RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION:

1. NAME OF THE CANDIDATE AND

ADDRESS

Ms.Vidhya Ramachandran

2. NAME OF THE INSTITUTION Sofia College of Nursing

3. COURSE OF STUDY AND SUBJECT Obstetrics and Gynecology

4. DATA OF ADMISSION OF THE

COURSE15-06-2011

5. TITLE OF THE TOPIC A descriptive study to assess the

knowledge of antenatal mothers

regarding nutritional anemia in

selected rural area at Bangalore.

6. BRIEF RESUME OF THE INTENTED WORK

INTRODUCTION

Antenatal care is the systemic medical supervision of women during pregnancy.

Its aim is to preserve the physiological aspect of pregnancy and labour and to prevent or

detect, as early as possible, all that is pathological. Early diagnosis during pregnancy can

prevent maternal ill-health, injury, maternal mortality, foetal death, infant mortality and

morbidity. Antenatal care begins with 'history-taking' and is followed by a complete

examination of the patient. Thereafter, the mother-to-be receives advice and instructions

about her mode of life, diet and regular antenatal check-ups till labour sets in.1

Early monitoring and on-going care during pregnancy is associated with more

favourable birth outcomes. Compared with no antenatal surveillance, some antenatal care

has a beneficial effect on affect on adverse factors such as preterm delivery, low birth

weight, maternal and perinatal mortality. While some traditional practices, such as strict

weight-gain restriction, the use of diuretics and the liberal use of x-rays, have been

discontinued, many current clinical practices fail to stand up to scientific scrutiny.

Despite this, antenatal care continues to be centered about awareness status as well as

nutritional regimen, with emphasis on the regularity of visits, rather than a focus on what

can be achieved at key visits during the antenatal period.2

Nutrition is an area that requires special attention during pregnancy, particularly

during the second and third trimesters. The foetus needs nutrients and energy to build

new tissue and the women needs nutrients to build her blood volume and maternal stores.

There is an increased demand for energy and for almost energy nutrient type. Most

nutrient requirements can be met through careful attention to diet, although there are

several nutrients including iron that require supplementation during pregnancy. Most

minerals can be obtained from a varied diet without Supplementation even during

pregnancy. If the mother’s intake of nutrient is not sufficient that limits the supply of

nutrients to the foetus this can lead to foetal malnutrition. 3

Anemia is a widespread public health problem associated with an increased risk

of morbidity and mortality, especially in pregnant women and young children. It is a

disease with multiple causes, both nutritional (vitamin and mineral deficiencies) and non-

nutritional (infection) that frequently co-occur. It is assumed that one of the most

common contributing factors is iron deficiency, and anemia resulting from iron

deficiency is considered to be one of the top ten contributors to the global burden of

disease.4

Prenatal care is the preventive obstetrics. The factors responsible for anemia in

pregnancy should be identified and eradicated. Iron supplement to prevent anemia in

pregnancy is a well known strategy. The National Nutritional Anemia Prophylaxis

Program (NNAPP) advised 60 mg of elemental iron and 500 \ig of folic acid daily for

100 days to all pregnant women. Prevention and management of nutritional anemia is

easy and cheap.5

6.1. NEED FOR THE STUDY

Anemia is a major public health problem throughout the world, particularly for

women of reproductive age in developing countries. In India, anemia is a common cause

of maternal morbidity and mortality and a key factor related to low birth weight. In 1992,

the World Health Organization estimated anaemia prevalence (Hb below 11g/dl) among

pregnant Indian women to be 88%, with a mean haemoglobin value of 9.1gmldl.6

It has been estimated that over half the pregnant women in the world have a

hemoglobin level indicative of anemia. In industrialized countries, anemia in pregnancy

occurs in less than 20% of women. Published rates of prevalence for developing countries

range from 35% to 72% for Africa, 37–75% for Asia and 37–52% for Latin America. Not

only is anemia common, it is often severe. From the published reports available, it can be

estimated that 2–7% of pregnant women have values < 7.0 g/dl, and, probably 15–20% <

8.0 g/dl. In 1993, the World Bank ranked anemia as the eighth leading cause of disease in

girls and women in developing countries.7

A study was carried out at an urban primary health institution in Delhi, to

assess feasibility of screening all pregnant women attending antenatal clinic for anaemia,

identifying those with moderate anaemia (haemoglobin between 5.0 - 7.9 g/dl). The study

results showed that over 80 per cent of 3698 women who attended the antenatal clinic

were anaemic; 745 (20.1%) had Hb between 5.0-7.9 g/dl. The study concluded that

anaemia in pregnancy remains a major public health problem associated with increased

risk of low birth weight deliveries.8

The Survey conducted by ICMR during 1987-1989 in six states of India found

that out of 1,968 women 62.3% had hemoglobin level less than 11g/dl. The district

Nutrition Survey [1999-2000], reported that prevalence of hemoglobin less than 11g/dl

was in 61%, 79%, 84%, and 91% in the districts of Himachal Pradesh, Uttar Pradesh,

Bihar, Assam and Kashmir respectively was shown. These national data suggest high

prevalence of nutritional Anaemia in pregnancy9.

Pregnancy anaemia is one of the important public health problems. About 4-16%

of maternal death is due to anaemia. It also increases the maternal morbidity, fetal and

neonatal mortality and morbidity significantly.Therefore the Investigator thought that

Nutritional Anaemia is the most frequent maternal complications during pregnancy, so

antenatal care should be concerned with its early detection and management.

6.2. REVIEW OF LITERATURE

A study was conducted to determine the prevalence of Anaemia in pregnant

women. The subjects were 1,248 pregnant women from 7 states; Himachal Pradesh,

Haryana, Assam, Orissa, Kerala, Tamil Nadu in South and Madhya Pradesh. The results

showed that a total of 84 percent pregnant and 92.2 per cent lactating women were

anaemic with severe anaemia in 9.2 and 7.3 per cent respectively; 39.2 and 27.3 per cent

in Madhya Pradesh, 14.4 and 8.6 per cent in Assam and 8.5 and 13.4 per cent in Haryana

had severe anaemia in pregnancy and lactation, respectively. Around 51 per cent women

in pregnancy and lactation had moderate degree of anaemia (Hb 7.0-9.9 g/dl). In Kerala

57.8 per cent pregnant women were anaemic with 2.9 per cent having severe anaemia.

The present findings showed that the interstate differences particularly in fertility, women

education, nutrition status and occupation; availability of antenatal services and iron

folate tablets are possible factors responsible for differences in prevalence of anaemia.10

A study was conducted to investigate the prevalence of Anaemia and iron

deficiency Anaemia (IDA) in healthy low income pregnant women in Canada. The

samples were 31 Antenatal mothers participating in the early childhood initiatives [ECI]

programme. The results revealed that among the 31 antenatal mothers, six (19.04%) were

Anemic and five (16.1%) suffered from IDA [Hb< 110g/L and SF< 10 micro g/L].The

study concluded that the prevalence of Anaemia in low income group antenatal mothers

are comparably higher to that of privileged women and effective strategies are needed to

prevent IDA in vulnerable groups.11

A cross sectional study was conducted to determine the prevalence of Anaemia and

to assess the effect of iron supplementation and nutritional educational programme. The

subjects were 100 pregnant women attending the antenatal clinics in two primary health

care units. Data was collected by structured questionnaires and haemoglobin analysis was

done during the first visit, after one month and four months. Chi square and paired “t”

test were applied to test the relationship among study variables. The results suggested that

after 3 months of nutrition education programme and iron supplementation the prevalence

declined down to 32% from 55% before programme. The study concluded that, Anaemia

is still high among pregnant women and integrated interventions programme should be

considered prior to conception. 12

A study was conducted to assess the status of anemia among 6,923 pregnant

women and 4,337adolescent girls from 16 districts of 11 states of India.A two-stage

random sampling method was used .Anemia was diagnosed by estimating the

hemoglobin concentration in the blood with the use of the indirect cyanmethemoglobin

method. The results showed that 84.9% of pregnant women were anemic, 13.1% had

severe anemia and 60.1% had moderate anemia. Among adolescent girls the overall

prevalence of anemia was 90.1%, with 7.1% having severe anemia. The study concluded

that any intervention strategy for this population must address not only the problem of

iron deficiency, but also deficiencies of other micronutrients, such as B12 and folic acid

and other possible causal factors.13

A study was conducted to assess effectiveness of nutritional education and Iron

supplementation on prevention of Anaemia during pregnancy among antenatal mothers of

Columbia. The samples were 42 pregnant women subjected to a nutritional education

programme along with administration of a supplement consisting of 60 mg elemental

iron, 400 micro folic acid, and 70mg vitamin c. The results revealed that, 94.4% of

women did not show Anaemia at the end of pregnancy. The study conclude that

nutritional education and iron supplementation are effective on prevention of anemia.14

A study was conducted to analyses the determinants of Anaemia in pregnant

women in rural Malawi area. The subjects were 4104 pregnant women attending the

antenatal-care facilities of two hospitals in a rural area. The results revealed that Mean

(S.D.) haemoglobin (Hb) concentration was significantly lower in the primigravidae 8.7

(1.6) g/dl and the variables associated with an increased risk for moderately severe

anaemia were iron deficiency (RR = 4.2; CI = 3.0-6.0) and malaria parasitaemia (RR =

1.9; CI = 1.3-2.7). The study concluded that illiteracy and poor nutritional status were

significantly associated with increased risk of anemia and the basis of Anaemia

prevention in this population of pregnant women was found to be malaria control and

haematinic supplementation. 15

A study was done to assess the effects of different treatments for anemia in

pregnancy attributed to iron deficiency (defined as hemoglobin less than 11 g/dL or other

equivalent parameters) on maternal and neonatal morbidity and mortality. The samples

were 3.198 women. The results revealed that the oral iron in pregnancy showed a

reduction in the incidence of anemia (risk ratio 0.38, 95% confidence interval 0.26 to

0.55) .The study concluded that despite the high incidence and burden of disease

associated with this condition,. Daily oral iron treatment improves hematological indices

and large, good quality trials, assessing clinical outcomes (including adverse effects) as

well as the effects of treatment by severity of anemia are required.16

A cross-sectional study was conducted to compare prevalence of anemia and

hemoglobin (Hb) levels in Brazilian pregnant women before and after flour fortification

with iron. The subjects were 12,119 pregnant women distributed in two groups: before

fortification and after fortification). Statistical analysis was carried out using chi-squared

tests, Student's t tests, and logistic regression, with a significance level of 5%.the results

indicated that prevalence of anemia fell from 25% to 20% after fortification (p<0.001)

and the logistic regression analysis showed that group, geographic region, marital status,

trimester of pregnancy, initial nutritional status, and prior pregnancy were associated with

anemia (p<0.05). The study concluded that prevalence of anemia decreased after

fortification.17

A study was conducted on effects of health education on knowledge, attitudes

and practices about Anaemia among rural women in Chandigarh. All the 60 married

women in the age group of 20 to 45 years were selected for the study. The study revealed

that socio-economic and demographic characteristics of both the intervention and control

groups were similar, all women in the intervention group could specify at least one

correct cause of Anaemia and identified signs and symptoms of Anaemia whereas, 73.3%

and 46.6% women in the control group did not specify the cause, signs and symptoms of

Anaemia respectively (p<0.001) and the knowledge about methods of Anaemia

prevention was significantly higher in intervention group compared with control group

(p<0.001). The results concluded that there was significant change in knowledge and

attitude of women who received health education. 18

According to the review of literature, it is evident that the percentage of

nutritional anemia among pregnant women is growing worldwide. A high proportion of

women in both industrialized and developing countries become anemic during pregnancy

The studies expose the fact that dietary habits, iron supplementation and nutritional

education are factors determining the prevalence of anemia. In short the studies showed

an increasing trend of nutritional anemia among pregnant women.

6.3. STATEMENT OF THE PROBLEM

A descriptive study to assess the knowledge of antenatal mothers regarding

nutritional anemia in selected rural area at Bangalore .

6.4. OBJECTIVES OF STUDY

The objectives of the study are:

1. To assess the knowledge of Antenatal mothers regarding nutritional anemia and its

prevention.

2. To find the awareness regarding right nutritional requirement for expectant mothers.

3. To plan and implement structured awareness programme regarding Anemia and its

prevention.

4. To find out the association between the knowledge of Antenatal mothers regarding

Anaemia and its prevention with selected socio-demographic variables.

6.5. HYPOTHESIS

H1:- The mean post test knowledge scores of antenatal mothers who have undergone the

structured awareness programme regarding Nutritional Anaemia and its prevention

will be significantly higher than their mean pre test knowledge scores.

H2:-There will be significant association between the mean pre test knowledge scores

of antenatal mothers regarding Nutritional Anaemia and its prevention with

selected socio- demographic variables.

6.6. OPERATIONAL DEFINITIONS OF TERMS

In this study it refers to:

EVALUATE:

Evaluate refers to the measure to determine the awareness in the pregnant women

about the nutritional Anaemia.

EFFECTIVENESS:

It refers to significant difference between the literate & illiterate knowledge

scores of Nutritional Anaemia and its prevention among Antenatal mothers.

STRUCTURED AWARNESS PROGRAMME:

It is a awareness programme given by the investigator for 15 minutes with the

help of Audio visual aids [charts] about Nutritional Anaemia and its prevention among

Antenatal mothers.

AWARNESS:

It refers to the understanding of Antenatal mothers regarding causes and

symptoms of Nutritional Anaemia and its prevention.

ANAEMIA:

Anaemia is the condition in which hemoglobin (iron deficiencies) concentration

in the blood is less than 10 gm/dl.

PREVENTION:

Prevention refers to all the actions taken to eliminate the risk factors of

Nutritional Anaemia and mitigate the chances of occurrence of Anaemia.

ANTENATAL MOTHERS:

Women in the period of conception and delivery of baby, who are educated by

the researcher.

6.7. ASSUMPTIONS

The study is based on the following assumptions:

1) Antenatal Mothers may be willing to co-operate and participate in the study.

2) The Antenatal mothers have interest to know about Nutritional Anaemia and its

prevention.

3) The audio visual aids may enhance the knowledge of antenatal mothers regarding

Nutritional Anaemia and its prevention.

6.8. DELIMITATIONS:

The study is delimited to:

- Antenatal mothers counseled about antenatal awareness of Nutritional Anemia

- Collection of data from the antenatal mothers residing at the selected urban

communities.

7. MATERIAL AND METHODS

7.1. SOURCES OF DATA

Antenatal mothers who have been visited by researcher

7.2. METHOD OF DATA COLLECTION

Research method : Quasi Experimental method

Research design : Descriptive design

Sampling technique : Purposive sampling

Sample size : 60 antenatal mothers

Setting of the study : Rural area at Bangalore (Hedge Nagar ).

7.2.1. CRITERIA FOR SELECTION OF SAMPLES

INCLUSION CRITERIA

-Antenatal mothers of selected community area.

-Antenatal mothers who are willing to participate in the study.

-Literate and can understand and communicate in English and Kannada.

-Antenatal mothers who are present at the time of data collection.

EXCLUSIVE CRITERIA

-Unable to communicate in English and Kannada.

-Health personnels.

7.2.2. DATA COLLECTION TOOL

A structured knowledge questionnaire will be prepared to assess the knowledge of

antenatal mothers regarding nutritional anemia and its prevention. Audio visual aids also

will be prepared regarding the nutritional anemia during pregnancy and its prevention.

Validity of the tool will be ascertained in consultation with the guide and experts of

Obstetrics and Gynecological nursing, Gynecological medicine and Community

medicine. Reliability of the tool will be established by split-half method.

A written consent will be obtained from the participants regarding their

willingness to participate in the study. A formal administrative permission will be

obtained from the authorities of the proposed settings. The tentative period of data

collection will be in August 2010.

7.2.3. DATA ANALYSIS METHOD

Data will be analyzed by using descriptive (mean, standard deviation) and

inferential (t-test) statistics. Frequency and percentage distribution will be used to analyze

demographic variables. The demographic variables will also be described descriptively

by using diagrams (columns, bar, cone and pie diagrams). Mean and standard deviation

will be used to assess the knowledge of antenatal mothers regarding the nutritional

anemia during pregnancy and its prevention. A‘t’-test will be done to compare the mean

pre-test and post test knowledge scores of antenatal mothers regarding the nutritional

anemia during pregnancy and its prevention. A Chi-square test (X2) will be done to find

out the association between the mean pre-test knowledge scores and the selected

demographic variables.

7.3. DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR

OTHER HUMANS OR ANIMALS?

No,

A structured knowledge questionnaire regarding the knowledge of antenatal mothers

regarding nutritional anemia and its prevention. Audio visual aids also will be prepared

regarding the nutritional anemia during pregnancy and its prevention. No other physical

or laboratory procedures will be conducted or done on the samples.

7.4. HAS ETHICAL CLEARENCE BEEN OBTAINED?

Yes,

1. A written permission from the concerned administrative authority will be obtained.

2. Consent will be obtained from the hypertensive patients before conducting the study.

3. Confidentiality and anonymity will be maintained.

8. LIST OF REFERENCES

1. Sheila Haldipur Antenatal Care. living.one india.2006 March. 9:35.

2. Online article available on www.pregnancycare.eu/pregnancy/antenatal-care.

3. Jayaraj Kumar. The Dietary Practices of antenatal Mothers with Anemia and

Other normal Antenatal Mothers in India. Authorstream.com. Dept of

Pharmaeutics.2008.14.

4. Online article available on www.sightandlife.org.

5. Online article available on www.malhotrahospitals.com/treatments/high-risk-

pregnancy/anemia-in-pregnancy.php

6. Peggy Bentley, Anjon Parekh.Perceptions of Anemia and Health Seeking

Behavior among Women In Four Indian States. Technical Working Paper.

Mother care. 1998 Oct.9.

7. Nynke van den Broek.Anaemia and micronutrient deficiencies reducing

maternal death and disability during pregnancy.Oxford Journals.2003. 67 (1):

149-160.

8. Anshu S, Rita P, Suman Garg, Prema R.Detection & management of anaemia in

pregnancy in an urban primary health care institution.Nutrition Foundation of

India and Defence Colony Maternity Centre. 2007March.32.

9. Gopalan C. Nutritional research in South East Asia. 1st ed. Delhi; ATB

Publishers; 1996. P.42-44.

10. Agarwal K.N. Agarwal DK Sharma A, Sharma K. Prasad K. Kalita MC, et al.

Prevalence of Anaemia in pregnancy women. Indian J Med. Res. 2006 Aug;

124(2) : 173-84.

11. Leblanc CP, Rioux FM. Iron deficiency Anaemia following prenatal Nutrition

Intervention. Can J Diet Pract Res. 2007; 68(4):222-5.

12. Gadallah M, Rady M, Salem B, AlyEM, Anwer W. The effect of Nutritional

Intervention programme on the prevalence of Anaemia among pregnant women

in rural area. Egypt public health assoc 2002; 77 (3-4): 261-73.

13. Toteja GS, Singh P, Dhillon BS, Saxena BN, et al. Prevalence of anemia among

pregnant women and adolescent girls in 16 districts of India. Food Nutr Bull.

2006 Dec; 27(4):311-5.

14. Parra BE, Manjarres LM, Gomez AL, Ailzate DM, Jaramillo ML. Assessment of

nutritional education and iron supplement impact on prevention of pregnancy

Anaemia universidade Antiquia, Medline, Colombia. Biomedica. 2005 Jun;

25(2):211-9.

15. Verhoeff F H, Brabin B J, Chimsuku L, Kazembe P. An analysis of the

determinants of anaemia in pregnant women in rural Malawi - A basis for

action.Annals of Tropical Medicine and Parasitology.1999; 93(2): 119-133.

16. Reveiz L, Gyte GM, Cuervo LG, Casasbuenas A.Treatments for iron-deficiency

anaemia in pregnancy. Cochrane Database Syst Rev.2011 Oct ;(10):CD003094.

17. Fujimori E, Sato AP, Szarfarc SC, Veiga GV,et al. Anemia in Brazilian pregnant

women before and after flour fortification with iron.Rev Saude Publica. 2011

Dec; 45(6):1027-1035.

18. Kaur AM and Singh K, effect of health education on knowledge about Anaemia

among rural women in Chandigarh. Indian Journal of community medicine.2001;

26(3).

9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE It is a feasible study.

11 NAME AND DESIGNATION

11.1 GUIDE

11.2 SIGNATURE

Mr.HITHESH CHOUDHARY

Assistant Professor

Community Health Nursing

11.3 HEAD OF THE DEPARTMENT

11.4 SIGNATURE

Mr.HITHESH CHOUDHARY

REMARKS OF CHAIRMAN OR

PRINCIPAL.

SIGNATURE

It is a feasible study