Incidence and factors of Anemia among Women Attending...
Transcript of Incidence and factors of Anemia among Women Attending...
Ribat UniversityThe National
Faculty of Nursing
of Anemia among Women and factors Incidence
Attending Delivery in River Nile State Sudan
fulfillment for the requirement of the award of M.Sc. researchA thesis submitted in
Ribat -degree in obstetric and gynecological nursing, faculty of nursing at AL
university
By:
Sulaiman rFaiza Abd Elrazig Elnazi Khartoum High nursing Collage 1985) -(diploma of nursing
Shendi University2004) -(B. Sc. Of nursing
Supervisor:
Abd Elrahman Khalid Abd Allah
PROF. ssociatedA -Md. Of Obstetrics and Gynecology Khartoum University 1996
Ribat University.-Faculty of Medicine At Al
(February 2015)
اىطـي بطـخ اشثــبعخ
ويخ ازشيغ
بيــــه السيــذات فــــي حالة الىالدة وعىامله حـــذوث فقـــر الـــــذم
بمستشفيات والية وهــــر الىيـــل، السىدانــــي ــــىي عـــــــــشط اسظــشـ ثـسـثـيــب اسعــــــــــــــــبــــــخ مذــــخ إيـــــفبء
اـــبخغزيش فــــــــي رــــــــشيغ اـغــــــبء وازـــــىيـــذدسخــــــخ
:خاطبج
عيب فبئضح عجذ اشاصق ازيش
1891 ويخ ازشيغ اعبي/ اخشطى -دثى ازشيغ اعبي
2002اعبي خبعخ شذي ازشيغثىبىسيىط
إشـــــــــــشاف:
د. عجذ اشز خبذ عجذ هللا
شبسن أــشاع اغــبء واــــزىيذأعـــزبر
خــــــــبعخ اــــــشثبط اـــىطـــــي
اطــــــــــتوــيخ
2011فجشايش
Dedication
To the soul of my darling father..
To my great mother, brothers and sisters..
To my lovely kids: Ahmed, Sara, Abdel Raziq, ElHaj and Khalid..
I dedicate this work with love and gratitude
Acknowledgements
Firstly, my thanks are due to God for bless and guidance for this work to
be established. I would like to express my deep appreciations and sincere
thanks to my advisor: Doctor. AbdelRahman Khalid, director of obstetric and
gynecology department, Faculty of Nursing, AlRibat University for keen
supervision, patient guidance and close follow for the present study. My
appreciations are due to my co-advisor, Dr. Hashim Gasim, Senior
obstitrition, ElShorta Hospital, Atbara for his close follow up. Also I would
like to thank Mr. AbdelBagi Sheikh Eldin for his great help in data analysis.
Special appreciations are extended to my colleagues in Shendi Teaching
Hospital, ElMc Nimir University Hospital, ElDamer Hospital, ElShorta
Hospital , Atbara Teaching Hospital and Berber Hospital for their technical
help and keen encouragement. Faithful appreciations are due to professor
AlBadri Mohamed ElAmin, President of ElSheikh AlBadri University and Dr.
Khalid Mohamed Taha, Director of Atbara Veterinary Research Laboratory
for their valuable help and keen care.
I would like to thank my children: Sara, Ahmed, Abdel Razig and ElHaj
for their efforts in printing this manuscript. Finally, I express my
appreciations to all women subjected to the study for their collaborative
behavior in filling the questionnaire.
Abstract
Introduction: Anemia is most common medical disorder in pregnancy and
post partum period. The term anemia describes condition in which
hemoglobin concentration less than 11 gm according to WHO estimation.
Folic acid and B12 play an important role in HB synthesis and can in
dependently affecting DNA synthesis .vitamin A and C also contributing to
the absorption and utilization of dietary iron. Blood loss during pregnancy
also consider to be a same causes of anemia with pregnancy and Post-
partum, ectopic pregnancy abortion.
Methods: This was a descriptive hospital based study conducted in six
governmental hospitals in River Nile State.
The study aimed to estimate the incidence and factors of anemia among women
attending delivery during the period from July 2013 to July 2014.
A total of 308 cases had been tested for hemoglobin estimation from whole
blood. Accompanied questionnaire was filled by the targeted cases seeking data
about age, social status, level of academic study and health status. Data
analyzed using Statistical Package for Social Studies (SPSS).
Result: The study revealed that 198 (64.3%) of the study population were
anemic, while 110 (35.7%) revealed normal ranges of hemoglobin
concentration. Pregnant women who use tonics and cared with ante-natal
medical follow up were significantly protected against anemia (P-value ˂ 0.05).
Accordingly, the study strongly recommends the use of tonics and regular
medical follow up for pregnant women. Also the investigator suggests the
addition of iron supplements to the bread of pregnants.
الذراسة ملخص
افبط . طجيخ في اس وفزشحأوجش اشبو ا فمش اذ
خشا عي زغت مبييظ هيئخ اظسخ اعبيخ. 11 يعي رشويض اذ أل فمش اذظطر
شهب عي اسغ اىوي وب ثو أ يعجب دوسا هبب في اهيىغىثي 12ـزغ افىيه و فبيزي ث
ذ في اغزاء.وعبدخ اسذي االزظبصفي ي )أ( و )ج(و فبيزيغبعذ
غجت فمش اذ في اىالدح وب ثعذهب , و أعجبة فمذ اس خبسج اذ ازي يفزمذ أثبء اس ي
.اخاإلخهبع ...... و اشز
ولذ هذفذ إي زذوس , اذساعخ عي وطف اغذ غزشفيبد اسىىيخ ثىاليخ هش اي اسرىضد
شذ , 3102 إي يىيى3102وعىا فمش اذ ثي اغيذاد في زبخ اىالدح في فزش يىيى
زبخ. 216عذد هيىغىثياذساعخ فسض عيبد اذ
ظبزت اسبالد سظش اىػع االخزبعي , اعزجيب اعزبسحر خالي اذساعخ ء
ر إخشاء رسي اجيببد ع طشيك ثشبح اسضخ , و اظسي سبالد ازعيي,اعش و اىػع
. اإلزظبئيخ عى االخزبعيخ
يذاد االئي ( ثسبخ طجيعيخ و اغ23.5) 001و اذ %( ثفمش 4242بئح اذساعخ إطبثخ ) وشفذ ز
وازي وبذ واليب في فزشح اس اذوسيخ يغزخذ زجىة اسذيذ وزغ افىيه ع ازبثعخ اطجيخ
فمش اذ.
ازبثعخ اطجيخ سىا زدت فمش اذ واعزعبي زجىة اسذيذ وزغ ثأهيخاذساعخ أوطذ
إػبفخ عظش اسذيذ خجض اسىا. الزشاذافىيه ع
Table of contents
Dedication…………………………………………………………..…I
Acknowledgements……………………………………………………II
Arabic abstract………………………………………………….…….III
English abstract………………………………………………………VI
Chapter one
1 Introduction
1.1 Justifications
1.2 Objectives
1.2.1 General objectives
1.2.2 Specific objectives
Chapter two
2.1 Literature review
List of Tables
1. Incidence of anemia among study population……………….24
2. Anemia incidence and Living area ………….………………25
3. Anemia incidence and age group…………………………….26
4. Anemia incidence and years of education …………………..27
5. Anemia incidence and work status……………………..........28
6. Anemia incidence and family members……………………...29
7. Anemia incidence and numbers of pregnancies……………..30
8. Anemia incidence and use of iron……………………….......31
9. Anemia incidence and visit to health facility………………..32
10. Anemia incidence and type of foods………………………..33
11. Anemia incidence and fatigue among the study population..34
12. Anemia incidence and poor appetite among the study
population………………………………………………...….35
13. Anemia incidence and repeated infection ………………..…36
Table of contents
Dedication…………………………………………………………..…I
Acknowledgements……………………………………………………II
Arabic abstract………………………………………………….…….III
English abstract………………………………………………………VI
Chapter one……………………………………………………....…….1
1 Introduction………………………………………………..….……..2
1.3 Justifications………………………………………….….….……..3
1.4 Objectives………………………………………………….………4
1.4.1 General objectives……………………………….…………..4
1.4.2 Specific objectives……………………………….…………..4
Chapter two………………………………………………..…………..5
2 Literature review……………………………………………………6
2. 1 Hematological changes during pregnancy……….….…………6
2.1.1 Blood volume…………………………………………………6
2.1.2 Hemoglobin concentration…………………………………...8
2.1.3 Iron metabolism………………………………………………8
2.2 Epidemiology of anemia………………………………….…….9
2.3 Grades of anemia………………………………………………11
2.4 the complex risk factors associated with anemia……………..12
2.4.1 Poor maternal nutrition and micronutrient deficiency…….....12
2.4.2 intestinal Heminths……………………………………………14
2.4.3 Obesity…………………………………………………...…...14
2.4.4 Low income……………………………………………….......15
2.5 Consequences of anemia……………………………………......16
2.6 Effect of anemia on mothers………...……………………..…...16
2.6.1 effect of anemia on maternal morbidity and mortality..….......16
2.6.2 Performance during delivery………………………………….18
2.6.3 Lactation performance………………………………………..18
2.6.4 Working capacity and general wellbeing……………………..19
2.6.5 Immunity status………………………………………….…....19
Chapter three…………………………………………………….….20
3 Methodology……………………………………………………..21
3.1 Research design………………………………………………......21
3.2 Study area…………………………………………………….…..21
3.3 Study population ………………………………………………...21
3.4 Sample …………………………………………………………...21
3.5 Data collection ………………………………………………..…21
3.6 Data analysis………………………………………………..……21
3.7 Pilot study……………………………………………..….……...22
3.8 Limitation of the study…………………………………..………22
Chapter four……………………………………………………..……...23
4 Results…………………………………………………………..…..23
Chapter five………………………………………………………….….37
5 Discussion and Findings……………………………….………...…37
Chapter six…………..………………………………………………..…47
6 Conclusion and Recommendations…………………………………47
6.1 Conclusion…………………………………………….………….48
6.2 Recommendations…………………………………….……....….48
References……………………………………………………..………..50
Appendix…………………………………………………….….………58
Chapter One
1- INTRODUCTION
Anemia is most common medical disorder in pregnancy and post partum
period. The term anemia describes condition in which hemoglobin
concentration less than 11 gm (WHO) or the number of red blood cells is
reduce below the normal values for age and sex. As a result of this decrease,
the oxygen carrying capacity of the blood is diminished a peripheral tissue.
(1)
Anemia is usually multi-factorial in origin in adequate diet in take is
considered one of the main factors contributing to anemia. Iron deficiency
account for approximatly97%of all anemia's during the reproductive age.
Iron is a key component of hemoglobin .so that if the body has low quantity
of iron it will affect the body oxygen delivery system. (2)
Folic acid and B12 play an important role in HB synthesis and can in
dependently affecting DNA synthesis .vitamin A and C also contributing to
the absorption and utilization of dietary iron.
Blood loss during pregnancy also consider to be a same causes of anemia
with pregnancy and Post-partum, ectopic pregnancy abortion as well as
vaginal and cervical lesion placenta previa and apruptio placenta are the
most common causes of blood loss at the lasts time of pregnancy in
developing countries. Parasites are play significant role in the etiology of
anemia .Hemorrhoids associated with pregnancy also can raised to chronic
blood loss as peptic ulcer disease and intrinsic bowel disease.(3)
Anemia directly and in directly contributes to 40% of maternal death in
the third world. Severe anemia can lead to cardiac failure in pregnancy
while lesser grade associated with decrease maternal well being and
contributes to maternal death due to hemorrhage and infection...Also the
physical activities or work may be difficult to perform because not enough
oxygen is available for using by the muscles. More over sensation of feeling
cold also a body temperature can not be regulated appropriately; the
immune systems compromised as well as, reflected in decreased wound
healing ability.(4)
Anemia can be the reason of mean impaired oxygen delivery to the fetus,
which have severe consequence and contribute to pre-natal mortality by
increasing both likely hood of intra uterine growth retardation, preterm
delivery and low birth weight more over and poor breast feeding.(5)
1.1 Justifications:
Hence, this study will be undertaken to shed light on the magnitude of low
hemoglobin level among women in the Rive Nile state which is considered a
common health problem facing females in their reproductive years, and
dramatically adversely affect her health later in life, her fertility, her
recovery from pregnancy and child birth, and the health of the outcome.
1.2 Objectives:
1.2.1. General objective:
To asses Incidence of Anemic among Women Attending Delivery In The
River Nile State.
1.2.2. Specific Objectives:
1- To Determine the Incidence of Anemia among Women Attending Delivery
in the River Nile State.
2- To Identify The Factors Affecting The Incidence of Anemia Among Those
Women.
Chapter Two
Literature Review
Chapter Two
2. Literature Review
2.1. Hematological Changes during Pregnancy:
Child birth appears to induce hemoglobin changes. These change are
found mainly in the following: - (1) blood volume; (2) hemoglobin
concentration and (3) Iron metabolism, (6)
2.1.1 Blood Volume:-
During pregnancy, the maternal blood volume increases markedly. The
blood volume expansion result from an increase on both plasma and
maternal circulation, the increase in the volume of erythrocytes averaging
450ml.Moderate Erythrocyte hyperplasia is present in the bone marrow,
and the reticulocyte count is elevated slightly during normal pregnancy.
This change is related to increase in maternal plasma erythropoietin level,
which peak early the third trimester and correspond to maximal
erythrocyte.(7)
In a sever studies of normal women ,by 12 menstrual weeks, the plasma
volume expands by approximately 15% while at or very near to averaged
about 40 to 45% above their non pregnant level. (5)
Pregnancy induced hypervolemia has several important functions (1) to
meet the demands of the enlarged uterus with its greatly hypertrophied
vascular system (2) to protect the mother and in turn the fetus against the
deleterious effects of impaired venous return in the supine and erect
positions and (3) to safeguard the mother against the adverse effects of
blood loss associated with parturition.(8)
After child birth, readjustment in the maternal blood volume is dramatic
and rapid .change in the blood volume after birth depends on several factors
such as blood loss during child birth and the amount of extra vascular water
(physiologic edema) mobilized and excreted .blood loss results in an
immediate but limited decrease in total blood volume .many women loss
approximately 500ml of blood during vaginal birth and the about twice this
much during cesarean birth. (9)
Pregnancy-induced hypervolemia allows most women to tolerate these
considerable blood losses during child birth. Therefore most of blood
volume increase during pregnancy is eliminated with in the first 2 weeks
after birth, with return to none pregnancy values by 6 months post
partum.(1)
More over postpartum physiologic changes protect the women from
excessive blood loss by elimination of utero-placental circulation reduces
the size of the maternal vascular bed by 10 to 15% loss of placental
endocrine function remove the stimulus for vasodilatation and mobilization
of extra vascular water stored during pregnancy increases blood volume.(5)
2.1.2 Hemoglobin concentration:-
Hemoglobin is the oxygen carrying compound contained in RBCs. The
amount of the hemoglobin per 100 millimeters of blood can be used as an
index of the oxygen-carrying capacity of the blood. Total hemoglobin
depends primarily on the number of the RBCs. The hemoglobin carries and
the extent on the amount of the hemoglobin in each RBCs. During normal
pregnancy hemoglobin and hematocrit concentration decrease .as the result
whole blood viscosity decrease .hemoglobin concentration at term average
12.5 g/dl thus hemoglobin concentration below 11 g/dl especially late in
pregnancy should be considered abnormal. (8)
After delivery the hemoglobin level typically fluctuate test other modest
degree and then rises to and usually exceeds the non pregnant level .the rate
and magnitude of increase early in the pauperism result from the amount of
hemoglobin added during pregnancy and the amount of blood loss at
delivery modified by a puerperal decrease in plasma volume. During the
first 72 hours after childbirth there is a greater loss of plasma volume than
in the number of blood cells. This results in an increase in hematocrit and
hemoglobin levels and decrease in blood cell destruction by seventeenth
day after birth. (5)
2.1.3 Iron Metabolism:-
The total iron content of normal iron women ranges from 2-2.5 about half
the amount found normally in men .More over, the iron store of normal
young women are only about 300mg.The hemoglobin contains about 70% of
the body iron, while storage iron account foremost of the remainder .Iron in
hemoglobin is responsible for distributing for oxygen throughout the body
and also assists enzymes in the use of oxygen by the cells. (5)
The total iron requirements of normal pregnancy is 1000 mg about 500
mg for maternal hemoglobin mass expansion 300 mg are actively
transferred to the fetus and placenta and about 200 mg are lost through
various normal routes of execration primarily the gastrointestinal tract.
these are obligatory losses and occur even the mother is iron deficient .the
average increase in the total volume circulatory erythrocytes(about 450 ml
during pregnancy when iron is available)uses the other 500 mg of iron
because 1 ml of normal erythrocytes contains 1.1 mg of iron. Therefore the
iron requirement becomes quite large during the second half of pregnancy
with averaging 6 to 7mg/day. (5)
In the absence of supplementation iron the hemoglobin concentration and
hematocrit fall appreciably as the maternal blood volume increase .if the
non anemic women are not given supplementation iron, serum iron and
ferreting concentration decline during the second half of pregnancy. Thus
amount of iron absorbed from diet together with that mobilized from stores
become insufficient to meet the maternal demands superimposed by
pregnancy. (10)
2.2. Epidemiology of anemia: -
Anemia remains the comment nutritional and most intractable problem
worldwide with its highest incidence among pregnant women, WHO
estimated that more than 2 billion people world wide, is anemic. It is
especially more common in developing countries because of poor nutrition
and high Incidence of parasitic infestation.(11)
National anemia surveys have been conducted in about 25 developing
countries. It was found that incidence of anemia among pregnant women in
developing countries average 56% with arrange of 35% to 100%among
various Region of the world .south Asia regional anemia incidence has been
estimated to be 75% among pregnant women . (12)
In African, anemia affects more than half of all pregnant women .according
to recent survey the center for disease control, the incidence of anemia in
low in come women , in the first trimester is approximately3.5% in white
women and 12.5 %in Africa associated with increase to (18.85% and38.1%
prospectively)by the third trimester. The human nutrition collaborative
Research support Program (NHCRSP) reported that incidence of anemia in
Sudan among pregnant, lactating and non-lactating and non-pregnant
women were.
Result of health population survey for the year 2000 in Sudan, revealed that
around 30% of pregnant women suffered from anemia and 40% of pregnant
women had mild anemia and 10% suffered from moderated anemia. (13)
The incidence of postpartum anemia was higher among those who had
anemia during pregnancy 49%, Inculding 48% of those who were 13 to14
weeks postpartum, compared to24% of women who had not suffered from
prenatal anemia. (3)
With distribution of different type of micronutrient deficiencies
contribute to anemia in different surveys, it was found that 98% of the
cases, the etiology of post partial anemia are iron deficiency of vitamin,
foliate and vitaminB12 were found in approximately 40%,30%and25%of
pregnant women of anemia.(5)
2.3. Grades of anemia: -
Anemia is Defined as low level of hemoglobin in red blood cells .Iron is
hemoglobin molecule fixes oxygen in the lung and relapses it’s the tissues
where oxygen generate energy for the body .According to who criteria
,anemia was defined as Hemoglobin (HB) of <11g/dl.so that any women
with hemoglobin 11g/dl or more is considered normal . Hemoglobin
between 9g/dl to 10.9g/dl is considered as mild anemia, between 7g/dl to
8.9g/dl moderate and hemoglobin less than 7g/dl is sever anemia (WHO
...).The center for disease control and prevention (.....) defined anemia as less
than 11 gm/dl in the first and third trimester less than 10.5g/ dl in the
secondtrimester.(14)
2.3.1. Severe anemia (hemoglobin<7 dl) is the public health problem if
incidence exceeds 2%. Its problem in most counties in Africa and south Asia
and some countries in East Asia and the pacific (e.g., Cambodia).(15)
2.3.2. Mild anemia developing over along period of time end to produce few
symptoms: e.g. fatigue, irritability, loss of sense of well being lack of interest
of life. 3.Moderat to sever Anemia that develop quickly will produce many
symptoms and signs these include pallor of skin and mucus membrane and
conjunctiva; tachycardia; dyspnea; headache; nausea and vomiting;
depression weight loss and edema; diaphoresis; paresthesia; a cold feeling
and burning sensation of tongue (glossies).(16)
With greater severity, anemia became debilitating as work capacity and
tolerance of physical execration are restricted. Finally, it can produce cardio
respiratory failure and death. Koilonychias, finger nail are thin, friable and
brittle, with distal half having a concave or spoon shape resulting from
impaired nail bed epithelial growth. It is considered path gnomonic of iron
deficiency. Also blue sclera with a definite bluish hue is a highly specific of
iron deficiency .The bluish ting results from thinning of the sclera, which
make the choroids visible. The thin sclera results from impairment of
collagen synthesis by iron deficiency.
2.4 The complex risk factors associated with anemia:-
Anemia is usually factorial in origin , and the following are the most
common risk factors associated with anemia:-
2.4.1 Poor maternal nutrition and micronutrient Deficiency:-
Poor nutrition status in pregnancy has adverse consequences that can
persist from one generation to the next; iron Defiance is common cause of
anemia in pregnant women. Iron Deficiency during lactation is mostly a
residual from pregnancy and delivery and can be partially alleviated
because of lactation amenorrhea .However once menstruation returns, if
lactation continues; iron requirements became higher to reach a median of
about 1.81 mg/day. Dietary iron absorption in the most populations of
Developing world may not be sufficient for fulfill these needs. (3)
Multiple micronutrient deficiency also contribute to anemia in pregnancy,
and deficiencies of vitamin A, foliate ,and vitamin B12 were found in
approximately 40%,30% and 25%, respectively of pregnant women with
anemia,.(17)
Also association between vitamin A deficiency and anemia has been
demonstrated in many nutritional surveys, and a number of intervention
studies. Vitamin A appear to protect against anemia through diverse
biologic mechanisms, including the enhancement of the growth and
differentiation of erythrocyte progenitor cells, modulation of immunity to
infectious diseases and mobilization of iron stores from tissues.(18)
Riboflavin deficiency is widespread in population consuming little milk or
products, and high incidence of biochemical deficiency has been observed in
studies from different parts of the developing world. Riboflavin deficiency
may impair iron mobilization, globing synthesis, and iron absorption and
mobilization. Vitamin C has and anti- oxidant properties and also facilitates
the absorption and mobilization of iron. Several studies suggest that vitamin
deficiency exacerbate anemia. (16)
An unusual behavior associated with anemia in pregnancy. Pica, which is
characterized by hunger and appetite for nonfood substances including ice,
clay, cornstarch and even dirt, creates health problem and decrease
minerals absorption. Excessive intake of antacids, oxalates and phosphates
competes with the absorption of sites of iron. Food with higher fiber and
diary product also decrease absorption of iron and then contribute to
Anemia. (19)
2.4.2 Intestinal Helminthes:-
Hook worm and other intestinal helminthes as schistosomiasis and in
some cases trichuriasis cause gastrointestinal blood loss, mal absorption,
and inhibition of appetite, there by exacerbating micro nutrition defensives
and maternal anemia .Several studies had shown that hook worms cause
severe anemia and magnetron in developing countries in tropics, with
estimated over billion infected worldwide. The parasite most commonly
associated with is hookworm followed by Ascaris (p<0.06). Infection of
pregnancy may cause decrease fetal growth and weight gain. (20)
2.4.3 Obesity:
Obesity is defined as body mass index (BMI) greater than 29.Several
studies suggest that higher pregnancy BMI substantially increases the risk
marker of postpartum anemia found that risk of postpartum anemia (21)
was similar for women with BMI values from 17 to 24 compared with
women with a BMI of 20.Adjusted relative risk increased as BMI increased
from 24 to 38. Women with aBMI0f 28 had 1,8 times the postpartum anemia
risk of women with a BMI of 20(955confidenece interval 1.8,2.5),and obese
women with a BMI of 36 had ~2.8 times the risk (95% confidence
interval1.7,4.7). (21)
In addition compared with non-obese women, obese women have greater
risk of postpartum hemorrhage, and cesarean delivery with adjusted OR
was 1.66(95%CL 1.51,1.82) The complication can result in blood losses
exceeding 1000 ml, the equivalent of 400 mg of iron . Base women also have
risk of delivering a macrocosmic infant (birth weight>4000g) which cause
higher delivery blood loss and lengthens the duration of lochia and then
contributes to Anemia. (22)
2.4.4 Low Income:
Recent suggested that anemia is common among low income women. The
incidence of iron deficiency anemia among women with poverty index
ratio<130%was substantially higher than those with a poverty index
ratio>130%.furthermore,compared with postpartum women who had
poverty index ratio>130%,their lower income counterparts were ~3 time as
likely to have anemia (%+_SEM: 22.2+_5.9 vs.6.3+_2.1)and iron deficiency
anemia (%+_SEM: 10.3+_ 3.3 vs.2.1+_1.3) incidence of anemia in poorest
compared to the richest quintile is to times higher in India and 1.4 times
higher in Sudan, Cambodia, LAC and ECA.(23)
Women of low socioeconomic status use multivitamin and mineral
supplements less often during pregnancy and have in adequate dietary than
women of higher socioeconomic status The difference is important because
red cells mass expansion among women who do not use iron prenatal iron
supplements is half that of women who are supplemented.(24)
Compared with higher in come women, women of low socioeconomic
status class frequently received in adequate or no pre natal or postpartum
care, which may prevent them from receiving risk assessment, education or
treatment for medical condition .Additionally inter pregnancy interval has
been shown to be shorter of women of low socioeconomic class. This in
adequate birth spacing may result in cycle in which iron status never
completely recovers. Moreover, low income women are not less likely to
initiate breast Feeding .Breast feeding may be protective against the
development of iron deficiency because it length amenorrhea, thereby
reducing bodily iron losses. (25)
2.5 Consequences of Anemia:-
Anemia is the one of most common risk factors in the area of obstetrics
and prenatal medicine. During pregnancy and in the pauperism, it is
associated with an increase incidence of both maternal and fetal morbidity
and mortality and morbidity .THE extend of which is dependent up on the
severity of Anemia and is resulting complications. (26)
2.6 Effect of Anemia on Mothers : -
2.6.1 Effect of Anemia on maternal morbidity and mortality:-
The major concern about the adverse effects of anemia on pregnant
women is the belief that this population is at greater risk of prenatal
morbidity and mortality .With sever anemia, most tissues of the body
become starved of oxygen, and the effect is the most marked on the heart
muscle which may fail together. (26)
The circulatory changes in sever anemia are due to oxygen lack in the
tissue caused by reduction in oxygen carrying capacity of the blood .these
change are rarely seen untie the hemoglobin concentration drops to 6.5 to
7mg/dl.the circulation is raised both heart and pulse rate rise, the skin and
mucus membranes, though pale, became warm suggesting arteriolar
dilatation .another effect of Arteriolar dilation is a decrease in peripheral
resistance, with a fall in diastolic blood pressure, since the systolic pressure
remains unchanged or slightly raised. The pulse pressure there for raises
and the pulse became water hammer in character. Vigorous pulsation of
large blood vessels of neck became visible and bruit is heard over them and
over other vessels. Renal hypoxia from reduced renal blood flow leads to
sodium retention and edema. Death from anemia is a result of heart failure,
shock, or infection that has taken advantage of impaired resistance to
diseases in the patient. Close to 500,00 maternal death ascribed to
childbirth or early post-partum occur every year, the vast majority taking
place in the developing world .Anemia is a major contributory or sole cause
in 20 -40% of such death In many regions anemia is a factor in maternal
mortality in selected developing countries ranges from 27 ( India) to 194
(Pakistan) death per100000 live births, Data show an associated between
higher risk of maternal mortality and severe anemia and an association
between hemoglobin concentrations at ,or close to ,delivery and subsequent
mortality . Maternal Death in the pauperism may be related to a poor ability
to withstand the adverse effects of excessive blood loss, an increase risk of
infection, and maternal fatigue .Since it reduces resistance to blood loss,
death may occur also from bleeding association with normal delivery .In
addition, Association of Anemia with adverse Maternal outcome such as
puerperal sepsis, ante partum hemorrhages, postpartum hemorrhages. (27)
2.6.2 Performance during Delivery:-
Delivery demands endurance and sever physical effort .physically fit
women perform better and have fewer complications during delivery when
contrasted with less fit women as in sever anemia. In sever anemia .cardiac
failure during labor is a major cause of death. WHO(1992),reported that
during child birth a healthy mother may tolerate a blood loss up to more
little .In an anemic mother .a loss of liter an 150 ml can be fatal. Anemic
Mother are poor Anesthetic and operative risk because Anemia lowers
resistance to infection and wounds may fail to heal promptly after surgery
,or may break down altogether.
2.6.3 Lactation Performance:-
Anemic mothers are less competent than their normal counterparts in the
process of lactation, and milk composition. Moreover, anemic mothers
reported a higher level of symptomatology associated with in sufficient milk
syndrome are not a only less likely to initiate breast feeding ,Also anemic
Mothers were not having enough milk ,baby nursing to often ,and baby not
gaining enough weight as the main reasons for discontinuing breast feeding
.
2.6.4 Working capacity and general wellbeing:-
The negative relationship between anemia and working capacity is well
established in both men and women. The impact of pregnancy it's residual
and iron deficiency anemia on the woman as a mother, as a worker and as a
person in general. In general anemia contribute to fatigue and is associated
with impaired aerobic capacity ,decrease voluntary activity ,and reduced
work capacity ,and then cause lower economic productivity . Anemia
interfaces with the patient `s usual activities she became accomplished usual
tasks at home, garden, or work return her from socialization with family or
friends.
2.6.5 Immunity status:-
Several anemic pregnant women have impaired cell mediated immunity
that is reversible with iron treatment .Also, iron storage are associated with
iron adverse changes in many component of the immune system ,including
resistance to the infection and delay wound healing ,resulting in prolonged
hospitalization .More over changes in the function of the immune system.(28)
Chapter three
Methodology
Chapter three 3. Methodology
3.1 Research design: This was a descriptive hospital based study
3.2 Study area:
Shendi teaching hospital, Eldamer hospital, Elshorta hospital, Elmakk Nimir
University hospital , Atbara teaching hospital and Barbar hospital.
3.3 Study population:
The population under study consists of all women attending delivery in the
period of the study.
3.4 Sample :
All women attending delivery in the period of the study (308).
3.5 Data collection:
Demographic data such as age, sex, education level, occupation, family
size, types of diet, chronic diseases, collected using direct interview after
taken consent.
In the interview, the researcher used the structured face to face
questionnaire. During the interview any vague information had been
simplified by the researcher to ensure exact and real answer by the
participants.
3.6. Data analysis:
Data of the questionnaire and results of blood tests were analyzed using
software program statistical package for social sciences (SPSS). Frequencies
and percentages were calculated and chi-square test was performed to
investigate the significance in the association of the different variables and
incidence of anemia. Correlations were considered significant if the
observed significance level (P-value was< 0.05).
3.7. Pilot study:
Pilot testing had been done prior to the beginning of data collection to
check validity of the questionnaire. Refining of questionnaire had been done
according to the result of the pilot study.
3.8 Limitation of the study: Budget was a limitation of this study.
Chapter four
Results
Chapter four
The Results
Out of 308 participants, 198 pregnant women were suffer from anemia
with a total incidence rate of (64.3%) while110 (35.7 %) of women have
normal hemoglobin based on WHO estimation.(Table 4.1 )
(Table 4.1 )Incidence of Anemia among study population: (N=308)
item frequencies %
Women with anemia 198 64.3
Women without anemia 110 35.7
TOTAL 308 100
Table (4.2) Anemia incidence and Living area : (N=308)
Variables Chi-
Square
Women
with anemia
Women
without
anemia
P-value
No % No %
Living
area
urban 2.141 116 59% 66 60% 0.710
rural 82 41% 44 40%
p-value (<0 .05 significant )
All participants are attending maternal health care centers and receiving
similar health services, however, a higher incidence rate of anemia was
found among urban inhabitance, 116 out of 182 (59%) compared to 82 out
of 126 (41%) among rural inhabitance [Table 4.2]. Differences in the
incidence rates were not significant (P = 0.71 at α = 0.05).
Table (4.3) (N=308) Anemia incidence and age group :
Variables Chi-
Square
Women
with anemia
Women
without
anemia
P-
value
No % No %
Age
(years)
24 - 29 4.617 72 37% 46 42% 0.32
30-34 80 40% 48 43%
35 > 46 23% 16 15%
p-value (<0 .05 significant )
table (4.3) shows Differences in the incidence rates among the various
age group were of no statistically significant values (P = 0.32 at α = 0.05).
Table (4.4)(N=308) Anemia incidence and years of education :
:Variables Chi-
Square
Women
with
anemia
Women
without
anemia
P-
value
No % No %
Years
of
education
6 and < 4.318 78 40% 37 36.6% .82
7-11 84 42% 45 40.9%
12 and > 36 18% 28 25.5%
p-value (<0 .05 significant )
Table (4.4) showed increased levels with increased years of education (≤
6, 40%; 7-11, 42% ) [Table 4.4]. Differences in incidence rates among the
various educational group were not statistically significant (P = 0.82 at α =
.05).
Table (4.5)(N=308) Anemia incidence and work status :
Variables Chi-
Square
Women
with
anemia
Women
without
anemia
P-
value
No % No %
Workin
g status
yes 3.638 46 .23% 42 38% .96
No 152 .77% 68 62%
p-value (<0 .05 significant )
Table (4.5) showed that incidence of anemia was much higher among non
working group (152 out of 22o: 77%) compared to working group (46 out of
88: 23%) [Table 4.5]. Differences in the incidence rates were not statistically
significant (P = 0.96 at α = 0.05).
Table (4.6)(N=308)Anemia incidence and family members
Variables Chi-
Square
Women
with
anemia
Women
without
anemia
P-value
No % No %
Family
members
3and< 1.741 147 74% 79 72% .94
4 - 6 43 21% 27 25%
7and> 8 4% 4 3%
p-value (<0 .05 significant )
Findings with respect to number of family members were also found as
with decreased number of family members an increased of the anemia
incidence rate was found (147 cases out of 226: 79%) less than 3members
compared with (51 controls out of 82 :25%) greater than 4 members (Table
4.6). Differences in incidence rates were not statistically significant (P = 0.94
at α = 0.05).
Table (4.7)(N=308)Anemia incidence and numbers of pregnancies
Variables Chi-
Square
Women
with anemia
Women
without anemia
P-value
No % No %
Number of
pregnancies
4and> 1.003 154 78% 86 78% .90
5and< 44 22% 14 22%
p-value (<0 .05 significant )
Participants with 5 or more pregnancies seems to show lower incidence
rates of anemia as (44 out of 58: 22% ) of anemic participants were with 5
or more pregnancies compared to (20 out of 87: 23%) for those with 4
pregnancies or less (Table 4.7). This is contradictory the expectation as
irons stores being depleted and exhausted due to frequent and close
intervals pregnancies and deliveries. Differences in incidence rates were not
statistically significant (P = 0.90 at α = 0.05).
Table (4.8)(N=308)Anemia incidence and use of iron
Variables Chi-
Square
Women
with
anemia
Women
without
anemia
P-value
No % No %
use of
iron
yes 15.295 43 22 102 92.8 0.00
No 155 78 8 7.2
p-value (<0 .05 significant )
Table (4.8), this is an expected observation as iron supplement is a major
treatment option. Dose differences of iron supplements seem to have effect
on incidence rates 0f anemia among the study population. Differences in
incidence rates were statistically significant (P = 0.00 at α = 0.05).
Table (4.9)(N=308)anemia incidence and visit to health facility
Variables Chi-
Square
Women
with
anemia
Women
without
anemia
P-value
No % No %
Number
of visits
Less than 4 2.361 129 66 76 69 0.04
4 and more 69 34 34 31
p-value (<0 .05 significant )
Table(4.9) This is clear from the findings among those participants at
more than 4 visits (34% suffering from anemia) compared to those
participants at less than 4 visits (66% suffering from anemia). It's clear that
the association between number of visits and incidence rates of anemia is
biggest . Differences in incidence rates were statistically significant (P = 0.04
at α = 0.05).
Table (4.10)(N=308)Anemia incidence and type of foods
: Variables Chi-
Square
Women with
anemia
Women
without
anemia
P-
value
No % No %
Red meat
and
chicken
Daily
5.939
75 38% 37 34% 0.204
Weekly 123 62% 73 66%
vegetables
Daily 4.658 91 46%
42 38% 0.79
Weekly 107 54% 68 62%
fruits Daily 7.129 93 47% 41 37% 0.129
Weekly 105 53% 69 63%
p-value (<0 .05 significant )
Table (4.10) we found that incidence showed increased levels with
increased type of food consumption. Differences in incidence rates among
the various food consumption type( red meat and chicken, vegetables, fruits
) were not statistically significant (P = 0.82 ,0.204,0.79,0,129) respectively .
Table (4.11)(N=308)Anemia incidence and fatigue among the study
population
Variables Chi-
Square
Women
with
anemia
Women
without
anemia
P-value
No % No %
fatigue Yes 9.922 119 60 46 42 0.007
No 79 40 64 58
p-value (<0 .05 significant )
table (4.11) Differences in incidence rates were statistically significant (P
= 0.007 at α = 0.05).
Table (4.12)(N=308)Anemia incidence and poor apitite among the study
population
Variables Chi-
Square
Women
with
anemia
Women
without
anemia
P-value
No % No %
poor
appetite
Yes 6.125 134 77 50 45 0.047
No 64 23 60 65
p-value (<0 .05 significant )
Table (4.12) shows the distribution of cases regarding to the poor
appetite among the study population .
Table (4.13)Anemia incidence and repeated infection (N=308)
Variables Chi-Square Women with
anemia
Women
without
anemia
P-value
No % No %
repeated
infection
Yes 3.726 110 55 50 45 0.155
No 88 45 60 55
p-value (<0 .05 significant )
As show in table (4.13) , incidence rate of anemia among women with
repeated infection were 110 (55%) compare with non repeated infection 88
(45%).
fiveChapter
Discussions and Findings
Chapter five
Discussions and Findings
Anemia is a major health problem that affects 25% to 50% of the population
of the world the prevalence of anemia in pregnancy shows a great variations in
different parts of the world. Studies from industrialized countries show that 45%
of pregnant women have a Hb less than 11 whereas the prevalence is generally
higher and the variation is greater in developing countries with 90% anemia (34)
.
Anemia in pregnancy is associated with increased rates of maternal and prenatal
mortality, premature delivery, low birth weight and other adverse outcomes
(35).The current study had been conducted among women attending delivery in
different six hospitals in the River Nile State, The main objective of the study
was to know the incidence of anemia regarding women attending delivery in the
different selected hospitals. The
findings indicated that, the study sample characterized by different demography.
Table (4-1) reflected that, such differences might be due to the fact that rural
communities with different eating habits and social beliefs as our data exclude
problems associated with compliance to iron supplements, knowledge, attitudes
and practices of pregnant women living in these areas.Table (4-2) showed age
from (24 - 29) in our study seems to show the highest incidence rate of anemia
(72out of 118; 37%, see Table 4.2). The finding of the present study is agreement
with findings reported in Karachi (36)
, in Iran (37)
. (17.9%) were with mild anemia
and in Tanzania (38)
.In Turkey (39)
, they have identified young age as a risk factor.
Women are at higher risk for developing anemic due to the fact that they must
meet their nutritional needs for their growth in addition to the nutritional needs
during pregnancy. It is also well known that iron needs are high in adolescent
girls because of the increased requirements for expansion of blood volume
associated with the adolescent growth spurt and the onset of menstruation.
Differences in incidence rates among the various age group were of no
statistically significant values (P = 0.32 at α = 0.05).
Table(4-3) Increased educational levels is expected to improve knowledge and
hence is expected to reflect more awareness regarding heath problems, however,
in the current study it was difficult to see any link between educational level and
incidence of anemia among the study population.
Table (4-4) showed With respect to the working status one also expect to see
higher incidence rates of anemia among the non working group of pregnant
women as they might be engaged in their work home and may not be able to pay
the required attention for their body needs of rest and nutrient. Our data in this
respect showed that incidence of anemia was much higher among non working
group (152 out of 22o: 77%) compared to working group (46 out of 88: 23%)
[Table 4-4]. Differences in incidence rates were not statistically significant (P =
0.96 at α = 0.05). The finding of the present study is lower than that finding,
reported in Turkey (39)
, found a high percentage (94%) of the pregnant women
were housewives this could be a possible reason for women having health
problem during their pregnancy (39)
.
Women of low socioeconomic status use multivitamin and mineral
supplements less often during pregnancy and have in adequate dietary than
women of higher socioeconomic status the difference is important because red
cells mass expansion among women who do not use iron prenatal iron
supplements is half that of women who are supplemente.(24).
The negative relationship between anemia and working capacity is well
established in both men and women. The impact of pregnancy it's residual and
iron deficiency anemia on the woman as a mother, as a worker and as a person in
general. In general anemia contribute to fatigue and is associated with impaired
aerobic capacity ,decrease voluntary activity ,and reduced work capacity ,and
then cause lower economic productivity . Anemia interfaces with the patient `s
usual activities she became accomplished usual tasks at home, garden, or work
return her from socialization with family or friends. (28)
Table (4-5) showed findings with respect to number of family members were
also found as with decreased number of family members an increased of the
anemia incidence rate was found (147 cases out of 226: 79%) less than 3
members compared with (51 controls out of 82 :25%) greater than 4 members
(Table 4.5). Differences in incidence rates were not statistically significant (P =
0.94 at α = 0.05). Compared with higher income women, women of low
socioeconomic status class frequently received in adequate or no prenatal or
postpartum care, which may prevent them from receiving risk assessment,
education or treatment for medical condition .Additionally inter pregnancy
interval has been shown to be shorter of women of low socioeconomic class.
This in adequate birth spacing may result in cycle in which iron status never
completely recovers. Moreover, low income women are not less likely to initiate
breast Feeding .Breast feeding may be protective against the development of iron
deficiency because it length amenorrhea, thereby reducing bodily iron losses. (25)
Table (4-6) showed participants with 5 or more pregnancies seems to show
lower incidence rates of anemia as (44 out of 58: 22% ) of anemic participants
were with 5 or more pregnancies compared to (20 out of 87: 23%) for those with
4 pregnancies or less (Table 4.6). the finding of the present study is was similar
with findings reported in India (28)
, and in Sudan (46)
, they found no significant
association between anemia and parity. But this result was disagrees to study in
Karachi (36)
in Iran (37)
, in Tanzania (40)
, in Turkey (39)
, in Saudi Arabia (41)
, in
Malaysia (42)
, and in Nigeria (43)
, identified increased parity 0-9 have also been
associated with more anemia this may be because underlying cause being
depleted iron stores (44, 45)
. Anemia was higher among pregnant women who had
more than 6 pregnancy, the same result were seen in Karachi (36)
, in Turkey (39)
,
& in Malaysia (42)
, reported increased gravidity was 1-10 have been associated
with more anemia this might be explained by underlying cause being depleted
iron stores (44, 45)
. Significant association was found between the last birth
intervals and anemia, pregnant who conceived within less than 24 months, were
at greater risk of having anemia when compared with normal group. This is
contradictory the expectation as irons stores being depleted and exhausted due to
frequent and close intervals pregnancies and deliveries. Differences in incidence
rates were not statistically significant (P = 0.90 at α = 0.05).
Table(4-7) A recommended strategy recommended by WHO to prevent iron
deficiency anemia in pregnant women is to provide universal supplementation of
iron (60mg per day) and folic acid (400μg/day) as soon as possible after
gestation starts-no later than the third month-and continuing for the rest of
pregnancy. however, in the current study, use of iron supplements seems to
affect the status of anemic patients as lower incidence rates among the study
population (current use; 78% compared to non use 22%; ). Anemia was high
among pregnant women who do not taking iron supplement. The same results
were seen in Iran (18)
, in Malaysia (42)
, in Pakistan (47)
, in Karachi (36)
; they found
anemia less common in ladies taking oral iron supplements compared with ladies
who were not taking oral iron supplements.
In the absence of supplementation iron the hemoglobin concentration and
hematocrit fall appreciably as the maternal blood volume increase .if the non
anemic women are not given supplementation iron, serum iron and ferreting
concentration decline during the second half of pregnancy. Thus amount of iron
absorbed from diet together with that mobilized from stores become insufficient
to meet the maternal demands s uperimposed by pregnancy. (10)
Most of women did not take their daily tablet of iron supplement regularly
and resisted it because of the perceived complications, such as; tables weakening
the blood of interfering with the digestive.
Liquid forms of iron that causes less gastrointestinal distress. However,
they can stain the teeth thus patients should be instructed to take this medication
through a straw, to rinse the mouth with water, and to practice good oral hygiene
after taking this medication. Finally, patients should be informed that iron salts
may color the stool dark green or black. (34)
Table(4-8) According to the WHO, a pregnant woman should pay at least 4-6
antenatal visits to a health facility in order for the visits to be effective. A clear
association between numbers of visits and incidence rates of anemia among
participants.
Table (4-9) Increased (red meat and chicken, vegetables, fruits ,et. )
consumption wear expected to improve family health and hence is expected to
reflect more awareness regarding heath problems, however, in the current study
it was difficult to see any link between type of food consumption and incidence
of anemia among the study population, and in contrast.
Food rich in vitamin C (e.g., citrus fruit, broccoli and capsicum) promote the
absorption of non-heme iron. A number of dietary factors inhibit non- heme
absorption, polyphones in tea and coffee phytates in wholegrain breads and
cereals, oxalic acid found in spinach and beer root and calcium especially
calcium supplements These inhibitors should not be taken with the main iron-
containing meal. (32)
The nurse should Instruct the patient to avoid foods that are gas forming,
because they cause abdominal distention, which may decrease the appetite and
also interfere with the respiratory efforts. The mother should be encouraged to
avoid hot, spicy, and acid fluids to decrease gastrointestinal irritation If the
mother is anorexic or a finicky eater, small, frequent meals may be better
tolerated. (28)
The nurse should advise pregnant women on the correct selection and
preparation of foods that are high in folic acid. Folic acid is found in leafy green
vegetable such as Brussels sprouts, broccoli and spinach but is destroyed easily
by prolonged boiling or steaming. Other sources include peanuts, chickpeas,
bananas and Chris fruits. It is also found in avocado pears, asparagus and
mushrooms. It is recommended that all women of childbearing age should eat
more folate-rich foods, eat food fortified with folic acid such as bread and
cereals. (33)
Table (4-10) Between incidence of anemia and fatigue among the study
population there was a statistically significant correlation. incidence of anemia
was higher in women with fatigue compared to women without fatigue.
The nurse should obtain the patient's medical history, and conduct a physical
examination. Because fatigue is one of the most common signs of anemia, the
nurse should assess the patient's level of physical activity, ability to perform the
usual activities of daily living, and sleep and rest pattern. Check vital signs and
observe for s
shortness of breath on exertion. Assess the patient's level of Knowledge about
the disorder, treatment, and care needed and instruct accordingly. Allow the
patient to ask questions and verbalize concerns. (31)
Table (4-11) showed the distribution of both cases and healths regarding to the
poor appetite among the study population . there are 134 (77%) of cases among
women had a poor appetite compare with 64 (23%) of cases among participants
had non poor appetite . Differences in incidence rates were statistically
significant (P = 0.047 at α = 0.05).
Table(4-12) showed incidence rate of anemia among women with repeated
infection were 110 (55%) compare with non repeated infection 88 (45%). in the
current study it was difficult to see any link between the repeated infection and
incidence of anemia among the study population, [Table 4.12].Differences in
incidence rates were not statistically significant (P = 0.155 at α = 0.05). The
infection is most common cause of death in anemic women that has taken
advantage of Impaired resistant to diseases in the patient. Maternal Death in the
puerperium may be related to a poor ability to with stand the adverse effects of
excessive blood loss, an increase risk of infection, and maternal fatigue . (27)
Chapter six
Conclusion & recommendations
Chapter six
6 Conclusion & recommendations
6.1 Conclusion:
Out of 308 pregnant women attended delivery rooms in the targeted
hospitals, a number of 198 (64.3%) were found to be anemic, while 110
(35.7%) were found to be within the normal ranges of hemoglobin
concentration. Pregnant women who use tonics and cared with ante-natal
medical follow up were significantly protected against anemia (P-value ˂ 0.05).
6.2 Recommendations:
Special attention should be taken towards the laboratories at hospitals
and clinics. Such laboratories should be well equipped with effective,
accurate and cheep means of haemoglobin determination to be reachable to
women during pregnancy and due delivery.
Strategically, all new mothers should be counseled by health care
providers about the risks of anemia throughout their pregnancy. Math
media should be used more effectively as a powerful way to disseminate
consistent knowledge to maximal numbers of target population about
anemia. Nurses should be implement a general health promotion and
prevention program about anemia to all women. This aspect of health
education should be given special importance in antenatal clinics and basic
health care settings were women come during and after pregnancy. Another
opportunity of this health education is places were family planning and
child health care services are provided. These considered efforts can lead to
better health of women and prevent anemia and morbid outcomes of
pregnancy.
On should counsel women about significant fatigue so the can do their
work and home environments in an attempt to achieve adequate rest.
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Appendix
بسم هللا الرحمن الرحيم
ــــــــــــــــــــــــــــــــــــا نإستبيــــــــــ
84ـــ 79 78ـــــ 69 68ــــ 59 العمر :
المستوى التعليمى لألم :ـــ
أمى أساس ثانوى جامعى فوق الجامعى
المهنة :ـــ
معلمة أخرى ربة منزل موظفة عاملة
المستوى التعليمى لألب :ـــ
أمى أساس ثانوى جامعى فوق الجامعى
المهنة :ـــ
موظف أعمال حرة أخرى
عدد مرات الوالدة :ــــ
فما فوق 9 8ــــ6بكرية
السكن :ـــ
ينة قريةمد
عدد أفراد األسرة :ـــ
أكثر >ـــ : 9ـــ 7 6ــــ5
نوع الغذاء:ــــ
وميا أسبوعيا شهريا يتم تناول االلياف ي
يتم تناول اللحوم الحمراء +البيضاء يوميا أسبوعيا شهريا
يتم تناول الفواكه يوميا أسبوعيا شهريا
يوميا أسبوعيا شهريا يتم تناول البقوليات
األمراض المزمنة:ـــ
هل هناك اصابة بالمالريا أثناء الحمل نعم ال
هل هناك نزيف أثناء الحمل نعم ال
نعم ال هل هنالك نزيف بعد الوالدة
هل هناك تاريخ إجهاض اوجنين ميت او ناقص نعم ال
نعم ال هل هناك اصابة بالسكر
ض القلب نعم ال هل هناك اصابة بامرا
هل هناك اصابة بالضغط نعم ال
هل هناك اصابة باالزما نعم ال
نعم ال هل هناك اصابة بالبلهارسيا
هل هناك اصابةبالديدان نعم ال
المتابعة أثناء الحمل :ـــ
شهور كل شهر نعم ال;هل توجد متابعة فى
هوركل أسبوعين نعم الش>هل توجد متابعة فى
هل توجد متابعة فى الشهرالتاسع كل أسبوع نعم ال
تناول المقويات :ــــ
هل ال نعم هل تناولتى حديد
نعم ال تناولتى فوليد أسيد
نعم ال هل تناولتى أخرى
األنميا:ـــ
ال هل نعم هل شعرتى باعباء
يوجد فقدان شهية نعم ال هل أصيبتى
نعم ال بااللتهابات المتكررة
الفحوصات :ــــ
ال وجود شحوب فى العين نعم
ال نعم CBC فحص الدم الكامل