Anemia

Anemia, one of the more common blood disorders, occurs when the number of healthy red blood
cells decreases in the body. The disc-shaped red blood cells contain hemoglobin, a unique molecule
that carries oxygen to the body's tissues.

Anemia occurs for different reasons. These include:

increased destruction (break down) of red blood cells (RBCs)
increased blood loss from the body
inadequate production of red blood cells by the bone marrow

In some cases anemia results from an inherited disorder, whereas in other cases the
condition is caused by something in a person's environment, such as a nutritional problem,
infection, or exposure to a drug or toxin.

Anemia Caused by Blood Loss

Blood loss can also cause anemia - whether it's because of excessive
bleeding due to injury, surgery, or a problem with the blood's clotting mechanism. Slower, longterm blood loss, such as intestinal bleeding due to inflammatory bowel disease, can also cause
anemia. Anemia can also result from heavy menstrual periods in teen girls and women. Any of
these factors will also increase the body's need for iron because iron is needed to make new red
blood cells.

Anemia Caused by Inadequate RBC Production

Infants are born with high levels of hemoglobin and RBCs in their blood. This occurs in the fetus to
help fetal blood carry enough oxygen while the developing baby is in the relatively oxygen-poor
environment inside the uterus. After birth, when more oxygen is available, the baby's hemoglobin
level normally drops to a low point at about 2 months of age, a condition known as physiologic.
anemia of infancy. After this occurs, the infant's body gets the signal to increase RBC production.
This temporary and expected drop in the blood count is considered normal and no treatment is
needed.
Anemia also occurs when the body isn't able to produce enough healthy red blood cells. This can
happen because of a deficiency of iron or certain other substances in the body or from inherited
defects or diseases that interfere with the production of red blood cells.
Iron is essential for the production of hemoglobin in red blood cells. Poor dietary iron intake (or
excessive loss of iron from the body) leads to iron-deficiency anemia, the most common cause of
anemia in children. Iron-deficiency anemia can affect children at any age, but it is most commonly
seen in children less than 2 years of age, and in teens, particularly in adolescent girls who have
started menstruating.

Signs and Symptoms of Anemia

The most common sign of iron deficiency and other types of nutritional anemia is mild paleness of
the skin, along with decreased pinkness of the lips, the lining of the eyelids, and the nail beds. A
friend or relative who sees your child only occasionally may be more likely to notice this than you
because the changes usually happen so gradually.
Other common signs of anemia may include:

Irritability
Fatigue
Dizziness, lightheadedness, and a rapid heartbeat

Depending on the condition causing the anemia, other signs and symptoms may occur, such as
jaundice (yellow-tinged skin), dark tea colored urine, easy bruising or bleeding, and enlargement of
the spleen or liver.
In infants and preschool children, iron-deficiency anemia can result in developmental delays and
behavioral disturbances, such as decreased motor activity and problems with social interaction and
attention to tasks.

Diagnosing Anemia
A complete blood count (CBC) may indicate that there are fewer red blood cells than normal. Other
diagnostic tests may include:

Blood smear examination: Microscopic examination of red blood cells after blood is
smeared on a glass slide can sometimes indicate the cause of the anemia.
Iron tests: These include total serum Iron and ferritin tests, which can help to determine
whether anemia is due to iron deficiency.
Hemoglobin electrophoresis: This test identifies various abnormal hemoglobin in the
blood and is used to diagnose sickle cell anemia and the thalassemias.
Bone marrow aspiration and biopsy: This test can help determine whether cell production
is happening normally in the bone marrow. It's the only way to diagnose aplastic anemia
definitively and is also used if it is suspected that a disease affecting the bone marrow (such
as leukemia) could be the cause for the anemia.

Treating Anemia

Treatment for anemia depends on the cause of the condition. It's important not to assume that any
symptoms your child may be having are due to iron deficiency. Be sure to have her checked by a
doctor, and don't attempt to treat her yourself before doing so;
If your child does have iron-deficiency anemia, the doctor may prescribe medication in the
form of drops (for infants) or a liquid or tablet form (for older children). The doctor also
may recommend adding certain iron-rich foods to your child's diet.
If you're teenage daughter is anemic and has heavy or irregular menstrual periods, in some
cases her doctor may prescribe a birth control pill to help regulate the bleeding.
Folic acid and vitamin B12 supplements may be prescribed if the anemia is traced back to a
deficiency of these nutrients.
If a certain medication appears to be the cause, your child's doctor may discontinue it or
replace it with something else - unless the benefit of the drug outweighs this side effect.
If an infection is the cause, the anemia will usually get better when the infection passes on
its own or it is cured by treatment.
Treatment for more severe or chronic forms of anemia may include (depending on the
cause):
transfusions of normal red blood cells taken from a donor.
removal of the spleen or treatment with medications to prevent blood cells from
being removed from the circulation or destroyed too rapidly.
medications to fight infection or stimulate the bone marrow to make more blood
-cells.

Antenatal care:

Antenatal care, is consider as very important aspect in primary health care sector In year 2000 ,
the total number of pregnant women has been reported in governmental Sector in Palestine are 26,
903, out of which 11,301 in Gaza strip with percentage 42% from the total pregnant women the
PCBs reported that about 95.6% of pregnant women receive antenatal care from skilled personnel
and about 95.2% of pregnant women receive antenatal care from completed three visits and over
during their recent pregnancy.
Rimal clinic: it includes many health facilities, one of them, central clinic providing MST and
ANC services, about 585 pregnant women attend the clinic for ANC Services monthly, (Annual
Report PRC Directorate).
Antenatal care: is deigned as the care that is given to the expectant mother for the Time of
conception until begging of labor, it aims to provide appropriate support to the pregnant women,
early detection and prevention of abnormalities associated with pregnancy.

Women's health indicator

1.
The maternal mortality rate "MMR":
MMR is one of the most important indicators to determine the health status for Women, MMR in
Gaza strip in 1998 at 42 per 100, and 000 live births among women Aged 15- 49 years
2. Total fertility rate:
Total fertility rate in Palestine is one of the highest rates in the world, in
year 2000 a Cording to M.O.H and PCBs. The total fertility rate in
Palestine is 4.31 (5.4 in Gaza Strip and 3.8 in West Bank)
3.Crude birth rate (CBR):
CBR is the number of live births per 1000 population per year. It is still high in Palestine compared
to other counties CBR declined from 46.5/ 1000 in year 2000

Anemia: refers to condition in which hemoglobin content of the blood is lower than Normal as
result of deficiency of one or more essential nutrients usually iron, less Frequently folate and
vitamin B 12, anemia is a common and serious problem in Pregnancy , prevention of anemia at the
time of delivery is one of the major goals of Antenatal care, in Gaza with high prevalence of
anemia, all pregnant women should Receive the standard prophylactic dose of iron /folate, starting
early in pregnancy The prevalence of anemia among pregnant women is significantly high and it is
Estimate about 55% in year 2000. The prevalence of anemia among refugee woman Is 44% in
Gaza strip and28%in West Bank despite the iron supplementation policy Etiology of anemia:
diminishing of iron stores results from an imbalance between iron absorption and the boys need, the
demand is increased in case of childbirth, blood loss related to menses.

Goal: Assess factors associated with compliance of iron supplementation among pregnant women
at Rimal clinic, for providing reliable information that help in planning to improve quality of
antenatal care at Rimal clinic.

Objectives:
1. To assess the level of adherence to iron supplementation among pregnant women in Rimal clinic
as prevention measures to control anemia.
2. To identify problems with iron supplement supply and prescription.
3. To examine the procedure of providing the iron supplementation at Rimal clinic.
4. To suggest measures for improving compliance with Iron supplementation in pregnancy.

Causes of iron deficiency anemia at Rimal clinic -Gaza strip:

1. Low compliance due to side effect forgetfulness, wrong beliefs, low knowledge & attitudes
2. Low total iron in take due to socioeconomic factors.
3. Low antenatal care coverage not all woman attends antenatal clinics.
4. Low coverage with supplement, lack of iron tab due to closure or donation system.
5. Lack of convenience of health workers, poor health education from care provide nurses,
physicians, pharmacist.
6. Low bioavailability of Iron Tab.

The team Investigates and Assessed the Compliance Rate at Clinic Through:
1. Interviews with pregnant women at Rimal antenatal care clinic using structured questionnaire.
2. Structured interviews with health care providers at ANC Rimal clinic.
3. Revision of relevant files and documents.
4. Observation of team , for ANC and the process of Treatment
Results of the interviews:
1. The rate of compliance with iron supplementation among the pregnant women 62% in Rimal
ANC.
2. The procedures of providing iron supplementation to pregnant women at Rimal.
ANC were as follow:
The ANC Physician prescribes iron supplementation for the pregnant women who attended
the clinic only in case of her blood hemoglobin level is below Ilgm/dl.
The pregnant women who were prescription of Iron supplementation must follow series of
procedures to stamp the prescription of iron supplement as co-payment exempted, then to
the pharmacy to receive it.
The pharmacy staffs check the prescription then offer Iron supplementation but with poor
dispensing procedures.
Intermittent shortage had occurred especially at the last days of the months, because of
periodic supplies, and recently due to closure and donation process.
There were no clear written guidelines for control measures to pregnancy related anemia.
Personal related factors like women education affected the compliance rate. ~ Service
related factors like long intervals of visits that were significant with compliance.
The knowledge abut necessity of Iron supplementation to the pregnant women was not
clear.

Recommendation to improve compliance among pregnant women with iron

supplementation antenatal clinic:

Correct and standardized procedure of iron supplement, preferably nursing

responsibility iron tab should be available at ANC.

Improve and intensify health education to pregnant women and In service education
to health professionals.

The should focus on prophylactic measures rather than curative ones, must
implement the standing orders for control of pregnancy related anemia.

Increase the amount of iron supplement must bridge the gap between the amount of
iron supplement, received by the pregnant woman and the intervals of visits.

Iron supplementation for every pregnant woman attending the ANC center at Rimal
clinic may improve the rate of compliance of anemIa.

And improve the quality of life of pregnant women.

Research studies is recommended to identify the lower outcomes of gestational

anima.

Control programs and to conduct health education and communication skills of the
Care givers.