Anemia in pregnancy constitutes a major public health problem in developing countries. It is defined as reduction in the oxygen carrying capacity of the blood as a result of fewer circulating erythrocytes than normal or a decrease in the concentration of Haemoglobin (Hb) (Hoque et al., 2009). During pregnancy, there is an increase in amount of iron required to increase red cell mass, expand plasma volume and to allow growth of fetal-placental unit (Scholl, 2005). The deficiency occurs through reduced production or an increased loss of red blood cells. Anaemia in pregnant women in developing countries is generally presumed to be the result of nutritional deficiency. In Malaysia, the incidence of anaemia among pregnant mothers attending public antenatal clinics was reported to be 35% (Jamaiyah et al., 2007). Hadipour et al. (2010) reported a higher incidence of anaemia among Iranian pregnant women i.e. 51.4%. Iron deficiency anaemia is the most prevalent nutritional deficiency problem affecting pregnant women. Pregnant women are considered to be the most vulnerable group, since the additional demands that are made on maternal stores during this period exposes them to various latent deficiencies that manifest themselves as anaemia (Hoque et al., 2009). Increased iron requirements, low pre-pregnancy iron stores and continued inadequate dietary intakes of iron exacerbate this physiologic anaemia during pregnancy in many regions of this world (Christian et al., 2003). Brabin et al. (2001) reported a strong association between severe anaemia (OR 3.51, 95% CI: 2.05-6.00) and maternal mortality.
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Anaemia may result from both nutritional and nonnutritional factors, specifically besides iron, deficiency of micronutrients such as vitamins A, C and B-12 and folic acid may contribute to the development of anaemia. These nutrients may affect haemoglobin synthesis either directly or indirectly by affecting absorption and/or mobilization (Ramakrishnan et al., 2004). Systemic evaluation of the efficacy of antenatal iron supplementation is known to raise haemoglobin concentration, although it effects are influenced by dose and compliance level (Christian et al., 2003). Inability to meet the required level for iron and other vitamins either as a result of dietary or supplementary gives rise to anaemia (Idowu et al., 2007). According to the World Health Organization (WHO, 1998), anaemia should be considered when the hemoglobin level is below 11 g/dL. Anaemia ranges from mild, moderate to severe and WHO classifies the hemoglobin level for each of these types of anemia in pregnancy at 10.0-10.9 g/dL (mild anemia), 7-9 g/dL (moderate anemia) and <7 g/dL (severe anemia).
The effects of maternal anemia on the fetus were considerable and include the following: the prematurity rate among infants of anemic mothers was 18.1%, 3 times that of infants born to nonanemic mothers; the perinatal loss in the anemic mother was 13.1%, twice that of the nonanemic mother (6.8%); and the stillbirth rate among infants born to anemic mothers was 91.0/1000 compared with a rate of 15.7/1000 among infants born to nonanemic mothers. The findings indicate the seriousness of severe anemia in pregnancy. Etiological factors are considered since this will be the basis of rational therapy.
Iron deficiency anemia may develop for several reasons. There is usually a dietary deficiency of iron, and there may also be a lowered absorption from the gut. Also, there may be excessive blood loss due to hookworm and menorrhagia, and there are the demands of repeated childbearing. Apart from hookworm infestation, insufficient dietary intake of iron was the principal cause of anemia among the women in the study with iron deficiency anemia. Among the women with megatoblastic anemia folic acid was the prime deficiency leading to this type of anemia. The anemia was aggravated by increasing malnutrition as demonstrated by diminished serum albumin and globulin concentration. The diagnosis of severe iron deficiency anemia was made by estimation of the hemoglobin concentration, supplemented in some cases by serum iron studies. Megaloblastic anemia in pregnancy can only be diagnosed with accuracy by a bone marrow smear. Consideration of the etiology of anemia in Malaysia led to a standard treatment among the pregnant women studies. The treatment approach is reviewed in detail.
In Malaysia, pregnant women from a lower social-economic group indicated the prevalence of anaemia was 30-40%. Since then, Malaysia has had tremendous economic changes and is expected to have changes in the prevalence of anaemia as well. This study was conducted with the aim of identifying of risk factors that contributing anaemia among antenatal mothers such as sociodemografic data, prenatal care and maternal health status.
1.1 PROBLEM STATEMENT
Anaemia still constitutes a public health problem in the world, especially in the developing countries (Royston & Armstrong),1989,Abou Zahr & Royston,1992).Nutritional anaemia is found more among rural mothers, where poor dietary intake and parasitic infections are more common. Many women start their lives with insufficient iron stores, but also, because of inadequate child spacing, they have little time to build up their iron levels between pregnancies (WHO,1975).
The effect of anaemia in pregnancy has been shown to be associated with an increase risk of maternal and fetal morbility (Tasker,1958;Llewellen-,1965;Lourdeadin,1969;Baker,1978). However, risk factors such as anaemia in pregnancy can be controlled and monitored by good antenatal care and appropriate action, including referral, in accordance to the level of severity of the anaemia.
In Malaysia, 30 to 40% of pregnant women and 25% of women from rural communities suffer from iron deficiency anaemia. The most common haematologic complication of pregnancy and is associated with increased rates of premature birth, low birth weight and perinatal mortality. According to Jamaiyah et al.(2007), found that the prevalence of anaemia during pregnancy is 35% and mostly of the mild type and more prevalent in the Indian and Malays.
WHO estimates that more than half of pregnant women in the world have a haemoglobin level indicative of anaemia. (< 11.Ogldl), the prevalence may however be as high as 56 or 61% in developing countries. Women often become anaemic during pregnancy because the demand for iron and other vitamins in increase due to physiological burden of pregnancy. The inability to meet the required level for these substances either as a result of dietary deficiencies or infection give rise to anaemia. It was supported by Van Den Broek N (1998).
Base on the many contradicting finding of this similar study, therefore the aim of this study is to determine the factors that contributing anaemia during pregnancy among mothers admitted at antenatal ward, Hospital Jeli, Kelantan.
1.2.1 General objectives
To determine factors associated with anaemia during pregnancy among mothers admitted at Antenatal Ward, Hospital Jeli, Kelantan.
1.2.2 Specific objectives
1. To determine the haemoglobin level for mothers who admitted at antenatal ward ,Hospital Jeli, Kelantan
2. To determine factors associated with anaemia mothers.
1.3 Benefit of study
Knowledge on factors associated anaemia during pregnancy among mothers such as factors social demographic, prenatal care of maternal status and maternal nutrition of the mothers.
To prevent and reduce the prevalence of low birth weight among infants and to prevent maternal and prenatal mortality.
1.4 Conception frame work
Figure 1: factors that contributing with anaemia
Anemia in pregnancy constitutes a major public health problem in developing countries. (Brabin et al.2001). This conceptual framework describe those maternal factors that may influence anaemia among antenatal mothers.
The important factors are the socio demographic data such as the age of mother, race, parity, education level of mothers, Occupation of mothers, Occupation of father and number of dependent.
Perinatal care variables that were studied were access to antenatal booking, number of visit to antenatal clinic ,parity,Period of Gestation (POG) ,vitamin and iron supplements, family planning and eating taboos.
Maternal health factors such as past medical history, Big baby, APH, placenta praevia, hyperemesis , Hb level ,Multiple pregnancy and others were included in this study to determine the factors that contributing anaemia mothers.
2.1 Definition of anaemia in pregnancy
In pregnancy , anemia has a significant impact on the health of the fetus as well as that of the mother. The physiologic expansion of the plasma volume is detactable as early as 6 to 8 weeks gestationan (Wood & Ronneberg, 2006). The world health organization (WHO) defines anemia in pregnancy as haemoglobin concentration of less than 11.0g/dl. WHO estimates that more than half of pregnant women in the world have a haemoglobin level indicative of anemia (<11.ogldl), the prevalence may however be as high as 56 or 61% in developing countries (WHO, 1994).
Iron is essential for multiple metabolic processes, including oxygen transport, DNA synthesis, and electron transport. Iron equilibrium in the body is regulated carefully to ensure that sufficient iron is absorbed in order to compensate for body losses of iron. While body loss iron quantitavely is as important as absorption in terms of maintaining iron equilibrium, it is a more passive process than absorption. Consistent errors in maintaining this equilibrium lead to either iron deficiency or iron overload.
Iron balance is achieved largely by regulation of iron absorption in the proximal small interstine. Either diminished absorbable dietary iron or excessive loss of body iron can cause iron deficiency. Decrease absorption usually is due to an insufficient intake of dietary iron is an absorbable form. It si support by Ladewig et al.(2006), found that the common anemia of pregnancy are due to either to insufficient haemoglobin production related to nutritional deficiency in iron or folic acid during pregnancy. Anemia is the most common haematologic complication of pregnancy and is associated with increased rates of premature birth, loe birth weight and perinatal mortality.
According to Allen (2000), iron deficiency anemia is a factor that can cause preterm birth and low birth weight and can effect the neonatal health status. Haemoglobin values drop during the second trimester of pregnancy because of the dilution of the blood caused by plasma increases and this physiologic anemia is normal. During the third trimester, haemoglobin levels generally return to pre pregnancy levels because of increased absorption of iron from the gastrointestinal tract. Generally, a women is considered anemia if her haemoglobin is less than 11 g/dl during the first and third trimester or less than 10.5 g/dl during the second trimester (Cunningham et al., 2001).
In malaysia, ion deficiencies always happen in malay and Indians pregnant women because their particular eating habits of different races. It support study done by mohanambal et al.(2002), found that iron deficiency was sees in Malays and Indians, no iron deficienciency was seen among the Chinese.
2.2 Factors associated with anemia
2.2.1 socio- demographic factors
Malaysian infant mortality diffentials, because socioeconomic development has very clearly had a diffential impact by ethnic group. The Chinese rates of infant mortality are significantly lower than the Malay or Intdian rates. Low socioeconomic level was the most important risk factor for anaemia among antenatal mothers. And was independent of other factors, including those related to production and nutrition, health service and prinatal care. It is support by Sohl & Moore (2000), reported that there are clear genetic and constituonal influences that act on foetal growth, it is estimated that 40% of birth weight is due to heredity and the remaining 60% to environmental factors.
According to kennedy et al.(1998) and Ecob and Smith (1999), among the socio-economic factors are income, education, occupation, household leadership and gender differences related to roles within the family. It support the findings studies by Tuntiserance et al. (1999), studied a cohort of 1797 pregnant women visiting antenatal clinics, they found that significantly factors between socio-economic indicators and pregnancy outcomes. The indicators were family socio-economic status, maternal education, maternal occupation, family income and work exposures, while the pregnancy outcomes were base on anaemia mothers.
Age of mother
Maternal age is an important and dependent risk factor for adverse pregnancy outcome(Delbaere et al.,2007). Epidemiological studies suggest that there is a trend in developing nations to delay the age of the first pregnancy. Maternal age > 35 years for first pregnancy is associated with low birth weight, intra uterine growth retardation and prematurity. It is supports the finding study by Ann et al. (2007) that have same conclusion that increasing maternal age to be associated with low birth weight and anaemia during delivery.
Educational level of mother
Educational level of mother are linked to certain prenatal risk factors such as anaemia and to proven detrimental to birth outcomes . this can help intervention workers to identify the at risk mother. Early identification can result in focused programs administered directly to the individuals most likely to benefit (Wasser, 1995). According to Currie and moretti (2003) started that the effect of maternal education on birth weight I the US with a policy increasing the supply of colleges when the mother was teenager. The rationale is that the opening of a college reduces the cost of higher education in a way that is uncorrelated with the unobservable term correlating both education and health.
Family income is generally considered a primary measure of a nation’s financial prosperity. Income or poverty status had a statistically significant effect on anaemia mothers and both low birth weight and the mortality rate. According to Duncan and Brooks-Gunn (1997), found the effects of income or poverty status and a number of pregnancy-related health services on birth outcomes for white and black women also found that for whites but not for blaks.
Prenatal care of mothers
Antenatal care is the clinical assessment of mother and fetus during pregnancy, for the purpose of obtaining the best possible outcome for the mother and child. Antenatal care traditionally involves a number of ‘routine’ visits for assessment, to a variety of healthcare professionals, on a regular basis throughout the pregnancy.
Number of children (parity)
Parity was determined to all the number of previous pregnancies resulting in either live birth or still births after 22 weeks of gestational age. Maternal parity and age were significantly positively associated with anaemia mothers.
Women often become anaemic during pregnancy because the demand for iron and other vitamins is increased. The mother must increase her production of red blood cells and, in addition, the fetus and placenta need their own supply of iron, which can only be obtained from the mother.
In order to have enough red blood cells for the fetus, the body starts to produce more red blood cells and plasma. It has been calculated that the blood volume increases approximately 50 per cent during the pregnancy, although the plasma amount is disproportionately greater. This causes a dilution of the blood, making the haemoglobin concentration fall. This is a normal process, with the haemoglobin concentration at its lowest between weeks 25 and 30. The pregnant woman may need additional iron supplementation, and a blood test called serum ferritin is the best way of monitoring this.
Many women are anaemic during pregnancy. A recent study by the Anaemia Working Group found that about one-third of pregnant Malaysian women are anaemic. (Dr. Milton Lum , 2009).Anaemia occurs because there is increased demand for iron and vitamins in pregnancy. The mother has to produce more red blood cells for herself and the foetus. More plasma is also produced.The blood volume increases by about 50% during pregnancy with a disproportionate increase in plasma. This leads to a dilution of the blood with the haemoglobin falling. The haemoglobin is at its lowest level between 24 and 30 weeks of pregnancy.
Poor diet: If the diet is low in iron and vitamins, especially folic acid, there is a risk of anaemia as these are the raw materials needed to produce sufficient numbers of red blood cells. Vegetarians who have a strict diet may not get enough iron or vitamin B12 in their food.
Family history: Some women whose family members have anaemia because of inherited genes are at increased risk. Chronic conditions like kidney or liver failure, and cancer increases the risk. Chronic blood loss from some parts of the body due to ulcers, haemorrhoids, etc, may lead to iron deficiency anaemia.
2.3 Regulation of iron transfer to the fetus
Transfer of iron from the mother to the fetus is supported by a substantial increase in maternal iron absorption during pregnancy and is regulated by the placenta .Serum ferritin usually falls markedly between 12 and 25 wk of gestation, probably as a result of iron utilization for expansion of the maternal red blood cell mass. Most iron transfer to the fetus occurs after week 30 of gestation, which corresponds to the time of peak efficiency of maternal iron absorption. Serum transferrin carries iron from the maternal circulation to transferrin receptors located on the apical surface of the placental syncytiotrophoblast, holotransferrin is endocytosed, iron is released, and apotransferrin is returned to the maternal circulation. The free iron then binds to ferritin in placental cells where it is transferred to apotransferrin, which enters from the fetal side of the placenta and exits as holotransferrin into the fetal circulation. This placental iron transfer system regulates iron transport to the fetus. When maternal iron status is poor, the number of placental transferrin receptors increases so that more iron is taken up by the placenta. Excessive iron transport to the fetus may be prevented by the placental synthesis of ferritin.
2.4 Effect of anemia on maternal mortality and morbidity
The major concern about the adverse effects of anemia on pregnant women is the belief that this population is at greater risk of perinatal mortality and morbidity. Maternal mortality in selected developing countries ranges from 27 (India) to 194 (Pakistan) deaths per 100000 live births. Some data show an association between a higher risk of maternal mortality and severe anemia, although such data were predominantly retrospective observations of an association between maternal hemoglobin concentrations at, or close to, delivery and subsequent mortality. Such data do not prove that maternal anemia causes higher mortality because both the anemia and subsequent mortality could be caused by some other condition. For example, in a large Indonesian study, the maternal mortality rate for women with a hemoglobin concentration <100 g/L was 70.0/10000 deliveries compared with 19.7/10000 deliveries for nonanemic women.
2.5 Maternal anemia and birth weight
The relation between maternal anemia and birth weight has been reviewed more extensively elsewhere in this issue. In several studies, a U-shaped association was observed between maternal hemoglobin concentrations and birth weight. Abnormally high hemoglobin concentrations usually indicate poor plasma volume expansion, which is also a risk for low birth weight. Lower birth weights in anemic women have been reported in several studies. In a multivariate regression analysis of data from 691 women in rural Nepal, adjusted decrements in neonatal weight of 38, 91, 187, and 153 g were associated with hemoglobin concentrations â‰¥20, 90-109, 70-89 and <70 g/L, respectively. The odds for low birth weight were increased across the range of anemia, increasing with lower hemoglobin in an approximately dose-related manner (1.69, 2.75, and 3.56 for hemoglobin concentrations of 90-109, 70-89, and 110-119 g/L, respectively). Trials that included large numbers of iron-deficient women showed that iron supplementation improved birth weight.
2.6 Maternal iron deficiency anemia and duration of gestation
There is a substantial amount of evidence showing that maternal iron deficiency anemia early in pregnancy can result in low birth weight subsequent to preterm delivery. For example, Welsh women who were first diagnosed with anemia (hemoglobin <104 g/L) at 13-24 wk of gestation had a 1.18-1.75-fold higher relative risk of preterm birth, low birth weight, and prenatal mortality. After controlling for many other variables in a large Californian study, Klebanoff et al showed a doubled risk of preterm delivery with anemia during the second trimester but not during the third trimester. In Alabama, low hematocrit concentrations in the first half of pregnancy but higher hematocrit concentrations in the third trimester were associated with a significantly increased risk of preterm delivery. When numerous potentially confounding factors were taken into consideration, analysis of data from low-income, predominantly young black women in the United States showed a risk of premature delivery (<37 wk) and subsequently of having a low-birth-weight infant that was 3 times higher in mothers with iron deficiency anemia on entry to care.
2.7 Maternal anemia and infant health
An association between maternal anemia and lower infant Apgar scores was reported in some studies. In 102 Indian women in the first stage of labor, higher maternal hemoglobin concentrations were correlated with better Apgar scores and with a lower risk of birth asphyxia. When pregnant women were treated with iron or a placebo in Niger, Apgar scores were significantly higher in those infants whose mothers received iron. A higher risk of premature birth is an additional concern related to the effect of maternal iron deficiency on infant health; preterm infants are likely to have more perinatal complications, to be growth-stunted, and to have low stores of iron and other nutrients. In the Jamaican Perinatal Mortality Survey of >10000 infants in 1986, there was an â‰ˆ50% greater chance of mortality in the first year of life for those infants whose mothers had not been given iron supplements during pregnancy, although the iron status of these infants and their mothers was not assessed. Apart from this survey, there is little known concerning the effects of maternal iron status during pregnancy on the subsequent health and development of the infant.
2.8 Benefits of iron supplementation on maternal iron status
There is little doubt that iron supplementation improves maternal iron status. Even in industrialized countries, iron supplements have been reported to increase hemoglobin, serum ferritin, mean cell volume, serum iron, and transferrin saturation. These improvements are seen in late pregnancy, even in women who enter pregnancy with adequate iron status. When compared with unsupplemented pregnant women, differences in iron status due to supplementation usually occur within â‰ˆ3 mo of the time supplementation begins. Supplementation can reduce the extent of iron depletion in the third trimester. However, for women who enter pregnancy with low iron stores, iron supplements often fail to prevent iron deficiency.
The benefits of iron supplementation on maternal iron status during pregnancy become even more apparent postpartum. This is illustrated by a Swedish study in which all pregnant women who did not take iron supplements had less than “sufficient” iron stores in late pregnancy compared with 43% of supplemented (200 mg Fe/d) women.
Use of nutritional supplements
Intake of iron supplements during pregnancy was also found to have a protective effect with anaemia in pregnancy. This is consistent with the findings of some other studies on iron supplementation and pregnancy outcome (Hesss et al.,2001). Iron supplementation during pregnancy protects a women from becoming anaemic because the required amounts may not be supplied from dietary intake during this period. Controlled trials of iron supplementation during pregnancy have consistently demonstrated positive effects on maternal iron status at delivery.
The prevalence of low hemoglobin or hematocrict is reduced: serum ferritin, serum iron and almost every other measure of maternal iron status, including bone marrow iron, are increased in comparison with controls (Mohamed, 1998). Malaysia has gone a long way towards improving the nutritional status of the population. Malnutrition has been defined as a “pathological state resulting from a relative or a absolute deficiency or excess of one or more essential nutrients,” it can comprise four forms-under-nutrition, over-nutrition, imbalance and specific deficiency (Park, 20000.
Antenatal booking is a an assessment of the physical, social, psychological and emosional state of the pregnant women. The main purpose of the booking visit to obtain a comprehensive history, establish the gestational age and identify maternal and ftal risk factors. Baseline investigations are performed. According to Adesina et al. (2003), stated that early antenatal booking and good control in pregnancy are strongly advocated as means of achieving good pregnancy outcome. It support by Tayie and Lartey (2008), found that early antenatal care was associated with pregnancy outcomes.
Number of visits to antenatal clinics
Antenatal clinic (ANC), refer to pregnancy related services provided between conception and delivery consisting of monitoring health status mother and her pregnancy. ANC was expected to ontain of mother to get anaemia and preterm delivery rete, a higher average birth weight and decreased neonatal mortality. According to Kost et al.(1998), antenatal clinic (ANC) visits could possibly be seen as indicator of the mother’s sense of responsibility to her unborn baby. Visit to ANC services could also have a positive influence on the attitude of the mother, will impact on birth-outcomes. Total numbers of ANC visits for the current pregnancy were categorized as >4 visit and < 4 visit, based on the World Health Organization (WHO) and UNUCEF criteria that women should have > 4 ANC visits with an appropriate health care provided (World health organization,2004)
ANC visits as part of primary health care to early detection and treatment of probable problem areas, and contribute to the quality of the birth outcome. ANC has been associated with improved maternal and perinatal outcome, but there is no agreement on the most effecting timing of visit antenatal mother. In Malaysia, the frequency of ANC visit depends on the gestational such as 0-28 week every one mont, 28-36 week every 2 week and 36-4- week every 1 weeks.
Antepartum haemorrhage (APH)
vagina bleeding is an important factor predictor of adverse effects anemia mothers. About 50% of women who bleeding in last half of pregnancy have placenta praevia or abruptio placenta. When ever the bleeding occurs at the beginning of pregnancy, however the cause is often unknown ( Valero de Bernabe et al.,2004).
3.1 Study Location
This study were carried out at the antenatal ward, Hospital Jeli, Kelantan.
3.2 Study Design
A cross-sectional study design were done in antenatal ward, Hospital Jeli, Kelantan from period of January until March 2011.
3.3.1 Sampling population
All mothers who admitted to antenatal ward, Hospital Jeli, Kelantan during the period of January until March 2011 were included in the study.
3.3.2 Sampling frame
A list of all antenatal mothers who are admitted at antenatal ward Hospital Jeli, Kelantan during the period of January – March 2011 were obtained.
3.3.3 Sampling Method
Simple random Sampling, where all antenatal mothers who fulfil inclusion criteria were selected.
3.3.4 Sample Size
The minimum sample size required in this study was 30. Data were collected by using close and open – ended questionnaires and recode review of admission registered at antenatal ward, Hospital Jeli, Kelantan. In this study, all antenatal mothers who admitted were choosing by Universal sampling.
3.3.5 Inclusion Criteria
Mothers who are willing to participate study
All The citizen mothers
3.3.6 Exclusion criteria
Mothers who’s refuse to participate in this study
Non citizen mothers
Mothers who not understand Malay and English language.
3.4 Research Instrument
An interviewer – administered questionnaire was developed with two sections:
Section A (demographic data)
Factors socio demographic (Maternal age, races, education level, family income, employment status, employment status of husband , Hb level and number of dependents.
Section B (prenatal care of mothers)
Period of gesational , antenatal booking, antenatal clinics ,parity, nutritional supplements,.
Section C ( Maternal Health Status)
Factors of maternal health status (past medical history, big baby, infection during pregnancy, Ante partum hemorrhage and hyperemesis during pregnancy.
3.5 Definition of study variables
The dependent variable:
The independent variables
socio demographic factors
Occupational of mothers
Occupational of husband
Agriculture & forestry
Montly family income. It is divided to 3 categories;
Hb level of mother during admission
Mild anemia ( 10.0 – 10.9 g/dL )
Moderate anemia (7.0 – 9 g/dL)
Severe anemia (<7.0 g/dL )
Number of dependents
ii. Prenatal care of mothers
Number of children (parity) all the numbers of previous pregnancies resulting in either live births or still births after 22 weeks of gestational age.
Number of visits to antenatal clinics that divided to 3 categories
Above 8 visit
Gestational age of mother – Time measured from the first day of the women’s last menstrual cycle to the current date.
Use of nutritional supplements such as iron, folic acid, multivitamin and others
iii. Maternal Health status
Past medical history -Gestational Diabetic Mellitus (GDM)
-Pregnancy Induced Hypertension (PIH)
Ante Partum Haemorrhage
3.6 Definition of terms
1. Anaemia: Anaemia is a lack of red blood cells, which can lead to a lack of oxygen – carrying ability, causing unusual tiredness.
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