Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Maternal and pediatric nutrition

A multilevel approach to correlates of anaemia in women in the Democratic Republic of Congo: findings from a nationally representative survey

European Journal of Clinical Nutrition volume 74, pages 720–731 (2020)Cite this article

Subjects

Abstract

Background/Objectives:

Anaemia accounts for a significant proportion of pre- and post-partum morbidity and mortality in low-income countries with sequelae, including an increased risk of infection. Factors contributing to anaemia need to be addressed through the introduction of evidence-based measures to control and prevent the disease. We aimed to determine the prevalence of anaemia in women of child-bearing age in the Democratic Republic of Congo (DRC) and investigate the associated individual, household and community level factors.

Subjects/Methods:

Cross sectional representative population data from the 2013–2014 DRC Demographic and Health Survey (DHS) was used. The primary outcome was anaemia in women, stratified according to pregnancy in those of child-bearing age. A haemoglobin level of below 11 g/dl for pregnant women and 12 g/dl for non-pregnant women was used as the indicator of anaemia. Using a three-level random intercept model this study explored risk factors at individual, household and community levels and quantified the observed and unobserved variations between households and communities.

Results:

Thirty-eight percent of women in the DRC are anaemic. Anaemia is significantly higher in younger, pregnant and underweight women, as well as those with comorbidities, including HIV and malaria who are living in the capital city Kinshasa. Anaemia varies within and between households and communities in the DRC.

Conclusions:

Integrated approaches to reduce anaemia in settings with high malaria and HIV prevalence such as the DRC should target households.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1

Similar content being viewed by others

References

  1. Wirth JP, Woodruff BA, Engle-Stone R, Namaste SM, Temple VJ, Petry N, et al. Predictors of anemia in women of reproductive age: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr. 2017;106(Suppl 1):416S–27S.

    PubMed  PubMed Central  Google Scholar 

  2. Ullrich C, Wu A, Armsby C, Rieber S, Wingerter S, Brugnara C, et al. Screening healthy infants for iron deficiency using reticulocyte hemoglobin content. JAMA. 2005;294:924–30.

    Article  CAS  Google Scholar 

  3. Kandala NI. Socio-demographic determinants of anaemia and nutritional status in the Democratic Republic of Congo, Uganda and Malawi (Unpublished Doctoral thesis). University of Southampton, Southampton, UK) https://eprints.soton.ac.uk/354347/. 2013.

  4. Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca F, et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. Lancet Glob Health. 2013;1:e16–25.

    Article  Google Scholar 

  5. Win H, Ko M. Geographical disparities and determinants of anaemia among women of reproductive age in Myanmar: analysis of the 2015–2016 Myanmar Demographic and Health Survey. WHO South-East Asia J Public Health. 2018;7:107–13.

    Article  Google Scholar 

  6. Kibret KT, Chojenta C, D’Arcy E, Loxton D. Spatial distribution and determinant factors of anaemia among women of reproductive age in Ethiopia: a multilevel and spatial analysis. BMJ Open. 2019;9:e027276.

    Article  Google Scholar 

  7. Benoist de B, McLean E, Egli I, Cogswell M. Worldwide prevalence of anaemia 1993–2005: WHO Global Database on Anaemia, WHO, ed. Geneva: WHO; 2008.

  8. van den Broek N. Anaemia and micronutrient deficiencies: Reducing maternal death and disability during pregnancy. Br Med Bull. 2003;67:149–60.

    Article  Google Scholar 

  9. Petry N, Olofin I, Hurrell RF, Boy E, Wirth JP, Moursi M, et al. The proportion of anemia associated with iron deficiency in low, medium, and high human development index countries: a systematic analysis of national surveys. Nutrients, 2016;8:pii:E693.

  10. Camaschella C. Iron-deficiency anemia. New Engl J Med. 2015;372:1832–43.

    Article  Google Scholar 

  11. Lanjouw JO, Lanjouw P. The rural non-farm sector: issues and evidence from developing countries. Agric Econ. 2001;26:1–23.

    Article  Google Scholar 

  12. Olusanya BO, Luxon LM, Wirz SL. Benefits and challenges of newborn hearing screening for developing countries. Int J Pediatr Otorhinolaryngol. 2004;68:287–305.

    Article  CAS  Google Scholar 

  13. Casey GJ, Montresor A, Cavalli-Sforza LT, Thu H, Phu LB, Tinh TT, et al. Elimination of iron deficiency anemia and soil transmitted Helminth infection: evidence from a fifty-four month iron-folic acid and de-worming program. PLoS Neglected Tropical Dis. 2013;7:e2146.

    Article  CAS  Google Scholar 

  14. Foote EM, Sullivan KM, Ruth LJ, Oremo J, Sadumah I, Williams TN, et al. Determinants of anemia among preschool children in rural, western Kenya. Am J tropical Med Hyg. 2013;88:757–64.

    Article  Google Scholar 

  15. Lakew Y, Biadgilign S, Haile D. Anaemia prevalence and associated factors among lactating mothers in Ethiopia: evidence from the 2005 and 2011 demographic and health surveys. BMJ Open. 2015;5:e006001–6001.

    Article  Google Scholar 

  16. Spottiswoode N, Duffy PE, Drakesmith H. Iron, anemia and hepcidin in malaria. Front Pharm. 2014;5:125.

    Article  Google Scholar 

  17. Engstrom EM, de Castro IRR, Margareth P, Cardoso LO, Monteiro CA. Effectiveness of Daily and Weekly Iron Supplementation in the Prevention of Anemia in Infants. Ann Nutr Metab. 2009;55:439–9.

    Google Scholar 

  18. WHO. World Malaria Report 2018, WHO ed. Geneva: WHO; 2018.

  19. Cox FEG. History of human parasitology. Clin Microbiol Rev. 2002;15:595.

    Article  CAS  Google Scholar 

  20. Smith JL, Brooker S. Impact of hookworm infection and deworming on anaemia in non-pregnant populations: a systematic review. Tropical Med Int Health: TM IH. 2010;15:776–95.

    Article  Google Scholar 

  21. Pasricha S-R, Caruana SR, Phuc TQ, Casey GJ, Jolley D, Kingsland S, et al. Anemia, iron deficiency, meat consumption, and hookworm infection in women of reproductive age in northwest Vietnam. Am J tropical Med Hyg. 2008;78:375–81.

    Article  CAS  Google Scholar 

  22. Dhurve SA, Dhurve AS. Bone marrow abnormalities in HIV disease. Mediterranean J Hematol Infect Dis. 2013;5:e2013033–33.

    Article  Google Scholar 

  23. van den Berg K, Murphy EL, Pretorius L, Louw VJ. The impact of HIV-associated anaemia on the incidence of red blood cell transfusion: implications for blood services in HIV-endemic countries. Transfus Apheresis Sci: Off J World Apheresis Assoc: Off J Eur Soc Haemapheresis. 2014;51:10–18.

    Google Scholar 

  24. van Ansem WJ, Schrijvers CT, Rodenburg G, van de Mheen D. Maternal educational level and children’s healthy eating behaviour: role of the home food environment (cross-sectional results from the INPACT study). Int J Behav Nutr Phys Act. 2014;11:113–113.

    Article  Google Scholar 

  25. DHS. Congo Democratic Republic DHS, 2013-14—Final Report 2014, Demographic Health Surveys. https://dhsprogram.com/Publications/Publications-by-Country.cfm.

  26. Gibson RS. Principles of nutritional assessment. Oxford, United Kingdom: Oxford University Press; 2005.

  27. Lu MC. We can do better: improving perinatal health in America. J Women’s Health. 2010;19:569–74.

    Article  Google Scholar 

  28. Kazembe LN, Appleton CC, Kleinschmidt I. Choice of treatment for fever at household level in Malawi: examining spatial patterns. Malaria J. 2007;6:6–40.

    Article  Google Scholar 

  29. Aarts E, Verhage M, Veenvliet JV, Dolan CV, van der Sluis S. A solution to dependency: using multilevel analysis to accommodate nested data. Nat Neurosci. 2014;17:491–6.

    Article  CAS  Google Scholar 

  30. Pfeffermann D, Skinner CJ, Holmes DJ, Goldstein H, Rasbash J. Weighting for unequal selection probabilities in multilevel models. J R Stat Soc Ser B-Stat Methodol. 1998;60:23–40.

    Article  Google Scholar 

  31. Chambers RL, Sugden RA, Longford N, Little RJ, Binder DA, Dorfman AH, et al. Weighting for unequal selection probabilities in multilevel models—Discussion on the papers by Firth and Bennett and Pfeffermann et al. J R Stat Soc Ser B-Stat Methodol. 1998;60:41–56.

    Article  Google Scholar 

  32. Rabe-Hesketh S, Skrondal A. Multilevel modelling of complex survey data. J R Stat Soc Ser a-Stat Soc. 2006;169:805–27.

    Article  Google Scholar 

  33. Ministère du PC, Macro I. République Démocratique du Congo Enquête Démographique et de Santé 2007. Ministère du Plan/Congo and Macro International: Calverton, MD, USA; 2008.

  34. FAO. Obesity in developing countries, FAO ed. FAO: Rome; 2000.

  35. Abalo EM, Agyemang S, Atio S, Ofosu-Bosompem D, Peprah P, Ampomah-Sarpong R. Environmental sanitation unleashed: effectiveness and challenges of the National Sanitation Day as a community sanitation participatory approach in Aboabo, Ghana. Cogent Environ Sci. 2017;3:1405888.

    Article  Google Scholar 

  36. FFI. Food Fortification Initiative :15 years of partnering for success. Food Fortification Initiative: USA; 2018.

  37. White NJ. Anaemia and malaria. Malar J. 2018;17:371.

    Article  CAS  Google Scholar 

  38. Kalenga MK, Nyembo MK, Nshimba M, Foidart JM. [Anemia and associated factors (Malaria and intestinal Helminthiasis) in Lubumbashi]. Sté Publique. 2003;15:413–21.

    Article  CAS  Google Scholar 

  39. Bedwell RM, Spielvogel H, Bellido D, Vitzthum VJ. Factors Influencing the use of biomedical health care by rural Bolivian anemic women: structural barriers, reproductive status, gender roles, and concepts of anemia. PLoS ONE. 2017;12:e0170475–75.

    Article  Google Scholar 

  40. Ugwuja EI, Ogbonnaya LU, Obuna AJ, Awelegbe F, Uro-Chukwu H. Anaemia in relation to body mass index (BMI) and socio-demographic characteristics in adult Nigerians in Ebonyi state. J Clin Diag Res. 2015; 9: LC04–7.

  41. Yasuda JL, Rufo PA. Protein-losing enteropathy in the setting of severe iron deficiency anemia. J Investig Med High Impact Case Rep. 2018;6:2324709618760078–78.

    PubMed  PubMed Central  Google Scholar 

  42. Brockerhoff M. Urban growth in developing countries: a review of projections and predictions. Popul Dev Rev. 1999;25:757–78.

    Article  Google Scholar 

  43. Seto KC, Güneralp B, Hutyra LR. Global forecasts of urban expansion to 2030 and direct impacts on biodiversity and carbon pools. Proc Natl Acad Sci. 2012;109:16083.

    Article  CAS  Google Scholar 

  44. Buttenheim AM. The sanitation environment in urban slums: implications for child health. Popul Environ. 2008;30:26–47.

    Article  Google Scholar 

  45. Bird K, Shepherd A. Livelihoods and chronic poverty in semi-arid Zimbabwe. World Dev. 2003;31:591–610.

    Article  Google Scholar 

  46. Roberts L. Kinshasa little relief for eastern Democratic Republic of Congo. Lancet. 2001;357:1421.

    Article  CAS  Google Scholar 

  47. Jack F, Alexis DA, Celeste S. Nutrition technical brief: a rapid initial assessment of the distribution and consumption of iron–folic acid tablets through antenatal care in the Democratic Republic of Congo. USAID ed. USAID: Arlington; 2014.

  48. Belitz HD, Werner G, Peter S. Food chemistry. 4 ed. Springer-Verlag: Berlin Heidelberg; 2009.

  49. Feinstein L, Dimomfu BL, Mupenda B, Duvall S, Chalachala JL, Edmonds A, et al. Antenatal and delivery services in Kinshasa, Democratic Republic of Congo: care-seeking and experiences reported by women in a household-based survey. Tropical Med Int Health. 2013;18:1211–21.

    Article  Google Scholar 

  50. Ivoke N, Ikpor N, Ivoke O, Ekeh F, Ezenwaji N, Odo G, et al. Geophagy as risk behaviour for gastrointestinal nematode infections among pregnant women attending antenatal clinics in a humid tropical zone of Nigeria. Afr Health Sci. 2017;17:24–31.

    Article  Google Scholar 

  51. Short SE, Mollborn S. Social determinants and health behaviors: conceptual frames and empirical advances. Curr Opin Psychol. 2015;5:78–84.

    Article  Google Scholar 

Download references

Acknowledgements

We are grateful to the USAID, DHS Programme for granting us access to the Democratic Republic of Congo 2013–2014 Demographic Health Surveys.

Author contributions

NK formulated the research question and designed the study. NK performed statistical analysis. NK, SP, NM, AC and GK wrote the paper. NK, SP, NM, GK and AC had primary responsibility for final content. All authors have read and approved the final manuscript.

Author information

Authors and Affiliations

  1. School of Health and Care Professions, PB Centre for Global Health, University of Portsmouth, Portsmouth, United Kingdom

    Ngianga II Kandala & Saseendran Pallikadavath

  2. Centre for Global Health and Policy, Faculty of Social Science, University of Southampton, Southampton, United Kingdom

    Andrew Amos Channon

  3. School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, United Kingdom

    Gavin Knight

  4. African Institute for Development Policy, Lilongwe, Malawi

    Nyovani Janet Madise

Authors
  1. Ngianga II Kandala
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Saseendran Pallikadavath
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andrew Amos Channon
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gavin Knight
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nyovani Janet Madise
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ngianga II Kandala.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kandala, N.I., Pallikadavath, S., Amos Channon, A. et al. A multilevel approach to correlates of anaemia in women in the Democratic Republic of Congo: findings from a nationally representative survey. Eur J Clin Nutr 74, 720–731 (2020). https://doi.org/10.1038/s41430-019-0524-8

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41430-019-0524-8

This article is cited by

Search

Advanced search

Quick links