PREVALENCE OF ANEMIA AND ASSOCIATED FACTORS IN

PREGNANT WOMEN IN SOUTH PUNJAB, PAKISTAN

BS in Medical Laboratory Technology

Session 2019-2023

Submitted by

Muhammad Bilal Jaon Muhammad

HESC19115014 HESC19115028

SUPERVISORS

Dr. Ghulam Mustafa Kamal

Ms. Aiman Noreen

Institute of Health Sciences

Faculty of Food, Health Sciences and Technology

Khawaja Fareed University of Engineering and Information

Technology, Rahim Yar Khan

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PREVALENCE OF ANEMIA AND ASSOCIATED FACTORS IN
PREGNANT WOMEN IN SOUTH PUNJAB, PAKISTAN

Name: Muhammad Bilal

Registration No. HESC19115014
Name: Jaon Muhammad
Registration No. HESC19115028

A thesis submitted in partial fulfilment of the requirement for degree of

BS-Medical Laboratory Technology

Supervisor : Dr. Ghulam Mustafa Kamal

Co-supervisor : Ms. Aiman Noreen

Institute of Health Sciences

Faculty of Food, Health Sciences and Technology

Khawaja Fareed University of Engineering and Information

Technology, Rahim Yar Khan

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 Declaration

We Muhammad Bilal and Jaon Muhammad hereby state that my BS thesis titled
“Prevalence of Anemia and Associated Factors in Pregnant Women in South Punjab, Pakistan.”
is our own work and has not been submitted previously by us for taking any degree from Khwaja
Fareed University of Engineering and Information Technology, Rahim Yar Khan or anywhere else
in the country/world.
We solemnly declare that research work presented in the thesis is solely our research work
with no significant contribution from any other person. Small contribution/help wherever taken
has been duly acknowledged and that complete thesis has been written by us.
At any time if our statement is found to be incorrect even after our graduation the
university has the right to withdraw our BS degree.

Rahim Yar Khan, on June, 2023

Muhammad Bilal (HESC19115014): Signature: __________________

Jaon Muhammad (HESC19115028): Signature: __________________

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 Institute of Health Science

Research Certificate

We the undersigned certify that Muhammad Bilal & Jaon Muhammad candidate for the degree
of BS-Medical Lab Technology presented their research project of the following title Prevalence
of Anemia and Associated Factors in Pregnant Women in South Punjab, Pakistan, as it
appears on the title page and front cover of the research project. That the research project is
acceptable in form and content and displays a satisfactory knowledge of the field of study.

Co-Supervisor Ms. Aiman Noreen Signature______________

Supervisor Dr. Ghulam Mustafa Kamal Signature______________

Deputy Director Dr. Ahmad Bilal Arif Signature_______________

Examiner

Additional Director Dr Shabbir Hussain Signature_______________

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 Acknowledgments

Thanks to the Almighty ALLAH, for granting knowledge and for all the blessings that he
has provided and poured upon us. Almighty Allah has shown unconditional and pure love by using
the people around us who are able to let us feel that we are loved and cared. We gratefully
acknowledge the support and patience of our family, school teachers, college teachers, professors
and friends throughout our studies and without them this project report could never have been
completed. We are grateful to Dr. Ghulam Mustafa Kamal & Ms. Aiman Noreen the supervisor
and co-supervisor of our project respectively for their support, guideline and great supervision. We
would also like to thank our institute, Khawaja Fareed University of Engineering and Information
Technology (KFUEIT) for providing us a platform where we were able to sharpen our skills and
develop as the individuals who can have a chance to grow in this ever-changing environment.

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 ABSTRACT

Background and Introduction: Anemia is a condition characterized by a deficiency of

red blood cells or hemoglobin in the blood, leading to reduced oxygen-carrying capacity. It is a
prevalent issue among pregnant women worldwide, affecting both maternal health and fetal
development. Anemia is a major global health problem affecting an estimated 42% of pregnant
women worldwide. Anemia can have adverse effects on the health of pregnant women. It is
associated with an increased risk of maternal complications, including fatigue, dizziness, and
shortness of breath. Anemic pregnant women are more susceptible to infections, experience higher
rates of preterm birth, and may have infants with low birth weight. Moreover, anemia can impact
the emotional well-being and bonding between the mother and child. The effects of anemia extend
beyond maternal health and can significantly impact the developing fetus. Inadequate oxygen
supply due to anemia can impair fetal growth and brain development. Studies have also shown a
higher incidence of congenital anomalies among infants born to anemic mothers, emphasizing the
importance of addressing anemia during pregnancy. Several factors contribute to anemia among
pregnant women, with nutritional deficiencies being a significant cause. Iron deficiency, folate
deficiency, and inadequate intake of vitamin B12 can lead to anemia. Additionally, other factors
such as chronic diseases, multiple pregnancies, and genetic predisposition may increase the risk of
developing anemia during pregnancy. Objective: Main objective of present study to determine
prevalence of anemia and associated factors among pregnant women and raise awareness about
anemia and its factors. Duration: The duration of study about 2-3 months till this thesis report.
Sample size and Material: A total of 132 patients were included those were from Dera Ghazi
Khan, Pakpattan Shareef, and few were from Rahim Yar Khan. Method: The present study was
based on a questionnaire which was filled by the participants. No blood samples were taken
manually, the value of Hb% was noted from the medical reports of the patients. Ethical approval
was sought from institutional review Board. Interpretation: Data was entered and interpreted in
SPSS 25.0. Result and Discussion: 95.55% pregnant women were anemic and only 4.45%
pregnant women were normal. According to present study Moderate anemia (Hb% from 8.0 – 9.9)
was most common in pregnant women. The prevalence of anemia among pregnant women is high.
The associated factors of anemia are iron deficiency, folic acid deficiency, B12 deficiency,
hypertension, exercise, abnormality in menstrual cycle, rate of pregnancy, miscarriage, and viral

6
infections. The rate of iron deficiency anemia was high in pregnant women and mostly women
were used iron supplements. Illiteracy and rural residence had more anemic patients. Mostly
patients were moderate anemic from urban area. The most affected pregnant women were second
and third trimesters of pregnancy.

Key words:
Anemia, Iron deficiency anemia, Megaloblastic anemia, Hypertension, Viral infections.

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Abbreviations and acronyms

8
Contents
DECLARATION............................................................................................................................. 3
ACKNOWLEDGMENTS .............................................................................................................. 5
ABSTRACT.................................................................................................................................... 6
CHAPTER 1 INTRODUCTION ....................................................................... 12
1.1 BACKGROUND ................................................................................................................................................... 12
1.2 INTRODUCTION ................................................................................................................................................. 12

CHAPTER 2 LITERATURE REVIEW............................................................ 14

CHAPTER 3 HYPOTHESIS AND PROBLEM STATEMENT ................................ 17
3.1 HYPOTHESIS...................................................................................................................................................... 17
3.2 PROBLEM STATEMENT...................................................................................................................................... 17

CHAPTER 4 OBJECTIVE .............................................................. 19

OBJECTIVE.............................................................................................................................................................. 19

CHAPTER 5 OPERATIONAL DEFINITIONS ............................................... 20

5.1 ANEMIA ............................................................................................................................................................. 20
5.2 TYPES OF ANEMIA ............................................................................................................................................ 20
5.2.1 Microcytic anemia...................................................................................................................................... 20
5.2.2 Macrocytic anemia ..................................................................................................................................... 21

CHAPTER 6 RESEARCH METHODOLOGY ............................................ 22

6.1 DURATION ......................................................................................................................................................... 22
6.2 SAMPLE SIZE..................................................................................................................................................... 22
6.3 SAMPLE SELECTION ......................................................................................................................................... 22
6.4 INCLUSION......................................................................................................................................................... 22
6.5 EXCLUSIONS...................................................................................................................................................... 22
6.6 DATA COLLECTION PROCEDURE...................................................................................................................... 22
6.7 STUDY DESIGN AND PARTICIPANTS ................................................................................................................... 23
6.8 DATA ANALYSIS PROCEDURE ........................................................................................................................... 23
6.9 ETHICAL CONSIDERATIONS .............................................................................................................................. 23

CHAPTER 7 RESULTS AND STATISTICAL ANALYSIS ........................................ 24

7.1 RESULTS ............................................................................................................................................................ 24
7.2 TABLES .............................................................................................................................................................. 24

CHAPTER 8 DISCUSSION .................................................................. 34

CHAPTER 9 CONCLUSION.................................................................... 37
CHAPTER 10 REFRENCES .................................................................. 38

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List of Tables

Table 7.3.1……………………………………………………………………………………..24
Table 7.3.2……………………………………………………………………………………..25
Table 7.3.3……………………………………………………………………………………..26
Table 7.3.4……………………………………………………………………………………..27
Table 7.3.5……………………………………………………………………………………..28
Table 7.3.6……………………………………………………………………………………..29

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List of Figures

Fig.7.3.1……………………………………………………………………………………….30
Fig.7.3.2……………………………………………………………………………………….31
Fig.7.3.3……………………………………………………………………………………….32
Fig.7.3.4……………………………………………………………………………………….33

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Chapter 1 INTRODUCTION

1.1 Background
Anemia, A prevalent health concern, particularly during pregnancy, is a disorder
characterized by a lack of red blood cells or hemoglobin. It can be harmful to both the mother and
the growing fetus and affects a sizable number of pregnant women globally.
The body undergoes a number of physiological changes during pregnancy in order to
support the developing fetus. These changes increase the demand for nutrients, including iron,
folate, and vitamin B12, which play crucial roles in red blood cell production. Anemia occurs when
there is an insufficient supply of these essential nutrients, resulting in decreased oxygen-carrying
capacity in the blood.
1.2 Introduction
Anemia is a common illness that many women have, but pregnant women are more likely
to experience it. Anemia is defined as a lack in either quantity or quality of red blood cells, resulting
in less oxygen getting to the body's tissues. This disease can result in weakness, exhaustion, and
other symptoms, which can be particularly troublesome during pregnancy when the body's oxygen
requirements rise (Sharif et al., 2023). Anemia in pregnant women can cause symptoms including
fatigue, weakness, dizziness, and shortness of breath that are also present in non-pregnant people.
However, because of the additional demands placed on the body during pregnancy, these
symptoms may be more severe. Preterm birth and low birth weight are two complications of
pregnancy that anemia might increase the risk of (Cappellini et al., 2020).
Anemia is a frequent pregnancy complication that affects 40% of pregnant women globally.
It is described as a drop in the quantity of red blood cells or a fall in hemoglobin levels below
normal. Geographical differences in the prevalence of anemia during pregnancy include greater
rates in low- and middle-income nations (Rahman et al., 2016). Anemia during pregnancy can
have detrimental effects on both the mother and the fetus, including preterm birth, low birth weight,
and a higher chance of maternal death. According to the World Health Organization (WHO),
anemia is defined as hemoglobin levels that are less than 11 g/dL in the first and third trimesters
and less than 10.5 g/dL in the second trimester. ). Worldwide, anemia affects about 38% of

12
expectant mothers, with Sub-Saharan Africa and South Asia having the greatest prevalence rates
(57.1% and 50.3%, respectively) (Abriha et al., 2014).
Anemia can develop in pregnant women for a variety of reasons. The most frequent causes
are poor nutrition, including iron, folic acid, and vitamin B12 deficiencies. The body of a pregnant
woman needs more iron to produce the additional blood volume needed to nourish the developing
fetus. Iron is used in the production of hemoglobin, a protein that is present in red blood cells and
is responsible for carrying oxygen to the body's tissues. A pregnant woman may not be able to
create the necessary amounts of hemoglobin if her diet does not contain enough iron, which could
result in anemia (Moll & Davis, 2017).
Folic acid, one specific B-vitamin, is essential for cell growth and development. It is
especially important during pregnancy as it helps with the development of the neural tube, which
eventually gives rise to the baby's brain and spinal cord (Hwang et al., 2018). When a woman is
pregnant, her body needs more folic acid than usual to support the growing fetus. A deficiency in
folic acid during pregnancy can lead to a type of anemia known as folate deficiency anemia. During
pregnancy, a woman's body requires more vitamin B12 to support the growing fetus's
development. If a woman is not consuming enough B12 in her diet, she may develop a deficiency.
Additionally, the absorption of B12 can be reduced during pregnancy due to changes in the
digestive system, further increasing the risk of deficiency.
Other factors include infections, such as malaria, hookworm infection, and HIV, which
increase the risk of anemia (Abriha et al., 2014). Anemia during pregnancy has also been linked
to other factors like low socioeconomic position, high parity, and teenage pregnancies. Anemia has
also been linked to unfavorable pregnancy outcomes, including low birth weight, early birth, and
maternal death, according to a number of studies.
According to a study done in Nigeria, inadequate nutrition and a lack of iron are the main
causes of anemia in pregnancy (Tukur et al., 2022). Anemia in pregnancy was found to be mostly
caused by hookworm infestations and iron deficiencies, according to another study carried out in
Ethiopia (Kefiyalew et al., 2014). Anemia during pregnancy has serious repercussions that can
harm both the mother and the unborn child. Pregnancy-related anemia raises the risk of maternal
death, early delivery, low birth weight, and infant death (Milman, 2011). Additionally, anemia
during pregnancy has a long-term impact on the child's growth and cognitive development.

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Chapter 2 LITERATURE REVIEW

Around the world, 1.62 billion people suffer from anemia. Anemia is thought to be more
common in underdeveloped nations than industrialized ones (43% versus 9%). Anemia has been
estimated to be responsible for 591 000 prenatal deaths and 115 000 maternal deaths annually
(Abriha et al., 2014). In different parts of the world, anemia is more or less common among
pregnant women. According to a 2019 systematic review and meta-analysis of 92 papers, the
prevalence of anemia in pregnancy was 38.2% worldwide, with Africa having the highest rates
(57.1%) and Europe having the lowest rates (18.7%) (Mahmood et al., 2019). In some countries,
such as India and Bangladesh, the prevalence of anemia in pregnant women is as high as 50% to
60% (Munshi et al., 2021).
Anemia in pregnant women has been linked to a number of risk factors. Anemia in
pregnancy was found to be substantially correlated with low socioeconomic position, inadequate
nutritional intake, and parasite illnesses in a cross-sectional study carried out in Nepal (Kalaivani
& Ramachandran, 2018). In a different Ethiopian study, it was discovered that maternal wealth,
education, and attendance at prenatal care are all protective factors against anemia in pregnancy.
The most frequent causes of anemia are poor nutrition, iron deficiency, micronutrient deficiencies
including those in folic acid, vitamin A, and vitamin B12, diseases like malaria, hookworm
infestation, and schistosomiasis, HIV infection, and hereditary hemoglobinopathies like
thalassemia (Hovdenak & Haram, 2012). Young mother age, high parity, and chronic illnesses
including diabetes and hypertension have also been connected to a higher risk of anemia during
pregnancy.
In India, a cross-sectional study estimated that the prevalence of anemia among pregnant
ladies was 58.2% (Antwi-Baffour et al., 2019). The study also discovered that socioeconomic
status, mother age, and education level were important predictors of anemia during pregnancy.
Similar findings were made by research carried out in Nepal, which discovered that 41.5% of
pregnant women had anemia. The study found that eating habits, income, and maternal education
level were all very significant risk factors for anemia during pregnancy
According to a meta-analysis, pregnant women in Africa (sub-Saharan) had anemia at a
prevalence of 43.4%. The study also found that major predictors of anemia during pregnancy

14
included variables including mother age, gestational age, and parity. Anemia was found to be
prevalent in pregnant women in Ghana, according to a different study, at a rate of 51.0% (Nartey
et al., 2023). The study found that major predictors of anemia during pregnancy included maternal
age, education, and occupation.
In Southeast Asia, a study conducted in Thailand found that the prevalence of anemia
among pregnant women was 23.1% (Tollenaar et al., 2020). The study found that major predictors
of anemia during pregnancy included parameters including maternal age, education level, and
occupation. In a similar vein, a study carried out in Bangladesh discovered that 34.6% of pregnant
women had anemia. The study found that major predictors of anemia during pregnancy included
parameters including maternal age, education level, and occupation (Rivera et al., 2016).
According to a study from Brazil, anemia affects pregnant women with a prevalence of
26.5% in Latin America. In the study, important predictors of anemia during pregnancy included
maternal age, education, and wealth (Finkelstein et al., 2020). Another investigation done in
Mexico revealed a 28.1% frequency of anemia in expectant mothers. The study found that major
predictors of anemia during pregnancy included parameters including maternal age, education
level, and occupation (Neogi et al., 2019).
The most typical cause of anemia during pregnancy is iron deficiency, and iron
supplementation is advised by the WHO to both prevent and cure anemia in pregnant women.
However, women may experience adverse effects such nausea and constipation and compliance
with iron supplements is frequently poor. Other interventions that have been demonstrated to be
successful in lowering the prevalence of anemia in pregnant women, in addition to iron
supplements, are nutrition education, deworming, and malaria prevention (Idris, 2005).
According to a study done in Karachi, Pakistan, 61% of pregnant women have anemia
(VanderMeulen et al., 2020). Another study conducted in Peshawar; Pakistan found that the
prevalence of anemia in pregnant women was 45.9% (Menard et al., 2020). In various nations,
including Canada, studies have looked into the prevalence and risk factors of anemia in pregnant
women. According to a 2019 study by the Public Health Agency of Canada (PHAC), anemia was
prevalent among pregnant women in Canada at a rate of 17.2%, with greater rates among those
with lower socioeconomic level, newcomers to the country, and those who had insufficient prenatal
care (Bordeleau, 2021).

15
 Another study carried out in Vancouver, Canada, found that pregnant women visiting
prenatal care clinics in Vancouver Coastal Health (VCH) had anemia at a prevalence of 17.8%
Another study carried out in Vancouver, Canada, found that pregnant women visiting prenatal care
clinics in Vancouver Coastal Health (VCH) had anemia at a prevalence of 17.8% (Christofides et
al., 2005). The study also discovered a number of risk factors for anemia in expectant mothers,
such as a poor intake of foods high in iron, a low socioeconomic position, and insufficient prenatal
care. In order to decrease the prevalence of anemia among pregnant women in Vancouver, the
study suggested expanding access to prenatal care and giving iron supplements to pregnant women
who are at risk of anemia.
Anemia among pregnant women in Vancouver, Canada, and its contributing factors were
the focus of a study that was carried out there. 434 pregnant women who were receiving prenatal
treatment in a sizable metropolitan maternity hospital in Vancouver were included in the study.
Based on the World Health Organization's (WHO) definition of hemoglobin levels less than 11
g/dL, the prevalence of anemia was calculated.

According to the survey, there were 17.3% of pregnant women in Vancouver who had
anemia. Only a handful of the anemic women had severe anemia, with the rest of them having
mild to moderate anemia. Additionally, the study discovered that women who were immigrants,
had poor incomes, had only completed high school, and had a body mass index (BMI) of less than
18.5 kg/m2 were at a higher risk of anemia. Women who had a history of anemia in prior
pregnancies also had an increased risk of developing anemia (Tran & McCormack, 2019).
Another study done in Vancouver looked at pregnant women who went to an urban
maternity hospital there to see how common anemia and iron insufficiency were. Using the WHO
definition of hemoglobin levels less than 11 g/dL. The prevalence of anemia was calculated for the
study's 528 pregnant participants. According to the survey, there were 14.9% of pregnant women
in Vancouver who had anemia. The study also discovered that iron deficiency was more common
in women than anemia, with 38.6% of them suffering the condition. According to the study, women
who were immigrants, had less education than a high school diploma, had low income, and had a
BMI under 18.5 kg/m2 had a higher chance of developing anemia. The research also revealed that
risk of anemia was higher in women who had a history of anemia in their previous pregnancies
(Bordeleau, 2021).

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Chapter 3 HYPOTHESIS AND PROBLEM STATEMENT

3.1 Hypothesis
If dietary deficiencies, nutrient deficiencies such as folate, vitamin B12 and vitamin A,
parasitic infection, socio-economic factors and genetic variations causes anemia then there is an
association of these factors with anemia.
3.2 Problem Statement
Anemia is a significant health concern affecting millions of people worldwide. This
condition occurs when the body lacks a sufficient number of healthy red blood cells or when the
red blood cells do not function properly. Understanding the problem of anemia is crucial for raising
awareness and developing effective strategies to address it.
Anemia is a common condition among pregnant women, with varying prevalence rates
across different regions and populations. The World Health Organization (WHO) estimates that
globally, approximately 38% of pregnant women are affected by anemia. However, the prevalence
can be significantly higher in low- and middle-income countries, reaching up to 60% or more in
some areas.
Several factors contribute to the development of anemia in pregnant women. Iron
deficiency is the leading cause of anemia in pregnancy. The increased demand for iron during
pregnancy, combined with inadequate dietary intake or poor iron absorption, can lead to iron
deficiency anemia. In addition to iron, deficiencies in other essential nutrients like folic acid,
vitamin B12, and vitamin C can contribute to anemia in pregnant women. Infections such as
malaria and hookworm infestation are prevalent in some regions and can increase the risk of
anemia in pregnant women. Adolescents who become pregnant are at a higher risk of developing
anemia due to their own growth and development needs, combined with the demands of pregnancy.
Women carrying multiple fetuses (e.g., twins or triplets) have a higher risk of anemia due to
increased blood volume requirements. Certain pre-existing medical conditions, such as chronic
kidney disease or inflammatory bowel disease, can predispose pregnant women to anemia.
Anemia in pregnancy can have several adverse effects. Anemia increases the risk of
complications during pregnancy, including preterm birth, low birth weight, and postpartum
hemorrhage. Insufficient oxygen supply to the fetus due to maternal anemia can lead to impaired
fetal growth and development, increasing the risk of preterm birth and developmental issues.

17
Anemic pregnant women often experience fatigue, weakness, and reduced overall well-being,
impacting their daily activities and quality of life.
Anemia is major problem in world. It also a major problem in Pakistan especially in
pregnant women. In South Punjab, the percentage of anemia during pregnancy is high. There are
small number of studies conducted in Pakistan about anemia and associated factors among
pregnant women. The present study examines the prevalence of anemia and associated factors in
pregnant women in some southern districts of Punjab. The main objective of study is to raise
awareness in pregnant women and observed associated factors which cause anemia during
pregnancy.
The questionnaire base study is conducted in Dera Ghazi Khan, Pakpattan Shareef and
Rahim Yar Khan. The mostly patients are from Dera Ghazi Khan and Pakpattan Shareef.

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Chapter 4 OBJECTIVE

Objective
Main objective of our study is:
• To study about prevalence of anemia and associated factors in pregnant women
• And raise awareness of anemia and its effects on expectant mothers and associated
factors in pregnant women

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Chapter 5 OPERATIONAL DEFINITIONS

5.1 Anemia
Anemia is a medical condition marked by a lack of red blood cells or hemoglobin in the
blood. A protein named hemoglobin is found in red cells(RBC), is in charge of carrying oxygen
throughout the body. Numerous factors, including insufficient red blood cell synthesis, increased
red blood cell oxidation, and excessive bleeding, can contribute to anemia. The most typical signs
of anemia include weakness, exhaustion, shortness of breath, pale complexion, and vertigo. A diet
change, medication, or blood transfusions may be used to treat anemia, depending on the
underlying reason.
5.2 Types of Anemia
5.2.1 Microcytic anemia is a kind of anemia that is specified by very small RBCs.
There are numerous reasons why this might happen, including:
• Iron deficiency anemia: The most prevalent reason for microcytic anemia is
this. It occurs when the body cannot produce enough hemoglobin, the protein
that transport oxygen in red blood cells, due to insufficiency of iron in the body
• Thalassemia: A genetic disorder of blood called thalassemia affects how much
hemoglobin is made. A thalassemia patient's defective hemoglobin might result
in the development of smaller red blood cells.
• Anemia of chronic disease: : Individuals with cancer, autoimmune disorders, or
long-term infections are susceptible to acquiring this type of anemia It is believed
to be brought on by inflammation and other elements that prevent the body from
producing red blood cells.
• Lead poisoning: Because lead interferes with the development of heme, a substance
essential to the formation of hemoglobin, exposure to high levels of lead can result
in microcytic anemia.
• Sideroblastic anemia: When the bone marrow is unable to utilize iron to create
hemoglobin, a rare form of anemia called hemolytic anemia develops

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5.2.2 Macrocytic anemia
A kind of anemia known as macrocytic anemia is characterized by unusually big red blood cells.
This can occur due to a number of different causes, including:

• Vitamin B12 deficiency anemia: The most frequent reason for macrocytic anemia is
this. It happens when the body is unable to produce enough healthy red blood cells due to
a lack of vitamin B12
• Folate deficiency anemia: : Another crucial vitamin for the creation of red blood cells is
folate. Macrocytic anemia can result from a folate deficiency.
• Liver disease: Some types of liver disease can affect the production of red blood cells,
leading to macrocytic anemia.
• Alcoholism: Chronic alcoholism can cause macrocytic anemia by interfering with the
absorption of nutrients like vitamin B12 and folate.
• Medications: Certain medications, such as chemotherapy drugs and some anticonvulsants,
can cause macrocytic anemia.

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Chapter 6 RESEARCH METHODOLOGY

6.1 Duration
03 months after the approval of synopsis.

6.2 Sample Size

132 Co-operative respondents were included.

The following simple formula was used for calculating the adequate sample size in prevalence
study:
𝑛 = Z2 P(P−1) /d2
The formula for calculating sample size is as follows: n = (Z2 * P * (1-P)) / (d2), where n represents
the sample size, Z is the statistic associated with the desired level of confidence, P is the expected
prevalence obtained from previous studies or a pilot study conducted by the researchers, and d is
the precision corresponding to the effect size. A commonly targeted level of confidence is 95%,
and many researchers typically report their findings using a 95% confidence interval (CI).
However, researchers who desire greater confidence may opt for a 99% confidence
interval.(Pourhoseingholi et al., 2013)
6.3 Sample Selection
Mode of research is Observational/ Cross-Sectional.

6.4 Inclusion
• Only Female Included

• Respondents from rural and urban areas will be included

• Respondents 18 to 35 years age group will be included

6.5 Exclusions
• Non cooperative respondents will be excluded

6.6 Data Collection Procedure

This cross-sectional study will be caried out in the private and public sectors for three
months after the approval of synopsis. Patients will be recruited in the study keeping in mind the
inclusion and exclusion criteria. Written informed consent will be obtained from all subjects before

22
and all possible benefits and expected risks will be explained to participants. Basic demographic
and clinical information about risk factors and medical history will be obtained from patients and
noted down on a pre designed data collection sheet.

6.7 Study design and participants:

This was a cross-sectional study based on a questionnaire conducted at District Head
Quarter hospital and a private hospital in Dera Ghazi Khan, City hospital Pakpattan Shareef and
a few samples are taken from Sheikh Zayed hospital Rahim Yar Khan. The study includes in 132
participants. The residency of participants is both rural and urban.

6.8 Data Analysis Procedure

Data collected through Questionnaire is analyzed by latest version of statistical software
named as SPSS 25.0 (Statistical packages for social sciences). Basic descriptive statistics will be
calculated (including median and quartile, SD, max/min, percentile). Then different statistical tests
applied to get results.

6.9 Ethical Considerations

i. Written informed consent (attached) will be taken from all the participants.
ii. All information and data collection will be kept confidential.
iii. Participants will remain anonymous throughout the study.
iv. The subjects will be informed about the disadvantages or risks of the procedure in the study.
v. They will also be informed that they will be free to withdraw at any time during the process
of the study.
vi. There will great benefits to the participant that would result from their participation in this
research.
vii. We will do everything we can to protect your privacy. Your identity will not be revealed in
any publication resulting from this study.
viii. Your participation in this research study is voluntary. You may choose not to participate
and you may withdraw your consent to participate any time. You will not be penalized in
any way should you decide not you participate or to withdraw from this study.

23
Chapter 7 RESULTS AND STATISTICAL ANALYSIS

7.1 Results
The research involved a sample of 132 patients, including normal and anemic patients.
The anemia may be mild, moderate or severe. The patients were randomly selected from pool of
patients who are referred to the Hematology department or hospital's gynecology department. The
hospital's ethics committee approved the research study and fully consent was obtained from all
participants.
There are no blood sample taken personally, the hemoglobin values are noted from the
reports of patients.
Statistical software was used to analyses the data collected., including the mean, frequency,
standard deviation, t-test, group statistic and other required tests. A p-value of less than 0.05 was
considered statistically significant.

7.2 Tables

Table 7.3.1 Mean and St. Deviation value of Hb%

N Mean Std. Deviation

Hemoglobin% 132 2.1288 .75569

Valid N 132
(listwise)

Table 7.3.1 based on the descriptive statistics it shows the result of Hb% of 132 patients which are
all pregnant. The mean value indicate that all the pregnant women are all most anemic. A few
patients are non-anemic. Standard Deviation show less variation it’s mean that there is no
variability in Hb% value in patients.

24
Table 7.3.2 Frequency and percentage of severity of anemia

Hb% Frequency Percentage%

below 8 24 18.2

8.0-9.9 73 55.3

10-11.5 29 22.0

above 11.5 6 4.5

Total 132 100.0

Table 7.3.2 shows the frequency of severity of anemia as we divided severity of anemia in the
base of Hb% value which is shown as:

Severity of anemia Hb%

Mild 10.0-11.5

Moderate 8.00-9.9

Severe Below 8.00

According to table 1.2, out of 132, 24 patients are in severe condition of anemia, 73 patients are
in moderate phase of anemia, 29 patients have mild anemia and only 6 patients are normal. This
table show that anemia is common in pregnant women.
Table 7.3.2 also indicates that there are 95.45% patients are anemic and only 4.55% patients are
normal.

25
 Table 7.3.3 Frequency of Iron Supplements

Frequency Percentage %
Yes 68 51.5
No 64 48.5
Total 132 100.0

Table 7.3.3 shows that out of 132 patients 68 (51.5%) patients take iron supplement to control
the iron deficiency anemia. Other patients may have any other type of anemia. Some normal
pregnant women also use iron supplements as prescribed by the doctor.

26
Table 7.3.4 Frequency of Balance Diet

Frequency Percent
Yes 76 57.6
No 56 42.4
Total 132 100.0

Table 7.3.4 shows that 57.6% patients take balance diet. Other 42.4% patients cannot take
normal diet. It causes anemia during pregnancy.

27
Table 7.3.5 Frequency of B12 or folic acid

Frequency Percent
Yes 28 21.2
No 104 78.8
Total 132 100.0

Table 7.3.5 indicates that 21.2% patients take B12 or folic acid supplements 78.8% patients
cannot take. It shows that mostly patients are of iron deficiency anemia who take iron
supplements.

28
 Table 7.3.6 Association of different factors with Anemia

Factors Frequency Percentage

Yes No Yes No
Education 45 87 34.1 65.90
Hypertension 33 99 25.0 75.0
Miscarriage 24 108 18.2 81.8
Exercise 43 89 32.6 67.4
Viral Infections 8 124 6.0 94.0
Abnormality in 17 115 12.9 87.1
menstrual cycle

Table 7.3.6 indicate the results of different factors which cause anemia during pregnancy.
According to table illiteracy, hypertension, miscarriage, no exercise, viral infections and
abnormality in menstrual cycle are the most common factors which cause anemia. Anemia and
levels of education in the current study, it was found that the percentage of anemia was higher in
illiterate people and lower in literate people.

29
 Figure7.3.1 Describing the severity of anemia

The given graph shows the severity of anemia . We divide severity of anemia into normal( Hb%
above 11.5), mild (Hb% 10.0-11.5), moderate( Hb% 8.0-9.9), severe ( Hb% below 8). Severity of
anemia along x-axis and number of patients along Y-axis.

30
Figure7.3.2 Indicates the education level of participants.

31
 Figure 7.3.3 Shows the age of different participants.

It shows that mostly patients are between 27-30 years old.

32
 Figure7.3.4 Determines the month of pregnancy

It shows that mostly women are in their second trimester of pregnancy.

33
Chapter 8 DISCUSSION

According to the current study, pregnant women had a higher percentage of anemia than
other groups. The percentage of anemia is 95.45%. The samples are calculated from both rural and
urban residency. According to the current study, anemia rates are higher in rural than urban areas.
However, some research indicate that anemia is more common among pregnant women living in
metropolitan areas. As contrast to our research and the present study, the prevalence of anemia is
observed to be high in some metropolitan areas of Pakistan, where it is reported to be 90.05%
(Baig-Ansari et al., 2008).
In present study we calculated percentage of anemia on the basis of its severity. On this
base we divided anemia into three phases i.e., mild, moderate and severe. The current research
demonstrates that the moderate anemia is common among expectant mothers. The percentage of
mild anemia is 22.0%, moderate anemia is 55.3% and severe anemia is 18.2%. In 2001, WHO
and another study have reported the moderate prevalence of anemia (33%) in Iran (Sadeghian et
al., 2013).
We found a lower relation between anemia and abnormality in menstrual cycle. Although
the menstrual cycle is not a primary determinant in the development of anemia, it may exacerbate
the condition in pregnant women.
Exercise as prescribed by doctor play important role in pregnancy. All most 67.4% patients
do not exercise daily as in our research and other also do not exercise regularly. In rural area mostly
women assume that daily house work is an exercise due to the lack of awareness and illiteracy.
But daily routine work is not a proper exercise. Proper exercise is that which is prescribed by
doctor during pregnancy. Due to these chances of anemia increase during pregnancy. A systematic
review was conducted that examined the relationship between exercise and oxygen delivery during
pregnancy. The review revealed that regular physical activity improved maternal oxygen-carrying
capacity, resulting in enhanced oxygen delivery to the placenta. This improved oxygenation can
positively impact fetal growth and development while supporting the prevention and management
of anemia (Serván-Mori et al., 2022).
Viral infections are the basic factors of anemia in any person. They cause anemia in
pregnant women because they cause blood deficiency. The present study shows that in 95.5%

34
anemic patients 6.0% patients have viral infection. Viral infection causes the severity of anemia.
Viral infections can contribute to an increased risk of anemia in pregnant women. Certain viral
pathogens, such as parvovirus B19 and cytomegalovirus (CMV), have been associated with the
development of anemia. The synthesis and survival of red blood cells are both directly impacted
by these viruses, which lowers hemoglobin levels.
Studies have indicated that pregnant women infected with parvovirus B19 or CMV may
experience a lack of red blood cells production due to the viral invasion of bone marrow cells
responsible for erythropoiesis. This disruption in red blood cell synthesis can contribute to the
development of anemia during pregnancy (Hardy, 1965).
The hypertension is another factor which cause anemia during pregnancy. The present
study indicate that 25.0% pregnant women are victim of anemia. Both anemia and hypertension
combine to cause other diseases. Hypertension can negatively affect blood flow to various organs,
including the placenta, reducing oxygen delivery to the developing fetus. This compromised
oxygenation can contribute to the development of anemia or worsen existing anemia. Additionally,
hypertensive disorders can disrupt the normal functioning of the kidneys, which play a vital role
in red blood cell production and the maintenance of overall blood composition (Milman, 2011).
Iron, B12, and folic acid deficiency are the other common causes of anemia in pregnant
women. Iron deficient women will see an exciting rise in their iron requirements throughout
pregnancy. If treatment is delayed in iron deficiency anemia, both the prevalence and the severity
of the condition may significantly rise when the ladies are pregnant.
The likelihood of anemia during pregnancy varies greatly by geographical area. Europe
and the Americas have the lowest frequency of iron deficiency anemia (25%) while South-East
Asia and Africa have the highest prevalence (48 and 57%, respectively). In Denmark, contrasting
to pregnant women who take 40 mg of iron supplements daily, who have anemia at a prevalence
of less than 5%, pregnant women who do not take iron supplements have a prevalence of anemia
of 25% (Milman, 2011).
Folic acid insufficiency is the other fundamental factor shortage that causes anemia. Since
folic acid deficiency anemia in many communities has not been as fully examined as iron
deficiency anemia or the usage of iron supplements up to this point, further study is necessary
before we can have a clearer picture of the incidence of folate insufficiency in numerous
populations. Megaloblastic anemia, which has a high mean cell volume, is a specific kind of

35
anemia caused by folic acid deficiency. According to estimates, up to 25% to 72% of pregnant
women in underdeveloped nations suffer from a folic acid shortage (de Benoist, 2008). Folic acid
deficiency is linked to a high risk of neural tube malformations and other organ problems in fetuses
and newborn newborns. The second most common vitamin deficiency that results in anemia, a
megaloblastic anemia with a high mean cell volume, is probably vitamin B12 deficiency. 40% of
pregnant women, according to studies from Lebanon and Turkey, had vitamin B12 deficiencies,
which may be brought on by the pernicious anemia or the food cobalamin malabsorption syndrome
in addition to inadequate dietary vitamin B12 consumption. The lack of vitamin B12 is a major
issue in poor nations (Al Khatib et al., 2006).
We found that 51.5% patients take iron supplements and 21.2% patients take folic acid or
B12 supplements to control anemia. The rest patients cannot use these supplements so the risks of
anemia are high in them. These nutritional supplements are used to manage anemia. mostly folic
acid or B12 deficient anemia and iron deficiency anemia.
Miscarriage is also a factor which cause anemia in next pregnancy. In our research 18.2%
patients are found who have the previous history of miscarriage. These patients are anemic with
different severity of anemia. The impact of miscarriage on anemia risk lies in the potential
depletion of essential nutrients during the pregnancy loss. If the body does not fully recover from
the miscarriage or if proper nutrition is not maintained, it can lead to deficiencies that increase the
risk of anemia during subsequent pregnancies (O’Kelly et al., 2022).
The other most important factor is education. Illiteracy causes anemia because pregnant
women who are un educated do not know the factors or diet plan become the victim of anemia. In
this present study 65.9% patients are uneducated. So, they do not know the factors of anemia or
how to overcome anemia, therefore they became the victim of anemia. 34.1% patients are educated
they control anemia by different methods as they know the risk factors and knowledge about
anemia. The situation of anemia increases steadily with the decrease of education level. Education
is connected with anemia high the education low the anemia and vice versa. Aurangabad City,
India, pregnant women with primary, middle, and secondary education had anemia rates of 96.4%,
94.8%, 92.1%, and 91.5%, respectively, according to a prior study. In Jima town, Southwest
Ethiopia, anemia prevalence among illiterate women was highest at 53.7% compared to literate
women's prevalence of 37.1% (Ullah et al., 2013).

36
Chapter 9 CONCLUSION

Among the current study, anemia was prevalent among pregnant women to a significant
degree (95.5%). The percentage was high in rural area as compared to the urban. We divided the
severity of anemia into three phases i.e., mild, moderate, and severe. The present study determines
that moderate anemia is high in pregnant women as compared to other. The percentage of mild,
moderate, and severe is 22.0%, 55.3%, and 18.2% respectively.
Also, the percentage of anemia among un educated pregnant women is high about 65%.
Moderate anemia is also determined in educated pregnant women. We found that in second and
third trimester of pregnancy, mostly pregnant women become the victim of any type of anemia
because the fetus requirements increase constantly. Mostly organs and body parts are formed in
these months so the requirements of fetus increase.
We also revealed the fundamental causes of anemia during pregnancy. The current
investigation found that a deficiency in iron, folic acid, or vitamin B12 commonly results in
anemia. Megaloblastic anemia is brought on by folic acid and vitamin B12 deficiency, whereas
iron shortage results in iron deficiency anemia. 51.5 % pregnant women take iron supplements that
is mean these are all victims of iron deficiency anemia. And 22% patients take folic acid or B12
supplements, it shows that they have megaloblastic anemia.
Other factors which are discussed here are hypertension, miscarriage, abnormality in
menstrual cycle etc. These all factors cause anemia in different ways.

37
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41
Questionnaire

A Survey Based Study to Find out the prevalence of Anemia and associated factors in
pregnant women in South Punjab.

We are students of BS Medical Laboratory Technology (8th semester) in Khawaja Fareed university
of engineering and Information Technology, Rahim Yar Khan. We have been assigned to do a
survey on to find out the prevalence of anemia and associated factors in pregnant women in South
Punjab. This survey is purely for educational and awareness purpose. We assure you that the
obtained data will be confidential in every respect. We shall appreciate your response.

The questionnaire consists of three parts. First part was concerned with demographics of the
respondents. The second part consist of survey based upon associated factors of anemia and the

third part differentiate severity of anemia.

Table: 1 Demographics Characteristics

Age

18-22

23-26

27-30

31-34

35………

Residence

Rural

Urban

42
 Month of pregnancy

1-3

4-6

7-9

Table: 2 Survey based upon associated factors of anemia regarding pregnancy

Questions Yes No Don’t Know value

• Education

• Hb% of the respondent

• House wife

• Doing job

• Do you have any pregnancy before?

•Do you have more than four pregnancies?

•Do you eat fresh fruits, vegetables and have milk daily?

• Are you using any sort of iron supplements?

• Are you using any sort of B12 or folic acid supplements?

• Are you suffering from nausea and vomiting?

• Do you have previous history of miscarriage?

• Are you suffering from any hemorrhagic disease?

• Do you take exercise daily?

43
• Are you suffering from viral infections?

• Are you suffering from stress or hypertension?

• Do you have normal Hb% before pregnancy?

•Is your Hb% low in every pregnancy?

•Do you feel any abnormality during menstrual cycle?

•Do you suffer from lethargy and light headedness During pregnancy?

Table: 3 Severity of anemia

Severity of anemia Hb%

Normal Above 11.5

Mild 10.0-11.5

Moderate 8.00-9.9

Severe Below 8.00

44