Magnitude and factors associated with anemia among pregnant women attending antenatal care at St. Paul's Hospital Millennium Medical College, Addis ababa, Ethiopia - a cross sectional type of study

This study aimed to assess magnitude and factors associated with anemia among pregnant women Methods Institution based cross sectional study design was conducted from December 1–30, 2018 on 405 pregnant women attending antenatal clinic. All pregnant women visiting the Antenatal care clinic during the study period and who fullled the eligibility criteria were included in the study. Secondary data was collected from clients register and personal les on hemoglobin, HIV, stool, and other variables. Descriptive statistics was used to analysis some variables by using SPSS. Logistic regression was carried out to identify factors associated with anemia in pregnancy. Adjusted odds ratio with their 95% of condence interval and p < 0.05 are consider to have signicant association.


Conclusion
This study showed that the magnitude of anemia among pregnant women was high especially at third trimester. Living with HIV /AIDS, parasitic infestation and no history of taking fruits after meal were the main factors.

Background
Anemia is a decrease in the oxygen carrying capacity of the blood. It can arise if the hemoglobin (Hgb) concentration of the red blood cells (RBCs) or the packed cell volume of RBCs. (PCV) is below the lower limit of the reference interval for the individual's age, gender, geographical location, and physiological status (1). The World Health Organization (WHO) has suggested that anemia is present in pregnancy when Hgb level is < 11 g/dl (during 1st and 3rd trimester of pregnancy and hemoglobin level below 10.5 g/dl during 2nd trimester of pregnancy. It also classi ed anemia in pregnancy as mild(10.0-10.9 g/dl), moderate(7.09.9 g/dl), and severe(lowerthan7.0 g/dl) based on the level of hemoglobin concentration (2). Anemia is a major health problem that affects 25-50% of the population of the world.
It is estimated that 41.8% of pregnant women worldwide are anemic, 17.5%-40.5% is in women of reproductive age (3) .
Approximately 50% of cases of anemia are considered to be due to iron de ciency. Anemia resulting from iron de ciency in pregnancy is an important factor associated with an increased risk of maternal, fetal, and neonatal mortality; poor pregnancy outcomes (low birth weight and preterm birth); impaired cognitive development, reduced learning capacity, and diminished school performance in children particularly in developing countries like Ethiopia. In neighboring Sudan, 20.3% of maternal deaths are associated with anemia(4). According to literatures the predisposing factors for anemia in pregnant women are, socioeconomic status, Parasitic Infestation (Malaria and Helminthes), and obstetric condition (5).The cutoff point suggested by United States Center for Diseases Control to determine anemia is when a hemoglobin level is less than 11 g/dl in the rst and third trimester and less than 10.5 g/dl in the second trimester of pregnancy (6).The World Health Organization (WHO) de ned anemia as hemoglobin concentration below 11 g/dl in pregnancy and will classify as mild, moderate and severe (7).The estimated global magnitude is 42% in pregnant women and it is a major cause of maternal mortality (8). In Africa 57.1% of the pregnant women were Anemic, more over anemia in pregnant women is a sever public health problem, in Ethiopia 29% and also different studies were conducted on magnitude of anemia among pregnant women, the magnitude range being from 9.7% in North Shoa Zone to 56.8% in Eastern Ethiopia (9). Studying the speci c etiology and magnitude of anemia in a given setting and population group is very important to prevent or treat anemia (10).However, there is very little data available in the study area. Therefore, this study is aimed to assess the magnitude and factors Hence the site is suitable for the study, because of the large numbers of women seen in this facility.

Study Design
Institution based cross sectional study design was conducted from December 1-30, 2018 on 405 pregnant women attending antenatal clinic

Study Population
Page 4/14 The study population was all pregnant women who came for antenatal care follow up to the hospital.

Data Collection Tools & Procedures
Secondary data was collected from clients register and personal les on hemoglobin, HIV, stool, and other variables. The data was collected using structured questionnaire that ful lled the objective of the study, adopted through reviewing of different literatures and previous similar studies. Hemoglobin count and clinical data was collected form 405 respondents by face to face interview. Clinical evaluation of laboratory results was also considered from ANC charts. Three data collectors (midwifery nurses) involved in the data collection. They were given one day training on the administration of the questionnaire and clinical evaluation of ANC mothers medical records, which has information on Hemoglobin count and stool examination for parasitic infestation. They were also involved in the pretesting of the questionnaire. The questionnaires were examined for clarity, ambiguity, time taken to ll it out and analyzability. Appropriate adjustments were made to keep quality of data.
After clients received the routine ANC services, the data collectors provide information for the clients about the study, its objectives, risks and bene ts and consent was taken from them. Medical records of the study participants were also reviewed for the results of routine laboratory tests (Hgb level, Stool examination, VDRL, HIV test etc). The respondents were interviewed in a private study room. The interviews were conducted in a safe, secure and con dential environment. From the anti natal cards, any respondent found to have hemoglobin level of less than 11 g/dl was linked to the physician in charge for further care and treatment after completion of the interview. Double participant recruitment was prevented by enquiring from the client if they had completed the interview before.

Data Analysis
During data entry attention was given to check errors and data cleaning considered. Data entry and clearing was done using Epi info version 7.2.2.6 and data was exported for analysis to Statistical Packages for Social Sciences (SPSS) version 23. During analysis, frequencies of the different variables determined and results were presented in texts, tables and graphs using summery measures such as percentages, mean and median.
For categorical variables, frequency, percentage and descriptive summaries were used to describe the study variables using univariate analysis.
Logistic regression was carried out to identify factory associated with Anemia. Independent variables found to be signi cant in the simple binary logistic regression analysis at a cut point of p-value < 0.2 with 95% of con dence interval were included in the multiple binary logistic regression models.
The effect of each independent variable on the occurrence of anemia was assessed by controlling for the possible confounders using adjusted odds ratios (AOR) and 95% con dence intervals with p-value of less than 0.05. Variables with P value which is less than 0.05 were considered to have signi cant association between anemia and the explanatory variables.

Magnitude of anemia in pregnant women
This study showed that the overall magnitude of anemia among the study participants was 19.75% (CI; 16.00-23.70). Among the participants, 13.2% had mild anemia, 4.4% had moderate anemia and 2.2% had severe anemia. The rest 80.25% didn't develop anemia.

Factors associated with anemia in pregnant women
Bivariate logistic regression was used to test the association between independent variables with P values less than 0.2 and anemia. However, only gravidity, history of bleeding in current pregnancy, HIV/AIDS, parasitic infection and history of no taking fruit after meal were signi cantly associated with anemia.
In multivariate analysis, HIV, parasitic infection and history of not taking fruits after meal were signi cantly associated with anemia.
Anemic women had six times the odds of being HIV-infected compared to non-anemic women (AOR = 6.1 (95% CI 2.197, 17.1).Anemia women had nearly twelve times the odds of having parasitic infection compared to those who are free from parasitic infections (AOR = 11.9 (95% CI 5.606,25.204)).
The habit of not taking fruits after meal was also statistically associatiated with anemia. Pregnant women that do not have the habit of taking fruit after meal were three times more likely to have anemia (AOR = 3.1 (95% CI 1.723, 5.679)) than those who have the habit of taking fruits after meal (11). Fruits with which have Vitamin C help your body absorb iron if eaten at the together with iron-rich foods(12).   (21) and southern Ethiopia 65% (22).
The possible reasons for the difference may be resulted from geographical variation of factors across different areas. In addition, lower magnitude can be attributed to gradual improvement of life style and living standards, using the iron supplementation ordered by the physician during follow up (23) This study nding showed a slightly higher magnitude than studies conducted in Hawassa (15.3%) (24) ,Tikur Anbesa Specialized Hospital (14.1%) (25), Adama town (11.3%) (26), North Shoa zone (9.7%)(9) and Adigrat General Hospital 7.9% (27). This variation might be due to differences in sample size, study design, study period, study setting, and socio-demographic characteristics. Pregnant women having parasitic infestation were nearly 12 times AOR = 11.886(95% CI 5.606, 25.204) more likely to be anemic than their counterparts. This nding is consistent with studies conducted in Gondar (28), Shire (14), Adigrat (27), and North Shoa (9). This might be due to the reason that parasites attach and injure upper intestinal mucosa and ingest blood. This brings gastrointestinal blood loss and induces depletion of iron, folic acid, and vitamin B12 that ultimately results in anemia (29).
This study also showed that HIV positive pregnant women were six times (AOR = 6.126 (95% CI 2.197, 17.084) more likely to develop anemia during pregnancy than those who are not infected with HIV. Studies conducted in Mizan (15),Gondar (13) and Shire (14) showed a similar association between anemia and HIV infection. This increased prevalence of anemia among HIV seropositive pregnant women might be explained by the fact that HIV infection is associated with lower serum folate, vitaminB12, and ferritin in pregnancy. In addition, Anemia in HIV/AIDS patients may arise from a number of causes, including deregulation of the host immune system leading to destruction or inhibition of hematopoietic cells (30).
Women who did not have the habit of taking fruits were found to be three times (AOR 3.128 (95% CI 1.723, 5.679) more likely be anemic than those who have the habit of taking fruits. This nding is similar with a study conducted in South West Arisi zone (20). This might be due to the fact that taking fruits before and after meal may facilitate iron absorption in gastro intestinal system. good knowledge about basic nutrients and adequate well balanced diet usually resulting in positive dietary practices which are important determinants of optimum health (31).

Conclusion
The magnitude of anemia among pregnant women was high especially at third trimester. Living with HIV/AIDS, parasitic infestations and no history of taking fruit after meal were the main predictors of maternal anemia during pregnancy. It is expected that this study will be used to obtaining information relating to anemia in pregnancy and will help in providing information relating to anemia magnitude and associated factors in the hospital to the hospital administration, health care workers and decision makers Written informed consent was obtained from each study participants and they agreed and signed on the consent form. Con dentiality and privacy of participants was ensured at all levels throughout the study by keeping the data and records in a safe place.

Consent to publish
The manuscript doesn't contain any individual person's data (individual details, images or videos) and we didn't obtain any consent for publication from the participants.
Availability of data and materials Figures Figure 1 Magnitude of anemia among the study participants