ANEMIA DURING PREGNANCY : A STUDY IN LOCAL DISTRICT OF SARAWAK

Christina Busak Henry Sum Agong

Bachelor of Nursing with Honours (2008)

Faculty of Medicine and Health Sciences

Faculty of Medicine and Health Sciences

ANEMIA DURING PREGNANCY: A STUDY IN A LOCAL DISTRICT OF SARAWAK

CHRISTINA BUSAK HENRY SUM AGONG

This project is submitted in partial fulfillment of the requirements for the degree of Bachelor of Nursing with Honours

Faculty of Medicine and Health Sciences UNIVERSITI MALAYSIA SARAWAK

(2008)

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AKNOWLEDGEMENTS

In my work toward completion of this research, I appreciate the help of a number of

people who supported my endeavor. I offer my most sincere gratitude to my supervisor

Miss Jane Buncuan, for guiding me through her critiques of the research study. I am

grateful for her constructive comments, intellectual stimulation, encouragement and

support. My sincere thanks to all lecturers for imparting invaluable knowledge through

their teachings of which I have also benefited.

Medical Officer of Lawas Hospital, Dr. Dayang Siti Rafidah for her support to enable me

to conduct my research in Lawas. All staffs from MCH Lawas, Sundar, Trusan, Kuala

Lawas and Merapok, the Medical Assistants of respective units and to all the participants.

Without your support and co-operation, this study is not possible.

All my colleagues and friends at the Institute of Health and Community Medicine,

UNIMAS for your insightful discussions, encouragement and the friendship that you

have shared with me.

All my sisters especially to Magdeline and my brothers, for their never ending support,

encouragement and love. My parents for always being there with me.

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TABLE OF CONTENTS

PAGE

Abstract ii Acknowledgements iii Table of contents iv List of Tables vii List of Figures viii Chapter 1: Introduction 1.1 Background of this study 1 1.2 Statement of problem 1 1.3 Demography of Lawas 2 1.4 Aims of this Research 5 1.5 Research Question 6 1.6 Scope of this study 6 1.7 Report Overview 6 Chapter 2: Literature review 2.1 Introduction 8 2.2 Anemia 8 2.3 Anemia in pregnancy 10 2.4 Global prevalence of anemia in pregnancy 12 2.5 Prevalence of anemia in pregnancy in Malaysia 13 2.6 Summary 14 Chapter 3: Research Methods 3.1 Introduction 15 3.2 Ethics and ethical approval 15 3.3 Research design 17 3.4 Instruments 17 3.5 Sample and Setting 18 3.6 Data analysis 19

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3.7 Summary 22 Chapter 4: Results 4.1 Introduction 23 4.2 Socio-Demographic characteristic of participant 23 4.2.1 Age 23 4.2.2 Ethnicity and marital status 24 4.2.3 Educational level 24 4.2.4 Occupational and monthly income 24 4.3 Distribution of hemoglobin level 26 4.4 Anemia trend by the different education level 32 4.5 Prevalence of anemia by nutrient, diet, medication and haematimic practice 36 4.6 The trend of anemia by gravida, para and spacing between pregnancies 37 4.7 Trend of anemia by trimesters 39 4.8 Trend of anemia by household monthly income 40 4.9 Summary 41 Chapter 5: Discussion 5.1 Introduction 42 5.2 Prevalence of anemia in relation to demographic 42 5.3 Prevalence of anemia in relation to ethnic 43 5.4 Prevalence of anemia in relation to education, knowledge, gravida, para

spacing and trimester 43 5.5 Prevalence of anemia related to dietary and medication 45 5.6 Summary 46 Chapter 6: Conclusion 6.1 Introduction 47 6.2 Implication of finding 47 6.3 Limitation of finding 47 6.4 Benefits 49 6.5 Recommendation 49 6.6 Conclusion 50 References 52 Appendix I: Application for ethical clearance from Ministry of Health 61

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Appendix II: Ethical clearance letter from Sarawak Ministry of Health 74

Appendix III:Ethical clearance from research and ethical committee 76

Appendix IV: Information sheet & informed consent form 79

Appendix V: Consent form 84

Appendix VI: Questionnaires 87

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List of Tables

Table 2.1 Normal range value 9 Table 4.1 Socio-demographic characteristics 25 Table 4.2 Distribution of haemoglobin levels in relation to demographic &

Obstetric 27 Table 4.3 Number of participants for each MCH clinics 28 Table 4.4 Anemia trend and educational level and background knowledge

on anemia 33

Table 4.5 Prevalence of anemia by nutrient, diet, medication & haematimic Intake 36 Table 4.6 Prevalence of anemia by monthly income 40 Table 4.7 Relationship between anemia and monthly income 40

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List of Figures Figure 1.1 Map of Sarawak 2 Figure 1.2 Birds eye view of Lawas Town 4 Figure 1.3 Lawas map 5 Figure 4.1a Distribution of hemoglobin levels 26 Figure 4.1b The prevalence of anemia among pregnant women 30 Figure 4.1c The prevalence by severity of anemia among pregnant women 30 Figure 4.1d The prevalence of anemia based on the five MCH clinic 31 Figure 4.1e The prevalence of anemia based on the different major ethnic group 32 Figure 4.2 Educational background and knowledge of anemia among subjects 35 Figure 4.3 Anemia trend by between pregnancy 37 Figure 4.4 Anemia trend by gravida and para 38 Figure 4.5 Anemia trend by the different trimesters of pregnancy 39

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ABSTRACT

Anemia during pregnancy is a serious public health problem particularly in developing

countries. This problem is not exceptional in Malaysia. However, there are limited data

available to show the prevalence of anemia during pregnancy especially in the state of

Sarawak. Most of the Malaysia’s available data on anemia during pregnancy are based on data

from West Malaysia. With the absence of data on prevalence of anemia during pregnancy, it

is difficult to evaluate intervention programs systematically. There is therefore, a need to

study the magnitude of the problem locally as well to understand its epidemiology. This is a

descriptive quantitative study conducted in Lawas District. Data collection was done from

23rd to 29th December 2007 and continued 4th till 8th February 2008. Triangulation method

was used to enhance the findings of this study. Random sampling technique was used to select

participants for this study. Five primary health care clinics were selected. A total of 80

antenatal mothers participated. This study highlighted several issues. Out of 80 participants

48.8% was identified to have anemia during pregnancy. The prevalence was highest among

the Malays, Tagal followed by Lun Bawang, while Chinese and Iban community being the

least anemic. The highest prevalence group of anemia in pregnancy also reported among the

grandmultiparas, third trimester, birth spacing between one to two years and mothers with low

level of education. On the other hand, mothers that had well balance diet on regular basis had

the lowest prevalence of anemia. These findings are useful for Maternal Health Services to

enhance health education activities.

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CHAPTER 1

INTRODUCTION

1.1 Background of this study

Anemia during pregnancy is a serious public health problem. Studies have shown that

anemia is a major contributor to maternal deaths especially in developing countries.

Brabin, Hakimi and Pelletier (2001) found a strong association of severe anemia with

maternal mortality. Report of a survey done in Mongolia (U.B, 2004) stated that anemia

during pregnancy does not only lead to maternal problems but it also contributes to

prenatal morbidity and mortality of infants because of the higher incidence of intrauterine

growth retardation and prematurity. This public health problem is also a major concern in

Malaysia.

1.2 Statement of problem

Although anemia among pregnant women is a widely known phenomenon, the

prevalence is still very high in developing countries. High prevalence of anemia during

pregnancy in this country suggests that there is indication that the number of cases on

anemia during pregnancy may be under reported. There is however, little study done on

anemia during pregnancy in Malaysia. In Sarawak, there is an absence of available

epidemiological data regarding prevalence and associated demographic risk factors of

anemia during pregnancy.

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The absence of available data on prevalence of anemia during pregnancy hinders the

intervention programs. There is therefore, a need to conduct study to assess anemia

during pregnancy in Sarawak and in Malaysia in general. Hence, this study offers a

preliminary data on anemia during pregnancy in a local district of Sarawak. In this study,

Lawas District is chosen.

1.3 Demography of Lawas

Figure 1.1 Sarawak Map- http://isarawak.com.my/cmsis/images/swak.jpg Retrieved: October 26, 2007

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Lawas District is 3,811.9 square kilometers in size with the population of 36,162

(Department of Statistics Malaysia, 2003). It is 1200 kilometers from the state capital,

Kuching and 200 kilometers from the capital city of Sabah, Kota Kinabalu. Lawas town

is a busy transit point between Sarawak, Sabah and Brunei, which had become an

advantage economically for the community living around the town. The population

consists mostly of Malay, Kedayan, Lun Bawang, Chinese, Murut (Tagal) and Iban.

There are two major religious groups, this namely Muslims and Christians. The main

economy of Lawas district is mostly timber and agricultural product.

Lawas has seen a total transformation following a decade of extensive urban

redevelopment and reengineering. Major development and changes had been made since

1995, especially in developing residential estates, agriculture projects, new shops,

commercial centres and roads (see Figure 1.2).

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Figure 1.2 Birds eye view of Lawas Town

There are nine health clinics located in Lawas District. Among these nine clinics, eight

clinics are combined with Outpatient Department and Maternal and Child Health Clinic.

These clinics which are Maternal and Child Health Clinic Lawas, Health Clinic Trusan,

Health Clinic Tang Lapadan, Health Clinic Sundar, Health Clinic Kuala Lawas, Health

Clinic Merapok, Health Clinic Long Sukang, Health Clinic Long Semadoh and Health

Clinic Ba’ Kelalan.

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Figure 1.3 Lawas Map- Google Earth. Retrieved: October 26, 2007

1.4 Aim of this Research

This research aims to determine the prevalence of anemia and the risk factors of anemia

among pregnant women in Lawas district. Additionally, the study also examines the

applicability and effectiveness of the assessment tool in identifying knowledge, attitude

and practice among pregnant women in this setting.

Sundar

Kuala Lawas

Trusan

Merapok

Lawas

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1.5 Research Question

Based on the reviewing of the literature and through questions that have raised research

question of the study are:

1. What is the prevalence of anemia in pregnancy in Lawas District.

2. What are the risk factors of anemia among pregnant women in Lawas District.

1.6 Scope of this study

This study attempted to identify the prevalence, risk factors, distribution of hemoglobin

and the associated socio-demographic characteristics of anemia in pregnancy, among

women attending Ministry of Health (MOH) primary care facilities in Lawas. This study

focused on expecting mothers visiting five Ministry of Health (MOH) antenatal clinics.

Pregnant mothers were selected randomly and are invited to answer the set of

questionnaire that include questions that are directed towards their knowledge of anemia,

their attitude towards taking proper medication, balance diet and their normal practices

during pregnancy. Additionally, the factors such as ethnicity, education background,

gravida, para and spacing between birth were compared to determine the affect of the

prevalence of anemia within these subjects.

1.7 Report overview

This write up are divided into five chapters. This first chapter is the general introduction

of the whole project, mainly reporting on the background and the statement of the

problem that lead to the initiating of this study. The second chapter is mainly focuses on

reviewing of the literature. In chapter 3, the framework or the design of this study were

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laid out. This enable the readers to understand the approaches taken in this study. The

findings of this study are stated in chapter 4. Data were analysized and presented to

identify the factors that are related to prevalence. In chapter 5, the results are discussed.

The chapter 6 focuses on conclusion which discusses on the implication of the findings,

limitation and benefits of the study, recommendations and finally, the conclusion at the

end of this chapter.

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CHAPTER 2

LITERATURE REVIEW

2.1 Introduction

The search of the literature on the prevalence and risk factors of anemia during pregnancy

in the community yielded few results. The literature review served to examine the

prevelance of anemia in women and the assessment tools used in identifying knowledge,

attitude and practice among this community.

2.2 Anemia

Anemia is the most common disorder of the blood. It is a condition that occurs when

hemoglobin level is inadequate. Hemoglobin is the oxygen-carrying protein in the red

blood cells. Lower level of hemoglobin will results in a reduced ability of the blood to

transfer oxygen to the tissues. Since all human cells depend on oxygen for survival,

different degrees of anemia may have a wide range of clinical disorder (Bennett, 1993).

Anemia is usually detected or at least confirmed by a complete blood count (CBC) test,

where the result shows a reduction from the normal range (Dacie and Lewis, 1984). The

normal range value for RBCs, hemoglobin and hematocrit in a healthy individual is as

stated in Table 1.1 below.

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Table 2.1 Normal range value of RBCs, hemoglobin and hematocrit in a healthy

individual.

COUNT NORMAL RANGE

Red blood cells (RBCs) Men : 4.5-6.5 x 1012/L

Women : 3.8-5.8 x 1012/L

Hemoglobin Men : 13.0-18.0 x 10 g/dL

Women : 11.5-16.5 x 10 g /dL

Hematocrit Men : 0.40-0.54

Women : 0.37-0.47

Anemia can be either asymptomatic or symptomatic. A person with anemia is commonly

reported with having a feeling of weakness or fatigue. Additional symptoms include

reduced ability in performing daily functions due to impaired cognitive function,

headache, dizziness, chest pain and shortness of breathe, nausea and depression (Bennett,

1993). The symptoms of anemia vary according to the type of anemia, the underlying

causes, and any underlying health problems. Anemia may be associated with other

medical conditions such as hemorrhage, ulcers, menstrual problems or cancer and

specific symptoms of those conditions may be noticed first. Potential causes include

blood loss, poor diet, many diseases, medication reactions, and various problems with the

bone marrow, where blood cells are made. Anemia is further aggravated in women

during pregnancy.

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2.3 Anemia in pregnancy

During pregnancy women get anemic because of the increase demand for iron and other

vitamins due to physiological burden of pregnancy. Additionally a woman loses

approximately 500mg of irons with each pregnancy (Beymann, 2002). The inability to

meet the required level of irons and other supplements usually results in dietary

deficiency or infection that will give rise to anemia.

Among the causes for anemia in pregnant women is, poor diet with inadequate iron, folic

acid deficiency, loss of blood from bleeding haemorroids or gastrointestinal bleeding and

even if iron and folic acid intake are sufficient, a pregnant woman may become anemic

because pregnancy alters the digestive process. The unborn child consumes some of the

iron or folic acid normally available to the mother’s body. Studies have shown that

anemia is more prevalence among uneducated and unemployed women (Idowu et al.,

2005, Agarwal et al., 2006).

Anemia during pregnancy is a known risk factor for many maternal and fetal

complications. For example, premature labor, poor weight gain, dsyfunctional labor,

prematurity, low birth weight, poor Apgar score, fetal distress and neonatal distress,

requiring prolonged resuscitation and causing neonatal anemia due to poor reserve

(Samar K. B, n.d). Prevalence of failure to thrive, poorer intellectual development

milestones, and higher rates of morbidities and neonatal mortalities is higher in infants

with anemia than infants without anemia (Scholl et al., 1992). In addition, babies of

anemic mothers during their first trimester in utero experience higher rates of

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cardiovascular diseases in their adult lives compares to those mothers who did not have

anemia during pregnancy (Kadyrov, Kosanke and Kingdom, 1998).

Iron deficiency anemia in pregnancy is a risk factor for preterm delivery and subsequent

low birth weight (Saha et al., 2000) and possibly for inferior neonatal health (Blot et al.,

1999). Study has shown that foetuses are at risk of morbidity and perinatal mortality due

to the impairment of oxygen delivery to the placenta and the foetus (Allen, 2000). A

study by Rusia, Madan and Agarwal (1995) indicates that anemia in pregnancy reduces

fetal iron stores well into the first year of life. This increases the tendency of infants to

develop iron deficiency anemia and causes adverse consequences in the infant condition

and development.

Preterm babies in anemic mothers can develop iron deficiency anemia because they have

lost the opportunity to store iron by being born too soon. Ankett et. al., (1986) indicates

that there is cumulative evidence that iron deficiency anemia in early life can retard

psychomotor development (Bennett, 1993). Anemia has a significant impact on the

health of the foetus as well as that of the mother (Idowu, Mafiana and Sotiloye, 2005).

Among the adverse effects of anemia on pregnant women are reduced resistance to

infection caused by impaired cell-mediated immunity, predisposition to postpartum

haemorrhage, problem caused by treatment and potential threat to life. The effects are not

only on the mother but also on the fetus/baby, which include increased risk of intra-

uterine hypoxia, growth retardation and higher perinatal morbidity and mortality. It is

also believed that if maternal haemoglobin is less than 6 g/dl, than this population also is

at a greater risk of perinatal mortality and morbidity (Bennett, 1993).

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Anemia is also the commonest nutritional problem worldwide and most prevalence

among pregnant women due to the high requirements of iron during pregnancy (Keller,

1999). This increases the risk of maternal mortality, infection, and lower productivity

(Allen, 2000; WHO, 1992; Husaini, Karyadi, Soewando et al., 1991; DeMaeyer &

Adiels-Tegman, 1985).

2.4 Global prevalence of anemia in pregnancy

The prevalence of anemia in pregnancy in developing countries, reportedly still high.

Nearly half of the pregnant women in the world are estimated to be anemic, with which

52% compared to 23% in industrialized countries (World Health Organization, United

Nations Children’s Fund and United Nation University, 2001). Recent World Health

Organization (WHO) data shows that approximately 10.8 million in African countries,

9.7 million in the Western Pacific and 24.8 million pregnant women in South East Asia

are anemic and the highest number being in South East Asia (World Health Organization,

United Nations Children’s Fund and United Nation University, 2001).

Subsequently, the World Health Organization (2001) also reported that nearly 40% of

world population having anemia. The prevalence may be as high as 56-61% in

developing countries. The WHO estimated that more than half of pregnant women in the

world have hemoglobin level of <11.0gldl which is indicative of anemia (1994). Higher

incidence and severity have been reported especially in malaria endemic area. This is

especially a major concern because Malaysia is a malaria endemic area. The study by

Matteli, Donato and Shein (1994), conclude that anemia during pregnancy may attribute

to as high as 20% of maternal deaths. The South Asian region has the highest prevalence

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of anemia, where 75% of the pregnant women are anemic during pregnancy, the highest

in the world (WHO, 1998).

2.5 Prevalence of anemia in pregnancy in Malaysia

Malaysia, being a developing country is not exceptional. Tee et al (1984) conclude that,

in Malaysia 30 to 60% of the prevalence of anemia during pregnancy were identified in

the town area. Other study had showed that among 46 pregnant women at UKM, 11%

were diagnosed with anemia (Norimah & Juliana, 1988), mainly due to iron deficiency.

Another study done in the urban area of Kelantan, showed that among 9,860 pregnant

women, 47.5% were diagnosed with anemia, with hemoglobin level less than 11.0g/dL

and 1.9% were having anemia with hemoglobin level less than 9.0g/dL (Ahmad et al,

1997).

A recent study done throughout 59 health care clinics in Malaysia showed that the

prevalence of anemic pregnancy in Malaysia is estimated at 35% (Haniff et al., 2007).

The majority of them were of the mild type (9-11g/dl). This study indicates that at a

cutoff point of 11g/dL, the prevalence among young mothers less than 20 years were

46%, grandmultigravidas 39%, grandmultiparas 45% and mothers in third trimester of

pregnancy 43%. The Malay and the Indian mothers found to be the two major races that

are equally affected by anemia while the Chinese had lower prevalence of anemia. This

study identifies two factors that remained positively associated with anemia, which are

gestational age and ethnicity.

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Today there are approximately 35% of overall prevalence of anemia in pregnancy and the

majority of them were of the mild type (9-11g/dl). At a cutoff point of 11g/dl, young

mothers less than 20 years had prevalence of 46%, grandmultigravidas 39%,

grandmultiparas 45% and mothers in third trimester of pregnancy 43% (Haniff et al.,

2007). In this study, the prevalence rate remaines comparable with studies done in

Indonesia (37.1% to 46.2%) (Nurdia, Sumami, Hakim & Winkvist, 2001; Suega

Dharmayuda, Sutarga & Bakta, 2002). However it is lower than in most developing

countries such as South India 69.5% (Abel, 2001) and most African countries (WHO,

2001). The prevalence rate seemed higher than that of Singapore (15%) and most

developed countries likes United Kingdom, France and Germany (Brabin, 2001)

2.6 Summary

As discussed in this chapter, anemia is the most prevalent nutritional deficiency during

pregnancy. Anemia during pregnancy is a known risk factor for many maternal and fetal

complications. Therefore, increases the risk of morbidity and mortality among pregnant

women as well as to the foetus or baby. The prevalence of anemia during pregnancy were

reported higher or highest in the world in the South Asian region. A study in Malaysia

showed that the prevalence of anemic pregnancy were of the mild type (9-11g/dl) among

the young mothers less than 20 years, mothers in third trimester of pregnancy, the Malays

and Indian mothers. Understanding of the methodologies, research techniques and

measuring instruments used in the literature review of various studies could allow the

researcher to analyze and compare data of the research finding of the prevalence of

anemia during pregnancy. Hence, the next chapter discusses on the research methods

used in this study.

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CHAPTER 3

RESEARCH METHODS

3. 1 Introduction

This study is initiated as a response to the Public Health concern in Malaysia, in

particular regarding anemia in pregnancy, which is an important health problem in this

country. This study attempts to identify the prevalence and risk factors of anemia among

pregnant mother who live in a local district, Lawas District, Limbang Division in

Sarawak, Malaysia. Therefore, in relation to this study, this chapter were described the

framework on the development of this research. It specifies the steps and discusses the

ethics and ethical approval, design of the study, the instruments that are used for selection

of respondents and statistical analysis of the study.

3.2 Ethics and Ethical Approval

Prior to commencement of the study, a range of ethical consideration were taken into

account. First, approval was obtained from the State Director of Health Sarawak to

conduct a study in the State of Sarawak Malaysia (see Appendix A). The research topic

was submitted to the course coordinator of Faculty Medicine and Health Sciences,

University Malaysia Sarawak (UNIMAS) and was approved. Subsequently, the research

proposal including the survey tool was submitted to Ethic Committee of Research and

Postgraduate Committee of Faculty Medicine and Health Sciences, Universiti Malaysia