1. Category of Public Health Significance Prevalence of anaemia (%)
Anaemia in pregnancy: factors associated with maternal anaemia in the Dadaab refugee camps, Kenya ( )
James Smith1*, Ismail Kassim1, Allison Oman2, Caroline Wilkinson3, Andrew Seal1 *
University College London, London, UK
United Nations High Commissioner for Refugees, Nairobi, Kenya
United Nations High Commissioner for Refugees, Geneva, Switzerland
INTRODUCTION:
Anaemia in pregnancy is associated with higher rates of both maternal morbidity and mortality.1
The Dadaab refugee camps present a series of additional challenges that can increase population susceptibility to micronutrient deficiencies, and impede efforts to implement effective supplementary nutrition programmes.
Using data from a study conducted in Hagadera and Ifo camps, Dadaab, Kenya, this secondary study aimed to identify factors associated with maternal anaemia in order to better understand the aetiology of this disorder among pregnant women in Dadaab, and to subsequently identify higher risk groups within this sub-population.
RESULTS:
817 women met the criteria for inclusion in the original micronutrient study. Women were included if they had been pregnant for ≤24 weeks, had resided in the camp for >6 months, had a baseline haemoglobin of >5.9g/dl, and if they did not have any serious underlying health problems.
The age of women in this study
ranged from 17 to 43 (mean: 25.7).
84% of women (n=686) had not
received any form of school-based
education. Only 9% of the women
(n=73) were engaged in some form
of income generating activity.
99% of the women were Somali
nationals. The women had lived in
the camp for between 1 and 12
years (mean: 8.4 years).
136 women tested positive for
malaria. 1.7% and 5% of women
tested positive for hookworm and schistosomiasis respectively. MUAC measurements ranged from 17-39cm (mean: 23.9), while BMI ranged from kg/m2 (mean: 20.7).
The prevalence of anaemia
(haemoglobin <11.0g/dl) among
pregnant women in Dagahaley and Ifo
camps was 75% at weeks gestation
(Fig 1 & Fig 2). This is considered a severe
Public health problem (Table 1). The
Prevalence of anaemia increased to 80%
by the middle of the third trimester,
before dropping to 35% in the post-partum period.
Iron deficiency was similarly widespread; 65% and 45% of women exceeded the threshold for iron deficiency as defined by ZPP and sTFR indicators respectively (Table 2).
Somali ethnicity, rural pre-displacement place of origin, low maternal education, low paternal education, lack of maternal employment, and higher parity were significantly associated with lower levels of haemoglobin following univariable analysis (p <0.05).
Of the nutritional indicators, higher BMI, higher MUAC, and a raised vitamin A concentration were significantly associated with higher levels of haemoglobin (p<0.05). Iron deficiency (as indicated by both ZPP and sTFR), a history of geophagia, and charcoal-specific pica were significantly associated with lower levels of haemoglobin (p<0.05).
Following regression analysis, Somali ethnicity, rural pre-displacement place of origin, and iron deficiency (as indicated by a raised sTFR) remained significantly associated with anaemia (p<0.05).
Fig 2: Histogram and kernel density overlay for haemoglobin at weeks (n=817)
Category of Public Health Significance
Prevalence of anaemia (%)
Severe
≥40
Moderate
Mild
5-19.9
Normal
≤4.9
2. WFP/UNHCR,
2011
Table 1: public health significance of anaemia, as defined by the WHO3
OBJECTIVES:
Describe the socioeconomic and health status of this population of pregnant refugee women;
Determine the prevalence of anaemia and iron deficiency using a series of diagnostic markers (haemoglobin, sTFR, and ZPP);
Explore the relationship between a variety of socio-demographic, nutritional, and disease-related factors, and haemoglobin status.
METHODS:
This paper was developed using data collected during a longitudinal cohort study conducted between , which investigated the effectiveness of a new antenatal micronutrient supplement. 
A preliminary literature review identified known biological and socioeconomic risk factors associated with maternal anaemia in the Horn of Africa.
Chi2, students t-test, correlation, and logistic regression analyses explored the strength of association between exposure variables and haemoglobin status.
Indicator
Anaemic
(<11g/dl)
Non-Anaemic (≥11g/dl)
% Iron Deficient
Iron Deficiency (>40umol ZPP/mol heme)
Yes
467 60
65.2% No
139
142
Iron Deficiency (sTFR >8.5mg/l) 90 2
45.2% 63 48
Table 2: iron deficiency measurements and associated haemoglobin status
RECOMMENDATIONS:
Robust mixed methods studies are needed to better investigate the community and household-level dynamics that affect haemoglobin status in the Dadaab camps;
Further aetiological investigations are needed to verify the findings of this study, and to explore other potential associations;
Given the high prevalence of anaemia, and of iron deficiency, it seems appropriate that blanket nutritional supplementation to pregnant women should continue – however;
Urgent and innovative multi-stakeholder engagement is required to address chronic micronutrient insufficiencies in the Dadaab camps.
Fig 1: Breakdown of anaemia by severity during pregnancy, and at 5-10 weeks post-partum.
van der Broek N (2003), Anaemia and micronutrient deficiencies: reducing maternal death and disability during pregnancy. British Medical Bulletin. Vol. 67(1):
WFP/UNHCR (2011), View from the air of Dadaab refugee camp [online] Available from: [access verified 2nd June 2014]
WHO (2011a), Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity [online]. Vitamin and Mineral Nutrition Information System (VMNIS), Geneva, World Health Organization. Available from: [access verified 2nd June 2014]
We welcome questions and queries. Full study available on request.
Acknowledgements: IK, AO, CW, AS, and Laird Ruth coordinated the original study, and provided regular input during the preparation of this paper. Staff affiliated to MSF-Belgium and UNHCR, along with the laboratory and research teams based in Dadaab and London, played an instrumental role during the completion of the original study. A particular thanks go out to the women who participated in the study, for whom we hope this research will ultimately be of benefit.