Hemoglobin profile of full term pregnant women admitted for delivery in a teaching hospital: a case series study

Background: Anemia in pregnancy is a common and serious public health problem in developing countries. It is associated with high incidence of premature births, postpartum hemorrhage, puerperal sepsis, etc in mother. Objective: 1) To assess the hemoglobin profile of full term pregnant women admitted for delivery. 2) To analyze the correlation of anemia with obstetrics parameters like gravida, parity, and history of abortions in the past. Methods: The present case series study was conducted among the pregnant women in latent stage of labor admitted in a teaching hospital by using pre- designed, pre-tested, structured schedule. Hemoglobin estimation was done by Shali’s method and anemia was classified according to WHO criteria. Statistical analyses were done by percentages and proportions, Mean and Chi- square test. Results: A high prevalence (88.4%) of anemia (Hb% - < 11.0 gm/dl) was observed among 130 pregnant women at labor. Majority (58.5%) had moderate degree of anemia (Hb%– 7.0 to 10.0 gm/dl) and (04.6%) had severe anemia (Hb% - < 7 gm/dl). The study observed significantly higher prevalence of anemia among those pregnant women who studied upto secondary level (90.3%), and those from below class IV socio- economic status (96%), among those cases less than one year of spacing between previous and index pregnancies (90%). Conclusion: Monitoring the compliance of women with ante- natal care services and strengthening of their health care seeking behavior are important health care measures to be undertaken at the community level.


Introduction
Anemia in pregnancy is a common and serious public health problem in developing countries. Anemia is the term used to describe the condition in which there is a reduction in the concentration of hemoglobin in the blood stream to level below 11 gm/dl for pregnant women [1]. A complete antenatal care is received by the pregnant women, still anemia is persisting during ante, intra and post natal period. In India, National Family Health Survey-2 in 1988 to 99 shows that 54% of women in rural and 46% women in urban areas are anemic. The relative prevalence of mild, moderate and severe anemia are 13%, 57% and 12% respectively in India (ICMR data) [2]. Anemia during pregnancy continues to be a major public health problem with the existing health care resources, despite the fact that anemia in pregnant women is largely preventable and easily treatable if detected in time. A very high prevalence of anemia during pregnancy was observed in studies conducted in India by different authors 50.1%, 82.9% , 58%, [1,3,4] etc. According to WHO hemoglobin level below 11gm/dl in pregnant women constitutes anemia.
Many studies are on record about the prevalence of anemia in pregnancy but no study is done to find out what proportions of women are still delivering in anemic status.
The present study was conducted to find out the degree and prevalence of anemia in full term pregnant women in latent stage of labor and to know correlation of anemia with obstetrics parameters like gravida, parity, and history of abortions in the past.

Material and Methods
The present case series study was conducted among the full term pregnant women of 37-42 weeks of gestation, who were in latent stage of labor admitted for delivery in the Department of Obstetrics and Gynecology, Belagavi Institute of Medical Sciences (BIMS) Hospital, Belagavi from September to December 2015. Ethical clearance was obtained from Institutional Ethical Committee (IEC). A formal permission to conduct the study was obtained from the authorities of the hospital and consent was taken from study participant.
All the full term pregnant women in latent stage of labor admitted during the study period were included. Pregnant women with twins and chronic diseases leading to anemia such as renal, cardiac, lung diseases and haemoglobinopathies were excluded. The information like age, age at marriage, age at first pregnancy, education, occupation, per capita income, type of family, diet, obstetric score, history of abortion, interval between previous and present pregnancy, history of blood transfusion in this pregnancy, duration of present pregnancy, duration of IFA tablets taken, previous Hb% etc was collected by interviewing the subjects by using pre-designed, pre-tested structured schedule. Later, Hemoglobin estimation was done by Shali's method. Anemia was classified according to WHO criteria [3].
Hemoglobin concentration of 10.0-10.9 gm/dl 7-10.0 gm/dl and less than 7.0 gm/dl were considered to indicate mild, moderate and severe anemia respectively. All those pregnant women with any associated illness like pregnancy induced hypertension, Rhesus factor negative, gestational diabetes mellitus, Preterm and post term pregnancy and twin pregnancy were excluded. For convenience, socio-economic status of the study subjects was classified into class I (>6100rs), class II (3050 -6099), class III (1830 -3049), class IV (915 -1829) and class V (<915) by using B.G. Prasad classification based on All India Consumer Price Index of September 2015 i.e. 266 (correction factor = 22.82) [5].
Sample size: The minimum sample size required for this study was estimated by assuming confidence interval of 95% and 10% margin of error and a prevalence of 58% for anemia among pregnant women as per National Family Health survey-III (NFHS) in India [6]. Accordingly, the minimum sample size required for the study was 98. However, the present study included 130 cases to increase the power of study. The statistical analyses were performed using SPSS version. The continuous and categorical data were expressed as mean + Standard Deviation and number of patients respectively. P < 0.05 was considered statistically significant.

Results
The present study included 130 pregnant women. The general profile of the study subjects is shown in Table 1. Average age of the cases was 23.24 + 3.06 years ranging from 18 to 32 years. The mean age at marriage was 19.27 + 1.83 years and that at first pregnancy was 20.75 + 2.19 years. The mean gestational age was 39.17 + 1.11 weeks. Average interval between previous and index pregnancies was 31.74 + 20.76 months.    The study observed significantly higher prevalence of anaemia among those women who studied up to secondary level (90.3%), and those from below class IV socio-economic status (96%) (p< 0.05). The prevalence of anaemia was relatively more among those women aged 18-21 years (97.5%), those from nuclear families (90.6%), those who were housewives (89.1%) and having vegetarian diet (94.4%). Table 3 depicts the obstetric and hemoglobin profile of study participants. High prevalence of anemia among those pregnant women at labor whose age at marriage was between 18-21 years (90%) and age at first pregnancy was less than 18 years (100%). However, this difference was statistically not significant. There was significant higher prevalence of anemia among those cases less than one year of spacing between previous and index pregnancies (90%), those who did not receive iron folic acid (IFA) tablets (100%) and among those who took IFA tablets from both government and private institutions (94.3%). Figure 1 shows hemoglobin % during earlier period of present pregnancy. The overall prevalence of anemia in earlier period of gestation was 91.3% with 29.8%, 58.6% and 02.8% prevalence of mild, moderate and severe anemia respectively. Significantly higher prevalence of anemia among delivering mother is seen in 3 rd trimesters (95.7%). The present study found that still 88.4% of full term pregnant women were admitted for delivery in anemic status.   [11].
The prevalence of anemia was significantly more in those studied up to secondary education and below Class IV socio economic status, similar to that reported by Viveki R G et al [3], Yadav R K et al [5] and by Taner C E et al [9]. Socio economic status reported similar to this study by Gautam V P et al [12]. Mean hemoglobin level among the pregnant women at labor were 9.3 + 1.24 gm/dl ranging between 5.7 to 12.9, Ansari N B et al [7] reported 9.9 + 1.0 gm/dl, while R G Viveki et al [3] reported 9.6 + 1.63 gm/dl ranging between 5.1 to 12.4 gm/dl.

Conclusion
As observed in this study, still a very high proportions of pregnant women (88.4%) were found to be delivering in anemic status, is an indicator of the failure of national and WHO Programmes to address this problem.
Socio-economic status, literacy status of women, child spacing and IFA tablets intake were significantly associated with anemia in this study. Therefore, monitoring the compliance of women with ante-natal care services and strengthening of their health care seeking behavior are important health care measures to be undertaken at the community level. It is time for realization that health system should focus on various factors that contribute to anemia and include them as an important indicator in the national health care policy.