Anaemia is the most common medical related disorder during pregnancy, and has become a major health related problem in a large number of developing nations, mainly where deficiency in nutrition, worm infestation and malaria are common. Both pregnant and non- pregnant women are affected by this disorder. Even so, most women lack adequate knowledge regarding causes of anaemia in pregnancy as the most commonly cited cause is inadequate iron. This study sought to determine Dietary management of anemia among pregnant women in Koko/Besse referral Hospital. The study adopted a descriptive cross sectional research design. The study targeted a population constituting of pregnant women aged 15-49 years in Koko/Besse Referral Hospital. At the time of the study, the hospital had an estimated number of 3651 pregnant women, and these formed the target population for the study. The study adopted simple random sampling and convenience sampling techniques. The study used a questionnaire to collect primary data. Data analysis was carried out using SPSS Version 22.0. The analyzed data was then presented in frequencies, cross tabulations and tables, which were accompanied by appropriate descriptions in line with the objectives. The study findings showed that most of the respondent were in their second or other pregnancies as they had been pregnant before [205, 65.7%] compared to those in their first pregnancy [107, 34.3%] (p =0.000). While on the stage of their pregnancies, slightly more than half [161, 51.6%] were in their second trimester compared to 25.3% in their first trimester (p >0.05). Half of the respondents indicated that they had two pregnancies, 80(25.6%) had three pregnancies. That majority (68.9%) of the respondents were not aware of iron (p value <0.05) and further that 44.2% of the respondents knew the sources of iron compared to 55.8 who neither knew or not sure on the sources (P value >0.05). Majority (199, 63.8%) faced challenges to access and availability of iron rich foods. Most women (249, 20.2%) were aware of Vitamin A, further 96.2% were not aware of the various sources of Vitamin A, and these responses were significant at 5%. Majority 46.2% and 42.3% took foods rich in Vitamin A on weekly and daily basis. The study recommends that there should be interventional measures to educate mothers and initiate importance of iron folic acid supplements as this would be vital in prevention of Anaemia during pregnancy.

1.1 Background to the Study
Anaemia is amongst the world’s most prevalent problems in health (Findley, 2020). Research has shown that the problem has affected approximately two billion people in the world, which translates to a third of the population in the world, hence; it has become an important problem in public health. In almost every developing nation, between a third and a half of children and female population has been referred as anaemic. Anaemia has as well been regarded as the most common medical related disorder during pregnancy, particularly in developing nations, where nutritional deficiency conditions like malaria and worm infestation are common. The condition mostly affects both pregnant and non-pregnant women (Ferreira et al., 2017).

Chronic anaemia, particularly when concomitant with chronic deficiencies of micronutrients can have major effects on children and women, and can as well affect the attendance of children to school, performance as well as physical work (Ikunaiye et al., 2018). Iron deficiency has become a rampant nutritional health deficiency condition, which has become a burden among people and governments in the global context. Nutritional related anaemia is the most rampant type of anaemia globally. It is caused by iron; folate and vitamin B12 insufficiencies (Khadija, 2016). Causes of anaemia are inclusive of nutritional deficiencies, genetic factors, and infectious agents. Therefore; deficiency of iron is perhaps the greatest and significant due to physiological changes related to pregnancy, that lead to a demand for extra iron that is required for foetus transfer (James et al., 2019).

The World Health Organization (WHO) projected that in countries that are developing; the rates of prevalence in expectant women usually range from 40% to 60%. Most people with anaemia suffer from deficiency of iron. Deficiencies in folate and other reasons usually account for a large percentage of other types of anaemia (Bekele et al, 2016). Maternal anaemia during pregnancy is normally taken to be a risk factor relating to pregnancy outcomes that are poor and could lead to problems threatening the lives of foetus and mother. Present knowledge shows deficiency in iron during the pregnancy period as a risk factor for miscarriage succeeding low birth weights and probable sub-standard neonatal health. The importance of this is to have information to adopt a positive attitude and practices in nutrition; most causes of anaemia are nutrition related (Ferreira et al., 2017).

A previous study done in India found that lower knowledge and attitude about anaemia during pregnancy increases risk in about five times (Thakur et al., 2020). This accelerates and worsens during pregnancy increasing the anaemia risk to about six times. Some of the possible risk aspects that were shown to increase anaemia were knowledge and attitudes regarding the anaemic condition in pregnant women (Schieve et al., 2014). Infections that include hookworm, malaria and other helminths also take part in anaemia pathogenesis during pregnancy. Expectant women are more susceptible to Malaria infections in endemic populations and this places them at a higher risk of anaemia. Anaemia may increase the prevalence of postpartum haemorrhage and predispose to puerperal infection. In developing countries, the two conditions are the leading factors of death in pregnant women. Lack of a balanced diet, especially insufficient intake of fruits, vegetables and animal sourced foods are the major causes of iron deficiency and poor birth outcomes (Semba et al., 2008).

Diets among low-income societies majorly comprise of legumes and cereals, which are slightly lower in iron. These foods are a source of non-heme iron. This type of iron is slightly complex and difficult to be absorbed in the human body (Bekele et al, 2016). The heme iron is absorbed two to three times better than the non heme iron. In addition, little amounts of heme iron necessitate the absorption of non-heme iron. These diets are common among pregnant women and a major determinant of the iron capacity that is absorbed in their bodies. The legumes and the whole grains contain phytic acid, which form insoluble compounds that prevent iron absorption hence deficiency in iron, which results into anaemia (Ferreira et al., 2017).

Majority of women have inadequate knowledge on causes of anaemia during pregnancy and most mothers are aware of the fact that inadequate iron containing diet as the cause of anaemia (Thakur et al., 2020). Regarding the knowledge on sources of rich iron containing foods, most of the women in ASAL regions and in slum regions are characterized with low socioeconomic status are not aware of the that green leafy vegetables, meat, fish, egg are good sources of iron (Weldekidan et al., 2018). Most women in the ASAL regions have no access to fresh supply of green vegetables and heavily rely on meat for iron. Coupled by their inadequate knowledge of proper and adequate nutrition, this has increased their risk of developing anaemia. However, early detection and effective management of anaemia can contribute substantially to reduction in maternal mortality. The rolling out of nutrition education on consumption of healthy foods during pregnancy and strengthening supplementation of iron and folate in pregnant women will ultimately reduce mortality of anaemia and other micronutrient, low birth weight among women (Renzi et al., 2016).

Inadequate knowledge concerning causes of anaemia in pregnancy is a common phenomenon among women. Additionally, they have little or no knowledge regarding iron rich diet; this remains the main cause of anaemia (Bekele et al, 2016). Most of the women living in ASAL and slum regions are characterized with low socioeconomic status and are not aware of iron rich sources of food such as eggs, meat, fish and green leafy vegetables. Most women in the ASAL regions have no access to fresh supply of green vegetables and heavily rely on meat for iron (Renzi et al., 2016). Coupled by their inadequate knowledge of proper and adequate nutrition have increased their risk of developing anaemia. However, early diagnosis and effective management of anaemia can contribute significantly to reduction in maternal mortality. Nutrition education and sensitization of balanced healthy diet before and during pregnancy as well as supplementing pregnant women with iron and folate help reduce mortality related anaemia, micronutrient and low birth weight in women (Semba et al., 2008).

A number of demographic, social economic factors have been closely associated with nutritional diet practice and diversity that many pregnant women adopt. They include occupation, age, level of education, income generated and their marital status (Price et al., 2020). Measuring the impact of national guidelines: what methods can be used to uncover time-varying. Level of education has closely been linked to the choice of diet and eating habits of the pregnant women. Patterns in dietary intake are closely determined by occupation, parity, level of education and age. An increased maternal age and high maternal education are often associated with a healthy and a diversified diet in pregnant women. Women with less education and are not working record a higher parity and are likely to indulge in unhealthy and less diversified diets (Ganapathy & Nieves, 2020).

1.2 Statement of the Problem
Globally, deficiency of iron is the leading cause of anaemia in women during pregnancy. Anaemia prevalence in Nigeria is moderately high and pregnant women have a poor nutritional status and anaemic (Abdo et al., 2019). On attendance of antenatal clinics, pregnant women are administered with iron supplements. However, the struggle to fully eradicate anaemia continues to be really high as well as foetal morbidity and maternal mortality in Nigeria due to low knowledge of anaemia and type of foods they consume (World Health Organization [WHO] & Centre for Disease Control [CDC], 2015). Many households in Koko/Besse Local government Area are vulnerable to food and nutrition insufficiency, poverty, illiteracy and drought have led to minimal access to essential services to the majority of the inhabitants of the County. The anaemia related problems are accelerated by factors such as difficulties in the access of quality maternal health services, which include antenatal services, delivery services and post-natal services. Moreover, marginalization, poor health care, lack of transparency and accountability, negative cultural and religious practices are other factors affecting efforts put in place to curb anaemia (Renzi et al., 2016).

A pregnant woman suffering from anaemia is likely to experience problems during pregnancy and can result to serious complications to the mother and the foetus. Deficiency in iron leads to preterm deliveries, inferior neonatal health and low birth weights (Findley, 2020). In Nigeria, the prevalence of anaemia is about 54% whereas 70% of pregnant women in the country suffer from anaemia. This creates the need to evaluate the factor associated causes of anaemia in pregnant women and their knowledge about good diet intake (Khadija, 2016). Most of the studies done in Nigeria have sought to evaluate the extent of anaemia and none has been done to and did not ascertain the KAP on anaemia among women. A study by Khadija (2016) carried out in Kakamega established prevalence of anaemia in pregnancy at 25.7%. Sawe et al. (2015) conducted a study in Kericho District and established a prevalence of anaemia during pregnancy at 24.5%. Currently, there is no study, which has been done to evaluate the knowledge and practices of nutritional causes of anaemia among women in northern part of Nigeria. Therefore, this study will seek to determine the Dietary management of anemia among pregnant women attending Koko/Besse Referral Hospital in Koko/Besse Local government Area.

1.3 The Purpose of Study
The study was aimed at identifying factors associated causes of anaemia in pregnant women in Koko/Besse Local government Area. The study seeks to help the health workers to improve on service delivery to prevent the cause anaemia in pregnant women and to provide awareness towards anaemia and look for ways of intervention.

1.4 Objectives of the Study
1.4.1 Main Objective
To examine the Dietary management of anemia among pregnant women, a case of Koko/Besse Local government Area Referral Hospital.

1.4.2 Specific Objectives
i. To determine the socio demographic characteristics of pregnant women attending Koko/Besse Local government Area Referral Hospital.

ii. To determine the intake of dietary iron among pregnant women attending Koko/Besse Local government Area Referral Hospital.

iii. To examine the intake of dietary folate among pregnant women attending Koko/Besse Local government Area Referral Hospital.

iv. To examine the intake of dietary vitamin A among pregnant women attending Koko/Besse Local government Area Referral Hospital.

1.5 Research Questions
i. What are the socio demographic characteristics of pregnant women attending Koko/Besse Local government Area Referral Hospital.?

ii. What is the intake iron among pregnant women attending Koko/Besse Local government Area Referral Hospital?

iii. What is the intake folate among pregnant women attending Koko/Besse Local government Area Referral Hospital.?

iv. What is of intake of Vitamin A among pregnant women attending Koko/Besse Local government Area Referral Hospital?

1.6 Limitation of the study
The study was majorly focusing on pregnant women attending Koko/Besse Referral Hospital. The study foresaw challenges during data collection due to the security reasons that have affected the region. The region is also characterized by high illiteracy rates among women and this posed challenges in data collection.

1.7 Delimitation of the study
To overcome the challenges, the researcher used research assistants who administered the questionnaire using the local dialect to overcome the language and illiteracy barrier. The data collected was collected at the healthcare facility where security was provided.

1.8 Significance of the Study
The study findings will be important to various stakeholders. It will provide the common causes of anaemia such as parasitic infestations such as malaria and hookworm, the predisposing factors, age, low socioeconomic status and illiteracy, which were critical in anaemia preventions, the knowledge level in nutritional causes of anaemia in pregnant women. Alternatively, the study will avail key information to other researchers and academicians by providing the KAP on the nutritional causes of anaemia in Nigeria. This is because few studies have been carried out in Koko/Besse Referral County Hospital and this will improve the information to the researchers and the government, which has been advocating and providing free iron supplementation to the pregnant women in Nigeria.

The study may provide key information to the mothers on the need of iron supplementation before and during their pregnancy period as well as the sources of folate and iron. This would contribute to their overall wellbeing through intake of adequate iron and folic nutrients. This may help the residents to observe healthy living to reduce the disease burden among pregnant women through their knowledge.

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