Two-thirds of pregnant women attending antenatal care clinic at the University of Gondar Hospital are found with subclinical iodine deficiency, 2017
BMC Research Notes volume 11, Article number: 738 (2018)
This study was aimed at determining the magnitude of prenatal iodine deficiency and its determinants among women attending antenatal care clinic at the University of Gondar Specialized Referral Hospital, Northwest Ethiopia. A cross-sectional study was conducted from March 13 to April 25/2017. Precisely, 378 pregnant women were included in the study selected via systematic random sampling technique. Urinary Iodine concentration was determined through spectrophotometer using Sandell-Kolthoff reaction. Iodine deficiency was defined as women having urinary iodine concentration of < 150 µg/L. Moreover, stool examination was done.
Subclinical iodine deficiency among pregnant women was 60.5% (95% CI 55%, 65.5%). The Median iodine concentration was 137 μg/L (IQR 80 μg/L). Being governmental employee [AOR = 0.42 (95% CI 0.1 = 20, 0.87)], cabbage consumption of twice or more times per week [AOR = 2.35 (95% CI 1.44, 3.82)], not consuming maize in the last 1 week [AOR = 0.29 (95% CI 0.18, 0.48)], poor household wealth status [AOR = 2.7 (95% CI 1.24, 5.89)], and second trimester of pregnancy [AOR = 2.43 (95% CI 1.37, 4.32)] were significantly associated with iodine deficiency. Prenatal iodine deficiency was high, which deemed a mild public Health problem. Therefore, improving household income, and nutrition education to minimize maize and cabbage consumption are recommended.
Iodine is an essential trace mineral, which is vital for the synthesis of Thyroid Hormones, as triiodothyronine (T3), and thyroxine (T4). These hormones are crucial for healthy growth and the development of the brain [1, 2]. In consonance with the World Health Organization (WHO), prenatal iodine deficiency (ID) is defined as urinary iodine concentration of < 150 µg/L . To eliminate ID at the country level, the salt iodization Council of Ministers enacted regulation No. 204/12011 on the implementation of universal iodized salt utilization . ID in Africa, Nigeria , Niger , and Ethiopia  bear 100%, 61.67, and 88.9% of the burden, respectively.
Prenatal ID exposes the newborn to long-term irreversible sequelae of brain damage following poor migration and myelination of neurons [8, 9]. Consequently, it compromises about 12–13.5 points of the newborn’s Intelligence Quotient (IQ) , which result in poor educational outcomes [11, 12]. Moreover, low birth weight and poor linear growth are another bad consequences of prenatal ID [13, 14].
People with dietary habits of cassava, cabbage, sorghum, and millet as staple foods are iodine-deficient . Besides, poor storage of salt, utilization of non-packed salt, and lack of knowledge towards iodized salt are extra factors of ID . Iodized salt utilization in Ethiopia is far lower (23.3%) than [17, 18] WHO’s recommendation (90%) .
Even though ID is one of the grave concerns in Ethiopia, little is known about the burden among pregnant women. Therefore, this study was aimed at investigating prenatal ID and associated factors among women attending the antenatal clinic at the University of Gondar Referral Hospital.
The study area, design, and population
This facility-based cross-sectional study was conducted from March 13 to April, 25/2017 among pregnant women attending ANC at the University of Gondar Referral Hospital. Participants with an established hypertensive disorder as their dietary salt restriction were excluded.
Sample size, Sampling technique, and procedure
The sample size was calculated considering the statistical assumptions for the prevalence of ID as 61.4% , 95% level of confidence, 5% margin of error, and 10% non-response rate, which yielded a sample size of 403. The systematic random sampling technique was employed. The average number of pregnant women attending the ANC clinic in the preceding one and half months was estimated to be 1545. Accordingly, a sampling fraction of 4 (Kth = N/n) was calculated. Following the selection of the first participant using the lottery method, every fourth woman of the initial participant was included. Nevertheless, the next participants were considered provided that the selected ones did not fulfill the inclusion criteria.
Data collection procedures and tools
The data were collected using a face-to-face interviewer-administered questionnaire. It comprised of socio-demographic characteristics, obstetric, and dietary practices.
Five-milliliter single-spot urine was collected using a clean plastic neck-tube with a tightly screw-cap labeled with participant’s identification number. The collected urine sample was stored in a cold-box for ease of transportation and kept below − 20 °C in the refrigerator until analysis. Furthermore, the stool was collected using a clean stool cup and processed within 30 min.
Assessment of urinary iodine concentration and Goiter
According to the WHO, prenatal ID is defined as women having urinary iodine concentration of < 150 µg/L. Maternal goiter status was diagnosed by physical examination of the neck. The severity of goiter was categorized as Grade 0 when there was no palpable and visible goiter; Grade 1, palpable but not visible, while the neck was in normal position, whereas Grade 2 was described as visible and palpable.
Maternal nutritional status and dietary diversity measurement
Maternal nutritional status was determined by Mid Upper Arm Circumference (MUAC). Accordingly, the participant was considered as underweight if her MUAC measurement was < 23 cm.
The minimum dietary diversity was measured using a 24-h-recall method to interview participants to report the food item consumed in the previous 24 h prior to the date of data collection. Accordingly, minimum dietary diversity was defined as when a woman consumed five and above food items .
Urine iodine level was measured by the Sandell-Kolthoff reaction method using ammonium persulfate as a digestion recommended by WHO/UNICEF/International Council for Control of Iodine Deficiency Disorder (ICCIDD) . Then, the sample was analyzed by the Varian Cary, 50 UV–Vis spectrophotometer-Agilent, Malaysia) machine. Likewise, stool wet mount test was prepared using saline and examined microscopically to detect intestinal Helminthes and protozoal Parasitosis.
The collected data were analyzed by STATA Version 14. Frequencies, percentages, and a measure of central tendencies with the appropriate measure of dispersion were used. Data were presented using tables, and text. The binary logistic regression was fitted to identify factors associated with the ID. All variables with p-values of < 0.2 were entered into the multi-variable analysis model to control the possible effects of a confounder. According to the variance inflation factor (VIF), there was no multicollinearity problem. Finally, variables independently associated with ID were identified on the basis of the Adjusted Odds Ratio (AOR) with a 95% CI and less than 0.05 p value.
The ethical clearance was obtained from the Institutional Review Board of the University of Gondar. Written informed consent was obtained from each study participants. The study participant’s confidentiality was maintained by avoiding possible identifiers, such as the name of the patient. During data collection time any woman who was with medical problem findings, such as malnutrition, nutrition education was provided. Likewise, women with intestinal parasitic infection were treated by appropriate medications. Women with grade one and two goiters were linked to the surgical department.
Sociodemographic characteristics of pregnant women
About 403 participants were included in the study making a response rate of 94%. The mean (± SD) age of the participants was 26.3 (± 5.8) years. More than half of the participants (55%) were in the age range of 25–34 years (Table 1).
Health, the dietary and nutritional status of the pregnant women
Approximately one-fifth (19.6%) of the participants lied in the category of underweight. One in every twenty women were infected with hookworm.
Nearly one-third (32%) of women consumed a diversified diet. About 61.4% of the participants consumed cabbage twice or more in a week. Besides, about 96%, 92.3%, and 97.9% of women never consumed sweet potato, soya bean, and fish in the previous 1 week, respectively.
Salt utilization characteristics
The vast majority (88.1%) of pregnant women habitually consume packed salt. Most of the participants (96%), and (98.4%) they hardly expose the salt to sunlight and wash salt to avoid impurities, respectively (Table 2).
Pregnant women attitude and knowledge towards iodized salt utilization and its importance
More than half (55.8%) of pregnant women had a favorable attitude to iodized salt utilization and ID, whereas 50.1% of study participants have adequate knowledge.
Prenatal sub-clinical ID was 60.5% (95% CI 55.6, 65.5) with the Median Urinary Iodine Concentration (MUIC) of 137 μg/L (IQR 80 μg/L) (< 20 μg/L). In addition, the goiter rate was reported to be 38%.
Factors associated with ID
The odds of ID were decreased by 58% (AOR = 0.42 (95% CI (0.20, 0.87)) among pregnant women whose husbands were governmental employees as compared to whose husbands who were unemployed. The likelihood of ID was higher by 2.4 folds among women in the second trimester than the third trimester, 2.43 (AOR = 2.43 (95% CI 1.37, 4.32). The odds of ID were higher among participants who consumed cabbage (AOR = 2.35 (95% CI 1.44, 3.82), and women lived in poor household income (AOR = 2.7 (95% CI 1.24, 5.89). A decreased odds of ID were detected among women who never consumed maize in the previous 1 week compared to their counterparts (AOR = 0.29 (95% CI 0.18, 0.48) (Table 3).
Prenatal ID is the major but preventable public health problem associated with unfavorable pregnancy outcomes and developmental failures following birth . In spite of an improvement in the implementation of universal salt iodization in Ethiopia, prenatal ID has not shown a significant reduction . In this study, prenatal ID was 60.5% (95% CI 55.6, 65.5). It remains a major public health problem, which requires comprehensive nutritional strategies to mitigate the burden.
Furthermore, the finding of the study is far greater than those of studies conducted in Nepal (28.9%) , and Kolkata (37%) [26, 27]. Poor dietary intake of iodine-rich food and low utilization of iodized salt could explain the observed discrepancies. As an illustration, iodized salt utilization coverage in Nepal was (66.7%) , which is far better than Ethiopia (23.3%) .
Though our finding has shown a significant low prevalence of ID compared to previous studies conducted in Ethiopia (88.9%), and (82.8%) [7, 29], the burden is still unacceptably high. This might be related to improvements in the utilization of iodized salt and public awareness as a result of aggressive media promotion regarding the importance of iodine. Furthermore, in the former studies, only 6.6% of the households utilized iodized salt in 2013 . However, this finding is in line with a study conducted in Gayint, and Niger [6, 20], which amounted to be 61.4%, and 61.6%, respectively.
Women whose husbands were government employees were found with 60% lesser odds of developing ID than women whose husbands were unemployed. Obviously, unemployment is a proxy indicator of lower-household income which adversely affects the food security. A study in China also showed that low-income was significantly associated with the development of micronutrient deficiency [30, 31]. Likewise, the current and previous local findings re-affirmed the negative effect of poor-household income on the risk of ID .
This study also revealed that the odds of ID were higher among women in the second trimester of pregnancy than the third trimester. This finding is in agreement with an earlier study in Ethiopia . Similarly, the finding is supported by a study in the UK , which reported a better concentration of urine iodine in the third than first and second trimester. This is because firstly, fetal thyroid gland formation begins at 12 weeks and ends in the second trimester. Secondly, at the 20th week of gestation, the fetal thyroid gland starts to synthesize the thyroid hormone with the assistance of a maternal hormone . As a result, lesser iodine is required. Moreover, the demand for Human Chorion Gonadotropins (HCG) production during the third trimester is not much required .
Although cabbage consumption has many health benefits, its overconsumption leads to bad consequences. The current study explored that cabbage consumption twice and more per week would result in ID. This finding is similar to studies conducted in Ethiopia [7, 29]. The substance thiocyanates found in cabbage and other cruciferous vegetables compete with the uptake of iodine by thyroidal cells; consequently, the activity of the Thyroid Peroxidase (TPO) enzyme is impaired . This explanation is further complemented by another study done in Bulgaria which showed women who had low urinary iodine were found to have high thiocyanates concentration in their urine and TSH . Even though literature has not shown enough on the effect of maize on ID among the human species, this study revealed that maize consumption is positively associated with the ID. A study in an animal model supports this finding. This study pointed out that a substance (thiocyanate) found in maize caused ID by interfering with the activities of TPO .
All in all, ID among pregnant women was high which depicts a mild public health problem. Maize consumption, cabbage consumption (twice or more times in a week), being in the second trimester of pregnancy, and poor household wealth status have increased the likelihood of ID. Therefore, special attention for women during the second trimester of pregnancy, enhancing of household income, and nutrition education to minimize maize, as well as cabbage consumption are recommended.
The study is not believed to be free from some limitations. Firstly, it has not determined household salt utilization status. Secondly, recall and social desirability bias regarding dietary practices could not be ruled out.
Ethiopian Demographic Health Services
gram per deciliter
Ministry of Health
Mid Upper Arm Circumference
thyroid stimulating hormone
Median Urinary Iodine Concentration
Eastman CJ, Zimmermann M. The iodine deficiency disorders. 2014. https://www.ncbi.nlm.nih.gov/books/NBK285556/.
Delange F. The role of iodine in brain development. Proc Nutr Soc. 2000;59(01):75–9.
Andersson M, De Benoist B, Delange F, Zupan J, Secretariat W. Prevention and control of iodine deficiency in pregnant and lactating women and in children less than 2-years-old: conclusions and recommendations of the Technical Consultation. Public Health Nutr. 2007;10(12):1606.
Salt Iodization Council of Ministers Regulation No. 204. 2011.
Igwe K, Ukoha A, NwaChukwu N, Ujowundu C. Iodine nutrition for pregnant women in three major villages of Ohafia local government area in Abia State of Nigeria. Afr J Biochem Res. 2011;5(2):81–3.
Sadou H, Seyfoulaye A, Malam Alma M, Daouda H. Inadequate status of iodine nutrition among pregnant women residing in three districts of Niamey, the Niger Republic’s capital. Matern Child Nutr. 2014;10(4):650–6.
Negeri Z, Gobena T, Rajesh R, Kassim M. Determining the magnitude of iodine deficiency and its associated risk factors among pregnant women visiting Jimma University specialized hospital for antenatal care. World J Med Med Sci. 2014;4:1–6.
Bernal J. Thyroid hormone receptors in brain development and function. Nat Rev Endocrinol. 2007;3(3):249.
Sethi V, Kapil U. Iodine deficiency and development of the brain. Indian J Pediatr. 2004;71(4):325–9.
Zimmermann MB. The effects of iodine deficiency in pregnancy and infancy. Pediatr Perinat Epidemiol. 2012;26(Suppl 1):108–17.
Pearce EN, Lazarus JH, Moreno-Reyes R, Zimmermann MB. Consequences of iodine deficiency and excess in pregnant women: an overview of current knowns and unknowns. Am J Clin Nutr. 2016;104(Suppl 3):918S–23S.
Hynes KL, Otahal P, Hay I, Burgess JR. Mild iodine deficiency during pregnancy is associated with reduced educational outcomes in the offspring: 9-year follow-up of the gestational iodine cohort. J Clin Endocrinol Metab. 2013;98(5):1954–62.
Rayman MP, Bath SC. The new emergence of iodine deficiency in the UK: consequences for child neurodevelopment. Ann Clin Biochem. 2015;52(6):705–8.
Rydbeck F, Rahman A, Grander M, Ekstrom EC, Vahter M, Kippler M. Maternal urinary iodine concentration up to 10 mg/L is positively associated with birth weight, length, and head circumference of male offspring. J Nutr. 2014;144(9):1438–44.
Abuye C, Berhane Y, Ersumo T: The role of changing diet and altitude on goiter prevalence in five regional states in Ethiopia. 2009. https://pdfs.semanticscholar.org/9b56/d2eef77cdcb16ae7b9fba935e09e334ed677.pdf.
Mesele M, Degu G, Gebrehiwot H. Prevalence and associated factors of goiter among rural children aged 6–12 years old in Northwest Ethiopia, cross-sectional study. BMC Public Health. 2014;14:130.
Institute. EpH: National salt iodization coverage towards Prevention of Iodine Deficiency Disorder in Ethiopia. 2014.
Gebremariam HG, Yesuf ME, Koye DN. Availability of adequately iodized salt at the household level and associated factors in Gondar town, Northwest Ethiopia. ISRN Public Health. 2013;1(3):134–9.
UNICEF, ICCID, PAMM, WHO: monitoring universal salt utilization program. Ottawa, Canada 1995. http://downloads.hindawi.com/journals/isrn.public.health/2013/160582.pdf.
Tefera D, Haidar J. Iodine deficiency disorder and its correlates among antenatal care service users from Northwest Ethiopia: evidence from Lai-Gayint District. Ethiop J Health Dev. 2016;27(3):208–15.
FAO, 360 F: Minimum Dietary Diversity for Women: A Guide for Measurement. Rome: FAO; 2016. http://www.fao.org/3/a-i5486e.pdf.
WHO, UNICEF, ICCIDD: Assessment of iodine deficiency disorders and monitoring their elimination: a guide for programme managers, WHO, Paris, 3rd ed, 2007. http://apps.who.int/iris/bitstream/handle/10665/61278/?sequence=1.
Abuye C, Berhane Y. The goiter rate, its association with reproductive failure, and the knowledge of iodine deficiency disorders (IDD) among women in Ethiopia: Cross-section community-based study. BMC Public Health. 2007;7(1):1.
Wahlin Å, Bunce D. Wahlin T-BR: Longitudinal evidence of the impact of normal thyroid stimulating hormone variations on cognitive functioning in very old age. Psychoneuroendocrinology. 2005;30(7):625–37.
AgrAwAl K, PAudel B, Singh P, Majhi S, Pokhrel H. Urinary iodine excretion in pregnancy: a pilot study in the region of Nepal. J Clin Diagn Res. 2013;7(7):1319.
Simpong DL, Adu P, Bashiru R, Morna MT, Yeboah FA, Akakpo K, Ephraim RK. Assessment of iodine status among pregnant women in a rural community in Ghana—a cross-sectional study. Arch Public Health. 2016;74:8.
Majumder A, Jaiswal A, Chatterjee S. Prevalence of iodine deficiency among pregnant and lactating women: experience in Kolkata. Indian J Endocrinol Metab. 2014;18(4):486.
Agrawal K, Paudel BH, Singh PN, Majhi S, Pokhrel HP. Urinary iodine excretion in pregnancy: a pilot study in the region of Nepal. J Clin Diagn Res. 2013;7(7):1319–21.
Kedir H, Berhane Y, Worku A. Subclinical iodine deficiency among pregnant women in Haramaya District, Eastern Ethiopia: a community-based study. J Nutr Metab. 2014;2014:878926.
Wong AY, Chan EW, Chui CS, Sutcliffe AG, Wong IC. The phenomenon of micronutrient deficiency among children in China: a systematic review of the literature. Public Health Nutr. 2014;17(11):2605–18.
Black RE. Global distribution and disease burden related to micronutrient deficiencies. Nestle Nutr Inst Workshop Ser. 2014;78:21–8.
Bath SC, Furmidge-Owen VL, Redman CW, Rayman MP. Gestational changes in iodine status in a cohort study of pregnant women from the United Kingdom: season as an effect modifier. Am J Clin Nutr. 2015;101(6):1180–7.
de Escobar GM, Obregón MJ, del Rey FE. Iodine deficiency and brain development in the first half of pregnancy. Public Health Nutr. 2007;10(12A):1554–70.
Hershman JM. Physiological and pathological aspects of the effect of human chorionic gonadotropin on the thyroid. Best Pract Res Clin Endocrinol Metab. 2004;18(2):249–65.
Ozpinar A, Kelestimur F, Songur Y, Can O, Valentin L, Caldwell K, Arikan E, Unsal I, Serteser M, Inal T, et al. Iodine status in Turkish populations and exposure to iodide uptake inhibitors. PLoS ONE. 2014;9(2):e88206.
Bivolarska A, Gatseva P, Nikolova J, Argirova M, Atanasova V. Effect of thiocyanate on iodine status of pregnant women. Biol Trace Elem Res. 2016;172(1):101–7.
Chandra AK, Ghosh D, Tripathy S. Effect of maize (Zea mays) on thyroid status under conditions of varying iodine intake in rats. J Endocrinol Reprod. 2009;13(1):17–26.
WWT and AT; conceived the research question, draft the proposal. TD and AT analyze and interpret the data. MA, and WWT wrote the result section and prepare the manuscript. All authors read and approved the final manuscript.
The authors would like to thank data collectors and study participants for their collaboration. We would also like to appreciate the University of Gondar specialized referral Hospital management team for their cooperation.
The authors declare that they have no competing interests.
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All necessary data are available in the manuscript if in case electronics data are requested is required, it will be accessed through the corresponding author.
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Ethical approval and consent to participate
The ethical clearance was obtained from the Institutional Review Board of the University of Gondar. Written informed consent was obtained from each study participants. For those participants who were unable to read and write, the information was read to them with their witnesses and they were convinced to put their fingerprints in the informed consent format. The study participant’s confidentiality was maintained by avoiding possible identifiers, such as the name of the patient, and using only numerical identification. During data collection time any woman who was with medical problem findings, such as malnutrition, nutrition education was provided.
The study was funded by the University of Gondar. However, the funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.
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Takele, W.W., Alemayehu, M., Derso, T. et al. Two-thirds of pregnant women attending antenatal care clinic at the University of Gondar Hospital are found with subclinical iodine deficiency, 2017. BMC Res Notes 11, 738 (2018). https://doi.org/10.1186/s13104-018-3829-0
- Pregnant women
- Subclinical iodine deficiency