International Journal of Public Health Science (IJPHS)

Vol.6, No.3, September 2017, pp. 213~220

ISSN: 2252-8806, DOI: 10.11591/ijphs.v6i3.7931  213

Prevalence and Determinants of Anemia in Pregnancy,

Sana’a, Yemen

Yousef M. Alflah1, Iman H. Wahdan2, Ali A. Hasab3, Dalia I. Tayel4

Public Health Specialist, Al Kuwait University Hospital, Sana’a University, Yemen
1
2,3 Department of Epidemiology, High Institute of Public Health, Alexandria University, Egypt
4 Department of Nutrition, High Institute of Public Health, Alexandria University, Egypt

Article Info ABSTRACT

Article history: Anemia is a global public health problem in both developing and developed
countries, especially among pregnant women. The aim of the study was to
Received May 28, 2017 estimate the prevalence of anemia among pregnant women in Sana'a
Revised Jul 26, 2017 governorate, Yemen, and to identify the determinants contributing to it, and
Accepted Aug 11, 2017 to assess knowledge regarding it. The study was conducted using a cross-
sectional approach. It included 360 pregnant women attending the maternity
clinics of maternity hospitals. A predesigned structured interviewing
Keyword: questionnaire was used to collect data from the pregnant women. Laboratory
investigations were done. The prevalence of anemia was found to be 40.3%,
Anemia and was higher among females aged 35 to less than 45 years, those with poor
Determinants of anemia income and poor nutritional level. The risk of anemia increased with the
Pregnant women gestational age, gravidity, decreased birth spacing, drinking tea and coffee
Prevalence after meals, decreased intake of proteins and low level of knowledge and
income. The binary logistic regression model indicated a significant impact
of the education and occupation on the level of knowledge of pregnant
women. Anemia was found out to be a severe public health problem among
pregnant women in Yemen. Identified risk factors should be considered for
its prevention and control.
Copyright © 2017 Institute of Advanced Engineering and Science.
All rights reserved.

Corresponding Author:
Yousef Mohammed Ali Al-Flah,
Public Health Specialist,
Alkuwait University Hospital,
Sana’a University, Sana’a, Yemen.
Email: [email protected]

1. INTRODUCTION
Anemia is a global public health problem affecting both developing and developed countries with
major consequences for human health as well as social and economic development. It occurs in all stages of
life but it is more prevalent in pregnant women and children [1]. The World Health Organization (WHO)
considered anemia to be one of the ten most important factors contributing to the global burden of
diseases [2]. The Centers for Disease Control and Prevention (CDC), estimated the worldwide prevalence of
anemia among pregnant women to be 52% in 2007. The majority of these women were living in developing
countries [3]. Globally, according to the WHO, in 2014, the prevalence of anemia among pregnant women
aged 15-49 years fell by 12% between 1995 and 2011 from 43% to 38% [4].
Anemia in pregnancy is defined as a decrease in the concentration of circulating red blood cells or in
the hemoglobin concentration (hemoglobin levels of below 11 g/dl) and a concomitant impaired capacity to
transport oxygen [2]. Anemia is a multi-factorial disorder. At least half of the global burden of anemia in
pregnancy is due to iron deficiency. Other contributing factors include nutritional deficiencies of folate,
vitamin B12 and vitamin A, chronic inflammation, parasitic infections and inherited disorders [5]. Anemia in

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pregnancy is also affected by socioeconomic conditions, lifestyles and health-seeking behaviors across
different cultures [2].
Studies have shown that anemia in pregnancy has adverse consequences that may not only affect the
pregnant but also affects the neonate and infant [6]. During pregnancy, anemia is associated with multiple
adverse outcomes for both mother and infant, including an increased risk of hemorrhage, sepsis, maternal
mortality, perinatal mortality, low birth weight [7] and reduced work capacity [8]. Forty percent of all
perinatal deaths are linked to anemia [7]. There is usually a 2 to 3 fold increase in perinatal mortality rate
when maternal hemoglobin levels fall below 8.0 g/d1 and 8-10 folds increase when maternal hemoglobin
levels fall below 5.0 g/dl [9].
The management of anemia in a pregnant woman depends on the duration of pregnancy, severity of
the anemia and complications [10]. The WHO reported that a combined treatment with iron and vitamin A
could have a greater impact on anemia treatment especially during the second trimester of pregnancy [11].
Interventions to control anemia in pregnancy include iron supplementation and iron fortification, dietary
modification, nutritional and health education, control of parasitic infections, and improvement of
sanitation [5],[12],[13].
In Yemen, anemia is one of the serious health problems among pregnant women. In 2011, the World
Bank estimated the prevalence of anemia in Yemen to be 36% among pregnant women [14]. Therefore, the
assessment of the extent of the problem and the factors responsible for it is needed. The present study aimed
to estimate the prevalence of anemia among pregnant women in Sana'a governorate, Yemen, to identify the
determinants contributing to it, and to assess knowledge regarding it.

2. METHOD
The study was carried out among pregnant women attending the outpatient clinics of four
governmental hospitals in Sana'a governorate (Alsba'aen Hospital, Alkuwait University Hospital, Althawra
General Hospital and Aljumhory Hospital) using a cross sectional design. The sample size was calculated
using Stats Direct 3.0.135, 2015. Based on prevalence of anemia of 36% among pregnant women, (14) the
minimum required sample size was calculated to be 360 pregnant women at 95% confidence interval, and 5%
acceptable absolute deviation of the sample from the population rate.
A pre-designed structured interviewing questionnaire was prepared by the researchers to collect data
from pregnant women about their sociodemographic characteristics including age, educational level,
occupation, income level, and residence. Obstetric and gynecological history was obtained (including
trimester of pregnancy, gravidity, previous births, and history of abortion). Medical history (chronic and
current diseases), dietary habits (use of vitamin and mineral supplements, consumption of enhancers and
inhibitors of iron absorption were obtained. The questionnaire also included knowledge about signs,
symptoms, complications and risk factors of anemia, iron rich foods and enhancers and inhibitors of iron
absorption. Laboratory investigations were done to assess the level of hemoglobin, hematocrit (Hct), packed
cell volume (PCV), mean corpuscular hemoglobin concentration (MCHC) and volume of the red blood cell.

MCHC = Hb (g/dl) / Hct (%) x 100

The collected data were revised, coded, and analyzed using the statistical package for social sciences
(SPSS version 21). Graphical presentations were done for visualization using Microsoft Excel. Mean (X)
with standard deviation (SD) were calculated to describe normally distributed scale data. Count and
percentage were used describing and summarizing qualitative data. A special scoring system was prepared
for assessment of dietary intake and knowledge. Chi-square (X2) was used for analysis of some categorical
data. Odds ratio was used to assess the risk of a particular outcome (or disease) if a certain factor (or
exposure) is present. Logistic regression was used to predict a dependent variable based on continuous and/or
categorical independents and to determine the effect size of the independent variables on the dependent; to
rank the relative importance of independents and to understand the impact of covariate control variables. The
Receiver Operating Characteristic (ROC) curve analysis was also used to study the diagnostic performance of
HB for diagnosis of anemia among pregnant females and discriminate anemic cases from normal cases.
The researcher sought the approval of the Ethics Committee of the High Institute of Public Health
for conducting the research and complied with the international guidelines for research ethics. An informed
written consent was taken from the study participants after explanation of the purpose and benefits of the
research. Anonymity and confidentiality were assured and maintained. There was no conflict of interest.

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3. RESULTS
The total number of pregnant women included in the study was 360 women. Their
Sociodemographic characteristics are shown in Table 1. The age of the pregnant women ranged between 15
and 45 years. The mean age was 26.55 years ± 5.713 SD. Most pregnant women (89.4%) were from urban
areas. More than three quarters of pregnant women (76.4%) were housewives. Only19.6% were students.
2.8% were employees and free workers and professionals constituted 0.6%. Only 12.2% of pregnant women
were illiterate. Those with primary education constituted 26.4%. Nearly half (48.6%) of the study population
had secondary education, while 12.8% had university and post graduate education. Pregnant women who had
enough income constituted 70.5%, compared to 21.7% who did not have enough income and borrow. Only
7.8% had enough income and saved.

Table 1. Distribution of Pregnant Women According to Socio-demographic Characteristics

Sociodemographic data (n=360) No %
Age (years)
15 - 148 41.2
25 - 169 46.9
35 – 45 43 11.9
Mean ±SD= 26.55 ±5.7 years
Residence
Urban 322 89.4
Rural 38 10.6
Occupation
Housewives 275 76.4
Students 71 19.6
Employees 10 2.8
Free workers 2 0.6
Professionals 2 0.6
Educational level
Illiterate 44 12.2
Primary 95 26.4
Secondary 175 48.6
University and post graduate 46 12.8
Income
Enough and save 28 7.8
Enough 254 70.5
Not enough and borrow 78 21.7

The study revealed that the overall prevalence of anemia among the study population was 40.3%,
where 16.6% of anemic pregnant women had mild anemia, 23.1% had moderate anemia, and only 0.6% of
them had severe anemia as shown in Figure 1. The mean Hb level among pregnant women was 11.4± 1.8
g/dl. It ranged between 4 and 17 g/dl.

40.30%
Anemic (<11g/dl) 59.70%

Figure 1. Distribution of pregnant women by their hemoglobin level

Table 2 shows that the highest prevalence of anemia (48.8%) was found among pregnant women
aged 35- 45 years, followed by those aged 25 to less than 35 years (42.6%). The difference between various
age groups in relation to anemia was not significant (p = 0.190). The prevalence of anemia increased with the
decrease in the level of income. The highest prevalence of anemia (49.9%) was among pregnant women who
had poor income. The relation between income and anemia was statistically significant (p = 0.036). The
prevalence of anemia increased with the increase in gestational age. It was 29.2% among women in the first
Prevalence and Determinants of Anemia in Pregnancy, Sana'a, Yemen (Alflah Y.)
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trimester and increased to 42.5% and 48.7% among those in second and third trimester respectively. This
increase is statistically significant (x2 = 9.356, p = 0 .009).

Table 2. Comparison Between Anemic and Non-anemic Pregnant Women in Relation to

Sociodemographic Characteristics and Gynecological History
Sociodemographic characteristics and Anemic n=145 Not anemic n=215
X2 p- value
gynecologic history No % No %
Age (years)
15 - 52 35.1% 96 64.9%
25 - 72 42.6% 97 57.4% 3.317 0.190
35 – 45 21 48.8% 22 51.2%
Income level
Enough and save 5 17.9% 23 82.1%
Enough 105 41.3% 149 58.7% 6.654 0.036
Not enough and borrow 35 44.9% 43 55.1%
Period of the current pregnancy
First trimester 33 29.2% 80 70.8%
Second trimester 57 42.5% 77 57.5% 9.356 0.009
Third trimester 55 48.7% 58 51.3%
Current pregnancy order
1- 62 32.8% 127 67.2%
3+ 83 48.5% 88 51.5% 8.573 0.003
Spacing between pregnancies (Years)
<1 38 33.0% 77 67.0%
1- 10 66.7% 5 33.3% 10.629 0.014
2- 67 46.9% 76 53.1%
3+ 30 34.5 57 65.5%

Regarding the relationship between current pregnancy order and anemia, the highest prevalence of
anemia (48.5%) was among pregnant women whose pregnancy was the third and more. (cOR = 0 .518 (0
.338, 0 .793), x2MH = 8.573, p = 0.003). The prevalence of anemia decreased with the increase in the interval
between pregnancies: The highest prevalence of anemia was among pregnant women who have had spacing
between pregnancies one year and below (X2 =10.629, p = 0.014.).
Logistic regression analysis shows that pregnant women how ate liver weekly, those who drank milk
one to six days per week and those who were in the third and second trimesters of pregnancy had a
significant impact on occurrence of anemia than the relevant categories (Table 3).

Table 3. Logistic Regression Analysis of Anemia Among Pregnant Women

95% C.I.for EXP(B)
Variable B Sig. Exp(B)
Lower Upper
Interval between pregnancies .104 .416 1.109 .864 1.424
Liver eating 1.080 .009 2.945 1.304 6.650
Milk drinking -1.260- .000 .284 .168 .478
Time of drinking tea .106 .690 1.112 .659 1.876
Current pregnancy -.549- .060 .578 .326 1.023
Time of cola drinking -.628- .157 .533 .223 1.275
Time of coffee drinking .310 .480 1.364 .577 3.223
Current pregnancy trimester -.673- .000 .510 .371 .702
Constant 4.361 .000 78.363

Regarding the knowledge of pregnant women about anemia, it appears from Figure 2 that the
prevalence of anemia among pregnant women was highest among those who had poor level of knowledge
constituted (63.2%) compared to those who had good and fair level of knowledge (Figure 2).

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80.00%
66.10% 63.20%

60.00% 54.80%
45.20% 36.80%
Anemic 33.90%
40.00%
Non anemic
20.00%

0.00%
Poor <50% (Inadequate)
Fair 50%-75% (Moderate)
Good ≥75% (Adequate)

Figure 2. Relationship between level of knowledge and anemia

The difference was statistically significant (p = 0.012). Logistic regression analysis of the factors
affecting knowledge showed that the literate and working pregnant women had a significant good knowledge
score than the relevant categories (Table 4).

Table 4. Logistic Regression Analysis of the Factors Affecting Knowledge

Among Pregnant Women (Sana'a, Yemen)
95% C.I.for EXP(B)
Variable B Sig. Exp(B)
Lower Upper
Age .287 .285 1.332 .788 2.251
Education 1.645 .000* 5.181 2.339 11.477
Income -.264- .346 .768 .443 1.330
Occupation -.219- .010* .803 .680 .948
Residence -.545- .141 .580 .281 1.198
Constant -1.450- .166 .234
Accuracy of the model was 64.4%.
*Significant (p< 0.05)

Figure 3. ROC curve analysis of probability of no anemia calculated from binary logistic model

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Figures 3 shows that the Area under the ROC curve (AUC) of Hb as a predictor of anemia among
pregnant women in Sana'a governorate in Yemen. The area under the ROC curve was significantly different
from 0.5 (null hypothesis area) and that therefore there is evidence that Hb has an ability to distinguish
between the two positive and negative groups (P (Area=0.5 was<0.000).

4. DISCUSSION
The overall prevalence of anemia in the present study was 40.3% among pregnant women attending
maternal outpatient clinics of the selected hospitals. This prevalence is consistent with the global study
results (41.8% and 38%) reported from WHO in 2008 [1] and 2014 [4] respectively. Also, the prevalence
estimated in the current study is in accordance with findings of a survey conducted in Yemen by the World
Bank in 2011 which found that 36% of pregnant women were anemic [14]. Other studies done in 2011 by the
World Bank estimated the prevalence of anemia among pregnant women to be 40% in Saudi Arabia, 38% in
Bolivia, 39% in Maldives and 44% in Afghanistan [14]. Many studies done in different countries around the
world showed that the prevalence of anemia was 41.4% in Jordan (2012) [15] 41.6% in Turkey (2015) [16]
and 39.9% in Southern Ethiopia (2015) [17].
The prevalence of anemia in the current study is lower than that reported in the WHO global
database on anemia between 1993 and 2005 in Yemen which was 58.1% among pregnant women [1]. This
might be attributed to improvement of health care services and socioeconomic state. It is lower than findings
of some developing countries which were reported by the World Bank in 2011, (Nigeria 58%, India 54% and
Pakistan 51%) [14]. The prevalence of anemia in the current study was higher than that reported by the
World Bank in 2011, in gulf and Arabian countries. It was 25% in Kuwait, 26% in United Arab Emirates,
27% in Lebanon, 27% in Jordan, 28% in Qatar, 31% in Iraq, 34% in Oman and 30% in Egypt [14]. It is much
higher than some developed countries as reported by the World Bank in 2011, such as 17% in United States,
23% in United Kingdom and 27% in Japan [14].
Anemia in pregnancy is related to different socio-demographic and behavioral factors [17]. The
causes of anemia are multi-factorial, including gestational factors and diet, infection and genetics [14]. The
current study revealed an association between prevalence of anemia and many factors as gestational age,
gravidity, child spacing, milk drinking, time of tea drinking, time of coffee drinking, time of cola drinking,
chicken eating, liver eating and level of knowledge. The relative contribution of each factor to anemia during
pregnancy varies greatly by geographical location, season, and dietary practice [18]. In the current study, the
prevalence of anemia increased with the decrease in the level of income. The highest prevalence of anemia
(49.9%) was among pregnant women who had poor income. Studies conducted in Turkey (2010 and 2015)
[9],[16], Azad Kashmir, Pakistan (2012) [19], Ethiopia (2013 and 2016) [20],[21], were consistent with the
current study and found a statistically significant association between the level of income and anemia in
pregnancy.
In the present study, the risk of developing anemia increased with the advance in pregnancy. The
risk of developing anemia among pregnant females was higher in third and second trimester when compared
with those in the first trimester. This finding is consistent with the study conducted among pregnant females
attending the primary health care centers in Makkah, Saudi Arabia (2012) [22], Additionally, studies
conducted in Turkey (2010 and 2015) [9],[16], Pakistan (2013) [23], Ethiopia (2015) [17], found that the
increase in gestational age is significantly associated with the risk of developing anemia. This could be due to
the fact that when the gestational age increases the mother becomes weak and the iron in the blood is shared
with the fetus in the womb therefore decreasing the iron binding capacity of the mother’s blood [18].
In the present study, multigravidity was significantly associated with anemia (p= 0.003). The risk of
developing anemia in pregnant women who had three and more pregnancies is increased when compared
with those who had less than 3 pregnancies. This finding is consistent with studies conducted in Saudi Arabia
(2012) [22] and Eastern Ethiopia (2014) [18]. This could be attributed to loss of iron and other nutrients as
result of repeated pregnancies [18]. Higher gravidity was documented in a number of studies as a cause of
anemia in pregnancy, as studies done in Jordan (2012) [15], Malaysia (2012) [24], Pakistan (2013) [23] and
Ethiopia (2015) [17]. This is because of reducing maternal iron reserves at every pregnancy and blood loss at
each delivery [22].
Child spacing was also found to be significantly associated with the occurrence of anemia in the
current study (p= 0.014). Other studies done in Saudi Arabia (2012) [22], and Ethiopia (2012) [25], revealed
similar findings. It could be noticed that the prevalence of anemia decreased with the increase in spacing
between pregnancies. These findings are consistent with the results of the current study and could be
explained by the fact that short intervals between births may not provide women with enough time to
replenish lost nutrient stores before another reproductive cycle begins. Another explanation is that child
spacing minimizes bleeding during delivery and enhances iron reserve in the body [25]. Results of the

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IJPHS ISSN: 2252-8806  219

present study showed that awareness had a very significant effect on the occurrence of anemia among
pregnant women. Anemic pregnant women who had poor level of knowledge constituted 63.2%. The
prevalence of anemia among pregnant women increased with the decrease in knowledge level. This finding is
consistent with study done in Sudan (2014) [26].
In the current study, logistic regression analysis of the factors affecting knowledge showed that
education and occupation (literacy and work) were significantly associated with knowledge of the pregnant
women. This finding is consistent with findings of previous studies done in India (2014) [27]. Results of the
present study showed that the area under the ROC curve of Hb as a predictor of anemia among pregnant
women was the highest of all various red cell indices. Other studies were in agreement and found that the
ROC for Hb give the maximum area under its curve and can predict iron deficiency anemia in the second and
third trimester with a high sensitivity and specificity [28],[29].

5. CONCLUSION
Anemia is a global public health problem affecting both developing and developed countries with
major consequences for human health as well as social and economic development. Anemia was found out to
be a severe public health problem in Yemen. Identified risk factors should be considered for prevention and
control of anemia among pregnant women.

ACKNOWLEDGEMENTS
The authors would like to thank all the study participants for their cooperation.

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