Prevalence and risk factors of preconception anemia: A community based cross sectional study of rural women of reproductive age in northeastern Tanzania

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Study Justification:
– Anemia is a significant public health problem that negatively impacts pregnancy outcomes.
– The prevalence and risk factors of preconception anemia in rural Tanzanian women of reproductive age are not well known.
– Understanding the prevalence and risk factors of preconception anemia is crucial for developing effective interventions to prevent anemia before and during pregnancy and improve birth outcomes.
Study Highlights:
– The study enrolled 1248 women of reproductive age before conception.
– The prevalence of anemia among these women was 36.7%, with 58.8% of anemic cases also having iron deficiency.
– Increased age, iron deficiency, malaria infection, and inflammation were identified as significant risk factors for preconception anemia.
– Increased mid-upper arm circumference was found to be protective against anemia.
– Interventions to ensure adequate iron levels and malaria control before conception are recommended to prevent anemia and improve birth outcomes.
Study Recommendations:
– Implement interventions to ensure adequate iron levels in women of reproductive age, such as iron supplementation and dietary counseling.
– Strengthen malaria control measures, including prevention and treatment, to reduce the risk of anemia.
– Raise awareness among women of reproductive age about the importance of maintaining a healthy weight and lifestyle to prevent anemia.
– Improve access to antenatal care and delivery services to monitor and manage anemia during pregnancy.
Key Role Players:
– Medical Research Coordinating Committee of the National Institute for Medical Research
– Village leaders
– Health care providers
– Opinion makers
– Community members
Cost Items for Planning Recommendations:
– Iron supplementation and dietary counseling materials
– Malaria prevention and treatment supplies
– Educational materials for raising awareness
– Training and capacity building for health care providers
– Antenatal care and delivery services improvement initiatives

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a community-based cross-sectional study with a large sample size. The study utilized logistic regression analysis to determine the adjusted odds ratios for the factors associated with preconception anemia. The study also received ethical approval and followed good clinical and laboratory practices. To improve the evidence, future studies could consider including a control group for comparison and conducting a longitudinal study to assess the long-term effects of preconception anemia.

Background Anemia is a major public health problem that adversely affects pregnancy outcomes. The prevalence of anemia among pregnant women before conception is not well known in Tanzania. The aim of this study was to determine the prevalence, types, and risk factors of preconception anemia in women of reproductive age from a rural Tanzanian setting. Methods Trained field workers visited households to identify all female residents aged 18–40 years and invited them to the nearby health facility for screening and enrolment into this study. Baseline samples were collected to measure hemoglobin levels, serum ferritin, vitamin B 12 , folate, C-reactive protein, alanine amino-transferase, the presence of malaria, HIV, and soil transmitted helminth infections. Anthropometric and socio-economic data were recorded alongside with clinical information of participants. Logistic regression analysis was used to determine the adjusted odds ratios (AOR) for the factors associated with preconception anemia. Findings Of 1248 women enrolled before conception, 36.7% (95% confidence interval (CI) 34.1–39.4) had anemia (hemoglobin <12 g/dL) and 37.6% (95% CI 34.9–40.4) had iron deficiency. For more than half of the anemic cases, iron deficiency was also diagnosed (58.8%, 95% CI 54.2–63.3). Anemia was independently associated with increased age (AOR 1.05, 95% CI 1.03–1.07), malaria infection at enrolment (AOR 2.21, 95% CI 1.37–3.58), inflammation (AOR 1.77, 95% CI 1.21–2.60) and iron deficiency (AOR 4.68, 95% CI 3.55–6.17). The odds of anemia were reduced among women with increased mid-upper arm circumference (AOR 0.90, 95% CI 0.84–0.96). Conclusion Anemia among women of reproductive age before conception was prevalent in this rural setting. Increased age, iron deficiency, malaria infection and inflammation were significant risk factors associated with preconception anemia, whereas increased mid-upper arm circumference was protective against anemia. Interventions to ensure adequate iron levels as well as malaria control before conception are needed to prevent anemia before and during pregnancy and improve birth outcomes in this setting.

The study received ethical approval from the Medical Research Coordinating Committee of the National Institute for Medical Research (reference number NIMR/HQ/R.8a/Vol. IX/1717).Written informed consent or thumbprint (for illiterate women) was obtained prior to enrolment. All study procedures were performed according to good clinical and laboratory practices and the Declaration of Helsinki [19]. This cross sectional study was conducted as part of a community-based epidemiological study entitled “Foetal exposure and epidemiological transition: the role of anemia in early life for non-communicable diseases in later life” (FOETALforNCD) fromJuly 2014 to December 2016 in Korogwe and Handeni districts, Tanga region, Tanzania. The aim of theFOETALforNCD project was toevaluate fetal growth alterations, placental development, and newborn susceptibility to non-communicable diseases in later life, following exposure to maternal anemia before and during pregnancy. The study population composed of women of the reproductive age. The analyses presented here utilized baseline data from women enrolled before they became pregnant. Inclusion into this study was based on their likelihood to conceive during the study period. To be included, women had to be aged 18–40 years, not be using modern contraceptive methods (except condom), or not be sub-fertile (defined as failure to conceive for two or more consecutive years for women who were trying to become pregnant), or not be pregnant at the time of enrolment (negative urine pregnancy test, HCG Vista Care Company, Shandong China), or not have a baby less than nine months old and live in an accessible area, and be willing to receive antenatal care and deliver at Korogwe District Hospital. Different stakeholders including village leaders, health care providers, opinion makers as well as community members were sensitized about the study goals and aims through village and health facility meetings prior to the implementation of the FOETALforNCD study. The primary means of identifying and recruiting eligible women was through contact at the household level within each village. Trained field workers made door-to-door visits to each household to explain the study, enumerate all women of reproductive age, and issue invitation cards for them to visit the nearby health facility for screening and enrolment. Other awareness and recruitment strategies included regular home visits by trained field workers (to identify new women moving into established households) and screening women as they sought other health care services. Eligible women were informed that after conception, the intention was to follow them throughout pregnancy until delivery. Upon conception transabdominal ultrasound (5–2 MHz abdominal probe, Sonosite TITAN and Sonosite Turbo, US High resolution, Sonosite, Bothell, WA, USA) was used to estimate gestational age (GA). Gestational age estimation was based on measurement of crown rump length in the first trimester [20] and head circumference in the second trimester [21]. From July 2014 to December 2015, 2629 women were screened for eligibility for inclusion into the FOETALforNCD study and 1415 were enrolled. Of the 1214 exclusions, 313 (25.8%) were not eligible by age, 322 (26.5%) were still using modern family planning methods, 116 (9.6%) were sub-fertile, 208 (16.6%) were already pregnant, 34 (2.8%) refused, 51(4.2%) migrated out of study area and 93 (7.7%) had a child <9 months old, while 77 (6.3%) were excluded due to other reasons. Of the 1415women included, 72 were later excluded because venous blood was not collected, and 11 did not fulfil the inclusion criteria. Furthermore, 84 women who conceived during the follow up were excluded because; 34 were already pregnant at enrolment based on the ultrasound estimated GA and 50 had a miscarriage before the GA could be ascertained, leaving 1248 women for the present analysis (Fig 1). Socio-demographic data including age, educational level, marital status, and economic (household size, house ownership and type of roofing materials, main source of drinking water and its ownership (private or public),type of toilet facility) and lifestyle factors (smoking, alcohol and tea consumption)were collected using a structured questionnaire. Previous medical histories, including gynecological and obstetric details, were documented. In order to define SES, a principal component analysis was applied and the variables which showed relevant contribution (greater than 10%) to the combined SES score were regarded as the ones which sufficiently described the SES of a woman [22]. Variables included in the final principal component analysis were educational level, occupation, type of house ownership, roofing materials, source of domestic water and its ownership as well as the type of toilet facility. The respective SES scores were categorized in tertiles as low, medium and high. Weight (in kilograms) was measured while on barefoot and wearing light clothes (precision 0.1kg, digital weighing scales, SecaGmbh& Co. Kg, Hamburg, Germany). Height in centimeters (cm) was measured with a stadiometer (precision 1 cm) [23]. Mid-upper arm circumference (MUAC) was measured on the upper right arm at the midpoint of the acromion process and the tip of the olecranon (precision 1mm). For measurement of skinfold thickness, trained staff pinched the skin above triceps muscle group to raise a double layer of skin and the underlying adipose tissue without the muscle. The HARPENDEN skinfold caliper (BATY International, England) was then applied 1 cm above and at right angle to the pinch, and a reading in millimeters (mm) taken after a few second. Waist circumference was measured just above the iliac crest in the horizontal plane, and hip circumference was measured at the point yielding the maximum circumference over the buttocks, all using a standard measuring tape to the nearest 1mm[24]. At enrolment, 15ml of venous blood was collected in ethylenediamine tetra acetic acid coated and plain serum tubes, transported at 2° to 8°C to the NIMR Korogwe Research Laboratory and processed within two hours of collection. To avoid photo degradation during transportation, all plain tubes were wrapped in aluminium foil. Separated serum samples were stored at -80°C and later shipped in dry ice to University Hospital Sealand, Denmark for micronutrients analysis. Hemoglobin level was measured by using Sysmex KX-21N hematological analyzer (Sysmex Corporation Kobe, Japan).According to WHO’s definition, anemia was defined as Hb<12.0 g/dL, and further categorized as mild (10.1–11.9 g/dL), moderate (8.0–10.0 g/dL) and severe (<8.0 g/dL) [3]. Microcytosis was defined as mean corpuscular volume (MCV) value <80 fL and hypochromic as mean cell hemoglobin concentration (MCHC) value <32 g/dL. Anemia was further classified as normocytic-normochromic (Hb32 g/dL), microcytic hypochromic (Hb<12 g/dL, MCV< 80 fL and MCHC<32 g/dL), megaloblastic (Hb<12g/dL, MCV≥100) or as mixed types (normocytic-hypochromic, microcytic-normochromic macrocytic-normochromic and macrocytic-hypochromic) anemia. For clinical care, Hb levels were measured using HemoCue 301 Hb analyzer (HemoCue AB, Angelholm, Sweden). Anemic women received treatments as follows: mild anemic (Hb10.1–11.9 g/dL) women with no symptoms received dietary counseling whereas women with symptoms were offered one combination tablet of 200 mg ferrous sulfate (~ 43 mg elemental iron) and 400μg folate per day (Ferrolic–LF, Laboratory and Allied LTD, Mombasa, Kenya). Moderately anemic patients with Hb 9.1–10.0g/dL received 2–3 combination tablets of iron and folic acid (Ferrolic–LFLaboratory and Allied LTD, Mombasa, Kenya) per day and monitored at each scheduled visit. Those with Hb 8.0–9.0 g/dL received a daily dose of 20 mL Hemovit multivitamin syrup (200 mg Ferrous sulfate, 0.5mg B6, 50 μg B12, 1500 μg Folic acid and 2.33mg Zinc per 5mL, Shelys Pharmaceuticals, Dar es Salaam, Tanzania) and monitored at each scheduled visit. Severely anemic (Hb5 mg/L and/or ALT >45 U/L [10]. To account for elevated serum ferritin due to sub-clinical infection and other inflammatory conditions, three approaches were applied to define ID and results compared. The first approach utilized arithmetic correction factor (CF)as proposed by Thurnhamet al.[26] to adjust for the increased serum ferritin levels due to inflammation. In this approach CF of 0.67 was applied only for samples that had evidence of inflammation (CRP>5 mg/L), and a cut-off of <15 μg/L was then applied to the adjusted ferritin levels to define ID. If CRP was not available, serum ferritin was coded as missing. In the second approach, a higher ferritin-cutoff (5 mg/L) to define ID, as proposed by the WHO [27]. In this approach ID was defined as serum ferritin <15μg/L (no inflammation) or 30μg/L (inflammation present). The third approach utilized the higher serum ferritin cutoff (5mg/L and/or ALT>45 U/L which is considered as a sign of liver disease [10]. In the core analyses presented here, ID anemia was defined as Hb<12g/dL in the presence of ID based on Thurnham approach. Vitamin B12 deficiency was defined as serum cobalamin <150 pmol/L, and folate deficiency as serum folate<10 nmol/L without adjusting for inflammation [28]. Malaria was diagnosed using malaria rapid diagnostic test (mRDT) kit, ParaHIT (span diagnostics, Gujarat, India) or CareStart Malaria Pf (HPR2), ACCESS BIO, New Jersey, USA) according to manufacturer instructions. In addition, thick and thin blood films were prepared for the detection and quantification of parasitemia. Malaria patients received oral artemether-lumefantrine, (Lumartem 20mg/120mg (Cipla Ltd, Patalganga, India), quinine or artesunate injections according to Tanzanian standard treatment guideline. Human immunodeficiency virus infection was tested by using DetermineHIV-1/2 test kit (Alere ltd, Stockport, UK) and seropositive cases were confirmed using Unigold test kit (Trinity Biotech Plc, Wicklow, Ireland) according to the manufacturers’ instructions. Newly diagnosed HIV patients were referred to the nearby care and treatment clinics for long-term care. Considering low prevalence of STH infestations in north eastern Tanzania [29], stool samples were collected from a subgroup of 434 women at the time of enrolment and preserved in 10% neutral buffered formalin solution. Formol-ether concentration technique was used to detect presence of STH infestations [30]. All confirmed (on stool samples)or clinical suspected cases of STH infestation received a single dose of albendazole (400mg) or mebendazole (500mg) tablets according to the existing Tanzanian standard treatment guideline. Microsoft Access software 2007 (Microsoft corporation, Redmond’s, USA) was used for data entry and validation. Stata version 13 (StataCorp, Lake Way drive, College station, USA) software was used for statistical analyses. Continuous variables were visually inspected for normality using histograms and described using mean and standard deviation if normally distributed or median (interquartile range—IQR) for skewed data. Univariate analysis was done using Student’s t-test or Mann-Whitney test for continuous parametric and non-parametric variables, and Chi-square (χ2) or Fisher's exact test for categorical variables. Factors associated with preconception anemia were determined using logistic regression analysis and expressed as unadjusted odds ratio (OR) and adjusted odds ratios (AOR). All variables with P-value <0.20 in the univariate analysis were entered into the multivariate models [31]. Using a stepwise backward elimination approach final models including variables with a P-value <0.10 were obtained. A P-value of <0.05 was considered statistically significant. Due to missing data on HIV infections in 350 (28.8%) women and considering HIV infection being an important confounding factor, two different models with and without adjusting for HIV infection were generated and compared. Finally, in order to illustrate the association between a risk factor and anemia, trendline figures were generated for each continuous risk factor found to be statistically significant or borderline significant in the multivariate model.

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide information and resources related to maternal health, including prenatal care, nutrition, and anemia prevention. These apps could also provide reminders for appointments and medication adherence.

2. Telemedicine: Implement telemedicine programs that allow pregnant women in rural areas to consult with healthcare providers remotely. This would improve access to prenatal care and allow for early detection and management of anemia.

3. Community Health Workers: Train and deploy community health workers in rural areas to provide education and support to pregnant women. These workers could conduct regular check-ups, provide iron supplements, and refer women to healthcare facilities when necessary.

4. Iron Supplementation Programs: Establish programs that provide iron supplements to women of reproductive age in rural areas. This could be done through community distribution centers or mobile clinics.

5. Health Education Campaigns: Launch targeted health education campaigns to raise awareness about the importance of preconception health and anemia prevention. These campaigns could include radio broadcasts, community workshops, and informational materials.

6. Integrated Healthcare Services: Integrate maternal health services with existing healthcare facilities in rural areas. This would ensure that pregnant women have access to comprehensive care, including anemia screening and treatment.

7. Public-Private Partnerships: Foster collaborations between government agencies, non-profit organizations, and private companies to improve access to maternal health services. This could involve leveraging private sector resources and expertise to expand healthcare infrastructure in rural areas.

8. Maternal Health Vouchers: Implement voucher programs that provide pregnant women with access to essential maternal health services, including anemia screening and treatment. These vouchers could be distributed through community health workers or local healthcare facilities.

9. Mobile Clinics: Set up mobile clinics that travel to remote areas to provide prenatal care, including anemia screening and treatment. This would bring healthcare services closer to pregnant women who may have limited transportation options.

10. Health Financing Initiatives: Develop innovative financing mechanisms to make maternal health services more affordable and accessible. This could include microinsurance programs or community-based health financing schemes.

It’s important to note that the implementation of these innovations would require collaboration among various stakeholders, including government agencies, healthcare providers, community organizations, and technology developers. Additionally, thorough evaluation and monitoring would be necessary to assess the effectiveness and impact of these interventions.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the study is to implement interventions that ensure adequate iron levels and malaria control before conception. This can help prevent anemia before and during pregnancy, leading to improved birth outcomes. Additionally, the study found that increased mid-upper arm circumference was protective against anemia, so interventions that promote healthy nutrition and weight gain in women of reproductive age can also be beneficial. It is important to raise awareness among healthcare providers, community members, and other stakeholders about the importance of addressing anemia and its risk factors in order to implement effective interventions.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Implement targeted interventions to address anemia: Given the high prevalence of anemia among women of reproductive age, it is crucial to implement interventions that focus on improving iron levels and preventing anemia before and during pregnancy. This can include providing iron supplementation, promoting iron-rich diets, and ensuring adequate antenatal care.

2. Strengthen malaria control measures: Malaria infection was found to be a significant risk factor for preconception anemia. Therefore, it is important to strengthen malaria control measures, such as distributing insecticide-treated bed nets, providing antimalarial medications, and promoting awareness about malaria prevention strategies.

3. Improve access to healthcare services: Enhancing access to healthcare services, particularly in rural areas, can help ensure that women receive timely and appropriate care. This can involve increasing the number of healthcare facilities, improving transportation infrastructure, and training healthcare providers to address the specific needs of pregnant women.

4. Enhance health education and awareness: Educating women about the importance of preconception health and the risks associated with anemia can empower them to take proactive measures to improve their health. This can be done through community-based health education programs, workshops, and the dissemination of educational materials.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the target population: Identify the specific population that will be impacted by the recommendations, such as women of reproductive age in rural areas of Tanzania.

2. Collect baseline data: Gather relevant data on the current status of maternal health access, including prevalence of anemia, malaria infection rates, healthcare utilization, and other relevant indicators.

3. Develop a simulation model: Create a mathematical model that incorporates the identified recommendations and their potential impact on improving access to maternal health. This model should consider factors such as population size, geographical distribution, healthcare infrastructure, and resource availability.

4. Input data and parameters: Input the collected baseline data into the simulation model, along with parameters related to the recommendations (e.g., coverage rates of interventions, effectiveness of interventions, etc.).

5. Run simulations: Use the simulation model to run multiple scenarios that reflect different levels of implementation and effectiveness of the recommendations. This can help estimate the potential impact on improving access to maternal health, such as reductions in anemia prevalence, improvements in healthcare utilization rates, and other relevant outcomes.

6. Analyze results: Analyze the simulation results to assess the potential impact of the recommendations on improving access to maternal health. This can involve comparing different scenarios, identifying key drivers of change, and evaluating the cost-effectiveness of the interventions.

7. Refine and validate the model: Continuously refine and validate the simulation model based on new data and feedback from stakeholders. This can help improve the accuracy and reliability of the model’s predictions.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of implementing the identified recommendations and make informed decisions to improve access to maternal health.

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