British Journal of Medical and Health Sciences

URL: http://www.bjmhs.baar.org.uk

Vol. 1, No. 4, pp 47-57, January 2013

IRON DEFICIENCY ANAEMIA AMONG ANTENATAL WOMEN IN SOKOTO, NIGERIA

Dr. Erhabor O, Associate Professor
(Corresponding Author)

Isaac IZ

Department of Haematology and Transfusion Medicine Usmanu

Danfodio University Sokoto, Nigeria.

Department of Haematology and Transfusion Medicine Usmanu

Danfodio University Sokoto, Nigeria.

E-mail: n_osaro@yahoo.com
Tel: +447932363217
Isah A

Udomah FP

Department of Haematology and Transfusion Medicine Usmanu

Danfodio University Sokoto, Nigeria.

Department of Haematology, University of Calabar Teaching

Hospital Nigeria.

ABSTRACT
roblem statement: Iron deficiency anaemia (IDA) is the
single most prevalent nutritional deficiency worldwide. It is
a major public health problem particularly among pregnant
women in developing countries with adverse effects on the mother
and the newborn.
Approach: This cross-sectional and case -control study was
conducted at the antenatal clinic of Maryam Abacha Hospital Sokoto
to determine the prevalence of IDA among 55 pregnant women
(subjects) and 33 apparently healthy non-pregnant women (controls).
The mean age and range of subjects was 33.25 11.50 and 18-40
years respectively.
Results: The mean values of the haematology and anaemia related
parameters among the pregnant subjects were; Haemoglobin (10.14
1.45 g/dL), PCV (30.567 4.492%), SI (153.55 66.061g/dl), TIBC
(4.33.18 97.248 g/dl), Serum Ferritin (32.9 14.2 ng/mL) and TS
(7.69 28.84%). The overall prevalence of anaemia based on WHO
criteria (Haemoglobin <11g/dL) and iron deficiency anaemia based
on Ferritin < 12.0 ng/mL and TS<16% was found to be 21.3%, 13.5%
and 7.69% respectively among pregnant women studied. The mean
MCV, MCH and MCHC observed among the pregnant subjects was
significantly lower compared to those of non-pregnant controls (70.9
11.5 fL, 25.4 3.6 pg/cell and 31.9 1.6 g/dl) compared to 84.9 fL
10.5, 27.8 3.4 pg/cell and 32.9g/dl 2.0 g/dl) respectively. Blood
film examination indicated that (58.3%) of subjects that met the WHO
definition of anaemia (HB <11g/dL) showed a microcytic and
hypochromic red cell picture. The prevalence of IDA was significantly
higher in women in the 3rd trimester of pregnancy compared to the
2nd trimester.

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Conclusions and recommendation: Anaemia, iron deficiency and
iron-deficiency anaemia are highly prevalent among pregnant women
in Sokoto, Nigeria. We advocate for targeted iron supplementation for
pregnant women in the area. Laboratory parameters for diagnosis of
IDA should be included in antenatal care protocol of pregnant women
to facilitate the diagnosis and monitoring of IDA. We advocate for the
implementation of WHO recommendation that anthelminthic and
intermittent preventive treatment (IPTp) to protect pregnant women
in the area against hookworm infestation and malaria. There is also
the need for the promotion of insecticide-treated bed nets (ITNs) and
interventions such as mass media campaigns peer /outreach
education, life skill programmes to educate women on the advantages
of early ANC booking and compliance with the use of prescribed
medications.
Key words: iron deficiency anaemia, pregnant women, Sokoto
State, Nigeria
Introduction
Iron deficiency anaemia (IDA) is a global health issue with disproportionately high prevalence in women in
developing countries. In addition to being an independent risk factor for decreased quality of life and increased
morbidity and mortality, IDA in women has been linked to unfavorable outcomes of pregnancy. It is the most
common nutritional disorder in the world affecting 2 billion people worldwide with pregnant women particularly at
risk. WHO data indicates that iron deficiency anaemia is a significant problem throughout the world ranging from
1% (average of 14%) in the industrialized countries to an average of 56% (ranging from 35-75%) in developing
countries [1]. The major risk groups for iron deficiency include women of childbearing age, pregnant women, and
lactating postpartum women [2]. According to the National Food Consumption and Nutrition Survey in 2003,
43.7% of pregnant women in Nigeria are iron deficient [3]. The most common causes of anaemia in Nigeria
include; nutritional deficiencies of iron and folate, parasitic diseases such as malaria and hookworm,
haemoglobinopathies such as sickle cell disease and recently human immunodeficiency virus infection [4]. In
developing countries, maternal iron deficiency and anaemia during pregnancy is a product of many compounding
factors, such as maternal malaria, intestinal parasitic infection, recurrent infection, haemoglobinopathies and
malnutrition associated with reduced dietary intakes of iron containing diets [5]. Treatment of IDA often involves
treating the underlying cause with oral or parenteral iron therapy in patients depending on their ability to tolerate or
absorb oral preparations [6]. Oral or parenteral iron therapy should aim at replenishing body iron deficits. Serum
ferritin levels are used to determine the proportion of women undergoing prenatal care who has iron deficiency
anaemia. Iron deficiency in pregnancy has been defined by the National Academy of Sciences Panel [7] on nutrition
and pregnancy as ferritin levels lower than 12 ng per mL. Ferritin levels are considered the gold standard for the
diagnosis of iron-deficiency anaemia in pregnancy [8, 9].
There is paucity of data on the incidence of iron deficiency anaemia among the pregnant population in Sokoto
Nigeria, the socioeconomic challenges associated with pregnant women with iron deficiency anaemia in this
metropolis is unknown. This study is thus an opportunity to investigate the incidence of iron deficiency anaemia
among pregnant women in Sokoto Nigeria with the hope of generating evidenced- based data than can improve the
quality of antenatal services offered antenatal women with iron deficiency anaemia in Sokoto State of Nigeria.

British Journal of Medical and Health Sciences

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Materials and methods
Study design
This was a prospective cross-sectional and case- control study designed to assess the prevalence of IDA among
52 pregnant women (subjects) and 33 non pregnant women (control). The difference in some haematological and
iron parameters was compared statistically. Fifty two consecutively recruited and consenting pregnant women
attending the Maryam Abacha Hospital Sokoto for routine antenatal care constituted the subjects for this study
while Thirty three non-pregnant, consenting and aged-match women well monitored as controls. The mean age and
range of subjects was 33.25 11.50 and 18-40 years respectively. All participant were counseled and those who
consented (written informed consent) to being part of the study were recruited. Non-consenting pregnant women,
those < 18 years and those with history of diabetes mellitus, hypertension, those on iron supplements, history of
blood transfusion within the last 3 months were excluded. Control participants included consenting apparently
healthy non-pregnant, non-menopausal and non- menstruating (at the time of recruitment and sample collection)
women 18 years old. Ethical clearance was obtained from the ethical review board of the Maryam Abacha
Hospital Sokoto, Nigeria.
Study Area
This present research work was carried out at the Maryam Abacha Women and Children Hospital in Sokoto
Metropolis, Sokoto State, Nigeria. The hospital is a district general hospital in the Northwest geopolitical zone of
Nigeria offering routine antenatal care to pregnant women in Sokoto metropolis. Sokoto State is located in the
extreme North Western part of Nigeria near to the confluence of the Sokoto River and the Rima River. With an
annual average temperature of 28.3 C (82.9 F), Sokoto is, on the whole, a very hot area. However, maximum
daytime temperatures are for most of the year generally under 40 C (104.0 F). The warmest months are February
to April when daytime temperatures can exceed 45 C (113.0 F). The rainy season is from June to October during
which showers are a daily occurrence. There are two major seasons, wet and dry which are distinct and are
characterized by high and low malarial transmission respectively. Report from the 2007 National Population
Commission indicated that the state had a population of 3.6 million [10].
Sample Collection and Methods
Eight milliliters of whole blood was collected from each study participants into S Monovete EDTA
anticoagulated vacutainer tubes (2.7mls) and into S-Monovete gel tube (5mls). Sample collected into a gel tube was
allowed to clot and centrifuged to produce serum for biochemical analysis of serum iron, serum ferritin and TIBC.
The sample from the EDTA anticoagulated tube was used for colorimetric determination of haemoglobin using the
Cyanmethaemoglobin method as recommended by the National Committee for Clinical Laboratory Standards [10].
Packed cell volume (PCV) was determined using a microhaematocrit centrifuge (Hawksley, United Kingdom). Red
cell count was determined manually using standard methods. Red cell indices MCV, MCH and MCHC was
calculated from the values of red cell count, haemoglobin and packed cell volume as follows: MCV = Haematocrit
x 10 by the Red cell count, MCV = Haematocrit x 10 by the Red cell count and MCH (pg) = (Hb x 10) RBC
(picograms/cell).. Blood film was made by the push wedge method and stained with Leishman stain. Serum iron,

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Vol. 1, No. 4, pp 47-57, January 2013

total iron binding capacity (TIBC) and transferrin saturation were estimated photometrically using a ferrozine
based iron/unsaturated Iron Binding Capacity (UIBC) reagent (Randox Diagnostics, UK). In the measurement of
serum iron, ferric iron is dissociated from its carrier protein, transferrin, in an acid medium and simultaneously
reduced to the ferrous form. The ferrous iron is then complexed with the chromogen, a sensitive iron indicator, to
produce a blue chromophore which absorbs at 595 nm. In the measurement of unsaturated iron binding capacity
(UIBC) a known amount of ferrous iron is added, in excess, to the serum at alkaline pH. This saturates the
unoccupied iron binding sites on the transferrin. The amount of free iron thus measured is subtracted from the total
amount added to calculate the UIBC. Test procedures were conducted as described in the manufacturer's standard
operating manual included with the kit. Transferrin saturation was calculated from the serum iron concentration and
TIBC values as follows: Transferrin saturation = serum Iron/TIBC x 100. Serum ferritin was measured using a
human ferritin latex-enhanced immunoturbidimetric assay (Randox Diagnostic, UK) for the determination of
ferritin. Ferritin in the patient sample reacts with specific antiserum coated onto microparticles to form an insoluble
complex which can be measured turbidimetrically. The kit has a wide measuring range (6-450 ng/ml). Test
procedures were conducted according to the instructions in the manufacturer's standard operating manual.
Statistical analysis
Statistical analyses were conducted using SPSS (version 11; SPSS Inc., Chicago, IL) software. Data were
expressed as mean standard deviation. Comparisons between pregnant subjects and non-pregnant controls were
made using the Student's t-test for parametric data and the Mann-Whitney test for non-parametric data. Descriptive
analyses of percentages of categorical variables were reported. An alpha value of < 0.05 denoted a statistically
significant difference in all statistical comparisms.
Results
Fifty two consecutively recruited and consenting pregnant women attending the Maryam Abacha Hospital
Sokoto for routine antenatal care constituted the subjects for this study. Thirty three non-pregnant, consenting and
aged match non-pregnant women well monitored as controls. The mean age and range of subjects 33.25 11.50
years and 18-40 years respectively. The mean values of the parameters among pregnant subjects were;
Haemoglobin (10.14 1.45 g/dL), PCV (30.567 4.492%), SI (153.55 66.061g/dl), TIBC (4.33.18 97.248
g/dl), serum ferritin (32.9 14.2 ng/mL) and TS (7.69 28.84%). Table 1 shows a comparison of Haemoglobin,
PCV, SI, TIBC, Ferritin and Transferrin saturation among pregnant subject and non-pregnant controls. The overall
prevalence of WHO defined anaemia (Haemoglobin <11g/dL) and iron deficiency anaemia based on Ferritin < 12.0
ng/mL and TS<16% was found to be 21.3%, 13.5% and 7.69% respectively among the pregnant women studied.
The mean MCV, MCH and MCHC observed among the pregnant subjects was significantly lower compared to
those of non-pregnant controls (70.9 11.5 fL, 25.4 3.6 pg/cell and 31.9 1.6 g/dl) compared to 84.9 fL 10.5,
27.8 3.4 pg/cell and 32.9g/dl 2.0 g/dl) respectively. Table 2 shows the differences in red cell indices between
pregnant subjects and non-pregnant controls. Blood film examination indicated that (58.3%) of subjects that met the
WHO definition of anaemia (HB <11g/dL) showed a microcytic, hypochromic red cell picture. Figure 1 shows the
blood film of one of the iron deficient pregnant subject showing a microcytic hypochromic red cell picture. The
prevalence of IDA was significantly higher in women in the 3rd trimester of pregnancy compared to the 2nd
trimester.

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Vol. 1, No. 4, pp 47-57, January 2013

Table 1: Some haematological parameters in pregnant subjects and non-pregnant control
Parameters
Packed Cell Volume (%)
Haemoglobin (g/dL)

Mean SD
Subjects
30.567 4.492
10.14 1.45

t-value

p-value

Controls
35.100 3.934

5.190

0.001

11.7 1.32

2.966

0.005

Serum Iron (g/dl)

Total Iron Binding
Capacity (g/dl)

94.919 39.053
433.18 97.24

153.55 66.061
386.11 59.761

5.050
2.734

0.001
0.007

Serum Ferritin (ng/mL )

32.9 14.20

78.4 24.25

3.486

0.004

Table 2: Mean values of Red Cell indices among pregnant subjects and non-pregnant controls
Red Cell Indices

Mean SD

t-value

p-value

Subjects

Controls

Mean Cell Volume

(MCV)

70.9 11.5 Fl

84.9 10.5 fL

4.740

0.001

Mean Cell
Haemoglobin (MCH)

25.4 3.6 pg/cell

27.8 3.4 pg/cell

3.562

0.003

Mean Cell
Haemoglobin
Concentration (MCHC)

31.9 1.6 g/dl

32.9g/dl 2.0 g/dl

2.350

0.005

Table 3: Distribution of Anaemia and Iron Deficiency Anaemia based of different diagnostic criteria

Anaemia Criteria

Diagnostic criteria

Haemoglobin
Serum Ferritin
Transferrin Saturation

<11g/Dl
< 12
< 16%

Key:
N = Number of participants
% = Percentage of participants

Subjects
N (%)
12 (23.1)
7 (13.5)
4 (6.7)

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Table 3: Prevalence of anaemia and iron deficiency anaemia based on trimester

Trimester of

Number of

Number (%)

Number with IDA

Number with IDA

pregnancy

subjects

with Anaemia

(Ferritin <12ng/ml)

(Transferrin

(Hb < 11g/dL)

saturation <16%)

Second

29

4 (33.3)

3 (42.9)

2 (50)

Third

23

8 (66.7)

4 (57.1)

2 (50)

Figure 1: Blood film from one of the subject with IDA showing microcytosis and hypochromia

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Vol. 1, No. 4, pp 47-57, January 2013

Discussion
Iron deficiency is the most common form of nutritional anaemia worldwide and is estimated to affect 1.3 to 2.2
billion persons worldwide. Justification for the screening of pregnant women for iron deficiency anaemia has been
based on an association of anaemia with an increased risk for preterm delivery and other complications. In this
present study we have investigated the prevalence of anaemia among pregnant women attending antenatal clinic in
Sokoto, Nigeria.
We observed that the mean haemoglobin, PCV, ferritin and Transferin Saturation were significantly lower
among the pregnant subjects compared to the non-pregnant controls. The prevalence of isolated anaemia. The
overall prevalence of anaemia based on WHO criteria (Haemoglobin <11g/dL) and iron deficiency anaemia based
on Ferritin < 12.0 ng/mL and TS<16% was found to be 21.3%, 13.5% and 7.69% respectively among pregnant
women studied. Anaemia in pregnancy is defined by the World Health Organization (WHO) as a haemoglobin
concentration below 11 g/dL [12]. We observed prevalence of anaemia among pregnant subjects studied (23.1%) is
consistent with previous report which reported the prevalence of anaemia in developing countries as relatively high
(33% to 75%) [13, 14]. Our observed prevalence is however higher than the 15% prevalence observed among
pregnant women in developed countries [15]. There are several compounding factors responsible for the higher
prevalence of anaemia in developing countries; malnutrition, haemoglobiopathies, hookworm infestation, history
of grandmultiparity, low socioeconomic status, malaria infestation, late booking, HIV infection, and inadequate
child spacing among others [16]. Several socioeconomic factors militate particularly against women in Nigeria. An
important factor is often socio-economic deprivation. This has been linked with the development, severity and
outcome of many medical conditions [17]. Poverty and low standards of living are still major problems in most
developing countries including Nigeria. Corruption in government continues to prevent majority of Nigerians from
enjoying the proceeds of the huge deposits of mineral resources present in the country. Nigeria still ranks the 13th
poorest country in the world with about 72% of the countrys population living below the poverty line (living on
less than $1 per day) [18]. Gender inequality, lack of employment opportunities, lack of ability of women to
command resources and make independent decisions about their fertility, their reproductive health and healthcare
also has an impact on maternal anaemia. Women have a lower status than men in society, their health needs are
often neglected, and existing health facilities may not be accessed by women in need. In addition, women lack of
access to education and understanding about health related issues can contribute to delays in seeking antenatal care
and makes them prone to self medication and patronage of quacks.
The prevalence of isolated iron deficiency anaemia based on ferritin level < 12 was 13.5% while the overall
prevalence of iron deficiency anaemia (IDA) based on TS <16% was 7.69% among pregnant women studied. Our
finding although lower than values previous reported among pregnant women in industrialized nations (average of
14%) and the average prevalence of 65% (range 35-75%) observed among pregnant women in developing
countries. The prevalence of Iron deficiency anaemia is dependent on the cut off value used in the various studies as
diagnostic for IDA. The lower prevalence obtained in our study may be due to the fact that we used a very
sensitive ferritin cut off value of <12. Some previous studies have used higher cut off value of <30. There are
several factors that may be responsible for the higher prevalence of IDA observed among pregnant women in this
study. Sokoto is a state in the North West geopolitical zone of Nigeria. Like in other developing countries there is a

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Vol. 1, No. 4, pp 47-57, January 2013

high incidence of malnutrition with resultant nutritional anaemia. There is a very high level of malaria parasitaemia
[19], hookworm, amoebiasis, schistosomiasis and whipworm infestation [20] which causes considerable faecal
blood loss and anaemia in the area. There is increased incidence of haemoglobinopathies and HIV infection [21,
22]. Malaria parasitaemia and hookworm infestation has been found to play a role in the high incidence of iron
deficiency anaemia [23, 24].
Iron deficiency in pregnancy has been defined by the National Academy of Sciences panel on nutrition and
pregnancy [7] as ferritin levels lower than 12 ng per mL. Ferritin levels are considered the gold standard for the
diagnosis of iron-deficiency anemia in pregnancy. The diagnosis of IDA using iron related parameter is associated
with a number of challenges. Serum iron levels are not helpful by themselves because they vary with time of the
day and due to various systemic insults [25]. Another challenge is that although serum iron levels can be measured
directly in the blood, but these levels increase immediately with iron supplementation (patient must stop
supplements for 24 hours), and pure blood-serum iron concentration in any case is not as sensitive as a combination
of total serum iron along with a measure of the serum iron-binding protein levels (total iron binding capacity or
TIBC). The ratio of serum iron to TIBC (transferrin saturation index or percent) is the most specific indicator of
iron deficiency, when it is sufficiently low. The iron saturation (or transferrin saturation) of <5% almost always
indicates iron deficiency, while levels from 5% to 10% make the diagnosis of iron deficiency possible but not
definitive. Saturations over 12% (taken alone) make the diagnosis unlikely. Normal saturations are usually slightly
higher for women (>12%) than for men (>15%), but this may indicate simply an overall slightly poorer iron status
for women in the normal population. Ferritin can be detected in serum and correlates well with body iron stores.
Ferritin is decreased with iron deficiency anemia and is increased with elevated total body stores of iron. Ferritin is
also an acute phase protein, and hyperferritinemia can occur with underlying disease, such as inflammatory disease,
neoplasia, liver disease, or haemolytic disease. Previous report indicates that virtually all patients with serum
ferritin concentrations less than 15 ng/mL are iron deficient, with a sensitivity and specificity of 59% and 99%,
respectively [26]. A cutoff limit of 30 ng/mL may increase its sensitivity to 92% [27].
We observed significantly lower values for red cell indices among the pregnant subjects studied compared to
the non-pregnant controls. There is advocacy [28] for the use of haematologic indices provided with complete
blood count determination in the diagnosis of iron deficiency anaemia in resource-limited settings based on the
justification that it would be more efficient and less costly than serum ferritin determination particularly if they are
shown to differentiate iron deficiency from other causes of anaemia in pregnant women. Scatter plots was used in a
previous study to estimate the discriminatory ability of continuous variables for discerning between patient
populations with WHO-defined anaemia. However none of these scatter plots suggested discriminatory ability for
any of these variables [29].
Blood film examination indicated that (58.3%) of subjects that met the WHO definition of anaemia (HB
<11g/dL) showed a microcytic, hypochromic red cell picture. Microcytosis and hypochromia are signs of lower
than normal MCV and MCH. Iron deficiency anaemia is characterized by microcytic, hypochromic erythrocytes
and low iron stores. The mean corpuscular volume is the measure of the average red blood cell volume and mean
corpuscular hemoglobin concentration is the measure of the concentration of haemoglobin in a given volume of
packed red blood cells. The normal reference ranges for mean corpuscular volume (80100 fL), Mean cell

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haemoglobin (27-32 pg) and mean corpuscular haemoglobin concentration (320360 g/L). The patients cells are
said to be microcytic and hypochromic, respectively, when these values are less than the normal reference range.
Our observation that 58.3% of pregnant women with WHO defined anaemia had a microcytic and hypochromic red
cell picture is consistent with previous report which indicated that up to 40% of patients with true iron deficiency
anaemia will have normocytic erythrocytes [30]. Iron deficiency is the most common cause of microcytic anaemia.
Red cell indices have been defined to quickly discriminate IDA based on red cell size and haemoglobinization and
may be effective for use as a preliminary screening tool for IDA in low resource settings. The absence of iron stores
in the bone marrow remains the most definitive test for differentiating iron deficiency from the other microcytic
states (anemia of chronic disease, thalassemia, and sideroblastic anaemia) [31-36].
We observed that incidence of anaemia and iron deficiency anaemia was significantly higher in women in the
rd
3 trimester of pregnancy compared to those in the second trimester (66.75% and 57.1% versus 33.3% and 42.9%)
respectively. This finding is consistent with previous report which observed that pregnant women in mid and late
pregnancies are at risk for iron deficiency and that anaemia at booking increased with gestational age [37-39].
However a previous study reported that IDA was common in healthy, iron-sufficient adolescent pregnant women
during the second trimester [40].
Conclusion
This present study indicates a high prevalence of anaemia and iron deficiency anaemia among pregnant women
in Sokoto. We advocate for targeted iron supplementation for pregnant women in the area to potentially improve
their iron status and reduce the incidence of iron deficiency anaemia. Laboratory measures of iron stores should be
included in antenatal care protocol of pregnant women to facilitate the diagnosis and the monitoring of pregnant
women with IDA. We recommend the implementation of WHO recommendation that anthelminthic therapy be
provided for pregnant women in the third trimester of pregnancy to control hookworm infection particularly in
areas in which the prevalence of infection is >2030% and anaemia is prevalent. There is also the need for the
promotion of insecticide-treated bed nets (ITNs) and intermittent preventive treatment (IPTp) to protect pregnant
women in the area from malaria. There is the need for interventions such as mass media campaigns peer /outreach
education, life skill programmes to educate women on the advantages of early ANC booking and compliance with
the use of prescribed medications. Pregnant women should be encouraged to eat iron-rich food (leafy vegetable,
cereals, fish, apples, dried fruits, liver, heart, red meat and kidney) to reduce the incidence of IDA.
Acknowledgment
The authors are grateful to staff of the Haematology and Blood Transfusion, Chemical Pathology and Obstetrics
and Gynaecology Departments of Usmanu Danfodiyio University Teaching Hospital (UDUTH) Sokoto for their
support and collaborations. We are also grateful to the participants in this study for their collaborations.

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