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BRIEF RESEARCH ARTICLE
Year : 2018  |  Volume : 62  |  Issue : 4  |  Page : 315-318  

Anemia at the time of delivery and its association with pregnancy outcomes: A study from a secondary care hospital in Haryana, India


1 Professor and Head, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Assistant Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
4 Associate Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication11-Dec-2018

Correspondence Address:
Dr. Ravneet Kaur
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_40_18

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   Abstract 


Maternal anemia has been reportedly associated with increased risk of maternal and fetal morbidity and mortality. Adverse pregnancy outcomes such as preterm birth, low birth weight, and stillbirth have been reported to be associated with anemia. However, different studies have shown inconsistent results. In the present study, we report the association between maternal hemoglobin levels at the time of delivery and outcomes among women at a secondary care hospital in northern India. Secondary analysis of routinely collected hospital data from January 2015 to December 2016 was carried out. Sociodemographic details, hemoglobin levels at the time of admission, and birth outcomes were retrieved from the records of women admitted for delivery. The outcomes were compared among anemic and nonanemic women. About 78% of the women were found to have anemia at the time of delivery. A significantly higher proportion of anemic women had preterm labor.

Keywords: Anemia, delivery, outcome, pregnancy, preterm


How to cite this article:
Kant S, Kaur R, Goel AD, Malhotra S, Haldar P, Kumar R. Anemia at the time of delivery and its association with pregnancy outcomes: A study from a secondary care hospital in Haryana, India. Indian J Public Health 2018;62:315-8

How to cite this URL:
Kant S, Kaur R, Goel AD, Malhotra S, Haldar P, Kumar R. Anemia at the time of delivery and its association with pregnancy outcomes: A study from a secondary care hospital in Haryana, India. Indian J Public Health [serial online] 2018 [cited 2019 Dec 15];62:315-8. Available from: http://www.ijph.in/text.asp?2018/62/4/315/247232



Anemia during pregnancy is an important public health problem in many developing countries, including India. According to the report of the National Family Health Survey, 2015–2016 (NFHS-4), 50.3% of the pregnant women in India were anemic.[1] The state of Haryana has a high burden of anemia. The NFHS-4 data show that 55% of pregnant women in Haryana had anemia. The prevalence was more in rural areas (58.1%) as compared to urban areas (50.2%).[2]

Anemia has been found to be an important contributor to adverse pregnancy outcomes such as preterm birth, low birth weight (LBW), small for gestational age, and delivery by cesarean section.[3],[4] However, the results are inconsistent across various studies, as some studies reported significant associations, while other studies did not. Majority of the studies conducted earlier were carried out at tertiary care centers in urban areas, with lack of information about women in rural areas or secondary level health facilities.

The present study was conducted among women admitted for delivery at a secondary care hospital in Haryana, northern India. The study aimed to determine the association between maternal hemoglobin levels at the time of delivery and pregnancy outcomes.

It was a record-based study, conducted at a secondary care hospital in district Faridabad, Haryana. Every year more than 4000 deliveries were conducted at this health facility. As a part of routine care, hemoglobin levels of all women admitted for delivery at the hospital were recorded at the time of admission. Hemoglobin was measured by the HemoCue method.

Records of all women admitted for delivery during the period from January 2015 to December 2016, were reviewed. A total of 8748 women were admitted for delivery during this period, and all of them were included in the study. Information such as sociodemographic details, hemoglobin levels at the time of admission, and birth outcomes were retrieved from the records. Outcomes in terms of birth weight, period of gestation at the time of delivery, fetal well-being, and maternal complications were recorded. The outcomes were compared among anemic and nonanemic women.

The anemic group was defined as women having hemoglobin level below 11 g/dL at the time of admission. The nonanemic group included women whose hemoglobin levels were above 11 g/dL.

Statistical analysis was done using SPSS version 22 (IBM, Armonk, New York). The prevalence of anemia was reported as percentage, with 95% confidence interval (CI). For comparison of birth outcomes, Chi-square/Fischer's exact test was used for qualitative variables, and t-test was used for continuous variables.

A total of 8748 women were admitted for delivery. Of these, 6827 (78%, 95% CI = 77.2–78.9) were anemic, and 1921 (22%, 95% CI = 21.10–22.84) were nonanemic. Majority (63.8%) had mild anemia, 30.5% had moderate anemia, while 5.7% had severe anemia. Mean standard deviation (SD) hemoglobin level among anemic women and nonanemic women was 9.0 (1.2) g/dL and 11.8 (0.8) g/dL, respectively.

The mean (SD) age of the women was similar in both groups, i.e., 24 (3.4) years in the nonanemic and 24 (3.5) years in the anemic group (P = 0.95). In the anemic group, significantly higher proportion of women was multipara as compared to nonanemic group (P < 0.001). There was a significant difference in the education status of women in the two groups (P < 0.001). In the anemic group, 46% of the women did not receive any antenatal care, while in the nonanemic group 34.3% of the women did not receive any antenatal care (P < 0.001). Among the women who received antenatal care, only 14.7% of the women in the anemic group had made adequate (at least four) visits the antenatal clinic, while the corresponding figure in the nonanemic group was 24.3%. The difference was statistically significant (P < 0.001).

Of total 8,748 women admitted for delivery, 1867 (21.3%) were referred to higher center due to maternal or fetal complications. The rate of referral was significantly higher (22.2%) in the anemic group, as compared to nonanemic group (18.2%) (P < 0.001, χ2 = 14.2). A significantly higher proportion of women (10.2%) in the anemic group had preterm delivery, as compared to 6.8% in the nonanemic group odds ratio (OR) =1.28, 95% CI = 1.05–1.55; P < 0.001) [Table 1].
Table 1: Sociodemographic and selected clinical characteristics of women admitted for delivery

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Unfavorable birth outcomes (i.e., intrauterine death, stillbirth) were seen in 1.5% and 1.4% of the women in the anemic group and nonanemic group, respectively, which was statistically not significant (P = 0.06). The percentage of neonates with LBW was 23.3% and 25.1% in the anemic group, and nonanemic group respectively, while those very LBW were 1.9% and 1.4% respectively. The difference was statistically not significant (OR = 0.93, 95% CI = 0.82–1.05; P = 0.33) [Table 2].
Table 2: Distribution of pregnancy outcomes by anemia status of women who delivered at SDH, Ballabgarh

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Other maternal and fetal complications were similar in both groups. These included – preeclampsia (5.3% in the anemic as compared to 5.2% in the nonanemic group), antepartum hemorrhage (0.9% in the anemic as compared to 0.5% in the nonanemic group), postpartum hemorrhage (0.5% in the anemic vs. 0.3% in the nonanemic group), and fetal distress (2.0% in the anemic as compared to 2.2% in the nonanemic group) (OR = 1.15, 95% CI = 0.97–1.36).

We found that 78% of the women admitted for delivery were anemic. This figure was higher than the state average (55%) as well as the figure for rural Haryana (58.1%). It may be due to hospital-based study setting. Although a number of studies are available about the prevalence of anemia in pregnancy, only few studies have reported the proportion of women who deliver in an anemic state. In our study, 78% of the women admitted for delivery had anemia. A study conducted in a teaching hospital in another state reported that 88.4% of the women admitted for delivery had anemia, a finding which was similar to our observation.[5]

In our study, maternal anemia was found to be significantly associated with low education, multiparity, and lack of antenatal care. We also found that anemia was significantly associated with preterm delivery. Similar findings have been reported in various other studies conducted in India and abroad.[6],[7],[8] This is also consistent with systematic reviews and meta-analyses that have reported a significant association of maternal anemia with preterm delivery.[9]

We did not find a significant association between LBW and maternal anemia. Some other studies conducted in India and other countries have reported similar results. However, several studies spanning over two decades have reported a significant association between maternal anemia and LBW.[6],[10] In the present study, association of LBW was not assessed with respect to severity of anemia as the majority of the women had mild (63.8%) or moderate anemia (30.5%). This might have led to an underestimation of association of LBW with maternal anemia.

It was found that besides preterm delivery; there was no significant difference in maternal complications or neonatal outcomes in both groups. This is consistent with some other studies that have reported similar findings.

In our study, 21.3% of the women admitted for delivery were referred to higher center due to or likely complications. The rate of referral was 22.2% in the anemic group, while 18.2% in the nonanemic group. In an earlier study, audit of emergency obstetric referrals from the study site was conducted. It was found that the most common indication for referral was preterm labor, which accounted for 30.6% of all referrals. Severe anemia was the cause of referral in 5.1% of the women. Hence, due to the high proportion of referrals, we might have missed the adverse maternal and neonatal outcomes associated with anemia.

Our study had few limitations. Since it was a secondary care hospital, there were women who were enrolled in the antenatal clinic of the hospital, as well as those came directly for delivery, and had not received ante-natal care from any health facility. Thus, records of ante-natal hemoglobin were not available for all the patients.

The strengths of the present study include large sample size and uniform method for measurement of hemoglobin for all women. The diagnosis of anemia at the time of admission is credible for measuring the association between anemia and pregnancy outcome. Although association between maternal anemia and pregnancy outcome have been studied earlier, however, most of the studies are from tertiary care centers in urban areas, and there is lack of information available from secondary care health facilities, catering primarily to rural areas. Our study attempts to fill this lacuna.

The study adds to the evidence that there is an increased incidence of preterm among women having anemia. The outcomes are comparable in terms of LBW, maternal complications, and fetal loss. This study highlights the importance of iron supplementation, preferably by parenteral administration in the last trimester, to quickly correct the anemia, and prevent preterm deliveries. Since anemia was more among women who did not receive adequate antenatal care, strengthening of antenatal care services and increasing their utilization could be an important measure to control anemia at the time of delivery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
National Family Health Survey (NFHS-4): India Fact sheet; 2015-16. Available from: http://www.rchiips.org/nfhs. [Last accessed on 2017 Nov 10].  Back to cited text no. 1
    
2.
National Family Health Survey (NFHS-4): Haryana; 2015-16. Available from: http://www.rchiips.org/nfhs/pdf/NFHS4/HR_FactSheet.pdf. [Last accessed on 2018 Jan 22].  Back to cited text no. 2
    
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Allen LH. Anemia and iron deficiency: Effects on pregnancy outcome. Am J Clin Nutr 2000;71:1280S-4S.  Back to cited text no. 3
    
4.
Rahman MM, Abe SK, Rahman MS, Kanda M, Narita S, Bilano V, et al. Maternal anemia and risk of adverse birth and health outcomes in low- and middle-income countries: Systematic review and meta-analysis. Am J Clin Nutr 2016;103:495-504.  Back to cited text no. 4
    
5.
Soumyashree MN, Viveki RG. Hemoglobin profile of full term pregnant women admitted for delivery in a teaching hospital: A case series study. Int J Public Health Rev 2016;3:95-100.  Back to cited text no. 5
    
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Kaur M, Chauhan A, Manzar MD, Rajput MM. Maternal anaemia and neonatal outcome: A Prospective study on urban pregnant women. J Clin Diagn Res 2015;9:QC04-8.  Back to cited text no. 6
    
7.
Kumar A, Chaudhary K, Prasad S. Maternal indicators and obstetric outcome in the North Indian population: A hospital-based study. J Postgrad Med 2010;56:192-5.  Back to cited text no. 7
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8.
Kumar KJ, Asha N, Murthy DS, Sujatha M, Manjunath V. Maternal anemia in various trimesters and its effect on newborn weight and maturity: An observational study. Int J Prev Med 2013;4:193-9.  Back to cited text no. 8
    
9.
Sukrat B, Wilasrusmee C, Siribumrungwong B, McEvoy M, Okascharoen C, Attia J, et al. Hemoglobin concentration and pregnancy outcomes: A systematic review and meta-analysis. Biomed Res Int 2013;2013:769057.  Back to cited text no. 9
    
10.
Nair M, Choudhury MK, Choudhury SS, Kakoty SD, Sarma UC, Webster P, et al. Association between maternal anaemia and pregnancy outcomes: A cohort study in Assam, India. BMJ Glob Health 2016;1:e000026.  Back to cited text no. 10
    



 
 
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