ABSTRACT

Anaemia in pregnancy is the leading cause of maternal morbidity and mortality, poor birth outcomes worldwide. Despite national and international efforts to redress this problem, maternal mortality and morbidity rates are far beyond the target of the fifth Millennium Development Goal particularly in developing countries. The current study aimed to assess the prevalence; knowledge and attitude of pregnant women towards control measures of anaemia in Mbulu District, Tanzania. This cross-sectional survey was conducted from November 2014 to July 2015 in Mbulu District in three health facilities whereby 354 pregnant women aged 15-49 years were involved. The anaemia status of the pregnant women was determined based on Hb cut-off value of <11g/dl as recommended by WHO. Malaria infection was tested by using Ag.pLDH/HRP2 MRDT. Socio-demographic factor and anaemia information were gathered by using semi-structured questionnaire. Statistical analyses were done by SPSS version 16.0 and results were presented as percentages, frequencies to describe social demographic characteristics. Knowledge and attitudes of pregnant women on anaemia were assessed using the index scale and Likert scale respectively. Fisher’s exact test was used to determine associations between variables at statistical significance level of <0.05. Multivariable logistic regression was run to quantify the risk factors for occurrence of anaemia. The overall prevalence of anaemia was 38.7% while the prevalence of malaria was 7.1%. Generally, the study revealed that pregnant women had low knowledge and negative attitude towards control measures of anaemia in Mbulu district. High parity was found to be a risk factor for anaemia in pregnancy (OR=13, 95% CI: 5.7-47 for 3-4 parity and OR=25, 95% CI: 12.5-37 for parity ≥ 5). Therefore, there is a need for strengthening health education on anaemia and related determinants to pregnant and non-pregnant women of child bearing age and sensitization on the usage of family planning method. iii

DECLARATION

I, Justina A. Margwe do hereby declare to the Senate of Sokoine University of Agriculture that this dissertation is my own original work done within the period of registration and that it has neither been submitted nor being concurrently submitted in any other institution.

_________________________ ________________________

Justina Amu. Margwe Date

(MSc. Candidate)

The above declaration is confirmed

_________________________ ________________________

Dr. Athumani. M. Lupindu Date

(Supervisor) iv

COPYRIGHT

No part of this dissertation may be reproduced, stored in any retrieval system or transmitted in any form or by any means without prior written permission of the author or Sokoine University of Agriculture in that behalf. v

ACKNOWLEGDEMENTS

First and foremost thanks to God, for bestowing me sounding health for the whole period of my pursuance of this study. I also pass my sincere thanks to Prof. S. I. Kimera, Head of Department of Veterinary Medicine and Public Health at Sokoine University of Agriculture for giving me a valuable opportunity for pursuing my post graduate studies. Also, I express my profound and sincere gratitude to my supervisor, Dr. A. M. Lupindu who patiently led me during my research and writing this dissertation, with constructive comments.

I deeply thank all lectures and all other staff members in the Department of Veterinary Medicine and Public Health for their great efforts and friendly relationship during my study journey at Sokoine University of Agriculture. I learned and gained a lot of knowledge from your experiences, thanks so much.

I also acknowledge and thank District Executive Director, Honourable Mr. Fortunatus Fwema, for giving me permission and facilitating my mission for data collection at Reproductive and child health in Mbulu District. I also pass my thanks to District Medical Officer, Director of Haydom Lutheran Hospital and all staff at Mbulu and Haydom Lutheran Hospitals for the same reason. Special thanks go to Clinical Officer in-charge of Yaeda Chini Dispensary for his constructive guidance and support during fieldwork.

My great thanks go to my classmates of the MSc. Programme in Public Health and Food Safety for spending nice times during our study journey at SUA. Special thanks go to pregnant women for their willingness to participate in the survey. vi

DEDICATION

I would like to dedicate this work to my parents Mr. A. Margwe and Mrs. Rehema Margwe for always being my pillar of support throughout my academic journey. It is also dedicated to my daughter Jubilate, because she missed my attention during the busy time of my research work but she was tolerant. The dissertation is also dedicated to my brothers Joseph, Joshua and B. Zawadi; and to my sisters Imani, Dorah and Neema who have been my source of inspiration, thank you all for being a blessing in my life. It is also dedicated to my friends and colleagues and to all pregnant women who voluntarily participated in the study in three public health facilities in Mbulu District, Manyara Region, Tanzania. vii

TABLE OF CONTENTS

ABSTRACT ........................................................................................................................ ii

DECLARATION ................................................................................................................ ii

COPYRIGHT .................................................................................................................... iv

ACKNOWLEGDEMENTS ................................................................................................ v

DEDICATION ................................................................................................................... vi

TABLE OF CONTENTS ................................................................................................. vii

LIST OF TABLES .............................................................................................................. x

LIST OF FIGURES .......................................................................................................... xi

LIST OF APPENDICES .................................................................................................. xii

LIST OF ABBREVIATIONS ......................................................................................... xiii

CHAPTER ONE .................................................................................................................. 1

1.0 INTRODUCTION ......................................................................................................... 1

1.1 Background Information ................................................................................................. 1

1.2 Problem Statement and Justification ............................................................................... 4

1.2 Objectives ........................................................................................................................ 5

1.2.1 Overall objective ................................................................................................... 5

1.2.2 Specific objectives ................................................................................................ 5

1.3 Research questions .......................................................................................................... 5

CHAPTER TWO ................................................................................................................. 6

2.0 LITERATURE REVIEW ............................................................................................. 6

2.1 Causes of Anaemia in Pregnancy .................................................................................... 6

2.2 Development of Anaemia ................................................................................................ 7

2.3 Risk Factors for Anaemia in Pregnancy .......................................................................... 8

2.4 Diagnosis of Anaemia in Pregnancy ............................................................................... 9 viii

2.5 Management of Anaemia in Pregnancy .......................................................................... 9

2.6 Prevention of Anaemia in Pregnancy .............................................................................. 9

CHAPTER THREE .......................................................................................................... 11

3.0 MATERIALS AND METHODS ................................................................................ 11

3.1 Study Area ..................................................................................................................... 11

3.2 Study Design and Population ........................................................................................ 13

3.3 Inclusion and Exclusion Criteria ................................................................................... 13

3.4 Sample Size ................................................................................................................... 13

3.5 Sampling Method .......................................................................................................... 14

3.6 Data Collection Methods ............................................................................................... 14

3.6.1 Structured questionnaire ..................................................................................... 15

3.6.2 Pre-testing of the Questionnaire ......................................................................... 16

3.6.3 Blood sampling and sample handling ................................................................. 16

3.6.3.1. Haemoglobin measurement .................................................................. 16

3.6.3.2 Malaria testing ....................................................................................... 17

3.7 Ethical Consideration .................................................................................................... 17

3.8 Data and Analysis .......................................................................................................... 18

HAPTER FOUR ................................................................................................................ 20

4.0 RESULTS ..................................................................................................................... 20

4.1 Socio-Demographic Characteristics of the Study Population ....................................... 20

4.2 Prevalence of Anaemia among Studied Population ...................................................... 22

4.3 Association of Social Demographic Variables with Anaemia in the Study Area ......... 22

4.4 Prevalence Rate of Malaria Infection among Pregnant Women ................................... 25

4.5 Association between Anaemia and Selected Independent Variables ............................ 25

4.6 Multivariate Analysis of Independent Variables among Women ................................. 27

4.7 Respondents’ Knowledge about Anaemia .................................................................... 29 ix

4.8 The Level of Knowledge on Anaemia with Respect to Socio-Demographic Characteristics .............................................................................................................. 30

4.9 Respondents’ Opinions and Attitude towards Control Measures and Prevention of Anaemia in Pregnancy ................................................................................................. 32

CHAPTER FIVE ............................................................................................................... 34

5.0 DISCUSSION .............................................................................................................. 34

5.1 Study Limitations .......................................................................................................... 40

CHAPTER SIX .................................................................................................................. 41

6.0 CONCLUSIONS AND RECOMMENDATIONS .................................................... 41

REFERENCES .................................................................................................................. 43

APPENDICES ................................................................................................................... 52 x

LIST OF TABLES

Table 1: Social demographic characteristics of the study population ................................. 21

Table 2: Association of anaemia with selected social demographic characteristics .......... 24

Table 3: Prevalence rate of malaria infection among pregnant women .............................. 25

Table 4: Association between anaemia and selected independent variables in the study ...................................................................................................................... 26

Table 5: Multivariate analysis of risk factors for anaemia in women ................................. 28

Table 6: The levels of knowledge about anaemia with respect to social demographic variables of pregnant women ................................................................................. 31 xi

LIST OF FIGURES

Figure 1: Summary of anaemia aetiology ............................................................................. 8

Figure 2: The map of Mbulu District indicating key health facilities ................................. 12

Figure 3: Prevalence of anaemia in the studied sample ...................................................... 22

Figure 4: Proportions of respondents with various levels of knowledge about anaemia .... 30

Figure 5: Respondents’ opinions and attitude regarding anaemia in pregnancy ................. 33 xii

LIST OF APPENDICES

Appendix 1: Questionnaires on knowledge and attitude of pregnant mothers on anaemia and risk factors of anaemia in pregnant ........................................... 52

Appendix 2: Reported knowledge on Anaemia among Pregnant Women in Mbulu District ............................................................................................................ 56

Appendix 3: Clearance certificate for conducting medical research in Tanzania ............... 57 xiii

LIST OF ABBREVIATIONS

AIDS Acquired Immunodeficiency Syndrome

ANC Antenatal Clinic

Bs Blood slide

CDC Centres for Disease Control

Hb Haemoglobin

HCT Haematocrit

HIV Human Immunodeficiency Virus

IDA Iron Deficiency Anaemia

IPT Intermittent Preventive Treatment

ITNs Insecticide Treated Nets

MDG’S Millennium Development Goals

MoHSW Ministry of Health and Social Welfare

MRDT Malaria Rapid Diagnostics Test

RBCs Red Blood Cells

RCH Reproductive and child health

SSA Sub Saharan Africa

UNICEF United Nations Children Fund

USAID United States Agency for International Development

W H O World Health Organization 1

Anaemia is a global public health problem affecting both developing and developed countries and its prevalence in pregnant women has been estimated to be 51% (Melku et al., 2014). Sub-Saharan Africa is the most affected region with an estimated anaemia prevalence of 57% pregnant women which corresponds to about 17.2 million affected women with severe consequences for human health as well as social and economic development. Anaemia occurs at all stages of the life cycle, but is more prevalent among pregnant women (Abriha et al., 2014).

Causes of Anaemia in Pregnancy

Globally, the most common cause of anaemia is iron deficiency, which is responsible for about half of anaemia cases in pregnancy, and it is estimated that in developed countries 38% of pregnant women have iron depletion (Jack et al., 2014). In sub-Saharan Africa, there are multiple causes of anaemia in pregnancy, which include inadequate diet, iron, folate and vitamin B12 deficiencies, impaired micronutrient absorption, blood loss resulting from haemorrhage, and helminth infestation (Olubukola et al., 2011). A research done by Buseri et al. (2012) revealed that, in developing countries, the major causes of anaemia in pregnancy are nutritional deficiencies, parasitic infestations, HIV infection, haemorrhage and some chronic medical disorders like renal and hepatic diseases. However, infectious diseases have been reported to cause a high prevalence of anaemia in sub-Saharan Africa (Alem et al., 2013). Malaria is considered to be the principal cause of severe anaemia in malaria-endemic areas in Africa (Imelda et al., 2011). In each year more than 30 million African women in malaria-endemic areas are at a high risk and it is estimated that malaria contributes for 3 to 5% of maternal anaemia, 8 to 14% of low birth weight and 3 to 8% of infant mortality (Akinleye et al., 2009). The other non-nutritional causes of anaemia include thalassemia, malaria and genetic blood disorders such as sickle cell diseases (Adam et al., 2011).

Development of Anaemia

The first stage of iron deficiency known as iron depletion occurs when iron stores are low and serum ferritin concentrations drop. The second stage is iron deficient erythropoiesis. This occurs when iron stores are depleted and the body does not absorb iron efficiently. Iron deficient erythropoiesis is characterized by a decrease in transferring saturation and increases in transferrin receptor expression and free erythrocyte protoporphyrin (FEP) concentration. Iron-deficiency anaemia (IDA) is the third and most severe stage of iron deficiency and is characterized by low haemoglobin and hematocrit values. Erythrocytes are hypochromic and microcytic during IDA and haemoglobin concentration falls (Shah et al., 2001). Iron deficiency is the most common cause of anaemia, although there are other nutritional and non-nutritional causes of anaemia (Rakick et al., 2013). As illustrated in Fig. 1, not all anaemia is caused by iron deficiency, and not all iron deficiency results into anaemia. For example, inadequate intakes of folate and vitamin B12 can also cause anaemia. Parasitic infestations, HIV infection, inflammatory condition such as renal diseases, Hemoglobinopathies and genetic disorders may also contribute to anaemia (Klemman et al., 2011). A number of non-iron deficiency causes of anaemia are summarised in Fig. 1, according to Klemman et al. (2011).

Risk Factors for Anaemia in Pregnancy

Pregnant women in developing countries are at risk of anaemia due to poverty, grand-multiparity, too early pregnancies, too many and too frequent pregnancies spacing of < 1 year, low socioeconomic status, illiteracy, and late booking of pregnant women at antenatal care units (Jufar et al., 2014). However, women’s behaviour of soil eating during pregnancy may contribute to anaemia due to worms’ infection. Mainly due to the above factors, the prevalence rates of anaemia were 65% in Kenya, 46% in Ghana 42% in Namibia, and 28% in Tanzania (Kawai et al., 2009). Furthermore, other risk factors are parasitic infestations, season, geographical location, food habits, gestational age, parity and pregnancies at early age (de Benoist et al., 2006).

Diagnosis of Anaemia in Pregnancy

Because of its low cost and feasibility, WHO has included clinical assessment of palmar pallor as an initial tool to detect severe anaemia. Although clinical examination is not accurate enough to detect mild to moderate anaemia with a sensitivity of 65% and specificity of 82%, the sensitivity and specificity were better in severe anaemia, 84% and 99% respectively (WHO, 2001) The clinical signs and symptoms of anaemia vary among pregnant women; the most common ones are weakness, fatigue, the skin appear pallor, and paleness of the conjunctiva and palm, shortness of breath and heart palpitations. In severe conditions it is associated with dizziness, chest pain; fainting and the patient may experience circulation disturbances and tachycardia (Vanden, 2014).

Management of Anaemia in Pregnancy

There is a marked increase in folate use during pregnancy, due to the acceleration of reactions requiring single-carbon transfer, the rapid rate of cell division in maternal and faetal tissues, and deposition in the foetus (Amoran et al., 2012). The study by Hoque et al. (2009) revealed that taking folic acid supplements before conception and at the first four weeks of pregnancy lowers risk of genetically predisposed women having a baby with a neural tube defect. Currently, WHO recommendation for treatment of anaemia in pregnancy is through improvements in dietary diversity; food fortification with iron, folic acid and other micronutrients; daily supplementation of iron and folic acid to each pregnant women and control of infections (WHO, 2011). Most sub-Saharan African countries, including Tanzania, currently, have national policies to prevent and treat anaemia and malarial prophylaxis for all pregnant women (Mutagonda, 2012).

Prevention of Anaemia in Pregnancy

Centres for Disease Control and Prevention (CDC) recommend screening for anaemia in pregnant women and universal iron supplementation to meet the iron requirements in pregnancy (Dwumfour, 2013). The interventions required to be delivered in health systems include general supportive measures to improve environmental and social conditions as well as interventions that address maternal nutrition (Brooker et al., 2008), and use of insecticide treated nets and case management of pregnant women with clinical signs of malaria (Simon et al., 2009). However, anaemia prevention programmes can contribute significantly in achieving the Millennium Development Goals (MDGs) including MGD-4 that is about child mortality reduction, and MGD-5 that is about improved maternal health (de Benoist et al., 2008).

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