|Year : 2019 | Volume
| Issue : 8 | Page : 2703-2707
High prevalence of anemia among postnatal mothers in Urban Puducherry: A community-based study
Ramya Selvaraj1, Jayalakshmy Ramakrishnan2, Swaroop Kumar Sahu2, Sitanshu Sekhar Kar2, Karthik Balajee Laksham1, KC Premarajan2, Gautam Roy2
1 Department of Community Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Karaikal, Puducherry, India
2 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
|Date of Submission||12-May-2019|
|Date of Decision||13-May-2019|
|Date of Acceptance||17-Jun-2019|
|Date of Web Publication||28-Aug-2019|
Dr. Jayalakshmy Ramakrishnan
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry - 609 602
Source of Support: None, Conflict of Interest: None
Background: Anemia is a common problem across all life stages and ages with a higher burden among women. The postnatal period is an often-neglected period for the provision of effective care to the mothers. Anemia burden is also high during this period, which leads to many morbidities and poor quality of life. Methods: A community-based cross-sectional study was done in the field practice area of two Urban Primary Health Centres (PHCs) in Puducherry between March 2015 and February 2016. A total of 227 postnatal mothers were selected by simple random sampling from the list of mothers delivered from the field practice area. House visit was done within 4 weeks of completion of their postnatal period. Socio-demographic details and third-trimester hemoglobin levels were collected using a pretested questionnaire. Hemoglobin level during post-partum was measured using Sahli's Hemoglobinometer. Paired t-test is done to assess the difference in hemoglobin antepartum and post-partum. Multiple Logistic Regression is done to identify factors associated with postpartum anemia. Results: The mean (SD) hemoglobin during postpartum was 10.95 (1.1) gm% ranging from 7.4 gm% to 13.8 gm%. The prevalence of anemia among postnatal mothers is 76.2% (n = 173, 95% CI: 70.4%-81.4%). Around 26% (59) had mild anemia, 49.8% (113) had moderate anemia and 0.4% (1) had severe anemia. One-fourth of the mothers who had a normal hemoglobin level in their third trimester had developed anemia in the postnatal period. There was a significant difference in mean hemoglobin during postpartum and that of third trimester (10.95 vs 10.69 gm%, t = 3.4, df 226, P = 0.001). Birth order of two or more is significantly associated with postpartum anemia (aOR 2.2, 95% CI: 1.07-4.39). Conclusions: The prevalence of anemia among postnatal mothers is high. Routine hemoglobin estimation, advice on consumption of iron-rich foods and Iron and Folic Acid (IFA) supplementation have to be provided to postnatal mothers to improve this situation.
Keywords: Anemia, iron and folic acid supplementation, postnatal mother
|How to cite this article:|
Selvaraj R, Ramakrishnan J, Sahu SK, Kar SS, Laksham KB, Premarajan K C, Roy G. High prevalence of anemia among postnatal mothers in Urban Puducherry: A community-based study. J Family Med Prim Care 2019;8:2703-7
|How to cite this URL:|
Selvaraj R, Ramakrishnan J, Sahu SK, Kar SS, Laksham KB, Premarajan K C, Roy G. High prevalence of anemia among postnatal mothers in Urban Puducherry: A community-based study. J Family Med Prim Care [serial online] 2019 [cited 2020 Apr 3];8:2703-7. Available from: http://www.jfmpc.com/text.asp?2019/8/8/2703/265579
| Introduction|| |
The postnatal period is a critical transitional phase for both the mother and the newborn. Anemia during the postnatal period is a major public health problem worldwide. Postpartum anemia alters the emotion and cognition and is also associated with postpartum depression., It also plays an important role in decreased milk production and immunity. Women with postpartum anemia are at increased risk of venous thromboembolism and endometritis., Studies have shown that antenatal anemia and postpartum hemorrhage (PPH) are the greatest risk factors for postpartum anemia., Women who undergo cesarean section are at risk of postpartum anemia because of their higher risk of developing PPH than women undergoing normal delivery., In a study from South India, postpartum anemia is the most common morbidity in women undergoing cesarean section.
In India, more emphasis and vigilance is given to the antenatal period. However, the postnatal period is often neglected especially with regards to the health of the mother. The entire focus of the family and the health system shifts to the newborn once the mother delivers the baby. Although there is enough published literature on the burden of anemia, studies on postnatal anemia are limited. A community-based study in Rajasthan has found that the most common maternal morbidity in the early postpartum period is anemia. National surveys like the District Level Household and Facility Survey-4 (DLHS-4) and National Family Health Survey-4 (NFHS-4) have not measured the hemoglobin levels of mothers in their postnatal period., We conducted this study to estimate the prevalence of anemia among postnatal mothers and to identify its determinants.
| Methods|| |
We conducted a community-based cross-sectional study in Puducherry, a coastal town in South India. Puducherry has a population of 1.1 million with a sex ratio of 943 and 100% institutional deliveries. Health services are catered by 27 Primary Health Centres, 54 Health Sub-centres, two Community Health Centres and two District hospitals along with Medical colleges. Under the National Health Mission (NHM), all pregnant women are registered and provided Antenatal Care along with 100 Iron and Folic Acid (IFA) Tablets. Among the 27 Primary Health Centres (PHCs) in Puducherry, 12 are urban and 15 are rural. The PHCs catering to a population of 30,000 and above and located in the urban region were included. Among the five eligible PHCs, two were selected randomly. Women aged 18 years and above, and who had registered for antenatal care in the two selected PHCs, and completed 6 weeks after delivery, residing in the service area were included. Eligible women who could not be contacted within 4 weeks of completion of their postnatal period were excluded. Postnatal anemia is defined as hemoglobin less than 12 gm% at the end of 6 weeks of delivery. The World Health Organization has classified the hemoglobin level of 11.0%-11.9 gm% as mild, 8.0-10.9 gm% as moderate and less than 8.0 gm% as severe anemia in non-pregnant women. The study was conducted between 1 March 2015 and 29 February 2016. Considering the prevalence of postnatal anemia as 26.5%, with an absolute precision of 6% and 10% non-response rate, the estimated sample size was 227 using OpenEpi software version 2.3.
An eligible list of mothers from the respective PHCs was prepared every month during the study period. Simple random sampling was done to select the proportionate sample of mothers to be covered from the respective PHC for that month. The contact details were collected from the Mother and Child Tracking Card (MCTC). At the end of 6 weeks postpartum, mothers were contacted over phone and their availability in the service area confirmed. House visit was done and participants interviewed after obtaining informed consent. A pre-tested semi-structured proforma was used to obtain information on socio-demographic characteristics such as age, education, place of residence, religion, occupation, family type, total family members, monthly family income, and comorbidities. Hemoglobin was measured using Sahli's Acid Hematin method. The principal investigator received the training in this technique and measured the hemoglobin of the participants once during the house visit. The study protocol was approved by the Institute Ethics Committee (Human studies) of JIPMER. Permission from the Deputy Director of Public Health (DDPH), Puducherry and the respective Medical Officer In-charge of the two PHCs was obtained. Informed written consent from the study participants was obtained after explaining the details of the study and its implications. Mothers identified to be anemic were referred to their respective PHC. Mothers and newborn having any health problems were referred to respective PHC for appropriate treatment. All participants were advised to take iron-rich foods and continue IFA tablets.
Data were entered using EpiData version 3.1 (EpiData Association, Odense, Denmark) and analysed using IBM SPSS version 20 for Windows. Continuous variables such as age and hemoglobin were summarised as mean and standard deviation (SD); and categorical variables such as education, occupation, family type, socio-economic status, parity, comorbities, delivery type and IFA consumption as percentage. The mean hemoglobin concentration during the last trimester and postpartum period were compared using a paired t-test. Univariate analysis of factors associated with postpartum anemia was done using the Chi-square test and a P < 0.05 is considered significant. Multivariate analysis was done using Multiple Logistic Regression and all important predictors of postnatal anemia as determined from previous studies such as age, education, socio-economic status, parity, anemia in third trimester and type of delivery were included in the model.
| Results|| |
We examined 227 postnatal mothers of which 123 (53.9%) were from the first PHC and 104 (45.6%) from the second PHC. The mean (SD) age of the participants was 26.5 (4.6) years and ranged between 19 and 42 years. The socio-demographic details of the participants are given in [Table 1]. Most of them had an education above primary schooling (90%) and were homemakers (91. 6%). More than half (58.1%) belonged to lower socio-economic status. All the mothers had institutional delivery (100%) and the majority (87.7%) delivered in a Government institution. Around one-third (30.4%) were delivered by Lower Segment Cesarean Section. Gestational Diabetes Mellitus (12.7%) and Pregnancy-induced Hypertension (9.2%) were notable co-morbidities observed during the antenatal period.
|Table 1: Socio-demographic characteristics of postnatal mothers in Urban Puducherry, 2016 (n=227)|
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The mean (SD) hemoglobin at third trimester was 10.69 (1.08) gm% and two-thirds (63.9%) had anemia during the third trimester. The mean (SD) hemoglobin during postpartum was 10.95 (1.1) gm% ranging from 7.4 to 13.8 gm%. The mean rise in the hemoglobin is 0.25 gm% (95% CI: 0.10-0.40) and this is statistically significant (t = 3.4, df 226, P = 0.001). The prevalence of anemia among postnatal mothers was 76.2% (n = 173, 95% CI: 70.4%-81.4%). In all, 26% (59) had mild anemia, 49.8% (113) had moderate anemia and 0.4% (1) had severe anemia [Table 2]. Half the mothers (115) who had anemia in the last trimester (Hb <11 gm%) continued to have postnatal anemia (Hb <12 gm%). One-fourth of the mothers who had normal hemoglobin levels during the third trimester had developed anemia in their postnatal period.
Following delivery, 82% (186) of the mothers were given IFA tablets at the respective health facility. Among the mothers who had received postnatal IFA supplementation, one-fourth had received the tablets for 1 month and 15% (34) received for 3 months. Univariate analysis of factors associated with postpartum anemia showed that birth order of two or more was significantly associated with postpartum anemia [Table 3]. Along with parity, other clinically important factors such as delivery type, education, anemia in the third trimester, age and socio-economic status were entered into a Logistic Regression Model [Table 4]. Birth order of two or more was significantly associated with postpartum anemia (aOR 2.2, 95% CI: 1.07-4.39).
|Table 3: Univariate analysis of factors associated with anemia at 6 weeks postpartum (n=227)|
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|Table 4: Logistic regression model for factors associated with postpartum anemia (n=227)|
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| Discussion|| |
In India, the prevalence of postnatal anemia is estimated at 65% and it ranged from 26.5% in a rural area of coastal Karnataka to 94.6% in a rural area of Rajasthan. In our study, the prevalence is 76.2% which is higher than the national average. Studies in other developing countries have shown that the prevalence varies from 50% to 80%.,, The huge variation in the prevalence may be due to the difference in the time of estimation following delivery and the method used for the estimation of hemoglobin. High prevalence of postpartum anemia highlights the fact that it is a major public health problem.
Our study has identified birth order as a significant factor associated with postpartum anemia which can be addressed by strengthening family welfare services. Half of the mothers who had antenatal anemia in the third trimester continued to have postnatal anemia. One-fourth of the mothers who had normal hemoglobin level in their third trimester had developed anemia in the postnatal period similar to the findings from other studies., These findings have a major policy implication in providing maternal care services. Mothers with antenatal anemia need to be vigilantly followed up during postnatal period for anemia. There is a need to routinely examine the hemoglobin levels during the postnatal check-ups at the health facility or during the home visit by the health worker. The Centres for Disease Control and Prevention (CDC) has also recommended screening for postnatal anemia in all women with antenatal anemia. The World Health Organisation recommends that IFA supplementation should be provided for at least three months after delivery. Postpartum iron supplementation should begin as early as possible after delivery. However, there is a lack of emphasis on the importance of postnatal IFA supplementation and poor implementation of this service provision at the health facility. Health workers can be trained to identify anemia clinically among postnatal mothers during their house visits and to give counseling regarding the importance of consuming iron-rich foods and IFA tablets. The mothers should be counseled adequately to collect the IFA tablets from their respective PHCs. Pill count method can be employed at the PHC level along with monitoring of the hemoglobin level of the mothers during their visit for immunization of their babies.
Sahli's method is cheap, less time consuming, more convenient and easy to perform. Therefore, it is a better alternative for field-based studies in resource constraint setting. This method has a sensitivity of 83.7% and specificity of 63.2% for capillary blood. It is comparable to the Drabkin's Cyanmethemoglobin method by finger prick as well as venepuncture method. The hemocue portable photometer is expensive when compared to Sahli's Hemoglobinometer. Health workers can be trained in estimating hemoglobin of postnatal mothers using Sahli's Hemoglobinometer. Primary care physicians need to be sensitized on the burden of postpartum anemia and the importance of screening for it in their clinics. Opportunistic screening can be done to all postpartum women approaching a physician for any illness or for vaccination of their babies.
The strengths of this study are that this is the first community-based study in Puducherry to estimate the burden of postnatal anemia. A single investigator did the hemoglobin estimation and interviewed the participants. Epidata software enabled to carry out an error free data entry procedure. The enrolment of study participants within 4 weeks of completion of their postnatal period helped to reduce the recall bias.
| Conclusion|| |
The prevalence of anemia among postnatal mothers is high. Routine hemoglobin estimation and advice on consumption of iron-rich foods and IFA supplementation need to be provided to postnatal mothers to improve this situation.
We thank the Deputy Director of Public Health, Puducherry and Medical officer-in charge of the PHCs for their support for conducting the project. We thank our study participants for giving their valuable time and information for the research.
Approval was received from Post-Graduate Research Monitoring Committee and the Institute Ethics Sub-Committee (Human studies) of JIPMER.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Milman N. Postpartum anemia I : Definition, prevalence, causes, and consequences. Ann Hematol 2011;90:1247-53.
Beard JL, Hendricks MK, Perez EM, Murray-Kolb LE, Berg A, Vernon-feagans L, et al
. Maternal iron deficiency anemia affects postpartum emotions and cognition. J Nutr 2005;135:267-72.
Corwin EJ, Murray-Kolb LE, Beard JL. Low hemoglobin level is a risk factor for postpartum depression. J Nutr 2003;133:4139-42.
Hen SJ, Anderson CM, Avery MD. Anemia and insufficient milk in first-time mothers. Birth 1995;22:87-92.
Galambosi PJ, Gissler M, Kaaja RJ, Ulander VM. Incidence and risk factors of venous thromboembolism during postpartum period: A population-based cohort-study. Acta Obstet Gynecol Scand 2017;96:852-61.
Axelsson D, Brynhildsen J, Blomberg M. Postpartum infection in relation to maternal characteristics, obstetric interventions and complications. J Perinat Med 2018;46:271-8.
Petersen LA, Lindner DS, Kleiber CM, Zimmerman MB, Hinton AT, Yankowitz J. Factors that predict low hematocrit levels in the postpartum patient after vaginal delivery. Am J Obstet Gynecol 2002;186:737-44.
Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B. Prevalence and risk factors of severe obstetric haemorrhage. BJOG 2008;115:1265-72.
Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 2010;110:1368-73.
Gayathry D, Guthi VR, Bele S, Vivekannada A. A study of maternal morbidity associated with caesarean delivery in tertiary care hospital. Int J Community Med Public Heal 2017;4:1542.
Iyengar K. Early postpartum maternal morbidity among rural women of Rajasthan, India: A community-based study. J Heal Popul Nutr 2012;30:213-25.
International Institute for Population Sciences. District Level Household and Facility Survey-4 (DLHS-4): State Fact Sheet Puducherry. Ministry of Health and Family Welfare. International Institute for Population Sciences, Mumbai; 2014.
International Institute for Population Sciences. National Family Health Survey-4 (NFHS-4). State Fact Sheet Puduchery 2015-16. International Institute for Population Sciences, Mumbai; 2015.
Health Management Information System. Puducherry District Factsheet: Maternal and Child Health Indicator (2015-16). 2015.
Directorate of Health and Family Welfare Services, Government of Puducherry, India. Primary Health Centres, Puducherry [Internet]. Available from: http://health.puducherry.gov.in
. [Last cited 2019 May 22].
World Heath Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. World Health Organization, Geneva; 2011.
Shidhaye P, Giri P, Nagaonkar S, Shidhaye RR. Prevalence of anemia in the postnatal women at a tertiary care teaching hospital in Mumbai. J Med Nutr Nutraceut 2012;1:54-7. [Full text]
Dean AG, Sullivan KM SM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version [Internet]. Available from: www. OpenEpi.com. [Last cited 2019 May 22].
Pal GK, Pal P. Textbook of Practical Physiology. Chapter-3, Estimation of Hemoglobin Concentration. 2nd
ed. Chennai, India: Orient Longman, 2005, p. 13-5.
Lauritsen JM, Bruus M. EpiData (version 3.1). A comprehensive tool for validated entry and documentation of data. The EpiData Association, Odense, Denmark, 2003-2005. The EpiData Association, Odense, Denmark, Odense, Denmark.
IBM Corporation. IBM SPSS Statistics for Windows. Armonk, NY; Version 20.0; 2010.
Ministry of Health and Family Welfare. National Iron+Initiative: Guidelines for Control of Iron Deficiency Anaemia. Adolescent Division. Adolescent Division, Ministry of Health and Family Welfare, Government of India, New Delhi; 2013.
Bhagwan D, Kumar A, Rao CR, Kamath A. Prevalence of anaemia among postnatal mothers in coastal Karnataka. J Clin Diagnostic Res 2016;10:LC17-20.
Noronha JA, Bhaduri A, Vinod Bhat H, Kamath A. Maternal risk factors and anaemia in pregnancy: A prospective retrospective cohort study. J Obs Gynaecol 2010;30:132-6.
Sserunjogi L, Scheutz F, Whyte SR. Postnatal anaemia: Neglected problems and missed opportunities in Uganda. Health Policy Plan 2003;18:225-31.
Manjunath K, George K, Prasad J. Determinants of postpartum anemia among women from a rural population in Southern India. Int J Womens Heal 2014;6:395-400.
Bodnar LM, Siega-Riz AM, Miller WC, Cogswell ME, McDonald T. Who should be screened for postpartum anemia? An evaluation of current recommendations. Am J Epidemiol 2002;156:903-12.
Centers for Disease Control and Prevention (CDC). Recommendations to Prevent and Control Iron Deficiency in the United States. MMWR. Vol. 47. U.S. Department of Health and Human Service, Atlanta, Georgia; 1998.
Department of Maternal, Newborn, Child and Adolescent Health. WHO Recommendations on Postnatal care of the Mother and Newborn. World Health Organization. Geneva, Switzerland; 2013.
World Heath Organization. Iron supplementation with or without folic acid to reduce the risk of postpartum anaemia. e-Library of Evidence for Nutrition Actions (eLENA) [Internet]. WHO. Geneva, Switzerland: World Health Organization; 2019 [cited 2019 May 20]. Available from: https://www.who.int/elena/titles/iron_postpartum/en/
van Lerberghe W, Keegels G, Cornelis G, Ancona C, Mangelschots EB, van Balen H. Haemoglobin measurement: The reliability of some simple techniques for use in a primary health care setting. Bull World Health Organ 1983;61:957-65.
Patil P, Thakare G, Patil S. Variability and accuracy of Sahli's method in estimation of haemoglobin concentration. Natl J Integr Res Med 2013;4:38-44.
Wasnik M, Tirpude R, Wasnik N, Agrawal VP. Validation of different tests for haemoglobin estimation. Int J Biomed Adv Res 2014;5:29-30.
Mangal A, Kumar V, Panesar S, Talwar R, Raut D, Singh S. Updated BG Prasad socioeconomic classification, 2014: A commentary. Indian J Public Health 2015;59:42-4.
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[Table 1], [Table 2], [Table 3], [Table 4]