Low serum ferritin and G6PD deficiency as potential predictors of anaemia in pregnant women visiting Prime Care Hospital Enugu Nigeria
Engwa et al. BMC Res Notes
Low serum ferritin and G6PD deficiency as potential predictors of anaemia in pregnant women visiting Prime Care Hospital Enugu Nigeria
Godwill Azeh Engwa 0
Marcellus Unaegbu 0
Marian N. Unachukwu 2
Mary‑Gloria C. Njoku 1
Kingsley N. Agbafor 5
Wilfred Fon Mbacham 4
Anthony Okoh 3
0 Biochemistry, Department of Chemical Sciences, Faculty of Natural and Applied Sciences, Godfrey Okoye University , P.M.B 01014, Thinkers Corner, Enugu , Nigeria
1 Department of Sociology/Psychology, Faculty of Social and Manage‐ ment Sciences, Godfrey Okoye University , P.M.B 01014, Thinkers Corner, Enugu , Nigeria
2 Department of Microbiology, Faculty of Natural and Applied Sciences, Godfrey Okoye University , P.M.B 01014, Thinkers Corner, Enugu , Nigeria
3 SAMRC Microbial Water Quality Monitoring Centre, Department of Biochem‐ istry and Microbiology, University of Fort Hare , Alice , South Africa
4 Laboratory for Public Health Research Biotechnologies, The Biotechnology Centre, University of Yaounde I , BP 8094, Yaounde , Cameroon
5 Department of Biochemistry, Ebonyi State University , P.M.B. 053, Abakaliki , Nigeria
Objectives: Though iron deficiency is known to be a major risk factor of anaemia, the association of G6PD deficiency and malaria with anaemia still remains unclear. Hence, a cross‑ sectional study involving 95 pregnant women visiting Prime Care Hospital in Trans‑ Ekulu region of Enugu Nigeria was conducted to determine possible predictors of anaemia in pregnancy. Results: The prevalence of anaemia, malaria and G6PD deficiency were 53.7, 12.6 and 60% respectively. Low serum ferritin (OR 5.500, CI 2.25-13.42, p < 0.05) and G6PD deficiency (OR 0.087, CI 0.03-0.23, p < 0.05) were associated with anaemia in pregnancy. On the other hand, malaria did not significantly associate (OR 1.184, CI 0.35-3.97, p = 0.964) with anaemia in pregnant women. These findings showed high prevalence of anaemia among pregnant women with low serum ferritin level and G6PD deficiency as high risk factors of anaemia.
Anaemia; Malaria; Pregnancy; G6PD deficiency; Serum ferritin; Haemoglobin concentration
Globally, anaemia affects about 2 billion people of which
over 800 million are children and pregnant women
particularly in Africa and Asia [
]. Of the estimated
1 million yearly deaths in Africa and South-East Asia, anaemia
is reported to account for about 75% . Anaemia in
pregnancy is even more prominent in developing
countries with an estimated prevalence ranging from about 56
to 61% [
]. It is estimated to be responsible for about 20%
of maternal death in sub-Sahara Africa [
Anaemia is characterized by low haemoglobin (Hb)
concentration in blood below the normal level [
is a major and essential component of Hb affix in the
porphyrin ring mainly to bind oxygen molecules thereby
facilitating its distribution in the body which is required
for cellular respiration and other cell functions [
is stored in the form of ferritin which is an intracellular
protein containing about 4000–4500 iron atoms, thus
serves as iron store in the body [
]. Low serum ferritin
level in the body has been shown to be associated with
iron deficiency and eventually anaemia [
]. Apart from
iron level and serum ferritin in blood, glucose 6
phosphate dehydrogenase (G6PD) deficiency [
] and malaria
] are other factors of concern. Deficiency of G6PD
enzyme results in decrease level of reduced glutathione
(GSH) thus making the red blood cells (RBCs) vulnerable
to oxidative damage and eventually haemolysis or
]. Malaria during pregnancy is among the most
common complications of pregnancy and highly
prevalent in sub-Sahara Africa [
]. In malaria-endemic areas,
especially sub-Sahara Africa, about 25% of pregnant
women are estimated to be infected with malaria parasite
]. Though most malaria infections in pregnant women
may be asymptomatic, the resultant anaemia may be fatal
] constituting a major risk of anaemia in pregnancy.
Though serum ferritin and malaria are well
documented as potential risk factors of anaemia in pregnancy,
limited data is available on the contribution of G6PD
deficiency with other predictors of anaemia in pregnancy.
This pilot study was carried out among pregnant women
attending anti-natal care (ANC) at Prime Care
hospital, Trans-Ekulu, Enugu, Nigeria. Prime care hospital is
located in Enugu East local government area of Enugu
with coordinates: 6°27′9.60″N 7°30′37.20″E.
Study design and inclusion criteria
This cross sectional study involved pregnant women of all
trimester visiting ANC from April to May, 2015 who had
not received any therapy for anaemia or iron supplement,
not severely ill, no complications and are willing to
participate were considered for inclusion and consecutively
recruited for the study.
Sample collection and analysis
Five millilitre of venous blood was collected into EDTA
tubes to estimate the Hb level, pack cell volume (PCV),
RBC count, and mean cell haemoglobin (MCV) using
haematological analyser CELL DYN 1800, Abott
Laboratories Diagnostic Division, USA. Thin and thick blood
films were prepared, incubated with 10% Giemsa stain
by Sigma-Aldrich Germany for 10 min then examined
microscopically for the presence of malaria parasite using
Model 3000FF microscope by Fisher Scientific, USA.
Serum ferritin level was determined according to the
method of Worwood and collaborators [
methaemoglobin reduction test of Brewer et al. [
] was used for
the determination of G6PD deficiency.
Data and statistical analysis
Anaemia in pregnancy was defined as Hb less than 11 g/
dL and further classified as mild, moderate, and severe
anaemia with Hb measurement between 10.0 and 10.9 g/
dL, 7.0 and 9.9 g/dL and less than 7.0 g/dL respectively.
For the MCV, anaemia was defined as < 80 fL/cell while
no anaemia or normal ≥80 fL/cell. A PCV of less than
30% was considered as anaemia while a PCV greater than
or equal to 30% was considered normal. RBC count of
less than 3.2 million/mm3 was defined as anaemia and
above 3.2 million/mm3 was considered normal. Anaemia
as defined by serum ferritin was considered at less than
30 μg/L while above 30 μg/L was normal.
The data was analysed using statistical package for
social sciences (SPSS) version 16 and presented in tables.
Frequencies and proportions of categorical variables were
compared with Chi square tests for association.
Predictive factors of anaemia were considered as the
independent variables and anaemia as the dependent variable to
determine the correlation coefficient (r) and significance
by Pearson correlation. Logistic regression was employed
to determine the odd ratio (OR of the various predictive
factors of anaemia. Confidence interval (CI) was taken at
95% and significant differences were considered at p ≤
Baseline characteristics of pregnant women
As shown in Table 1, 95 pregnant women enrolled in the
study among which 37 (38.9%) were in their first
trimester, 35 (36.8%) in their second trimester and 23 (24.2%)
in their third trimester. Their ages ranged from 20 to
35 years with a mean of 27.33 ± 4.21 years while the most
frequent age was 30 years. The Hb level of the women
ranged from 5.5 to 13.5 g/dL with a mean of 9.9 ± 2.04 g/
Prevalence of anaemia, malaria and G6PD deficiency
Among the 95 pregnant women, 51 were anaemic with
a prevalence of 53.7% of which 14 (14.7%) was mild, 30
(31.6%) moderate and 7 (7.4%) severe anaemia. Malaria
had a prevalence of 12.6% (12/95) while the prevalence
of G6PD deficiency was 60% (57/95).
Association of anaemia with diagnostic parameters
Anaemia was more prominent in pregnant women of the
age group between 20 and 29 years than those between
30 and 39 years but there was no significant correlation
between age group and anaemia (r 0.231, CI 0.12–0.28,
p = 0.166). Anaemia in pregnancy was mostly present
in the second trimester, followed by the first trimester,
and least in third trimester. Anaemia was not associated
with the trimester of pregnancy (r 0.184, CI 0.71–0.87,
p = 0.789). Also, the MCV did not correlate with
anaemia in pregnancy (r 0.182, 0.25–0.44, p = 0.370). On
the other hand, PCV level was associated with anaemia
(r 0.875, CI 0.00–0.03, p < 0.05) as most of the women
with anaemia had a PCV level below 30%. Similarly,
anaemia in pregnancy was associated with RBC count below
3.2 million/mm3 (r 0.679, CI 0.00–0.03, p < 0.05). Results
are summarized in Table 2.
Association of anaemia with risk factors (ferritin, malaria and G6PD deficiency)
Low serum ferritin was associated with anaemia in
pregnancy (OR 5.500, CI 2.25–13.42, p < 0.05) as anaemia
was not usually present when the serum ferritin level
was above 30 µg/L, while it was mostly present when
serum ferritin level was below 30 µg/L. G6PD deficiency
correlated with anaemia in pregnancy (OR 0.087, CI
0.03–0.23, p < 0.05). There was little or no association
between malaria and anaemia in pregnant women (OR
1.184, CI 0.35–3.97, p = 0.964). The results are
summarized in Table 3.
Anaemia in pregnancy remains a problem of public
health concern especially in developing countries where
it can lead to so many adverse conditions or
consequences which can affect the productivity and
reproductive capacity of women and also lead to maternal
]. The prevalence of anaemia in pregnancy
was 53.7% of which moderate anaemia was the most
prevalent (31.6%) while severe anaemia was the least
(7.4%). This results fall within the range of previous data
reported in developing countries which showed the
prevalence of anaemia in pregnancy to range from 35.0
to 75.0% [
]. Also, previous studies in Nigeria [
] and South East Africa [
] have shown
the prevalence of anaemia to be in a close range to that
found in this study.
One of the main contributing risk factors of anaemia
is iron deficiency which accounts for about 50% of all
cases of anaemia [
]. Serum ferritin has been used as a
measure for iron deficiency since it serves as iron store
in the body [
]. Malaria in pregnancy has also been
shown to be characterized by secondary anaemia which
is at risk to mother and off-spring [
]. This is as a result
of malaria parasite that destroys erythrocytes during cell
division and merozoite release [
]. Another risk factor
of anaemia is G6PD deficiency whereby a deficiency in
r Pearson correlation coefficient; CI confidence interval
this enzyme makes erythrocytes to be vulnerable to
oxidative damage hence, liable to haemolysis and
eventually anaemia [
]. The evaluation of these parameters for
association with anaemia showed low serum ferritin (OR
5.5) and G6PD deficiency (OR 0.087) as high risk factor
of anaemia. Thus, low serum ferritin or iron deficiency
is found to be the most prevalent risk factor of anaemia.
This has been confirmed in other studies which have
shown iron deficiency to be responsible for anaemia [
and iron supplementation as a protective measure [
]. G6PD deficiency which had a prevalence of 60% was
also shown to be associated with anaemia. This confirms
previous studies which have earlier shown this
]. However, malaria which had a prevalence
of 12.6% showed little or no association (OR 1.184) with
anaemia in pregnancy and thus not a potential risk factor.
This is in contrast to the findings of a study by Matangila
and collaborators which showed asymptomatic
Plasmodium falciparum infection with a prevalence of about
30% to be associated with anaemia in pregnancy [
is possible that seasonal variation may have accounted
for this difference in malaria prevalence as this present
study was carried out between April and May, a period
whereby the rainy season was at an early stage in
Nigeria compared to the study of Matangila and collaborators
which was conducted from July to August deep into the
rainy season where malaria transmission was at its peak
accounting for the high prevalence and hence association
with anaemia. The low prevalence of malaria observed in
this study was hence a positive factor that minimized the
extent of pregnancy associated anaemia as the presence
of malaria is a known predictor of anaemia [
In conclusion, anaemia was found highly prevalent in
pregnant women attending antenatal care at Prime Care
Hospital in Trans-Ekulu region of Enugu Nigeria and
was strongly associated with low serum ferritin level and
G6PD deficiency as potential risk factors.
This study is a pilot study and was focused on one
hospital, thus the small sample size may be limiting to
generalize the findings to a large geographic area. Also, the study
was carried out between April and May, a period during
the rainy season where malaria transmission is not at its
peak, thus low prevalence of malaria.
WHO: World Health Organisation; Hb: haemoglobin; G6PD: glucose 6 phos‑
phate dehydrogenase; GSH: reduced glutathione; RBC: red blood cell; MCV:
mean cell volume; PCV: pack cell volume; ANC: anti‑natal care; OR: odd ratio;
SPSS: statistical package for social sciences; CI: confidence interval.
GAE conceived and designed the study along with MU, and AO. GAE carried
out the field work and laboratory work along with MU and MNU. WFM, MGCN
and GAE were involved in data analysis and interpretation. WFN, AO, MGCN,
MNU, KNA and GAE were all involved in drafting the manuscript. All authors
read and approved the final manuscript.
We thank the staff of Prime Care Hospital for the care of the participants and
their assistance throughout the study.
The authors declare that they have no competing interests.
Availability of data and materials
All data generated or analysed during this study are included in this published
article and its additional files.
Consent for publication
Ethics approval and consent to participate
The study design was reviewed and approved by the Local Ethical Institu‑
tional Review Board of the Department of Biological Sciences, Godfrey Okoye
University, Enugu, Nigeria. Written informed consent was obtained from all
pregnant women willing to participant in the study.
GAE is grateful to Rev. Fr. Prof. Christian Anieke, the Vice Chancellor of Godfrey
Okoye University Enugu and the South Africa Medical Research Council for
Springer Nature remains neutral with regard to jurisdictional claims in pub‑
lished maps and institutional affiliations.
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