Discussion

In this study, 74.7% of pregnant women were anemic, with a mean hemoglobin level of 9.77 ± 1.60 g/dL, which is well below the WHO cut-off of 11 g/dL for defining anemia in pregnancy [1]. The median hemoglobin concentration was 10.1 g/dL (IQR: 8.7-11.6 g/dL), indicating a substantial burden of anemia among the study population. The prevalence observed in the present study was considerably higher than the national estimates reported by the NFHS-4 (50.3%) and NFHS-5 (52.2%) among pregnant women in India [7,17] but comparable with Mangla and Singla (75.4%) [4]. Tomar et al. (67.0%) [16] and Raj and Mangasuli (85.4%) [17] suggest that anemia continues to be a major public health problem among pregnant women in India despite ongoing supplementation programs.

Anemia was most common in the second trimester (78.6%), followed by the first (70.0%) and third (66.7%) trimesters. This finding is consistent with known pregnancy physiology where plasma volume increases by 40%-60%, while red blood cell mass rises by only 20%-50%. This causes dilutional anemia, especially in the second trimester [18]. The higher prevalence of anemia in the second trimester (78.6%) is consistent with physiological hemodilution during pregnancy and increasing iron requirements for maternal and fetal growth [12,18]. Similar trimester-wise patterns have been reported in previous Indian studies [4,16]. The increased anemia rates in the second trimester reflect the need for targeted screening and interventions at all antenatal visits during this critical time.

No significance was found between anemia severity and age, caste, religion, or family type in our study (p>0.05). However, educational status (p=0.008), occupation (p=0.002), and per-capita income (p=0.002) were significantly associated with anemia severity. In this study, severe anemia was most common among illiterate women (24.1%) and those in the lower-income group (25.0%). In contrast, only 2.7% of women with high school education or higher had severe anemia, and the same is reflected in NFHS-5 data [8]. In our study, women without formal education had nearly four times higher odds of severe anemia (AOR: 3.89, 95% CI: 1.76-6.82) than educated women. Similar associations between low educational status and anemia have been reported by Tomar et al. [16] and Ghosh-Jerath et al. [14]. Education helps women get timely antenatal care, know their dietary needs, and take iron supplements. Unemployed pregnant women had significantly higher odds of anemia than employed women (AOR: 4.98, 95% CI: 1.31-10.91). Lower-income women struggle to access iron-rich foods, antenatal services, and supplements. These socioeconomic disparities require targeted health programs to reduce anemia effectively.

Low dietary iron intake (<35 mg/day) was the factor most strongly and independently associated with anemia in the multivariable logistic regression analysis (AOR: 7.84). Among women consuming less than 35 mg/day of dietary iron, 83.6% were anemic, including 41.8% with moderate anemia. Iron deficiency is the leading cause of anemia in pregnancy, accounting for about 50% of all cases worldwide. Adherence to IFA supplementation also significantly influenced anemia rates. Anemia affected 88.5% of women with inadequate folic acid intake in the first trimester (p=0.004) and 92.6% of those lacking IFA intakes in the second trimester (p=0.04). This aligns with findings from North India, where consistent IFA use was strongly linked to lower anemia rates (OR=0.26, 95% CI: 0.12-0.55) [19]. However, uptake remains low due to supply chain gaps and demand-side barriers. These findings denotes the importance of strong supply chains, Accredited Social Health Activist-led counseling, and early antenatal care registration. This ensures continuous supplementation starting from the first trimester.

A history of worm infestation was also independently associated with anemia (AOR: 4.82), with 93.3% being anemic among them. Soil-transmitted helminths, such as hookworms, cause chronic blood loss. This impairs iron absorption and can lead to anemia in women of reproductive age. A Cochrane review found that intestinal helminthiasis leads to blood loss and less nutrients for blood production. This causes iron deficiency anemia, impacting 44 million pregnancies globally each year [20]. Despite this, deworming treatments are underused in antenatal care program in India. Routine deworming with albendazole after the first trimester should be integrated into antenatal services, especially in endemic areas, to tackle this preventable cause of maternal anemia.

Higher gravida status was independently associated with increased odds of anemia. The prevalence of anemia increased from 68.4% among primigravid women to 89.3% among women with three or more pregnancies (AOR: 2.33). This finding supports the concept that repeated pregnancies progressively deplete maternal iron stores when adequate replenishment does not occur between pregnancies. Multiparous women have been reported to have lower serum ferritin concentrations than nulliparous women, increasing their risk of anemia during pregnancy and at delivery. Similarly, Munro et al. reported that multiparity was associated with an increased risk of anemia, whereas primigravid women were 61% less likely to be anemic than multigravida women [21]. These findings underscore the importance of preconception nutritional optimization, adequate iron supplementation, and appropriate interpregnancy intervals to restore maternal iron stores and reduce the risk of anemia in subsequent pregnancies.

A history of menstrual spotting was also independently associated with anemia (AOR: 1.52), with 87.0% of these women being anemic, consistent with the findings of Sinha et al. [18]. Chronic blood loss resulting from abnormal uterine bleeding before pregnancy may contribute to depleted iron stores and increase the risk of anemia during pregnancy. Menstrual abnormalities are often overlooked as a contributing factor to maternal anemia. These findings highlight the importance of screening for menstrual disorders during the preconception period, providing timely gynecological evaluation and treatment, and strengthening the AMB program to improve iron status before pregnancy.

Study strengths

This study provides recent evidence on the prevalence and determinants of anemia among pregnant women in a rural primary care setting. Hemoglobin estimation was performed using the validated HemoCue point-of-care device, ensuring reliable assessment, and a comprehensive evaluation of sociodemographic, obstetric, dietary, and supplementation-related factors was undertaken. The study provides important evidence on the burden and determinants of anemia among pregnant women in a rural primary care setting, supporting the need for strengthened screening and targeted interventions.

Study limitations

This study was limited by its facility-based cross-sectional design, and consecutive recruitment from a single rural antenatal clinic may have introduced selection bias and limited the generalizability of the findings. The cross-sectional design also precludes establishing temporal relationships or causal inferences. Information on dietary intake, IFA supplementation, and history of worm infestation was self-reported and may be subject to recall bias. Although hemoglobin estimation using the HemoCue system is a validated point-of-care method, confirmatory laboratory investigations were not performed.