Anaemia status is associated with insufficient iodine levels in pregnant women in rural settings; a two-centre observational study

Anaemia status is associated with insufficient iodine levels in pregnant women in rural settings; a two-centre observational study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Anaemia status is associated with insufficient iodine levels in pregnant women in rural settings; a two-centre observational study David Larbi Simpong, Charles Ekow Spike Cartey, Olivia Mawunyo Timpo, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5675773/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: Adequate maternal hemoglobin and iodine are essential for optimal fetal-placental oxygenation, and, fetal brain development respectively. Intra-pregnancy anemia and iodine insufficiency are associated with adverse fetal-maternal outcomes. This study explored the potential association between intra-pregnancy anemia and iodine insufficiency and identified factors associated with third-trimester anemia. Methods: This study recruited pregnant women attending antenatal care in two rural health centres in the Ellembelle District, Ghana. Participants were followed from first-trimester visit until delivery. Demographic information, iodized salt usage, birth outcomes, urinary iodine concentration, and hemoglobin levels were collected per trimester; statistical significance was set at p<0.05. Results: Despite 97.0% of participants reporting iodized salt use, 48.0%, 54.0%, and 51.0% had iodine insufficiency in trimesters 1, 2, and 3, respectively. Anemia rates were 44.0%, 32.0%, and 41.0% in trimesters 1, 2, and 3, respectively, with higher prevalence among pregnant teenagers. In all trimesters, anemic individuals had iodine insufficiency [T1: 141.4 vs 158.7 μg/L (p=0.1173); T2: 135.1 vs 155.3 μg/L (p=0.0327; T3: 139.2 vs 156.8 μg/L (p=0.0325)], or reduced gestational weight [T1: 55.35 vs 58.20 kg (p=0.4272); T2: 55.50 vs 63.25 kg (p=0.0094); T3: 60.0 vs 68.2 μg/L (p=0.0388)] than non-anemic individuals. Logistic regression analyses found that third-trimester anemia was prevalent in married women (aOR: 2.15, p=0.011), with non-formal (aOR: 11.477; p=0.076), basic (aOR: 3.559; p=0.286), or secondary (aOR: 9.562; p=0.044) education, and is associated with higher risk of cesarean section delivery (aOR:.41.070; p=0.011). Conclusion: Further research is needed to determine any potential causal relationship between insufficient iodine levels and anemia status during pregnancy. Ammonium persulfate Iodine deficiency pregnant women Urinary Iodine concentration Figures Figure 1 Introduction Adequate macro- and micronutrient intake is crucial for optimal fetal-maternal outcomes during pregnancy [ 1 ]. Micronutrients, particularly those involved in hematological processes, significantly impact the expectant mother's health. Sufficient hemoglobin levels are essential for improved nutrient supply, fetal oxygenation, and favorable birth outcomes [ 2 ]. Conversely, anemia, characterized by low hemoglobin levels, is associated with adverse outcomes, including low birth weight, miscarriage, and maternal mortality [ 2 , 3 ]. Iodine is another micronutrient vital for neuronal development. Insufficient iodine intake, especially during the early first trimester, can impair thyroid hormone production [ 4 , 5 ], affecting fetal brain development and increasing the risk of cretinism [ 6 , 7 ]. The median urinary iodine concentration (UIC) is a reliable indicator of iodine status. The World Health Organization recommends classifying iodine status based on UIC levels: 250 µg/L (excess) [ 8 ]. However, both iodine deficiency and excess can have adverse pregnancy outcomes [ 9 , 10 ]. Anemia [ 11 , 12 ] and iodine deficiency [ 13 , 14 ] are significant public health challenges among reproductive-aged women in sub-Saharan Africa (SSA). Previous studies have demonstrated associations between maternal hemoglobin levels and fetal birth weight [ 15 , 16 ]. However, research exploring the co-existence of iodine deficiency and anemia among pregnant women in SSA is limited, despite the high prevalence of each of these conditions in SSA. This prospective study investigated the dynamics of iodine and anemia trajectories per trimester in a cohort of pregnant women in two rural settings. Although there are general challenges to accessing healthcare in SSA, the rural settings are particularly disproportionately impacted by significantly limited access [ 17 ]. Thus, the aim was to generate rural settings-centric baseline data on the association of intra-pregnancy anaemia and iodine insufficiency that could potentially stimulate future mechanistic studies on plausible causal relationships between these two endemic public health challenges within the SSA context. Materials and methods Study design/site This study was undertaken at the Aiyinasi and Esiama health centres in the Ellembele district in Western Region, Ghana. The Ellembele district is subdivided into Aiyinasi, Esiama, Eikwe, Nkroful and New Aiyinasi sub-districts. It is located in the southern part of the Western Region between longitudes 2 o 05 and 2 o 35 west and latitudes 4 o 40 and 5 o 20 north and is bound in the south by the Gulf of Guinea, north by Prestea Huni Valley, Wassa Amenfi East district and north of Nzema East Municipality. From the East, it shares a boundary with the South of Nzema East Municipality and West of Jomoro District. The 2010 population census of Ghana put the population of the district at 87, 501 with a percentage sex distribution of 48.4% for males and 51.6% for females. The 2015 population for the district is 96,623 projected from the 2010 census figures given an annual growth rate of 2%. Study period The study was undertaken between February 2019 to August 2021. Sampling technique Given the number of antenatal care attendance at the two health centres, the study employed a convenience sampling technique to consecutively recruit all consenting pregnant women who visited any of the facilities during the period of the study. Although 137 pregnant women were recruited within their first antenatal care visit, complete data was obtained from only 100 individuals (see Fig. 1 for a detailed sampling strategy). Definition of gestational ages employed for this study were: trimester 1 (1–13 weeks); trimester 2 (14–27 weeks); trimester 3 (28–41 weeks). Inclusion and exclusion criteria All pregnant women within the first trimester who visited any of the two health centres were approached for potential recruitment into the study; only those who gave verbal informed consent were recruited for the study. All pregnant women who reported for their first antenatal clinic in the second or third trimester were excluded from the study. Although the two centres where the study was undertaken refers women for ultrasound in non-government facilities to determine gestational age, not all the women were able to go for the ultrasound procedure given the cost implications. Therefore, for consistency and data accuracy, only women with ultrasound-confirmed gestational age were included in the study. However, any pregnant woman with clinically diagnosed thyroid and/or renal dysfunctions were excluded. Data collection A questionnaire was administered to collect the socio-demographic characteristics of participants. To ensure that English language literacy was not a barrier to participation, given the rural settings of the study, the researchers assisted participants in completing the questionnaire. Filling of the questionnaire was Weight, urine iodine concentration, haemoglobin levels, blood pressure and duration in weeks of pregnancy were also measured and/or recorded as applicable. Laboratory methods Urinary iodine concentration (UIC) estimation The participants were supplied with sterile universal container and were instructed on the correct technique for collecting the urine sample into the container. About 5–10 milliliters (mL) urine sample was collected. Iodine concentrations were determined immediately after each urine sample was received in the laboratory. Urinary iodine concentration (UIC) was measured using the ammonium persulfate digestion based on the Sandell-Kolthoff reaction method [ 18 ]. For each participant, UIC was estimated three times from the urine provided; the median was then calculated and presented as the median UIC in the results section. Haemoglobin estimation Estimation of haemoglobin (Hb) concentration was done using the Cyanmethaemoglobin method. Using a well-mixed sample of EDTA blood specimen, 20µL of blood was transferred into 5ml of Drabkin’s reagent. The solution was allowed to stand for 5 minutes and was transferred into a cuvette to be measured photometrically using a UV-6300PC Spectrophotometer (VWR Int., China) at an absorbance of 540nm. The absorbance read was converted into its equivalent concentration from an absorbance–concentration chart drawn using a hemiglobincyanide standard [ 19 , 20 ]. The value obtained was recorded for each participant. Total WBC estimation The total white blood cell (WBC) count was performed using 2% acetic acid tinged with methylene blue. A 1-in-20 dilution of participants’ blood was undertaken by adding 20µLl of well-mixed EDTA blood sample to 380µL of acetic diluting fluid and allowed to stand for 5 minutes lyse all erythrocytes. A New improved Neubauer counting chamber was charged with the diluted sample. The chamber was allowed to stand for 5 minutes for the white cells to settle. Using a 10x objective lens with reduced light intensity, the white cells in the large four corner squares of the chamber were counted. The WBC counted was calculated per previous protocols [ 21 ] and the values obtained were recorded for each participant. Blood Grouping Participants’ ABO blood group was determined using a slide haemagglutination reaction method. The blood grouping was undertaken using monoclonal anti-A, and anti-B (Lab-Care Diagnostic, India) following manufacturer’s protocol. Weight measure The weights of the children were measured and recorded using Crown Electronic scale (CR – 2032; Qingdao, China); the weight of each pregnant woman was measured using Terraillon scale T74 (France). Birth weight 4.0kg were classified as underweight and macrosomia respectively. Placental weight (together with the membranes and the cord) was estimated using a tabletop beam weighing scale. Statistical handling/analysis The data was entered in Microsoft Office Excel 2016 and was analyzed with SPSS Software (IBM Inc., USA). Overall, the 37 participants with incomplete data were excluded from the data analyses (Fig. 1 ). Descriptive analyses were performed on demographics and categorical variables and were presented in percentages. The maternal median urinary iodine concentration (UIC) was classified as follows: median UIC 250 µg/L (more than adequate-to-excessive iodine levels) [ 8 ]. Following WHO recommendations, trimester-specific anaemia was defined as per haemoglobin cutoffs of 11.0 g/dL, 10.5 g/dL, and 11.0 g/dL for the first, second and third trimesters respectively [ 22 ]. The differences in the median urine iodine concentration, and maternal gestational weights of participants (both anaemic and non-anaemic) per respective trimesters were compared using the Mann-Whitney test. Spearman correlation coefficient was used to determine the relationship between variables. Logistic regression analysis to determine the factors associated with third-trimester anaemia, the independent variables were participants’ demographics, birth outcomes (placental weight, baby birth weight, and mode of delivery), total white blood cell count, and median UIC. In all statistical analyses, statistical significance was set at p < 0.05, under the two-tailed assumption. Results The baseline characteristics of the participants are presented in Table 1 . More than half of the participants were between 20–29 years old (54.0%, mean age 26.47 ± 5.713 years), in marriage (65.0%), or were blood group O (60.0%). Whereas secondary education was the predominant highest educational attainment (49.0%), 16.0% had no formal education. Furthermore, although 43.0% of participants self-reported not having any child, only 24.0% self-reported not having had any previous pregnancy. Table 1 Baseline characteristics of the study participants Variables Categories N (%) Age (years), mean age 26.47 (± 5.713) 16–19 14 (14.0) 20–29 54 (54.0) 30–39 32 (32.0) Educational attainment No formal 16 (16.0) Basic 21 (21.0) Secondary 49 (49.0) Vocational/tertiary 14 (14.0) Marital status Married 65 (65.0) Single 35 (35.0) ABO blood type A 16 (16.0) AB 4 (4.0) B 20 (20.0) O 60 (60.0) Number of previous pregnancies 0 24 (24.0) 1–2 40 (40.0) 3–4 26 (26.0) 5 or more 10 (10.0) Number of children 0 43 (43.0) 1 20 (20.0) 2 18 (18.0) ≥ 3 19 (19.0) The haemato-biochemical and obstetric details of participants were explored in Table 2 . Although, only 3% of the participants self-reported not using iodated salt, 48.0%, 54.0% and 51.0% of participants in trimesters 1, 2 and 3 respectively had insufficient iodine levels (< 150 µg/L) as estimated by median urinary iodine concentration. Respectively, only 2.0%, 1.0%, and 1.0% of the participants had median urinary iodine concentrations above the requirement in trimesters 1, 2, and 3. Although the mean haemoglobin levels (did not significantly differ per trimester, there was a slight drop in trimester 2 [T1 (11.11 g/dL ± 1.5780) vs T2 (10.99g/dL ± 1.2133) vs T3 (11.23 g/dL ± 1.1383)]. Furthermore, 44.0%, 32.0% and 41.0% of participants were classified as anaemic per trimester-specific reference ranges in trimesters 1, 2, and 3 respectively. Moreover, whereas only 9% of deliveries were through cesarean section, 12.0% of the babies did not have ideal birthweight (6% underweight vs 6.0% macrosomia). Table 2 Haemato-biochemical and obstetric details of study participants Variables Categories N (%) Use of iodized salt No 3 (3.0) Yes 97 (97.0) UIC (µg/L) T1 (median: 151.7; IQR: 123.6, 172.7) Insufficient ( 249) 2 (2.0) T2 (median: 144.8; IQR: 124.3, 173.5) Insufficient ( 249) 1 (1.0) T3 (median: 148.6; IQR: 129.4, 177.4) Insufficient ( 249) 1 (1.0) T1 [Haemoglobin] g/dl (range: 4.1–14.1) Anaemia ( 13.0) 12 (12.0) T2 [Haemoglobin] g/dl (range: 7.6–13.2) Anaemia ( 13.0) 3 (3.0) T3 [Haemoglobin] g/dl (range: 7.9–13.4) Anaemia ( 13.0) 9 (9.0) Mode of delivery CS 9 (9.0) Vaginal 91 (91.0) Baby weight at delivery Underweight 6 (6.0) Normal 88 (88.0) Macrosomia 6 (6.0) UIC: urinary iodine concentration; IQR: inter-quartile range; T: trimester; CS: cesarian section. Participants' median UIC, gestational weight and age were compared based on anaemia status per respective trimester (Table 3 ). The median UIC (p = 0.1173) and maternal gestational weight (p = 0.4272) did not significantly differ between anaemic and non-anaemic participants in trimester 1. However, the median UIC was significantly lower in anaemic participants during trimesters 2 (p = 0.0327) and 3 (p = 0.0325) when compared to non-anaemic participants. Furthermore, the median maternal gestational weight was significantly lower in anaemic participants during trimesters 2 (p = 0.0094) and 3 (p = 0.0388) when compared to non-anaemic participants. Moreover, a higher proportion of participants within the teenage category were anaemic in all the trimesters when compared to those in their twenties or thirties. Whereas more than half of teenage participants were anaemic in each trimester, less than half of participants in the 20–29 or 30–39-year-old group were anaemic in any trimester. Table 3 Stratification of participants' UIC and gestational weight per anaemia status Variable Anaemia p-value Yes No Urinary iodine concentration (µg/L) T1 UIC 141.40 158.70 0.1173 T2 UIC 135.10 155.30 0.0327 T3 UIC 139.20 156.80 0.0325 Maternal Gestational weight (Kg) T1 55.35 58.20 0.4272 T2 55.50 63.25 0.0094 T3 60.00 68.20 0.0388 Age (years); n (%) Trimester 1 16–19 9 (64.3) 5 (35.7) 0.2311* 20–29 23 (42.6) 31 (57.4) 30–39 12 (37.5) 20 (62.5) Trimester 2 16–19 8 (57.1) 6 (42.9) 0.0939* 20–29 15 (27.8) 39 (72.2) 30–39 9 (28.1) 23 (71.9) Trimester 3 16–19 9 (64.3) 5 (35.7) 0.1612* 20–29 20 (37.0) 34 (63.0) 30–39 12 (37.5) 20 (62.5) All statistical significance determined via comparison of median using Mann-Whitney test; *indicates that statistical significance was determined by Chi-square test. The data was further explored for relationships between variables through correlation coefficient analyses (Table 4 ). The age of participants was inversely weakly related to T1 UIC (-0.062, p > 0.05), T3 UIC (-0.088, p > 0.05), and T1 haemoglobin (-0.011, p > 0.05). Although the age of participants was positively related to T2 UIC, T2 haemoglobin, T3 haemoglobin, and baby weight, this positive association only reached statistical significance with placental weight (0.234, p < 0.01). The T1 UIC was statistically significantly positively related to T2 UIC (0.820, p < 0.01), T3 UIC (0.698, p < 0.01), T3 haemoglobin (0.308, p < 0.01) and placental weight (0.218, p < 0.05). Also, T2 UIC was statistically positively related to T3 UIC (0.742, P < 0.01), T3 haemoglobin (0,285, p < 0.01), placental weight (0.260, p < 0.01), and bay weight (0.234, p < 0.05). Furthermore, the T3 haemoglobin was statistically significantly positively related to T3 UIC (0.249, P < 0.05), T1 haemoglobin (0.587, p < 0.01), T2 haemoglobin (0.742, p < 0.01), placental weight (0.283, p < 0.01), and baby weight (0.313, p < 0.01). Table 4 Relationships between participants’ variables Age (years) T1 UIC T2 UIC T3 UIC T1 HB T2 HB T3 HB Placental weight Baby weight Age (years) R 1 p T1 UIC R -0.062 1 p 0.543 T2 UIC R 0.076 0.820 ** 1 p 0.454 0.000 T3 UIC R -0.088 0.689 ** 0.742 ** 1 p 0.385 0.000 0.000 T1 HB R -0.011 0.159 0.071 0.124 1 p 0.913 0.113 0.485 0.219 T2 HB R 0.042 0.183 0.157 0.150 0.720 ** 1 p 0.678 0.068 0.119 0.136 0.000 T3 HB R 0.129 0.308 ** 0.285 ** 0.249 * 0.587 ** 0.742 ** 1 p 0.202 0.002 0.004 0.013 0.000 0.000 Placental weight R 0.234 * 0.218 * 0.260 ** 0.120 0.025 0.108 0.283 ** 1 p 0.019 0.029 0.009 0.233 0.808 0.283 0.004 Baby weight R 0.175 0.181 0.234 * 0.114 0.032 0.143 0.313 ** 0.667 ** 1 p 0.081 0.072 0.019 0.260 0.751 0.157 0.001 0.000 Correlation coefficients were established using Spearman correlation coefficients; *Correlation is significant at the 0.05 level (2-tailed); **Correlation is significant at the 0.01 level (2-tailed). Given the significant positive correlations between T3 haemoglobin estimates and participant variables, the data was further analysed to determine variables that could be associated with anaemia in trimester 3 (Table 5 ). Compared to vaginal delivery, Third-trimester anaemia was associated with 41-fold increased odds of delivery through the cesarian section (aOR: 41.070, p = 0.011). Also, married women had a 2-fold increase in being anaemic compared to single participants (aOR: 2.150, p = 0.375). Furthermore, those with non-formal education (aOR: 11.477, p = 0.076), basic education (aOR: 3.559, p = 0.286), or secondary education (aOR: 9.562, p 0.044) had increased odds of developing anaemia in trimester 3. However, in terms of age, participants aged 16–19 years (aOR: 0.224, p = 0.400) or 20–29 years (aOR: 0.647, p = 0.737) had a reduced chance of anaemia in trimester 3. Table 5 Logistic regression analyses for factors associated with third trimester anaemia B S.E. Wald Sig. aOR 95% C.I. Mode of delivery CS 3.715 1.469 6.396 0.011 41.070 2.307 -731.132 Vaginal Referent Placental weight -8.591 7.137 1.449 0.229 0.000 0.000–220.931 Marital status Married 0.765 0.862 0.788 0.375 2.150 0.397–11.641 Single Referent Age (years) 16–19 -1.495 2.362 0.400 0.527 0.224 0.002–22.994 20–29 -0.436 1.297 0.113 0.737 0.647 0.051–8.222 30–39 Referent Educational attainment Non-formal 2.440 1.376 3.144 0.076 11.477 0.773–170.333 Basic 1.270 1.191 1.137 0.286 3.559 0.345–36.727 Secondary 2.258 1.122 4.047 0.044 9.562 1.060–86.261 Vocational/Tertiary Referent Age (years) 0.000 0.134 0.000 0.997 1.000 0.769–1.301 T1 UIC -0.012 0.010 1.306 0.253 0.988 0.968–1.009 T1 WBC -0.477 0.324 2.172 0.141 0.620 0.329–1.171 T2 WBC -0.056 0.426 0.017 0.896 0.946 0.411–2.179 T3 WBC 0.323 0.346 0.873 0.350 1.381 0.702–2.719 Baby weight -4.781 1.204 15.775 0.000 0.008 0.001–0.089 aOR: adjusted odds ratio; T1 UIC: Urinary iodine concentration at trimester 1; T1 WBC: total white blood count at trimester 1; T2 WBC: total white blood count at trimester 2; T3 WBC: total white blood count at trimester 3; “B is the estimated coefficient/unstandardized regression weight of the regression model; Wald is the test statistic for the individual predictor variable derived from (B/ S.E.) 2 .” Discussion Adequate maternal hemoglobin and iodine levels are essential for favorable pregnancy outcomes. Hemoglobin ensures oxygen and nutrient supply to the developing fetus, while iodine is crucial for fetal brain development. This longitudinal study examined maternal hemoglobin and urinary iodine levels per trimester in pregnant women in rural settings. Our study found fluctuating anemia prevalence (44.0%, 32.0%, and 41.0% respectively in trimesters 1, 2, and 3) and a consistent iodine insufficiency rate of approximately 50% across trimesters. Moreover, delivery through caesarian section (aOR: 41.07; p = 0.011), women who were married (aOR: 2.150; p = 0.375), had non-formal education (aOR: 11.477; p = 0.076), or basic education (aOR: 3.559; p = 0.286), or secondary education (aOR: 9.562; p = 0.044) were associated with increased odds of anemia in third trimester. When taken together, the high prevalence of anemia and iodine insufficiency indicates an urgent need for multifaceted interventions to improve intra-pregnancy nutrition in the study population. While the World Health Organization recommends a cesarean section rate of 10–15% [ 23 ], recent evidence suggests a global increase in cesarean deliveries [ 23 , 24 ]. Our study's cesarean section rate of 9.0% aligns with the WHO recommendation, potentially reflecting a conservative approach. A previous study at the Korle-Bu Teaching Hospital (KBTH) [ 25 ] in Ghana reported a higher cesarean section rate of 40.1% at a tertiary healthcare facility. Among other things, the sample size in the KBTH study was comparatively larger (20270 participants vs 100 participants in the present study) and might be a factor in the disparate findings. Notably, this disparity may be attributed to the referral nature of the tertiary facility, which often receives women with pregnancy complications. Our study, conducted in a primary healthcare facility, likely referred women with pregnancy complications to higher levels of care, potentially underestimating the true cesarean section rate. The Robson classification system [ 25 , 26 ] provides a structured approach for monitoring cesarean section rates [ 26 , 27 ], considering factors such as pregnancy category, obstetric history, labor course, and gestational age. Our logistic regression analysis supports the association between third-trimester maternal anemia and increased risk of cesarean section delivery. Consistent with our findings, previous studies have linked anemia in pregnancy with increased odds of cesarean section [ 28 – 30 ], further highlighting the adverse consequences of intra-pregnancy anemia. The universal salt iodization program is a cost-effective strategy for improving iodine levels in populations. Iodine deficiency can lead to cretinism, impaired cognitive function, and irreversible mental retardation due to its critical role in fetal brain development [ 31 , 32 ]. In our study, despite 97.0% of participants reporting iodized salt use, insufficient iodine levels were observed in 48.0%, 54.0%, and 51.0% of participants in trimesters 1, 2, and 3, respectively. This suggests that iodine intake may not be meeting increased pregnancy demands, potentially due to higher thyroid hormone production and renal clearance [ 33 , 34 ]. While our study did not directly measure iodine concentrations in iodized salt, the high self-reported usage and insufficient iodine levels suggest potential issues in the salt supply chain, cooking methods, or additives [ 35 , 36 ]. Per the design adopted for this study, it is difficult to determine the reason(s) why the self-reported high usage of iodized salt did not translate into the lower proportion of participants with insufficient iodine levels. Previous research has theorized that exposure of iodized salt to sunlight during transportation and the addition of certain additives during cooking can affect iodine levels [ 37 , 38 ]. We propose the need for research to interrogate the entire supply chain of iodized salt (from production points to consumer homes) to identify potential actionable points and explore the potential impact of cooking methods and/or additives on iodine intake. A previous experimental study that subjected iodated salts to various cooking temperatures found that the residual iodine contents in the salts depended on the type of food and the water content of the food to which the iodated salt was added [ 39 ]. Additionally, a previous study in Brazil found increased odds of insufficient iodine levels in pregnant women who used industrialized seasoning during cooking [ 40 ]. Interestingly, participants with anemia consistently had lower urinary iodine levels in all trimesters, reaching statistical significance in trimesters 2 and 3. Notably, the urinary iodine levels in anemic participants were insufficient (< 150 µg/L) compared to participants with normal hemoglobin levels who had sufficient median urinary iodine levels (≥ 150 µg/L) in all trimesters. While the study design does not allow for establishing a direct causal association, the positive correlation between urinary iodine concentrations and hemoglobin levels suggests the need for further research to investigate a potential link between iodine deficiency and anemia during pregnancy. Previous studies have demonstrated a synergistic relationship between iodine and iron, suggesting that co-administration can improve iron absorption and bioavailability [ 40 , 41 ]. This highlights the potential importance of both micronutrients for blood cell formation. In our pregnant women cohort, anemia was a moderate public health problem in trimester 2 but a severe problem in trimesters 1 and 3. Teenage pregnant participants were disproportionately affected by anemia in all trimesters in agreement with a previous study [ 41 ]. Additionally, anemic participants had lower median maternal weight than non-anemic participants in all trimesters, reaching statistical significance in trimesters 2 and 3. Considering the positive correlation between maternal hemoglobin concentrations and placental and baby weight, this finding is not surprising. Our analysis further revealed that anemia in trimester 3 was associated with higher odds of cesarean section delivery [ 30 ]. Cesarean section can lead to blood loss, potentially exacerbating anemia in mothers and negatively impacting both mother and child during the lactation period [ 42 , 43 ]. Participants who were married and had lower educational attainment (non-formal, basic, or secondary) were more likely to be anemic in trimester 3. The data also showed a strong positive correlation between hemoglobin levels in trimesters 1, 2, and 3, suggesting that preconception hemoglobin levels may influence pregnancy outcomes [ 44 ]. While our data shed light on the association between intra-pregnancy UIC, and trimester-specific anemia and how these may associate with pregnancy outcomes, our study design is such that we could not establish causality. Moreover, iron supplementation is a government of Ghana policy in which all pregnant women are given iron supplementation as part of the routine antenatal care at no cost to the pregnant women. However, research has found low compliance with iron supplementation among pregnant women across SSA for various reasons despite government policies [ 45 ]. Thus, we are not able to estimate how much this important national policy impacted the anemia prevalence reported in the present study. Furthermore, while our study sheds light on the relationship between iodine levels, anemia, and pregnancy outcomes, it has limitations. The sample size and single-district design may limit the generalizability of the findings. For example, while the anemia prevalence was disproportionately high among teenagers, the small sample size of teenagers (14) did not allow us to undertake exhaustive exploration. Future work targeting only teenage pregnant women will shed light on the dynamics of iodine sufficiency vis-a-viz anemia prevalence among this uniquely vulnerable group. Additionally, the study design only allowed for correlation analysis, but not causal inferences. Future longitudinal studies, including animal models, could provide mechanistic insights into the interactions between iodine levels, anemia status, and pregnancy outcomes. Conclusion The significant associations between insufficient iodine levels and anemia status in our pregnant women cohort require empirical research to determine if a causal relationship exists. Abbreviations UIC: urinary iodine concentration CS: caesarian section WBC: white blood cells T: trimester Hb: hemoglobin. Declarations Ethical consideration Ethical clearance was obtained from the Institution Review Board of the University of Cape Coast (UCCIRB/CHAS/2019/206). Permission was also sought from all Health Facility heads and midwives in charge of the respective antenatal clinics before the study commenced. Before recruitment to the study, each participant gave written informed consent after the protocols for the study had been explained to them. Availability of data and materials The data supporting the conclusions of this study are presented in the main manuscript. Any additional data can be obtained by contacting the corresponding author. Competing interests Authors have no competing interest to declare Funding This research did not receive any funding from any public or private organization; it was entirely self-funded by the researchers. Author contributions Patrick Adu: Conceptualization; Methodology; Project administration; Supervision; Formal analysis; Writing – original draft; Writing – review & editing. Olivia Mawunyo Timpo : Conceptualization; Data curation; Supervision; Methodology; Validation; Writing – review & editing. David Larbi Simpong: Conceptualization; Data curation; Formal analysis; Supervision; Validation; Investigation; Writing – review & editing. Joseph Boachie: Data curation; Formal analysis; Investigation; Methodology; Writing – review & editing. Charles Ekow Spike Cartey: Data curation; Formal analysis; Investigation; Writing – review & editing. Consent for publication All participants provided consent to publish their anonymous data collected during the study. 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Neuroscience. 2017;342:68–100. Chen ZP, Hetzel BS. Cretinism revisited. Best Pract Res Clin Endocrinol Metab. 2010;24(1):39–50. Epub 2010/02/23. doi: 10.1016/j.beem.2009.08.014 . PubMed PMID: 20172469. Zhou SJ, Anderson AJ, Gibson RA, Makrides M. Effect of iodine supplementation in pregnancy on child development and other clinical outcomes: a systematic review of randomized controlled trials. The American journal of clinical nutrition. 2013;98(5):1241–54. Stagnaro-Green A, Abalovich M, Alexander E, Azizi F, Mestman J, Negro R, et al. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid. 2011;21(10):1081–125. Pearce EN, Lazarus JH, Moreno-Reyes R, Zimmermann MB. Consequences of iodine deficiency and excess in pregnant women: an overview of current knowns and unknowns1,2. The American Journal of Clinical Nutrition. 2016;104:918S-23S. doi: https://doi.org/10.3945/ajcn.115.110429 . Adu P, Sarpong DL. Addressing the challenge of iodine deficiency in developing countries. 2017. Simpong NL, Afefa CT, Yimpuri L, Akum B, Safo A, Edziah S-J, et al. Establishing pregnancy-specific haematological reference intervals in Ghana; a three-center cross-sectional study. PLOS ONE. 2023;18(2):e0274422. doi: 10.1371/journal.pone.0274422 . Mare KU, Aychiluhm SB, Sabo KG, Tadesse AW, Kase BF, Ebrahim OA, et al. Determinants of anemia level among reproductive-age women in 29 Sub-Saharan African countries: A multilevel mixed-effects modelling with ordered logistic regression analysis. PLOS ONE. 2023;18(11):e0294992. doi: 10.1371/journal.pone.0294992 . Businge CB, Longo-Mbenza B, Kengne AP. Iodine nutrition status in Africa: potentially high prevalence of iodine deficiency in pregnancy even in countries classified as iodine sufficient. Public Health Nutr. 2021;24(12):3581–6. Epub 2020/08/04. doi: 10.1017/s1368980020002384 . PubMed PMID: 32744219; PubMed Central PMCID: PMCPMC8369456. 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Epub 20220131. doi: 10.1136/bmjopen-2021-054397 . PubMed PMID: 35105635; PubMed Central PMCID: PMCPMC8804632. Dunn JT, Crutchfield HE, Gutekunst R, Dunn AD. Two simple methods for measuring iodine in urine. Thyroid. 1993;3(2):119–23. Epub 1993/01/01. doi: 10.1089/thy.1993.3 .119. PubMed PMID: 8369650. Davis BH, Jungerius B, International Council for the Standardization of H. International Council for Standardization in Haematology technical report 1-2009: new reference material for haemiglobincyanide for use in standardization of blood haemoglobin measurements. Int J Lab Hematol. 2010;32(2):139 – 41. doi: 10.1111/j.1751-553X.2009.01196.x . PubMed PMID: 19863683. Verbrugge SE, Huisman A. Verification and standardization of blood cell counters for routine clinical laboratory tests. Clin Lab Med. 2015;35(1):183–96. doi: 10.1016/j.cll.2014.10.008 . PubMed PMID: 25676379. Cheesbrough M. District Laboratory Practice in tropical countries 2. Second ed. Cambridge: Cambridge University Press; 2006. WHO. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization. Accessed January 21, 2022 2016. Betran AP, Torloni MR, Zhang JJ, Gulmezoglu AM, Section WHOWGoC. WHO Statement on Caesarean Section Rates. BJOG. 2016;123(5):667–70. Epub 2015/12/19. doi: 10.1111/1471-0528.13526 . PubMed PMID: 26681211; PubMed Central PMCID: PMCPMC5034743. Vogel JP, Betrán AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, et al. Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys. Lancet Glob Health. 2015;3(5):e260-70. Epub 2015/04/14. doi: 10.1016/s2214-109x(15)70094-x . PubMed PMID: 25866355. Samba A, Mumuni K. A review of caesarean sections using the ten-group classification system (Robson classification) in the Korle-Bu Teaching Hospital (KBTH), Accra, Ghana. Gynecol Obstet (Sunnyvale). 2016;6(385):2161-0932.1000385. Robson MS, Scudamore IW, Walsh SM. Using the medical audit cycle to reduce cesarean section rates. Am J Obstet Gynecol. 1996;174(1 Pt 1):199–205. Epub 1996/01/01. doi: 10.1016/s0002-9378(96)70394-0 . PubMed PMID: 8572006. Robson MS. Can we reduce the caesarean section rate? Best Practice & Research Clinical Obstetrics & Gynaecology. 2001;15(1):179 – 94. doi: https://doi.org/10.1053/beog.2000.0156 . Drukker L, Hants Y, Farkash R, Ruchlemer R, Samueloff A, Grisaru-Granovsky S. Iron deficiency anemia at admission for labor and delivery is associated with an increased risk for Cesarean section and adverse maternal and neonatal outcomes. Transfusion. 2015;55(12):2799–806. Patel A, Prakash AA, Das PK, Gupta S, Pusdekar YV, Hibberd PL. Maternal anemia and underweight as determinants of pregnancy outcomes: cohort study in eastern rural Maharashtra, India. BMJ open. 2018;8(8):e021623. Adam I, Salih Y, Hamdan HZ. Association of Maternal Anemia and Cesarean Delivery: A Systematic Review and Meta-Analysis. J Clin Med. 2023;12(2). Epub 2023/01/22. doi: 10.3390/jcm12020490 . PubMed PMID: 36675421; PubMed Central PMCID: PMCPMC9867340. Kapil U. Health consequences of iodine deficiency. Sultan Qaboos Univ Med J. 2007;7(3):267–72. Epub 2007/12/01. PubMed PMID: 21748117; PubMed Central PMCID: PMCPMC3074887. Zimmermann MB. The Effects of Iodine Deficiency in Pregnancy and Infancy. Paediatric and Perinatal Epidemiology. 2012;26(s1):108–17. doi: https://doi.org/10.1111/j.1365-3016.2012.01275.x . Simpong DL, Adu P, Bashiru R, Morna MT, Yeboah FA, Akakpo K, et al. Assessment of iodine status among pregnant women in a rural community in ghana - a cross sectional study. Archives of Public Health. 2016;74(1):8. doi: 10.1186/s13690-016-0119-y . Simpong DL, Awuku YA, Kye-Amoah KK, Morna MT, Adoba P, Anin SK, et al. High Iodine Deficiency among Pregnant Women in Periurban Ghana: A Hospital-Based Longitudinal Study. J Nutr Metab. 2018;2018:9706805. Epub 2018/07/04. doi: 10.1155/2018/9706805 . PubMed PMID: 29967696; PubMed Central PMCID: PMCPMC6008623. Cheatham Carol L. Nutritional Factors in Fetal and Infant Brain Development. Annals of Nutrition and Metabolism. 2020;75(Suppl. 1):20–32. doi: 10.1159/000508052 . Candido AC, Azevedo FM, Machamba AAL, Pinto CA, Lopes SO, de Souza Macedo M, et al. Implications of iodine deficiency by gestational trimester: a systematic review. Arch Endocrinol Metab. 2021;64(5):507–13. Epub 2021/05/26. doi: 10.20945/2359-3997000000289 . PubMed PMID: 34033289; PubMed Central PMCID: PMCPMC10118970. Agbozo F, Der JB, Glover NJ, Ellahi B. Household and market survey on availability of adequately iodized salt in the Volta region, Ghana. International Journal of Health Promotion and Education. 2017;55(3):110–22. doi: 10.1080/14635240.2016.1250658 . Appiah PK, Fenu GA, Yankey FW-M. Iodine Content of Salt in Retail Shops and Retailers’ Knowledge on Iodized Salt in Wa East District, Upper West Region, Ghana. Journal of Food Quality. 2020;2020(1):6053863. doi: https://doi.org/10.1155/2020/6053863 . Wang GY, Zhou RH, Wang Z, Shi L, Sun M. Effects of storage and cooking on the iodine content in iodized salt and study on monitoring iodine content in iodized salt. Biomed Environ Sci. 1999;12(1):1–9. Epub 1999/08/12. PubMed PMID: 10442215. Momentti AC, de Souza Macedo M, de Sousa Silva AF, de Oliveira Souza VC, Júnior FB, do Carmo Castro Franceschini S, et al. Household Salt Storage and Seasoning Consumption Are Predictors of Insufficient Iodine Status Among Pregnant Women in Southeastern Brazil. Biological Trace Element Research. 2023;201(12):5529-39. doi: 10.1007/s12011-023-03615-1 . Annan RA, Gyimah LA, Apprey C, Edusei AK, Asamoah-Boakye O, Aduku LNE, et al. Factors associated with iron deficiency anaemia among pregnant teenagers in Ashanti Region, Ghana: A hospital-based prospective cohort study. PLoS One. 2021;16(4):e0250246. Epub 2021/04/28. doi: 10.1371/journal.pone.0250246 . PubMed PMID: 33905433; PubMed Central PMCID: PMCPMC8078754 publication of this study. Sivahikyako SA, Owaraganise A, Tibaijuka L, Agaba DC, Kayondo M, Ngonzi J, et al. Prevalence and factors associated with severe anaemia post-caesarean section at a tertiary Hospital in Southwestern Uganda. BMC Pregnancy and Childbirth. 2021;21(1):674. doi: 10.1186/s12884-021-04157-x . Butwick AJ, Walsh EM, Kuzniewicz M, Li SX, Escobar GJ. Patterns and predictors of severe postpartum anemia after C esarean section. Transfusion. 2017;57(1):36–44. Díaz-López A, Ribot B, Basora J, Arija V. High and low haemoglobin levels in early pregnancy are associated to a higher risk of miscarriage: a population-based cohort study. Nutrients. 2021;13(5):1578. Mare KU, Aychiluhm SB, Mulaw GF, Sabo KG, Ebrahim OA, Tebeje TM, et al. Non-adherence to antenatal iron supplementation and its determinants among pregnant women in 35 sub-saharan African countries: a generalized linear mixed-effects modeling with robust Poisson regression analysis. BMC Pregnancy Childbirth. 2024;24(1):872. Epub 20241228. doi: 10.1186/s12884-024-07105-7 . PubMed PMID: 39732634; PubMed Central PMCID: PMCPMC11681747. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 Apr, 2025 Reviews received at journal 05 Apr, 2025 Reviewers agreed at journal 03 Apr, 2025 Reviewers invited by journal 03 Apr, 2025 Submission checks completed at journal 02 Apr, 2025 First submitted to journal 23 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5675773","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":438008453,"identity":"754e148d-ca3c-4bbf-948e-ce05541d5e44","order_by":0,"name":"David Larbi Simpong","email":"","orcid":"","institution":"University of Cape Coast","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"Larbi","lastName":"Simpong","suffix":""},{"id":438008455,"identity":"980d470f-3d0b-4613-9534-73ffe12d2950","order_by":1,"name":"Charles Ekow Spike Cartey","email":"","orcid":"","institution":"University of Cape Coast","correspondingAuthor":false,"prefix":"","firstName":"Charles","middleName":"Ekow Spike","lastName":"Cartey","suffix":""},{"id":438008456,"identity":"76bba269-1614-4ca4-8451-4d551266b988","order_by":2,"name":"Olivia Mawunyo Timpo","email":"","orcid":"","institution":"Ghana Health Service","correspondingAuthor":false,"prefix":"","firstName":"Olivia","middleName":"Mawunyo","lastName":"Timpo","suffix":""},{"id":438008457,"identity":"b73c9c66-c160-4fc0-a54b-1faefe667987","order_by":3,"name":"Joseph Boachie","email":"","orcid":"","institution":"University of Cape Coast","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Boachie","suffix":""},{"id":438008458,"identity":"694f25d2-66d3-4235-968d-d58b542fe3cc","order_by":4,"name":"Patrick Adu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYBAC+wYgkQCEQJLxAUQMyGFswK3F4AAzXAuzAfFaGCBa2CSI03L8/LEPD2rSGPjbc8yqeWrsGPjZcwwYv+7A45eeZOYZCcdyGCTOvDG7zXMsmUGy540Bs+wZPLYwJDMzJDZUMDDcyDG7zdtwgMHgRo4Bs2QbHi38jyFa5IFaikFa7AlqkQDbkgMy3IwZbIsE0C8f8Wp5bMyQcCyNx/DMs2LJOceSeSTOPCs4zIjXYYmPGX/UJMvJHU/e+OFNjZ0cf3vyxoc/8WiBAR4UxmEe3CpxAMYfJGsZBaNgFIyCYQwAyUZNzjapDSAAAAAASUVORK5CYII=","orcid":"","institution":"University of Cape Coast","correspondingAuthor":true,"prefix":"","firstName":"Patrick","middleName":"","lastName":"Adu","suffix":""}],"badges":[],"createdAt":"2024-12-19 10:08:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5675773/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5675773/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80042394,"identity":"9202b3b8-cc97-4690-82e9-c0c42de54088","added_by":"auto","created_at":"2025-04-07 09:23:53","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":90294,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchematic of data collection procedures. \u003c/strong\u003e[T: trimester].\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5675773/v1/a022089a4f7484684c7482ee.jpeg"},{"id":80042852,"identity":"73caf274-3c56-4497-a2e4-96318e2976cd","added_by":"auto","created_at":"2025-04-07 09:31:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1443691,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5675773/v1/73cfb976-c495-44aa-98e8-f6fb6ca1569c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anaemia status is associated with insufficient iodine levels in pregnant women in rural settings; a two-centre observational study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdequate macro- and micronutrient intake is crucial for optimal fetal-maternal outcomes during pregnancy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Micronutrients, particularly those involved in hematological processes, significantly impact the expectant mother's health. Sufficient hemoglobin levels are essential for improved nutrient supply, fetal oxygenation, and favorable birth outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Conversely, anemia, characterized by low hemoglobin levels, is associated with adverse outcomes, including low birth weight, miscarriage, and maternal mortality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIodine is another micronutrient vital for neuronal development. Insufficient iodine intake, especially during the early first trimester, can impair thyroid hormone production [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], affecting fetal brain development and increasing the risk of cretinism [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The median urinary iodine concentration (UIC) is a reliable indicator of iodine status. The World Health Organization recommends classifying iodine status based on UIC levels: \u0026lt;100 \u0026micro;g/L (moderate-to-severe deficiency), 100\u0026ndash;149 \u0026micro;g/L (mild deficiency), 150\u0026ndash;249 \u0026micro;g/L (sufficiency), and \u0026gt;\u0026thinsp;250 \u0026micro;g/L (excess) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, both iodine deficiency and excess can have adverse pregnancy outcomes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnemia [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and iodine deficiency [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] are significant public health challenges among reproductive-aged women in sub-Saharan Africa (SSA). Previous studies have demonstrated associations between maternal hemoglobin levels and fetal birth weight [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, research exploring the co-existence of iodine deficiency and anemia among pregnant women in SSA is limited, despite the high prevalence of each of these conditions in SSA. This prospective study investigated the dynamics of iodine and anemia trajectories per trimester in a cohort of pregnant women in two rural settings. Although there are general challenges to accessing healthcare in SSA, the rural settings are particularly disproportionately impacted by significantly limited access [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Thus, the aim was to generate rural settings-centric baseline data on the association of intra-pregnancy anaemia and iodine insufficiency that could potentially stimulate future mechanistic studies on plausible causal relationships between these two endemic public health challenges within the SSA context.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design/site\u003c/h2\u003e \u003cp\u003eThis study was undertaken at the Aiyinasi and Esiama health centres in the Ellembele district in Western Region, Ghana. The Ellembele district is subdivided into Aiyinasi, Esiama, Eikwe, Nkroful and New Aiyinasi sub-districts. It is located in the southern part of the Western Region between longitudes 2\u003csup\u003eo\u003c/sup\u003e05 and 2\u003csup\u003eo\u003c/sup\u003e35 west and latitudes 4\u003csup\u003eo\u003c/sup\u003e40 and 5\u003csup\u003eo\u003c/sup\u003e20 north and is bound in the south by the Gulf of Guinea, north by Prestea Huni Valley, Wassa Amenfi East district and north of Nzema East Municipality. From the East, it shares a boundary with the South of Nzema East Municipality and West of Jomoro District. The 2010 population census of Ghana put the population of the district at 87, 501 with a percentage sex distribution of 48.4% for males and 51.6% for females. The 2015 population for the district is 96,623 projected from the 2010 census figures given an annual growth rate of 2%.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy period\u003c/h3\u003e\n\u003cp\u003eThe study was undertaken between February 2019 to August 2021.\u003c/p\u003e\n\u003ch3\u003eSampling technique\u003c/h3\u003e\n\u003cp\u003eGiven the number of antenatal care attendance at the two health centres, the study employed a convenience sampling technique to consecutively recruit all consenting pregnant women who visited any of the facilities during the period of the study. Although 137 pregnant women were recruited within their first antenatal care visit, complete data was obtained from only 100 individuals (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for a detailed sampling strategy). Definition of gestational ages employed for this study were: trimester 1 (1\u0026ndash;13 weeks); trimester 2 (14\u0026ndash;27 weeks); trimester 3 (28\u0026ndash;41 weeks).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eAll pregnant women within the first trimester who visited any of the two health centres were approached for potential recruitment into the study; only those who gave verbal informed consent were recruited for the study. All pregnant women who reported for their first antenatal clinic in the second or third trimester were excluded from the study. Although the two centres where the study was undertaken refers women for ultrasound in non-government facilities to determine gestational age, not all the women were able to go for the ultrasound procedure given the cost implications. Therefore, for consistency and data accuracy, only women with ultrasound-confirmed gestational age were included in the study. However, any pregnant woman with clinically diagnosed thyroid and/or renal dysfunctions were excluded.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eA questionnaire was administered to collect the socio-demographic characteristics of participants. To ensure that English language literacy was not a barrier to participation, given the rural settings of the study, the researchers assisted participants in completing the questionnaire. Filling of the questionnaire was Weight, urine iodine concentration, haemoglobin levels, blood pressure and duration in weeks of pregnancy were also measured and/or recorded as applicable.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLaboratory methods\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eUrinary iodine concentration (UIC) estimation\u003c/h2\u003e \u003cp\u003eThe participants were supplied with sterile universal container and were instructed on the correct technique for collecting the urine sample into the container. About 5\u0026ndash;10 milliliters (mL) urine sample was collected. Iodine concentrations were determined immediately after each urine sample was received in the laboratory. Urinary iodine concentration (UIC) was measured using the ammonium persulfate digestion based on the Sandell-Kolthoff reaction method [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. For each participant, UIC was estimated three times from the urine provided; the median was then calculated and presented as the median UIC in the results section.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eHaemoglobin estimation\u003c/h3\u003e\n\u003cp\u003eEstimation of haemoglobin (Hb) concentration was done using the Cyanmethaemoglobin method. Using a well-mixed sample of EDTA blood specimen, 20\u0026micro;L of blood was transferred into 5ml of Drabkin\u0026rsquo;s reagent. The solution was allowed to stand for 5 minutes and was transferred into a cuvette to be measured photometrically using a UV-6300PC Spectrophotometer (VWR Int., China) at an absorbance of 540nm. The absorbance read was converted into its equivalent concentration from an absorbance\u0026ndash;concentration chart drawn using a hemiglobincyanide standard [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The value obtained was recorded for each participant.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTotal WBC estimation\u003c/h2\u003e \u003cp\u003eThe total white blood cell (WBC) count was performed using 2% acetic acid tinged with methylene blue. A 1-in-20 dilution of participants\u0026rsquo; blood was undertaken by adding 20\u0026micro;Ll of well-mixed EDTA blood sample to 380\u0026micro;L of acetic diluting fluid and allowed to stand for 5 minutes lyse all erythrocytes. A New improved Neubauer counting chamber was charged with the diluted sample. The chamber was allowed to stand for 5 minutes for the white cells to settle. Using a 10x objective lens with reduced light intensity, the white cells in the large four corner squares of the chamber were counted. The WBC counted was calculated per previous protocols [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and the values obtained were recorded for each participant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBlood Grouping\u003c/h2\u003e \u003cp\u003eParticipants\u0026rsquo; ABO blood group was determined using a slide haemagglutination reaction method. The blood grouping was undertaken using monoclonal anti-A, and anti-B (Lab-Care Diagnostic, India) following manufacturer\u0026rsquo;s protocol.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eWeight measure\u003c/h2\u003e \u003cp\u003eThe weights of the children were measured and recorded using Crown Electronic scale (CR \u0026ndash; 2032; Qingdao, China); the weight of each pregnant woman was measured using Terraillon scale T74 (France). Birth weight\u0026thinsp;\u0026lt;\u0026thinsp;2.5 kg and \u0026gt;\u0026thinsp;4.0kg were classified as underweight and macrosomia respectively. Placental weight (together with the membranes and the cord) was estimated using a tabletop beam weighing scale.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStatistical handling/analysis\u003c/h2\u003e \u003cp\u003eThe data was entered in Microsoft Office Excel 2016 and was analyzed with SPSS Software (IBM Inc., USA). Overall, the 37 participants with incomplete data were excluded from the data analyses (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Descriptive analyses were performed on demographics and categorical variables and were presented in percentages. The maternal median urinary iodine concentration (UIC) was classified as follows: median UIC\u0026thinsp;\u0026lt;\u0026thinsp;150 \u0026micro;g/L (iodine insufficiency), 150\u0026ndash;249 \u0026micro;g/L (iodine sufficiency), and \u0026gt;\u0026thinsp;250 \u0026micro;g/L (more than adequate-to-excessive iodine levels) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Following WHO recommendations, trimester-specific anaemia was defined as per haemoglobin cutoffs of 11.0 g/dL, 10.5 g/dL, and 11.0 g/dL for the first, second and third trimesters respectively [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The differences in the median urine iodine concentration, and maternal gestational weights of participants (both anaemic and non-anaemic) per respective trimesters were compared using the Mann-Whitney test. Spearman correlation coefficient was used to determine the relationship between variables. Logistic regression analysis to determine the factors associated with third-trimester anaemia, the independent variables were participants\u0026rsquo; demographics, birth outcomes (placental weight, baby birth weight, and mode of delivery), total white blood cell count, and median UIC. In all statistical analyses, statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, under the two-tailed assumption.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe baseline characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. More than half of the participants were between 20\u0026ndash;29 years old (54.0%, mean age 26.47\u0026thinsp;\u0026plusmn;\u0026thinsp;5.713 years), in marriage (65.0%), or were blood group O (60.0%). Whereas secondary education was the predominant highest educational attainment (49.0%), 16.0% had no formal education. Furthermore, although 43.0% of participants self-reported not having any child, only 24.0% self-reported not having had any previous pregnancy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), mean age 26.47 (\u0026plusmn;\u0026thinsp;5.713)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (14.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54 (54.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (32.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational attainment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBasic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (21.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49 (49.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocational/tertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (14.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65 (65.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (35.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eABO blood type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of previous pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (24.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (26.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (10.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43 (43.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (18.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (19.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe haemato-biochemical and obstetric details of participants were explored in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Although, only 3% of the participants self-reported not using iodated salt, 48.0%, 54.0% and 51.0% of participants in trimesters 1, 2 and 3 respectively had insufficient iodine levels (\u0026lt;\u0026thinsp;150 \u0026micro;g/L) as estimated by median urinary iodine concentration. Respectively, only 2.0%, 1.0%, and 1.0% of the participants had median urinary iodine concentrations above the requirement in trimesters 1, 2, and 3. Although the mean haemoglobin levels (did not significantly differ per trimester, there was a slight drop in trimester 2 [T1 (11.11 g/dL\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5780) vs T2 (10.99g/dL\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2133) vs T3 (11.23 g/dL\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1383)]. Furthermore, 44.0%, 32.0% and 41.0% of participants were classified as anaemic per trimester-specific reference ranges in trimesters 1, 2, and 3 respectively. Moreover, whereas only 9% of deliveries were through cesarean section, 12.0% of the babies did not have ideal birthweight (6% underweight vs 6.0% macrosomia).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHaemato-biochemical and obstetric details of study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of iodized salt\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 (97.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUIC (\u0026micro;g/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT1\u003c/b\u003e (median: 151.7; IQR: 123.6, 172.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsufficient (\u0026lt;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (48.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdequate (150\u0026ndash;249)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove requirement (\u0026gt;\u0026thinsp;249)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT2\u003c/b\u003e (median: 144.8; IQR: 124.3, 173.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsufficient (\u0026lt;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (54.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdequate (150\u0026ndash;249)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (45.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove requirement (\u0026gt;\u0026thinsp;249)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT3\u003c/b\u003e (median: 148.6; IQR: 129.4, 177.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsufficient (\u0026lt;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (51.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdequate (150\u0026ndash;249)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (48.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove requirement (\u0026gt;\u0026thinsp;249)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT1 [Haemoglobin] g/dl (range: 4.1\u0026ndash;14.1)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnaemia (\u0026lt;\u0026thinsp;11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (44.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (11.0\u0026ndash;13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (44.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh (\u0026gt;\u0026thinsp;13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (12.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT2 [Haemoglobin] g/dl (range: 7.6\u0026ndash;13.2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnaemia (\u0026lt;\u0026thinsp;11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (32.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (11.0\u0026ndash;13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (65.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh (\u0026gt;\u0026thinsp;13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT3 [Haemoglobin] g/dl (range: 7.9\u0026ndash;13.4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnaemia (\u0026lt;\u0026thinsp;11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (41.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (11.0\u0026ndash;13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh (\u0026gt;\u0026thinsp;13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (9.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMode of delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (9.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (91.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaby weight at delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (88.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMacrosomia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUIC: urinary iodine concentration; IQR: inter-quartile range; T: trimester; CS: cesarian section.\u003c/p\u003e \u003cp\u003eParticipants' median UIC, gestational weight and age were compared based on anaemia status per respective trimester (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The median UIC (p\u0026thinsp;=\u0026thinsp;0.1173) and maternal gestational weight (p\u0026thinsp;=\u0026thinsp;0.4272) did not significantly differ between anaemic and non-anaemic participants in trimester 1. However, the median UIC was significantly lower in anaemic participants during trimesters 2 (p\u0026thinsp;=\u0026thinsp;0.0327) and 3 (p\u0026thinsp;=\u0026thinsp;0.0325) when compared to non-anaemic participants. Furthermore, the median maternal gestational weight was significantly lower in anaemic participants during trimesters 2 (p\u0026thinsp;=\u0026thinsp;0.0094) and 3 (p\u0026thinsp;=\u0026thinsp;0.0388) when compared to non-anaemic participants. Moreover, a higher proportion of participants within the teenage category were anaemic in all the trimesters when compared to those in their twenties or thirties. Whereas more than half of teenage participants were anaemic in each trimester, less than half of participants in the 20\u0026ndash;29 or 30\u0026ndash;39-year-old group were anaemic in any trimester.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStratification of participants' UIC and gestational weight per anaemia status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAnaemia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrinary iodine concentration (\u0026micro;g/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1 UIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e141.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e158.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.1173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2 UIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e155.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0327\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3 UIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e139.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e156.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0325\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal Gestational weight (Kg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.4272\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0094\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0388\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years); n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTrimester 1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.2311*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (57.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTrimester 2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0939*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (71.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTrimester 3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.1612*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (37.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (63.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll statistical significance determined via comparison of median using Mann-Whitney test; *indicates that statistical significance was determined by Chi-square test.\u003c/p\u003e \u003cp\u003eThe data was further explored for relationships between variables through correlation coefficient analyses (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The age of participants was inversely weakly related to T1 UIC (-0.062, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), T3 UIC (-0.088, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and T1 haemoglobin (-0.011, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Although the age of participants was positively related to T2 UIC, T2 haemoglobin, T3 haemoglobin, and baby weight, this positive association only reached statistical significance with placental weight (0.234, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The T1 UIC was statistically significantly positively related to T2 UIC (0.820, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), T3 UIC (0.698, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), T3 haemoglobin (0.308, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and placental weight (0.218, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Also, T2 UIC was statistically positively related to T3 UIC (0.742, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), T3 haemoglobin (0,285, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), placental weight (0.260, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and bay weight (0.234, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Furthermore, the T3 haemoglobin was statistically significantly positively related to T3 UIC (0.249, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), T1 haemoglobin (0.587, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), T2 haemoglobin (0.742, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), placental weight (0.283, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and baby weight (0.313, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelationships between participants\u0026rsquo; variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT1 UIC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT2 UIC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT3 UIC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eT1 HB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eT2 HB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eT3 HB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePlacental weight\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eBaby weight\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eT1 UIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e 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colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eT2 HB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.720\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd 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align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eT3 HB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.308\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.285\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e 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\u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.234\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.218\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.260\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.283\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.808\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBaby weight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.234\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.313\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.667\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.751\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCorrelation coefficients were established using Spearman correlation coefficients; *Correlation is significant at the 0.05 level (2-tailed); **Correlation is significant at the 0.01 level (2-tailed).\u003c/p\u003e \u003cp\u003eGiven the significant positive correlations between T3 haemoglobin estimates and participant variables, the data was further analysed to determine variables that could be associated with anaemia in trimester 3 (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Compared to vaginal delivery, Third-trimester anaemia was associated with 41-fold increased odds of delivery through the cesarian section (aOR: 41.070, p\u0026thinsp;=\u0026thinsp;0.011). Also, married women had a 2-fold increase in being anaemic compared to single participants (aOR: 2.150, p\u0026thinsp;=\u0026thinsp;0.375). Furthermore, those with non-formal education (aOR: 11.477, p\u0026thinsp;=\u0026thinsp;0.076), basic education (aOR: 3.559, p\u0026thinsp;=\u0026thinsp;0.286), or secondary education (aOR: 9.562, p 0.044) had increased odds of developing anaemia in trimester 3. However, in terms of age, participants aged 16\u0026ndash;19 years (aOR: 0.224, p\u0026thinsp;=\u0026thinsp;0.400) or 20\u0026ndash;29 years (aOR: 0.647, p\u0026thinsp;=\u0026thinsp;0.737) had a reduced chance of anaemia in trimester 3.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analyses for factors associated with third trimester anaemia\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS.E.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eaOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% C.I.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMode of delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.715\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e41.070\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.307 -731.132\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlacental weight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-8.591\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.449\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.000\u0026ndash;220.931\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.765\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.862\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.788\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.397\u0026ndash;11.641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.495\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.362\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.002\u0026ndash;22.994\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.436\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.297\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.737\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.647\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.051\u0026ndash;8.222\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational attainment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-formal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.440\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.376\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.477\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.773\u0026ndash;170.333\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.270\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.559\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.345\u0026ndash;36.727\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.044\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.060\u0026ndash;86.261\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVocational/Tertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.769\u0026ndash;1.301\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT1 UIC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.988\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.968\u0026ndash;1.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT1 WBC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.477\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.620\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.329\u0026ndash;1.171\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT2 WBC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.426\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.896\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.946\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.411\u0026ndash;2.179\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT3 WBC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.381\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.702\u0026ndash;2.719\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaby weight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-4.781\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.001\u0026ndash;0.089\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eaOR: adjusted odds ratio; T1 UIC: Urinary iodine concentration at trimester 1; T1 WBC: total white blood count at trimester 1; T2 WBC: total white blood count at trimester 2; T3 WBC: total white blood count at trimester 3; \u0026ldquo;B is the estimated coefficient/unstandardized regression weight of the regression model; Wald is the test statistic for the individual predictor variable derived from (B/ S.E.)\u003csup\u003e2\u003c/sup\u003e.\u0026rdquo;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAdequate maternal hemoglobin and iodine levels are essential for favorable pregnancy outcomes. Hemoglobin ensures oxygen and nutrient supply to the developing fetus, while iodine is crucial for fetal brain development. This longitudinal study examined maternal hemoglobin and urinary iodine levels per trimester in pregnant women in rural settings. Our study found fluctuating anemia prevalence (44.0%, 32.0%, and 41.0% respectively in trimesters 1, 2, and 3) and a consistent iodine insufficiency rate of approximately 50% across trimesters. Moreover, delivery through caesarian section (aOR: 41.07; p\u0026thinsp;=\u0026thinsp;0.011), women who were married (aOR: 2.150; p\u0026thinsp;=\u0026thinsp;0.375), had non-formal education (aOR: 11.477; p\u0026thinsp;=\u0026thinsp;0.076), or basic education (aOR: 3.559; p\u0026thinsp;=\u0026thinsp;0.286), or secondary education (aOR: 9.562; p\u0026thinsp;=\u0026thinsp;0.044) were associated with increased odds of anemia in third trimester. When taken together, the high prevalence of anemia and iodine insufficiency indicates an urgent need for multifaceted interventions to improve intra-pregnancy nutrition in the study population.\u003c/p\u003e \u003cp\u003eWhile the World Health Organization recommends a cesarean section rate of 10\u0026ndash;15% [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], recent evidence suggests a global increase in cesarean deliveries [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our study's cesarean section rate of 9.0% aligns with the WHO recommendation, potentially reflecting a conservative approach. A previous study at the Korle-Bu Teaching Hospital (KBTH) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] in Ghana reported a higher cesarean section rate of 40.1% at a tertiary healthcare facility. Among other things, the sample size in the KBTH study was comparatively larger (20270 participants vs 100 participants in the present study) and might be a factor in the disparate findings. Notably, this disparity may be attributed to the referral nature of the tertiary facility, which often receives women with pregnancy complications. Our study, conducted in a primary healthcare facility, likely referred women with pregnancy complications to higher levels of care, potentially underestimating the true cesarean section rate.\u003c/p\u003e \u003cp\u003eThe Robson classification system [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] provides a structured approach for monitoring cesarean section rates [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], considering factors such as pregnancy category, obstetric history, labor course, and gestational age. Our logistic regression analysis supports the association between third-trimester maternal anemia and increased risk of cesarean section delivery. Consistent with our findings, previous studies have linked anemia in pregnancy with increased odds of cesarean section [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], further highlighting the adverse consequences of intra-pregnancy anemia.\u003c/p\u003e \u003cp\u003eThe universal salt iodization program is a cost-effective strategy for improving iodine levels in populations. Iodine deficiency can lead to cretinism, impaired cognitive function, and irreversible mental retardation due to its critical role in fetal brain development [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In our study, despite 97.0% of participants reporting iodized salt use, insufficient iodine levels were observed in 48.0%, 54.0%, and 51.0% of participants in trimesters 1, 2, and 3, respectively. This suggests that iodine intake may not be meeting increased pregnancy demands, potentially due to higher thyroid hormone production and renal clearance [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile our study did not directly measure iodine concentrations in iodized salt, the high self-reported usage and insufficient iodine levels suggest potential issues in the salt supply chain, cooking methods, or additives [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Per the design adopted for this study, it is difficult to determine the reason(s) why the self-reported high usage of iodized salt did not translate into the lower proportion of participants with insufficient iodine levels. Previous research has theorized that exposure of iodized salt to sunlight during transportation and the addition of certain additives during cooking can affect iodine levels [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. We propose the need for research to interrogate the entire supply chain of iodized salt (from production points to consumer homes) to identify potential actionable points and explore the potential impact of cooking methods and/or additives on iodine intake. A previous experimental study that subjected iodated salts to various cooking temperatures found that the residual iodine contents in the salts depended on the type of food and the water content of the food to which the iodated salt was added [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Additionally, a previous study in Brazil found increased odds of insufficient iodine levels in pregnant women who used industrialized seasoning during cooking [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterestingly, participants with anemia consistently had lower urinary iodine levels in all trimesters, reaching statistical significance in trimesters 2 and 3. Notably, the urinary iodine levels in anemic participants were insufficient (\u0026lt;\u0026thinsp;150 \u0026micro;g/L) compared to participants with normal hemoglobin levels who had sufficient median urinary iodine levels (\u0026ge;\u0026thinsp;150 \u0026micro;g/L) in all trimesters. While the study design does not allow for establishing a direct causal association, the positive correlation between urinary iodine concentrations and hemoglobin levels suggests the need for further research to investigate a potential link between iodine deficiency and anemia during pregnancy. Previous studies have demonstrated a synergistic relationship between iodine and iron, suggesting that co-administration can improve iron absorption and bioavailability [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. This highlights the potential importance of both micronutrients for blood cell formation.\u003c/p\u003e \u003cp\u003eIn our pregnant women cohort, anemia was a moderate public health problem in trimester 2 but a severe problem in trimesters 1 and 3. Teenage pregnant participants were disproportionately affected by anemia in all trimesters in agreement with a previous study [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Additionally, anemic participants had lower median maternal weight than non-anemic participants in all trimesters, reaching statistical significance in trimesters 2 and 3. Considering the positive correlation between maternal hemoglobin concentrations and placental and baby weight, this finding is not surprising.\u003c/p\u003e \u003cp\u003eOur analysis further revealed that anemia in trimester 3 was associated with higher odds of cesarean section delivery [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Cesarean section can lead to blood loss, potentially exacerbating anemia in mothers and negatively impacting both mother and child during the lactation period [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Participants who were married and had lower educational attainment (non-formal, basic, or secondary) were more likely to be anemic in trimester 3. The data also showed a strong positive correlation between hemoglobin levels in trimesters 1, 2, and 3, suggesting that preconception hemoglobin levels may influence pregnancy outcomes [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. While our data shed light on the association between intra-pregnancy UIC, and trimester-specific anemia and how these may associate with pregnancy outcomes, our study design is such that we could not establish causality. Moreover, iron supplementation is a government of Ghana policy in which all pregnant women are given iron supplementation as part of the routine antenatal care at no cost to the pregnant women. However, research has found low compliance with iron supplementation among pregnant women across SSA for various reasons despite government policies [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Thus, we are not able to estimate how much this important national policy impacted the anemia prevalence reported in the present study.\u003c/p\u003e \u003cp\u003eFurthermore, while our study sheds light on the relationship between iodine levels, anemia, and pregnancy outcomes, it has limitations. The sample size and single-district design may limit the generalizability of the findings. For example, while the anemia prevalence was disproportionately high among teenagers, the small sample size of teenagers (14) did not allow us to undertake exhaustive exploration. Future work targeting only teenage pregnant women will shed light on the dynamics of iodine sufficiency vis-a-viz anemia prevalence among this uniquely vulnerable group. Additionally, the study design only allowed for correlation analysis, but not causal inferences. Future longitudinal studies, including animal models, could provide mechanistic insights into the interactions between iodine levels, anemia status, and pregnancy outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe significant associations between insufficient iodine levels and anemia status in our pregnant women cohort require empirical research to determine if a causal relationship exists.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUIC: urinary iodine concentration\u003c/p\u003e\n\u003cp\u003eCS: caesarian section\u003c/p\u003e\n\u003cp\u003eWBC: white blood cells\u003c/p\u003e\n\u003cp\u003eT: trimester\u003c/p\u003e\n\u003cp\u003eHb: hemoglobin.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical consideration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the Institution Review Board of the University of Cape Coast (UCCIRB/CHAS/2019/206). Permission was also sought from all Health Facility heads and midwives in charge of the respective antenatal clinics before the study commenced. Before recruitment to the study, each participant gave written informed consent after the protocols for the study had been explained to them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the conclusions of this study are presented in the main manuscript. Any additional data can be obtained by contacting the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors have no competing interest to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any funding from any public or private organization; it was entirely self-funded by the researchers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatrick Adu:\u003c/strong\u003e Conceptualization; Methodology; Project administration; Supervision; Formal analysis; Writing \u0026ndash; original draft; Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOlivia Mawunyo Timpo\u003c/strong\u003e: Conceptualization; Data curation; Supervision; Methodology; Validation; Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDavid Larbi Simpong:\u003c/strong\u003e Conceptualization; Data curation; Formal analysis; Supervision; Validation; Investigation; Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJoseph Boachie:\u003c/strong\u003e Data curation; Formal analysis; Investigation; Methodology; Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharles Ekow Spike Cartey:\u003c/strong\u003e Data curation; Formal analysis; Investigation; Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided consent to publish their anonymous data collected during the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMousa A, Naqash A, Lim S. 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Household Salt Storage and Seasoning Consumption Are Predictors of Insufficient Iodine Status Among Pregnant Women in Southeastern Brazil. Biological Trace Element Research. 2023;201(12):5529-39. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12011-023-03615-1\u003c/span\u003e\u003cspan address=\"10.1007/s12011-023-03615-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnnan RA, Gyimah LA, Apprey C, Edusei AK, Asamoah-Boakye O, Aduku LNE, et al. Factors associated with iron deficiency anaemia among pregnant teenagers in Ashanti Region, Ghana: A hospital-based prospective cohort study. PLoS One. 2021;16(4):e0250246. 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Non-adherence to antenatal iron supplementation and its determinants among pregnant women in 35 sub-saharan African countries: a generalized linear mixed-effects modeling with robust Poisson regression analysis. BMC Pregnancy Childbirth. 2024;24(1):872. Epub 20241228. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-024-07105-7\u003c/span\u003e\u003cspan address=\"10.1186/s12884-024-07105-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PubMed PMID: 39732634; PubMed Central PMCID: PMCPMC11681747.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ammonium persulfate, Iodine deficiency, pregnant women, Urinary Iodine concentration","lastPublishedDoi":"10.21203/rs.3.rs-5675773/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5675773/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Adequate maternal hemoglobin and iodine are essential for optimal fetal-placental oxygenation, and, fetal brain development respectively. Intra-pregnancy anemia and iodine insufficiency are associated with adverse fetal-maternal outcomes. This study explored the potential association between intra-pregnancy anemia and iodine insufficiency and identified factors associated with third-trimester anemia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eThis study recruited pregnant women attending antenatal care in two rural health centres in the Ellembelle District, Ghana. Participants were followed from first-trimester visit until delivery. Demographic information, iodized salt usage, birth outcomes, urinary iodine concentration, and hemoglobin levels were collected per trimester; statistical significance was set at p\u0026lt;0.05.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Despite 97.0% of participants reporting iodized salt use, 48.0%, 54.0%, and 51.0% had iodine insufficiency in trimesters 1, 2, and 3, respectively. Anemia rates were 44.0%, 32.0%, and 41.0% in trimesters 1, 2, and 3, respectively, with higher prevalence among pregnant teenagers. In all trimesters, anemic individuals had iodine insufficiency [T1: 141.4 vs 158.7 μg/L (p=0.1173); T2: 135.1 vs 155.3 μg/L (p=0.0327; T3: 139.2 vs 156.8 μg/L (p=0.0325)], or reduced gestational weight [T1: 55.35 vs 58.20 kg (p=0.4272); T2: 55.50 vs 63.25 kg (p=0.0094); T3: 60.0 vs 68.2 μg/L (p=0.0388)] than non-anemic individuals. Logistic regression analyses found that third-trimester anemia was prevalent in married women (aOR: 2.15, p=0.011), with non-formal (aOR: 11.477; p=0.076), basic (aOR: 3.559; p=0.286), or secondary (aOR: 9.562; p=0.044) education, and is associated with higher risk of cesarean section delivery (aOR:.41.070; p=0.011).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eFurther research is needed to determine any potential causal relationship between insufficient iodine levels and anemia status during pregnancy.\u003c/p\u003e","manuscriptTitle":"Anaemia status is associated with insufficient iodine levels in pregnant women in rural settings; a two-centre observational study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-07 09:23:18","doi":"10.21203/rs.3.rs-5675773/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-08T09:01:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-05T14:39:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28718177279830422308311427039642659809","date":"2025-04-03T14:16:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-03T08:57:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-02T10:22:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2025-03-23T12:11:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"74ec59b4-4687-40d1-85aa-82ebd2ed248d","owner":[],"postedDate":"April 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-04-25T11:23:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-07 09:23:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5675773","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5675773","identity":"rs-5675773","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}