Study Design
This study will be conducted using a hospital-based prospective cohort study aimed at enrolling pregnant women in the first trimester to identify anemia or no anemia at the baseline. The selected subjects will be followed up to delivery to determine whether anemia during different trimesters of pregnancy and hypertension disorders is associated with the risk of adverse maternal and perinatal outcomes in Bekwai Municipality, Ghana.
Study settings
This study will be conducted in four selected hospitals across the Bekwai municipality specifically, Bekwai Municipal hospital, Bekwai, Kotwia Hospital, Kotwia, Abenkyiman hospital, Anwiankwanta, and Adventist hospital, Dominate all in the Ashanti Region of Ghana between February and August 2020. The surveillance system will be established in March 2020 and covers the member hospitals, each of which manages more than 500-1800 deliveries annually. The population of Bekwai municipality, according to the 2010 Population and Housing Census, is 118,024 with the women aged 15-49 years representing 23.9%. The rural population constitutes 97,277 which represent 82.4 percent of the total population whiles the urban areas have a population of 20,747 (17.6%). The total number of live births in the Municipality for the last 12 months prior to the census night was 2,897. The data further indicates that the total fertility rate was approximate 3.5.
Sample size considerations
The sample size will be calculated using a PASS for determining proportions for the study population. Where N1=the first sample size, Power (1-Beta )=0.90, Inspection performance is 90% Alpha (Significance Level)=0.05, Inspection level is 0.05N2 (Sample Size Group 2): Use R, Two groups of sample ratio coefficient R (Sample Allocation Ratio): 1, Two groups of cases Equivalent R1 (Ratio|H1=P1/P2)= 0.5, RR value is 2P2 (Control Group Proportion)=0.23, Control event rate is 23%, Alternative Hypothesis (H1)= Two-Sided, Alternative Hypothesis (Two Sides Test)=Test Type= Z Test ( Pooled). Then, the total sample size for exposed/unexposed will be 225 each for the group. Hence the total sample size for exposed/unexposed with a 10% continuity correction will be approximately 250 each for group and total of 500. Therefore, for a normally distributed continuous outcome, it is possible to detect with a type I error of 5%, two-sided significance level (1-alpha) of 95% confidence interval, and a type II error of 10% with 90% power (1-beta, % chance of detecting).
Eligibility criteria
Inclusion criteria
Pregnant women who had no bleeding at the time of recruitment will be included. All pregnant women aged 15-49 years who has given consent personally with anemia or without will be included, regardless of whether or not they had taken iron supplementation. Women under the age of 18, for whom a written permission to participate has been obtained from a parent or guardian , pregnant women who were not lately been given blood or transfused, who had no chronic medical diseases, who had no early bleeding at recruitment will be included in the study.
Exclusion criteria
Pregnant women with severe immunodepression and women who do not permanently reside in the study area (i.e., less than 6 months residency in the study area) will be excluded.
Selection and recruitment of study participants
The data will be collected at two stages: (i) prenatal data collection from pregnant women and (ii) post-delivery data collection.
Study population
Pregnant women, at the time they scheduled their initial antenatal care visit, which occurred between 6 to 12weeks of gestation will be recruited for the study. The exposed (history of anemia) and non-exposed (no anemia) will be identified as shown in figure 1, since about 88.3% of all pregnant women booked for antenatal care before 12 weeks, and seen at intervals in maternity units where hemoglobin concentrations are routinely measured in each trimester in the study area. Baseline data collection, anthropometric measurements, and blood investigations will be also collected.
Exposed and non-exposed definition
- Exposed: The prevalence of anemia will denote pregnant women with hemoglobin levels below 11 g/dL, i.e hemoglobin levels < 11g/dL will be stratified by trimester and women having anemia in more than one trimester will be allocated to that trimester in which their anemia was first recognized.
- Non-Exposed: Pregnant women without anemia will denote hemoglobin levels ≥11 g/dl, i.e. with three normal hemoglobin tests, one per trimester. For each exposed, the non-exposed will be recruited.
Follow-up period
The mid-pregnancy follow-up visits with pregnant women at the time of the routine antenatal care visit will be conducted between 20 to 24 weeks and 32 to 34weeks of gestation. Postnatal follow-up will be done with the mothers and newborn in the hospital during the birth admission at >37 to 42weeks of gestation. Participant’s recruitments and followed-up periods will last for 26weeks to record maternal and perinatal outcomes.
Prenatal data collection and management
In prenatal data collection, a cross-sectional study will be conducted by using a semi-structured questionnaire. The questionnaire will be consisting of socio-demographic factors (age, marital status, religious belief, place of residence, ethnicity, education status, occupation and housing and household) about the participants. This will also include obstetric and gynecological factors (Gravidity, parity, abortions, stillbirth, inter-pregnancy interval, haemorrhage, type of delivery, birth interval, previous low birth weight, previous preterm, previous pregnancy complications, and all the related information for knowledge menstruation, contraceptives and its usage. This study will acquire behavioural factors (alcohol use, tobacco use, ITN usage, mosquito’s prevention methods, food taboos, Geophagia, herbal usage weight and weight control, physical activity, psychosocial behaviour, adherence to folic acid and iron supplements). Information on medical history (hypertension, diabetes and etc (past and this pregnancy), genetic factors (sickling status, G6PD status and type of blood) infectious diseases (malaria, intestinal worms, HIV, hepatitis B, syphilis, and etc) will be also assessed. Anthropometric measurements (weight, height, body mass index, will be conducted from enrolled pregnant women. Furthermore, nutritional Adequacy and frequency of food consumption will be undertaken from enrolled pregnant women. This food frequency questionnaire will help to assess the die consumed by women in district Municipality. Besides, information of occupation and income status of the husband and be examined.
Hypertensive disorders in pregnancy
Following the course of the pregnancy, the following information will be collected from exposed and non-exposed. Blood pressure will be measured in each trimester with the validated Omron RCHS automated digital sphygmomanometer. All participants will be seated in an upright position with back support for 5 min. An appropriate cuff will be placed around the non-dominant upper arm, which will be supported at the level of the heart, with the bladder midline over the brachial artery pulsation. The mean value of two blood pressure readings will be documented over a 2min interval. Information on chronic hypertension superimposed preeclampsia, preeclampsia or eclampsia, and gestational hypertension will be derived from maternal antenatal registries.
Post-delivery data collection
All participants will be followed-up and will be also contacted twice during their pregnancy over the telephone to enquire about their well-being. Post-delivery data will be collected involving in daily identification of all the women who had delivered during the previous 24 h in the hospital by the support of station nurse. Baseline data will be extracted from patients’ folders, admission and discharge registers at the labor wards. After the initial daily baseline data extraction on all the parturient incomes (fetal distress, neonatal intensive care (NICU) admission, stillbirth, early neonatal death, low birth weight, small for gestation age, birth weight, macrosomia, preterm delivery, APGAR score < 7 at 1 min and APGAR score <7 at 5 min) and mothers outcomes (transfusion, hypertensive disorders, postpartum hemorrhage, gestational diabetes, and maternal mortality) will be identified and their folder numbers recorded. Post-delivery data collection will be completed by August 30, 2020.
Data management and quality control
The data collectors and key informants will be staff midwives nurses and one research assistant supervised by the principal investigator. Training and practical demonstrations on the interview techniques and measurement procedures will be given to data collectors for two consecutive days. A pilot study will be done on 20 ANC attendants over a period of 5days to determine the appropriateness and completeness of the questionnaire for the study. Information that will be retrieved from the ANC books will be confirmed by the principal investigator for its consistency. After informed consent has been obtained, eligible participants will be interviewed using a semi-structured questionnaire. Maternal records will be reviewed on specific items related to the study. Data collected will be then entered into a safe computerized database using a unique code to ensure data accuracy. The databases will have patient-identifiable information attached such as name and address, and each patient will have an anonymized study ID. A copy of the anonymized database (without a name, address) will be sent to SPSS for data analysis. The patient identity will be protected and only aggregate summary data will be released publically (e.g., in the form of a peer-reviewed publication),
Study endpoints and statistical analyses
Perinatal outcomes
Data will be available to performed analyses for the following perinatal outcomes: (1) stillbirth, (2) preterm birth (3), low birth weight (4), small for gestational age (5) perinatal mortality; and (6) NICU admission, (7) APGAR score < 7 at 1 min, (8) APGAR score <7 at 5 min, (9) macrosomia (10) neonatal mortality. The results for these outcomes will be presented by (1) time period: first, second, and third trimesters anemia; (2) cutoff: ≤7.0 g/dL, 7.0-9.9 g/dL, 10-10.9 g/dL, and ≥11.0 g/dL (3) overall estimate of anemia throughout pregnancy will be analyzed. The results of the association between maternal anemia and perinatal outcomes will be summarized in tables.
Maternal health outcomes
Data will be available to performed analyses for the following selected maternal health outcomes: (1) transfusion, (2) hypertensive disorders, (3) postpartum hemorrhage, (4) and gestational diabetes and (5) maternal mortality. The results for these outcomes will be presented by (1) time period: first, second, and third trimesters anemia; (2) cutoff: ≤7.0 g/dL, 7.0-9.9 g/dL, 10-10.9 g/dL, and ≥11.0 g/dL (3) overall estimate of anemia throughout pregnancy will be analyzed. Results of the association between prenatal anemia and maternal outcomes will be summarized in tables.
Data analysis
Statistical analysis
The distribution of the study variables such as sociodemographic factors, nutritional factors, genetic factors, behavioral factors and obstetric factors of exposed and non-exposed will be calculated using means with standard deviations for normal continuous variables and frequencies and percent for categorical variables. Univariate comparisons will be performed using the Pearson Chi-square (χ2) for categorical variables; the independent t-test and Mann–Whitney U test for parametric and nonparametric continuous variables, respectively when the quality of variances is satisfied. Binary logistic regression analysis will be used to evaluate the risk associated between anemia and adverse maternal and perinatal outcomes, using history of anemia (Hb<11g/dL) in different trimester by calculating the odds of different exposures and non-exposed, taking into account, when the interaction terms are observed followed by multiple logistic regression and adjusting for potential confounders. Similar models will be used to examine the associations between hypertensive disorders and adverse maternal and perinatal outcomes. The variables for which p-value turns out to be less than 0.2 will be included in the multivariable analysis. In multivariate analysis of significant effects (p<0.05) will be based on multiple logistic regression analysis. Confidence intervals will be evaluated at 95%. During this analysis interaction between the variables will be assessed. This analysis will also be helpful in identifying the potential confounders such as sociodemographic factors, nutritional factors, genetic factors, behavioral factors and obstetric factors related to the study. In addition, we will also explore the role of first-trimester anemia only, second-trimester anemia only, third-trimester anemia only, first-trimester anemia and second-trimester anemia only, first-trimester anemia and third-trimester anemia on, second-trimester anemia and third-trimester anemia and adverse maternal and perinatal outcomes. Data will be coded and examined using the SPSS program IBM version 20.