Assessment of nutritional status of under five children in katagum local government, Bauchi state

CHAPTER ONE/Introduction

Background to the Study

The quality of nutrition throughout life determines the growth, development and disease susceptibility. Nutrition is a critical part of health and development.  World Health OrganizationWHO (2000) stated that nutrition improves children’s health, enhances stronger immune system, longevity and lower risk of non-communicable diseases. Healthy children learn better and children with adequate nutrition are more productive. Mandndhar, Krishna and Patowary (2008) opined that the nutritional status is an indicator of the level of the quality of life of school children. WHO (2009) maintained that children’s nutritional status is a reflection of their overall health, when children have access to  adequate food supply, they can reach their growth potential and are considered well nourished. Nutritional status is essential for identifying undernourished and over nourished states of children and in estimating the optimum intake of adequate nutrition to promote normal growth and well-being. Height and weight are the most commonly used indicators of the nutritional status of primary school children. (Himes, 2009).Hence the need for the anthropometric method.
The anthropometric method which involved the measurement of weight and height to determine the nutritional status of an individual is an easy-to-use method *because it requires weighing scale and a tape measure. The anticipated nutritional status of school children are as follows: < (-2)SD to<(-3)SD indicates weight-for-age(underweight) children, < (-2)SD to< (-3)SD indicates height-for-age (stunting) children,< (-2)SD to < (-3)SD indicates weight-for- height(wasting) and -1SD< X< +2SD of NCHS/CDC median indicates normal children while>+2SD indicates over-nourished children between the ages 6years to 12years (Odenigbo, Odenigbo & Oguejiofor, 2010).According to WHO (2000) appropriate height-for-age of children reflect linear growth and can measure long term growth or stunting (indicator of past or long term under- nutrition) while appropriate weight-for-height reflects proper body proportion or the harmony of growth. Weight-for-height is particularly sensitive to acute growth disturbances and is useful to detect the presence of wasting (indicator of present under nutrition). Weight-for-age represents a convenient synthesis of both linear growth and body proportion and thus can be used for the diagnosis of underweight (convenient synthesis of both present and past under nutrition) children. The presence of under nutrition in children was assessed using these anthropometric parameters thus; weight-for-age, height-for-age and weight-for-height and compared it with internationally accepted reference standards. The outcome showed that children that have a low height-for-age, a z-score below two standard deviations of the reference population mean (-2 Z-score) are categorized as “stunted”. Similarly, a low weight-for-age is diagnosed as “underweight” children, while a low weight-for-height is indicative of “wasting” children (WHO, 2009).
According to Suvama (2007) growth is the major characteristics of school children and this is dependent on adequate supply of nutrients.  Growth and development of the children is largely dependent on its nutritional status. Ijarotimi and Ijadunola (2007) asserted that nutritional status is very necessary to be determined because it helped in estimating the optimum intake of nutrition to promote good quality of life among primary school children. Hence, the present study used the anthropometrics parameters to determine the nutritional status of primary school children. The parameters are height- for-age which is the index used to compare children’s height with the expected value of children of the same age from a reference population. It is a measure of stunting. Secondly, weight -for-height, is the index used to compare children’s weight with the expected value of children of the same height. It is a measure of wasting. Thirdly, weight-for-age is the index used to compare children’s weight with the expected value of children of the same age. It is a measure of   underweight (Pullum, 2008). Davis (2001) maintained that it is vital to recall that the fundamental pillar of children’s life, health and development across their entire life span is nutrition.
Nutrition is the process by which living things receive the food necessary for them to grow and be healthy. Nutrition is the study of food in relation to the physiological processes that depends on its absorption by the body growth, energy production, repair of body tissues (Martin, 2003). Nutrition is basically the use of food by the body for the processes of growth, repair and work. (Akinsola, 2006). Basavanthappa (2008) defined nutrition as combination of dynamic process by which the consumed food is utilized for nourishment, structural and functional efficiency of every cell of the body.  Panebianco (2009) maintained that nutrition is also known as nourishment   from food in order to support life. Nutrition is the intake of nutrients and their subsequent absorption and assimilation by the tissue. Hence, in this study nutrition was referred to as a combination of dynamic processes by which the consumed food is utilized for nourishment, structural and functional efficiency of every cell of the body, adopted from Basavanthappa (2008) because the definition is easy and clearly articulated. Foods that contain the elements necessary to perform various functions in the body are nutrients.
Harper (1999) defined nutrients as a substance present in food and used by the body to promote normal growth, maintenance, and repair. Nutrients are defined as organic and inorganic complexes contained in food (Park, 2009). The present study referred to nutrients as a substance present in food and used by the body to promote normal growth, maintenance, and repair. Nutrients include carbohydrates, fats, proteins, minerals, vitamins and water (Martin, 2003).
Basavanthappa (2008) maintained that carbohydrates are the main sources of energy required by children to carry out daily activities and exercise. Any extra energy is stored in the body until it is needed. Fats are required in children’s diet to help them attain normal growth and development. Proteins are essential for children’s growth, repair and maintenance of body tissue. Minerals help the children to develop, grow and stay healthy. It is necessary to many mental and physical bodily functions, including emotional and cognitive functions. Vitamins are important in children’s diet for making red blood cells, formation of strong bones and teeth, and contribute to maintenance of their eyes, skin, liver and lungs. Water is the most important nutrient required by children because the function of cells depends on a fluid environment. Tanko (2006) observed that good nutrition is reflected not only in the growth and functions of the cell but in body appearance.  This implies that the eyes, skin, hair and teeth indicate whether body nourishment is good or poor. Poorly nourished children will fail to grow properly and deficiency diseases may occur.
Poor nutrition may result from excesses in the diet as well as deficiencies of certain vitamins or minerals which are capable of producing potentially lethal diseases.  Excess of carbohydrates or fats can result in obesity among primary school children. A diet deficient in protein causes a disease called kwashiorkor in children; a diet deficient in both protein and calories results in marasmus with lethargy and abdominal enlargement. Generally, deficiency diseases can be treated successfully and cured by ensuring that the nutritional needs of the primary school children are met on a daily basis (Harvey, 2011). Poor growth and development will result, unless the whole children’s health is good as well as their status.
Status is the situation at a particular time (Hornby, 2006). Merrian (2007) defined status as a particular state or condition. Specifically, Bourdieu (2011) identified that status are internalized at an early age and school children eat food which indicates their status as it relates to nutrition. For instance, children from the lower end of the social hierarchy are predicted to eat “heavy fatty foods which are cheap” than adequate diet and these bring about obesity, underweight, wasting and stunted growth among these children. In this study status was referred to as a particular state or condition.  The ability of children to be productive and grow can be hampered as a result of their nutritional status.
Nutritional status is the conditions of health of a person that is influenced by the intake and utilization of nutrients (Typpo, 2011). Winstead (2009) defined nutritional status as the state of a person’s health in terms of the nutrients in his or her diet. He further added that how well the body functions is a direct reflection of what the body takes as food and the balance between the two. When one or several of the body systems are malfunctioning, it most likely relates in some degree to nutritional status. David (1999) defined nutritional status as a state of the body in relation to the consumption and utilization of nutrients. The present study referred to nutritional status as the state of a person’s health in terms of the nutrients in his or her diet.  Odenigbo, Odenigbo and Oguejiofor (2010) affirmed that nutritional status can be determined using different methods such as Body Mass Index (BMI), clinical examination, biochemical examination, anthropometry, dietary assessment, questionnaires and checklist. The anthropometric method which involves the measurement of height and weight to determine the nutritional status of an individual is an easy-to-use method because it requires only tape and scale measure. Anthropometric method was used in this study to determine the nutritional status of primary school children because of changes in their body composition.  Frisancho (2011) maintained that nutritional status of children are determined with reference to height and weight using the standard from the National Center for  Health Statistics (NCHS) as a reference to determine the extent to which children are growing either normally, advanced, or delayed for their age.
Furthermore, the standard was also used to infer whether children are either obese, or undernourished for their height. Using height and weight standards, malnourished children can be classified as either stunted, if they have low height-for-age, or wasted, if they have low weight- for-height. Schlenker and Long (2007) asserted that  the conditions of the body  includes malnourished and well-nourished conditions,  nutritional levels which are optimal nutrition and under nutrition which may affect children’s ability to resist infectious diseases, ability to learn,  become productive, grow and develop properly. It is vital to identify the proportion of primary school children’s nutritional status.
Nutritional status ranges from nutrient levels in the body the products of their metabolism to the functional processes they regulate. Children’s low height-for-age is considered stunting, while low weight-for-height indicates wasting. (Himes, 1991).  In this study the proportion of stunted,   wasted and underweight   was determined among school children.
Skyes (2000) defined children as young males or females that have not reached the age of discretion. All over the world, children are seen as those who have to be provided for with such needs as food, shelter and protection until they are capable of looking after themselves. Children are young humans who are not yet an adult (Hornby, 2006).Whereas school children are children that attend school. Children are young humans between the ages of 0-13 years. Primary school children that were used in the present study are referred to as young human beings between the ages of 6-13 years. When a child reached primary school, he develops an eating style that becomes more and more independent of the influence and scrutiny of his parent (Suskind, 2009).  Moreover, children are in the period of rapid growth and development, and therefore total health cannot be attained without good nutrition. Adequate supply of food and proper nutritional habits are helpful for healthy living, normal growth and development of children (Onuzulike, 2005). Some children eat a lot due to affluence while other eats less due to poverty and ignorance. This may result to over nutrition or under nutrition  as  the case may be and they can be exposed to nutritional problem like obesity, stunting and wasting (Akinsola, 2006).The nutritional  status could be traced to some factors.
Some socio-demographic factors were capable of contributing to the nutritional status of primary school children. Such factors  includes location, age, gender, level of education and income.   Gender was identified as a factor that influences nutritional status. Usually prevalence of severe malnutrition is much more in young females as compared to young males of 5 years of age due to differential child rearing practices including feeding and health care seeking behaviour (Sunderlal, Adarsh & Penkay, 2010). Suskind (2009) observed that no gender distinction is made between the nutritional needs of male and female until the age of 11.  He added that males between the ages of 11 and 14, however, have a greater need for calories, vitamin A, thiamin, riboflavin, niacin, iodine and magnesium than to female of the same age and these differences reflect the greater muscle development and physical activity of boys in contrast to the slightly greater fatty deposits and lesser physical activity of girls. The greater need for some of the B vitamins is related to the greater quantity of food that was ingested by boys than was ingested by girls of the same age. Hence, there were differences in nutritional status, that higher percentage of stunting are more in female than male children. Another variable that can affect nutritional status is location.
Location had influence on nutritional status. As opined by Florentino, Villavieja and Lana (2002) children from urban area tends to consume more total food, more animal foods,   fats and more beverages. According to SunderLal et al (2010) higher proportions of rural children are suffering from Protein Energy Malnutrition (PEM) compared to urban areas. Urban slum areas have as much prevalence of PEM as in rural areas and more often the situation of PEM in urban slum areas may be worse than rural areas because of poor living conditions and presence of all the risk factors for malnutrition. Higher intake of calories, protein, iron, and vitamins A, with less physical activities results in higher proportion of over nutrition and a lower proportion of under nutrition.
Children from rural area are of low-socio economic group (Suskind, 2009). This has effect on their diet which may be deficient in all nutrients except carbohydrate, iron and thiamine. The effect is that they suffer from malnutrition, sign of protein-calorie deficiency, vitamin A, vitamin D and essential fatty acid deficiency. Malnutrition has a dampening effect on their growth potential particularly during the spurt period (Adesola, 2006).Hence; urban children may be over nourished more than their rural compatriots. Another variable that can affect nutritional status is age.                           Age had influence on nutritional status. Evidence has shown that physical growth and cognitive development in children are faster during early years of life, and that by the age of five years, 50 per cent of adult intellectual capacity has been attained and before thirteen years 92 per cent of adult intellectual capacity is attained Sizer and Whitney (2000).
Christian and Greger (1998) reported that peer influence increases with age and extend to food attitude and choice, due to the sensory appeal of children. The children have strong influence in food choice and sensory characteristics that tastes sweet. Sizer and Whitney (2000) asserted that children of the same age group will prefer particular food choice despite the nutritional value. Another variable affecting nutritional status is level of education of the parents.
Level of education of parents had strong influence on nutritional status of primary school children. The information parents received about nutrition is capable of changing their child’s nutritional status. Additionally, the more knowledge about nutrition the parent, caregiver, and guardian have, the better the nutritional status of children (Mclaren, Burman, Belton &Williams, 1991).  Akinsola (2006) stated that the major problem was the insufficient knowledge and understanding of how to plan and choose good food.  When the diet is deficient in any food nutrient for a long period, illness such as kwashiorkor, marasmus can occur.
Income had influence on the nutritional status of primary school children.Lucas and Gill (2003) opined that household food shortages may be temporary, seasonal or persistent and have many causes including low income and low food production.Also middle income groups eat twice as much fat and have much more obesity, underlying causes are environmental and social factors such as sedentary lifestyles, availability of transport and fat-rich fast meals.
Number of children in the family (family size) was a contributing factor in the nutritional status of primary school children. It must be taken to mean that standard of living; naturally falls if the size of family increases and income remains constant. The ideal family size in Nigeria according to National population policy (1988) classification is six (parents and children). Any number less or equal to six is regarded as small family, while number greater than six constitutes larger family size in this study.  This study was anchored on a theory.
The theory that applied to explain the primary school children nutritional status is the precede model. Precede model is a participatory model for creating successful community health promotion and other public health interventions. It is based on the premise that behavior change is by and large voluntary; improving nutritional status of school children are more likely to be effective if adequate diet are planned and eaten with the active participation of children who will have to implement them. The precede model is aimed at understanding the factors that influence the individual’s health and develop interventions to promote total wellbeing. This was useful because the nutritional status of primary school children was associated with some demographic factors such as gender, location, age and level of education. Proper understanding of the effect of these factors and how to overcome them, will harmonize the nutritional status of primary school children in Enugu South Local Government Area.
The study was carried out in Enugu South Local Government Area of Enugu state. The Local Government covers 67 square kilometers away from the state capital in the Eastern part of the state. It shares boundary with Enugu North LGA to the North, it also shares boundaries with Enugu East LGA to the East, Nkanu West Local Government Area to the West, and its headquarters is located at Uwani in Enugu south. Enugu South Local Government Area is essentially inhabited by the Igbo people and among them are farmers and traders.
WHO (2000) estimated that between 48 per cent and 53 per cent of school age children   are stunted. In many cases, children do not know they have nutritional problem and fatigue, hence inability to concentrate is considered normal. Children who lack certain nutrients in their diet are more likely to be absent from school than healthy children, they also have a diminished capacity for learning, repeat grades and  may drop out of school(WHO,2000).
The primary school children in Enugu South may need adequate nutrition for good health and well-being. But it is likely that preferences to a particular food nutrient among some school children or the proportions of adequate diet given to the children by their parents/caregivers/guardians may prevent them from eating the quality food they need for their well-being. The tendency is that they may be prone to malnutrition, weight loss, stunted growth, underweight, fatigue, and lack concentration in learning

Table of Contents

• CHAPTER ONE: Introduction

• Background to the Study

• Statement of the Problem

• Purpose of the Study

• Research Questions

• Hypotheses

• Significance of the Study

• Scope of the Study

• CHAPTER TWO: Review of Related Literature

•   Conceptual Framework

• Nutrition and nutrients

•  Status and nutritional status                                                                   Children

• Socio-demographic factors associated with nutritional status

• Theoretical Framework

•       Precede model

•  Empirical studies of Nutritional Status

• Summary of Literature Review

•  CHAPTER THREE: Methods

• Research Design

• Area of Study

• Population for the Study

• Sample and Sampling Technique

• Instrument for Data Collection

• Validity of the instrument

• Reliability of the instrument

• Method of Data Collection

• Method of Data Analysis

• CHAPTER FOUR: Results and Discussion

• Results

• Summary of Major Findings

• Discussions of Findings

• Nutritional status of primary school children

• Nutritional status of PSC according to gender, location and age group

•  The proportion of food given to PSC according to gender,

• location and age group

• The proportion of food given to PSC according level of education, income of parents/guardian/caregiver and number of children in the family

• CHAPTER FIVE: Summary, Conclusions and Recommendations

• Summary

• Conclusions

• Recommendations

• Suggestions for Further Study

• Limitations of the Study

• References

ABSTRACTS

CONTEXT
Malaria in pregnancy poses a serious public health threat in Nigeria due to its antecedent adverse consequences on the mother and her foetus. It can be prevented through the correct and consistent use of insecticide treated mosquito nets. However, its use is deficient among pregnant women I Nigeria. Therefore, this study explores the various factors that influence the use of insecticide treated nets among pregnant women in Nigeria.
OBJECTIVE
The objective of this study is to systematically appraise primary studies on the utilization of insecticide treated nets among pregnant women in Nigeria and to formulate a concept map of these factors.
METHODS
This study utilized systematic review procedures although it has a narrower scope. Literature search was conducted across four electronic databases namely; MEDLINE, CINAHL, Web of Knowledge and BioMed. In addition, the references of articles were further examined to identify articles which may not have been captured in the initial search. A total hit count of 3305 was arrived at and seven high quality studies were selected for critical and systematic appraisal after all relevant studies were subjected to a predefined inclusion and exclusion criteria.
FINDINGS
This study found that several issues have been identified as factors that influence the utilization of insecticide treated nets among pregnant women in Nigeria. However, the main factors include; socioeconomic and demographic factors, level of knowledge about malaria and its consequences, level of misconceptions about malaria, access to antenatal care facilities and availability of the mosquito nets. However, the socioeconomic class of the pregnant woman is the strongest predictor of utilization as it directly or indirectly influences other factors.
CONCLUSION
There is the need to make antenatal care services more available and accessible especially to the rural poor communities. There is also the need to widen the scope of free ITN distribution to include tertiary hospital and also enhance free community distribution in association with the provision of social and behavioural change enlightenment and interventions to the pregnant women, their husbands, community leaders and traditional birth attendants. Furthermore, preconception care should be incorporated into the focused antenatal care services in order to provide early access to malaria prevention enlightenment. In addition, malaria prevention enlightenment should be provided to young girls in primary and secondary schools. It is also important to ensure socioeconomic empowerment of women, reduce gender inequality and encourage girl child education.

LIST OF ABBREVIATIONS

Abbildung in dieser eseprobe nicht enthalten

CHAPTER ONE INTRODUCTION

1.1 CHAPTER OVERVIEW

This chapter aims to provide a general introduction to this research. It puts the study in relevant context of available literature and justifies the rationale behind the need to understand the factors that influence the utilization of Insecticide Treated Nets (ITNs) in the prevention and control of malaria among pregnant women in Nigeria. It concludes by providing a statement of the aims of the research and the research question.

1.2 BACKGROUND

Malaria is a serious and sometimes life threatening disease caused by the plasmodium parasite which is transmitted through the bite of infected female Anopheles mosquitoes (Adebayo et al., 2015). There are five species of the plasmodium parasite, however plasmodium falciparum is the major cause of malaria infection and is the main cause of life threatening malaria (Ezire et al., 2015). According to the World Health Organization (WHO), about half of the global population is at risk of malaria (WHO, 2016a). It was estimated that there were about 212 million cases and 429,000 malaria related deaths in 2015 (Falade et al., 2016; WHO, 2016a).
However, the greatest percentage of the global burden of malaria is disproportionately carried by sub-Saharan Africa with 90% of cases and 92% of malaria deaths, thus making malaria a serious public health threat and a huge epidemiological burden to Africa (WHO, 2016b). According to the National Malaria Control Program (NMCP), malaria is endemic in Nigeria as 97% of the population live in high malaria risk areas (NMCP, 2014). Further evidence have also shown that Nigeria carries a significant proportion (25%) of the burden in Africa with an estimated 110 million clinically diagnosed cases per year and about 110,000 malaria related deaths in 2015 (WHO, 2016c; Federal Ministry of Health [FMH], 2009). It is also responsible for 60% of all outpatient attendance and 30% of all hospital admissions (Ezire et al., 2015; Salihu and Sanni, 2013).

1.3 BURDEN AND CONSEQUENCES OF MALARIA IN PREGNANCY

It has been estimated that malaria in pregnancy has a prevalence of about 48% in health facilities in Nigeria. This figure is likely an underestimation considering the fact that 40% of pregnant women in Nigeria do not attend health facilities for antenatal care (Onyeneho et al., 2014). Furthermore, 70% of pregnant women in Nigeria suffer from malaria, thereby putting them at risk of negative pregnancy outcome (Adebayo et al., 2015).
Nigeria has one of the highest maternal mortality in the world with 814 maternal deaths per 100,000 live births and an estimated 58,000 maternal death with malaria in pregnancy being responsible for 33% (WHO, 2016c; Ezire et al., 2015). Other major causes of maternal mortality in Nigeria include; Obstetrics hemorrhage, eclampsia, obstructed labour and complications from unsafe abortions (Ezugwu et al., 2014). It is also responsible for 12-30% of under-five mortality (Ezire et al., 2015; FMH, 2009), thus making it one of the most serious public health problem in Nigeria (WHO, 2016c). Furthermore, it results in significant danger to the mother, her foetus and infant which leads to increased morbidity and mortality (Salihu and Sanni, 2013; WHO, 2007). It also leads to abortion, intrauterine foetal death, low birth weight and infant mortality (Ankoma et al., 2012).
Evidence has shown that the prevalence and susceptibility to malaria parasitaemia is highest during the second trimester and may persist into early postpartum period (NMCP, 2014). Pregnant women are also susceptible to sub-clinical malaria infection which may lead to negative consequences such as maternal anaemia, preterm delivery and low birth weight (Obieche et al., 2015; NMCP, 2014).
It has been estimated that malaria in pregnancy causes about 15% of maternal anaemia and 35% of preventable low birth weight and neonatal mortality (Onyeneho et al., 2014). Recent estimates in developing countries including Nigeria have shown that 60% of pregnant women are anaemic with 7% being severely anaemic (Olatunbosun et al., 2014). And the severity of anaemia is directly related to the density of parasitaemia especially among primigravidas (Agan et al., 2010).
This is compounded by the fact that most pregnant women in Nigeria have background nutritional deficiency anaemia which results from lack of healthy diet especially in women due to poverty (Oye-adeniran et al., 2014). This is even more severe in pregnant women with sickle cell anaemia considering the fact that Nigeria has one of the highest prevalence of sickle cell anaemia globally (Adewoyin, 2015).
On the other hand, low birth weight secondary to malaria is also responsible for between 3 and 17 deaths per 1000 live births and has been associated with increased risk of foetal and neonatal morbidity and mortality, growth inhibition and impairment in cognitive development (Ezire et al., 2015; Onyeneho et al., 2014). Furthermore, malaria in pregnancy causes an estimated 11.4% of neonatal deaths and 5.7% of infant deaths in malaria endemic areas of Africa (Onyeneho et al., 2014).

1.4 MALARIA CONTROL STRATEGIES IN PREGNANT WOMEN

The enormous public health burden of malaria among pregnant women in Nigeria has led the Federal Government of Nigeria in 2004 to adopt the WHO strategic framework for the prevention of malaria among pregnant women (FMH, 2014). The strategy involves Focused Antenatal Care (FANC) which incorporates the provision of malaria prevention services and antenatal care in health facilities with a view to reducing its burden in Nigeria (Onyeneho et al., 2014). However, evidence from the National Demographic and Health Survey (NDHS) has shown that despite the fact that malaria prevention services among pregnant women are free in health facilities across the country, utilization has remained very low (less than 30%) especially in northern states due low antenatal attendance (NPC, 2014). Major reasons behind the low ANC attendance in Northern Nigeria includes; poverty, low education, cultural beliefs, distance from health facility, unavailability of transportation as well as violence due to insurgency that has led to destruction of health facilities and massive internal displacement (WHO, 2017a; Fagbamigbe and Idemudia, 2015; Adamu and Salihu, 2002).
The principal strategies for malaria prevention include; vector control which reduces mosquito bites through the use of insecticide treated bed nets (ITNs) and indoor residual spray; intermittent preventive treatment (IPTp) of asymptomatic pregnant women with Sulphadoxine-pyrimethamine in order to suppress blood- stage infection and early diagnosis, prompt and effective case management of malaria (WHO, 2015; Olatunbosun et al., 2014). These services are provided free especially in primary and secondary health facilities as such people from poor socio- economic background and rural communities can have access to them too (NMCP, 2016). However, despite the evidence that the use of ITN is the best strategy for malaria prevention and control in Nigeria, only 36% of households have access to it and only 18% of pregnant women slept under ITN the night before the survey (NPC, 2014). This makes programmes that target its improved utilization a vital part of malaria control among pregnant women (Ezire et al., 2015).
Furthermore, appropriate prevention and treatment of malaria in pregnancy will lead to a reduction in the number of pregnant women requiring blood transfusion due to severe anaemia thus reducing their risk of transfusion-related infections such as HIV and Hepatitis B (FMH, 2014). In addition, studies have also shown that effective prevention of malaria infection through intermittent presumptive treatment and use of ITNs reduces the risk of severe maternal anaemia by 38%, perinatal mortality by 27% and low birth weight by 45% (a leading cause of infant mortality) (Onyeneho et al., 2014; Hughes, 2011). It also reduces the risk of spontaneous abortion, premature delivery and still birth (WHO, 2017b).

1.5 JUSTIFICATION OF THE STUDY

Considering the fact that ITN use is the single most important strategy to prevent malaria in pregnancy when used consistently and correctly, improving its utilization can effectively reduce the burden of malaria among pregnant women and improve pregnancy outcome (Ezire et al., 2015; FMH, 2014; Hill et al., 2013). However, It has been found that despite the fact that ownership of ITN might promote its use, it does not necessary lead to increased usage based on the fact that increasing household number of ITNs did not translate to any significant increase in its utilization, thus the need to identify the facilitators and inhibitors of ITN use among pregnant women (Ezire et al., 2015; Ankomah et al., 2012). Some of the factors that have been identified by individual studies to influence the level of utilization of ITNs include; ethnic origin, educational level, socio-economic and cultural factors as well as knowledge and perception about the medical condition and interventions (Onyeneho et al., 2016; Singh et al., 2013; Ankomah et al., 2012).
Findings from this study will help to improve the strategies employed by the government for malaria control among pregnant women by shedding more light on the factors influencing their perception and reception to those programs and services (Adebayo et al., 2014; Salihu and Sanni, 2013). This will subsequently contribute towards the attainment of the Sustainable Development Goal (SDG) three which is concerned with the improvement of maternal and child health (United Nations [UN], 2017).
Furthermore, preliminary search of literature have shown that there is deficiency of reviews on the topic conducted in Nigeria and most of the primary studies found were limited in context in the sense that they involve single locality or region of the country, as a result their findings cannot be generalized. Thus, this appraisal becomes necessary as it will provide a better picture of the Nigerian context and more reliable evidence on the factors influencing ITN utilization among pregnant women in Nigeria.

1.6 RESEARCH QUESTION

1. What factors influence the utilization of Insecticide Treated Nets (ITNs) among pregnant women in Nigeria?

1.7 AIMS OF THE STUDY

1. To systematically appraise published studies and determine the factors that influences the utilization of Insecticide Treated Nets among pregnant women in Nigeria.
2. Attempt to draw a conceptual map of the various factors that influence the utilization of ITNs among pregnant women in Nigeria.

1.8 CHAPTER SUMMARY

This chapter has provided a brief overview of malaria in pregnancy, its consequences and control interventions. It also discussed why a systematic appraisal is important and gave the aims and research question.

CHAPTER TWO LITERATURE REVIEW

2.1 CHAPTER OVERVIEW

This chapter presents a comprehensive review of the relevant literature surrounding the utilization of ITNs among pregnant women. It begins with brief notes on the conceptualization of the research question and trend in malaria control policies and strategies. It will also discuss theories relating to behavioural change and the factors that influence the utilization of ITN among pregnant women.

2.2 CONCEPTUALIZATION OF THE RESEARCH QUESTION AND LITERATURE SEARCH METHOD

Conceptualization refers to the careful analysis of general ideas known as concepts thereby forming clearer and more distinct constructs to aid better understanding (Henn et al., 2009). It is a process by which a researcher clearly defines the principal terms and ideas he intends to study (Sequeira, 2014). This is based on the fact that the concepts or terms employed in research might have various interpretations by different categories of people, making it vital for the researcher to explicitly specify the context in which he intends to limit the terms of his research (Henn et al., 2009; Sedgeman, 1996). The principal concepts in the research question of this appraisal are pregnant women, insecticide treated net use and influential factors.
The population involved in this study is pregnant women who are within the reproductive age group of 15 to 49 years (WHO, 2017a; United Nations Population Fund [UNPF], 2016). According to the WHO, pregnancy refers to the nine month period in which a woman carries a developing embryo or foetus in her uterus (WHO, 2017a).
On the other hand, insecticide-treated nets (ITNs/LLITNs) are any form of mosquito nets that have been treated with insecticides (Padonou et al., 2012), while their use refers to the conceptualized use of ITN/LLITN when sleeping by pregnant women. The influential factors in this appraisal refer to the factors that can either encourage or discourage the utilization of ITNs/LLITNs among pregnant women in Nigeria. They may include poverty, education, misconceptions or access to health facilities and services.

2.3 EVOLUTION OF POLICIES AND STRATEGIES FOR MALARIA PREVENTION AND CONTROL

Several global and national strategies to reduce the burden of malaria have been implemented even prior to the establishment of the WHO in 1948 (WHO, 2017c). The period between the 1940s to the mid-1960s following the discovery of Dichlorodiphenyltrichloroethane (DDT) and the establishment of the WHO was considered a period of optimism (WHO, 1999). This ushered in the DDT era of malariology which involves special campaigns of DDT spraying, chloroquine chemotherapy and active surveillance which led to tremendous success in reducing the incidence of malaria (Van den Berg, 2009). However, resistance to DDT developed as well as concerns about its safety which ultimately led to its abolishment (Van den Berg, 2009). In the following decades, several control strategies were developed outside the health system with no clear guidelines, these strategies coupled with the development of resistance to chloroquine were largely unsuccessful (Borrmann, 2002; WHO, 1999). However, vital lessons about the importance of a supportive health system in control strategies were learnt (WHO, 1999).
By the year 1998, the Roll Back Malaria Partnership (RBM) was initiated with the objective of reducing the global malaria burden by half by the year 2010 (WHO, 2001). It is a global framework formed by a partnership between the WHO, United Nations International Children Education Fund (UNICEF), United Nations Developmental Programme (UNDP), World Bank and other development partners (WHO, 2015). It is aimed at harmonizing and mobilizing the fight against malaria in endemic areas through a coordinated global response (WHO, 2015).
In the year 2008, the RBM partnership developed the Global Malaria Action Plan (GMAP) endorsed at the 2008 MDG malaria summit. It was regarded as the single most comprehensive blueprint for malaria control and elimination outlining strategies, goals, costs, and timeline to build on the momentum towards malaria control globally (GMAP, 2008). This strategy has succeeded in achieving its target of stopping the increasing incidence of malaria and beginning its reduction globally by the year 2015 (WHO, 2015).
Despite the fact that the technical strategy for malaria control between 2000 and 2014 was quite successful, malaria continues to be a major public health threat. As a result, a new strategy was formulated by the WHO called the Global Technical Strategy for Malaria 2016-2030 (GTSM) which was adopted by countries that are working towards the reversal and elimination of malaria (WHO, 2015). It aims to reduce the global malaria incidence and mortality by 90% and eliminate malaria from at least 35 countries (WHO, 2015).
Nigeria, as one of the countries with a huge burden of malaria has worked hand in hand with the WHO and other development partners in the development of programs and strategies for malaria prevention and control along the line of the WHO strategic malaria control framework (NMCP, 2014). These include; Roll Back Malaria Initiative (1998), Abuja Declaration and Framework for Action on Roll Back Malaria (2001), Road Map for Malaria Control in Nigeria- Strategic Plan 2009-2013, National Malaria Strategic Plan (NMSP) 2014-2020 (NMSP, 2014; FMH, 2009; African Union [AU], 2007).
The global efforts to prevent malaria have succeeded in preventing 663 million cases since 2001 in Sub-Saharan Africa alone. This success is largely attributed to the use of ITNs which accounted for about 69% of prevented cases through control interventions (WHO, 2017d).

2.4 CURRENT STRATEGIES FOR MALARIA PREVENTION AND CONTROL

2.4.1 VECTOR CONTROL

This remains the principal method to prevent and reduce the transmission of malaria (WHO, 2017e). It consists of Insecticide-treated mosquito nets and indoor residual spray. The WHO recommends the use of Long-lasting insecticide nets (LLINs) as the ideal form of ITNs for preventive public health programs (WHO, 2017e). It recommends that all people at risk of malaria should have access to LLITNs. In an effort to ensure equality in access, the WHO advocates the free distribution of LLITNs coupled with effective behavioural change communication strategies to encourage people to use the nets appropriately and consistently (WHO, 2017e; Ezire et al., 2015). Over, 60 million LLITNs were distributed in Nigeria between 2009 and 2013 as part of the universal LLITNs campaign to protect an estimated 29 million households in Nigeria (NMCP, 2014). However, findings from the 2013 National Demographic and Health Survey (NDHS) have shown that only 36 percent of the households in the country have access to an ITN and only 18 percent of the pregnant women slept under some kinds of mosquito nets the night before the survey. Thus, its poor utilization is a matter of great concern (NMCP, 2014; NPC, 2014).
On the other hand, indoor residual spray is another powerful way of rapidly reducing malaria transmission. It has been found to be effective for 3 to 6 months depending on the nature of surface sprayed and insecticide combination (WHO, 2017e). In order to attain its full potential, at least 85% of structures in the target area need to be covered and there may be the need for multiple sprays (FMH, 2009). However, evidence has shown that only 2 percent of households surveyed by the National Populations Commission in 2013 have been sprayed in the previous 12 months (NPC, 2014). Most of the IRS is carried out by state governments or by organizations supported through government programmes. The rest is carried out by non-governmental organizations (NPC, 2014).

2.4.2 EARLY DIAGNOSIS AND TREATMENT

The principal approaches recommended for malaria cases is early diagnosis (through the use of rapid diagnostic tests and microscopy) and institution of effective anti-malaria combination therapy (Falade et al., 2016). This is aimed at reducing the number of cases progressing to severe malaria, prevent the development of resistant strains to antimalarials and break the chain of transmission (Mahende et al., 2016).

2.4.3 INTERMITTENT PREVENTIVE TREATMENT IN PREGNANCY (IPTP)

This refers to the process by which antimalarial medications are given to pregnant women at predefined intervals in an effort to clear a presumed level of malarial parasitaemia in asymptomatic pregnant women (WHO, 2013). The best and most effective medication recommended for IPTs is the single dose antimalarial drug Sulphadoxine-pyrimethamine (SP) (Ezire et al., 2015; FMH, 2014). IPT is given to pregnant women free of charge during antenatal visits at public health facilities and non-governmental organization (NGO) facilities as part of the federal government’s protocol for focused antenatal care. However, only 23 percent of pregnant women received IPT during their last pregnancy in 2013 with a higher proportion of women in urban areas than rural area (NMCP, 2014). This has been associated with higher level of education and wealth quintile among women in urban areas (NPC, 2014).
Evidence has shown that administering SP to pregnant women from early in the second trimester and continued monthly until delivery reduces the incidence of low birth weight by 20% (FMH, 2014; WHO, 2012). It also reduces the incidence of maternal anaemia, miscarriage, stillbirth, preterm delivery and maternal mortality (Kayentao et al, 2013).
Despite the side effects attributable to sulphonamides, SP used in pregnancy for intermittent preventive treatment is generally well tolerated and pose no demonstrable risk to the foetus (Clarke et al., 2008). However, mild side effects such as nausea, vomiting, dizziness and weakness have been reported by some pregnant women especially with the first dose (NMCP, 2014; WHO, 2014). These side effects tend to decrease with subsequent doses (Kayentao et al., 2013).

2.5 BEHAVIOURAL CHANGE THEORIES

Behaviour refers to the range of actions and mannerisms made by individuals in association with their environment as a response to various stimuli or imputes whether internal or external, overt or covert, conscious or unconscious, voluntary or involuntary (Minton and Khale, 2014). The behaviour of an individual, community or population is one of the main determinants of their health outcome. Thus, achieving changes in health related behaviour is an important element of any health related intervention (Davis et al., 2015; National Institute for Health and Clinical Excellence [NICE], 2010). These changes in behaviour might involve reduction or elimination of a harmful behaviour, promotion of a healthier lifestyle or adherence to medical regimens (Young, 2014).
Health related human behaviours such as alcohol consumption, tobacco smoking, dietary behaviours, sexual practices and physical activities play a significant role in many of the principal causes of death (NICE, 2010; WHO, 2008). Evidence has shown that even minor changes in behaviours can have significant effect on population health outcomes (Butts and Ridge, 2013). This makes it vital to understand these behaviours and the factors influencing their occurrence in order to develop and incorporate effective evidence-based health behaviour change interventions and policies for reducing avoidable morbidity and mortality (Davis et al., 2015; Ramsier and Suvan, 2015).
Health related human behaviour is greatly influenced by socio-economic status of the individual or the community and by extension the level of inequality within the society. As a result, policies geared towards economic empowerment and reducing inequality will go a long way in improving health outcome (Wilkinson and Pickett, 2009).
The most dominant theories of health behaviour are the health belief model, the social cognitive theory and the transtheoretical model (Butts and Ridge, 2013). However, most studies on the determinants of ITN use by pregnant women were based on the health belief model which hypothesizes that personal health-related action is largely determined by the existence of adequate motivation or health concern, perceived threats of serious outcome and the belief that the recommended health action will reduce or eliminate the perceived threat (Ankomah et al., 2012).
A proper understanding of health behavioural theories is necessary for this systematic appraisal as it will aid in understanding the actions of pregnant women and the factors or circumstances that have influenced them to act in a particular way (Ankomah et al., 2012; NICE, 2006). This is based on the fact that behaviour is mainly determined by the opportunities and conditions in which individuals are placed (NICE, 2014). This will help policy makers to develop the most appropriate behavioural change interventions that will encourage the utilization of ITNs.

2.6 FACTORS INFLUENCING ITN USE BY PREGNANT WOMEN

Factors that have been identified to influence ITN utilization are numerous but can be broadly categorized into the following; knowledge of the health condition, sociodemographic factors, misconceptions and access.

2.6.1 KNOWLEDGE OF THE HEALTH CONDITION

Several studies have identified the presence of correlation between the level of knowledge about malaria and its preventive measures and the utilization of ITNs among pregnant women across varied socio-demographic groups (Russel et al., 2015; Ankomah et al.,2012; Arogundade et al., 2011). Pregnant women generally receive health education including information on malaria prevention and control during antenatal care visits to health facilities (Amako, 2016). This service is generally provided by doctors, nurses, midwives and other auxiliary staff in English language and the local dialect of the community (Fagbamigbe and Idemudia, 2015)
Arogundade et al., (2011) found that one of the key predictors of ITN use among pregnant women in Nigeria is the knowledge that ITN use prevents malaria. Pregnant women who knew about the specific risks of malaria in pregnancy (such as anaemia, low birth weight, abortion) were more likely to use ITNs than those who did not. This is similar to what was obtained by Russel et al., (2015) and Belay and Deressa, (2008). However, Russel et al., (2015) found that despite knowing that mosquitoes cause malaria, only 2.3% of the respondents knew that malaria could result in spontaneous abortion, stillbirth, prematurity or intrauterine growth restriction.
Further evidence has also shown that education and correct knowledge about malaria, its modes of prevention as well as its fatal consequences were found to be significantly associated with increased use (Arogundade et al., 2011; Deressa et al., 2011). However, Aluko and Oluwatosin (2012) found that despite the relatively high knowledge of malaria by the respondents, the use of ITN is significantly low. This has been attributed to the negative attitudes of the respondents to ITN use, poverty or unavailability.

2.6.2 SOCIO-DEMOGRAPHIC FACTORS

Evidence has shown that the presence of social and emotional support is an important determinant of increased ITN use (Russell et al., 2015; Glanz et al., 2008). Wagbatsoma and Aigbe, (2010) found that most married women use ITN compared to unmarried women. However, small family size is another predictor of increased ITN usage. This finding is similar to findings obtained by Ankomah et al., (2012) where women from monogamous families use ITNs more than polygamous ones implying that a woman who is the only wife to her husband gets the necessary social and financial support from him. In addition, women in middle-class families are more likely to use ITNs (NPC, 2014). However, this is contrary to the findings by Belay and Deressa (2008) where age, marital status, occupation, parity, number of rooms, family size and location of residence did not influence the use of ITNs by pregnant women.
It was also found that women with higher number of previous pregnancies have increased chances of sleeping under an ITN, this has been attributed to the fact that they are likely to have better knowledge about the dangers of malaria and a better chance that they will attend ANC clinics, thus increasing their chances of accessing ITN (Muhumuza et al., 2016; Ankomah et al., 2012).
Belay and Deressa (2008) found that urban residence is a key predictor of increased ITN access and utilization with 76.2% of urban pregnant women using ITNs as against 56.7% of rural women. However, there was no difference between rural and urban areas in terms of perceived symptoms and knowledge about malaria and its preventive measures. This is despite the fact that pregnant women in rural communities are at an increased risk (Ajayi, 2013). This might be related to the fact that urban bias exists in terms of public health expenditure coupled with inadequate financing and provision of incentives to attract health personnel to work in rural areas (Omo-Aghoja et al., 2010). All these have resulted in inequalities in rural-urban health facilities and reduced access to health services (Ajayi, 2013).

2.6.3 ECONOMIC FACTORS

Women from poor socioeconomic background and poor household wealth are less likely to use ITN compared to those from higher socioeconomic class (Ruyange et al., 2016; Auta, 2012). However, Mugisha and Arinaitwe (2003) found that women without formal education and from poor socioeconomic background were more likely to use ITN compared to those from higher socioeconomic class. This may be associated with their perceived vulnerability to malaria or due to targeted public health campaigns and free ITN distribution in Primary and secondary health centres (Auta, 2012). Furthermore, women who are dependent were more likely to sleep under ITNs compared to their counterparts who engage in at least one type of employment (Auta, 2012; Aluko and Oluwatosin, 2012).
People in rural areas are at a disadvantage in terms of employment opportunities with majority engaged in agriculture and other informal means of livelihood (Ekpe et al., 2014). However, women in Nigeria have always been at a disadvantage when it comes to socio-economic activities where men take most of the employment opportunities in the formal sector (Ekpe et al., 2014; NPC, 2014). Only 7% of women are employed in the formal sector with the majority engaged in sales, unskilled services and subsistence agriculture (NPC, 2014; Fapohunda, 2012). This has been attributed to their relative lack of education and training, social and cultural barriers (marriage, childbirth, permission from husband) and gender biased government policies (Fapohunda, 2012). As such, gender equality and socio-economic empowerment of women must be considered in order to design any viable health program (Emmanuel et al., 2016; Ekpe et al., 2014).

2.6.4 EDUCATION

The level of education was found to have variable effects on the utilization of ITNs among pregnant women in several studies (Iwuafor et al., 2016; Ashikeni et al., 2013; Ankomah et al., 2012). Some studies found a good correlation between the possession of higher education and increased use of ITNs (Muhumuza et al., 2016; Ashikeni et al., 2013; Oresanya et al., 2008). Iwuafor et al., (2016) found that although possession of a higher education increases the likelihood of possessing ITN, it was not found to increase utilization.
Belay and Deressa (2008) also found that higher education attainment is the strongest predictor of ITN use by pregnant women. Education generally improves awareness and compliance to therapy. This assertion is also supported by Muhumuza et al., (2016) who found that women with post-primary education were two times more likely to use ITNs compared to lower education levels. This has been attributed to their better knowledge about the dangers of malaria and the need for prevention. This reinforces the importance of girl-child education as a means of women empowerment.
Conversely, Auta (2012) found that women with lower level of education or those without formal education were more likely to use ITNs. On the other hand, Yassin et al., (2010) found no correlation between educational level and ITN use. However, the study did not explore the physical attributes of ITNs in explaining user preferences and their potential influence on consistent use of ITN.

2.6.5 MISCONCEPTIONS

Misconceptions about malaria and its prevention have been some of the important determinants of ITN use among pregnant women (Iwuafor et al., 2016; Ankomah et al., 2012). Women who had misconceptions about the causes and prevention of malaria were less likely to use ITN even though they may have one (Arogundade et al., 2011).
Some of the misconceptions that have been identified to reduce the ownership and utilization of ITN include; perceiving malaria as ordinary fever caused by over-work, sunlight, excessive sex, noise, witchcraft, not resting/sleeping enough, drinking too much alcohol/beer, eating too much palm/groundnut oil, physical contact with a malaria patient, exposure to cold air or drinking contaminated water (Iwuafor et al., 2016; Wagbatsoma, and Aigbe, 2010; Belay and Deressa (2008). Identifying such misconceptions for the purpose of designing appropriate educational interventions could significantly lead to improvement in health-seeking behaviour and preventive practices (Iwuafor et al., 2016; Chirdan et al., 2008). However, the study is limited by the fact that it did not measure the degree of exposure to the social intervention necessary to have a significant influence on ITN use (Chirdan et al., 2008).
Due to the strong correlation between misconceptions and ITN use, there is the need for correcting these misconceptions about malaria and its prevention through health education (Belay and Deressa, 2008).

2.6.6 ACCESS/AVAILABILITY

Evidence from some studies found that the reason for the poor ITN utilization is attributable to difficulty or lack of access to ITN by pregnant women. This is because ITNs are given out at health facilities, some of which are far from the mothers (Muhumuza et al., 2016). Wagbatsoma and Aigbe (2010) found that despite the fact that the respondents have good knowledge about malaria and its prevention, ITNs are simply not available to them.
The health structure of Nigeria is divided into primary (primary health centres), secondary (General hospitals) and tertiary (teaching hospitals, specialist hospitals and research centres) which are managed by local, state and federal governments respectively (Oyedeji and Abimbola, 2014). According to data from the federal ministry of health, 88.1 percent of health centres in Nigeria are primary health centres, 11.7 percent are secondary facilities while only 0.2 percent are tertiary (NMCP, 2014). Sixty-four percent of the population are within 20km of a hospital, however, urban areas are more favoured with 78% of households within 20km of a hospital as opposed to 58% for rural areas. In the same vein, 80% of households in urban areas being within 5km of a PHC as opposed to 66% in rural areas (NMCP, 2014).
It is thus evident that a lot of Nigerians especially those in rural areas do not have access to public health facilities either as a result of the long distance between them or lack of well equipped and manned facilities which affect their utilization of such services. Since malaria prevention services are provided during ANC services in health facilities, a lot of pregnant women will be left out (Teryla et al., 2014).

2.6.7 OTHERS

Singh et al., (2013) found that some reasons given for not using ITNs include discomfort, heat or inconvenience, limited perceived benefit or the preference to use other malaria preventive methods. This is supported by a study conducted by Aluko and Oluwatosin (2012) where more than one-quarter of women who slept under ITNs experience at least one form of discomfort with excessive heat being the major discomfort. This might be attributable to the typical hot weather of Africa and lack of electricity.

2.7 CHAPTER SUMMARY

This chapter has provided an extensive review of the available literature on the factors influencing the utilization of ITNs among pregnant women. It also discussed the historical trend in malaria prevention policies as well as the current strategies for malaria prevention. It also discussed behavioural change theory in relation to ITN us

Prevalence Of Bacterial Vaginosis, Trichomoniasis And Vulvovaginal Candidiasis In Pregnant Women Attending Antenatal Clinic

ABSTRACT 
Introduction: Vaginal infections are usually caused by Candida albicans, Trichomonas vaginalis and organisms responsible for bacterial vaginosis including Gardneralla vaginalis, Bacteriodes spp, and Mobilincus. These infections in pregnancy are associated with considerable discomfort and adverse pregnancy outcome including preterm delivery, low birth weight, miscarriage.
Objectives: The study determined the prevalence of bacterial vaginosis, trichomoniasis and vulvovaginal candidiasis in pregnant women attending antenatal clinic
Methods: A prospective study of 589 consecutive vaginal swabs of pregnant women was taken after administration of a semi-structured questionnaire. The samples were analysed using wet mount, culture and Gram stain for vaginal infection. Univariate and multivariate analysis were used to investigate association of vaginal symptoms and risk factors to vaginal infections.
Results: The overall prevalence of vaginal infections was 56.4%. The individual prevalence of bacterial vaginosis, trichomoniasis and vulvovaginal candidiasis was 30.6%, 1.4% and 36.5% respectively. In multivariate analysis, vaginal symptom pruritus was significantly associated with vulvovaginal candidiasis. Considering number of pregnancies, less than three pregnancies was an independent risk factor for bacterial vaginosis. Being in the third trimester of pregnancy was however found to be protective to bacterial vaginosis.
Conclusion: The prevalence of vaginal infections was high among pregnant women. The data confirms pruritus as a key symptom of vulvovaginal candidiasis. Adequate investigations and early treatment of vaginal infections will reduce the disease burden and avoid complications associated with it.

Prevalence Of Anaemia Among Pregnant Women Attending Antenatal Clinic Of Dutsinma Town

ABSTRACT

Anaemia in pregnancy is a common problem in most developing countries and a major cause of morbidity and mortality especially in malaria endemic areas. In pregnancy, anaemia has a significant impact on the health of the foetus as well as that of the mother. 20% of maternal deaths in Africa have been attributed to anaemia. Anemia during pregnancy is highly preventable and treatable.This study is aimed at determining the Prevalence Of Anaemia Among Pregnant Women Attending Antenatal Clinic Of Dutsinma Town.This was a cross sectional study of 406 women attending the antenatal clinic for their booking visit. The capillary technique was used for the estimation of the packed cell volume (PCV) to assess level of anaemia; Questionnaires were also administered to obtain demographic information- age, parity, social class and gestational age at booking were obtained and analyzed. Out of the 406 women studied, 229 were anaemic thus making the prevalence of anaemia to be 56.4%. Most, 89.5% were mildly anaemic, 10.5% were moderately anaemic while none of the women were severely anaemic. Two hundred and sixty, (64%) of the women booked in the first trimester, 33.3% booked in the second trimester while only 2.7% booked in the third trimester. More women were anaemic in the 2nd trimester of pregnancy, with a higher prevalence among the multigravidae (59.3%). Anaemia was highest among company workers and least among civil servants. The women who had birth intervals of ≤1 year had the highest prevalence of anaemia (53.3%), followed by those who had a birth inter of 2-4 years, while those women who had a birth interval of more than 4years had the least Prevalence (44.5%) of anaemia. The prevalence of anaemia amongst the participants was high. The parity, gestational age at booking, educational status and the birth interval are factors that were found to have affected the prevalence of anaemia in this study. Therefore educating women on early antenatal booking and compliance with the use of prescribed medications (Iron Supplements, Folate and Antimalarials) should also be emphasized to reduce the problem of anaemia in pregnancy in Nigeria.
 

TABLE OF CONTENTS

• Title page

• Declaration

• Certification

• Dedication

• Acknowledgement

• Table of Contents

• List of Tables

• List of Figures

• List of Appendices

• List of Abbreviation

• Summary

• CHAPTER ONE

• 1.0 Background

• 1.1 Problem Statement

• 1.2 Justification

• 1.3 Research Questions

• 1.4 Aim and Objectives

• 1.5 Scope of the Study

• CHAPTER TWO/Literature Review

• Introduction

• Definitions

• Epidemiology

• Causes of Anaemia in pregnancy

• Clinical features of Anaemia

• Effects of Anaemia on Pregnancy Outcome

• Diagnosis and assessment of Anaemia

• Management of Anaemia

• Prevention of Anaemia in pregnancy

• CHAPTER THREE

• Methodology

• Background of Study Area

• Study Population

• Study design

• Sampling Size Determination

• Sampling technique

• Data Collection Tools

• Data Collection Technique/Procedure

• Data Analysis

• Ethical Considerations

• Limitations of Study

• CHAPTER FOUR

• 4.0 Results

• 4.1 Discussions

• CHAPTER FIVE

• Conclusions and Recommendations

• Conclusions

• Recommendations

• References

• Appendices

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