An analysis of anemia and pregnancy-related maternal mortality

Understanding the Determinants of Anemia Reduction among Women of Reproductive Age: Exemplar Country Case-Studies' Methodology

BACKGROUND

Since 2000, only a few countries have substantially reduced the burden of anemia among women 15-49 years of age. The Exemplars in Anemia Reduction among Women of Reproductive Age (WRA) studied the determinants of success among these countries.

OBJECTIVE

To describe the methodology used to determine the factors associated with anemia reduction in high-performing countries, with the aim to guide policy and programmatic decisions in other countries with similar sociodemographic and health indices.

METHODS

This paper describes the process used to identify countries with exemplary reduction in WRA anemia burden, compared to their peers. We describe the Exemplars in Global Health methodology, the mixed-methods approach used to identify and quantify the macro- and micro-level characteristics associated with anemia burden decline among WRA. Quantitative analyses include descriptive and equity analyses, multivariate linear regression, and Oaxaca-Blinder decomposition analysis (OBDA). Qualitative analyses include in-depth interviews (IDIs) and focus group discussions (FGDs) with national, subnational, and community stakeholders, as well as review of programs and policies with the potential to impact women's health and/or nutrition, enacted in the countries over the last 20 years. A technical advisory group (TAG) oversaw all research activities.

RESULTS

We identified five countries, namely Mexico, Pakistan, Philippines, Uganda, and Senegal, as Anemia Exemplars, after considering the magnitude of anemia decline between 2000 and 2018, availability of at least two nationally representative anemia surveys, geographical diversity to account for the complex etiology of anemia, regional representation, and logistics of in-country work.

CONCLUSION

Exemplars in Anemia Reduction among WRA seeks to create awareness of how little anemia prevalence has changed globally and aims to inform and spur global efforts for improving women's health and nutrition.

Anemia in Pregnancy With CKD

Chronic kidney disease (CKD), anemia, and iron deficiency are global health issues affecting individuals in both high-income and low-income countries. In pregnancy, both CKD and iron deficiency anemia increase the risk of adverse maternal and neonatal outcomes, including increased maternal morbidity and mortality, stillbirth, perinatal death, preterm birth, and low birthweight. However, it is unknown to which extent iron deficiency anemia contributes to adverse outcomes in CKD pregnancy. Furthermore, little is known regarding the prevalence, pathophysiology, and treatment of iron deficiency and anemia in pregnant women with CKD. Therefore, there are many unanswered questions regarding optimal management with oral or i.v. iron and recombinant human erythropoietin (rhEPO) in these women. In this review, we present a short overview of the (patho)physiology of anemia in healthy pregnancy and in people living with CKD. We present an evaluation of the literature on iron deficiency, anemia, and nutritional deficits in pregnant women with CKD; and we evaluate current knowledge gaps. Finally, we propose research priorities regarding anemia in pregnant women with CKD.

Anaemia and red blood cell transfusion in women with placenta accreta spectrum: an analysis of 38,060 cases

Placenta accreta spectrum (PAS) has become a significant life-threatening issue due to its increased incidence and associated morbidity and mortality. Pregnancy is often associated with states of anaemia, and severe maternal haemorrhage represents a major risk factor for red blood cell (RBC) transfusion. The present study retrospectively analyzed the prevalence of anaemia, transfusion requirements and outcome in women with PAS. Using data from the German Statistical Office pregnant patients with deliveries hospitalized between January 2012 and December 2021 were included. Primary outcome was the prevalence of anemia and administration of RBCs. Secondary outcome were complications in women with PAS who received RBC transfusion. In total 6,493,606 pregnant women were analyzed, of which 38,060 (0.59%) were diagnosed with PAS. The rate of anaemia during pregnancy (60.36 vs. 23.25%; p < 0.0001), postpartum haemorrhage (47.08 vs. 4.41%; p < 0.0001) and RBC transfusion rate (14.68% vs. 0.72%; p < 0.0001) were higher in women with PAS compared to women without PAS. Women with PAS who had bleeding and transfusion experienced significantly more peripartum complications than those who did not. A multiple logistic regression revealed that the probability for RBC transfusion in all pregnant women was positively associated with anaemia (OR 21.96 (95% CI 21.36-22.58)). In women with PAS, RBC transfusion was positively associated with the presence of renal failure (OR 11.27 (95% CI 9.35-13.57)) and congestive heart failure (OR 6.02 (95% CI (5.2-7.07)). Early anaemia management prior to delivery as well as blood conservation strategies are crucial in women diagnosed with PAS.

Prevalence of and risk factors for iron deficiency among pregnant women with moderate or severe anaemia in Nigeria: a cross-sectional study

BACKGROUND

Anaemia during pregnancy causes adverse outcomes to the woman and the foetus, including anaemic heart failure, prematurity, and intrauterine growth restriction. Iron deficiency anaemia (IDA) is the leading cause of anaemia and oral iron supplementation during pregnancy is widely recommended. However, little focus is directed to dietary intake. This study estimates the contribution of IDA among pregnant women and examines its risk factors (including dietary) in those with moderate or severe IDA in Lagos and Kano states, Nigeria.

METHODS

In this cross-sectional study, 11,582 women were screened for anaemia at 20-32 weeks gestation. The 872 who had moderate or severe anaemia (haemoglobin concentration < 10 g/dL) were included in this study. Iron deficiency was defined as serum ferritin level < 30 ng/mL. We described the sociodemographic and obstetric characteristics of the sample and their self-report of consumption of common food items. We conducted bivariate and multivariable logistic regression analysis to identify risk factors associated with IDA.

RESULTS

Iron deficiency was observed among 41% (95%CI: 38 - 45) of women with moderate or severe anaemia and the prevalence increased with gestational age. The odds for IDA reduces from aOR: 0.36 (95%CI: 0.13 - 0.98) among pregnant women who consume green leafy vegetables every 2-3 weeks, to 0.26 (95%CI: 0.09 - 0.73) among daily consumers, compared to those who do not eat it. Daily consumption of edible kaolin clay was associated with increased odds of having IDA compared to non-consumption, aOR 9.13 (95%CI: 3.27 - 25.48). Consumption of soybeans three to four times a week was associated with higher odds of IDA compared to non-consumption, aOR: 1.78 (95%CI: 1.12 - 2.82).

CONCLUSION

About 4 in 10 women with moderate or severe anaemia during pregnancy had IDA. Our study provides evidence for the protective effect of green leafy vegetables against IDA while self-reported consumption of edible kaolin clay and soybeans appeared to increase the odds of having IDA during pregnancy. Health education on diet during pregnancy needs to be strengthened since this could potentially increase awareness and change behaviours that could reduce IDA among pregnant women with moderate or severe anaemia in Nigeria and other countries.

Association of iron therapy with incidence of chronic kidney disease

OBJECTIVE

We investigated the association of oral iron replacement with the incidence of chronic kidney disease (CKD) in a population with normal kidney function to study the effects of iron replacement on the development of new onset CKD.

METHODS

In a national cohort of US Veterans with no pre-existing CKD, we identified 33 894 incident new users of oral iron replacement and a comparable group of 112 780 patients who did not receive any iron replacement during 2004-2018. We examined the association of oral iron replacement versus no iron replacement with the incidence of eGFR <60 mL/min/1.73 m2 and the incidence of urine albumin creatinine ratio (UACR) ≥30 mg/g in competing risk regressions and in Cox models. We used propensity score weighing to account for differences in key baseline characteristics associated with the use of oral iron replacement.

RESULTS

In the cohort of 146 674 patients, a total of 18 547 (13%) patients experienced incident eGFR <60 mL/min/1.73 m2 , and 16 117 patients (11%) experienced new onset UACR ≥30 mg/g. Oral iron replacement was associated with significantly higher risk of incident eGFR <60 mL/min/1.73 m2 (subhazard ratio, 95% confidence interval [CI]: 1.3 [1.22-1.38], p < .001) and incident albuminuria (subhazard ratio, 95% CI: 1.14 [1.07-1.22], p < .001).

CONCLUSION

Oral iron replacement is associated with higher risk of new onset CKD. The long-term kidney safety of oral iron replacement should be tested in clinical trials.

Determinants of anemia level among reproductive-age women in 29 Sub-Saharan African countries: A multilevel mixed-effects modelling with ordered logistic regression analysis

BACKGROUND

Despite the implementation of different nutritional and non-nutritional interventions, 43% of reproductive-age women in Africa suffer from anemia. Recent evidence also shows that none of the Sub-Saharan African (SSA) countries are on the track to achieve the nutrition target of 50% anemia reduction by 2030. To date, information on the level of anemia and its determinants among reproductive-age women at the SSA level is limited. Thus, this study aimed to estimate the pooled prevalence of anemia level and its determinants in SSA countries.

METHODS

We used a pooled data of 205,627 reproductive-age women from the recent demographic and health surveys of 29 SSA countries that were conducted between 2010-2021. A multilevel mixed-effects analysis with an ordered logistic regression model was fitted to identify determinants of anemia level and the deviance value was used to select the best-fitted model. First, bivariable ordinal logistic regression analysis was done and the proportional odds assumption was checked for each explanatory variable using a Brant test. Finally, in a multivariable multilevel ordinal logistic regression model, a p-value<0.05 and AOR with the corresponding 95% CI were used to identify determinants of anemia level. All analyses were done using Stata version 17 software.

RESULTS

The pooled prevalence of anemia among women of reproductive age in SSA was 40.5% [95% CI = 40.2%-40.7%], where 24.8% [95% CI: 24.6%-25.0%], 11.1% [95% CI = 10.9%-11.2%], and 0.8% [95% CI = 0.7%-0.8%] had mild, moderate, and severe anemia, respectively. The prevalence significantly varied from the lowest of 13% in Rwanda to the highest of 62% in Mali, and anemia was found as a severe public health problem (prevalence of ≥ 40%) in 18 countries. The regression result revealed that polygamous marriage, women and husband illiteracy, poor household wealth, shorter birth interval, non-attendance of antenatal care, underweight, unimproved toilet and water facilities, and low community-level women literacy were positively linked with high anemia level. Additionally, the likelihood of anemia was lower in women who were overweight and used modern contraception.

CONCLUSIONS

Overall results showed that anemia among women of reproductive age is a severe public health problem in SSA countries, affecting more than four in ten women. Thus, enhancing access to maternal health services (antenatal care and contraception) and improved sanitation facilities would supplement the existing interventions targeted to reduce anemia. Moreover, strengthening women's education and policies regulating the prohibition of polygamous marriage are important to address the operational constraints.

Quantifying differences in iron deficiency-attributable anemia during pregnancy and postpartum

Pregnant women in resource-limited settings are highly susceptible to anemia and iron deficiency, but the etiology of postpartum anemia remains poorly defined. To inform the optimal timing for anemia interventions, changes in iron deficiency-attributable anemia through pregnancy and postpartum need to be understood. In 699 pregnant Papua New Guinean women attending their first antenatal care appointment and following up at birth and 6 and 12 months postpartum, we undertake logistic mixed-effects modeling to determine the effect of iron deficiency on anemia and population attributable fractions, calculated from odds ratios, to quantify the contribution of iron deficiency to anemia. Anemia is highly prevalent during pregnancy and 12 months postpartum, with iron deficiency increasing the odds of anemia during pregnancy and, to a lesser extent, postpartum. Iron deficiency accounts for ≥72% of anemia during pregnancy and 20%-37% postpartum. Early iron supplementation during and between pregnancies could break the cycle of chronic anemia in women of reproductive age.

Maternal Nutritional Status and the Microbiome across the Pregnancy and the Post-Partum Period

Appropriate nutrition during pregnancy and the post-partum period is vital for both the mothers and their offspring. Both under- and over-nourished status may have important microbial implications on the maternal and infant gut microbiomes. Alterations in the microbiome can have implications for a person's risk of obesity and metabolic diseases. In this review, we examine alterations in the maternal gut, vaginal, placental, and milk microbiomes in the context of pre-pregnancy BMI, gestational weight gain, body composition, gestational diabetes, and maternal diet. We also investigate how the infant gut microbiome may be altered by these different parameters. Many of the microbial changes seen in under- and over-nourished states in birthing parents may result in long-term implications for the health of offspring. Differences in diet appear to be a major driver of the maternal and subsequently milk and offspring microbiomes. Further prospective longitudinal cohort studies are needed to examine nutrition and the microbiome to better understand its implications. Additionally, trials involving dietary interventions in child-bearing age adults should be explored to improve the mother and child's risks for metabolic diseases.

The interplay between maternal-infant anemia and iron deficiency

Iron deficiency anemia in pregnancy is a major public health problem known to cause maternal morbidity and adverse birth outcomes, and it may also have lasting consequences on infant development. However, the impact of the maternal hematological environment on fetal and infant hemoglobin and iron stores in the first year of life remains unclear. This review of the epidemiological evidence found that severe maternal iron deficiency anemia in pregnancy is associated with lower ferritin, and to a lesser degree hemoglobin levels, in infants at birth. Emerging data also suggests that severe anemia in pregnancy increases the risk of iron deficiency and anemia in infants 6-12 months of age, although longitudinal studies are limited. Effective anemia prevention in pregnancy, such as iron supplementation, could reduce the risk of infant anemia and iron deficiency during the first year of life; however, more evidence is needed to determine the functional impact of iron supplementation in pregnancy on infant hematological indices.

Optimal predelivery hemoglobin to reduce transfusion and adverse perinatal outcomes

BACKGROUND

Maternal anemia has been associated with poor obstetrical outcomes; however, the optimal hemoglobin level for reducing blood transfusion at delivery has not been well-defined.

OBJECTIVE

This study aimed to measure the association of maternal anemia immediately before delivery with peripartum transfusion and other adverse perinatal outcomes. We also sought to identify the optimal hemoglobin level for predicting transfusion.

STUDY DESIGN

This was a retrospective cohort study of patients who had hemoglobin or hematocrit collected before delivery of live, nonanomalous neonates at ≥23 weeks' gestation at a single center (2013-2018). Patients were excluded if they had sickle cell disease or were receiving anticoagulation. Patients were categorized as having anemia or no anemia on the basis of predelivery hemoglobin or hematocrit levels using criteria set by the American College of Obstetricians and Gynecologists. The primary outcome was transfusion of ≥1 unit of packed red blood cells during the delivery admission. Secondary outcomes included select adverse perinatal outcomes. Bivariable analyses compared baseline characteristics and outcomes between the anemia and no-anemia groups. Multivariable logistic regression estimated the association between anemia and outcomes. The hemoglobin cutoff optimizing sensitivity and specificity for transfusion was identified by the Liu method.

RESULTS

Of the 18,357 patients included in the analysis, 5444 (30%) had predelivery anemia (mean hemoglobin, 10.0±0.8 g/dL) vs 12,913 (70%) who did not (mean hemoglobin, 12.3±1.1 g/dL). Patients with anemia were more likely to be non-Hispanic Black and publicly insured and less likely to be nulliparous. Anemia was associated with 5-fold higher odds of packed red blood cell transfusion (6.0% vs 1.3%; adjusted odds ratio, 5.23 [95% confidence interval, 4.09-6.69]) compared with no anemia. For each 1 g/dL increase in predelivery hemoglobin, the odds of transfusion were 56% lower (adjusted odds ratio, 0.44 [confidence interval, 0.40-0.48]). The optimal hemoglobin for prediction of transfusion was 10.6 g/dL (sensitivity: 80%, specificity: 86%). There was no association between anemia and composite maternal or neonatal morbidity after adjustment for covariates, but anemia was associated with higher odds of postpartum readmission (adjusted odds ratio, 1.35 [1.11-1.64]).

CONCLUSION

Maternal anemia before delivery was associated with 5-fold higher odds of packed red blood cell transfusion and postpartum readmission, but not other perinatal morbidity. Optimizing predelivery hemoglobin, particularly ≥10.6 g/dL, may reduce peripartum transfusion.

Nutrition Profile for Countries of the Eastern Mediterranean Region with Different Income Levels: An Analytical Review

The World Health Organization's (WHO) Eastern Mediterranean Region (EMR) is suffering from a double burden of malnutrition in which undernutrition coexists with rising rates of overweight and obesity. Although the countries of the EMR vary greatly in terms of income level, living conditions and health challenges, the nutrition status is often discussed only by using either regional or country-specific estimates. This analytical review studies the nutrition situation of the EMR during the past 20 years by dividing the region into four groups based on their income level-the low-income group (Afghanistan, Somalia, Sudan, Syria, and Yemen), the lower-middle-income group (Djibouti, Egypt, Iran, Morocco, Pakistan, Palestine, and Tunisia), the upper-middle-income group (Iraq, Jordan, Lebanon, and Libya) and the high-income group (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates)-and by comparing and describing the estimates of the most important nutrition indicators, including stunting, wasting, overweight, obesity, anaemia, and early initiation and exclusive breastfeeding. The findings reveal that the trends of stunting and wasting were decreasing in all EMR income groups, while the percentages of overweight and obesity predominantly increased in all age groups across the income groups, with the only exception in the low-income group where a decreasing trend among children under five years existed. The income level was directly associated with the prevalence rates of overweight and obesity among other age groups except children under five, while an inverse association was observed regarding stunting and anaemia. Upper-middle-income country group showed the highest prevalence rate of overweight among children under five. Most countries of the EMR revealed below-desired rates of early initiation and exclusive breastfeeding. Changes in dietary patterns, nutrition transition, global and local crises, and nutrition policies are among the major explanatory factors for the findings. The scarcity of updated data remains a challenge in the region. Countries need support in filling the data gaps and implementing recommended policies and programmes to address the double burden of malnutrition.

Comparison of Anemia Screening Methods Using Paired Venous Samples in Women of Reproductive Age in Southern India

BACKGROUND

Anemia is an important public health problem, and accurate estimates may inform policy and programs. Although hemoglobin (Hb) assessment of venous blood via automated hematology analyzers (AHAs) is recommended, most population-based surveys estimate anemia prevalence based on analysis of capillary blood via portable hemoglobinometers.

OBJECTIVES

We aimed to evaluate screening methods for hemoglobin and anemia assessment using paired venous samples.

METHODS

Participants were women 15-40 y who were not pregnant or lactating. Paired venous whole blood samples (n = 896) were analyzed for hemoglobin (Hb) via portable hemoglobinometer (HemoCue 301) and Coulter Counter AHA. Anemia and severe anemia were defined as Hb <12.0g/dL and <8.0 g/dL, respectively. Bland-Altman methods were used to assess the level of agreement for Hb results (mean difference, SD of differences, limits of agreement). Diagnostic accuracy parameters (sensitivity, specificity, positive predictive value, negative predictive value, accuracy) were calculated to evaluate HemoCue performance compared to the AHA reference, overall and by sociodemographic, nutritional, and metabolic characteristics.

RESULTS

The estimated anemia prevalence was significantly lower via HemoCue vs. AHA (36.3% compared with 41.6%; P value < 0.0001). The HemoCue had 84.4% accuracy for anemia screening and 98.8% for severe anemia, compared to the AHA reference. The HemoCue had 74.8% sensitivity and 91.2% specificity, compared to AHA. HemoCue sensitivity was higher in women with iron deficiency [serum ferritin (SF) <15.0 μg/L: 81.6% compared with SF ≥15.0 μg/L: 41.3%], and lower in women with metabolic risk factors, including overweight [BMI ≥25.0 kg/m2: 63.9% vs. BMI <25.0 kg/m2: 78.8%], or elevated CRP (>1.0 mg/L: 67.2% vs. ≤1.0 mg/L: 82.9%), trunk fat (>35%: 62.7% vs. ≤35%: 80.1%), or whole-body fat (>35%: 63.9% vs. ≤35%: 80.3%).

CONCLUSIONS

Findings suggest that women with anemia may be incorrectly identified as not anemic via portable hemoglobinometer, and anemia prevalence may be underestimated at the population level.This study was registered at clinicaltrials.gov as NCT04048330.

Maternal Mortality in a Rural District of Pakistan and Contributing Factors

INTRODUCTION

Pakistan is among the ten countries that account for 60% of global maternal mortality. Lack of accurate data on maternal mortality and a complex interrelation of access and quality of healthcare services, healthcare delivery system, and socio-economic and demographic factors contribute significantly to inadequate progress in reducing maternal mortality.

MATERIAL AND METHODS

A population-based prospective cohort study was conducted in a rural district of Pakistan using data obtained from an enhanced surveillance system. A total of 7572 pregnancies and their outcomes were recorded by 273 Lady Health Workers and 73 Community Health Workers over 2016-2017. Logistic regression was used to calculate the unadjusted and adjusted odds ratios (OR) for maternal mortality for each risk factor. Population Attributable Fraction (PAF) was derived from the ORs and risk factor prevalence.

RESULTS

The study recorded 18 maternal deaths. The maternal mortality rate was estimated at 238/100,000 pregnancies (95% CI 141-376), and the maternal mortality ratio was 247/100,000 live births (95% CI 147-391). Half of the maternal deaths (9) were from obstetric hemorrhage, and 28% (5) from puerperal sepsis. Postpartum hemorrhage was associated with a 17-fold higher risk of maternal mortality (PAF = 40%) and puerperal sepsis with a 12-fold higher mortality risk (PAF = 29%) compared to women without these conditions. Women delivered by unskilled birth attendants had a three-fold (PAF = 21%), and women having prolonged labour had a fourfold risk of maternal mortality compared to those with these conditions. Women with leg swelling (47%) and pre-eclampsia (26%) are at seven times the risk of maternal mortality compared to those without these conditions. Mortality in women delivered by unskilled birth attendants was three times higher than with skilled attendants.

CONCLUSION

The study, among a few large-scale prospective cohort studies conducted at the community level in a rural district of Pakistan, provides a better understanding of the risk factors determining maternal mortality in Pakistan. Poverty emerged as a significant risk factor for maternal mortality in the study area and contributes to the underutilization of health facilities and skilled birth attendants. Incorporating poverty reduction strategies across all sectors, including health, is urgently required to address higher maternal mortality in Pakistan. A paradigm shift is required in Maternal and Child health related programs and interventions to include poverty estimation and measuring mortality through linking mortality surveillance with the Civil Registration and Vital Statistics system. Accelerated efforts to expand the coverage and completeness of mortality data with risk factors to address inequalities in access and utilization of health services.

Preeclampsia development and neonatal outcomes in pregnant women who were anemic in the first trimester

Background/Aim: Anemia is a disease that can be easily treated, but it is still widespread worldwide. Anemia can affect nearly 40% of women. Anemia has been extensively studied and related to a variety of pregnancy complications. The primary purpose of our study was to discover the relationship between preeclampsia and anemia in the first trimester, and the secondary goal was to analyze the outcomes of newborns born to these mothers. Methods: This study was compiled as a retrospective cohort study. Age, gravida, parity, and thyroid stimulating hormone (TSH) levels were recorded in a patient’s first visit file. Hemoglobin counts in the first trimester were analyzed as hemogram values. Those with a hemoglobin value <11 g/dl during pregnancy were classified as anemic. The patients' file records were reviewed to determine mode of delivery, birth weight, and Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) scores. To confirm a diagnosis of preeclampsia, the American Congress of Obstetricians and Gynecologists (ACOG) criteria were used. Results: After the exclusion of 186 women due to comorbidities and multiple pregnancies, 364 women were evaluated. The number of anemic pregnant women in the first trimester was 87 (23.9%), and 277 non-anemic women were matched with the anemic group. No statistical difference between the groups in terms of demographic characteristics, such as age, gravida, body mass index (BMI), and TSH were found. No statistical difference between the groups in terms of delivery type, infant birth weight, and APGAR scores were found (P > 0.05). Preeclampsia frequency was statistically higher in pregnant women who were anemic in the first trimester (P = 0.032). Conclusion: Preeclampsia was found to be more common in pregnant women who were anemic in the first trimester. Although it would seem that neonatal outcomes are unaffected, we believe that the unaffected outcomes are due to iron replacement. To avoid pregnancy complications, it is crucial for women not to be anemic prior to becoming pregnant.

A systematic review of individual and ecological determinants of maternal mortality in the world based on the income level of countries

BACKGROUND

This systematic review was conducted to map the literature on all the existing evidence regarding individual and ecological determinants of maternal mortality in the world and to classify them based on the income level of countries. Such a systematic review had not been conducted before.

METHODS

We conducted an electronic search for primary and review articles using "Maternal Mortality" and "Determinant" as keywords or MeSH terms in their Title or Abstract, indexed in Scopus, PubMed, and Google with no time or geographical limitation and also hand searching was performed for most relevant journals. STROBE and Glasgow university critical appraisal checklists were used for quality assessment of the included studies. Data of the determinants were extracted and classified into individual or ecological categories based on income level of the countries according to World Bank classification.

RESULTS

In this review, 109 original studies and 12 review articles from 33 countries or at global level met the inclusion criteria. Most studies were published after 2013. Most literature studied determinants of low and lower-middle-income countries. The most important individual determinants in low and lower-middle-income countries were location of birth, maternal education, any delays in health services seeking, prenatal care and skilled birth attendance. Household-related determinants in low-income countries included improved water source and sanitation system, region of residence, house condition, wealth of household, and husband education. Additionally, ecological determinants including human resources, access to medical equipment and facilities, total fertility rate, health financing system, country income, poverty rate, governance, education, employment, social protection, gender inequality, and human development index were found to be important contributors in maternal mortality. A few factors were more important in higher-income countries than lower-income countries including parity, IVF births, older mothers, and type of delivery.

CONCLUSION

A comprehensive list of factors associated with maternal death was gathered through this systematic review, most of which were related to lower-income countries. It seems that the income level of the countries makes a significant difference in determinants of maternal mortality in the world.

Trends in prevalence and treatment rate of anemia in the U.S. population: cross-sectional study using data from NHANES 2005-2018

OBJECTIVES

To determine the trends in anemia prevalence, treatment rates, and their associated demographic and socioeconomic status factors in the U.S. nationally representative population.

METHODS

We extracted data from individuals ≥20-year-old from the NHANES from 2005 to 2018. The trends of anemia prevalence and treatment were assessed by Cochran-Armitage test. The association between two dependent variables (anemia status and treatment) and demographic were examined by multiple logistic regression.

RESULTS

The general anemia prevalence has a significant increasing trend from 5.71% to 6.86% (P trend<.001) from 2005 to 2018, whereas the trend in general anemia treatment rate was not significant (p = .148). Logistic regression showed that age groups (OR: 2.15for 60 or older vs. 20-39 years old), sex (0.47 for male vs. female), race (0.22 for NHW vs. NHB), education (0.80for some college or AA degree vs. less than high school), PIR (0.60 for ≥3.5 vs.≤1.3), and birthplace (0.88 for U.S. vs. other) were significantly associated with anemia. The factors significantly associated with anemia treatment were age group (1.51 for 60 years and older vs. 20-39 years old), sex (0.53 male vs. female), birthplace (1.88 U.S. vs. other), and insurance (1.80 for Yes vs. No).

CONCLUSION

While there was no significant increase in anemia treatment between 2005 and 2018, the anemia prevalence increased significantly, particularly among individuals with lower income, less education, and born outside the U.S. Moreover, the high anemia prevalence among NHB compared to other races indicated that more resources are needed to reduce disparities.

Diet cost and quality using the Healthy Eating Index-2015 in adults from urban and rural areas of Mexico

OBJECTIVE

To assess the association between diet cost and quality by place of residence.

DESIGN

We analysed cross-sectional data of the National Health and Nutrition Survey-2012. Diet cost was estimated by linking dietary data, obtained from a 7-d SFFQ, with municipality food prices, which were derived from a national expenditure survey. Diet quality was assessed using the Healthy Eating Index-2015 (HEI-2015). Association between quintiles of diet cost and HEI-2015 was assessed using linear regression analysis.

SETTINGS

Mexico.

PARTICIPANTS

2438 adults (18-59 years).

RESULTS

Diet cost was positively associated with diet quality (HEI-2015) in urban but not in rural areas. Compared with quintile (Q1) of cost, the increment in diet quality score was 1·17 (95 % CI -0·06, 4·33) for Q2, 2·14 (95 % CI -0·06, 4·33) for Q3, 4·70 (95 % CI 2·62, 6·79) for Q4 and 6·34 (95 % CI 4·20, 8·49) for Q5 (P-trend < 0·001). Individuals in rural v. urban areas on average have higher quality diets at lower cost with higher intakes of whole grains and beans and lower intakes of Na, added sugars and saturated fats. Living in the South, being indigenous and having low socio-economic status were also associated with higher quality diets.

CONCLUSIONS

Diet cost was positively associated with diet quality, but only in urban areas. Further studies are needed to understand the relation between diet cost and quality in rural areas. To improve overall diet quality in Mexico, strategies that aim to reduce the cost of high-quality diets should consider the heterogeneity by place of residence.

Association Between Early Pregnancy Body Mass Index and Gestational Weight Gain in Relation to Neonatal Birth Weight

Introduction: Maternal early pregnancy body mass index (BMI) and gestational weight gain (GWG) strongly correlate with pregnancy outcomes. Gestational hypertension and diabetes have been associated with overweight and obesity in pregnancy. A low pre-pregnancy BMI has been associated with low birth weight and preterm birth.

Method: This observational study was carried out from November 2018 to July 2020 in a tertiary care hospital in South India with a sample size of 100. Pregnant women with uncomplicated singleton pregnancies booked for regular antenatal care by 10 weeks of gestation were included in the study. During the participants' antenatal check-ups, detailed history and examinations were made. The weight of the participants was recorded at every antenatal check-up. Information about the gestational age at delivery and the birth weight of the neonates were collected following delivery.

Results: The mean age of women was 25.83 + 2.74 years. Of women who delivered low birth weight neonates (<2.5 kg), 86% had GWG below the Institute of Medicine (IOM) recommendation. A total of 57% of women with normal early pregnancy BMI and 67% of obese women had GWG within the IOM recommendation. Early pregnancy BMI had a positive correlation with neonatal birth weight (r (98) = 0.779, p = 0.001). Of the underweight pregnant women, 72% gave birth to small for gestational age (SGA) babies, and 97% percent of normal early pregnancy BMI women delivered neonates with normal weight for gestational age. A total of 33% of overweight and 50% of obese women had large for gestational age (LGA) babies.

Conclusion: Results from this study suggest that maternal early pregnancy BMI is more strongly associated with neonatal birth weight than GWG. Therefore, early pregnancy BMI may be an important focus for counseling during pregnancy.

Iron Absorption: Factors, Limitations, and Improvement Methods

Iron is an essential element for human life since it participates in many functions in the human body, including oxygen transport, immunity, cell division and differentiation, and energy metabolism. Iron homeostasis is mainly controlled by intestinal absorption because iron does not have active excretory mechanisms for humans. Thus, efficient intestinal iron bioavailability is essential to reduce the risk of iron deficiency anemia. There are two forms of iron, heme and nonheme, found in foods. The average daily dietary iron intake is 10 to 15 mg in humans since only 1 to 2 mg is absorbed through the intestinal system. Nutrient-nutrient interactions may play a role in dietary intestinal iron absorption. Dietary inhibitors such as calcium, phytates, polyphenols and enhancers such as ascorbic acid and proteins mainly influence iron bioavailability. Numerous studies have been carried out for years to enhance iron bioavailability and combat iron deficiency. In addition to traditional methods, innovative techniques are being developed day by day to enhance iron bioavailability. This review will provide information about iron bioavailability, factors affecting absorption, iron deficiency, and recent studies on improving iron bioavailability.

Individual, household and area predictors of anaemia among children aged 6–59 months in Nigeria

Objectives

This study aims to determine the prevalence of anaemia among children aged 6–59 months in all states of Nigeria, including the Federal Capital Territory (FCT), and to quantify the predicted probabilities by individual, household and area factors.

Study design

This study is a secondary analysis of data sets from two national representative cross-sectional surveys in Nigeria: the Nigeria Demographic and Health Survey (2018 NDHS) and the National Human Development Index (2018 NHDR). The state human development index (HDI) and the state multidimensional poverty index (MPI) from the 2018 NHDR were incorporated into the 2018 NDHS.

Methods

The study included a weighted sample of 10,222 children aged 6–59 months. Both univariate and bivariate analyses were computed to determine the prevalence and factors associated with anaemia status, respectively. Multiple binary logistic regression analyses with adjusted predicted probabilities (APPs) were performed to quantify the predictors’ probabilities.

Results

The prevalence of anaemia among children aged 6–59 months in Nigeria was 68.1% (6962/10,222). Zamfara state had the highest prevalence (84.0% [266/317]), while Kaduna state recorded the lowest (50.0% [283/572]). The APPs of being anaemic decreased from 82.9% (95% confidence interval [CI]: 80.0–85.8) for children aged 6–18 months to 60.6% (95% CI: 56.8–64.4) for children aged 43–59 months, when other predictors were held constant. The APP for a child of an anaemic mother is 10.2% points higher than the APP for a child whose mother is not anaemic. In addition, the APPs for children decreased as the age group of their mothers increased. A child from a state that is mildly deprived in the MPI has a lower APP (67.2% [95% CI: 62.2–72.2]) compared with a child from highly deprived MPI state (79.0% [95% CI: 73.4–84.5]).

Conclusions

Health strategies, including supplementation programmes, should be carried out at both ante-natal and post-natal clinics to reduce the prevalence of anaemia, especially in vulnerable population groups.

Global Prevalence of Anemia in Pregnant Women: A Comprehensive Systematic Review and Meta-Analysis

BACKGROUND

Anemia is one of the most critical health conditions affecting people worldwide. The disease is silent, with a slow progression and a few physical symptoms. Anemia during pregnancy carries the risk of premature birth, low birth weight, and fetus malformations and can impose additional costs on society and families. Therefore, the aim of this study is to conduct a systematic review and meta-analysis on the prevalence of anemia in pregnant women worldwide.

METHODS

In this work, we have conducted a systematic review and meta-analysis of the studies that have examined the prevalence of anemia in pregnant women globally. The Google Scholar, Cochrane, ScienceDirect, Medline (PubMed), and Web of Science (WoS) databases were searched for articles published between 1991 and 2021. The search keywords were anemia, pregnancy, prevalence, and meta-analysis. In order to analyze the eligible studies, the stochastic effects model was used, and the heterogeneity of the studies was examined using the I² index. Data analysis was performed within the Comprehensive Meta-Analysis software (Version 2).

RESULTS

The search resulted in 338 deduplicated studies, of which 52 studies with a total sample size of 1,244,747 people were included in this review. According to the results of the meta-analysis, the overall prevalence of anemia in pregnant women is 36.8% (95% confidence interval: 31.5-42.4%). The highest prevalence of anemia is mild at 70.8 (95% CI 58.1-81) and highest in the third trimester of pregnancy with the prevalence of 48.8 (95% CI 38.7-58.9), while the highest prevalence of anemia in pregnant women was in Africa with the prevalence of 41.7 (95% CI 32.3-49.4).

CONCLUSION

The results of this study show a high prevalence of anemia among pregnant women worldwide, and the highest of this prevalence is mild anemia. The prevalence of anemia in the third trimester was higher than in the first and second trimesters. Anemia in pregnant women in developing countries is significantly higher than in developed countries due to pregnancy's economic, sociological, and health factors.

Time to detection of anaemia and its predictors among women of reproductive-age living with HIV/AIDS initiating ART at public hospitals, Southwest Ethiopia: a multicentre retrospective follow-up study

OBJECTIVE

To assess the time to development of anaemia and its predictors among women of reproductive-age receiving antiretroviral therapy (ART) in public hospitals, Southwest Ethiopia.

DESIGN

Hospital-based retrospective follow-up study SETTING: Mizan-Tepi University Teaching Hospital, and Gebretsadik Shawo General Hospital Southwest Ethiopia.

PARTICIPANTS

A total of 389 records of women living with HIV/AIDS at public hospitals were reviewed using a systematic sampling method. The data were entered using Epi-Data Manager V.4.2 and exported to STATA V.14 for data analysis. A Cox-regression model was used and variables with a p-value of <0.05% and 95% confidence level in multivariable analysis were declared as statistically significant predictors for anaemia.

PRIMARY OUTCOME

Time to development of anaemia and its predictors among women of reproductive-age on ART in public hospitals.

RESULTS

Of 370 records of women of reproductive-age, 203 (54.86%, 95% CI (49.77% to 59.96%)) were anaemic with an incidence rate of 12.07 per 100 person months of observation, and the overall median survival time of 60 months. The total of 2.97%, and 80.26% of women were developed anaemia within the first 6 months and the last 6 months period of follow-up, respectively. Moreover, non-employed women, women with advanced WHO stage, women with baseline opportunistic infections and women who were on ART for long-duration were significantly associated with anaemia among women living with HIV/AIDS.

CONCLUSION

In this study, the incidence rate of anaemia was significantly high. The development of anaemia among women on ART was also increased with increased follow-up time. The risk of anaemia is increased in women living with HIV/AIDS due to advanced baseline WHO staging, presence of OIs at baseline, an increased duration on ART and low occupational status. Therefore, early identification and treatment of opportunistic infections and other coinfections are required to decrease the incidence of anaemia among women living with HIV/AIDS.

Age-modified factors associated with placental malaria in rural Burkina Faso

BACKGROUND

Malaria in pregnancy can result in placental infection with fetal implications. This study aimed at assessing placental malaria (PM) prevalence and its associated factors in a cohort of pregnant women with peripheral malaria and their offspring.

METHOD

The data were collected in the framework of a clinical trial on treatments for malaria in pregnant women . Placental malaria (PM) was diagnosed by histopathological detection of parasites and/or malaria pigment on placenta biopsies taken at delivery. Factors associated with PM were assessed using logistic regression.

RESULTS

Out of 745 biopsies examined, PM was diagnosed in 86.8 % of women. Acute, chronic and past PM were retrieved in 11 (1.5 %), 170 (22.8 %), and 466 (62.6 %) women, respectively. A modifying effect was observed in the association of gravidity or anemia at the study start with pooled PM (presence of parasites and/or malaria pigment). In women under 30, gravidity ≤ 2 was associated with an increased prevalence of pooled PM but in women aged 30 years or more, gravidity was no more associated with pooled PM (OR 6.81, 95 % CI 3.18 - 14.60; and OR 0.52, 95 % CI 0.10 - 2.76, respectively). Anemia was associated with pooled PM in women under 30 (OR 1.96, 95 % CI 1.03 - 3.72) but not in women aged 30 years or more (OR 0.68, 95 % CI 0.31 - 1.49). Similarly, the association of gravidity with past-chronic PM depended also on age. A higher prevalence of active PM was observed in women under 30 presenting with symptomatic malaria (OR 3.79, 95 % CI 1.55 - 9.27), while there was no significant increase in the prevalence of active PM (presence of parasites only) in women with symptomatic malaria when aged 30 years or more (OR 0.42, 95 % CI 0.10 - 1.75). In women with chronic PM, the prevalence of low birth weight or prematurity was the highest (31.2 %) as compared with past PM or no PM.

CONCLUSION

Despite the rapid diagnosis and efficacious treatment of peripheral infection, the prevalence of placental malaria remained high in women with P. falciparum peripheral infection in Nanoro, especially in younger women This underlines the importance of preventive measures in this specific group.

Geographic Access and Maternal Health Services Utilization in Sélingué Health District, Mali

Introduction

Maternal mortality is one of the main causes of death for women of childbearing age in Mali, and improving this outcome is slow, even in regions with relatively good geographic access to care. Disparities in maternal health services utilization can constitute a major obstacle in the reduction of maternal mortality in Mali and indicates a lack of equity in the Malian health system. Literature on maternal health inequity has explored structural and individual factors influencing outcomes but has not examined inequities in health facility distribution within districts with moderate geographic access. The purpose of this article is to examine disparities in education and geographic distance and how they affect utilization of maternal care within the Sélingué health district, a district with moderate geographic access to care, near Bamako, Mali.

Methods

We conducted a cross sectional survey with cluster sampling in the Sélingué health district. Maternal health services characteristics and indicators were described. Association between dependent and independent variables was verified using Kendall’s tau-b correlation, Chi square, logistic regression with odds ratio and 95% confidence interval. Gini index and concentration curve were used to measure inequity.

Results

Most respondents were 20 to 24 years old. Over 31% of our sample had some education, 65% completed at least four ANC visits, and 60.8% delivered at a health facility. Despite this evidence of healthcare access in Sélingué, disparities within the health district contribute to inadequate utilization among approximately 40% of the women in our sample. The concentration index demonstrated the impact of inequity in geographic access,

comparing women residing near and far from the referral care facility.

Conclusion

Maternal health services underutilization, within a district with moderate geographic access, indicates that deliberate attention should be paid to addressing geographic access even in such a district.

A Life Course Approach to the Prevention of Iron Deficiency Anemia in Indonesia

Iron deficiency anemia (IDA) has a long-term impact on each life stage and remains worldwide a major public health problem. Eleven experts were invited to participate in a virtual meeting to discuss the present situation and the available intervention to prevent iron deficiency anemia in Indonesia. The experts consisted of obstetric gynecologists, pediatricians, nutritionists, midwives, a clinical psychologist, and an education expert. Existing interventions focus attention on preconception and early childhood stages. Considering the inter-generational effects of IDA, we call attention to expanding strategies to all life stages through integrating political, educational, and nutritional interventions. The experts agreed that health education and nutritional intervention should be started since adolescence. Further research to explore the effectiveness of these interventions would be important for many regions in the world. The outcome of this Indonesian consensus is applicable worldwide.

Spatial location, temperature and rainfall diversity affect the double burden of malnutrition among women in Kenya

Studies have looked into how environmental and climate covariates affect under-and over-nutrition, but little is known about the spatial distribution of different forms of malnutrition in Kenya and whether there are locations that suffer from double-burden of malnutrition. This research quantifies spatial variations and estimates how climatic and environmental factors affect under-and over-nutrition among women in Kenya. This enables us to determine if the patterns in which these factors affect the malnutrition indicators are similar and whether there are overlaps in the spatial distributions. The study used data from the Demographic and Health Survey, which included cross-sectional data on malnutrition indicators as well as some climate and environmental variables. A multicategorical response variable that classified the women into one of four nutritional classes was generated from the body mass index (BMI) of the women, and a Bayesian geoadditive regression model with an estimate based on the Markov chain Monte Carlo simulation technique was adopted. Findings show that women in Turkana, Samburu, Isiolo, Baringo, Garissa, and West Pokot counties are more likely to be underweight than women in other counties while being overweight is prevalent in Kirinyag'a and Kitui counties. Obesity is prevalent in Kirinyag'a, Lamu, Kiambu, Murang'a, and Taita Taveta counties. The study further shows that as mean temperature and precipitation increase, the likelihood of being underweight reduces. The chances of being underweight are lower among literate women [OR: 0.614; 95% CrI: 0.513,0.739], married women [OR: 0.702; 95% CrI: 0.608,0.819] and those from rich households [OR: 0.617; 95% CrI: 0.489,0.772], which is not the case for overweight and obesity. The generated spatial maps identify hot spots of the double burden of malnutrition that can assist the government and donor agencies in channeling resources efficiently.

•

Low- and middle-income countries have been experiencing double burden of malnutrition.

•

The generated spatial maps identify hot spots of the double burden of malnutrition.

•

Carefully thought-out policy plans are required to curb the challenges of the double burden of malnutrition.

•

Burden of undernutrition has decreased but the cost of being overweight or obese is increasing among women.

Nutrition-specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews

BACKGROUND

Anaemia is a prevalent health problem worldwide. Some types are preventable or controllable with iron supplementation (pills or drops), fortification (sprinkles or powders containing iron added to food) or improvements to dietary diversity and quality (e.g. education or counselling).

OBJECTIVES

To summarise the evidence from systematic reviews regarding the benefits or harms of nutrition-specific interventions for preventing and controlling anaemia in anaemic or non-anaemic, apparently healthy populations throughout the life cycle.

METHODS

In August 2020, we searched MEDLINE, Embase and 10 other databases for systematic reviews of randomised controlled trials (RCTs) in anaemic or non-anaemic, apparently healthy populations. We followed standard Cochrane methodology, extracting GRADE ratings where provided. The primary outcomes were haemoglobin (Hb) concentration, anaemia, and iron deficiency anaemia (IDA); secondary outcomes were iron deficiency (ID), severe anaemia and adverse effects (e.g. diarrhoea, vomiting).

MAIN RESULTS

We included 75 systematic reviews, 33 of which provided GRADE assessments; these varied between high and very low. Infants (6 to 23 months; 13 reviews) Iron supplementation increased Hb levels and reduced the risk of anaemia and IDA in two reviews. Iron fortification of milk or cereals, multiple-micronutrient powder (MMNP), home fortification of complementary foods, and supplementary feeding increased Hb levels and reduced the risk of anaemia in six reviews. In one review, lipid-based nutrient supplementation (LNS) reduced the risk of anaemia. In another, caterpillar cereal increased Hb levels and IDA prevalence. Food-based strategies (red meat and fortified cow's milk, beef) showed no evidence of a difference (1 review). Preschool and school-aged children (2 to 10 years; 8 reviews) Daily or intermittent iron supplementation increased Hb levels and reduced the risk of anaemia and ID in two reviews. One review found no evidence of difference in Hb levels, but an increased risk of anaemia and ID for the intermittent regime. All suggested that zinc plus iron supplementation versus zinc alone, multiple-micronutrient (MMN)-fortified beverage versus control, and point-of-use fortification of food with iron-containing micronutrient powder (MNP) versus placebo or no intervention may increase Hb levels and reduce the risk of anaemia and ID. Fortified dairy products and cereal food showed no evidence of a difference on the incidence of anaemia (1 review). Adolescent children (11 to 18 years; 4 reviews) Compared with no supplementation or placebo, five types of iron supplementation may increase Hb levels and reduce the risk of anaemia (3 reviews). One review on prevention found no evidence of a difference in anaemia incidence on iron supplementation with or without folic acid, but Hb levels increased. Another suggested that nutritional supplementation and counselling reduced IDA. One review comparing MMN fortification with no fortification observed no evidence of a difference in Hb levels. Non-pregnant women of reproductive age (19 to 49 years; 5 reviews) Two reviews suggested that iron therapy (oral, intravenous (IV), intramuscular (IM)) increased Hb levels; one showed that iron folic acid supplementation reduced anaemia incidence; and another that daily iron supplementation with or without folic acid or vitamin C increased Hb levels and reduced the risk of anaemia and ID. No review reported interventions related to fortification or dietary diversity and quality. Pregnant women of reproductive age (15 to 49 years; 23 reviews) One review apiece suggested that: daily iron supplementation with or without folic acid increased Hb levels in the third trimester or at delivery and in the postpartum period, and reduced the risk of anaemia, IDA and ID in the third trimester or at delivery; intermittent iron supplementation had no effect on Hb levels and IDA, but increased the risk of anaemia at or near term and ID, and reduced the risk of side effects; vitamin A supplementation alone versus placebo, no intervention or other micronutrient might increase maternal Hb levels and reduce the risk of maternal anaemia; MMN with iron and folic acid versus placebo reduced the risk of anaemia; supplementation with oral bovine lactoferrin versus oral ferrous iron preparations increased Hb levels and reduced gastrointestinal side effects; MNP for point-of-use fortification of food versus iron and folic acid supplementation might decrease Hb levels at 32 weeks' gestation and increase the risk of anaemia; and LNS versus iron or folic acid and MMN increased the risk of anaemia. Mixed population (all ages; 22 reviews) Iron supplementation versus placebo or control increased Hb levels in healthy children, adults, and elderly people (4 reviews). Hb levels appeared to increase and risk of anaemia and ID decrease in two reviews investigating MMN fortification versus placebo or no treatment, iron fortified flour versus control, double fortified salt versus iodine only fortified salt, and rice fortification with iron alone or in combination with other micronutrients versus unfortified rice or no intervention. Each review suggested that fortified versus non-fortified condiments or noodles, fortified (sodium iron ethylenediaminetetraacetate; NaFeEDTA) versus non-fortified soy sauce, and double-fortified salt versus control salt may increase Hb concentration and reduce the risk of anaemia. One review indicated that Hb levels increased for children who were anaemic or had IDA and received iron supplementation, and decreased for those who received dietary interventions. Another assessed the effects of foods prepared in iron pots, and found higher Hb levels in children with low-risk malaria status in two trials, but no difference when comparing food prepared in non-cast iron pots in a high-risk malaria endemicity mixed population. There was no evidence of a difference for adverse effects. Anaemia and malaria prevalence were rarely reported. No review focused on women aged 50 to 65 years plus or men (19 to 65 years plus).

AUTHORS' CONCLUSIONS

Compared to no treatment, daily iron supplementation may increase Hb levels and reduce the risk of anaemia and IDA in infants, preschool and school-aged children and pregnant and non-pregnant women. Iron fortification of foods in infants and use of iron pots with children may have prophylactic benefits for malaria endemicity low-risk populations. In any age group, only a limited number of reviews assessed interventions to improve dietary diversity and quality. Future trials should assess the effects of these types of interventions, and consider the requirements of different populations.

Fuzzy soft set theory: Application of classification rules in decision making during medical diagnosis*

 Present study is an interdisciplinary approach towards rapid and efficient medical diagnosis. The research articulated on data set of cross-sectional study of pregnant females dwelling rural area of Pakistan. The prognosis of gestational wellbeing followed through analyzing heterogenic medical information to develop a holistic picture of ongoing pregnancy. Therefore, for rapid medical diagnosis and precision in decision-making, Fuzzy Soft Set (denoted as FSS) theory selected to develop an algorithm. The algorithm constructed as single point, multipoint and cumulative diagnosis for predicting health status with respect of Hemoglobin, Body Mass Index and Random Glucose Concentration (Respectively denoted as Hb, BMI and RGC) of subjects under study. We successfully proposed novel approach for complex modeling and provision of algorithm for medical diagnosis. The algorithms successfully dealt with analyzing diversely attributed detailed medical tests/reports as input. The output of complex modeling effectively served efficient decision-making in predicting gestational wellbeing.

Branched-chain Amino Acids: Catabolism in Skeletal Muscle and Implications for Muscle and Whole-body Metabolism

Branched-chain amino acids (BCAAs) are critical for skeletal muscle and whole-body anabolism and energy homeostasis. They also serve as signaling molecules, for example, being able to activate mammalian/mechanistic target of rapamycin complex 1 (mTORC1). This has implication for macronutrient metabolism. However, elevated circulating levels of BCAAs and of their ketoacids as well as impaired catabolism of these amino acids (AAs) are implicated in the development of insulin resistance and its sequelae, including type 2 diabetes, cardiovascular disease, and of some cancers, although other studies indicate supplements of these AAs may help in the management of some chronic diseases. Here, we first reviewed the catabolism of these AAs especially in skeletal muscle as this tissue contributes the most to whole body disposal of the BCAA. We then reviewed emerging mechanisms of control of enzymes involved in regulating BCAA catabolism. Such mechanisms include regulation of their abundance by microRNA and by post translational modifications such as phosphorylation, acetylation, and ubiquitination. We also reviewed implications of impaired metabolism of BCAA for muscle and whole-body metabolism. We comment on outstanding questions in the regulation of catabolism of these AAs, including regulation of the abundance and post-transcriptional/post-translational modification of enzymes that regulate BCAA catabolism, as well the impact of circadian rhythm, age and mTORC1 on these enzymes. Answers to such questions may facilitate emergence of treatment/management options that can help patients suffering from chronic diseases linked to impaired metabolism of the BCAAs.

Food Consumption as a Risk Factor of Anemia among Indonesian Pregnant Women: A Cross-sectional Study among Javanese Ethnic Group

BACKGROUND: Anemia during pregnancy causes several adverse effects. Furthermore, in Indonesia, this leads to restrictions among pregnant women. The information on this situation is still limited, and more research needs to be conducted. AIM: Therefore, this study aims to investigate the association between food consumption and anemia among pregnant women. METHODS: This is a cross-sectional descriptive research that involved 424 pregnant women. Furthermore, written informed consent was obtained from respondents before data collection. A self-administered questionnaire was used to assess the food consumption and demographic data. Hemoglobin concentration was further measured using a haemoglobinometer, and data were analyzed using a descriptive statistical Chi-square, and a Multiple Logistic Regression test. RESULTS: It was found that half of the respondents suffered from anemia (46.5%). Furthermore, the Multiple Logistic Regression test showed that tea, liver, eggs, and iron consumption with values of (odds ratio [OR] = 5.075, p < 0.001), (OR = 4.128, p < 0.001), (OR = 3.590, p < 0.01), and (OR = 3.837, p < 0.05), respectively, had significant correlations with anemia among pregnant women. CONCLUSIONS: Anemia is commonly experienced by Indonesian pregnant women. Therefore, health-care providers should focus on preventing anemia in pregnant women by reducing their tea intake and increasing the consumption of iron-rich foods or supplements.

High burden of anemia among pregnant women in Tanzania: a call to address its determinants

Background

Anemia in pregnancy is behind a significant burden of maternal mortality and poor birth outcomes globally. Efforts to address it need evidence on trends and its pertinent factors as they vary from one area to another.

Methods

We pooled data of 23,203 women of reproductive age whose hemoglobin levels were measured from two Tanzania Demographic and Health Surveys (TDHS). Of them, 2,194 women were pregnant. Analyses employed descriptive analyses to determine the burden of anemia, its characteristics, and severity; GIS mapping to determine the regional changes of anemia between 2005 and 2015; and logistic regression to determine the remaining determinants of anemia among pregnant women using Stata 15.

Results

The burden of anemia among pregnant women in Tanzania has remained unprecedently high, and varies between regions. There was no significant decline of anemia in general between the two periods after adjusting for individual, households, reproductive, and child characteristics [AOR = 0.964, 95% CI = 0.774–1.202, p = 0.747). Anemia is currently prevalent in 57% of pregnant women in Tanzania. The prevalence is more likely to be higher among women aged 15–19 years than those aged between 20–34 years. It is more likely to be prevalent among those within large families, with no formal education, food insecurity, lack of health insurance, had no antimalaria during pregnancy, and had low frequency of ANC attendance. On the other hand, delivery in a health facility may be potentially protective against anemia.

Conclusions

Anemia in pregnancy remained persistently high and prevalent among 57% of pregnant women in Tanzania. Efforts to address anemia are crucial and need to be focused in regions with increasing burden of anemia among pregnant women. It is imperative to address important risk factors such as food insecurity, strengthening universal health coverage, empowering women of reproductive age with education and especially nutritional knowledge and advocating for early antenatal booking, attendance, and facility delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-021-00726-0.

Advanced and feasible pulses processing technologies for Ethiopia to achieve better economic and nutritional goals: A review

Background

Pulses are the dried seeds of the Leguminosae family that serve as cheaper proteins, particularly in developing countries. They contain proteins ranging 20-25%. Pulses play important roles in the farming systems and in the diets of poor people. They are ideal crops for simultaneously achieving three key developmental goals: reducing poverty, improving human health, and enhancing ecosystem sustainability. The year 2016 was declared as the year of pulses by the United Nations. These growing global attentions given to legumes has resulted in increasing their nutritional and economic desirability.

Objectives

This review presents the potential of pulses processing in Ethiopia for enhanced nutritional and economic outcomes. Pulses are important foods and export commodity in Ethiopia, which are exported in unprocessed form, fetching low returns.

Data and discussions

There are advanced but simple pulses processing technologies that include concentrating or isolation of proteins for nutritional and other uses. Pin milling of legumes and air classification of the flour helps to obtain protein concentrate of 60-75% purity. Protein isolation by alkaline extraction and isoelectric precipitation results in proteins of 90-95% purity. Legume proteins are mainly globulins and albumins that are nutritionally of great quality. The protein products are being texturized by thermal and mechanical means to make meat analogues, substitutes and extenders.

Summary and conclusion

Ethiopia being one of the significant legume producers, can benefit from this growing market by adopting the processing technologies and exporting premium quality plant proteins. This help Ethiopia satisfy domestic protein needs for child nutrition. This review summarizes the potentials for developing pulses processing technologies in Ethiopia for better economic and nutritional benefits.

Global prevalence of intestinal parasitic infections and associated risk factors in pregnant women: a systematic review and meta-analysis

BACKGROUND

Intestinal parasitic infections (IPIs) during pregnancy, if left untreated, can cause adverse effects for the mothers, foetuses and newborns. However, limited information is available about the global status of IPIs in pregnant women. Here we undertook a meta-analysis to estimate the global prevalence of IPIs and associated risk factors in pregnant women.

METHODS

We searched the PubMed, Science Direct, Scopus, Web of Science and Google Scholar databases for relevant studies that were published between 1 January 1987 and 30 December 2019. A random effects meta-analysis model was used to estimate the pooled prevalence, odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 114 studies comprising 98 342 pregnant women across 35 countries were included in the systematic review and meta-analysis. Among IPIs identified from pregnant women, three helminth infections (hookworm 19% [95% CI 15 to 23], Ascaris lumbricoides 17% [95% CI 13 to 21] and Trichuris trichiura 11% [95% CI 7 to 16]) and three protozoan infections (Blastocystis sp. 21% [95% CI 4 to 46], Entamoeba histolytica/dispar 9% [95% CI 3 to 19] and Giardia sp. 8% [95% CI 4 to 13]) were identified as the most prevalent intestinal parasites. Moreover, we found that there was a significant association between IPIs with increased risk of anaemia in pregnant women (OR 2.65 [95% CI 2.08 to 3.37]). The prevalence of IPIs was slightly higher in geophagic pregnant women compared with controls, but this was not significant (OR 1.22 [95% CI 0.87 to 1.71]). According to species, the pooled OR of A. lumbricoides infection had a significantly higher risk in geophagic pregnant women compared with controls (OR 2.66 [95% CI 1.37 to 5.16]). There was a positive relationship between the high prevalence of IPIs in pregnant women living in rural areas compared with urban residents (OR 3.36 [95% CI 1.57 to 7.19]).

CONCLUSIONS

The current review revealed a relatively high prevalence of IPIs in pregnant women, especially in some low- and middle-income countries. These results suggest a need for improved prevention and control efforts to reduce the health risks to pregnant women.

The epidemiological landscape of anemia in women of reproductive age in sub-Saharan Africa

The role of geographical disparities of health-related risk factors with anemia are poorly documented for women of reproductive age in sub-Saharan Africa (SSA). We aimed to determine the contribution of potential factors and to identify areas at higher risk of anemia for women in reproductive age in SSA. Our study population comprised 27 nationally representative samples of women of reproductive age (15–49) who were enrolled in the Demographic and Health Surveys and conducted between 2010 and 2019 in SSA. Overall, we found a positive association between being anemic and the ecological exposure to malaria incidence [adjusted odds ratio (AOR) = 1.02, 95% confidence interval (CI) 1.02–1.02], and HIV prevalence (AOR = 1.01, CI 1.01–1.02). Women currently pregnant or under deworming medication for the last birth had 31% (AOR = 1.31, CI 1.24–1.39) and 5% (AOR = 1.05, CI 1.01–1.10) higher odds of having anemia, respectively. Similarly, women age 25–34 years old with low education, low income and living in urban settings had higher odds of having anemia. In addition, underweight women had 23% higher odds of suffering anemia (AOR = 1.23, CI 1.15–1.31). Females with low levels of education and wealth index were consistently associated with anemia across SSA. Spatial distribution shows increased risk of anemia in Central and Western Africa. Knowledge about the contribution of known major drivers and the spatial distribution of anemia risk can mitigate operational constraints and help to design geographically targeted intervention programs in SSA.

Pro-poor policies and improvements in maternal health outcomes in India

BACKGROUND

Since 2005, India has experienced an impressive 77% reduction in maternal mortality compared to the global average of 43%. What explains this impressive performance in terms of reduction in maternal mortality and improvement in maternal health outcomes? This paper evaluates the effect of household wealth status on maternal mortality in India, and also separates out the performance of the Empowered Action Group (EAG) states and the Southern states of India. The results are discussed in the light of various pro-poor programmes and policies designed to reduce maternal mortality and the existing supply side gaps in the healthcare system of India. Using multiple sources of data, this study aims to understand the trends in maternal mortality (1997-2017) between EAG and non EAG states in India and explore various household, economic and policy factors that may explain reduction in maternal mortality and improvement in maternal health outcomes in India.

METHODS

This study triangulates data from different rounds of Sample Registration Systems to assess the trend in maternal mortality in India. It further analysed the National Family Health Surveys (NFHS). NFHS-4, 2015-16 has gathered information on maternal mortality and pregnancy-related deaths from 601,509 households. Using logistic regression, we estimate the association of various socio-economic variables on maternal deaths in the various states of India.

RESULTS

On an average, wealth status of the households did not have a statistically significant association with maternal mortality in India. However, our disaggregate analysis reveals, the gains in terms of maternal mortality have been unevenly distributed. Although the rich-poor gap in maternal mortality has reduced in EAG states such as Bihar, Odisha, Assam, Rajasthan, the maternal mortality has remained above the national average for many of these states. The EAG states also experience supply side shortfalls in terms of availability of PHC and PHC doctors; and availability of specialist doctors.

CONCLUSIONS

The novel contribution of the present paper is that the association of household wealth status and place of residence with maternal mortality is statistically not significant implying financial barriers to access maternal health services have been minimised. This result, and India's impressive performance with respect to maternal health outcomes, can be attributed to the various pro-poor policies and cash incentive schemes successfully launched in recent years. Community-level involvement with pivotal role played by community health workers has been one of the major reasons for the success of many ongoing policies. Policy makers need to prioritise the underperforming states and socio-economic groups within the states by addressing both demand-side and supply-side measures simultaneously mediated by contextual factors.

Utilization of Deworming Drugs and Its Individual and Community Level Predictors among Pregnant Married Women in Cameroon: A Multilevel Modeling

BACKGROUND

Although deworming pregnant women is one of the strategies to reduce parasites (roundworms and hookworms) causing anemia and related perinatal and maternal complications, utilization of deworming medication among pregnant women in Cameroon is suboptimal. Comprehensive assessment of individual, household (including women's autonomy), and community-level factors associated with utilization of deworming medication has not been done so far. Therefore, we investigated the individual/household and community-level factors associated with deworming among pregnant married women in Cameroon.

METHODS

Our study was limited to pregnant women because they have a greater risk due to increased chances of anemia. We used data from the 2018/19 Cameroon Demographic and Health Survey. Analysis on 5,013 pregnant married women was carried out using multilevel logistic regression. Odds ratios with a 95% confidence interval (CI) were reported.

RESULTS

Our findings showed that about 29.8% of pregnant married women received deworming medications. The individual/household level predictors of deworming medications utilization identified in this study were women's educational level, wealth quintile, and skilled antenatal care. Distance to health facility and region were identified as community-level predictors of deworming medications utilization. Higher odds of receiving deworming medication occurred among educated and wealthier pregnant married women as well as among pregnant married women who had skilled antenatal care or lived in the south region, whereas lower odds were observed among pregnant married women living in the north region.

CONCLUSION

Access to education and economic empowerment of pregnant married women in remote areas and the north region should be the primary focus of the Cameroon government to enhance deworming coverage in the country.

Are Pregnant Women Who Are Living with Overweight or Obesity at Greater Risk of Developing Iron Deficiency/Anaemia?

Low-grade inflammation is often present in people living with obesity. Inflammation can impact iron uptake and metabolism through elevation of hepcidin levels. Obesity is a major public health issue globally, with pregnant women often affected by the condition. Maternal obesity is associated with increased pregnancy risks including iron deficiency (ID) and iron-deficiency anaemia (IDA)-conditions already highly prevalent in pregnant women and their newborns. This comprehensive review assesses whether the inflammatory state induced by obesity could contribute to an increased incidence of ID/IDA in pregnant women and their children. We discuss the challenges in accurate measurement of iron status in the presence of inflammation, and available iron repletion strategies and their effectiveness in pregnant women living with obesity. We suggest that pre-pregnancy obesity and overweight/obese pregnancies carry a greater risk of ID/IDA for the mother during pregnancy and postpartum period, as well as for the baby. We propose iron status and weight gain during pregnancy should be monitored more closely in women who are living with overweight or obesity.

Anemia and Vitamin B-12 and Folate Status in Women of Reproductive Age in Southern India: Estimating Population-Based Risk of Neural Tube Defects

BACKGROUND

Women of reproductive age (WRA) are a high-risk population for anemia and micronutrient deficiencies. However, there are few representative population-level data from India, which could help inform evidence-based recommendations and policy.

OBJECTIVE

To conduct a population-based biomarker survey of anemia and vitamin B-12 and folate status in WRA as part of a periconceptional surveillance program in southern India.

METHODS

Participants were WRA (15-40 y) who were not pregnant or lactating. Whole blood (n = 979) was analyzed for hemoglobin via a Coulter counter (Coulter HMX). Plasma, serum, and RBCs were processed and stored at -80°C or less until batch analysis. Vitamin B-12 concentrations were measured via chemiluminescence; RBC and serum folate concentrations were evaluated via microbiological assay. Anemia and severe anemia were defined as hemoglobin <12.0 g/dL and <8.0 g/dL, respectively. Vitamin B-12 deficiency and insufficiency were defined as total vitamin B-12 <148 pmol/L and <221 pmol/L, respectively. Folate deficiency and insufficiency were defined as RBC folate <305 nmol/L and <748 nmol/L. A previously developed Bayesian model was used to predict neural tube defect (NTD) prevalence per 10,000 births.

RESULTS

A total of 41.5% of WRA had anemia and 3.0% had severe anemia. A total of 48.3% of WRA had vitamin B-12 deficiency and 74.3% had vitamin B-12 insufficiency. The prevalence of RBC folate deficiency was 7.6%, and 79.3% of WRA had RBC folate <748 nmol/L, the threshold for optimal NTD prevention. Predicted NTD prevalence per 10,000 births based on RBC folate concentrations was 20.6 (95% uncertainty interval: 16.5-25.5).

CONCLUSIONS

The substantial burden of anemia, vitamin B-12 deficiency, and RBC folate insufficiency in WRA in this setting suggests an opportunity for anemia and birth defects prevention. Findings will directly inform the development of a randomized trial for anemia and birth defects prevention in southern India.This study was registered at clinicaltrials.gov as NCT04048330.

Are Countries of the Eastern Mediterranean Region on Track towards Meeting the World Health Assembly Target for Anemia? A Review of Evidence

Anemia is a multifactorial condition, with a complex etiology that involves nutritional and non-nutritional factors. The misconception that iron deficiency is equivalent to anemia may mask the need to address other potential causative factors. This review paper aims to (1) assess the burden of anemia vs. iron deficiency anemia (IDA) amongst women of reproductive age (WRA), pregnant women (PW), and children under five years old (underfive children, U5C) in the Eastern Mediterranean region (EMR); (2) evaluate trends in anemia prevalence and whether countries are on track towards meeting the World Health Assembly (WHA) target for 2025; and (3) characterize anemia reduction efforts and provide a road map for future programs. A search of pertinent literature and databases was conducted. Anemia prevalence in the EMR ranged between 22.6% and 63% amongst PW, 27% and 69.6% amongst WRA, and 23.8% and 83.5% amongst U5C. Data showed that the EMR is not on course towards meeting the WHA target. The contribution of IDA to anemia was found to be less than half. Other potential contributors to anemia in the region were identified, including micronutrient deficiencies, parasitic infestations, and poor sanitation. A framework of action was proposed as a roadmap to meet the targets set by the WHA.

Mathematical modeling and analysis of anemia during pregnancy and postpartum

Anemia is a significant public health problem worldwide especially among pregnant women in low- and middle-income countries. In this study, a mathematical model of the population dynamics of anemia during pregnancy and postpartum is constructed. In the modeling process, four independent variables have been considered: (1) the numbers of nonpregnant nonanemic women, (2) anemic nonpregnant women, (3) anemic pregnant or postpartum women and (4) anemic pregnant or postpartum women with complications. The mathematical model is governed by a system of first-order ordinary differential equations. The stability analysis of the model is conducted using Routh-Hurwitz criteria. There is one nonnegative equilibrium point which is asymptotically stable. The equilibrium point obtained indicates the influential parameters that can be controlled to minimize the number of patients at each stage. The proposed model can be employed to forecast the future incidence and prevalence of the disease and appraise intervention programs.

The effect of boiled feed on trace elements of longissimus dorsi muscle in Hanwoo steers

Boiled feed is obtained by mixing and boiling agricultural by-products such as rice straw, rice bran, and bean curd with grains. The study explored the change in fatty acid, free amino acid, nucleotide, mineral, cholesterol, myoglobin and collagen of longissimus dorsi muscle in Hanwoo steers fed with boiled feed. Forty steers, 20 heads per group, were divided into two groups: a control group and a boiled feed group. The steers were raised for 10 months. The boiled feed group was enriched with palmitoleic acid, oleic acid, arachidonic acid and unsaturated fatty acids compared with the control group. There were no significant differences in amino acid and nucleic acid composition between the two groups. The boiled feed group contained higher levels of iron and manganese in the boiled feed group compared with the control group. The total cholesterol level was significantly increased, whereas calorie levels, myoglobin and collagen composition showed no differences. As the supply of boiled feed increases the content of fatty acids, unsaturated fatty acids and minerals related to flavor, it should be a feed that leads to the production of high-quality beef.

Comparison between Iberet Folic® and Zincofer® in treatment of iron deficiency anaemia in pregnancy

OBJECTIVES

To compare the effect of Iberet Folic^® and Zincofer^® on haemoglobin (Hb) and serum ferritin level; and its adverse effect.

METHODS

This randomised controlled trial conducted from January 2018 until December 2018. Pregnant women below 34 weeks of gestation, with Hb concentration less than 11 g/dL and serum ferritin level less than 12 ug/L were randomised to receive either one tablet Zincofer^® or one tablet Iberet Folate^® daily for four weeks. Both groups were compared in terms of effect on Hb level, serum ferritin level, and other haematological indices adverse effect related to treatment, and treatment cost.

RESULTS

Hundred and thirty patients were recruited in this study with 68 patients in Iberet Folic group and 62 patients in Zincofer group. The change in the Hb and serum ferritin level from baseline to day 30 did not differ significantly between treatment groups. The mean (±SD) change from baseline to day 30 was 2.15 (±0.59) g/dL in the Iberet Folic group, and 1.98 (±0.49) in the Zincofer (p value = 0.08). Mean serum ferritin at day 30 was 17.2 (±3.68) ug/L and 16.7 (±4.28) ug/L with 8.44 (±3.41) and 8.55 (±3.50) difference, respectively (p = 0.86). Adverse events were comparable in between groups, with p value >0.05. GI intolerance and constipation were among the common side effects, occurred in 34.6 and 29.2% cases, respectively.

CONCLUSIONS

Zincofer^® offers equivalent efficacy and side effect profile in comparison with Iberet Folic^® for the treatment of iron deficiency anaemia (IDA) during pregnancy, but with lower cost.

Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine versus single screening and treatment for the control of malaria in pregnancy in Papua, Indonesia: a provider perspective analysis from a cluster-randomised trial

BACKGROUND

Malaria infection during pregnancy is associated with serious adverse maternal and birth outcomes. A randomised controlled trial in Papua, Indonesia, comparing the efficacy of intermittent preventive treatment with dihydroartemisinin-piperaquine with the current strategy of single screening and treatment showed that intermittent preventive treatment is a promising alternative treatment for the reduction of malaria in pregnancy. We aimed to estimate the incremental cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine compared with single screening and treatment with dihydroartemisinin-piperaquine.

METHODS

We did a provider perspective analysis. A decision tree model was analysed from a health provider perspective over a lifetime horizon. Model parameters were used in deterministic and probabilistic sensitivity analyses. Simulations were run in hypothetical cohorts of 1000 women who received intermittent preventive treatment or single screening and treatment. Disability-adjusted life-years (DALYs) for fetal loss or neonatal death, low birthweight, moderate or severe maternal anaemia, and clinical malaria were calculated from trial data and cost estimates in 2016 US dollars from observational studies, health facility costings and public procurement databases. The main outcome measure was the incremental cost per DALY averted.

FINDINGS

Relative to single screening and treatment, intermittent preventive treatment resulted in an incremental cost of US$5657 (95% CI 1827 to 9448) and 107·4 incremental DALYs averted (-719·7 to 904·1) per 1000 women; the average incremental cost-effectiveness ratio was $53 per DALY averted.

INTERPRETATION

Intermittent preventive treatment with dihydroartemisinin-piperaquine offers a cost-effective alternative to single screening and treatment for the prevention of the adverse effects of malaria infection in pregnancy in the context of the moderate malaria transmission setting of Papua. The higher cost of intermittent preventive treatment was driven by monthly administration, as compared with single-administration single screening and treatment. However, acceptability and feasibility considerations will also be needed to inform decision making.

FUNDING

Medical Research Council, Department for International Development, and Wellcome Trust.

Coombs-negative haemolytic anaemia in pregnancy: A case report

We present a rare case of Coombs-negative autoimmune haemolytic anaemia in a multiparous woman in secondary care. There were no known underlying medical or obstetric risk factors for haemolytic anaemia. Following extensive investigation and a therapeutic trial of oral corticosteroids, a diagnosis was made. Autoimmune haemolytic anaemia is potentially fatal, and prompt diagnosis with haematology input is essential to ensure maternal and fetal safety in pregnancy and the puerperium. With only a small number of cases of Coombs-negative autoimmune haemolytic anaemia reported in the literature, we present this rare case for discussion. We highlight the importance of thorough investigation of refractory anaemia in pregnancy and consider the associated challenges.

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Anaemia is pregnancy is common.

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Refractory anaemia should be thoroughly investigated, it can be associated with increased maternal morbidity and mortality.

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Coombs negative anaemia in pregnancy is rare

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We report a case report of Coombs negative anaemia in pregnancy, with no significant underlying medical or family history.

Spatio-temporal trends in anaemia among pregnant women, adolescents and preschool children in sub-Saharan Africa

OBJECTIVE

We investigated the spatiotemporal trends in the burden of maternal, adolescent and child anaemia in sub-Saharan Africa (SSA) and evaluated some individual and household predictors of anaemia.

DESIGN

Average Hb concentrations and anaemia prevalence were estimated, plotted over time and mapped by country and sub-region. Multilevel linear regression models were used to evaluate individual and household predictors of Hb concentration.

PARTICIPANTS

Data from Demographic and Health Surveys (DHS) spanning 2000-2018 were merged into data sets for 37 623 pregnant women, 89 815 older adolescent girls and 401 438 preschool children.

SETTING

The merged DHS represent nationally representative samples from thirty-three countries.

RESULTS

Prevalence of anaemia remains high in SSA, affecting 60, 36 and 44 % of children, adolescents and pregnant women, respectively. Anaemia prevalence among children did not materially improve from 2000 to 2018. Anaemia prevalence among older adolescent girls and pregnant women did not also improve, but this masks a period of improvement followed by depreciation in population anaemia status. Pregnant adolescents had 12·5 g/l (95 % CI: 11·3, 13·6) lower Hb concentration compared with non-pregnant adolescents and 1·7 g/l (95 % CI: 0·7, 2·6) lower Hb concentration compared with pregnant women > 40 years, respectively. Stunting and wasting were associated with 1·3-3·3 g/l lower Hb concentration among children. Other significant predictors of Hb concentration were educational attainment, wealth quintiles, source of drinking water, number of children < 5 years in the household and possession of bed-nets.

CONCLUSION

Anaemia in SSA has not improved remarkably since year 2000 and remains excessive among children.

Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine for malaria during pregnancy: an analysis using efficacy results from Uganda and Kenya, and pooled data

BACKGROUND

Prevention of malaria infection during pregnancy in HIV-negative women currently relies on the use of long-lasting insecticidal nets together with intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). Increasing sulfadoxine-pyrimethamine resistance in Africa threatens current prevention of malaria during pregnancy. Thus, a replacement for IPTp-SP is urgently needed, especially for locations with high sulfadoxine-pyrimethamine resistance. Dihydroartemisinin-piperaquine is a promising candidate. We aimed to estimate the cost-effectiveness of intermittent preventive treatment in pregnancy with dihydroartemisinin-piperaquine (IPTp-DP) versus IPTp-SP to prevent clinical malaria infection (and its sequelae) during pregnancy.

METHODS

We did a cost-effectiveness analysis using meta-analysis and individual trial results from three clinical trials done in Kenya and Uganda. We calculated disability-adjusted life-years (DALYs) arising from stillbirths, neonatal death, low birthweight, mild and moderate maternal anaemia, and clinical malaria infection, associated with malaria during pregnancy. Cost estimates were obtained from data collected in observational studies, health-facility costings, and from international drug procurement databases. The cost-effectiveness analyses were done from a health-care provider perspective using a decision tree model with a lifetime horizon. Deterministic and probabilistic sensitivity analyses using appropriate parameter ranges and distributions were also done. Results are presented as the incremental cost per DALY averted and the likelihood that an intervention is cost-effective for different cost-effectiveness thresholds.

FINDINGS

Compared with three doses of sulfadoxine-pyrimethamine, three doses of dihydroartemisinin-piperaquine, delivered to a hypothetical cohort of 1000 pregnant women, averted 892 DALYs (95% credibility interval 274 to 1517) at an incremental cost of US$7051 (2653 to 13 038) generating an incremental cost-effectiveness ratio (ICER) of $8 (2 to 29) per DALY averted. Compared with monthly doses of sulfadoxine-pyrimethamine, monthly doses of dihydroartemisinin-piperaquine averted 534 DALYS (-141 to 1233) at a cost of $13 427 (4994 to 22 895), resulting in an ICER of $25 (-151 to 224) per DALY averted. Both results were highly robust to most or all variations in the deterministic sensitivity analysis.

INTERPRETATION

Our findings suggest that among HIV-negative pregnant women with high uptake of long-lasting insecticidal nets, IPTp-DP is cost-effective in areas with high malaria transmission and high sulfadoxine-pyrimethamine resistance. These data provide a comprehensive overview of the current evidence on the cost-effectiveness of IPTp-DP. Nevertheless, before a policy change is advocated, we recommend further research into the effectiveness and costs of different regimens of IPTp-DP in settings with different underlying sulfadoxine-pyrimethamine resistance.

FUNDING

Malaria in Pregnancy Consortium, which is funded through a grant from the Bill & Melinda Gates Foundation to the Liverpool School of Hygiene and Tropical Medicine.

Is fatigue a cue to obtain iron supplements in Odisha, India? A mixed methods investigation

OBJECTIVES

This study aims to understand if fatigue, the main symptom of anaemia, is a health concern that cues women and their referent groups to obtain iron folic acid supplements.

DESIGN

This is a mixed methods study that consisted of a cross-sectional perceptual mapping and card sorting activity along with 16 focus group discussions with women of reproductive age, mothers-in-law and men. Participants of the perceptual mapping and card sorting activity were asked to compare images of anaemia-related items and concepts. Participants in the focus group discussions were asked about their daily life, aspirations and concerns among women and perceptions of anaemia and iron supplementation in the community. The quantitative data were analysed through multidimensional scaling and analyses of variance in SPSS. The qualitative data were analysed through applied thematic analysis using NVivo.

SETTING

Bhubaneswar, Odisha, India.

PARTICIPANTS

Women of reproductive age (n=30), mothers-in-law (n=30) and married men (n=30) were randomly selected to participate in the perceptual mapping and card sorting exercise. A separate sample of each group was randomly selected for the focus group discussions (n=148).

PRIMARY AND SECONDARY OUTCOME MEASURES

We collected perceptions of dissimilarity between anaemia-related items, including fatigue and medical items; the extent to which these items were perceived as important to health or likable; and qualitative information about gender norms.

RESULTS

Cognitive maps and card sorting revealed that fatigue was conceptualised distinctly from items related to medical treatment and that perceptions around fatigue's importance to health were low. Women from the focus groups reported that fatigue is a regular part of their daily life.

CONCLUSION

Our results indicate that fatigue is currently not an adequate cue to seek treatment, perhaps due to the normalisation of fatigue as a part of women's daily life.

Anemia and its associated factors among women of reproductive age in eastern Africa: A multilevel mixed-effects generalized linear model

Background

Anemia in women of reproductive age is a major public health challenge for low- and middle-income countries with a long-term negative impact on the health of women, their children, and the economic growth of the society. Even though the world health organization targeted a 50% global reduction of anemia among women of reproductive age by 2025, with the current trend it is unlikely to achieve this goal.

Objective

This study aimed to assess the prevalence and associated factors of anemia among women of reproductive age in eastern Africa.

Methods

A secondary data analysis, using demographic and health survey (DHS) data of 10 eastern African countries, was conducted. For our study, a total weighted sample of 101524 women of reproductive age was used. We employed a multilevel mixed-effects generalized linear model (using Poisson regression with robust error variance). Both unadjusted and adjusted prevalence ratios with their 95% confidence interval were reported.

Results

The prevalence of anemia in eastern Africa was 34.85 (95%CI: 34.56–35.14) ranging from 19.23% in Rwanda to 53.98% in Mozambique. In the multivariable multilevel analysis, being older age, having primary and above education, being from households with second to highest wealth quantiles, being currently working, not perceiving distance as a big problem, use of modern contraceptive methods, and rural residence was associated with a lower prevalence of anemia. While, being married and divorced/separated/widowed, women from female-headed households, women from households with unimproved toilet facility and unimproved water source, ever had of a terminated pregnancy, having high parity, and being from large household size was associated with a higher prevalence of anemia.

Conclusion

The prevalence of anemia in eastern Africa was relatively high. Both individual level and community level factors were associated with the prevalence of anemia in women of reproductive age. Therefore, giving special attention to those women who are at a higher prevalence of anemia such as younger women, those who are from households with low socioeconomic status, unimproved toilet facility, and source of drinking water, as well as pregnant women could decrease anemia in women of reproductive age.

Gestational anaemia and severe acute maternal morbidity: a population-based study

Anaemia is frequently diagnosed during pregnancy. However, there are few data regarding its incidence, and the association with severe maternal morbidity remains uncertain and potentially biased in high-resource countries. The purpose of this study was to explore the association between gestational anaemia and severe acute maternal morbidity during and after delivery. We performed a cohort-nested case-control analysis from the epidemiology of severe maternal mortality (EPIMOMS) prospective study conducted in six French regions (2012-2013, n = 182,309 deliveries). There were 1669 women with severe acute maternal morbidity during or after delivery, according to a standardised definition obtained by expert consensus. The control group were randomly selected among women without severe morbidity who delivered in the same health centres (n = 3234). We studied the association between gestational anaemia and severe acute maternal morbidity during or after delivery overall, by cause, and by mode of delivery, using multivariable logistic regression and multiple imputation. Gestational anaemia was significantly more frequent in women with severe acute maternal morbidity (25.3%) than in controls (16.3%), p < 0.001, and mostly mild in both groups. After adjustment for confounders, women with gestational anaemia were at increased risk of overall severe acute maternal morbidity during and after delivery (adjusted OR (95%CI) 1.8 (1.5-2.1)). This association was also found for severe postpartum haemorrhage (adjusted OR (95%CI) 1.7 (1.5-2.0)), even after omitting the transfusion criterion (adjusted OR (95%CI) 1.9 (1.6-2.3)), and for severe acute maternal morbidity secondary to causes other than haemorrhage or pregnancy-related hypertensive disorders (adjusted OR (95%CI) 2.7 (1.9-4.0)). These results highlight the importance of optimising the diagnosis and management of anaemia during pregnancy.