CHAPTER 1 INTRODUCTION

Anemia is a major cause of many risk factors related to pregnancy for example heavy bleeding leading to maternal death, cardiac problems, decreased capability of mothers to do physical work and mental stress. Especially this reduction in blood causes increases in blood transfusion that is also very dangerous. Anemia can be caused by multiple factors that are long term bleeding during pregnancy due to placenta prevail or after delivery as post-partum hemorrhage (PPH). This postpartum bleeding is due to uterine softness, tears or any other problems that disturb the clotting property of blood. So it is better to treat anemia at early stage so that to prevent the dangerous after effects. Maternal death is very high in women having anemia. Hemoglobin level is important in pregnant women because fetal attached to mother for surviving in uterine cavity. To decrease the maternal and fetal mortality it is necessary to correct the Hb level in mother that that could provide solution of many problems related to anemia in adults. Medical scientists believe Hb production depends on red blood cells (RBCs) production, and RBC production is related to proper functioning of bone marrow. For adequate production of hemoglobin bone marrow need iron 30 to 40mg for normal functioning of body and every day 6gm Hb is produced by RBCs. This is natural mechanism in healthy individuals to keep the balance. When rate of destruction increase, Hb falls but its not a sudden process, it is a long term process that leads to decreased Hb production. So when we diagnosed anemia, we should treat the actual cause of that is either its due to decreased production of red blood cells , more blood loss and other metabolic problem. For example blood transfusion is not treatment of whole causes of anemia it only elevates the sudden Hb but does not increase the red blood cells production. So we should realize the level of treatment from production to utilize of Hb level. As anemia affects the whole body functioning, when Hb level decreased, it cause many problems especially cardiac hyper stimulation (Cavill et al, 2005). Haemoglobin level could vary mainly due to factors like age, sex and psychological condition. In developing countries anemia affects pregnant and lactating females and

growing children. Females were affected more than males due to iron deficiency anemia in ratio of 5 to 1 ratio. Most patients are suffering from anemia in moderate condition that is approximately 53 percent. Anemia is a common type of disease in Pakistan it is most common in females in age 21 to 60 years (Idris and Rehman, 2005). In India anemia is prevailing at highest in the world. Anemia ratio is higher in women and preschool children. Even in some higher income and educated families 50 percent girls and pregnant women are anemic. It is cause of low use of iron, vegetables, vitamin
B12

and

poor availability of safe food. Anemia is responsible for about 40 percent maternal death in India. Many women are died due to low haemoglobin level. Anemia deficiency is a cycle that rotates from poor to poor and leads to death. To control anemia in pregnancy use food items like salts with iron to increase the dietary intake of iron. In girls and women prior to pregnancy, we should educate to dietary food to improve the intake of iron. To know the haemoglobin concentration we should use prophylactic therapy. In pregnant women moderate haemoglobin level between 8 and 11 g/dl and between 5 to 8 g/dl is deficient. To improve delivery health care we should educate and communicate with the women and her family member to utilize available source. Both for mother and fetus anemia in pregnancy have adverse effects. Studies about maternal anemia show that not only effects on infant but also increase the risk of other disease in growing phase to adults they have risk to low birth weight from generation to generation. The treatment of anemia is available and it is possible and affordable. The implementation of anemia treatment could go long way to reduce symptoms and consequences of anemia (Kalavian, 2009). According to studies it is observed that 71 percent anemic patients are mildly affected and 29 percent are in moderate condition. Furthermore, anemia was found at the age of 20 to 35 years old, 53.2 percent are found in second trimester 50.35 percent. The haemoglobin level in our population is deficient that observed is 10.1 g/dl. In working women prevalence of anemia is 38.8 percent this deficiency is due to low nutrition because most of them are housewife. Iron deficiency anemia however, could be reduced if these unemployed wives could exceed to food aid program for food which is rich in iron, calcium, protein and vitamins. Iron deficiency is due to low iron supplementation and has many disadvantages such as poor complains with treatment adverse gastrointestinal effect and low absorption.

Anemic problems in women are persisting mild public health problems. This problem can be reduced by continuing daily iron supplementation with vitamins B12 from beginning of pregnancy (Ubah, 2011). Nutrition is necessary for women to continue their life cycle as its deficiency starts in girls and women and it goes from generation to generation. It starts from childhood to adolescence and when pregnancy start it shows negative impact on infants such as low birth weight and other related disease low immunity and developmental deficits and stunted in early life. In some developing countries when baby born after at least 37 weeks of gestation and their weight is less than 2.5 kg then it is called effected by intrauterine growth retardation. Low birth weight helps us to understand the state of our population. Low birth weight in new infants is due to poor nutrition that causes poor growth (Jolly and Rabeneck, 2000). World health organization analyzed evidences from many years on global health problems and shows many hard warning and open healthier future door for all countries. The number of diseases and death can be reduced to work on different risk to human health. If we dont remove these risk factors it itself get multiplied and make a burden to next generation. Some possible reductions can be achieved in the range of cost effective ways. It is necessary to all government to raise the healthy life expectancy for their population. Healthy life can be made for heavy expenditures which can be found merely in different poorest countries and is common in most of industrial countries with higher per capita income. Apart from anemic issues there are many other risk factors associated with consequences of anemia like viruses and bacteria. These risks are dangerous for health and cause some severe disease which could change on people life. The report published by WHO identifies globally top ten risks associated with anemia and they cause some diseases like underweight, high blood pressure, alcohol consumption, unsafe sex, iron deficiency, tobacco consumption, unsafe water, indoor smoke, high cholesterol, bad sanitation and obesity. This disease causes one third deaths in all over the world. Fever and underweight a consequence of anemia cause three million childrens deaths a year in developing countries (WHO, 2002). Low serum of iron causes anemia this deficiency also causes reduction of red blood cells in bone marrow. When all iron stored have been utilized it changes red blood cell

picture. As a result bone marrow is not produced efficiently and decreased haemoglobin level leads to anemia. Reduction of iron in blood causes illness and anemia that affects in pregnancy; due to these deficiencies many patients become anemic in pregnancy (Abbott, 1968). During pregnancy women face many problems these are related to nutritional deficiencies mainly because of poor family background. Other main cause is physiological effects that cause many problems such as hypertension, iron deficiency, mental disorder. During pregnancy women face much complication such as child birth, low age marriage, family attitude, and risky labor work. Liking of more children directly affects mothers health. The Interval between two births also affects women health. When this interval is less than 24 months that shows a negative impact on women health that cause many problems during pregnancy. Another problem that women are facing is religious bindings during pregnancy. Muslim women face many health problems as compare to Hindu or women from other religion mainly due to some conservative religious values. Another big problem facing our women is low education level as educated women have better health indicators as compare to non-educated women. Mostly, educated women are less anemic as compare to uneducated women because educated women are conscious about their food intake and work. Many women are bound in economic and social activities such as household, relatives care, child care that are the basic cause loss of energy and restlessness. Working women are more anemic as compare to non-working due to duel work. Another cause of anemia in women is unemployment because of low income, low food and low nutrition. Iron deficiency anemia can be cover by good nutrition and through awareness (Raj, 2005). During pregnancy the effect of anemia on maternal health has been enormous. Mostly pregnant women who are victims of anemia usually represent a major reproductive health problem especially in developing countries. Due to lack of education women do not utilize health services during pregnancy. The most usual consequences of Iron deficiency anemia are complications in delivery, low birth weight, pre term delivery and growth restriction. The gestational age in anemic women is usually greater than non-anemic women. In pregnant and non-pregnant women there is great difference in their maternal body weight, delivery and gestational age (fareh et al, 2005).

In South Asian countries along with many other developing countries birth rate is usually higher mainly because of families preferred sons. Due to multiple pregnancies and lesser birth interval women health remain at stake in low income countries mainly as most women could not get access to better food due to low income, burden of more children and caring of family members (Mahmood, 1996). Factors like marital duration, nuclear family residence, number of existing sons and dowry have influential effect on women self-sufficiency. In the subcontinent the religion remains a vital hurdle in the enlightenment of societal conservatism. Self-sufficiency among women in term of liberty from aggressive relations with husband, access and control over economic resources, participation in decision making and mobility to access health facilities is extremely undervalued concept in Pakistan (Jejeebhoy and sathar, 2001). In our society women are suffering from many problems such as low social status, poverty, unpaid labor. During pregnancy many women died due to this condition. Public sector in Pakistan lack in capacity and will to improve health status of women and pulling them from poverty by adding towards nutrition of women. In some developing countries there is very poor condition of women health. Sex ratio is one of the most critical concern for women health that result female mortality during childhood. In Pakistan 340 maternal deaths reported over every 100,000 live births and it is shown as one woman died over 38 women during child birth, and half children died due to low nutrition and poor maternal health. Family health planning is being adopted among more than 80 countries. Women with small family size usually have better nutrition and food as compare to large family size (Ann, G. 1998). Women health problems are due to socio-cultural and complex biological factors. Women with reproductive problem are the effect of lower socio-economic status that results with huge burden on women from unsafe sex, which causes both infectious diseases and unwanted pregnancy. This burden could cause future disability, loss of life and injury. The examination of health issues in women could make it more apparent that once a girl was not fed properly in her childhood it would evidently effect on her growth and leads to higher risk of complications during pregnancy. Similarly, sexual abuse during childhood possibly increases maternal depression and repeated reproductive tract infection (RTI) that sometime

leads to infertility and anemia. These infections cause many complications in pregnancy and can also cause permanent damage such as uterine prolapse and obstetric fistulae complication. These biological factors also cause STI, HIV and cervix gynecological cancer. In developing countries women are usually facing malnutrition that in combination with some socio-cultural, economic and environmental discomforts cause anemia among women especially during pregnancy and lactating period. The women who have higher fertility rates were usually living in poorest households as compare to skilled and professional women who show a bit concentration on their reproductive health. In social life women are facing many problems such as family roles, poor health, low diet, early and frequent pregnancy and continuous cycle of poverty. In many countries women receive less medical treatment when they are very sick and advanced stage of disease. These women are less educated, having lesser family resources, less option to understand health problem and low decision making power those effects on their health and life care. Women are generally exposed to unwanted pregnancy due to unequal power in sexual relationship. Another contributing factor towards anemia and other women health problems is forced prostitution (Tinker et al., 2000). Education and development are linked to socio-economic development of any country and play an important role in defining the health standards for community especially for poorer segments of society like dependent women in rural areas. Traditions have a direct effect on female education continuing and indirectly on women health concerns (Shahzadi, 2011). Pakistan is a developing country which is far behind from its neighboring country in

term of resolving population health issues. Many researches had been done on the issues of environmental, socio-cultural and health challenges faced by the women and children which are a threat to maternal health. Mostly women are malnourished and this malnourishment started from the birth of a baby girl. In Pakistani society sons are preferred over daughters in all aspects i.e. breast feeding, diet, clothing and education and as a result the deprived female baby remains undernourished throughout her life and in her productive ages mostly these females faces iron deficiency anemia (Anjum, 2005). Anemia is a situation in which iron deficiency is at its lower end or long-term poor iron imbalance. The term iron deficiency anemia, anemia and iron deficiency can be used interchangeably. This disease is often occurred in the under-privileged communities. The main cause of anemia is poor diet, which is deficient in nutrients like vitamins A, B12, C and

folic acid (WHO, 2001). Low nutrition in pregnancy results into poor birth outcome. Nutritional deficiencies affect the pregnancy due to unavailability of additional nutrition for pregnant women and for her fetus. The common deficiencies in a pregnant woman are iron, vitamins and iodine. According to Tanzania Demographic and Health Survey (TDHS) 58 percent of pregnant women are anemic and only 10 percent women are using supplements for three months as per WHO recommendation. Iron supplement can control infectious diseases such as worm infestation and malaria (Seumo and Abdullah, 2008). Maternal mortality rate in Pakistan is very high and it is noticeable that on timely emergency services, proper diet and care could prevent most of the maternal and child deaths. In Pakistani society socio-cultural limitations and the impact of feudal and tribal formation on women are main hurdles in the process of women empowerment. Status of women in Pakistan is diverse across classes and area. Rural and urban areas are divided due to irregular socio-economic and cultural conditions which lead to a situation where women are not given proper care during pregnancy. They have to face different sort of problems during pregnancy due to iron deficiency in their body which should be given proper attention by government (Ali et al., 2008) In many countries some efforts have been made to improve the maternal and child health. The progress in maternal and child health is not equal in all the countries of the world. There is transition in the maternal and child mortality trend among different countries. This change in trend is due to different socio-economic and environmental conditions of different regions. Still, there is hope that this difference will be eliminated from the whole world with the government efforts of all the states (Wook, 2005). The measuring size of population, poverty and unemployment seem to be involved as major factors which cause iron deficiency. Dera Ghazi Khan is the remote area of southern Punjab which is deprived and deficient in many basic facilities. The ratio of anemic women is increasing day by day in Tehsil D. G. Khan due to some stresses and the social circumstances are vital cause of stress which adds to the number of anemic women. Due to poverty women of D. G. Khan could not get education, better food and better health facilities (Mubarak, 2009). This study will investigate about anemia conditions among pregnant women within socio-cultural, demographic and nutritional context along with effect of anemia on maternal health of Tehsil D. G. Khan. Normally in Pakistani society females are

anemic due to lack of basic food. Usually, pregnant womens inaccessibility to health facilities makes them susceptible to anemia. It is usually perceived that pregnant women (aged 15-45 years) are mostly victim of anemia. Therefore present study will focus to attain the information regarding the causes and consequences of iron deficiency anemia and give some proposal for prevention of anemia. The objectives of this study are following: To study the socio-economic characteristics of respondents. To find out the causes and consequences of iron deficiency anemia in pregnant females. To give some suggestions to the policy makers for the improvement of females health.

Chapter 2 REVIEW OF LITERATURE

The most important part of a thesis is the review of literature that aims to develop the scope of research. The reference contrast is provided through review of literature for the importance of research study. Review of literature is characterized with current and related reference through reference style, use of expressions and an unbiased and inclusive view of the prior research on the issue. According to study conducted by Cook et al. (1971) it was found that iron deficiency anemia can be measured by the high and low haemoglobin level. In hundred pregnant women 48 were iron deficient and 24 were anemic. 24 iron deficient women had haemoglobin level 11g/100 ml. which are count to be true anemic. The factors affecting anemia in pregnant women were number of pregnancy, household work and low nutrition. It was also found that poor diet is main causes of iron deficiency anemia. According to Thomson (1997) concluded that haemoglobin concentration are due to socio economic factors, area of residence, age, trimester, malaria parasite, geography of diet, pots used to cooking, vitamins and minerals. A linked between haemoglobin concentration and dietary intakes was studied, many studies are conducted to view iron deficiency anemia that result poor intake of iron contain food. In Middle East country anemia are found in mild condition in a large proportion of pregnant women. Iron deficiency is more complicated than folate deficiency. It is now identifiable that it has multifunctional orders. It was found that there exist the strong relationship between low income family and the poor behavior of people regarding taking iron supplement. UNICEF (1998) pointed out that iron deficiency is result of imbalance between iron requirement of body and the amount of iron absorbed. Some other factors are involved in iron deficiency anemia such as poor dietary habit, low bioavailability of iron in diet and low absorption of iron by the body due to any disorder. Someother importance causes of iron deficiency anemia are more number of pregnancy, extra bleeding, use of contraceptive method and excessive menstrutional bleeding low socio-economic status, food insecurity, lack of access to health facilities regarding antenatal and postnatal care and sanitation are common reasons harmful for health to delelop life cycle. In pregnancy, women should use

iron containing food to maintain hemoglobin concentration level. Sathar and Kiani (1998) concluded that in developing countries child marriage patterns is still prevailing. Young girls and boys married at early age in Pakistan. Due to early marriages different health problems are found among both males and females. Not only the spouses are disturbed, their family is also disturbed. It was found that problems of early marriages were social, economical and reproductive. Anemia not only start in adulthood, it mostly starts in childhood and increase with age. It was found by Khan (2000) she said that it affects both male and female but mostly it harms the women in their pregnancy as demand for haemoglobin increases. Anemia is common in Pakistan and mostly identified to influence girls and women, which become major cause of increased death rates in women. Anemia is of many types the most important is iron deficiency anemia and it can be so mild that no harm for the mother and baby and sometime it become very serious. This study was conducted by Brabin et al. (2001). Different epidemiological factors are related to the outcomes of anemia in pregnant women. As anemia is of wide variety, it is very difficult to know all the risk and the factors causing it. Shaheen et al. (2001) conducted study regarding health problems. They identified a number of barriers in taking iron supplement as less income, lack of awareness about IDA, poor dietary patterns having less iron, hypertension, less utilization of prenatal health facilities and cultural and traditional believes. Musaiger (2001) also found that iron deficiency anemia is due to social and economical health problem in Arab country. Other factors of IDA were poor diet, age, habits and gender discrimation. Iron deficiency anemia can be decreased by using fruits that have great amount of vitamin c. Control trend of early age marriages could also be helpful in reducing the risk of anemia. More number of deliveries is considered to be the basic cause of anemia. If no treatment is given to the pregnant women then iron deficiency increased month by month and become a serious health problem in last trimester. In Gulf country many women not use iron and folic acid because they think that it could be harmful for their developing baby they think that it was harmful to their developing baby. It is necessary to provide awareness to the women about children health and their own health through different prenatal visits. To decrease iron deficiency anemia women should give awareness about

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nutrition, iron supplement, control of infection and importance of healthy food habits. It is necessary that to decreased iron deficiency anemia among female, girls from high school level in all over the country should be educated regarding health issues. In developing countries iron deficiency anemia is basic health, social and economic problem. IDA reduces physical work capacity and in some cases this risk increased the mortality during prenatal period. Beard et al. (2002) noted that anemia reduced growth of fetus and increase morbidity. It causes different infections and more the blood loss. It is necessary to develop and implement programs which helping preventing and controlling the anemia in pregnant women. due to anemia, less amount of red blood cells decreased the amount of oxygen that transport to cells of body. Generally red blood cells are smaller than normal microcitic and paler than normal hypocromic cells. Burger and Louis (2002) stated that iron deficiency anemia physically cannot be seen until anemia become severe. Normal sign of anemia are fatigue, shortness of breath, colour of skin and inner eyelid. In our life cycle iron intake is critical during childhood growth, adolescent growth and during pregnancy. Heme iron is found in meat and non-heme iron is found in eggs, plant foods and dairy products. Heme iron is absorbed in our body up to 15 to 35 percent and non-heme iron is 2 to 20 percent. In all over the world but especially in developing countries iron deficiency anemia (IDA) is common health problem. The frequency of IDA in pregnant women is increased due to poor dietary habits and poor socio economic conditions. According to Karimi et al. (2002) the prevalence of IDA was 25 to 35 percent and this was more than that occurred in the urban areas and industrialized countries 5 to 8 percent. There is dire need of iron supplement identified in health care centers and should be provided free of cost by government to maintain the iron demand. Iron requirement is needed to provide energy and its requirement increase especially at time of pregnancy studied by Barclay and Tiwari (2002). Food and supplement as vitamin are necessary to fulfill the iron deficiency in pregnant women. These vitamins are also necessary for the proper function of iron in the body. In all developing countries anemia is a major health problem. According to WHO children and pregnant women are the major victim of anemia. Alemayehu et al. (2003) studied that anemia effects the school going about 37 percent male adults 18 percent and 35

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percent pregnant women faced the iron deficiency. They founded that generally 40.5 percent population is anemic. In Ethiopia anemic ratio in pregnant women was 57 percent. Other causes of anemia in women and children were poor nutrition, premature babies, long term breast feeding and high bleeding. There are some other reasons of iron deficiency such as low intake of meat due to poverty, less intake of balance. WHO (2003) identified the relationship between the prevalence of anemia and socioeconomic condition of households. Richer Women received more antenatal care as compare to poorest households. Antenatal care includes awareness about complication related with pregnancy, knowledge about well balanced diet, importance of exercises during pregnancy period and care of fetus. It focused on programs working for the better maternal and child health reduced maternal death and improves safe motherhood techniques. Osanai (2004-2005) pointed out that in rural area Dai play a major role for childbirth at home. About 79.0 percent birth occurred by Dai. Socio-cultural norm, financial cost along with less access to health care services is the factors due to which rural people prefer to take services from Dai. Lack of knowledge about delivery related complications are the causes of inadequate access to antenatal and postnatal care. Therefore focus should be given to skilled birth attendance for safe motherhood practices. Maternal health situation is slightly improved in urban area of Pakistan due to the services provided by LHWs and LHVs. During pregnancy iron is required to increase haemoglobin level. Iron is less required to those mothers who are healthy and significantly large amount of iron stored in their body. Iron required in pregnant women during pregnancy in milligrams required for fetus 300, placenta, expansion of maternal erythrocyte mass 450, basal iron loss 240 total iron required 1040. After delivery iron concentration is maternal erythrocyte mass plus 450, maternal blood loss minus 250, net iron balance is 200 and net iron requirement for pregnancy is 840. Iron deficiency was occurred due to low absorption of iron during pregnancy. This study is conducted by WHO, (2004). According to study it was founded that in first trimester paradoxical compound in blood that decreases iron absorption. In second trimester absorption rate is increased about 50 percent and in third trimester it is increased about four times than a normal women. Most developing countries it is very difficult for mothers to cover her iron deficiency through normal diet. It is necessary to use iron supplement to cover deficiency of iron that is about 400 to 500 mg in pregnant women as compare to normal women.

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During third world war women especially child bearing women were affected by vitamins and mineral deficiency. This is a serious global health problem, Donors and national resources have been directed to cover such micro nutrient deficiency. It is necessary that to improve children health, women health should be given importance. Hill et al. (2005) stated that women of south Asia improved their health on their own behalf and become able to lead and performed productive role in their societies. In this way married female young age girl can achieved their micro nutrients demands. Balanced diet is increased for female life because it will help to break the cycle of malnutrition and reduced the nutrients deficiency in females. In some developing countries there are some disadvantages for women and young girls for their health as compare to men. According to development research education is necessary to improve economic health and welfare and encourage political and society system. With the help of education economic, health and demographic benefits will be increased. Hannum and Buchmann (2005) stated that sociological and technical education is necessary for women to support their family and reduced responsible factors acting against women. Bhargava et al. (2005) concluded that iron deficiency in women is due to social and economic determinants that affect the food intake pattern of females. Women of reproductive age group living in poor families are mostly victims of IDA. It was found that family income is associated with the good health of the females. High income of families provide better food enriched in nutritional values i-e use of iron rich food from three main sources chicken, mutton, beef, fish and additional animal sources. Child spacing is necessary for improving the mother health. USAID (2005) concluded that mostly poor social status of women has less opportunity of healthy reproductive behavior. In addition, more number of children, less spacing between births has adverse effect on maternal and child health. Different contraceptive methods contributed considerably towards more spacing between children and reduced maternal and neonatal mortality and morbidity. Anemia during pregnancy is universal problem. Lot of studies about anemia showed different unfavorable effects of anemia in pregnant women and her baby, argued by Sukrat and Sirichotiyakul (2006). During pregnancy its symptoms come out but at delivery time complication due to iron deficiency appeared in form of low weight of baby and found to be

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the main cause of maternal mortality. During pregnancy due to iron deficiency some risks increased such as preterm delivery, prenatal mortality and low birth weight conducted by Calonge (2006). This rate was very high in minority and poor children. Iron deficiency anemia was associated with depression, postpartum haemorrhage, and poor performance on mental and psychological things. Haemoglobin is very important to measure iron deficiency anemia and nutritional deficiencies cause low production of haemoglobin. Iron deficiency is more common disease in all over the world that is caused by number of factors in pregnant women such factors are heavy menstrutional blood loss, blood loss due to abortion and pregnancy. Iron deficiency anemia cause greater risk of death during prenatal period. He was founded that the chance of morbidity and infection is increased in iron deficient people. Iron deficiency is also decreased morbidity and capacity of physical work. In a survey Aikawa et al. (2006) is suggested that low intake of iron tablets, hook worm infestation, low use of egg, traditional medicine and living in rural area are common factors of iron deficiency anemia in pregnant women, this result can help us to control iron deficiency anemia control program. Some educational and additional programs required to educate women against traditional medicine and seasonal differences to control anemia. Iron is the basic component of growth. Through iron haemoglobin (Hb) increases and as Hb carry oxygen with it, so oxygen also increases in blood circulation. The human body can improve iron deficiency through food. This study was conducted by Abu- Hasira (2007). Lack of iron in body can affect proper circulating of oxygen and ultimate cause will be less functioning of cells in body, for example in brain cells if oxygen decreases it causes hypoxia and result in brain damage. Red blood cells also contain haemoglobin which pass through oxygen to the body tissue, can lead to health complication. Fatigue and stress of body organs are the complication of anemia. Plante et al. (2007) highlighted that there are two million people in world suffering from iron deficiency anemia. Iron deficiency mostly appears in low income family because poor mothers do not take proper food during pregnancy. In pregnancy all of the causes indicate the poverty. The poverty is a basic reason to cause anemia and also see in the fewer developing countries where mother not get proper health facilities during pregnancy due to unawareness or economic crisis.

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It is observed that 50 percent anemia is caused due to iron deficiency. According to a study conducted by Shekar et al. (2007) the red blood cell decreases in quality or quantity which cause anemia. In pregnancy iron is not only required for the mother but also for the growing fetus who gets food through placenta, which links closely with the mother circulation to carry out functions which fetus is unable to perform itself during intra uterine life. Mostly spouses fail at the time of marriage to plan their fertility. In early periods of marriage they think that they will be bear more children, when they have more than four to five children they become worried about their financial sources, but they already a large number of children. This study is conducted by Arif and Kamaran (2007). But at that time, they dont use the contraceptive because they are unaware about these contraceptive and their fertility process still go on. More number of pregnancy mother become victim of pregnancy related complication. Catanzaro and Artal (2008) discussed that during pregnancy it is necessary to do exercise daily. Generally population and women are well for the benefits of the exercises. Light exercises during pregnancy have no adverse effects. It is helpful in changing the lifestyle of pregnant women and prevents many risks such as obesity, chronic hypertension and diabetes. Iron deficiency anemia causes many problems for mother and her developing fetus. The data show that impact of anemia in first trimester such as gestational age and birth rate. Severity of anemia in pregnant women appears to be a determinant of postnatal development of infants and their neurodevelopment in the first and second year of life. For women this condition is very critical if they do not use clinical treatment or iron supplementation against anemia, women who take treatment during pregnancy, their health is very good in pregnancy. Postnatal period is most valuable for both mother and newborn. After first week of birth 61 percent death occurs and nearly half of babies died during delivery birth. The role of the nutrition food is important for neonatal and maternal health in pregnancy. It is very important for women to lead a happy reproductive life. A study was conducted in District Mardan and North West frontier to know socio-economic and cultural problem of women by Jalal and Khan (2008). The result of 100 sample respondents showed that the socio-

economic status of women is linked with literacy rate, awareness, lack of skilled, poor

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income generating option. It is male dominant society male have decision power, of all family matters. Women have no opinion about any decision and considered to remain at home and care for their children. In this study it is suggested that women education is necessary to improve their lifestyle, solve problems for decision making, and to support their family. In developing countries 58 percent pregnant women are anemic. Many policies are made by ministries of health for reducing the maternal anemia in developing countries through providing the iron supplement stated by Yekta et al (2008). They also mentioned that due to lack of health facilities maternal anemia has not declined considerably. The aim of his study was to identify the current problems faced by local population and to explain the factors affecting on the iron supplement during pregnancy such as lack of awareness about iron use and long duration of iron supplement. Mostly females do not get antenatal care during pregnancy. Therefore due to lack of health awareness, they become the victim of anemia. Parents education and awareness has high influence on both mother and child wellbeing. Tembon and Fort (2008) stated that utilization of education has direct and indirect impact on child and mother health. Awareness and understanding about better investment on health and good relationship among family also affect the maternal and child health. Good income the family is strongly associated with the reproductive health of mothers. Living standard could be improved by increasing the income and education of family. Anemia has many risk factors in all over the world. Iron deficiency can start at any age but it mostly occurs in reproductive age and it can be decreased by fulfilling complete nutritional demand during pregnancy. A study of 100 patients having symptom of anemia conducted by Ansari et al. (2009 89 patients were found to be iron deficiency anemia in various ages. It was also found that iron deficiency is due to poor diet habit. It was noted that iron deficiency anemia were to maximum use of less iron containing supplement in pregnancy and maximum use of higher contents of phytate (not iron contains food). Other factors affecting iron deficiency anemia were low education, traditional practices, less supplementation and low income. Implementation of nutrition plan with the help of public health education sectors, community and media can play role to decrease iron deficiency anemia.

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According to WHO 42 percent of pregnant women are anemic in the world. World is facing some great risky health problems and some countries increasingly face double burden from the risk of communicable diseases and maternal and child outcomes that traditionally effect the poor. Some poor countries are facing intense problem such as poor sanitation, malnutrition and gender discrimation. Other factors such as Indoor smokes from solid fuel are the cause of iron deficiency stated by WHO (2009). At the same time dietary risk factors are cause of some medical problems such as obesity, blood pressure and cholesterol. Average age in high income countries is greater than low income countries. The iron deficiency can be controlled with balanced diet, iron supplements and food protection as stated by Ndiaye et al (2009). They argued that the councelling of pregnant women during antenatal programs could be beneficial to avoid the factors responsible for this disease. On her antenatal visit health care provider must aware the mother about the sign and symptoms of anemia to control this chronic disease at early stage. In our society early age marriages pattern is prevailing. Mostly in rural areas women are not allowed to get secondary or higher education, concluded by Naz et al (2009). When girls reach to their reproductive age, they are forced to be married in early years of reproduction rather to waste time in getting education. The reason behind is that mostly rural parents are unaware about the problems of early marriages, as psychological problem. According to WHO anemia is public health problem. As the anemia prevalence is equal or greater than 40 percent in our population. Karaoglu et al. (2010) conducted a research in which they found that a woman having more than four children and have low family income are found as anemic in pregnancy. It was also founded that anemia is moderate health problem in pregnancy. Calder (2010) found that women have no ability to take proper care of their children because they have low iron status and low nutrition that increase risk of iron deficiency anemia. To decreased intra pregnancy period we should make limit to reduce iron deficiency. To reduced iron deficiency anemia faces should be on control intra pregnancy period and change factors such as nutrition diet, education, socio-economic status and maternal morbidity. Parents give preference to son over daughter noted by Bharadwaj and Nelson (2010). health problem and

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Mothers visit antenatal clinics and received nutrition food when pregnant with boy. His study was cleared that in all religions prenatal treatment of males is given more importance than females because they thought male babies are superior to female babies in sense of income generating, honor of wealth and respect in society. In sex selective role son is superior to daughter in all sense such as fertility, causality, abortion rate and neonatal mortality in India. In pregnant women IDA is most common disease. For increasing the blood supplies then requirement of iron also increase. During intrauterine development of fetus iron requirement is increase and they use it after birth, so mother demands more iron according to Sabah et al. (2010). Anemia is extremely common in women especially in third world country like Pakistan where 60 to 70 million people are subjected to iron deficiency anemia; the possible factors behind this high occurrence are poor diet, early marriages, several births and lack of proper health facilities and low availabilities of iron from diet. It is observed that more than 40 percent people are deficient in the South Asia and South Africa. About 700 to 800 million people are anemic they are not able to provide iron according to their body demand. Pregnancy is not a disease and 80 percent of pregnancy and deliveries are normal. All pregnant women are at threat of developing complications and some complications are right to use appropriate emergency to women and her baby stated by Edwards (2010). Millennium development goal can be achieved 75 percent up to 2015 and also maternal mortality reduces. In this regard efforts need to build relationship through local political motivation for change. Iron deficiency is the most common disease due to nutritional deficiency stated by Batool (2010) that cause the size of red blood cells decreases with the passage of time. Anemia can occur at any stage of pregnancy due to one or more factors. A female should be screened for anemia during pregnancy, if the test is positive, then proper treatment should be given. Important risk factors for anemia are low intake of iron rich food, multiple pregnancy, heavy menstruation, and abortion, use of intrauterine devices, impaired absorption, low socioeconomic status, hereditary medical disorders and excessive blood loss during delivery.

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Anemic ratio in south Asia especially in India is very high concluded by Singh et al. (2011). Most of anemic patient are in mild condition that is 14 percent and maximum ratio is of in moderate condition which is 77.2 percent. The ratio of anemia is very high due to low dietary folic acid and poor iron intake. Anemic problem is maximum found in pregnant women, it can be decreased by proper intake of folic acid and iron supplementation. During pregnancy anemia must be treated before delivery. During pregnancy, women were more anemic that were not using calories and protein, not more than 2500 kilo calories per day. Pregnancy is a difficult period of women life where socio-demographic factors not only effect her health but also effect next generation. According to Madhavi and Singh (2011), different factors affect the reproductive status of women such as age, religion, and socio-economic status, type of family, house, methods, utilization, weight, height and body mass. The prevalence of anemia was found to be very high among illiterate women and women in the age of 20 years. Only 58.97 percent women received iron and folic tablets and 70.94 percent women take injection of tetanus from government hospitals. In developing countries 500 million women were affected by anemia as reported by Klemm et al. (2011). Iron deficiency anemia leads to an unaffordable burden of preventable morbidity and mortality. Moreover decline in economic well being and lost opportunities for human, societal, and financial development also associated with this problem. Among pregnant women micronutrients deficiencies are common due to contribution of ID according to Haider et al. (2011). For example, anemia affects just about 41.8% of each and every one pregnancy worldwide. The half of the cases has verified a high rate of maternal mortality in anemic pregnant women. In underdeveloped countries anemia is a problem. It is studied that in these countries people have changeable frequency of anemia. This study was conducted by Taseer et al. (2011). Often the multi gravid were more anemic due to loss of blood in multiple deliveries. It is universally believed that the main cause of anemia in pregnancy is the iron deficiency. Reveiz et al. (2011) stated that iron deficiency anemia can be mild, moderate and severe. Mild anemia can be reduced through rich iron food and moderate anemia can be control through proper iron supplement if mild and moderate anemia is not controlled then it became

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severe anemia. Severe anemia can be controlled through blood transfusion. Otherwise severe anemia can have serious consequences for mother and babies. When we treat anemia it provides more benefits than harm (fatigue and weakness). Iron deficiency

anemia is a basic health issue in women during reproductive age and it also cause chronic hookworm infections, which cause low birth weight and stop growth of fetus. Low weight birth had a great risk factor for neonatal mortality and morbidity. Passerini et al. (2012) revealed that in many developing countries hookworm infection and iron deficiency anemia are common diseases. It was found that mother was not using regularly iron rich food, folic acid and iron supplements. This iron deficiency anemia can be reduced by starting a health programs both in rural and urban areas. Health of women and new born could improve by enhancing antenatal program. Rammohan et al.

(2012) identified that in India women belonged to age group of 15 to 49 years were facing iron deficiency and their percentage was 52 percent. In India vegetarian women were more iron deficient as compare to non vegetarian women. It was also noted that in India poverty is another cause of iron deficiency anemia. Poor women preferred to become a vegetarian because of low source of income, which inhabits their ability to purchase nutrition food. Economic factors, unemployment, negative thoughts, household are common reason for iron deficiency anemia. To reduce this major health problem in India government should make a plan on large scale to cover women. In south Asian countries

gender was a most popular problem from last hundred years. If women give birth to male child she is considered very respectable in family. In most societies son preference is factor of poor health of female. Saeed (2012) pointed out that male child is preferable in all societies in term of treatment, wealth, education and communication. Sons are usually preferred because they are considered as a symbol of prestige for their families. This is most common reason to pressurize the women to continue her fertility until they deliver a male baby. More number of pregnancies is a main factor of IDA in women. Gender

issues are now linked with global development agendas. Malnutrition is one of the prominent features of nearly all developing countries specially among rural women with lesser degree of socio-economic choices. Multiple pregnancies along will less than optimum dietary habits often lead to complication in delivery and is one of the main reason behind maternal and infant mortality. Most common health disorder among pregnant women is iron deficiency

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anemia. Many social scientists have worked to explore the factors associated with this chronic disease, however present study is a remarkable contribution in this field as it focuses the area which is disadvantages and selected from the mainstream society. The study would help to identify some core reasons behind the prevalence of anemia among pregnant women.

CHAPTER 3 MATERIAL AND METHOD

Methodological techniques are very important for analyzing sociological problems empirically. Sound methodology is vitally important to establish chain for knowledge and empirical verification of hypothesis. The purpose of the research is to explain various tools to be employed for conducting the study. The scientific methodology is a system of explicit rules and procedures upon which research is based and against which claims for knowledge evaluated (Nachmias and Nachmias, 1992). Research tools and techniques differ from discipline to discipline and researchers also have specific biases in research. There are many

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approaches and different study designs are used to inquire different questions. Qualitative research is a naturalistic and interpretive approach that seeks to discuss and explain how and why people act and make decisions. Quantitative research seeks to identify determinants or relationships in a sample that can be assumed and assessed to be true of the population from which the sample is drawn. This study empirically investigated causes and consequences of iron deficiency anemia in pregnant women. For this purpose one approach, quantitative method was employed. The sequence of methodology to conduct research for quantitative data collection and for estimation is described in terms of study design, the universe of study, selection of respondents, sampling procedure, sample size, development of questionnaire and data analysis techniques. Study Design: Choice of the study design in scientific research is important for collecting reliable and meaningful information, data analysis, data management and generalization of research findings. Reliability and validity of research findings can only be established with appropriate relevant research designs. Regardless of any study design, research methods need to ensure that valid and reliable answers are retrieved (Dunham, 1999). Considering the objectives of study, time and cost the integrated approach is employed for data collection.

To conduct this study, primary research work was conducted in order to understand iron deficiency anemia, causes and consequences in pregnant women. Previous studies were reviewed to understand how different authors and scholars have defined iron deficiency anemia study and what some major causes and consequences are pointed out by them. Review of literature helped out to direct the dimensions of the study. Information from the respondents was obtained through a well structured questionnaire based on close and open ended questions. Responses are analyzed by using various tools as discussed at the end of this chapter. Sample Size: The question about the sample size is often asked that how much it has to be large. The answer depends on various aspects such as population size, population characteristics,

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time, available resources and kind of data analysis to select a representative sample size. It is not necessary that a large sample size would be a true representative sample. In order to enhance the scope of study maximum variation is captured in hospitals of Thesil D. G. Khan. (At first stage two hospitals were selected through convenient sampling technique. I had selected two hospital of Thesil D. G. Khan out of 9 rural health centers and 35 BHU because they were working twenty-four hour and provide free laboratory services to patients. So i selected these hospitals because it is affordable to me as a student. At second stage, a sample of 120 (60 respondent from each hospital) pregnant women age of (15-45) years were selected conveniently. Data Collection: Interview method was used to get meaningful and detailed information. Information was collected using interviewing schedule, consisting of both open and closed ended questions relevant to research objectives. Before starting actual data collection activity pre-testing on 15 respondents was carried out to examine the workability and sensitivity of the questionnaire. Researcher alone has collected data from 120 respondents from 13-082012 to 1-09-2012. Blood sample from pregnant women was collected by the technicians of the hospitals.

Field Experience: Data collection is not an easy task. During data collection the researcher faced many difficulties. Human beings are master of their own will and they can be or cannot be responding in desired manner. The respondents thought that the information collected might be used against them. The misunderstanding of the respondents was removed by explaining the purpose of study and research. Some respondents began to explain their own problem, most of them were hesitant to discuss their income. The researcher assured them that information collected will be kept confidential and was intended to be used for the research purpose. Conceptualization:

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Conceptualization is much more difficult in social science as compared to any other discipline because the same concepts are sometimes used with different meaning by different researchers. The need for conceptualization and defining the general concepts with specific and purified component is therefore, important. The main concepts used in this study and which need operationizalition are as follows. Age: It is defined as a total number of years completed by the respondents since her birth to the time of interview. The following age categories were made:

Family:

15 years 16-25 26-35 36-45

Family is a group of intimate people emotionally involved and related weather by blood, marriage or adoption, responsible for the production and rearing, living together. There are three major types of family discussed in the study. 1. Nuclear family: Where husband, wife and their dependent children are living together. 2. Joint family: Joint family consists of respondent, their parents, their married and unmarried children living within one boundary and cooking at one health. 3. Extended: Extended family consists of respondent, their parent, their married unmarried children and with their other relatives, i.e. Grandfather, uncle and that family relatives etc. Education: By education is meant the formal years of schooling by the respondent in an educational institution like school or college. Education was categorized as under: Illiterate (0) Primary (1-5) years of schooling Metric (6-10)

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Intermediate (11-12) Graduation (13-14) Master (15-16) and above

Occupation: Occupation has been defined as a kind of work performed by the individual regardless of the working place, where work is performed to earn his livelihood. The option of question asked regarding occupation are given as. No occupation Agricultural related House wife Sewing and embroidery Government employee Any other i.e. labor working, self employ,

Age at Marriage: Age at marriage is an important factor in fertility control, it is expected that later a person marries the greater is the likelihood of her having less number of children. In the present study age at marriage of the respondents was recorded. It is defined as total number of year completed by the respondents since his birth to the time of marriage. It was categories as: Income: In the present study income means monthly income of the respondent from all sources. The income of the respondent was categorized as below: Less than Rs 7000 Less than 15 years 16-20 21-25 26-30 Above 30

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Rs 7,001 to 12,000 Rs 12,001 to 17000 Rs 17001 to 22000 Above 22000

Number of Pregnancies: By number of pregnancies meant how many she conceive a baby. It was categorized as under: pregnancies 1-2 pregnancies 3-4 pregnancies 4-5 6 and more

Number of prenatal visit: By number of prenatal visit meant how many time she attend antenatal visit during this and previous pregnancies: Knowledge: This implies the awareness on the part of the respondent with regard to awareness about balance diet and attendening the antenatal visit to get information regarding the health improvement through health education program and minimize the pregnancy related complication due to iron deficiency anemia. Attitude: An attitude is a mental and natural state of reading organized through experience exerting a directive or dynamic influence upon the individual responses to all objective and situations with which it is related .an individual's attitude toward something is high predisposition to prepare, perceive, think and feel in relation to it. It is in fact a readiness to respond. Measurement of severity of anemia: < 4 visits 4-5 6 and more

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Anemia is measured by symptoms and level of haemoglobin. For measuring the symptoms, there were detailed questions consisting signs and symptoms of anemia. Weakness and fatigue are common symptoms of anemia. To find out the level of haemoglobin in pregnant women, their blood was tested. There are several methods to measure and report anemia the most general of which are volume and the concentration of hemoglobin (its the oxygen transforming molecule in RBCs). Home cue meter was used to analyze the blood test. It is an efficient instrument which gives accurate results in few minutes. Hemoglobin ranges were categorized according to the hemoglobin levels into mild (10.0-10.9 g /dl), moderate (8.0-9.9 g/dl) and severe (< 8.0 g/dl) anemia. Characteristics of the respondents: Study had limitations regarding the data collection; only those females were selected who were pregnant in the age of 15-45 years and were attending antenatal visit from both hospitals.

Some aspects to improve the data quality: Some important points such as sequence of questions, coding, time and relevant questions, field management, pretest and data editing were applied to improve the data quality while in designing questionnaire and collecting the information from the respondents. Developing the sensitive questions: In order to design the questionnaire, two basic principles were kept in mind. First, questions were made by keeping the viewpoint of respondents so that chance of confusion be eliminated. Second, during construction of questionnaire some biases were avoided such as jargon, slang, ambiguity, confusion, emotional language, prestige biases, double barreled questions, threatening questions, false premises and double negatives. These principles helped the researcher to motivate the respondents for maximum information.

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Avoiding sensitive and awkward questions in questionnaire formulation led to win the trust of respondents during interview (Adam and Cox, 2008; Nachmias and Nachmias, 1992).In addition, formulating the questionnaire, the major aspects contents, structure, format and sequence were taken into account Sequence of questions: Researchers are concerned that the order in which the questions are presented may influence the respondents answers. So, maximum care was exercised in sequencing the questions in order to minimize the discomfort and confusion of the respondents. In the beginning of questionnaire information about respondent age at marriage, family income, education, profession, family structure was obtained after words information about their health issues was taken. Coding: To get the accuracy, the majority of questions were pre coded to save time for data collection, processing and analysis. Then, collected data was shifted to coding sheets to make sure the intact accuracy. The software Statistical Package of Social Sciences (SPSS) version 20 was used for data analysis. Time and relevant questions: Length of questionnaire depends on the survey layout. Commonly, one hour is considered for face to face interviews but time span should be less for sustaining interest of the respondents, if we want to get required information. Fisher et al. (1998) supported this argument and suggested that questionnaire should be squeezed so as to restrain the sinking of responses considerably. In view of that, only those questions which are relevant to the objectives of the study were incorporated during construction of questionnaire so that minimum time would require for its administration. All the questions were included in data analysis reflecting validity of the questionnaire. On an average, the researcher consumed half an hour for conducting interview. Training and field supervision:

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Data quality depends on trained and well skilled interviewers in the area in which the study is planned. In this regard, the interviewer (researcher herself) conducted all the interviews because she fully understands the meaning and contents of the questions. The field work was supervised by the supervisor. Supervisor was in touch with researcher telephonically during the time of data collection in the field. Data editing and management: In order to ensure the quality of data, the completed questionnaire was examined after the interview for error, omission and inconsistencies as a key step during the field survey. The researcher carefully examined and edited the questionnaire after conducting interview. The cleaning of data process was accomplished by matching the codes with coding sheets or by original questionnaire. For this reason, data editing was done by computer and eliminated mismatching codes, irregularities and unlikelihood. Analysis: Quantitative data was analyzed through various statistical techniques as, univariate and bivariate techniques. In univariate analysis such as frequency and

percentage were used to describe the data. In bivariate analysis, relationship among different variables was examined through applying chi-square and gamma tests. 1: Use of SPSS: SPSS is the one of the most widely used software packages in the world of social sciences. It is clear that SPSS technology has made difficult analytical targets easier by advances in usability and to data access and also enabling the researchers to benefit from the use of quantitative techniques in making decisions. It helps researcher to input the data on computer and can save time from the laborious and exhaustive work of an analysis. 2: Univariate Analysis: It is defined as methods for analyzing data on a single variable at a time. In

univariate analysis, each variable in any data set is explored separately. It also looks at the range of the values but as well as the central tendency measures of the values. It describes the

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pattern and trend of response to the variable, also describes the variable on its own. Descriptive /univariate statistics interpret and summarize data and also it describes individual variables. Percentage: For the description of the basis characteristics of the sample, percentages were calculated. The purpose of using percentage is to simplify quantitative characteristics into numeric form. The percentage was calculated by using the following formula: P = F/N* 100

Where F = Frequency N = Total number of frequencies P = Percentage of frequencies 3: Bivariate analysis: Bivariate analysis is applied to see the relationship/association between the two variables. It is explained in other words, the variation which is explained by one variable is pattern in such a manner that its variance is not randomly distributed in connection with the other variable. Chi-square and gamma statistics were used to check the association and testing hypotheses.

Chi-Square: Chi-square was applied to ascertain the relationship between certain independent and dependent variable. The formula for Chi-Square is as under: (O-E) X2 = E
2

Where O= stands for observed value E = stands for expected value

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= denotes total sum In order to judge the significance of results, the calculated value of chi-square were compared with tabulated value at a given degree of freedom. The result was considered significant of calculated value of chi-square was greater than table value otherwise it was regarded a non-significance.

Gamma Statistics: The value of gamma showed the strength and direction of the relationship between independent and dependent variables. formula. Ns -Nd Gamma= Ns + Nd Where Ns = same order pairs Nd = different order pairs Calculations were made by using the following

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CHAPTER 4 RESULTS AND DISCUSSION The purpose of this chapter is to present analysis and interpretation of data relating to the research problems under investigation. This chapter has been divided into two parts, part A and part B. Part A presents major characteristics and certain information about the respondents. Part B the hypothesis has also been tested by applying chi-square and gamma test. PART: A Age: Age has an important role in the information of an individual in a social setup. It is an important variable which effect thinking and attitude patterns of an individual in negative or positive way. So in this study age is identified as complex number of years since birth. Table 1: Percentage distribution of the respondents according to their age. Respondents Age 16-25 26-35 36-45 Total Frequency 53 61 6 120 Percent 44.2 50.8 5.0 100.0

In this study the mothers were selected under age category 15-45 years. Table 1 reveals that majority of the respondents 50.8 percent belonged to age category 26-35 years, 44.2 percent belonged 16-25 and 5.0 percent belonged to 36- 45. Anemia has many risk factors in all over the world due to iron deficiency. Iron deficiency can start from any age in women especially in reproductive age and it can be decreased by complete fulfill nutritional demand during pregnancy (Ansari, 2009).

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Table 2: Percentage distribution of the respondents according to their husbands age. Husbands Age 16-25 years 26-35 36-45 Total Frequency 39 45 36 120 Percent 32.5 37.5 30.0 100.0

The data in table 2 displays that 37.5 percent of respondent's husbands belonged to 26-35 year of age group followed by 32.5 percent were belonged to 16-25 years of age groups, 30.0 percent were belonged to 36-45 year of age group and 5 percent were belonged to above 45 year of age group. Obviously the predominating age categoriesappearing in the sample were 26-35 and 36-45 years. Results showed that a large majority of the respondent's husbands were belonged to fertile age. Mostly spouses fail at the time of marriage to plan their fertility. In early periods of marriage they think that they will be bear more children, when they have more than four to five children they become worried about their financial sources, but they already a large number of children. This study is conducted by Arif and Kamaran (2007). But at that time, they dont use the contraceptive because they are unaware about these contraceptive and their fertility process still go on. More number of pregnancy mother become victim of pregnancy related complication. Table 3: Percentage distribution of the respondents according to their age at marriage. Respondents age at marriage time Up to 15 years 16-20 21-25 Total Frequency 29 83 8 120 Percentage 24.2 69.2 6.6 100.0

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Table 3 shows that 69.2 percent of the respondents got married in age 16- 20 years, 24.2 percent of the respondents had their marriages in teen ages up to 15 years, and 6.6 were married when they were 21-25 years. In our society early age marriages are still prevailing. Mostly in rural areas women are not allowed to get secondary or higher education Naz et al (2009) declared in her study. When they reach to their reproductive age women were married in early ages because their parents are unaware about the problem of early marriages such as social problem, health problem and psychological problem, its impacts on the health of young women. Similarly Musaiger (2001) Iron deficiency anemia can be decreased by using fruits that have great amount of vitamin c, use food that reduce iron absorption, change our habits, early age marriage and some parasitic infection. More number of deliveries is basic cause of anemia and decrease haemoglobin level. Table 4: Percentage distribution of the respondents according to their husbands age at marriage. Husband Age at marriage time 16-20 21-25 26-30 Total Frequency 82 34 4 120 Percentage 68.3 28.3 3.4 100

Table 4 reflects the percentage distribution of the respondent in according their husbands age at marriage and in the present study age of the respondent was recorded as the number of respondent own reply .Results showed that 28.3 percent of the respondents husband were 21-25 years old while 68.3 percent belonged to age group of 16-20 years and with a relatively small proportion 3.4 percent in age group of 26-30 years old. Sathar and Kiani (1998) concluded that in developing countries child marriage patterns is still prevailing. Young women and men married at early age in Pakistan.

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Table 5: Percentage distribution of the respondents according to their education. Education is highly linked with the health of women. Uneducated women due to lack of health information are deficient in promoting their health: its an alarming issue of today because country population is increasing. Different groups and feminist organizations are making their efforts to eliminate social injustices against women in Pakistan. Respondents Education Illiterate Primary Middle Metric Intermediate Graduation Post-graduation &above Total Education of the respondents: Frequency 99 13 2 3 1 1 1 120 Percentage 82.5 10.8 1.7 2.5 .8 .8 .8 100

This table 5 shows that 82.5 percent of the respondents were illiterate. 10.8 percent of the respondents had education primary level, 1.7 percent had education middle level, 2.5 percent had metric education, .8 percent had intermediate education, .8 percent women had graduation level education and .8 percent women had post-graduation &above level of education. According to development research education is necessary to improve economic health and welfare and encourage political and society system. With the help of education economic, health and demographic benefits will be increased. Hannum and Buchmann (2004) stated that sociological and technical education is necessary for women to support their family and reduced responsible factors acting against women. Husband's education (Years of Schooling): Table 6 shows that 45.8 percent of the respondents husbands were illiterate. 26.7 percent of them had education primary level, 8.3 had middle education, 10.0 percent had metric education, 5.0 percent had intermediate education, 2.5 percent women had graduation

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level education and 1.7 percent women had post-graduation &above level of education. Table 6 clearly reflects massive disparity between wifes and husband years of schooling. In Pakistan women education is not respected, valued and honored by the husband, husband family and society. Womans prime role is to bear and rear her children. It is also the womans responsibility to look after the family elders along with husbands loyalty. The husband or males role as bread earner is valued and honored in Pakistani society. Table 6: Percentage distribution of the respondents according to their husbands education. Respondents husband Education Illiterate Primary Middle Metric Intermediate Graduation Post-graduation &above Total Frequency 55 32 10 12 6 3 2 Percentage 45.8 26.7 8.3 10.0 5.0 2.5 1.7

120 100.0 Mother and father education and awareness has thoughtful influence on both mother

and child wellbeing. Tembon and Fort (2008) stated that utilization of education has direct and indirect impact on child and mother health, awareness and understanding about better investment on health and good relationship in family is the direct influence. Another is the indirect influence of education that is return over education in form of earning and better access to health facilities and good nutrition. So remove the gender inequalities and increase the living standard through increase households. In our male dominated society mostly women are restricted to move in society because women socially, culturally, and economically dependent on men. Women are also largely

excluded from making decisions, have limited access to and control over resources, are restricted in their mobility, and are often under threat of violence from male relatives.

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Table 7: Percentage distribution of the respondent according to their occupation. Profession: Respondents Occupation Agri related House wife Sewing & embroidery Govt. job Total Frequency 3 109 7 10 120 Percentage 2.5 90.9 5.8 1 100

Profession is a engaging in a given activity as a source of income or as a career. Profession is an occupational position and considered as a summary indicator for explaining different characteristics of the individuals. Table displays the working status of the women. Regarding the profession of the respondents as showed in table 7, 90.9 percent of the respondents were housewives, 5.8 percent were Sewing & embroidery , 2.5 percent worked on farm or cared livestock and only 1 percent were the govt. employees. In Pakistan women participation in economic activity (cash earning is quite negligible as reflected from the study findings). Although changes in womans role are covering still traditional values, rearing and bearing of children, marital loyalty and performing household chores are honored. In developing countries iron deficiency anemia is basic health, social and economic problem Harris (2002). This table 8 also indicates the respondents husbands prof essions. Income of husbands reflects the economic condition of the family that reflects the health. Majority of them 55 percent were laborers, 31 percent doing their own business, 17 percent of them were private employees while 4.2 percent were doing government services, 9.2 percent were belonged to agriculture and .8 percent were no occupation. This diversity of

professions shows that people are involved in different profession other than agriculture. Women related to farm families viewed that their hu sbands have

limited access to technology, its affordability and marketing problems. Some of

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them had sell land and started business. They also viewed that agriculture sector demands excess physical labor which directly affects on health of their hu sbands. Table 8: Percentage distribution of the respondents husbands according to their husband's occupation. Husbands Occupation No occupation Agriculturalist Govt. job Private job Own business (self employe) Any other ( labor) Total Frequency 1 11 5 16 57 12 120 Percentage .8 9.2 4.2 17 31 55 100

Musaiger (2001) also found that iron deficiency anemia is a main social and economical health problem in Arab country. In iron deficiency anemia there are other factors are also engaged such as socio-economic status, diet, age, habits and gender discrimation. Table 9: Percentage distribution of the respondents according to their monthly family income from all sources. Family income RS/Less than 7000 7001-12000 12001-17000 17001-22000 Total Frequency 73 40 5 2 120 Percentage 60.8 33.3 4.2 1.7 100

Income is one of the major factors, which determine the attitude of the individual towards adoption of family planning.

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Rural poverty is a complex and multi dimensional phenomenon. The main issues of rural poverty and income inequality are difficult to comprehend without through examination of several interrelated aspects of changes in the agriculture sector like expensive technology, seed cost, marketing and water problems. 60.8 percent of the respondents had less than 7000 family monthly income. This finding shows that majority people or farmers had no own land and work. They worked as labor on fewer wage or farmer worked on rent land; most of farm income share goes to the owners land. About 33.3 percent had 7001-12000 income while 4.2 percent had 12001-17000 and 1.7 percent had 17001-22000 income. Study shows the link of hemoglobin level. The purpose of study is that to determine the prevalence and factors in pregnant women and serum iron folate and vitamin B12. In which study Karaoglu et al. (2010) correlates women having more than four children and have low family income are found as anemic in pregnancy. In pregnancy anemia is moderate health problem. According to study it is shown that anemia is due to iron deficiency, folate and vitiminB12, socio-economic factors and low monthly family income. Table 10: Percentage distribution of the respondents according to their status of house. Status of the House Rented Owned Total Frequency 16 104 120 Percentage 13.3 86.7 100.0

House is a basic need of human beings. It provides shelter to family. With the condition of the house we can understand the economic condition of the family and as we know the economic play important role in achieving good nutrition and health facilities. The percentage about the status of house in my study is that 13.3 percent of the respondents lived in rented houses, while 86.7 percent were lived in owned houses. In rural areas people like to

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live in their own houses and the concept to live in rented houses is very rare as compared to urban areas. The result show that the socio-economic status of women was due to more literacy rate, awareness, and lack of education facility, lack of skill, poor economic condition, and insecure environment of society for working women. It is male dominant society male have making decision power, family and household expenditure Jalal and Munir (2008). Table 11: Percentage distribution of the respondents according to their type of house. House is the basic need of human-being. It provides shelter to family. With the condition of the house we can understand the economic condition of the family and as we know the economic play important role in achieving good nutrition and health facilities. In this present study for better understanding of the respondents economic condition, we get knowledge about the status of the house and the condition of the house. The type of the house was divided into four categories 1) mud-made 2) concrete 3) Sami-concrete 4) cottage/hut. See table 11. Type of House Mud Concrete Semi Cottage Total Frequency 67 16 34 3 120 Percentage 55.9 13.3 28.3 2.5 100.0

The percentage about the structure of the in my study is that 13.3 percent of the respondents lived in concrete houses, 28.3 percent lived in Semi-concrete, 55.9 were belonged to poor families and they lived in mud-made houses and 2.5 percent lived in cottage/hut. According to Thomson (1997) haemoglobin concentration effects are due to some extent residential area, socio economic factors, age, trimester, malaria parasite, and geography of diet, pots used to cooking, vitamins and minerals. In the result of presence study it is shown that maximum pregnant women are

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Hindus that are 88.80 percent and 87.15 percent are in moderate condition and 92.30 percent women are live in kaccha house 48.70 percent women are nuclear type family and 51.30 percent are in joint family conducted by Tinker and Elizabeth (2002). Anemia is found in moderate condition in working pregnant women and their ratio is 83.34 percent, total ratio of anemic patient reported in government hospital is 64.11 percent. Table 12: Percentage distribution of the respondents according to their type of family. Family Type Nuclear Joint Extended Total Frequency 55 60 5 120 Percentage 45.8 50.0 4.2 100.0

Family is a group of intimate individuals emotionally involved and blood related marriage or adoption responsible for the reproduction and rearing of the children living together. Normally, family type in all countries varies depending upon their style of living and culture. In Pakistan there are three types of families nuclear, joint and extended but most common form of families are joint and nuclear. In cities most families are living in nuclear family system and joint family rapidly changing into nuclear families due to changes. In urban and rural areas people are also giving preference to live in nuclear family to address their socio-economic needs properly. The results indicate that 50.0 percent of the respondents belonged to joint family, 45.8 percent of the respondents belonged to nuclear family and 4.2 percent of the respondent belonging to extended family. In the result of presence study it is shown that maximum pregnant women are Hindus that are 88.80 percent and 87.15 percent are in moderate condition and 92.30 percent women are live in kaccha house 48.70 percent women are nuclear type family and 51.30 percent are in joint family conducted by Tinker and Elizabeth (2002). Anemia is found in moderate condition in working pregnant women and their ratio is 83.34 percent, total ratio of anemic patient reported in government hospital is 64.11 percent.

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Table 13: Distribution of the respondents according to their visit health center, prenatal during this pregnancy. Frequency Prenatal visit <4 4-5 5 & more Total 106 11 3 120 Frequency 88.3 9.2 2.5 100.0

Prenatal care visits are essential for women during pregnancy. Health professionals advise that pregnant women should have proper pre- and postnatal care during pregnancy and after childbirth, respectively. In Pakistan visits are needed to keep in touch with health status of women for normal cases. More visits can be recommended according to pregnancy health. Prenatal visits help women to be careful about health complications, birth interval, importance of breast feeding and need of contraceptives in future birth control. This table 13 shows that 88.3 percent of the respondents made < 4 visit to any health professional, reasons behind that they were unaware of health importance, lack of education and family restrictions. 9.2 percent made 4-5 visits, 2.5 percent visited 5 & more times. It is point of attention that the rural and poor respondents visits to health centers is less as it should be. Rural pregnant are more anemic. They need best guide of nutrition. If they visit properly and collect nutritional pieces of advices from the professionals, improvement would be there. WHO (2003) identified the relationship between the prevalence of anemia and socio-economic condition of households. Richer Women received more antenatal care as compare to poorest households. Antenatal care includes awareness about complication related with pregnancy, knowledge about well balanced diet, nutrition and importance of exercises during pregnancy period, care of infant. Reduced maternal death and improve safe motherhood programs for minimized complication at early stage. Early registration of women for antenatal cares as early as possible after the establishment of pregnancy status in order to ensure early assessment of the risk status and carry out effective and timely intervention, as and when necessary. The table 14 shows that majority of respondents visits for antenatal during this pregnancy 47.5 percent in the gestational age of

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above 5 months, 33.3 percent in the gestational age of 4-5 months and 19.2 percent came during 1-3 month of early age. Table 14: Distribution of the respondents according to their gestational age. Gestational age 1-3 4-5 months Above 5 months Total Frequency 23 40 56 120 Percentage 19.2 33.3 47.5 100

The iron deficiency can be controlled with balanced diet, iron supplements and food protection as stated by Ndiaye et al (2009). They argued that the councelling of pregnant women during antenatal programs could be beneficial to avoid the factors responsible for this disease. On her antenatal visit health care provider must aware the mother about the sign and symptoms of anemia to control this chronic disease at early stage. Health indicators of Pakistani women are among the worst in the world. In food biasness, intra-household distribution leads to nutritional deficiencies among female children. Early age at marriage of girls, poor reproductive health, excessive childbearing, and a high level of illiteracy adversely affect women's health and their autonomy. Above table 15 shows the different symptoms of anemia as asked from the respondents. Responses of respondents reflect that 63.3 percent of the respondents noted unusually tired or fatigue to a great extent, while 36.7 percent to some extent. Majority 65.0 percent of the respondents told that they felt unusual weakness to a great extent while 35.0 percent to some extent. To a great extent, 48.3 percent told about the shortness of the breathe while 32.5 percent had to some extent and 19.2 percent did not had symptoms of shortness of breathe. 45.0 percent of the respondents felt dizziness to a great extent and 38.3 percent to some extent and 16.7 percent did not feel dizziness. Majority 48.3 percent had pale skin to a great extent while 32.5 percent had also pale skin to some extent and 19.2 percent did not have pale skin. 41.7 percent of the respondents to great extent decreased pinkness in lips; most 20.0 percent to some extent and 38.3 percent had not at all this problem. To a great extent, table shows 40.0, 44.2, 40.9, 50.0, 62.5 percent of the respondents respectively had decreased pinkness in

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gums, decreased pinkness in nails, a rapid heartbeat, unusual cold and sadness/depressed. To some extent, 19.2, 23.3, 30.8, 38.3, 31.7 percent of the respondents had problems of decreased pinkness in gums, decreased pinkness in nails, a rapid heartbeat, unusual cold and sadness/depressed respectively. While remaining were 40.8, 32.5, 28.3, 11.7, 5.8 percent no symptoms of iron deficiency anemia. Table 15: Distribution of the respondents according to the symptoms of iron deficiency anemia. Statements Feel unusually tired or fatigued Experience unusual weakness Experience shortness of breath Feel dizziness Unusually pale skin Decreased pinkness of lips Decreased pinkness of gums Decreased pinkness of nails Experience a rapid heartbeat Feel unusually cold Feel sad or depressed 60 (50.0) 75 (62.5) 14 (11.7) 7 (5.8) 46 (38.3) 38 (31.7) 120 (100.0) 120 (100.0) 49 (40.9) 34 (28.3) 37 (30.8) 120 (100.0) 53 (44.2) 39 (32.5) 28 (23.3) 120 (100.0) 48 (40.0) 49 (40.8) 23 (19.2) 120 (100.0) 54 (45.0) 58 (48.3) 50 (41.7) 20 (16.7) 23 (19.2) 46 (38.3) 46 (38.3) 39 (32.5) 24 (20.0) 120 (100.0) 120 (100.0) 120 (100.0) 58 (48.3) 23 (19.2) 39 (32.5) 120 (100.0) 78 (65.0) 0 42 (35.0) 120 (100.0) To great extent
Frequency (%)

Not at all
Frequency (%)

To some extent
Frequency (%)

Total
Frequency (%)

76 (63.3)

44 (36.7)

120 (100.0)

Burger and June (2002) stated that iron deficiency anemia physically cannot be seen until anemia become severe. Normal sign of anemia are fatigue, shortness of breath, colour

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of skin and inner eyelid. In our life cycle iron intake is especially critical when we need it very high such as in childhood growth, adolescent growth and during pregnancy. Table 16: Distribution of the respondents according to the prevention after feeling pale/ fatigue/ weakness. Prevention Rest Visit doctor Visit Hakeem Food Multivitamins Total Frequency 109 3 1 6 1 120 Percent 90.9 2.5 .8 5.0 .8 100.0

Rural women have very low education and lack of awareness about health knowledge and practices. They do not take symptoms very seriously. Data shows that to take rest is a temporary care; the problems can attack again severely. Few of them dont care due to lack of access to health facilities. Table 16 shows the respondents visits of different health professionals after feeling the pale/ fatigue/ weakness. 90.9 percent took rest after the problems faced, 2.5 percent visited doctors, .8 percent visited dispensers/hakims while 5.0 percent took food and .8 percent takes multivitamins. Musaiger (2001) in pregnancy iron deficiency increases month by month and become a serious health problem in last trimester. In Gulf country many women not use iron and folic acid they think it is harmful to their developing baby. It is necessary to educate women about children health through different prenatal visits. To decrease iron deficiency anemia we should educate women about nutrition, iron supplement, control of infection, educate them about healthy food habits, use of food that increased iron absorption. It is necessary to educate girls from school level in all over the country to decrease iron deficiency anemia. Jalal and Munir (2008) study shows that the socio-economic status of women was due to more literacy rate, awareness, and lack of education facility, lack of skill, poor economic condition, and insecure environment of society for working women. It is male dominant society male have making decision power, family and household expenditure. Women have no opinion about any decision and considered to remain at home and care for their children.

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Only some of people found in society they make decision independently against education, literacy and household, but these persons are not enough to change society. In this study it is suggested that women education is necessary to improve their lifestyle, solve problems and support their family. We should make possibility to make essay education for women. Table 17: Distribution of the respondents according to the preparation of meal in home, knowledge about balanced diet. Preparation of meal at home Factors Your self Daughter Any other Total Not at all Knowledge about balanced diet To some extent To great extent Total Frequency 101 1 18 67 49 4 120 Percent 84.2 .8 15.0 55.9 40.8 3.3 100.0

Preparation of meal: The respondents were asked questions about the preparing of food. Majority 84.2 percent of them prepared food themselves, .8 percent of the respondents daughters and 15.0 other relatives helped out to prepare meal. The women, who were prepared food at home themselves, were preferred to always prepare dishes using the fresh food ingredients. But it has been studied that majority rural households had no proper kitchen and raw food was not handled properly. Bacterial and infection diseases were mostly seen. Balanced diet: Balanced Diet is defined as when all food groups are represented in healthy proportions or percentages. Micronutrients and macronutrients are as fats, carbohydrates, and proteins. Nutritional aspects and balanced diets are often difficult to understand. Table 17 shows the respondents knowledge about different food groups of balance diet. 55.9 percent of the respondents had never information that only fruits and vegetables are balanced diet. Only 40.8 percent of the respondents had knowledge to some extent that balanced diet is the

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only meat, fish and legumes. 3.3 percent said balanced diet is combination of different food groups. Rammohan et al. (2012) identified that in India vegetarian women are more iron deficient as compare to non vegetarian women. It was also noted that in India poverty was another cause of iron deficiency anemia. Poor women preferred to become a vegetarian because of low source of income, which inhabits their ability to purchase nutrition food. Economic factors, unemployment, negative thoughts, household are common reason for iron deficiency anemia. Daily low use of meat, fish, egg and nutrition are common cause of anemia. In India according to survey socio-economic factors such as higher wealth, in paid employment and rural residence are causes of iron deficiency anemia in Indian women. Table 18: Distribution of the respondents according to knowledge about specific food that makes blood. specific blood Fish and Meat Fruits and Vegetable Grains and pulses Milk and Butter food make To great extent
Freq (%) Freq (%)

Not at all

To some extent
Freq (%)

Total

Freq (%)

36 (30.0) 43 (35.8) 16 (13.3) 39 (32.5)

28 (23.3) 21 (17.5) 48 (40.0) 28 (23.3)

56 (46.7) 56 (46.7) 56 (46.7) 53 (44.2)

120 (100.0) 120 (100.0) 120 (100.0) 120 (100.0)

Some specific Food and blood: Table 18 also shows the knowledge of women about specific food items which are essentials to generate blood. Four groups were mentioned to respondents to know that knowledge. To a great extent, table shows 30.0, 35.8, 13.3, 32.5 percent of the respondents respectively had knowledge of fish and meat, fruits and vegetable, grains and legumes, milk and butter. To some extent, 46.7, 46.7, 46.7, 44.2, percent of the respondents had knowledge of fish and meat, fruits and vegetable, grains and legumes, milk and butter. While remaining had 23.3, 17.5, 40.0, 23.3 percent no knowledge about specific food that makes blood. The Pakistani rural women have low education, less awareness and knowledge of nutritional diet. Bhargava et al. (2005) showed the result of iron deficiency in women is due to social

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and economic determinants that affecting the iron intake form poultry, fish and meat. IDA influences on a large number of women that living in developing countries and mostly in reproductive period. Various study showed that if the family income increase that were linked with more use of iron rich food from three main sources chicken, mutton, beef, fish and additional animal sources. Rammohan et al. (2012) identified that in India vegetarian women are more iron deficient as compare to non vegetarian women. It is also noted that in India poverty is another cause of iron deficiency anemia. Poor women preferred to become a vegetarian because of low source of income, which inhabits their ability to purchase nutrition food. Economic factors, unemployment, negative thoughts, household are common reason for iron deficiency anemia. Daily low use of meat, fish, egg and nutrition are common cause of anemia. In India according to survey socio-economic factors such as higher wealth, in paid employment and rural residence are causes of iron deficiency anemia in Indian women. To reduce this major health problem in India we should make a plan on large scale to cover women such as poor iron vegetarian diets due to religious, economic and cultural through using extra nutrition food to reduced iron deficiency anemia. Table 19: Distribution of the respondents according to know that each person needs energy/calories. Needs energy/calories. To great extent Not at all To some extent Total Frequency 10 30 80 120 Percent 8.3 25.0 66.7 100.0

Required nutrition is essential for health and cure for any disease. Eating is irregular where as energy needs are in continuous way. Table 19 shows that need of energy 8.3 percent had to great extent, 25.0 percent had no knowledge about need of nutrition and to some extent respondent know about need of energy/calories to some extent. Iron requirement is increased in pregnancy and iron is needed for whole body energy, tissues and blood as studied by Barclay and Tiwari (2002). This requirement also increased due to heavy work. Iron rich food and other supplement as vitamins are necessary for increasing demand of iron and this iron should be in active form and proper heme iron

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(contain iron compound) so the requirement can be fulfilled properly. Vitamins are necessary for proper absorption and function of iron. Table 20: Distribution of the respondents according to their meals per day and reasons of non-regularity in meals. Habit/ reasons One Two Three Total Due to work Child care Aged members Economic All Total Frequency 9 89 22 120 7 2 2 79 30 120 Percent 7.5 74.2 18.3 100.0 5.8 1.7 1.7 65.8 25.0 100.0

Take meal/day

Reasons of nonregularity

Regularity in meals and reasons of non-regularity: The table 20 reveals that 50.8 percent of the women were used to take regular meals per day 7.5 percent one times per day, 74.2 percent take meal two times per day and 18.3 percent take meals three. In case of non-regularity, women expressed few reasons they were facing. However 5.8 percent of women were over burdened as work outside at home, income generating activities. But 1.7 percent of the women were busy in their child care and to look after the old and ill people. 65.8 percent shows that they had the economic problem and 25.0 percent face non regularity due to work, child care, aged member, economic problem and all above. Plante et al. (2007) highlighted that there are two million people in world suffering from iron deficiency anemia. Iron deficiency mostly appears in low income family because poor mothers do not take proper food during pregnancy. In pregnancy all of the causes indicate the poverty. The poverty is a basic reason to cause anemia and also see in the fewer developing countries where mother not get proper health facilities during pregnancy due to unawareness or economic crisis.

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Table 21:

Distribution of the respondents according to calories intake per day, take

these food on doctor advice. Calories intake per day Amount/ advise Less than 1500 1501-2300 Total Yes Doctor advice No Total Frequency 18 102 120 20 100 120 Percent 15.0 85.0 100.0 16.7 83.3 100.0

Results table 21 show that 15.0 percent of the respondents were used to take less than 1500 calories per day, as results indicates that majority of the mothers were deficient in food intake due to low socio-economic status. Only 85.0 percent of the respondents took 15012300 calories. It shows that mostly of the respondents were only habitual of normal food intake per day. Thats why rural women are facing nutritional iron deficiency anemia. Nutritional deficiency is one of the most prevalent public health problems in rural area. Mostly respondent take food according their family income, table showed that 83.3 percent not take these food on doctor advice and 16.7 percent takes these food to some extent on doctor advice increase their health status because victim of highly symptom of iron deficiency anemia. According to Madhavi and Singh (2011) in pregnancy women are more anemic that are not using calories and protein, they not use more than 2500 kilo calories per day. Pregnancy is a difficult period of women life where socio demographic factors not only effects her health it is also effect next generation. In Pakistani society son is preferred because boys are considered to contribute to the familys income, prestige and family name. Sons are expected to carry out certain traditional resources, and sons and not daughters are expected to contribute towards parents in their old age. Table 22 shows that to great extent .8 percent preferred son over daughter, 18.3 percent disagree that son prefer over daughter and 31.7 percent had no knowledge about family or society prefer son over daughter, 44.2 percent are agree that family prefer sons and 5.0 percent strongly agree that family prefer over daughter.

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Table 22: Distribution of the respondents according to son preference over daughters (in food and family matters). Statement Response Strongly disagree Disagree No Prefer sons over daughter Agree Strongly agree Total Strongly disagree Disagree boys need more diet than girl No Agree Strongly agree Total Frequency 1 22 38 53 6 120 1 22 38 53 6 120 Percent .8 18.3 31.7 44.2 5.0 100.0 .8 18.3 31.7 44.2 5.0 100.0

The nutritional diets assist to ensure optimal work ability and better reproductive performance, and to develop immunity against infections. Poor nutrition increases chances of infection and disease, and also reduces work ability and efficiency. Poverty comprised with socio-cultural norms regarding food habits, and food distribution within the household often causes nutritional deficiencies in women. The table 22 shows that about .8, 18.3, 31.7, 44.2, and 5.0 reported that boys need good nutritional diet than girls to strongly disagree, Disagree, No, Agree, Strongly agree. According to micro health data from India it is highlighted that parents try to make male superior to female. Bharadwaj and Nelson (2010) are noted that mother visit antenatal clinics and received nutrition food when pregnant with boy. In all religions prenatal treatment of males is greater than females because they thought male babies are superior to female babies in sense of income generating, honor of wealth, respect in society. Survey and calculations are shown sex selective prenatal care is superior. In sex selective role son is superior to daughter in all sense such as fertility, causality, abortion rate and neonatal mortality in India. There are same results are found in other countries such as China,

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Bangladesh, Pakistan and south Asia. Saeed (2012) pointed out male child is preferable in all societies in term of treatment, wealth, education, and communication. Sons are usually preferable because they are considered as a symbol of prestige for their families. This is most common reason to pressurize women to continue give birth until they deliver a male baby. The objective of the study not only male child but it is also to note effects and factors such as family type, type of place, household, agriculture and non agriculture women education inter cousin, surviving children, marriages, husband level of education. Table 23: Distribution of the respondents according to the number of Pregnancies, total live births, total dead births. No. of pregnancies 1-2 3-4 4-5 6 & more Total a: Number of pregnancies: In Pakistan the basic aim of marriage is to bear the children. This thinking is depends upon on socio-cultural beliefs. In Pakistani society womans position gets stronger when she gets pregnant and gives birth to a child particularly a boy child. In first category 32.5 percent of the respondents became pregnant for 1-2 times. 17.5 percent of the respondents got pregnant for 3-4 times, 14.2 percent got pregnant 4-5 times and 35.8 percent got pregnant 6 and more time. The trend of more number of pregnancies shows the high fertility preference. In the earlier table, the majority of the respondents had low family income. Basically this was the problem which made them prone to suffering and they remained illiterate. In underdeveloped countries anemia is a problem. It is studied that in these countries people have changeable frequency of anemia. This study was conducted by Taseer et al. (2011). Often the multi gravid were more anemic due to loss of blood in multiple deliveries. Frequency 39 21 17 43 120 Percent 32.5 17.5 14.2 35.8 100.0

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Total live birth No child* 1-3 4-6 7-9 10 and above Total
* First pregnancy or have no live child

Frequency 30 54 26 9 1 120

Percentage 25.0 45.0 21.7 7.5 0.8 100.0

b: Live births: In this table 23 most of the respondents 25.0 percent had first pregnancy and they have no child and some have no live child, 45.0 percent had delivered 1-3 live birth and 21.7 percent of the respondents delivered 4-6 live births. 21.7 percent had delivered 7-9 live births and 0.8 percent of the respondents delivered 10 and above live births. This shows the high fertility trend in Pakistan even the health status of women is not good and fertility rate is still high. There are many reasons for many numbers of children in Pakistan: desire for son, inlaws desire for large family, lack of education, prestige and less empowerment. Unplanned births are also a cause of large number of children in Pakistan. As a result of unplanned pregnancies, women have to bear more children than they would prefer. Total live births (both) Freq. First pregnancy 1-3 4-6 7 and above Total 52 53 15 0 120 Boy % 43.3 44.2 12.5 0 100 Freq. 46 63 10 1 120 Girl % 38.4 52.5 8.33 0.8 100

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c: Total live boys and girls: According to table 23 distribution live girl showed that 38.4 percent had first pregnancy or have no live girl child, 1-3 had 52.5 percent of total girl, 4-6 had 8.33 percent, 7 and above had 0.8 percent. 4 had 4.2 percent. According to table distribution live boys showed that 43.3 percent had first pregnancy or have no live boy children, 1-3 had 44.2 percent of total boys and 4-6 had 12.5 percent. Total dead/ still birth First pregnancy or have no died child 1-3 4-6 7 and above Total d: Total no. of died children: In this table most of the respondents 69.2 percent had first pregnancy and they have no child and some have no died child, 29.2 percent had delivered 1-3 died births and 0.8 percent of the respondents delivered 4-6 died births. .8 percent had delivered more than seven. The percentage distribution of the respondent's according to their No. of died children through this we will able to know the wish of the respondent about more children. Total dead child (both) Freq. No 1-3 4-6 Total e: Total died boys and girls: According to table 23 distribution live girl showed that 86.7 percent had first pregnancy or have no died girl child, 1 had 13.3 percent of total girls, 2 had 2.5 percent, 4 had .8 percent 93 26 1 120 Boy % 77.5 21.7 0.8 100 Freq. 104 16 0 120 Girl % 86.7 13.3 0 100 Frequency 83 35 1 1 120 Percentage 69.2 29.2 0.8 0.8 100.0

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According to table 23 distribution died boys showed that 2.5 percent had first pregnancy or have no died boy children, 1- had 16.7 percent of total boys. Saeed (2012) pointed out male child is preferable in all societies in term of treatment, wealth, education, and communication. Sons are usually preferable because they are considered as a symbol of prestige for their families. This is most common reason to pressurize women to continue give birth until they deliver a male baby. Table 24: Distribution of respondent according to their birth interval in all pregnancy. birth interval First pregnancy 1 yr 2 yr 3 yr More than 3 yr Total Frequency 25 46 39 7 3 120 Percent 20.9 38.3 32.5 5.8 2.5 100.0

Data presenting in table 24 also showed that 20.9 percent respondent has first pregnancy, majority respondent has 38.3 percent of birth spacing of one year and 32.5 percent had two years of birth interval. 5.8 percent showing 3 years birth interval and 2.5 percent had 2.5 percent for more than 2.5 year. Calder (2010) suggested that women have low intra pregnancy period have not proper time to replace nutrients. The women have no ability to develop their child because they have low iron status and low nutrition that increase risk of iron deficiency anemia. To decreased intra pregnancy period we should make limit to reduce iron deficiency. To reduced iron deficiency anemia we should control intra pregnancy period and change factors such as nutrition diet, education, socio-economic status and maternal morbidity. According to Study in UK in which they give ideas of iron as absorption, nutrition diets in pregnancy and lactation that effect on mother health. Birth of child is a natural practices, birth is best as it is natural. Child spacing is necessary for improving the mother health. USAID (2005) concluded that mostly poor socio status of women has less opportunity of usual reproductive behavior. In addition more number of children, less spacing between birth adverse effect on maternal and child health.

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Family planning methods introduced and couple entrance to family planning method, and get more spacing pregnancy and reducing maternal and neonatal mortality and morbidity. Table 25: Distribution of the respondents according to the number of abortions, loss of blood, heavy blood loss. Statement Abortion No of time/ agreed No abortion 1 2 More than 3 Total No abortion Loss of Blood Yes No Total No abortion Yes If yes (heavy loss of blood) No Total Frequency 68 30 16 6 120 68 50 2 120 68 34 18 120 Percent 56.7 25.0 13.3 5.0 100.0 56.6 41.7 1.7 100.0 56.7 28.3 15.0 100.0

The certainty of miscarriage is frequently during the first 12 weeks of pregnancy. About 56.6 percent of the respondents were no experienced about abortions and miscarriages in the present study. About 25.0 percent of the respondents had one abortion or miscarriage and 13.3 percent of the respondents had more than two. About 5.0 percent had more than three abortions. One rural woman viewed that abortion of unwanted pregnancies are due to lack of knowledge and availability of contraceptives and poor quality of family planning services. She spoke that counseling should be provided to women on the contraceptives choices and at the same time men and women should be make aware about the dangers of unsafe abortions. Iron deficiency is the most common disease due to nutritional deficiency stated by Batool (2010) that cause the size of red blood cells decreases with the passage of time. Anemia can occur at any stage of pregnancy due to one or more factors. A female should be

56

screened for anemia during pregnancy, if the test is positive, then proper treatment should be given. Important risk factors for anemia are low intake of iron rich food, multiple pregnancy, heavy menstruation, and abortion, use of intrauterine devices, impaired absorption, low socioeconomic status, hereditary medical disorders and excessive blood loss during delivery. Heavy blood: Abortion is a risky element from the health point of view. It leads towards the different health reproductive complications for future. About 41.7 percent of the respondents faced blood loss while 1.7 percent of the respondents did not face this problem. Among those who had blood loss 28.3 percent faced heavy blood loss, while 15.0 percent faced light blood loss. .Table 26: Distribution of the respondents according to their last baby age Last baby age First pregnancy and abortions 1 year 2 3 More than 3 Total Frequency 26 36 43 6 9 120 Percent 21.7 30.0 35.8 5.0 7.5 100.0

. Table 26 shows that 30.0 percent of the respondents their child age were one year, 35.8 percent of the respondents their last child age were 2 years, 5.0 percent of the respondents their last child age were 3 years and 7.5 percent of the respondents their last child age were more than 3 years. Among pregnant women micronutrients deficiencies are common due to contribution of ID according to Haider et al. (2011). For example, anemia affects just about 41.8% of each and every one pregnancy worldwide. The half of the cases has verified a high rate of maternal mortality in anemic pregnant women

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Table 27: Distribution of the respondents according to their visit health center, prenatal and postnatal care during last pregnancy. Statement Response First pregnancy Never Visit Some times Frequently Total First pregnancy and never attend <4 No. of prenatal visits 4-5 Above 5 Total Frequency 23 39 54 4 120 60 53 4 3 120 Percent 19.2 32.5 45.0 3.3 100.0 50.0 44.2 3.3 2.5 100.0

First pregnancy and never attend 1 Visits of post natal care 2 3 Total Visit to any health centre:

68 41 10 1 120

56.7 34.2 8.3 .8 100.0

This table 27 shows that 19.2 percent of the respondents had first pregnancy. 32.5 percent of the respondents did not visit any health centre during last pregnancy. 45.0 respondents visit sometimes during last pregnancy and 3.3 percent visit frequently during last pregnancy. The reasons behind in the rural areas were lack of health centers, absence of professional staff, less resources and lack of awareness. There is a severe need to address health issues.

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Visits for prenatal care: Prenatal care visits are essential for women during pregnancy. Health professionals advise that pregnant women should have proper pre- and postnatal care during pregnancy and after childbirth, respectively. Prenatal care visits are essential for women during pregnancy. Health professionals advise that pregnant women should have proper pre- and postnatal care during pregnancy and after childbirth, respectively. This table 27 shows that 50.0 percent of the respondents have first pregnancy and include that who were not attend antenatal visit during last pregnancy reasons behind that they were unaware of health importance, lack of education and family restrictions. 44.2 percent made < 4 visits, 3.3 percent visited 4-5 times and 2.5 percent visited more than five. The iron deficiency can be controlled with balanced diet, iron supplements and food protection as stated by Ndiaye et al (2009). They argued that the councelling of pregnant women during antenatal programs could be beneficial to avoid the factors responsible for this disease. On her antenatal visit health care provider must aware the mother about the sign and symptoms of anemia to control this chronic disease at early stage. Visits of post natal care: Post natal care is also essential like prenatal care. In Pakistan, according to health professionals one post natal visit is needed for mother and child. Visits for postnatal care can be save from different problems like level of hemoglobin, tetanus, gastrointestinal problems for both mother and child. From the above table 26, 56.7 did not visit and include respondents those who were current pregnancy, 34.2 percent visited one time while 8.3 percent also visited two times and .8 percent visited three times for postnatal checkup. To be safe motherhood is critical to saving newborns. Jalal and Munir (2008) reported the postnatal period is most valuable for both mother and newborn. During first week of birth 61 percent death occurs and nearly half of babies died during birth. First day of delivery tetanus toxide is common in females. The role of the nutrition food is important for neonatal and maternal health in pregnancy. Nutrition and

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weight gaining is first step during pregnancy. Nutrition is very important for women and girls for healthy life. Table 28: Distribution of the respondents according the complications during last pregnancy. Complications First pregnancy Frequency (%) 23 (19.2) 23 (19.2) To great extent Frequency (%) 6 (5.0) 44 (36.6) Not at all Frequency (%) 76 (63.3) 21 (17.5) To some extent Frequency (%) 15 (12.5) 32 (26.70 Total Frequency (%) 120(100.0) 120(100.0)

Vaginal bleeding Hand, feet facial swelling Anemia Severe anemia High BP Abdominal, pain Diabetes Urinary complications Fits Baby stopped moving Water bag broken Other cramps

23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2)

49 (40.8) 45 (37.5) 12 (10.0) 57 (47.5)

32 (26.7) 39 (32.5) 72 (60.0) 17 (14.1)

16 (13.3) 13 (10.8) 13 (10.8) 23 (19.2)

120(100.0) 120(100.0) 120(100.0) 120(100.0)

23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2)

94 (80.0) 10 (8.3) 0 9 (7.5) 35 (29.2) 0

0 80 (66.7) 92 (76.6) 66 (55.0) 59 (49.2) 97 (80.8)

0 7 (5.8) 5 (4.2) 22 (18.3) 3 (2.5) 0

120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0)

Complications /problems during last pregnancy: The unconducive conditions of Pakistani women, restrictions on them and lack of opportunities during pregnancy are very obvious to all. Pakistan is one of the countries where maternal mortality rate (MMR) and fetal mortality rate are very high. Major causes are almost lack of adequate health facilities, ignorance, poverty, inadequate diet, early marriages, and large number of children. A number of complications were involved during pregnancy, like 25.8 percent respondents faced vaginal bleeding, 19.2 percent respondents have first times pregnant and have no experience previous pregnancy related complication. 5.0 percent faced vaginal bleeding, to great extent. 63.3 percent had no faced vaginal

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bleeding and 12.5 percent faced to some extent vaginal bleeding. 19.2 percent respondents have first times pregnant and have no experience previous pregnancy related complication. 36.6 percent faced hand and facial swelling, to great extent. 17.5 percent had no faced hand and facial swelling and 26.7 percent faced to some extent hand and facial swelling. 19.2 percent respondents have first times pregnant and have no experience previous pregnancy related complication. 40.8 percent faced anemia, to great extent. 26.7 percent had no faced anemia and 13.3 percent faced to some extent anemia. 19.2 percent respondents have first times pregnant and have no experience previous pregnancy related complication. 37.5 percent severe anemia, to great extent. 32.5 percent had no faced severe anemia and 10.8 percent faced to some extent severe anemia. 19.2 percent respondents have first times pregnant and have no experience previous pregnancy related complication. 10.0 percent faced high blood pressure, to great extent. 60.0 percent had no faced high blood pressure and 10.8 percent faced to some extent high blood pressure. Similarly to great extent, 47.5, 8.3, 7.5, complication faced during last pregnancy respectively Cramps pain, Urinary complications, Baby stopped moving. To some extent respondents faced complication

respectively Cramps pain 19.2 percent, Urinary complications 5.8 percent, fits 4.2 percent and 18.3 faced baby stopped moving other show not at all mean no experience of these complication. Anemia during pregnancy is universal problem. Lot of studies about anemia showed different unfavorable effects of anemia in pregnant women and her baby, argued by Sukrat and Sirichotiyakul (2006). During pregnancy its symptoms come out but at delivery time complication due to iron deficiency appeared in form of low weight of baby and found to be the main cause of maternal mortality. According to WHO (2009) 42 percent of pregnant women are anemic in the world. World is facing some great risky health problems and some countries increasingly face double burden from the risk of communicable diseases and maternal and child outcomes that traditionally effect the poor.

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Table 29: Distribution of the respondents according to their visits to health facilities. Visits to health facilities Govt. hospitals BHU Private hospitals Dai/ Mid wife Total Frequency 83 4 7 26 120 Percent 69.2 3.3 5.8 21.7 100.0

In above table 29 the respondents visited different health places during pregnancy period. 5.8 percent of the respondents visited private hospitals/clinics. Private hospitals/ clinics are situated at faraway places, 69.2 percent attended Govt. hospitals, and 21.7 percent visited dais/TBAs and remaining. In pregnant women IDA is most common disease. For increasing the blood supplies then requirement of iron also increase. During intrauterine development of fetus iron requirement is increase and they use it after birth, so mother demands more iron according to Sabah et al. (2010). Anemia is extremely common in women especially in third world country like Pakistan where 60 to 70 million people are subjected to iron deficiency anemia; the possible factors behind this high occurrence are poor diet, early marriages, several births and lack of proper health facilities and low availabilities of iron from diet. Delivery Places: Table 29 indicates the different places where the respondents delivered their last baby. Majority 47.5 percent of the respondents delivered their last baby at home, followed by 14.1 percent at private hospitals and 19.0 at government hospital. Birth deliveries at home are very dangerous. It increases the chances of bleeding, stillbirth, infant death or maternal death or at least health complications for either or both. This high percentage of delivery at home also shows the helplessness and miserable condition of women. Osanai (2004-2005) pointed out that in rural area Dai play a major role for childbirth at home. 79.0 percent birth is occurred by Dai. Socio-cultural norm, financial cost alongside with less access to health care services. Lack knowledge of delivery related complication were the causes of inadequate access to antenatal and postnatal care. Therefore increase

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skilled birth attendance for safe motherhood. Maternal health situation is slightly improved in urban area of Pakistan; there are still urban and rural disparities. Table 30: Distribution of the respondents according to their visits to place of delivery and supervision of delivery. Place of delivery/ supervised at home Response First pregnancy Govt Delivery Places Private Home Supervised the last delivery at home Total No / Current pregnancy Dai Total Supervised last delivery: Access to care is a very major barrier. Pakistan needs a well- established network of midwifes or TBAs (trained birth assistants) with the established hospitals. This table 30 shows the distribution of health personnel who helped out at home delivery. 47.5 percent of the respondents delivered through dais/TBAs A majority of the births in most developing countries, particularly in the rural areas, take place at home, usually assisted by relatives or traditional birth attendants (TBAs). Birth of child is a natural practices, birth is best as it is natural. Child spacing is necessary for improving the mother health. USAID (2005) concluded that mostly poor socio status of women has less opportunity of usual reproductive behavior. In addition more number of children, less spacing between birth adverse effect on maternal and child health. Family planning methods introduced and couple entrance to family planning method, and get more spacing pregnancy and reducing maternal and neonatal mortality and morbidity. Frequency 23 23 17 57 120 63 57 120 Percent 19.2 19.2 14.1 47.5 100.0 52.5 47.5 100.0

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Table 31: Distribution of the respondents according to the complications/ problems that occurred during labor / delivery. Complications First pregnancy Frequency (%) 23 (19.2) To great extent Frequency (%) 54 (45.0) Not at all Frequency (%) 11 (9.2) To some extent Frequency (%) 32 (26.7) Total Frequency (%) 120(100.0)

Hand, feet facial swelling High BP Mild anemia Moderate anemia Severe anemia Baby stopped moving Vaginal bleeding Water bag broken Multiple pregnancy Baby low weight Born early Difficult labor Instrument delivery C-section

23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2) 23 (19.2)

13 (10.8) 11 (9.2) 2 (1.6) 50 (41.7) 32 (26.6) 87 (72.5) 35 (29.2) 59 (49.2) 39 (32.5) 36 (30.0) 16 (13.3) 16 (13.3) 5 (4.2)

65 (54.2) 76 (63.3) 90 (75.0) 38 (31.7) 48 (40.0) 3 (2.5) 59 (49.1) 34 (28.3) 33 (27.5) 48 (40.00 73 (60.8) 79 (65.80 92 (76.7)

19 (15.8) 10 (8.3) 5( 4.2) 9 (7.5) 17 (14.2) 7 (5.8) 3 (2.5) 4 (3.3) 25 (20.8) 13 (10.8) 8 (6.7) 2 (1.7) 0

120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0) 120(100.0)

Complications / problems that occurred during labor: Labor and delivery period is a sensitive time for women. There are diverse factors which complicate delivery. Uncertainties and complications can be avoided by taking appropriate health care measures. In Pakistan most of the deliveries supervised at home without proper hygienic and medical facilities and sterilized equipments. Problems may arise like severe bleeding, difficult labor and consequent maternal deaths etc. This table 31 shows that 45.0 percent, 10.8 percent, 9.2 percent, 1.6 percent and 41.6 percent of the respondents faced problems respectively of hand, feet and facial swelling, high blood pressure, mild anemia, moderate and severe anemia, to great extent. 26.7 percent, 15.8 percent, 8.3 percent, 4.2 percent and 7.5 percent of the respondents faced problems respectively of hand, feet and facial swelling, high blood pressure, mild anemia, moderate

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and severe anemia, to some extent. 9.2 percent, 54.2 percent, 63.3 percent, 75.0 percent and 31.7 percent of the respondents faced problems respectively of hand, feet and facial swelling, high blood pressure, mild anemia, moderate and severe anemia, not at all. Result showed that to great extent 26.6 percent, 72.5 percent, 29.2 percent of the respondents respectively experienced their babies stopped moving; vaginal bleeding, water bag broke. To some extent 14.2 percent, 5.8 percent, 2.5 percent of the respondents respectively experienced their babies stopped moving; vaginal bleeding, water bag broke. Other results like 49.1 percent, 32.5 percent, 30.0 percent, 13.3 percent, and 13.3 percent and of the respondents had multiple pregnancies, baby low weight/ weak, born early, difficult labor, instrumental delivery. 4.2 percent faced c-section problems to great extent. About 3.3 percent, 20.8 percent, 10.8 percent, 6.7 percent, 1.7 percent and of the

respondents had multiple pregnancies, baby low weight/ weak, born early, difficult labor, instrumental delivery had to some extent. During pregnancy due to iron deficiency some risks are increased such as preterm delivery, prenatal mortality and low birth weight conducted by Calonge (2006). This rate is very high in minority and poor children. Iron deficiency anemia is associated with depression, postpartum haemorrhage, and poor performance on mental and psychological things. Haemoglobin is very important to measure iron deficiency anemia and nutritional deficiencies cause abnormality in haemoglobin. Anemia is related to acute and chronic infection that is due to low income, education and socio economical factors are responsible for iron deficiency anemia. Iron deficiency is more common disease in all over the world that is caused by number of factors in pregnant women such factors are heavy menstrutional blood loss, blood loss due to abortion and pregnancy. Iron deficiency anemia cause greater risk of death during prenatal period, morbidity infection is increased in iron deficient people. Iron deficiency is also decreased morbidity and capacity of physical work. In all developing countries anemia is a major health problem. Main victim of anemia are children and pregnant women and their ratio is 48 percent in children and 51 percent in pregnant women. Alemayehu et al. (2003) studied that in Ethiopia anemic ratio in pregnant women is 57 percent. In our world there are many cause of anemia in women and children such as poor nutrition, premature babies, long term breast feeding and to let blood out from body according to some traditional practices.

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Table 32: Distribution of the respondents according to communicable diseases and non communicable in last five years. Communicable Diseases Cholera Pneumonia Measles Tuberculosis Polio Malaria Cough Tetanus Diarrhea Other (chickenpox) Communicable diseases: Communicable diseases are major cause of morbidity and mortality in Pakistan. Deficiencies in iron, zinc, vitamin A, folate, as well as other micronutrients elements are responsible for a substantial proportion of morbidity. Communicable diseases like cholera, tuberculoses, malaria and cough easily communicate from one to another. The major reasons are water pollution and sanitation problems. In this table 32 about 5.8 percent of the respondents were caught up by cough, 34.2 percent from malaria, 25.8 percent from diarrhea and 15.0 percent from cholera respectively. As results shows that cough problem was in respondents because in poor community people less use of nutritional diet especially iron. Malaria is due to mosquitoes, which exist at pounds and garbage. In rural society there is no arrangement of disposal of wastage. Diarrhea was 41.0 percent that too high among women. The reasons were unhygienic food and environment that is discussed above. Cholera is 15.0 percent that was comprised of different factors. 1.7 percent that was also alarms for future outcomes, measles 4.2 percent and polio .8 percent. Iron deficiency anemia is a basic health issue in women during reproductive age and it is also cause a chronic hookworm infections, which cause low birth weight and stop Yes Frequency (%) 18 (15.0) 0 5 9 (4.2) 0 1 (.8) 41 (34.2) 7 (5.8) 0 31 (25.8) 2 (1.7) No Frequency (%) 102 (85.0) 0 115 (95.8) 0 119 (99.2) 79 (65.8) 113 (94.2) 0 89 (74.2) 118 (98.3) Total Frequency (%) 120 (100.0) 120 (100.0) 120 (100.0) 120 (100.0) 120 (100.0) 120 (100.0) 120 (100.0) 120 (100.0) 120 (100.0) 120 (100.0)

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growth. Due to low birth weight there is a great risk factor for neonatal, infant mortality and morbidity. Passerini et al. (2012) revealed that in many developing countries hookworm infection and iron deficiency anemia are common diseases. World is facing some great risky health problems and some countries increasingly face double burden from the risk of communicable diseases and maternal and child outcomes that traditionally effect the poor. Some poor countries are facing intense problem such as poor sanitation, malnutrition and gender discrimation. Other factors such as Indoor smokes from solid fuel are the cause of iron deficiency stated by WHO (2009). Table 33: Distribution of the respondents according to walk/exercise. Walk/exercise Some times Never Total Daily walk/exercise: The important scientific evidence has demonstrated that a daily 30- minute brisk walk is an important for health of males and females. Regular walk/exercise tends to deplete iron stores. Although the exact cause is unknown, a number of factors may contribute, including physical stress, hem concentration processes (shifting of blood plasma), muscular damage and even nitric oxide. Iron is used in aerobic metabolism and problems maintaining adequate iron stores, and even taking a supplement may help. This table 33 shows that a large number of 93.3 percent respondents did not take walk/ exercise daily, while 6.7 percent were taking walk sometimes. Keefe et al. (2008) disused that in women life there is a great time in pregnancy much health awareness increased; medical physical and total life style has been changed. During pregnancy it is necessary to do exercise daily. Generally population and women are well known for the benefit of the exercise. Exercises provide healthy pregnancy women health and have no adverse effects. During pregnancy exercise could change the lifestyle of the women and prevent for many risks such as obesity, chronic hypertension and diabetes. Iron deficiency anemia causes many problems for mother and her developing fetus. Frequency 8 112 120 Percent 6.7 93.3 100.0

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Table 34: Distribution of the respondents according to take iron supplement. Taking iron supplement Frequently Some times Never Total Frequency 12 69 39 120 Percent 10.0 57.5 32.5 100.0

Vitamin and minerals are very important to maintain the acquired blood components. Balanced diet can fulfils the body requirement too, but malnutrition and poor diet intake minimize the proper function of red blood cells and other necessary elements. A balanced diet also provides sufficient amounts of vitamins for pregnant women, however, need more folic acid and iron. This table 34 shows that 32.5 percent were not taking any iron supplement, and a large number of respondents 57.5 percent were taking sometimes iron supplement due to lack of knowledge, less resources and 10.0 percent take frequently iron supplement on doctor advice. In a survey Aikawa et al. (2005) is suggested that low intake of iron tablets, hook worm infestation, low use of egg, traditional medicine and living in rural area are common factors of iron deficiency anemia in pregnant women, this result can help us to control iron deficiency anemia control program. Some educational and additional programs required to educate women against traditional medicine and seasonal differences to control anemia. Table 35: Distribution of the respondents is according to agree that iron supplement affect mother and fetus health. Affect mother To great extent Not at all To some extent Total Frequency 8 57 55 120 Percent 6.7 47.5 45.8 100.0

Table 35 shows that number of respondent 47.5 percent not agree that supplement affect on mother and child health due to lack of awareness, 6.7 percent agree to great extent that supplement effect on mother and child health and 45.8 percent had agree to some

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extent. Dreyfuss (1998) identified a number of barrier in taking iron supplement include lack of awareness about IDA, its consequences on women, mismanagement system of distribution of iron supplement, lack of knowledge and other misconceptions of negative physiological impacts for using iron supplement such as hypertension related diseases and less utilization of prenatal health facilities and other belief such as cultural and traditional. Table 36: Distribution of the respondents according to take iron supplement after eating. After eating Not take iron supplement Frequently Some times Never Total Frequency 39 71 9 1 120 Percent 32.5 59.2 7.5 .8 100.0

Knowledge on the importance of use of iron tablets after meals and its effect on reduction of heart burning, vomiting. Mostly respondent 59.2 percent take iron supplement on doctor advice so take these tablets after meals on doctor advice, 7.5 percent take these supplement sometimes after meal due to lack of awareness and .8 percent not take supplement after eating. 32.5 percent are those who never take iron supplement. In developing countries 58 percent pregnant women are anemic. Many policies are made by ministries of health for reducing the maternal anemia in developing countries through providing the iron supplement stated by Yekta et al (2008). They also mentioned that due to lack of health facilities maternal anemia has not declined considerably. The aim of his study was to identify the current problems faced by local population and to explain the factors affecting on the iron supplement during pregnancy such as lack of awareness about iron use and long duration of iron supplement. Mostly females do not get antenatal care during pregnancy. Therefore due to lack of health awareness, they become the victim of anemia.

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Table 37: Distribution of the respondents according to take iron supplement with fruit juice. Fruit juice Not takes supplement Frequently Some times Never Total Frequency 37 2 7 74 120 Percent 30.8 1.7 5.8 61.7 100.0

The table 37 show that 30.8 Percent not take iron supplement, 1.7 percent takes iron frequently with juice, 5.8 percent take iron with juice to some extent and 61.7 percent not take iron with juice. According to Study in UK in which they give ideas of iron as absorption, nutrition diets in pregnancy and lactation that effect on mother health Calder (2010). Iron deficiency anemia can be decreased by using fruits that have great amount of vitamin c, use food that reduce iron absorption, change our habits, early age marriage and some parasitic infection Musaiger (2001). Tabl 38: Distribution of the respondent according to knowledge about iron supplement/ absorption and side effects. Knowledge about to take iron supplement To extent Freq (%) Decreases heart burning. Tea coffee reduce iron absorption Fruit increase iron absorption Anti -acids reduce iron absorption Table 38 shows that the knowledge about iron supplement/ absorption and side effects, knowledge on the importance of use of iron tablets after meals ant it effects on 1 (.8) 1 (.8) 116 (96.7) 118 (98.4) 3 (2.5) 1 (.8) 120 (100.0) 120 (100.0) 34 (28.4) 5 (4.2) Freq (%) 67 (55.8) 109 (90.8) great Not at all To some Total

extent Freq (%) 19 (15.8) 6 (5.0) Freq (%) 120 (100.0) 120 (100.0)

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reduction of heart burning and vomiting were at low level as only 55.8 percent not know, 28.4 percent know that if use the tablets after meals reduced the heart burning to great extent and 15.8 percent know to some extent. On the other hand, knowledge regarding the effect of tea, coffee and milk on iron absorption was at 90.8 percent had no knowledge, 4.2 percent know that it reduced iron absorption and 5.0 percent know to some extent. Knowledge on the role of fruits juice and its role in improvement of iron absorption was at low level as only .8 and percent to great extent and 2.5 percent of IDA was aware of this fact. 96.8 percent had no knowledge. Absorption of iron is Inhibited by tea and coffee but enhanced ascorbic acid, which is present in orange juice and fresh juice. Knowledge regarding anti-acids use and its effects in reducing iron absorption was also at low level as only .8 percent to great extent and .8 percent to some extent was aware of these facts. Anemic ratio in south Asia especially in India is very high concluded by Singh et al. (2011). Most of anemic patient are in mild condition that is 14 percent and maximum ratio is that are in moderate condition is 77.2 percent. The ratio of anemia is very high due to low dietary folic acid and poor iron intake. Anemic problem is maximum found in pregnant women it can be decreased proper intake of folic acid and iron supplementation. During pregnancy we should care and treat anemia before delivery. Status of menstrual: Women in their reproductive period have chronic gynecologic problems. Women, who had heavy menstrual bleeding, had a lot of health complications in their lives. Menorrhagia is the most common cause of anemia in women and women in their reproductive years have iron deficiencies and iron levels low enough to cause iron deficiency anemia. This table 38 shows the status of menstrual period that a large number 90.0 percent of respondents status was regular and 10.0 percent respondents status was irregular. UNICEF (1998) pointed out another cause of iron deficiency anemia is more number of pregnancies, extra bleeding; to use of contraceptive that cause excessive menstrutional bleeding, rapid growth in early childhood and adolescent, iron deficiency start in infants is directly related to iron deficiency in pregnancy.

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Table 39: Distribution of the respondents according to the status of menstrual, duration of menstruation and heavy menstrual, rest in a day. Menstrual status/ rest Response Regular Status of menstrual Irregular Total 3 days 5 days Duration of menstruation 7 days More than 7 days Total Frequently Heavy menstrual Not at all Sometimes Total 1-2 hrs Rest in day time (hours) 3-4 hrs Total Duration of menstruation and heavy menstrual: This table 39 shows that 30.8 percent respondents duration were 5-days, 26.7 percent respondents duration were 3-days, whereas 32.5 , 10.0 percents duration was 7days and more than 7 days. Mothers with a previous history of taking NSAIDs (non steroidal anti-inflammatory drugs) and antacids have a higher risk for anemia. Non steroidal antiinflammatory drugs are key elements sometimes used to decrease heavy bleeding or menstrual pain. Poor nutrition plays a role in several cases; the issue is compounded in women who have heavy periods. 5.0 of the respondent reported that they had heavy periods frequently, 85.8 percent reported heavy menstrual some times while 9.2 percent had not at all this problem. Iron deficiency is the most common disease due to nutritional deficiency stated by Batool (2010) that cause the size of red blood cells decreases with the passage of time. Frequency 108 12 120 32 37 39 12 120 6 11 103 120 98 22 120 Percent 90.0 10.0 100.0 26.7 30.8 32.5 10.0 100.0 5.0 9.2 85.8 100.0 81.7 18.3 100.0

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Anemia can occur at any stage of pregnancy due to one or more factors. A female should be screened for anemia during pregnancy, if the test is positive, then proper treatment should be given. Important risk factors for anemia are low intake of iron rich food, multiple pregnancy, heavy menstruation, and abortion, use of intrauterine devices, impaired absorption, low socioeconomic status, hereditary medical disorders and excessive blood loss during delivery. Rest in day (hours): This table 39 shows that 81.7 percent respondents took rest 1-2 hours in a day, while 18.3 percent did take rest 3-4 hours in a day. Table 40: Distribution of the respondents according to the services provider should provide the information about iron deficiency anemia. Staff provide information To great extent Not at all To some extent Total Frequency 29 16 75 120 Percent 24.2 13.3 62.5 100.0

This table 40 explored better attitudes of health care providers can increase patients' confidence. As attitudes concerned 24.2 percent , 62.5 percent and 13.3 of the respondents responded that attitude of staff is good and cooperative, staff deal equally to all patients, inspiration by doctors behavior during the treatment to a great extent , to some extent and not at all respectively. The iron deficiency can be controlled with balanced diet, iron supplements and food protection as stated by Ndiaye et al (2009). They argued that the councelling of pregnant women during antenatal programs could be beneficial to avoid the factors responsible for this disease. On her antenatal visit health care provider must aware the mother about the sign and symptoms of anemia to control this chronic disease at early stage. Healthiness is a strong attractor in the human kingdom and can be signaled to potential paramours by a variety of physical traits. By investigating the issue of health appearance, symmetry in facial and physical attractiveness play a significant role in the measurement. Socio-cultural and environment of rural women is depressive which effect on their mental, physical, and reproductive health and make them apparently sick and dull. There

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forceful agents continuo increasing the uncertainty, fear, poor performance and creating fatigue tiredness and depress which are significant associate with anemia. Table 40 shows that 1.7 percent, 48.3 percent and 50.0 percent represented the physical appearances good, normal and bad. While 3.3 percent, 45.0 percent and 51.7 percent represent the overweight, normal and weak. Table 41: Distribution of the respondents according to health status. Respondents appearance Status Good Physical appearance Normal Bad Total Over weight Weight Normal Weak Total Frequency 2 58 60 120 4 54 62 120 Percent 1.7 48.3 50.0 100.0 3.3 45.0 51.7 100.0

In developing countries iron deficiency anemia is basic health, social and economic problem. IDA reduces physical work capacity and in some cases this risk is increased to mortality during prenatal period. Harris (2002) is also noted that anemia reduced growth and increase morbidity. It is necessary to develop and implement programs to prevent and controlling anemia. We should understand difference between anemia and iron deficiency, it is accepted that anemia cause different infections inflammatory and blood loss. . Burger and June (2002) stated that iron deficiency anemia physically cannot be seen until anemia become severe. Normal sign of anemia are fatigue, shortness of breath, color of skin and inner eyelid. In our life cycle iron intake is especially critical when we need it very high such as in childhood growth, adolescent growth and during pregnancy. As table 42 indicated that 30 percent, 26.7 percent and 43.3 percent of the respondents had the levels of hemoglobin mild, moderate, severe. In Pakistan as a developing country, people have low socio-economic and demographic status and also culturally bound. Almost one fourth of the respondents are quite healthy with mild/normal level of

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hemoglobin which is commonly untreated. While One third are in moderate level of HB who are at risk situation. Majority of them are severely deficient which represents a poor picture of mother health status. The study also indicates that mostly women take low level of calories per day which directly effect on their health, also emerge different health problems and severely effect on their reproductive performance. Malnutrition and malabsorption reduce the immunity and the main agent to reduce the level of hemoglobin too. Table 42: Distribution of the respondents according to level hemoglobin. Hemoglobin level of mother Mild Moderate Severe Total Frequency 36 32 52 120 Percent 30 26.7 43.3 100.0

Iron is the basic component of growth. Through iron haemoglobin (Hb) increases and as Hb carry oxygen with it, so oxygen also increases in blood circulation. The human body can improve iron deficiency through food. This study was conducted by Abu- Hasira (2007). Lack of iron in body can affect proper circulating of oxygen and ultimate cause will be less functioning of cells in body, for example in brain cells if oxygen decreases it causes hypoxia and result in brain damage. Red blood cells also contain haemoglobin which pass through oxygen to the body tissue, can lead to health complication. Fatigue and stress of body organs are the complication of anemia. It is universally believed that the main cause of anemia in pregnancy is the iron deficiency. Reveiz et al. (2011) stated that iron deficiency anemia can be mild, moderate and severe. Mild anemia can be reduced through rich iron food and moderate anemia can be control through proper iron supplement if mild and moderate anemia is not controlled then it became severe anemia. Severe anemia can be controlled through blood transfusion. Otherwise severe anemia can have serious consequences for mother and babies. When we treat anemia it provides more benefits than harm (fatigue and weakness).

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Part B Testing of Hypothesis:

Hypothesis 1: Higher will be the family income, lower will be the chance of anemia. Table 43: Association between family income of the respondents and level of hemoglobin of respondent. Effect Mild Moderate Severe Total

Less than 7000

11 (15.06)

16 (21.91) 16 (40) 0 (0) 0 (0) 32 (26.67) d.f=6,

46 (63.01) 5 (12.5) 1 (20) 0 (0) 52 (43.33)

73 (60.83) 40 (33.3) 5 (4.17) 2 (1.67) 120 (100.0) Sig. Level: .000**

7001-12000

19 (47.5)

12001-17000

4 (80)

17001-22000

2 (100)

Total Chi-Square: 38.888a,

36 (30.0)

Gamma: -.732

The Chi-Square shows that significant association between family income and the level of haemoglobin. So the hypothesis Higher will be the family income, lower be the chance of anemia accepted. Gamma values show negative and weak co -relation between the variables.

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Hypothesis 2: Higher will be the symptoms of iron deficiency anemia, lower will be the calorie intake per day. Table 44: Association between symptoms of IDA and calories intake per day. Calories intake Weakness To great extent (%) Less than 1500 16 (88.8) 1501-2300 62 (60.8) Total Chi-Square: 5.312a, 78 (65.0) d.f: 1, Gamma: .675 To some extent (%) 2 (11.11) 40 (39.22) 42 (35.0) Total (%) 18 (15.0) 102 (85.0) 120 (100.0) Sig. Level: .021

The Chi-Square shows that significant association between symptom of iron deficiency anemia and calories intake. So the hypothesis Higher will be the symptoms of iron deficiency anemia, lower will be the calorie intake per day accepted, Gamma values show positive co-relation between the variables.

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Hypothesis 3: Higher will the calories intake per day, lower will be the symptoms of anemia. Table 45: Association between calories intake per day and symptoms of anemia. Tired (symptom of IDA) To great extent (%) Less than 1500 1501-2300 16 (88.88) 60 (58.82) Total Chi-Square: 5.956a, 76 (63.33) d.f: 1, To some extent (%) 2 (11.11) 42 (41.17) 44 (36.66) Gamma: .697 Total (%) 18 (15.0) 102 (85.0) 120 (100.0) Sig. Level: .015

Calories intake

The Chi-Square shows that significant association between calorie intake and symptom of anemia. So the hypothesis Higher will the calories intake per day, lower will be the symptoms of anemia accepted, Gamma values show positive co-relation between the variables.

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Hypothesis 5: Higher will be the symptoms of anemia, weaker will be the health appearance of respondents. Table 46: respondents. Effect Physical appearance Good Mild (%) 2 (100.0) 33 (56.89) 1 (1.66) 36 (30.0) d.f: 4, Moderate (%) 0 (0) 24 (41.37) 8 (13.33) 32 (26.66) Gamma: .980 Severe (%) 0 (0) 1 (1.72) 51 (85.0) 52 (43.33) Total (%) 2 (1.66) 58 (48.33) 60 (50.0) 120 (100.0) Sig. Level: .000** Association between chance of anemia and health appearance of

Normal

Bad

Total Chi-Square: 90.628a,

The Chi-Square shows that highly significant association between physical appearance and the level of hemoglobin. So the hypothesis Higher will be the symptoms of anemia, weaker will be the health appearance of respondents was showed strong relationship. Gamma values show positive and strong relationship between the variables.

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Hypothesis 5: More number of pregnancies of the respondents, higher the symptoms of anemia. Table 47: Association between number of pregnancies of the respondents and

symptoms of anemia. Effect No. of pregnancies 1-2 Mild (%) 25 (64.10) 10 (47.61) 1 (5.88) 0 (0) 36 (30.0) d.f: 6, Moderate (%) 14 (35.89) 5 (23.80) 7 (41.17) 6 (13.95) 32 (26.66) Gamma: .848 Severe (%) 0 (0) 6 (28.57) 9 (52.94) 37 (86.04) 52 (43.33) Total (%) 39 (32.5) 21 (17.5) 17 (14.17) 43 (35.83) 120 (100.0) Sig. Level: .000

3-4

4-5

6 & more

Total Chi-Square: 75.169a,

The Chi-Square shows that highly significant association between more number of pregnancies and the chance of anemia. So the hypothesis More number of pregnancies of the respondents, higher the chance of anemia. was showed strong relationship. Gamma values show positive and strong co relation between the variables.

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CHAPTER 5 SUMMARY
This chapter presents main findings of the study followed by conclusions and policy recommendations. The main findings have been presented through four separate

categories of variables i.e. socio-economic or background variables, cultural, demographic and nutritional variables. The relevance of these findings in the context of theoretical perspectives has also been discussed briefly. Iron deficiency anemia is a cause of maternal deaths in most of the cases. More number of pregnancies reduces the mother immunity that leads to anemic conditions. A woman, who has anemia, is five times more likely to die of pregnancy related problems than a woman who is not anemic. Anemic women have less immunity to resist against infection and less able to survive in bleeding (hemorrhage) or other complications of labor, delivery and miscarriage. Anemia also causes preterm delivery and low birth weight babies. It is one of the important factors that hampers the daily activities of almost every woman and in multiple pregnancies even makes it worse. Low levels of maternal hemoglobin are associated with increased risk of abortion, pre- term delivery, Low Birth Weight babies, and deaths. Socio-economic characteristics play a vital role to understand and identify the issues relating to reproductive health of females. In present study, education and family monthly income and family type were the main variables to study the social and economic status of the respondents. The education has important place in womens life. It trains the mind to think rationally and to understand the proper functioning of the body. Females through educational attainment are enabled to expand their exposure to different aspects of life, to communicate effectively, enhance and stimulate their creativity. Educated women can better understand health problems and importance of access to health care services. This study examines the effect of maternal education on their anemia status. Educated mothers have less symptoms of anemia and usually have normal level of hemoglobin due to better knowledge about health care, nutrition,and healthier behavior. They also make more effort to ensure hygienic sanitary and safer environments for their family members.

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Rural poverty is a complex and multi dimensional phenomenon. The issues of rural poverty and income inequality are difficult to comprehend without thorough examination of several interrelated aspects of their livelihood. Income inequalities between the rich and poor highly correlated with lower life expectancy and causes of health complications. Women of age 15-45 years face an increased risk of health and economic difficulties. In addition, income is directly related with health problems of the family. Family structure in any country depends upon its culture and living style. Sociologists, anthropologists and philosophers have argued that the main function of the family is to formulate the society. From the perspective of children the family is a centre of orientation and it serves to locate children socially. In Pakistan people perceive and believe that function of family is to produce and acculturates and socialize children. Nuclear family also constitutes one of the most important demographic and social transformations in society. In nuclear family members are in more prosperous condition than in joint family in term of social conflicts, money distribution and empowerment. It has emphasized on the individual autonomy, affection, parents and children relationship. So in the nuclear families women have more chances to take good health services as compare to women of joint family system. Attitude towards health facilities is quite important for identification and the treatment of anemia status. The female health issues and utilization of health facilities are rising problem which need to be addressed. A number of reproductive problems occurred among pregnant women in rural areas of Pakistan due to limited health care centers, less access and its utilizations. Females are also culturally restricted to utilize these facilities. Their decisions to visits the centers are not made by them rather depend upon their husband and in-laws. Furthermore only those women are permitted to visit antenatal care, who becomes victim of anemia. In Pakistan gender bias in food distribution within the household is normally due to certain traditions and norms. Food status differences create varying female health and

nutritional outcomes. Pakistani society is a male dominant society, where females are given full protection and great respect. Rural Pakistan is a rigidly patriarchal society in which women are treated to spend their lives in the service of a male dominated social system. Despite of this the place of women and their role in the division of labor differs very widely from region to region

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and also between different classes in one region. Due to these factors, womens health needs are often regarded to be restricted only to reproduction. The universe for the pre-test research consisted of pregnant females attending antenatal visits from both hospital DHQ hospital and civil hospital Sakhi serwar of Thesil D.G. Khan. The sample size of study was 120 interviewing schedule was used for data collection. Data were tabulated and interpreted with the help of SPSS test. Major Findings: Majority of the respondents i-e 50.8 percent were in the age group of 26-35 years. About 37.5 percent of the respondents husbands were in the age of 26-35 years. Most of the respondents i-e 69.2 percent got marriage in the age group of 16-20 years. About 68.3 percent of the respondent husbands got marriage in the age group of 1620 years. Majority, 82.5 percent of the respondents were illiterate. About 45.8 percent of the respondents husbands were illiterate. A great majority i-e 90.8 percent of the respondents were not having any job They were house wives. About 55 percent of the respondents husbands were labor. About 60.8 percent of the respondents had family income less than 7000. Most of the respondents 55.8 percent were living in mud made houses. About 50.0 percent of the respondents were living in joint family. Major proportion i-e 88.3 percent respondents had attended < 4 prenatal visits during this pregnancy. About 33.3 percent attended their first visits in 4-5 month of gestational age. About 63.3 percent respondents felt the tiredness during pregnancy. Majority, 65.0 percent respondents felt weakness. About 48.3 percent of the respondents had problem of shortness of breath. About 48.3 percent felt usually pale skin. Major proportion i-e 90.8 percent replied that they took rest after weakness/fatigue. About 84.2 percent respondents cooked meal themselves.

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 About 55.8 percent respondent had no knowledge about balance diet. About 46.7 percent were having knowledge that meat and fish make blood. About 46.7 percent were having knowledge that fruits and vegetables make blood Major proportion i-e 85.0 percent respondents took 1501-2300 calories per day, but during pregnancy 2500 calories are required About 44.2 percent agreed that son is preferred over daughter. About 35.8 percent respondents had more than 6 times pregnancies. About 25.0 percent respondents faced abortion. About 28.3 percent respondents faced heavy blood loss during abortion. About 28.3 percent respondents visited government hospitals. About 47.5 percent respondents delivered their last child at home. Major proportion i-e 85.8 percent respondents had problem of heavy menstruation. About 43.3 percent respondents were under severe condition of Anemia. Suggestion: Education is the basic factor for change. Government should design strategies and policies to enhance women education to ensure their independence in socioeconomic and cultural decisions, which directly and indirectly enhances women health status. Government should appoint nutritional officers at BHU level as it is being part for urban hospitals for creating awareness about the importance of balanced diet and implications of non-food items on women health. Government of Pakistan should launch public health awareness campaigns to make people aware about the benefits of small family, prenatal and postnatal care and utilization of health facilities in the context of women general and in particular reproductive health. A majority of the births in Pakistan, particularly in the rural areas, takes place at home. Pelvic sepsis may occur after these deliveries or abortions and when untreated may lead to blood loss, inflammatory disease which is the underlying cause of many cases of blood loss, menstrual disorders and tetanus. Government should address this issue of proper place of delivery to enhance women and child health.

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 Seminars regarding awareness of blood deficiency anemia should be arranged in rural areas to address this issue.

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