Unlocking the Mystery of the Role of Vitamin D in Iron Deficiency Anemia in Antenatal Women: A Case Control Study in a Tertiary Care Hospital in New Delhi

Unlocking the Mystery of the Role of Vitamin D in Iron Deficiency Anemia in Antenatal Women: A Case Control Study in a Tertiary Care Hospital in New Delhi | 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Unlocking the Mystery of the Role of Vitamin D in Iron Deficiency Anemia in Antenatal Women: A Case Control Study in a Tertiary Care Hospital in New Delhi Tanishq Hitesh, Ritu Khatuja, Poonam Agrawal, Deepak Dhamnetiya, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3135046/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Oct, 2023 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 8 You are reading this latest preprint version Abstract Background Vitamin D deficiency and anemia are clinical conditions that coexist during pregnancy. High prevalence of Vitamin D deficiency ranging from 50–94% is seen throughout the country. The aim of the study was to discover the association between Vitamin D status and iron deficiency anemia during pregnancy. Improving the vitamin D status of pregnant women is crucial to prevent iron deficiency anemia and can improve maternal and fetal outcomes. Methods A case control study including 94 primigravida women of age within the age group 18 to 30 years, divided into two groups: a Case Group of 48 patients with already diagnosed iron deficiency anaemia (mild to moderate) and a Control Group of 46 antenatal women with normal haemoglobin levels. Data on sociodemographic, clinical characteristics and the levels of 25(OH) Vitamin D was estimated in both the groups. The association of 25(OH)D levels and anaemia was then determined using suitable statistical analysis. Results Among pregnant women affected with anemia, 75% of women had serum Vitamin D concentrations < 20ng/ml compared to 52.2% of women in the controls. Maternal serum vitamin D was significantly lower in pregnant women affected with anemia (p = 0.024). A positive correlation was found between hemoglobin and vitamin D levels in pregnant women (Pearson’s r = 0.200, p = 0.05). Conclusions These findings provide evidence suggesting that Vitamin D deficiency or insufficiency during pregnancy may be a risk factor for anemia and correction of Vitamin D levels can improve hemoglobin levels. Educational efforts should be made to include safe vitamin D intake in antenatal care. pregnant women vitamin D deficiency anemia obstetrics maternal developing countries hemoglobin Figures Figure 1 Background Vitamin D deficiency is recognised as a public health concern characterised by low levels of serum 25 hydroxy Vitamin D [25(OH)D] below 20 ng/ml. High prevalence of Vitamin D deficiency ranging from 50–94% is seen throughout the country [ 1 ] . Major factors that are significantly associated with its deficiency include dietary habits and inadequate sunlight exposure [ 2 ] . Increasing pollution due to escalating urbanisation, and lifestyle with poor outdoor activities likely to worsen the condition [ 3 ] . In addition, its requirement further increases during pregnancy as it is crucial for maternal health, foetal skeletal growth, and optimal maternal and foetal outcomes. Anemia is also a common problem during pregnancy especially in developing countries. In India, as per National Family Health Survey (NFHS-4) data, the prevalence of anemia during pregnancy is around 50% [ 4 ] . Maternal anemia has been linked with an increased risk of preterm delivery, low birth weight, intrauterine growth retardation, and adverse perinatal outcomes [ 5 ] . Vitamin D deficiency and anemia are clinical conditions that coexist during pregnancy. Studies suggest an association between Vitamin D deficiency and upregulation of mRNA expression of hepcidin, a molecule resulting in decreased level of ferroportin responsible for iron absorption, which indicates adequate Vitamin D serum levels can provide additional protection against iron deficiency in pregnant women [ 6 ] . Vitamin D receptors have already been demonstrated in bone marrow and its concentration is several hundred fold higher in bone marrow as compared to plasma [ 7 ] . Vitamin D also has an important role in erythropoiesis and it is also demonstrated that Vitamin D supplementation may improve anaemia management [ 8 ] . However association of vitamin D deficiency and iron deficiency anemia among antenatal women remain underexplored. This study aims to bring out the potential relationship between vitamin D deficiency and iron deficiency anemia in pregnant women. Additionally, this study will provide data related to the magnitude of Vitamin D Deficiency in iron deficient pregnant women. This study emphasised the need to improve vitamin D status in pregnant anemic women through Vitamin D supplementation along with iron supplements. To the best of our knowledge, clinical evidence is still scarce in this field to comprehend their correlation. Through this study we were able to conclude that future research should focus on more unified approaches to vitamin D testing and preventative strategies that can be integrated into already existing antenatal care settings to prevent Iron Deficiency Anemia. Aims and Objectives: Primary Objective : To assess the association of Vitamin D levels between iron deficient anemic and nonanemic pregnant women. Secondary Objectives: To assess the association of various socio-demographic factors among the study subjects. To assess the association of selected maternal characteristics with iron deficiency anemia among the study subjects. To assess the association of anthropometric and biochemical parameters with iron deficiency anemia among the study subjects. Methods Design and Study Population : A Hospital based Case Control Study was conducted among pregnant women between 28th August 2022 to 15th October 2022 in the Maternity Ward/Antenatal Clinic of the Department of Obstetrics and Gynaecology at the Dr. Baba Saheb Ambedkar Medical College and Hospital, Delhi. Sample size was calculated by taking the proportion of Vitamin D Deficiency in non anemic and anemic pregnant women as 40% and 75% respectively, at 95% level of confidence and 80% power with the same number of cases and controls [9]. The minimum sample size calculated by Fleiss formula was 31 subjects for cases and controls each. We enrolled 107 pregnant women who came for antenatal check up or at time of delivery and were willing to participate in study. They were thoroughly screened by history and examination. Thirteen subjects were excluded from the study due to incomplete medical records or their samples were hemolyzed. Remaining 94 pregnant women were divided into two groups: total 48 antenatal women with already diagnosed iron deficiency anemia (mild to moderate) were included in the Case group and 46 antenatal women with normal hemoglobin levels included in the Control group. Eligibility Criteria : The included subjects in both groups were primigravida women within the age group of 18 to 30 years, with confirmed singleton uncomplicated pregnancy at or after 28 weeks of gestation defined through their last menstrual period or through their first trimester ultrasound result were included. The inclusion criteria also included the ability to provide the consent, no history of blood transfusion during current pregnancy. Exclusion criteria included pregnant women with any active comorbid disease (eg: thyroid diseases, chronic hypertension, seizure disorder, renal diseases, diabetes mellitus, chronic liver diseases etc.) and anemia other than iron deficiency anemia. Patients already taking Vitamin D supplementation during pregnancy were also excluded. Patients with thalassemia (as per Mentzer Index) or history of thalassemia, sickle cell anemia, hemolytic anemia, peptic ulcer disease, gastritis, malabsorption syndrome, chronic blood loss, presence of chronic hematological diseases were also not recruited. Information and Sample Collection : Detailed history and examination was performed with regard to current pregnancy. A pre-validated and semi structured data collection form was used to collect information on socio-economic, demographic details, personal details, pregnancy history which comprised past/ongoing medical and treatment history, iron, folic acid and Vitamin D supplement intake, regular milk consumption and information regarding present pregnancy. Antenatal investigations were noted which included blood investigations and Mentzer Index, where Mentzer Index was calculated to detect any pregnant women of 𝛽 thalassemia trait. Those pregnant women who provided the informed written consent, 5ml peripheral venous blood was collected under strict aseptic conditions by a licensed laboratory technician and 2ml of the blood was sent for. Serum was separated in a cold centrifuge within 30 minutes and was kept in frozen aliquots at -40°C on the same day until analysed. 25(OH) Vitamin D 2 and D 3 was measured with the help of commercially available kit using chemiluminescent immunoassay technology (CLIA). Rest of the blood was used to measure other standard blood parameters using impedance method measurement (Sysmex XP-100, Japan). The serum Vitamin D test done was an addition to the standard antenatal investigation performed in the third trimester with no extra needle prick. The levels of 25(OH) Vitamin D was estimated in both the groups. The association of 25(OH)D levels and anaemia was then determined using suitable statistical analysis. Criteria for Analysis : Anemia in pregnant women was defined as haemoglobin level of equal and more than 11 g/dl as normal, 10-10.9 g/dl as mild anaemia, 7-9.9 g/dl as moderate anaemia and 4-6.9 g/dl as severe anaemia as per the guidelines of Indian Council of Medical Research (ICMR) [ 16 ] . During pregnancy, less than 20 ng/ml of serum 25(OH)D levels is considered as deficient, 20-29.99 ng/ml as insufficient, while more than or equal to 30 ng/ml is considered as sufficient [ 17 ] . Statistical Analysis : Entries were performed and data cleaning was done from case study form into our customised Excel Sheet (Microsoft Corp., USA). Differences of maternal characteristics and serum Vitamin D concentrations between both groups was calculated by χ 2 test (for categorical variables), Mann-Whitney test (for Vitamin D concentrations) and Odds Ratio (for strength of association). All analyses were conducted using the SPSS for Windows 11.5 program (SPSS Inc, Chicago, IL, USA), and p ≤ 0.05 is statistically significant. Results We successfully analysed serum 25(OH)D concentrations from all 94 samples (48 pregnant women affected with anemia and 46 controls not having anemia). The selected characteristics and sociodemographic details of the anemic women (Case) and non anemic women (Controls) are summarised in Table 1 . The mean age was 23.2 ± 3.3 years (median 22 years) for anemic pregnant women and 24.1 ± 3 years (median 24 years) for the matched controls. Almost all the cases were housewives (97.9%), but 8.7% in controls were employed. According to the Modified Kuppuswamy scale, nearly three-quarters (70.8%) of the cases fall under the upper lower class, while almost half (47.3%) are above the lower middle class [ 18 ] . While 56.5% of the controls have finished their intermediate class, 70.9% of the cases have not finished up to that point in their schooling. Supplementation with Iron and Folic Acid (IFA) was lacking in 43.8% of cases but present in 78.3% of controls. In contrast to the 73.9% of controls who regularly consume milk, regular milk consumption was found in only 45.8% of cases. Majority of women in both groups (89.6% in the case group and 93.5% in the control group) have more than 4 antenatal care visits to monitor the progress of their pregnancy. Nearly more than half of studied pregnant women in both groups (58.3% in the case group and 56.5% in the control group) are non vegetarian by diet. Among pregnant women affected with anemia, 75% of women had serum Vitamin D concentrations < 20ng/ml compared to 52.2% of women in the controls. Table 2 . represents the association of BMI, blood and serum parameters of pregnant anemic women with controls. Maternal serum vitamin D was significantly lower in pregnant women affected with anemia (p = 0.024). It also clarifies statistically significant lower levels of Hemoglobin (p = 0.000), RBC count (p = 0.000), MCV (p = 0.015), MCH (p = 0.000), MCHC (p = 0.000), Hematocrit (p = 0.000) in case group as compared to control group. The study did not find any statistically significant correlation for anemia against Body Mass Index (BMI) (p = 0.762), Total Leucocyte Count (TLC) (p = 0.264), platelet count (p = 0.213). Table 3 . summarises positive association of iron folic acid consumption and milk consumption with anemia in pregnant women (p = 0.023; 0.006). The study did not find any statistically significant correlation for anemia against women’s religion or their dietary habits (p = 0.829; 0.829). A positive correlation was found between hemoglobin and vitamin D levels in pregnant women (Pearson’s r = 0.200, p = 0.05) ( Fig. 1 ) . Table 1 Distribution of study subjects according to socio-demographic and maternal characteristics Maternal Characteristics Variable Cases (n = 48) [Frequency (%)] Controls (n = 46) [Frequency (%)] Age 18–21 17(35.4%) 10(21.7%) 22–25 20(41.7%) 20(43.5%) ≥ 26 11(22.9%) 16(34.8%) Occupation Housewife 47(97.9%) 42(91.3%) Employed 1(2.1%) 4(8.7%) Education Till Primary School 20(41.7%) 10(21.7%) High School 14(29.2%) 10(21.7%) Intermediate 8(16.7%) 11(23.9%) Graduate 6(12.5%) 9(19.6%) Post Graduate 0 6(13.0%) Religion Hindu 41(85.4%) 40(87%) Others 7(14.6%) 6(13%) Socio economic status Lower 10(20.8%) 5(10.9%) Upper Lower 24(50.0%) 19(41.3%) Lower Middle 13(27.1%) 17(37.0%) Upper Middle 1(2.1%) 4(8.7%) Upper 0 1(2.2%) Iron / Folic Acid Supplementation Present 27(56.2%) 36(78.3%) Absent 21(43.8%) 10(21.7%) ANC Visits < 4 visits 5(10.4%) 3(6.5%) ≥ 4 visits 43(89.6%) 43(93.5%) Dietary Habits Non-Vegetarian 28(58.3%) 26(56.5%) Vegetarian 20(41.7%) 20(43.5%) Milk Consumption Present 22(45.8%) 34(73.9%) Absent 26(54.2%) 12(26.1%) Serum Vitamin D Level Deficient 36(75.0%) 24(52.2%) Insufficient 3(6.3%) 9(19.6%) Sufficient 9(18.8%) 13(28.3%) Table 2 Association of BMI, Blood and Serum Parameters between Anemic and Non Anemic Pregnant Women Measurements Cases(N = 48) Controls (N = 46) P value a Mean ± SD Median (IQR) Mean ± SD Median (IQR) BMI(kg/m 2 ) 23.94 ± 3.88 23.24 (4.73) 23.99 ± 3.17 23.33 (3.17) 0.762 Haemoglobin (g/dL) 9.35 ± 1.03 9.50 (1.03) 12.13 ± 0.83 12.05 (0.83) 0.000 RBC count (x10 6 /µL) 3.62 ± 0.59 3.62 (0.59) 4.06 ± 0.50 4.05 (0.50) 0.000 TLC (Total Leucocyte Count) (x10 3 /µL) 11.32 ± 2.99 10.45 (2.99) 11.69 ± 2.63 11.25 (2.63) 0.264 Platelet Count (x10 3 /µL) 234.48 ± 103.72 222.50 (103.72) 202.46 ± 72.30 202.50 (72.31) 0.213 MCV (fL) 86.20 ± 11.78 85.30 (85.31) 90.76 ± 8.72 89.65 (8.72) 0.015 MCH (pg) 26.33 ± 4.08 26.25 (4.08) 30.22 ± 3.50 29.90 (3.50) 0.000 MCHC (g/dL) 30.43 ± 2.95 31.05 (2.95) 33.27 ± 1.63 33.10 (1.63) 0.000 Hematocrit (%) 30.64 ± 3.66 31.25 (3.66) 36.50 ± 2.49 36.45 (2.49) 0.000 Serum Vitamin D Levels (ng/ml) 19.61 ± 13.12 15.18 (13.13) 29.43 ± 24.05 19.59 (24.05) 0.024 a P value < 0.05 (Mann-Whitney test); BMI, body mass index; RBC, red blood cell; MCV, mean corpuscular volume; MCH, mean corpuscular hemoglobin; Table 3 Association of anemic pregnant women’s maternal characteristics and lifestyle habits with controls Maternal Characteristics Variable Cases (n = 48) [Frequency (%)] Controls (n = 46) [Frequency (%)] P Value Religion Hindu 41(50.6%) 40(49.4%) 0.829 Others 7(53.8%) 6(46.2%) Iron / Folic Acid Supplementation Present 27(42.9%) 36(57.1%) 0.023 Absent 21(67.7%) 10(32.3%) Dietary Habits Non-Vegetarian 28(51.9%) 26(48.1%) 0.829 Vegetarian 20(50.0%) 20(50.0%) Milk Consumption Present 22(39.3%) 34(60.7%) 0.006 Absent 26(68.4%) 12(31.6%) Serum Vitamin D Level Deficient 36(60.0%) 24(40.0%) 0.048 Insufficient 3(25.0%) 9(75.0%) Sufficient 9(40.9%) 13(59.1%) Discussion Vitamin D deficiency has been linked to a variety of health consequences during pregnancy, and is a global public health concern. In this hospital based case control study conducted on pregnant women, our main aim was to find the association between Vitamin D status and iron deficiency anemia during pregnancy. We found maternal serum Vitamin D concentrations were significantly less in women affected with anemia as compared to normal pregnant women (mean: 19.61ng/ml in case group vs 29.43ng/ml in control group). Our results are in line with recent studies suggesting a strong association of low Vitamin D levels with anemia in pregnant women. Several studies reported low maternal vitamin D levels may be a risk factor for gestational anemia [ 19 – 23 ] . There are various possible explanations for the link between vitamin D deficiency and maternal anaemia. Calcitriol, the active form of vitamin D, may upregulate erythropoietin receptor expression on erythroid progenitor cells and may have a proliferative impact on erythroid burst generating units, which is synergistic with erythropoietin [ 24 , 25 ] . Calcitriol has an essential part in the immune function control by reducing the activity of pro-inflammatory cytokines which could be critical to its involvement in anemia prevention [ 26 ] . Studies suggest an association between Vitamin D deficiency and upregulation of mRNA expression of hepcidin, a molecule resulting in decreased level of ferroportin responsible for iron absorption, which indicates adequate Vitamin D serum levels can provide additional protection against iron deficiency in pregnant women [ 6 ] . Vitamin D receptors have already been found in bone marrow, where its concentration is hundreds folds higher than in plasma. [ 7 ] . One of the most important findings of our study was the unexpectedly high prevalence of deficient Vitamin D levels among both groups (75% in case and 52.2% in control group). Hypovitaminosis D among North Indian pregnant women have also been widely reported [ 27 – 30 ] . The rationale might be owing to insufficient sun exposure, dark skin complexion and a lack of dietary calcium consumption, as Vitamin D synthesis initiates in the skin after sun exposure [ 31 , 32 ] . High amounts of atmospheric pollution in Indian metropolitan cities could also be an important factor [ 33 ] . We also accounted for several parameters as a risk factor for maternal anemia where we reported the education status and socioeconomic status of the mother can also be a risk factor for anemia. This may be attributed to the fact that educated women belonging to middle socioeconomic status tend to prioritize self-care, actively engage in antenatal care, maintain a nutritious diet, supplement with iron and calcium, and take measures to prevent potential parasitic infections. The educational component makes the subject group more aware and responsive to new concepts and contents of public health campaigns, making them more likely to adopt good healthy living and treatment seeking behaviour. On the other hand, uneducated and economically disadvantaged mothers are expected to lack proper nutrition [ 34 ] . This explains education and socioeconomic status are linked with maternal anemia. Our results show a positive correlation of the effect of iron and folic acid (IFA) supplementation on maternal anemia which are consistent with various other studies [ 35 , 36 ] . Although India has incorporated iron and folic acid supplementation schemes for pregnant women since 1970, these programmes have been hampered by a variety of problems and supply and coverage restrictions [ 37 ] . These schemes were relaunched in 2018 as Anemia Mukt Bharat (AMB) Abhiyan to address basic difficulties such as programme finance, execution, and last mile delivery but still the prevalence of anemia was very high during pregnancy [ 38 ] . We discovered a link between regular milk consumption and anaemia. In contrast to our findings, coffee and milk have been recognised as possible iron absorption inhibitors, but only when high amounts of these items are ingested in the same meal as the iron [ 39 ] . This also shows that pregnant women are better aware of the need to take calcium and iron supplements not in the same meal. Still pregnant women should be concerned about their milk consumption as milk is an excellent source of protein and minerals like calcium, and it is linked to an increased birth weight [ 40 ] . A limitation of our study was the relatively small sample size. Therefore, further research involving a larger population size and considering long-term impacts is necessary to have a significant impact on public healthcare policy. Conclusion The purpose of this study was to compare vitamin D levels in iron-deficient anemia and non anemic pregnant women. These findings provide evidence suggesting that Vitamin D deficiency or insufficiency during pregnancy may be a risk factor for anemia and correction of Vitamin D levels can improve hemoglobin levels. This study emphasised the need of improving vitamin D level in pregnant anaemic women by supplementing with vitamin D and iron. Further investigations at a larger scale on national level and multicentric trials need to be conducted to evaluate the direct relation of Vitamin D deficiency and iron deficiency anemia. Currently, Vitamin D supplementation is not recommended as a part of antenatal care program in India. In view of the high prevalence of low Vitamin D levels in pregnancy, educational efforts need to be made to include regular safe Vitamin D intake as a part of public health strategy to improve the health of both mothers and their offsprings. Abbreviations 25(OH)D: 25-hydroxyvitamin D; NFHS: National Family Health Survey; MCV: Mean Corpuscular Volume; MCH: Mean Corpuscular Hemoglobin; MCHC: Mean Corpuscular Hemoglobin Concentration; HIV: Human Immunodeficiency Virus; CLIA: Chemiluminescent Immunoassay Technology; SPSS: Statistical Package for Social Sciences; ANC: Antenatal Care; BMI: Body Mass Index; IQR: Interquartile Range; RBC: Red Blood Corpuscle; TLC: Total Leucocyte Count; AMB: Anemia Mukt Bharat; ICMR: Indian Council of Medical Research; STS: Short Term Studentship. Declarations Ethics Approval and Consent to Participate: Ethical approval has been obtained from the Institutional Research Review Committee and Institutional Ethical Committee of Dr. Baba Saheb Ambedkar Medical College and Hospital (IRRC-5/2022), Delhi prior to the start of the study, and the methods were carried out in accordance with the approved guidelines. Informed written consent has been taken from all subjects before including them in the study. Prior to recruitment, pregnant women were given information about the study using the Participation Information Sheet. Confidentiality of all the data is ensured by keeping the responses and the collected data under a secure setting. Consent for publication: Not applicable Availability of Data and Materials: The datasets used in the present study are available with the ICMR STS-2022 registry (ICMR STS ID: 2022-02037) and with the corresponding author on reasonable request. Competing Interests: The authors declare that there are no competing interests. Funding: None Authors’ Contribution: TH, RK and DD were responsible for conception of the study. TH, RK, DD and PA were advised to design. TH and RK collected the data. TH, RK, DD and RPJ analysed the data and interpreted the findings. TH and RK drafted and revised the manuscript. All authors approved the final version. Acknowledgement: Authors would like to thank Dr. S.N. Bhattacharya, Principal of Dr. Baba Saheb Ambedkar Medical College and Hospital, Delhi for examining this project and for sharing his valuable feedback. They would also like to thank ICMR for approving and supporting this project under the Short Term Studentship (STS) programme. References Aparna P, Muthathal S, Nongkynrih B, Gupta SK. Vitamin D deficiency in India. J Fam Med Prim Care. 2018;7(2):324. Holick MF. Vitamin D and health: evolution, biologic functions, and recommended dietary intakes for vitamin D. 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New findings on iron absorption conditioning factors. Revista Brasileira de Saúde Materno Infantil. 2004;4:241–8. Mannion CA, Gray-Donald K, Koski KG. Association of low intake of milk and vitamin D during pregnancy with decreased birth weight.Cmaj 2006 Apr25;174(9):1273–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Oct, 2023 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Major revision 25 Jul, 2023 Reviews received at journal 14 Jul, 2023 Reviewers agreed at journal 13 Jul, 2023 Reviewers invited by journal 13 Jul, 2023 Editor assigned by journal 13 Jul, 2023 Editor invited by journal 12 Jul, 2023 Submission checks completed at journal 12 Jul, 2023 First submitted to journal 03 Jul, 2023 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies 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-3135046","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":218158577,"identity":"b80f4a99-9cc3-4f8f-ad6c-b4148547af2d","order_by":0,"name":"Tanishq Hitesh","email":"","orcid":"","institution":"Dr. Baba Saheb Ambedkar Medical College and Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tanishq","middleName":"","lastName":"Hitesh","suffix":""},{"id":218158578,"identity":"79fbe9d6-a93f-41c4-bd27-33ca8f5df131","order_by":1,"name":"Ritu Khatuja","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYDCCA2DEYMDY3gCiLIjUcgCkpQesU4I4LSBswCCRAOISoYXv9tmHhz+2MRgzz3x+dcOPAgkG/vbuBLxaJM+lGxw42MZgxjg7p+xmD9BhEmfObsCrxeAMGwNIiw1QS9oNHqAWA4lcYrXMPJN28w8pWswYZ7Afu02ULZIgLWfOSRgz9uSw3ZYxkOAh6Be+M2zMHyrKbAw3th9/dvPNHxs5/vZe/FqgQILBsIHHAMTiIUY5BMgzsD8gXvUoGAWjYBSMKAAAe6RKHbQNeb0AAAAASUVORK5CYII=","orcid":"","institution":"Dr. Baba Saheb Ambedkar Medical College and Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ritu","middleName":"","lastName":"Khatuja","suffix":""},{"id":218158579,"identity":"400c955f-ecdb-44c7-915d-0fbe4b2bee63","order_by":2,"name":"Poonam Agrawal","email":"","orcid":"","institution":"Dr. Baba Saheb Ambedkar Medical College and Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Poonam","middleName":"","lastName":"Agrawal","suffix":""},{"id":218158580,"identity":"f63523fb-153e-458f-a1ef-e73ea3d9d4c4","order_by":3,"name":"Deepak Dhamnetiya","email":"","orcid":"","institution":"Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Deepak","middleName":"","lastName":"Dhamnetiya","suffix":""},{"id":218158581,"identity":"32d15ef7-9aa0-4168-a76f-6f58f7d1f764","order_by":4,"name":"Ravi Prakash Jha","email":"","orcid":"","institution":"Dr. Baba Saheb Ambedkar Medical College and Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ravi","middleName":"Prakash","lastName":"Jha","suffix":""}],"badges":[],"createdAt":"2023-07-03 09:59:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3135046/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3135046/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-023-06047-w","type":"published","date":"2023-10-24T15:01:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":40137833,"identity":"24ca54e7-006d-4229-b9c2-17eb039f50da","added_by":"auto","created_at":"2023-07-17 14:20:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23185,"visible":true,"origin":"","legend":"\u003cp\u003eGraph showing the correlation between hemoglobin and serum vitamin D levels for pregnant women.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3135046/v1/e6f003b9a3c286abc2eeb0ab.jpg"},{"id":45453803,"identity":"7b1bddc1-f013-4e63-94fd-4fd61f51c67e","added_by":"auto","created_at":"2023-10-30 15:06:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":478084,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3135046/v1/2d219001-b860-406b-8a07-51d9241444dc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Unlocking the Mystery of the Role of Vitamin D in Iron Deficiency Anemia in Antenatal Women: A Case Control Study in a Tertiary Care Hospital in New Delhi","fulltext":[{"header":"Background","content":"\u003cp\u003eVitamin D deficiency is recognised as a public health concern characterised by low levels of serum 25 hydroxy Vitamin D [25(OH)D] below 20 ng/ml. High prevalence of Vitamin D deficiency ranging from 50\u0026ndash;94% is seen throughout the country\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Major factors that are significantly associated with its deficiency include dietary habits and inadequate sunlight exposure\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Increasing pollution due to escalating urbanisation, and lifestyle with poor outdoor activities likely to worsen the condition\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In addition, its requirement further increases during pregnancy as it is crucial for maternal health, foetal skeletal growth, and optimal maternal and foetal outcomes.\u003c/p\u003e\n\u003cp\u003eAnemia is also a common problem during pregnancy especially in developing countries. In India, as per National Family Health Survey (NFHS-4) data, the prevalence of anemia during pregnancy is around 50%\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Maternal anemia has been linked with an increased risk of preterm delivery, low birth weight, intrauterine growth retardation, and adverse perinatal outcomes\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eVitamin D deficiency and anemia are clinical conditions that coexist during pregnancy. Studies suggest an association between Vitamin D deficiency and upregulation of mRNA expression of hepcidin, a molecule resulting in decreased level of ferroportin responsible for iron absorption, which indicates adequate Vitamin D serum levels can provide additional protection against iron deficiency in pregnant women\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Vitamin D receptors have already been demonstrated in bone marrow and its concentration is several hundred fold higher in bone marrow as compared to plasma\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Vitamin D also has an important role in erythropoiesis and it is also demonstrated that Vitamin D supplementation may improve anaemia management\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eHowever association of vitamin D deficiency and iron deficiency anemia among antenatal women remain underexplored. This study aims to bring out the potential relationship between vitamin D deficiency and iron deficiency anemia in pregnant women. Additionally, this study will provide data related to the magnitude of Vitamin D Deficiency in iron deficient pregnant women. This study emphasised the need to improve vitamin D status in pregnant anemic women through Vitamin D supplementation along with iron supplements.\u003c/p\u003e\n\u003cp\u003eTo the best of our knowledge, clinical evidence is still scarce in this field to comprehend their correlation. Through this study we were able to conclude that future research should focus on more unified approaches to vitamin D testing and preventative strategies that can be integrated into already existing antenatal care settings to prevent Iron Deficiency Anemia.\u003c/p\u003e\n\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\n \u003ch2\u003eAims and Objectives:\u003c/h2\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003ePrimary Objective\u003c/strong\u003e: To assess the association of Vitamin D levels between iron deficient anemic and nonanemic pregnant women.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSecondary\u003c/strong\u003e \u003cstrong\u003eObjectives:\u0026nbsp;\u003c/strong\u003e\n \u003cul\u003e\n \u003cli\u003eTo assess the association of various socio-demographic factors among the study subjects.\u003c/li\u003e\n \u003cli\u003eTo assess the association of selected maternal characteristics with iron deficiency anemia among the study subjects.\u003c/li\u003e\n \u003cli\u003eTo assess the association of anthropometric and biochemical parameters with iron deficiency anemia among the study subjects.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDesign and Study Population\u003c/b\u003e: A Hospital based Case Control Study was conducted among pregnant women between 28th August 2022 to 15th October 2022 in the Maternity Ward/Antenatal Clinic of the Department of Obstetrics and Gynaecology at the Dr. Baba Saheb Ambedkar Medical College and Hospital, Delhi.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSample size was calculated by taking the proportion of Vitamin D Deficiency in non anemic and anemic pregnant women as 40% and 75% respectively, at 95% level of confidence and 80% power with the same number of cases and controls [9]. The minimum sample size calculated by Fleiss formula was 31 subjects for cases and controls each. We enrolled 107 pregnant women who came for antenatal check up or at time of delivery and were willing to participate in study. They were thoroughly screened by history and examination. Thirteen subjects were excluded from the study due to incomplete medical records or their samples were hemolyzed. Remaining 94 pregnant women were divided into two groups: total 48 antenatal women with already diagnosed iron deficiency anemia (mild to moderate) were included in the Case group and 46 antenatal women with normal hemoglobin levels included in the Control group.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEligibility Criteria\u003c/b\u003e: The included subjects in both groups were primigravida women within the age group of 18 to 30 years, with confirmed singleton uncomplicated pregnancy at or after 28 weeks of gestation defined through their last menstrual period or through their first trimester ultrasound result were included. The inclusion criteria also included the ability to provide the consent, no history of blood transfusion during current pregnancy. Exclusion criteria included pregnant women with any active comorbid disease (eg: thyroid diseases, chronic hypertension, seizure disorder, renal diseases, diabetes mellitus, chronic liver diseases etc.) and anemia other than iron deficiency anemia. Patients already taking Vitamin D supplementation during pregnancy were also excluded. Patients with thalassemia (as per Mentzer Index) or history of thalassemia, sickle cell anemia, hemolytic anemia, peptic ulcer disease, gastritis, malabsorption syndrome, chronic blood loss, presence of chronic hematological diseases were also not recruited.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInformation and Sample Collection\u003c/b\u003e: Detailed history and examination was performed with regard to current pregnancy. A pre-validated and semi structured data collection form was used to collect information on socio-economic, demographic details, personal details, pregnancy history which comprised past/ongoing medical and treatment history, iron, folic acid and Vitamin D supplement intake, regular milk consumption and information regarding present pregnancy. Antenatal investigations were noted which included blood investigations and Mentzer Index, where Mentzer Index was calculated to detect any pregnant women of \u0026#120573; thalassemia trait. Those pregnant women who provided the informed written consent, 5ml peripheral venous blood was collected under strict aseptic conditions by a licensed laboratory technician and 2ml of the blood was sent for. Serum was separated in a cold centrifuge within 30 minutes and was kept in frozen aliquots at -40\u0026deg;C on the same day until analysed. 25(OH) Vitamin D\u003csub\u003e2\u003c/sub\u003e and D\u003csub\u003e3\u003c/sub\u003e was measured with the help of commercially available kit using chemiluminescent immunoassay technology (CLIA). Rest of the blood was used to measure other standard blood parameters using impedance method measurement (Sysmex XP-100, Japan). The serum Vitamin D test done was an addition to the standard antenatal investigation performed in the third trimester with no extra needle prick. The levels of 25(OH) Vitamin D was estimated in both the groups. The association of 25(OH)D levels and anaemia was then determined using suitable statistical analysis.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCriteria for Analysis\u003c/b\u003e: Anemia in pregnant women was defined as haemoglobin level of equal and more than 11 g/dl as normal, 10-10.9 g/dl as mild anaemia, 7-9.9 g/dl as moderate anaemia and 4-6.9 g/dl as severe anaemia as per the guidelines of Indian Council of Medical Research (ICMR)\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eDuring pregnancy, less than 20 ng/ml of serum 25(OH)D levels is considered as deficient, 20-29.99 ng/ml as insufficient, while more than or equal to 30 ng/ml is considered as sufficient\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eStatistical Analysis\u003c/b\u003e: Entries were performed and data cleaning was done from case study form into our customised Excel Sheet (Microsoft Corp., USA). Differences of maternal characteristics and serum Vitamin D concentrations between both groups was calculated by χ\u003csup\u003e2\u003c/sup\u003e test (for categorical variables), Mann-Whitney test (for Vitamin D concentrations) and Odds Ratio (for strength of association). All analyses were conducted using the SPSS for Windows 11.5 program (SPSS Inc, Chicago, IL, USA), and p\u0026thinsp;\u0026le;\u0026thinsp;0.05 is statistically significant.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe successfully analysed serum 25(OH)D concentrations from all 94 samples (48 pregnant women affected with anemia and 46 controls not having anemia). The selected characteristics and sociodemographic details of the anemic women (Case) and non anemic women (Controls) are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age was 23.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3 years (median 22 years) for anemic pregnant women and 24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3 years (median 24 years) for the matched controls. Almost all the cases were housewives (97.9%), but 8.7% in controls were employed. According to the Modified Kuppuswamy scale, nearly three-quarters (70.8%) of the cases fall under the upper lower class, while almost half (47.3%) are above the lower middle class\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. While 56.5% of the controls have finished their intermediate class, 70.9% of the cases have not finished up to that point in their schooling. Supplementation with Iron and Folic Acid (IFA) was lacking in 43.8% of cases but present in 78.3% of controls. In contrast to the 73.9% of controls who regularly consume milk, regular milk consumption was found in only 45.8% of cases. Majority of women in both groups (89.6% in the case group and 93.5% in the control group) have more than 4 antenatal care visits to monitor the progress of their pregnancy. Nearly more than half of studied pregnant women in both groups (58.3% in the case group and 56.5% in the control group) are non vegetarian by diet. Among pregnant women affected with anemia, 75% of women had serum Vitamin D concentrations\u0026thinsp;\u0026lt;\u0026thinsp;20ng/ml compared to 52.2% of women in the controls.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. represents the association of BMI, blood and serum parameters of pregnant anemic women with controls. Maternal serum vitamin D was significantly lower in pregnant women affected with anemia (p\u0026thinsp;=\u0026thinsp;0.024). It also clarifies statistically significant lower levels of Hemoglobin (p\u0026thinsp;=\u0026thinsp;0.000), RBC count (p\u0026thinsp;=\u0026thinsp;0.000), MCV (p\u0026thinsp;=\u0026thinsp;0.015), MCH (p\u0026thinsp;=\u0026thinsp;0.000), MCHC (p\u0026thinsp;=\u0026thinsp;0.000), Hematocrit (p\u0026thinsp;=\u0026thinsp;0.000) in case group as compared to control group. The study did not find any statistically significant correlation for anemia against Body Mass Index (BMI) (p\u0026thinsp;=\u0026thinsp;0.762), Total Leucocyte Count (TLC) (p\u0026thinsp;=\u0026thinsp;0.264), platelet count (p\u0026thinsp;=\u0026thinsp;0.213).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. summarises positive association of iron folic acid consumption and milk consumption with anemia in pregnant women (p\u0026thinsp;=\u0026thinsp;0.023; 0.006). The study did not find any statistically significant correlation for anemia against women\u0026rsquo;s religion or their dietary habits (p\u0026thinsp;=\u0026thinsp;0.829; 0.829).\u003c/p\u003e \u003cp\u003eA positive correlation was found between hemoglobin and vitamin D levels in pregnant women (Pearson\u0026rsquo;s r\u0026thinsp;=\u0026thinsp;0.200, p\u0026thinsp;=\u0026thinsp;0.05) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\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\u003eDistribution of study subjects according to socio-demographic and maternal characteristics\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCases (n\u0026thinsp;=\u0026thinsp;48) [Frequency (%)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControls (n\u0026thinsp;=\u0026thinsp;46) [Frequency (%)]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(35.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(21.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(43.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(22.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16(34.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47(97.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42(91.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(8.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTill Primary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(21.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(29.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(21.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(23.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(19.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost Graduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(13.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHindu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41(85.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40(87%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(14.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eSocio economic status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(20.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(10.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper Lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19(41.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower Middle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(27.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(37.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper Middle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(8.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eIron / Folic Acid Supplementation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(56.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36(78.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(43.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(21.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eANC Visits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;4 visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(6.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4 visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(89.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43(93.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDietary Habits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Vegetarian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26(56.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVegetarian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(43.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMilk Consumption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(45.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34(73.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(54.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(26.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSerum Vitamin D Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36(75.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24(52.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(19.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(28.3%)\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\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\u003eAssociation of BMI, Blood and Serum Parameters between Anemic and Non Anemic Pregnant Women\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasurements\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCases(N\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eControls (N\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI(kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.24 (4.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.99\u0026thinsp;\u0026plusmn;\u0026thinsp;3.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.33 (3.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHaemoglobin (g/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.50 (1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.05 (0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRBC count (x10\u003c/b\u003e\u003csup\u003e\u003cb\u003e6\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/\u0026micro;L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.62 (0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.05 (0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTLC (Total Leucocyte Count) (x10\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/\u0026micro;L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.45 (2.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.69\u0026thinsp;\u0026plusmn;\u0026thinsp;2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.25 (2.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlatelet Count (x10\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/\u0026micro;L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e234.48\u0026thinsp;\u0026plusmn;\u0026thinsp;103.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e222.50 (103.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e202.46\u0026thinsp;\u0026plusmn;\u0026thinsp;72.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e202.50 (72.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.213\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMCV (fL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.20\u0026thinsp;\u0026plusmn;\u0026thinsp;11.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.30 (85.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.76\u0026thinsp;\u0026plusmn;\u0026thinsp;8.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89.65 (8.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMCH (pg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.33\u0026thinsp;\u0026plusmn;\u0026thinsp;4.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.25 (4.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.22\u0026thinsp;\u0026plusmn;\u0026thinsp;3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.90 (3.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMCHC (g/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.05 (2.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.10 (1.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHematocrit (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.64\u0026thinsp;\u0026plusmn;\u0026thinsp;3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.25 (3.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.45 (2.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSerum Vitamin D Levels (ng/ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.61\u0026thinsp;\u0026plusmn;\u0026thinsp;13.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.18 (13.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.43\u0026thinsp;\u0026plusmn;\u0026thinsp;24.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.59 (24.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (Mann-Whitney test); BMI, body mass index; RBC, red blood cell; MCV, mean corpuscular volume; MCH, mean corpuscular hemoglobin;\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\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\u003eAssociation of anemic pregnant women\u0026rsquo;s maternal characteristics and lifestyle habits with controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCases (n\u0026thinsp;=\u0026thinsp;48) [Frequency (%)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControls (n\u0026thinsp;=\u0026thinsp;46) [Frequency (%)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHindu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41(50.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40(49.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.829\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(53.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(46.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eIron / Folic Acid Supplementation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36(57.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(67.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(32.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDietary Habits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Vegetarian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(51.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26(48.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.829\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVegetarian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMilk Consumption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(39.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34(60.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(68.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(31.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSerum Vitamin D Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36(60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24(40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.048\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(75.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(40.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(59.1%)\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\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eVitamin D deficiency has been linked to a variety of health consequences during pregnancy, and is a global public health concern. In this hospital based case control study conducted on pregnant women, our main aim was to find the association between Vitamin D status and iron deficiency anemia during pregnancy. We found maternal serum Vitamin D concentrations were significantly less in women affected with anemia as compared to normal pregnant women (mean: 19.61ng/ml in case group vs 29.43ng/ml in control group). Our results are in line with recent studies suggesting a strong association of low Vitamin D levels with anemia in pregnant women. Several studies reported low maternal vitamin D levels may be a risk factor for gestational anemia\u003csup\u003e[\u003cspan additionalcitationids=\"CR20 CR21 CR22\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere are various possible explanations for the link between vitamin D deficiency and maternal anaemia. Calcitriol, the active form of vitamin D, may upregulate erythropoietin receptor expression on erythroid progenitor cells and may have a proliferative impact on erythroid burst generating units, which is synergistic with erythropoietin\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Calcitriol has an essential part in the immune function control by reducing the activity of pro-inflammatory cytokines which could be critical to its involvement in anemia prevention\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Studies suggest an association between Vitamin D deficiency and upregulation of mRNA expression of hepcidin, a molecule resulting in decreased level of ferroportin responsible for iron absorption, which indicates adequate Vitamin D serum levels can provide additional protection against iron deficiency in pregnant women\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Vitamin D receptors have already been found in bone marrow, where its concentration is hundreds folds higher than in plasma.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOne of the most important findings of our study was the unexpectedly high prevalence of deficient Vitamin D levels among both groups (75% in case and 52.2% in control group). Hypovitaminosis D among North Indian pregnant women have also been widely reported\u003csup\u003e[\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. The rationale might be owing to insufficient sun exposure, dark skin complexion and a lack of dietary calcium consumption, as Vitamin D synthesis initiates in the skin after sun exposure\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. High amounts of atmospheric pollution in Indian metropolitan cities could also be an important factor\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe also accounted for several parameters as a risk factor for maternal anemia where we reported the education status and socioeconomic status of the mother can also be a risk factor for anemia. This may be attributed to the fact that educated women belonging to middle socioeconomic status tend to prioritize self-care, actively engage in antenatal care, maintain a nutritious diet, supplement with iron and calcium, and take measures to prevent potential parasitic infections. The educational component makes the subject group more aware and responsive to new concepts and contents of public health campaigns, making them more likely to adopt good healthy living and treatment seeking behaviour. On the other hand, uneducated and economically disadvantaged mothers are expected to lack proper nutrition\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e. This explains education and socioeconomic status are linked with maternal anemia.\u003c/p\u003e \u003cp\u003eOur results show a positive correlation of the effect of iron and folic acid (IFA) supplementation on maternal anemia which are consistent with various other studies\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. Although India has incorporated iron and folic acid supplementation schemes for pregnant women since 1970, these programmes have been hampered by a variety of problems and supply and coverage restrictions\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e. These schemes were relaunched in 2018 as Anemia Mukt Bharat (AMB) Abhiyan to address basic difficulties such as programme finance, execution, and last mile delivery but still the prevalence of anemia was very high during pregnancy\u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe discovered a link between regular milk consumption and anaemia. In contrast to our findings, coffee and milk have been recognised as possible iron absorption inhibitors, but only when high amounts of these items are ingested in the same meal as the iron\u003csup\u003e[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e. This also shows that pregnant women are better aware of the need to take calcium and iron supplements not in the same meal. Still pregnant women should be concerned about their milk consumption as milk is an excellent source of protein and minerals like calcium, and it is linked to an increased birth weight\u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA limitation of our study was the relatively small sample size. Therefore, further research involving a larger population size and considering long-term impacts is necessary to have a significant impact on public healthcare policy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe purpose of this study was to compare vitamin D levels in iron-deficient anemia and non anemic pregnant women. These findings provide evidence suggesting that Vitamin D deficiency or insufficiency during pregnancy may be a risk factor for anemia and correction of Vitamin D levels can improve hemoglobin levels. This study emphasised the need of improving vitamin D level in pregnant anaemic women by supplementing with vitamin D and iron. Further investigations at a larger scale on national level and multicentric trials need to be conducted to evaluate the direct relation of Vitamin D deficiency and iron deficiency anemia. Currently, Vitamin D supplementation is not recommended as a part of antenatal care program in India. In view of the high prevalence of low Vitamin D levels in pregnancy, educational efforts need to be made to include regular safe Vitamin D intake as a part of public health strategy to improve the health of both mothers and their offsprings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e25(OH)D: 25-hydroxyvitamin D; NFHS: National Family Health Survey; MCV: Mean Corpuscular Volume; MCH: Mean Corpuscular Hemoglobin; MCHC: Mean Corpuscular Hemoglobin Concentration; HIV: Human Immunodeficiency Virus; CLIA: Chemiluminescent Immunoassay Technology; SPSS: Statistical Package for Social Sciences; ANC: Antenatal Care; BMI: Body Mass Index; IQR: Interquartile Range; RBC: Red Blood Corpuscle; TLC: Total Leucocyte Count; AMB: Anemia Mukt Bharat; ICMR: Indian Council of Medical Research; STS: Short Term Studentship.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u0026nbsp;\u003c/strong\u003eEthical approval has been obtained from the Institutional Research Review Committee and Institutional Ethical Committee of Dr. Baba Saheb Ambedkar Medical College and Hospital (IRRC-5/2022), Delhi prior to the start of the study, and the methods were carried out in accordance with the approved guidelines. Informed written consent has been taken from all subjects before including them in the study. Prior to recruitment, pregnant women were given information about the study using the Participation Information Sheet. Confidentiality of all the data is ensured by keeping the responses and the collected data under a secure setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eThe datasets used in the present study are available with the ICMR STS-2022 registry (ICMR STS ID: 2022-02037) and with the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contribution:\u0026nbsp;\u003c/strong\u003eTH, RK and DD were responsible for conception of the study. TH, RK, DD and PA were advised to design. TH and RK collected the data. TH, RK, DD and RPJ analysed the data and interpreted the findings. TH and RK drafted and revised the manuscript. All authors approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u0026nbsp;\u003c/strong\u003eAuthors would like to thank Dr. S.N. Bhattacharya, Principal of Dr. Baba Saheb Ambedkar Medical College and Hospital, Delhi for examining this project and for sharing his valuable feedback. They would also like to thank ICMR for approving and supporting this project under the Short Term Studentship (STS) programme.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAparna P, Muthathal S, Nongkynrih B, Gupta SK. Vitamin D deficiency in India. J Fam Med Prim Care. 2018;7(2):324.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolick MF. Vitamin D and health: evolution, biologic functions, and recommended dietary intakes for vitamin D. 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Int J Trichology. 2019Mar;11(2):49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaleem SM. Modified Kuppuswamy scale updated for year 2018. Paripex Indian J Res. 2018Mar;7(3):217\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith EM, Alvarez JA, Martin GS, Zughaier SM, Ziegler TR, Tangpricha V. Vitamin D deficiency is associated with anaemia among African Americans in a US cohort. Br J Nutr. 2015Jun;113(11):1732\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas CE, Guillet R, Queenan RA, Cooper EM, Kent TR, Pressman EK, Vermeylen FM, Roberson MS, O\u0026rsquo;Brien KO. VitaminDstatusisinverselyassociatedwithanemiaandserumerythropoietinduringpregnancy.TheAmericanJournalofClinicalNutrition.2015Nov1;102(5):1088-95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaludjerovic J, Vieth R. Relationship between vitamin D during perinatal development and health. Journal of midwifery \u0026amp; women's health.2010 Nov1;55(6):550\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXia LI, Yao XI, Ge SO, Zhi-peng YU, Ling-ling WE, Ju-ying JI. Wei-min LI. Correlation between vitamin D concentration and gestational anemia. Xi'an jiao tong da xue xue bao.Yi xue ban.2019(5):819.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarei E, ُElmaghraby D, Gad AA. Vitamin D assessment in iron deficiency anemic pregnant women and their newborns. Egypt J Radiation Sci Appl. 2017;30(1):63\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAucella F, Scalzulli RP, Gatta G, Vigilante M, Carella AM, Stallone C. Calcitriol increases burst-forming unit-erythroid proliferation in chronic renal failure. Nephron Clin Pract. 2003;95(4):c121\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlon DB, Chaimovitz C, Dvilansky A, Lugassy G, Douvdevani A, Shany S, Nathan I. Novelroleof1,25(OH)2D3ininductionoferythroidprogenitorcellproliferation.Experimentalhematology.2002May1;30(5):403-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBikle D. Nonclassic actions of vitamin D.J Clin Endocrinol Metabolism 2009 Jan1;94(1):26\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSachan A, Gupta R, Das V, Agarwal A, Awasthi PK, Bhatia V. HighprevalenceofvitaminDdeficiencyamongpregnantwomenandtheirnewbornsinnorthernIndia.TheAmericanjournalofclinicalnutrition.2005May1;81(5):1060-4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSahu M, Bhatia V, Aggarwal A, Rawat V, Saxena P, Pandey A, Das V. Vitamin D deficiency in rural girls and pregnant women despite abundant sunshine in northern India. Clin Endocrinol. 2009May;70(5):680\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma S, Kumar A, Prasad S, Sharma S. 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SkinasthesiteofvitaminDsynthesisandtargettissuefor1,25-dihydroxyvitaminD3:useofcalcitriol(1,25-dihydroxyvitaminD3)fortreatmentofpsoriasis.Archivesofdermatology.1987Dec1;123(12):1677-83a.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgarwal KS, Mughal MZ, Upadhyay P, Berry JL, Mawer EB, Puliyel JM. TheimpactofatmosphericpollutiononvitaminDstatusofinfantsandtoddlersinDelhi,India.Archivesofdiseaseinchildhood.2002Aug1;87(2):111-3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiteti MC, Namasaka SD, Ariya OP, Injete SD, Wanyonyi WA. Anaemia in pregnancy: Prevalence and possible risk factors in Kakamega County, Kenya.Sci J public health 2014 May20;2(3):216\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanghvi TG, Harvey PW, Wainwright E. Maternal iron\u0026ndash;folic acid supplementation programs: evidence of impact and implementation. FoodNutr Bull. 2010Jun;31(2suppl2):100\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYakoob MY, Bhutta ZA. Effect of routine iron supplementation with or without folic acid on anemia during pregnancy. BMC publicly health. 2011Dec;11(3):1\u0026ndash;0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVijayaraghavan K, Brahmam GN, Nair KM, Akbar D, Pralhad Rao N. Evaluation of national nutritional anemia prophylaxis programme. Indian J Pediatr. 1990Mar;57(2):183\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKishore S, Singh M, Jain B, Verma N, Gawande K, Kishore S, Aggarwal P, Verma SK. A study to assess prevalence of anaemia among beneficiaries of Anaemia Mukt Bharat Campaign in Uttarakhand. J family Med Prim care. 2020Mar;9(3):1691.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePereira RC, Diniz AD, Ferreira LO. New findings on iron absorption conditioning factors. Revista Brasileira de Sa\u0026uacute;de Materno Infantil. 2004;4:241\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMannion CA, Gray-Donald K, Koski KG. Association of low intake of milk and vitamin D during pregnancy with decreased birth weight.Cmaj 2006 Apr25;174(9):1273\u0026ndash;7.\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":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pregnant women, vitamin D deficiency, anemia, obstetrics, maternal, developing countries, hemoglobin","lastPublishedDoi":"10.21203/rs.3.rs-3135046/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3135046/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eVitamin D deficiency and anemia are clinical conditions that coexist during pregnancy. High prevalence of Vitamin D deficiency ranging from 50\u0026ndash;94% is seen throughout the country. The aim of the study was to discover the association between Vitamin D status and iron deficiency anemia during pregnancy. Improving the vitamin D status of pregnant women is crucial to prevent iron deficiency anemia and can improve maternal and fetal outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA case control study including 94 primigravida women of age within the age group 18 to 30 years, divided into two groups: a Case Group of 48 patients with already diagnosed iron deficiency anaemia (mild to moderate) and a Control Group of 46 antenatal women with normal haemoglobin levels. Data on sociodemographic, clinical characteristics and the levels of 25(OH) Vitamin D was estimated in both the groups. The association of 25(OH)D levels and anaemia was then determined using suitable statistical analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong pregnant women affected with anemia, 75% of women had serum Vitamin D concentrations\u0026thinsp;\u0026lt;\u0026thinsp;20ng/ml compared to 52.2% of women in the controls. Maternal serum vitamin D was significantly lower in pregnant women affected with anemia (p\u0026thinsp;=\u0026thinsp;0.024). A positive correlation was found between hemoglobin and vitamin D levels in pregnant women (Pearson\u0026rsquo;s r\u0026thinsp;=\u0026thinsp;0.200, p\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThese findings provide evidence suggesting that Vitamin D deficiency or insufficiency during pregnancy may be a risk factor for anemia and correction of Vitamin D levels can improve hemoglobin levels. Educational efforts should be made to include safe vitamin D intake in antenatal care.\u003c/p\u003e","manuscriptTitle":"Unlocking the Mystery of the Role of Vitamin D in Iron Deficiency Anemia in Antenatal Women: A Case Control Study in a Tertiary Care Hospital in New Delhi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-17 14:20:48","doi":"10.21203/rs.3.rs-3135046/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-07-25T08:13:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-07-14T12:44:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5389134b-e574-48e1-be3e-3779a9be2d32","date":"2023-07-13T04:33:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-07-13T04:16:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-07-13T04:08:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-07-13T03:44:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-07-13T03:41:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2023-07-03T09:51:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"412e79c3-f881-46e8-9270-5f9be63fd588","owner":[],"postedDate":"July 17th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-30T15:03:59+00:00","versionOfRecord":{"articleIdentity":"rs-3135046","link":"https://doi.org/10.1186/s12884-023-06047-w","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2023-10-24 15:01:37","publishedOnDateReadable":"October 24th, 2023"},"versionCreatedAt":"2023-07-17 14:20:48","video":"","vorDoi":"10.1186/s12884-023-06047-w","vorDoiUrl":"https://doi.org/10.1186/s12884-023-06047-w","workflowStages":[]},"version":"v1","identity":"rs-3135046","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3135046","identity":"rs-3135046","version":["v1"]},"buildId":"369fNeqWncA4NS6XSWjrt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}