Background: Anemia in pregnancy is a major public health problem in developing countries. In sub-Saharan Africa, such anemia is generally accepted as resulting from nutritional deficiencies, particularly iron deficiency. Objective: We comprehensively assessed the full spectrum of nutritional and nonnutritional factors associated with pregnancy anemia. Design: Iron, folate, vitamin B-12, and vitamin A were measured in serum in a cross-sectional study of 150 pregnant women in Blantyre, Malawi. Bone marrow aspirates were evaluated, peripheral blood films were examined for malaria parasites, stool and urine samples were examined for helminthic infection, and tests were done for genetic disorders and for HIV infection. Creactive protein (CRP) concentrations and erythrocyte sedimentation rates were measured as markers of inflammation. Results: Of the 150 anemic women, 23% were iron deficient with no evidence of folate, vitamin B-12, or vitamin A deficiencies; 32% were deficient in iron and one or more of the other micronutrients; 26% were not iron deficient but had evidence of one of the other micronutrient deficiencies, most often vitamin A; and 19% were not deficient in any of the micronutrients studied. CRP concentrations were notably high in 54% of the anemic women with no nutritional deficiencies and in 73.5% of the anemic women who were iron replete by bone marrow assessment. Conclusion: The role of chronic inflammation as a possible contributing factor to anemia in pregnancy has important implications for the clinical evaluation and treatment of women.

Abstract. Malaria and anemia are common in pregnant African women. We screened 4,764 Malawian women at first antenatal visits for malaria and anemia. A total of 42.7% had a malaria infection, which was more common and of higher density in primigravidae (prevalence ϭ 47.3%, geometric mean ϭ 332 parasites/l) and teenagers (49.8%, 390/1) than in multigravidae (40.4%, 214/l) or older women (40.6%, 227/l). However, 35% of gravida 3ϩ women were parasitemic. A total of 57.2% of the women was anemic (hemoglobin Ͻ 11 g/dl), with moderate anemia (7.0-8.9 g/dl) in 14.9% and severe anemia (Ͻ 7 g/dl) in 3.2%. Prevalences of malaria and anemia were highest in the rainy season. Women with moderate/severe anemia had higher parasite prevalences and densities than women with mild/no anemia. Logistic regression showed that age, season, and trimester of presentation were significantly associated with the prevalence of malaria, but gravidity was not. In this urban setting, age and season are more important than gravidity as predictors of malaria at first antenatal visit, and parasitemia is frequent in women of all gravidities.

Abstract. The relationship between asymptomatic human immunodeficiency virus (HIV) infection and blood hemoglobin (Hb) concentration was examined in anemic pregnant women from a population with high prevalence of both anemia (60%) and HIV seropositivity (30%). Sera from 155 pregnant women with Hb levels Ͻ 10.5 g/dL were tested for HIV status, C-reactive protein (CRP), vitamin B 12 , retinol, and folate levels. The observed prevalence of HIV seropositivity in the group of women with anemia was 47.1% (95% confidence interval ϭ 39.2-55.0%). This is significantly higher than the HIV prevalence in the whole population (30.1%; P Ͻ 0.001). Median Hb values in HIV-seropositive and -seronegative women with anemia were 8.40 g/dL and 8.95 g/dL, respectively. Serum retinol, vitamin B 12 , and folate levels were not significantly different in the HIV-seropositive and -seronegative groups. In women who were HIV-seropositive with normal levels of CRP, a median decrease in Hb of 0.4g/dL was observed. For those with serum CRP levels Ͼ 25 mg/l, the median decrease in Hb was 0.7 g/dL. Results indicate that asymptomatic HIV infection is associated with increased prevalence and severity of anemia in pregnancy in this population.The World Health Organization estimates that at least 50% of pregnant women in Africa are anemic. 1 In sub-Saharan Africa, the prevalence rates reported are between 58% and 75%.

The prevalence of anaemia in pregnancy in our population is unacceptably high and deserves more attention. Prophylaxis of all women rather than an 'at risk' group based on age or gravidity is recommended.

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