Evaluation of the Evaluation of the performance of physicians performance of physicians

working in rural health working in rural health care units in Mansours care units in Mansours

district when dealing with district when dealing with anemia in pregnancyanemia in pregnancy

introductionintroduction

Anemia is a global public health Anemia is a global public health problem affecting both Developing and problem affecting both Developing and developed countries with major developed countries with major consequences for human health as well consequences for human health as well as social and economic development. It as social and economic development. It occurs at all stages of the life cycle, occurs at all stages of the life cycle, but is more prevalent in pregnant but is more prevalent in pregnant women and young children. (WHO women and young children. (WHO 2005)2005)..

Anemia in pregnancy is defined by Anemia in pregnancy is defined by the World Health Organization as a the World Health Organization as a hemoglobin value below 11 g/dl hemoglobin value below 11 g/dl (WHO 1992; WHO 2001)(WHO 1992; WHO 2001)..

Nearly half of the pregnant women in Nearly half of the pregnant women in the world are estimated to be the world are estimated to be anemicanemic::

52%52% in developing- as compared with in developing- as compared with 23% in developed– countries. 23% in developed– countries. Throughout Africa, about 50% of Throughout Africa, about 50% of pregnant and 40% of non-pregnant pregnant and 40% of non-pregnant women is anemic. (WHOwomen is anemic. (WHO 2001)2001)..

Physiologically During pregnancy, there is Physiologically During pregnancy, there is an increase in both red cell mass and an increase in both red cell mass and plasma volume to accommodate the needs plasma volume to accommodate the needs of the growing uterus and fetus. However, of the growing uterus and fetus. However, plasma volume increases more than the red plasma volume increases more than the red cell mass leading to a fall in the cell mass leading to a fall in the concentration of hemoglobin in the blood concentration of hemoglobin in the blood (Letsky 1991).this so-called (Letsky 1991).this so-called physiological physiological anemia of pregnancyanemia of pregnancy. (Steven G. et al 2002). (Steven G. et al 2002)

Prophylactic iron supplementation in all Prophylactic iron supplementation in all women is recommended to prevent women is recommended to prevent anemia. (Vincenzo Berghella 2007)anemia. (Vincenzo Berghella 2007)..

Evidence suggests that without Evidence suggests that without supplemental iron, women can exhaust supplemental iron, women can exhaust their serum ferritine (iron stores) their serum ferritine (iron stores) markedly between the 12th and 25th markedly between the 12th and 25th week of gestation (Allen 2001)week of gestation (Allen 2001)..

The main causes of anemia are: The main causes of anemia are: dietarydietary iron deficiency; iron deficiency; infectious diseasesinfectious diseases such such as malaria, hookworm infections and as malaria, hookworm infections and schistosomiasis; schistosomiasis; deficiencies of other key deficiencies of other key micronutrientsmicronutrients including folate, vitamin including folate, vitamin B12 and vitamin A; or iB12 and vitamin A; or inherited nherited conditions that affect red blood cells conditions that affect red blood cells (RBCs), such as thalassaemia. (RBCs), such as thalassaemia. (WHO2004)(WHO2004)..

Iron deficiency with or without Iron deficiency with or without anemia have important anemia have important consequences for human health and consequences for human health and child development: anemic women child development: anemic women and their infants are at greater risk and their infants are at greater risk of dying during the perintal periodof dying during the perintal period..

Iron deficiency anemia can cause Iron deficiency anemia can cause increased risk for maternal infectionincreased risk for maternal infection..

It is also associated with infant and child It is also associated with infant and child morbidity and mortality from morbidity and mortality from prematurity .low birth weight, lower infant prematurity .low birth weight, lower infant iron reserve, and heavier placentasiron reserve, and heavier placentas..

In addition, these infants can have In addition, these infants can have developmental, cognitive, and growth developmental, cognitive, and growth delay. (Jacqueline E. 2008)delay. (Jacqueline E. 2008)

The four basic approaches to the The four basic approaches to the prevention of iron deficiency anemia prevention of iron deficiency anemia are are supplementationsupplementation with medicinal with medicinal iron, iron, educationeducation and associated and associated measures to measures to increase dietary iron increase dietary iron intakeintake, the , the control of infectioncontrol of infection, and , and the the fortification of a staple food with fortification of a staple food with ironiron..

The success of all technical The success of all technical approaches to anemia control approaches to anemia control depends on the active participation depends on the active participation of the populationof the population. . Hence the need for Hence the need for a public education support strategy a public education support strategy based on careful analysis of the based on careful analysis of the behavioral changes requiredbehavioral changes required..

The major changes in behavior that are The major changes in behavior that are needed centre on needed centre on compliance with compliance with supplementation regimenssupplementation regimens, , changes in changes in eating habits,eating habits, and and measures for infection measures for infection controlcontrol, including , including better personal better personal hygienehygiene and more rational feeding of and more rational feeding of sick children-responsibilities that in sick children-responsibilities that in many societies are assigned primarily to many societies are assigned primarily to womenwomen. .

Rational and Rational and justificationjustification

According to WHO 2005 the According to WHO 2005 the prevalence of anemia in EGYPT in prevalence of anemia in EGYPT in women was 39.2% in rural areas, women was 39.2% in rural areas,

39.7% in urban areas, 36% in lower 39.7% in urban areas, 36% in lower Egypt, 42% in upper Egypt and 40% Egypt, 42% in upper Egypt and 40% in urban governorates. (WHO 2005)in urban governorates. (WHO 2005)..

Dietary iron intake can be increased in Dietary iron intake can be increased in poor communities bypoor communities by enhancing the enhancing the bioavailability of the iron ingested, bioavailability of the iron ingested, rather than its total amountrather than its total amount, , based based either on promoting the intake of iron either on promoting the intake of iron absorption enhancers, including haem absorption enhancers, including haem iron, or on reducing the ingestion of iron, or on reducing the ingestion of absorption inhibitors such as tannin absorption inhibitors such as tannin and phytic acid . (E.M. DeMaeyer et al and phytic acid . (E.M. DeMaeyer et al 19891989))

Iron absorption can vary from 1% to Iron absorption can vary from 1% to 40%, depending on the mix of 40%, depending on the mix of enhancers and inhibitors in the meal. enhancers and inhibitors in the meal. (WHO(WHO 20012001))

Pregnant women are a priority group Pregnant women are a priority group for iron supplementation. Identifying for iron supplementation. Identifying this group and distributing iron this group and distributing iron tablets to each pregnant woman is a tablets to each pregnant woman is a task within the competence of the task within the competence of the health care membershealth care members..

Supplementation should occur Supplementation should occur primarily during the second half of primarily during the second half of pregnancy, when the iron pregnancy, when the iron requirement is greatest. During early requirement is greatest. During early pregnancy, morning sickness will in pregnancy, morning sickness will in any case reduce the effectiveness of any case reduce the effectiveness of supplementationsupplementation..

The major obstacle to iron The major obstacle to iron supplementation is poor compliance supplementation is poor compliance with treatment. This is often due to with treatment. This is often due to side-effects, but it may also because side-effects, but it may also because women's lack of awareness of the women's lack of awareness of the importance of iron supplementation importance of iron supplementation to herself and to her fetusto herself and to her fetus..

All of the above reasons lead to the All of the above reasons lead to the need of the presence of the family need of the presence of the family physician in the health care unit to physician in the health care unit to achieve the valuable goal of achieve the valuable goal of preventing anemia among pregnant preventing anemia among pregnant womenwomen..

Family physicians provide diagnosis and Family physicians provide diagnosis and treatment, health protection and treatment, health protection and promotion, coordination of care and other promotion, coordination of care and other community facilities particularly in rural community facilities particularly in rural areasareas..

They are clinically competent to provide They are clinically competent to provide the greater part of their care, taking into the greater part of their care, taking into account the cultural, socioeconomic and account the cultural, socioeconomic and psychological background. (WONCA 1991psychological background. (WONCA 1991))

Aim of the workAim of the work

Improve the performance of Improve the performance of physicians working in a family health physicians working in a family health care unit and in a primary health care unit and in a primary health care unit when dealing with anemia care unit when dealing with anemia in pregnancyin pregnancy..

Decrease the high prevalence of Decrease the high prevalence of anemia during pregnancy leading to anemia during pregnancy leading to decrease of both morbidity and decrease of both morbidity and mortality among pregnant women in mortality among pregnant women in the perinatal periodthe perinatal period..

ObjectivesObjectives::

11 - -Evaluation of the physicians' Evaluation of the physicians' performance when dealing with performance when dealing with anemia in pregnancyanemia in pregnancy..

22 - -Assessment of the prevalence of Assessment of the prevalence of anemia among pregnant women in anemia among pregnant women in both family health centers and both family health centers and primary health care units in primary health care units in MANSOURA districtMANSOURA district..

Subject and methodSubject and method

- -Study designStudy design:: Observational studyObservational study..

- -PopulationPopulation:: - - The physicians The physicians

working in the rural health care units working in the rural health care units in Mansoura district will be included in Mansoura district will be included in the studyin the study..

- -sample sizesample size : : Will be calculatedWill be calculated

- -Sample techniqueSample technique:: Randomly selectedRandomly selected

- -Time of scheduleTime of schedule : : One month for One month for

preparing questionnaire and pilot preparing questionnaire and pilot studystudy..

And 3 months for data And 3 months for data collection and analysiscollection and analysis..

Tools of the studyTools of the study::

11 - -The physicians will be divided into The physicians will be divided into two groups according to whether two groups according to whether they work in a family health care unit they work in a family health care unit or a primary health care unit to or a primary health care unit to evaluate both systems in dealing evaluate both systems in dealing with anemia in pregnancywith anemia in pregnancy..

22 - -The physicians will be observed The physicians will be observed about their performance on dealing about their performance on dealing with pregnant womenwith pregnant women..

33 - -Check list will be recorded for each Check list will be recorded for each physician including all items required physician including all items required to be done for each pregnant women to be done for each pregnant women attending the health care unitattending the health care unit..

44 - -the Check list will include a special the Check list will include a special part about dealing with anemia in part about dealing with anemia in pregnancy ( iron supplementation, pregnancy ( iron supplementation, health education and hemoglobin health education and hemoglobin assessment )assessment )

55 - -A record for each health care unit will A record for each health care unit will be done to include information about the be done to include information about the number of population they serve, number of population they serve, average number of pregnant women average number of pregnant women attending per month, the average attending per month, the average number of visits to each pregnant number of visits to each pregnant woman attending during her antenatal woman attending during her antenatal period and the prevalence of anemia in period and the prevalence of anemia in the last six monthsthe last six months..

66 - -Pilot study will be done to test the Pilot study will be done to test the check list designed and to detect any check list designed and to detect any

obstacles of the studyobstacles of the study