Anaemia and Associated Factors Among Pregnant Women Attending Antenatal Care Follow-Up at Yabello General Hospital Living in Pastoralist Borena Zone, Oromia, Ethiopia From From July to August, 2019

Objective: The purpose of the study is to assess magnitude of anemia and associated factors among pregnant women attending antennal care follow-up at Yabello General Hospital in Pastoralist Borena Zone from July-August, 2019. Method: A hospital based cross-sectional study design was employed among 265 pregnant women attending antenatal care at Yabello General Hospital from June 17-August 16 2019. A systematic random sampling technique was used to select two hundreds sixty ve study subjects. The rst study subject was chosen randomly by simple random sampling method blindly picking one of two using pieces of papers named for the rst two visitors. The sampling interval (K) calculated to be 2, and then, every second pregnant woman who attending antenatal care was recruited.Socio-demographic, maternal nutrition, information and obstetric and medical characteristics were assessed. Hemoglobin value, stool examination, HIV and syphilis test results were collected from their regular laboratory tests. Blood lm was conducted for pregnant women who had signs and symptoms and whose hemoglobin value less than the established cut of values and data were analyzed using SPSS version 20.0 software Results: Magnitude of anemia with median hemoglobin value were (11.10g/dl ± 1.66); majority 46(63.9%) had mildly anemia, 24(33.3%) moderate and 2(2.8%) were severe anemia. Urban dwellers women (AOR, 95% CI: .18(.05-.64)), for those who had abortion before current pregnancy (AOR, 95% CI: 3.08(1.17-8.13)); coffee/tea drinking immediately after meal (AOR, 95% CI: 4.39(1.82-10.59), & who had excessive menstrual bleeding before current pregnancy were (AOR, 95% CI: 3.39(1.47-7.84)) & mid-upper arm circumference less than 23cm (AOR, 95% CI: 6.27(1.15-14.30)) were found to be independent predictors of anemia among pregnant women. Conclusion: Anemia in study area among pregnant women in Ethiopia was higher as compare with similar study elsewhere. Malnutrition, green leafy vegetables, not consuming fruits after meal, history of malaria before the current pregnancy, not using Iron-Folic-Acid (IFA) supplementation and educational level, are not signicantly associated with maternal anemia, but they were signicantly associated with maternal anemia by other similar studies ndings (5, 6, 17, 19, 28 & 38-39)

pregnancy, no eating of enough foods that are rich with iron, poor absorption of iron by the body, parasitic infections, parity, gravidity, poverty, culture, infections, less awareness about anemia, excessive blood loss during pregnancy poor health seeking behavior and so on (6,8). The occurrence of anemia during pregnancy is preventable and reversible when it occurs due to de ciencies of nutrients particularly, micronutrients, vitamins and proteins and adverse effects of smoking on vitamin C, vitamin B12, folic acid and vitamin A, and therefore, according to Centers of Disease Control and Prevention (CDC) and World Health Organization (WHO), anemia during pregnancy is de ned as the concentration of hgb. less than 11g/dl (7,9).The magnitudes of anemia among pregnant women vary from countries to countries due to socially, geographically and economic status of the countries, and hence, in Sub-Saharan Africa countries the magnitude of anemia among pregnant women is 57.1 %, in south-east Asia 48.2 %, and this magnitude is twice as common as in America 21.1 % and Europe 25.1 % (10).
2. Figure 1. The Conceptual Frame work adapted from Abie A. 2018 Methods: The study aimed to assess magnitude of anemia and associated factors among pregnant women attending antennal care follow-up at Yabello General Hospital in Pastoralist Borena Zone, Ethiopia from July-August, 2019. A hospital based cross-sectional study design was applied.
The source population for this study was all pregnant women with the age between 15 to 49 years old who live in Yabello Town and its catchment area. The study population was pregnant women who attending antenatal care in Yabello General Hospital and study subjects were pregnant women who give full information for research team. Inclusion criteria was a pregnant women who living in the catchment area and able to respond to the interview whereas exclusion criteria was a pregnant woman who severely ill and unable to respond to the interview and those who referred from other health facilities.
Sampling technique: A systematic and simple random sampling technique was used. The first study subject was chosen simple random sample by blindly picking one of two using pieces of papers named for the first two visitors. The sampling interval (K) calculated to be 2, and then, every second pregnant woman who attending antenatal care was recruited.
Data collection procedure: Data was collected using a face to face interview and MUAC measurement by trained duty-off mid-wife nurses at the ANC clinic and the results of stool investigation, the value of hgb. and PHICT (HIV) were collected by duty-off assigned laboratory technologists in the laboratory and recorded on to the corresponding questionnaires immediately after the final results were approved by the laboratory technologists. A blood smear was conducted to investigate the morphology of RBCs for those whose hgb. value was less than the established cut-off value (<11.0g/dl).
Statistical analysis: Data was entered in to Epi-Info version 7.0 and then exported to SPSS Software Version 20.0. Descriptive statistics were done and summarized by frequencies proportions for categorical predictors. Variables with p< 0.25 in a binary logistic regression were subjected to a multivariate logistic regression to control the possible confounding effects of other predictors and the strength of association was estimated using odds ratio with p<0.05 at 95% confidence interval.
Data quality management: The questionnaire is adapted from prior related studies and modified to the context of the study area and was translated in to local languages by whom, who is familiar with both languages and back to English. A pre-test was done on 5 % with similar population of non-pregnant women in outpatient department at Yabello general hospital to check the understandability of the questionnaire. Data collectors were oriented on data collection tools and the procedures. In the laboratory, the quality of results was ensured through appropriate samples collection and analysis by experienced laboratory personnel. Samples were analyzed using internationally recommended HemoCue-301 hgb.
analyzer and Olympus microscope. Appropriate standard operating procedures during sample collection and investigations were followed and completeness of data was checked by supervisor and principal investigator in a daily basis. The value of hgb. was adjusted for altitude and trimesters using WHO hgb. adjustment factors (44).

Sample size determination:
The sample size was determined using both single population proportion formula by computing the proportion of anemia among pregnant women from Arba Minch was 32.8 % (46), 5% of margin of error and 95% confidence interval and a double population proportion formula using Stat-calc Epi Info statistical software version 7.0 with the Since the total population is less than 10,000, the final sample size needs to be corrected using the correction formula: Where; n f = the desired sample size (when the study population is less than 10,000) n = the desired sample size (when the study population is greater than 10,000) N = the average pregnant women who is expected to visit the ANC during the study period of two months is 547 (YGH, HMIS March to April report 2019). n f = 340 * 547 = 210 340 + 547 The final sample size including 10% non-response rate is calculated to be 231 Sample size determination for second objectives: The sample size for the second objective was calculated using double population proportion formula using the Stat-calc of Epi Info statistical software version 7.0 with the following assumptions: Confidence level = 95%, Power = 80%, the ratio of unexposed to exposed 1.5.

2017)
The maximum sample size that was obtained from the second objective is 260; therefore, this sample is the larger sample size than the sample size from the first objective which was 231, therefore the final sample size that used for this study was the sample size that obtained from the second objective (260).

Results:
A total 265 pregnant women were participated in the study with 100% response rate.   Discussion: The aim of study was to know the magnitude of anemia and associated factorst among pregnant women. According to nding, the overall magnitude of anemia is 27.2%, this is similar when compare with study conducted in the South Nations and Nationalities People of Ethiopia which showed (27.6%) (36); however, the nding is higher than a study conducted in Adama Hospital Medical College (14.9%) (41), North Shoa (10%) (37), Gondar (16.6%) (31), and was slightly higher compared to the national prevalence (23%) (10) and study conducted in China (23.5%) (8). Furthermore, the nding is lower than the study ndings conducted in the Arba-Minch hospital (32.8%), Neqemte hospital (52.0%), Kenya (57.0%), South Africa, (57.7%), India (64.0%) and Baghdad (67.0%)- (46, 40, 30, 22, 17 and 13). The differences might be because of the geographical variations, sampling techniques, software used for data analysis, skill of research teams, information and recall biases. Based up on the classi cation degree of anemia by WHO among all anemic pregnant women about (63.9%) were mild anemic, 33.3% were moderately anemic and (2.8%) were severely anemic. Our study ndings also contradict with the study conducted in Egypt (92.2% mildly anemic, 7.8% moderately anemic and no severely anemic was reported). This variation might be resulted from different geographic location and advancement in quality of ANC and standardized living conditions (29).
Multiple logistic regression analysis reveals that, the odds of anemia among pregnant women who were urban dwellers (AOR 95% CI: .178(.050-.635) times less likely compared to the odds of anemia among pregnant women who were rural dwellers. Similar nding of the study was reported from Ambiya health center (33). This variation could be due to; difference in educational level (55.5% from urban compared to 5.3% from rural; at least with one of educational categories), being informed about anemia and the possible risk factors (46.4%) urban dweller compared to pregnant women from rural (18.1) and being supplemented with IFA during their ANC visit 61.1% and 389% pregnant women from urban and rural respectively.
Among pregnant women who encountered abortion before the current pregnancy, the probability being anemic was 3.081times higher than pregnant women who did not encounter abortion before the current pregnancy (AOR=95% CI: (1.167-8.131)). This could be resulted because abortion might expose women to loss more blood through prolonged hemorrhage and this condition leads to extra requirements of iron by the body (4). Study also showed that pregnant women who used to drink coffee/tea immediately after meal were (AOR=95% CI: 4.394(1.823-10.589) times more likely to be anemic compared to pregnant women who did not drink coffee/tea immediately after meal. The similar study conducted in Durame health center showed similar result (48). The possible reason could be some chemicals could inhibit nonheme iron absorption by Tannin acid in coffee/tea. According to ndings pregnant women with heavy menstrual bleeding than usual before the current pregnancy were (AOR= 95% CI: 3.394(1.469-7.844)) times more affected by anemia compare to pregnant women with normal menstrual bleeding; this nding is similar with the study in Mizan Tepi (4). Because of excessive loss of blood through menstrual bleeding, the pregnant women might encounter anemia due to the expansion of the blood plasma volume.
The odds of anemia among pregnant women with mid-upper arm circumference less than 23cm were (AOR=95% CI: 6.274(1.148-14.298) which is lower than odds of similar study conducted in Kenya, Nairobi (30). In this study the ndings show that, age, meal frequency per day, gravidity, not consuming green leafy vegetables, not consuming fruits after meal, history of malaria before the current pregnancy, not using Iron-Folic-Acid (IFA) supplementation and educational level, are not signi cantly associated with maternal anemia, but they were signi cantly associated with maternal anemia by other similar studies ndings (5, 6, 17, 19, 28 & 38-39) Conclusions: The research is intent to assess current status of anemia among pregnant women. Anemia prevalence in study area among pregnant women was moderate as compare with similar study conducted elsewhere. A multitude of external factors can affect the amount of iron available for absorption as either inhibitors or promoters. In this study malnutrition, abortion, excessive bleeding and nutrition interaction with other inhibitors like coca cola, tea and coffee drinking immediately after meals were independent predictors for anemia development. Therefore, health education should be given by health professional to enhance knowledge of pregnant on adequate dietary intake and Iron-folic combination supplement. institutions. Data were collected through structured questionnaire after translated into local language from pregnant women attending antenatal care follow up at different private and government higher clinics and Hospital. Verbal informed consent was obtained from participants who visit the facilities during the data collection period. In the informed consent form signi cant information such as aim of the study, con dentiality of the information and participant's right to drop and withdraw from study have been explained.
Consent for publication: As there are no identi able details on individual participants reported in the manuscript, consent to publish is not required.
Availability of data and materials: The datasets examined during the current study are available from the both authors corresponding and second authors on sensible inquiry.
Competing interests: As the authors we did not have any competing interest. Percentage of anemia by severity among anemic pregnant women (n=72) Figure 3 Red blood cells morphologic distribution among anemic pregnant women (n=72)