Anemia in pregnancy is defined by the World Health Organization as a hemoglobin (Hb) concentration below 11 g/dL and is classified as mild, moderate, or severe depending on Hb level. It is a major global public health concern that disproportionately affects pregnant women in low- and middle-income settings and is associated with maternal morbidity, adverse birth outcomes, and reduced functional capacity. Causes are multifactorial and include iron deficiency, infections (including malaria and helminths), micronutrient deficiencies, inherited hemoglobinopathies, and social determinants such as poverty and limited access to health services. Prior to this study there was limited published evidence specifically describing anemia prevalence and determinants among pregnant women in Garowe City, Puntland, Somalia.
An institution-based cross-sectional study was conducted from December 1, 2023, to January 1, 2024, among pregnant women attending antenatal care (ANC) in public health facilities of Garowe City, the capital of Puntland state in northeastern Somalia. Garowe hosts multiple public and private health facilities and several non-governmental organizations. Four public health facilities were randomly selected for this study.
All pregnant women who attended ANC in the selected public facilities during the study period constituted the study population. The final sample size was 422 pregnant women, determined using a single-proportion formula based on a previously reported prevalence and allowing for a 10% non-response rate. Study participants were selected through systematic random sampling using facility registration records and proportional allocation across the selected institutions. Pregnant women unable to provide information due to severe illness or disability were excluded.
Data were collected using a structured questionnaire administered face-to-face by trained data collectors. The questionnaire gathered socio-demographic data, obstetric history, recent illnesses, service utilization and dietary practices; it was prepared in English and translated into Somali. Hemoglobin values, results of malaria blood film, and stool examinations were abstracted from routine ANC records and patient charts. Anemia was defined as Hb <11 g/dL and categorized per WHO criteria into mild (10.0–10.9 g/dL), moderate (7.0–9.9 g/dL), and severe (<7.0 g/dL). Gravidity categories followed standard definitions (primigravida, multigravida, grand multigravida). Malaria status was based on microscopic blood film results recorded in the medical charts.
Data were double-entered into EpiData v4.6 and analyzed with SPSS v25. Descriptive statistics were used to summarize participant characteristics. Bivariate logistic regression identified candidate variables (p < 0.25), which were entered into multivariable logistic regression. Multicollinearity and model fit were checked; the Hosmer–Lemeshow test result reported P = 0.67. Statistical significance was declared at P < 0.05 with adjusted odds ratios (AOR) and 95% confidence intervals (CI). Ethical approval was obtained from Haramaya University Institutional Health Research Ethics Review Committee and informed written consent was secured from participants.
All 422 invited women participated (100% response rate). Mean age was 28.68 years (SD ±5.6), with 65.6% aged 25–34 years. Most participants were urban residents (92.2%), Muslim (97.9%), and of Somali ethnicity (91.5%). A majority were housewives (68.2%), and 63.2% had no formal education. Approximately 64.1% of households reported a monthly income below US$300.
Mean gravidity was 2.7 (SD 1.14); 33.4% were classified as multigravida. The majority (78.2%) had only one ANC visit for the current pregnancy. Half of the women (49.8%) reported receiving health and nutrition education during the current pregnancy, and 43.6% received iron/folic acid supplementation during ANC.
Within the cohort, 10.7% reported illness in the two weeks before data collection. Chart-documented conditions included hypertension in 6.6% and diabetes mellitus in 4.7% of participants. Stool examination recorded intestinal parasites in 5.9% of women. Malaria blood film results were positive in 3.8% of the cohort.
The study found an overall anemia prevalence of 38.6% (95% CI: 33.9%–43.6%). Among cases, 16.4% of participants had mild anemia and 22.3% had moderate anemia. The distribution of anemia varied by age and parity; for example, 24.2% of women aged 25–34 years and 30.9% of multiparous women were anemic.
In the adjusted multivariable analysis, five factors remained significantly associated with anemia among pregnant women:
Rural residence: women from rural areas had higher odds of anemia compared with urban residents (AOR = 2.58; 95% CI: 1.18–5.64).
Multigravidity: women with two or more pregnancies had increased odds relative to primigravida mothers (AOR = 2.01; 95% CI: 1.03–3.89).
Lack of nutritional counseling: women who did not receive nutritional counseling during ANC had greater odds of anemia (AOR = 1.65; 95% CI: 1.09–2.52).
Positive malaria blood film: a positive malaria test was associated with substantially higher odds of anemia (AOR = 3.58; 95% CI: 1.08–11.98).
Not consuming an extra meal during pregnancy: women who did not take one additional meal were more likely to be anemic (AOR = 2.19; 95% CI: 1.15–4.19).
These associations indicate contributions from socio-demographic, obstetric, service-related, infectious, and dietary factors.
The prevalence of anemia among pregnant women attending ANC in Garowe City was 38.6%, indicating a moderate public health problem by WHO criteria. Independent correlates included rural residence, multigravidity, absence of nutritional counseling, malaria infection, and inadequate meal frequency during pregnancy. The authors recommend public health strategies that strengthen nutritional counseling in ANC, promote extra meal consumption during pregnancy, ensure iron/folic acid supplementation, and emphasize prevention and management of malaria in pregnancy. These targeted interventions are intended to reduce anemia burden and improve maternal and neonatal outcomes in the region.
The manuscript provides detailed prevalence estimates, associated adjusted odds ratios and confidence intervals for identified risk factors. Details on the proportion with severe anemia were not explicitly reported beyond the mild and moderate categories described. The study used routine ANC laboratory records for hemoglobin and malaria results, and interviewer-administered questionnaires for socio-demographic and behavioral information.