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1.1 Background Information

Anaemia has been defined by the World Health Organization (WHO) as “a condition in which the number of red blood cells (RBCs) or their oxygen-carrying capacity is inadequate to meet physiologic demands in the body, in which the haemoglobin level may vary by age, sex, altitude, smoking, and pregnancy status” (Gogoi et al.,2013). Anaemia in pregnancy is identified by the WHO as haemoglobin level less than 11g/dl and is divided into three levels of severity, Mild anaemia (Hb level, 9 - 10.9g/dl), Moderate anaemia (Hb level, 7 - 8.9g/dl) and severe anaemia (Hb level 7 - 4.5 g/dl) (Nkegoum et al., 2009). Pregnancy is a period of a significant increase in iron requirement, and hence the risk of suffering from anaemia is higher than in non-pregnant state. Although iron requirements are reduced in the first trimester because of the absence of menstruation, they rise steadily thereafter from approximately 0.8 mg per day in the first month to approximately 10 mg per day during the last 6 weeks of pregnancy (Tay et al., 2013). The demand is higher due to physiological changes in maternal red blood cell mass and also due to the needs of the development and growing of the placenta and foetus (Dim et al., 2007). Despite increased iron requirements, pregnancy is also a period of increased risk for anaemia; so far reduction and control of anaemia prevalence among women remains prioritized as a public health problem, especially in women of childbearing age worldwide (Noronha et al., 2012).

Anaemia constitutes a public health problem worldwide, in both developed and developing countries with major consequences for human health, economic and social development (Oyedeji, 2012). Anaemia affects over two billion people globally, among


whom over 40 million are pregnant women, where iron deficiency is thought to be the most common cause of anaemia and it’s account for 75% - 95% of cases (Osungbade et al., 2012). Iron deficiency and other micronutrients are the main cause of anaemia throughout the world and it’s common in women of reproductive age where these deficiencies may lead to birth defects, preterm labour, low birth weight and resulting in an increase in perinatal death (Karaogulu et al., 2010). Moreover, malaria infection contributes to anaemia throughout the life, especially during pregnancy, and it is estimated that in sub-Saharan Africa 23 milion pregnant women are exposed to malaria infection annually and approximately 400 000 pregnant women develop moderate or severe anaemia each year (Getachew et al., 2012). Despite anaemia having been identified as a global public health problem for several years, no rapid progress has been observed, and the prevalence of the disease is still high globally (Ghislain et al., 2012). The WHO and the United Nations Children's Fund have stated that there is an immediate need to reduce the prevalence of anaemia and highlighted the importance of identifying its numerous determinants, in order to reach the global nutrition targets of 50% reduction of anaemia in women of reproductive age by 2025 (WHO,2014). Recent statistics indicate that anaemia affects 57% of pregnant women globally with the highest prevalence in sub-Saharan Africa (Abriha et al., 2014). In India, a study identified that iron deficiency anaemia is the risk factor of preterm delivery, low birth weight and prevalence of anaemia among pregnant women ranged from 33.0% to 89.0 % (Viveki et al., 2012).

In Africa, the prevalence of anaemia in pregnant women is reported to be 66.8% (Niguse et al., 2013). Furthermore, other studies in Africa have shown high prevalence of anaemia in pregnancy ranging from 41 to 84% in different settings (Alem et al., 2013; Haggas et al., 2010; Abdehefaz et al., 2012). WHO identifies and categorizes anaemia prevalence as a mild public health problem when it is between 5.0% and 19.9%, a moderate public


health problem when it is between 20.0% and 39.9% and a severe public health problem when the prevalence is ≥40.0% (Rosmawati et al., 2012). A study done by Abdelhameed et al. (2012) revealed that multiparity, poor socio-economic and educational statuses are the principal reasons for high prevalence of anaemia in pregnancy in developing countries. In Tanzania, prevalence of anaemia among pregnant women is estimated to be 51% (WHO, 2012). However, the prevalence of anaemia during pregnancy shows great variations in different geographical settings. Urassa et al. (2002) has reported a high prevalence of anaemia in pregnant women in Rufiji District, where the rate ranged from 50 to 60%. In Dar es Salaam, a study identified that iron deficiency, malaria and other infections are major causes of anaemia and its prevalence was 68% (Kidanto et al., 2009). In Kilimanjaro Region, Msuya et al. (2004) reported that 47.4% of pregnant women had anaemia. In Manyara Region, a study by Hinderaker et al. (2001) indicated that prevalence of anaemia in pregnant women in Hanang and Mbulu districts was 36%.

Improving maternal health is a high priority for the United Nations international development agenda, as part of the fifth Millennium Development Goal (MDG) set in year 2000. Maternal mortality is targeted for substantial reduction by 2015, and unfortunately progress in sub-Saharan Africa towards this target has stalled (WHO, 2014). Tanzania Demographic and Health Surveys report exemplifies this lack of progress in recent years, with an estimated maternal ratio of 578 deaths per 100 000 live births reported for 2004-2008 compared to 454 deaths per 100 000 live births mortality in 2010, but the figure is still high and far beyond attainment of the fifth Millennium Development Goals (MDGs) of reduction of maternal mortality ratio to 193 per 100,000 live births by 2015 (MoHSW, 2010). The Tanzania government, through the Ministry of Health and Social Welfare, has been implementing a public health package to combat anaemia in pregnancy through public and private healthcare facilities. The public health package includes


supplementation with iron and folic acid, promotion of antenatal care, prevention and control of malaria infection with intermittent preventive treatment (IPT), use of insecticide treated mosquito nets (ITNs), treatment and control of helminths infestation (MoHSW, 2009-2015).

1.2 Problem Statement and Justification

Anaemia in pregnancy is a worldwide public health problem affecting both developing and developed countries with significant impact on the health of mothers and foetus (Erharbor, 2013). Anaemia is an indicator of nutritional deficiencies that significantly contribute to birth defects, preterm labour and low birth weight, hence it causes global public health problem. However, iron deficiency anaemia is a leading cause of maternal morbidity and mortality, prenatal and perinatal infant loss; physical and cognitive losses thus in developing countries stall social and economic development. In sub-Saharan countries the magnitude of anaemia in pregnancy is quite alarming, whereby its prevalence is widely contributed by poor nutrition, iron and other micronutrients deficiencies, parasitic infestations, chronic infections, illiteracy, and short pregnancy intervals (Okeke, 2011). According to the WHO classification, any prevalence level of anaemia that exceeds 40% in any population group is an indicator of a severe public health problem, for which Tanzania qualifies.

Despite the national health policy of routine iron supplementation and intermittent preventive treatment for malaria with anti malarial drugs, still maternal anaemia continues to be a common cause of morbidity and mortality. In Manyara region, a study by Hinderaker et al. (2001) indicated that prevalence of anaemia in pregnant women in Hanang and Mbulu Districts was 36%. Despite interventions of treating and preventing maternal anaemia, still many pregnant women are affected by anaemia related health


problems and the contributing factors for the persistence of high incidences are not empirically known. Therefore, the aim of the study on which this dissertation is based was to determine the current status of anaemia in pregnant women in Mbulu District and assess its association with knowledge, attitude towards anaemia control in pregnancy. The findings from this study will help to improve control of maternal anaemia and reduce anaemia related health problems in Mbulu District and other areas of similar settings.

1.2 Objectives

1.2.1 Overall objective

To determine the prevalence of anaemia and asses the knowledge and attitude of pregnant women towards control measures of anaemia in pregnancy in Mbulu District, Tanzania.

1.2.2 Specific objectives

i. To determine the prevalence of anaemia among pregnant women in Mbulu health facilities.

ii. Assess the level of knowledge on anaemia and attitude of pregnant women towards control measures of anaemia in pregnancy, in Mbulu District, Tanzania.

1.3 Research questions

i. What is the magnitude of anaemia in pregnant women in Mbulu District health facilities?

ii. What knowledge do pregnant women have about causes, symptoms, complications, interventions, and experiences about anaemia during pregnancy?

iii. What are the fillings of pregnant women regarding the current interventions measures

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