CHAPTER ONE

INTRODUCTION

1.1       Background of the study

Pregnancy is almost certainly the greatest physiological stress and the most common major change of the normal biological process to which the woman is subjected during her life. Anemia is the most common nutritional problem among women and is on the wholerampant among pregnant women (Admad, Saeid, & Leila, 2008).However, anaemia is defined as a shortened amount of haemoglobin (Hb) in the blood. It is a shortage in the size or number of red blood cells (RBCs) or the quantity of Hb they contain (Mahan, Escott-Stump & Raymond 2012). Haemoglobin is a substance in the blood that carries oxygen from the lungs to all parts of the body. The most common type of anaemia, iron deficiency anaemia, is more often than not caused by low iron intake or absorption and/or excessive iron loss (Thomas & Bishop, 2007).

Iron forms an indispensableconstituent of the Hb molecule and nutritional anaemiafallout fromnot enough intake of iron, protein, vitamin B12, folic acid, pyridoxine, ascorbic acid, and copper(Mahan, Escott-Stump & Raymond, 2012).Anaemia is classified based on Hb content as hypochromic (pale colour from deficiency of Hb) and normochromic (normal colour),depicted according to cell size as macrocytic (larger than normal), normocytic (normal), and microcytic (small).Haemoglobin levels differ with age, sex, pregnancy, and lifestyle. Different levels of Hb are considered typically for different categories of people, under which an individual can be classified as anaemic. For example, the normal Hb level of pregnant women at sea level is 11g/dl or 110g/L. A pregnant woman that hasHb level below 11g/dl or 110g/L is said to be anaemic (WHO, 2008).

According to Ghana Health Service (2004), pregnant woman with anaemia will present with any of the following: angular stomatitis, pallor, glossitis spoon shaped nails, dizziness, fatigue and shortness of breath.Reducing this anaemia burden in pregnant women has improved minimally, especially in African countries and Nigeria is no exemption.The episode of anemia as a major public health problem all over the world isextensively recognized. In developing countries, the occurrence of anemia among pregnant women the averages is 56%, ranging between 35-100% among different regions of the world (GHS Annual Report 2004).

World Health Organization in 2008 estimation, approximately 500 million women in the world are iron deficient and in addition anemia affects so many women in the developing world, including two thirds of pregnant women (WHO, 2008).Anaemia is asignificant public health problem worldwide and the most susceptible group, are pregnant women and children.The causes of anaemiaconsist of genetic factors, nutritional deficiencies, and infectious agents. Of the nutritional causes of anaemia, iron deficiency is perhaps the most common and important because the physiological changes associated with pregnancy put fortha demand for additional iron needed for transfer to the foetus(Webster-Gandy, Madden&Holdsworth, 2012). Infections, together with malaria, worm infestations are as well involved in the pathogenesis of anaemia in pregnancy.

Pregnant women are on the wholevulnerable to malaria in endemic populations and often have higher prevalence as well as severity including anaemia (Amenger-Glover, Owusu&Akanmori, 2005). The changes in the immune system linkedwith pregnancy have been postulated as the reason mentioned above. Worm infestations however impair micronutrient absorption;consequently increasing the susceptibility of pregnant women to anaemia. The materialization of HIV is an additional risk factor for anaemia among pregnant women. A good number of studies aimed at identifying the causes ofanaemia in pregnancy have concentrated on specific categories of factors such as excessive blood loss and excessive breakdown of erythrocytes (Amenger-Glover, Owusu&Akanmori, 2005).Globally, anemia contributes to 20% of all maternal deaths. Although not always shown to have a causal link, severe anemia contributes to maternal morbidity and mortality. Anemia in pregnancy may moreover lead to premature births, low birth weight, fetal impairment and infant deaths. Besides, maternity-related complications, anemia has major consequences on human health and social and economic development. It adversely affects physical and cognitive development in children and is associated with increased frailty risk in community-dwelling older adults (WHO, 2008).

In recent times, increased risk of psychiatric disorders among children and adolescents with iron deficiency anemia has also been documented. Anaemiaarrays from mild, moderate to severe and WHOhangers the haemoglobin level for each of these types of anaemia in pregnancy at 10.0 – 10.9g/d1 (mild anaemia) 7 – 9.9g/dl (moderate anemia) and < 7g/dl (severe anaemia).Commonness of anaemia can be as high as 61% in developing countries; 14 with a high incidence and severity occurring among primigravidaeliving in malaria endemic areas. In pregnancy, anaemia has animportant impact on the health of the foetus as well as that of the mother. Twenty percent (20%) of maternal deaths in Africa have been attributed to anaemiaand over half of all women in the world experience anemia during their pregnancies.Foetuses are susceptible of preterm deliveries, low birth weights, morbidity and perinatal mortality due to the impairment of oxygen delivery to placenta and foetus(Amenger-Glover et al, 2005).

In Sub-Saharan Africa, the causes of anemia during pregnancy are multifactorial. These consist of an iron and folate deficient diet and infections such as malaria, hookworms, and increasingly human immunodeficiency virus. Most of these conditions can be prevented by creating awareness and providing affordable interventions.Determination of the magnitude of anemia among pregnant women helps to monitor health of the pregnant women, contributing to reduction in maternal morbidity and mortality. Also, assessment of factors predisposing to anemia in a local area enables to take targeted intervention activities. The management and control of anaemia in pregnancy is improved by the availability of local prevalence statistics, which is conversely not adequately provided in Nigeria. For that reason, this study aims at providing occurrence statistics of anaemia in pregnancy and to evaluate the effectiveness of antenatal care and awareness level in preventing anaemia among pregnant women in IbesikpoAsutan. Knowledge of the relative importance of the diverse etiological factors forms the basis for intervention strategies to control anemia. Therefore, this study also aimed at determining anemia and assessing associated risk factors among pregnant women attending antenatal care (ANC) at Primary Health Center NungUdoe.

1.2       Theoretical framework

In effect social cognitive models propose that determinants that shape human behavior are imparted through socialization and may be disposed, vulnerable and susceptible to change. While appraising the literature, two theories were found to offer a strong theoretical framework for this research namely: the social cognitive theory (SCT) and the Health Belief Model (HBM).

1.2.1    Social cognitive theory

The Social Cognitive Theory stems from the Social Learning Theory and was suggested by Alfred Bandura in 1986. The pregnant women knowledge, attitude, beliefs, care and control, role model, willingness to change, were identified as malleable factors in order to influence the dietary habits, and adherence to Iron Folic-Acid (IFA) supplements. The design of the intervention is guided by the Social Cognitive Theory (SCT). According to the SCT, at least two principal sources of self-efficacy; verbal persuasion and performance accomplishment are intended to mediate the effect of this intervention. The education of pregnant women about anemia, nutrition, and Iron Folic-Acid (IFA) supplementationcould foster the perception that their actions can control anemia in them (Bandura, 1989).

1.2.2    Health Belief Model

Health Belief Model was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels. The model uses constructs that represent perceived threats and net benefits such as perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy. The model asserts that these constructs account for aperson’s “readiness to act” (Rosenstock, 1988). The most important role is figured in teaching and providing pregnant women with information needed based on social and psychological behavioral changes to maintain health during pregnancy mainly those related to nutritional aspects.  Using health belief model during health education session nurses emphasize on behavioral changes to assist pregnant women to change their eating habits and practices that contribute to nutritional deficit(Bandura, 1989).

1.3       Statement of the problem

This study was to determine awareness level on knowledge regarding anaemiaand its prevention among pregnant women attending Antenatal Clinic at Primary Health Center NungUdoe inIbesikpoAsutan.However, anaemia is the foremost cause of maternal mortality since it is very common among pregnant women.It is well thought-out to be high in countries with prevalence greater than 40% (WHO, 2008).In lots of African countries including Nigeria, chronic protein energy malnutrition,and poor weight gain during pregnancy, anaemia, and other hidden hunger deficiencies are common among women (Huffman, Harvey, Martin, Piwoz, Ndure, Combest, Mwadime& Quinn, 2001). Despite this, few studies have assessed the possible causes of anaemia among pregnant women in Nigeria. In order to reduce this trend, it is necessary to determine possible causes of anaemia, especially due to nutrition, inIbesikpoAsutan Local Government Area of AkwaIbom State.Iron deficiency is the most frequent nutritional disorder in the world. It occurs when the amount of iron absorbed in the body is inadequate to meet its necessities, and if lingering, results in iron deficiency anaemia (IDA). It is anticipated that about1.3 billion people suffer from anaemia, of which most is due to iron deficiency. Iron deficiency anaemia is amajor cause of morbidity and mortality. This situation persists although the interventions necessary for prevention and treatment are available, effective and inexpensive (Bhanushali, Shirode, Joshi, and Kadam, 2011)

1.4       Purpose of the study

The general purpose of the study is to determine the level of awareness on the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State.

Specifically, the study will:

    Establish the influence of educational qualification of pregnant women on prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State.

    Determine the influence of age of pregnant women on the prevention of anaemia among pregnant women in IbesikpoAsutan

    Find out the influence of nutritional status of pregnant women on the prevention of anaemia among pregnant women in ibesikpoAsutan Local Government Area of AkwaIbom State.

    Identify the influence of the attitude of pregnant women on the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State.

    Determine the influence of economic status of pregnant women on the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State.

1.5       Research questions

The following research questions were formulated to guide the study:

    To what extent does the educational qualification of pregnant women influence the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State?

    Would age of pregnant women influence the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State?

    To what extent does the nutritional status of pregnant women influence the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State?

    Would attitude of pregnant women influence the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State?

    To what extent does the economic status of pregnant women influence the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State?

1.6       Statement of hypotheses

To guide the researcher, the following research hypotheses were formulated:

    Educational qualification of pregnant women would not have any significant influence on the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State.

    Nutritional status of pregnant women would not have any significant influence on the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State.

    Attitude of pregnant women would not have any significant influence on the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State.

1.7  Significance of study

Although many scholars have written on the prevalence of anaemia in Nigeria, it is significant to note however that micronutrient deficiencies lead to anaemia in pregnancy. Therefore this study is basically for pregnant women, expectant mothers and women who are ready for marriage. Hence the study hopefully is significant to the extent that the above specify persons should be able; to know what causes anaemia, to understand the important, benefits of enough nutrients and enhanced their nutrition, to understand the efficacy of micronutrients,to know some other factors that could lead to anaemia in pregnancy, such as poor weight gain and to understand the double jeopardy of anaemic condition at the end of the study.

The health workers will make use of this study in updating their knowledge about anaemia in pregnancy, so as to be able to make proper assessment, diagnosis, planning and implementation of modalities geared towards competent management of cases in order to reduce the incidence of anaemia among pregnant women.Findings from this study will hopefully be useful in providing appropriate preventive measures to reduce the maternal mortality of which anaemia is one of the leading causes.It is believed that the proposition from this study will help the pregnant women have more knowledge on what anaemia is all about.As a final point, it possibly would serve as a work of reference to future researchers in that area.

1.8       Assumptions of the study

The study assumes that:

    The pregnant women have some knowledge regarding Anaemia and its prevention.

    The result of the study will help to prevent the Anaemia among the pregnant women.

  1.9       Scope of the study

The study is delimited to the pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State. The major concentration of our consideration is the question of what causes anaemia in pregnancy. To do this effectively, a critical appraisal of the various variables supporting the research work will be done pointing out their contributions to the cause of anaemia in pregnancy. Since this research is aimed at determining the level of awareness on the prevention of anaemia among pregnant women in IbesikpoAsutan Local Government Area of AkwaIbom State, thoughtfulness will be paid to the several preventive measures against the occurrence of anaemia in pregnancy.

    1.10  Limitations of the study

            The challenges that posed a threat to this study include the following; fund to be able to assess materials even online and equally type the work, collections and retrieval of documents from health centers archives, and even those of hospitals and attitudes turned to be huge obstacles and time constraints due to other academic pressure. However efforts were made to address these problems or limitations.

1.11     Definitions of terms

Knowledge:Refers to the perceptive of Antenatal mothers regarding causes and symptoms of Anaemia and its prevention.

Anaemia:Anaemia is the condition in which haemoglobin concentration in the blood is less than 10 gm/dl.

Prevention:In this study, prevention refers to all the actions taken to diminish the risk factors of Anaemia and hinder the chances of occurrence of Anaemia.

Pregnant women:Are the women between the period of conception and delivery of baby, who are attending the Antenatal clinic at Primary Health Centre NungUdoe in IbesikpoAsutan

Educational qualifications:are thecertificates, professional titles that an individual has acquired either by studying full-time, part-time study or private study, whether by educational authorities, distinctive examining bodies or qualified bodies.

Age:is the specific period of life at which a person becomes naturally or conventionally qualified or disqualified for anything.

Nutritional status: the condition of the body in those respects influenced by the diet; the levels of nutrients in the body and the ability of those levels to maintain normal metabolic integrity.

Attitude: is feeling or thinking that affects the behavior of a person, a predisposition or a tendency to react positively or deleteriously to a particular idea, object, person, or situation, a mental position with regard to a fact or state.

Economic Status: is an economic and sociological shared complete measure of work experience of a person and of its economic and social situation of the family compared to others, depending on income, education, and occupation of or a person.

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