|Year : 2019 | Volume
| Issue : 1 | Page : 51-55
Anemia among pregnant women attending antenatal clinic at a secondary health care facility in district Faridabad, Haryana
Shashi Kant, Sumit Malhotra, Partha Haldar, Ravneet Kaur, Rakesh Kumar
Comprehensive Rural Health Services Project, Ballabgarh, Haryana; Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||4-Jul-2019|
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Background: India confronts a high burden of anemia among pregnant women, that contributes to significant morbidity and mortality for mother and child. Anemia Mukt Bharat strategy launched by Government of India envisages provision of variety of facility-based interventions for management of anemia in pregnancy. Secondary care hospitals prescribe injectable iron treatment for moderate anemia and blood transfusion services for severe anemia.
Objective: To estimate the magnitude and severity of anemia among pregnant women when they presented themselves for the first time at the antenatal care clinic of a secondary care hospital so as to forecast adequate supplies of medicines for managing anemia.
Materials and Methods: This was a descriptive study using routinely maintained hospital clinical records during the years 2013–2015. It was conducted in a subdistrict hospital, Ballabhgarh in Faridabad district of Haryana state. Hemoglobin (Hb) level was routinely measured at first visit for all pregnant women using BC-3000 plus autohematology analyzer. Anemia in pregnancy was considered when Hb concentration was <11.0 g/dL.
Results: The Hb level at first visit was available for 13,467 women during the study period. The mean Hb level (standard deviation) was 9.3 g/dL (1.3). The proportion of anemic pregnant women was 91.3% (95% confidence interval [CI]: 90.8, 91.7). The most common category of anemia was moderate anemia 62.5% (95% CI: 61.6, 63.2).
Conclusion: We found a very high prevalence of anemia in pregnant women presenting to a secondary care setting of a North Indian hospital during their first visit to the facility during the antenatal period.
Keywords: Anemia, Ballabhgarh, pregnancy, secondary care
|How to cite this article:|
Kant S, Malhotra S, Haldar P, Kaur R, Kumar R. Anemia among pregnant women attending antenatal clinic at a secondary health care facility in district Faridabad, Haryana. Indian J Community Fam Med 2019;5:51-5
|How to cite this URL:|
Kant S, Malhotra S, Haldar P, Kaur R, Kumar R. Anemia among pregnant women attending antenatal clinic at a secondary health care facility in district Faridabad, Haryana. Indian J Community Fam Med [serial online] 2019 [cited 2019 Jul 20];5:51-5. Available from: http://www.ijcfm.org/text.asp?2019/5/1/51/262125
| Introduction|| |
Anemia is one of the most common prevalent nutritional public health problems globally and in India. Anemia has significant adverse health consequences affecting social and economic development. The World Health Organization (WHO) estimates anemia to affect 800 million children and women in year 2011. The global prevalence of anemia for pregnant women was 38.2% (95% confidence interval [CI] 33.5–42.6) during the year 2011. According to recent round of National Family Health Survey-4 (NFHS-4) (2015–2016), 50% pregnant women in India were anemic, indicative that the condition is of severe public health significance.
Approximately 50% of anemia among women is due to iron deficiency. Iron deficiency anemia during pregnancy is associated with higher morbidity and mortality among both mother and child. In year 2012, the World Health Assembly Resolution 65.6 endorsed a comprehensive implementation plan on maternal, infant, and young child nutrition that targeted 50% reduction of anemia in women of reproductive age group.
The Indian Public Health Service Standards and quality benchmarks for secondary care hospitals prescribes injectable iron treatment for moderate anemia and blood transfusion services for severe anemia., Early identification of pregnant women with moderate and severe anemia is of particular importance. It would give us sufficient time to correct their anemic status; and thus, the mother–child pair could expect to reap benefit from the intervention.
Therefore, we tried to estimate the magnitude and severity of anemia among pregnant women when they presented themselves for the first time at the antenatal care clinic of a secondary care hospital. For provision of efficient services and inventory management of supplies, such an information is a necessity.
| Materials and Methods|| |
This was a descriptive study using routinely maintained hospital clinical records.
The study was conducted in a subdistrict hospital (SDH), Ballabhgarh in Faridabad district of Haryana state. This was a secondary care hospital, with outpatient and inpatient services. Antenatal care clinic was held thrice in a week. The hospital also provided delivery services that included normal, assisted deliveries, and cesarean sections. Both basic and emergency obstetric care services were available for pregnant women at SDH Ballabhgarh.
The study population comprised of pregnant women attending antenatal outpatient department at SDH Ballabhgarh during the years 2013–2015 (January–December). The hospital is located in Ballabhgarh town with a population around 187,000. Pregnant women who registered themselves for the first time for antenatal care were included. These pregnant women mostly resided in area adjoining SDH Ballabhgarh and surrounding areas from Faridabad and Palwal districts. Largely, the population belonged to urban and peri-urban area and represented lower to middle socioeconomic strata. More details about our hospital and other services are mentioned elsewhere. Hemoglobin (Hb) level was routinely measured at first visit for all pregnant women.
Hb was measured using BC-3000 plus autohematology analyzer (Mindray bio-medical electronics Co., Ltd.; Shenzen, Guangdong, China). This was a quantitative, automated hematology analyzer for in vitro diagnostic use in clinical laboratories. Two milliliters of blood was obtained by venepuncture following aseptic conditions by a trained laboratory technician within SDH, Ballabhgarh, and collected in a salt of dipotassium ethylenediaminetetraacetic acid. The sample was then subjected to analyzer, and hemoglobin was estimated using colorimetric method. Well-qualified laboratory technician performed the testing procedure. For each batch of test, simultaneous running control panels as recommended by the manufacturer of the machine were also included as a quality control measure.
Data collection, entry, and analysis
Data were retrieved through records and registers maintained within the laboratory of SDH, Ballabhgarh. The relevant details pertaining to registered pregnant women including registration number, age, and Hb level at the time of first visit were entered in Microsoft Office Excel spreadsheet database. Women, whose Hb measurement was missing, were excluded from the analysis. The analysis was done by STATA software version 12.0 (StataCorp., College Station, Texas, USA). The data are descriptively summarized.
Operational definitions for the study: The WHO recommendations for Hb concentrations were used for reporting anemia in this study. Anemia in pregnancy was considered when Hb concentration was <11.0 g/dL. Mild anemia was considered when Hb concentration range was between 10.0 and 10.9 g/dL. Moderate anemia was considered when Hb concentration was between 7.0 and 9.9 g/dL and severe anemia was taken as Hb concentration less <7.0 g/dL.
| Results|| |
A total of 17,428 pregnant women were registered during 2013–2015. Of these, measurement of Hb level at first visit was available for 13,467 women. The remaining 3961 (23%) pregnant women whose Hb level was not available were excluded from further analysis. The mean age (standard deviation [SD]) of the pregnant women was 23.8 (3.6) years.
The range of Hb level was from 2.5 g/dL to 15.2 g/dL. The distribution of Hb level is shown in [Figure 1]. The mean Hb level (SD) was 9.3 g/dL (1.3).
|Figure 1: Distribution of pregnant women at subdivisional hospital, Ballabhgarh by their hemoglobin level|
Click here to view
The proportion of anemic pregnant women was 91.3% (95% CI: 90.8, 91.7) [Table 1]. The proportion of mild anemia was 23.9% (95% CI: 23.2, 24.6). The most common category of anemia was moderate anemia 62.5% (95% CI: 61.6, 63.2). The proportion of severe anemia was 4.9% (95% CI: 4.6, 5.3). Mean Hb concentrations in these categories are represented in [Table 1].
|Table 1: Distribution of first-time antenatal care clinic attendees at subdistrict hospital, Ballabhgarh by their anemia status, 2013–2015|
Click here to view
| Discussion|| |
The WHO defines anemia to be of severe public health significance when it is present in >50% of the concerned population group. The reported prevalence of anemia among antenatal women ranges from 50% to 96%.,,,, The wide range in the reported prevalence in these studies could be due to variation in demographic profile, place of residence, sociocultural reasons, dietary differences, study methodology, sample size, Hb testing procedures, etc., The most recent round of NFHS-4 (2015–2016) reported overall 50% of pregnant women in urban Haryana to be anemic. The Hb level in NFHS-4 was measured by HemoCue method. We had used automated hematology analyzer for measuring Hb. Automated analyzers have higher precision for detecting anemia over HemoCue method. Despite the decline noted over different rounds of NFHS, the prevalence of anemia had remained >50%, indicating that anemia was of severe public health significance. Our finding of 91.3% of pregnant women reporting to SDH being anemic was much higher than the 55% (overall) reported for pregnant women in Haryana in NFHS-4. One possible reason could be due to our antenatal services being free, had attracted urban poor in greater proportion. Urban poor are more likely to be anemic.,
A study conducted in two villages of Delhi among women in early pregnancy (12–20 weeks of gestation) reported similar high proportions of pregnant women to be anemic (96.5%) as found in our study. A multicentric study conducted in seven states of India reported anemia in 84% of pregnant women. The study found maximum women having moderate degree of anemia (51%), which was similar to our findings. A previous community-based study in our study area had reported 73.4% of pregnant women deficient in iron and 75% were consuming <50% of the recommended iron. However, we had not ascertained factors associated with anemia in our study. Urban poor are likely to be underweight with low education and higher number of births. These factors have been found to be associated with higher odds for moderate and severe anemia. We had not collected information on socioeconomic status and residential address. However, if our assumption that large proportion of pregnant women reporting to SDH were urban poor is correct, then it would explain the high rate of prevalence observed.
The proportion of pregnant women with moderate anemia was largest. Correction of their anemic status or even shifting them to milder status of anemia through appropriate therapeutic interventions will be beneficial to the women themselves as well as the unborn baby. The Indian Obstetric Surveillance System in Assam reported women with severe anemia had higher odds of Post-Partum Hemorrhage (PPH) (adjusted odds ratio [aOR] 9.5, 95% CI:2.6, 34.0); low birth weight babies (aOR 6.2, 95% CI: 1.4, 26.7) and small for gestational age babies (aOR 8.7, 95% CI: 4.4, 61.5). Odds of PPH increased seventeen fold among women with moderate-to-severe anemia who underwent induction of labor and nineteen fold among women who had infection and moderate-to-severe anemia. We found that the proportion of severely anemic pregnant women were 5%. Such women were thus at a higher risk of adverse pregnancy outcome.
In year 2016, the hospital took a policy decision to implement recommendations of Indian Public Health Services Standards for treatment of moderately anemic pregnant women by injectable iron. We had chosen to administer intravenous iron-sucrose (IVIS) which came as vial each containing 100 mg of elemental iron. The management was faced with the question regarding numbers of vials of IVIS to be procured to implement the program. To answer this question, two information were crucial, i.e., total number of moderately anemic women and their mean Hb level. The current study findings provided both the information. Thus, based on these information, we could use Ganzoni formula to calculate average amount of elemental iron required for each moderately anemic pregnant women. This formula considers weight of woman and current Hb level to calculate dose for computing iron deficit. The recently initiated test and treat strategy under Anemia Mukt Bharat strategy as part of Intensified National Iron plus Initiative recommends point-of-care treatment for anemic individuals including oral and injectable preparations. It requires planning and maintaining adequate supplies at the facility level for providing appropriate care to anemic women. We were therefore able to take informed decision regarding the number of IVIS vials to be procured for efficient service provision. Our findings are of great relevance to similar settings and facilities that are managing anemia in pregnancy. Our study found that moderate anemia is the most common presentation among pregnancy, and thus, if these women be managed adequately during the pregnancy period, the iron reserves can sufficiently be increased to mitigate the risks posed during pregnancy and childbirth both for mother and baby.
The data were retrieved from records/registers and therefore likely to be unbiased. Tool used for measurement of Hb was appropriate. The staff was well qualified, and quality control measures were in place. Hence, the Hb measurement was valid. The analysis included large numbers of pregnant women who reported to ANC clinic of a secondary care hospital. This yielded a more precise estimate of prevalence of anemia with narrow CIs. We did not have Hb level of 3961 women and were excluded from this analysis. Missing data is a usual limitation of retrospective reviews conducted with routine clinical records. We could not identify any particular reason which could cause those included to be systematically different from those excluded. Therefore, though a large proportion (23%) of pregnant women were excluded from the analysis, we believe it would not adversely affect the validity of the findings. Based on our personal experience, we had assumed that the pregnant women came from area adjoining SDH. However, we do not have firm data to validate this assumption. In the absence of residential address of the pregnant women attending this hospital, the findings of this study may not be extrapolated to any specific population group. Hence, severity in public health terms cannot be directly deemed. Furthermore, we did not have details of women regarding their period of gestation, past obstetric history, etc., that could affect their Hb concentration. This was because Hb level of women were retrieved from laboratory registers that did not capture these additional information. Furthermore, our primary objective was to see the distribution of Hb concentrations among the pregnant women and not ascertain the determinants of anemia in these women. To examine them, additional details would be required including the dietary intake of the women and can be captured in future by conducting further cross-sectional and prospective studies in our setting.
| Conclusion|| |
We found a very high prevalence of anemia in pregnant women (91%) with moderate degree of anemia the most common (62.5%) among all categories of anemia. Based on the magnitude and proportion of different categories of anemia, we were able to forecast the requirement of iron-sucrose vial for managing pregnant women reporting to SDH Ballabhgarh.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. The Global Prevalence of Anaemia in 2011. Geneva: World Health Organization; 2015.
International Institute for Population Sciences (IIPS) and Government of India. National Family Health Survey-4. 2015-16. India Fact Sheet. International Institute for Population Sciences (IIPS) and Government of India; 2017.
World Health Organization. Haemoglobin concentrations for the Diagnosis of Anaemia and Assessment of Severity. Vitamin and Mineral Nutrition Information System. Geneva: World Health Organization (WHO/NMH/NHD/MNM/11.1); 2011. Available from: http://www.who.int/vmnis/indicators/haemoglobin.pdf
. [Last accessed on 2017 Jun 01].
Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca F, et al.
Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: A systematic analysis of population-representative data. Lancet Glob Health 2013;1:e16-25.
Kalaivani K. Prevalence and consequences of anaemia in pregnancy. Indian J Med Res 2009;130:627-33.
] [Full text]
World Health Organization. Resolution WHA 65.6. comprehensive implementation plan on maternal, infant and young child nutrition. In: Sixty-fifth World Health Assembly Geneva, 21-26 May, 2012. Resolutions and Decisions, Annexes. Geneva: World Health Organization; 2012. p. 12-3. Available from: http://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1
. [Last accessed on 2017 Jun 01].
National Health Mission. Assessor's Guidebook for Quality Assurance in Community Health Centres (First Referral Unit). Ministry of Health and Family Welfare. Government of India; 2014.
National Health Mission. Assessor's Guidebook for Quality Assurance in District Hospitals. Ministry of Health and Family Welfare. Government of India; 2013.
Kant S, Misra P, Gupta S, Goswami K, Krishnan A, Nongkynrih B, et al.
The Ballabgarh health and demographic surveillance system (CRHSP-AIIMS). Int J Epidemiol 2013;42:758-68.
Prashant D, Jaideep KC, Girija A, Mallapur MD. Prevalence of anaemia among pregnant women attending antenatal clinics in rural field practice area of Jawaharlal Nehru Medical College, Belagavi, Karnataka, India. Int J Community Med Public Health 2017;4:537-41.
Vemulapalli BK, Rao K. Prevalence of anaemia among pregnant women of rural community in Vizianagaram, North Costal Andhra Pradesh, India. Asian J Med Sci 2014;5:21-5.
Bano F, Mahajan PC. Study of anaemia among pregnant women in urban areas of Kanpur. Rama Univ Med Sci 2016;2:1-5.
Kumar GS, Premarajan K, Kar SS. Anemia among antenatal mothers with better healthcare services in a rural area of India. J Res Med Sci 2013;18:171.
Lokare PO, Karangekar VD, Gattani PL, Kulkarni AP. A study of prevalence of anaemia and sociodemographic factors associated with anaemia among pregnant women in Aurangabad city, India. Ann Niger Med 2012;6:30-5.
International Institute for Population Sciences (IIPS) and Government of India. National Family Health Survey-4. 2015-16. State Fact Sheet. Haryana: International Institute for Population Sciences (IIPS) and Government of India; 2017.
Adam I, Ahmed S, Mahmoud MH, Yassin MI. Comparison of HemoCue® hemoglobin-meter and automated hematology analyzer in measurement of hemoglobin levels in pregnant women at Khartoum hospital, Sudan. Diagn Pathol 2012;7:30.
World Health Organization. Iron Deficiency Anaemia – Assessment, Prevention and Control. A Guide for Programme Managers. World Health Organization; 2001.
Diamond-Smith NG, Gupta M, Kaur M, Kumar R. Determinants of persistent anemia in poor, urban pregnant women of Chandigarh city, North India: A mixed method approach. Food Nutr Bull 2016;37:132-43.
Agarwal S, Sethi V. Nutritional disparities among women in urban India. J Health Popul Nutr 2013;31:531-7.
Gautaum VP, Bansal Y, Taneja DK, Saha R. Prevalence of anaemia amongst pregnant women and its socio-demographic associates in a rural area of Delhi. Indian J Community Med 2002;27:157-60.
Agarwal KN, Agarwal DK, Sharma A, Sharma K, Prasad K, Kalita MC, et al.
Prevalence of anaemia in pregnant lactating women in India. Indian J Med Res 2006;124:173-84.
] [Full text]
Pathak P, Kapil U, Kapoor SK, Saxena R, Kumar A, Gupta N, et al.
Prevalence of multiple micronutrient deficiencies amongst pregnant women in a rural area of Haryana. Indian J Pediatr 2004;71:1007-14.
Nair M, Choudhury MK, Choudhury SS, Kakoty SD, Sarma UC, Webster P, et al.
Association between maternal anaemia and pregnancy outcomes: A cohort study in Assam, India. BMJ Glob Health 2016;1:e000026.
Ganzoni AM. Intravenous iron-dextran: Therapeutic and experimental possibilities. Schweiz Med Wochenschr 1970;100:301-3.