The overall prevalence of anemia among pregnant women was 42.1%. This finding is comparable with Nepal Demographic and Health Survey 2016 (10), a study conducted by World Bank (40%) in 2016 (17), and a study conducted in Turkey (18). However, the prevalence in our study observed to be higher than other similar studies conducted in Ethiopia (19), 27.9%, Iran, 13.6% (20) and Sudan, 10% (21). The difference in anemia prevalence might be due to socio-economic differences, food habits linked with culture, dietary variations and available health services and utilization. Among 177 anemic pregnant women, 45.8% were mild anemic, 40.5% found moderate and 13.6% were severely anemic which is comparable with a study done in India (22).
In the current study, pregnant women below 20 years and between 20-24 years were 7.2 and 2.8 times more likely to be anemic compared to those in other age groups. This coincides with similar studies from Ethiopia (23) and Nepal Demographic and Health Survey (10), where the women below 20 years were found associated with anemia. The likelihood of anemia among women belonging to Buddhist, Muslim, Kirat, and Christian religion was 3.1 times higher than those belonging to the Hindu religion. However, this finding contrasts from a similar study in India where women belonging to Hindu religion had higher odds of having anemia compared to Muslim (24). These differences might be due to cultural variation, food beliefs and health service access. In this study, type of family, residence, alcohol and smoking habits were however not significantly associated with anemia.
Regarding alcohol consumption and smoking, the consistent result was found in the study among blacks of the United States where the women with alcohol and smoking habit were not found associated with anemia (25). But, as evidenced, alcohol and smoking help to reduce the absorption of iron as identified in the study of micronutrients during pregnancy at the United States (26). This finding must be taken with caution that only a quantitative measure with minimum sample size might not be adequate to access the association of anemia with alcohol and smoking habits.
In this study, the dietary habit of women who consume vegetarian diet were more likely to be anemic than the women eating non-vegetarian diet. The study conducted in rural Wardha also revealed that vegetarian women were significantly associated with anemia (27). Iron and Zinc are supposedly less bioavailable in vegetarian diets as compared to non-vegetarian diets (28), which might be the reason for having higher chances of anemia who follow the vegetarian diet pattern in comparison to non-vegetarians.
Pregnant women consuming Dark Green Leafy Vegetables (DGLV) only once in a week were at greater risk of developing anemia compared to those consuming every day or every other day. Similar studies conducted in different parts of Ethiopia also explored that lower consumption of DGLV increases the risk of having anemia among pregnant women (29, 30). The possible reason to lead anemia might be the less intake of DGLV reduces getting non-heme iron and vitamin A & C in a body.
In the current study, pregnant women who were not taking any forms of multivitamins were 7.9 times more likely to be anemic than those who took multivitamins. The study from Hungary also reveals that multivitamin supplementation protects from developing anemia (31). Similarly, intake of fruits less than two times in a week had 2.7 odds of having anemia among the pregnant compared to those who intake more than two times in a week. The result from the study in Parakou pregnant women too support that lack of consumption of fruits increases the occurrence of anemia(32). On the other hand, the preceding study had explored vitamin A & C helps to promote the absorption of non-heme iron (33). Along with this, vitamin A is involved in the formation of erythrocytes and the mobilization of stored iron in the body (34). Thus, regular intake of DGLV, fruits and multivitamin supplementation plays a crucial role in reducing anemia during pregnancy.
Dietary diversity was found independently associated with anemia. Those pregnant with a low diversity diet were found with higher odds of developing anemia compared with the high dietary diversity. The result is consistent with the study of Ethiopia (35), Mekelle town (36) and also with the study in nine regional states of Ethiopia (37). The previous study among women of the Terai belt of Nepal also explored diets of women have less diversity and inadequacy in nutrition (38). Diet with diverse foods or ingredients provides a number of essential nutrients. Especially, pregnant women require adequate nutrients for them as well as for the development of a fetus. Dietary diversity is considered as a key indicator for assessing the access, utilization and quality of diet at an individual or household level (39).
For the policy and program implication, this study suggests that the government and other stakeholders should develop anemia control interventions, focusing on pregnant women and ethnic minority or disadvantaged groups. Multifaceted nutrition interventions, including promotion on regular intake of DGLV, fruits, diet diversity; proper health education including counseling on nutrition should be made mandatory during the time of ANC visit.
This study also has some limitations. This was an institution-based study and conducted among pregnant women visiting a hospital, therefore it may not be generalized to the whole population. Besides, history questions like 24 hours dietary recall and questions targeted to explore the situation before the pregnancy might not be free from recall bias.