Prevalence and Risk Factors of Anemia During Pregnancy in Saudi Arabia: A Systematic Review

The prevalence of anemia during pregnancy in Saudi Arabia is variable. Nulliparous, multiparous >3, and multi-gravidity are associated risk factors with a higher incidence of anemia during pregnancy. Other risk factors comprised working, women in university, past history of anemia, obesity, women younger than 25 years, low income, longer menstrual cycle >5 days, bleeding during pregnancy, reduced birth spacing, a low level of education, and decreased intake of iron-rich foods.


Introduction And Background
Anemia during pregnancy is a prevalent concern, characterized by a decrease in the blood's capacity to transport oxygen, primarily due to a reduction in hemoglobin levels.This decline can be either absolute or relative in nature.It is widely acknowledged that the majority of pregnancies lead to a greater increase in plasma volume compared to red blood cell mass, resulting in what is termed "physiologic anemia."This phenomenon, historically referred to as "plethora gravidarum," has been recognized for centuries to describe these physiological changes.The debate surrounding whether this "hydremia" is within the bounds of normalcy or represents a pathological condition remains ongoing [1][2][3].
The prevalence of anemia among pregnant women in Saudi Arabia ranges from 18% to 58% among pregnant women in different parts of the country.These rates may also vary based on factors such as socioeconomic status, access to healthcare, and dietary habits.Overall, anemia in pregnancy remains a significant public health concern in Saudi Arabia [2].
A hematocrit of less than 33% or a hemoglobin level of less than 11 g/dL at any point during pregnancy is considered anemia of pregnancy, according to the World Health Organization (WHO) [1].The US Centers for Disease Control and Prevention classifies anemia of pregnancy as having hemoglobin levels less than 11 g/dL, hematocrit levels less than 33% in the first or third trimester or having hemoglobin levels less than 10.5 g/dL, or hematocrit levels less than 32% in the second trimester [3].
With each stage of pregnancy, the risk of anemia increases.According to CDC standards, among American low-income pregnant women, in the first trimester, 8% of women are anemic; in the second, 12%; and the third, 34% [4].According to the US Department of Health and Human Services (DHHS), the prevalence of third-trimester anemia is a significant indicator of reproductive health.With regard to prevalence, African Americans have the highest prevalence rate (48.5%), subsequently followed by Whites (27.5%),Asians, Native Hawaiians, and other Pacific Islanders (29%), Hispanics and Latinas (30.1%),American Indians and Alaska Natives (33.9%), and Hispanics and Latinas [4,5].
Doctors have known for a long time that hydremia alone cannot explain why 10% to 70% of pregnant women described in early 20th-century research had hemoglobin levels less than 7 g/dL.The 1950s demonstrated a significant function for iron deficiency in pregnancy anemia due to the frequent detection of hypochromia, microcytosis, and anisocytosis in blood smears of pregnant women with anemia and the correction of such anomalies following the administration of iron supplements [6].Since then, the iron shortage has been acknowledged as the most prevalent cause of anemia in pregnancy around the world.This anemia typically manifests in the third trimester, when the iron is most maximally collected to support erythropoiesis in the developing baby [7].
This systematic review aims to study the prevalence and associated risk factors with anemia in pregnancy among Saudi women.Our results are anticipated to provide specific guidance for future studies and what needs to be addressed to fill in knowledge gaps at this time.

Review Methodology
Investigating the prevalence and risk factors for anemia in pregnancy among Saudi women is the objective of this systematic review.To locate the pertinent literature, a thorough search was conducted across four significant databases, including PubMed, Web of Science, EBSCO, and Cochrane Library, while restricting our search to English and taking into account each database's specific requirements.The following keywords were converted into PubMed Mesh terms and used to find the relevant studies: "Anemia," "Iron deficiency anemia," "Pregnancy," "Pregnant women," "Maternal," "Saudi Arabia," and "KSA."To match the necessary keywords, the Boolean operators "OR" and "AND" were applied.The search returned a list of publications containing complete English text, free papers, and human trials.

Inclusion criteria
Studies that determined the prevalence of iron deficiency anemia in pregnancy and risk factors, studies that included Saudi women, and studies in the English language.

Exclusion criteria
Women with underlying chronic disease and women with chronic types of anemia, e.g., sickle cell anemia.
We applied Rayyan (QCRI) to detect duplicates in the output of the search technique [8].To assess the appropriateness of the titles and abstracts, the researchers narrowed the combined search results based on a set of inclusion/exclusion criteria.The papers that matched the requirements for inclusion were carefully read by the reviewers.The writers discussed methods for settling disagreements.A data extraction form was constructed, and it was used to upload the approved study.The study titles, authors, city, participant count, mean age, prevalence of anemia, potential risk variables, and primary outcomes were all extracted by the authors.Utilizing the information gathered from the pertinent studies, summary tables were made to provide a qualitative analysis of the outcomes and study components covered.The most effective method for utilizing the data from the included study articles was selected after data for the systematic review had been extracted.
Using the ROBINS-I risk of bias assessment method for non-randomized trials of treatments, the included studies' quality was assessed [9].The seven themes that were assessed were confounding, participant selection for the study, intervention classification, intervention deviations from intended interventions, missing data, outcome evaluation, and choice of the reported result.

Results
The systematic search produced 320 study articles in total after removing 30 duplicates.Two thousand ninety studies were subjected to title and abstract screening; 222 studies were disregarded.Only 8 of the 68 reports that were searched for recovery could not be found.The final analysis of 60 papers revealed that 20 had erroneous research outcomes, 18 lacked information on anemia of pregnancy among Saudi women, and 12 had an inappropriate population type.This systematic review contained 10 appropriate study papers.Figure 1 displays a summary of the study selection procedure.
The included studies reported that anemia remains a major issue for pregnant women [10][11][12][13][14][15][16][17][18][19].Antenatal or prenatal screening for anemia should be individualized for each pregnant person [11,19].Two studies reported the importance of compliance for iron supplementation combined with adequate intake of ironrich dietary sources during pregnancy and for three months after delivery should be covered in health education programs at the PHCCs [12,18], as illustrated in Table 1.

Discussion
Anemia is related to maternal physical and psychological comorbidity, as well as a higher risk of neonatal and maternal morbidity and mortality [20].The current study results indicate a wide variation in the prevalence of anemia among Saudi pregnant women.The records show that the Eastern region of Saudi Arabia has the highest prevalence of anemia in pregnant women.The wide variation in the prevalence could be due to cultural diversity in socioeconomic conditions, lifestyle, and health-seeking practices, anemia in pregnancy is more common than one may think.A recent systematic review and meta-analysis reported that the worldwide prevalence of anemia during pregnancy of 36.8% (95% CI: 31.5%-42.4%),and the highest prevalence was in Africa (41.7%) [21,22].
This review reported that the risk factors to increase the incidence of anemia in pregnancy included nulliparous [10,12], while multigravida/ multiparous >3 was a risk factor in four studies [13][14][15]19].This might result from multiple pregnancies depleting a pregnant woman's iron reserves [23].Grand multigravida women had a greater percentage of anemia (66.7%), according to a Malaysian study [24].
Multiparity is a significant risk factor linked to iron deficiency anemia, claim Okafor et al. and Isah et al. [25,26].The iron shortage will develop from having too many pregnancies too soon apart because pregnancy uses up a lot of iron [27].The need for iron during pregnancy is three to four times greater than that of non-pregnant women [28].Women, in general, are observed to have low iron stores, perhaps as a result of the monthly blood loss during menstruation, even though it can be mobilized from the maternal stores to meet this requirement [29].The mother would get iron deficiency after these reserves are gone [30].
Iron deficiency anemia can develop from a decrease in the hemoglobin production rate caused by an iron deficiency [31].Women's iron deficiency anemia can be managed by reducing the overall number of pregnancies and lengthening the period between pregnancies.Family planning and child spacing will lower a woman's need for iron, preventing iron depletion and the effects of iron deficiency anemia.
According to the included research, anemia is still a significant problem for pregnant women [10][11][12][13][14][15][16][17][18][19].Each pregnant woman should get personalized antenatal or prenatal anemia screening [11,19].According to two studies, health education programs at PHCCs should cover the need for compliance for iron supplementation and adequate intake of iron-rich dietary sources during pregnancy and for three months following delivery [12,18].Iron and folic acid supplementation should be a priority for the government and nongovernmental organizations as part of standard antenatal care for all pregnant women.In Saudi Arabia's regions with a higher prevalence of anemia, it is crucial to employ long-acting family planning techniques to prevent frequent pregnancies.Health extension workers should promote antenatal follow-ups and community-based awareness campaigns.Further investigations conducted around the country are required to comprehend the causes of anemia in pregnant women.

Strengths and limitations
The following are some strengths of this thorough literature review: In order to avoid reviewer biases as much as possible, we feel that (a) we followed PRISMA recommendations and used reputable methods for data extraction and quality evaluation, and (b) we presented all study findings graphically to the reader.We also mention the following restrictions: In our search, we cannot completely rule out the potential of missing some studies.But we also looked through a number of databases, reference books by hand, and grey literature.The heterogeneity of the studies prevented us from performing a meta-analysis.The ability of analyses to attain significance may be constrained by the small sample sizes and methodological problems in some of the included research.The validity and generalizability of the results in some studies with small sample numbers and high rates of loss-to-follow-up may be compromised by selection bias.

Conclusions
The prevalence of anemia during pregnancy among Saudi women was variable.Multiparous >3, multigravidity, and nulliparous were associated risk factors with a higher incidence of anemia during pregnancy.
Other risk factors comprised working, women in university, past history of anemia, obesity, women younger than 25 years, low income, longer menstrual cycle >5 days, bleeding during pregnancy, reduced birth spacing, a low level of education, and decreased intake of iron-rich foods.There should be ongoing health education and awareness campaigns on the value of using family planning and antenatal care services, as well as the provision of health facilities in remote areas to promote early booking and use of antenatal care services.Women should also have access to education and economic empowerment opportunities.

FIGURE 1 :
FIGURE 1: PRISMA flowchart summarizes the study selection process.