Our findings revealed that the magnitude of anemia among married women in Ethiopia was relatively high 30.5% (95% CI = 29.5–31.4) compared to those reported in the nationwide study among lactating and reproductive age of women [5, 22]. This indicates that married women are at a greater risk of anemia. The majority of respondents (61%) in our sample had low decision-making autonomy at home. Therefore, the greater magnitude of anemia in our sample could be due to the low decision-making capacity of women to access resources and health information. Gender power dynamics influence how and who makes health-related decisions .) In families and communities, this power dynamics can affect health-seeking processes such as healthy eating patterns and health outcomes. Globally and especially in sub-Saharan African countries such as Ethiopia, men frequently make decisions regarding their wives’ health [28, 29].. Poor women’s welfare is a barrier to reaching the eventual aim of universal health. This suggests that substantial work is required to decrease the magnitude of anemia among married females, as it has a negative impact on the well-being of mothers, children, and the rest of the family.
This study has determined that in comparing the impact of individual-level women’s decision-making with anemia, the effect of group level decision making power was considered significant. Women living in a society with a high percentage of women with high decision-making status were less likely to develop anemia even after we controlled their decision-making status and other factors at the individual and group level. This may be because social interactions in Ethiopia are often intertwined and therefore, the effect of group group-level autonomy on individual behavior may exceed the individual’s autonomy . The group level may indicate that even though Ethiopian women have low decision-making power, living in a strong decision-making society for women can lead to increased use of shared information and resources and ultimately, help improve the quality of life for women and their family members as well . Female decision-making power at the group level had a beneficial effect on lowering the risk of anemia, implying that gender disparity, as measured by low decision-making power, may influence the development of anemia among married women.
In addition to group-level women’s autonomy, our analyses revealed that the group-level wealth index had a greater impact than the effects of the individual-level wealth index on anemia. A high group-level wealth index was related to reduce odds of having anemia. Prior studies also demonstrated the positive relationship between community economic status and women’s health; economically poorer communities have deficient health information and services [31, 32]. Therefore, interventions aimed at empowering women economically at the group level should be considered to reduce the prevalence of anemia and other health-related problems.
Unlike the findings of other studies [6, 9, 33, 34], our study found that older women had a lower risk to develop anemia than younger ones. The possible reason for this finding is that during adolescence, pregnancy and lactation, younger women have increased iron requirements and to compensate for menstruation-related blood loss . The high percentage of early married women in our sample may provide another possible explanation. Our study found that more than 83% of women were married before the age of 20 years and according to our bivariate analysis, the prevalence of anemia among them was also significantly higher (10.8% vs. 5.0%). %). In Ethiopia, child marriage is common, and decisions about having children and using birth control are often made by husbands [36, 37]. Furthermore, the customs of Ethiopian society strongly oppose the postponement of the first child after marriage, leading to a higher rate of adolescent birth. Therefore, the greater magnitude of anemia among younger females might be because of adolescent pregnancy and childbirth. This implies interventions such as educating the parents and community members who eventually bear the majority of determinations about girls marriage; empowering girls with information (such as exposure to media) about the consequences of early marriage and pregnancy, improving the accessibility and standard of formal education for girls must be prioritized in order to preclude girls marriage and having children. Furthermore, all females of childbearing age need to take iron and folic acid supplements to avoid anemia .
In this study, we found that when compared to orthodox followers, Muslim and Protestant women were 37 and 62% more likely to develop anemia, respectively. The possible reason for this result may be due to different dietary patterns among different religious followers. In Ethiopian Orthodox Church, more than 200 days including every Wednesday and Friday in a year are dedicated to religious fasting, which includes abstaining from all types of animal-based foods . Good plant sources of iron including legumes (beans, peas, and lentils), pumpkin, flaxseeds, and vegetables such as spinach, beets and chard are common foods in the fasting dishes. Moreover, Shiro wot, basically made from ground beans/chickpeas, and is also particularly popular as a fasting food among orthodox followers in Ethiopia and relatively inexpensive. Thus, women may get enough non-heme iron from plant-based foods. A longitudinal study conducted in Greek also reported that orthodox fasters had significantly higher iron intake at the end of the fasting period compared to non-fasters . Another potential explanation for the greater magnitude of anemia amongst Muslim females, perhaps because of large family sizes [41,42,43]. An additional reason may be the frequent consumption of milk and milk product (attribute to iron absorption inhibitor) among Muslim women because most of them are living in the lowlands of the eastern part of Ethiopia (Afar and Somali regions) mostly live on pastoralism. Consumption of iron-rich cereals such as Teff (Eragrostis tef), which is common in the highlands of Ethiopia is also rare in these regions of the country . However, further studies regarding the relationship between religion and anemia status in Ethiopia are worth doing.
Our findings supported the findings of other studies by demonstrating that female employment was negatively associated with anemia [22, 45, 46]. The lower prevalence of anemia among working women could indicate financial advantage as women who were employed can earn relatively a higher wage and purchase a wider range of foods including iron-rich ones . Another reason could be that married women who are employed have better decision-making autonomy to receive health-related information and the ability to practice a healthy dietary pattern .
This study showed that pregnancy augmented the likelihood of anemia occurrence among married females. During pregnancy, the volume of bloodlines increases, consequently iron and vitamins are needed to make more red blood cells .. Greater fluid is produced to help fetal growth and development, however this is only feasible if the body can bulid the desired number of red blood cells; these physiological alterations rise the threat of anemia, particularly if the woman’s nutritional desires are not met . Pregnant ladies who are anemic have poor pregnancy consequences such as low birth weight and stillbirths, and can even result in the mother’s death . This suggests emphasizing proper nutrition and iron supplement for women, especially during pregnancy.
This study found that, women who have ever given birth have a higher risk of developing anemia than women who have never had a child. Moreover, the prevalence of anemia increased with an increased number of children. This might be related with a reduction of maternal iron reserves at every pregnancy and blood loss at each delivery. Another possible reason may be due to the fact that increasing family size could be linked with food insecurity. This finding is consistent with other previous study findings [51, 52].
Contraceptive use was found to be inversely related to anemia in our study. A possible explanation is that contraception use can have a significant impact on achieving good nutrition outcomes by assisting women in delaying pregnancy, spacing births, and reducing a woman’s fertility. Well-spaced births allow women’s bodies to recover and replenish essential nutrients such as iron, resulting in better nutritional outcomes . The inverse relationship between contraceptive use and anemia has important implications for educating healthcare providers and women about the additional nutritional benefits of contraception use .
In this study, underweight women were more likely to suffer from anemia compared to overweight women. Studies conducted in Nepal, South Asia, Jordan, Japan and Rwanda [55,56,57,58,59], also reported similar findings. Women who are malnourished are a greater risk to be insufficient in crucial nutrients including iron, which may be linked with an expanded the threat of anemia . Based on our findings, we suggest that anemia prevention interventions in Ethiopia must focus on encouraging secure nutritional exercises to keep a healthy body mass index and endorse iron supplements to confirm ideal nourishment among women, because overweight/obesity is an emerging problem in developing countries, including Ethiopia.
This research has some limitations. First, due to the nature of a cross-sectional study design, we were unable to establish cause-and-effect relationships among explanatory and outcome variables. Second, due to the fact this study is based on secondary records analysis, we are not able to account for all confounding factors. Third, the use of administratively defined boundaries has possible to introduce misclassification for improper administrative classifications. Fourth as most previous empirical studies, our study not completely integrated theory into our conceptualizations and selection of factors. As a result, some measurements might be inaccurate or biased. In spite of these limitations, this study employed a large sample of married women in Ethiopia; consequently our findings may be representative of Ethiopian married women.