration was in the range of 7.8g/dl to 16g/dl, with mean value of 12.3g/dl.
The overall prevalence of anemia was 21.2% in the present study. Out of the total anemic
samples, 11.2% and 10% were mildly and moderately anemic, respectively (figure one )

13
Figure: 1. Anemia prevalence among pregnant mother who visited the hospital for ANC service

4.1.3. Prevalence of under-nutrition

The MUAC of the pregnant of was in the range of 13cm- 30cm, with their mean value of 23.8 A
summary of under-nutrition prevalence of the present study participants is indicated table two.

Table 2:Under-nutrition prevalence

Variable Frequency Frequency
Under-nutrition 19 23.8
Normal 61 76.2

14
4.2.4. Obstetric characteristic of pregnant mother
Around half 31 (38.8%) of the study participants were prim gravida and almost all 70(87.5%) of
the mother were in second trimester during their first ANC Visit.

Majority 41 (52.2 %) of the participants were revived nutritional counseling during current
pregnancy (ANC). However, only 24(30%) of participants were taken iron folic acid supplement
during current pregnancy. A summary of obstetric characteristic of the present study participants
is indicated in table 3.

Table 3: Obstetric characteristic of pregnant mother

Variables n(%)
Parity
Prim gravida 31(38.8%)
Multigravida 49(61.2%)

Gestation age
1st trimester 6(7.5)
2nd trimester 70(87.5%)

3rd trimester 4(5%)

Have you faced one following disease
during current pregnancy?
Malaria 23(28.8%)
Gestational Diabetic 5(6.8%)
Intestinal worm 20(25%)
Diarrhea 12(15%)
No 20(25%)
In a day (24hous) how many meals
do you eat?
Twice 16(18.8%)
Thrice 60(75%)
>Thrice 5(6.2%)

22
Did you receive Nutritional
counseling during this pregnancy? 41(51.2%)
Yes 39(48.8%)
No
Did You receive any of the
following supplement during
current pregnancy? 24(30%)
Iron-folic acid 10(12.5%)
Calcium 22(27.5%)
Multi-vitamin 2(1.2%)
Other 23(28.7%)
No

Anemia is a considerable public health problem worldwide. In

developing countries such as Ethiopia, this becomes even more
of a problem during pregnancy. Anemia has multiple causes,
and the associated risk factors vary widely across populations
and communities. The current study identified three predictors
of anemia among pregnant women who were attending
antenatal care in Jigjiga, Ethiopia.

One of the main objectives of the present study was to relate

the presence of anemia with dietary intake during pregnancy.
The odds of developing anemia were significantly higher in
pregnant mothers who consumed red meat 1–2 times
a Pregnant women who attended antenatal care for their first
visit, and were measured to have a hemoglobin level less than
11 g/dl were recruited into the anemia group. Pregnant women
who attend antenatal care for their first visit and presented
with hemoglobin levels greater than 11 g/dl were recruited
into the control group. Any attendee who was ill with confirmed
acute and/or chronic disease-causing anemia, and/or who was
undergoing invasive or non-invasive anemia treatment
(regardless of their hemoglobin level) was excluded from the
study.

Data Collection Techniques and Tools

22
A validated questionnaire was designed to obtain participant
information on socio-demographic factors, obstetrics
characteristics, nutrition-related characteristics, and parasitic
infection-related characteristics. The Dietary Diversity
Questionnaire (DDQ) was used to assess the typical dietary
intake of pregnant women over the past six months. This
comprised a detailed review of their typical intake of various
food groups, and the quantity per day, week, or month. The
questionnaire was initially developed in English and translated
to the local language (Somali) before being translated back to
English. Data were collected by interview by four midwives,
and specimen collection and processing were carried out by
two trained laboratory technologists. Specimen collection,
processing, and analysis were supervised by skilled and trained
laboratory technicians and trained health professionals with
research experience. All data collectors and supervisors were
trained for two days on the data collection process and
questionnaire.

Blood Sample Collection and Examination

Hemoglobin levels were measured using a portable heme

Analyzer (HemoCue 301 Hb; HemoCue, Ä ngelholm, Sweden).
The middle finger of the non-dominant hand was pricked at the
side of the fingertip. A drop of blood was drawn, and placed
onto a micro-cuvette, which was then inserted into the heme
Analyzer. After calibration of the machine, hemoglobin levels
were read and recorded to one decimal place. The packed cell
volume was estimated by tripling the hemoglobin values (in
g/dl) and dropping the units. Anthropometric measurements
(MUAC; mid-upper arm circumference) were measured using a
tape measure. A MUAC of less than 23 cm was considered to
signify malnutrition.14

Data Quality Control

22
To ensure data quality, an appropriate data collection
instrument was developed. Data collectors were regularly
supervised for proper data collection; all the questionnaires
were checked for completeness and consistency on a daily
basis. A pretest pilot study was conducted on 5% of the sample
size in a single nearby public hospital degahbou hospital; not
one of the recruitment sites for the main study), following
which the questionnaire was revised and edited, and any
questions found to be unclear or ambiguous were removed or
corrected accordingly.

Data Processing and Analysis

Data were entered into Epidata version 3.1 and analyzed using
Statistical Package for Social Sciences (SPSS) version 20.0.
Descriptive statistics were used to inspect frequencies and
percentages. Bivariate and multivariate logistic regression
analyses were used to test for the association between
dependent and independent variables. Variables that showed
an association in the bivariate analysis with p<0.25 were
entered into a multivariate logistic regression model.

22
References
Abel G and Afework M. Prevalence of Anemia and Associated Factors among Pregnant Women
in North Western Zone of Tigray, Northern Ethiopia, Journal of Nutrition and Metabolism,
Volume 2015, Article ID 165430, 7 pages.

Abriha et al.: Prevalence and associated factors of anemia among pregnant women of Mekelle
town: a cross sectional study. BMC Research Notes 2014 7:888. pmid:25487251

Acheampong K, Appiah S, Baffour-Awuah D et al. Prevalence of anemia among pregnant

women attending antenatal clinic of a selected hospital in Accra, Ghana. Int J Health Sci Res.
2018; 8(1):186–193.

Alene Kefyalew Addis and Dohe Abdulahi Mohamed. Prevalence of Anemia and Associated
Factors among Pregnant Women in an Urban Area of Eastern Ethiopia, Hindawi Publishing
Corporation Anemia, Volume 2014, Article ID 561567, 7 pages

Amnesty International.(2005). the state of the world‘s human rights Kenya.Harsh Prison
Conditions and Deaths in Custody, .149-151
Benoist B, McLean E, Egli I, Cogswell M. World Health Organization, centers for disease
control and prevention: worldwide prevalence of anemia 1993–2005. Geneva: World Health
Organization; 2008
Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al. Maternal and child
undernutrition: global and regional exposures and health consequences.
Lancet.2008;371(9608):243–260. doi: 10.1016/S0140-6736(07)61690-0
Bloem, M. W., Matzger, H., and Huq, N. 1995. ―Vitamin A Deficiency among Women in the
Reproductive Years: An Ignored Problem.‖ In Proccedings of the XVI International Vitamin A
Consultative Group Meeting, 78.

Brown, L. S. 2011. ―Nutrition Requirement during Pregnancy.‖

Bureau of Democracy, Human Right, and Labour. (2003). Country Reports on Human Rights
Practice
Central StasticalAgency.Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia,
2017.
Christian, P., West, K. P. Jr., Khatry, S. K., Katz, J., Shrestha, S. R., Pradhan, E. K., LeClerq, S.
C., and Pokhrel, R. P. 1998. ―Night Blindness of Pregnancy in Rural Nepal—Nutritional and
Health Risks.‖International Journal of Epidemiology 27 (2): 231-7.

22
Chudasama, R. K., Amin, C. D., & Parikh, Y. N. (2009). Prevalence of exclusive breastfeeding
and its determinants in first 6 months of life: A prospective study. Journal of Health Allied
Sciences, 8(1),
Ethiopia Central Statistical Agency and ICF International. 2011. Ethiopia Demographic and
Health Survey. Central Statistical Agency and ICF International, Addis Ababa, Ethiopia and
Calverton, Maryland, USA.
Ethiopia Central Statistical Agency and ORC Macro.2005.Ethiopia Demographic and Health
Survey.Central Statistical Agency and ORC Macro, Addis Ababa, Ethiopia and Calverton,
Maryland, USA.
Ethiopian Health and Nutrition Research Institute (EHNRI). 1998. Food Composition Table for
Use in Ethiopia. Addis Ababa: EHNRI, 34.
Facts about FASDS, 2015.www.wekepedia.com
Federal Democratic Republic of Ethiopia Ministry of Health. Complimentary feeding practices
for children aged 6 up to 24 months. Addiss Ababa, Ethiopia, 2012.

Ferro-LuzziA., Scaccini, C., Taffese, S., Aberra, B., and Demeke, T. 1990.―Seasonal Energy
Deficiency inEthiopian Rural Women.‖European Journal of Clinical Nutrition 44 (1): 7S-18S.
Gebre-Medhin, M., Killander, A., Vahlquist, B., and Wuhib, E. 1976.―Rarity of Anemia in
Pregnancy in Ethiopia.‖Scandinavian Journal of Haematology16 (3):168-75.
Gibson, R. S., and Ferguson, E. L. 1999.An Interactive 24 Hour Recall Method for Assessing
Intakes of Iron in Developing Countries.Washington, DC: ILSI Press,31-43. Gibson, R. S., and
Huddle, J. M. 1998. ―Suboptimal Zinc Status in Pregnant Malawian Women: Its Association
with Low Intakes of Poorly Available Zinc, Frequent Reproductive Cycling and Malaria.‖
American Journal of Clinical Nutrition 67 (4): 702-9.
Girma, W., and Timotiows, G. 2002.Determinants of Nutritional Status of Women and Children
in Ethiopia.Calverton, Maryland, USA: ORC Macro, 2-13.
Goldenberg, R. L., Tamura, T., Neggers, Y., Copper, R. L., Johnston, K. E., DuBard, M. B., and
Hauth, J. C. 1995. ―The Effect of Zinc Supplementation on Pregnancy Outcome.‖Journal of the
American Medical Association 274 (6): 463-8.
Huffman, S. L., Zehner, E. R., Harvey, P., and Martin, L.2001. ―Essential Health Sector
Actions to Improve Maternal Nutrition in Africa.‖ Regional Centre for Quality of Care and
Linkages
Project, Academy for Educational Development, Washington, DC
Hutter, I. 2005.―Reduction of Food Intake during Pregnancy in Rural South India.‖Tropical
Medicine and International Health 1 (3): 399-405.
IBFAN.(2011). Children of incarcerated parents.Considerations on Infant and Young Child
Feeding, 1-6.WHO.Girma.W and Genebo.T 2002.Determinants of Nutritional Status of Women
and Children in Ethiopia. Calverton, Maryland, USA: ORC Macro.

22
Infant and Young Child Feeding Practices. Collecting and Using Data: A Step-by- Step Guide.
Cooperative for Assistance and Relief Everywhere, Inc. (CARE). 2010.
Joint FAO/WHO.2009Vitamin and Mineral Requirements in Human Nutrition.Report of a Joint
FAO/WHO Expert Consultation, Bangkok, Thailand.
Karim, R., Bhat, D., Troy, L., Lamstein, S., and James-Levinson, F. 2002. ―Determinants of
Food Consumption during Pregnancy in Rural Bangladesh: Examination of Evaluative Data from
the Bangladesh Integrated Nutrition Project.‖ Discussion Paper No. 11, IDEAS.
Kathryn, G. D. 2003. ―Facilitating Improved Nutrition for Pregnant and Lactating Women and
Children 0-5 Years of Age Commenting: Black, Reifsnider and Devaney.‖ Encyclopedia on Early
Childhood Development.
Kefiyalew et al.: Anemia among pregnant women in Southeast Ethiopia: prevalence, severity and
associated risk factors. BMC Research Notes 2014 7:771. pmid:25362931

Kenea Adamu, Negash Efrem, Bacha Lemi, and Wakgari Negash. Magnitude of Anemia and
Associated Factors among Pregnant Women Attending Antenatal Care in Public Hospitals of Ilu
Abba Bora Zone, South West Ethiopia, Hindawi Anemia Volume 2018, Article ID 9201383, 7
pages

Kennedy, G., Nantel, G., and Shetty, P. 2001. ―The Scourge of ‗Hidden Hunger‘: Global
Dimensions ofMicronutrient Deficiencies.‖ Food and Agriculture Organization. Accessed
November 2014.

King, J. C. 2000. ―Physiology of Pregnancy and NutrientMetabolism.‖Am. J. Clin. Nutr. 71 (5):

1218S-25S.
Kitila KT, Tulu BL, Bedaso DG, Negwo DT, Gemeda MN (2018) Prevalence of Anemia and
Associated Risk Factors among Pregnant Women Attending Antenatal Care in Selected Health
Centers in Addis Ababa, Ethiopia. J Women's Health Care 7: 443.
Lebso M, Anato A, Loha E (2017) Prevalence of anemia and associated factors among pregnant
women in Southern Ethiopia: A community based cross-sectional study. PLoS ONE 12(12):
e0188783. pmid:29228009.

Loaiza, E. 2007―Maternal Nutritional Status.‖ Demographic and Health Surveys Comparative

Studies No. 24, Macro International Inc., Calverton, Maryland, USA.
Malay K (2012). Acceptability of Lipid-Based Nutrient Supplements and Micronutrient Powders
among Pregnant and Lactating Women and Infants and Young Children in Bangladesh and their
Perceptions about Malnutrition and Nutrient Supplements, FANTA-2., FHI 360.

22
ANNEX-I
QUESTIONNAIRE EASTERN AFRICA UNIVERSITY: COLLEGE OF DRY
AGRICULTURE DEPARTMENT OF FOOD SICENCE AND NUTRITION
I would like to thank you for giving your consent to participate in the study entitled
“Assessment of Anemia among pregnant women who have Anc follow up at degahbur general
Hospital degahbur, Somali region.

This questionnaire is for to collect relevant socio- demographic, clinical or related information
about pregnant women attending the Anc follow up at degahbur general hospital. Your
response to the study items will highly contributes to the success of the study, There is no risk
involve in this study therefore you should kindly have to participate and response to each item

22
22
 any pregnancy occurred.

204 What is parity of the mother?

That is any delivery that passed Parity: __________
28 weeks of gestation.
205 Have you ever had an abortion? 1. Yes
2. No
206 What is the pregnancy interval
of the previous birth? (years __________
205 How many living children do
you have? __________
Section III: Maternal Nutritional Status

Hemoglobin level (g/dl) (check __________Hg%

301 from records)
Mid-upper arm ___________cm
302 circumference (cm) (Take
left hand if right- handed, and
right
hand if left- handed)
How many meals were you taking 1. One
303 in a day (24hours) during this 2. Twice
pregnancy 3. Three
4. > Three

Did you receive nutritional 1. Yes

304 counseling in the clinic during 2. No
pregnancy?
Did you receive any of the 1. Iron folic Acid
305 following 2. Calcium
food supplements during 3. Multivitamins
pregnancy 4. Other
specify_____
___

22
Inclusion and Exclusion Criteria

A facility-based unmatched case-control study design was used.

The study was conducted in Sheik Hassan degahbour hospital
is a city situated 626 km east from Addis Ababa, the capital city
of Ethiopia. As of the 2015 Ethiopian fiscal year, degahbour had
a total population of 426,122, of which 85,650 are considered
to be in the reproductive age group (15–49 years). The city is
divided into 30 sub-districts (the smallest administration
units), of which 20 are urban and 10 are rural. The vast
majority of the population are ethnic Somalis (97%), and
Muslim (98%).12 This study was conducted between March 1
and April 30, 2019.

Sample Size Determination and Sampling Technique

The sample size was calculated using Epi Info version 7.2
assuming a 95% confidence interval (CI) and power of 80, with
a case to control ratio of 1:1. The effect size used was an odds
ratio for factors associated with anemia of 2.34 from a recent
study conducted in Durame, Ethiopia. 13 The resulting maximum
sample size was 114 cases and 114 controls with a total of 228
study participants. J degahbour has two public health facilities
that provide antenatal care services to pregnant mothers. Of
these, two facilities were selected by simple random sampling.
The number of study subjects was allocated to each selected
facility proportionally to their average patient attendance per-
month by reviewing registration books from each antenatal
care unit. The average number of pregnant women who
attended antenatal care per month was multiplied by the total
sample size (n =228) divided by the total number of pregnant
women attending across all antenatal care facilities per month
(460). Systematic random sampling was used to select study

22
participants on this basis, such that 114 anemia cases and 114
controls were identified.

Ethical Approval

Ethical approval was obtained from the Institutional Review

Board (IRB) of degahbour Town , College of Medicine and
Health Science in accordance with the Declaration of Helsinki.
Written permission was obtained from degahbour
administrative health department, and from each selected
facility. Participants were informed that participation was on a
voluntary basis. Informed, written consent was obtained from
each study participant. In participants aged under 18 years,
written assent was obtained from someone with parental
responsibility. All study data were anonymized at source.
Anemic cases were provided with free iron-folic acid
supplements and counseled to prepare and increase their
dietary iron intake.

Inclusion and Exclusion Criteria

22