Prevalence and aetiologies of anaemia among first trimester pregnant women in Sri Lanka; the need for revisiting the current control strategies

Inadequate food diversity and food taboo associated with maternal iron deficiency among pregnant women living in slum settlements in Makassar City, Indonesia

BACKGROUND

Anemia in pregnancy is a major public health problem, especially in developing countries. The most common cause is nutritional deficiencies, especially iron deficiency. Adequate nutritional intake from food is essential during pregnancy. Therefore, this study aimed to investigate the relationship between food access and intake patterns with the incidence of iron deficiency among pregnant women living in the slum settlement in Makassar City.

MATERIALS AND METHODS

This research is a sub-study of the Indonesian Birth Cohort Study based in Makassar City. This sub-study used a cross-sectional design and recruited 173 pregnant women in their second and third trimesters using total sampling. All data were collected using a structured questionnaire and recorded using KoboToolbox software. Serum ferritin levels were examined for iron status using the ELISA method at the Microbiology Laboratory Unit at Hasanuddin University Teaching Hospital. The statistical data were analyzed using STATA version 14 with Chi-square analysis and logistic regression.

RESULTS

The prevalence of iron deficiency in pregnant women living in slum settlements in Makassar City was 78%. Logistic regression analysis showed that inadequate food diversity (AOR: 2.58; 95% CI: 1.17-5.69; P = 0.019) and food taboos (AOR: 2.81; 95% CI: 1.26-6.26; P = 0.011) were significantly associated with the incidence.

CONCLUSIONS

Most pregnant women living in slum settlements in Makassar City experienced iron deficiency. Pregnant women who experience iron shortages have been connected to food taboos and dietary diversity.

Iron deficiency and thyroid dysfunction among sudanese women in first trimester of pregnancy: a cross-sectional study

BACKGROUND

Pregnant women are more susceptible to iron deficiency (ID), and it can lead to several maternal and perinatal adverse effects. There are some published data on the effect of ID on thyroid function, but none of the studies were conducted in sub-Saharan African countries including Sudan. This study was conducted to investigate association between ID (ferritin < 15 µg/L) and thyroid functions [thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4)] among Sudanese women in the first trimester of pregnancy.

METHOD

A cross-sectional study was conducted in Saad Abuelela Maternity Hospital, Sudan. Obstetric/sociodemographic characteristics were gathered through questionnaires. Hemoglobin, serum ferritin, TSH, FT3, and FT4 were measured in all pregnant women. Continuous variables were compared with either independent sample t-test if they were normally distributed, or with Mann-Whitney U- test if they were not-normally distributed. Spearman correlations were performed between the continuous variables.

RESULTS

In total, 127 pregnant women with mean [standard deviation (SD)] age of 27.0 (5.5) years and gestational age of 10.5 (3.0) weeks, respectively, were enrolled in this study. Forty-seven (37.0%) of these 127 women had ID. While the median [interquartile range (IQR)] of the parity, TSH, and FT3 were not different between women with ID and women without ID, the median (IQR) of FT4 was significantly lower in women with ID compared with women without ID [1.020 (0.910‒1.120) vs. 1.095 (0.990‒1.217) pmol, P = 0.014]. Serum ferritin was inversely correlated with FT3, (r = -0.225, P = 0.011). There was no significant correlation between serum ferritin, TSH, and FT4.

CONCLUSIONS

Iron deficiency was common during the first trimester of pregnancy and was associated with thyroid dysfunctions. Therefore, ID should be evaluated to avoid thyroid dysfunction.

The geo-spatial perspective of biological, social and environmental determinants of early pregnancy anaemia in rural Sri Lanka: Need for context-specific approaches on prevention

We provide a novel approach to understanding the multiple causations of maternal anaemia in a geospatial context, highlighting how genetics, environment and socioeconomic disparities at the micro-geographical level lead to the inequitable distribution of anaemia. All first-trimester pregnant women registered for the antenatal care programme in Anuradhapura District, Sri Lanka from July to September 2019 were invited to the Rajarata Pregnancy Cohort (RaPCo), which assessed the prevalence of anaemia in early pregnancy. The combination of the prevalence of anaemia and minor haemoglobinopathy-related anaemia (MHA) with the poverty headcount index of the 22 health divisions in the district was investigated using GeoDa spatial K-means clustering. Sociodemographic and economic data at the divisional level were compared between identified clusters. Combining the analysis with the geographical and environmental characteristics of the region, further hypotheses regarding anaemia in this community were formulated. The study included data from 3,137 pregnant women in early pregnancy. The anaemia and MHA prevalence varied from 13.6 to 21.7% and from 2.6% to 5%, respectively. We identified four distinct spatial clusters. The cluster with the highest anaemia prevalence also included high poverty and the highest prevalence of MHA. The clusters had significant differences with regard to ethnic distribution, access to water, sanitation and dietary patterns. Areas supplied by major irrigation projects had significantly low levels of anaemia, probably attributable to internal migration and improved livelihood. It was evident that genetic, socioeconomic and environmental risk factors were grouped at the divisional level, and that their complex interactions make controlling anaemia with blanket interventions unsuccessful. Analysis of the distribution of heterogeneous risk factors at the micro-geospatial level helped identify context-specific approaches to tackle anaemia in pregnancy.

Redesigning New Policy Options for Thalassemia Prevention in Sri Lanka

Sri Lanka, a country with 22 million people, has nearly 2000 thalassemia patients with severe thalassemia, two-thirds of whom have beta thalassemia major (TM). The current prevention program based on promoting “safe marriages”, which has been in existence for over 15 years, has failed to reduce thalassemia major births. We set about to examine the cost-effectiveness of novel policy options for thalassemia prevention in Sri Lanka. Methods: The current cost for treatment of a thalassemia major patient (USD 2602/yr) was compared against the cost per reduction of single birth with three novel strategies, namely intensifying the screening in the current five districts combined with an education program (policy option 1), a nationwide screening program (policy option 2), and antenatal screening combined with the termination of pregnancy (policy option 3). The incremental cost-effectiveness ratio (ICER) of the different strategies was calculated. Results: The status quo was considered to reduce one TM birth whilst the new policy options were able to reduce births by 14, 35, and 48, respectively. The costs incurred for the program for a year for status quo and the three novel programs were USD 104,788, 173,884, 781,372, and 904,186 respectively. Cost per prevention of a thalassemia major birth was USD 87,324, 12,420, 22,324, and 20,084, respectively. The lifetime cost per treatment of a thalassemia major patient was USD 34,653. Conclusions: Given the current legal restriction on termination of pregnancy for fetal indications, policy option 2, an island-wide screening with mass education, is the most cost-effective and will be expected to deliver a substantial reduction in new births.

Factors associated with early pregnancy anemia in rural Sri Lanka: Does being 'under care' iron out socioeconomic disparities?

Globally, more than a third of pregnant women are anemic, and progress in its prevention and control is slow. Sri Lanka is a lower-middle-income country with a unique public health infrastructure that provides multiple interventions across the lifecycle for anemia prevention, despite which anemia in pregnancy remains a challenge. Studying the factors associated with maternal anemia in this context would provide unique information on challenges and opportunities encountered as low-and-middle-income countries attempt to control anemia by improving health care coverage. All first-trimester pregnant women registered for antenatal care in the Anuradhapura district between July 2019 to September 2019 were invited to participate in the baseline of a cohort study. Interviewer-administered and self-completed questionnaires were used. Anemia was defined using a full blood count. A hierarchical logistic regression model was built to identify factors associated with anemia. Out of 3127 participants, 451 (14.4%) were anemic. According to the regression model (Chi-square = 139.3, p<0.001, n = 2692), the odds of being anemic increased with the Period of gestation (PoG) (OR = 1.07, 95% CI = 1.01-1.13). While controlling for PoG, age and parity, history of anemia (OR = 3.22, 95%CI = 2.51-4.13), being underweight (OR = 1.64, 95%CI = 1.24-2.18), having the last pregnancy five or more years back (OR = 1.57,95%CI = 1.15-2.15) and having used intrauterine devices for one year or more (OR = 1.63, 95%CI = 1.16-2.30) increased the odds of anemia. Breast feeding during the last year (OR = 0.66, 95%CI = 0.49-0.90) and having used contraceptive injections for one year or more (OR = 0.61,95%CI = 0.45-0.83) reduced the risk of anemia. Proxy indicators of being in frequent contact with the national family health program have a protective effect over the socioeconomic disparities in preventing early pregnancy anemia. Maintaining the continuum of care through the lifecycle, especially through optimizing pre and inter-pregnancy care provision should be the way forward for anemia control.

Prevalence and factors associated with anaemia among pregnant women attending reproductive and child health clinics in Mbeya region, Tanzania

Anaemia is a global public health issue, disproportionately affecting vulnerable populations such as pregnant women. The aim of this study was to assess the prevalence of anaemia and to identify factors associated with the condition among pregnant women attending antenatal clinics in the Mbeya Region of Tanzania. A cross sectional study was conducted with 420 pregnant women (<28 weeks of gestation) attending antenatal visits in the 7 districts of the Mbeya Region. A structured questionnaire was used to collect demographic information and eating habits using a 24hours dietary recall. A blood sample was collected and tested for hemoglobin content using the HemoCue 201+. Multivariate analysis was performed using standard logistic regression to explore the association between anaemia status with socio-demographic, reproductive and nutritional factors. Overall prevalence of anaemia in pregnant women was 25.5%. Out of 107 pregnant women diagnosed with anaemia and, sixty six had mild anaemia. In a multivariate logistical regression analysis anaemic women was associated with pregnant women coming from lower socio-economic status [adjusted OR = 2.40, 95%CI (1.05, 5.48)]. Moreover, anaemia was less associated with pregnant women who were living in Mbeya district council [adjusted OR = 0.28, 95%CI (0.11, 0.72)], consume at least once a day dark green leafy vegetables [adjusted OR = 0.53, 95% CI (0.30, 0.94)], and vegetable liquid cooking oil [adjusted OR = 0.56, 95% CI (0.34, 0.98)]. The prevalence of anaemia among the pregnant women falls in the category of moderate public health problem according to the WHO classification. Low socio-economic status, consumption of green leafy vegetables and vegetable liquid cooking oil were significantly and independently associated with anaemia during pregnancy. Thus, special attention should be given to pregnant women who are in lower socio-economic status and those not consuming vegetables. Interventions that integrate health and nutrition education in reproductive and child health clinics are needed to combat anaemia.