The Prevalence Of Anaemia.
Anaemia, a most common haematologic condition marked by an abnormal reduction in red blood cells, is a leading global health threat ranking highest in countries including Nigeria (Harvey, 2003).
World Health Organization (2008) report estimates that 35% to 80% of pregnant women in developing countries are anaemic: notably, in Nigeria (60% pregnant women are anaemic), Tanzania (86% pregnant women have iron deficiency anaemia and 1/3 of the anaemic women had malaria), Costal Kenya (75.6% are anaemic while 9.8% are severely anaemic). Also a WHO study in Guinea during 2000-2006 revealed that 58% of pregnant women who died during child birth were anaemic while a small percentage (18%) of the pregnant women from industrialized countries is anaemic.
In Nigeria, studies carried out by various groups have shown varying results. For instance, a study done by Donald et al (2008) at the University Teaching Hospital Abakaliki, Ebonyi State, revealed that anaemia in pregnancy has a prevalence rate of 56% out of a population of 3,400 women who attended antenatal clinic at the hospital that year. The study also revealed that out of the 1,904 (56%) cases of severe anaemia having haemoglobin level less than 10.5g/dl, 1,850 women responded to treatment with oral and parentheral haematinics while the remaining 54 women required blood transfusion. Unfortunately 2 women developed complications (pre-mature labour and still birth at 2nd and 1st trimester of pregnancy respectively).
Also a prevalence rate of 30.7% was found by Ogbeide et al (2007), in a study involving 435 pregnant women who attended ante-natal clinic at Parklane Specialist Hospital, Enugu State, from 2000-2005.
The World Health Organization (2007) defined Anaemia as a haematologic condition and a sign of an underlying disorder characterized by a reduction in the number of red blood cells, or a reduction in the concentration of haemoglobin in the blood stream to a level below 10.5g/dl.
Anaemia has also been defined as a reduction below normal in the number of red corpuscles per cubic millimeter, the quantity of haemoglobin and the volume of packed red cells per 100ml of blood as a result of impaired erythrocyte production or increased erythrocyte loss which leads to impaired tissue perfusion (Ojo and Briggs, 2009).
The causes of anaemia according to WHO (2005) includes the following; pregnancy and child birth, repeated infections (malaria, hookworm), poor feeding due to socioeconomic factors (poverty and low educational status) and haematologic conditions (such as impaired erythrocyte production or increased erythrocyte loss).
Donald (2006) confirmed that malaria in pregnancy is the predominant cause of anaemia in pregnancy in Nigeria. He further stated that malaria accounted for more than 56% anaemic cases in pregnancy in Nigeria.
Harvey (2006) studied the complications/ effects of anaemia on pregnancy for both mother and foetus and status thus;
For the anaemic woman: resistance to infection is lowered and thus the incidence of pueperal sepsis is increased, in severe Pregnancy anaemia, the patient may go into heart failure from which she may never recover.
For the foetus: anaemia increases the incidence of abortion, premature labour and intra- uterine death of the foetus with the delivery of a macerated foetus, still births occurring in the first week of intra-uterine life, also there is increased risk of neural tube defects in the newborn, foetal hypoxia and an elevated risk for preterm or low birth weight infants, just to mention a few of the life threatening hazards of anemia in pregnancy.
Management of anemia in pregnancy according to Campbell (2008) entails the following: Dietary advice, administration of oral or parenteral haematinics, pre-natal supplementation with iron and folic acid coupled with malaria chemoprophylaxis in places where malaria is endemic and blood transfusion in severe cases. Not excluding personal protection (use of mosquito treated bed nets, and mosquito proof houses) and environmental hygiene as potent preventive measures against the dreaded condition anemia.
This study is therefore carried out on pregnant women who attended ante-natal clinic at Federal Medical Centre, Abakaliki, Ebonyi State, from January 2008 – January 2009 to determine the
prevalence of anaemia.
1.1 Statement of the Problem
From the various studies done by World Health Organization (WHO, 2006) and confirmed by Shah and Gupta (2007), it is established that there is an increased incidence of anemia and maternal death in the whole world with a particular emphasis on the developing countries of Africa having the greater percentage.
Despite the efforts made by Nurses in conjunction with other health workers in Ebonyi state to reduce the incidence of maternal and child morbidity and mortality from anemia, the scourge is still on the rise (Kelvin, 2008). Hence the need to examine the factors, medical and social- economic that are responsible for the prevalence of anemia among pregnant women who attended ante-natal clinic at Federal Medical Centre, Abakaliki.
1.2 Objectives of the Study.
1. To determine the prevalence of anaemia among pregnant women who attended ante-natal clinic at Federal Medical Centre, Abakaliki.
2. To determine the factors responsible for the occurrence of anemia in pregnancy among pregnant women who attended ante-natal clinic at Federal Medical Centre, Abakaliki.
3. To determine the effects of anaemia in pregnancy among pregnant women who attended antenatal clinic at Federal Medical Centre, Abakaliki.
4. To determine the management of anaemia in pregnancy among these group of women.
In order to find out reasons for the high prevalence of anaemia among pregnant women who attend antenatal clinic at Federal Medical Centre Abakaliki, the following research questions were raised for the study.
1.3 Research Questions
1) What is the prevalence of anemia in pregnancy in Federal Medical Centre between 2008 and 2009?
2) What are the factors responsible for the occurrence of anaemia in pregnancy among pregnant women who attended antenatal clinic at Federal Medical Centre Abakaliki?
3) What are the effects of anaemia in pregnancy among pregnant women who attended antenatal clinic at Federal Medical Centre between 2008-2009?
4) What are the management received by these anaemic pregnant women who attended antenatal clinic at Federal Medical Centre between 2008 – 2009?
1.4 Research Hypothesis.
– The gestational age of the mother at ante-natal booking is a significant factor in the prevalence of anaemia among pregnant women who attended ante-natal clinic at Federal Medical Centre Abakaliki.
1.5 Significance of the study.
The result of this work will be useful in the following ways:
a) The result of this work will form a basis in organizing health programmes/ awareness campaigns by the nurses to enlighten women about pregnancy anaemia
b) Women in general especially those residing in rural areas will utilize the information they have received to determine the causes and prevention of anaemia in pregnancy including measures to be taken by the predisposed women.
c) Nurses and other health workers will make use of this study in updating their knowledge about anaemia in pregnancy so as to be able to make proper assessment, diagnosis, planning and implementation of modalities geared towards competent management of cases. So as to reduce the incidence of anemia among pregnant women.
d) This work is also expected to provide information and statistics for health care administrators in the Ministry of Health and related paralstatals for use in the designing of strategies and programmes geared towards the reduction of material and child morbidity and mortality from anemia.
e) Information is also provided to other researchers who may wish to carryout similar or related studies.
1.6 Scope of the study
This study is exclusively to determine the prevalence of anaemia among pregnant women who attended ante- natal clinic at Federal Medical Centre Abakaliki Ebonyi State from 2008-2009.
1.7 Operational Definition of Terms
1. Prevalence: the number of pregnant women who had pregnancy anaemia that attended antenatal clinic at Federal Medical Centre Abakaliki within 2008 and 2009.
2. Anaemia: this refers to an abnormal reduction in haemoglobin concentration in blood, which is less than 10.5g/dl as diagnosed in these pregnant women by the doctor.
3. Pregnant women: this refers to women confirmed pregnant and attended antenatal clinic at Federal Medical Centre Abakaliki between 2008 to 2009.
In view of the above background, I wish to move further to review literature on anaemia in pregnancy to add to the already established knowledge.
This chapter reviews the concept of anaemia in pregnancy.
2.1 Definition of Anemia.
According to WHO (2007), anaemia is defined as a haematologic condition and a sign of an underlying disorder characterized by a reduction in the number of red blood cells or a reduction in the concentration of haemogolobin in the blood stream to a level of 10.5g/dl and below resulting in impaired tissue perfusion.
2.2 Definition of Pregnancy.
WHO (2005), defined pregnancy as a normal physiologic process that takes place in the uterus (womb) of women of child-bearing age which commences from the period of conception (implantation of fertilized ovum in the uterus) and ends with the onset of labour and imposes marked physical, anatomical, physiological and even psychological changes in the woman.
2.2.1 Trimesters of Pregnancy: it’s relationship with anaemia
Johnstone (2001), identified three trimesters in pregnancy, which includes: first, second and third trimesters.
First trimester: This is the period between conception and the first 3 months of pregnancy which is marked by unique physiological and psychological changes in the body of the pregnant woman (e.g intense nausea and vomiting, tiredness and emotional lability).
At this period the woman is more predisposed to anaemia and its complications;
– Due to hyperemesis gravidarum (increased nausea and vomiting in pregnancy), experienced by the woman at this stage of pregnancy, she undergoes great loss of essential nutrients if she doesn’t feed well, consequently predisposing herself to lowered immunity against infections, thus the incidence of chronic illnesses, heart failure, even pueperal sepsis, as such the woman looks very pale, emaciated and sickly.
– For the foetus, at this stage consequent upon the above reasons, it is more predisposed to the complications of anaemia much more than any other stage of pregnancy.
At this stage, there is increased incidence of intrauterine deaths (still birth) occurring mostly in the first week of intra-uterine life of the foetus. There is increased incidence of abortion; neural tube defects in the foetus and foetal hypoxia all as a result of anaemia in pregnancy.
Second trimester: This is the period between the first three months and six months of pregnancy (middle pregnancy), which is marked by unique physiological and psychological changes in the body of the pregnant woman.
– At this stage the foetus is faced with certain complications of anaemia such as; increased risk for abortion and premature labour with the birth of preterm or low-birth weight infants.
Third trimester: This is the period between six months and nine months of pregnancy (last stage of pregnancy), which is marked by its own unique physiological and psychological changes in the body of the pregnant woman for both mother and foetus.
– At this stage foetus is now well developed and heading towards expulsion.
– For the foetus to have reached this stage of pregnancy means that it has successfully escaped most if not all the complications or effects of anaemia in pregnancy.
– There are not many complications or effects of anaemia in pregnancy for the foetus at this stage except for rare cases of premature labour with birth of preterm of low birth weigh babies.
In a nutshell effects of anaemia in pregnancy is experienced in the three different trimesters of pregnancy exhibiting unique complications in each, hence the first and second trimesters are mostly affected in women who are predisposed to the causes of anaemia in pregnancy.
2.3 Causes of Anaemia in Pregnancy
According to Ogunbode (2006), the main causes of anaemia among pregnant women in Nigeria have been identified as haemolysis of red blood cells (as in malaria infestation or other parasitic infections like hookworm, haemolytic disease of the newborn), folic acid and iron deficiency (as in severe malnutrition), increased physiological demand for red blood cells and iron as in pregnancy and lactation.
Harrison (2007), also found that low standard of living, unavailability of adequate diet, food taboos based on some cultural practices, poor eating and cooking habits, parasitic infections, iron and folate deficiency, chronic systemic disorders caused anaemia in pregnancy in Nigeria.
Myles (2008) stated that causes of high incidence of anaemia include infections such as amoebic dysentery, malaria and Clostridium welchii which cause increased haemolysis.
Allen (2009) asserted that there are nine main underlying causes of anaemia and their types which includes; Haemolytic anaemia, sickle cell anaemia, thalassaemia, Glucose-6-phosphate dehydrogenase (G6PD) deficiency anaemia, anaemia caused by blood loss, inability of the body to produce enough healthy red blood cells, poor dietary iron, folic acid and vitamin B12 intake, bone marrow disorder (as in aplastic anaemia).
2.3.1 Classification of Anaemia
According to Famakinwa (2002), anaemia is classified according to the cause and characteristics feature of the erythrocytes.
Classification according to the cause:
A. Anaemia due to decreased erythropoiesis
1. Deficiency anaemia – iron deficiency anaemia, vitamin B12 deficiency (pernicious) anaemia, and folic acid deficiency anaemia
2. Aplastic anaemia due to depressed bone marrow activity
B. Anaemia due to excessive rate of haemolysis (haemolytic anaemia) which can be acquired or hereditary.
1. Hereditary haemolytic anaemia: Sickle cell anaemia, Thalassemia (Mediterranean or cooley’s anaemia), congenital haemolytic jaundice (hereditary spherocytosis).
2. Acquired haemolytic anaemia which may be due to: certain infective agents (malaria parasites, etc), certain drugs and chemicals, autoimmune reactions.
C. Haemorrhagic anaemia
Classification according to the characteristic features of the erythrocytes.
1. Macrocytic anaemia: This refers to an anaemia condition whereby the erythrocytes are larger than normal.
2. Hypochromic/microcytic anaemia: This refers to iron deficiency anaemia whereby haemoglobin is smaller than normal
3. Megaloblastic anaemia: This refers to an anaemic condition whereby the erythrocytes are abnormally large due to increased proliferation resulting from vitamin B12 and or folic acid deficiency.
In summary anaemia may be classified as:
a. Deficiency anaemia
b. Aplastic anaemia
c. Haemorrhagic anaemia
d. Haemolytic anaemia
e. Idiopathic anaemia (anaemia of unknown origin)
According to WHO (2006) and Ogunbode (2006), the most prevalent types of anaemia that occurs among pregnant women in Nigeria includes: iron and folate deficiency anaemia, haemolytic anaemia due to malaria parasites and hookworm infestation. These two types of anaemia are predominant due to low socio-economic status of the people and the fact that Nigeria is a malaria endemic region.
2.4 Clinical manifestations of Anaemia in Pregnancy
According to Watson (2008), the signs and symptoms of Anaemia are as follows:
A Pallor of skin and mucous membrane, Brittle nails, Dry hair,
Pallor of conjunctiva of eyes Due to the effects of decreased erythrocyte concentration on the skin and mucous membrane.
B Shortens of breath on exertion, increased respiratory rate, and fluid in base of lungs. Due to the effects of impaired oxygen carrying capacity of blood i.e lowered haemoglobin concentration.
C Increased pulse rate, cardiac palpitation, Angina pectoris, increased stroke volume, Ankle oedema (due to severe fluid retention associated with pregnancy). Due to impairment to oxygen carrying capacity of blood which affects the cardiac muscles.
D Dizziness, General fatique, Headache, Tinglings or pins and needles in extremities, Fainting. Due to the effects of decreased haemoglobin concentration on the neuromuscular system, Tingling sensation due to Vit. B12 deficiency.
E Anorexia, Diarrhoea or constipation, Flatulence. Due to the effects of decreased haemoglobim concentration on the Gastrointestinal system
F Irregular menstruation, Decreased renal function. Due to the effects of decreased erythrocyte concentration on the genitor-urinary system
G Increased sensitivity to cold Due to the effects of decreased erythrocyte concentration which impairs the skin’s thermo regulatory functions
2.5 Complications/Effects of Anaemia in Pregnancy for both mother and foetus
Harvey (2006) studied the complications/effects of anaemia in pregnancy for both mother and foetus and stated thus:
For the woman:
– Resistance to infection is lowered: due to impaired defence mechanism offered by the blood resulting in the incidence of chronic infections like pre-natal and puerperal sepsis.
– Heart failure: due to severe hypotension resulting from excessively depleted blood volume where by the heart is unable to pump out enough blood to maintain adequate tissue perfusion as seen in severe anaemia.
– Brain damage: due to grossly reduced or diminished blood circulation to the brain cells, secondary to grossly reduced haemoglobin concentration and blood volume as seen in severe anaemia.
– Organs infarction: due to impaired tissue perfusion in vital organs secondary to grossly reduced or diminished haemoglobin concentration and blood volume reaching the organs as seen in severe anaemia in pregnancy.
– Angina pectoris: due to highly reduced haemoglobin concentration and blood volume leading to impaired tissue perfusion of the heart muscles, signified by pain in the chest
– Hepato-spleenomegaly: enlargement of spleen and liver due to severe anaemia, secondary to malaria.
For the foetus
Anaemia in pregnancy predisposed the foetus to the following complication in severe cases:
– Increased risk of intra-uterine deaths (still birth) occurring mostly in the first week of intrauterine life of the foetus.
– Increased risk of abortion and premature labour with the birth of a macerated preterm or low birth weight infant especially in the second trimester due to iron deficiency anaemia which is associated with increased size and weight of the placenta.
– Increased risk for neural tube defects in the foetus due to the effects of anaemia (i.e low level of folate) on the neuromuscular system of the foetus
– Increased risk for foetal hypoxia and intra-uterine death in severe cases, due to the effect of impaired oxygen carrying capacity of blood and reduced blood volume reducing the foetus chances of receiving adequate oxygen and blood supply for its’ growth and maintenance (Caldwell 2003).
Myles (2004), also added that anaemia reduces the enjoyment of pregnancy and motherhood due to fatique and also precipitated to post partum haemorrhage (blood loss within the period of 6 weeks after delivery). She further stated that the resistance to infection is lowered and thus incidence of peuperal sepsis may be increased.
Donald (2003) reports that pregnancy poses a great risk for iron deficiency anaemia and pregnant women with low haemoglobin levels have an elevated risk for preterm or low birth weight infants.
WHO (2007) report states that pregnancy increases the risk for anaemia and that an anaemic woman is five times more likely to die of pregnancy related causes as compared to a woman who is not anaemic.
Okoh et al (2008) carried out a retrospective study on a population of 8,000 pregnant women who attended antenatal clinic at the University Teaching Hospital, Abakaliki Ebonyi State during 2004-2008 using 400 anaemic women as sample size. The study revealed the following results: 40% of the anaemic pregnant women had lowered immunity and as a result were suffering from; urinary tract infections especially candidiasis, respiratory tract infections especially pulmonary tuberculosis and common cold. 25% of the anaemic pregnant women had premature labour and abortions at the 1st trimester of pregnancy and second trimester. 30% of the women gave birth to low birth weight babies and premature labour at the 2nd trimester and mid third trimester. The remaining 5% of the anaemic women had increased risk for intra-uterine foetal deaths as a result of diagnosed foetal hypoxia, secondary to maternal anaemia and they eventually had still births which occurred in the first trimester of pregnancy.
2.6 Diagnosis of Anaemia in Pregnancy
According to W.H.O. (2007), anaemia is defined as a reduction in haemoglobin level to 10.5g/dl and below. The same report also states that anaemia can be diagnosed from its cardinal signs and symptoms.
According to Famakinwa (2002), anaemia in pregnancy can be diagnosed through the following laboratory investigations:
– Red blood cell count: It will reveal a decrease from normal value of 3.8-5.8×1012/litre to a red blood cell count of below 3.8 x1012/L.
– Haemoglobin estimation will reveal a reduction from average concentration of 12g/dl to haemoglobin level of 10.5g/dl and below.
– Packed cell volume (PCV) haemacrit will reveal a decrease in value from normal value of 37-47% to PCV level of below 37%
– In a few selected cases of severe anaemia in pregnancy, it becomes necessary to do a bone marrow biopsy.
These are the common blood tests carried on pregnant women in Nigeria especially at the Federal Medical Centre, Abakaliki, Ebonyi State, to confirm the diagnosis of anaemia (Donald, 2007).
2.7 Management of Anaemia in Pregnancy
According to World Health Organization (2004), management of anaemia in pregnancy is achieved using the three levels of prevention and care namely;
– Primary level of prevention and care
– Secondary level of care
– Tertiary level of care
a) Primary level of prevention and care: According to W.H.O. (2004) and confirmed by Ojo (2005), the primary level of prevention and care of anaemia in pregnancy entails the following:
Community Assessment: nurses and other health care professionals should jointly perform the role of community assessment to identify the women at risk of anaemia by taking an accurate medical, obstetric and social history (Lifestyle, food taboos, poor cooking and feeding habits).
Community mobilization and health education: from the findings gotten from the above community assessment, a massive community mobilization is carried out where by the nurses having planned out an effective health program in the community, educates the women in an understandable manner, the causes and prevention of anemia in pregnancy, advice given to the women includes:
– Dietary advice: this entails educating the women on the need to feed on adequate diet which is rich in all the nutrients like protein, vitamin, minerals, etc, so as to avoid iron/ folate deficiency anemia in pregnancy.
– Personal hygiene and protection: this entail educating the women on the need to maintain personal hygiene like regular bathing, washing of personal effects and prompt treatment of minor infections like urinary tract infections, worm infections and malaria and also the use mosquito treated bed nets and mosquito-proof houses are encouraged so as to avoid haemolytic anemia which is caused by repeated infections in pregnancy.
– Environmental hygiene and sanitation: this entails educating the women on the need to cut down and clear surrounding bushes and stagnant water including proper refuse disposal method so as to eradicate and destroy the mosquito larva and other disease vector that harbour disease parasites and transmits malaria and other infections to the pregnant women.
– Prevention and treatment of malaria in pregnancy: according to Ojo (2003) malaria should be prevented in pregnant women in areas where malaria is endemic (e.g Nigeria). This is done by administration of anti- malaria drugs which includes prophylactic drugs like Daraprim used weekly and chemotherapeutic drugs like chloroquine as prescribed by the doctor.
b) Secondary level of care: According to W.H.O (2007), the secondary level of management of anemia in pregnancy involves diagnosis and treatment of anemia and predisposing infections mainly malaria, the same report further states the following:-
After proper investigation is carried out in the pregnant women and a haemoglobin level of 10.5g/dl or below is determine, W. H. O recommends that women in an area where malaria is endemic should receive intermittent presumptive malaria treatment (IP) with an effective, preferable one dose, anti-malaria prophylactic drugs such as 25mg of pyrimethamine (Daraprim) weekly as part of routine ante- natal care during their first and second pregnancies and pueperium.
According to Campbell (2003), anemia in pregnancy can be managed by; Administration of folic acid (5mg daily), iron in the form of ferrous gluconate (325mg) given twice or thrice daily through out pregnancy as part of routine anti- natal care of pregnant women so as to prevent nutritional iron and folate deficiency anaemia and consequently boost the haemoglobin level of the pregnant women, strengthening the women and her baby for delivery and building her resistance against infections.
W.H.O (2008), states that malaria in pregnancy can also be treated using chloroquine sulphate (800mg) to eradicate malaria parasite from the blood stream in areas where malaria is endemic. Intermittent presumptive malaria treatment with anti-malaria drugs (sulfadoxine / pyrimethamine) known as fansider, is used in the treatment of chloroquine resistant malaria in pregnancy.
Ogunbode (2004) states that correction of anemia in pregnancy is possible with oral haematinics and parenteral haematinics. Blood transfusion can also be used in cases of severe anaemia with a potent diuretic example frusemide 40mg, given intramuscularly or by intravenous route and exchange blood transfusion. He states that the choice of method of correction depends on the severity of the anaemia.
In another study carried out by Bola (2005), it was established that adequate diet , diet rich in all the food nutrients in their right proportion e.g proteins, carbohydrates, vitamins and minerals go a long way in correcting and managing effectively anaemia in pregnancy and boosting the health of both mother and foetus.
Akande et al (2007) carried out a retrospective study on a population of 7,500 pregnant women who attended ante-natal clinic at Federal Medical Centre, Abakaliki Ebonyi State. During 2005-2007 using 250 anaemic women as his sample size, studying on the topic; management of anaemia in pregnancy, revealed the following results: 70% of the cases were mild to moderate anaemia and received treatments which included; administration of oral and parenteral haematinics, supplementary drugs such as folic acid tablets and ferrous glubconate (5mg and 325mg, once and twice daily respectively). After treatment these patients recovered fully from the symptoms of anaemia. 20% of the cases of anaemia in pregnancy had malaria, as such were treated with; chloroquine sulphate (800mg). After treatment with the antimalaria drug the patients recovered fully from the symptoms of anaemia. While the remaining 10% of cases had severe anaemia in pregnancy and as such received blood transfusion through intravenous route with a potent diuretic (Frusemide 40mg I.V.). After treatment with the blood transfusion, the patient recovered fully from the symptoms of anaemia.
c) Tertiary level of care: This involves making appropriate referrals for the management of complications of anaemia in pregnancy (Harvey 2006).
In summary, anaemia in pregnancy is a dreaded condition causing severe complications for both mother and foetus and can be effectively managed by the administration of oral and parenteral haematinics, chloroquine, and blood transfusions depending on the severity of the case. (Akande et al, 2007).
2.7.1 General Nursing Care of a patient with Anaemia in
The anaemic patient usually ill. She runs a risk of going into cardiac failure at the slightest strain and as such the nursing care must be that which would restore good health and prevent strain on the patient.
According to Ojo and Briggs (2007) and confirmed by Donald et al (2007), the general nursing care of a patient with anaemia in pregnancy includes the following;
– The patient must be admitted in the hospital in severe cases but in mild case patient is treated on out patient bases.
– Patient is propped up in bed (sitting position or cardiac position) so as to allow for easy breathing and prevents congestion in the lungs.
– Adequate rest should be encouraged since the anemic patient gets tired easily and may faint on exertion.
– Activities that increase oxygen demand should be avoided and nursing procedures should be carried out in such a way as to provide for uninterrupted rest period and conserve the patient’s energy.
d) Oxygen Therapy
– Dyspnoea normally accompany severe anemia, if present the patient is better nursed in fowler’s position (head of bed elevated) and if shortness of breath persists at rest, humidified oxygen is administrated.
– In severe cases blood transfusion of packed cells may be given to increase the oxygen- carrying capacity of the blood.
– On admission or report to the hospital, base- line vital signs are monitored and recorded and they include: temperature, pulse, respiration and blood pressure assessment which are made hourly.
– The nurse must report any undue rise in pulse rate or respiratory rate; these may be sign of impending cardiac failure. Breathlessness and cough could be due to pulmonary congestion and increased body temperature may be the sign of infection.
– The patient should also be observed for signs of confusion and indication of cerebral hypoxia.
– A fluid chart is kept to determine urinary output, especially when the patient has been transfused or is very edematous and is placed on antidiuretics.
f) Care during Blood Transfusion
– The blood for transfusion must be double checked by the nurses, the nurse must ensure that the correct tag, name of blood and hospital number are on the container of the blood.
– The nurse must also make sure from the laboratory/ blood
bank that is necessary tests were carried out on the blood to be transfused and that the blood is certified wholesome for transfusion.
– The nurse regulates the flow of transfusing blood as prescribed by the physician. A pint of blood (packed cells) should run for about six hours.
– The nurse must observe and record vital signs like pulse rate, respiratory rate and blood pressure half-hourly and observe/ record temperature every hour so as to detect early signs of transfusion reaction.
– Alterations in vital signs, haematuria and sensitivity reaction such as: presence of rash or itching in the skin, chest pain, breathlessness etc. These may be the sign of transfusion reaction. If any of these occurs, the nurse immediately clamps off the transfusion and inform the doctor.
g) Administration of Prescribed Drugs
– Drugs such as haematinics, chloroquine etc should be administrated to the patient by the nurse if in the hospital as prescribed by the doctor.
h) Nutritional Care
– The nurse should ensure that the patient takes adequate diet rich in protein, iron, vitamins, folic acid and vitamin B12 in appropriate proportions.
– Adequate fluid intake should also be encouraged, especially for patient with haemolytic anemia.
i) Physical Care
– The nurses should assist the patient on admission in the performance of personal hygiene such as bed bathing, oral toileting/ hygiene; this is done because ulceration of the oral mucosa and sour tongue are common problems associated with pernicious and iron deficiency anemias.
– Frequent changes in position for bed ridden patients is done (1-2 hours interval), this is done because reduced oxygen supply to the tissues as seen in anemia predisposes the skin to pressure sores.
– Pressure sores should be treated if any and protected with soft material e g sponge rubber or soft pillow to prevent skin excoriation.
– Extra bed linens should be used to provide wrath since patient generate less body heat due to decreased metabolism.
j) Prevention of Infection
– Efforts should be made by the nurse to prevent the patient from contact with infectious persons and also infections already acquired by the anaemic patient should be promptly treated because the anemic patient has increased susceptibility to infections (especially the patient with aplastic anemia)
k) Health Education
– The nurse should educate patient and family on the importance of a diet which contains adequate iron, vitamins and proteins (Dietary advice).
– The nurse should educate patient and family on the importance of adequate rest balanced with planned activities within the patient’s limit so as to avoid undue stress on the patient.
– The pernicious anemia patient is taught to continue with the maintenance dose of prescribed vitamin B12 and the necessity of compliance with medication explained to him.
– The prevention of infections, recognition of early symptoms and need for prompt treatment should be explained to the patient with chronic anemia.
2.8 THEORETICAL FRAMEWORK
The Health Belief Model is the theoretical framework and conceptual background that was used in the course of this research. The health belief model is one of the most widely used conceptual frameworks for understanding health behaviours. Developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working in the United States Public Health Services, the health belief model is a framework for motivating people to take positive health actions that use the desire to avoid a negative health consequence as a prime motivation. The health belief model is based on the calculated understanding that a pregnant woman will take a health related action (comply with antenatal health services), if that woman feels that a negative health condition (anaemia in pregnancy) can be avoided. Has a positive expectation that by taking a recommended action (attend antenatal clinics), she will avoid a negative health condition (i.e., by complying with antenatal clinics, she will be able to avoid the incidence of anaemia in pregnancy), and believes that she can successfully take the recommended health action with confidence and comfort.
The Health Belief Model is based on six basic concepts. The concepts include perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self efficacy. These concepts are independent predictors of health behavior. In the view of Onwumere (2006), the model hypothesizes that health-related actions depend upon the simultaneous occurrence of the following:
• The existence of sufficient motivation, e.g. a health concern/scare, to make health issues salient or relevant.
• The belief that one is susceptible to a serious health problem or the perception of a threat of disease.
• The performing of a particular behaviour/action will be beneficial by reducing the threat of disease, with few barriers to performing the behaviour.
The perception of the pregnant mothers in respect of the above mentioned facts in view of anaemia in pregnancy prevention is the bone of contention of the health belief model, rather than their objective status in determining their decision to take action. According to Rosenstock as quoted by Onwumere (2006), the concepts can be represented pictorially as:
Figure 1: Conceptual Framework of Health Belief Model
Source: Rosenstock in Onwumere (2006)
(1) Individual patient’s perception
The individual patient’s perception of threats of anaemia in pregnancy is motivated by the value she places on her health, her perception of her susceptibility to pregnancy anaemia and the severity of the condition when developed. These will influence her belief in antenatal services utilization and readiness for change of health behaviour.
(2) Modifying Factors
These are the factors that influence mothers’ perception of their exposure to pregnancy anaemia. These include demographic variables like age, sex, marital status, and ethnicity. They also involve educational qualification, professional status, knowledge and socio-economic variables.
(3) Motivating and Environmental Factors
These are the variables that stimulate the utilization of antenatal services. These include the mothers’ perception’ of the benefits of the services in eliminating pregnancy anaemia and the barriers to the utilization. These are enhanced by cues to motivate mothers’ utilization of antenatal services like antenatal education, medical information, seminars/health talks, community mobilization and reminders posted in strategic places in the communities. These factors influence the likelihood of behavioural change in the favour of utilizing antenatal services.
I take the freedom to modify concepts using the tabular representation of the concepts as excerpted from Glanz et al (2005), to suit my study. Below is the tabular representation of the basic concepts of the health belief model.
CONCEPT DEFINITION APPLICATION APPLIED IN ANTENATAL CLINIC ATTENDANCE
(1) Perceived Susceptibility One’s belief of the chances of getting a negative health condition. Define population at risk and their risk level. Personalize risk based on personal traits and behavours. The pregnant woman believes that she is at risk of anaemia in pregnancy and other pregnancy induced disorders.
(2) Perceived Severity One’s belief of how serious a negative health condition can be and its consequences. Specify the consequences of the risk of the negative health condition. The pregnant woman believes that the prognosis of pregnancy induced disorders is poor.
(3) Perceived Benefits One’s belief in the efficacy of the recommended health behaviour to reduce risk of the negative health condition. Define action to take and its procedure. Explain positive effects of the action in reducing the risk of the condition. The expectant woman attends antenatal clinic and knows that compliance will eliminate prevent the disorders.
(4) Perceived Barriers One’s belief of the cost and set-back to compliance with the recommended health behaviour. Identify and reduce barriers to enhance compliance. Lack of adequate resources, shortage of manpower, poverty and inadequate funding are barriers to accessing antenatal services.
(5) Cues to Action Strategies to activate readiness. Promote awareness, provide how-to information, and provide reminders. Provide adequate resources, funding and service subsidization. Promote awareness, and provide reminders to stimulate compliance.
(6) Self Efficacy Confidence in one’s ability to take action successfully. Provide training, guidance and positive reinforcement. Health educate all women of child bearing age, stimulate readiness for attendance.