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      Prevalence and factors associated with anemia among women of reproductive age in seven South and Southeast Asian countries: Evidence from nationally representative surveys

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          Abstract

          Background

          Anemia remains a major public health challenge with high prevalence among women in South and Southeast Asian countries. Reductions in anemia rates have been stalled, despite the implementation of different maternal health and nutrition programs. This study aimed to assess the prevalence and factors associated with anemia among women of reproductive age in seven selected South and Southeast Asian countries.

          Methods

          This cross-sectional analysis utilized data from the most recent demographic and health surveys from seven selected South and Southeast Asian countries (Bangladesh, Cambodia, India, Maldives, Myanmar, Nepal, and Timor-Leste) between 2011 and 2016. This study included 726,164 women of reproductive age. Multiple logistic regression was performed to assess the factors associated with anemia among women for each country separately.

          Results

          The combined prevalence of anemia was 52.5%, ranged from 22.7% in Timor-Leste to 63% in the Maldives. Results from multiple logistic regression suggest that likelihood of anemia is significantly higher among younger women (15–24 years), women with primary or no education, women from the poorest wealth quintile, women without toilet facilities and improved water sources, underweight women, and women with more than one children born in last five years in most of the countries.

          Conclusions

          The prevalence of anemia is high among women of reproductive age in the seven selected South and Southeast Asian countries. The results of this study suggest that various household, environmental and individual factors contribute to the increased likelihood of anemia. Evidence-based, multidisciplinary policies and programs targeting mothers' health and nutrition status, in addition to scaling-up women's education and socioeconomic status, are warranted to combat anemia.

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          Most cited references17

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          “We have to clean ourselves to ensure that our children are healthy and beautiful”: findings from a qualitative assessment of a hand hygiene poster in rural Uganda

          Background Neonatal sepsis is a major cause of mortality worldwide, with most deaths occurring in low-income countries. The World Health Organisation (WHO) ‘5 Moments for Hand Hygiene’ poster has been used to reduce hospital-acquired infections, but there is no similar tool to prevent community-acquired newborn infections in low-resource settings. This assessment, part of the BabyGel Pilot study, evaluated the acceptability of the ‘Newborn Moments for Hand Hygiene in the Home’ poster. This was an educational tool which aimed to remind mothers in rural Uganda to clean their hands to prevent neonatal infection. Methods The BabyGel pilot was a cluster randomised trial that assessed the post-partum use of alcohol-based hand rub (ABHR) to prevent neonatal infections in Mbale, Uganda. Fifty-five women in 5 village clusters received the ABHR and used it from birth to 3 months postnatally, with use guided by the new poster. Following the study, 5 focus group discussions (FGDs) were conducted consisting of 6–8 purposively sampled participants from intervention villages. FGDs were audio-recorded, transcribed then translated into English. Transcripts were inductively coded using ATLAS.ti® and qualitatively analysed using thematic content analysis. Results Most mothers reported that they understood the message in the poster (“The picture shows me you must use these drugs to keep your baby healthy”) and that they could adhere to the moments from the poster. Some participants used the information from the poster to encourage other caregivers to use the ABHR (“after explaining to them, they liked it”). Other potential moments for hand hygiene were introduced by participants, such as after tending to domestic animals and gardening. Conclusion The poster was well-received, and participants reported compliance with the moments for hand hygiene (although the full body wipe of the baby has since been removed). The poster will be adapted into a sticker format on the ABHR bottle. More focus could be put into an education tool for other caregivers who wish to hold the baby. Overall, the study demonstrated the acceptability of an adapted version of the WHO Moments for Hand Hygiene poster in the introduction of an intervention in the community. Trial registration ISRCTN67852437, registered 02/03/2015. Trial funding Medical Research Council/ Wellcome Trust/ DfID (Global Health Trials Scheme).
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            Anemia epidemiology, pathophysiology, and etiology in low‐ and middle‐income countries

            Anemia affects a third of the world's population and contributes to increased morbidity and mortality, decreased work productivity, and impaired neurological development. Understanding anemia's varied and complex etiology is crucial for developing effective interventions that address the context-specific causes of anemia and for monitoring anemia control programs. We outline definitions and classifications of anemia, describe the biological mechanisms through which anemia develops, and review the variety of conditions that contribute to anemia development. We emphasize the risk factors most prevalent in low- and middle-income countries, including nutritional deficiencies, infection/inflammation, and genetic hemoglobin disorders. Recent work has furthered our understanding of anemia's complex etiology, including the proportion of anemia caused by iron deficiency (ID) and the role of inflammation and infection. Accumulating evidence indicates that the proportion of anemia due to ID differs by population group, geographical setting, infectious disease burden, and the prevalence of other anemia causes. Further research is needed to explore the role of additional nutritional deficiencies, the contribution of infectious and chronic disease, as well as the importance of genetic hemoglobin disorders in certain populations.
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              Moderate to severe, but not mild, maternal anemia is associated with increased risk of small-for-gestational-age outcomes.

              Anemia is highly prevalent globally, estimated at 40-50% in women of reproductive age. Prior studies have produced inconclusive evidence as to the association between maternal anemia and intrauterine growth restriction (IUGR). We conducted a systematic review of the literature containing associations between maternal anemia and small for gestational age (SGA) outcomes (as a proxy for IUGR). A meta-analysis was performed to pool associations, categorized by the hemoglobin cutoffs presented by the authors. We identified 12 studies reporting associations between maternal anemia and SGA. For the meta-analysis, there were 7 associations with a hemoglobin cutoff <110 g/L, 7 with a cutoff <100 g/L, and 5 with a cutoff <90 or <80 g/L. Although the <110- and <100-g/L categories showed no significant relationship with SGA, the <90- or <80-g/L category was associated with a 53% increase in risk of the newborn being SGA [pooled OR = 1.53 (95% CI: 1.24-1.87); P < 0.001]. Moderate to severe, but not mild, maternal anemia appears to have an association with SGA outcomes, but the findings must be viewed with caution due to the great heterogeneity of the studies. Further examination should be conducted using datasets with better standardized definitions and measurements of exposure and outcome.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Project administrationRole: SoftwareRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Project administrationRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                13 August 2020
                2020
                : 15
                : 8
                : e0236449
                Affiliations
                [1 ] Department of Nutrition and Dietetics, Armed Police Force Hospital, Kathmandu, Nepal
                [2 ] Department of Public Health, Asian College for Advance Studies, Purbanchal University, Lalitpur, Nepal
                [3 ] Research and Innovation Section, Southeast Asia Development Actions Network (SADAN), Lalitpur, Nepal
                [4 ] Department of Radiology, Nepal Orthopaedic Hospital, Kathmandu, Nepal
                [5 ] Department of Community Medicine, Maharajganj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
                [6 ] Department of Emergency, Patan Academy of Health Sciences, Lalitpur, Nepal
                [7 ] Department of Nutrition and Dietetics, College of Applied Food and Dairy Technology, Purbanchal University, Kathmandu, Nepal
                Universidade de Sao Paulo, BRAZIL
                Author notes

                Competing Interests: The authors have declared that no competing interests exist

                Author information
                http://orcid.org/0000-0002-2544-8296
                http://orcid.org/0000-0003-1450-9476
                Article
                PONE-D-20-10365
                10.1371/journal.pone.0236449
                7425935
                32790764
                1e4fceb8-c5de-43d2-921c-c8ab655537c6
                © 2020 Sunuwar et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 10 April 2020
                : 5 July 2020
                Page count
                Figures: 2, Tables: 2, Pages: 17
                Funding
                The author(s) received no specific funding for this work
                Categories
                Research Article
                Medicine and Health Sciences
                Hematology
                Anemia
                People and Places
                Geographical Locations
                Asia
                Medicine and Health Sciences
                Hematology
                Anemia
                Iron Deficiency Anemia
                People and Places
                Geographical Locations
                Asia
                Maldives
                People and places
                Geographical locations
                Asia
                Timor-Leste
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Pregnancy
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Pregnancy
                People and Places
                Geographical Locations
                Asia
                India
                Biology and Life Sciences
                Nutrition
                Medicine and Health Sciences
                Nutrition
                Custom metadata
                We used data of Demographic and Health Surveys that are publicly available and can be freely downloaded upon the formal request from the DHS website ( https://www.dhsprogram.com/data/available-datasets.cfm)

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                Uncategorized

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