Anaemia and thrombocytopenia among pregnant women attending Aminu Kano Teaching Hospital,Kano State,North Western Nigeria

Abstract

BACKGROUND:

Pregnancy induces a number of physiologic changes either directly or indirectly that affect the haematologic parameters. The most frequent haematologic complication associated with pregnancy is anaemia and thrombocytopenia.

OBJECTIVES:

The aim of this case-control study was to investigate the prevalence of anaemia and thrombocytopenia among one hundred and twenty consecutively-recruited pregnant subjects and sixty age-matched non-pregnant controls.

METHOD:

Socio-demographic and clinical data were obtained using a questionnaire. Three milliliters of blood were obtained from both the pregnant subjects and non-pregnant controls and distributed into EDTA and used for full blood count was determined using the fully automated Mythic 18 3-part differential haematology analyzer.

RESULT:

The socio-demographic distribution among the subjects showed that the age group 25–29 years had the higher number of participants 41 (34.2%) followed by 30–34 years 39 (32.5%). Distribution based on socio-demography indicated that majority of the subjects were of Hausa ethnic group 47 (78.3), had no formal or Islamic education 53 (44.2%) and predominantly housewives 74 (61.7%). Distribution based on obstetric variables indicated that majority of the subjects were multiparous 86 (71.7%), had no problem in their previous pregnancies 99 (82.5%) and are not having problem in this current pregnancy 109 (90.8%). The HBG and HCT were significantly lower among the pregnant subjects compared to controls ( $p=$ 0.05 and 0.0308) respectively. The prevalence of anaemia and thrombocytopenia among the pregnant subjects was 75% and 6.7% respectively. The prevalence of anaemia (80%) and thrombocytopenia (8.0%) was higher among pregnant women in the second trimester compared to those in the first and third trimesters.

CONCLUSION:

The values obtained from this research showed an increase in prevalence of anaemia and thrombocytopenia among pregnant women compared to the non-pregnant controls. It is vital to routinely monitor the indices of anaemia and thrombocytopenia among pregnant women to reduce the incidence of these diseases and of their complications.

Keywords

Anaemia thrombocytopenia pregnant women Aminu Kano Teaching Hospital Kano State North Western Nigeria

1. Introduction

Pregnancy can be defined as a period of reproduction during which a woman carries one or more than one live offspring from implantation of a fertilized zygote in the uterus throughout gestation. Pregnancy induces a number of physiologic changes that affect the haematologic indices among women [1]. World health organization (WHO) defines anaemia in pregnancy as haemoglobin concentration $<$ 11 g/dl [2]. It is one of the major global public health problems with diverse consequences [3].

The most frequent haematologic complication during pregnancy is anaemia [1]. A number of normal physiologic processes occur during pregnancy leading to the term physiologic anaemia of pregnancy. The plasma volume increases (40–50%) relative to red cell mass (20–30%) and accounts for the fall in haemoglobin concentration [4]. Anaemia in pregnancy is one of the most common indirect obstetric factors responsible for maternal mortality particularly in developing countries and it is associated with poor maternal and foetal outcomes [5].

The most more common causes of anaemia in developing countries includes inadequate diet, poor prenatal vitamins and iron and folic acid intake, shorter interpregnancy interval, malaria infection, parasitic infections particularly hookworm and blood losses [6, 7, 8]. The most common type of anaemia is iron deficiency anaemia which affects predominantly women of reproductive age group particularly pregnant women [9].

The global prevalence of anaemia in pregnant women is 41.8% and the highest proportions of pregnant women affected are in Africa (57.1%) [10]. The prevalence of anaemia in developing countries can be as high as 56 or 61% [11]. Anaemia in pregnancy is a major public health problem problem in Nigeria. The prevalence of anaemia recorded in a previous study in Abeokuta, Nigeria was 76.5% [12]. Similarly, the prevalence of anaemia observed among two thousand, six hundred and fifty pregnant Nigerian women attending antenatal booking clinic of the Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu indicated that 55.3% of the women were anaemic [13].

A meta-analysis on global trend in the prevalence of anaemia indicates that 38% of pregnant women were anaemic in 2011 [14]. In East Africa, the prevalence of anaemia among pregnant women residing in low-income region is 36% and 22% prevalence in high-income regions [5]. There are several obstetric and non-obstetrics complications associated with anaemia in pregnancy; abortion, prematurity, intrauterine foetal death, low birth weight and perinatal mortality, impaired cognitive development, reduced learning capacity, diminished school performance in children and decreased productivity in adults [15, 16].

The exact causes of thrombocytopenia in pregnancy has been shown to be diverse and the clinical features vary widely. It is vital to identify the primary cause of thrombocytopenia to enable appropriate therapy to be implemented in a bid to improve the prognosis of pregnancies [17]. Thrombocytopenia is a common haematologic abnormality during pregnancy. It is commonly associated with increased risk of bleeding antepartum and post-partum particularly during caesarean section or other surgical intervention during pregnancy. The prevalence of thrombocytopenia is higher among pregnant women in Nigeria (13.5%) compared to non-pregnant controls (4.3%) [18]. It is second only to anaemia as the most common haematologic abnormality during pregnancy [19].

The prevalence of thrombocytopenia seems higher among pregnant women of African descent compared to Caucasian women. A previous report among Ghanaian pregnant women indicated a prevalence of 15.3% [20] and 7.2% [22] reported among Caucasians women. Thrombocytopenia in pregnant has a number of possible etiologies; PAT is the most common cause, followed by PIH and ITP. Other medical diseases notably leukaemia, aplastic anaemia, systemic lupus erythematosus (SLE) and sicca syndrome has been shown to potentially thrombocytopenia during pregnancy [23].

There is paucity of data on the prevalence of anaemia and thrombocytopenia among pregnant women in Kano State, Nigeria. The aim of this case-control study was to investigate the prevalence of anaemia and thrombocytopenia among ppregnant women attending Aminu Kano Teaching Hospital, Kano State, North Western Nigeria.

2. Materials and methods

2.1 Study area

Kano state of the Federal Republic of Nigeria lies between latitude 13 ${}^{\circ}$ N in the North and 11 ${}^{\circ}$ N in the South and longitude 8 ${}^{\circ}$ W in the West and 10 ${}^{\circ}$ E in the East. Kano State is made up of 44 local government areas. The total land area of Kano State is 20,760 sq kilometers with a population of 9,383,682 [25]. Kano State is a state located in the North-Western Nigeria and was created in contemporary Nigerian political development on May 27, 1967 from part of the Northern Region. Kano State borders Katsina State to the North-West, Jigawa State to the North-East, and Bauchi State and Kaduna State to the South. The capital of Kano State is Kano. Prior to 1991, Kano included the present Jigawa State, which was made a separate entity in 1991. Historically, Kano State has always been a commercial and agricultural state, which is well known for the production of groundnut as well as for its solid mineral deposits. The state has more than 18,684 kilometers of land most suitable for cultivation and is the most extensively irrigated state in the country. Kano state is a showcase in terms of its agricultural self-reliance and highly admirable resource management. Kano is known today, as the most irrigated state in the country with more than 3 million hectares of cultivable land. Kano state is a pacesetter in educational project; its senior secondary schools are emulated by others, while the State Universal Basic Education has now become a national phenomenon. Initially it was the primary focus of the State and the State’s vigorous adult literacy programmes has won national and international recognition [26]. In the area of tourism, Kano stands out as an excellent destination whose vast resources, both natural and cultural, are beginning to host a large number of tourists [27] which makes it a very attractive and a destination to many tourists. The Emir of Kano hosts a Durbar to mark and celebrate the two annual Muslim festivals of Eid-el-Fitr and Eid-al-Adha. The Durbar culminates in a procession of highly elaborately dressed horsemen who parade in a colourful pageantry through the city of Kano at various locations [26].

2.2 Post-colonial Kano

British forces captured Kano in 1903 and made it the administrative center in Northern Nigeria. It was replaced as the center of government by Kaduna, and only regained its administrative significance with the creation of Kano State in 1967, seven years after Nigerian independence. Kano is now the most populous state as revealed by 2006 Nigerian population Census with nine million, three hundred and eighty-three thousand, six hundred and eighty-two (9,383,682) people. It is predominantly a Muslim Hausa/Fulani State, where Hausa is the vernacular spoken by all [27]. It is a cosmopolitan settlement comprising of a significant number of other Nigerian ethnic groups, West Africans and few Sudanese, Lebanese, Syrians, Indo-Pakistanis, Europeans and the Chinese. Christians and followers of other non-Islamic religions form a small part of the population, and traditionally most of them live in the Sabon Gari area of the city. Foreign investment and investors can be seen all over the city. Kano is arguably one of the first five states in term of commercial activity in Nigeria [26].

2.2.1 Study subjects

The study subjects consisted of pregnant women attending antenatal clinic in Aminu Kano Teaching Hospital Kano State, who were consecutively recruited for the study.

2.2.2 Inclusion and exclusion criteria

2.2.2.1. Inclusion criteria

Inclusion criteria included; age $\geqslant$ 18 years, confirmation of pregnancy by a Consultant Obstetrician and willingness to offer a written informed consent to participate in the study.

2.2.2.2. Exclusion criteria

The following individuals who do not meet the inclusion criteria were excluded from participating as subject in this study; non-pregnant women, pregnant women $<$ 18 years and non-consenting pregnant women.

2.3 Calculation of sample size

Using $n=Z^{2}$ pq/d ${}^{2}$

Where $n=$ sample size, $Z=$ standard normal deviate, $P=$ prevalence in secondary data, $q=$ complement of $P$ , $d=$ tolerable Margin of error

$Z=$ 95% $=$ 1.96

$p=$ 50% $=$ 0.5

$q=$ 1–0.5 $=$ 0.5

$d=$ 0.05

$n=$ (1.96) ${}^{2}$ $\times$ 0.5 $\times$ 0.5/(0.05) ${}^{2}$

$n=$ 3.8416 $\times$ 0.5 $\times$ 0.5/0.0025

$n=$ 384

Table 1
Socio-demographic distribution of subjects and controls

Variables	Test group no. (%) $N=$ 120		Control group no. (%) $N=$ 60
Age group (years)
15–19	2	(1.7)	12	(20.0)
20–24	22	(18.3)	26	(43.3)
25–29	41	(34.2)	8	(13.3)
30–34	39	(32.5)	4	(6.7)
35–39	11	(9.2)	4	(6.7)
40–44	4	(3.3)	2	(3.3)
45–49	1	(0.8)	3	(5.0)
50–54	0	(0.0)	1	(1.7)
Ethnic group
Babur	1	(0.8)	0	(0.0
Ebira	1	(0.8)	2	(3.3)
Fulani	14	(11.7)	7	(11.7)
Hausa	77	(64.2)	47	(78.3)
Igala	2	(1.7)	2	(3.3)
Igbo	7	(5.8)	0	(0.0)
Igedel	1	(0.8)	0	(0.0)
Kanuri	2	(1.7)	1	(1.7)
Kilba	1	(0.8)	0	(0.0)
Mada	2	(1.7)	0	(0.0)
Nupe	1	(0.8)	1	(1.7)
Owan	1	(0.8)	0	(0.0)
Shuwa	1	(0.8)	0	(0.0)
Yoruba	9	(0.8)	0	(0.0)
Educational level
Primary	3	(2.5)	2	(3.3)
Secondary	32	(26.7)	13	(21.7)
University	31	(25.8)	31	(51.7)
Other	53	(44.2)	7	(11.7)
Illiterate	1	(0.8)	7	(11.7)
Occupation
House wife	74	(61.7)	12	(20.0)
Teaching	14	(11.7)	0	(0.0)
Other	32	(26.7)	48	(80.0)

2.3.1 Study design

This cross-sectional case-control study was designed to investigate the prevalence of anaemia and thrombocytopenia among one hundred and twenty (120) pregnant women attending antenatal clinic in Aminu Kano Teaching Hospital Kano, Kano State of Nigeria. Sixty age-matched non-pregnant women will be monitored as controls.

2.3.2 Ethical clearance

Ethical clearance was sought from the Ethical committee of Aminu Kano Teaching Hospital Kano State (NHREC/21/08/2008/AKTH/EC/2032 Dated 7 ${}^{\rm th}$ August, 2017).

2.3.3 Informed consent

Written informed consent was obtained from all participants in the study.

2.4 Questionnaire

A structured questionnaire was administered by an interviewer and was used to collect socio-demographic and other bio-data from each participant.

2.4.1 Sample collection

About three milliliters (3 mls) of blood was collected by venepunture using aseptic technique from each participant into an ethylene diamine tetra acetic acid (EDTA) anticoagulated tube which was used for Full blood count (FBC) testing using the 3 part-differential Mythic 18 haematology autoanalyzer (Orphee, Switzerland).

3. Results

The socio-demographical distribution among the subjects showed that the 25–29 years age group had the highest number of participants 41 (34.2%) followed by 30–34 years 39 (32.5%) among test group while among the control group age, the 20–24 years 26 (43.3%) had the highest number followed by the 25–29 years 8 (13.3%). The least number of participants were in the groups 50–54 years in both the test and control group with 0 (0.0%) and 1 (1.7%) respectively. It was observed that the Hausa ethnic group was the dominant ethnic group among the subjects and control participants; 77 (64.2%) and 47 (78.3%) respectively. Women with no formal educational had the highest number of participants 53 (44.2%) followed by those educated up to secondary educational level 32 (26.7%). Occupational distribution indicated that a significant number of the subjects 74 (61.7%) were housewives. Table 1 shows the socio-demographic distribution of subjects and controls.

Distribution of subjects was compared based on obstetrics variables. More than half of the subjects 86 (71.7%) were multiparous. One hundred and fifteen (95.8%) of the subjects have been married once. Among the subjects, 21 (17.5%) reported history of problem in their previous pregnancy and 11 (9.2%) have problem with their present pregnancy. Table 2 shows the distribution of subjects based on obstetrics variables.

Table 2
Distribution of subjects based on obstetrics variables

Variables	Test group no. (%)
Parity
Null parity	0	(0.0)
Primly parity	34	(28.3)
Multi parity	86	(71.7)
Number of marriage
0	0	(0.0)
1	115	(95.8)
2	5	(4.2)
Problem with previous pregnancy
Yes	21	(17.5)
No	99	(82.5)
Problem with present pregnancy
Yes	11	(9.2)
No	109	(90.8)

Table 3

Mean haematological parameters of the subjects and controls

Haematological variables	Mean $\pm$ Std. Deviation ( $N=$ 120)	Mean $\pm$ Std. Deviation ( $N=$ 60)	$t=$ value	$P$ -value
RBC	3.75 $\pm$ 0.51	4.31 $\pm$ 0.48	1.1289	0.6116
HBG	10.19 $\pm$ 1.15	11.55 $\pm$ 0.92	1.5625	0.0579
HCT	30.82 $\pm$ 3.29	35.12 $\pm$ 2.55	1.6646	0.0308

Table 4

Effect of trimester on some haematological parameters of the subjects

Haematological	Trimesters			$p$ -value
parameters	First trimester ( $n=$ 18)	Second trimester ( $n=$ 50)	Third trimester ( $n=$ 52)
RBC	3.81 $\pm$ 0.46	3.67 $\pm$ 0.50	3.79 $\pm$ 0.53	0.398
HGB	10.45 $\pm$ 1.07	10.17 $\pm$ 1.20	10.12 $\pm$ 1.14	0.576
HCT	31.63 $\pm$ 3.17	30.59 $\pm$ 0.59	30.77 $\pm$ 3.029	0.516

Table 5

Prevalence of anaemia and thrombocytopenia among the subjects and the controls

Haematology abnormality	Subjects		Controls
	N	%	N	%
Anaemia (HB $<$ 11 g/dl for subjects and 12 g/dl for controls)	90	75	40	66.7
Thrombocytopenia (Platelet count $<$ 140 $\times$ 10 ${}^{9}$ /L)	8	6.7	0	0

Table 6

Prevalence of anaemia and thrombocytopenia among the subjects based on trimester

Haematological abnormality	First trimester N (%)	Second trimester N (%)	Third trimester N (%)
Anaemia	12 (66.7)	40 (80.0)	38 (73.1)
Thrombocytopenia	1 (5.6)	4 (8.0)	3 (5.8)

The mean PCV was significantly higher among the non-pregnant controls compared to the pregnant subjects ( $p=$ 0.0308). Table 3 shows the mean haematological Parameters of the Subjects and Controls. Table 4 shows the effect of Trimester on some haematological parameters of the subjects. Table 5 shows the prevalence of Anaemia and Thrombocytopenia among the Subjects and the Controls. Table 6 shows the prevalence of Anaemia and Thrombocytopenia among the Subjects based on trimester.

4. Discussion

Pregnancy induces a number of physiologic changes that affect the haematologic indices among women. In this study, we investigated the prevalence of anaemia and thrombocytopenia among pregnant women visiting antenatal clinic at Aminu Kano Teaching Hospital in Kano State, North Western Nigeria. Sociodemographic data of the study population indicated that a higher number of pregnant women were unemployed fulltime housewives and have non-formal education. This finding is in agreement with previous reports [27, 28].

In term of medical history, about 71.7% of subjects were multiparous. Previous report [29] indicated that women who have more than four children are more at increased risk of infant and maternal mortality.

In this study, we observed that the prevalence of anaemia was higher among women in the second trimester (80%). Our finding is at variance with a previous report among pregnant women in Gondar, Northwest Ethiopia which indicated that the prevalence of anaemia was higher among pregnant women in the third trimester. Our finding is in agreement with previous report [30] which indicated that trimester (second and third) was one of the key factors associated with anaemia among pregnant women in Southern Ethiopia. Our finding is also consistent with a previous report [31] which indicated a high prevalence of anaemia of 48.4% among second and third trimester pregnant females in western Rajasthan.

In this study, we observed a statistically significant decrease ( $p=$ 0.0308) in the HCT of the pregnant subjects compared to the non-pregnant controls. Our finding is consistent with previous reports [32, 33] which indicated that haematocrit value were significantly lower in pregnant women compared to non-pregnant women. Similarly, Verma et al. [34] showed that HCT fall progressively from the end of the first trimester until a few weeks, before term returning to normal 1–2 months post-partum. During pregnancy, an increased plasma volume with the lack of an adequate increase in erythrocytes mass results in a decrease in haemoglobin level and the development of anaemia, which is defined as dilution anaemia [35, 36, 37, 38]. Nonetheless Lurie and Mamet [39] also found that erythropoietin and erythrocyte production are increased during normal pregnancy while erythrocyte mass per unit of body weight remains constant throughout the entire pregnancy, and haemoglobin and haematocrit continuously decrease into the third trimester. Erythrocyte life span is decreased during normal pregnancy due to emergency haemopoiesis in response to elevated erythropoietin levels. Also, Osoagbaka et al. [40] reported among pregnant women that there is a decrease in mean packed cell volume when compared to the corresponding values for non-pregnant women. Previous report indicated that there is marked demand of extra iron during pregnancy especially in the second half [41]. In such condition, HCT is expected to be lower in the pregnant women compared to controls. Thus, the fall in haemoglobin concentration during pregnancy is due to combined effect of haemodilution and negative iron balance that is due to increased demand.

Anaemia is one of the most commonly encountered medical disorders during pregnancy. According to WHO, haemoglobin level below 11 g/dL in pregnant women constitutes anaemia [42]. It is estimated that more than half of pregnant women in the World have a haemoglobin level indicative of anaemia ( $<$ 11.0 gldl), the prevalence may however be as high as 56 or 61% in developing countries [43]. In this study we observed a prevalence of anaemia of 75% among our cohort of pregnant women in Kano North Western Nigeria. The WHO estimates that anaemia affects over half of the pregnant women in developing countries [44]. Recent estimates in the developing countries including Nigeria put the prevalence at 60.0% in pregnancy and about 7.0% of the women are said to be severely anaemic [44, 45, 46]. Our observed prevalence is lower than the 76.5% prevalence reported in Abeokuta [12]. The prevalence of anaemia of 54.5–62.6% has been observed in South-southern region of Nigeria [47, 48] while prevalence rates of anaemia of 24.5% and 40.4% have been reported in Kano and Enugu [49, 50] respectively. Our observed prevalence is also higher than a prevalence of 39.2% observed previously by Buhari et al. [51] among their cohort of 273 pregnant women at Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. However, 21.3–32.5% prevalence of anaemia has been documented in Ethiopia and Uganda [52, 53]. Our observed prevalence is also higher than the 53.05% among pregnant women attending antenatal booking at Ahmadu Bello University teaching hospital, Kaduna, Nigeria [54]. There are several reasons for the high anaemia prevalence observed among pregnant women in this study. Women often become anaemic during pregnancy because the demand for iron and other vitamins is increased due to physiological burden of pregnancy. The inability to meet the required level for these substances either as a result of dietary deficiencies or infection gives rise to anaemia [55]. Predisposing factors for anaemia among pregnant women include; young age, grand multiparity, low socioeconomic status, illiteracy, ignorance, and short inter-pregnancy intervals [56]. Infection with hookworm and intestinal helminthes causes gastrointestinal blood loss resulting in depletion of the iron stores and consequently impaired erythropoiesis.

Thrombocytopaenia is a common haematologic abnormality during pregnancy. Pregnant women with thrombocytopenia defined as platelet count of $<$ 140 $\times$ 10 ${}^{9}$ /L have a higher risk of bleeding excessively during or after childbirth, particularly if they need to have a caesarean section or other surgical intervention during pregnancy, labour or in the puperium. In this study we observed a prevalence of thrombocytopenia defined as platelet count of $<$ 140 $\times$ 10 ${}^{9}$ /L of 6.7% among the pregnant subjects. Our observed prevalence is lower than the 13.5% prevalence observed among pregnant women in Lagos, Nigeria [57]. The reason for the difference in prevalence may be due to the fact that unlike our study that used a platelet cut-off of $<$ 140 $\times$ 10 ${}^{9}$ /L, Ajibola and Colleagues [57] defined thrombocytopaenia as a platelet count of less than 150 $\times$ 10 ${}^{9}$ /L.

Our finding is almost comparable to the results of previous studies; 7.67% [58], 8.8% [58], 8.17% [60] 8% [61], 8%–10% [62], 8% [63] 7%–10% [64], 11.6% in Switzerland [65], 13.5% in Ethiopia [66], 15.3% in Ghana [67] and 21.8% in Israel [68]. Our observation is in agreement with a previous report [69] which showed that thrombocytopenia is a common haematologic issue encountered by obstetricians and haematologists and detected in about 10% of all pregnancies. The varied differences in the prevalence of thrombcytopaenia in the various reports may be due to sociodemographic differences of the study subjects and differences in the study design. The cause of gestational thrombocytopaenia is unclear, although it might be secondary to accelerated platelet consumption and the increased plasma volume have been associated with gestational thrombocytopaenia [18]. Anti-platelet antibodies have been detected in the serum and may also play a role in gestational thrombocytopaenia [70]. Apart from gestational thrombocytopenia, low platelet during pregnancy can also be associated with several non-pregnancy-specific diseases such as preeclampsia, HELLP syndrome, or idiopathic thrombocytopenic purpura (ITP). Other causes include infection, such as malaria or folate deficiency, and diseases, such as leukemia and aplastic anaemia. The differential diagnosis between ITP and gestational thrombocytopenia is clinically important with regards to the developing foetus, due to the risk of neonatal thrombocytopenia. However, this differential diagnosis is very difficult during pregnancy. Thrombocytopenia in pregnancy which need to be investigated are the following; thrombocytopenia known before pregnancy, thrombocytopenia occurring during the first and second trimester, platelet count $<$ 75 $\to,es$ 10 ${}^{9}$ /L in the third trimester and thrombocytopenia in pregnancy with complications [66].

The prevalence of thrombocytopenia was compared based on trimester. The prevalence was higher among women in the second trimester (8%). Our finding is at variance with previous reports [71, 72] which showed that there was no association between the trimesters and thrombocytopenia.

5. Conclusion

This study has shown that pregnancy is associated with anaemia and thrombocytopenia. The prevalence of anaemia and thrombocytopenia was highest among women in the second trimester. There is need to routinely monitor the indices of anaemia among pregnant women in the area. Supplementation with daily iron, vitamin and mineral may be indicated to reduce the risk anaemia in pregnancy.

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Anaemia and thrombocytopenia among pregnant women attending Aminu Kano Teaching Hospital,Kano State,North Western Nigeria

Abstract

BACKGROUND:

OBJECTIVES:

METHOD:

RESULT:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 Study area

2.2 Post-colonial Kano

2.2.1 Study subjects

2.2.2 Inclusion and exclusion criteria

2.2.2.1. Inclusion criteria

2.2.2.2. Exclusion criteria

2.3 Calculation of sample size

Table 1 Socio-demographic distribution of subjects and controls

2.3.2 Ethical clearance

2.3.3 Informed consent

2.4 Questionnaire

2.4.1 Sample collection

3. Results

Table 2 Distribution of subjects based on obstetrics variables

5. Conclusion

References

Table 1
Socio-demographic distribution of subjects and controls

Table 2
Distribution of subjects based on obstetrics variables