Anemia is defined as “decrease in hemoglobin levels in blood, leading to a decreased oxygen carrying capacity of blood”(1). According to WHO, Anemia is estimated to affect about half a billion women of reproductive age group (15–49 years) and 269 million children (6–59 months of age) worldwide(1). In 2019, 30% (539 million) of non-pregnant women and 37% (32 million) of pregnant women aged 15–49 years had anemia (1). The prevalence of anemia among pregnant women in India is as high as 57% according to some studies. National family health survey (NFHS) 5 (2019-21) revealed 52.2% pregnant women to be anemic and 1.4% to be severely anemic (2)(3).  Prevalence of anemia in pregnancy in Telangana state is 52.2% and even more in rural Telangana (3). Anemia is a huge burden to the nation’s economy and health system. It can cause 20-40% of maternal deaths.

Maternal anemia hampers the growth and development of the fetus and newborn (3). Low Birth weight (LBW) is defined as birth weight <2500g measured within one hour of birth irrespective of gestational age (4)(5). LBW is also an important indicator of antenatal care. The global prevalence of LBW is 14.6% (12.4-17.1) accounting for 25 million LBW infants born every year (4)(6). The prevalence of LBW in India (estimate from nationally representative survey data) reduced from 22% (National Family Health Survey [NFHS-3], 2005-6) to 17.4% in NFHS -5 (5)(4)(7). Prevalence of low-birth-weight babies is 1.49 times more common among pregnant women with anemia than those without anemia (5).  The LBW babies are more likely to die during their first month of life or face consequences like stunted growth, low IQ, adult-onset chronic diseases like obesity and diabetes(2). The risk factors for low birth weight are associated with unfavorable biological, social and environmental conditions before or during the pregnancy period. Thus, inadequate maternal caloric intake, due to nutritionally poor diet, leads to deficiency of essential micronutrients, such as vitamin B12 and iron, which are required for fetal growth (8)(9).

Although there are several studies proving a significant association between anemia in pregnancy and low birth weight, but a few studies have also shown no significant association between the two. Global and national level surveys and studies have revealed overarching figures but it’s the local hospital-based studies like the current study which provide localized insight into the real burden and management challenges. Both anemia and low birth weight continue to pose significant public health challenges. A clear link exists between maternal hemoglobin levels and neonatal birth weight, supported by both global and Indian literature (10). The current study undertaken at GGH siddipet aims to determine the prevalence of anemia among pregnant women and evaluate its effect on birth weight, thereby contributing to locally relevant data and recommendations for improved antenatal care.

Aims & Objectives

To determine the prevalence of maternal anemia among pregnant women delivering at Government General Hospital (GGH), Siddipet, and its impact on neonatal birth weight.

Objectives: 

1. To determine the prevalence of anemia among pregnant women delivering at GGH, siddipet.
2. To evaluate the association between maternal hemoglobin levels and neonatal birth weight.

An observational study was conducted at Government General Hospital (GGH), Siddipet, over a period of six months from October 2024 to march 2025. Consent was obtained from the participants regarding the study. All pregnant women getting admitted at GGH, siddipet for delivery, were initially evaluated for Hemoglobin levels through a complete blood count and screened for other medical comorbidities, at the time of admission. Data regarding the diagnosis, grade of anemia, treatment received, other medical comorbidities and neonatal birth weight was collected from hospital records. Pregnant women with term gestational age (>37 completed weeks) with or without anemia (Hb <10.9g/dl) were included in the study (inclusion criteria), while those with preterm deliveries, multiple pregnancies, or medical comorbidities such as hypertension, diabetes were excluded from the study (exclusion criteria). Data was analyzed to determine the prevalence of anemia among pregnant women who delivered at GGH, Siddipet. The participants were categorized into 5 groups based on the severity of anemia: normal Hb, mild anemia, moderate anemia, severe anemia and very severe anemia. The proportions of normal and low birth weight were recorded in each group.  Statistical analysis was performed using the chi square test to assess the significance of association between different grades of maternal anemia and neonatal birth weight at GGH, siddipet.

Review of Literature:

Anemia during pregnancy remains a significant public health issue in both developing and developed countries. Anemia in pregnancy and low birth weight are two critical and interlinked public health concerns, especially in low- and middle- income countries like India. Both conditions have serious implications for maternal and neonatal health, contributing significantly to maternal and perinatal morbidity and mortality.

PREVALENCE OF ANEMIA: It is the percentage of pregnant women who delivered at Government General Hospital (GGH), Siddipet, having hemoglobin levels below 10.9 g/dL, compared to the total number of pregnant women delivered at the hospital.

According to WHO, Anemia is estimated to affect about half a billion women of reproductive age group (15–49 years) and 269 million children (6–59 months of age) worldwide. In 2019, 30% (539 million) of non-pregnant women and 37% (32 million) of pregnant women aged 15–49 years were affected by anemia (1). The highest prevalence is reported in South Asia. The prevalence of anemia among pregnant women in India is as high as 57% according to some studies. The prevalence varies in different regions. National family health survey 5 (2019-21)revealed 52.9% pregnant women to be anemic and 1.4% to be severely anemic ²(1). Prevalence of anemia in pregnancy in Telangana state is 52.2%(11) and it is even more in rural Telangana.

A hospital-based study by Kumar et al (2019) reported 64.2% of pregnant women admitted in tertiary care centers had some form of anemia with moderate anemia being most common (12).

DEFINITION AND CLASSIFICATION OF ANEMIA IN PREGNANCY:

Anemia in pregnancy is defined as a hemoglobin level below 11 g/dL, (WHO guidelines), and below 10.5 g/dL in the third trimester (13).

Anemia is categorized into grades based on hemoglobin levels (WHO): (14)

10. mild anemia (9-10.9 g/dL),
11. moderate anemia (7-8.9 g/dL),
12. severe anemia (4-6.9 g/dL), and
13. Very severe anemia (less than 4 g/dL).

ETIOLOGY and RISK FACTORS:

• Iron deficiency due to poor dietary intake or increased demand
• Folate or vitamin B12 deficiency
• Parasitic infections
• Frequent pregnancies with inadequate spacing
• Low socioeconomic status, poor antenatal care and inadequate iron supplementation are major risk factors contributing to high prevalence. (1)

ANEMIA AND ADVERSE PREGNANCY OUTCOMES

Anemia is a huge burden to the nation’s economy and health system. It can cause 20-40% of maternal deaths.  Anemia, especially moderate to severe, has been consistently linked with:

• IUGR (intrauterine growth restriction)
• Low birth weight (LBW): Prevalence of low birth weight babies is 1.49 times more common among pregnant women with anemia than those without anemia. Maternal anemia reduces oxygen carrying capacity and hampers the growth and development of the fetus and newborn (1).
• Preterm delivery
• Increased perinatal and maternal morbidity and mortality

LOW BIRTH WEIGHT: DEFINITION AND GLOBAL BURDEN

• Neonates are classified as low birth weight if they weigh less than 2500 g or fall below the 10th percentile (WHO) measured within one hour of birth irrespective of gestational age(4)(15).
• The prevalence of low birth weight is determined by the number of neonates weighing less than 2500 g compared to the total number of live births during a given time period.
• The global prevalence of LBW is 14.6% (12.4-17.1) accounting for 25 million LBW infants born every year (4). India contributes to over 40% of global LBW cases. The prevalence of LBW in India (estimate from nationally representative survey data) reduced from 22% (National Family Health Survey [NFHS-3], 2005-6) to 17.4% in NFHS -5 (4)(7)  (15). In Telangana, NFHS-5 reported LBW in 13.5% of institutional births.
• LBW can result from premature delivery (<37weeks) or Intrauterine growth restriction (IUGR), both of which are exacerbated by maternal anemia.

LBW RISK FACTORS AND CONSEQUENCES:

• The LBW babies are more likely to die during their first month of life or face consequences like stunted growth, low IQ, adult-onset chronic diseases like obesity and diabetes(15)
• The risk factors for low birth weight are associated with unfavorable biological, social and environmental conditions before or during the pregnancy period. Thus, inadequate maternal caloric intake, due to nutritionally poor diet, leads to deficiency of essential micronutrients, such as vitamin B12 and iron, which are required for fetal growth (8).

ANEMIA AND LBW:

• LBW is also an important indicator of antenatal care. Prevalence of low-birth-weight babies is more common among pregnant women with anemia than those without anemia.
• A study by Kalaivani (2009) concluded that the risk of LBW in anemia mothers is nearly two-fold higher compared to non-anemic mothers (16). Nair et al. (2014) observed a strong correlation between hemoglobin levels and neonatal birth weight in a cohort study of 1200 pregnant women (17). A systematic review by Rehman et al. (2016) concluded that iron-deficiency anemia in the second trimester is most strongly associated with LBW and preterm birth (18).
• The underlying pathophysiology includes reduced placental perfusion, fetal hypoxia, and nutrient deficiency, all leading to restricted fetal growth.

CONTRASTING EVIDENCE: While several studies have demonstrated a significant association between maternal anemia and low birth weight, some have not observed this association. A prospective cohort study of 500 pregnant women by Lone FW et al. (2004) showed no statistically significant association between mild anemia and LBW, but moderate to severe anemia were associated with adverse outcomes (19). A study by Singh J et al. (2013) in a rural area of north India where prevalence of anemia was high but no significant difference in birth weight among anemic and non-anemic mothers. This may be probably due to small sample size, high nutritional supplement coverage, misclassification bias, confounding factors like age, parity, socioeconomic status. Suryanarayana R et al. (2017) evaluated anemia in third trimester only and found no statistically significant association with LBW. Thus, suggesting that early trimester anemia might have a stronger effect and late detection may not reflect the full impact (20). Sharma N et al. (2018) observed that birth weight was not affected by anemia and suggested confounding factors like maternal age, parity and antenatal care practices could dilute the effect. Thus, mild or late onset anemia may not independently influence birth weight, emphasizing the importance of severity of anemia, timing and correction through supplementation. These findings highlight the need for contextual interpretation of anemia’s effects, considering multiple maternal and fetal factors.

These contrasting results emphasize the need for careful stratification of anemia by severity and gestational age, as well as adjustment for confounding variables in analyzing its impact on fetal outcomes. They also highlight that while anemia remains a critical concern, its independent effect on birth weight may vary across populations and healthcare settings.

REGIONAL AND LOCAL DATA:

While national and state-level data provide an overview, hospital-based studies such as those conducted in Government hospitals like GGH siddipet, offer real-world insights and management challenges. These studies reflect the effectiveness of public health interventions and gaps in antenatal nutritional care at the grassroot levels. Limited literature is available on anemia and LBW association in semi-urban Telangana districts, which, this study seeks to address.

 GAPS IN LITERATURE:

Although the association between anemia and low birth weight is well established, only few studies specifically address the pattern of anemia in semiurban and rural government settings in Telangana. There is a need to assess the severity-wise impact of anemia on fetal outcomes in local populations. The present study aims to bridge the regional data gap by evaluating the prevalence and effect of anemia on fetal birth weight among pregnant women delivering at GGH Siddipet, thereby contributing to local evidence based antenatal care strategies.

The study evaluated the prevalence of anemia and distribution of severity of anemia among participants. A total of 1745 pregnant women, at term gestational age, who delivered at GGH, Siddipet were included in the study after eliminating the cases with exclusion criteria. 1398 (80.1%) individuals, were found to have normal hemoglobin levels. Among the 347 (19.9%) individuals with anemia, 327 (94.2%) women had mild anemia, 16 (4.6%) had moderate anemia, and only 3 (1.2%) women had severe anemia and very severe anemia in 1 woman.

Table 1: PREVALANCE OF MATERNAL ANEMIA

Of the total 1745 newborns, 1320 newborns (75.7%) had a normal birth weight, while 425 newborns (24.3%) were had low birth weight (LBW).

Table 2: Comparison of neonatal birth weight with maternal haemoglobin (normal vs mild anemia)

Among the women with normal hemoglobin levels, 27.3% had low birth weight. Among women with mild anemia, only 12.3% had low birth weight neonates. There is a significant difference in birth weight distribution between the two groups (P = 0.0125), while the prevalence of LBW is lower among women with mild anemia.

Table 3: Comparison of neonatal birth weight with maternal haemoglobin (normal vs. moderate anemia)

Pregnant women with moderate anemia lower proportion of LBW (6.2%), compared to those with normal hemoglobin group. The difference is highly statistically significant (p<0.00014).

Table 4: Comparison of neonatal birth weight with maternal haemoglobin (normal vs severe anemia)

Pregnant women with severe anemia had a slightly higher proportion of low birth weight (33.3%) compared to those with normal hemoglobin levels (27.3%), the difference is not statistically significant. (p>0.05).

100% of women with very severe anemia had low birth weight babies compared to 27.3% LBW in normal Hb group giving a p-value of 3.89X 10^-26 which indicates extremely significant association.

Table 5: Comparison of birth weight with different grades of anemia

The prevalence of anemia among pregnant women delivering at GGH, siddipet, is 347 out of 1745 pregnant women i.e 19.9%. This is notably lower than the Telangana state prevalence of 52.2% and 57% in India. This implies potential improvements in local antenatal care practices, nutritional supplementation, or health care access. Although limitations of this study include small sample size, confounding factors, limited population i.e those delivering at GGH siddipet and not the whole population in general.

The current study examined the relationship between severity of maternal anemia and neonatal birth weight outcomes. The global prevalence of LBW is estimated at 14.6% (range: 12.4–17.1), accounting for approximately 25 million infants born annually with LBW. In India, there is a decline in LBW prevalence from 22% in NFHS-3 (2005–06) to 17.5% in NFHS-4 (2015–16) and 17.4% in NFHS-5 (9)(21). LBW can be due to preterm or IUGR. Anemia in pregnancy and nutritional status of the mother apart from other medical comorbidities are the major factors causing LBW. Hence, LBW is an important indicator of antenatal care. LBW infants face increased risks of neonatal mortality, stunted growth, cognitive impairment, and adult-onset chronic diseases such as obesity and diabetes. In our present study however, we have eliminated all the women with anemia who have coexistent medical disorders like hypertension and gestational diabetes and overt diabetes which can also lead to low birth weight.

In the current study, 27.3% of pregnant women with normal Hemoglobin levels had low birth weight newborns.

Only 12.3% of pregnant women with mild anemia had low birth weight newborns, surprisingly showing slightly better outcomes than normal Hb. (p value 0.0125). This could suggest that, mild anemia may not adversely affect birth weight or it might reflect confounding factors like better antenatal care, early iron supplementation, nutritional awareness among mildly anemic women. The clinical impact needs cautious interpretation due to the unexpected trend. The significance, despite the inverse trend, highlights that the distribution of birth weight differs meaningfully between the two groups.

Only 6.2% of pregnant women with moderate anemia had low birth weight newborns (p value 0.00014), which is highly statistically significant. This result possibly reflects some confounding factors like maternal age, parity etc. or a small sample size. Although counterintuitive, this finding might be due to: early detection and effective management of moderate anemia, relatively small sample size, demographic/ clinical differences between the groups.  33.3% of pregnant women with severe anemia had low birth weight newborns (p value 0.44) which is although not statistically significant, but showing a worse outcome compared to normal Hb group. These unexpected results of no statistical significance, warrant further more detailed investigation, as it challenges the usual expectation that more severe anemia is associated with worse fetal outcomes. This observed variation may be due to random chance or small sample size rather than a true difference. Thus, this finding may not be reliable unless validated with a larger sample size. 100% of babies born to pregnant women with very severe anemia were low birth weight, clearly emphasizing the detrimental impact of very severe anemia. This aligns with the established evidence that very severe anemia severely compromises oxygen and nutrient supply to the fetus, leading to intrauterine growth restriction and poor neonatal outcomes. This finding reinforces the need for urgent intervention and close monitoring in pregnancies complicated by very severe anemia. A Chi-square test was conducted to evaluate the association between maternal hemoglobin levels and neonatal birth weight outcomes (normal vs low birth weight). The p-value obtained from the test was 2.99×10^-52, which is highly statistically significant (p<0.001).

This extremely low p-value strongly indicates that the distribution of birth weight is not independent of maternal hemoglobin levels. In simpler terms, there is a clear and statistically significant relationship between severity of maternal anemia and likelihood of low birth weight in newborns.

The findings of this study are consistent with previous research. Kalaivani K et al reported a strong association between maternal anemia and poor intrauterine growth, increased risk of preterm delivery, and elevated LBW rates (16). Bedi R et al. and Kumar KJ et al. observed a high prevalence of anemia during the third trimester, with significantly more LBW infants born to anemic mothers (22)(23). Thus hemoglobin levels are a critical determinant of neonatal birth weight. Srinivas et al. conducted a retrospective study and reported no correlation between maternal anemia and LBW (24).

The prevalence of anemia in pregnancy is 19.9% among pregnant women delivering at GGH, siddipet which is significantly less compared to the prevalence in Telangana state (52.2%). This implies potential improvements in local antenatal care practices, nutritional supplementation, or health care access. Further studies need to be conducted to determine the prevalence of anemia and its impact on pregnancy in all trimesters, through prospective studies in antenatal OP in GGH, siddipet.

The present study highlights the significant impact of maternal anemia on neonatal outcomes, particularly birth weight distribution. While the global prevalence of low birth weight (LBW) remains a concern, the declining trends in India reflect progress in maternal and child health. However, the study emphasizes that anemia during pregnancy, remains a critical determinant of neonatal birth weight. The findings align with previous research, confirming that maternal anemia is associated with increased risks of LBW, preterm delivery, and poor neonatal outcomes. Despite inconsistencies in the literature regarding the impact of high hemoglobin levels or anemia in early pregnancy, the evidence consistently points to the importance of monitoring and addressing anemia during pregnancy to optimize fetal growth and reduce LBW prevalence. Despite lower prevalence of anemia in pregnancy at GGH, siddipet, the association between severity of anemia and low birth weight was statistically significant, reinforcing the need for early detection and targeted interventions, including iron supplementation and nutritional support etc. High prevalence of low birth weight even among pregnant women without anemia warrants further studies to know the cause of such low birth weight and measures to improve birth weight and fetal outcomes.

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