STRENGTHS AND LIMITATIONS OF THIS STUDY

The study used a systematic random sampling method, which enhances the representativeness of the sample.

Data collection was done using KoboCollect software, ensuring efficient and accurate data entry.

The cross-sectional design limits the ability to establish causality between identified factors and immediate postpartum anaemia.

The study was conducted in public hospitals, which may not capture anaemia prevalence and associated factors in private or rural health facilities.

Self-reported data on adherence to iron and folic acid supplementation could be subject to recall bias.

Introduction

The postpartum period is a critical phase in the lives of both mothers and newborns. It is during this time that the majority of maternal and infant deaths occur. Despite its importance, the postpartum period is often neglected in terms of quality care, particularly in developing countries.1 The postpartum period begins immediately after the birth of the baby and extends up to 6 weeks (42 days) after birth. Postpartum period was classified into immediate, early and late periods based on care provision. The immediate postpartum period refers to the time just after the birth of the baby and covers the first 24 hours from birth.2

Anaemia is defined as low levels of haemoglobin in the blood and has been found to be a public health issue affecting both developing and developed countries. Anaemia, characterised by low haemoglobin levels in the blood, is recognised as a significant public health concern in both developing and developed countries.3 While there is no universally accepted definition of postpartum anaemia, many researchers define it as haemoglobin levels below 110 g/L at 1 week postpartum and below 120 g/L at 8 weeks postpartum.4 5

Anaemia is a global public health problem affecting more than 800 million reproductive-age women. Anaemia is associated with adverse effects on the population’s health and social and economic development in low, middle and high-income countries.6–8 Anaemia in the postpartum period is a widespread global health problem, with high prevalence rates in low-income countries ranging from 50% to 80%.4

In developing countries, postpartum anaemia is the most common cause of maternal morbidity and mortality. Among 500 000 maternal deaths occurring each year on a global scale in association with childbirth, 20% are caused by peripartum haemorrhage and anaemia.9 In sub-Saharan Africa, the magnitude of immediate postpartum anaemia is much higher due to the burden of infectious diseases such as malaria, helminth infestation and HIV/AIDS.10–12

Globally, the magnitude of anaemia in the immediate postpartum period was 22% in Berlin, Germany, and 29% in Madrid, Spain.13 14 In Africa, the prevalence of postpartum anaemia ranges from 16% to 73%.15 16 Between 24.2% and 28.1% of women in Ethiopia experience anaemia during the immediate postpartum period.17–19 Postpartum anaemia was a severe public health problem in the Somali and Afar regions and a moderate health problem in other regions of Ethiopia.20 Anaemia is an indirect cause of maternal mortality in Ethiopia, accounting for 2% of all maternal deaths.21

Despite its high prevalence and significant burden, postpartum anaemia is challenging to predict. A study conducted in Madrid, Spain, revealed that selective screening for postpartum anaemia failed to identify 23% of cases.14 Reducing immediate postpartum anaemia is a key element of Target 2 in the WHO’s (WHO) plan to achieve a 50% reduction in anaemia by the end of 2025, aligning with the Sustainable Development Goals (SDGs).22 In Ethiopia, postpartum anaemia among lactating women increased from 18% in 2011 to 28.6% in 2016.23 24

Anaemia can arise from various causes, with iron deficiency being the most significant. Iron deficiency accounts for approximately 50% of anaemia cases, though this proportion likely varies across populations and regions based on local conditions. Often preceding anaemia, iron deficiency is recognised as one of the most common forms of nutritional anaemia.3 4 6 Anaemia during pregnancy is one of the strongest factors contributing to postpartum anaemia, beginning just after childbirth and continuing throughout the postpartum period.7

In many low- and middle-income countries, women may also experience significant iron loss from bleeding during childbirth and diets that are low in bioavailable iron.8 In the majority of women, postpartum anaemia is caused by moderate-to-heavy bleeding in association with delivery. Due to interindividual differences in coagulation profiles between women, blood loss at normal deliveries is considerably different. Bleeding greater than average blood losses of approximately 300 mL may cause an increased reduction of body iron stores and elicit prolonged iron deficiency and iron deficiency anaemia (IDA) in the postpartum period.4 9

Factors that contribute to immediate postpartum anaemia were low educational status of the mother, young maternal age <20 years, rural residence, caesarean mode of delivery, episiotomy-assisted delivery, anaemia during pregnancy, antepartum haemorrhage (APH), postpartum haemorrhage (PPH), antenatal care (ANC) visits less than four times, malaria and poor adherence to iron and folic acid (IFA) intake during pregnancy.11 13 14 17

The effects of anaemia during the postpartum period can be serious and have long-term health implications for the mother and her infant.3 Postpartum anaemia is associated with an increased prevalence of tiredness, breathlessness, lowered work performance and infections, particularly in the urinary tract and mastitis. It delays wound healing, increases the risk of readmission and prolongs hospitalisation.4 25–27

Immediate postpartum anaemia decreases cognitive performance, induces emotional instability and distress and increases the risk of postpartum depression. These disturbances with the mother’s emotional and cognitive functioning may, in turn, affect her interactions with the infant and may negatively impact infant behaviour and development.4

While anaemia has been studied extensively in pregnant women, anaemia in the immediate postpartum period is the least emphasised illness. Despite the WHO recommendation of iron and folic acid supplementation to postpartum women for 6–12 weeks following delivery to reduce the risk of anaemia, the supplementation of iron and folic acid is low in Ethiopia.3 Since postnatal follow-up is low in Ethiopia, 34%,28 early identification is very important for the prevention and treatment of postpartum anaemia.

In Ethiopia, particularly in the study area, screening for immediate postpartum anaemia after delivery is selective, which may result in an increased number of unidentified cases. Immediate postpartum anaemia is caused by a number of factors, and it can be difficult to generalise the causes to all mothers who reside in different regions. Early detection and the identification of potential risk factors are important to manage immediate postpartum anaemia promptly to avoid further complications. Therefore, this study is intended to determine the magnitude and associated factors of anaemia among immediate postpartum mothers at public hospitals in the North Shoa Zone, Oromia regional state, Ethiopia, 2022.

Materials and methodsStudy setting and period

This study was conducted in the North Shoa Zone public hospitals from 25 August to 26 October 2022. North Shoa Zone is located in the Oromia regional state bordered on the South by Addis Ababa, on the Southwest by West Shoa, on the North by the Amhara Region and on the Southeast by East Shoa. Fitche town is the capital city of the North Shoa Zone located 114 km north of Addis Ababa. There are five public hospitals in the North Shoa Zone serving more than 1 598 658 people.29 All hospitals provide maternal and child health services like delivery service, ANC service, postnatal care service, caesarean section, family planning and immunisation services.

Study design

A facility-based cross-sectional study design was conducted.

Source and study populationSource population

All immediate postpartum mothers who gave birth in North Shoa Zone public hospitals and mothers who gave birth somewhere else but come to the hospital within 24 hours of the postpartum period.

Study population

All randomly selected immediate postpartum mothers who gave birth in selected public hospitals or gave birth somewhere else but came to the hospital within 24 hours of the postpartum period were considered as a study population.

Sampling unit

Sampling units were immediate postpartum mothers who were selected for the study.

Inclusion and exclusion criteriaInclusion criteria

All immediate postpartum mothers who gave birth in public hospitals or gave birth somewhere else but came to the hospital within 24 hours of the postpartum period were included.

Exclusion criteria

Postpartum mothers who were anaemic during pregnancy were excluded from this study.

Sample size determination and sampling techniqueSample size determination

Sample size calculation was based on a single population proportion formula by using the following assumptions: 28.1% of the population proportion from previous studies done in eastern Ethiopia,19 95% confidence level and 5% margin of error. Accordingly, the sample size was calculated using single population proportion formula as follows:

n= ((Zα/2)2*(p)(1 p))/d2

where: n=the minimum sample size.

Zα/2=the standard normal distribution curve value at the 95% confidence level (1.96)

p=population proportion (28.1%)

d=margin of error (5%)

Therefore, the value of n will be calculated as follows

n= ((1.96)2*(0.281)(0.719))/0.052.

n=310

Finally, by adding a 10% non-response rate, the final sample size was 341.

Sampling technique

The study was conducted in three public hospitals in the North Shoa Zone. Three public hospitals were selected purposively among five hospitals in the North Shoa Zone. Systematic random sampling was employed to select the study participants. The sum of the 2-month delivery report, which is 678, was taken from three hospitals, and the kth-value was calculated. The sampling fraction (kth–value) is determined by dividing the average number of women previously delivered by the sample size (678/341=2). After proportional allocation of the sample size, a lottery method was employed to select the first study participant. Postnatal registration numbers were used to select postpartum mothers with a systematic random sampling technique, using every second registration number. Data collection was continued at every kth-value until the sample size was reached.

Study variablesDependent variable

Immediate postpartum anaemia.

Independent variables

Sociodemographic-related variables include age, maternal educational level, maternal occupation, religion, residence, marital status and estimated monthly income.

Obstetrics-related variables include antenatal care visits, frequency of antenatal care visits, parity, antepartum haemorrhage, multiple pregnancies, history of abortion, inter-pregnancy interval, place of delivery, mode of delivery, episiotomy, perineal tear, weight of newborn baby, and postpartum haemorrhage.

Comorbid disorder-related variables include helminth infestation and malaria infection

Dietary and micronutrient uptake-related variables include hot drink (tea, coffee or milk) while taking iron, meal frequency per day, food diversity, iron and folic acid supplementation, adherence to IFA, and MUAC.

Operational definitions

Immediate postpartum period is the first 24 hours after childbirth.2

Immediate postpartum anaemia is when the haemoglobin level is less than 110 g/L within 24 hours of the postpartum period. Haemoglobin concentration was measured at 8 hours after delivery.9 30

Good adherence to iron and folic acid supplementation means women who had taken iron and folate supplements for greater than 90 days during the most recent pregnancy. Poor adherence to iron and folic acid supplementation means women who had taken iron and folate supplements for less than 90 days during the most recent pregnancy.24 31

High food diversity if the women consumed at least five food groups out of ten food groups within 24 hours.32

Low food diversity if women consumed less than five food groups out of ten food groups within 24 hours.32

Data collection tools and procedures

Data were collected by KoboCollect software using an interviewer-administered structured questionnaire. The questionnaire was adapted from different literature14 17–19 conducted in different countries. The questionnaire was prepared in English and translated by language translators into Afan Oromo and then back to English to keep consistency. Three BSc midwives and two MSc midwives were recruited for data collection and supervision, respectively. Three BSc laboratory technicians were recruited to collect blood samples and analyse haemoglobin levels. After taking written informed consent, data were collected through both face-to-face interviews and retrospective clinical chart reviews using a structured questionnaire. All of the mothers' medical record charts were checked for any diagnosed obstetric and medical complications, newborn weight, parasite illness and other clinical characteristics. The questionnaire contains four parts: part 1 sociodemographic characteristics, part 2 obstetric characteristics, part 3 dietary and micronutrient uptake characteristics and part 4 comorbid disorder-related variables (for details, refer to online supplemental table 1(Annex)).

MUAC was measured by WHO and United Nations International Children’s Emergency Fund (UNICEF) standard MUAC tape measures on the nondominant hand, mostly the left hand. It is measured at the point between the tips of the shoulder and elbow by using nonstretchable tape. WHO recommendations of cut-off point <23 cm as undernourished and ≥23 cm as well-nourished were used to interpret the result.33 A blood sample was collected and processed using the standard procedures for haemoglobin determination. About 2 mL blood was collected with an EDTA tube, and haemoglobin concentration was determined by using the automated blood analyser Cell-Dyne 1800 (Abbott Laboratories Diagnostic Division, USA) by the laboratory technician. A blood sample was collected from each study participant after 8 hours of delivery. Based on the haemoglobin level, postpartum anaemia is classified as mild 100–109 g/L, moderate (70–99 g/L) and severe anaemia <70 g/L.34 The value of haemoglobin level was recorded, disclosed to each participant and attached to their respective charts.

Dietary diversity developed as a proxy indicator to indicate the micronutrient adequacy of women’s diets. Ten food groups were recommended by the United States Agency for International Development (USAID) and the Food and Nutrition Technical Assistance Project (FANTA) to classify reproductive-age women as higher or lower dietary diversity if they consumed least five and less than five of ten food groups.32

Data quality control and management

One-day training was provided for both data collectors and a supervisor. Training was provided on the objectives of the study, the data collection method and the data collection tool. The questionnaire was pretested at Canco General hospital which is out of the study area with 5% (17) of the sample size. After the pretest, the questionnaire’s appropriateness, clarity and completeness were modified accordingly. Completeness of data was checked daily by supervisors and principal investigators.

Data processing and analysis

Collected data were checked for completeness, consistency and clarity. The data were cleaned and coded. Collected data were exported to the Statistical Package for Social Science (SPSS) version 26 for analysis. Descriptive analysis, frequency, magnitude, means and SD were computed and presented with texts, tables, charts and graphs. A multicollinearity test was done by using the variance inflation factor (VIF), which was less than 10. Bivariable logistic regression and multivariable logistic regression were done to see the association between variables. A variable with a p-value <0.2 in binary logistic regression was entered into a multivariable logistic regression to control for possible confounders. Crude ORs and adjusted ORs with 95% confidence intervals were calculated. The model goodness of fit was checked by Hosmer–Lemeshow statistics. Statistical significance was declared at a p-value of <0.05 and a 95% confidence level.

ResultsSociodemographic characteristics

Out of 341 immediate postpartum mothers, 328 were involved in this study, giving a response rate of 96.2%. Among the nonrespondents, five of them refused to give a blood sample, and the data collected from eight mothers were incomplete. The mean age of the study participants was 26.92 years with a SD of±5.39. Nearly one-third (31.4%) of the mothers were able to write and read, and ninety six (29.3%) mothers were government employees by their occupation. Three-fourth of the study participants (74.7%) were Orthodox Christian followers. Close to half (43%) of the study respondents were from rural areas. Nearly one-third (31.1%) of the study participants' estimated monthly income was between 3001 and 5000 ETB, with a median income of 4000 birr and IQR±4000 birr (table 1).

Table 1

Sociodemographic characteristics of postpartum mothers who delivered at North Shoa Zone public hospitals, Oromia regional state, 2022 (n=328)

Obstetrical related characteristics

Among the total 328 study participants, 173 (52.7%) of them were multipara mothers. One hundred fourteen (56.7%) mothers had a short interpregnancy interval of less than 2 years. A majority, 274 (83.5%), of the study participants had ANC follow-up during the most recent pregnancy. Among mothers who had ANC follow-up, 173 (63.1%) of them had at least four ANC visits, and half, 137 (50%), of them started the follow-up before 16 weeks of gestation. Almost all, 322 (98.2%), of the mothers delivered their babies in a health facility, and close to three-fourth, 243 (74.1%),of the study respondents gave childbirth through spontaneous vaginal delivery (table 2).

Table 2

Obstetrics-related characteristics of postpartum mothers who delivered at North Shoa Zone public hospitals, Oromia regional state, 2022 (n=328)

Dietary practice and micronutrient related characteristics

Two hundred sixty-seven study participants were started on iron and folic acid tablets during the most recent pregnancy, and only 121 (45.3%) of them had good adherence. Among those mothers who took IFA tablets, 122 (45.7%) of them were started before 16 weeks of gestation. Among mothers who supplemented with IFA tablets, 114 (42.7%) participants drank hot drinks when they took iron. Two hundred fourteen (65.2%) study participants had low food diversity. Slightly more than half, 167 (50.9%), of mother’s MUAC was greater than 23 cm (table 3).

Table 3

Dietary and micronutrients-related characteristics of postpartum mothers who delivered at North Shoa Zone public hospitals, Oromia regional state, 2022 (n=328)

Comorbid disorder related characteristics

Thirty-four (10.4%) study participants had parasites and medical illnesses that were clinically confirmed before and/or during the latest pregnancy. Among these, preeclampsia was the most common complaint in 22 (62.9%), whereas malaria was the least one in 2 (5.7%) (figure 1).

Figure 1

Comorbid disorders during pregnancy among postpartum mothers who delivered at North Shoa Zone public hospitals, Oromia Regional State, 2022. The figure illustrates the percentage distribution of comorbid disorders among postpartum mothers in North Shoa Zone, Oromia. Disorders include preeclampsia, helminth infestations, HIV/AIDS, malaria and others. The data are represented as percentages of the total number of mothers who experienced each condition during pregnancy.

Magnitude of immediate postpartum anaemia

The magnitude of anaemia in the immediate postpartum period was 28.4% (95% CI 23.5 to 33.3). Postpartum haemoglobin levels of study participants were between 64 g/L and 160 g/L, with a mean value of 115.2 g/L and SD±16.4 g/L. From the total 93 (28.4%) anaemic postpartum mothers, 51 (15.6%), 40 (12.2%) and 2 (0.6%) of them were classified as mild, moderate, and severe anaemia, respectively (figure 2).

Figure 2

Magnitude of immediate postpartum anaemia among mothers who delivered at North Shoa Zone public hospitals, Oromia regional state, 2022. The figure shows the distribution of anaemia severity among postpartum mothers in North Shoa Zone. Categories include no anaemia (blue colour), mild anaemia (red colour), moderate anaemia (green colour) and severe anaemia (light purple colour), with percentages representing the proportion of mothers in each category. The data highlight the prevalence of anaemia in the immediate postpartum period.

Factors associated with immediate postpartum anaemia

In bivariable logistic regression analysis, age, parity, mode of delivery, rural residence, PPH, history of abortion, poor adherence to IFA, APH, multiple pregnancy and MUAC were variables associated with immediate postpartum anaemia at a p value of <0.2. In multivariable logistic regression analysis, rural residence, postpartum haemorrhage, history of abortion, poor adherence to IFA supplementation and MUAC <23 cm were independent variables associated with immediate postpartum anaemia with a p value of <0.05.

The odds of immediate postpartum anaemia were 3-fold higher among postpartum mothers who reside in rural areas (AOR=3.03; 95% CI 1.49 to 6.16) compared with urban residents. The odds of immediate postpartum anaemia were 4.95-fold higher among postpartum mothers who had experienced postpartum haemorrhage compared with their counterparts (AOR=4.95; 95% CI 2.09 to 11.76). The odds of anaemia in the immediate postpartum period were four times higher among mothers who had a history of abortion compared with those who do not have a history of abortion (AOR=4.01; 95% CI 1.93 to 8.35). The odds of immediate postpartum anaemia were 2.66 times higher among mothers who had poor adherence to IFA supplementation compared with their counterparts (AOR=2.66; 95% CI 1.27 to 5.58). The odds of immediate postpartum anaemia were 2.19-fold higher among postpartum mothers who had MUAC measurements <23 cm compared with those whose MUAC measurements were ≥23 cm (AOR=2.19; 95% CI 1.08 to 4.42) (table 4).

Table 4

Bivariable and multivariable regression analysis of factors associated with immediate postpartum anaemia among postpartum mothers who delivered at North Shewa Zone public hospitals, Oromia regional state, 2022 (n=328)

Discussions

This study determined the magnitude of immediate postpartum anaemia and associated factors among postpartum mothers who delivered at North Shoa Zone public hospitals. The magnitude of immediate postpartum anaemia was 28.4% (95% CI 23.5 to 33.3). This value was in line with the studies conducted in Debre Markos (24.3%)17; Mekelle (24.2%)18; Jimma, southwestern Ethiopia (28.7%)35; Harari (28.1%)19; meta-analysis studies done in Ethiopia (28.9%)20; Costal Karnataka, India (26.5%)36; Madrid, Spain (29%)14 and China (32.7%).37

The magnitude of immediate postpartum anaemia in this study was lower than the studies done in Puducherry, India (76.2%)27; Southern Enugu, Nigeria (72.8%)16; Indonesia (60%)38; Myanmar, Southeast Asia (73.8%)39; Bursa, Turkey (45.11%)30; Dar es Salaam, Tanzania (67.4%)11 and Bahir Dar, Ethiopia (43%).10 The possible explanation for this discrepancy might be due to the exclusion of anaemic mothers during pregnancy from this study and the difference in postpartum period of screening. Geographical differences, sample size and inclusion criteria might also be another factor. For instance, a study done in Bursa, Turkey, included only postpartum mothers who had experienced episiotomy and studies conducted in Myanmar, Southeast Asia and Indonesia used small sample sizes of 65 and 40, respectively.

However, the magnitude of immediate postpartum anaemia in this study was higher than studies done in Germany (22%)13 and Ghana (16%).15 The difference might be because studies done in Berlin, Germany, used a large sample size and included only women who had benefited from antenatal care. Studies done in Ghana included all lactating mothers at 6 weeks of the postpartum period not immediately after childbirth compared with this study. This implies that mothers will have adequate time to recover from anaemia as the postpartum period lengthens.

Having a history of abortion, experiencing a postpartum haemorrhage during the most recent birth, poor adherence to iron and folic acid supplementation during the recent pregnancy, living in a rural area and having MUAC <23 cm at the time of the data collection were independent factors that were significantly associated with immediate postpartum anaemia.

Mothers who had postpartum haemorrhage were more likely to be anaemic in the immediate postpartum period, compared with their counterparts. Similar findings were reported in Madrid, Spain,14 Tanzania,12 Ghana,15 Harari19 and Debre Markos.17 Excessive bleeding after delivery lowers the haemoglobin concentration of blood. In every millilitre of blood loss, 0.5 mg of iron will be reduced in the blood.9

The odds of immediate postpartum anaemia were higher among postpartum mothers who had a history of abortion compared with their counterparts. This finding is in line with findings from Bahir Dar, Ethiopia.10 The possible explanation is due to the reason that abortion increases the risk of excessive bleeding. The other possible explanation for this variation might be mothers who had experienced abortion may become pregnant before recovering from blood loss.40

The odds of immediate postpartum anaemia were higher among postpartum mothers who had poor adherence to iron and folic acid supplementation compared with their counterparts. This finding is inconsistent with studies done in Tanzania11 and Debre Markos, Ethiopia.17 The possible reason might be due to the reduction of maternal iron reserves since physiological demands for iron during pregnancy are high. Dietary iron cannot fulfil iron requirements in the majority of pregnant women. It is well known that prenatal iron supplementation is crucial for both the mother’s health and the proper growth of the foetus. Therefore, improper taking of iron and folic acid during pregnancy could decrease iron stores and result in anaemia even with a small amount of blood loss following delivery.9

The odds of immediate postpartum anaemia were higher among mothers whose MUAC measurements were <23 cm compared with their counterparts. This finding was inconsistent with studies conducted in Bahir Dar, Debre Markos, Ethiopia and Myanmar.10 17 39 The possible reason might be iron deficiency anaemia, which is usually related to undernutrition. A MUAC less than standard measurements indicates poor nutritional status, and the women might be at risk of micronutrient deficiencies.8 33 First, MUAC primarily measures muscle and fat mass rather than specific nutrient levels, which makes it inadequate for detecting deficiencies in micronutrients like iron, vitamin A and folate. Additionally, MUAC does not account for variations in body composition due to age, sex or pregnancy, which can influence nutritional needs and micronutrient status. Moreover, MUAC measurements can be influenced by factors such as fluid retention, which may mask or mimic malnutrition signs, potentially leading to misdiagnosis. Therefore, while MUAC is valuable for screening, clinical and biochemical tests—such as blood tests for specific vitamins and minerals—are necessary to confirm the presence and severity of micronutrient deficiencies for effective treatment and intervention planning.

Areas of residence were also significantly associated with immediate postpartum anaemia. Mothers who came from rural areas were more likely to be anaemic during the postpartum period than those who came from urban areas. This finding is supported by studies conducted in Bahir Dar and meta-analysis studies done in Ethiopia.10 20 This might be due to the fact that women in rural areas are in low socioeconomic status, which prevents them from having access to iron-rich foods. The other explanation for this variation is that mothers who came from rural areas have low healthcare service utilisation so that counselling on iron-rich diets might be low.24

The cross-sectional design of this study presents a limitation in establishing causality between the factors identified and the occurrence of immediate postpartum anaemia. Since the study was conducted exclusively in public hospitals, it may not capture the full prevalence of anaemia or the associated factors that could be present in private or rural health facilities. Additionally, the reliance on self-reported data for adherence to iron and folic acid supplementation introduces the possibility of recall bias, as participants may not accurately remember or report their supplement intake. These limitations should be considered when interpreting the findings and applying them to broader populations.

Conclusion and recommendationsConclusion

The magnitude of immediate postpartum anaemia in North Shoa Zone public hospitals was a moderate public health problem according to WHO cut-off values for the public health classification of anaemia. Postpartum haemorrhage, history of abortion, poor adherence to iron and folic acid, rural residence and MUAC <23 cm were independent factors significantly associated with immediate postpartum anaemia.

RecommendationFor Oromia regional health Bureau

✓To empower women who reside in rural areas on maternal health service utilisation through using social media.

✓To promote a balanced diet intake and sustained provision of iron and folic acid supplementation.

✓To promote the benefits of good adherence to iron and folic acid supplementation.

For North Shoa Zone public hospitals and health professionals

✓To give timely and appropriate interventions for postpartum haemorrhage during labour and delivery.

✓To work on nutritional counselling to prevent and control anaemia in the postpartum period.

✓To promote the benefits of good adherence to IFA and appropriate counselling during pregnancy.

✓To promote maternal health service utilisation for women who reside in the rural area.

✓To promote supplementation of iron and folic acid for a woman who had undergone abortion to reserve and prevent depletion of iron stores.

Data availability statement

Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by Ambo University, College of Medicine and Health Sciences Ethical Review Board (ERB)ID: AU/PGC/406/2014. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

GN would like to acknowledge Dilla University for providing the chance for doing this research for postgraduate education. Secondly, GN would like to express an acknowledgement to Ambo University, College of Medicine and Health Sciences for providing an opportunity to prepare this research thesis. Thirdly, GN is extremely grateful to each and every woman whose blood was voluntarily taken; without their participation, this thesis would not have been able to be accomplished. Additionally, GN would like to thank data collectors and supervisors for their kind cooperation during data collections. Lastly, but not the least, GN would like to extend his deepest gratitude to his family for their vigorous support throughout his entire career.