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Abstract

Background:

Anemia during pregnancy remains a significant global health concern, particularly in developing countries, contributing to adverse maternal and fetal outcomes. In The Gambia, despite national health policies promoting iron supplementation and malaria prevention, maternal anemia continues to be a common cause of morbidity and mortality. This study aimed to determine the prevalence and determinants of anemia among pregnant women attending maternal and child health clinics at Sukuta Health Center in The Gambia.

Methods:

An analytical institutional-based cross-sectional study was conducted on 425 pregnant women attending antenatal care. Data were collected using a structured questionnaire covering sociodemographic characteristics, knowledge of anemia, and anemia prevention practices. Hemoglobin levels were measured to determine the anemia status. Chi-square tests and a binary logistic regression model were used to assess the associations between variables, with statistical significance set at p < 0.05, adjusted odds ratio (aOR) with 95% confidence intervals (CI).

Results:

The prevalence of anemia among pregnant women was 21.6%. The majority of women (55.3%) demonstrated good knowledge of anemia during pregnancy. The husbands’ occupational status was significantly associated with anemia (p = 0.036). Recognition of anemia symptoms was strongly associated with anemia status (p < 0.001). While 88.7% of the women recognized the importance of a nutritious diet in preventing anemia, only 46.9% mentioned iron supplements as a preventive measure. Nurses were the primary source of information about anemia (97.2%). Pregnant women who were Muslim had 4.3 times higher odds of being anemic (aOR = 4.295, 95% CI: 1.103–16.727) than those who were Christian after controlling for confounders.

Conclusion:

Despite the lower prevalence of anemia, there remains a need for improved comprehensive understanding and prevention practices. The significant association between husbands’ occupation and anemia status highlights the importance of considering household economic factors in anemia prevention. There is a need to design culturally tailored interventions targeting larger, resource-constrained Muslim households to effectively address anemia during pregnancy.

Plain language summary

Understanding anemia in pregnant women: A health study from The Gambia

In developing countries like The Gambia, anemia (low blood levels) is a significant health concern for pregnant women. Our study of 425 pregnant women at Sukuta Health Center found that 22% had anemia, which is lower than rates reported in similar regions. While most women (55%) demonstrated good knowledge about anemia, with nurses being their primary source of information, we identified several important patterns. The husband’s occupation was linked to anemia risk, and most women understood the importance of nutritious food for prevention, though fewer than half knew about iron supplements as a preventive measure. Although we found that Muslim women in our study were more likely to have anemia than Christian women, this finding needs further research due to the small number of Christian participants. Our findings suggest the need for improved education about anemia prevention, particularly regarding iron supplementation, and highlight the importance of considering family circumstances and cultural practices when designing prevention programs. Since our study focused on women from one predominantly urban area, more research is needed to understand if these patterns apply across different regions and populations in The Gambia. This research provides valuable insights for healthcare workers and policymakers to better identify and support pregnant women at risk of anemia.

Keywords

anemia pregnancy maternal health knowledge antenatal care

Introduction

Anemia during pregnancy remains a significant global health concern, particularly in developing countries. The World Health Organization (WHO) defines anemia in pregnancy as a hemoglobin concentration below 11.0 g/dL in the first and third trimesters and below 10.5 g/dL in the second trimester.¹ Recent estimates suggest that anemia affects approximately 40% of pregnant women worldwide, with higher prevalence rates in low and middle-income countries.² Anemia is associated with adverse maternal and neonatal outcomes, including an increased risk of maternal mortality, preterm birth, and low birth weight.^3
–6 The etiology of anemia during pregnancy is multifactorial, with iron deficiency being the most common cause globally.⁷ Other contributing factors include deficiencies in folate and vitamin B12, infectious diseases such as malaria and helminth infections, hemoglobinopathies, and chronic conditions.^8,9 The physiological demands of pregnancy further exacerbate preexisting anemia or increase the risk of developing anemia.

Globally, the burden of anemia during pregnancy shows significant regional variations, with South Asia reporting rates of 52%, Africa at 46%, and developed regions at 23%.^10
–12 These disparities reflect complex interactions between socioeconomic factors, healthcare access, and nutritional practices across different regions.^13,14 In developed countries, routine prenatal care and iron supplementation have helped reduce anemia rates, while resource-limited settings continue to struggle with the implementation of similar interventions.^15,16 In sub-Saharan Africa, anemia during pregnancy is particularly prevalent, with significant regional variations. Factors contributing to this high prevalence include nutritional deficiencies, high rates of infectious diseases, and inadequate healthcare services.¹⁷ In The Gambia, a low-income country in West Africa with a population of approximately 2.4 million,¹⁸ anemia in pregnancy remains a pressing public health issue. The country faces challenges related to poverty, food insecurity, and malnutrition, which contribute to the high prevalence of anemia among pregnant women. Recent studies have shown that micronutrient deficiencies, particularly iron deficiency anemia, vitamin A deficiency, and iodine deficiency disorders, are widespread in The Gambia, disproportionately affecting women and children.¹⁹

In The Gambia, anemia in pregnancy remains a persistent public health challenge, with prevalence rates varying significantly across regions. Studies have highlighted anemia rates ranging from 60% to 70% among pregnant women, underscoring its role as a major maternal health concern.¹⁹ Key factors contributing to anemia include traditional dietary practices, limited access to iron-rich foods, and the high burden of malaria, which remains a strong predictor of anemia among pregnant women in malaria-endemic regions like The Gambia.²⁰ Coastal communities face unique challenges, with high rates of anemia paradoxically found in fishing communities despite their proximity to protein-rich seafood.²¹ Additionally, regional disparities in healthcare access and literacy levels influence anemia prevalence, with peri-urban areas like Sukuta presenting a mix of traditional practices and modernizing healthcare systems.²²

Despite national health policies promoting routine iron supplementation and intermittent preventive treatment for malaria during pregnancy, maternal anemia continues to be a significant cause of morbidity and mortality in The Gambia.^19,23,24 The persistence of high anemia rates suggests that current interventions may be insufficient or that there are underlying factors impeding their effectiveness.²⁵ The Sustainable Development Goals (SDGs) highlight critical areas for improvement. Specifically, SDG 2 focuses on zero hunger and aims to reduce anemia among reproductive-age women by 50% by 2030. Additionally, SDG 3 seeks to ensure healthy lives and promote well-being for all ages by lowering the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.²⁶ These goals underscores the significance of addressing anemia during pregnancy.²⁶

Despite the recognized importance of addressing anemia in pregnancy, there remains a critical knowledge gap in understanding how anemia manifests in peri-urban settings, particularly in West Africa. These settings represent unique environments where traditional practices intersect with modernizing healthcare systems, potentially creating distinct risk patterns that differ from both rural and urban areas. This study addresses this knowledge gap by focusing on Sukuta, a peri-urban area in The Gambia, where the interplay between traditional and modern factors may influence anemia prevalence and its determinants in ways that have not been previously documented. Understanding these patterns is crucial for developing targeted interventions that are appropriate for similar peri-urban settings across sub-Saharan Africa. Policy frameworks such as the WHO’s Global Nutrition Targets 2025 and the African Union’s Agenda 2063 also emphasize the need for concerted efforts to combat anemia and improve maternal health.²⁷

In The Gambia, despite national policies promoting iron supplementation and malaria prevention during pregnancy, there is limited recent data on anemia prevalence and its determinants, particularly in peri-urban settings like Sukuta. While previous studies have documented high rates of micronutrient deficiencies in The Gambia, most existing research focuses on either urban centers or rural areas, leaving a knowledge gap regarding peri-urban communities. This study aims to address this gap by determining the current prevalence and predictors of anemia among pregnant women attending Sukuta Health Center, providing essential baseline data for the region. Understanding these patterns is crucial for developing targeted interventions and informing local health policy, particularly given the unique characteristics of peri-urban settings where traditional and modern healthcare practices often intersect.

Methods

Study design and setting

This institutional-based cross-sectional study was conducted at Sukuta Health Center from November 1 to December 30, 2022, in Kombo North District, West Coast Region of The Gambia. This design was chosen to systematically describe and establish the magnitude of anemia during pregnancy and test the study hypotheses. Kombo North District is in Brikama Local Government Areas (LGAs). Brikama has a land size of 1764.2 km² with 355 settlements.²⁸ According to The Gambia Bureau of Statistics, the total population of Brikama LGA is 699,704 and has population distribution by Sex: male 50.2% and female 49.8%. Brikama LGA is predominantly inhabited by people of the Mandinka, Fula, Wollof, Jola, and Serere tribes, with other minor tribes and nationalities.²⁸

Sukuta is a peri-urban area situated approximately 25 km west of Banjul, its capital city. The health center serves as a primary healthcare facility for Sukuta and its surrounding communities. The catchment area of Sukuta Health Center covers more than 15 villages/communities and serves a population of approximately 50,000.²⁸ The area is characterized by a mix of urban and rural settlements, with agriculture and small-scale trading being the primary economic activities. The population is predominantly young, with approximately 40% of patients under the age of 15 years.¹⁸ Health centers provide a range of services, including antenatal care, which is a crucial component of maternal health services in the area. The facility is staffed by trained healthcare professionals including midwives, nurses, laboratory personnel, and community health workers. Catchment areas face challenges related to poverty, limited access to nutritious food, and inadequate health infrastructure. These factors contribute to the health vulnerabilities of the population, particularly in pregnant women who are at a higher risk of anemia and other pregnancy-related complications.²⁵

Measures

Outcome variable

The primary outcome variable in this study was anemia status among pregnant women. Anemia was defined according to WHO criteria for pregnant women: hemoglobin concentration <11 g/dL.¹ After obtaining consent, capillary blood samples were collected and tested for hemoglobin levels with digital hemoglobinometers (HemoCue 201+). The microcuvettes were filled from second and third drops of capillary blood (from middle or ring finger) according to the manufacturer’s guidelines. Internal quality control was run on a daily basis for digital hemoglobinometer and results were recorded on the quality control log sheet. Women were classified as anemic (hemoglobin <11 g/dL) or non-anemic (hemoglobin ⩾11 g/dL).

Covariates

This study considered a comprehensive set of covariates to examine their potential association with anemia status among pregnant women. Sociodemographic factors included age, which was categorized into two groups: 15–37 and 38–60 years. Ethnicity was recorded with major groups being Mandinka, Fula, Wollof, Aku, Jola, Serere, Serehuleh, Manjago, and non-Gambian. Marital status was categorized as married, single, or unmarried. Educational level was assessed across six categories: never to school, Arabic, elementary, junior secondary, senior secondary, and university/college. Religious status was recorded as either Islamic or Christian. The occupational status of both the woman (employed, unemployed, petty trading, gardening, student) and her husband (business, employed, unemployed) was included as a potential economic indicator. The place of residence was classified as either rural or urban. Household characteristics, including the total number of people in the household and the number of under-5 children, were also recorded.

Pregnancy-related factors were considered, with the current gestational age categorized into three trimesters: 1–12, 13–24, and 25–36 weeks. This allowed for the examination of potential variations in anemia status across different stages of pregnancy.

Several factors are included in the assessment of knowledge and awareness. Participants were asked if they had heard of anemia during pregnancy and their sources of information. Their understanding of anemia during pregnancy, as well as whether they had received information on anemia during antenatal care visits. Knowledge of anemia was assessed using a structured questionnaire developed based on WHO guidelines for anemia in pregnancy. Participants’ responses were scored based on key domains: understanding of anemia (4 points), recognition of signs and symptoms (4 points), awareness of risk factors and complications (4 points), and knowledge of prevention methods (4 points). The total possible score was 16 points. Participants scoring ⩾8 points (50% or higher) were categorized as having “good knowledge” while those scoring <8 points were categorized as having “low knowledge.” This tool was adapted with little modification from previous studies^29,30 and has not been formally validated in The Gambian context.

Anemia prevention practices were examined using several variables. These included knowledge of locally available foodstuffs for anemia prevention, awareness of drugs used in anemia prevention and treatment, source of iron tablets, and whether iron tablets were provided for free. These factors allowed for the assessment of both knowledge and access to anemia prevention resources.

Study population and sampling

The target population comprised pregnant women attending antenatal clinics at Sukuta Health Center. Eligible participants were pregnant women aged 15–49 years who consented to participate in this study. Exclusion criteria included recent blood transfusion (within 3 months), diagnosis of chronic renal disease, antepartum hemorrhage, or bleeding disorders, multiple antenatal visits during the data collection period, and mental conditions preventing informed consent or interview participation.

The sample size was calculated using a single population proportion formula³¹:

n = (p (1 - p) \times Z^{2} α) / d^{2}

where n is the minimum sample size, Zα is the standard normal deviation (1.96 for 95% confidence level), p is the estimated prevalence of anemia during pregnancy (55.9% in The Gambia²), and d is the desired degree of accuracy (0.05). The calculated sample size was 381, which increased to 425 to account for potential non-responses and incomplete questionnaires.

Simple random sampling was used to select the participants. Eligible women were assigned codes in Microsoft Excel 2013, and a randomization function was used to select the required sample.

Data collection

A structured questionnaire was adapted based on the research objectives, covering sociodemographic characteristics, knowledge, practices related to anemia in pregnancy, and the prevalence of anemia in similar studies.^32
–34 The questionnaire was pilot-tested at Brufut Health Centre, which serves a population with similar demographic characteristics within the Kombo North District. The pilot test included 43 pregnant women (10% of the target sample size). Reliability was assessed using Cronbach’s alpha test, and items scoring below 0.70 were either revised or removed. The final questionnaire demonstrated good internal consistency with a Cronbach’s alpha of 0.86, which meets the threshold of 0.82 (see supplemental material for more details).³⁵

Statistical analysis

The data were analyzed using IBM SPSS Statistics version 22 by IBM Corporation. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize sociodemographic data and knowledge. The prevalence of anemia was calculated as the percentage of participants with anemia among all study participants. Chi-square analysis was used to determine factors associated with anemia among pregnant women, with statistical significance set at p < 0.05.³⁶ Binary logistic regression analysis was conducted to identify factors independently associated with anemia status. Variables were selected for the model based on their theoretical importance from literature review and statistical significance (p < 0.20) in the bivariate analysis. Based on these, five variables included in the final model: age (continuous), number of under-5 children in household (continuous), gestational age (continuous), religion (categorical), and knowledge level (categorical). Although husband/partner occupation showed significance in bivariate analysis, it was excluded from the final model due to collinearity with number of under-5 children in the household. Signs of anemia in pregnancy, while significant at the group level, were excluded from the model as it was a multiple-response variable that showed no significance at individual item levels. The strength of associations was expressed as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Both unadjusted and adjusted estimates were calculated and presented in Table 5.

Ethical considerations

Ethical approval was obtained from the American International University West Africa Ethics and Research Committee (Ref#: MLP03123/24). Permission was granted by participating in the health facilities. The participants were informed about the study’s purpose, assured of confidentiality, and provided with information sheets and consent forms. Participation was voluntary and data were reported anonymously to ensure privacy and confidentiality. Informed consent to participate in this study was obtained from the parents or legal guardians of any participant under the age of 16 years.

Results

In total, 425 pregnant women participated in this study, with a response rate of 100%. The sociodemographic profile of pregnant women attending Sukuta Health Center revealed a predominantly young population (mean age 28.1 years) with diverse ethnic backgrounds, although Mandinka (44.9%) was the most represented group. The vast majority were married (95.8%), Muslim (97.9%), and residing in urban areas (97.6%). Notably, a significant proportion (40.5%) had never attended formal schooling and unemployment was high (63.3%) among the respondents. Large household sizes (mean 19.4 persons) and a considerable number of young children per household (mean 5.1 under-5 children) are common. Most women were in their first (44.2%) or second (42.8%) trimester of pregnancy (Table 1).

Table 1.

Sociodemographic characteristics of respondents.

Variables	Frequency (n)	Percentage
Age
15–37	267	62.8
38–49	158	37.2
Mean ± SD	28.1 ± 12.9
Ethnicity
Aku	2	0.5
Fula	99	23.3
Jola	31	7.3
Mandinka	191	44.9
Wollof	79	18.6
Sarehuleh	5	1.2
Serere	5	1.2
Manjago	5	1.2
Bambara	3	0.7
Non-Gambian	5	1.2
Marital status
Married	407	95.8
Single	14	3.3
Unmarried	4	0.9
Highest educational level
Never been to school	172	40.5
Primary/Arabic	195	45.9
Secondary and tertiary	58	13.6
Religious status
Christianity	9	2.1
Islam	416	97.9
Occupational status
Employed	23	5.4
Gardening	12	2.8
Petty trading	119	28.0
Student	2	0.5
Unemployed	269	63.3
Occupational status of your husband
Business	166	39.1
Employed	247	58.1
Unemployed	12	2.8
Place of residence
Rural	10	2.4
Urban	415	97.6
Total number of people in your household
1–16	102	24.0
17–32	323	76.0
Mean ± SD	19.4 ± 10.9
Number of under-5 children in your household
1–7	306	72.0
8–14	119	28.0
Mean ± SD	5.1 ± 3.8
Current gestational age (in weeks)
1–12	188	44.2
13–24	182	42.8
25–36	55	12.9
Mean ± SD	14.3 ± 9.1

SD: standard deviation.

The data from Table 2 reveal a mixed picture of knowledge about anemia in pregnancy among respondents. While 58.8% had heard of anemia during pregnancy, with nurses being the primary source of information (97.2%), there were gaps in understanding and awareness. Most respondents (76.7%) correctly associated anemia with a lack of blood; however, misconceptions existed, such as 78.8% incorrectly identifying insomnia as a sign of anemia. Positively, 83.5% recognized that pregnant women are more vulnerable to anemia, and many were aware of serious complications, such as maternal death (64.0%) and premature delivery (61.9%). With regard to prevention, 88.7% acknowledged the importance of a nutritionally sufficient diet, but only 46.9% mentioned iron supplements. While 79.7% identified vegetables as locally available foods for anemia prevention, knowledge of specific drugs for anemia treatment was limited, with only 38.1% being aware of them. However, among those who were aware, 97.5% correctly identified the iron supplements. Importantly, 87.5% of participants reported that iron tablets were provided for free, suggesting good accessibility to this crucial intervention. Overall, while there is basic awareness of anemia in pregnancy, there are significant opportunities for improving comprehensive knowledge and addressing misconceptions through targeted health education.

Table 2.

Knowledge of respondents on anemia in pregnancy.

Variables	Frequency (n)	Percentage
Heard of anemia in pregnancy
No	175	41.2
Yes	250	58.8
Source of information about anemia^a
Radio	62	14.6
Traditional birth attendant	3	0.7
Nurse	412	97.2
Doctor	60	14.2
Understanding of anemia in pregnancy^a
Lack of blood	325	76.7
No blood	136	32.1
Low hemoglobin	204	48.1
Bleeding through vagina during pregnancy	10	2.4
Paleness of the eyes and palms	66	15.6
I don’t know	2	0.5
Received information on anemia in pregnancy during ANC clinic
No	198	46.6
Yes	227	53.4
Speak with a health care worker about anemia in pregnancy during an ANC visit
No	189	44.5
Yes	236	55.5
Signs of anemia in pregnancy^a
Easy tiredness and blackout	69	16.3
Paleness of the eyes and palms	82	19.3
Swelling of face, upper and lower limbs	11	2.6
Lack of sleep (insomnia)	334	78.8
Bilateral stomatitis	38	9.0
Feel sick or ill	228	53.8
Severe vomiting	107	25.2
Dizziness	1	0.2
I don’t know	9	2.1
Pregnant women are more vulnerable to anemia
No	70	16.5
Yes	355	83.5
Risks or complications of anemia in pregnancy^a
Stillbirth	121	28.8
Premature delivery	260	61.9
Low weight baby	190	45.2
Heart diseases	26	6.2
Maternal death	269	64.0
Ways of preventing anemia in pregnancy^a
Eating a nutritionally sufficient diet	376	88.7
Use of multivitamins	124	29.2
Treatment of illness	54	12.7
Malaria prevention	1	0.2
Blood transfusion	21	5.0
Use of iron supplement	199	46.9
Locally available foodstuffs for anemia^a
Vegetables rich in iron and vitamins	338	79.7
Meat	280	66.0
Fish	120	28.3
Nuts	10	2.4
Know about drugs used in anemia prevention and treatment
No	263	61.9
Yes	162	38.1
Drugs used in anemia prevention and treatment^a
Antibiotics	1	0.6
Iron supplements	158	97.5
Multivitamins	22	13.6
Fansidar	35	21.6
Anti-worm medications	1	0.6
Who provides the iron tablets^a
Health worker	404	95.3
Health facility	41	9.7
Buy from the drugstore	13	3.1
Government	43	10.1
Self	33	7.8
Are the iron tablets free?
No	53	12.5
Yes	372	87.5

ANC: antenatal care.

Multiple responses.

Figure 1 shows the overall knowledge level of respondents; 55.3% had a low knowledge level.

Figure 1.

Showing overall knowledge level of pregnant women on anemia in pregnancy.

Figure 2 shows that the overall anemic level of respondents was 21.6%, 5.2% had moderate anemia levels, and 12.2% had severe anemia. The normal/non-anemia level was observed in 78.4% of the study sample.

Figure 2.

Showing the current anemic levels among pregnant women.

The analysis of sociodemographic factors and their association with anemia status among pregnant women attending Sukuta Health Center is reported in Table 3. Analysis of husband’s occupational status revealed a significant association with anemia (p = 0.036). Women whose husbands were engaged in business had the highest prevalence of anemia (26.5%), followed by those whose husbands were employed (19.4%). Interestingly, no anemia cases were observed among women whose husbands were unemployed, though this group comprised only 2.8% of the sample. Other factors, such as women’s age, ethnicity, marital status, educational level, religion, occupation, place of residence, household size, number of young children, and gestational age were not significantly associated with anemia status.

Table 3.

Showing the association between sociodemographic factors and anemic status among pregnant women.

Variable	Anemic	Non-anemic	p-Value
Variable	n (%)	n (%)	p-Value
Age group			0.113
15–37	51 (19.1)	216 (80.9)
38–49	41 (25.9)	117 (74.1)
Ethnicity			0.358
Aku	0 (0.0)	2 (100.0)
Fula	21 (21.2)	78 (78.8)
Jola	5 (16.1)	26 (83.9)
Mandinka	43 (22.5)	148 (77.5\|)
Wollof	14 (17.7)	65 (82.3)
Marital status			0.893
Married	89 (21.9)	318 (78.1)
Single	2 (14.3)	12 (85.7)
Unmarried	1 (25.0)	3 (75.0)
Educational level			0.201
Never been to school	38 (20.1)	134 (77.9)
Primary/Arabic	31 (15.9)	164 (84.1)
Secondary and tertiary	8 (13.8)	50 (86.2)
Religion			0.107
Christianity	4 (44.4)	5 (55.6)
Islam	88 (21.2	328 (78.8)
Occupational status			0.449
Employed	8 (34.8)	15 (65.2)
Gardening	3 (25.0)	9 (75.0)
Petty trading	22 (18.5)	97 (81.5)
Student	0 (0.0)	2 (100.0)
Unemployed	59 (21.9)	210 (78.1)
Husband/partner’s occupation			0.036*
Business	44 (26.5)	122 (73.5)
Employed	48 (19.4)	199 (80.6)
Unemployed	0 (0.0)	12 (100.0)
Place of residence			0.457
Rural	3 (30.0)	7 (70.0)
Urban	89 (21.4)	326 (78.6)
Number of people in your household			1.000
1–16	22 (21.6)	80 (78.4)
17–32	70 (21.7)	253 (78.3)
Number of under-5 children in your household			0.116
1–7	60 (19.6)	246 (80.4)
8–14	32 (26.9)	87 (73.1)
Current gestational age (in weeks)			0.308
1–12	40 (21.3)	148 (78.7)
13–24	44 (24.2)	138 (75.8)
25–36	8 (14.5)	47 (85.5)

Statistical significance at p < 0.05.

Among the various factors examined for their association with anemia status in pregnant women attending SHC, only one factor showed a statistically significant relationship: signs of anemia in pregnancy (p < 0.001), as shown in Table 4. This suggests that women’s awareness or experience of anemia symptoms is strongly associated with their anemia status. Interestingly, all other factors, including knowledge about anemia, sources of information, understanding of anemia, receipt of anemia information during antenatal care visits, awareness of risks and complications, knowledge of prevention methods, awareness of locally available nutritious foods, knowledge about anemia drugs, and access to iron tablets did not show statistically significant associations with anemia status (all p > 0.05).

Table 4.

Showing the association between selected factors with anemic status among pregnant women in Sukuta Health Center.

Variable	Anemic	Non-anemic	p-Value
Variable	n (%)	n (%)	p-Value
Heard of anemia in pregnancy			0.403
No	34 (19.4)	141 (80.6)
Yes	58 (23.2)	192 (76.8)
Source of information about anemia^a			0.323
Radio	14 (22.6)	48 (77.4)
Traditional birth attendant	2 (66.7)	1 (33.3)
Nurse	90 (21.8)	322 (78.2)
Doctor	13 (21.7)	47 (78.3)
Understanding of anemia in pregnancy^a			0.698
Lack of blood	67 (20.6)	258 (79.4)
No blood	32 (23.5)	104 (76.5)
Low Hb	47 (23.0)	157 (77.0)
Bleeding through vagina during pregnancy	1 (10.0)	9 (90.0)
Paleness of the eyes and palms	11 (16.7)	55 (83.3)
I don’t know	0 (0.0)	2 (100.0)
During your last ANC visit, do you receive information about anemia			0.409
No	39 (19.7)	159 (80.3)
Yes	53 (23.3)	174 (76.7)
During your last ANC visit, do you speak with HCW about anemia			0.637
No	43 (22.8)	146 (77.2)
Yes	49 (20.8)	187 (79.2)
Signs of anemia in pregnancy^a			<0.001*
Easy tiredness and blackout	76 (21.4)	54 (78.3)
Paleness of the eyes and palms	15 (18.3)	67 (81.7)
Swelling of face, upper and lower limbs	3 (27.3)	8 (72.7)
Lack of sleep (insomnia)	73 (21.9)	73 (21.9)
Bilateral stomatitis	4 (10.5)	34 (89.5)
Feel sick or ill	46 (20.2)	182 (79.8)
Severe vomiting	19 (17.8)	88 (82.2)
Dizziness	0 (0.0)	1 (100.0)
I don’t know	3 (33.3)	6 (66.7)
Pregnant women are more vulnerable to anemia			0.427
No	18 (25.7)	52 (74.3)
Yes	74 (20.8)	281 (79.2)
Risks or complications of anemia in pregnancy^a			0.627
Stillbirth	19 (15.7)	102 (84.3)
Premature delivery	55 (21.2)	205 (78.8)
Low weight baby	41 (21.6)	149 (78.4)
Heart diseases	5 (19.2)	21 (80.8)
Maternal death	61 (22.7)	208 (77.3)
Prevention of anemia in pregnancy^a			0.867
Eating nutritionally sufficient diets	86 (22.9)	290 (77.1)
Use of multivitamins	28 (22.6)	96 (77.4)
Treatment of illness	14 (25.9)	40 (74.1)
Malaria prevention	0 (0.0)	1 (100.0)
Blood transfusion	3 (14.3)	18 (85.7)
Use of iron supplement	41 (20.6)	158 (79.4)
Locally available foodstuffs for anemia treatment/prevention^a			0.997
Vegetables rich in iron and vitamins	73 (21.6)	265 (78.4)
Meat	59 (21.1)	221 (78.9)
Fish	25 (20.8)	95 (79.2)
Nuts	2 (20.0)	8 (80.0)
Do you know about drugs used in anemia prevention and treatment			0.335
No	61 (23.2)	202 (76.8)
Yes	31 (19.1)	131 (80.9)
If yes, those drugs/supplements that treat/prevent anemia^a			0.774
Antibiotics	0 (0.0)	1 (100.0)
Iron supplements	31 (19.6)	127 (80.4)
Fansidar	8 (22.9)	27 (77.1)
Anti-worm medications	0 (0.0)	1 (100.0)
Who provides you with iron tablets^a			0.764
Health worker	87 (21.5)	317 (78.5)
Buy from the drugstore	4 (30.8)	9 (69.2)
Government	10 (23.3)	33 (76.7)
Self	8 (24.2)	25 (75.8)
Were the iron tablets free			0.375
No	14 (26.4)	39 (73.6)
Yes	78 (21.0)	294 (79.0)

Hb: hemoglobin; ANC: antenatal care.

Multiple responses.

Statistical significance at p < 0.05.

As shown in Table 5, religious affiliation showed a statistical association with anemia risk (aOR = 4.295, 95% CI: 1.103–16.727), with Muslim women showing higher odds of anemia compared to Christian women. However, this finding should be interpreted with caution due to the small number of Christian participants (2.1% of the sample) and potential unmeasured confounding factors. Other factors, such as age, number of young children, gestational age, and knowledge level, were not significantly associated with anemia.

Table 5.

Logistic regression on factors associated with anemia in pregnancy.

Variable	95% CI for cOR			95% CI for aOR
Variable	cOR	Lower bound	Upper bound	aOR	Lower bound	Upper bound
Age of women	1.023	0.987	1.062	1.004	0.949	1.062
Number of under-5 children in household	0.993	0.971	1.016	1.083	0.979	1.197
Gestational age	0.995	0.968	1.023	0.991	0.963	1.02
Religion (Ref: Christian)	1			1
Islam	3.759	0.985	14.339	4.295*	1.103	16.727
Knowledge (Ref: Low)	1			1
High	1.038	0.632	1.704	1.351	0.775	2.355

Hb level “Anemic = 1”. cOR: crude odds ratio; aOR: adjusted odds ratio; CI: confidence interval; Hb: hemoglobin.

Statistical significance at p < 0.05.

Discussion

Our study found that the prevalence of anemia among pregnant women was 21.6%, which is notably lower than rates reported in other West African countries. For instance, recent studies have reported anemia prevalence of 52.2% in Ghana,³⁷ 55.8% in Nigeria,³⁸ and 54.4% in Burkina Faso.³⁹ The lower prevalence in our study population could be attributed to several factors including the urban setting of our study site, where access to healthcare services and nutritional resources may be better than in rural areas. Similar to our findings, studies from Ghana and Nigeria have also identified husband’s occupation as a significant predictor of anemia, highlighting the importance of household socioeconomic factors in determining maternal health outcomes across West Africa.^37,38 The significant difference in prevalence rates could be attributed to several factors. The quality of consultation, distribution of primary health services, accessibility to maternal health services, maternal dietary intake, and the ratio of clients to nurses could all contribute to these disparities.^40
–43

The sociodemographic characteristics of the study population elucidate several salient factors that may influence the risk of anemia. The majority of participants were young (mean age 28.1 years), married, and Muslim, with a substantial proportion lacking formal education and being unemployed. These characteristics are consistent with other studies in sub-Saharan Africa, where early marriage and limited educational opportunities for women are common.¹⁷ Our study found that husband’s occupational type was significantly associated with anemia risk, with the highest prevalence observed among women whose husbands were involved in business (26.5%). This finding suggests that the nature of husband’s occupation, rather than simply employment status, may influence anemia risk. However, these results should be interpreted cautiously given the uneven distribution across occupational categories and the particularly small number of unemployed husbands/parters (2.8%). The relationship between husband’s occupation and anemia risk may reflect underlying socioeconomic factors, including household income stability, access to nutritious food, and healthcare utilization patterns. Similar results have been reported in studies from other developing countries, where husbands’ employment and income levels were found to be significant predictors of maternal anemia.⁴⁴ This association could be attributed to better access to nutritious food and healthcare services in households with employed or business-owned husbands/partners. The lack of significant associations between other sociodemographic factors and anemia status is noteworthy. Factors such as women’s age, education level, and occupation, which have been identified as predictors of anemia in other studies,³⁴ did not show significant relationships in our study. This discrepancy may be due to the relatively homogeneous nature of our study population or the presence of other overriding factors specific to The Gambian context.

The observed higher likelihood of anemia among Muslim pregnant women in this study may be linked to sociocultural and household dynamics specific to The Gambia. Polygamous families, common in Muslim communities, tend to have larger household sizes, which can stretch financial and nutritional resources, leading to inadequate dietary intake and a higher risk of anemia.^45,46 In contrast, Christian families in The Gambia are more often nuclear and report higher educational attainment among both women and their partners, which enhances health literacy and practices surrounding antenatal care and nutrition.⁴⁷ While our analysis showed an association between religious affiliation and anemia risk, this finding requires careful interpretation. The small proportion of Christian women in our sample (2.1%) limits the robustness of this comparison and may not be representative of the broader Christian population in The Gambia. Additionally, this observed association may be confounded by unmeasured socioeconomic factors, educational differences, dietary patterns, and other cultural practices that vary between religious groups. Further research with more balanced religious representation and detailed assessment of potential confounders would be needed to better understand any true relationship between religious affiliation and anemia risk in this population.

The findings of this study indicate a moderate level of awareness regarding anemia in pregnancy, with 58.8% of the respondents reporting familiarity with the condition. However, this awareness did not translate with a comprehensive understanding of anemia or its preventive measures. The finding that nurses were the primary source of information about anemia (97.2%) highlights the crucial role of health care providers in health education. However, the persistence of misconceptions, such as identifying insomnia as a sign of anemia (78.8%), suggests that the quality and effectiveness of health education require improvement. The significant association between recognizing signs of anemia and anemia status (p < 0.001) was a key finding of this study. This suggests that women who can identify anemia symptoms may be more likely to seek medical attention or implement preventive measures as highlighted in other studies.^11,48 However, the overall low level of knowledge about anemia prevention and treatment indicates a need for more effective health education strategies. These findings differ from those of previous studies that revealed that two-thirds of their study subjects knew little about anemia during pregnancy.^49
–51

While a high proportion of women (88.7%) recognized the importance of a nutritious diet in preventing anemia, fewer (46.9%) mentioned iron supplementation as a preventive measure. The discrepancy between dietary knowledge and awareness of medical interventions suggests a potential gap in antenatal care education. The high rate of free iron tablet provision (87.5%) indicates good accessibility to this crucial intervention; however, the effectiveness of its utilization requires further investigation. The lack of significant associations between knowledge of anemia prevention methods and anemia status raises questions about the translation of knowledge into practice. This finding aligns with studies from other developing countries that have reported a gap between knowledge and practice of maternal health behaviors.⁵²

Implications for public health practice

The findings of this study have several implications for public health practice in The Gambia and similar settings:

Targeted interventions: Given the significant association between husbands’ occupation and anemia status, interventions should consider the household economic context. Programs that combine nutritional support with economic empowerment may be more effective in reducing anemia prevalence.

Improved health education: While awareness of anemia is moderate, there is a need for more comprehensive and effective education regarding its causes, symptoms, and prevention. Strategies should focus on correcting misconceptions and emphasizing the importance of iron supplementation along with dietary measures.

Symptom recognition: The strong association between recognizing anemia symptoms and anemia status suggests that empowering women to identify and respond to these symptoms could be an effective strategy in anemia management.

Holistic approach: The complex interplay of factors associated with anemia calls for a holistic approach that addresses not only medical interventions but also the social and economic determinants of health.

Limitations and future research

The cross-sectional design limits our ability to establish causal relationships. Furthermore, while our study was conducted at Sukuta Health Center, which serves a population of approximately 50,000 in Kombo North District, our findings may not be fully representative of the broader Gambian population. Our sample consisted predominantly of urban residents (97.6%) and Muslim women (97.9%), which may not reflect the demographic diversity of other regions in The Gambia. Additionally, as our study only included women who attended antenatal care services, we may have missed the most vulnerable women who do not access formal healthcare services. These factors limit the generalizability of our findings to rural areas, other religious groups, and women who do not engage with the healthcare system.

The knowledge assessment tool used in this study was not formally validated for The Gambian context, which could raise potential contextual variations, validity, and reliability issues. Another key limitation was the lack of data on participants’ iron-folic acid supplementation usage, which is a primary intervention for preventing maternal anemia. While we collected information about awareness of iron supplementation, we did not gather data on actual supplement use, adherence patterns, or duration of supplementation. We were unable to determine the specific types of anemia (iron deficiency, folate deficiency, or other causes) as we did not collect data on serum ferritin, folate levels, or other biomarkers. Future research should consider longitudinal designs to better understand the temporal relationships between various factors and anemia status. Moreover, qualitative studies could provide deeper insights into the cultural and social factors influencing anemia during pregnancy in this context.

Conclusion

This study provides valuable insights into the prevalence of and factors associated with anemia among pregnant women in Sukuta, The Gambia. The findings highlight the complex interplay of socioeconomic factors, knowledge, and practices in determining anemia status. While awareness of anemia is moderate, there are significant gaps in the comprehensive understanding and prevention practices. The strong association between symptom recognition and anemia, coupled with the influence of household economic factors, suggests the need for targeted, holistic interventions that go beyond traditional health education approaches. This study indicates that more culturally specific interventions might be necessary, particularly those targeting religious groups that show a higher risk of anemia. These findings can inform the development of more effective strategies to combat anemia in pregnancy, ultimately contributing to improved maternal and child health outcomes in The Gambia and similar settings.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251338380 – Supplemental material for Prevalence and determinants of anemia among pregnant women attending maternal and child health clinics at Sukuta Health Center, The Gambia: An institutional-based cross-sectional study

Supplemental material, sj-docx-1-whe-10.1177_17455057251338380 for Prevalence and determinants of anemia among pregnant women attending maternal and child health clinics at Sukuta Health Center, The Gambia: An institutional-based cross-sectional study by Fatou Mbowe, Kalifa Sanneh Darboe, Abdoulie M. Sanyang and Amadou Barrow in Women’s Health

Footnotes

Acknowledgements

The authors would like to express their gratitude to the study participants for their willingness and participation throughout the study.

ORCID iD

Amadou Barrow

Ethical considerations

The study protocol was reviewed and granted ethical clearance by the American International University West Africa Ethics and Research Committee (Ref#: MLP03123/24). All procedures were conducted in adherence to relevant guidelines and regulations.

Consent to participate

Participation in the study was completely voluntary, and only individuals who provided their consent were recruited. Each participant who agreed to take part in the study signed a written informed consent form. Informed consent to participate in this study was obtained from the parents or legal guardians of any participant under the age of 16 year.

Author contributions

Fatou Mbowe: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Validation; Visualization; Writing – original draft; Writing – review & editing.

Kalifa Sanneh Darboe: Conceptualization; Formal analysis; Methodology; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Abdoulie M. Sanyang: Conceptualization; Formal analysis; Investigation; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Amadou Barrow: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data used to support the findings of this study are available from the corresponding author.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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Prevalence and determinants of anemia among pregnant women attending maternal and child health clinics at Sukuta Health Center,The Gambia: An institutional-based cross-sectional study

Abstract

Background:

Methods:

Results:

Conclusion:

Plain language summary

Keywords

Introduction

Methods

Study design and setting

Measures

Outcome variable

Covariates

Study population and sampling

Data collection

Statistical analysis

Ethical considerations

Results

Discussion

Implications for public health practice

Limitations and future research

Conclusion

Supplemental Material

sj-docx-1-whe-10.1177_17455057251338380 – Supplemental material for Prevalence and determinants of anemia among pregnant women attending maternal and child health clinics at Sukuta Health Center, The Gambia: An institutional-based cross-sectional study

Footnotes

Acknowledgements

ORCID iD

Ethical considerations

Consent to participate

Author contributions

Funding

Declaration of conflicting interests

Data availability statement

Supplemental material

References

Supplementary Material