Results

The median hemoglobin level was 10.1 g/dL (IQR: 8.7-11.6 g/dL), which was below the WHO cut-off of 11 g/dL. The mean hemoglobin concentration was 9.77 ± 1.60 g/dL. Overall, 74.7% of pregnant women were anemic, indicating a substantial burden of anemia in the study population (Figure 1).

Figure 1: Distribution of hemoglobin levels among pregnant women (n=186)

The prevalence of anemia was highest during the second trimester (78.6%), followed by the first trimester (70.0%) and third trimester (66.7%). Non-anemic women constituted only 21.4% of second-trimester participants. These findings suggest that anemia remains common throughout pregnancy, particularly during the second trimester (Figure 2).

Figure 2: Prevalence of anemia across trimesters of pregnancy (n=186)

No statistically significant association was observed between anemia severity and age, caste, religion, or family type (p>0.05). Moderate anemia was the predominant category across most socio-demographic groups. A relatively higher proportion of severe anemia was observed among women from scheduled tribe communities and three-generation families (Table 1).

Socio-demographic characteristics |  | Mild anemia, n (%) | Moderate anemia | Severe anemia | Anemia absent | Total | ꭓ2 | p-value
Age in years | 18-24 | 29 (33.3) | 23 (26.4) | 9 (10.3) | 26 (29.9) | 87 | 4.61 | 0.59
25-30 | 25 (31.3) | 29 (36.2) | 7 (8.7) | 19 (23.8) | 80
>30 | 7 (36.8) | 8 (42.1) | 2 (10.4) | 2 (10.4) | 19
Caste | SC | 10 (26.3) | 15 (39.5) | 4 (10.5) | 9 (23.7) | 38 | 8.62 | 0.19
ST | 14 (37.8) | 13 (35.1) | 6 (16.2) | 4 (10.8) | 37
OBC | 37 (33.3) | 32 (28.8) | 8 (7.2) | 34 (30.6) | 111
Religion | Hindu | 48 (32.2) | 53 (35.6) | 13 (8.7) | 35 (23.5) | 149 | 4.73 | 0.57
Muslim | 7 (36.8) | 4 (21) | 2 (10.5) | 6 (31.5) | 19
Others | 6 (33.3) | 3 (16.7) | 3 (16.7) | 6 (33.3) | 18
Type of family | Nuclear | 31 (28.7) | 37 (34.3) | 7 (6.5) | 33 (30.5) | 108 | 10.30 | 0.11
Joint | 11 (33.3) | 11 (33.3) | 3 (9.1) | 8 (24.2) | 33
Three generation | 19 (42.2) | 12 (26.7) | 8 (17.7) | 6 (13.3) | 45

Educational status (p=0.008), occupation (p=0.002), and per-capita income (p=0.002) showed significant associations with anemia severity. Socioeconomic status was classified using the modified BG Prasad scale of 2017, grouping monthly per-capita income into upper (Class I and II), middle (Class III), and lower (Class IV and V) socioeconomic strata. Severe anemia was highest among illiterate women (24.1%) and women from the lower-income group (25.0%), compared to 2.7% among women educated up to high school and above. Anemia was present among 83.8% of unemployed women. Normal hemoglobin levels were highest among women with high school education and above (40.5%) and skilled workers (65.0%) (Table 2).

Socio-demographic characteristics | Category | Normal, n (%) | Anemia | Total, n | ꭓ2 | p-value
Mild, n (%) | Moderate, n (%) | Severe, n (%)
Education | Illiterate | 3 (10.3) | 12 (41.3) | 7 (24.1) | 7 (24.1) | 29 | 14.10 | 0.008*
Primary and middle | 29 (24.2) | 37 (30.8) | 44 (36.6) | 10 (8.3) | 120
High school and above | 15 (40.5) | 12 (32.4) | 9 (24.3) | 1 (2.7) | 37
Occupation | Unemployed | 18 (16.2) | 44 (39.6) | 38 (34.2) | 11 (9.9) | 111 | 21.54 | 0.002*
Unskilled | 5 (25) | 5 (25) | 7 (35) | 3 (15) | 20
Semiskilled | 11 (31.4) | 8 (22.8) | 13 (37.1) | 3 (8.5) | 35
Skilled and above | 13 (65) | 4 (20) | 2 (10) | 1 (5) | 20
Per-capita income | Upper | 26 (33.3) | 34 (43.6) | 15 (19.2) | 3 (3.8) | 78 | 18.73 | 0.002*
Middle | 15 (23.4) | 20 (31.25) | 25 (39) | 4 (6.2) | 64
Lower | 6 (13.6) | 7 (15.9) | 20 (45.4) | 11 (25) | 44

Dietary iron intake was significantly associated with anemia severity (p=0.001), whereas calorie intake (p=0.29) and protein intake (p=0.23) were not. Among women consuming <35 mg/day of iron, 83.6% were anemic, including 41.8% with moderate anemia. In contrast, among those consuming ≥35 mg/day, 61.5% had normal hemoglobin levels (Table 3).

Nutrient intake | Category | Normal, n (%) | Anemia | Total, N | ꭓ2 | p-value
Mild, n (%) | Moderate, n (%) | Severe, n (%)
Calorie intake (kcal/day) | <2250 | 41 (23.7) | 57 (32.9) | 58 (33.5) | 17 (9.8) | 173 | 3.74 | 0.29
>2250 | 6 (46.1) | 4 (30.8) | 2 (15.4) | 1 (7.7) | 13
Protein intake (g/day) | <78 | 41 (23.5) | 58 (33.3) | 58 (33.3) | 17 (9.7) | 174 | 4.27 | 0.23
>78 | 6 (50) | 3 (25) | 2 (16.6) | 1 (8.3) | 12
Iron intake (mg/day) | <35 | 15 (11.2) | 48 (35.8) | 56 (41.8) | 15 (11.2) | 134 | 25.46 | 0.001*
≥35 | 32 (61.5) | 13 (25) | 4 (7.7) | 3 (5.7) | 52

Dietary iron intake was significantly associated with anemia severity (p=0.001), whereas calorie intake (p=0.29) and protein intake (p=0.23) were not. Among women consuming <35 mg/day of iron, 83.6% were anemic, including 41.8% with moderate anemia. In contrast, among those consuming ≥35 mg/day, 61.5% had normal hemoglobin levels.

Among first-trimester women, anemia was present in 88.5% of those with inadequate folic acid intake compared with 53.4% among those with adequate intake (p=0.004). In the second trimester, anemia was observed in 92.6% of women with inadequate IFA intake compared with 74.1% among those with adequate intake (p=0.04). The lack of statistical significance in the third trimester (p=0.59) is likely due to low statistical power caused by the small number of participants (n=18) in this subgroup (Table 4).

Trimester (supplement) | Intake | Normal, n (%) | Anemic, n (%) | Total, n | ꭓ2 | p-value
First trimester (folic acid tablet intake) | Adequate | 14 (46.6%) | 16 (53.4%) | 30 | 8.38 | 0.004*
Inadequate | 3 (11.5%) | 23 (88.5%) | 26 | 
Second trimester (IFA tablet intake) | Adequate | 22 (25.9%) | 63 (74.1%) | 85 | 4.22 | 0.04*
Inadequate | 2 (7.4%) | 25 (92.6%) | 27 | 
Third trimester (IFA tablet intake) | Adequate | 5 (31.2%) | 11 (68.8%) | 16 | 0.29 | 0.59
Inadequate | 1 (50.0%) | 1 (50.0%) | 2 | 

Anemia was significantly associated with duration of menstruation (p=0.03), menstrual spotting (p=0.04), gravida status (p=0.002), and history of worm infestation (p=0.001). The prevalence of anemia was 87.0% among women with a history of spotting and 93.3% among those reporting worm infestation. Anemia prevalence increased from 68.4% in primigravida women to 89.3% among gravida 3 women (Table 5).

 | Category | Normal, n (%) | Anemic, n (%) | Total, n | ꭓ2 | p-value
Duration of menstruation | 3-7 days | 44 (24.8) | 133 (75.2) | 177 | 7.02 | 0.03*
<3 days | 2 (40) | 3 (60) | 5
>7 days | 1 (25) | 3 (75) | 4
Spotting | Yes | 3 (13) | 20 (87) | 23 | 4.22 | 0.04*
No | 44 (27) | 119 (73) | 163
Gravida | Primi | 36 (31.6) | 78 (68.4) | 114 | 12.43 | 0.002*
Gravida 2 | 8 (18.2) | 36 (81.8) | 44
Gravida 3 | 3 (10.7) | 25 (89.3) | 28
History of worms in stools | Yes | 3 (6.7) | 42 (93.3) | 45 | 11.87 | 0.001*
No | 44 (31.2) | 97 (68.8) | 141

Educational status was dichotomized as illiterate, primary education, and above. Per capita income was categorized as Classes I-III and Classes IV-V according to the Modified BG Prasad socioeconomic classification (Table 6).

Independent variable | Category | β coefficient | Wald χ² | Adjusted OR (AOR) | 95% CI | p-value
Maternal education | Primary and above (ref) | – | – | 1.00 (ref) | – | –
Illiterate | 1.36 | 2.66 | 3.89 | 1.76-6.82 | 0.020*
Maternal occupation | Employed (ref) | – | – | 1.00 (ref) | – | –
Unemployed | 1.61 | 5.57 | 4.98 | 1.31-7.91 | 0.019*
Per-capita income | Class I-III (ref) | – | – | 1.00 (ref) | – | –
Class IV-V | 0.46 | 0.51 | 1.58 | 1.05-3.59 | 0.040*
Dietary iron intake | ≥35 mg/day (ref) | – | – | 1.00 (ref) | – | –
<35 mg/day | 2.06 | 8.56 | 7.84 | 4.91-12.14 | <0.001*
IFA/folic acid intake | Adequate (ref) | – | – | 1.00 (ref) | – | –
Inadequate | 1.09 | 3.91 | 2.98 | 1.01-4.79 | 0.038*
History of worms in stools | No (ref) | – | – | 1.00 (ref) | – | –
Yes | 1.57 | 5.15 | 4.82 | 1.24-8.67 | 0.023*
Obstetric profile (gravida) | Primigravida/gravida 2 (ref) | – | – | 1.00 (ref) | – | –
Gravida 3 | 0.85 | 1.28 | 2.33 | 1.54-4.12 | 0.030*
Menstrual spotting history | No (ref) | – | – | 1.00 (ref) | – | –
Yes | 0.42 | 0.72 | 1.52 | 1.11-3.41 | 0.040*

Low dietary iron intake (<35 mg/day) was the factor most strongly associated with anemia (AOR: 7.84) (Table 6), followed by maternal unemployment (AOR: 4.98), history of worm infestation (AOR: 4.82), and illiteracy (AOR: 3.89). Lower socioeconomic status, inadequate IFA supplementation, gravida ≥3, and menstrual spotting were also independently associated with increased odds of anemia (Figure 3).

Figure 3: Forest plot of adjusted odds ratios for factors associated with anemia among pregnant women (n=186)