Anemia in pregnancy is one of the most common preventable causes of maternal morbidity and poor prenatal outcome [
Anemia is a global public health problem affecting both developing and developed countries with major consequences for human health as well as economic development [
Anemia in pregnancy is a condition with effects that may be deleterious to mothers and fetuses and it is a known risk factor for many maternal and fetal complications [
Despite the efforts made by the government and other stakeholders, anemia during pregnancy is still a public health problem in Ethiopia [
This study was conducted in public health facilities of Durame Town, Kembata Tembaro zone, southern Ethiopia, from February 16 to May 08, 2017. Durame Town is the capital city of Kembata Tembaro Zone. In Durame there are three health centers, one hospital, and four private clinics. The catchment area of the hospital is Kembata Tembaro Zone and that of the three health centers is Durame Town. Durame General Hospital is the only public hospital serving as referral hospital for Kembata Tembaro Zone. Durame Town is located 309 km south of Addis Ababa and 126 km far from Hawassa city which is the capital city of SNNPR. The altitude of the area is 2213 m above sea level. According to report from CSA, the total population of the town is about 46638 people [
All pregnant women aged 15–49 years who were receiving their first antenatal care in Durame town were the source population. The study population was pregnant women aged 15–49 years who were receiving their first antenatal care in Durame town during February16 to May 08, 2017. Pregnant women who were severely ill and those with 2nd and 3rd visits were excluded from the study.
The sample size was calculated using the double population proportion approach and it was calculated using Epi Info version 7.02 statistical software package with the assumption of 95% confidence level (Z
Systematic random sampling technique is used to select study participants using their average previous month’s antenatal care users used as the sampling frame. In Durame Town there were four public health facilities that give antenatal care service to the pregnant mother. All health facilities found in the town were included and sample was allocated proportionally to population across four health facilities. Cases were selected using systematic random sampling technique and two consecutive controls who came after selection of cases were allocated for each cases.
Anemia was defined according to WHO criteria [
A structured pretested interviewer administered questionnaire was developed in English and then translated into Amharic language for simplicity then back-translated to English language for its consistency by two different language expert individuals who speak both English and Amharic fluently. The questionnaire has four parts sociodemographic, obstetrics characteristics, nutritional related characteristics, and parasitic infection related characteristics were used. Pretesting of the questionnaire was done on 5% of the sample among ANC attendees who attend ANC at Kedida Gamella district who were not included in the study; that was a week before commencement of the actual data collection. Based on the pretest, a questionnaire was corrected to ensure clarity, wording, and logic sequence and skip patterns. Data was collected using exit interview by 10 diploma midwives and supervised by two trained health professionals who had BSc. All data collectors & supervisors were trained for one day and performed practical exercises to be familiar with the questionnaire. The data collectors were regularly supervised for proper data collection; all the questionnaires were checked for completeness and consistency in daily basis.
The specimen collection and processing were carried out by two trained laboratory technologists. Each step of specimen collection, processing, and analysis was supervised by experienced and trained laboratory technologist. The blood for hemoglobin concentration was done based on the Standard Operational Procedures (SOPs). A venous blood sample was taken from the study participants; using a HemoCue Hb 301 analyzer (manufactured by HemoCue AB), a precalibrated instrument was designed for the measurement of hemoglobin concentration and labeled with identification number. Venous blood was drawn, through microcuvettes, and inserted into the HemoCue Hb analyzer and the result was recorded. Stool samples were collected by using a clean and labeled container from the study participants. A portion of the stool was processed with direct microscopic technique to detect intestinal parasites immediately. For detection of helminthes, eggs, larvae, and cysts of protozoan parasites, the samples were examined microscopically first with 10x and then with 40x objective. The remaining part of the sample was emulsified in a 10% formalin solution. Stool examinations were done using formal ether concentration technique, which is considered the most sensitive for most intestinal helminthes. The same method was carried out across all centers.
The collected data were coded, cleaned, and entered by Epi-Info version 7.2 and exported to statistical package for social science (SPSS) version 20.0 for analysis. Descriptive statistics including graphs, charts, tables, and proportion was used to describe the data. Bivariate and multivariate logistic regression analysis was performed to see the association between dependent and independent variables. Variables that showed association in bivariate analysis and which have P-value less than 0.20 were entered into multivariate logistic regression model [
The study was conducted after getting ethical clearance from Arba Minch University, College of Medicine and Health Science Institutional Review Board (IRB). Support letter was obtained from Zonal Health Department as per the recommendation letter from the public health department. Written informed consent was secured from study participants after explaining about the objective and purpose of the study to each study participant. The participants were also assured about the confidentiality of the data. While assessing status of anemia, the result of the test was communicated immediately to each participant and if the pregnant woman was anemic as well as infected with parasites, they were referred to the health personnel for treatment and follow-up.
A total of 333 respondents (111 cases and 222 controls) participated in the study with 100% response rate. Seventy-six (68.8%) cases and 176 (71.6%) controls were in the age group between 20 and 29 years. The dominant ethnic group of the participant were Kembata in both groups, 92 (82.9%) cases and 175 (78.8%) controls. With regard to religion, 101 (91%) cases and 176 (79.3%) controls were Protestants. Pertaining to maternal educational status, 40 (36%) cases and 107 (48.2%) controls were at the primary educational level. Regarding educational status of husband, 44 (39.6%) cases and 108 (48.6%) controls have completed primary educational level. Concerning occupational status of the participant, 35 (31.5%) cases and 89 (40.1%) controls were housewives (Table
Socio-demographic characteristics of pregnant mother attending ANC in public health facilities of Durame Town, February to May 2017.
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15 – 19 | 8 (7.2) | 9 (4.1) |
20 – 24 | 41 (37) | 67 (30.2) | |
25 – 29 | 35 (31.5) | 92 (41.4) | |
30 – 35 | 23 (20.7) | 44 (19.8) | |
>35 | 4 (3.6) | 10 (4.5) | |
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Urban | 69 (62.2) | 138 (62.2) |
Rural | 42 (37.8) | 84 (37.8) | |
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Kembata | 92 (82.9) | 175 (78.8) |
Tembaro | 5 (4.5) | 21 (9.5) | |
Hadiya | 9 (8.1) | 25 (11.3) | |
Other |
5 (4.5) | 1 (10.5) | |
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Protestant | 101 (91) | 176 (79.3) |
Catholic | 6 (5.4) | 23 (10.4) | |
Orthodox | 2 (1.8) | 15 (6.8) | |
Others |
2 (1.8) | 8 (3.6) | |
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Have no formal education | 37 (33.3) | 45 (20.3) |
Primary | 40 (36.0) | 107 (48.2) | |
Secondary and above | 34 (30.6) | 70 (310.5) | |
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Have no formal education | 32 (28.8) | 25 (11.3) |
Primary | 44 (39.6) | 108 (48.6) | |
Secondary and above | 35 (31.6) | 89 (40.1) | |
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House wife | 35 (31.5) | 89 (40.1) |
Merchant | 25 (22.5) | 80 (36) | |
Employed | 38 (34.2) | 45 (20.3) | |
Other |
13 (11.7) | 8 (3.6) |
Among pregnant mothers who were receiving antenatal care at health facilities, 86 (77.5%) cases and 156 (70.9%) controls had previous history of pregnancy. From those who had history of birth, nearly one-third of the cases, 33(38.4%), and 125 (80.1%) controls had birth interval of more than two years. Among those who had history of birth, 53 (47.7%) cases and 155 (69.8%) controls had the less than or equal to four children. Among ANC attendees, 43 (38.7%) cases and 125 (56.3%) controls had history contraceptive use. More than half of the ANC attendees, 73 (65.8%) cases and 195 (87.8%) women, had no heavy menstrual flow before they become pregnant. Concerning gestational age, the majority of the participants, 50 (45%) cases and 93 (42%) controls, were at second trimester of their first antenatal care booking (Table
Obstetrics related characteristics of pregnant mother attending ANC in public health facilities of Durame Town, February to May 2017.
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Yes | 86 (77.5) | 156 (70.9) |
No | 25 (22.5) | 66 (29.7) | |
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Primigravida | 25 (22.5) | 66 (29.7) |
< 2 year | 53 (47.7) | 31 (14) | |
>2 year | 33 (29.7) | 125 (56.3) | |
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≤ 4 | 53 (47.7) | 155 (69.8) |
>4 | 58 (52.3) | 67 (30.2) | |
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Yes | 43 (38.7) | 125 (56.3) |
No | 68 (61.3) | 97 (43.7) | |
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Yes | 38 (34.2) | 27 (12.2) |
No | 73 (65.8) | 195 (87.8) | |
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14 (12.6) | 44 (19.8) |
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50 (45 ) | 93 (42) | |
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47 (42.4) | 85 (38.2) |
Majority, 88 (79.3%), of cases and 20 (9%) controls were not consuming additional food during current pregnancy. Majority of pregnant women who received ANC, 72 (64.9%) cases and 77 (34.7%) controls, had not eaten meat at least one day per week. Regarding the tea/coffee consumption, 83 (74.8%) cases and 110 (49.5%) controls were taking tea/coffee immediately after food every day (Table
Nutritional related characteristics of pregnant mother attending ANC in public health facilities of Durame Town, February to May 2017.
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Yes | 23 (20.7) | 202 (91) |
No | 88(79.3) | 20 (9) | |
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Don’t eat | 72 (64.9) | 77 (34.7) |
Eat one days per week | 39 (35.1) | 145 (65.3) | |
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Don’t drink | 28 (25.2) | 112 (50.5) |
Drink | 83 (74.8) | 110 (49.5) |
Forty-nine (44.1%) cases and 35 (15.8%) controls had intestinal parasitic infection. Among intestinal parasites detected in the pregnant women, 19 (17.1%) cases and 17 (7.7%) controls were infected by
Parasitic infection related characteristics of pregnant mother attending ANC in public health facilities of Durame Town, February to May 2017.
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Yes | 49 (44.1) | 43 (19.4) |
No | 62 (55.9) | 179 (80.6) | |
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Ascaris Lumbricoides | 19 (17.1) | 17 (7.7) |
Hook worm | 11 (9.9) | 5 (2.3) | |
Giardia Lamblia | 14 (12.6) | 10 (4.5) | |
Mixed infection | 5 (4.5) | 11 (5.0) | |
No parasite | 62 (55.9) | 179 (80.6) | |
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Yes | 37 (33.3) | 39 (17.6) |
No | 74 (66.7) | 183 (82.4) |
Bivariable logistics regression was performed for each independent variable. Variables having a p-value of less than 0.25 were transferred to multivariable logistic regression. The results of multivariable logistic regression with backward method after checking of model fitness test by Hosmer and Lemeshow as well as omnibus test which had nonsignificant and significant test result were tested, respectively. And also multicollinearity was checked by using standard error of greater than two indicating that there was no multicollinearity.
The result in multivariable logistic regression showed that the odds of getting anemia in pregnant mothers were higher among mothers whose birth interval was less than two years (AOR=4.78, 95% CI:2.68 -9.64). This study showed that pregnant women who had heavy menstrual blood flow were 2.6 times more likely to have a risk of developing anemia than who did not have history of heavy menstrual blood flow (AOR=2.62, 95% CI:1.18 – 5.84).
According to this study odds of getting anemia in pregnant mothers who did not consume additional food during their pregnancy were 2.5 times greater than the odds of mothers who consume additional food at least one times per day during their pregnancy (AOR=2.49,95% CI:1.22- 5.08). Similarly, pregnant mothers who were not eating meat at least one time per week had two times more likelihood to develop anemia than who ate meat at least one times per week (AOR=2.07, 95% CI: 1.03 – 4.15). The odds of developing anemia among pregnant mothers who were consuming tea/coffee immediately after food were 3.6 times greater than the odds of mothers who did not consume tea/coffee immediately after food during their current pregnancy (AOR=3.57, 95% CI: 1.72 – 7.42).
In this study parasitic infection was also found to be a significant determinant of anemia. Those mothers who were infested by parasitic infection were 3.7 times more likely to develop anemia than those who were not infested by parasitic infection during the current pregnancy (AOR=3.67, 95% CI: 1.72- 7.85) (Table
Determinants of anemia among pregnant mothers attending ANC in public health facilities of Durame Town, February to May 2017.
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≤ 2 year | 53 (47.7) | 31 (14) | 6.4 (3.6-11.6) | 4.77 (2.68-9.64) |
0.01 |
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>2 year | 33 (29.7) | 125 (56.3) | 1 | 1 | |
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Yes | 38 (34.2) | 27 (12.2) | 3.76 (2.14 -6.6) | 2.62 (1.18,5.84) |
0.01 |
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No | 73 (65.8) | 195 (87.8) | 1 | 1 | |
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House wife | 94 (84.7) | 130 (58.6) | 3.9 (2.2-6.99) | 2.5 (1.01– 5.56) |
0.04 |
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Has work | 17 (15.3) | 92 (41.4) | 1 | 1 | |
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Yes | 23 (20.7) | 202 (91) | 1 | 1 | |
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No | 88 (79.3) | 20 (9) | 2.88 (1.8 - 4.6) | 2.5 (1.22-5.08 ) |
0.01 |
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Don’t eat | 72 (64.9) | 77 (34.7) | 4.0 (2.47-6.59) | 2.1 (1.1 – 4.15) |
0.04 |
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Eat one days per week | 39 (35.1) | 145 (65.3) | 1 | 1 | |
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Don’t drink | 28 (25.2) | 112 (50.5) | 1 | 1 | |
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Drink | 83 (74.8) | 110 (49.5) | 3.02 (1.83 - 5) | 3.6 (1.72 - 7.41) |
0.01 |
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Yes | 49 (44.1) | 35 (15.8) | 4.223 (2.5-7.1) | 3.7 (1.7- 7.85) |
0.01 |
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No | 62 (55.9) | 187 (84.2) | 1 | 1 |
AOR = adjusted odd ratio; CI = confidence interval; COR = crude odd ratio;
In order to effectively prevent anemia during pregnancy, its important to identify the factors which contribute to the development of anemia. In this study, pregnant women who had heavy menstrual blood flow before the index pregnancy were 2.6 times more likely to have a risk of developing anemia than who did not have history of heavy menstrual blood flow. This finding is consistent with previous studies conducted in southern and southeast Ethiopia which showed that having heavy menstrual flow was more likely to develop anemia [
In this study, birth interval was found to be a significant determinant of anemia. Those pregnant mother whose birth interval was less than two years were five times more likely to develop anemia than whose birth interval reported to be greater than two years. This finding is consistent with previous studies conducted in Addis Ababa and Sudan [
According to this study, odds of getting anemia in pregnant mothers who did not consume additional food during their pregnancy were 2.5 times greater than the odds of mothers who consume additional food at least one times per day during their pregnancy. This result is consistent with previous studies conducted in Mekele town and study conducted in Hawassa and Yirgalem cities of southern Ethiopia [
From this study, it was observed that pregnant housewives were two times more likely to develop anemia than who have job. The same result was documented in retrospective case control study done in Turkey and Mekelle town in Ethiopia [
Pregnant women who were not eating meat at least one time per week compared to those who ate two times had the likelihood of developing anemia. This result is consistent with other studies done in Ethiopia [
However, consuming tea/coffee immediately after food has a negative association with anemia during pregnancy. The odds of developing anemia among pregnant mothers who were consuming tea/coffee immediately after food were 3.6 times greater than the odds of mothers who did not consume tea/coffee immediately after food during their current pregnancy. This result is in agreement with a study done in Egypt and Ethiopia, which showed significant association between anemia and consumption of tea [
There was a strong significant association between intestinal parasitic infection and anemia in pregnant women. Those mothers who were infected by parasitic infection were 3.7 times more likely to develop anemia than those who were not infected by parasitic infection during the current pregnancy. This finding is in agreement with a study done in Yirgalem and Hawassa cities, Dessie town and Canada [
This study identified important factors that determine anemia among pregnant women in the study area. Among the studied factors, drinking tea/coffee immediately after food intake, not eating meat, not taking additional diet during current pregnancy, presence of parasitic infestations, short birth interval, previous heavy menstrual blood flow, and being housewife are the factors which was associated with anemia during pregnancy. It is recommended that community based health education and mass deworming of intestinal parasites is important for prevention of anemia in pregnancy. A community based study with large sample size and more strong study design should be conducted.
Antenatal care
Adjusted odds ratio
Confidence interval
Crude odds ratio
Ethiopia Demographic and Health Survey
Odds ratio
World Health Organization.
The data used to support the findings of this study are available from the corresponding author upon request.
The university has no role in the design of the study, collection, analysis, and interpretation of the data and in writing the manuscript.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
The authors thank all the study participants for their participation. Arba Minch University supported this research financially.