|Year : 2020 | Volume
| Issue : 4 | Page : 203-209
Determinants of Compliance with Iron Supplementation Among Pregnant Women in a Tertiary Care Hospital in Oman
Esra M Alkhasawneh1, Vidya Seshan2, Judie Arulappan2, Savithri Raman2
1 Associate Professor, Public Health Practice, Faculty of Public Health, Kuwait University, Kuwait
2 Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, Al Khoudh, Muscat, Oman
|Date of Submission||24-Jun-2020|
|Date of Decision||27-Jun-2020|
|Date of Acceptance||19-Jul-2020|
|Date of Web Publication||27-Oct-2020|
Assistant Professor, College of Nursing, Sultan Qaboos University, Al Khoud, Muscat, Sultanate of Oman
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Anemia in pregnancy is one of the most common widespread public health problems in the world and it remains as emerging problem in the developing countries and is an important indicator for maternal mortality and morbidity in the Middle East. Objective: This study aimed to determine the level of compliance with iron supplementation and its determinants among pregnant women. Methods: The study adopted a descriptive cross-sectional research design. Noronha compliance questionnaire was used to determine the level of compliance to iron supplementation and its determinants. One hundred and sixty five Omani pregnant women of 20 weeks of gestation and above visiting antenatal outpatient department were the participants of the study. Descriptive and inferential statistics were used to analyze the data. Results: The results showed that 72.7% of the women were compliant and 27.3% of them were non-compliant to iron supplementation. A chi-square test showed that there was a significant relationship between side effect and non-compliance to iron supplementation X2 (1, N = 165) = 6.53, P < 0.05. Results of Logistic regression analysis showed that side effects of iron supplementation significantly predicted the non-compliance to iron supplementation b = −1.76, Wald X2 (165) = 8.36, P < 0.05. Conclusion: Increasing awareness among the pregnant women on the importance of iron supplementation during pregnancy is essential to expect desirable outcomes in both the mother and the newborn.
Keywords: Anemia, compliance, iron supplementation, pregnancy
|How to cite this article:|
Alkhasawneh EM, Seshan V, Arulappan J, Raman S. Determinants of Compliance with Iron Supplementation Among Pregnant Women in a Tertiary Care Hospital in Oman. Int J Nutr Pharmacol Neurol Dis 2020;10:203-9
|How to cite this URL:|
Alkhasawneh EM, Seshan V, Arulappan J, Raman S. Determinants of Compliance with Iron Supplementation Among Pregnant Women in a Tertiary Care Hospital in Oman. Int J Nutr Pharmacol Neurol Dis [serial online] 2020 [cited 2021 Jan 19];10:203-9. Available from: https://www.ijnpnd.com/text.asp?2020/10/4/203/299267
| Introduction|| |
Anemia in pregnancy is considered to be the most common and prevalent public health problems in the world. Iron deficieny anemia (IDA) in pregnancy is a chief problem in the developing countries.,,, Center for Disease Control and Prevention defined anemia in pregnancy as the hemoglobin level less than 11g/dl during the first and third trimesters or less than 10.5 g/dl in the second trimester.
Anemia affected more than two billion people across the world. It accounted for 60,534 deaths in women of reproductive age group in the year 2010. In Arab Gulf countries, 22.7% to 54% of pregnant women are affected with anemia. WHO reported that the highest number of pregnant and non-pregnant women suffering from IDA live in Middle East and North Africa (MENA) region. In Oman, the prevalence of anemia is very high among pregnant women. In a survey in 2016, 41.8% pregnant Omani women were reported to be anemic.
The contributing factors including malnutrition, bacterial and parasitic diseases, incompatibility between actual needs and intake, hematological disorders, and chronic diseases can cause anemia. The pregnant women are predominantly at risk of IDA due to the increased demands of nutrients during pregnancy.
IDA leads to adverse pregnancy outomes including increased maternal mortality, maternal low weight gain, preterm labor, placenta previa, premature rupture of membrane, cardiac arrest, hemorrhage, poor resistance to infection, poor cognitive development and reduced work capacity., The poor neonatal outcomes include low birth weight, prematurity, fetal distress and growth retardation., In Asia, anemia is the second leading cause of maternal deaths.
Iron supplementation during pregnancy is an effective and most convenient measure for treating and preventing IDA. WHO recommends that all pregnant women should consume a daily dose of 30-60 mg of elemental iron and 400 μg of folate. This is expected to improve the pregnancy outcomes. The iron and folate supplements are provided free of cost to the pregnant women in most of the countries. Though the iron supplements are provided to the pregnant women, the poor adherence to iron and folic acid supplementation is a major problem in some developing countries.
The non-compliance to iron and folic acid supplementation may be due to personal behaviours, environmental factors, sociodemographic status, cultural issues, lack of awareness, economic factors, side effects and inadequate service delivery. The unpleasant side effects includes diarrhea, constipation, gastric cramping, vomitting, black tools and metalic taste. The unpleasant side effects are reported in various studies in different countries., Appropriate assessment of adherence to Iron and folic acid supplementation in pregnancy is necessary to improve maternal and prenatal health.
While many antenatal care programs are in place to distribute iron supplements to pregnant women, low compliance is thought to be a major reason for the low effectiveness of iron supplementation programs. Barriers to compliance includes experience of gastrointestinal side effects, inadequate supply of tablets including inadequate counseling by health care providers concerning the utility of tablets, forgetfulness to take the pill at prescribed time, financial inability and unwillingness to take pills due to lack of knowledge on anemia and certain beliefs. Experts recommend better access and follow-up of antenatal care elements as essential strategies to improve iron-folate supplementation. Emphasis on reduction of side effects by providing alternative iron preparations or intermittent dose regimens including weekly dose schedules were also suggested to increase the compliance and effectiveness of iron supplementation.
Little use of antenatal care (ANC) and inadequate supplies of iron/folate tablets largely affects the effectiveness of the antenatal care programs in controlling anemia during pregnancy. Many developing countries are now looking for in-depth studies on designing iron supplementation program strategies.
Studies on assessment of compliance with iron and folic acid supplementation and prevalence of anemia in pregnant women reported that the Pill count method to be the most suitable method for estimation of adherence to iron and folic acid supplementation than self-reported adherence. Successful compliance to iron supplementation depends on accurate and acceptable methods in detecting the determinants for non-compliance, as poor compliance has been associated with poor outcomes particularly in affecting the maternal and fetal wellbeing.
In Oman, there are no published reports available on the determinants of compliance with iron supplementation in pregnancy, although the prevalence of anemia is high. Therefore, the authors of this study explored the determinants of compliance with iron supplementation. This can help to propose an intervention aiming at increasing the compliance with iron supplementation, thereby reducing the prevalence of anemia in pregnancy.
| Methods|| |
A descriptive cross-sectional research design was adopted in this study. The study was carried out for a period of six months. The study was carried out in the antenatal outpatient department of Sultan Qaboos University hospital in Oman, which is one of the hospitals that provide tertiary care and is a national referral hospital receiving the critical cases referred from the different regions of the country. As it is a public hospital, the services are extended to Omani population.
Ethical approval was obtained from the Research and Ethics committee of College of Nursing, Sultan Qaboos University, as well as from the data collection setting (Project No. 9IG/CN/MCHH/13/01). The purpose and the study protocol were explained to the study participants and written informed consent was obtained from the participants who were willing to participate in the study. Confidentiality was assured to the participants.
The population comprised of the pregnant Omani women who came for their routine antenatal visit to the antenatal outpatient department. The study excluded pregnant women diagnosed to have sickle cell disease or thalassemia; hemoglobin < 8gm/dl, and those who needed blood transfusion. Convenient sampling technique was adopted to select the participants. With the effect size (ƒ2 = 0.02), 0.05 significance level, and a power of 0.80, the calculated sample size was 138 pregnant women assuming that 10% of women may have low compliance to iron supplementation with the confidence interval of 95%. However, an additional 20% of samples were recruited in the study. Thus, the sample size reached to 165 pregnant women.
The investigators adopted interview technique to collect data from the participants. The data collection questionnaire had two sections. The first section comprised of socio-demographic characteristics of pregnant women. The socio-demographic data included age in years, level of education, occupation, family income, number of children, and number of antenatal attendance. The second section included the questions related to determinants of non-compliance to iron supplements during pregnancy.
The tool to assess the factors contributing to non-compliance to iron supplements during pregnancy was developed by Noronha and tested for the reliability on a large sample in India. This tool was adopted in our study as the tool was found to be more appropriate to the Omani culture. The original tool was available in English. As we conducted the study in Oman, the Noronha compliance questionnaire was translated to Arabic. The translated tool was back-translated by two different bi-lingual language experts in order to ensure the language validity and to ascertain the precision of translation. The translated tool was pretested with 15 samples in our study setting. The content validity of the tool was tested with the experts in the field of Nursing, Midwifery, Obstetricians and Bio-statistics. The precision, feasibility, and appropriateness of the tool were tested. Reliability was examined by Cronbach alpha. The “r” value of the tool is r = 0.81 which showed that the tool is highly reliable. Two trained research assistants collected the data for a period of two months. The data were collected through face to face interview.
Data were entered into Statistical Package for Social Sciences (SPSS) version 20 (SPSS Inc., Chicago, Illinois). Descriptive statistics including frequency and percentage was calculated to determine the sample characteristics, compliance and non-compliance to iron supplementation and reasons for non-compliance to iron supplementation. Chi-square test was done to analyze the association between variables and non-compliance to iron supplementation. Logistic regression analysis and Wald Chi-Square test statistics were conducted to find out the most important determinants of non- compliance with iron supplements. The P value of < 0.05 was considered to be statistically significant.
| Results|| |
[Table 1] shows the socio-demographic characteristics of participants in the study. Overall, 165 women were enrolled in the study. Of the total, majority of the pregnant women were less than 30 years of age. The majority of pregnant women were either illiterate (47.9%) or had a high school education (46.1%). Only 6.1% were graduates. The majority of pregnant women had low (32.1%) or middle family income (61.5%) according to National Oman income standards. Majority of the women (46.1%) had 2–4 children. Most of the pregnant women participated in the study (83.6%) were in the gestational age between 30 and 39 week of pregnancy. The participants mentioned that they received information on iron supplements either from doctors (65.5%) or from nurses (27.9%).
The data pertaining to compliance and non-compliance to iron supplements are presented in [Table 2]. The majority (35.8%) of pregnant women started taking iron supplements before 5 months. Most of them (81.8%) reported that they were taking one tablet daily, and 18.1% of them reported that they were consuming two tablets daily. Majority (43.0%) have been taking the iron supplements for 7 to 9 months, followed by 4 to 6 months (32.1%) and 1 to 3 months (24.8%). The women who were regularly taking the tablets were considered as compliant with iron supplements (72.7%). Those women who experienced side effects or discontinued taking the iron supplements for any other reasons were considered as non-compliant (27.3%).
The reasons for non-compliance to iron supplements are also appended in [Table 2]. The main reasons for non-compliance to iron supplements were lack of knowledge on importance of iron supplements (64.8%) and side effects of the drug (nausea 16.9%, vomiting 8.8%, constipation 41.1%, abdominal distention 14%, headache 9.7%, diarrhea 6.2%, stomatitis 4.7%, bad taste 25.2%). Few pregnant women perceived that they were healthy and iron tablets were not needed (15.7%) and some of the women who disliked medication in general were not compliant to iron supplementation (14.1%).
Few of the pregnant women (20.7%) expressed that the health workers explained the need to take iron supplements. Some of the pregnant women (14.6%) believed that it is important to take iron supplements. Very few pregnant women (3.5%) mentioned that their family members encouraged regular check-up during pregnancy.
The determinants of non-compliance to iron supplements are illustrated in [Table 3]. A Pearson chi-square test was performed and found that there is a significant relationship between side effects and non-compliance to iron supplementation X2 (1, N = 165) = 6.53, P = 0.011). Logistic regression analysis was computed with predictor variables such as age, education, income, number of children, side effects, family support and non-compliance to iron supplementation as the outcome variable. The side effects of iron supplements significantly predicted non-compliance to iron supplementation b = −1.76, Wald X2 (165) = 8.36, P < 0.004.
| Discussion|| |
The current study was carried out to identify the determinants of compliance with iron supplementation among pregnant women in a public tertiary care hospital in Oman.
The results of our study shows that 72.7% of pregnant women were compliant with iron supplementation. Our study reported that few of the pregnant women were aware of the importance of consuming Iron and Folic acid supplements during pregnancy and health workers explained the need to take iron supplements. Also, the family members encouraged the pregnant women to attend to the hospital for regular check-up during pregnancy. However, 27.3% of pregnant women were non- complaint to iron supplementation during pregnancy.
The main reasons for their non-compliance to the iron supplementation were side effects of the drug that included nausea, vomiting, diarrhea, constipation, abdominal distention, headache, stomatitis and bad taste. Some women perceived that they were healthy, therefore there is no need to take medications. Few of the pregnant women generally disliked the medications.
Our study has reported that the side effect of the drug is the main determinant to non-compliance to iron supplementation. Similar results are reported in few other studies. Habib et al. found that side effects of the iron supplements, forgetfulness and pregnant women’s perception that they had an adequate diet as the determinants of noncompliance to iron supplementation during pregnancy. Another focused group discussion having the pregnant women of African-American and Hispanic race identified that the quality of prenatal supplements, adverse effects and poor communication from health care providers on the benefits of iron supplement uses as the barriers for compliance with iron supplementation.
Seck and Jackson reported in their study that the overall compliance to iron supplementation rate was 69%. Women with low compliance reported that the main factors for non-compliance were the side effects, misconception that medication to be continued throughout the pregnancy and forgetfulness. The study concluded that compliance to iron/folic acid supplementation could be increased by providing women with clear instructions on intake of iron supplements and by educating them on the health benefits of the tablets.
Fouelifack, Sama and Sone determined the adherence to iron supplementation among pregnant women. The study reported that 16.4% of pregnant women were highly compliant, 27.6% of them were moderately compliant and 56% were low complaint with iron supplementation during pregnancy. The study reported that the side effects, inaccessibility to iron supplements, forgetfulness and feeling of being bored to take medication daily as the reasons for non-adherence to iron supplementation during pregnancy. The study also reported that the women with side effects were thrice most likely to be non-adherent to iron supplements during pregnancy. The study concluded saying that the women aged 25 years and above were most likely to be non- complaint to iron supplements than youngsters. Therefore, we also conclude saying that the results of this study are consistent with our study findings. The authors hereby state that though the pregnant women belong to different region or country, all the pregnant women share the common reasons as the determinants for non-compliance to iron supplementation during pregnancy.
Taye, Abeje and Mekonen assessed the factors related to adherence to prenatal iron and folic acid supplementation in Western Amhara. The authors reported that there was a significant association between history of anemia during previous pregnancy and adherence to iron supplementation. The authors recommended that the future studies should test the hemoglobin level of pregnant women before assessing the adherence to iron supplementation. Another study commented that maternal and fetal morbidity related to iron deficiency may affect adherence to iron supplementation during pregnancy. Therefore, educational programmes should be focusing on the health benefits of iron supplementation during pregnancy especially in developing countries.
In summary, all the above-mentioned literatures including our study findings reported that side effects, poor motivation, lack of understanding of the benefit of the drug, forgetfulness and inadequate information from health care providers as the main determinants to non-compliance to iron supplementation among pregnant women. It is now the major challenge for the health care providers to change the attitude of pregnant women by educating them with correct information on the benefits of taking iron supplementation during pregnancy. This will enhance the knowledge of pregnant women, thereby the compliance to iron supplementation shall be improved.As iron deficiency anemia is associated with increased maternal and perinatal morbidity and mortality, and long-term adverse effects in the new born,,, awareness of such consequences among the mothers has to be enhanced to augment the compliance with iron supplementation. The antenatal mothers should be motivated to utilize the health services available in their area and should be encouraged to have regular antenatal visits during their first, second and third trimester of pregnancy. Home visits by village health nurses should be emphasized with health education to antenatal mothers on health problems that complicate pregnancy. The use of a specially designed culturally-tailored nutrition education intervention for pregnant women supplemented with follow-up reminders can reduce the occurrence of gestational anemia. Therefore, it is high time that with the support of health care providers we start to move towards educational strategies to enhance the compliance to iron supplementation among pregnant women.
Unless the factors affecting the non-compliance of iron supplements are managed well, the prevalence of anemia in Oman may remain high and will be a cause of concern. Continuous compliance with iron supplementation throughout pregnancy is a challenge to health care workers and pregnant women. Keeping in mind the level of education and the religious taboos among Omani women, the major task for the health care providers is to provide quality care to overcome the challenges of anemia. Thereby only professional planning, management, and implementation to ensure pregnant women’s compliance to iron supplementation can achieve the same.
As side effects are considered as the serious determinant of non-compliance in most of the studies, further interventional studies are needed to deal with the side effects of the iron supplementation. Increasing the awareness of the public, especially the pregnant women is highly recommended by the authors to bring positive behavioral change and improved compliance to iron supplementation during pregnancy.
The health care providers have to impart the knowledge and educate the pregnant women on the importance of consuming iron supplements, the negative consequences of non-compliance to iron supplementation to both the mother and newborn, its side effects and the ways to overcome the side effects, and enhancing absorption of iron with vitamin C. The health care providers must insist on the importance of regular intake of iron supplementation and reinforce the benefit of taking the same. Every pregnant woman during their routine antenatal visit must be provided with pamphlets containing information on benefits of iron supplementation to mother and the newborn; the importance of specific vitamins and the sources to include in their diet to enhance iron absorption viz., vitamin C; the food to be avoided while taking iron supplements which reduces the absorption of iron, viz., coffee, and tea; and tips to manage the side effects such as taking iron supplements after the meals. Reinforcement can be done through mobile phone reminders, and text messages every week. Hitherto, the prevalence of anemia in adolescent girls is high in Oman. Therefore, prevention of IDA can be done through iron and folic acid supplements to these adolescent girls at the early stage, thereby anemia can be prevented during pregnancy later.
| Conclusion|| |
The findings of the study would help nurses to understand the level and determinants of non-compliance to iron supplementation among pregnant women. Monitoring the compliance to iron supplementation is a major challenge to health care providers. However, the health care providers should focus on creating awareness on the importance of compliance to iron supplements during pregnancy and reinforce them in every visit. This will benefit both the mother and the newborn and will bring excellent maternal and neonatal outcome in the future.
This study was funded by the Internal research Grant of Sultan Qaboos University, Muscat, Sultanate of Oman. (Project No. 9IG/CN/MCHH/13/01).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization, Worldwide Prevalence of Anemia 1993-2005, World Health Organization, Geneva, Switzerland, 2008.
Ibrahim ZM, El-hamid SA, Mikhail H, Khattab MS. Assessment of adherence to iron and folic acid supplementation and prevalence of anemia in pregnant women. The Medical Journal of Cairo University 2011;79:115-21.
King JC. Physiology of pregnancy and nutrient metabolism. Am J Clin Nutr 2000;71:1218S-25S.
WHO. Guideline: Daily iron and folic acid supplementation in pregnant women. Geneva: World Health Organization 2012.
Beard JL. Effectiveness and strategies of iron supplementation during pregnancy. The American Journal of Clinical Nutrition 2000;71:1288S-94S.
World Health Organization. The world health report 2002: reducing risks, promoting healthy life. World Health Organization;2002.
De Benoist B, McLean E, Egli I, editors. CM. Worldwide prevalence of anemia 1993-2005: WHO global database on anemia. Geneva: WHO, CDC 2008.
Musaiger AO. Iron deficiency anaemia among children and pregnant women in the Arab Gulf countries: the need for action. Nutrition and Health 2002;16:161-71.
Al-Farsi YM, Brooks DR, Werler MM, Cabral HJ, Al-Shafei MA, Wallenburg HC. 2011. Effect of high parity on occurrence of anemia in pregnancy: a cohort study. BMC Pregnancy and Childbirth 11 1.
Rahman MM, Abe SK, Rahman MS, Kanda M, Narita S, Bilano V et al.
Maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. Am J Clin Nutr 2016;103:495-504.
Peña-Rosas JP, Viteri FE. Effects and safety of preventive oral iron or iron+folic acid supplementation for women during pregnancy. Cochrane Database Syst Rev 2009;CD004736.
Rasmussen K. Is there a causal relationship between iron deficiency or Iron-deficiency anemia and weight at birth, length of gestation and perinatal Mortality? J Nutr 2001;131:590S-601S. discussion 601S-3S.
Zakia M, Ibrahim MD, Seham Abd El-Hamid MDH, Mikhail MS et al.
Assessment of adherence to iron and folic acid supplementation and prevalence of anemia in pregnant women Ismailia governorate, Egypt. Med J 2011;79:115-21.
Begum S. Factors associated with adherence to iron folic acid supplementations during pregnancy in Uttar Pradesh. BMC Pregnancy and Childbirth 2012;12.
Van den Broek NR, White SA, Neilson JP. The relationship between asymptomatic human immunodeficiency virus infection and the prevalence and severity of anemia in pregnant Malawian women. Am J Trop Med Hyg 1998;59:1004-7.
Billimale A, Anjum J, Sangolli HN, Mallapur M. Improving adherence to oral iron supplementation during pregnancy. Australasian Medical Journal 2010;3:281-90.
Oriji VK, Enyindah CE, Nyeche S. Factors determining compliance to routine iron supplementation in pregnancy at the University of Portharcout Teaching Hospital. Nigerian Journal of Medicine 2011;20:131-4.
Blot I, Diallo D, Tchernia G. Iron deficiency in pregnancy: effects on the newborn. Curr Opin Hematol 1999;6:65-70.
Ugwu EO, Olibe AO, Obi SN, Ugwu AO. Determinants of compliance to iron supplementation among pregnant women in Enugu, Southeastern Nigeria. Niger J Clin Pract 2014;17:608-12.
] [Full text]
Zakia MI, Seham AEH, Hend M, Maged SK. Assessment of adherence to iron and folic acid supplementation and prevalence of anemia in pregnant women. Med J Cairo University 2011;79:115-21.
Lacerte P, Pradipasen M, Temcharoen P, Imamee N, Vorapongsathorn T. Determinants of adherence to iron/folate supplementation during pregnancy in two provinces in Cambodia. Asia Pac J Public Health 2011;23:315-23.
Hyder SM, Persson LA, Chowdhury AM, Ekstrom EC. Do side-effects reduce compliance to iron supplementation? A study of daily and weekly dose regimens in pregnancy. Health Popul Nutr 2008;20:175-9.
Seck BC, Jackson RT. Determinants of compliance with iron supplementation among pregnant women. Public Health Nutrition 2008;11:596-605.
Noronha J, Bhaduri A, Vinod B, Kamath A. Interventional study to strengthen the health promoting behaviors of pregnant women to prevent anemia in southern India. Midwifery 2013;29:35-41.
IBM, Corporate headquarters, 1 New Orchard Road, Armonk, New York 10504-1722, United States, US: 914-499-1900
Habib F, Albadin EHZ, Alenazy M. 2015 Compliance to iron supplementation during pregnancy. Journal of obstetric Gynecology 209;29:487-92.
Tessema J, Jefferds ME, Cogswell M, Carlton E. Motivators and barriers to prenatal supplement use among minority women in the United States. J Am Diet Assoc 2008;109:102-8.
Fouelifack FY, Sama JD, Sone CE. Assessment of adherence to iron supplementation among pregnant women in the Yaounde gynaeco-obstetric and paediatric hospital. The Pan African Medical Journal 2019;34.
Taye B, Abeje G, Mekonen A. Factors associated with compliance of prenatal iron folate supplementation among women in Mecha district, Western Amhara: a cross-sectional study. Pan Afr Med J 2015;20 article 43
Taye B, Abeje G, Mekonen A. Factors associated with compliance of prenatal iron folate supplementation among women in Mecha district, Western Amhara: a cross-sectional study. Pan Afr Med J 2015;20:43. doi: 10.11604/pamj.2015.20.43.4894
Goonewardene M, Mishkat S, Hamat A. Anemia in pregnancy. Best Practice Res in Obstetrics and Gynecology 2012;26:3-24.
Bakhtiar UJ, Khan Y, Nasar R. Relationship between maternal hemoglobin and Perinatal outcome. Rawal Medical Journal 2007;32:102-4.
Mamum AA, Padmadas SS, Khatun M. Maternal health during pregnancy and perinatal mortality in Bangladesh: evidence from a larger-scale community-based clinical trial. Paediatric Perinat Epidemiology 2006;20:482-90.
Johncyrani R, Arulappan J. Assessment of knowledge of antenatal mothers regarding selected health problems of complicated pregnancy − a cross sectional study. Biosciences Biotechnology Research Asia 2018;15:561-6.
Seshan V, Alkhasawneh E, Al Kindi S, Al Simadi FA, Arulappan J. Can gestational anemia be alleviated with increased awareness of its causes and management strategies? implications for health care services. Oman Medical Journal 2018;33:322.
[Table 1], [Table 2], [Table 3]