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  • Research note
  • Open Access

Two-thirds of pregnant women attending antenatal care clinic at the University of Gondar Hospital are found with subclinical iodine deficiency, 2017

  • 1Email author,
  • 2,
  • 3 and
  • 3
BMC Research Notes201811:738

https://doi.org/10.1186/s13104-018-3829-0

  • Received: 3 September 2018
  • Accepted: 9 October 2018
  • Published:

Abstract

Objective

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.

Results

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.

Keywords

  • Pregnant women
  • Subclinical iodine deficiency
  • Ethiopia

Introduction

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 [3]. 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 [4]. ID in Africa, Nigeria [5], Niger [6], and Ethiopia [7] 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) [10], 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 [15]. Besides, poor storage of salt, utilization of non-packed salt, and lack of knowledge towards iodized salt are extra factors of ID [16]. Iodized salt utilization in Ethiopia is far lower (23.3%) than [17, 18] WHO’s recommendation (90%) [19].

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.

Main text

Methods

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% [20], 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 [21].

Laboratory analysis

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) [22]. Then, the sample was analyzed by the Varian Cary, 50 UVVis spectrophotometer-Agilent, Malaysia) machine. Likewise, stool wet mount test was prepared using saline and examined microscopically to detect intestinal Helminthes and protozoal Parasitosis.

Data analysis

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.

Ethical approval

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.

Results

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).
Table 1

Sociodemographic characteristics of pregnant women attending ANC service at the University of Gondar Referral Hospital, Northwest Ethiopia, 2017 (n = 378)

Characteristics

Frequency

Percentage

Age

 15–24

126

33.3

 25–34

208

55

 35–49

44

11.6

Residence

 Rural

66

17.5

 Urban

312

82.5

Religion

 Orthodox

340

89.9

 Muslim

33

8.7

 Others

5

1.4

Ethnicity

 Amhara

356

94.2

 Tigre

22

5.8

Women’s Educational status

 Unable to read and write

22

5.8

 Primary

129

34.1

 College and above

227

60.1

Women’s occupation

 Governmental worker

99

26.2

 Merchant

54

14.3

 Housewife

200

52.9

 Daily laborer

25

6.6

Husband educational status

 Unable to read and write

85

25.1

 Primary

74

22.3

 College and above

188

52.6

Husband employment

 Governmental worker

144

38.1

 Merchant

78

23.3

 Unemployed

54

16.9

 Farmer

30

10.8

 Daily laborer

41

10.8

Water source

 Tap water

359

96

 Spring/river

19

4

Toilet

 Flush to piped sewer

126

33.3

 Flush to the septic tank

28

7.4

 Ventilate improved Pit (VIP) latrine

86

22.7

 VIP without slab

88

23.2

 Open field

50

13.2

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).
Table 2

Salt utilization characteristics of pregnant women attending ANC service at the University of Gondar referral hospital, Northwest Ethiopia, 2017 (n = 378)

Characteristics

Frequency

Percentage

Types of salt utilization

 Packed

333

88.1

 Non packed

45

11.9

Exposure to sunlight/fire

 Never

363

96.0

 Sometimes

15

4.0

Salt storage

 Dry

212

56.1

 Moist

166

43.9

Do you wash the salt

 Never

372

98.4

 Sometimes

6

1.6

Salt containing container

 Open

35

9.3

 Closed

343

90.7

The timing of salt added to the food

 At the beginning

6

1.6

 At the middle

15

4.0

 At the end

357

94.4

Salt storage duration (months)

 ≤ 2

354

93.7

 ≥ 3

24

6.3

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.

Iodine deficiency

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).
Table 3

Factors associated with iodine deficiency among pregnant women attending ANC service at University of Gondar Referral Hospital, Northwest Ethiopia, 2017 (n = 378)

Variables

Urine iodine status

Crude odds ratio (COR)

Adjusted odds ratio (AOR)

Deficient

Not deficient

Husband employment

 Governmental

81

63

0.54 (0.28, 1.01)

0.42 (0.20, 0.87)**

 Merchant

54

34

0.67 (0.33, 1.33)

0.57 (0.26, 1.26)

 Farmer

24

17

0.59 (0.26, 1.35)

0.58 (0.22, 1.56)

 Daily laborer

25

16

0.65 (0.28, 1.5)

0.72 (0.28, 1.83)

 Unemployed

45

19

1.00

1.00

Trimester

 First trimester

35

21

1.36 (0.67, 2.62)

1.3 (0.65, 2.72)

 Second trimester

77

27

2.4 (1.4, 4.11)

2.43 (1.37, 4.32)**

 Third trimester

117

101

1.00

1.00

Gravidity

 Primi-gravida

158

29

1.54 (0.77, 3.09)

 

 Multigravida

71

101

1.00

 

Parity

 Nulliparous

97

79

1.00

 

 Para one

72

33

1.50 (0.73, 3.09)

 

 Multiparous

60

37

1.05 (0.48, 2.30)

 

Cabbage consumption

 ≤ 1/week

73

73

1.00

1.00

 ≥ 2 times/week

156

76

2.05 (1.34, 3.13)

2.35 (1.44, 3.82)***

Sorghum consumption in the previous 1 week

 Yes

89

46

1.42 (0.9, 2.2)

*

 No

140

103

1.00

1.00

Maize consumption in the previous 1 week

 Yes

129

45

1.00

1.00

 No

100

104

0.33 (0.21, 0.51)

0.29 (0.18, 0.48)***

Toilet

 Flush to piped sewer

72

54

1.00

 

 Flush to septic tank

20

8

1.8 (0.76, 4.57)

 

 Ventilate improved Pit (VIP) latrine

60

26

1.7 (0.96, 3.09)

 

 VIP without slab

45

43

0.7 (0.45, 1.35)

 

 Open field

32

18

1.3 (0.67, 2.62)

 

Wealth index

 Richest

35

40

1.00

1.00

 Rich

46

30

1.(0.91, 3.34)

1.56 (0.76, 3.22)

 Middle

47

26

2 (1.06, 3.9)

1.88 (0.88, 3.97)

 Poorer

52

23

2.5 (1.32, 5.04)

2.7 (1.24, 5.89)**

 Poorest

49

30

1.8 (0.98, 3.540

1.38 (0.65, 2.91)

1.00 reference category

*** p value < 0.001

** p value < 0.01

* p-value < 0.05

Discussion

Prenatal ID is the major but preventable public health problem associated with unfavorable pregnancy outcomes and developmental failures following birth [23]. In spite of an improvement in the implementation of universal salt iodization in Ethiopia, prenatal ID has not shown a significant reduction [24]. 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%) [25], 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%) [28], which is far better than Ethiopia (23.3%) [17].

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 [29]. 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 [7].

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 [20]. Similarly, the finding is supported by a study in the UK [32], 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 [33]. As a result, lesser iodine is required. Moreover, the demand for Human Chorion Gonadotropins (HCG) production during the third trimester is not much required [34].

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 [35]. 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 [36]. 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 [37].

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.

Limitations

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.

Abbreviations

ANC: 

antenatal care

EDHS: 

Ethiopian Demographic Health Services

G/dl: 

gram per deciliter

ID: 

iodine deficiency

IQ: 

Intelligent Quotient

ML: 

milliliter

MoH: 

Ministry of Health

MUAC: 

Mid Upper Arm Circumference

TSH: 

thyroid stimulating hormone

μ/L: 

microliter

MUIC: 

Median Urinary Iodine Concentration

Declarations

Authors’ contributions

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.

Acknowledgements

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.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

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.

Consent for publication

Not applicable.

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.

Funding

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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Authors’ Affiliations

(1)
Department of Community Health Nursing, School of Nursing College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
(2)
Department of Environmental Health, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
(3)
Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

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