Abstract

Anemia has been identified as a serious public health problem in both developed and
developing countries, affecting around 2 billion people and accounting for three-quarters of a
million fatalities per year in Africa and Southeast Asia. Anemia in pregnancy is common,
according to research from around the world. The purpose of this study was to determine the
level of awareness, causes, and prevention of anemia in pregnancy among pregnant mothers
attending Asogbon PHC Bariga in Lagos State, Nigeria. A well-structured questionnaire was
used for data collection. The respondents were given a questionnaire. One hundred and nine
( 109) questionnaires were distributed, collected, and analyzed by respondents. The study's
data was examined and processed with the Statistical Package for Social Science (SPSS)
V21. To assess participant characteristics and offer responses to the study's research
questions, descriptive analysis, frequency, average, and percentage were employed. The study
discovered that knowledge about anemia signs, vulnerability, food, and prenatal visits was
good, but information about causes and perceived effects of anemia was inadequate.
According to the findings, the most common known cause of the condition is a poor diet,
followed by malaria, worm infestations, and other factors. Despite widespread recognition
that poor diet is the leading cause of anemia in pregnancy, there is little information about
food sources that can assist in combating the disease. Also, less than half of those who
profess knowledge of anemia-fighting foods eat them throughout pregnancy.
The study found that the pregnant women were of reproductive age and had
completed secondary and higher secondary school. The study revealed that while there
was good awareness and prevention of anemia in pregnancy, To obtain a better feto-maternal
outcome
in pregnancy, there is a need to raise awareness about anemia in pregnancy and implement
effective health education programs on anemia prevention.

Table of Contents

Chapter 1: Introduction
1. 1 Background and Rationale
1.2 Problem Statement
1.3 Research Questions
1.4 Objectives of the Study
1 . 5 Significance of the Study
1.6 Scope and Limitations
1 . 7 Organization of the Thesis

Chapter 2: Literature Review

2. 1 Overview of Hypertension
2 . 2 Theoretical Framework
2.3 Conceptual Model
2.4 Lifestyle Modification in Hypertension Management
2.5Educational Interventions for Lifestyle Modification
2 . 6 Summary of Key Findings
Chapter 3: Methodology
3.1 Research Design
3.2 Study Setting and Participants
3.3 Sampling Technique
3.4 Data Collection Methods
3.5 Intervention Protocol
3.6 Outcome Measures
3.7 Data Analysis Plan
3 . 8 Ethical Considerations

Chapter 4 : Results
4 . 1 Participant Characteristics
4.2 Baseline Assessment of Knowledge and Practices
4.3 Description of the Educational Intervention
4.4 Post-Intervention Assessment of Knowledge and Practices
4.5 Analysis of Clinical Outcomes
4.6 Qualitative Insights on Behavioral Changes
4 . 7 Summary of Findings

Chapter 5: Discussion
5. 1 Interpretation of Findings
5.2 Comparison with Existing Literature
5 . 3 Theoretical Implications
5.4 Practical Implications
5.5 Strengths and Limitations of the Study
5.6 Recommendations for Future Research
5.7 Conclusion

Chapter ONE
1. 1 Background of the study
Anemia is recognized as a sign of both inadequate nutrition and poor health. It is harmful to
women's health and well-being and increases the chance of adverse maternal and neonatal
impacts (Teshome et al., 2020). Anemia is responsible for a variety of complications in pregnant
women. Anemia is a global public health issue that affects people of all ages, with
pregnant women bearing the brunt of the burden (Zekarias et al., 2017). It covers up to 20% of
all maternal deaths. Pregnancy anemia also causes low birth weight, fetal damage, premature
deliveries, and infant losses ( Zekarias et al. , 2 0 1 7 ) . Anemia is the leading cause of maternal
death (Ayano and Amentie, 2017).
Iron deficiency anaemia (IDA) is the most frequent nutritional deficit in pregnancy. The World
Health Organization (WHO) defines anaemia as "haemoglobin less than 11 gm/dl and a
haematocrit less than 0.33." Most women begin their pregnancy with partially or completely
reduced iron levels. Thus, the severity of anaemia is inversely related to the amount of iron
stores ( Nimbalkar et al. , 2 0 1 7 ) . Anaemia is a global public health issue that affects both poor
and developed countries, with serious ramifications for human health. Anaemia during
pregnancy and lactation has a negative impact on maternal and child health. According to the
WHO, the prevalence of anaemia among pregnant women is 14% in industrialized nations and
51% in underdeveloped countries (Nimbalkar et al., 2020).
Anemia during pregnancy is defined as a hemoglobin concentration of less than 11 g/dL. It is the
most prevalent hematologic condition that impairs the normal functioning of the organ system by
reducing the amount of oxygen that reaches different tissues and organs via blood circulation
( Liyew et al. , 2 0 2 1 ) . Although anemia can develop in any human population, pregnant women
and small children are the most common victims of this hematologic disorder.
Anemia during pregnancy causes major maternal and fetal problems and can even result in
maternal death. Anemia is responsible for 20% of all maternal mortality, according to research
(Deficiencies, 2017). Anemia during pregnancy is caused mostly by nutritional deficiencies (iron,
vitamin B12, folate), parasitic diseases (hookworm, malaria, and so on) and acute blood loss
(Getahun et al., 2017).
Anemia in pregnant women must be addressed seriously by health care workers, particularly at
the primary care level, due to the potential health consequences for mothers and babies,
despite the fact that appropriate iron treatment is freely available at all levels of health care
facilities (Margwe, 2017). Pregnant women are more vulnerable, and healthcare providers must
emphasize teaching pregnant women appropriate long-term eating habits as part of a health
promotion strategy (Alswailem et al., 2018). Anemia education and attitude in pregnant women
are significantly lower, which can be a major cause of pregnancy-related issues. So, proper
awareness and educational programs regarding diet and lifestyle pattern during pregnancy can
reduce the prevalence rate of anemia.
In the previous studies, wealth index (Nankinga and Aguta, 2019) maternal education (Hailu et
al., 2019) maternal age, parity (Ali et al., 2019), place of residence (Hailu et al., 2019, Ali et al.,
2019), maternal occupation (Hailu et al., 2019), history of terminated pregnancy (Berhe et al.,
2019), iron intake during pregnancy (Ali et al., 2019), unimproved source of water and
marital status (Hakizimana et al., 2019) were factors associated with anemia during pregnancy.
Despite the fact that anemia has been acknowledged as a global public health problem for
numerous years, no rapid progress has been recorded, and the disease's incidence remains
high globally (Ghislain and Manfred, 2012). Maternal knowledge of anemia is crucial because it
has the ability to motivate women to take iron supplements during pregnancy and after
childbirth, affecting both the mother's and the child's iron status. Furthermore, despite the
national health
strategy of frequent iron supplementation and intermittent preventive malaria therapy with
anti-malarial medications, maternal anemia remains a common cause of morbidity and mortality.
Despite the fact that anemia has been recognised as a global public health problem for several
years, no significant progress has been made, and the disease's prevalence remains high
globally (Ghislain, 2012). Despite efforts to treat and prevent maternal anemia, many pregnant
women continue to suffer from anemia-related health issues, and the contributing causes to the
persistence of high occurrences remain unknown (Margwae, 2015). The reduction and control
of anemia prevalence among women remains a public health priority (Margwae, 2015).
Despite the high incidence of anemia as a cause of maternal mortality in Nigeria, relatively few
initiatives currently address anemia as a key safe motherhood concern in Nigeria. Currently,
only around 58% of pregnant Nigerian women obtain iron supplements during pregnancy.
The study thus attempted to investigate the level of awareness, as well as the cause and
prevention of anemia in pregnancy, among expectant mothers attending a clinic in Asogbon
PHC, Bariga, and Lagos State, Nigeria.

1.2. Statement of Problem

In Nigeria, the prevalence of anaemia among pregnant women is 55.1%. If the prevalence of
anaemia among pregnant women is 40.0% or more, it is considered as a severe public health
problem . The population groups most vulnerable to anaemia include pregnant women and
postpartum women. (Global Health Metrics 2019).
Anaemia is estimated to affect half a billion women 1 5 – 4 9 years of age and 2 6 9 million children
6–59 months of age worldwide. In 2019, 30% (539 million) of non-pregnant women and 37% (32
million) of pregnant women aged 1 5 – 4 9 years were affected by anaemia.
The WHO Regions of Africa and South-East Asia are most affected with an estimated 106
million women and 103 million children affected by anaemia in Africa and 244 million women
and 83 million children affected in South- East Asia( global Health Metrics 2019). From
this information it can be estimated that the high prevalence of anaemia among pregnant
women in Nigeria is considered to be the main factor for maternal death(WHO 2017).
Anaemia during pregnancy is also a major risk factor for low birth weight, preterm birth and
intrauterine growth restriction (WHO 2017). Deficiency in folic acid during pregnancy can result
in serious neural tube defect, heart defects and cleft lips ( WHO 2 0 1 9 ) , limb defects, and urinary
tract anomalies.
Pregnant women attending antenatal clinics in Nigeria are routinely put on iron supplementation
throughout their pregnancy. However, the prevalence of anaemia among pregnant women is still
high. Moreover the available data concerning prevalence and specific ethologic factors of
anaemia during pregnancy in Nigeria are limited.

1.3. Objective of the Study

The general objective of the study is the knowledge on cause and prevention of anaemia among
pregnant women attending antenatal clinic, the specific objectives are as follows:
i.To examine the causes of anaemia among pregnant women attending antenatal clinic.
ii.To evaluate if pregnant women attending antenatal clinic have a knowledge on the prevention
of anaemia.
iii.To find out the effect of anaemia on pregnant women attending antenatal clinic.
iv.To evaluate the preventive measures pregnant women can adhere to so as not to contract
anaemia.

1 . 4 Relevant Research Questions

1.What are the causes of anaemia among pregnant women attending antenatal clinic?
2. Do pregnant women attending antenatal clinic have a knowledge on the prevention of
anaemia?
3.What are the the effect of anaemia on pregnant women attending antenatal clinic?
4. what are the preventive measures pregnant women can adhere to so as not to contract
anaemia?
1.5. Relevant Research Hypothesis
1. There is no significant correlation between awareness and practice of anemia prevention
among antenatal women in Hospital Universiti Sains Malaysia
2. There is a significant correlation between awareness and practice of anemia
prevention among antenatal women in Hospital Universiti Sains Malaysia
3. There is no significant association between selected demographic variables (age, ethnicity,
educational status, occupational status, household income) and practice of anemia prevention
among antenatal women in Hospital Universiti Sains Malaysia
4.There is a significant association between selected demographic variables (age, ethnicity,
educational status, occupational status, household income) and practice of anemia prevention
among antenatal women in Hospital Universiti Sains Malaysia

1.6. Significance of the Study

Anemia is one of the most frequent complications related to pregnancy. Severe anemia may
develop a risk for the baby as an infant. People with anaemia are more likely to give birth
prematurely or with a low-weight baby. Anemia makes it more difficult to fight infection since it
raises the danger of blood loss during birth (Geng C., 2021).
Anemia in pregnant women is still a serious and difficult health problem in Malaysia. We know
the causes of anaemia and how to treat it, thus efforts should be focused on improving the
implementation of early oral iron and vitamin prophylaxis, early anaemia
diagnosis, and boosting women's low compliance with prophylactic programmes (Milman,
2015).
This study determined the level of awareness and practice of anemia prevention among
antenatal women in Hospital Universiti Sains Malaysia. This topic is crucial since anemia in
pregnancy can give a bad impact to the mother and baby and also increase the
rate of morbidity and mortality among women. This study can be benefit because the finding
from this research can contribute updated of awareness and prevention of anemia in pregnancy.
On the other hand, this study’s finding can be used as a baseline and
references for future research.

1.7 Scope of the Study

The study will be to ascertain the level of awareness and prevention of anaemia in pregnancy
among pregnant women with special reference to Ibesikpo-Asutan LGA. Apart from the main
objectives, the study seek to find out factors affecting the development of anaemia e.g factors
like spouse’s demographic characteristics, Ante-natal care visit and taking of IFAS, awareness
on consequences, dietary habits and life style, food consumption based on 24 hours re-call,
health conditions and anthropometric measurements.

1 . 8 Operational definition of Terms

The terms used in this research thesis is referring to the definition below:
1. Awareness
Awareness refers to the state or level of consciousness and knowledge or perception of
a situation or fact (Oxford Learner’s Dictionary, 2021). This study refers to antenatal
mother’s awareness in anemia in pregnancy.
2. Prevention
Prevention means an action that taken to decrease the chance of getting a disease or condition
( Merriam- Webster, 2021). In this study, it refers to the prevention that pregnant women take
from getting the anemia.
3. Anemia
According to World Health Organization, anemia occurs when the quantity of red blood cells or
the concentration of haemoglobin within them is lower than usual. Haemoglobin is required to
transport oxygen, and if there are a few malformed red blood cells or not
enough haemoglobin, the blood's capacity to transport oxygen to the body's tissues will be
reduced (WHO, 2021 )
4. Antenatal Women
Pregnant women undergo a time of physical and physiological preparation for birth
and parenthood, including prenatal health care during their pregnancy (Lowdermilk, 2013).
In this study, antenatal women from antenatal ward and Obstetrics and Gynecology Clinic
in Hospital Universiti Sains Malaysia aged more than 19 years old were selected as the
respondents.

Chapter Two: Literature Review

2.1. Preamble
This chapter reviews the current literature related on awareness and prevention among
antenatal women in Hospital Universiti Sains Malaysia by credited scholars and researchers.
This chapter provides information about anemia in pregnancy, including its definitions, types,
complications, prevention and treatment of anemia in pregnancy. It also provides an overview of
the epidemiology and global impact of anemia in pregnancy respectively. Finally, this chapter
also detailed the conceptual framework chosen for the
study.

2 . 2 . Conceptual Literature Review

According to the World Health Organization, anemia occurs when the number of healthy red
blood cells or hemoglobin level and thus their oxygen-carrying capacity is insufficient to meet
the body's physiologic needs (WHO, 2021). The hemoglobin concentrations mention by WHO
are 12.0 g/dL in women of reproductive age, 11.0 g/dL in pregnant women in the first and third
trimesters, and 10.5 g/dL in the second trimester (Milman, 2015). Iron deficiency anemia is
linked to poor reproductive outcomes in pregnant women, including preterm birth,
low-birth-weight newborns, and lower iron storage in neonates, which can contribute to
developmental delays. Failure to address anemia could affect the health and quality of life of
millions of mothers, as well as their children's development and learning (WHO, 2021).
There are several causes of anemia in pregnancy which is iron deficiency anemia,
folate deficiency anemia and vitamin B12 deficiency (Web MD, 2021). i.Iron deficiency
anemia occur when the body does not have enough iron to produce adequate amount
of hemoglobin. Therefore, causes the blood not to carry enough oxygen to tissue throughout
the
body. Usually, ferrous sulfate 325 mg orally once a day was given to pregnant mothers to treat
iron deficiency.
ii.Then, folate deficiency anemia means that pregnant mother does not get enough folates from
their diet. Folate deficiency occur in 0.5 to 1.5 percent of pregnant women (Friel, 2021). During
pregnancy, women need extra folates to produce new cells, including healthy red blood cells.
Folate are vitamin found naturally in certain foods such as green leafy vegetables. Manmade
folate supplements are folic acid, which is 1 mg twice daily. Folate deficiency has been linked to
neural tube anomalies which is spina bifida and low birth weight, among other birth problems.
iii.vitamin B12 deficiency
Vitamin B12 is needed to form a healthy red blood cell. Pregnant mothers can prevent vitamin
B12 deficiency by eating meat, poultry, dairy products and eggs (Web MD, 2021).
Anemia is a condition that almost all pregnant women experience. That is because they need
more iron and folic acid than usual. But the risk is higher when pregnant women with two
pregnancies close together, pregnant with multiples, which means more than one child, vomit a
lot because of morning sickness and pregnancy at a teenage age.
Furthermore, the symptoms of anemia during pregnancy are feeling tired or weak, shortness of
breath, pale skin, lips and nails and rapid heartbeat. For the early stage of anemia, there are no
obvious symptoms. Not all the symptoms might be anemic as long as pregnant mother get
routine blood tests during prenatal appointments ( Web MD, 2 0 2 1 ) .

2.3. Empirical Review of Previous Study

Awareness of Anemia in Pregnancy
Regarding the awareness of anemia, among 244 respondents, only 44.3 percent of the women
are aware of anemia while 55.7 percent has poor comprehensive awareness of anemia
(Tadesse B, et al., 2017). Then, the study on knowledge, attitude and practices of prevention in
pregnancy among pregnant women in the Antenatal Clinic at Ifako-Ijaiye General Hospital,
Lagos, Nigeria conforms to the present study in their finding of a majority which is 95 percent of
respondents being aware of anemia in pregnancy (Yesufu et al., 2013). Furthermore, in the
study by Naresh & Shantini (2016), among 316 pregnant women, only 39.87 percent of the
participants were of aware and understood anemia.
A study about awareness of anaemia during pregnancy among pregnant women attending a
health facility in District Srinagar shows that among 110 participants, 32 percent were aware of
the anemia symptoms. In contrast, 69 percent were not aware of it (Nelofar, 2018).
Most women were aware that iron was included in their diet and that it was important for their
health. Women with children and those from the working group knew
more about iron deficiency anemia. Iron deficiency anemia awareness is strongly tied to a
community's educational and social status, and it has been observed to increase over time due
to increased exploration and access to media and health care facilities. Compared to older
women, younger women are more concerned about their health and are more
cautious about the dietary needs of their unborn children ( Hussain & Shu, 2 0 1 0 ) .
In a study conducted in a general hospital in Lagos, although the majority of the respondents
which is 95 percent were aware of anemia in pregnancy, the average knowledge score was only
56.5 percent. Less than half of 46.3 percent of the respondents thought that contraceptives
could help prevent anemia in pregnancy by reducing closely spaced pregnancies (Yesufu et al.,
2013).
Anemia awareness is often poor among pregnant women accessing antenatal care services at
South Ethiopia, as pregnant women have less than average awareness about anemia. For
example, uneducated, unemployed pregnant women with only one antenatal
care visit had a low awareness of anemia. Women of childbearing age, and pregnant women in
particular, should be educated about the dangers of anemia during pregnancy (Tadesse et al.,
2017). Although the majority of women recognize the importance of iron
supplements in their diet, there are still some who do not see any benefits from taking them,
which could be due to their high cost, a lack of education and counselling provided by
community elders and health practitioners, or a combination of these factors (Hussain & Shu,
2010).

2.4. Theoretical and Conceptual Framework of Study

The Health Belief Model (HBM) connects concepts, empirical data, and relevant theories to
improve and systematize knowledge about linked concepts or concerns. It is crucial role in
locating the research and illustrating it with a figure. It establishes significant knowledge bases
that lay the foundation for the importance of problem formulation and research topics (Rocco &
Plakhotnik, 2009). The HBM was adopted in
this study to explore the health behaviors among antenatal women based on their
understanding and health-related action toward anemia.

Figure 2. 1 Health Belief Model adapted from Glanz, Rimer & Lewis (2002)
In the 1950s, public health researchers in the United States began constructing psychological
models to improve the efficacy of health education programs.
Demographic factors such as socioeconomic level, gender, ethnicity, and age have long been
linked to preventative health-related behavior patterns such as patterns of behavior that predict
disparities in morbidity and death, and differential health-care utilization
( Rosenstock, 1974). Furthermore, it is the most commonly used in health education and health
promotion (Glanz, Rimer, & Lewis, 2002). In HBM, four constructs are included, which are
perceived severity, perceived susceptibility, perceived benefits and perceived barriers.
Perceived susceptibility is a belief about getting a disease or condition. It causes the adoption of
prescribed health behaviors. The greater the risk to be perceived, the higher the chance
of behavior change. In perceived severity, people believe about the
seriousness of the condition, or leaving it untreated and its consequences. Next, perceived
benefits are a belief about the potential positive aspects of health action. Perceived benefits can
help to lessen the threat that a health behavior poses. For the perceived
barriers, people believe about the potential negative aspects of particular health
action. Perceived barriers impede health behaviours. Benefits minus barriers support health
behaviour change (Abraham & Sheeran, 2014).
Figure 2.2 shows the adapted Theory of Health Belief Model within this study.
This conceptual framework explained the readiness of antenatal women to change health
related beliefs through obtaining awareness and participation in antenatal care and prevention
programs regarding anemia.

Figure 2.2 The adopted theory of Health Belief Model (HBM)

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