Food Insecurity, Prenatal Care and Other Anemia Determinants in Pregnant Women from the NISAMI Cohort, Brazil: Hierarchical Model Concept

Demétrio, Fran; Teles-Santos, Carlos Antônio de Souza; Santos, Djanilson Barbosa dos

doi:10.1055/s-0037-1604093

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Original Article • Rev. Bras. Ginecol. Obstet. 39 (08) • Aug 2017 • https://doi.org/10.1055/s-0037-1604093 copy

Food Insecurity, Prenatal Care and Other Anemia Determinants in Pregnant Women from the NISAMI Cohort, Brazil: Hierarchical Model Concept

Insegurança alimentar, cuidado pré-natal e outros determinantes da anemia em mulheres grávidas da coorte Nisami, Brasil: modelo conceitual hierárquico

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To identify the prevalence of anemia and its relation to food insecurity (FI) and other determinants in pregnant women.

Methods

A cross-sectional, cohort-nested study, with the participation of 245 pregnant women who were cared for at Family Health Units in the municipality of Santo Antônio de Jesus, Bahia, Brazil. The participants underwent blood tests for hemoglobin levels, anthropometric examinations, and answered a structured questionnaire. The hemoglobin (Hb) parameter (Hb < 11 g/dL) was used for the classification of the diagnosis of anemia. Food insecurity was evaluated using the North American short-scale food insecurity assessment. Logistic regression was adopted for the statistical analyses, based on a hierarchical conceptual model that enabled the measurement of the decomposition of the total effect of its non-mediated and mediated components using the proposed hierarchical levels.

Results

The prevalence of anemia in the studied population was of 21.8%, and the average hemoglobin was 12.06 g/dL (standard deviation [SD]: 1.27). Food insecurity was identified in 28.16% of the pregnant women. The average maternal age was 25.82 years (SD: 5.94). After ranking, the variables positively associated with anemia remained significant: FI (odds ratio [OR] =3.63; 95% confidence interval [95%CI]: 1.77-7.45); not undergoing prenatal care (OR = 5.15;95%CI: 1.43-18.50); multiparity (OR = 2.27;95%CI: 1.02-5.05); and non-supplementation of iron medication (OR = 2.45; 95%CI: 1.04-5.76). The results also indicated that the socioeconomic and environmental factors were largely mediated by food insecurity and factors regarding prenatal care.

Conclusions

In the present study, the chance of occurrence of anemia in pregnant women was significantly higher,mainly among women: in situations of food insecurity, not undergoing prenatal care, not having received iron supplements, and who are multiparous.

Keywords:
women’s health; pregnant women; anemia; prenatal care; food and nutrition security

Questions
Item 1. During the past twelve months, did the food in your house finish and you had no money to buy more?
Item 2. During the past twelve months, could you offer varied food to your family, with beans, rice, meat, salad and fruit?
Item 3. During the past twelve months, did you or any other member of your household have to decrease the quantity of food or not have a meal for lack of money to buy more food?
Item 4. In how many months did this occur?
Item 5. During the past twelve months, did you eat less than you would wish to because you had no money to buy more food?
Item 6. During the past twelve months, did you feel hungry but did not eat because you had no money to buy more food?

Variables (n= 245)	n	%	Anemia				p*
			No		Yes
			n	%	n	%
Block I
Family income (monthly income in minimum wages)							0.30
< 2	51	20.82	36	70.59	15	29.41
2 to 4	129	52.65	103	79.84	26	20.16
≥ 5	65	26.53	53	81.54	12	18.46
Receiving social welfare (“Bolsa família” program)							0.21
Yes	54	22.04	39	72.22	15	27.78
No	191	77.96	153	80.1	38	19.8
Schooling (years)							0.83
8 or more	94	38.37	73	77.66	21	22.34
Up to 7	151	61.63	119	78.81	32	21.19
Marital status							0.12
With partner	196	80.00	65	84.42	12	15.58
Without partner	49	20.00	127	75.60	41	24.40
Position in the labor market							0.01
Working	104	42.45	89	85.58	15	14.42
Unemployed	141	57.55	103	73.05	38	26.95
Skin color							0.09
Not black	30	12.24	27	90.00	3	10.00
Black	215	87.76	165	76.74	50	23.26
Number of inhabitants in the household							0.02
< 4	148	60.41	123	83.11	25	16.89
≥ 4	97	39.59	69	71.13	28	28.87
Block II
Food insecurity							< 0.0001
No	176	71.84	150	85.23	26	14.77
Yes	69	28.16	42	60.87	27	39.13
Block III
Block III.a
Planned pregnancy							0.07
Yes	100	40.82	84	84.00	16	16.00
No	145	59.18	108	74.48	37	25.52
Prenatal care							< 0.01
Yes	187	76.33	154	82.35	33	17.65
No	58	23.67	38	65.52	20	34.48
Quarter in which the prenatal care began							0.29
I	43	17.55	30	69.77	13	30.23
II	189	77.14	151	79.89	38	20.11
III	13	5.31	11	84.62	2	15.38
Period of gestation (months)							0.38
I Quarter	38	15.51	33	86.84	5	13.16
II Quarter	195	79.59	150	76.92	45	23.08
III Quarter	12	4.90	9	75.00	3	25.00
Number of prenatal consultations							0.56
< 6	5	2.04	3	60.00	2	40.00
6 to 9	42	17.14	34	80.95	8	19.05
≥ 10	198	80.82	155	78.28	43	21.72
Parity							0.04
Primipara	109	44.49	92	84.4	17	15.6
Multipara	136	55.51	100	73.53	36	26.47
Use of medicinal iron supplementation							0.02
Yes	88	35.92	76	86.36	12	13.64
No	157	64.08	116	73.89	41	26.11
Block III.b
Received prenatal nutritional guidance							0.13
Yes	112	45.71	83	74.11	29	25.89
No	133	54.29	109	81.95	24	18.05
Pregestational anthropometrical nutritional status							0.23
Low weight	138	56.33	113	81.88	25	18.12
Adequate	22	8.98	14	63.64	8	36.36
Excess weight	85	34.69	65	76.47	20	23.53
Block III.c
Alcohol consumption							0.18
No	210	85.71	167	79.52	43	20.48
Yes	35	14.29	25	71.43	10	28.57
Age (years)							0.12
< 18	17	6.94	10	58.82	7	41.18
18 to 30	170	69.39	135	79.41	35	20.59
> 30	58	23.67	47	81.03	11	18.97

Variables	Model A(block I)⁺	Model B(blocks I, II)⁺	Model C(blocks I, II, III.a)⁺	Model D(blocks I, II, III.a)⁺	Model E(blocks I, II, III)⁺
Level 1–Block I: Socioeconomic and environmental factors
Marital status
With partner	1	1			1
Without partner	1.88 (0.89–3.99)	1.95 (0.90–4.25)	0.71 (0.22–1.86)	0.86 (0.34–2.15)	0.78 (0.29–2.09)
Position in the labor market
Working	1	1			1
Unemployed	2.06 (1.04–4.05)	1.62 (0.80–3.28)	1.64 (0.79–3.42)	1.73 (0.83–3.58)	1.65 (0.77–3.53)
Number of residents in the household
< 4	1	1			1
≥ 4	1.83 (0.97–3.43)	1.93 (1.01–3.70)	2.31 (1.15–4.64)	2.25 (1.13–4.48)	1.97 (0.95–4.09)
Schooling (years)
8 or more	1	1			1
Up to 7	1.35 (0.69–2.63)	1.40 (0.70–2.80)	0.38 (0.12–1.14)	0.38 (0.12–1.16)	0.36 (0.11–1.15)
Level 2–Block II
Food insecurity
No		1			1
Yes		3.46 (1.78–6.75)	3.60 (1.78–7.28)	3.74 (1.86–7.54)	3.63 (1.77–7.45)*
Level 3–Block III
Block III.a. Prenatal care factors
Prenatal care
Yes					1
No			5.98(1.74–20.52)	5.15 (1.52–17.36)	5.15(1.43–18.50)*
Parity
Primipara					1
Multipara			1.89(0.91–3.94)		2.27(1.02–5.05)*
Use of medicinal iron supplementation
Yes					1
No			2.46(1.10–5.48)	2.42 (1.09–5.35)	2.45(1.04–5.76)*
Block III.b. Nutritional Factors
Received nutritional prenatal guidance
Yes					1
No					0.64 (0.31–1.33)
Block III.c. Lifestyle and maternal factors
Alcohol consumption
No					1
Yes					1.89 (0.72–4.90)
Age (years)
< 18					0.64 (0.31–1.33)
18 to 30					1
> 30					0.38 (0.91–1.62)
AIC	253.46	242.08	231.21	232.22	234.53

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[1] Address for correspondence Fran Demétrio, PhD, Centro de Ciências da Saúde, Universidade Federal do Recôncavo da Bahia, Av. Carlos Amaral, n° 1015, Cajueiro, 44570-000 - Santo Antônio de Jesus, BA, Brazil (e-mail: frandemetrio7@gmail.com; fdemetrio@ufrb.edu.br).