The magnitude and associated factors of immediate postpartum anemia among women who gave birth in east Gojjam zone hospitals, northwest- Ethiopia, 2020

Background Globally around half a million maternal death occurred annually related to labor and delivery of which twenty percent is contributed by post-partum anemia. Postpartum anemia contributes about two percent of total maternal mortality in Ethiopia. Immediate postpartum anemia is a common public health problem in most parts of the globe, being frequent in low and middle-income countries including in the developed world. The previous studies cut off point for immediate postpartum Anemia is 11mg/dl which is the cutoff point of anemia after one week of postpartum, environmental factors like barefoot were not addressed in the previous studies and the previous studies were conducted in a single facility This study aimed to assess the magnitude and associated factors of immediate post-partum anemia among women who gave birth in East Gojjam zone hospitals, Northwest Ethiopia. Methods Institutional based cross-sectional study was conducted from October 20-November 20 2020 on immediate post-partum anemia. During the study 467 study participants were included by using systematic random sampling method Data were collected using a structured interviewer-administered questionnaire and a blood sample was used for hemoglobin determination. Data were checked, coded, and entered into Epi-Data Version 4.2 and then exported to SPSS version 25 for analysis. Binary logistic regressions were done to identify predictors of immediate post-partum anemia and a 95% confidence interval of odds ratio at a p-value less than was taken as a significance level. Results The overall magnitude of immediate postpartum anemia among mothers who gave birth in East Gojjam Zone Hospitals were found to be 21.63% (95% CI:18.12%, 25.11%), not having antenatal care follow-up (Adjusted Odds Ratio (AOR) = 2.92;95% CI:1.20,7.06), assisted instrumental delivery (AOR = 2.72; 95% CI:1.08,6.78),mid-upper arm circumferences less than 23cm (AOR = 5.75;95% CI:3.38, 9.79), antepartum hemorrhage (AOR = 4.51; 95% CI:2.42, 8.37), never wearing shoes (AOR = 2.60; 95% CI:1.10, 6.14) were found to be significantly associated with immediate postpartum anemia. Conclusion This study indicates that immediate postpartum anemia is a moderate public health problem in the study area. A more careful strategy is ideal to increase antenatal care follow-up that sticks to national guideline contact schedule, safe reduction of instrumental and cesarean deliveries to the minimum, quick and timely linkage and treatment of malnourished pregnant mothers to the center where they get adequate health care services, along with a high index of suspicion in mothers diagnosed with antepartum hemorrhage, wise and vigilant advice on consistent use of the shoe for pregnant mothers are recommended to tackle the burden of immediate post-partum anemia. An institutional-based cross-sectional study was conducted in East Gojjam zone Hospitals of Amhara regional state from October 20 to November 20, 2020 GC. East Gojjam zone is one of the 3rd most populous zones in the Region. It is found at 37.8087693 longitudes; 10.3287484 latitudes with 807meter minimum and 4236 meters elevation· It covered a total area of 14,009.74 square Kms. Based on the 2007 National Census conducted by the Central Statistical Agency of Ethiopia (CSAE), projection, and East Gojjam zone administration office report; this zone in 2019 has an estimated 2,719,118 population, of whom 1,335,123 are females, and 1,383,995 are males and the total female reproductive age groups are 91,634. It has 19 districts and 5 town administrations, which have 392 administrative kebeles and 40 urban kebeles. Debre Markos is the capital town of the East Gojjam zone, located 265 Km from Bahir Dar and 299 Km from Addis Ababa. This Zone has one comprehensive specialized Hospital, one General Hospital, 8 Primary Hospitals, 104 Health Centers, and 406 Health Posts [13]. There are about 10 hospitals in the study area as we stated above and a total of 2090 deliveries in ten Hospitals per month. Debre Markos Comprehensive Specialized hospital accounts 505, Mota General hospital 287, Lumamie Primary Hospital 249, Bibugn primary Hospital 186, Shebel Berenta primary hospital 183, Merto-lemariam primary hospital 160, Yejube primary hospital 160, Dejen Primary hospital 132, Bichena Primary hospital and Debre- work primary hospital 112 per month. This zone also has 22 seniors, 160 midwives, and 101 general practitioners in gynecology and obstetrics-related area of service [14]. A total of 467 sample size was calculated by using Epi-Info stat Calc version 7.2 population survey by taking assumption of population size >10,000,95% confidence level, prevalence of immediate post-partum anemia 24.3% from previous study [15], margin of error 5%,design effect 1.5, 10% non-response rate. The sample size for the factor /the second objective was calculated by using Epi-Info statclc by taking five associated factors from previous studies and the greatest sample size among the five was 272 which is less than the sample size from the first objective then we took the sample size of the first objective. A multistage sampling technique was employed to select the hospitals and the study participants with the assumption of homogeneity of the service in East Gojjam Zone hospitals. Five out of the ten were selected by simple random sampling technique using the lottery method. Bichena Primary hospital, Lumamie Primary Hospital, Shebel Berenta primary hospital, Merto-lemariam primary hospital, and Motta general hospital. The study participants were allocated to the proportion of client flow in each Hospital and the participants were selected by using a systematic random sampling technique every 2 case intervals before the mothers were discharged. Kth- interval, K = Nn, where: N = Total population immediate post-partum at the selected five Hospitals, n = Total sample size, then k = 1,065/467 = approximately every 2 mothers will take but, calculating K-value for each hospital was necessary by using K1 = N1/n1, K2 = N2/n2… (K = 2.27, 2.24, 2.25 …. approximately every 2 immediate postpartum women was taken to each hospital after the first case selecting randomly between 1 and K). Immediate postpartum anemia. Socio-demographic factors (age, residence, religion, ethnicity, marital status, educational status, occupation, and family income). Obstetrics history-related variables (parity, multiple pregnancies, ANC follow-up, birth interval, previous abortion history, history of previous anemia, mode of delivery, tear, episiotomy, and neonatal birth weight). Dietary and micronutrient utilization variables (iron-folic acid intake and mid-upper arm circumference). Environmental-related variables (distance from a health facility, shoe-wearing status, and availability of toilet facility). Co-existing disease-related variables (malaria, HIV/AIDS, tuberculosis). Operational definitions. Immediate postpartum period: the time just after the child’s birth by any mode of delivery via spontaneous vertex delivery, instrumental and cesarean delivery to the first 24 hours [16]. Immediate postpartum anemia (IPA): when the hemoglobin level is less or equal to 10g/dl in the immediate postpartum period, within 24 hours of post-delivery. Good adherence to IFA: Supplementation means women who had taken iron folate supplements ≥90 days during the most recent pregnancy [17]. Distance from health facility: If the living house of the individual is greater than two hours walking from the health facility is considered as far from a health facility. MUAC: If the individual postpartum woman has less than 23 cm of arm circumferences considered a lower MUAC in this study. Availability of toilet: If an individual has any type of toilet in their compound or nearby their compound that is not used commonly consider as availability of toilet facility. Barefoot walking: If people do not wear any types of shoes in their life considered as barefoot in this study. English version of the data collection interviewer-administered questionnaire, which was adapted from various kinds of literature [15, 18, 19] was used to collect the data from study participants and client’s medical records from October 20-November 20,2020. It has five parts, socio-demographic characteristics, obstetrics history related, dietary and micronutrient utilization, Co-existing disease-related, and environmental-related characteristics. Five non-employed diploma midwives collected the data and two additional BSC midwives supervised the data collection process. Those data collectors and supervisors were recruited randomly by lottery method among non-employees. Data collection was done by these midwives who were not employed to minimize social desirability bias, one data collector for each hospital and two supervisors for all were assigned. The data collectors took the lab request to the laboratory department for determination of the hemoglobin level after obtaining verbal informed consent eight hours after delivery then data collectors went to the laboratory and brought the EDTA tube and syringe with needle back to the mother then after 1 ml of venous blood was drowned from participants using aseptic technique by data collectors then taken to laboratory back for hemoglobin determination by using automated hematology analyzer Mindray done by laboratory technologies working at each hospital and determined. Data on IFA was collected by interviewing the woman for how long she took the supplement daily for a minimum of ninety days and MUAC was measured by tape meters measurement on a non-dominant hand following delivery, likewise, data on Co-existing disease was collected by reviewing her chart for investigations and interviewing her about known co-existing disease. To assure the data quality high emphasis was given to designing data collection tools. The pretest was conducted on 5% of the sample size at Fenot Selam general hospital and necessary corrections on the instrument were employed accordingly. the one-day training was provided for data collectors and supervisors regarding the objectives of the study, data collection methods, the significance of the study, data collection tool, ethical considerations, and way of abstracting necessary information from the client’s medical records and themselves. During data collection, assigned supervisors visited and supervised the data collection process and checked the completeness of the filled questionnaires. All collected questionnaires were rechecked for completeness and coded; then, the data were entered and cleaned using Epi data version 4.2software and exported to SPSS version 25, for further analysis. Descriptive Statistics like frequency and cross-tabulation were carried out to characterize the study populations using socio-demographic and other variables. Bivariable logistic regression was employed to identify the association between dependent and independent variables, those variables having a p-value of <0.25 in the Bivariable analysis were fitted into multivariable logistic regression analysis with backward like hood ratio to control the effects of confounding factors. Ninety-five percent confidence interval of odds ratios was computed and a p-value of less than 0.05 was considered to declare the statistical significance. The assumption of the binary logistic regression model was checked by using the Hosmer and Lemeshow test of goodness of fit test. Tables and graphical presentations were used to present the findings of the study. An ethical clearance letter was obtained from the Ethical Review Committee (ERC) of Debre Markos University College of Health Science with a reference number of HSC/R/C/Scr/Co/34/11/13. Upon bearing ethical review; the administration of each Hospital provided us permission to access the sample from the clients. The purpose of the study was explained and informed consent was obtained from each study participant. Privacy and confidentiality of all information were kept by coding throughout the research work.