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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Prevalence and determinants of anemia among pregnant women in Ethiopia; a systematic review and meta-analysis</title><author><name sortKey="Kassa, Getachew Mullu" sort="Kassa, Getachew Mullu" uniqKey="Kassa G" first="Getachew Mullu" last="Kassa">Getachew Mullu Kassa</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.449044.9</institution-id><institution>College of health Sciences,</institution><institution>Debre Markos University,</institution></institution-wrap>Debre Markos, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Muche, Achenef Asmamaw" sort="Muche, Achenef Asmamaw" uniqKey="Muche A" first="Achenef Asmamaw" last="Muche">Achenef Asmamaw Muche</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="ISNI">0000 0000 8539 4635</institution-id><institution-id institution-id-type="GRID">grid.59547.3a</institution-id><institution>Department of Epidemiology and Biostatistics, Institute of Public Health,</institution><institution>University of Gondar,</institution></institution-wrap>Gondar, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Berhe, Abadi Kidanemariam" sort="Berhe, Abadi Kidanemariam" uniqKey="Berhe A" first="Abadi Kidanemariam" last="Berhe">Abadi Kidanemariam Berhe</name><affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1783 9494</institution-id><institution-id institution-id-type="GRID">grid.472243.4</institution-id><institution>Department of Nursing, College of Medicine and Health Science,</institution><institution>Adigrat University,</institution></institution-wrap>Tigray, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Fekadu, Gedefaw Abeje" sort="Fekadu, Gedefaw Abeje" uniqKey="Fekadu G" first="Gedefaw Abeje" last="Fekadu">Gedefaw Abeje Fekadu</name><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 0439 5951</institution-id><institution-id institution-id-type="GRID">grid.442845.b</institution-id><institution>School of Public Health, College of Medicine and Health Sciences,</institution><institution>Bahir Dar University,</institution></institution-wrap>P.O.Box 79, Bahir Dar, Ethiopia</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">29075500</idno><idno type="pmc">5646153</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5646153</idno><idno type="RBID">PMC:5646153</idno><idno type="doi">10.1186/s12878-017-0090-z</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">000601</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000601</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Prevalence and determinants of anemia among pregnant women in Ethiopia; a systematic review and meta-analysis</title><author><name sortKey="Kassa, Getachew Mullu" sort="Kassa, Getachew Mullu" uniqKey="Kassa G" first="Getachew Mullu" last="Kassa">Getachew Mullu Kassa</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.449044.9</institution-id><institution>College of health Sciences,</institution><institution>Debre Markos University,</institution></institution-wrap>Debre Markos, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Muche, Achenef Asmamaw" sort="Muche, Achenef Asmamaw" uniqKey="Muche A" first="Achenef Asmamaw" last="Muche">Achenef Asmamaw Muche</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="ISNI">0000 0000 8539 4635</institution-id><institution-id institution-id-type="GRID">grid.59547.3a</institution-id><institution>Department of Epidemiology and Biostatistics, Institute of Public Health,</institution><institution>University of Gondar,</institution></institution-wrap>Gondar, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Berhe, Abadi Kidanemariam" sort="Berhe, Abadi Kidanemariam" uniqKey="Berhe A" first="Abadi Kidanemariam" last="Berhe">Abadi Kidanemariam Berhe</name><affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1783 9494</institution-id><institution-id institution-id-type="GRID">grid.472243.4</institution-id><institution>Department of Nursing, College of Medicine and Health Science,</institution><institution>Adigrat University,</institution></institution-wrap>Tigray, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Fekadu, Gedefaw Abeje" sort="Fekadu, Gedefaw Abeje" uniqKey="Fekadu G" first="Gedefaw Abeje" last="Fekadu">Gedefaw Abeje Fekadu</name><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 0439 5951</institution-id><institution-id institution-id-type="GRID">grid.442845.b</institution-id><institution>School of Public Health, College of Medicine and Health Sciences,</institution><institution>Bahir Dar University,</institution></institution-wrap>P.O.Box 79, Bahir Dar, Ethiopia</nlm:aff></affiliation></author></analytic><series><title level="j">BMC Hematology</title><idno type="eISSN">2052-1839</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p id="Par1">Anemia during pregnancy is one of the most common indirect obstetric cause of maternal mortality in developing countries. It is responsible for poor maternal and fetal outcomes. A limited number of studies were conducted on anemia during pregnancy in Ethiopia, and they present inconsistent findings. Therefore, this review was undertaken to summarize the findings conducted in several parts of the country and present the national level of anemia among pregnant women in Ethiopia.</p></sec><sec><title>Methods</title><p id="Par2">Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed for this systematic review and meta-analysis. The databases used were; PUBMED, Cochrane Library, Google Scholar, CINAHL, and African Journals Online. Search terms used were; anemia, pregnancy related anemia and Ethiopia. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal of studies. The meta-analysis was conducted using STATA 14 software. The pooled Meta logistic regression was computed to present the pooled prevalence and relative risks (RRs) of the determinate factors with 95% confidence interval (CI).</p></sec><sec><title>Results</title><p id="Par3">Twenty studies were included in the meta-analysis with a total of 10, 281 pregnant women. The pooled prevalence of anemia among pregnant women in Ethiopia was 31.66% (95% CI (26.20, 37.11)). Based on the pooled prevalence of the subgroup analysis result, the lowest prevalence of anemia among pregnant women was observed in Amhara region, 15.89% (95% CI (8.82, 22.96)) and the highest prevalence was in Somali region, 56.80% (95% CI (52.76, 60.84)). Primigravid (RR: 0.61 (95% CI: 0.53, 0.71)) and urban women (RR: 0.73 (95% CI: 0.60, 0.88)) were less likely to develop anemia. On the other hand, mothers with short pregnancy interval (RR: 2.14 (95% CI: 1.67, 2.74)) and malaria infection during pregnancy (RR: 1.94 (95% CI: 1.33, 2.82)) had higher risk to develop anemia.</p></sec><sec><title>Conclusions</title><p id="Par4">Almost one-third of pregnant women in Ethiopia were anemic. Statistically significant association was observed between anemia during pregnancy and residence, gravidity, pregnancy interval, and malaria infection during pregnancy. Regions with higher anemia prevalence among pregnant women should be given due emphasis. The concerned body should intervene on the identified factors to reduce the high prevalence of anemia among pregnant women.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (10.1186/s12878-017-0090-z) contains supplementary material, which is available to authorized users.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Stevens, Ga" uniqKey="Stevens G">GA Stevens</name></author><author><name sortKey="Finucane, Mm" uniqKey="Finucane M">MM Finucane</name></author><author><name sortKey="De Regil, Lm" uniqKey="De Regil L">LM De-Regil</name></author><author><name sortKey="Paciorek, Cj" uniqKey="Paciorek C">CJ Paciorek</name></author><author><name sortKey="Flaxman, Sr" uniqKey="Flaxman S">SR Flaxman</name></author><author><name sortKey="Branca, F" uniqKey="Branca F">F 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<front><journal-meta><journal-id journal-id-type="nlm-ta">BMC Hematol</journal-id><journal-id journal-id-type="iso-abbrev">BMC Hematol</journal-id><journal-title-group><journal-title>BMC Hematology</journal-title></journal-title-group><issn pub-type="epub">2052-1839</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">29075500</article-id><article-id pub-id-type="pmc">5646153</article-id><article-id pub-id-type="publisher-id">90</article-id><article-id pub-id-type="doi">10.1186/s12878-017-0090-z</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group></article-categories><title-group><article-title>Prevalence and determinants of anemia among pregnant women in Ethiopia; a systematic review and meta-analysis</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Kassa</surname><given-names>Getachew Mullu</given-names></name><address><email>gechm2005@gmail.com</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Muche</surname><given-names>Achenef Asmamaw</given-names></name><address><email>ashua2014@gmail.com</email></address><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Berhe</surname><given-names>Abadi Kidanemariam</given-names></name><address><email>abadik021@gmail.com</email></address><xref ref-type="aff" rid="Aff3">3</xref></contrib><contrib contrib-type="author"><name><surname>Fekadu</surname><given-names>Gedefaw Abeje</given-names></name><address><email>abejegedefaw@gmail.com</email></address><xref ref-type="aff" rid="Aff4">4</xref></contrib><aff id="Aff1"><label>1</label><institution-wrap><institution-id institution-id-type="GRID">grid.449044.9</institution-id><institution>College of health Sciences,</institution><institution>Debre Markos University,</institution></institution-wrap>Debre Markos, Ethiopia</aff><aff id="Aff2"><label>2</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0000 8539 4635</institution-id><institution-id institution-id-type="GRID">grid.59547.3a</institution-id><institution>Department of Epidemiology and Biostatistics, Institute of Public Health,</institution><institution>University of Gondar,</institution></institution-wrap>Gondar, Ethiopia</aff><aff id="Aff3"><label>3</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1783 9494</institution-id><institution-id institution-id-type="GRID">grid.472243.4</institution-id><institution>Department of Nursing, College of Medicine and Health Science,</institution><institution>Adigrat University,</institution></institution-wrap>Tigray, Ethiopia</aff><aff id="Aff4"><label>4</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 0439 5951</institution-id><institution-id institution-id-type="GRID">grid.442845.b</institution-id><institution>School of Public Health, College of Medicine and Health Sciences,</institution><institution>Bahir Dar University,</institution></institution-wrap>P.O.Box 79, Bahir Dar, Ethiopia</aff></contrib-group><pub-date pub-type="epub"><day>17</day><month>10</month><year>2017</year></pub-date><pub-date pub-type="pmc-release"><day>17</day><month>10</month><year>2017</year></pub-date><pub-date pub-type="collection"><year>2017</year></pub-date><volume>17</volume><elocation-id>17</elocation-id><history><date date-type="received"><day>30</day><month>6</month><year>2017</year></date><date date-type="accepted"><day>9</day><month>10</month><year>2017</year></date></history><permissions><copyright-statement>© The Author(s). 2017</copyright-statement><license license-type="OpenAccess"><license-p><bold>Open Access</bold>This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><abstract id="Abs1"><sec><title>Background</title><p id="Par1">Anemia during pregnancy is one of the most common indirect obstetric cause of maternal mortality in developing countries. It is responsible for poor maternal and fetal outcomes. A limited number of studies were conducted on anemia during pregnancy in Ethiopia, and they present inconsistent findings. Therefore, this review was undertaken to summarize the findings conducted in several parts of the country and present the national level of anemia among pregnant women in Ethiopia.</p></sec><sec><title>Methods</title><p id="Par2">Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed for this systematic review and meta-analysis. The databases used were; PUBMED, Cochrane Library, Google Scholar, CINAHL, and African Journals Online. Search terms used were; anemia, pregnancy related anemia and Ethiopia. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal of studies. The meta-analysis was conducted using STATA 14 software. The pooled Meta logistic regression was computed to present the pooled prevalence and relative risks (RRs) of the determinate factors with 95% confidence interval (CI).</p></sec><sec><title>Results</title><p id="Par3">Twenty studies were included in the meta-analysis with a total of 10, 281 pregnant women. The pooled prevalence of anemia among pregnant women in Ethiopia was 31.66% (95% CI (26.20, 37.11)). Based on the pooled prevalence of the subgroup analysis result, the lowest prevalence of anemia among pregnant women was observed in Amhara region, 15.89% (95% CI (8.82, 22.96)) and the highest prevalence was in Somali region, 56.80% (95% CI (52.76, 60.84)). Primigravid (RR: 0.61 (95% CI: 0.53, 0.71)) and urban women (RR: 0.73 (95% CI: 0.60, 0.88)) were less likely to develop anemia. On the other hand, mothers with short pregnancy interval (RR: 2.14 (95% CI: 1.67, 2.74)) and malaria infection during pregnancy (RR: 1.94 (95% CI: 1.33, 2.82)) had higher risk to develop anemia.</p></sec><sec><title>Conclusions</title><p id="Par4">Almost one-third of pregnant women in Ethiopia were anemic. Statistically significant association was observed between anemia during pregnancy and residence, gravidity, pregnancy interval, and malaria infection during pregnancy. Regions with higher anemia prevalence among pregnant women should be given due emphasis. The concerned body should intervene on the identified factors to reduce the high prevalence of anemia among pregnant women.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (10.1186/s12878-017-0090-z) contains supplementary material, which is available to authorized users.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Prevalence of anemia</kwd><kwd>Anemia during pregnancy</kwd><kwd>Short birth interval</kwd><kwd>Malaria during pregnancy</kwd><kwd>Ethiopia</kwd><kwd>Meta-analysis</kwd><kwd>Systematic review</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2017</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1"><title>Background</title><p id="Par11">World health organization (WHO) defines anemia as a low blood hemoglobin concentration. It is one of the major public health problems globally with diverse consequences [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR2">2</xref>]. It affects the physical health and cognitive development of individual causing low productivity and poor economic development of a country [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR3">3</xref>]. The problem is also related to high maternal and infant morbidity and mortality especially in developing countries [<xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR5">5</xref>].</p><p id="Par12">WHO report showed that anemia affects more than half a billion reproductive age women globally. From this, 38% of the anemic women were pregnant [<xref ref-type="bibr" rid="CR5">5</xref>]. Anemia is the most common complication related to pregnancy, which affects almost half of pregnant women globally [<xref ref-type="bibr" rid="CR6">6</xref>–<xref ref-type="bibr" rid="CR10">10</xref>]. It usually results due to the normal physiological changes of pregnancy resulting in hemoglobin concentration [<xref ref-type="bibr" rid="CR6">6</xref>, <xref ref-type="bibr" rid="CR11">11</xref>]. The problem is more common in developing countries where there is inadequate diet and poor prenatal vitamins and iron and folic acid intake [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR6">6</xref>, <xref ref-type="bibr" rid="CR12">12</xref>]. The most common type of anemia is iron deficiency anemia which mainly affects women of reproductive age group, particularly pregnant women [<xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR13">13</xref>].</p><p id="Par13">Several studies have shown that anemia during pregnancy has several adverse effects. Based on the type and severity of anemia, the pregnancy may have poor maternal and fetal outcomes. The most common obstetric problems of anemia include; abortion, prematurity, intrauterine fetal death, low birth weight and perinatal mortality [<xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR6">6</xref>, <xref ref-type="bibr" rid="CR14">14</xref>–<xref ref-type="bibr" rid="CR16">16</xref>].</p><p id="Par14">Even though studies have been conducted on the magnitude of anemia among pregnant women in Ethiopia, they present inconsistent and inconclusive findings. So, this systematic review and meta-analysis was conducted to determine the prevalence and determinants of anemia among pregnant women in Ethiopia using the available published evidence. The study will be important to design appropriate interventions to reduce the high burden of the disease.</p></sec><sec id="Sec2"><title>Methods</title><sec id="Sec3"><title>Study design and search strategy</title><p id="Par15">A systematic review of published studies was used to determine the prevalence of anemia and its determinant factors among pregnant women in Ethiopia. Review of all published studies was done in the following major databases; PubMed, Cochrane Library, Google Scholar, CINAHL, and African Journals Online. The search for published studies was not restricted by time, and all published articles up to January 01/2017 were included into the review. Search of the reference list of already identified studies to retrieve additional articles was done. The search terms used were; “anemia OR anemia during pregnancy OR determinants of anemia AND Ethiopia”. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was strictly followed when conducting this review [<xref ref-type="bibr" rid="CR17">17</xref>].</p></sec><sec id="Sec4"><title>Study selection and eligibility criteria</title><p id="Par16">This review included studies that were conducted and published on anemia among pregnant women in Ethiopia. All studies conducted at the community or health institution level were included. Studies that provide the prevalence of anemia in pregnant women using the WHO definition (hemoglobin level less than 11 g/dl), and published in the English language were included. Studies conducted among pregnant women but who had comorbidities like; like HIV/AIDS, renal disease, and other medical or surgical conditions were excluded from this study. Articles were assessed for inclusion using their title, abstract and then a full review of papers was done before inclusion to the final review.</p></sec><sec id="Sec5"><title>Outcome of interest</title><p id="Par17">The primary outcome of this study was magnitude of anemia during pregnancy. The WHO defines anemia in pregnany as low blood hemoglobin concentration, below 11 g/dl or hematocrit level less than 33% [<xref ref-type="bibr" rid="CR1">1</xref>]. The determinant variables included in this review were; residence (urban vs rural), pregnancy interval (less than two years, greater than or equal to two years), malaria infection during pregnancy and total number of pregnancy (primigravida or multigravida). Primigravida refers to women who are pregnant for the first time and multigravida refers to women who are pregnant two or more times [<xref ref-type="bibr" rid="CR18">18</xref>, <xref ref-type="bibr" rid="CR19">19</xref>].</p></sec><sec id="Sec6"><title>Quality assessment and data collection</title><p id="Par18">Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal of studies [<xref ref-type="bibr" rid="CR20">20</xref>]. Two reviewers independently assessed the articles for overall study quality and for inclusion in the review. Any unlear information and disagreement which arises between the reviewers was resolved through discussion and by involving a third reviewer. The researchers developed a data extraction tool. The tool included information on the name of the author/s, publication year, study period, study design, sample size, study area, age of study participants, response rate, mean hemoglobin level, and the prevalence of anemia. Inaddition, the tool contains questions on the prevalence of anemia by residence, number of pregnancy, malaria infection during pregnancy and pregnancy gap.</p></sec><sec id="Sec7"><title>Publication bias and heterogeneity</title><p id="Par19">Publication bias and heterogeneity were assessed using the Egger’s and Begg’s tests [<xref ref-type="bibr" rid="CR21">21</xref>, <xref ref-type="bibr" rid="CR22">22</xref>]. A <italic>p</italic>-value less than 0.05 were used to declare statistical significance of publication bias. The heterogeneity of studies was also checked using <italic>I</italic><sup><italic>2</italic></sup> test statistics. The <italic>I</italic><sup><italic>2</italic></sup> test statistics of 25%, 50%, and 75% was declared as low, moderate and high heterogeneity respectively [<xref ref-type="bibr" rid="CR23">23</xref>]. A p-value less than 0.05 was used to declare heterogeneity. For the test result which indicates the presence of heterogeneity, random effect model was used as a method of analysis, since it reduces the heterogeneity of studies [<xref ref-type="bibr" rid="CR23">23</xref>].</p></sec><sec id="Sec8"><title>Statistical methods and analysis</title><p id="Par20">Data were entered into Microsoft Excel and then exported to STATA 14 software for further analysis. Forest plot was used to present the combined estimate with 95% confidence interval (CI) of the meta-analysis. Subgroup analysis was conducted by regions of the country and type of study design. The effect of selected predictor variables which include; number of pregnancy, malaria infection during pregnancy, pregnancy gap, and residence on the anemia during pregnancy was analyzed using separate categories of meta-analysis. The findings of meta-analysis were presented using forest plot and relative risk (RR) with its 95% CI.</p></sec></sec><sec id="Sec9"><title>Results</title><sec id="Sec10"><title>Study selection</title><p id="Par21">This review included published studies on anemia among pregnant women in Ethiopia. The electronic search was done on several databases, which include; PUBMED, Cochrane Library, Google Scholar, CINAHL, and African Journals Online. The review found a total of 1592 published articles. From this, 86 duplicate records were removed and 1467 records were excluded after screening by title and abstracts. A total of 39 full-text articles were screened for eligibility. From this, 19 articles were excluded since they included non-pregnant women and the outcome variables was not reported. Finally, 20 studies were included in the final quantitative meta-analysis (Fig. <xref rid="Fig1" ref-type="fig">1</xref>).<fig id="Fig1"><label>Fig. 1</label><caption><p>Flow diagram of the studies included in the Meta-analysis</p></caption><graphic xlink:href="12878_2017_90_Fig1_HTML" id="MO1"></graphic></fig></p></sec><sec id="Sec11"><title>Characteristics of included studies</title><p id="Par22">All included studies were cross-sectional conducted among pregnant women. The minimum sample size was 150 participants in a study conducted in Nekemte [<xref ref-type="bibr" rid="CR24">24</xref>]. While, the higher sample size was 1678, conducted in Haramaya district of Oromia region [<xref ref-type="bibr" rid="CR25">25</xref>]. Overall, this meta-analysis included a total of 10, 281 pregnant women. All studies used the WHO definition of anemia during pregnancy [<xref ref-type="bibr" rid="CR1">1</xref>]. The minimum and maximum age of pregnant women included in this review were 14 years and 42 years respectively. Thirteen, 65% of the included studies were conducted at health institution [<xref ref-type="bibr" rid="CR24">24</xref>, <xref ref-type="bibr" rid="CR26">26</xref>–<xref ref-type="bibr" rid="CR37">37</xref>] and 7(35%) of studies were community-based studies [<xref ref-type="bibr" rid="CR25">25</xref>, <xref ref-type="bibr" rid="CR38">38</xref>–<xref ref-type="bibr" rid="CR43">43</xref>]. Most of the regions in Ethiopia were represented in this review. One of the study was conducted in Addis Ababa, capital city of Ethiopia [<xref ref-type="bibr" rid="CR34">34</xref>], 3 were from Amhara region [<xref ref-type="bibr" rid="CR27">27</xref>, <xref ref-type="bibr" rid="CR28">28</xref>, <xref ref-type="bibr" rid="CR36">36</xref>], 6 from Oromia region [<xref ref-type="bibr" rid="CR24">24</xref>, <xref ref-type="bibr" rid="CR25">25</xref>, <xref ref-type="bibr" rid="CR30">30</xref>, <xref ref-type="bibr" rid="CR35">35</xref>, <xref ref-type="bibr" rid="CR37">37</xref>, <xref ref-type="bibr" rid="CR42">42</xref>], 1 from Somali region [<xref ref-type="bibr" rid="CR38">38</xref>], 5 from SNNPR [<xref ref-type="bibr" rid="CR29">29</xref>, <xref ref-type="bibr" rid="CR32">32</xref>, <xref ref-type="bibr" rid="CR33">33</xref>, <xref ref-type="bibr" rid="CR40">40</xref>, <xref ref-type="bibr" rid="CR43">43</xref>], 2 from Tigray region [<xref ref-type="bibr" rid="CR26">26</xref>, <xref ref-type="bibr" rid="CR31">31</xref>], and 2 were nationwide studies [<xref ref-type="bibr" rid="CR39">39</xref>, <xref ref-type="bibr" rid="CR41">41</xref>] (Table <xref rid="Tab1" ref-type="table">1</xref>).<table-wrap id="Tab1"><label>Table 1</label><caption><p>Summary characteristics of included studies in the meta-analysis</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Author, year of publication</th><th>Study area</th><th>Study year</th><th>Type of cross sectional study</th><th>Sample size</th><th>Response rate (%)</th><th>Mean hemoglobin level (in g/dl)</th><th>Prevalence of anemia among pregnant women</th></tr></thead><tbody><tr><td>Alene KA. and Dohe AM., 2014 [<xref ref-type="bibr" rid="CR38">38</xref>]</td><td>Gode town, Somali Region</td><td>2013</td><td>Community based</td><td>581</td><td>99.3</td><td>10.79</td><td>56.8</td></tr><tr><td>Abriha A. et al., 2014 [<xref ref-type="bibr" rid="CR26">26</xref>]</td><td>Mekele town, Tigray Region</td><td>2014</td><td>Facility based</td><td>632</td><td>97.9</td><td>11.7</td><td>19.7</td></tr><tr><td>Alem M. et al., 2013 [<xref ref-type="bibr" rid="CR27">27</xref>]</td><td>Azezo Health Center, Gondar, Amhara Region</td><td>2011</td><td>Facility based</td><td>384</td><td>100</td><td>–</td><td>21.6</td></tr><tr><td>Alemu T. & Umeta M., 2015 [<xref ref-type="bibr" rid="CR39">39</xref>]</td><td>Data from 2011 EDHS</td><td>2011</td><td>Community based</td><td>1212</td><td>–</td><td>–</td><td>23</td></tr><tr><td>Ayenew F. et al., 2014 [<xref ref-type="bibr" rid="CR28">28</xref>]</td><td>Debre Birhan, Amhara region</td><td>2013</td><td>Facility based</td><td>330</td><td>89.4</td><td>–</td><td>9.7</td></tr><tr><td>Bekele A.et al., 2016 [<xref ref-type="bibr" rid="CR29">29</xref>]</td><td>Arba Minch, SNNPR</td><td>2015</td><td>Facility based</td><td>332</td><td>100</td><td>–</td><td>32.8</td></tr><tr><td>Ejeta E. et al., 2014 [<xref ref-type="bibr" rid="CR30">30</xref>]</td><td>Nekemte Referral Hospital, Oromia Region</td><td>2014</td><td>Facility based</td><td>286</td><td>100</td><td>12.67</td><td>29</td></tr><tr><td>Gebre A. & Mulugeta A., 2015 [<xref ref-type="bibr" rid="CR31">31</xref>]</td><td>Northwestern zone, Tigray Region</td><td>2014</td><td>Facility based</td><td>714</td><td>97.7</td><td>11.21</td><td>36.1</td></tr><tr><td>Gebremedhin S. et al., 2014 [<xref ref-type="bibr" rid="CR41">41</xref>]</td><td>Eight rural woredas of Tigray, Amhara, Oromia and SNNP regions</td><td>2012</td><td>Community based</td><td>445</td><td>93</td><td>11.5</td><td>33.2</td></tr><tr><td>Gebremedhin S, Enquselassie F., & Umeta M., 2014 [<xref ref-type="bibr" rid="CR40">40</xref>]</td><td>Sidama, SNNPR</td><td>2011</td><td>Community based</td><td>700</td><td>93.1</td><td>11.4</td><td>31.6</td></tr><tr><td>Gedefaw L.et al., 2015 [<xref ref-type="bibr" rid="CR32">32</xref>]</td><td>Wolayita Soddo Otona Hospital, SNNPR</td><td>2014</td><td>Facility based</td><td>363</td><td>100</td><td>11.55</td><td>39.9</td></tr><tr><td>Getachew M. et al., 2012 [<xref ref-type="bibr" rid="CR42">42</xref>]</td><td>Districts around Gilgel Gibe Dam area, Oromia Region</td><td>2011</td><td>Community based</td><td>388</td><td>98.7</td><td>10.9</td><td>53.9</td></tr><tr><td>Gies S. et al., 2003 [<xref ref-type="bibr" rid="CR33">33</xref>]</td><td>Awassa, SNNPR</td><td>2001</td><td>Facility based</td><td>403</td><td>100</td><td>12.3</td><td>15.1</td></tr><tr><td>Jufar AH. & Zewde T., 2014 [<xref ref-type="bibr" rid="CR34">34</xref>]</td><td>Tikur Anbesa Specialized Hospital, Addis Ababa</td><td>2013</td><td>Facility based</td><td>395</td><td>100</td><td>12</td><td>21.3</td></tr><tr><td>Kedir H.et al., 2013 [<xref ref-type="bibr" rid="CR25">25</xref>]</td><td>Haramaya district, Oromia Region</td><td>2010</td><td>Community based</td><td>1678</td><td>94.7</td><td>11</td><td>43.9</td></tr><tr><td>Kefiyalew F. et al., 2014 [<xref ref-type="bibr" rid="CR35">35</xref>]</td><td>Bisidimo Hospital, Babile Woreda, Somalie</td><td>2013</td><td>Facility based</td><td>258</td><td>100</td><td>11.4</td><td>27.9</td></tr><tr><td>Melku M.et al., 2014 [<xref ref-type="bibr" rid="CR36">36</xref>]</td><td>Gondar University hospital, Amhara region</td><td>2012</td><td>Facility based</td><td>302</td><td>100</td><td>11.96</td><td>16.6</td></tr><tr><td>Mihiretie H. et al., 2015 [<xref ref-type="bibr" rid="CR24">24</xref>]</td><td>Nekemte, Oromia region</td><td>2011</td><td>Facility based</td><td>150</td><td>100</td><td>–</td><td>52</td></tr><tr><td>Nega D.et al., 2015 [<xref ref-type="bibr" rid="CR43">43</xref>]</td><td>Arba Minch Town, SNNPR region</td><td>2013</td><td>Community based</td><td>354</td><td>96.3</td><td>11.73</td><td>34.6</td></tr><tr><td>Obse N.et al., 2013 [<xref ref-type="bibr" rid="CR37">37</xref>]</td><td>Shara woreda, West Arsi zone, Oromia region</td><td>2011</td><td>Facility based</td><td>374</td><td>100</td><td>12.05</td><td>36.6</td></tr></tbody></table></table-wrap></p></sec><sec id="Sec12"><title>Prevalence of anemia among pregnant women</title><p id="Par23">The minimum prevalence of anemia was 9.7% observed in a study conducted in North Shoa zone [<xref ref-type="bibr" rid="CR28">28</xref>]. The highest, 56.8% was observed in a study conducted in Eastern Ethiopia [<xref ref-type="bibr" rid="CR38">38</xref>]. The <italic>I</italic><sup><italic>2</italic></sup> test result showed high heterogeneity (I<sup>2</sup> 97.7%, p = <0.001). Using the random effect analysis, the pooled prevalence of anemia among pregnant women in Ethiopia was 31.66% (95% CI (26.20, 37.11)) (Fig. <xref rid="Fig2" ref-type="fig">2</xref>).<fig id="Fig2"><label>Fig. 2</label><caption><p>Forest plot displaying the pooled prevalence of anemia among pregnant women in Ethiopia</p></caption><graphic xlink:href="12878_2017_90_Fig2_HTML" id="MO2"></graphic></fig></p><p id="Par24">A subgroup analysis by region in Ethiopia was computed to compare the prevalence of anemia acroos different participants characterstics. Based on this analysis, the lowest prevalence of anemia among pregnant women was observed in Amhara region, 15.89% (95% CI (8.82, 22.96)) and the highest prevalence was in Somali region; 56.80%(95% CI (52.76, 60.84)). A higher prevalence (39.49%) of anemia among pregnant women was observed in studies conducted at community level than facility based studies (27.31%) (Table <xref rid="Tab2" ref-type="table">2</xref>).<table-wrap id="Tab2"><label>Table 2</label><caption><p>Sub-group analysis of prevalence of anemia among pregnant women in Ethiopia</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Sub group</th><th>No. of included studies</th><th>Prevalence (95% CI)</th><th>Heterogeneity statistics</th><th><italic>p</italic>-value</th><th><italic>I</italic><sup><italic>2</italic></sup></th></tr></thead><tbody><tr><td colspan="6">By region</td></tr><tr><td>Addis Ababa City</td><td>1</td><td>21.30 (17.26, 25.34)</td><td>–</td><td>–</td><td>–</td></tr><tr><td>Amhara region</td><td>3</td><td>15.89 (08.82, 22.96)</td><td>19.89</td><td><0.001</td><td>89.9</td></tr><tr><td>Oromia region</td><td>6</td><td>40.44 (32.67, 48.20)</td><td>83.85</td><td><0.001</td><td>94.0</td></tr><tr><td>SNNPR</td><td>5</td><td>30.71 (21.74, 39.68)</td><td>87.75</td><td><0.001</td><td>95.0</td></tr><tr><td>Somali region</td><td>1</td><td>56.80 (52.76, 60.84)</td><td>–</td><td>–</td><td>–</td></tr><tr><td>Tigray region</td><td>2</td><td>27.88 (11.81, 43.95)</td><td>46.91</td><td><0.001</td><td>97.9</td></tr><tr><td>Nationwide study</td><td>2</td><td>28.10 (18.11, 38.10)</td><td>36.12</td><td><0.001</td><td>97.2</td></tr><tr><td colspan="6">By study type</td></tr><tr><td>Community based study</td><td>7</td><td>39.49 (30.84, 48.14)</td><td>321.93</td><td><0.001</td><td>98.1</td></tr><tr><td>Institutional based study</td><td>13</td><td>27.31 (21.51, 33.10)</td><td>289.66</td><td><0.001</td><td>97.7</td></tr></tbody></table></table-wrap></p></sec><sec id="Sec13"><title>Association of malaria infection and anemia during pregnancy</title><p id="Par25">Women who had malaria infection during pregnancy were almost two times more likely to develop anemia during pregnancy than women had no such infection, RR: 1.94 (95% CI (1.33, 2.82)). The heterogeneity test showed statistical evidence of heterogeneity, <italic>p</italic> = <0.001. As a result, weights were calculated using the random-effects analysis. The Begg’s and Egger’s test for publication bias showed no statistical evidence of publication bias, <italic>p</italic>-value = >0.05 and <italic>p</italic>-value = 0.543 respectively (Fig. <xref rid="Fig3" ref-type="fig">3</xref>).<fig id="Fig3"><label>Fig. 3</label><caption><p>Forest plot displaying the effect malaria attack and anemia among pregnant women in Ethiopia</p></caption><graphic xlink:href="12878_2017_90_Fig3_HTML" id="MO3"></graphic></fig></p></sec><sec id="Sec14"><title>Association of number of pregnancy with anemia during pregnancy</title><p id="Par26">The meta-analysis showed that premigravida women were 61% less likely to develop anemia during pregnancy compared tomultigravida women, RR: 0.61 (95% CI (0.53, 0.71)). The heterogeneity test showed no statistical evidence of heterogeneity, <italic>p</italic> = 0.530. The Begg’s and Egger’s test for publication bias also showed no statistical evidence of publication bias, <italic>p</italic>-value = 0.36 and <italic>p</italic>-value = 0.397 respectively (see Additional file <xref rid="MOESM1" ref-type="media">1</xref>).</p></sec><sec id="Sec15"><title>Association of short pregnancy interval with anemia during pregnancy</title><p id="Par27">Women who had short pregnancy interval were more than two times more likely to develop anemia during the current pregnancy than women who had more than two years pregnancy interval, RR: 2.14 (95% CI (1.67, 2.74)). The heterogeneity test showed no statistical evidence of heterogeneity, <italic>p</italic> = 0.108. The Begg’s and Egger’s test for publication bias also showed no statistical evidence of publication bias, <italic>p</italic>-value = 0.266 and <italic>p</italic>-value = 0.112 respectively (see Additional file <xref rid="MOESM2" ref-type="media">2</xref>).</p></sec><sec id="Sec16"><title>Association of residence with anemia during pregnancy</title><p id="Par28">Women living in urban areas were 73% less likely to be anemic during pregnancy than women in the rural area, RR: 0.73 (95% CI (0.60, 0.88)). The heterogeneity test showed statistical evidence of heterogeneity, <italic>p</italic> = 0.003. But, the Begg’s and Egger’s test for publication bias showed no statistical evidence of publication bias, <italic>p</italic>-value = 0.602 and <italic>p</italic>-value = 0.581 respectively (<bold>see</bold> Additional file <xref rid="MOESM3" ref-type="media">3</xref>).</p></sec></sec><sec id="Sec17"><title>Discussion</title><p id="Par29">This review was conducted to determine the pooled prevalence and determinants of anemia among pregnant women in Ethiopia using published studies. Anemia during pregnancy is associated with increased risk of obstetric problems [<xref ref-type="bibr" rid="CR44">44</xref>]. Studies have shown that anemia is associated with maternal physical and psychological comorbidity, and with an increased risk of perinatal and maternal morbidity and mortality [<xref ref-type="bibr" rid="CR45">45</xref>–<xref ref-type="bibr" rid="CR47">47</xref>].</p><p id="Par30">The pooled meta-analysis of this review found that the prevalence of anemia among pregnant women in Ethiopia was 31.66% (95%CI: (26.20, 37.11)). The 2016 Ethiopian demographic and health survey (EDHS) report showed a lower (24%) prevalence of anemia among reproductive-aged women, and 29% among pregnant women [<xref ref-type="bibr" rid="CR48">48</xref>]. This showed a higher prevalence of anemia among pregnant women than non-pregnant reproductive age women. This could be explained by an extra demand of iron by the pregnant women for fetal growth and development during pregnancy. This report is lower than the current finding. The possible explanation for the difference could be related to the sampling and study period. The EDHS was conducted in a nationally representative sample across all regions of the country, while this study included only few regions of the country. The current review also included studies conducted since 2001.</p><p id="Par31">A meta-analysis on global trend of anemia showed that 38% of pregnant women were anemic in 2011 [<xref ref-type="bibr" rid="CR3">3</xref>]. The review also showed that 36% prevalence of anemia among pregnant women in East Africa and 22% prevalence in high-income regions [<xref ref-type="bibr" rid="CR3">3</xref>]. The East African finding is relatively higher than the findings of this review. A possible explanation could be the time difference between the two reviews in which the current review also included recent studies and the difference in the sociodemographic characteristics of participants included in the review.</p><p id="Par32">Subgroup analysis based on the regions of the country showed a lower and higher prevalence of anemia in Amhara region (15.89%) and Somali region (56.8%) respectively. The difference in the prevalence between the regions in Ethiopia could be attributed due to the difference in the sociodemographic, socioeconomic, iron-folic acid intake and the difference in the magnitude of the communicable and non-communicable diseases. The difference in the number of studies included in each category of analysis could also be the reason for the difference.</p><p id="Par33">The result of the meta-analysis showed that primigravida women were 61% less likely to develop anemia during pregnancy compared to multigravida women. This could be because of the effect of repeated pregnancy in depleting the iron store of a pregnant woman [<xref ref-type="bibr" rid="CR49">49</xref>, <xref ref-type="bibr" rid="CR50">50</xref>]. A study conducted in Malaysia also found a higher proportion of anemia (66.7%) among grand multigravida women [<xref ref-type="bibr" rid="CR51">51</xref>].</p><p id="Par34">A shorter interpregnancy interval increases the risk of adverse obstetric outcomes [<xref ref-type="bibr" rid="CR52">52</xref>]. Short birth interval is associated with preterm births, low birth weight, stillbirth and early neonatal death [<xref ref-type="bibr" rid="CR52">52</xref>]. The current study also found that pregnant women with short pregnancy interval were more than two times more likely to develop anemia during the current pregnancy than women who had more than two years pregnancy interval. This could be explained by the effect of repeated and short interpregnancy interval and breastfeeding on the overall physiologic status of the mother. The woman will not get enough time to recover from the depleted nutrients [<xref ref-type="bibr" rid="CR50">50</xref>]. A systematic review of the effect of birth spacing on the maternal and child nutritional status found that short birth intervals are related to maternal anemia [<xref ref-type="bibr" rid="CR49">49</xref>]. Similar findings were also observed in a study conducted in Tanzania [<xref ref-type="bibr" rid="CR53">53</xref>].</p><p id="Par35">Pregnant women living in urban areas are 73% less likely to be anemic during pregnancy than women in the rural area. The difference in the socioeconomic status, educational and occupational status of pregnant women, difference in the health service access between rural and urban areas could be the justification for the difference. Additionally, inadequate counselling by health professionals in resolving the wrong beliefs and myths regarding the iron supplementation could contribute to higher prevalence of anemia among pregnant women in rural areas [<xref ref-type="bibr" rid="CR54">54</xref>, <xref ref-type="bibr" rid="CR55">55</xref>]. A study conducted in India also showed that pregnant women from the rural areas are more likely to develop anemia than women from the urban area [<xref ref-type="bibr" rid="CR54">54</xref>].</p><p id="Par36">WHO recommends early diagnosis and effective treatment of malaria infections and the use of long-lasting insecticidal nets (LLINS) during pregnancy [<xref ref-type="bibr" rid="CR56">56</xref>]. The result of this meta-analysis showed that women who had malaria attack during pregnancy are almost two times more likely to develop anemia during pregnancy. A review of studies conducted in Sub-Saharan African countries also found that there is a higher (26%) risk of severe anemia in pregnant women secondary to malaria infection. Malaria infection is responsible for one in ten cases of severe anemia in pregnant women [<xref ref-type="bibr" rid="CR46">46</xref>]. Similar findings was also observed in a study conducted in Kenya [<xref ref-type="bibr" rid="CR57">57</xref>].</p><p id="Par37">This review used a comprehensive search strategy and more than one reviewer was involved in each step of the review process. PRISMA guideline was strictly followed during the review process. This review has certain limitations. Studies included were cross-sectional and the outcome variable may be affected by other confounding variables. Some studies included in this review didn’t consider respondents’ residential altitude above sea level to define anemia. Studies have shown that there is an increase in the hemoglobin level when people’s live at high altitude [<xref ref-type="bibr" rid="CR58">58</xref>, <xref ref-type="bibr" rid="CR59">59</xref>]. These limitations could affect the overall prevalence of anemia in the country presented in this review.</p></sec><sec id="Sec18"><title>Conclusions</title><p id="Par38">Almost one-third of pregnant women in Ethiopia were anemic. Statistically significant association was observed between anemia during pregnancy and residence, gravidity, pregnancy interval and malaria infection during their pregnancy. Regions with higher anemia prevalence among pregnant women should be given due attention. Further studies should be conducted to better understand the determinant factors in these regions.</p><p id="Par39">The government and non-governmental organizations should focus on strengthening iron and folic acid supplementation for all pregnant women as part of the routine antenatal care. The use of long-lasting insecticidal nets during pregnancy, early diagnosis and appropriate treatment of malaria in pregnant women, and the use of long-acting family planning methods to prevent short pregnancy intervalsis important and should be stengtehend in areas of higher anemia prevalence in Ethiopia. Health extension workers should be involved in the promotion of antenatal follow-ups and community-based awareness programs, especially in rural areas. Further nationwide studies are needed to understand the determinant factors for anemia in pregnant women.</p></sec><sec sec-type="supplementary-material"><title>Additional files</title><sec id="Sec19"><p><supplementary-material content-type="local-data" id="MOESM1"><media xlink:href="12878_2017_90_MOESM1_ESM.docx"><label>Additional file 1:</label><caption><p>Forest plot displaying the effect of gravidity in a pregnant woman and anemia among pregnant women in Ethiopia. Description of figure: This figure presents the effect of gravdity on anemia during pregnancy. Multigravida women are more likely to develop anemia during pregnancy than primigravida. (DOCX 18 kb)</p></caption></media></supplementary-material><supplementary-material content-type="local-data" id="MOESM2"><media xlink:href="12878_2017_90_MOESM2_ESM.docx"><label>Additional file 2:</label><caption><p>Forest plot displaying the effect of short pregnancy interval and anemia among pregnant women in Ethiopia. Description of figure: This figure presents the effect of short pregnancy interval on anemia during pregnancy. Women who have shorter pregnancy interval are more likely to develop anemia during pregnancy than women with pregnancy interval of more than two years. (DOCX 17 kb)</p></caption></media></supplementary-material><supplementary-material content-type="local-data" id="MOESM3"><media xlink:href="12878_2017_90_MOESM3_ESM.docx"><label>Additional file 3:</label><caption><p>Forest plot displaying the effect residence of pregnant woman and anemia among pregnant women in Ethiopia. Description of figure: This figure presents the effect of residence on anemia during pregnancy. Women who are residing in rural areas are more likely to develop anemia during pregnancy than pregnant women in urban areas. (DOCX 18 kb)</p></caption></media></supplementary-material></p></sec></sec></body><back><glossary><title>Abbreviations</title><def-list><def-item><term>CI</term><def><p id="Par5">Confidence Interval</p></def></def-item><def-item><term>EDHS</term><def><p id="Par6">Ethiopian Demographic and Health Survey</p></def></def-item><def-item><term>LLINS</term><def><p id="Par7">Long-lasting insecticidal nets</p></def></def-item><def-item><term>RR</term><def><p id="Par8">Relative Risk</p></def></def-item><def-item><term>SNNPR</term><def><p id="Par9">Southern Nations, Nationalities, and Peoples’ Region of Ethiopia</p></def></def-item><def-item><term>WHO</term><def><p id="Par10">World Health Organization</p></def></def-item></def-list></glossary><fn-group><fn><p><bold>Electronic supplementary material</bold></p><p>The online version of this article (10.1186/s12878-017-0090-z) contains supplementary material, which is available to authorized users.</p></fn></fn-group><ack><title>Acknowledgements</title><p>We would like to acknowledge to authors of studies included in this review.</p><sec id="FPar1"><title>Funding</title><p id="Par40">No funding was obtained for this study.</p></sec><sec id="FPar2"><title>Availability of data and materials</title><p id="Par41">All data pertaining to this study are contained and presented in this document.</p></sec></ack><notes notes-type="author-contribution"><title>Authors’ contributions</title><p>GMK involved in the design, selection of articles, data extraction, statistical analysis and manuscript writing. AAM, AKB, and GAF also involved in data extraction, analysis, and manuscript editing. All authors read and approved the final draft of the manuscript.</p></notes><notes notes-type="COI-statement"><sec id="FPar3"><title>Ethics approval and consent to participate</title><p id="Par43">Not applicable.</p></sec><sec id="FPar4"><title>Consent for publication</title><p id="Par44">Not applicable.</p></sec><sec id="FPar5"><title>Competing interest</title><p id="Par42">The authors declare that they have no competing interest.</p></sec><sec id="FPar6"><title>Publisher’s Note</title><p id="Par45">Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p></sec></notes><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><element-citation publication-type="book"><person-group person-group-type="author"><collab>WHO</collab></person-group><source>The global prevalence of anaemia in 2011</source><year>2015</year><publisher-loc>Geneva</publisher-loc><publisher-name>World Health Organization</publisher-name></element-citation></ref><ref id="CR2"><label>2.</label><mixed-citation publication-type="other">Black RE, Allen LH, Bhutta ZA, Caulfield LE, De Onis M, Ezzati M, Mathers C, Rivera J, Maternal and child undernutrition study group. 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