‫بسم هللا الرحمن الرحيم‬
Maternal Iron-Deficiency Anemia and
pregnancy outcomes
Retrospective Study
Submitted by 4th year student
Faculty of Nursing
Name of student:
Ahmed Shaarawi
Ahmed Ishtia
Hana Odeh
Salah Mnazel
Supervised by:
Dr. Adnan Sarhan
Mariam Altell
Supervisor Name:
Miss. Najwa Subuh
1st semester 2008-2009
Is there a Causal Relationship between Iron- Deficiency Anemia and
Weight at Birth, Length of Gestation and Perinatal Mortality?
1.1 Abstract
Iron-deficiency anemia is a health problem that often goes untreated, especially in
developing countries, where it can be most dangerous. Many severe health
complications of iron-deficiency anemia are evident in pregnancy. The World Health
Organization (WHO) estimates that an average of 56% of pregnant women in
developing countries is anemic. This percentage ranges from 35% to 75% in specific
areas, and is much higher than the 18% of anemic pregnant women in developed
countries. Iron deficiency during pregnancy is known to be caused by combination of
factors such as previously decreased iron supply, the iron requirements of the growing
fetus, and expansion of maternal plasma volume. While plasma volume and red cell
mass are both known to expand during pregnancy, plasma volume swells to a greater
extent, therefore diluting the maternal hemoglobin concentration (Hb). It is necessary
to take this into consideration when diagnosing anemia in pregnant women. Effective
diagnosis has been achieved by accurate laboratory tests of hemoglobin and
hematocrit levels.
1.2 Key Words
• Hemoglobin.
• Iron deficiency anemia.
• Pregnancy. • Perinatal mortality.
• Birth weight. • Preterm delivery. • Low birth weight.
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1.3 Introduction
Iron-deficiency anemia is a common and easily treated condition that occurs when
there is not enough iron in the body. It is the most common type of anemia. A lack of
iron in the body can come from; bleeding, not eating enough foods that contain iron,
or not absorbing enough iron from food that is eaten. Iron deficiency (ID) is one of
the risks to pregnant women. Causes of ID include extra iron required by the growing
fetus and the placenta and the increased maternal red cell mass.
As part of a critical review process to examine the importance of iron-deficiency
anemia, this review was undertaken to determine whether these conditions in pregnant
women cause low birth weight (LBW) or prenatal mortality and other birth outcome.
Because LBW (<2.5 kg at birth) infants include both those who are preterm (<37 wk
gestational age) and those who are small for their gestational age, the distinction
between preterm and fetal growth retardation was maintained where the data
permitted.
Iron deficiency is the most common nutritional disorder in the world, affecting
approximately 25% of the world's population.)WHO, 2002) Pregnant women are
particularly at high risk for iron-deficiency anemia because of increased iron needs
during pregnancy. The prevalence of iron-deficiency anemia in pregnant women is
estimated to be between 35 and 75% (average 56%) in developing countries whereas
in industrialized countries the average prevalence is 18%. (WHO, 1992, 2001)
Anemia during pregnancy has been shown to be associated with a two-fold risk for
preterm delivery and a three-fold risk for low birth-weight (Scholl TO, et,al,1992) as
well as maternal mortality. (ACC/SCN, 1992.WHO, 1991, 1993) The World Health
Organization (WHO) estimates that anemia contributed to approximately 20% of the
515,000 maternal deaths worldwide in 1995. (WHO, 1999) Moreover, iron-deficiency
3
anemia is associated with impaired physical and work capacity as shown in nonpregnant women. (Li R, et al 1994).
By using WHO criteria maternal anemia was defined as Hb less than 11g\dl in any
stage of gestation & prematurity was defined as any delivery of a live single infant
between 24- 36 weeks of gestation. (WHO,1977).
1.3.1 Hematological measurements
Maternal and neonatal hematocrit were measured by drawing blood into capillary
tubes, which were then centrifuged in a high-speed hematocrit centrifuge (Universal
32R, Hettich; Scientific Laboratory Supplies, Coatbridge, UK) and read in a
microhaematocrit reader.
The provision of iron supplements to pregnant women is one of the most widely
practiced public health measures, yet surprisingly little is known about the benefits of
supplemental iron for the mother or her offspring during fetal or postnatal life.
(WHO,1992).
Iron (Fe) deficiency in pregnancy has serious consequences for both the mother
and her baby. In the immediate postnatal period, these include increased risk of low
birth-weight, increased morbidity and mortality. In the neonatal period, there is an
increased risk of impaired motor development and coordination.
Iron supplementation in appropriate cases therefore is clearly warranted. However,
there is still debate whether supplementation should be universally provided.
Additionally, neither the optimal time period nor the dose has been agreed. For
example, World Health Organization has recommended supplementation of about 60
mg days to all women from the second trimester onward ( Scholl TO,& Hediger ML
1994. Allen, LH. 2000) suggest that 60 mg day–1 in normal women are too high, and
4
results in haemoconcentration, decreased birth-weight and increased prematurity. The
US Institute of Medicine recommends a flexible approach, ranging from no
supplementation during the first two trimesters to 120 mg day, depending on a variety
of parameters. (Viteri FE 1998).
There is very little information about the mechanisms underpinning the differential
effects of dose and timing. It is generally agreed that the mother uses both Fe stores
and increased absorption to supply the developing fetus. However, how much each
can or will contribute is not known. Nor is it clears how the mother will adapt to lower
Fe status.
1.3.2 Regulation of iron transfer to the fetus
Transfer of iron from the mother to the fetus is supported by a substantial increase in
maternal iron absorption during pregnancy and is regulated by the placenta. (Harris
ED,1992. Starreveld JS,et,al,1995).
Serum ferritin usually falls markedly between 12 and 25 wk of gestation, probably
as a result of iron utilization for expansion of the maternal red blood cell mass. Most
iron transfer to the fetus occurs after week 30 of gestation, which corresponds to the
time of peak efficiency of maternal iron absorption. Serum transferrin carries iron
from the maternal circulation to transferrin receptors located on the apical surface of
the placental syncytiotrophoblast, holotransferrin is endocytosed, iron is released, and
apotransferrin is returned to the maternal circulation. The free iron then binds to
ferritin in placental cells where it is transferred to apotransferrin, which enters from
the fetal side of the placenta and exits as holotransferrin into the fetal circulation.
This placental iron transfer system regulates iron transport to the fetus. When
maternal iron status is poor, the number of placental transferrin receptors increases so
that more iron is taken up by the placenta. Excessive iron transport to the fetus may be
5
prevented by the placental synthesis of ferritin. Evidence is accumulating that the
capacity of this system may be inadequate to maintain iron transfer to the fetus when
the mother is iron deficient.
1.3.3 Maternal anemia and birth weight
The relation between maternal anemia & birth weight has been reviewed more
extensively elsewhere in this issue (Steer, PJ. 2000). In several studies, a U-shaped
association was observed between maternal hemoglobin concentrations and birth
weight (Murphy JF, et al.1986).
Abnormally high hemoglobin concentrations usually indicate poor plasma volume
expansion, which is also a risk for low birth weight (Garn SM,et al. 1981. Steer, PJ.
2000 ). Lower birth weights in anemic women have been reported in several studies
(Hemminki E, 1991. Singla PN, et al, 1997).
1.3.4 Maternal iron deficiency anemia and duration of gestation
There is a substantial amount of evidence showing that maternal iron deficiency
anemia early in pregnancy can result in low birth weight subsequent to preterm
delivery. For example, Welsh women who were first diagnosed with anemia
(hemoglobin <104 g/L) at 13–24 wk of gestation had a 1.18–1.75-fold higher relative
risk of preterm birth, low birth weight, and prenatal mortality (Murphy JF, et al.1986).
After controlling for many other variables in a large Californian study, Klebanoff et
al, showed a doubled risk of preterm delivery with anemia during the second trimester
but not during the third trimester (Klebanoff MA, et al,1991). In Alabama, low
hematocrit concentrations in the first half of pregnancy but higher hematocrit
concentrations in the third trimester were associated with a significantly increased risk
of preterm delivery (Lu ZM, et al, 1991). When numerous potentially confounding
factors were taken into consideration, analysis of data from low-income,
6
predominantly young black women in the United States showed a risk of premature
delivery (<37 wk) and subsequently of having a low-birth-weight infant that was 3
times higher in mothers with iron deficiency anemia on entry to care. There was no
such increased risk for mothers who were anemic but not iron deficient at entry to
care, or for those who had iron deficiency anemia in the third trimester (Scholl TO, et
al, 1992).Thus, the results of several studies are consistent with an association
between maternal iron deficiency anemia in early pregnancy and a greater risk of
preterm delivery. The apparent loss of this association in the third trimester is
probably, because a higher hemoglobin concentration at this time may reflect poor
plasma volume expansion and an inability to discriminate between low hemoglobin
caused by iron deficiency from that caused by plasma volume expansion (Singh K, et
al, 1998).
1.3.5 Maternal anemia and infant health
An association between maternal anemia and lower infant Apgar scores was
reported in some studies. In 102 Indian women in the first stage of labor, higher
maternal hemoglobin concentrations were correlated with better Apgar scores and
with a lower risk of birth asphyxia (Rusia U, et al, 1995). When pregnant women
were treated with iron or a placebo in Niger, Apgar scores were significantly higher in
those infants whose mothers received iron (Preziosi P, et, al, 1997).
A higher risk of premature birth is an additional concern related to the effect of
maternal iron deficiency on infant health; preterm infants are likely to have more
Perinatal complications, to be growth-stunted, and to have low stores of iron and other
nutrients.
In the Jamaican Perinatal Mortality Survey of > 10 000 infants in 1986, there was
an <50% greater chance of mortality in the first year of life for those infants whose
7
mothers had not been given iron supplements during pregnancy (Greenwood R,
Golding J, et al, 1994), although the iron status of these infants and their mothers was
not assessed.
Apart from this survey, there is little known concerning the effects of maternal iron
status during pregnancy on the subsequent health and development of the infant.
1.3.6 Benefits of maternal iron supplementation on iron status of the fetus and
infant
It is generally assumed that the iron status of the fetus, and subsequently the infant,
is quite independent of maternal iron status during pregnancy (Institute of Medicine,
Food and Nutrition Board, 1993), except perhaps when infants are born to severely
anemic women. A review of the literature on this issue indicates that indeed, with rare
exceptions (Gaspar MJ, et al, 1993), there is no significant association between
maternal hemoglobin concentrations at or near term and cord blood hemoglobin
concentrations. This lack of an association was reported in countries as diverse as
Niger (Preziosi P, et, al, 1997), India (Agrawal RMD, et al, 1983), China (Lao TT, et
al, 1991), Japan (Hokama T, et al, 1996), and Ireland (Barton DPJ, et al 1994). A lack
of association between maternal and cord blood hemoglobin was also found in France
(De Benaze C, et al, 1989), and Denmark (Milman N, et al, 1994), even when half of
the women were provided with iron supplements. However, although there was no
relation between low hemoglobin concentrations in unsupplemented British women in
the third trimester and hemoglobin concentrations in infants' 3–5 d postpartum, infants
born to nonanemic mothers had distinctly higher blood volumes, red cell volumes, and
circulating hemoglobin mass than those of infants born to anemic mothers (Sisson
TR,& Lund CJ (1958).
8
Cord blood ferritin was, however, related to maternal hemoglobin or maternal ferritin
in most of these and other nonintervention and intervention studies (Gaspar MJ, et al,
1993. Agrawal RMD, et al, 1983. Hokama T, et al, 1996. De Benaze C, et al, 1989.
Ajayi OA, 1988. Tchernia G, et al, 1996). With few exceptions (Barton DPJ, et al,
1994. Zittoun J, et al, 1983. Rusia U, et al, 1995 ). In the study by Rusia et al, serum
transferrin receptor concentrations were higher in infants born to anemic mothers.
(Rusia U, et al, 1995) De Benaze et al, found the relation between the iron status of
French pregnant women and serum ferritin concentrations of their infants to still be
apparent 2 months postpartum (Gaspar MJ, et al, 1993). Maternal hemoglobin at
delivery was correlated with serum ferritin in 2-mo-old infants (Tekinalp, et al, 1996).
Colomer et al. analyzed the relation between the hemoglobin concentration of
pregnant women and the risk of anemia in their infants at 12 mo of age. Infants born
to anemic mothers were more likely to become anemic themselves, when feeding
practices, morbidity, and socioeconomic status were controlled for (Colomer J, et al
,1990).
Because of the high prevalence of iron deficiency in infants after 6 mo of
age, especially in developing countries, there is a clear need for more studies that
assess the relation between the iron status of pregnant women and the iron status of
their infants postpartum, preferably in controlled interventions. Any association will
be more difficult to detect when infants are feed iron-fortified foods from an early age.
Preterm delivery associated with iron deficiency could also contribute to lower fetal
iron stores. Nonetheless, the effect of the mother's iron status on her infant's iron
stores postpartum needs to be clarified because of the known detrimental effects of
iron deficiency anemia on the mental & motor development of infants.
Iron is needed to form hemoglobin. Iron is mostly stored in the body in the
hemoglobin. About 30 percent of iron is also stored as ferritin & hemosiderin in the
9
bone marrow, spleen, and liver. Iron is required for many essential body functions,
including oxygen transport, ATP production, DNA synthesis, mitochondrial function,
and protection of cells from oxidative damage. Everyone requires iron for growth &
development, health maintenance & the prevention of chronic disease. It is especially
important for women of childbearing age to ensure adequate iron intake & avoid iron
deficiency & iron deficiency anemia.
Iron deficiency is the most common form of nutritional deficiency. The size and
number of red blood cells are reduced. There is a spectrum of iron deficiency ranging
from iron depletion, which causes no physiological impairments, to iron-deficiency
anemia, which affects the functioning of several organ systems. The terms anemia,
iron deficiency, & iron-deficiency anemia are often used interchangeably, but aren’t
equivalent. Anemia can only be diagnosed as iron-deficiency anemia when there is
additional evidence of iron deficiency. Symptomatic iron deficiency during pregnancy
has deleterious effects on maternal & prenatal health (Colomer J, et al ,1990).
Iron deficiency anemia during pregnancy is associated with higher rates of
premature birth and low birth weight. Severe maternal anemia increases the risk of
reproduction-related mortality at delivery and during the prenatal period (Yip R,
2001). Women should be screened for anemia's at their first prenatal care visit, using
the anemia criteria for the specific stage of pregnancy. If the screen is positive for
anemia, the diagnosis should be confirmed by repeat hemoglobin concentration or
hematocrit test.
World Health Organization (WHO) has recommended supplementation of about 60
mg day to all women from the second trimester on world.
10
There is very little information about the mechanisms underpinning the
differential effects of doses and timing. It's generally agreed that the mother uses both
Fe stores and increased absorption to supply the developing fetus.
Placenta up-regulates some of the proteins of Fe transport as a response to maternal
deficiency. Iron is transferred from transferin receptor in the endocytotic vesicle into
the cell through a channel called divalent metal transporter1 (DMT1), there are at
least two isoforms of this protein. One is regulated by an iron responsive element
(IRE) and other is not. IRE is also up-regulated in the placenta by maternal Fe
deficiency.
Maternal iron (Fe) deficiency not only reduces fetal size, but also increases blood
pressure in the offspring when they are adult. Supplementation from the beginning of
the first, second, or third week all reduced the effect.
1.3.7 Prevalence & Etiology of Iron Deficiency In women
Iron deficiency is the most common recognized nutritional deficit in either the
developed or the developing world. During their reproductive years women are at risk
of iron deficiency due to blood loss from menstruation, in particular that 10% who
suffer heavy losses (>80 mL/mo). Contraceptive practice also plays a part—the
intrauterine devices increases menstrual blood loss by 30%–50% while oral
contraceptives have the opposite effect. Pregnancy is another factor. During
pregnancy there is a significant increase in the amount of iron required to increase the
red cell mass, expand the plasma volume and to allow for the growth of the fetalplacental unit. Finally, there is diet. Women in their reproductive years often have a
dietary iron intake that is too low to offset losses from menstruation and the increased
iron requirement for reproduction (Institute of Medicine, 1990). Consequently, the
11
overall prevalence of iron deficiency in non-pregnant women of reproductive age in
the United States, 9%–11%, is higher than at other ages apart from infancy. The
prevalence of IDA in the same age group is 2%–5%. Prevalence of iron deficiency
and IDA is increased 2-fold or more for those women who are minorities, below the
poverty level or with < 12 y of education. Risk is also increased with parity—nearly 3fold higher for women with 2–3 children and nearly 4-fold greater for women with 4
or more children, thus implicating pregnancy (Rasmussen, K, 2001).
It is estimated that < 50% of women do not have adequate iron stores for
pregnancy (Institute of Medicine, 1990. Gambling.L, et al, 2003). Because the iron
required for pregnancy (3–4 mg/d) is substantial, risk of iron deficiency and IDA
should increase with gestation. However, the prevalence of anemia and IDA in
pregnant women from the United States is not well defined but must be substantial,
particularly among the poor. During pregnancy, anemia increases > 4-fold from the 1st
to the 3rd trimester in the low-income women monitored as part of pregnancy
nutritional surveillance by the CDC (47). In the Camden Study where the cohort is
mostly minority, current data (2000–2004) suggest that the prevalence of anemia
increases > 6-fold from 6.7% (1st trimester) to 27.3% (2nd trimester) to 45.6% in the
3rd trimester. Only a fraction of anemic women in Camden have iron deficiency
anemia. Based on low hemoglobin for gestation by CDC criteria plus low ferritin
(<12), iron deficiency anemia in Camden gravidas is lower—1.8% in 1st trimester, to
8.2% in 2nd trimester, and 27.4% in 3rd trimester. Thus, anemia and IDA are not
synonymous, even among low-income minority women in their reproductive years.
12
1.3.8 Pregnancy Outcome with Maternal Anemia Detected Early in Pregnancy
Some of the increase in anemia and iron deficiency anemia with gestation is an
artifact of the normal physiologic changes of pregnancy (Looker AC, et al, 1997).
Although the maternal red -cell mass and plasma volume both increase during
gestation, they do not do so simultaneously. Hemoglobin and hematocrit decline
throughout the 1st and 2nd trimesters, reach their lowest point late in the second to
early in the 3rd trimester and then rise again nearer to term (Perry GS, et al, 1995). In
late pregnancy it is difficult to distinguish physiologic anemia from iron deficiency
anemia (Looker AC, et al, 1997. Scholl. TO, & Hediger ML, 1994). It is thus
becoming clear that the best time to detect any risk associated with maternal anemia
may be early in pregnancy.
1.3.9 Importance of the study
The purpose of this study was to incorporate current pregnancy and altitude Hb
parameters for diagnosing anemia and evaluate the effects of adjusted Hb
concentration on pregnancy outcome. Although research has demonstrated the effects
of altitude on Hb concentrations, many patients in developing countries still remain
undiagnosed of anemia due to the lack of application of these Hb adjustments. In this
study we provide data that supports previous research on the effects of maternal Hb
level on various pregnancy outcomes. Our work demonstrates that the application of
altitude-specific Hb adjustments for anemia is useful in the prediction of pregnancy
outcome. Finally, we determine which specific aspects of pregnancy outcome are
most clearly affected by maternal Hb concentration.
13
Chapter one:
Literature Review
14
Literature Review
An extensive literature review was conducted to identify whether iron deficiency,
iron-deficiency anemia and anemia from any cause are causally related to low birth
weight (LBW), preterm birth or prenatal mortality. Severe maternal anemia (<80 g/L)
is associated with birth weight values that are 200–400 g lower than in women with
higher (>100 g/L) hemoglobin values, but researchers generally have not excluded
other factors that might also have contributed to both LBW and the severity of the
anemia. Supplementation of anemic or no anemic pregnant women with iron (Fe),
folic acid or both does not appear to increase birth weight or the duration of gestation,
but the intervention trials on which this conclusion is based generally suffered from
design problems that would tend to produce false-negative findings. (Rasmussen,
K,2001).
Fe deficiency during pregnancy is common and has serious consequences both in
the short and the long term such as fetal growth retardation and cardiovascular
problems in the adult offspring. The placenta minimizes the effect of the deficiency by
up-regulating the proteins involved in Fe transfer. For example, transferring receptor
levels increase inversely to maternal Fe levels. The consequences are serious both for
the mother and her developing fetus, and many studies have shown that anemia during
pregnancy increases the risk of maternal mortality and morbidity, among the
consequences of IDA during pregnancy are lower birth weight and an increased risk
of cardiovascular disease in adulthood (Gambling.L, et al, 2003).
Iron deficiency anemia during pregnancy is associated with higher rates of
premature birth and low birth weight. Severe maternal anemia increases the risk of
reproduction-related mortality at delivery and during the prenatal period. Iron
deficiency in infants may also adversely influence cognitive development and may
15
have long-term consequences. The net amount of
57
Fe in the neonates’ circulation
(from maternal oral dosing) was significantly related to maternal iron absorption (P <
0.005) and inversely related to maternal iron status during the third trimester of
pregnancy: serum ferritin (P < 0.0001), serum folate (P < 0.005), and serum
transferring receptors (P < 0.02). Significantly more
57
Fe was transferred to the
neonates in non-iron-supplemented women the transfer of dietary iron to the fetus is
regulated in response to maternal iron status at the level of the gut (O’Brien. k, et al
.2003).
Iron (Fe) deficiency in pregnancy has serious consequences for both the mother
and her baby. In the immediate postnatal period, these include increased risk of low
birth-weight, increased morbidity and mortality. We have previously shown that
maternal iron (Fe) deficiency not only reduces fetal size, but also increases blood
pressure in the offspring when they are adults. Fe deficiency throughout pregnancy
reduces neonatal size. Supplementation from the beginning of the first, second or third
week all reduced the effect (Gambling. L, et al, 2004).
This review, intended for a broad scientific readership, summarizes evidence
relevant to whether a causal relation exists between dietary iron deficiency with
(ID+A) or without (ID-A) anemia during development and deficits in subsequent
cognitive or behavioral performance. Although this review focuses on dietary iron
deficiency, there are other causes of iron deficiency in children. Infants subjected to
conditions of pregnancy resulting in intrauterine growth restriction (IUGR), infants
who are small-for-gestational age (SGA), infants of diabetic mothers (IDMs), or
infants born of preeclamptic mothers can also be iron deficient. Other factors
associated with iron deficiency in infants are early umbilical cord clamping,
prematurely, and fetal blood loss (Joyce C McCann and Bruce N Ames. 2007).
16
Anemia in pregnancy is a major health problem in many developing countries
where nutritional deficiency contributes to increased maternal and prenatal mortality
and morbidity. The objective of this review was to assess the effects of routine iron
and folate supplementation on hematological and biochemical parameters and on
pregnancy outcome. Routine supplementation with iron and folate appears to prevent
low hemoglobin at delivery. There is very little information on other outcomes for
either mother or baby. There are few data derived from communities where iron and
folate deficiency is common and anemia is a serious health problem (Mahmomed, K,
2007).
This review showed many gaps in our knowledge about the adverse effects of
maternal anemia and iron deficiency on pregnancy outcome. Current knowledge
indicates that iron deficiency anemia in pregnancy is a risk factor for preterm delivery
and subsequent low birth weight, and possibly for inferior neonatal health. Likewise,
the benefits of maternal iron supplementation on these outcomes are unclear, even for
women who develop anemia during pregnancy. However, there is substantial
evidence that maternal iron deficiency anemia increases the risk of preterm delivery
and subsequent low birth weight, and accumulating information suggests an
association between maternal iron status in iron status of infants postpartum (Allen,
LH. 2000).
The relationship between anemia or iron deficiency anemia and increased risk of
preterm delivery (<37 wk gestation) has been supported by several studies (Klebanoff
et al. 1991 ; Lu et al. 1991 , Murphy et al. 1986 , Scholl et al. 1992 , Scholl and
Hediger 1994 , Zhou et al. 1998 ). Studies have attempted to distinguish actual iron
deficiency anemia from the normal influences of pregnancy-associated hemodilution
as gestation proceeds by studying pregnant women early in gestation.
17
Pregnancy requires additional maternal absorption of iron. Maternal iron status
cannot be assessed simply from hemoglobin concentration because pregnancy
produces increases in plasma volume and the hemoglobin concentration decreases
accordingly. This decrease is greatest in women with large babies or multiple
gestations. However, mean corpuscular volume does not change substantially during
pregnancy and a hemoglobin concentration <95 g/L in association with a mean
corpuscular volume <84 fL probably indicates iron deficiency. Severe anemia
(hemoglobin <80 g/L) is associated with the birth of small babies (from both preterm
labor and growth restriction), but so is failure of the plasma volume to expand. (Steer,
P. 2000).
A negative association between anemia and duration of gestation and low birth
weight has been reported in the majority of studies, although a causal link remains to
be proven. This paper explores potential biological mechanisms that might explain
how anemia, iron deficiency or both could cause low birth weight and preterm
delivery. The risk factors for preterm delivery and intrauterine growth retardation are
quite similar, although relatively little is understood about the influence of maternal
nutritional status on risk of preterm delivery (Allen, LH. 2000).
Risk of preterm birth was increased in women with low hemoglobin level in the
first and second trimester. The odds ratio (OR) for preterm birth with moderate-tosevere anemia during the first trimester (more than three standard deviations [SD]
below reference median hemoglobin, equivalent to less than 95 g/L at 12 weeks’
gestation) was 1.68 (95% confidence interval [CI] 1.29, 2.21). Iron supplementation
during pregnancy is a routine practice intended to prevent iron-deficiency anemia. Our
study suggests that iron supplementation may prevent preterm birth, if the observed
association can be established as causal (Kelley S, Scanlon 2000).
18
Iron but not folic acid supplementation reduces the risk of low birth weight in
pregnant women without anaemia: Folic acid only (15 mg/day) was unrelated to
LBW; whereas iron supplementation (80 mg ferrous sulphate) was associated with a
lower risk of LBW Iron supplementation is associated with a lower risk of LBW in
pregnant women without anemia. Current knowledge indicates that anaemia in
pregnancy is a risk factor for preterm delivery & subsequent low birth weight routine
iron & folic acid supplementation is recommended during pregnancy to avoid the
deleterious effect of anaemia on birth weight .It has been suggested that a selective
supplementation reserved for women with anaemia should be preferred to routine
supplementation because iron is a potentially toxic element & unjustified
supplementation could expose women to high levels of iron and to oxidative stress,
which is also observed in pregnancy pathologies preeclampsia, gestational diabetes
(Palma S, et al 2008).
Although most causal criteria are supported by at least some evidence from either
human or animal studies, significant gaps suggest that it would be premature to
conclude that a causal connection exists between iron deficiency per se during
development and subsequent cognitive or behavioral performance. In humans,
although several causal criteria have been at least partially satisfied, the specificity of
both cause and effect has not been clearly established. Animal studies provide
important support for results in humans and also supply information that cannot be
obtained in human studies. In the rodent experiments discussed here, plausible
biological rationales have been identified, the specificity of cause has been better
established than in humans, an association between deficits in motor activity and
severe ID+A have consistently been observed, and the reversibility or irreversibility of
effects of iron treatment parallel observations in humans. However, the specificity of
19
effect has not established in animal studies, relatively few cognitive and behavioral
tests have been conducted, results have not been independently replicated, and doseresponse relations have essentially not been investigated. Although there is some
logical support for and suggestive evidence from a few human studies of the possible
effects of ID-A on cognitive or behavioral development, the literature is surprisingly
uninformative on this extremely important topic, primarily because so few studies
have been conducted. Because 2 billion women and children are iron deficient
worldwide, and the greatest prevalence of ID±A in the United States is among
adolescent girls (9–16%) and children during the brain growth spurt. (Joyce C
McCann, & Bruce N Ames. 2007)
Effort should be directed toward using the available observational data to estimate
the risk of LBW and preterm birth that is attributable to iron-deficiency anemia as
distinct from anemia from other causes. This requires studies in which iron deficiency
was ascertained by some method in addition to maternal hemoglobin concentration.
Because data in many of the published papers were not presented in a way that would
permit this calculation to be made, access to the original data, which was not possible
for the present review, will be required to estimate this risk.
Priority should be given to conducting studies of iron and folate supplementation
during pregnancy that meet the criteria for demonstrating a positive effect of
supplementation on birth outcomes, should such an effect exist. In particular, this
means studying a population in which the mean birth weight is <3.3 kg, treating all
women to eliminate other causes of LBW or preterm birth, selecting women with irondeficiency anemia for iron supplementation (or folate deficiency for folic acid
supplementation), and including a sufficient number of subjects for adequate
statistical power. (Rasmussen, K, 2001)
20
This review showed many gaps in our knowledge about the adverse effects of
maternal anemia and iron deficiency on pregnancy outcome. Such disparities include
inadequate documentation of anemia's effects on maternal mortality, morbidity, and
well-being, and on infant health and development. Likewise, the benefits of maternal
iron supplementation on these outcomes are unclear, even for women who develop
anemia during pregnancy. However, there is substantial evidence that maternal iron
deficiency anemia increases the risk of preterm delivery and subsequent low birth
weight, and accumulating information suggests an association between maternal iron
status in pregnancy and the iron status of infants postpartum. Certainly, iron
supplements improve the iron status of the mother during pregnancy and during the
postpartum period, even in women who enter pregnancy with reasonable iron stores.
The advisability of routine iron supplementation during pregnancy, regardless of
whether the mother is anemic, has been heavily debated in the United States , and
routine supplementation is not universally practiced in all industrialized countries . In
my opinion, the mass of evidence supports the practice of routine iron
supplementation during pregnancy, although iron supplementation is certainly most
important for those pregnant women who develop anemia. (Allen, LH. 2000).
This review showed many gaps in our knowledge about the adverse effects of
maternal anemia and iron deficiency on pregnancy outcome. Such disparities include
inadequate documentation of anemia's effects on maternal mortality, morbidity, and
well-being, and on infant health and development. Likewise, the benefits of maternal
iron supplementation on these outcomes are unclear, even for women who develop
anemia during pregnancy. However, there is substantial evidence that maternal iron
deficiency anemia increases the risk of preterm delivery and subsequent low birth
weight, and accumulating information suggests an association between maternal iron
21
status in pregnancy & the iron status of infants postpartum. Certainly, iron
supplements improve the iron status of the mother during pregnancy and during the
postpartum period, even in women who enter pregnancy with reasonable iron stores
(Allen, LH. 2000).
Severe maternal anemia (<80 g/L) is associated with birth weight values that are
200–400 g lower than in women with higher (>100 g/L) hemoglobin values, but
researchers generally have not excluded other factors that might also have contributed
to both LBW and the severity of the anemia.
Supplementation of anemic or nonanemic pregnant women with iron, folic acid or
both does not appear to increase birth weight or the duration of gestation, but the
intervention trials on which this conclusion is based generally suffered from design
problems that would tend to produce false-negative findings. (Rasmussen, K, 2001)
Pregnancy requires additional maternal absorption of iron. Maternal iron status
cannot be assessed simply from hemoglobin concentration because pregnancy
produces increases in plasma volume and the hemoglobin concentration decreases
accordingly. This decrease is greatest in women with large babies or multiple
gestations.
In summary, plasma volume expansion in normal pregnancy causes a drop in
maternal hemoglobin to concentrations commonly regarded as indicating anemia; in
fact, concentrations of 95–115 g/L with a normal mean corpuscular volume (84–99
fL) should be regarded as optimal for fetal growth and well-being and are associated
with the lowest risk of preterm labor. Routine hematinic administration to women
with values in these ranges is probably unnecessary. (Steer, P. 2000)
Iron-deficiency anemia was associated with significantly lower energy and iron
intakes early in pregnancy and a lower mean corpuscular volume. The odds of low
22
birth weight were tripled and of preterm delivery more than doubled with iron
deficiency, but were not increased with anemia from other causes. When vaginal
bleeding at or before entry to care accompanied anemia, the odds of a preterm
delivery were increased fivefold for iron-deficiency anemia and doubled for other
anemias. Inadequate pregnancy weight gain was more prevalent among those with
iron-deficiency anemia & in those with anemias of other etiologies. (Scholl TO, et al,
1992).
When maternal anemia is diagnosed before midpregnancy, it has been associated
with an increased risk of preterm delivery. Maternal anemia detected during the later
stages of pregnancy, especially the third trimester, often reflects the expected (and
necessary) expansion of maternal plasma volume. Third-trimester anemia usually is
not associated with increased risk of preterm delivery. Although, controlled trials of
iron supplementation during pregnancy have consistently demonstrated positive
effects on maternal iron status at delivery.
Associations between low maternal hemoglobin concentrations and hematocrits at
delivery and poor pregnancy outcome have been reported in several studies. Reported
the effects of maternal anemia on pregnancy in >50,000 pregnancies. (Garn SM, et al,
1981).
Maternal anemia at the time of delivery and preterm delivery was an artifact of
blood sample collection time. During pregnancy, the normal physiologic changes in
plasma volume and red cell mass occur at different periods during gestation. Because
these changes are asynchronous, lower hematocrits typify earlier stages of pregnancy
when preterm delivery commonly occurs, and higher hematocrit values are associated
with pregnancies delivered at later gestational periods. (Theresa O. et al, 2000).
23
Relationships between hemoglobin concentrations and birth outcomes have not
been well characterized in African-American adolescents despite the fact that this
group is at a higher risk of early childbearing. To address this issue, we characterized
the prevalence of anemia and maternal factors associated with anemia in pregnant
African-American adolescents. (Agarwal KN, et al. 1991)
Multiparity, inadequate prenatal care, low prepregnancy BMI, history of selfreported cigarette use and infection with sexually transmitted diseases were
significantly associated with lower hemoglobin during pregnancy.
Extremes of iron status during pregnancy may adversely impact birth outcomes.
Relationships between anemia and adverse birth outcomes have been inconsistent:
Some studies have found anemia to significantly increase the risk of adverse birth
outcomes whereas, others have not. At the other end of the spectrum, elevated
Hemoglobin concentrations during pregnancy also increase the risk of adverse birth
Outcomes, including preterm delivery, low birth weight (LBW), fetal death and
intrauterine growth. (O’Brien k, et al .2003)
24
Chapter two:
Methodology
25
2.1 Aim of the study
The aim of this study was to determine the effect of the timing of iron deficiency
rates during pregnancy on fetal growth and pregnancy outcome, the developing fetus
is very sensitive to maternal iron status, and the period of supplementation is critical
in reversing the effects of maternal anemia.
2.2 Objectives
1- The main objective of the present research is to determine the association between
iron deficiency anemia in pregnancy and birth outcomes.
2- To assess whether iron deficiency anemia increase risk of fetal growth.
3- Assess the effects of routine iron & folate supplementation on haematological
& biochemical parameters and on pregnancy outcome.
We will have the permission from the Administration of Rafidia Governmental
Hospital, Etihad Hospital, Arab Hospital & Nablus specialist Hospital at Nablus city,
a visit to the hospitals and checking the chart number of all babies who were admitted
to neonatal I.C.U and also the mother’s chart number for these babies from the
archive in governmental and Private hospitals in north areas of Palestine will be done.
The students prepare a special questionnaire (self-designated questionnaire), which
offered to neonatologist and gynecologist in hospitals and offered also to midwives
and the Dean of Nursing College at An-Najah National University to have an
agreement about the quality of questions and to confirm a validity in questions which
was prepared.
The students will visit the Rafidia, Etihad hospitals, Arab Hospital & Nablus
Specialist Hospital to fulfill the questionnaire prepared from the chart of all baby who
26
admitted to neonatal I.C.U with birth outcomes after delivery such as, prematurity,
low birth weight, and other birth outcomes and in the other hand looking to maternal
serum Hb levels to identify if their is there a causal relationship between iron
deficiency anemia in pregnant women and birth outcome. So the sample of this study
is selected randomly
2.3 Conceptual framework
The primary question addressed in this review is whether maternal anemia,
assessed primarily as hemoglobin concentration, is causally related to weight at birth
or duration of gestation or both. As it is used in the diagram, LBW refers to the
weight of the fetus at delivery, which may be before term. Furthermore, a second
question is whether maternal anemia is causally related to perinatal mortality, either
directly or indirectly via weight at birth or duration of gestation.
It is unknown to what extent maternal hemoglobin concentration at various stages
of pregnancy influences fetal growth and the timing of birth; thus, this diagram shows
multiple influences of maternal hemoglobin concentration on this outcome. figure(39)
2.4 Hypothesis
The association between anemia and birth outcomes may be stronger if the anemia
occurs at one time during pregnancy rather than at another time. This is because of
differences in the rates of fetal growth and development during gestation.
2.5 Study design
Retrospective study will use to identify the effects of anemia and iron deficiency
on pregnant outcome & to determine the extent to which maternal anemia might
contribute to perinatal mortality.
27
2.6 Ethical consideration
This study is performed and is approved by the research ethics committee of the
Ministry of Health and the Faculty of Nursing – An-Najah National University.
The data was collected retrospective related to the patient's charts and protects
concentrates on the patient's health and well being.
The results are protected in a way to ensured that it is not possible to identifying
any of the individuals.
2.7 Materials and methods
This is a retrospective study conducted using simple random sampling method in
Nablus areas including Rafidia Governmental Hospital, Etihad Hospital, and Arab
Specialist, Nablus Specialist Hospital. We obtained informed consent from all
hospitals included in the study and the Ministry of Health. After working Etihad
Hospital was dismissed, because the files aren't containing some of the information
that needed to fill in the questionnaire. The sample size including 69 pregnant women
who referred to these hospitals were enrolled. We selected this number because it is
difficult to take mothers and babies charts from the archive.
Self reported and filling questionnaire will be used to collect data in this study and
in these study use of 21 questions to determine the effects of iron deficiency anemia
on pregnancy outcome, and the questions has three concepts , the first , contain the
especial information & demographic data , the second , information about pregnant
women , and the third , about the child.
Some questions have two choices Yes or No and other determination answer of
question. The purpose of questions is to examine the effects of maternal iron
deficiency anemia on pregnancy outcome.
28
Chapter three:
Data analysis
29
3.1 The Hypothesis
3.1.1 Baby weight
1. There exists no significant relationship, in the significance level 0.05, between
taking iron during pregnancy and baby weight.
2. There exists no significant relationship, in the significance level 0.05, between
having bleeding before or after the delivery and baby weight.
3. There exists no significant relationship, in the significance level 0.05, between
having antacids with iron during this pregnancy and baby weight.
4. There exists no significant relationship, in the significance level 0.05, between Hb
level during the pregnancy and baby weight.
5. There exists no significant relationship, in the significance level 0.05, between age
of the women and baby weight.
3.1.2 Type of delivery
6. There exists no significant relationship, in the significance level 0.05, between
taking iron during pregnancy and type of delivery.
7. There exists no significant relationship, in the significance level 0.05, between
having bleeding before or after the delivery and type of delivery.
8. There exists no significant relationship, in the significance level 0.05, between
having antacids with iron during this pregnancy and type of delivery.
9. There exists no significant relationship, in the significance level 0.05, between Hb
level during the pregnancy and type of delivery.
30
10. There exists no significant relationship, in the significance level 0.05, between age
of the women and type of delivery.
3.1.3 Gestational age in the delivery
11. There exists no significant relationship, in the significance level 0.05, between
taking iron during pregnancy and gestational age in the deliver.
12. There exists no significant relationship, in the significance level 0.05, between
having bleeding before or after the delivery and gestational age in the deliver.
13. There exists no significant relationship, in the significance level 0.05, between
having antacids with iron during this pregnancy and gestational age in the deliver.
14. There exists no significant relationship, in the significance level 0.05, between Hb
level during the pregnancy and gestational age in the deliver.
15. There exists no significant relationship, in the significance level 0.05, between age
of the women and gestational age in the deliver.
31
3.2 Distributions of the Sample
The tables below show the frequencies and the percentages of the study sample.
1- Age of the mother
Table (1) distribution of study sample According to age of mother
Valid
Frequency
Percent
Less than 20 years
3
4.3
20-30 years
46
66.7
31-40 years
16
23.2
Missing System
4
5.8
Total
69
100.0
We notice from table(1) above that 66.7% of cases the mothers age is between 2030 years,23.3% between 31-40 years and only 4.3% of cases less than 20 years .
2- Do you take iron during pregnancy?
Table (2) distribution of study sample According do you take iron during
pregnancy?
Do you take iron during
Frequency
Percent
Yes
62
89.9
No
7
10.1
Total
69
100.0
pregnancy?
32
From table (2) above we notice that the majority of the cases take iron during
pregnancy with 89.9% of them and only 10.1% doesn't take.
3- Have you bleeding before or after this delivery?
Table (3) distribution of study sample According to have you bleeding before or
after this delivery.
Have you bleeding before or after
Frequency
Percent
this delivery?
Yes
4
5.8
No
65
94.2
Total
69
100.0
We notice from the table above that 94.2% of the cases have not bleeding before
or after and only 5.8% they bleeding.
4- Have you take antacids with iron during this pregnancy?
Table (4) distribution of study sample According to take antacids with iron
during this pregnancy?
Have you take antacids with
Frequency
Percent
Yes
4
5.8
No
50
72.5
Frequently
15
21.7
Total
69
100.0
iron during this pregnancy?
33
We notice from the table above that 72.5% of the cases of the mother doesn't take
antacids with iron during this pregnancy, 21.7% frequently and only 5.8% take the
antacids.
5- Hb level during this pregnancy
Table (5) distribution of study sample according to Hb level during this
pregnancy.
Hb level during this
Frequency
Percent
Grater than> 10g\L
40
58.0
Less than<=10\l
29
42.0
Total
69
100.0
pregnancy
We notice from the table above that 58% of cases the mothers Hb level during
pregnancy is greater than 10g/L and 42% less and equal 10g/L.
6- Gestational age in the delivery
Table (6) distribution of study sample According to: Gestational age in the
delivery.
Gestational age in the
Frequency
Percent
Less than 35 wk
11
15.9
Between 35-42 wk
58
84.1
Total
69
100.0
delivery
34
The table above shows that the 84.1% of the sample a gestational age in the
delivery is between 35-42 weak and only 15.9% less than 35 weak.
7- Baby weight
Table (7) distribution of study sample According to baby weight.
Baby weight
Frequency
Percent
Less than 2.50g
21
30.4
2.5-4.5 g
48
69.6
Total
69
100.0
We notice from table (7) above that 69.6% of cases the baby weight is between
2.5 and 4.5 g and 30.4% of the cases the baby weight is less than 2.5 g.
8- Type of delivery
Table (8) distribution of study sample According type of delivery.
Type of delivery
Frequency
Percent
C\S
43
62.3
N\D
26
37.7
Total
69
100.0
We notice from table (8) above that 62.3% of samples have cesareans delivery and
37.7% normal delivery.
35
3.3 Questionnaire
The questionnaire was including demographic information, including
age of
mother , taking iron during pregnancy , has she bleeding before or after this delivery
,Has she take antacids with iron during this pregnancy?, Hb level during this
pregnancy, Gestational age in the delivery ,baby weight, type of delivery.
3.4 Validity of the tool
For verifying the validity of the tool and knowing if the questionnaire with its
sections really measure what they were designed to, it was presented to arbitrators, the
items were adopted after being accepted by arbitrators ,and there was unanimity on
the tool of the study ,as well as acceptance of the modifications made by the
researcher on the questionnaire.
3.5 Procedure
The study was carried out in accordance with the following steps:-
1.Preparing the tool of the study in its final form after being presented to the
arbitrators and verifying its validity and reliability.
2.Deciding on the subject of the study sample.
3.The relevant data were analyzed and entered to the statistical model using SPSS to
find results for the established hypotheses.
36
3.6 Operational definition of the study variable:
The statistical analysis of the study focused on the relationship between IDA is
strong with the birth outcome.
First: Dependent variable:

Baby weight.

Type of delivery.

Gestational age in the deliver
Second: independent variables:

Taking iron during pregnancy.

Having bleeding before or after the delivery.

Having antacids with iron during this pregnancy.

Hb level during the pregnancy.

Age of the women.
3.7 Statistical treatment:
1. Frequencies and percentages.
2. ANOVA.
3. Simple Linear Regression Model.
4. Correlation Coefficient R.
37
Chapter four:
Results of the hypothesis
38
4.1 First hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between taking iron during pregnancy and
baby weight." in order to test the significant of simple linear regression model We
use ANOVA test and the table below show the result of the test:-
Table (9): ANOVA test between taking iron during pregnancy and baby weight
Sum of
.
Mean
Df
Squares
.003
1
.003
Residual
14.606
67
.218
Total
14.609
68
Regression
F
Sig.
.012
.912
Square
Since the level of significance (0.912) is bigger than 0.05, we accept the
hypothesis and conclude that "There exists no significant relationship, in the
significance level 0.05, between taking iron during pregnancy and baby weight.
And the equation of the simple linear Regression is shown in table below:-
Table (10): Simple Linear Regression model between taking iron during
pregnancy and baby weight.
(Constant)
Do you take iron during
pregnancy?
39
B
t
1.673
7.868
2.074E-02
.111
The equation of the simple linear Regression is:-
a=0.0207b+1.673
a: is baby weight
b: taking iron during pregnancy
Since the R equal (0.014) and R square equal (0.000) there is no correlation
between taking iron during pregnancy and baby weight.
4.2 Second hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between having bleeding before or after
the delivery and baby weight" in order to test the significant of simple linear
regression model We use ANOVA test and the table below show the result of the
test:-
Table (11): ANOVA test between having bleeding before or after the delivery
and baby weight.
Sum of
Mean
Df
Squares
Sig.
.754
.388
Square
.163
1
.163
Residual
14.446
67
.216
Total
14.609
68
Regression
F
40
Since the level of significance (0.388) is bigger than 0.05, we accept the hypothesis
and conclude that “There exists no significant relationship, in the significance level
0.05, between having bleeding before or after the delivery and baby weight.
The equation of the simple linear Regression is shown in table below.
Table (12): Simple Linear Regression model between having bleeding before or
after the delivery and baby weight.
B
t
(Constant)
1.292
2.762
Have you complain of bleeding
before or after this delivery?
.208
.868
The equation of the simple linear Regression is:-
a=0.208b+1.292
a: is baby weight
b: having bleeding before or after the delivery
Since R equal (0.105) and R square equal (0.011) there is a very weak correlation
between the between having bleeding before or after the delivery and baby weight.
4.3 Third hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between having antacids with iron during
this pregnancy and baby weight " in order to test the significant of simple linear
41
regression model We use ANOVA test and the table below show the result of the
test:-
Table (13): ANOVA test between: having antacids with iron during this
pregnancy, and baby weight.
Sum of
Mean
Df
Squares
.408
1
.408
Residual
14.201
67
.212
Total
14.609
68
Regression
F
Sig.
1.924
.170
Square
Since the level of significance (0.170) is bigger than 0.05, we accept the
hypothesis and conclude that “There exists no significant relationship, in the
significance level 0.05, between having antacids with iron during this pregnancy and
baby weight.
The equation of the simple linear Regression is shown in table below.
Table (14): Simple Linear Regression model between having antacids with iron
during this pregnancy and baby weight
B
t
(Constant)
2.028
8.252
Having antacids
-.154
-1.387
42
The equation of the simple linear Regression is:-
a=-0.154b+2.028
a Dependent Variable: baby weight
a: is baby weight
b: having antacids with iron during this pregnancy
Since R equal (0.167) and R square equal (0.028) there is a very weak correlation
between having antacids with iron during this pregnancy and baby weight.
4.4 Fourth hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between Hb level during the pregnancy
and baby weight " in order to test the significant of simple linear regression model
We use ANOVA test and the table below show the result of the test:-
Table (15): ANOVA test between Hb level during the pregnancy and baby
weight.
Sum of
Mean
Df
Squares
.198
1
.198
Residual
14.410
67
.215
Total
14.609
68
Regression
F
Sig.
.922
.340
Square
43
Since the level of significance (0.340) is bigger than 0.05, we accept the hypothesis
and conclude that “There exists no significant relationship, in the significance level
0.05, between Hb level during the pregnancy and baby weight.
The equation of the simple linear Regression is shown in table below.
Table (16): Simple Linear Regression model: between Hb level during the
pregnancy and baby weight.
B
t
(Constant)
1.541
9.063
Hb level during the pregnancy
.109
.960
The equation of the simple linear Regression is:-
a=0.109b+1.541
a: is baby weight
b: Hb level during the pregnancy
Since R equal (0.117) and R square equal (0.014) there is a very weak correlation
between Hb level during the pregnancy and baby weight.
4.5 Fifth hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between age of the women and baby
weight " in order to test the significant of simple linear regression model We use
ANOVA test and the table below show the result of the test:-
44
Table (17): ANOVA test between: age of the women and baby weight.
Sum of
Mean
Df
Squares
Sig.
2.600
.112
Square
.549
1
.549
Residual
13.297
63
.211
Total
13.846
64
Regression
F
Since the level of significance (0.112) is bigger than 0.05, we accept the
hypothesis and conclude that “There exists no significant relationship, in the
significance level 0.05, between age of the women and baby weight.
The equation of the simple linear Regression is shown in table below.
Table (18): Simple Linear Regression model: between age of the women and
baby weight.
B
t
(Constant)
1.290
5.038
Age of the women
.183
1.612
The equation of the simple linear Regression is:-
a=0.183b+1.290
a: is baby weight
b: age of the women
45
Since R equal (0.199) and R square equal (0.040) there is a very weak correlation
between age of the women and baby weight.
4.6 Sixth hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between taking iron during pregnancy and
type of delivery." in order to test the significant of simple linear regression model
We use ANOVA test and the table below show the result of the test:-
Table (19): ANOVA test: between taking iron during pregnancy and type of
delivery.
Sum of
Mean
Df
Squares
.021
1
.021
Residual
16.182
67
.242
Total
16.203
68
Regression
F
Sig.
.086
.770
Square
Since the level of significance (0.770) is bigger than 0.05, we accept the
hypothesis and conclude that “There exists no significant relationship, in the
significance level 0.05, between taking iron during pregnancy and type of delivery.
And the equation of the simple linear Regression is shown in table below:-
46
Table (20): Simple Linear Regression model: between taking iron during
pregnancy and type of delivery.
B
t
1.313
5.869
5.760E-02
.294
(Constant)
Do you take iron during
pregnancy?
The equation of the simple linear Regression is:-
a=0.0577b+1.313
a: is type of delivery.
b: taking iron during pregnancy
Since the R equal (0.036) and R square equal (0.001) there is a very weak
correlation between taking iron during pregnancy and type of delivery.
4.7 Seventh hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between having bleeding before or after
the delivery and type of delivery." in order to test the significant of simple linear
regression model We use ANOVA test and the table below show the result of the
test:-
47
Table (21): ANOVA test between having bleeding before or after the delivery
and type of delivery.
Sum of
Mean
Df
F
Squares
.591
1
.591
Residual
15.612
67
.233
Total
16.203
68
Regression
Sig.
Square
2.538
.116
Since the level of significance (0.116) is bigger than 0.05, we accept the
hypothesis and conclude that “There exists no significant relationship, in the
significance level 0.05, between having bleeding before or after the delivery and
gestational age in the deliver.
The equation of the simple linear Regression is shown in table below.
Table (22): Simple Linear Regression model between having bleeding before or
after the delivery and type of delivery
B
t
(Constant)
2.146
4.412
Have you complain of bleeding
-.396
-1.593
before or after this delivery
The equation of the simple linear Regression is:-
a=-0.396 b+2.14
48
a: is gestational age in the deliver
b: having bleeding before or after the delivery
Since R equal (0.191) and R square equal (0.036) there is a very weak correlation
between the between having bleeding before or after the delivery
and type of
delivery.
4.8 Eightty hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between having antacids with iron during
this pregnancy and type of delivery " in order to test the significant of simple linear
regression model We use ANOVA test and the table below show the result of the
test:-
Table (23): ANOVA test between having antacids with iron during this
pregnancy and type of delivery.
Sum of
Mean
Df
Squares
.076
1
.076
Residual
16.127
67
.241
Total
16.203
68
Regression
F
Sig.
.316
.576
Square
Since the level of significance (0.576) is bigger than 0.05, we accept the
hypothesis and conclude that “There exists no significant relationship, in the
significance level 0.05, between having antacids with iron during this pregnancy and
type of delivery.
49
The equation of the simple linear Regression is shown in table below.
Table (24): Simple Linear Regression model between having antacids with iron
during this pregnancy and type of delivery.
B
t
1.520
5.805
-6.639E-02
-.562
(Constant)
Having antacids
The equation of the simple linear Regression is:-
a=-0.066b+1.52
a Dependent Variable: gestational age in the deliver
a: is type of delivery
b: having antacids with iron during this pregnancy
Since R equal (0.068) and R square equal (0.005) there is a very weak correlation
between having antacids with iron during this pregnancy and type of delivery.
4.9 Ninth hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between Hb level during the pregnancy
and type of delivery " in order to test the significant of simple linear regression model
We use ANOVA test and the table below show the result of the test:-
50
Table (25): ANOVA test between: Hb level during the pregnancy and type of
delivery.
Sum of
Mean
Df
Squares
.000
1
.000
Residual
16.203
67
.242
Total
16.203
68
Regression
F
Sig.
.001
.971
Square
Since the level of significance (0.971) is bigger than 0.05, we accept the
hypothesis and conclude that “There exists no significant relationship, in the
significance level 0.05, between Hb level during the pregnancy and type of delivery.
The equation of the simple linear Regression is shown in table below.
Table (26): Simple Linear Regression model between Hb level during the
pregnancy and type of delivery.
(Constant)
Hb level during the pregnancy
The equation of the simple linear Regression is:-
a=0.109b+1.541
a: is type of delivery
51
B
t
1.371
7.601
4.310E-03
.036
b: Hb level during the pregnancy
Since R equal (0.004) and R square equal (0.000) there is no correlation between
Hb level during the pregnancy and type of delivery.
4.10 Tenth hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between age of the women and type of
delivery " in order to test the significant of simple linear regression model We use
ANOVA test and the table below show the result of the test:-
Table (27): ANOVA test between age of the women and type of delivery.
Sum of
Mean
Df
Squares
F
Sig.
16.626
.000
Square
Regression
3.161
1
3.161
Residual
11.977
63
.190
Total
15.138
64
Since the level of significance (0.000) is smaller than 0.05, we reject the
hypothesis and conclude that “There exists a significant relationship, in the
significance level 0.05, between age of the women and type of delivery".
The equation of the simple linear Regression is shown in table below.
52
Table (28): Simple Linear Regression model between age of the women and type
of delivery.
B
t
(Constant)
.403
1.660
Age of the women
.439
4.078
The equation of the simple linear Regression is:-
a=0.439b+0.403
a: is type of delivery
b: age of the women
Since R equal (0.457) and R square equal (0.209) there is a weak correlation
between age of the women and type of delivery
4.11 Eleventh hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between taking iron during pregnancy and
gestational age in the deliver." in order to test the significant of
simple linear
regression model We use ANOVA test and the table below show the result of the
test:-
53
Table (29): ANOVA test between: taking iron during pregnancy and gestational
age in the delivery.
Sum of
Mean
Df
Squares
F
Sig.
1.466
.230
Square
Regression
.198
1
.198
Residual
9.048
67
.135
Total
9.246
68
Since the level of significance (0.230) is bigger than 0.05, we accept the
hypothesis and conclude that “There exists no significant relationship, in the
significance level 0.05, between taking iron during pregnancy and gestational age in
the delivery.
And the equation of the simple linear Regression is shown in table below:-
Table (30): Simple Linear Regression model: between taking iron during
pregnancy and gestational age in the delivery.
B
t
(Constant)
1.645
9.831
Do you take iron during
.177
1.211
pregnancy?
The equation of the simple linear Regression is:-
a=0.177b+1.645
a: is gestational age in the deliver
54
b: taking iron during pregnancy
Since the R equal (0.146) and R square equal (0.021) there is a very weak
correlation between taking iron during pregnancy and gestational age in the deliver
4.12 Twelfth hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between having bleeding before or after
the delivery and gestational age in the deliver." in order to test the significant of
simple linear regression model We use ANOVA test and the table below show the
result of the test:-
Table (31): ANOVA test between having bleeding before or after the delivery
and gestational age in the delivery.
Sum of
Mean
Df
Squares
F
Sig.
3.770
.056
Square
Regression
.493
1
.493
Residual
8.754
67
.131
Total
9.246
68
Since the level of significance (0.056) is bigger than 0.05, we accept the
hypothesis and conclude that “There exists no significant relationship, in the
significance level 0.05, between having bleeding before or after the delivery and
gestational age in the delivery.
The equation of the simple linear Regression is shown in table below.
55
Table (32): Simple Linear Regression model between having bleeding before or
after the delivery and gestational age in the delivery.
B
t
(Constant)
1.138
3.126
Have you bleeding before
.362
1.942
/after this delivery?
The equation of the simple linear Regression is:-
a=0.362 b+1.138
a: is gestational age in the deliver
b: having bleeding before or after the delivery
Since R equal (0.231) and R square equal (0.053) there is a very weak correlation
between having bleeding before or after the delivery
and gestational age in the
delivery.
4.13 Thirteenth hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between having antacids with iron during
this pregnancy and gestational age in the deliver " in order to test the significant of
simple linear regression model We use ANOVA test and the table below show the
result of the test:-
56
Table (33): ANOVA test between: having antacids with iron during this
pregnancy and gestational age in the delivery.
Sum of
Mean
Df
Squares
F
Sig.
.659
.420
Square
Regression
.090
1
.090
Residual
9.156
67
.137
Total
9.246
68
Since the level of significance (0.420) is bigger than 0.05, we accept the
hypothesis and conclude that "There exists no significant relationship, in the
significance level 0.05, between having antacids with iron during this pregnancy and
gestational age in the deliver.
The equation of the simple linear Regression is shown in table below.
Table (34) Simple Linear Regression model: between having antacids with iron
during this pregnancy and gestational age in the delivery.
B
t
1.997
10.119
-7.227E-02
-.812
(Constant)
Having antacids
The equation of the simple linear Regression is:-
a=-0.0722b+1.977
a: is gestational age in the delivery
b: having antacids with iron during this pregnancy
57
Since R equal (0.099) and R square equal (0.010) there is a very weak correlation
between having antacids with iron during this pregnancy and gestational age in the
delivery.
4.14 Fourteenth hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between Hb level during the pregnancy
and gestational age in the deliver " in order to test the significant of simple linear
regression model We use ANOVA test and the table below show the result of the
test:-
Table (35): ANOVA test between: Hb level during the pregnancy and gestational
age in the delivery.
Sum of
Mean
Df
Squares
F
Sig.
.061
.805
Square
Regression
.008
1
.008
Residual
9.238
67
.138
Total
9.246
68
Since the level of significance (0.805) is bigger than 0.05, we accept the
hypothesis and conclude that “There exists no significant relationship, in the
significance level 0.05, between Hb level during the pregnancy and gestational age in
the delivery
The equation of the simple linear Regression is shown in table below.
58
Table (36): Simple Linear Regression model between: Hb level during the
pregnancy and gestational age in the delivery.
B
t
1.872
13.751
-2.241E-02
-.247
(Constant)
Hb
level
during
the
pregnancy
The equation of the simple linear Regression is:-
a=-0.022 b+1.872
a: is gestational age in the deliver
b: Hb level during the pregnancy
Since R equal (0.030) and R square equal (0.001) there is a very weak correlation
between Hb level during the pregnancy and gestational age in the delivery.
4.15 Fifteenth hypothesis
In order to study the truth of
the hypotheses “There exists no significant
relationship, in the significance level 0.05, between age of the women and gestational
age in the deliver. " in order to test the significant of simple linear regression model
We use ANOVA test and the table below show the result of the test:-
59
Table (37): ANOVA test between: age of the women and gestational age in the
delivery.
Sum of
Mean
Df
Squares
F
Sig.
.020
.888
Square
Regression
.002
1
.002
Residual
7.751
63
.123
Total
7.754
64
Since the level of significance (0.888) is bigger than 0.05, we accept the
hypothesis and conclude that “There exists no significant relationship, in the
significance level 0.05, between age of the women and gestational age in the deliver."
The equation of the simple linear Regression is shown in table below.
Table (38): Simple Linear Regression model between age of the women and
gestational age in the delivery.
B
t
1.888
9.661
-1.220E-02
-.141
(Constant)
Age of the women
The equation of the simple linear Regression is:-
a=-0.0122b+1.888
a: is gestational age in the deliver.
b: age of the women
60
Since R equal (0.018) and R square equal (0.000) there is no correlation between
age of the women and gestational age in the delivery.
61
Chapter five:
Discussion
62
Discussion
When the discussion of the hypothesis results done, we find their is No correlation
between baby weight and taking iron supplement during pregnancy, and No
correlation between type of delivery and gestational age with mother Hb level during
pregnancy. And the other hypothesis supported that is weak or very weak correlation
between each variables.
The aim of this study was to determine the effect of iron deficiency anemia during
pregnancy on the birth outcome. The data presented in this paper shows that the
severity of Fe deficiency had no effect on maternal growth and number of live
neonates. This is in agreement with our previous study (Gambling L, et al. 2002).
Showing that, maternal Fe deficiency does not affect viability and the number of
fetuses.
Supplementation of anemic or no anemic pregnant women with (IDA) does not
appear to increase birth weight or the duration of gestation. (Rasmussen, K, 2001).
A negative association between anemia and duration of gestation and low birth
weight has been reported in the majority of studies, although a causal link remains to
be proven. This paper explores potential biological mechanisms that might explain
how anemia, iron deficiency or both could cause low birth weight and preterm
delivery (Allen, LH. 2000).
Iron supplementation during pregnancy is a routine practice intended to prevent
iron-deficiency anemia. Our study suggests that iron supplementation may prevent
preterm birth, if the observed association can be established as causal (Rasmussen, K,
2001).
63
Iron-deficiency anemia was associated with significantly lower energy and iron
intakes early in pregnancy and a lower mean corpuscular volume. The odds of low
birth weight were tripled and of preterm delivery more than doubled with iron
deficiency, but were not increased with anemia from other causes. (Scholl TO, et al.
1992)
Relationships between hemoglobin concentrations and birth outcomes have not
been well characterized in African-American adolescents despite the fact that this
group is at a higher risk of early childbearing. (Agarwal KN, et al. 1991).
Finally; we reject our hypothesis, and found that their was no association between
(IDA), and birth outcomes.
5.1 Recommendations for project
Recommended Guidelines for Preventing And Treating Iron Deficiency Anemia
In Pregnant Women
Screen for Anemia at the Third-Trimester Visit and Treat as Appropriate
1. At a scheduled third-trimester visit, or if the first prenatal visit occurs in the
third trimester, obtain a blood specimen and determine the hemoglobin
concentration. Obtain medical evaluation when the hemoglobin concentration
is <9.0 g/dl.
2. Prescribe 60-120 mg of supplemental iron per day when the hemoglobin
concentration is between 9.0 - 10.9 g/dl.
3. Prescribe 30 mg of supplemental iron per day when the hemoglobin
concentration is 11.0 g/dl.
64
4. Stop supplemental iron at delivery (at the 4 to 6-week postpartum visit if
anemia continued through the third trimester).
Screen High-Risk Women for Anemia at the 4 To 6-Week Postpartum Visit
Screen women at high risk for iron deficiency anemia at the 4 to 6-week
postpartum visit (risk factors include anemia continued through the third trimester,
excessive blood loss during delivery, or multiple births). Obtain a blood specimen and
determine the hemoglobin concentration. Interpret the results with the same criteria as
for no pregnant women.
Among pregnant women, iron-deficiency anemia during the first two trimesters of
pregnancy is associated with a twofold increased risk for preterm delivery and a
threefold increased risk for delivering a low-birth weight baby (U.S. Preventive
Services Task Force .1996). Evidence from randomized control trials indicates that
iron supplementation decreases the incidence of iron-deficiency anemia during
pregnancy (Anonymous. 2002. Scholl TO, et al. 1992. Svanberg B, et al. 1975), but
trials of the effect of universal iron supplementation during pregnancy on adverse
maternal and infant outcomes are inconclusive (Steer, P. 2000. Taylor DJ, 1982.
Hemminki E,& Rimpela U .1991. Hemminki E,& Merilainen J 1995 ).
65
5.2 Limitation of the study
We believe this study may have limitations; interpretation of the results must take
these into account.
First, there is a chance of recall bias in the process of gathering data. Given low
income and low socioeconomic status of the pregnant women of this study, it was not
feasible to carry out longitudinal studies.
Second, it is difficult to determine the prevalence of iron deficiency in the
pregnant women because of the criteria used to define iron deficiency, even though
we used the usually accepted criterion.
Third; our result indicate that the third trimester of pregnancy have the affect or
not on birth outcomes, but it doesn’t measure the effect of the second or first trimester
pregnancy & in another study we suggest to follow a pregnant woman in the early
pregnancy to check the prevalence of suggested birth outcomes in any stage of
pregnancy.
5.3 Acknowledgment
We would like to express our sincere gratitude to everyone who has supported us
in different ways and especially the nurses in the neonate and workers in archive
within our population study.
We would like to thanks the Dean of Nursing College at Al Najah University Dr
Adan Sarhan
And to Miss Mariam Al Tell The coordinator of the course
To our supervisor Miss. Najwa Subuh.
We would also like to thank all colleagues, student, teacher, doctors, at AnNajah National University.
66
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74
Annexes
Figure (39): General approach to the review of the literature. FGR, fetal
growth retardation
75
‫بسم هللا الرحمن الرحيم‬
‫رقم االستبيان ‪:‬‬
‫رقم ملف الطفل‪:‬‬
‫رقم ملف األم ‪:‬‬
‫التاريخ ‪:‬‬
‫أوال ‪ :‬البيانات الشخصية‪:‬‬
‫‪ .1‬مكان السكن ‪:‬‬
‫‪ .2‬العمر‪ - :‬اقل من ‪ 22‬سنة‬
‫ ‪02– 22‬سنة‬‫ ‪ 02 -01‬سنة‬‫ اكثر من ‪ 01‬سنة‬‫‪ .3‬هل تعملين؟‬
‫مدينة‬
‫نعم‬
‫قرية‬
‫ال‬
‫إذا كان الجواب نعم ما هي مهنتك ‪:‬‬
‫طبيبة‬
‫مدرسة‬
‫والدة)‬
‫‪ . 0‬عدد الوالدات ‪( :‬‬
‫‪ . 5‬عدد مرات اإلجهاض ‪( :‬‬
‫مخيم‬
‫ممرضة‬
‫حددي ‪............‬‬
‫غير ذلك ‪,‬‬
‫مرة)‬
‫‪ . 6‬عدد األطفال الذين ولدوا أحياء ‪( :‬‬
‫طفل)‬
‫ثانيا ‪ :‬البيانات الخاصة باألم الحامل ‪:‬‬
‫‪ .1‬ما هو ترتيب الحمل الحالي ؟‪..................‬‬
‫‪ .2‬وزن الطفل األخير عند الوالدة ‪( :‬‬
‫‪ .0‬المدة الحالية للحمل ‪( :‬‬
‫كغم)‬
‫شهر)‬
‫‪ .0‬هل تعانين من مشاكل صحية أثناء الحمل الحالي ؟‬
‫نعم‬
‫إذا كان الجواب نعم ‪:‬‬
‫أمراض القلب‬
‫ضغط الدم‬
‫السكري‬
‫غير ذلك ‪ ,‬حددي ‪...............................................................‬‬
‫‪ . 6‬هل تتناولين أقراص الحديد أثناء الحمل الحالي ؟‬
‫نعم‬
‫ال‬
‫إذا كان نعم ‪ ,‬كم مرة في اليوم ‪................................‬‬
‫‪76‬‬
‫ال‬
‫الجهاز الهضمي‬
‫‪ . 7‬هل عانيت من نزف قبل أو بعد الوالدة الحالية ؟‬
‫ال‬
‫نعم‬
‫إذا كان الجواب نعم ‪ ,‬ما هو السبب ‪................................................................‬‬
‫‪ .8‬هل تناولت مضادات الحموضة مع أقراص الحديد أثناء الحمل الحالي ؟‬
‫نعم‬
‫أحيانا‬
‫ال ال‬
‫‪ .9‬وزن األم في بداية الحمل الحالي ‪( :‬‬
‫‪ . 12‬وزن األم في نهاية الحمل الحالي ‪( :‬‬
‫كغم)‬
‫كغم)‬
‫‪ . 11‬مستوى (‪ )Hb‬أثناء الحمل الحالي‬
‫‪>10g\L‬‬
‫‪<10\L‬‬
‫‪ . 12‬عدد األطفال الذين ولدوا تحت الوزن الطبيعي ‪( :‬‬
‫باألسابيع)‬
‫‪ . 10‬مدة الحمل عند والدة الطفل ‪( :‬‬
‫ثالثا ‪ :‬البيانات الخاصة بالطفل ‪:‬‬
‫‪ . 1‬وزن الطفل بعد الوالدة ‪( :‬‬
‫كغم)‬
‫‪ . 2‬كانت والدة الطفل الحالي ‪:‬‬
‫والدة طبيعية‬
‫والدة قيصرية‬
‫‪77‬‬
‫طفل)‬