NUTRITIONAL AND IRON STATUS OF PREGNANT WOMEN ATTENDING ANTENATAL CLINIC AT THE UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ITUKU OZALLA, ENUGU

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TABLE OF CONTENTS

Title page       –           –           –           –           –           –           –           –                       i

Table of contents     –           –           –           –           –           –           –                       ii

List of tables –          –           –           –           –           –                       iv  

ABSTRACT   –           –           –           –           –           –           –           –                       viii

CHAPTER ONE

1.0                   INTRODUCTION     –           —         –           –           –           –           1         

1.1                   Background of the study     –           –           –           –                       1

1.2                   Statement of problem          –           –           –           –                       2

1.3                   Objectives of the study       –           –           –           –                       3

1.4                   Significance  –           –           –           –           –           –                       3

CHAPTER TWO

2.0                   LITERATURE REVIEW      –           –           –           –           –           4

2.1                   Maternal nutritional and physiological adjustment in pregnancy       5

2.2                   Micronutrient status in pregnancy         –           –                       6

2.3                   Nutritional requirements of pregnant women     –       7

2.4         Energy expenditure and its implication on the pregnant woman 8

2.5                   Socio-economic and nutritional status     –           –                       9

2.6                   Nutritional status: it’s implication for pregnancy         –          10

2.7                   Maternal nutrition and infant development         –      –   10

2.8                   Maternal malnutrition and organ development   –        10

2.9                   Methods of nutritional assessment           –        –                       11

2.9.1               Historical information         –           –           –           –                       11

2.9.1.1       Diet history   —         –           –           –           –           –                       12

2.9.1.2         24-Hour recall          –           –           –           –           –                       12

2.9.1.3        Usual food intake     –           –           –           –           –                       12

2.9.1.4         Food record   –           –           –           –           –           –                       13

2.9.1.5         Food frequency checklist   –           –           –           –                       13

2.9.2           Anthropometric data           –           –           –           –                       13

2.9.3          Physical examination (clinical assessment)        –           14

2.9.4       Biochemical analysis (laboratory tests)   –           –                       15

2.10          Methods of assessing iron status   –           –           –                       16

CHAPTER THREE

3.0                   MATERIALS AND METHODS      –           –           –                     18         

3.1                   Study area     –           –           –           –           –           –                       18

3.2                   Study population      –           –           –           –           –                       18

3.3                   Study design             –           –           –           –           –                       18

3.4                   Sample size   –           –           –           –           –           –                       18

3.5                   Sampling technique –           –           –           –           –                       18

3.6                   Methods of data collections           –           –           19

3.6.1               Questionnaire           –           –           –           –                  19

3.6.2               Clinical assessment of pregnant women  –           –                       19

3.6.3               Anthropometric measurements      –           –           –                       19

3.6.3.1            Weight           –           –           –           –           –           –                       19

3.6.3.2          Height            –           –           –           –           –           –           –    19

3.6.4        Biochemical analysis of iron         –           —         –               20

3.6.5  Dietary assessment of pregnant women using 24-hr dietary recall-20

3.6.6      Food consumption pattern of pregnant women using food frequency  check  list         20

3.6.7              Ethical clearance and consent forms        –           –                       21

3.7                   Data analysis            –           –           –    –           –                       21

CHAPTER FOUR

4.0                   RESULTS      –           –           –           –           –           –                       22

4.1                   Basic characteristics of mothers    –           –           –                       22

4.1.1               Socio-economic characteristics of mothers         –       23

4.1.2               Ante natal history of mothers        –           –           –                       25

4.1.3               Medical conditions influencing nutritional status     26

4.2                   Nutritional status     –           –           –           –           –                       27

4.2.3.1          24-Hr dietary recall –           –           –           –           –                       29

4.2.3.2          Responses to diet history questions          –      –                       30

4.2.3.3            Mothers’ food craving/taboos by trimesters       –                       31

4.2.3.4            a  Food taboos based on mothers’ religion/culture –           32

4.2.3.4b          Reasons for food taboos by mothers’ religion/culture              33

4.2.4       Frequency of food consumption by the mothers            34

4.2.5      Mothers’ frequency of consumption of various food types by trimester    –   35

4.2.6        Frequency of consumption of specific foods from various food types   –           –           –           –           –                       36

4.2.6       Frequency of consumption of starchy roots/tubers according to their specific types   –           –           –                       36

4.2.6.1       Frequency of consumption of cereal/cereal products according to their specific types   –           –           –                       37

4.2.6.2        Frequency of consumption of meat/milk by specific type  38

 4.2.6.3    Frequency of consumption of iron rich foods by specific types – -39

4.2.6.4    Frequency of consumption of legume/legume products by specific types      –           –           –           –           –                       40

4.3.0               Biochemical assessments   –           –           –           –                       42

4.3.1      Mothers’ haemoglobin levels and packed cell volume values – – 42

4.3.2               Haemoglobin levels of mothers in different trimesters   43

4.3.3    Medical conditions associated with low haemoglobin levels – – 44

4.3.4        Basic characteristics of mothers and their haemoglobin levels – 45

CHAPTER FIVE

5.0                   DISCUSSION               –           –           –           –           47         

5.1                   Background information of pregnant mothers          47

5.2                   Assessment of nutritional status    –           –           –                       48

5.2.1               Anthropometric assessment of pregnant mothers- – –       48

5.2.2               Anthropometric weight gain in pregnancy    –                       49

5.2.3               Clinical/physical assessment         –           –           –           49

5.2.4               Dietary studies         –           –           –           –           –                       50

5.3.0               Iron status of pregnant mothers     –           –           –                       52

5.3.1               Biochemical measurements            –           –           –           – 52

5.4.0        Factors that may influence iron status of pregnant mothers     53

5.5.0               Conclusion    –           –           –           –           –           –                       53

5.6.0               Recommendation     –           –           –           –           –                       55

                        REFERENCES          –           –           –           –           –        56           

ABSTRACT

Pregnant and lactating women are nutritionally, the most vulnerable group especially in developing regions of the world. This is because of repeated pregnancies and lactation which are aggravated by food taboos and poor maternal stress. The poor nutrition experienced by these women results to “maternal depletion syndrome”, the most common of which is protein-energy malnutrition (PEM). This study therefore had the following key objectives: (i) to assess the nutritional status of pregnant mothers attending antenatal clinic at the University of Nigeria Teaching Hospital, Ituku, Ozalla, Enugu (ii) to assess the iron status of the mothers and  (iii) determine factors that are associated with iron deficiency in pregnant mothers. A retrospective and prospective review of pregnant mothers in the University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu was carried out to assess their nutritional status using anthropometry, dietary, clinical/physical and biochemical methods. The mothers were enrolled as they came within a period of six months. A total of 405 mothers were enrolled, only those who met the inclusion criteria were selected. Those who were included were in their first or second trimesters, consistent in their visits and were able to do prescribed tests. A total of 263 mothers were qualified to be selected.  The results of the study showed that of the 263 pregnant mothers that participated, about 7.6% delivered their babies in a peripheral hospital. The majority (92.4%) of the mothers were married. About 38.4%  were within the age range of 27 – 31 years and almost the same number (38.3%) were multiparous. More than a  half of the mothers (68.8%) were in their  second trimester and 34.2% were in their  first trimester. Only 9.1% had no formal education and 18.6% stopped at primary school level. Paleness of the eyes and swollen legs in 61.2% and 29.3% of the subjects were the clinical signs of malnutrition observed . The biochemical analysis showed that 39.5% of the mothers had mild anaemia, 37.3% had moderate anaemia and 10.3% had severe anaemia in their  second trimester. Only 12.9% of the mothers had normal haemoglobin. Mothers’ parity, trimester, hours of work and marital status affected their haemoglobin levels. Th mean height of of the mothers was 1.64 ± 0.6m, weight 79.9 ± 10.9kg and age 30.8 ± 3.7 years. Malaria (19.8%)  was the main cause of low haemoglobin in the mothers. The 24-hr food recall and food frequency analysis showed that on daily basis, the bulk of the mothers food consisted mainly of starchy roots\tubers, about 19.0%  and 28.1% in the first and second trimesters and consumed less of meat\milk products  ( 8.0% and 14.4%) in the respective trimesters. About 9.0% and 7.0% of mothers in the first trimester consumed fruits and vegetables and nearly 17.0% and 19.0% of mothers in the second trimester consumed fruits and vegetables. The mothers on weekly basis consumed  diets containing adequate foods. The overall nutritional status of the pregnant mothers was poor. Mothers’ occupations, parity and literacy levels significantly (P < 0.05) affected their consumption of  vegetables, fruits, legumes and starchy roots/tubers at various levels. The inadequate consumption of these foods may result to micronutrient deficiency (hidden hunger). Women’s under nutrition translates into loss of economic productivity and of lives. Appropriate interventions in addressing maternal nutritional status depend on the factors affecting their status in a particular household and community. A common cause in Nigeria, Enugu in particular is one in which women are underfed and over worked. 

CHAPTER ONE

1.0       INTRODUCTION

1.1       Background of the study

Pregnant and lactating women are nutritionally, the most vulnerable group especially in developing regions of the world because comparatively little is known of their nutritional needs(World Health Organization (WHO), 2001). The pregnant woman may find herself being alien to her most favourite dish or going for a particular type of diet that she previously hated, while some crave for non-food substances that have no nutritional value. All these are due to physiological changes occurring in pregnancy as a result of hormonal changes. This change in food or eating pattern predisposes the woman to a state of malnutrition and low iron reserve, an important cause of morbidity and when severe, could lead to mortality in pregnant women.

Malnutrition is intrinsically a problem affecting individuals and nations which the pregnant women are part of (UN/SCN, 2002). Large numbers are at risk of specific nutrient deficiencies like iron. This is because majority are either too poor to acquire foods containing essential nutrients or are ignorant of the proper cooking technique and combination of food classes and others have many children and large family size (ACC/SCN, 2003).

Women in some areas are in a state of nutritional stress always. The whole of their adult life may be continuously reproductive as pregnancies and lactation follow one another without pause (Ojo/Briggs, 2008). Their nutritional needs are high and this is more in some cultures where women may be responsible for such heavy work carried out with inefficient and clumsy tools (ACC/SCN, 2002) even during  pregnancy. Such strenuous work includes farming, carrying heavy things to market, cooking, collecting water and wood and pounding foofoo. The already poor nutritional state is further aggravated by food taboos applying to women. Cultural beliefs and food taboos such as women labour, early marriage, female genital mutilations and superstitions prohibiting women from eating certain foods like chicken, eggs, mutton, snails, certain types of fish, cereals and vegetables which are the main sources of animal protein, vitamins and iron etc also influence the health and nutrition of the pregnant women.

The poor nutrition experienced by these women results to “maternal depletion syndrome”, the most common of which is protein-energy malnutrition (PEM). Others are iron deficiency, megaloblastic anaemia and iodine deficiency (East Wood, 2007) in women of child bearing age which can lead to low birth weight  babies, failure to gain weight in pregnancy, decrease in subcutaneous fat and muscle tissue. All these undoubtedly contribute to premature ageing and early death seen in women in the developing countries.

Nutritional assessment is an indispensable component of nutritional care of pregnant mothers in antenatal clinics because the failure to identify and treat malnourished pregnant mothers poses a threat to the mothers and their fetus in utero.

1.2       Statement of the problem

 Food consumption and state of nutrition are dependent on a whole complex of socio-economic factors which are inter-related (Ngwu, 1992). Meeting nutrient needs  depends on what foods and combinations consumed. This is particularly important for pregnant women whose nutritional state is very important; the cost of iron balance on the mother is more in pregnancy than the non pregnant state. More iron and other nutrients are needed in pregnancy for the expansion of the maternal red cell mass though most of the iron is returned to stores after delivery (INACG, 2006).

A lot of women enter into pregnancy with poor or low iron reserve and general malnutrition and pass through the clinics unnoticed resulting to lots of complications during pregnancy, labour and puerperium (INACG, 2006). The low reserve of iron and general malnutrition could be due to low iron and other essential nutrients like protein, minerals, vitamins, carbohydrates content in food probably from ignorance, cultural practices, poverty, type of occupation and environment or due to bioavailability of iron and other nutrients from gastric enzyme alterations.

The pregnant women are also given nutrition education in the clinics by unqualified personnel. The nutrition education given is not meaningful with the result that they remain in the dark about the benefits and adverse effects of low or non consumption of these food components. The pregnant women are also in a more nutritional and health dilemma because of the severe economic situation in the country affecting the poor and the rich, young and old. It is therefore necessary to identify the pregnant women with poor nutritional and iron status with a view to monitoring and helping them pass through child birth with no complications to them and their babies.

It is improper to correct nutrition inadequacies of the pregnant women without understanding their food consumption pattern and socioeconomic background (DeMaeyer, 2008). This study was therefore undertaken to assess the nutritional and iron status of pregnant mothers attending antenatal clinic at the University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu.

1.3       Objectives of the study

  • General objectives

The general objective of this study was to assess the nutritional and iron status of pregnant women attending antenatal clinic at the University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu.

  • Specific objectives

The study has the following specific objectives:

  1. to assess the nutritional status of pregnant mothers attending ante natal clinic at University of Nigeria Teaching Hospital using anthropometric, biochemical, dietary and clinical methods.
  2. to assess the iron status of the pregnant mothers using their haemoglobin and haematocrit counts.
  3. to determine factors that are associated with iron deficiency in the mothers.

1.4       Significance of the study:

(1)       The study will provide basic information on the nutritional status of pregnant mothers attending antenatal clinic at the University of Nigeria Teaching Hospital in particular and Enugu State in general and will be of great importance to nurses, doctors, nutritionists and policy makers on the best way to care for women before, during and after pregnancy.

(2)       Women as a whole should have their own health and nutritional policies because of the physiological changes that take place in them pre, intra, and post natally

(3)       It will be an “eye opener” for health workers at the clinics who concentrate more on treatment of diseases with drugs than relating the disease condition to the individuals nutritional state. This will mean more adequate foods/nutrients and less drugs.

NUTRITIONAL AND IRON STATUS OF PREGNANT WOMEN ATTENDING ANTENATAL CLINIC AT THE UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ITUKU OZALLA, ENUGU