|Year : 2016 | Volume
| Issue : 3 | Page : 132-136
Prevalence of sickle cell disease among pregnant women in a tertiary health center in south-south Nigeria
Ogbonna Collins Nwabuko1, Dorathy Adaunwa Okoh2, Caroline Iyalla3, Hannah Omunakwe2
1 Department of Hematology, Abia State University, Uturu, Abia State; Department of Pathology, Braithwaite Memorial Specialist Hospital, Port Harcourt, Nigeria
2 Department of Pathology, Braithwaite Memorial Specialist Hospital, Port Harcourt, Nigeria
3 Department of Hematology, Blood Transfusion and Immunology, University of Port Harcourt, Rivers State, Nigeria
|Date of Submission||20-Jun-2015|
|Date of Acceptance||31-May-2016|
|Date of Web Publication||19-Sep-2016|
Ogbonna Collins Nwabuko
Department of Hematology, Abia state University, Uturu, Abia State
Background: Sickle cell disease (SCD) is relatively prevalent in Nigeria and it is associated with obstetric complications, especially in unsupervised pregnancies. This study was to determine the prevalence of SCD among pregnant women seen in an antenatal clinic in a tertiary health center in South-South Nigeria. Materials and Methods: This was a 10-year retrospective study of all registered pregnant women seen at the antenatal clinic of Braithwaite Memorial Specialist Hospital (BMSH) (2004-2013). Sociodemographic data and hemoglobin (Hb) electrophoresis were obtained using questionnaires and alkaline cellulose acetate electrophoretic machines (Helena), respectively. Data were analyzed using Epi-info version 7.02 by the WHO, Geneva, Switzerland, and CDC, USA. Results: A total of 35,976 pregnant women were seen at the antenatal clinic of BMSH within the study period, out of which 28,815 (80.09%) were Hb AA, 7,109 (19.77%) were Hb AS, and 52 (0.14%) were SS. The average gestational age of booking was 22.1 weeks. More women with tertiary education registered earlier than those with secondary education. Anemia in pregnancy (Hb <11 g/dl) was found in 94.2% of the pregnant women with Hb SS, while 5.8% was above 11 g/dl (P = 0.001). Conclusion: There is a high prevalence of SCD among pregnant women in this region. Late antenatal booking, anemia, and poor education are the predictive markers of poor pregnancy outcome in this region.
Keywords: Hemoglobin variant, pregnancy, sickle cell disease, South-South Nigeria
|How to cite this article:|
Nwabuko OC, Okoh DA, Iyalla C, Omunakwe H. Prevalence of sickle cell disease among pregnant women in a tertiary health center in south-south Nigeria. Sub-Saharan Afr J Med 2016;3:132-6
|How to cite this URL:|
Nwabuko OC, Okoh DA, Iyalla C, Omunakwe H. Prevalence of sickle cell disease among pregnant women in a tertiary health center in south-south Nigeria. Sub-Saharan Afr J Med [serial online] 2016 [cited 2020 Feb 18];3:132-6. Available from: http://www.ssajm.org/text.asp?2016/3/3/132/190843
| Introduction|| |
Sickle cell disease (SCD) is one of the greatest public health problems of this age. It is a genetic disease of the globin chain of the red blood cells. , It affects millions of people worldwide and is more common among those whose ancestors came from sub-Saharan Africa.  In the West and Central Africa where it is the most common hemoglobinopathy, 25% of the people have sickle cell (SC) trait while 2-3% of all infants are born with a form of this disease. It is estimated that SC occurs in one in every 500 Africans.  In the USA, an estimated 80,000-90,000 Americans of African extraction are affected by SCD, while about 3 million have SC traits.  In Nigeria, about 45,000-90,000 infants with SCD are born annually compared to only 1000 infants born in the USA. ,
The SC gene disorder occurs in a high frequency in malaria-endemic regions, especially in the Plasmodium falciparum pressure belt of low- and middle-income countries.  These areas account for three-quarter of an estimated 300,000-500,000 children born with SC disease worldwide every year. The high prevalence stems from an evolutionary link between the sickle hemoglobin and resistance to malaria, a feature that also underpins the common inclusion of SC screening in health research in malaria-endemic zones where the gene may be predominant. ,
SCD is reported to be associated with a very high rate of childhood mortality. It contributes to 5% of under-5 death in the African continent.  Other health problems associated with SCD include a decrease in median survival, chronic anemia, end-stage renal failure, acute chest syndrome, and episodes of vaso-occlusive, hyper-hemolytic, aplastic, and sequestration crises.  All these complications pose a significant burden on the scarce health resources, especially in economically constrained settings found in sub-Saharan Africa.
Pregnancy in patients with SCD is associated with an increased maternal and fetal morbidity and mortality. Maternal complications may include recurrent anemia, bone pain crises, recurrent malaria infection, acute chest syndrome, spontaneous abortion, lobar pneumonia, HIV, pseudo toxemia, hemolytic crises, pre-eclampsia, retained placenta, and maternal mortality, just to mention a few. The fetal complications may include low birth weight (LBW), intrauterine fetal death, stillbirth, breech presentation, and etcetera. ,
Although progress has been made in the management of SCD in high-income countries over the past one decade, in most of the middle- and low-income countries where SCD is a major public health problem, its management has remained inadequate.  There are no strong national health policies to control SCD in these countries, and so, the basic facilities to screen, diagnose, or manage the patients (e.g., prophylactic antibiotics and immunization) are usually absent. More often, diagnoses are first made when complications have set in.  Without early diagnosis and treatment, pregnant mothers and infants with SCD often die due to labor complications and chronic anemia.
This study was to determine the prevalence of SCD among pregnant women in South-South Nigeria and the relationship of the hemoglobin (Hb) variants of the pregnant women with their packed cell volume at booking.
| Materials and methods|| |
This was a retrospective study of antenatal care patients seen at the Braithwaite Memorial Specialist Hospital (BMSH) in Port Harcourt, Rivers State, South-South Nigeria. Port Harcourt is a cosmopolitan city. This study was carried out from 2004 to 2013 with a total of 35,976 pregnant women seen during the study period, and all the pregnant women who attended BMSH were included in the study.
Ethical clearance for the study was obtained from the Ethical Committee of the BMSH.
Data were obtained using a pro forma. Data on gestational age, hemoglobin electrophoretic pattern, age, occupation, educational status, Hb concentration, blood group, screening status of HIV, veneral disease research laboratory, and hepatitis B surface antigen tests were obtained. The data obtained were entered and analyzed using Epi-info statistical software version 7.02 by the WHO, Geneva, Switzerland, and CDC, USA. The mean and standard deviation were calculated, and Student's t-test was used to determine the significant differences between the mean values. P = 0.05 was set as the level of statistical significance.
| Results|| |
A total of 35,976 women were seen at the antenatal clinic of BMSH, Port Harcourt, between 2004 and 2013, out of which 28,815 (80.09%) had Hb AA, 7,109 (19.77%) had Hb AS, and 52 had Hb SS [Table 1]. Out of 33,939 participants who had their levels of education documented, 74 (0.2%) had primary school education, 811 (2.4%) had junior secondary school education, 13,417 (39.5%) had senior secondary school education, 19,447 (57.3%) had tertiary level of education, while 190 (0.6%) had postgraduate level of education [Table 2]. The mean gestational age at booking was 29.18 ± 4.69 weeks. The minimum and maximum gestational age of booking was at 11 and 79 weeks, respectively. About 13,416 (39.4%) presented with Hb concentration <11.0 g/dl while 20,604 (60.6%) presented with Hb value >11.0 g/dl [Table 3]. Out of the 52 Hb SS pregnant women in the study, 49 (94.2%) had Hb concentration <11.0 g/dl while 3 (5.8%) were above 11.0 g/dl (P = 0.001) [Table 4].
|Table 2: Levels of education of pregnant women at booking: Sickle cell disease compared to nonsickle cell disease pregnant women|
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|Table 3: Pattern of hemoglobin concentrations in sickle cell disease and nonsickle cell disease pregnant women at booking|
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|Table 4: Cross-tabulation of hemoglobin concentrations with genotypes in pregnant women at booking|
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| Discussion|| |
This study showed 0.14% prevalence of SCA among pregnant women in the health center. It is, therefore, estimated that one out of every 714 women seen in our antenatal clinic in the region will likely have Hb SS genotype. The prevalence rate in this study is relatively lower than an earlier reported prevalence in another tertiary institution in Port Harcourt, Nigeria, which was 0.2%.  Although there is a paucity of prevalence of SCD among pregnant women from previous studies, 52 women with Hb SS in pregnancy over a 10-year period was higher than that documented by Ocheni et al. in Enugu, South-East Nigeria, where only ten women with SCD in pregnancy were documented over a period of 30 years. However, Odum et al.  in South-West Nigeria found sixty women with SCD in pregnancy within a 3-year period. Ocheni et al. and Odum et al. in their studies were interested in the outcome of pregnancies in SCD patients, but their actual prevalence could not be ascertained.
The study showed that over 57% of the booked patients in the clinic had a tertiary level of education. This shows that female education has a role to play in creating awareness for maternal care. There is, therefore, a need to empower women through education. This could be a strategy in the right direction of reducing maternal mortality in our environment. The prevalence of 0.2% reflects that women with a low level of education do not seek comprehensive care, but resort to traditional birth attendants.  Although the patterns of level of education of the SCD patients were not captured, future studies will look at these demographic parameters.
The average gestational age of 22.1 weeks at booking from this study indicate a late booking. This means that majority of the women registered at the second trimester. This was relatively similar to the gestational age of 24.33 weeks documented at a booking in Abakaliki, South-East Nigeria.  In this study, it was found that 83.1% of the pregnant women booked after the first trimester. This may not be in the interest of the maternal and fetal well-beings. Antenatal care is one of the pillars of the Safe Motherhood Initiative aimed at preventing adverse pregnancy outcome. Early antenatal booking is recommended for this benefit. When a woman books late in the antenatal clinic, the benefit of safe motherhood is defeated. The advocacy has always been early booking as the panacea for a favorable outcome. Only very few registered at the late first trimester.
The factor anemia in pregnancy used in this study was based on the WHO definition as Hb concentration <11 g/dl. , This study showed that 39.3% of the patients presented with Hb value <11.0 g/dl. This showed that more than one-third of the women were already having anemia at booking. This was similar to the values obtained in the previous studies in Nigeria. , Anemia in pregnancy is very common in low- and middle-income countries. About 49 (94.2%) out of the 52 women with SCD had anemia, which is one of the greatest burdens of SCD in pregnancy. Pregnant women with SC anemia are classified as high risk. This is because SCD increases the risk of certain complications such as miscarriage, hypertension, and premature death, just to mention a few. The fetal complications include LBW, intrauterine death, and abnormal presentations.  Odum et al. in 2002 in Lagos found that antenatal and postpartum blood transfusion rates for the SCD patients were 45.0% and 81.6%, respectively. Anemia, evidenced by low Hb concentration, could be a predictive marker of women who may require blood transfusion during pregnancy or postpartum period.
One of the challenges facing SCD globally is underfunding and lack of publicity. SCD is the single most common life-threatening genetic disease. Racial disparities come into play in private and public funding of SCD (believed to be more common in the African descent) compared to other genetic diseases such as cystic fibrosis (which are more common in Caucasians) in high-income countries such as the USA.  For example, the National Institutes of Health spends nearly four times as much per patients on cystic fibrosis research as it does on SCD, despite the fact that four times the number of people suffer from SCD as those with cystic fibrosis. The cost of managing SCD is so enormous that it is unprecedented, yet it is less funded and less advocated. ,
SCD is associated with a higher childhood mortality in low-income countries compared to high-income and some middle-income countries. , With the current advances in the management of SCD more common in high- and middle-income countries, the average lifespan of people living with SCD has improved up to four-five decades of life, hence a transition from mortality to morbidity (burden) of the disease.  The implication is that more funds will be channeled toward managing the SCD crises and obstetric complications of SCD in pregnancy. Poor funding leads to poor motivation of the facilitators of SCD research projects. Most projects in Nigeria are funded by donor agencies and they are not readily available. The few available help partners do not have enough financial strength to drive SCD projects in the country.  In addition, the lack of political will on the side of the government to own up research projects on SCD or to improve budgetary allocation to health sector has further worsened the care of people living with SCD in Nigeria.  In addition, there is a poor health information management system in most health centers in Nigeria. This could lead to prolong turn-around-time in information retrieval system.
| Conclusion|| |
There is a high prevalence of SCD among pregnant women in this region. Late antenatal booking, anemia, and poor education are the predictive markers of poor pregnancy outcome in this region. There is, therefore, a need to create awareness through persuasive media networking, involving the government and other donor agencies to institutionalize appropriate health interventions aimed at early detection and treatment of SCD in Nigeria.
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Conflicts of Interest
There are no conflicts of interest.
| References|| |
Grosse SD, Odame I, Atrash HK, Amendah DD, Piel FB, Williams TN. Sickle cell disease in Africa: A neglected cause of early childhood mortality. Am J Prev Med 2011;41 6 Suppl 4:S398-405.
Piel FB, Hay SI, Gupta S, Weatherall DJ, Williams TN. Global burden of sickle cell anaemia in children under five, 2010-2050: Modelling based on demographics, excess mortality, and interventions. PLoS Med 2013;10:e1001484.
Cooper R. A note on the biologic concept of race and its application in epidemiologic research. Am Heart J 1984;108 (3 Pt 2):715-22.
Sickle Cell Disease is a Global Public Health Issue. Available from:www.sicklecelldisease.org/index.cfm?page=scd-global.
Steinberg MH. Management of sickle cell disease. N Engl J Med 1999;340:1021-30.
Hickman M, Modell B, Greengross P, Chapman C, Layton M, Falconer S, et al.
Mapping the prevalence of sickle cell and beta thalassaemia in England: Estimating and validating ethnic-specific rates. Br J Haematol 1999;104:860-7.
Piel FB, Patil AP, Howes RE, Nyangiri OA, Gething PW, Williams TN, et al.
Global distribution of the sickle cell gene and geographical confirmation of the malaria hypothesis. Nat Commun 2010;1:104.
Fleming AF, Storey J, Molineaux L, Iroko EA, Attai ED. Abnormal haemoglobins in the Sudan savanna of Nigeria. I. Prevalence of haemoglobins and relationships between sickle cell trait, malaria and survival. Ann Trop Med Parasitol 1979;73:161-72.
Makani J, Cox SE, Soka D, Komba AN, Oruo J, Mwamtemi H, et al.
Mortality in sickle cell anemia in Africa: A prospective cohort study in Tanzania. PLoS One 2011;6:e14699.
United Nations Press Office Press Conference on Raising Awareness of Sickle-cell Anemia; June, 2009. Available from:www.un.org/News/briefings/docs/2009/090619_Anaemia.doc.htm.
Graham RS, Luana LL, Mark C, Ian RB, Minerva T. Outcome of pregnancy in homozygous sickle cell disease. Am Coll Obstet Gynecol 2004;103:1278.
Ocheni S, Onah HE, Ibegbulam OG, Eze MI. Pregnancy outcomes in patients with sickle cell disease in Enugu, Nigeria. Niger J Med 2007;16:227-30.
Ugboma HA, George IO. Sickle cell disease in pregnancy: Maternal and fetal outcome in Port Harcourt, Nigeria. Br J Med Med Res 2015;7:40-4.
Odum CU, Anorlu RI, Dim SI, Oyekan TO. Pregnancy outcome in HbSS-sickle cell disease in Lagos, Nigeria. West Afr J Med 2002;21:19-23.
Augustine JM, Cavanagh SE, Crosnoe R. Maternal education, early child care and the reproduction of advantage. Soc Forces 2009;88:1-29.
Onoh R, Umerora O, Agwu U, Ezegwui H, Ezeonu P, Onyebuchi A. Pattern and determinants of antenatal booking at Abakaliki Southeast Nigeria. Ann Med Health Sci Res 2012;2:169-75.
World Health Organization. The Prevalence of Anemia in Women: A Tabulation of Available Information. WHO/MCH/MSM/92.2. Geneva, Switzerland: WHO; 1992.
World Health Organization. Prevention and Management of Severe Anemia in Pregnancy: Report of a Technical Working Group. WHO/FNE/MSM/93.5. Geneva, Switzerland: World Health Organization; 1993.
Aluka C, Amadi AN, Kamanu CI, Feyi-Waboso PA. Anemia in pregnancy in Abia State University Teaching Hospital, Aba. J Med Invest Pract (JOMIP) 2002;2:58-61.
Adinma JI, Ikechebelu JI, Onyejimbe UN, Amilo G, Adinma E. Influence of antenatal care on the hematocrit value of pregnant Nigerian Igbo women. Trop J Obstet Gynaecol 2002;19:68-70.
How Race Plays an Ugly Role in the Drastic Underfunding of Sickle Cell Research and Advocacy. Available from::www.dailykos.com/story/2015/05/05/1382655/-How-race-plays.
Centers for Disease Control and Prevention (CDC). SWOT Analysis Tool; 1 October, 2014. p. 117. Available from:www.cdc.gov/phcommunities/resourcekit/resources.html#swot_analysis.
Howson CP, Christianson AC, Modell B. Controlling birth defects: Reducing the hidden toll of dying and disabled children in lower-income countries. Washington (Columbia): Disease Control Priorities Project; 2008.
Nnodu OE. Interventions for the prevention and control of sickle cell disease at primary health care centers in Gwagwalada area council of federal capital territory, Nigeria. Cureus 2014;6:e194.
Platt OS, Brambilla DJ, Rosse WF, Milner PF, Castro O, Steinberg MH, et al.
Mortality in sickle cell disease. Life expectancy and risk factors for early death. N Engl J Med 1994;330:1639-44.
Sickle Cell Disease Foundation Nigeria. Available from: http//:www.sicklecellfoundation.com/.
Sickle Cell Disease Prevention and Control - Regional Office for Africa. Available from::www.afro.who.int/en/nigeria/nigeria-publications/1775-s.
[Table 1], [Table 2], [Table 3], [Table 4]