Rajiv Gandhi University of Health Sciences, Karnataka



Rajiv Gandhi University of Health Sciences, Karnataka

SYNOPSIS

FOR REGISTRATION OF SUBJECT FOR DISSERTATION

|1 |Name of the Candidate |Ms. AMANJEET KAUR |

|2. | | |

| |Name of the Institution |Diana College of Nursing No. 68, Chokkanahalli, Jakkur Post, |

| | |Bangalore – 64 |

|3. |Course of Study and Subject |Master of Science in Nursing |

| | |Community health nursing. |

|4. |Date of Admission to Course |10.06.2009. |

| | |Assess the Knowledge on Iron deficiency anemia among pregnant women |

|5. | |attending antenatal clinic at Primary health centre of rural district|

| | |Bangaluru, Karnataka. |

| |Title of the Topic | |

6. Brief resume of the intended work

6.1 Need for study

YOU CAN TELL THE CONDITION OF A NATION BY LOOKING AT THE STATUS OF ITS WOMEN-JAWAHARLAL NEHRU.

Women’s health is central to the survival of the society. They are pivot of the family, the nurtures of the next generation and care givers for elderly. Apart from their familiar duties, women are first and fore most free human beings who have a primary responsibilities towards their own health and happiness. Women’s lives have to be seen as continuum and culmination. (1)

The different stages of their lives segue into each others seamlessly and one such stage is pregnancy which is a special event in women’s life and joyful anticipation. But sometimes it can be a time of fear of suffering and death in case women begins pregnancy with low or absent stores of iron because of heavy menstrual period, a previous pregnancy, poor iron intake , substance abuse and increase fetal demands of iron leads to iron deficiency anemia.(2)

Iron-deficiency anemia is the most common form of malnutrition in the world and is the eighth leading cause of disease in girls and pregnant women in developing countries leading to the low birth weight which is in turn an important risk factor for infant mortality.

It is a condition in which the hemoglobin content /level in the blood is lower than the normal as a result of deficiency of one or more nutrients specially iron.

Normal hemoglobin level in the blood is 14gms/dl=100%.According to WHO ,the cut off value for adult women(pregnant) is 11gms/dl.

With a global population of 6.5 million ,about 3.6 million people have iron deficiency and out of these about 2.0 billion are suffering from iron deficiency anemia. In India ,it is very high among nutritionally vulnerable group such as mothers and children, it varies from 60-70%.Among pregnant women, it is about 85%.(3)

World Health Organization in 2009 reported that 35% to 75% of pregnant women in developing countries, and 18% of women from industrialized countries are anemic . However, many of these women were already anemic at the time of conception, with an estimated prevalence of anemia of 43% in nonpregnant women in developing countries and of 12% in women in wealthier regions . (4)

Anemia affects more than 2 billion people worldwide – one-third of the world's population. Prevalence among pregnant women and children under 2 years of age is more than 50 %.Anemia contributes to 20% of all maternal deaths.(5)

In India, the incidence of anemia among pregnant women is alarmingly high. 500 million women in the world are iron deficient .In India 13 million out of 22 million pregnant women suffer from anemia whereas the incidence of anemia ranges between 20-30% in the middle income group. It is Much higher in the lower income group that is 60% in the urban women and 70% in rural women. Iron deficiency anemia is a serious problem in pregnancy which affect 60-70% pregnant women with Hb level less than 11gm%, 15-30% of all maternal deaths are due to anemia. Maternal anemia was found to be significantly associated with more frequent preterm birth and increased low birth weight new born. (6)

It was estimated by National family health survey (NFHS)3 2005-2006 that the prevalence of anemia founded to be 70% in pregnant as compared to the report of NFHS2(1998-1999).There has been an increased trend.(7)

Iron deficiency anemia affects more than a billion people in the entire world. In developing world alone ,370 million women suffer from anemia with the prevalence being higher in pregnant women (51%)than in non pregnant women(41%).The prevalence among pregnant women in southeast Asia varies from 13% in Thailand to the highest prevalence of 88% in India. (8)

Anemia is one of the most common problem of pregnancy as estimated 20%-60% of women will be anemic at some time during pregnancy.

In 2003 ,ICMR reported that in India approximately 52% of women have some degree of anemia and 40% women in every subgroup of population are anemic.(9)

It was indicated by NNMB in 2003 that prevalence of anemia in adolescent girls was (70%)pregnant women(74%)and lactating mother(78%).

It was stated that during pregnancy the maternal plasma volume gradually expands by 50% or an increases of approximately 1200ml by term .The total increase in RBCs is 25% of approximately 300ml.The relative haemodilution produces a fall in Hb concentration .These changes are also considered to represent a physiological alteration of pregnancy necessary for the development of the fetus. Fetal outcomes appear with an increased incidence of low birth weight and preterm birth in mothers who have either a very low or very high Hb concentration.

Iron deficiency anemia in women is aggravated by blood loss associated with placental abnormalities like placenta previa,placenta abruption, incidental abnormalities like piles, cervical erosion, cervical polyp, and more importantly malaria and hookworm diseases. A pregnant women needs a daily intake of 40-60mg of iron as comparative to non-pregnant women’s diet 20-22mg .

Iron deficiency anemia is an important cause of maternal mortality ,it is directly responsible for 20% maternal deaths and indirectly for another 20% of maternal deaths. Anemia also contributes to abnormal pregnancy outcome and high perinatal morbidity and mortality .(10)

Iron deficiency anemia is common in poor class since intake is poor mainly due to the non-availability of healthy foods. In higher classes, the personal likes and dislikes and food taboos leads to anemia. (11)

Poverty ,ignorance ,lack of knowledge regarding nutritive value of foods and inadequate sanitary environment are the major factor responsible for low intake of iron rich food.In developing countries located in tropical climates ,the most common cause of iron deficiency anemia is infestation with hookworm . (12)

It was stated that iron deficiency anemia is prevalent in 10% to 30% of the world’s population .Inadequate intake of iron may be an important causative factor when the body requires more iron than usual .the increased fiber in diets increased incidence of iron deficiency anemia because too much fiber in the diet renders available iron unabsorbed.

Iron deficiency anemia during pregnancy putts the woman at three times greater risk of delivering LBW babies and nine times higher risk of perinatal mortality .Thus, contributing significantly for increased infant mortality rate and maternal mortality rate.30% of maternal deaths are due to anemia. (3)

Iron deficiency anemia contributes to 20% of maternal deaths and is a contributory factor in another 20%of maternal deaths following obstetrical haemorrhage,obstructed labor, sepsis and other causes. Reduction in infant and maternal mortality is a priority goal for all the nations and also for both WHO and UNICEF.(6)

Long term Iron deficiency anemia during pregnancy may lead to intra uterine growth retardation, pre term labour,intra uterine death, low birth weight infants and bleeding during delivery.

Gastrointestinal and female genital tract are the two most common sources of blood loss. Hookworm infections is an important cause of blood loss. vitamin C is known to increase iron absorption example:lemon,fresh fruits and specially leafy vegetables.(13)

Pregnancy makes considerable nutritional demands on the mother as a consequences of anemia is a very common. Particularly when consecutive pregnancies are not well spaced, the presence of anemia increases morbidity in pregnant, the risk of infections and the hazards of PPH .

NHPI which is now a part of RCH-II program prophylactic treatment for expected and nursing mothers are given one tablet containing 100mg elementary iron and 0.5 mg folic acid nutrition education to improve dietary intakes in family for receiving needed macro/micro nutrients as protein ,iron and vitamins like folic acid,B,C etc for Hb synthesis is important.(14)

According to “12 by 12 initiative”, under national nutritional anemia prophylaxis programme states that the millennium development goal is to be achieved to reduce high rate of global child and maternal deaths by the year 2015.Goals focus on to decrease the prevalence of anemia among adolescents to ensure healthy parenthood and to increase the awareness among adolescents regarding anemia and appropriate nutrition.(3)

Anemia can be prevented and control in pregnant women by improvement in diet and prophylactic treatment by iron folic acid, improvement of diet and treatment for worm infestation and malaria.(15)

Maternal health ,nutrition and education are important for the survival and well being of women and are key determinants of health and well being of the fetus.

Iron deficiency anemia is a silent epidemic which is a critical health concern. The treatment and preventive measures are cheap and easy to follow by the pregnant women .(16)

Hence,I felt there is a need to assess the knowledge of pregnant women on iron deficiency anemia.

2. Review of literature

The review of literature entails systemic identification, selection, critical analysis and reporting of existing information in relation to the problem of interest.a literature review is a written summary of the state of existing knowledge on a research problem.the talk of reviewing research literature involves the identification ,selection ,critical analysis and written description of existing information on a topic.

The review of literature involves “the selection of available documents on the topic,which contain information,ideas,data and evidence written from a particular stand point to fulfill certain aims or express certain views on the nature of topic and how it is to be investigated and the effective evaluation of these documents in relation to the research being proposed”

The purpose of review of literature is to obtain comprehensive knowledge and in depth information about iron deficiency anemia among pregnant women. Thus literature review will help in developing a broad conceptual context into which research problem will fit.(17)

The review of Literature will be organized under following headings:

1. Incidence and prevalence of iron deficiency Anemia among pregnant women.

2. Knowledge of mothers on prevention of iron deficiency anemia.

3. Nurses role in prevention of iron deficiency anemia.

4. National Nutritional Anemia Prophylaxis Program.

Section A: Incidence and prevalence of Iron deficiency Anemia among pregnant women.

Women have a primary responsibility towards their own health and happiness. But sometimes ,women enters the pregnancy with low or absent stores of iron which leads to iron deficiency anemia. It is a condition in which the hemoglobin level in blood is lower than the normal as a result of deficiency of one or more nutrients specially iron.

In developing regions of the world, the prevalence of anemia among pregnant women, has been estimated as 59% as against 14% in developed regions and in south Asia ,the prevalence is 65%.Anemia also increases with increasing parity ;severe anemia becomes almost three times more frequent among women conceiving beyond fourth parity .Iron deficiency is principle cause of anemia of pregnancy .(10)

It is estimated that prevalence in South-East Asia is 50% to 70% .Little progress has been made in reducing iron-deficiency anemia among women in developing countries, in spite of the introduction of iron-supplementation programmes in many of them. In Indonesia, for example, iron supplementation for pregnant women was started some 10 years ago, but the prevalence of anemia among pregnant women still remains at 63.5% .(18)

Anemia is not only caused by deficiency of iron but is also caused by other conditions such as malaria, hookworm diseases. On considering all of these factors, it is estimated that about 700-800 million people are affected by anemia worldwide.(19)

A study was conducted on Prevalence of anemia among Pregnant Women and Birth Weight in Five Areas in China. Blood hemoglobin concentration (Hb) was measured by the cyanomethemoglobin method in 6,413 women in third trimester of pregnancy. The study concluded that the prevalence of anemia in Chinese pregnant women was high both in rural areas and towns. Area of residence, education level and type of job influenced the prevalence of anemia. Low maternal Hb concentrations influenced birth weight. (20)

A study was conducted on Iron Deficiency Anemia and Depleted Body Iron Reserves Are Prevalent among Pregnant African-American Adolescents. The degree of iron depletion and deficiency would be marked.In conclusion, iron-deficiency anemia was prevalent among pregnant minority adolescents. Targeted screening and interventions to improve diet and compliance with prenatal iron supplementation are warranted for this at-risk group. (21)

Iron deficiency anemia is a problem in Ethiopia and there is a need for improved supplementation to vulnerable groups is warranted to achieve the United Nation's Millennium Development Goals. Chronic illnesses are another important cause of anemia. (22)

The study on Prevalence of anemia in pregnant & lactating women of India was conducted in selected seven States and used the same districts and villages studied in the NFHS-2, to see if the reported reduction in prevalence of anemia was due to health and nutrition inputs and/or due to a different method for hemoglobin estimation. A total of 1751 women was estimated for Hemoglobin by the cyanmethaemoglobin method, so that comparison was possible with earlier studies. At last study concluded that Prevalence as well as severity of anemia was significantly higher in the present study as compared to the NFHS-2(1998-1999) study data.(23)

A study was conducted on Prevalence of Iron Deficiency in the United States . It was concluded that iron deficiency and iron deficiency anemia are still relatively common in adolescent girls, and women of childbearing age. (24)

As Hb is a necessary for oxygen transport and cell respiration, in iron deficiency anemia every tissue cell suffers from lack of oxygen. The clinical symptoms such as headache,giddiness,lassitude,pale and puffy face, pale conjunctiva, dry and lusterless hairs, pale and smooth tongue with atrophied papillae,anorexia,acidity,ascites.dysphagia,breathlessness,rapid and week pulse, edematous feet, brittle and koilonychias nails. (25)

Iron deficiency anemia is caused due to reduced intake or decreased absorption of iron ,excess demand such as multiple pregnancies, frequent or number of pregnancies, chronic inflammation particularly of urinary tract infections, blood loss from menorrhagia before conception, bleeding haemorrhoids,antepartum hemorrhage, postpartum hemorrhage and hookworm ,decreased absorption due to decreased gastric acidity and dietary imbalance. (3)

A study was conducted on 60 pregnant women of Bathinda city who were selected during 7th month of pregnancy to study the Impact of Iron Status of Pregnant Women on the Anthropometry of Newborns in Industrial and Non-Industrial Areas The study concluded that poor nutrient intake, iron deficiency anemia resulted in low birth weight babies . (26)

It was founded that the review focuses on iron balance during pregnancy and postpartum in the Western affluent societies.Average requirement during the entire gestation is approximately 4.4 mg/day. In placebo-controlled studies on healthy pregnant women, there is no relationship between the women's haemoglobin and birth weight of the newborns and no increased frequency of preeclampsia in women taking iron supplements.(27)

During pregnancy ,approximately 1500 mg iron is needed for the increase in maternal Hb(400-500mg),the fetus and placenta(300-400mg),replacement of daily loss through urine, stools and skin(250mg),replacement of blood loss at delivery(200mg)and lactation(1mg per day).(28)

A study was conducted on Importance of pre-pregnancy and pregnancy iron status. Most women worldwide enter pregnancy without adequate iron reserves or are already iron deficient. Estimates of iron needs during pregnancy are markedly reduced when iron reserves are available. Pre-pregnancy and prenatal weekly supplementation can improve iron reserves effectively and safely, preventing excess iron and favoring better pregnancy outcomes. (29)

There was a high prevalence of micronutrient deficiencies amongst the pregnant women of the area, possibly due to the poor dietary intake of food and low frequency of consumption of food groups rich in micronutrients. (30)

The prevalence of iron deficiency anemia is highest in women of childbearing age (particularly pregnant women). In pregnant women, iron deficiency increases the risk for a preterm delivery and delivering a low-birth weight baby. In developing countries, iron deficiency anemia is frequently exacerbated by malaria and worm infections. (31)

A study was conducted on prevalence of anemia among women of reproductive age group in Rajapur.The study involves sample size of 420 women of age 15-44 years. The study concluded that there was no association found between Hb status with education of women ,occupation and knowledge of women. No relationship was observed between type of family and Hb staus of women. (32)

Section B: Knowledge of mothers on prevention of iron deficiency anemia.

A study was conducted on Prevalence of Anemia and Its Determinants Among Nonpregnant and Pregnant Women in India. A national survey was conducted in 26 states of India to collect data on hemoglobin, height, weight, and certain economic and biosocial factors of 72 660 nonpregnant and 5619 pregnant women. Women's education and standard of living in the households have a vital role in reducing anemia. Urban and well-nourished women also suffer less from anemia. The severity of anemia is higher among pregnant than nonpregnant women. Efforts must be made to educate women and enhance their level of economic status so that the prevalence of anemia can be reduced substantially.(33)

A study was conducted on Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries. The women those who visit prenatal health services are often familiar with iron supplements, but commonly do not know why they are prescribed. Contrary to the belief that women stop taking iron tablets mainly due to negative side effects, only about one-third of women reported that they experienced negative side effects in these studies. in most countries, fears that taking too much iron may cause too much blood or a big baby, making delivery more difficult. (34)

Women need to be taught about the sources of iron and ways in which absorption can be increased .Iron intake is closely linked with calorie intake 2000Kcal per day will contain approximately 12-14mg of iron ,sufficient to cover the recommended daily amount of 113mg for pregnant women. (28)

Section C: Nurses role in prevention of iron deficiency anemia.

Iron deficiency anemia has some ill effects on mother and child as well. Maternal effects includes reduced physical capacity and work performance, impaired immune response predisposing for infections, decrease in peripartum reserve, risk of cardiac failure and increased need for blood transfusions leading to negative reproductive consequences.

Fetal effects include the low birth weight baby who suffers from impaired psychomotor and cognitive function. Infants born to severely anemic mothers have higher risk of irreversible brain damage, lower school achievement, a reduced physical and exercise tolerance and poor immune response.(35)

A study was conducted on Anemia and iron deficiency: effects on pregnancy outcome. Current knowledge indicates that iron deficiency anemia in pregnancy is a risk factor for preterm delivery and subsequent low birth weight, and possibly for inferior neonatal health. Mounting evidence indicates that maternal iron deficiency in pregnancy reduces fetal iron stores, perhaps well into the first year of life. This deserves further exploration because of the tendency of infants to develop iron deficiency anemia .The weight of evidence supports the advisability of routine iron supplementation during pregnancy. (36)

The midwife can help to identify women at risk of iron deficiency anemia by taking accurate history of medical, obstetrics and social history. She will be able to provide explanation appropriate to particular woman taking into account her health and socio-cultural preferences. (28)

A study was conducted on Predicting Factors in Iron Supplement Intake among Pregnant Women in Urban Care Setting. The world health organization estimates that 58% of pregnant women in developing countries are anemic. In spite of the fact that most ministries of health in developing countries have policies to provide pregnant women with iron supplementation, prevalence of maternal anemia has not declined significantly. At last the study concluded that the compliance was rather high but knowledge of subjects was low. Therefore, increasing effort is required to mobilize health workers including nurses to distribute information on anemia prevention and using iron supplements properly.(37)

Nurses plays vital role in prophylaxis of iron deficiency anemia .She increases the awareness of women by teaching them to avoid frequent childbirths. Supplementary iron therapy should be encouraged when woman becomes free of nausea of pregnancy ,daily administration of 200mg of ferrous sulphate along with 1mg of folic acid is a quite effective prophylactic procedure. Proper nutritional education should be given to encourage increase intake of iron rich diet. Adequate treatment of disease like hookworm infestation ,dysentery, bleeding piles, malaria and urinary tract infection should be done to prevent iron deficiency anemia. Early detection of Hb should be estimated at 1st antenatal visit, at 28th and finally at 36th week. (38)

When anemia exists after acute blood loss, dietary sources of iron will probably not be adequate to maintain iron pools. For every 2ml of blood lost 1 mg of iron is also lost. Oral or parental iron preparations can be administered. Nursing interventions includes treating shock in acute blood loss and locating the cause and take measures everyday in both acute and chronic blood loss.(39)

Nurse should give nutritional education to increase the awareness of people especially mothers ,pregnant and lactating women on the importance of consuming iron rich nutritious diet that can satisfy their specific requirement .They must consume adequate quantities of cereals,pulses,green leafy vegetables and also citrus fruits to increase the intake of iron and facilitate its absorption in presence of vitamin C.They must avoid drinking of tea or coffee and chewing of betel shortly after meals ,to avoid interference in the absorption of iron.Non vegetarian should increase their intake of meat ,poultry,fish,eggs because these contain haem iron of high bio-availability that can promotes the absorption of non-haem iron present in vegetarian foods.(10)

A study was conducted on High prevalence of anemia among women in Mumbai, India. Iron-deficiency anemia is highly prevalent among women of reproductive age in South-East Asia. In this study, the haemoglobin levels of 2,813 women were estimated living in inner-city Mumbai, India, The study concluded that nutritional interventions that focus on reducing fertility or iron supplementation during pregnancy are beneficial, but many women remain iron deficient. Action is needed to improve nutritional status before pregnancy - a policy that is feasible given the current interest in adolescent sexual and reproductive health programmes.(18)

Nurse should educate women about food fortification with iron. Food fortification is the way to prevent iron deficiency anemia. There should be fortification of floor, corn meal,grits,milk products. In India ,salt is also fortified with ferric orthophosphate and sodium acid sulphate at a level that provides 1mg of elemental iron for each gram of salt.The double fortified salt is acceptable to Indian consumers and is compatible with Indian dishes and Indian cooking practices. The double fortified iron has a better availability of iron than single fortified iron. Public should be given health education about change in cooking and eating habits, infection control, better personal hygiene.(19)

Nurse should instruct women for taking iron preparations and its side effects. Iron should be taken on an empty stomach (1 hr or 2hrs after meals).Iron absorption is reduced with food especially with dairy products. To prevent gastro intestinal distress ,start with only 1 tablet/day for few days, then increases to 2 tablets/day and then 3 tablets/day. This method permits the body to adjust gradually to iron.eat foods high in fiber to minimize problems with constipation. Use of straw or placing spoon at the back of the mouth to take liquid preparation to prevent staining of teeth. Rinse the mouth thoroughly afterwards.Always take iron rich foods with a source of vitamin C which enhances the absorption of iron.(40)

Iron deficiency Anemia is commonly treated with iron supplements. Nurse must educate the women about the intake of iron supplements and their side effects to maximize absorption, supplements should be taken on an empty stomach with a food or beverage containing vitamin C, but not with calcium-containing foods or antacids. Calcium hinders iron absorption. Common side effects of iron supplement treatment include constipation, nausea, and dark stools. Some women are able to reduce these symptoms by using a time-release supplement or by taking supplements in smaller doses throughout the day. For women who remain anemic despite supplements, intra-muscular iron injections may be given.(41)

It was stated that ,A "conservative" approach to iron supplementation during pregnancy in developing countries was may be that, such women do not require routine iron supplementation during pregnancy who are generally healthy and have access to adequate nutrition, the benefits of iron supplementation was unclear to them.The midwifery philosophy of individualizing care based on a woman's history and health status is one that should be taken in approaching the issue of iron supplementation in pregnancy.(42)

A study was conducted on Iron supplement use among women in the United States ,it was founded thatCopyright American Institute of Nutrition Jun 2003. Provided by ProQuest LLC. (Hide copyright information) the use of iron supplements is an accepted treatment for nonhereditary anemia. The use of iron supplements as prophylaxis is more controversial.(43)

The study was carried out to determine the extent of pregnant women's compliance with iron supplementation program through Primary Health Care system in Iran. Pregnant women's compliance with taking the iron pills was assessed through direct interview and was controlled using a qualitative test for detecting iron in stool. It may be concluded that supplying pregnant women with iron tablets may not ensure the success of program in itself. Effective measures must therefore be taken to encourage the women to take their prophylactic pills. (44)

A study was conducted to evaluate the effectiveness of three regimens according to the frequency of ingesting the tablets using ferrous sulfate to treat anemia in pregnant women of Brazil. The study concluded that the regimen with iron administered daily is still the best option for treating anemia. However, treatment with ferrous sulfate administered twice a week is an alternative for patients who are unable to adhere to daily treatment.(45)

A study was conducted on 130 antenatal mothers to determine the prevalence of anemia among registered antenatal mothers in MMIMs&R antenatal OPD with a view to develop and evaluate and management of iron deficiency anemia in pregnancy in terms of knowledge and practice of mothers. The study concluded that the planned health teaching programme was effective in terms of enhancing the knowledge as well as improving the practices of antenatal mothers regarding prevention and management of iron deficiency anemia in pregnancy. (6)

Section D: National nutritional anemia prophyllaxis program.

A “12 by 12 initiative” is launched by federation of obstetrics and gynecology society of India(FOGSI) Delhi,in collaboration with government of India, WHO, and UNICEF on 23rd April 2007 at all India institute of medical sciences, new Delhi.

A motive behind “12 by 12 initiative” is to reduce lower birth weight, infant mortality rate, maternal mortality rate by the year 2015. There is a need to combat to anemia during adolescence so that women enter pregnancy and motherhood free of anemia and that newborns and infants are assured of good health.(3)

A study was conducted study on Researching Women's Health in Asia. Available studies on prevalence of iron deficiency anemia in India shows that 85% pregnant women were anemic. National programmes to control and prevent anemia have not been successful. Experiences from other countries in controlling moderately-severe anemia guide to adopt long-term measures i.e. fortification of food items like milk, cereal, sugar, salt with iron. Use of iron utensils in boiling milk, cooking vegetables etc may contribute significant amount of dietary iron. Nutrition education to improve dietary intakes in family for receiving needed macro/micro nutrients as protein, iron and vitamins like folic acid, B12, A and C etc. for hemoglobin synthesis is important. As an immediate measure medicinal iron is necessary to control anemia. (46)

Under National Anemia Control Program ,every woman must be supplemented by large iron folic acid tablets each containing 80 mg of ferrous sulphate(60 mg of elemental iron)and 0.5 mg of folic acid,1 tablet must be consumed each day for 100 days, starting after the 1st trimester of pregnancy. For severely anemic cases 2 large tablets can be taken daily for 100 days. Lactating women should consume these tablets for 100 days.(10)

National Nutritional Anemia Prophylaxis Programme was started in 1970 and is a responsibility of state health departments. It is an integral part of the maternal and child component of primary health care.

The objectives of NNAPP are the prevention of anemia in pregnancy, the avoidance of anemia associated morbidity in the mother and the future baby and the prevention of nutritional anemia in children.

Till 1992 the strategy of the programme was to give pregnant women 100 tablets of 60 mg elemental iron plus 500µgm of folate to be taken at the rate of 1 tablet per day. For children a combination tablet containing 20 mg elemental iron and 100µgm of folate was prescribed ,1 tablet a day for 100 consecutive days. With a launching of CSSM programme the dose has become 100 mg of elemental iron and 500µgm of folate per day for 100 days for pregnant women. NNAPP has become a part of RCH programme. (16)

Apart from the prevention of anemia among pregnant women and young children, There are more objectives of programme like to put mothers with Hb level less than 1ogm/dl and children less than 8gm/dl on anti anemic treatment.Additionally,monitoring the quality of iron tablets ,distributions and to assess periodically the Hb levels of beneficiaries is also a part of programme.(11)

It is to be considered that anemia is responsible for 20% of maternal deaths, which could be prevented with appropriate intervention, it becomes a critical issue. Despite program in place, anemia prevalence does not change or in fact has increased over time. Interventions are known but often they do not work, either because of the way of implementation or the way supply is neglected. NRHM provided decentralization for Iron Folic Acid (IFA) procurement that did not work with most of the states making non availability for IFA a long process of three years in most of the states.

Maternal anemia is so common and acknowledged so long but needs multiple pathways and not only IFA supply. Besides ensuring adequate nutrition to mother during pregnancy, the strategy that would work includes 1) effective behavior change communication; 2) ensuring availability and accessibility of IFA with counseling for its importance (this will counter side effects to be tolerated, when mothers know its benefits to her and her child); 3) checking for side effects; 4) providing deworming where worm load is high; 5) and protection from malaria. For performing all these services front line workers need support and encouragement.

A study was conducted on Multiple Approaches to Improve Hemoglobin Levels, Madanapalle.The Rural Health Centre of Rishi Valley Education Centre (KFI), works with Dai's to counsel pregnant women and their husbands and in-laws. Along with encouraging consumption of IFA tables, it also promote eating homegrown green leafy vegetables, jaggery made in iron pots, groundnuts and gooseberry to improve iron absorption. These multiple approaches have worked successfully to improve hemoglobin levels even in women with hemoglobin levels as low as 5 gm%.

A study was conducted on Evaluation of National Nutritional Anaemia Control Programme (NNACP) in Dharwad ,Karnataka.The study concluded that Evaluation of the NNACP revealed about 11% of women within reproductive age did not receive IFA tablets and were not registered by any health functionaries.(47)

Statement of the problem

Assess the Knowledge on Iron deficiency anemia among pregnant women attending antenatal clinic at Primary health centre of rural district Bangaluru ,Karnataka.

6.3. Objectives of the study

1) To assess the knowledge on iron deficiency anemia among pregnant women attending antenatal clinic.

2) To associate the knowledge scores on iron deficiency anemia among pregnant women with demographic variables.

Operational definition:

Assess: It refers to statistical measurement of knowledge from the scores obtained from structured interview questionnaire on iron deficiency anemia among pregnant women attending antenatal clinic at primary health centre of rural district,,Bangaluru.

Knowledge: It is a correct verbal responses of pregnant women to the items on structured interview questionnaire related to Iron deficiency anemia.

Iron deficiency anemia: It refers to hemoglobin level ≤ 11gms/dl as per WHO classification among pregnant women attending antenatal clinic.

Pregnant women: It refers to a women between the age of 18 to 45 years of age attending antenatal clinic for antenatal checkup in Primary health centre of rural district, Bangaluru.

Antenatal clinic: A place in the Primary health centre where antenatal care will be provided to pregnant women on every Thursday as fix per Central Government Norms.

Hypothesis

Ho1: There is no significant association between the knowledge on Iron deficiency anemia among pregnant women and demographic variables.

Assumptions

1) Pregnant women attending antenatal clinic may have some knowledge on Iron deficiency anemia.

2) Knowledge of pregnant women on Iron deficiency anemia attending antenatal clinic may be measured by structured interview questionnaire.

Limitations

The study is limited to pregnant women:

1. between the age of 18 to 45 years .

2. attending antenatal clinic at Primary Health Centre of rural district, Bangaluru, Karnataka.

7. Materials and methods

|7.1 Source of Data |Data will be collected from pregnant women attending antenatal |

| |clinic at Primary health centre of rural district Bangaluru, |

| |Karnataka. |

|7.2 Method of Data Collection |Non-Experimental descriptive design will be used to assess the |

|Research Design |knowledge on Iron deficiency anemia among pregnant women. |

|Setting |One Primary health centre will be selected under Devanahalli |

| |Taluk ,rural district ,Bangaluru. |

|Population |Pregnant women attending antenatal clinic at primary health |

| |centre of rural district Bangaluru will be the population for the|

| |study. |

|Sample | Pregnant women attending antenatal clinic at primary health |

| |centre of rural district Bangaluru will be the sample for the |

| |study. |

|Sample size | The sample size will be 90 pregnant women attending antenatal |

| |clinic at primary health centre of rural district |

| |Bangaluru,Karnataka. |

|Sampling technique |Convenient sampling technique will be used to select the pregnant|

| |women attending antenatal clinic in primary health centre of |

| |rural district Bangaluru,Karnataka. |

| |Inclusion Criteria |

| |The pregnant women- |

| |-who understand kannada |

| |-willing to participate in the study |

|Sampling criteria | |

| | |

| |Exclusion criteria |

| |The pregnant women- |

| |-who suffers from speech and hearing disorders |

| |-who will be undergoing treatment for Iron deficiency anemia. |

| |Structured Interview questionnaire will be used to assess the |

|Tool |knowledge on iron deficiency anemia among pregnant women. |

| |Prior to the data collection the investigator will obtain |

|Data Collection |permission from the concerned authorities of the Primary health |

| |centre. Further ,consent will be taken from every subject and |

| |confidentiality will be maintained. The data will be collected |

| |from pregnant women by the investigator herself. |

| |Descriptive and inferential statistics will be used for data |

|Data analysis, Data Presentation |analysis.chi square test will used to find the association |

| |between the knowledge and selected demographic variables. The |

| |finding will be presented in the form of tables, diagrams and |

| |graphs. |

7.3. Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so, describe briefly.

Yes, the study will be conducted on pregnant women attending antenatal clinic in Primary health centre of rural district Bangaluru,Karnataka.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

yes, informed consent will be obtained from concerned authority of Primary health centers and subjects prior to study, Privacy, confidentiality and anonymity will be guarded. Scientific objectivity of the study will be maintained with honesty and impartiality

Ethical Committee

| |Assess the knowledge on Iron deficiency anemia among pregnant women |

|Title of the topic |attending antenatal clinic at Primary health centre of rural district|

| |Bangaluru, Karnataka. |

|Name of the Candidate |Ms.Amanjeet kaur |

| | |

|Course of the subject |M.Sc. (N) 1st year. |

| |Community Health Nursing. |

| | |

| |Prof.Veda Vivek |

|Name of the guide |Principal and Head of the Department. |

| |Department of community health nursing |

| |Diana College of Nursing, Bangaluru – 64 |

| | |

|Ethical committee |Approved |

Member of Ethical committee

1. Prof. Veda Vivek

Principal and HOD

Department of Community Health Nursing

Diana College of Nursing, Bangalore – 64.

2. Prof. Elizabeth Dora

Head of the Department

Department of Child Health Nursing

Diana College of Nursing, Bangalore – 64.

3. Prof. Kalaivani

Head of the Department

Department of Obstetrics and Gynecological Nursing

Diana College of Nursing, Bangalore – 64.

4. Prof. Vasantha Chitra. D

Head of the Department

Department of Medical Surgical Nursing

Diana College of Nursing, Bangalore – 64.

5. Prof. Ranga Raju

Biostatistician GKVK

Jakkur International Airport Road, Bangalore

6.Prof.Kalai Selvi. S.

Head of the Department

Department of Psychiatric Nursing

Diana College of Nursing, Bangalore – 64.

8. List of References

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2. The Trained Nurses Association of India(1998-1999).Indian Nursing Journal Year Book:60-61.

3. Suryakanth munity Medicine with Recent Advances.1st ed.Jaypee publishers; 2009.

4. Loretta Brabin,Sarala Nicholas,Alka Gogate,Sharad Gogate. High prevalence of anemia among women in Mumbai,India.F&N Bulletein.2000.19(3).

5. Nandan Deoki .Strategies for effective implementation of National Programmes for prevention and control of anemia in Mothers and Children. 2009.

6. Jyothi Sarin .Evaluate and Management of Iron deficiency anemia in pregnancy in terms of Knowledge and Practice .Nursing and Midwifery Research Journal.2008 April;4(2).

7. National Family Health Survey 3.2005-2006;Government of India.

8. Vijayaraghavan .K.Iron Deficiency Anemia.Public Health Nutrition &Nutrition Society Text book Series.Blackwill Publications.2005.

9. ICMR(2003).Report of District Nutrition Project;Indian Council of Medical Research.

10. G M Dhaar,I Robbani.Foundations of Community Medicine.2nd ed.Elsevier Publishers;2008.

11. B T munity Health Nursing.2nd ed.Jaypee Publishers;2008.

12. K.Park.Preventive and Social Medicine.19th ed.Bhanot Publishers;2007.

13. B.K Mahajan,M.C Gupta.Textbook of Preventive and Social Medicine.3rd ed.Jaypee Publishers;2003.

14. G N Prabhakara.Textbook of Community Health For Nurses. 2nd ed.Peepee Publishers;2005.

15. K.K munity Health Nursing Principles and Practices.1st ed.Kumar Publishing House;2005.

16. B.Sridhar Rao .Community Health Nursing. 4th ed.AITBS Publications;2005.

17. Denise F Polit, Cheryl Tatano. Nursing Research.7thed.Lippincott Publication;2006.

18. Loretta Brabin,Sarala Nicholas,Alka Gogate,Sharad Gogate. High prevalence of anemia among women in Mumbai,India.F&N Bulletein.2000.19(3).

19. Neelam Kumari .Community Health Nursing-1.1st ed.Pee vee Publishers; 2009.

20. Y.Wang,E.Schouten,R.X Xu,Y.Li. Prevalence of anemia among Pregnant Women and Birth Weight in Five Areas in China.International Journal of the Kuwait University Health Sciences Centre.2009;18(5).

21. Lora L. Iannotti,J.Mancini,M.Schulman,Z.L Harris.Iron deficiency anemia and depleted body reserves are prevalent among pregnant African American.J Nutrition.2001 November 1st ;135(11):2572-2577.

22. Jemal A Haidar,Rebecca Pobocik.Iron deficiency anemia is not a rare problem among women of reproductive ages in Ethopia.BMC Blood Disorders;2009:1471-2326.

23. K.N Aggarwal,D.K Aggarwal,Sharma A,Sharma K,Prasad K.Prevalance of anemia among in pregnant and lactating women of India.The Indian Journal of Medical Research Published in India.2006 August;124(2):173-84.

24. Anne C .Looker,Dallman,Margaret,Elaine W. Gunter.Prevalance of Iron deficiency in the United States.Journal of the American Medicine Association.1997 March 26th ;277(12):973-976.

25. D.C Dutta.Textbook of Obstetrics .7th ed.Central Book Agency L,td; 2006.

26. Sachdeva R.Kaur P,Kochhar A & Chawla P.Impact of iron status of pregnant women.2009;11(3):219-224.

27. Milman.Iron Balance during Pregnancy and Postpartum in Western Affluent Societies.Epub.2006 May 12th; 85(9):559-65.

28. Annamma Jacob. A comprehensive Textbook of Midwifery.1st ed.Jaypee Publishers ;2005.

29. Viteri FE,Berger J. Importance of pre-pregnancy and pregnancy iron status.Nutr.Rev.2005 December;63(12pt2):S65-76.

30. Pathak P,Kapil V,Kapoor SK,Saxena R,Kumar A,Gupta N.Prevalance of multiple micronutrient deficiencies amongst pregnant women in a rural area of Haryana.Indian Journal of pediatrics.2004 November;71(11):1007-14.

31. Ann Hematol.Prepartum anemia:Prevention and Treatment. Epub.2006 May 12th; 85(9):559-65.

32. Sharad.Prevalance of anemia among women of Reproductive age group in Rajapur .Souvenir Abstracts,Community Health Department ,St.John Medical College Bangalore.2007.

33. Premanand Bharti.Prevalance of anemia and its determinants among non pregnant and pregnant women in India.Asia Pacific Journal of Public Health.2008;20(4):347-359.

34. Rae Galloway,Elin Dusch,Leslie Elder,Endang A chadi,Mike Favin. Women's perceptions of iron deficiency and anemia prevention and control.Social Science and Medicine.2002 August;55(4):529-544.

35. Diane M Fruser.Myles Textbook of Midwifery.14 th ed;2006.

36. Lindsay H Allen. Anemia and iron deficiency: effects on pregnancy outcome.American Journal of Clinical Nutrition.2000 May;71(5):1280S-1284S.

37. Yekta Z,Ayatollahi H,Pourali,Frazin A. Predicting Factors in Iron Supplement Intake among Pregnant Women in Urban Care Setting. J.Res Health Sci.2008;8(1):39-45.

38. Joyce M.Black.Medical Surgical Nursing . 8th edition Elsevier Publisher ;2009.

39. BT Basvanthappa.Medical Surgical Nursing.7th ed.Jaypee Publishers.2009.

40. Brunner and Suddharth’s.Textbook of Medical Surgical Nursing.11th ed.LWW Publishers;2008.

41. Marcia munity and Public Health Nursing. 6th edition.Mosby Publications.;2004.

42. Graves BW,Bargar MK.A Conservative approach to iron supplementation during pregnancy.J Midwifery womens-Health.2001May-June;46(3):159-66.

43. Kettle Khan.Iron Supplement use among women in the United States.American Journal of Clinical Nutrition.2005 May;81(5):12185-2225.

44. D.Bondarianzadeh,F.Siassi,Nomidvan Golestan,Keighobadi. Determine the extent of pregnant women's compliance with iron supplementation program through Primary Health Care system in Iran.Nutrition Research.1998 June ;18(6):945-952.

45. De Souza,Batista Filho.M,Figueria JN.The effectiveness of three regimens using ferrous sulphate to treat anemia in pregnant women.Rev Panam Salud Publica.2004 May;15(5):313-9.

46. S.Griffiths.Researching women’s Health in Asia.Asia Pacific Journal of Public Health.2008 October 1st ;20(4):265-266.

47. Anuradha TN,Kotech prakash,Kalyanram Kartik,Malagai Usha.Maternal and Child Health Community-Food and Nutrition Security Community.2008 July 14th.

| | |

|9.Signature of candidate | |

| |There is a great need to enhance the knowledge on Iron deficiency |

|10. Remarks of the guide |anemia among pregnant women attending antenatal clinic at Primary |

| |Health Centre of rural district,Bangaluru,Karnataka.. Hence, the |

| |research topic selected for the candidate is suitable. |

| |Prof.Veda Vivek |

|11.Name and designation of guide |Principal and Head of the Department. |

| |Department of community health nursing |

| |Diana College of Nursing, Bangalore – 64 |

| | |

| |Prof.Veda Vivek |

|Signature |Principal and Head of the Department. |

| |Department of community health nursing |

|Head of the Department |Diana College of Nursing, Bangalore – 64 |

| | |

| | |

| | |

| | |

| | |

| | |

|Signature | |

|12. Remarks of the chairman & principal |The selected study is feasible and researchable and forwarded for |

| |needful action. |

| Signature | |

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