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Does effective counseling play an important role in controlling iron deficiency anemia among pregnant women.

INTRODUCTION

Pregnancy is a physiological condition, and there is usually no side effect on general health of a pregnant woman. Pregnancy results in hematological and hemodynamic changes. Changes such as increased total blood volume and hemostatic changes are indeed very helpful to combat the hazards of hemorrhage during the time of delivery. [1] The increase of plasma volume is less in iron deficient women than in those with optimum iron reserves. In some iron deficient women, this inability to expand plasma volume may sometimes even mask a decrease in hemoglobin (Hb) concentration. [2]

Iron requirements are greater in pregnancy. Although iron requirements are reduced in the 1st trimester in absence of menstruation, these raise steadily thereafter as high as [greater than or equal to] 10 mg/day. [3] The amounts that can be absorbed from even an optimal diet, however, are less than the iron requirement in later pregnancy and women must enter pregnancy with iron stores of >300 mg if she is to meet her requirement fully. This is more than most women possess especially in developing countries. [4]

Etiology of Iron Deficiency Anemia (IDA)

Nutritional deficiencies, mainly of iron, caused by inadequate diet are the predominant cause of anemia in the South East Asia region (SEAR). [5] Intestinal parasites cause anemia by causing blood loss in the stool, lack of appetite, increased motility of food through the intestine, competition for nutrients, and damage to the intestinal wall that leads to decreased absorption of nutrients, including iron, Vitamin B12, and folic acid. [6,7]

Open defecation, the practice of defecating outside without a toilet or latrine, may be an important cause of hemoglobin deficiency around the world, and particularly in regions of sub-Saharan Africa and SEAR which continue to have the lowest sanitation coverage. [8] Failing of good hygiene practices may lead to fecal-oral route of transmission of pathogens leading to environmental enteropathy. In a recent systematic review, it was observed handwashing with soap in 19 countries, that only 19% of people worldwide wash their hands after potential contact with excreta. [9]

Consequence of IDA Among Pregnant Women

IDA early in pregnancy may increase the risk of having a premature delivery or a low birth weight baby. [10] When maternal iron stores are depleted, the fetus also cannot accumulate much iron resulting in decrease in fetal iron stores. Studies have suggested that behavioral abnormalities occur in children with iron deficiency, which are related to changes in the concentration of some chemical mediators in the brain. [11] Hence, iron supplements are widely recommended and used during pregnancy worldwide. [12]

Past Efforts and Current Scenario

Iron deficiency during pregnancy is still common in developed countries. [13-15] It is projected that India has the utmost prevalence of anemia, i.e., 57-96.2%, among the South Asian countries. [16-18] To combat the high prevalence of IDA several government programs and state level schemes were rolled out in various states of India. National nutritional anemia prophylaxis program 1970, national anemia control program 1991, 12/12 initiative 2007 are some of the nationwide initiatives. Few state-specific schemes include "Madilu" scheme, "Thayi bhagya" scheme, and "Janani suraksha yojana," but these program have not made the desired impact due to irregular supply of iron-folic acid (IFA) tablets as well as non-adherence by the pregnant women. [19-22] In spite of government's persistent and prolonged efforts, the problem continues to fester as is documented by recent surveys of National Family Health Survey (NFHS): In NFHS-3 (2005-06) data the problem even increased from 49.7% (NFHS-2, 1998-99) data to 57.9%. In Chhattisgarh, according to NFHS-3 data anemia among pregnant women was 63.7%.[23]

Present Aims of the Study

As per existing knowledge, there have been no randomized controlled trials regarding the impact of education/counseling on rural population especially in the state of Chhattisgarh, regarding negative impact of IDA, benefits of adherence to IFA supplementation and also benefits of good hygiene practices among anemic pregnant women. In view of the above, this study was, hence, undertaken with a view that such a trial would make an important contribution to the literature on the determinants of anemia among rural pregnant women.

MATERIALS AND METHODS

This is a longitudinal interventional study done on IDA pregnant women of rural population.

Place of Study

District Mungeli of state Chhattisgarh.

Period of the Study

This study was from November 2014 to January 2016.

With due discussion with program officers of women and child development office of the district and block medical officer, five villages of were chosen for this study where anemia prevalence was suspected to be more common among women, and those place which are not endemic to malaria. With the due consent of the pregnant women who volunteer for the study, the screening test was first done to find out the women suffering from anemia, and then those found to be anemic were screened for IDA.

The CDC/WHO expert groups on May 7, 2004, recommended that hemoglobin and serum ferritin are the most valuable indicators of the impact program to control iron deficiency. [24]

Exclusion Criteria

Women who have been found to be suffering from a chronic inflammatory disease or have history of such after questioning them about such diseases were excluded from the study as an inflammatory disease would interfere with the ferritin results.

Non-pregnant lactating and pregnant and lactating women were excluded as a lactating mother also have more demand for iron and may interfere in our study results.

Furthermore, women informing having recent major surgery or hemorrhagic incident were excluded.

Inclusion Criteria

Apparently healthy non lactating pregnant women who were in their first trimester of pregnancy and were detected suffering from IDA were included in the study.

Sample Size

A total of 250 women who were in their first trimester of pregnancy were screened for hemoglobin out of which 80% that is 200 were found to be anemic. Anemic pregnant were then tested for ferritin test out of which 68% that is 136 pregnant women were found to be suffering from IDA.

According to the classification of the World Health Organization (WHO), pregnant women with hemoglobin levels <11.0 g/dl in the first and third trimesters and <10.5 g/dl in the second trimester are considered anemic.

WHO graded anemia in 1st and 3rd trimester of pregnancy as mild, moderate, and severe (at sea level) when hemoglobin range is between 10.0 and 10.9 g/dl, 7.0-9.9 g/dl and lower than 7.0 g/dl of blood, respectively.

IDA was considered when hemoglobin values (during the first trimester) fall below 11.0 g/dl of blood and ferritin value <12.0 ng/ml of blood. [25,26]

At the baseline, purposive random sampling done in pregnant women and divided in the experimental group and control group, containing 68 women in each group.

At the beginning of the study, basic demographic information such as age, level of education, and socioeconomic status was noted for all pregnant women by interviewing them.

Information regarding registration with antenatal care center (ANC), compliance of supplementation of IFA tables, was taken into account.

Baseline hematological study includes estimation of Hb, ferritin, total iron binding capacity (TIBC) estimation of women. Practice of good hygiene predictors such as use of latrine for defecation, use of slippers during defecation, regular trimming of nails, washing of hands before taking meals and washing of hand after defecation, or when hands get contacted with excreta were taken into account of both experimental and control group by interviewing the pregnant women in the study.

Hemoglobin was estimated by cyanmethemoglobin method by commercially available Drabkin's reagent solution (Sigma-Aldrich Co USA.), ferritin by radioimmunoassay kit (Beckman Coulter USA). TIBC was estimated by estimated by iron and TIBC kit (Coral, Tulip diagnostic India) in semi autoanalyzer, by Ferrozine method. [27,28]

The Hb levels were not required to be adjusted for smoking, as all of the pregnant women were non-smokers. No adjustment for the altitude of the enumeration areas was made because the place of study in Chhattisgarh is at an altitude below 1,000 meters.

Blood Sample Collection

Blood samples were taken to perform Hb and to determine serum concentrations of ferritin and TIBC. Each sample consisted 5 mL of blood taken from the antecubital vein of the arm after cleaning of the zone with isopropyl alcohol. From this, 4 mL was used to obtain serum, and 1 mL was treated with EDTA for hemoglobin. Serum samples were obtained by centrifugation of blood samples, within 4 hrs of extraction. Serum was kept at optimum temperature and protected from light until analysis.

Intervention Techniques

Counseling includes basic health concepts about IDA as public health problems.

Counseling them to get themselves registered in local ANC centers, eliminating different myths prevailing regarding regular consumption of IFA supplementation, and benefits of IFA supplementation to them and their coming newborn child.

Our focus was also to provide counseling to women in the experimental group to inculcate good hygiene practices. To educated them about sources of parasitise infection and how it leads to IDA, fecal-oral route of parasite infection transmission and how better hygiene practices can be adopted for the prevention of the same. Hygiene practice that was counseled to them was the use of latrine for defecation, use of slippers during defecation, trimming of nails, washing of hands before eating and washing of hands with soap after defecation or when in contact with excreta. Easily available and economical tools were suggested to them so that the counseling does not become burdensome and unacceptable to them. Interactions with the women were done in the local language in a very simple communicable way. Posters regarding hygiene practices were used for better understanding. Intervention was only for the pregnant women in the experimental group, while the pregnant women of the control group were not provided any such intervention.

After baseline study, at the 2nd trimester, ANC registration and regular IFA supplementation were again studied for both the groups, but only in the experimental group those women still found not registered with ANC or irregular intake of IFA supplementation were again re-counseled but not those women in control group. At the 8th month/3rd trimester (end of the study), the data of both experimental and control group were statistically analyzed to study the impact of counseling on the hematological indices.

Necessary ethical approval was taken for this study.

Statistical Analyses

The Kolmogorov-Smirnov test was used to assess normality of the continues (hematological) data. Since our Kolmogorov-Smirnov test results showed that our data were not normally distributed, we opted for non-parametric tests. [29]

Mann-Whitney U-test was conducted to compare the median of hematological indicators, namely, Hb, Ferritin, and TIBC. Chi-square test of significance was run between the two groups for categorical data. All statistical tests were two-tailed, and differences were considered significant at P < 0.05 at 95% CI. Statistical analysis was done by SSPS version 22. [30]

RESULTS

Demographic profile of women. At the end of the study that is after the third trimester (8th months) of pregnancy 9 women opted out of the study in the experimental group that is 59 women were left, and 5 women opted out from the control group. To keep the sample size equal, we kept sample size of both group at 59.

Mean age of women in the experimental group was 22.7 years [+ or -] 2.9 and ranging from 19 years to 29 years and for control group the mean age was 22.8 years [+ or -] 3.1 years and ranging from 19 years to 29 years.

As per religion, all women were predominately Hindu. Nearly, all the subjects were from families engaged in agriculture or agriculture labor.

Socioeconomic data were taken by Aggarwal et al. method, and accordingly, the population was classified into poor, lower middle, middle and high-income group. [31] In experimental group 13 (22%), 23 (39%), 21 (35.6%), and 02 (3.4%) subjects were in poor, lower middle, middle, and high-income group, respectively, while in control group 11 (18.6%), 27 (45.8%), 19 (32.3%), and 02 (3.4%) subjects were in poor, lower middle, middle, and high income group, respectively.

In terms education in experimental group 15 (25.4%), 19 (32.2%), 16 (27.1%), and 9 (15.3%) subjects completed education till 5th standard, 10th standard, 12th standard and graduation level, respectively, while in control group 14 (23.7%), 22 (37.3%), 16 (27.1%), and 7 (11.9%) subjects completed education till 5th standard, 10th standard, 12th standard and graduation level, respectively. None of the women in both groups were illiterate.

In the experimental Group 2, 12, and 45 pregnant women were in their 1st, 2nd, and 3rd month of pregnancy and out of 59 pregnant women, only 41 (69.5%) of them got themselves registered in local ANC centers. Out of 41 registered women 1 (2.4%), 2 (4.9%), and 38 (92.7%) pregnant women got themselves registered in their 1st, 2nd, and 3rd month of pregnancy.

In the control Group 2, 15, and 42 pregnant women were in their 1st, 2nd, and 3rd month of pregnancy and out of 59 pregnant women only 38 (64.4%) of them got themselves registered in local ANC centers. Out of 38 registered women, none (0.0%), 3 (7.9%), and 35 (92.1%) pregnant women got themselves registered in their 1st, 2nd, and 3rd month of pregnancy.

Table 1 shows the Mann-Whitney U-test results. Median Hb scores (10.4) for experimental group and Hb scores (9.2) for control group were statistically significant in experimental then in control [mu] = 1064.5, Z = -3.6, P < 0.001.

Median ferritin score (8.70), for experimental group and ferritin score (7.90) for control group were statistically significant in experimental then in control [mu] = 886.0, Z = -4.60, P < 0.001.

Median TIBC score (540.0), for experimental and, TIBC score (567.0) for control group was statistically significant in experimental then in control [mu] = 3211.0, Z = 7.93, P < 0.001.

Tables 2 and 3 show the changes in hygiene practices among the experimental and control group. Table 2 shows that after receiving counseling there was an improvement of latrine use by the pregnant women in the experimental group from baseline 25.4 to 37.35% at the end of the study while in the control group the improvement was from 23.7% to only 25.4%, though the improvement was not statistically significant P > 0.05.

There were a statistically significant changes in regard to use of slippers during defecation [X.sup.2] (1) = 9.13 from 10.2 to 42.4% in experimental group while in control group the change was from 13.6% to 16.9%, P = 0.003. Table 3 shows in respect to regular trimming of nails, there was a statistically significant changes [X.sup.2] (1) = 12.29 in experimental group from 40.7% to 69.5% P < 0.001 while in control group the change was from 32.2% to 37.3%. There were also statistically significant changes among experimental and control group with respect to washing of hands before eating food [X.sup.2] (1) = 7.24 P = 0.007 and in respect to washing of hands after defecation or when hands come in contact with excreta [X.sup.2] (1) = 8.70 P = 0.003.

During the 2nd trimester, all women of both groups have registered themselves in their local ANC centers.

Table 4 shows the changes in regular consumption of IFA tablets among the experimental and control group. The table shows that after receiving counseling there was improvement of regular consumption of IFA tablets by the pregnant women in the experimental group from baseline 5.1 to 55.9% at the end of the study while in the control group the improvement was from 3.4% to only 10.2% a statistically significant change [X.sup.2] (1) = 27.92 P < 0.005.

From Table 5, it can be stated that there is a statistically significant change [X.sup.2] (1) = 5.73 P = 0.017 at the end of the study in anemic status among pregnant women in experimental and control group.

DISCUSSION

Our results show a statistically significant increase in compliance with IFA supplementation and hygiene practices among pregnant women of the experimental group which in turn also significantly benefited the hematological indices of them. From our results, it may be stated that our goal was successful in reducing the condition of anemia among the anemic pregnant women.

Our results echo similar results from studies of Mora, Sanghvi et al., in Nicaragua where anemia rates in pregnant women reduced nationwide from 23.7% to 11.2% in 5 years. [32,33] In Nepal, similar study by Pandey et al. showed that IFA coverage increased from 27% during 2nd trimester to 73% in just 3 years. [34]

Adherence or compliance with medication (IFA tablets) regimen is usually defined as the extent to which patients take medications as prescribed by their healthcare providers. [35] Reasons for non-compliance with iron deficiency treatment include: Inadequate program support; insufficient service delivery; and patient factors (as misunderstanding instructions, side effects, frustration about the frequency and number of pills taken, fear of having big babies, nausea that accompanies pregnancy, and the subtlety of anemia which makes demand for treatment low).

Although ANC programs distribute iron supplements to pregnant women; poor compliance with iron treatment (e.g., failure to take pills) is the probable reason for the ineffectiveness of such programs. [36] Previously unavailability of iron supplements was also the most common reason why women did not take iron supplements, [37] though nowadays care has been taken to solve this problem. Care has also been taken about the side effects that women might experience during iron therapy. Successful management of anemia in pregnancy depends on accurate and acceptable methods of detecting anemia, assessing its severity and monitoring response to treatment. [36] In women with mild-to-moderate anemia, timely treatment is likely to prevent the development of more severe anemia and, therefore, reduce the need for blood transfusion with its associated risks. [38]

Strength and Limitation of this Study

The main strengths were that we not only counsel about regular IFA supplementation but also counseled about good hygiene practices among pregnant women both which are beneficial for reducing anemia. Limitation of our study is that there were chances of recall bias among the study subjects regarding skipping of IFA doses.

CONCLUSION

Diverse religions, cultures, languages, food habits, lifestyle, and traditions present a challenge to the implementation of the health program. Hence, there is a continuing requirement for county-specific or more precisely region specific harmonized guideline for the control of IDA in India. From our study, it may be tentatively concluded that more practical approach like counseling through effective communication would increase the compliance of IFA supplementation and good hygiene practice necessary for controlling anemia among pregnant women.

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How to cite this article: Saha J, Mazumder S, Samanta A. Does effective counseling play an important role in controlling iron deficiency anemia among pregnant women. Natl J Physiol Pharm Pharmacol 2018;8(6):840-847.

Source of Support: Nil, Conflict of Interest: None declared.

Jayanta Saha (1), Sahana Mazumder (2), Amalendu Samanta (3)

(1) Department of Physiology, University of Calcutta, Kolkata, West Bengal, India, (2) Department of Physiology, Rammohan College (P.G. Studies), University of Calcutta, Kolkata, West Bengal, India, (3) Ex. ARO Physiologist, All Indian Institute of Hygiene & Public Health Calcutta, Kolkata, West Bengal, India

Correspondence to: Jayanta Saha, E-mail: jsaha4130@gmail.com

Received: January 21, 2018; Accepted: February 05, 2018

Access this article online

Website: www.njppp.com

DOI: 10.5455/njppp.2018.8.0104305022018
Table 1: Mann-Whitney U-test output of hematological indicators after
the end of the study (3rd trimester/8th months of pregnancy) between
experimental and control groups

Hematological        Interventional               Control group n=59
indicators           group (experimental group)
                     n=59
                     Median   SD      Mean rank   Median   SD      Mean
                                                                   rank

Hemoglobin (g/dl)     10.4     0.95   70.96         9.2     0.98   48.04
Ferritin (ng/ml)       8.70    0.74   73.98         7.90    0.72   45.02
TIBC ([micro]g/dl)   540.0    13.0    34.58       567.0    18.8    84.42

Hematological          Mann-Whitney      Z value     P value
indicators

Hemoglobin (g/dl)      1064.5            -3.68       P=0.001
Ferritin (ng/ml)        886.0            -4.60       P=0.001
TIBC ([micro]g/dl)     3211.0             7.93       P=0.001

n: Number of pregnant women, SD: Standard deviation

Table 2: Frequency and percentage distribution of regular uses of
latrine and uses of slippers during defecation among pregnant anemic
women between experiment and control group along with the Chi-square
test results

Personal hygiene        Baseline                  After 8 months
indicators              (first trimester)         (3rd trimester)
In terms of         Experimental   Control     Experimental   Control
frequency and       n=59           n=59        n=59           n=59
percentage

Latrine use
 Frequency (%)      15 (25.4)      14 (23.7)   22 (37.3)      15 (25.4)
No use of latrine
 Frequency (%)      44 (74.6)      45 (76.3)   37 (62.7)      44 (74.6)
Shoe use
 Frequency (%)      06 (10.2)       8 (13.6)   25 (42.4)      10 (16.9)
No use of shoe
 Frequency (%)      53 (89.8)      51 (86.4)   34 (57.6)      49 (83.1)

Personal hygiene     P value     [X.sup.2] value
indicators
In terms of
frequency and
percentage

Latrine use
 Frequency (%)       0.165       1.92
No use of latrine
 Frequency (%)
Shoe use
 Frequency (%)       0.003       9.13
No use of shoe
 Frequency (%)

n: Number of pregnant women

Table 3: Frequency and percentage distribution of regular trimming of
nails, regular washing of hands before taking of food and washing of
hands with soap after defecation among anemic pregnant women between
experiment and control group along with the Chi-square test results

Personal hygiene                           Baseline (1st trimester)
indicators
                                    Experimental        Control
                                    n=59                n=59

Regular trimming of nails
 Frequency (%)                      24 (40.7)           19 (32.2)
No regular trimming of nails
 Frequency (%)                      35 (59.3)           40 (67.8)
Washing of hand before eating
 Frequency (%)                      32 (54.2)           30 (50.8)
Non-washing of hand
before
eating
 Frequency (%)                      27 (45.8)           29 (49.2)
Washing of hand with soap
after defecation
 Frequency (%)                      24 (40.7)           20 (33.9)
Non-washing of hand with
soap after defecation
 Frequency (%)                      35 (59.3)           39 (66.1)

Personal hygiene                     After 8 months
indicators                           (3rd trimester)
                                     Experimental       Control
                                     n=59               n=59

Regular trimming of nails
 Frequency (%)                       41 (69.5)          22 (37.3)
No regular trimming of nails
 Frequency (%)                       18 (30.5)          37 (62.7)
Washing of hand before eating
 Frequency (%)                       45 (76.3)          31 (52.5)
Non-washing of hand
before
eating
 Frequency (%)                       14 (23.7)          28 (47.5)
Washing of hand with soap
after defecation
 Frequency (%)                       36 (61.0)          20 (33.9)
Non-washing of hand with
soap after defecation
 Frequency (%)                       23 (39.0)          39 (66.1)

Personal hygiene                      P value      [X.sup.2] value
indicators

Regular trimming of nails             0.001        12.29
 Frequency (%)
No regular trimming of nails
 Frequency (%)
Washing of hand before eating         0.007         7.24
 Frequency (%)
Non-washing of hand
before
eating
 Frequency (%)
Washing of hand with soap             0.003         8.70
after defecation
 Frequency (%)
Non-washing of hand with
soap after defecation
 Frequency (%)

n: Number of pregnant women

Table 4: Shows the counts and percentage changes in regular intake of
IFA supplementation among pregnant women of experimental and control
groups in different stages of the study along with the Chi-square test
results

Groups              Baseline                      2nd trimester
                    (1st trimester)
                   Yes          No              Yes           No

Experimental
n=59
Counts (%)         3 (5.1)      56 (94.9)       19 (32.2)     40 (67.8)
Control n=59
Counts (%)         2 (3.4)      57 (96.6)         3 (5.1)     56 (94.9)

Groups              8 months                  P value    [X.sup.2] value
                    (3rd trimester
                     Yes         No

Experimental                                  0.001      27.92
n=59
Counts (%)          33 (55.9)    26 (44.1)
Control n=59
Counts (%)           6 (10.2)    53 (89.8)

n: Number of pregnant women, Yes: Regular intake of IFA tablets, No:
Irregular intake of IFA tablets

Table 5: Shows the frequency and percentage changes in anaemic status
of pregnant women in experimental and control  groups in different
stages of the study along with the Chi-square test results after 8
months

Category of         Baseline                   8 months
anemia              (1st trimester)            (3rd trimester)
               Experimental    Control       Experimental     Control
               n=59            n=59          n=59             n=59

Mild
 Count (%)     22 (37.3)       26 (44.1)     37 (62.7)        24 (40.7)
Moderate
 Count (%)     37 (62.7)       33 (55.9)     22 (37.3)        35 (59.3)

Category of      P value     [X.sup.2] value
anemia

Mild
 Count (%)       0.017       5.735
Moderate
 Count (%)

n: Number of pregnant women
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Title Annotation:RESEARCH ARTICLE
Author:Saha, Jayanta; Mazumder, Sahana; Samanta, Amalendu
Publication:National Journal of Physiology, Pharmacy and Pharmacology
Article Type:Report
Geographic Code:9INDI
Date:Jun 1, 2018
Words:5211
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