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©Attribution 3.0 Unported (CC BY 3.0)
HC 2015, 3(2):21-26
DOI: 10.12966/hc.05.01.2015
A Comparative Study of Anemia among Pregnant Women in
Rural and Urban Areas of Ogun State, Southwest, Nigeria
Oluwafolahan O. Sholeye1,2,*, Olubukunola A. Jeminusi1,2, Tessie O. Shorunmu2, Albert A. Salako1,2, Ramota
Ademola-Raheem2
1
Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
Faculty of Clinical Sciences, Olabisi Onabanjo University, Ogun State, Nigeria
2
*Corresponding author (Email: [email protected])
Abstract - A major contributor to the high levels of pregnancy – related morbidity and mortality, is anemia in pregnancy, often
precipitated by poor dietary intake of iron and other mineral elements. Anemia in pregnancy is a global problem requiring
concerted efforts to reduce its impact on maternal morbidity and mortality. A cross-sectional comparative study on the
prevalence of anemia was carried out among 720 pregnant women at selected Primary Health Centers in rural and urban areas of
Ogun state, southwestern Nigeria, using multi-stage sampling technique. Severe anemia was found in 1.7% of rural participants
and 2.8% of urban participants; 17.2% of rural participants and 12.2% of urban participants had moderate anemia. More
respondents in the rural (51.1%) and urban areas (62.2%) had normal hemoglobin concentration values. There was a significant
difference (p=0.009) between the hemoglobin concentrations of rural and urban respondents. Regular dietary intake of iron,
folate and other mineral elements in form of supplements should be encouraged.
Keywords - Anemia, Pregnant, Rural, Urban, Ogun
1. Introduction
In many developing countries of the world, particularly in
Southeast Asia and sub-Saharan Africa, the maternal
mortality and morbidity ratios are unacceptably high. Several
strategies have been put in place to correct the anomaly, at
international, country and local levels (Cohen and Richards,
1994; World Bank, 1994). A major contributor to the high
levels of pregnancy – related morbidity and mortality, is
anemia in pregnancy, often precipitated by poor dietary intake
of iron and other mineral elements (Madukosiri and Adoga,
2011). The World Health Organization has identified anemia
in pregnancy as a global problem requiring concerted efforts
to reduce its impact on maternal morbidity and mortality
(WHO, 1992). It is more common in developing countries
than in developed ones. Studies show that prevalence of
anemia in pregnancy in developing countries of Africa, Asia
and Latin America, range from 35% to 75% in contrast to less
than 30% in the United States (Vanderjagt et al, 2007; Brahin
et al, 2001; Van den Broek, 1998). According to the World
Health Organization, about 42% of all pregnant women
worldwide are anemic, with 90% of these living in Africa and
Asia (McLean et al, 2009). Pregnant women are at an
increased risk for iron and multi-nutrient deficiency, as well
as iron deficiency anemia (Mungen, 2003) - Maternal deaths
from anemia in the developing world have been documented
to vary significantly from 34 per 100,000 live births in Nigeria,
to 194 per 100,000 live births in Pakistan (Vanderjagt et al,
2007; WHO, 1996). About 20% of maternal deaths in Africa
have been attributed to anemia (Harrison, 1975).Severe
anemia may directly cause death and even mild anemia may
increase the probability that hemorrhage or exhaustion will be
fatal (Ross, 1998; Nnaem and Udofia, 2010).An association
has been shown to exist between maternal hemoglobin
concentration and birth weight, as well as between maternal
hemoglobin concentration and preterm birth (Ramussen, 2001;
Scholl, 2005).In northern Tanzania, the prevalence of anemia
among study participants was 47.4%; mild anemia accounted
for 35.3%; moderate anemia was found in 9.9% of subjects;
only 2.1% of the women had severe anemia. Analysis of
pregnancy outcomes showed that anemic women were more
likely to have low birth weight infants, compared with their
non-anemic counterparts (Msuya et al, 2011). A study of the
hematocrit levels of 530 gravid women in Enugu, south
eastern Nigeria, found a prevalence of 40.4% for anemia in
pregnancy. Of these, 90.7% were mildly anemic; 9.3% were
moderately anemic; while no case of severe anemia was
reported (Dim and Onah, 2007). A total of 735 pregnant
women participated in a study on maternal hematocrit and
pregnancy outcome in Ibadan. These women were followed
up from the booking clinic until delivery. At booking, 15% of
the women were anemic, while in labor, only about 10.4%
remained anemic. Mild anemia was reported in 6.6% of study
participants, while moderate anemia was found in only 3.8%
22
Health Care (2015) 21-26
of the women studied. The proportion of mothers with
negative birth outcomes like stillbirths was higher among
patients with moderate anemia (Aimakhu et al, 2003). A
cross-sectional study carried out in Abeokuta, Ogun State,
reported about 76.5% of the pregnant women studied to be
anemic at one trimester or the other. Of these, 57.8% were
moderately anemic; 40.3% were mildly anemic; while 7%
were severely anemic. Anemia was of a higher prevalence
(80.6%) among primigravidae compared with the
multigravidae (74.5%). All severely anemic women were
aged less than 30 years. More women in the second trimester
of pregnancy were anemic than in any other trimester (Idowu
et al, 2005).
Rural – urban differences in the prevalence of anemia in
pregnancy have been documented in literature. In Owerri,
southeast Nigeria, a study of the predisposing factors to iron
deficiency anemia among 910 urban and 477 rural pregnant
women, found an overall prevalence of 67.1% for iron
deficiency anemia. Rural women had a significantly higher
prevalence of anemia and significantly lower mean
hemoglobin concentration compared with the urban subjects.
Less-educated women, those aged 24 years and younger, as
well as women with child spacing less than one year had
significantly lower mean hemoglobin concentration and a
significantly higher prevalence of anemia, compared with
other study participants (Okwu and Ukoha, 2008). Nutritional
factors, including multi-nutrient deficiency, have been
associated with anemia in pregnant women in Nigeria and
other developing countries of the world. Folate, Vitamin B12,
Iron and other mineral elements have been found to be
deficient among these groups of women (Vanderjagt et al,
2007; Abdelrahim et al, 2009; Al Khalib et al, 2006).
This study therefore determined the prevalence of
nutritional anemia among pregnant woman utilizing rural and
urban Primary Health Centers.
2. Methodology
Ogun state is located in the southwest geo-political zone of
Nigeria. It was created in 1976 from the defunct Western
Region and has twenty Local Government Areas, grouped
into three senatorial districts in the state. It is bounded in the
north by Oyo and Osun states, in the east by Ondo state, in the
south by Lagos state and in the west by the Republic of Benin.
The Ogun-East Senatorial zone is made up of nine Local
Government Areas; Ogun Central senatorial zone is made up
of five LGAs, while Ogun West senatorial zone has six LGAs
comprising it.
A cross-sectional comparative study was carried out
among pregnant women at selected Primary Health Centers in
rural and urban areas of Ogun state, between 4th December
2012 and 6th May 2013. The following categories of women
were excluded from the study:
a. Pregnant adolescents younger than 18 years and
women older than 49 years of age; and,
b. Women with bleeding disorders, peptic ulcer disease
and chronic medical conditions, including hemoglob
in pathies.
The sample size was derived with a formula for the
comparison of two independent proportions,
N = (Z1-α/2 + Z1-β)2 [P1(1-P1) + P2(1-P2)] / (P1-P2)2
Using a prevalence of 30% for nutritional anemia in
pregnancy, from a facility-based study in northern Nigeria(V
anderjagt et al, 2007) and considering P1 – P2 to be 10%;
N = (1.96 + 0.84)2 [0.3(0.7) + (0.2(0.8)] / (0.3 – 0.2)2
N = 290.008
Taking into account a 20% non-response rate,
incompletely-filled questionnaires and other unforeseen
challenges with data collection, the calculated sample size (N)
was rounded up to 360, per group. A total of 720 pregnant
women were studied in all.
Multi – stage sampling technique was used for the
selection of study participants. The first stage involved the
selection of a senatorial district/zone, from the three zones
present in the state, by simple random sampling resulted in the
selection of Ogun-East senatorial zone.
The second stage involved the selection of one rural and
one urban LGA, by simple random sampling. Sagamu LGA
was selected as the urban study location, out of the two urban
LGAs, while Remo-North LGA was selected from a list of six
LGAs, as the rural study location, by simple random sampling.
Odogbolu LGA, which is classified as semi-urban, was
exempted from the sampling frame.
The third stage of sampling involved the selection of two
wards, from each of the selected LGAs, by simple random
sampling. In Remo-North LGA, wards 7 and 9 were selected
from the 15 existing wards, by simple random sampling
(balloting). The PHCs, located within the selected wards,
constituted the rural study sites. In Sagamu LGA, wards 5 and
8 were selected through a process of simple random sampling
(balloting). The PHCs, located within the two selected wards,
constituted the urban study sites. Therefore, a total of four
PHCs were utilized for the study in both LGAs.
All pregnant women, who met the inclusion criteria and
were willing to participate in the study, constituted the
sampling frame. They were recruited consecutively till the
desired sampling size was reached.
Interviewer-administered, semi–structured questionnaires,
pretested in Ikenne and Ijebu-Ode LGAs, were used to collect
data on respondents’ socio-demographic characteristics,
record Hb and PCV values.
Hemoglobin (Hb) level was assessed using the
hemoglobin meter. The finger prick technique was used.
Participants had their first fingers cleaned with methylated
spirit, which were allowed to dry up, after which a sterile
lancet was used to pierce the skin. Blood samples measuring
about 2.5millilitres in volume, were collected into the
microcurvettes and loaded into a chamber in the hemoglobin
meter. The Hb values were displayed on the monitor of the
portable machine. New batteries were used for each PHC
visited, in order to ensure the reliability of test results.
Participants also had their packed cell volume (PCV)
Health Care (2015) 21-26
measured using capillary tubes and a centrifuge, into which
the tubes were loaded, prior to the measurement of the PCV,
as documented in literature (Dim and Onah, 2007; Adinma et
al, 2002; Gonzales et al, 2009).
Data Analysis was done using the International Business
Machines (2004) Statistical Package for the Social Sciences
(SPSS) version 14.00. Anemia was defined as hemoglobin
concentration less than 11g/dl and a Packed Cell Volume of
less than 33%. Proportions, means and frequencies were
calculated, presented as tables and charts, and compared
between the two groups using the appropriate statistical tests.
Chi square test and Fisher’s exact test were used to test for
association between categorical variables, while t test was
used for comparison of means. Level of significance was
placed at p = 0.05.
Ethical approval was obtained from the Ogun State
Primary Health Care Board, Ogun State Ministry of Health, as
well as the Health Research and Ethics Committee of Olabisi
Onabanjo University Teaching Hospital, Sagamu. Written
approval was also sought from the Local Government Health
Authorities in Sagamu LGA and Remo-North LGA, through
the Medical Officer for Health/Director, Primary Health Care
Department. Participants’ informed consent was obtained
verbally and by thumb printing, prior to the commencement
of the study. Strict confidentiality was ensured throughout the
course of the research. Participants were free to withdraw
from the study, if they deemed it necessary and were assured
that such would not affect the quality of care received at the
facility. All hemoglobin concentration and packed cell
volume results were made available to the respective
participants, through the nursing staff on duty, at the four
PHCs utilized for the study.
3. Results
3.1. Age of respondents
51.7% of rural and 53.9% of urban respondents were aged
between 26 and 33 years. This was followed by those aged 18
– 25 years, comprising 27.2% and 26.4% of rural and urban
respondents respectively. Only 19.4% of rural women and
17.8% of urban respondents were aged between 34 and
41years.The mean age of rural women (28.14 ± 5.49 years)
was not significantly different (p=0.553) from that of the
urban women (28.38 ±5.53 years).
3.2. Marital Status of respondents
Almost 96% of respondents in both urban and rural areas were
married. Both areas had only 3.1% of single respondents.
Divorced and separated respondents constituted 1.3% and
1.1%of study participants at the rural and urban locations
respectively. There was no significant association (p=0.945)
between marital status and respondents’ location.
3.3. Respondents’ Parity
More than a quarter (28.3%) of rural respondents had no
23
previous pregnancy greater than 28 weeks, compared with
23.3% of their urban counterparts. The proportion of
respondents with more than five previous pregnancies, were
10.8% for rural and 13.3% for urban areas. The mean parity of
respondents was 3.13 for rural and 3.32 for urban respondents.
There was no significant difference (p=0.329) between both
means.
3.4. Respondents’ Average Monthly Income
Most respondents in the rural areas (62.5%) and urban areas
(66.4%) earned NGN 2,000.00 or less monthly. About a third
(34.4%) of respondents in the rural areas and 21.1% of
respondents in the urban areas earned no income. The mean
income of rural respondents (NGN 120.49 ± 37.17) was
significantly lower (p=0.021) than the mean income of urban
respondents (NGN 450 ±16.47).
3.5. Sewage Disposal Method
About sixty-seven percent (67.2%) of rural respondents and
60.6% of urban respondents used water closets; 5.3% of rural
respondents had no toilet facilities in their homes, while only
1.9% in the urban areas lacked toilet facilities.
3.6. Vegetable Consumption Pattern of Respondents
Vegetable consumption pattern among respondents was found
to be occasional among 21.7% of rural and 27.8% of urban
women: three times or more a week for 34.4% of rural
respondents compared with 31.1% for urban respondents;
weekly among 30.0% of rural and 27.8% of urban
respondents; daily among 13.9% and 13.3% of respondents.
There was no significant difference (p=0.298) between the
frequency of vegetable consumption of rural and urban
participants.
3.7. Medical History and Use of mineral supplements
(Table 1)
Respondents with medical conditions like gestational
Diabetes, Pregnancy – Induced Hypertension and Asthma
accounted for 1.9% of rural women and 2.8% of urban study
participants. About 85.0% of respondents in both rural and
urban areas used Folic acid, Vitamin B Complex, Multivite,
Iron and Vitamin C tablets daily. There was no significant
difference (p=0.917) between both groups of study
participants.
3.8. Hemoglobin Concentration and Packed Cell Volume
(Table 2)
Severe anemia was found in 1.7% of rural participants and 2.8%
of urban participants; 17.2% of rural participants and 12.2%
of urban participants had moderate anemia. More respondents
in the rural (51.1%) and urban areas (62.2%) had normal
hemoglobin concentration values. There was a significant
difference (p = 0.009) between the hemoglobin concentratio
ns of rural and urban respondents. The mean PCV of rural
participants (33.1 ± 4.4) was significantly lower (p = <0.001)
than the mean for urban participants (34.6 ± 4.6). Slightly
24
Health Care (2015) 21-26
higher proportions of normal participants (52.8% rural; 63.1%
classification, there was also a significant difference between
urban) were reported using the packed cell volume
the PCV readings of both groups of women.
Table 1. Medical History and Drug Use among Respondents
Presence of medical conditions
Yes
No
Use of mineral supplements
Yes
No
Prescribed at antenatal clinic
Yes
No
Location
Rural (n=360)
Urban (n=360)
Frequency (%)
Frequency (%)
7 (1.9)
10 (2.8)
353 (98.1)
350 (97.2)
Rural ( =360)
Urban (n=360)
Frequency (%)
Frequency (%)
305 (84.7)
306 (85.0)
55 (15.3)
54 (15.0)
Rural (n=305)
Urban (n=306)
Frequency (%)
Frequency (%)
266 (87.2)
278 (90.8)
39 (12.8)
28 (9.2)
Test Statistic
X2=0.542;
p=0.462.
X2 =0.071;
p=0.917.
X2=2.069;
p=0.150.
Table 2. Respondents’ Hemoglobin Concentration and Packed Cell Volume
Hemoglobin concentration (g/dl)
Severe anemia (less than 7.0)
Moderate anemia (7.0 – 9.9)
Mild anemia (10.0 – 10.9)
Normal (11.0 and above)
Packed Cell Volume (%)
Severe anemia (less than 21.0)
Moderate anemia (21.0 – 29.9)
Mild anemia (30.0 – 32.9)
Normal (33.0 and above)
Mean (%)
Location
Rural (n=360)
Urban (n=360)
Frequency (%)
Frequency (%)
6 (1.7)
10 (2.8)
62 (17.2)
44 (12.2)
108 (30.0)
82 (22.8)
184 (51.1)
224 (62.2)
Rural (n=360)
Urban (n=360)
Frequency (%)
Frequency (%)
5 (1.4)
62 (17.2)
103 (28.6)
190 (52.8)
33.1 ±4.4
9 (2.5)
43 (11.9)
81 (22.5)
227 (63.1)
34.6 ±4.6
4. Discussion
The mean age of rural respondents was 28.14 ± 5.49 years
while that of urban respondents was 28.38 ± 5.33 years, a
finding that is different from a similar study in Balasore
District India, where the mean age of all respondents was 24.2
years (Sahoo and Panda, 2006). There was no statistically
significant difference between both means (p=0.553), There
was a significant difference between the waste disposal
methods of rural and urban respondents (p =0.002). The poor
waste disposal practices is an established predisposing factor
to parasitic infections and the resultant malnutrition, as
reported in studies conducted in Nigeria and the Ghana (ORC
Macro,2005;Egwunyenga et al,2001).Vegetable consumption
was fair among study participants, with less than 14% of
respondents reporting a daily consumption pattern; 34.4% and
31.1% consuming vegetables at least three days a week in
rural and urban study locations respectively. This is consistent
with findings from other studies in Nigeria and other countries,
which reported sub-optimal dietary intake of vegetables and
folate (Huybregs et al, 2009; Oguntona and Akinyele, 2002;
Test statistic
X2= 11.536;
df = 3;
p=0.009
X2=10.494;
df=3;
p=0.015.
t=4.369;
p=<0.001
Chang et al, 2009; Esmailzadeh et al, 2008).It is however
different from the vegetable consumption patterns reported by
researchers in the Vararian district of India and Osun State,
southwest, Nigeria, where consumption of vegetables along
with its folate content, were adjudged optimal (Ojofeitimi et
al, 2008; Mehrotra and Tiwari, 2009). The slightly better
vegetable consumption pattern among rural women compared
to their urban counterparts could be as a result of availability
of home-grown vegetables in rural areas in contrast to urban
settlements.
The hematological indices of respondents, in form of
hemoglobin concentration and packed cell volume, were
measured to determine the presence or otherwise of anemia,
as documented in medical literature (Koryo-Dabrah et al,
2012;Saxena et al, 2000; Story and Alton, 1995). Hemoglobin
concentration of respondents, classified according to World
Health Organization guidelines, showed that 1.7% of rural
participants and 2.8% of their urban counterparts were
severely anemic, with Hb concentration less than 7.0g/dl. This
is higher than previously reported findings from Sagamu,
Health Care (2015) 21-26
where only 0.7% of the pregnant women were severely
anemic (Lamina and Shorunmu, 2003). The observed
difference between the proportions could be due to the fact
that the previous study was carried out among women
accessing the teaching hospital’s ANC services, while this
study was strictly limited to women accessing PHC services.
The time interval of 10 years, since the research was
published, could also account for the difference observed
between both results from the urban LGA. Although the
proportion of severe anemia was higher among the urban
respondents (2.8%), the values reported in this study are far
lower than that reported by researchers in another urban LGA
of Ogun State, where 7.0% of the women were severely
anemic (Idowu et al, 2005).These findings contrast sharply
with those from Enugu, Ibadan, and some other southeastern
states and outside the Nigeria, where no case of severe anemia
was reported among all their pregnant subjects (Msuya et al,
2011; Van den Broek et al, 2000; Dim and Onah, 2007;
Adinma et al, 2002; Aimakhu et al, 2003).
Moderate anemia was found in 17.2% of rural and 12.2%
of urban respondents. These proportions are higher than
findings from previous studies in Sagamu, Ibadan, Enugu and
other countries, but lower than those from Orissa, India and
Abeokuta, southwest, Nigeria (Lamina and Shorunmu, 2003;
Aimakhu et al, 2003; Dim and Onah, 2007; Adinma et al,
2002; Idowu et al, 2005; Sahoo and Panda, 2006). More rural
respondents (30.0%) were mildly anemic, compared with
their urban counterparts with a prevalence of 22.8% for mild
anemia. The prevalence of mild anemia among the rural
pregnant women is similar to that reported in Abeokuta,
where 30.8% of study participants were mildly anemic
(Idowu et al, 2005). It however, contrasts with findings from
Ibadan, where only 6.6% of study participants were mildly
anemic (Aimakhu et al, 2003). Among the rural respondents,
51.1% had normal Hb concentrations, compared with 62.2%
of urban women.This implies that 48.9% of rural respondents
were anemic, while 37.8% of the urban women were anemic.
These findings are consistent with WHO report on vitamins
and minerals consumption, which states that 42% of pregnant
women worldwide are anemic (McLean et al, 2009).The
prevalence of anemia in this study is similar to those from
studies in Enugu, Tanzania and Malawi, but lower than
findings from Sagamu and Abeokuta (Msuya et al, 2011; Van
den Broek et al 2000; Dim and Onah, 2007; Lamina and
Shorunmu, 2003; Idowu et al, 2005). It is however much
lower than findings from Sudan, where 80.3% of the pregnant
women studied were anemic, with 14.3% having iron
deficiency (Abdelrahim et al, 2009).The higher prevalence of
anemia in the rural subjects is similar to results obtained in
Owerri, southeast Nigeria (Okwu and Ukoha, 2008).
Hemoglobin concentration was significantly associated with
location (p=0.009) in this study. This is similar to findings in
Owerri, where rural pregnant women had a significantly
higher prevalence of anemia than their urban counterparts
(Okwu and Ukoha, 2008).
The mean PCV of rural participants (33.1 ± 4.4) was
25
significantly lower (p=0.000) than the mean PCV (34.6 ±4.6)
of urban participants. The prevalence of anemia based on
PCV measurements was slightly lower than that obtained
using the participants’ Hb concentration. With the PCV
classification, there was also a statistically significant
difference (p=0.015) between the blood levels of rural and
urban participants. With the various limitations of the use of
PCV as an indicator of nutritional status in pregnancy, several
studies have reported it alongside other parameters,
particularly the hemoglobin concentration (Lamina and
Shorunmu, 2003). Researchers in Sagamu, investigated 2,650
pregnant women accessing antenatal care at the teaching
hospital for the presence of anemia in pregnancy. A
prevalence of 55.3% was reported for anemia among the
study participants. Most (88.9%) of the anemic participants
had mild anemia, while moderate anemia was found in 10.4%
of them. Only 0.7% of the pregnant women studied were
found to be severely anemic, with a hemoglobin concentration
of less than 7g/dl (Lamina and Shorunmu, 2003).
Researchers in Anambra, southeast Nigeria, studied 186
booked pregnant women and reported a prevalence of 35.5%
for anemia at booking, using a PCV of 30% as cut off point for
anemia in pregnancy (Adinma et al, 2002).
Nigeria hopes to meet the 2015 deadline for attainment of
the Millennium Development Goals, but the health indices
suggest otherwise. Maternal and peri-natal mortality can be
significantly reduced if adequate mineral and vitamin intake,
as well as optimal hemoglobin concentrations are promoted
and monitored among pregnant women. The PHCs provide a
unique opportunity for providing the best of care to women by
well trained personnel. Since the Ward Health System is
operational in Nigeria, nutrition education, hygiene education,
dietary supplementation and other strategies, aimed at
improving the health status of pregnant women and ultimately
their chances of survival will have a very wide coverage,
thereby achieving the desired results.
The study excluded pregnant teenagers less than 18years
and therefore could not report on the differences in the
prevalence of anemia between rural and urban gravid
teenagers. This study also did not follow up the participants to
determine pregnancy outcome, due to its cross sectional
comparative nature. Therefore, it could not test for association
between maternal anemia and pregnancy outcome. This could
be a subject for further research in the near future. However,
the findings of this study typify the hematological profile of
the generality of pregnant women in both rural and urban
areas of Ogun State, Nigeria.
5. Conclusion
The prevalence of anemia was higher among the rural
pregnant women than their urban counterparts. Regular
dietary intake of iron, folate and other mineral elements in
form of supplements should be encouraged.
26
Health Care (2015) 21-26
Acknowledgement
We are most grateful to our colleagues, Dr Tope Ladi-Akiny
emi, Dr Solomon Oyetoyan, Mrs Adebisi Orenuga, Mr. Lekan
Aina, and Professor Olayinka Abosede, for their very useful
contributions to the completion of this study.
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