This was a hospital based cross-sectional study that covered a period of three months from August 2021 to October 2021.
The study was conducted at the antenatal care clinic of Hoima Regional Referral Hospital located in the centre of Hoima city, western Uganda, about 230 kilometers from the capital Kampala. HRRH is a public hospital owned by the government of Uganda but also serves as a satellite tertiary teaching hospital for Kampala International University Western Campus. The hospital is well equipped with an overall bed capacity of 400. The facility offers several services among which include obstetrics and gynecology services including antenatal care which attends to about 25 women per day.
All pregnant teenagers aged 13 years to 19 years in the third trimester who attended the antenatal care clinic at this hospital during the study period were enrolled for the study. We registered no exclusions like pregnant teenagers with emergency obstetric conditions such as antepartum hemorrhage.
Sample size and sampling
A sample size of 288 was considered. This was calculated using the Daniel formula (10) for sample size estimation.
n = Desired sample size
z = z-statistic = 1.96 at 95% level of confidence
p = 25% = proportion of pregnant teenagers with anemia ccording to Obai et al., (11)
q = 1-p
d = Level of precision = 0.0
Consecutive enrollment of all the study participants was done until the required sample size of 288 was reached. The participants were consecutively selected which ensured that they had equal opportunities to participate in the study. Participants were free to withdraw from the study at any time they wished without coercion or compromise of care they were entitled to
Eligible pregnant teenagers were recruited in the study after consenting in writing, following sensitization, education, and counseling about the study. Laboratory report forms were used to collect data on whether or not the respondent was anemic basing on the hemoglobin status. A self generated structured investigator administered questionnaire was used to obtain data for the predictors of anemia status. Validity of the questionnaire was checked using the Content Validity Index. We got 15 respondents not part of the sample population and gave them the questionnaire and measured the inter-respondent agreement. The agreement of more than 75% was considered as a measure that the items of the questionnaire could give us a true picture of factors associated with anemia in pregnant teenagers at Hoima Regional Referral Hospital. The reliability was achieved using the Cronbach’s coefficient alpha test. By using the Cronbach’s coefficient alpha of more than 0.8, it was considered that the items of our questionnaire were reproducible and consistent. Sample collection for Complete Blood Count (CBC) to ascertain the hemoglobin levels was done according to the standard WHO protocols by the principle investigator under the guide of the laboratory technologist. The phlebotomy site selected was either the antecubital fossa or forearm, where a vein of good size, visible, straight, and clear was located. A tourniquet was applied about 4–to-5 finger-widths above the venipuncture site and the vein was re-examined (12). While wearing clean gloves, the chosen site was swabbed with 70% alcohol and allowed to dry completely. The vein was anchored by holding the patient's arm and placing a thumb below the venipuncture site, phlebotomy was performed at approximately 30-degree angle and 4ml of blood was collected and put in well-labeled vacutainers which contained ethylenediaminetetraacetic acid (12). The pressure was applied to the site until bleeding completely stopped. The sample was then taken to the laboratory for complete blood count analysis (12). We used an automated analyzer (Celltac, Automated Haematology Analyzer, MEK-6400. NIHON KOHDEN). The manufacturer-supplied controls were run every morning to ensure that the analyzer was operating within 2.0 standard deviations. The closed model of blood sampling was used; the analyzer automatically sampled blood, processed, analyzed, and printed out the hemoglobin concentration levels. All collected samples were processed and analyzed in the laboratory by a laboratory technologist. Pregnant teenagers with a hemoglobin concentration of less than 11.0 g/dl were categorized as anemic. Anemia was considered severe when the hemoglobin concentration was less than 7.0 g/dl, moderate when hemoglobin was between 7.0g/dl and 9.9g/dl, and mild from 10.0g/dl to 10.9 g/dL.
Data management and analysis
Data were coded and entered in Excel version 2010 and later exported to IBM SPSS version 23. Both bivariate and multivariate logistic regression analyses were carried out. The variables in the final multivariate model were considered significant when p<0.05. The measure of association was reported as odds ratios with corresponding 95% confidence interval and p-value. All statistical analyses were carried out in SPSS version 23.
This study was conducted in accordance with the Declaration of Helsinki. Eligible pregnant teenagers both adults and emancipated minors were recruited in the study after consenting in writing, following sensitization, education and counseling about the study. Informed consent from the participants was obtained after fully explaining the details of the study to them in English and Runyoro-Rutooro, the dominant local language for those who did not understand English. Emancipated minors did not require adult relatives to consent. The process of obtaining blood was done gently and professionally to minimize the risk of pain and infection as far much as possible. Personal protective gear like gloving was used throughout the procedure. Standard operating procedures for COVID-19 which included social distancing, use of face masks and regular cleaning of hands using a sanitizer and/or soap. Priority was not given in terms of tribe, interest group, race, or religion. Appropriate treatment for the laboratory conformed anemic teenagers were recommended by the principle investigator and administered accordingly by the ward staff. Nutrition counseling was also done.