Prevalence, Aetiology, Maternal and Neonatal Outcome of Term Mothers with Anaemia, Presenting to a Tertiary Care Unit for Confinement in Sri Lanka

Objective: To describe the proportion of women presenting with undiagnosed anaemia at confinement and to explore associations between anaemia and socio economic factors, dietary pattern and compare maternal and neonatal outcome among term mothers with anaemia compared to non-anaemic pregnant women at a tertiary care centre in Sri Lanka. Method: A comparative cross-sectional study was performed by recruiting anaemic and non-anaemic term mothers who delivered at the Teaching Hospital Peradeniya during the period March 2018-March 2019. Pregnant mothers whose haemoglobin level was less than 10.5 g/dl were considered as anaemic and compared with the mothers whose haemoglobin level was above this level. With written consent, demographic data, etiological factors, maternal and neonatal outcomes of term mothers were evaluated by an interview and blood samples were withdrawn to carry out anaemia related investigations. Results: Among 2854 pregnancies, a total of 234 (8.19%) term pregnant mothers were anaemic and they were and compared with 199 non-anaemic mothers. Out of the anaemic mothers (Hb < 105 g/l), 133 (56.76%) had moderate anaemia, 100 (42.79%) had mild anaemia and 1 mother (0.45%) had severe anaemia. Low monthly family income was significantly associated with the incidence of anaemia. Anaemia was also associated with low weekly consumption of red meat (OR 8.994; 95% CI, 5.74 14.09, p < 0.05) and high weekly tea intake (OR 0.217; How to cite this paper: Kandauda, I.C., Manatunga, S.L., Maduwage, K., Rathnayake, P.M., Tennakoon, S. and Gunathilake, C.T. (2020) Prevalence, Aetiology, Maternal and Neonatal Outcome of Term Mothers with Anaemia, Presenting to a Tertiary Care Unit for Confinement in Sri Lanka. Advances in Reproductive Sciences, 8, 221-233. https://doi.org/10.4236/arsci.2020.84019 Received: October 2, 2020 Accepted: November 9, 2020 Published: November 12, 2020 Copyright © 2020 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access I. C. Kandauda et al. DOI: 10.4236/arsci.2020.84019 222 Advances in Reproductive Sciences 95% CI 0.144 0.327, p < 0.05). Among anaemic mothers, 215 (67.44%) had low serum ferritin (<30 ng/mL) while most of them were diagnosed with iron deficiency anaemia (58.24%) (n = 113) based on haemoglobin. Most anaemic mothers had undergone elective caesarean section (46.26%) while vaginal deliveries (33.33%) were common among non-anamic group. Conclusions: A moderate prevalence of anaemia among term pregnant women in Peradeniya, Sri Lanka was observed and was associated with low socio economic status, low consumption of tea and poor nutrition lacking in red meat.


Introduction
Anaemia in pregnancy is a long known major health problem in developed and developing countries. Prevalence of anaemia in pregnancy varies from 15% in developed countries [1] and 33% to 75% in developing countries [2]. World health organization (WHO) defines a haemoglobin concentration of 110 g/l as the cut off level to diagnose anaemic during pregnancy. It is subcategorized as mild (10.0 -10.9 g/dl), moderate (7.0 -9.9 g/dl) and severe (<7.0 g/dl) anaemia [3]. According to the UK guidelines for haematology and the RCOG NICE guidelines, anaemia in pregnancy is defined as haemoglobin concentration (Hb) < 110 g/l in first trimester and <105 g/l in second and third trimesters and <100 g/l immediately postpartum [4] [5]. Sri Lankan college of haematologists recommends the cut of values given by the UK guidelines and it is currently used in Sri Lanka to diagnose anaemia in pregnancy.
During the period of pregnancy, blood plasma volume begins to increase physiologically at the beginning of the first semester and plateaus in the third semester. This occurs at a higher rate than the red blood cell and haemoglobin production, which causes a haemodilution effect and the resulting condition is referred to as physiological anaemia [4]. Hence, during the second and third trimesters of pregnancy, Hb < 105 g/l is considered as anaemia while a normal person is diagnosed as anaemic when the Hb < 110 g/l. Due to the haemodilution effect, the risk of developing anaemia is higher during pregnancy. It is associated with adverse maternal outcomes, such as puerperal sepsis, antepartum haemorrhage, postpartum haemorrhage, and more [6]. Apart from maternal risks, it is also responsible for premature delivery, low birth weight babies and high perinatal mortality [7]. The causes of anaemia in pregnancy are Folate and vitamin B12 deficiency, inflammatory disorders, thalassemia, haemolysis and blood loss and the most common nutritionally related iron deficiency anaemia [4]. There is a huge demand for iron during the period of pregnancy as the frequency of maternal erythropoiesis is high due to increased plasma volume and the utilization of iron for the fetal growth. Iron-deficiency anaemia occurs when I. C. Kandauda et al. Advances in Reproductive Sciences there is shortage of iron stores, transport and functional iron, resulting in reduced haemoglobim in addition to low serum ferritin, low transferrin saturation and increased erythrocyte protoporphyrin concentration [4]. Beside poor nutrition, late booking, low financial status, multiparity, abortion, frequent pregnancies, infections, consuming excess tea or coffee after meals determined as the predictors of anaemia in pregnancy [8].
Due to high prevalence and known complications of anaemia in pregnancy, every mother is checked for anaemia at booking visit, at 28 weeks of gestation and on admission for confinement in most of the countries. The Sri Lankan maternal health programme contains several strategies to prevent anaemia during pregnancy. They are oral iron, vitamin C, folate and food supplementations provided at antenatal clinics for every pregnant woman free of charge.
In Sri Lanka, where there are wide variations in socioeconomic status, dietary patterns and different cultural taboos, the prevalence of anaemia could vary in different geographical areas. WHO estimated that prevalence of pregnancy associated anaemia is around 29% in Sri Lanka [9]. In 2007, a demographic and health survey (DHS) reported an overall prevalence of 34% with 20.7% mild and 13.3% moderate to severe anaemia [10]. In 2009, there was a survey, which showed 17% prevalence of anaemia during pregnancy in Sri Lanka, with 7% in Kurunegala district to 29% in Colombo district [11].
Although several studies had been conducted to identify the prevalence of anaemia among pregnant women in Sri Lanka, there are only few reports available on the prevalence of anaemia among term pregnant mothers. A survey study conducted in Anuradhapura district in 2012 had found that the prevalence of anaemia in first, second and third trimesters was 7.6%, 19.7%, and 19.3% respectively [12]. Even though several studies show a wide range of prevalence, all these show lower estimations than WHO records. A reliable estimate of the prevalence of anaemia in Sri Lanka is needed as it will enable a proper evaluation of the public health of the country. Hence, the present study was conducted to describe the prevalence of anaemia among term mothers in Peradeniya, Sri Lanka and to describe the aetiology, socio economic factors, and dietary pattern and maternal and neonatal outcomes among term mothers with anaemia. The study protocol was approved by the ethical committee Faculty of Medicine, University of Peradeniya (2017/EC/42), Sri Lanka. Informed written consent was obtained from each participant after explaining the study procedure.

Materials and Methods
An information sheet was provided in all three official languages (Sinhala, Tamil, English) as to include all ethnic groups. Participants had a chance to clarify their doubts and only those consented for the research had been included in the study. The confidentiality of the research data was well maintained. The benefits from this study to the health sector and to the society were explained.
In analysing the dietary habits among anaemic women, 183 (81.7%) had low consumption (less than 4 times per week) of red meat. Among non-anaemic group, 133 (66.8%) had an adequate amount of red meat and only 33.2% had low consumption of red meat. Therefore, there is a significant relationship between anaemia and red meat consumption among anaemic and non anaemic women (OR, 8.994; 95% CI, 5.74 -14.09, p < 0.05). Mothers who consumed tea more than two times per week were considered as high tea consumers and the mother who consumed tea twice or less than that per week were considered sufficient tea intakes. Of the anaemic mothers, 158 (70.5%) had high weekly tea intake (OR, 0.217; 95% CI, 0.144 -0.327, p < 0.05) while 29.5% had sufficient tea intake. Moreover, the percentage of tea intake was higher among (53.79%) the women with lower income (<Rs. 30,000) per month.
Serum haemoglobin level (Hb) was available only for 222 anaemic mothers on admission. The mean value for the anaemic group for Hb was 9.51 ± 0.74 g/dl and for the non-anaemic group was 11.95 ± 1.06 g/dl. Out of the non-anaemic group, only 182 had reports on red blood cell count (RBC), HCT, MCV, MCH, mean corpuscular haemoglobin concentration (MCHC) and red cell distribution width coefficient of variation (RDW-CV). Except the mean RDW value, all other values were lower in anaemic women comparing with non anaemic women. As seen in Table 2 the mean Hb, HCT, and MCV were significantly lower and RDW-CV was significantly higher among anaemic and non anaemic group (p < 0.05). Among anaemic mothers, 221 had low HCT value (<37%) and only one had a higher value (>54%). Regarding MCV 142 women had lower values (<80 fL), four of them had higher values (>100 fL) and the rest of them were in normal range (80 -100 fL). Advances in Reproductive Sciences Of the anaemic women, 188 postpartum blood reports were compared with 98 non anaemic mothers. As observed in Table 3, there was a significant difference    Among the non-anaemic group, 61.92% have undergone vaginal delivery. Therefore, there was a significant difference in the method of delivery among anaemic and non-anaemic mothers. Nevertheless, there was no statistical difference in the birth weight of the baby (p = 0.238). Nevertheless, there was a significant difference in APGAR score at 5 minutes. Average APGAR score at 5 minutes, 10 minutes for anemic group was 9.67 ± 0.48 and 10 ± 0.07 whereas 10 ± 0.00, 10 ± 0.00 for non-anaemic mothers. Also non had Apgar scores below seven at 5 and 10 minutes.

Discussion
Sri Lanka is one of the countries in the world that provides the highest quality of free health care despite its low economic development. Over the past few decades, it has provided optimal antenatal care in comparison to the other South Asian Countries. Though several steps were taken to prevent anaemia such as preconception care for early detection, but still there are women who present for deliveries with anaemia.
The prevalence of anaemia in this study was 8.19% among term pregnant women: it was less than the prevalence that was reported in third trimester mothers in the Anuradhapura district [12]. As we have taken only the term mothers our finding did not correlate with the result reported by WHO, DHS and with the Senadheera et al. study [5] [6]. The prevalence of anaemia in our study was lower than those reported from Tanzania (47%) [13] and South Nigeria 30.03% [14], but was similar to the study from Iran conducted in 2009 [15].
Expectedly, as in the study from India, most of the anaemic patients in this study presented with moderate anaemia [7], whereas 0.45% were noted with severe Anaemia unlike in Nigeria where no case of severely anaemic pregnant mothers were present [16]. Socio economic status is a known factor for anaemia in pregnancy. In this study, anaemia was more prevalent among women who had low monthly family income similar to the study conducted in Turkey [8].
Anaemia was more prevalent in women with one to three living children than women with no child. However, we did not observe a homogeneous increase in anaemia with regard to the increase in maternal age. Hence, further studies are required to explain its effect on anaemia in pregnancy.
This data also highlights the fact that prevalence of anaemia was high in women with low consumption of red meat and high tea intake. that only 4% of the pregnant women in Sri Lanka were provided with information regarding the behavioural and nutritional habits that should be followed during pregnancy [25]. Therefore, education about nutrition should be developed according to the guideline for antenatal care. Findings of this research will motivate antenatal care providers toward early detection of anaemia and promote the necessary management of anaemia in pregnancy.
As in the prevalence study from Turkey [8], all haematological values were low at booking in anaemic group compared with the non-anaemic group except the mean RDW-CV value. Our study also concludes that 67.44% of anaemic women had serum ferritin < 30 ng/mL. This is important because it is the most appropriate method for the diagnosis of iron deficiency anaemia. But in routine antenatal care in Sri Lanka serum ferritin is not assessed due to its high cost.
In this study, iron deficiency anaemia was predominant among anaemic pregnancies, as in Senadheera et al. study [26]. But the prevalence of iron deficiency anaemia is higher compared to the Senadheera et al. study 36.9% [26].
Hence, this study shows number of areas to be improved in pre-conceptional care specially in Iron and folic acid supplementation. Results of the study found that 20.58% had low cord blood haemoglobin. Nevertheless, it needs further investigation as the present study did not assess the cord blood Hb of babies delivered by non-anaemic mothers. Moreover, there was a significant difference in APGAR score at 5 minutes. Other parameters, however, did not find any association between maternal anaemia and adverse pregnancy outcome.
The major drawback of the study was regarding ferritin assay. It was carried out only for the anaemic mothers at the booking visit. Therefore, we could not compare the serum ferritin values in between anaemic and non-anaemic pregnancies. In addition, we had used only the blood picture to diagnose thalassemia, as the facility to use HPLC is not freely available in the Sri Lankan health sector.
Also due to a data loss, only 234 anaemic mothers and 199 non anaemic mothers were taken for the study, even though the calculated sample size was 239 for each group.

Conclusion
In conclusion, there was a moderate prevalence of iron deficiency Anaemia in pregnant women in Peradeniya, Sri Lanka. Devastating effects of anaemia associated with pregnancy could be prevented by early registration, close antenatal follow up, early detection and treatment of anaemia with proper guideline according to the haematologist and nutritionist before delivery. All of these would help to guarantee safe motherhood and babyhood.