Open Access Original

Article DOI: 10.7759/cureus.38491

Factors Related to Anemia Prevalence Among

Women of Childbearing Age in the Period of
Review began 04/20/2023
Global Pandemic
Review ended 04/30/2023
Published 05/03/2023 Muhammad Hammad 1 , Sadaf Fardoos 2 , Rasikh Arif 3 , Ali Zeb Khan 4 , Anmol Rasheed 5

© Copyright 2023
Hammad et al. This is an open access 1. Pharmacy, Shifa Tameer-E-Millat University, Shifa College of Pharmaceutical Sciences, Islamabad, PAK 2. Riphah
article distributed under the terms of the Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, PAK 3. Al-Shifa Research Centre, Al-
Creative Commons Attribution License CC- Shifa Trust Eye Hospital, Rawalpindi, PAK 4. Clinical Research, Al-Shifa Trust Eye Hospital, Rawalpindi, PAK 5. Riphah
BY 4.0., which permits unrestricted use, School of Leadership, Riphah International University, Rawalpindi, PAK
distribution, and reproduction in any
medium, provided the original author and
source are credited. Corresponding author: Muhammad Hammad , mhhammad497@gmail.com

Abstract
Background
Health authorities in Pakistan in collaboration with local and foreign non-government organizations are
working hard to achieve the targets set by World Health Organization in 2012, that is, to reduce anemia
prevalence and its related factors. However, due to the prevailing COVID-19 crisis, all resources and
attention were diverted toward it, which led to ignorance of existing basic health issues.

Objective
This study assesses anemia prevalence and its related factors among women of childbearing age in the
period of global pandemic.

Methods
A time-lagged, cross-sectional survey was conducted using a self-administered questionnaire among 1,702
volunteer women aged between 15 and 49 years across five major cities of Pakistan from January 2021 to
December 2021 using the non-probability consecutive sampling technique. Blood sample results were
analyzed to determine prevalence and anemia severity. The chi-squared test and multiple logistic regression
were performed to examine the relationship and effect of related factors with hemoglobin levels using SPSS
version 26.

Results
Among the 1,702 respondents, 788 (46.3%) were non-anemic and 914 (53.7%) were anemic. Anemia
prevalence in Karachi was slightly greater (n=294, 55.48%) compared to other cities, and the mean
hemoglobin level was 11.98 ± 0.92 g/dL. The chi-square test and multiple logistic regression indicated that
the respondents’ employment status, mother’s profession, family income, living conditions, chronic health
conditions, use of iron and folic acid supplements, junk food, source of drinking water, and knowledge about
anemia and its preventive measures were associated significantly with anemia during the pandemic.

Conclusion
Results confirmed that anemia is a multi-factor health problem and that it was totally ignored during the
COVID-19 pandemic, as the prevalence increased during the pandemic. Therefore, more attention should be
paid to anemia surveillance, anemia awareness programs, and mobilization of community health workers
and volunteers to reach a wide range of the population, including women of childbearing age even during
the pandemic.

Categories: Epidemiology/Public Health, Nutrition, Health Policy

Keywords: pakistan, prevalence, women of childbearing age, related factors, anemia, covid-19

Introduction
Iron is one of the essential minerals that our bodies require to perform some of its fundamental activities.
Iron, as part of structural component of hemoglobin, plays an important role in the transportation of oxygen
from the lungs to the body cells [1]. Iron is essential to produce hemoglobin by erythroblasts; thus, if there is
an insufficient supply of iron, the cells fail to produce hemoglobin, resulting in a condition known as
“anemia” [2]. The normal level of hemoglobin for non-pregnant women and males (aged 15 years and above)
is 120 gm/L and 130 gm/L respectively, according to the World Health Organization. If the level is detected
below the normal range, we call the condition as “anemia” [2-3].

How to cite this article

Hammad M, Fardoos S, Arif R, et al. (May 03, 2023) Factors Related to Anemia Prevalence Among Women of Childbearing Age in the Period of
Global Pandemic. Cureus 15(5): e38491. DOI 10.7759/cureus.38491
 In the past few decades, anemia has been one of the major global developmental health problems, and this
non-communicable disease is increasing rapidly in both developed and developing countries [4]. However,
the prevalence of anemia is much higher in underdeveloped countries than in developed countries due to
low socioeconomic status and limited healthcare facilities [5-6]. In Pakistan, anemia is categorized as a
major nutritional deficiency disorder among infants, pregnant women, and non-pregnant women [6-7]. The
COVID-19 pandemic further deteriorated healthcare system and economies of the developing countries,
which led to ignorance of existing basic health issues [8].

Almost two billion people across the globe are affected by anemia, either directly or indirectly. The common
effects are as follows: delayed normal motor function in infants, increasing risk of low birth weight or
premature babies, fatigue in adults, effect on memory, and poor academic performance [9]. An anemic
person shows different signs and symptoms, but the common signs and symptoms are chronic fatigue, loss
of appetite, headaches, irritability, and loss of concentration [10-11].

Various studies have been conducted among women of different ages across the globe, but no study has been
conducted to date that highlights anemia and its related factors during the global pandemic. Moreover,
factors such as healthcare utilization, chronic health conditions, junk food, use of iron and folic acid
supplements, and availability of clean drinking water have not been studied yet. The current study aims to
evaluate the prevalence of anemia in women of childbearing age and to determine the factors linked with it
during the global pandemic. The results of the study can help plan nutritional intervention and address the
causes that lead to anemia among women of childbearing age in the period of global pandemic.

Materials And Methods

A time-lagged, cross-sectional survey was carried out using a self-administered questionnaire in five major
cities of Pakistan (Peshawar, Islamabad, Rawalpindi, Lahore, and Karachi) to study anemia prevalence and
its associated characteristics among women of childbearing age between 15 and 49 years from January 2021
to December 2021. Factors such as age, education level, marital status, employment status, family size,
father's profession, mother's profession, family income, BMI, menstrual period duration, healthcare
utilization, exercise habits, chronic health condition, knowledge about anemia, use of iron and folic acid
supplements, use of multi-vitamins, tobacco use, number of meal per day, knowledge about anemia causes,
fertility status, breastfeeding, and knowledge about preventive measures were part of the designed
questionnaire. The ethical clearance of the study was taken from the Institutional Review Board of Riphah
International University, Rawalpindi, Pakistan (Reference no. FMS/RSL/ERC.009). A total of 1,702
respondents’ blood samples were taken, and the questionnaires were distributed after orally explaining to
them the purpose of the study and after taking written informed consent from them. Respondents with
cognitive or perceptive problems were excluded from the study. The data were collected, compiled, and
analyzed using the SPSS (Statistical Package for the Social Science) Version 26 (IBM Corp. Armonk, NY). The
blood sample results were used for classification of anemia severity. The independent variable of the study
was all related factors, and the dependent variable was hemoglobin levels in women of childbearing age.
Descriptive statistics was used to describe the study population characteristics. The chi-square test was used
to assess the relationship between associated characteristics and hemoglobin levels, whereas multiple
logistic regression analysis was used to assess the individual factors affecting hemoglobin levels. A p-value
of ≤0.05 was considered statistically significant.

Results
Table 1 shows the results of anemia severity in women of childbearing age based on hemoglobin levels.
Among the respondents, 788 (46.3%) were non-anemic and 914 (53.7%) were suffering from anemia. Among
the 914 (53.6%) respondents with anemia, the prevalence of mild, moderate, and severe anemia was 493
(29.0%), 342 (20.1%), and 79 (4.9%) respectively. The sum of mean hemoglobin levels among all women of
childbearing age was 11.98 ± 0.92 g/dL.

2023 Hammad et al. Cureus 15(5): e38491. DOI 10.7759/cureus.38491 2 of 11

 Anemia Severity Frequency (n) Percent (%) Mean ± SD (g/dL)

Normal 788 46.4 13.05 ± 0.54

Mild 493 29.0 11.33 ± 0.25

Moderate 342 20.1 9.95 ± 0.47

Severe 79 4.9 7.12 ± 0.12

Total 1,702 100.0 11.98 ± 0.92

TABLE 1: Results of anemia severity in women of childbearing age based on the hemoglobin
levels.

Table 2 shows the prevalence of anemia and its level of severity in different cities of Pakistan. Results
showed that the prevalence of anemia in Karachi was slightly greater (n=294, 55.48%) compare with that in
Peshawar (n=209, 55.00%) and Rawalpindi and Islamabad (n= 211, 54.42%). However, the prevalence of non-
anemic respondents was significantly higher in Lahore (n= 205, 50.62%) than other cities. Moreover, the
number of severe anemic women was much higher in Karachi (n= 36, 6.78%) compared to other cities.

Anemia Severity Peshawar Rawalpindi and Islamabad Lahore Karachi Total

n % n % n % n % n %

Normal 171 45.00 176 45.48 205 50.62 236 44.52 788 46.30

Mild 110 28.95 121 31.27 89 21.98 173 33.64 493 29.00

Moderate 86 22.63 71 18.34 100 24.68 85 16.03 342 20.10

Severe 13 3.42 19 4.91 11 2.72 36 6.78 79 4.90

Total 380 100.00 387 100.00 405 100.00 530 100.00 1702 100.00

TABLE 2: Prevalence of anemia and their levels of severity in different cities of Pakistan.

Table 3 shows the results of the chi-square test to find the relationship between associated factors and
hemoglobin levels. Of the total 1,702 women, the majority of the women belong to the age group of 31-49
years (41.71%) and 15.15% of them were obese. Also, 50% of them were unmarried and had intermediate
education (30.43%); 52.41% of women were unemployed and 34.61% of them had a family income of greater
than 100,000. Around 9.93% of them lived in slums and 48.88% of them had knowledge about anemia
causes. Most of the women (75.21%) were fecund, 29.14% were using contraception pills, 20.98% breastfed
their babies, 77.56% had a one- to two-year gap between their babies, and 91.95% of them lived in urban
areas. Moreover, 19.62% and 17.51% of women used iron and folic acid supplements, respectively. The
majority of them (90.83%) were non-smokers and had two meals a day, 46.83% and 54.76% drank tap or
government supply water or tanker, respectively, 29.20 of them had other chronic health conditions, and
66.86% of them visited healthcare facilities only at the time of illness. Around 25.92% were having two or
three children and 35.84% had a family size of seven and more; 55.17% of the women were housewives and
29.91% women’s husbands or fathers were working in the private sector. Around 94.07% have not had any
adverse pregnancy outcome, whereas 28.43% had a menstrual period duration of more than five days. The
chi-square test showed that age, educational level, marital status, employment status, family size, mother’s
profession, family income, menstrual period duration, healthcare utilization, exercise habits, chronic health
conditions, living condition, iron supplements, folic acid supplements, junk food, tobacco use, number of
meal per day, knowledge about anemia and preventive measures, fertility status, breastfeeding, place of
residence, drinking water source, husband’s or father’s occupation, number of children, contraception pill
use, and adverse pregnancy outcome had a relationship with hemoglobin levels, whereas pregnancy gap, and
BMI showed no significant relationship with hemoglobin levels.

Anemic Non-Anemic Total

Factors Total (Weighted) p-value
N % n % n %

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 Age 1702

15-30 118 12.91 222 28.17 340 19.98

0.001
31-40 353 38.62 299 37.94 652 38.31

31-49 443 48.47 267 33.89 710 41.71

Educational level 1702

Illiterate 291 31.84 101 12.82 392 23.03

Matric 240 26.26 145 18.40 385 22.62 0.001

Intermediate 248 27.13 270 34.26 518 30.43

Bachelor& above 135 14.77 272 34.52 407 23.92

Marital status 1702

Married 337 36.87 433 54.95 770 45.24

0.001
Unmarried 515 56.35 336 42.64 851 50.00

Divorce 62 6.78 19 2.41 81 4.76

Employment status 1702

Employed 448 49.02 362 45.94 810 47.59 0.001

Unemployed 466 50.98 426 54.06 892 52.41

Family size 1702

≤4 101 11.05 147 18.65 248 14.57

0.001
5-6 493 53.94 351 44.54 844 49.59

≥7 320 35.01 290 36.81 610 35.84

Mother profession 1702

House wife 508 55.58 431 54.70 939 55.17

Government employee 123 13.46 118 14.97 241 14.16

0.001
Private sector 145 15.86 132 16.74 277 16.27

Business 119 21.77 90 11.42 209 12.28

Others 19 2.08 17 2.16 36 2.12

Family income 1702

≤ 20000 195 21.33 85 10.79 280 16.45

0.001
20001-50000 110 12.04 213 27.03 323 18.98

50001-99999 247 27.02 263 33.38 510 29.96

≥ 100000 362 39.61 227 28.80 589 34.61

BMI 1702

Underweight 238 26.04 111 14.09 349 20.51

0.180
Normal 351 38.40 476 60.41 827 48.59

Overweight 165 18.05 103 13.07 268 15.75

Obese 160 17.51 98 12.43 258 15.15

Menstrual period duration 1702

No 108 11.82 56 7.11 164 9.64

2-3 days 170 18.59 170 21.57 340 19.98 0.001

4-5 days 242 26.48 472 59.90 714 41.95

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 >5 days 394 43.11 90 11.42 484 28.43

Healthcare utilization 1702

Only in illness 566 61.93 572 72.59 1138 66.86

0.001
1-2 years 276 30.19 165 20.94 441 25.91

Every 6 months 72 7.88 51 6.47 123 7.23

Exercise habits 1702

Not at all 492 53.83 453 57.49 945 55.52

0.001
Sometimes 288 31.51 243 30.84 531 31.20

Daily 134 14.66 92 11.67 226 13.28

Chronic health condition 1702

Yes 306 33.48 191 24.24 497 29.20 0.001

No 608 66.52 597 75.76 1205 70.80

Living conditions 1702

Normal house/Flat 768 84.03 765 97.08 1533 90.07 0.001

Slums 146 15.97 23 2.92 169 9.93

Iron supplements use 1702

Yes 134 14.66 200 25.38 334 19.62 0.001

No 780 85.34 588 74.62 1368 80.38

Folic acid supplements 1702

Yes 104 11.38 194 24.62 298 17.51 0.022

No 810 88.62 594 75.38 1404 82.49

Junk food 1702

Mostly 519 56.78 335 42.51 854 50.18 0.001

Rarely 395 43.22 453 57.49 848 49.82

Tobacco use 1702

Yes 73 7.99 83 10.53 156 9.17 0.001

No 841 92.01 705 89.47 1546 90.83

No of meals per day 1702

1 85 9.30 45 5.71 130 7.64

0.001
2 414 45.30 383 48.60 797 46.83

≥3 415 45.40 360 45.69 775 45.53

Knowledge about anemia causes 1702

Yes 383 41.90 449 56.98 832 48.88 0.001

No 531 58.10 339 43.02 870 51.12

Preventive measure knowledge 1702

Yes 377 41.25 530 67.26 907 53.29 0.001

No 537 58.75 258 32.74 795 46.71

Fertility status 1702

In fecund 55 6.01 140 17.77 195 11.46

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 Fecund 702 76.81 578 73.35 1280 75.21 0.001

Pregnant 54 5.91 25 3.17 79 4.63

Post-partum amenorrhea 103 11.27 45 5.71 148 8.70

Breastfeeding 1702

Yes 227 24.84 130 16.50 357 20.98 0.001

No 687 75.16 658 83.50 1345 79.02

Place of residence 1702

Rural 58 6.35 79 10.03 137 8.05% 0.001

Urban 856 93.65 709 89.97 1565 91.95%

Husband or Father occupation 1702

Government employee 230 25.16 132 16.75 362 21.27

Private sector 268 29.33 241 30.59 509 29.91

0.001
Business 274 29.98 189 23.98 463 27.20

Skilled worker 128 14.00 162 20.56 290 17.04

Agriculture 14 1.53 64 8.12 78 4.58

Drinking water source 1702

Tap or Government supply or Tanker 553 60.50 379 48.10 932 54.76
0.035
Well 201 21.99 285 36.16 486 28.55

Others (Mineral water) 160 17.51 124 15.74 284 16.69

No of children 1702

0 368 40.26 488 61.93 856 50.29

1-2 126 13.79 96 12.18 222 13.04 0.001

2-3 289 31.62 152 19.30 441 25.92

>3 131 14.33 52 6.59 183 10.75

Adverse pregnancy outcome 1702

No 833 91.14 768 97.46 1601 94.07 0.001

Yes (stillbirth, miscarriage, abortion) 81 8.86 20 2.54 101 5.93

Contraception pill 1702

Yes 318 34.79 178 22.59 496 29.14 0.001

No (others) 596 65.21 610 77.41 1206 70.86

Pregnancy gap 1702

0 years 56 6.13 78 9.90 134 7.87

0.735
1-2 years 735 80.42 585 74.24 1320 77.56

3-4 years 3 13.45 125 15.86 248 14.57

TABLE 3: Results of the chi-square test to reveal the factors and their association with
hemoglobin levels among women of childbearing age.

The computed results of multiple logistic regression analysis in Table 4 showed that BMI, family size,
healthcare utilization, exercise habits, tobacco use, number of meals per day, and place of residence did not
show a significant association with hemoglobin levels, whereas education level, employment status, chronic

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 health conditions, junk food, anemia cause knowledge, preventive measure knowledge, breastfeeding,
husband’s or father's occupation, contraception use, and repeated pregnancy have a negative association
with hemoglobin levels. On the other hand, age, source of drinking water, marital status, mother's
profession, family income, menstrual period duration, living conditions, iron supplement use, folic acid use,
fertility status, number of children, and adverse pregnancy outcome have a positive impact on hemoglobin
levels among women of childbearing age.

95% CI
Associated Characteristics B df P-value
Lower Upper

Age 0.083 2 0.060 0.105 0.001

Educational level -0.091 3 -0.107 -0.075 0.001

Marital status 0.091 2 0.035 0.147 0.001

Employment status -0.078 1 -1.33 -0.023 0.005

Family size -0.006 2 -0.030 0.019 0.637

Mother’s profession 0.051 4 0.034 0.067 0.001

Family income 0.028 3 0.000 0.056 0.043

BMI -0.005 3 -0.022 0.012 0.580

Menstrual period duration 0.051 3 0.026 0.077 0.001

Healthcare utilization 0.010 2 -0.030 0.051 0.619

Exercise habits 0.001 2 -0.046 0.048 0.973

Chronic health condition -0.408 1 -0.467 -0.349 0.001

Living conditions 0.657 1 0.574 0.740 0.001

Iron supplement use 0.241 1 0.138 0.345 0.001

Folic acid supplement use 0.353 1 0.250 0.456 0.001

Junk food -0.121 1 -0.171 -0.071 0.001

Tobacco use 0.045 1 -0.034 0.125 0.263

Number of meals per day -0.056 2 -0.119 0.006 0.074

Knowledge about anemia causes -0.263 1 -0.338 -0.188 0.001

Preventive measures knowledge -0.260 1 -0.309 -0.211 0.001

Fertility status 0.049 3 0.026 0.073 0.001

Breastfeeding -0.053 1 -0.096 -0.010 0.017

Place of residence -0.010 1 -0.086 0.067 0.803

Husband’s or father’s occupation -0.096 4 -0.116 -0.076 0.001

Drinking water source 0.024 2 -0.010 0.058 0.0162

Number of children 0.058 3 0.034 0.083 0.001

Adverse pregnancy outcome 0.247 1 0.173 0.321 0.001

Contraception pill -0.120 1 -0.168 -0.072 0.001

Pregnancy gap -0.121 2 -0.154 -0.089 0.001

TABLE 4: Results of multiple logistic regression to reveal the effect of related factors on
hemoglobin levels.

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 Discussion
Anemia is the most common nutritional deficiency disorder among infants, pregnant women, and non-
pregnant women [6]. The targets and action plans were designed and approved by the World Health
Organization for reducing the prevalence of anemia [12-13]. The current study was designed to reveal the
factors that influence anemia and its prevalence among women of childbearing age in Pakistan during this
period of the COVID-19 pandemic.

The results from this study showed total anemic respondents to be greater (53.7%) than non-anemic
respondents (46.3%). The results from previous studies were in accord with the present findings, but the
prevalence of anemia increased during the pandemic [9]. Around half a million women of reproductive age
are anemic worldwide, with a higher burden of anemia in low- and middle-income countries. Specifically,
the maximum of anemia burden lies in Southeast Asian countries [10]. This study also indicated severe
anemia to be present in 4.9% of women of childbearing age. A long-term vitamin and mineral deficiency,
especially of iron, can lead toward anemia [14]. Anemia, especially iron deficiency anemia, progresses
gradually usually without any signs and symptoms until anemia attains severity [15]. The mean hemoglobin
level reported in this study was 11.98 ± 0.92 g/dL, which is in close accord with previous findings (12.35 ±
1.80 g/dL) [16]. Table 2 shows the citywise distribution of anemia in Pakistan. Karachi is the largest city with
anemia prevalence (n=294, 55.48%) followed by Peshawar (n=209, 55.00%) and Rawalpindi and Islamabad
(n= 211, 54.42%). Previous studies conducted in Agha Khan University also reported similar findings [17].
While the prevalence of anemia was reported to be low in this study, a previous study conducted in Lahore
reported low income to be the most significant factor of anemia presence [18]. Therefore, a greater
understanding of the various determining factors that can potentially lead towards anemia is of great
importance for local investors to effectively resolve this issue [19].

Table 3 presents the results of the chi-square test to reveal the relationship between associated factors and
hemoglobin levels, while Table 4 shows results of multiple logistic regression to reveal the effect of
associated characteristics on hemoglobin levels. All the other factors showed a significant relationship with
hemoglobin levels similar to the ones revealed by the chi-square test except for BMI, healthcare utilization,
family size, exercising habits, tobacco use, number of meals per day, and place of residence, which all had an
insignificant impact on hemoglobin levels. The results showed age to have a significant relationship with
hemoglobin levels. The World Health Organization estimated that the majority (56%) of pregnant and
women of childbearing age were anemic. Iron deficiency at this age is thought to be caused by a multitude of
factors such as previously decreased iron supplies, growing requirement of the fetus, and increased blood
volume [20]. Level of education was also significantly associated with hemoglobin levels. Previous studies
conducted in this regard reported contradictory findings. In a study of low- and middle-income countries,
education levels along with cultural norms were a major determinant of anemia severity [21]. Another study
suggested level of schooling to not be the determining factor for anemia in Nepal and Pakistan, whereas it
was inverse for countries like India and Bangladesh where there existed a relationship between the two
factors [22]. Moreover, the results of this study regarding family income, fathers' and mothers’ profession,
and family size were also in accord with previous findings that higher monthly income of both parents was
associated with a lower occurrence of anemia [9]. Similarly, menstrual period duration and exercise habits
were also significantly related to anemia. According to Kamruzzaman et al., high menstrual bleeding
decreases iron levels and hemoglobin amount, leading to severe anemia if not treated [23]. The results of
this study also indicated economic status and living conditions to be significantly associated with
hemoglobin levels, which is also in agreement with previous findings of studies from different parts of the
world and in Pakistan [24]. Moreover, the prevalence of anemia was higher among women whose mothers
were housewives as compared with government employee or businesspersons. Similarly, the prevalence was
low among women with fathers or husbands who were government employees, and these findings were
synchronous with the findings of previous studies [25].

As this study indicated that anemia has a strong association with chronic health conditions, such as
infections, autoimmune diseases, cancer, and chronic kidney disease, it is a matter of great concern to
prevent such chronic conditions; the results were coeval with previous findings [24]. The use of supplements
especially iron supplement was significantly associated with hemoglobin level. Therefore, all women of
reproductive age should take supplements especially of iron to prevent anemia [26]. The past literature
suggested junk food consumption and smoking to be associated with anemia presence. Factors such as
consuming tea and coffee after meals, not using iron supplements, decreased consumption of vegetables,
and more emphasis on junk food were linked to anemia severity [27]. Similarly, the presence of anemia was
significantly higher in smokers and opium users, which is in accord with the present findings [28]. Previous
literature also suggested that receiving antenatal and perinatal care and proper follow-ups was associated
with decreased likelihood of anemia. Anemia was much higher for mothers with less or no antenatal care
[29]. Similarly, the number of children in the family, meals consumed in a day, contraception use, and
adverse pregnancy outcomes were all associated with anemia presence. As there is a need to feed more
children, the demand for food will increase, leading to poor quality of care and a greater anemia risk [25].
The risk was also greater among meal skippers or people who consumed a smaller number of meals a day. It
was reported that meal frequency of less than two meals a day was found to be associated with anemia
presence in pregnant women [1]. Anemia in the third trimester of pregnancy is associated with adverse
maternal and neonatal outcomes. A retrospective study from Pakistan reported both adverse maternal and

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 neonatal outcomes such as postpartum hemorrhage, prolonged or obstructed labor, gestational
hypertension, and preeclampsia, with neonatal complications ranging from early neonatal death, stillbirth,
preterm delivery, to low birth weight [2]. Moreover, anemia risk in urban women is reduced up to 73% due to
better health and sanitation facilities [3]. Similarly, the study indicated a strong association of living
conditions and source of drinking water, with hemoglobin levels, as women living in houses with unhygienic
toilet facility and source of drinking water were more likely to develop anemia as they could be more prone
to both water- and food-borne infections such as helminthic infections such as hookworm, which might, in
turn, increase anemia severity [4]. While the results revealed some significant factors, BMI and pregnancy
gap had no significant association with hemoglobin levels. A study conducted by Habib et al. found no
significant association between anemia and BMI [5]. Another study suggested odds of anemia decrease with
obesity [7]. The difference in results between studies might be due to difference in age and geographic
location of the study participants, as suggested by Hess et al. [1]. The present study findings suggested an
insignificant relationship between pregnancy gap and hemoglobin levels, which is in contradiction to
previous studies. A systematic review on effect of birth spacing on maternal and child health revealed that
short birth intervals were associated with maternal anemia [8]. Women who had less than two years between
pregnancies were more likely to be anemic this can be justified by the fact that such women got less time to
recover from depleted nutrients, thereby increasing anemia severity [3].

Lastly, the results of this study were convergent with previous studies that indicated that family income
[19], exercise habits [10], number of meals [24], and education levels [11] were the societal determinants of
anemia among women of reproductive age. Awareness about appropriate age for marriage, education status,
employment opportunities, healthcare utilization, avoidance of excessive blood loss, provision of iron and
folic acid supplements, adverse, junk food, and family planning should be imparted to masses especially in
slums and rural areas to reduce the prevalence of anemia among women of childbearing age. Furthermore,
the results showed that anemia is a multi-factorial health problem, and prevention strategies should focus
on addressing these significant determinants for reducing the severity of anemia even during the time of a
global pandemic.

Limitations of the study

The current study had a few limitations. First, we had no knowledge of the hemoglobin levels before the
pandemic; therefore, we classified anemia based on the current hemoglobin levels as per defined guidelines
by the World Health Organization. Second, we did not assess serum iron, ferritin, or transferrin levels, which
are further anemia indicators. Third, factors such as cultural background, domestic violence, and drug abuse
have not been studied.

Conclusions
The current study illustrates the risk factors for anemia among women of childbearing age in Pakistan during
the COVID-19 pandemic. It is evident from the current findings that significant improvement should need
to be made to further improve the overall health status of women. The prevalence of anemia is 53.7%
according to this study, which was significantly more than the previous study conducted before the COVID-
19 pandemic. The results also confirmed that anemia is a multi-factor health problem and was ignored
during the pandemic. It was also found that awareness about the appropriate age for marriage, education
status, employment opportunities, clean drinking water, healthcare utilization, avoidance of excessive blood
loss, provision of iron and folic acid supplements, junk food, and family planning should be imparted to
masses especially in slums and rural areas to reduce the anemia prevalence; therefore, more attention
should be given to anemia surveillance and awareness programs, as well as mobilization of community
health workers and volunteers to reach a wide section of the populace, including women of childbearing age
during the times of pandemic.

Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Muhammad Hammad
issued approval FMS/RSL/ERC.009. This is to certify that Muhammad Hammad presented his proposal to
conduct a research study on “Factors Related to Anemia Prevalence Among Women of Childbearing Age in
the Period of Global Pandemic.” He has devised the plan by following the guidelines for Ethical Approval of
Research involving human participants and has accepted the responsibility for the conduct of the procedures
set out in the participation. The Ethical Review Committee (ERC) has received this project and considers the
methodological aspects of the presented proposal to be appropriate. They study project doesn’t raise any
ethical issues. Animal subjects: All authors have confirmed that this study did not involve animal subjects
or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare
the following: Payment/services info: All authors have declared that no financial support was received
from any organization for the submitted work. Financial relationships: All authors have declared that they
have no financial relationships at present or within the previous three years with any organizations that
might have an interest in the submitted work. Other relationships: All authors have declared that there are
no other relationships or activities that could appear to have influenced the submitted work.

2023 Hammad et al. Cureus 15(5): e38491. DOI 10.7759/cureus.38491 9 of 11

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