Maternal anaemia and maternal, fetal, and neonatal outcomes in a prospective cohort study in India and Pakistan

Single-dose intravenous iron vs oral iron for treatment of maternal iron deficiency anemia: a randomized clinical trial

BACKGROUND

Maternal iron deficiency anemia is a persistent global health challenge with increased risk of adverse perinatal outcomes. Obstetric guidelines advocate for first-line treatment of moderate iron deficiency anemia with twice-daily oral iron; however, rates of iron deficiency anemia in pregnancy remain above global targets and are rising.

OBJECTIVE

Determine whether single-dose intravenous iron for primary treatment of maternal iron deficiency anemia in the second trimester is superior to twice daily oral iron in reducing incidence of low birth weight infants and maternal anemia at delivery.

STUDY DESIGN

This is a parallel, 3-arm, semiblind superiority randomized controlled multicenter trial across 4 sites in India from March 15, 2021-May 12, 2023. Participants were singleton pregnancies at 14 to 17 weeks with moderate iron deficiency anemia (hemoglobin 7.0-9.9 g/dL) who were randomized 1:1:1 to (1) 60 mg oral ferrous sulfate twice daily; or single-dose infusion of (2) intravenous ferric derisomaltose or (3) intravenous ferric carboxymaltose. Two intravenous arms were selected as these are the only 2 intravenous iron formulations publicly available in India. All participants received folic acid supplementation throughout pregnancy and antihelminthic therapy, as recommended by national guidelines. The dual primary outcomes were: (1) low birth weight (<2500 grams) and (2) attainment of a maternal nonanemic state (hemoglobin ≥11.0 g/dL at 30-34 weeks or delivery) for each intravenous iron arm vs oral iron; intravenous iron arms were not compared to each other. Secondary outcomes included safety measures, and other maternal and infant outcomes. Participants with hemoglobin <7 g/dL or <1 g/dL improvement on therapy received rescue treatment with intravenous iron or blood transfusion as determined by their provider. Sensitivity analyses included defining nonanemic state as achieving hemoglobin ≥11.0 without need for additional IV iron or transfusion. Comparison of each intravenous iron arm to oral iron was conducted with a 2-sided alpha set at 0.0005 for achieving nonanemic state and 0.0245 for low birth weight for each intravenous iron arm using a Cochran-Mantel-Haenszel chi-square test stratified by enrollment site.

RESULTS

The oral iron, ferric derisomaltose, and ferric carboxymaltose arms included 1450, 1456, and 1462 participants respectively. There was a reduced rate of low birth weight with intravenous ferric carboxymaltose (25·2%, relative risk 0·87 [97·55% confidence interval 0.75, 0.99], P=.017), but not intravenous ferric derisomaltose (29.1%, relative risk 0.98 [97.55% confidence interval 0.86, 1.12], P=.71) vs oral iron (29.3%). Achievement of nonanemic state was not improved: intravenous ferric carboxymaltose (relative risk 1.05 [99.95% confidence interval 0.97-1.15]) and intravenous ferric derisomaltose (relative risk 1.06 [99.95% confidence interval 0.98, 1.16]) vs oral (69.7%). In sensitivity analysis, there was increased rate of achieving nonanemic state without use of additional IV iron or transfusion in both intravenous ferric derisomaltose (relative risk 1.25 (1.13-1.396), P<.0001) and intravenous ferric carboxymaltose (relative risk 1.24 (1.12-1.38), P<.0001) vs oral iron.

CONCLUSION

First-line treatment of moderate maternal iron deficiency anemia with single-dose infusion of intravenous iron results in a reduced incidence of low birth weight infants (intravenous ferric carboxymaltose vs oral) and a higher incidence of attaining maternal nonanemic state without use of additional iron or blood transfusion (intravenous ferric carboxymaltose and ferric derisomaltose vs oral). Clinical guidelines should address the potential benefit of single-dose intravenous iron as the primary treatment of moderate iron deficiency anemia in pregnancy.

Anemia during pregnancy and adverse pregnancy outcomes: a systematic review and meta-analysis of cohort studies

Objectives

Anemia in pregnancy has been a topic of interest for researchers due to its potential impact on various adverse pregnancy outcomes. This study aims to explore the relationship between anemia and adverse pregnancy outcomes such as preterm birth, low birth weight, and maternal mortality.

Methods

We conducted both a systematic review and a meta-analysis on the associations between anemia during pregnancy and adverse pregnancy outcomes. We searched Chinese databases (CNKI, Wanfang, CBM, VIP) and English ones (Cochrane Library, PubMed, Embase, Web of Science). Two researcher-authors independently assessed study quality with the Newcastle-Ottawa Scale. After extracting data, we analyzed heterogeneity and used a random-effects model for higher heterogeneity and a fixed-effects model for low heterogeneity in the meta-analysis while also systematically synthesizing and narratively describing findings in the systematic review.

Results

A total of 31 cohort studies were included. Meta-analysis showed that the risk of postpartum hemorrhage [RR [95% CI], 2.76 [1.63, 4.66]], premature rupture of membranes (PROM) [1.94 (1.26, 3.00)], preterm delivery [1.51 (1.33, 1.72)], low birth weight (LBW) [1.40 (1.19, 1.63)], cesarean section[1.33 (1.02, 1.74)], gestational hypertension[1.28 (1.14, 1.44)] and neonatal asphyxia[1.21 (1.07, 1.37)] was higher in the group of anemia in pregnancy than in the control group.

Conclusion

Maternal anemia is associated with an increased risk of seven adverse pregnancy outcomes: postpartum hemorrhage, PROM, preterm delivery, LBW, cesarean section, gestational hypertension and neonatal asphyxia. Appropriate nutritional supplementation and screening for anemia before and during pregnancy are recommended to improve maternal health and manage adverse pregnancy outcomes.

Anemia during pregnancy and adverse maternal outcomes in Georgia-A birth registry-based cohort study

BACKGROUND

Anemia in pregnancy is an important public health challenge; however, it has not been thoroughly studied in Georgia. We assessed the prevalence of anemia during pregnancy across Georgia and the association between anemia in the third trimester of pregnancy and adverse maternal outcomes.

METHODS

We used data from the Georgian Birth Registry and included pregnant women who delivered between January 1, 2019, and August 31, 2022 (n = 158,668). The prevalence of anemia (hemoglobin (Hb) < 110 g/L) at any time during pregnancy was calculated per region. Pregnant women were classified into anemia severity groups based on their lowest measured Hb values, taking into account the thresholds for each trimester of pregnancy as defined by the WHO recommendations for anemia classification. Adjusted odds ratios (aOR) with 95% confidence intervals (CIs) were calculated for the associations between anemia status and post-delivery intensive care unit (ICU) admission and preterm delivery.

RESULTS

The prevalence of anemia occurring at least once during pregnancy was 33.1%, with large regional differences in anemia prevalence (19.2%-32.8%). Of 105,811 pregnant women with Hb measurements in the third trimester, 71.0% had no anemia; 20.9%, mild anemia; and 8.1%, moderate or severe anemia. The odds of post-delivery ICU admission did not increase linearly with decreasing Hb value (P for trend .13), and the relationship was inverse for preterm delivery (P for trend .01).

CONCLUSIONS

A considerable proportion of pregnant women in Georgia have anemia during pregnancy, and the prevalence and quality of reporting differ across regions. Anemia occurring in the third trimester did not substantially increase the odds of maternal ICU admission or preterm delivery. To progress toward sustainable development goals and alleviate the public health burden of anemia, it is essential to not only identify and manage anemia during pregnancy but also address underlying factors with a multifaceted response.

Effect of nutrition education and iron-folic acid supplementation on anemia among pregnant women in Ethiopia: a quasi-experimental study

The aim of this study was to assess the effect of nutrition education and counseling using health belief health model constructs along with iron-folic acid supplementation on hemoglobin level and adherence to IFAs during pregnancy. The study was a three-month quasi-experimental study design in Butajira town, Ethiopia. Community-based nutrition education and counseling sessions using the Health belief model, and IFAS for six weeks were given to the pregnant women. Compliance with iron-folic acid supplementation (IFAS) was assessed using pill counts based on the number of remaining pills in the retained prescribed bottles or strips. End-line data were collected from 97 interventions and 96 control groups of pregnant women after 6 weeks of nutrition education interventions. The analysis of the effect of the intervention was done using difference-in-difference and a generalized estimation equation (GEE) approach. At the end of the nutrition education intervention, there was a significant drop in the proportion of anemia in the intervention group compared to the control group. The prevalence of anemia among the intervention group declined from 27.8% at baseline to 7.2% after intervention. The change in the knowledge score regarding IFAS and maternal adherence to IFAS were significantly higher in the intervention group as compared to the control group (p < 0.001). In this study, the odds of adherence to IFA supplementation were 2.26 (95% CI 1.55 to 3.29) times higher among those who received nutrition education interventions as compared to the control group. Implementation of community-based nutrition education and counseling along with IFAS improved the hemoglobin level and adherence to IFAS among pregnant women. Therefore, there is need to integrate community-based nutrition education approach by using HBM constructs with antenatal IFAS distribution to improve supplementation and hemoglobin level of pregnant women.

Maternal Anemia during Pregnancy and Infant Birth Outcomes: A Prospective Cohort Study in Eastern Maharashtra, India

Background

Anemia during pregnancy may be associated with poor infant outcomes, although its consequences may vary based on etiology and timing.

Objectives

We examined the associations between anemia and anemia-related biomarkers during pregnancy and infant outcomes [birthweight, gestational age at birth, birthweight-for-gestational age percentile, and infant hemoglobin (Hb) at 6 wk of age] in Nagpur, Eastern Maharashtra, India.

Methods

We conducted a prospective cohort study of 200 pregnant women. In the first trimester, venous blood was collected to assess Hb via cyanmethemoglobin analysis, micronutrient status (ferritin, vitamin B12, and folate), and inflammation (C-reactive protein). Hb was also assessed in capillary samples using a hemoglobinometer in the first and third trimesters for mothers and at 6 wk for infants. Associations were assessed using generalized linear models controlling for background characteristics.

Results

In the first trimester, high (compared with normal) venous Hb was significantly associated with lower gestational age at birth [β: -1.0 wk, 95% confidence interval (CI): -1.9, -0.2] and higher birthweight-for-gestational age percentile (β: 20.1, 95% CI: 9.0, 31.2). Mild anemia, moderate anemia, and high (compared with normal) capillary Hb were significantly associated with lower birthweight (β: -147.7 g, 95% CI: -243.4, -51.7; β: -77.7 g, 95% CI: -123.9, -31.4; and β: -236.0 g, 95% CI: -478.0, -48.1) and birthweight-for-gestational age percentile (β: -7.3, 95% CI: -13.7, -0.9; β: -8.4, 95% CI: -14.1, -2.8; and β: -8.9, 95% CI: -15.9, -1.9). Higher serum ferritin was significantly associated with higher birthweight (β: 2.0 g, 95% CI: 0.1, 3.9) and gestational age at birth (β: 0.01 wk, 95% CI: 0.00, 0.01). In the third trimester, mild anemia was significantly associated with lower gestational age at birth (β: -0.5 wk, 95% CI: -0.7, -0.3).

Conclusions

Associations between maternal anemia during pregnancy and infant outcomes were mixed indicating further studies are needed to better understand these relationships.

Community-based nutrition education and counselling provided during pregnancy: effects on knowledge and attitude towards iron-folic acid supplementation

Maternal malnutrition is pervasive throughout the world, notably in sub-Saharan Africa, including Ethiopia. This study examined the effect of community-based iron-folic acid supplementation (IFAS) nutrition education on IFAS knowledge and attitude among pregnant women in urban settings in South Ethiopia. A community-based quasi-experimental study was conducted among 198 randomly selected pregnant women attending antenatal care (ANC) (99 intervention and 99 control). We used a multistage sampling technique followed by systematic sampling to select the pregnant women. Pregnant women who participated in the intervention arm received six nutrition education sessions and counselling using a health belief model (HBM), while the control group received only routine ANC services. Baseline and endline data were collected during the ANC and compared. The data was analysed using statistical package for social sciences. Analyses of the effect of the intervention were done using difference-in-difference and generalised estimation equation to allow correlation of repeated observations over time. The results indicated a significant effect of intervention on maternal knowledge towards IFAS; with intervention, group levels increased by 35 percentage points (P < 0.001). The odds of being knowledgeable at the endpoint in the intervention group were 2.6 times higher than baseline (OR = 2.67, 95% CI 1.88-3.80). There was a significant (P = 0.001) change in proportion with a favourable attitude towards IFAS between the two time points. The community-based nutrition education intervention approach has significantly improved maternal knowledge and a favourable attitude towards IFAS among pregnant women. The HBM is effective in improving knowledge and attitude among pregnant women.

Daily oral iron supplementation during pregnancy

BACKGROUND

Iron and folic acid supplementation have been recommended in pregnancy for anaemia prevention, and may improve other maternal, pregnancy, and infant outcomes.

OBJECTIVES

To examine the effects of daily oral iron supplementation during pregnancy, either alone or in combination with folic acid or with other vitamins and minerals, as an intervention in antenatal care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Registry on 18 January 2024 (including CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO's International Clinical Trials Registry Platform, conference proceedings), and searched reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials that evaluated the effects of oral supplementation with daily iron, iron + folic acid, or iron + other vitamins and minerals during pregnancy were included.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed trial eligibility, ascertained trustworthiness based on pre-defined criteria, assessed risk of bias, extracted data, and conducted checks for accuracy. We used the GRADE approach to assess the certainty of the evidence for primary outcomes. We anticipated high heterogeneity amongst trials; we pooled trial results using a random-effects model (average treatment effect).

MAIN RESULTS

We included 57 trials involving 48,971 women. A total of 40 trials compared the effects of daily oral supplements with iron to placebo or no iron; eight trials evaluated the effects of iron + folic acid compared to placebo or no iron + folic acid. Iron supplementation compared to placebo or no iron Maternal outcomes: Iron supplementation during pregnancy may reduce maternal anaemia (4.0% versus 7.4%; risk ratio (RR) 0.30, 95% confidence interval (CI) 0.20 to 0.47; 14 trials, 13,543 women; low-certainty evidence) and iron deficiency at term (44.0% versus 66.0%; RR 0.51, 95% CI 0.38 to 0.68; 8 trials, 2873 women; low-certainty evidence), and probably reduces maternal iron-deficiency anaemia at term (5.0% versus 18.4%; RR 0.41, 95% CI 0.26 to 0.63; 7 trials, 2704 women; moderate-certainty evidence), compared to placebo or no iron supplementation. There is probably little to no difference in maternal death (2 versus 4 events, RR 0.57, 95% CI 0.12 to 2.69; 3 trials, 14,060 women; moderate-certainty evidence). The evidence is very uncertain for adverse effects (21.6% versus 18.0%; RR 1.29, 95% CI 0.83 to 2.02; 12 trials, 2423 women; very low-certainty evidence) and severe anaemia (Hb < 70 g/L) in the second/third trimester (< 1% versus 3.6%; RR 0.22, 95% CI 0.01 to 3.20; 8 trials, 1398 women; very low-certainty evidence). No trials reported clinical malaria or infection during pregnancy. Infant outcomes: Women taking iron supplements are probably less likely to have infants with low birthweight (5.2% versus 6.1%; RR 0.84, 95% CI 0.72 to 0.99; 12 trials, 18,290 infants; moderate-certainty evidence), compared to placebo or no iron supplementation. However, the evidence is very uncertain for infant birthweight (MD 24.9 g, 95% CI -125.81 to 175.60; 16 trials, 18,554 infants; very low-certainty evidence). There is probably little to no difference in preterm birth (7.6% versus 8.2%; RR 0.93, 95% CI 0.84 to 1.02; 11 trials, 18,827 infants; moderate-certainty evidence) and there may be little to no difference in neonatal death (1.4% versus 1.5%, RR 0.98, 95% CI 0.77 to 1.24; 4 trials, 17,243 infants; low-certainty evidence) or congenital anomalies, including neural tube defects (41 versus 48 events; RR 0.88, 95% CI 0.58 to 1.33; 4 trials, 14,377 infants; low-certainty evidence). Iron + folic supplementation compared to placebo or no iron + folic acid Maternal outcomes: Daily oral supplementation with iron + folic acid probably reduces maternal anaemia at term (12.1% versus 25.5%; RR 0.44, 95% CI 0.30 to 0.64; 4 trials, 1962 women; moderate-certainty evidence), and may reduce maternal iron deficiency at term (3.6% versus 15%; RR 0.24, 95% CI 0.06 to 0.99; 1 trial, 131 women; low-certainty evidence), compared to placebo or no iron + folic acid. The evidence is very uncertain about the effects of iron + folic acid on maternal iron-deficiency anaemia (10.8% versus 25%; RR 0.43, 95% CI 0.17 to 1.09; 1 trial, 131 women; very low-certainty evidence), or maternal deaths (no events; 1 trial; very low-certainty evidence). The evidence is uncertain for adverse effects (21.0% versus 0.0%; RR 44.32, 95% CI 2.77 to 709.09; 1 trial, 456 women; low-certainty evidence), and the evidence is very uncertain for severe anaemia in the second or third trimester (< 1% versus 5.6%; RR 0.12, 95% CI 0.02 to 0.63; 4 trials, 506 women; very low-certainty evidence), compared to placebo or no iron + folic acid. Infant outcomes: There may be little to no difference in infant low birthweight (33.4% versus 40.2%; RR 1.07, 95% CI 0.31 to 3.74; 2 trials, 1311 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. Infants born to women who received iron + folic acid during pregnancy probably had higher birthweight (MD 57.73 g, 95% CI 7.66 to 107.79; 2 trials, 1365 infants; moderate-certainty evidence), compared to placebo or no iron + folic acid. There may be little to no difference in other infant outcomes, including preterm birth (19.4% versus 19.2%; RR 1.55, 95% CI 0.40 to 6.00; 3 trials, 1497 infants; low-certainty evidence), neonatal death (3.4% versus 4.2%; RR 0.81, 95% CI 0.51 to 1.30; 1 trial, 1793 infants; low-certainty evidence), or congenital anomalies (1.7% versus 2.4; RR 0.70, 95% CI 0.35 to 1.40; 1 trial, 1652 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. A total of 19 trials were conducted in malaria-endemic countries, or in settings with some malaria risk. No studies reported maternal clinical malaria; one study reported data on placental malaria.

AUTHORS' CONCLUSIONS

Daily oral iron supplementation during pregnancy may reduce maternal anaemia and iron deficiency at term. For other maternal and infant outcomes, there was little to no difference between groups or the evidence was uncertain. Future research is needed to examine the effects of iron supplementation on other maternal and infant health outcomes, including infant iron status, growth, and development.

Prevalence and Factors Associated with Adherence to Iron-Folic Acid Supplementation Among Pregnant Women in Eastern Sudan: A Cross-Sectional Study

Purpose

The present study was conducted to determine the prevalence and factors associated with adherence to iron-folic acid supplementation (IFAS) among pregnant women in eastern Sudan.

Methods

A cross-sectional survey was conducted among pregnant women who obtained antenatal care (ANC) at Gadarif Maternal Hospital in eastern Sudan between May 1 and August 31, 2023. Face-to-face interview questionnaires were used to gather sociodemographic, obstetric, and clinical data (age, parity, education, residence, and previous medical diseases). Knowledge of anemia and IFAS was assessed. Multivariate analysis was performed to adjust for confounders.

Results

A total of 568 pregnant women were enrolled in the present study. Among them, 449 (79.0%) adhered to the IFAS. The multivariate analysis showed that the adjusted odds ratio (AOR) of IFAS adherence increased with ANC visits > 4 (AOR = 1.68, 95.0% CI = 1.01-2.77) and knowledge of anemia (AOR = 2.06, 95.0% CI = 1.437-3.276). In the univariate analysis, maternal occupation and knowledge of IFAS adherence were the only factors associated with IFAS adherence. Maternal age, parity, gestational age, education, residence, occupation, medical insurance, medical disease, and husband's occupation were not associated with IFAS. Forgetfulness (71.0%), frustration from taking many drugs (54.6%), and unpleasant tests of the supplement (50.7%) were the main reasons for not taking the IFAS.

Conclusion

About four out of five pregnant women adhered to the IFAS, indicating a good level of adherence, especially among women who attended more than four ANC visits and those with good knowledge of anemia. More attention is needed to encourage ANC to increase adherence to IFAS.

Effects of Maternal Anemia Affecting Fetal Outcomes: A Narrative Review

This review's main objective was to assess the obstacles to anemia prevention, as well as the attitudes and behaviors of anemic women toward their condition. Since iron is crucial for neurodevelopment, iron deficiency anemia (IDA) accounts for the majority of pregnant mothers having anemia. In India and other developing countries, anemia is a serious health problem. More than half of pregnant women have anemia. The search strategy was conducted in PubMed. Few of the articles were searched without using MeSH terms. Strong correlations between mothers' anemia and that of their offspring point to intergenerational anemia with lasting consequences. Children who were underweight at birth and those who were malnourished had a higher risk of having anemia. Clinicians usually evaluate anemia, and the criteria for determining the cause of anemia are outlined in this brief review.

Prevalence and influencing factors of anemia among pregnant women across first, second and third trimesters of pregnancy in monitoring areas, from 2016 to 2020: a population-based multi-center cohort study

OBJECTIVE

To assess the prevalence of anemia among pregnant women across their entire pregnancy and the factors affecting it in the monitoring areas.

METHODS

A total of 108,351 pregnant women who received antenatal health care and delivered from January 1, 2016 to December 31, 2020 in 15 monitoring counties of 8 provinces in the Maternal and Newborn Health Monitoring Program (MNHMP) of National Center for Women and Children's Health (NCWCH) were selected as the study subjects. The anemia status among the subjects across their first, second and third trimester of pregnancy and the influencing factors were analyzed.

RESULTS

From 2016 to 2020, the prevalence of anemia at any stage during pregnancy in the monitoring areas was 43.59%. The prevalence of anemia among pregnant women across all three trimesters was 3.95%, and the prevalence of mild and moderate-to-severe anemia was 1.04% and 2.90%, respectively. Protective factors were living in the northern area (OR = 0.395) and being a member of an ethnic minority (OR = 0.632). The risk factors were residing in rural areas (OR = 1.207), with no more than junior high school education (OR = 1.203), having ≥ 3 gravidities (OR = 1.195) and multiple fetuses (OR = 1.478).

CONCLUSIONS

Although the prevalence of anemia among pregnant women across all trimesters in the monitoring area was low, the severity of anemia was high. Since the prevalence of anemia among pregnant women across their entire pregnancy in the monitoring area is affected by many different factors, more attention should be paid to pregnant women living in rural areas, with low literacy, ≥ 3 gravidities and multiple fetuses for early intervention.

Iron deficiency anemia among women: An issue of health equity

Iron deficiency is the most common and widespread nutritional deficiency in the world. For women, the risk of iron deficiency and iron deficiency anemia increases due to iron demands during pregnancy and regular iron losses due to menstruation during reproductive years. These interrelated conditions are of public health concern as they are highly prevalent, and the negative consequences such as chronic fatigue, cognitive impairment and poor quality of life are broad and multifaceted. People of low socioeconomic status are at higher risk of iron deficiency due to low intake of expensive iron-rich foods, and decreased access to healthcare. In this review, we applied a health equity lens to describe the current state of care for women with iron deficiency with or without anemia. We have highlighted several structural challenges that span from the laboratory diagnosis, inconsistent screening guidelines, and stigma associated with heavy menstrual bleeding, to treatment barriers.

Anaemia in the first trimester and poor physiological plasma expansion during pregnancy negatively impact foetal weight and newborn anthropometrics: An observational cohort study in Tanzania

OBJECTIVES

Anaemia during pregnancy is a major health challenge affecting pregnancy outcome worldwide. The objectives of this study were to investigate the impact of severe-moderate anaemia in the first trimester, as well as changes in haemoglobin during pregnancy among non-anaemic women, on foetal weight, placental blood flow and newborn anthropometrics.

METHODS

In a prospective cohort study, 346 women residing in rural Tanzania were followed throughout pregnancy with serial ultrasound and newborn anthropometrics assessed within 24 h of delivery. Associations between placental blood flow, foetal weight and newborn anthropometrics with either first trimester severe-moderate anaemia (haemoglobin≤9.5 g/dL) or changes in haemoglobin from the first to the third trimester among non-anaemic women, were assessed by mixed model regression and multiple linear regression, adjusting for maternal and foetal co-variables. Foetal weights and birthweight were converted to z-scores using a population based sex-specific weight reference.

RESULTS

Severe-moderate anaemia in the first trimester was associated with significantly reduced foetal weight z-scores (adjusted mean difference (aMD) -0.44 (95% CI -0.81, -0.07)) and newborn anthropometric indices (birth weight z-score aMD -0.55 (-0.9, -0.13), abdominal circumference aMD -11 mm (95% CI -20, -3)). There were no association between first trimester severe-moderate anaemia and placental blood flow. Among women who were non-anaemic in the first trimester, women with the least reduction in haemoglobin (Δ ≥ -0.3 g/dL) delivered significantly smaller newborns (birthweight z-score aMD -0.55 (-0.91, -0.20), abdominal circumference aMD -10 mm (95% CI -17, -3), compared to women with the greatest reduction (Δ haemoglobin ≤ -1.4 g/dL)).

CONCLUSIONS

Severe-moderate anaemia in early pregnancy was associated with smaller newborn anthropometrics which was reflected in smaller mean foetal weights in the second and third trimester. Furthermore, among women who were non-anaemic in the first trimester, there was an association between smaller newborn anthropometrics and limited haemoglobin decrease during pregnancy, possibly reflecting insufficient plasma expansion.

Association Between Anemia Status and the Risk of Different Types of Heart Failure: A RCSCD-TCM Study in China

We investigated the association between anemia status and the risk of heart failure (HF) in patients with coronary heart disease (CHD) based on a multi-center, large-sample and retrospective cross-sectional study including 89,207 patients. Heart failure was categorized as HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), and HF with mid-range ejection fraction (HFmrEF). In multi-adjusted models, compared with patients without anemia, mild anemia (odds ratio [OR] 1.71; 95% confidence interval [CI] 1.53-1.91; P < .001), moderate anemia (OR 3.68; 95% CI, 3.25-4.17; P < .001), and severe anemia (OR 8.02; 95% CI, 6.50-9.88; P < .001) were associated with the risk of HF among CHD patients. Men aged <65 years were more likely to develop HF. In subgroup analyses, the multi-adjusted ORs and 95% CI of HFpEF, HFrEF, and HFmrEF related to anemia were 3.24 (95% CI 1.43-7.33), 2.22 (95% CI 1.28-3.84), and 2.55 (95% CI 2.24-2.89), respectively. These findings suggest that anemia might be associated with increased risk of different types of HF, especially HFpEF.

Prevalence of anemia and comparison of perinatal outcomes among anemic and nonanemic mothers

BACKGROUND

The prevalence of anemia is a significant public health challenge. Approximately half of all pregnant women in India experience anemia during pregnancy. This study aims to determine the prevalence of anemia and perinatal outcomes among anemic and nonanemic pregnant mothers.

MATERIALS AND METHODS

The quantitative research approach was adopted using a descriptive comparative design. The study was conducted in the Obstetrics and Gynecology and Pediatric departments of a tertiary care hospital. Hemoglobin (Hb) was recorded using antenatal records of pregnant mothers in their III trimester. Based on their Hb level, subjects were divided into two groups, anemic and nonanemic as per World Health Organization criteria. The subjects were followed up until the first week after birth.

RESULTS

The prevalence of anemia was 48% [N = 410]; 70.6% had mild, 13.7% had moderate, and 15.7% had severe. The anemic group had a significantly higher incidence of low birthweight (30.9% vs 10.3%, P = 0.001) and preterm births (24.2% vs 3.2%, P = 0.001) compared to the nonanemic group. Additionally, there were significant differences in various quantitative perinatal parameters such as weight (P = 0.001), length (P = 0.001), head circumference (P = 0.001), chest circumference (P = 0.034), APGAR score at one minute (P = 0.022), and APGAR score at five minutes (P = 0.001) between the anemic and nonanemic.

CONCLUSION

The maternal anemia is associated with increased risk of unfavorable perinatal outcomes. Identifying and managing anemia among pregnant women is critical to minimize adverse outcomes. Adequate antenatal care can play a significant role in preventing avoidable complications associated with anemia during the third trimester.

Maternal anaemia and birth weight: a cross-sectional study from Jiangxi Province, China

BACKGROUND

Association between maternal haemoglobin (Hb) and low birth weight (LBW) remains a controversial topic, and data in China were sparse.

AIMS

We aimed to investigate the association between maternal Hb and LBW among pregnant women in Jiangxi Province, China.

METHODS

In this cross-sectional study, 1,029 participants were enrolled. Anaemia was classified according to World Health Organization's definition of anaemia in pregnancy. Logistic regression analysis was performed to evaluate the association between maternal Hb and LBW. Generalized additive model and smooth curve fitting (penalized spline method) were conducted to explore the exact shape of curve between them.

RESULTS

The overall prevalence of anaemia was 58.2% in our study. A significantly higher risk of LBW was found in moderate anaemia subjects (odds ratio [OR] = 2.93; 95% confidence interval [CI]: 1.16-5.31) and severe anaemia subjects (OR = 63.86; 95% CI: 25.66-158.90) compared with maternal Hb concentration >100 g/L. The fully adjusted smooth curve fitting presented an L-shaped association between the maternal Hb and LBW, with a turning point at about 110 g/L. Subgroup analyses showed that stronger associations between maternal Hb and LBW were detected in pregnant women with high education, long duration of gestation and multiple antenatal visits (all P for interaction <0.05).

CONCLUSIONS

Anaemia in delivering women was associated with an elevated risk of LBW and the risk increased with the severity of anaemia, especially among pregnant women with high education, long duration of gestation and multiple antenatal visits from Jiangxi Province, China.

Predicting risk of postpartum hemorrhage associated with vaginal delivery of twins: A retrospective study

Many studies have only focused on the risk factors for postpartum hemorrhage (PPH) in singleton vaginal deliveries and twin cesarean deliveries. We analyzed the factors of influencing PPH occurrence in twin vaginal deliveries and developed a nomogram for clinical application. This retrospective study included 274 pregnant women with twin pregnancies who were hospitalized for delivery from January 2014 to December 2018. The patients opted for vaginal delivery and experienced spontaneous labor. Univariate analysis of PPH risk factors was performed. Multivariate analysis was performed using the least absolute shrinkage and selection operator (LASSO) to obtain relevant factors and build a prediction model, which was presented as a nomogram. The model was internally validated by bootstrap self-sampling method. Model accuracy was evaluated with the concordance index (C-index). There were 36 (13.14%) and 238 (86.9%) patients in the PPH and no PPH groups, respectively. Univariate analysis identified twin chorionicity, hypertensive disorders complicating pregnancy (HDCP), anemia in pregnancy, delivery mode of the second twin, oxytocin use during labor, postpartum curettage, cervical laceration, intrapartum fever, fibrinogen degradation products (FDP), and platelet count (PLT) as significant PPH factors. On multivariate analysis, HDCP, anemia in pregnancy, intrapartum fever, oxytocin use during labor, fetal distress, PLT, direct bilirubin, and FDP were noted as significant PPH factors and were included in the prediction model. A C-index of 0.816 was noted after internal validation, and the calibration curve showed good consistency. We developed a model to predict PPH risk in the vaginal delivery of twin pregnancies and visualized it with a nomogram that can be applied clinically to assess PPH risk and aid PPH prevention.

Maternal anemia is associated with adverse maternal and neonatal outcomes in Mbarara, Uganda

PURPOSE

Maternal anemia is a significant risk factor for maternal morbidity and mortality, increasing risk of preterm birth, intrauterine growth restriction, stillbirth, and death. Moderate and severe anemia in pregnancy is defined as hemoglobin (Hb) <10 g/dl and Hb < 7 g/dl, respectively. We aimed to characterize the association of maternal anemia with maternal, neonatal, and placental outcomes in a resource-limited setting.

METHODS

Data were collected from a prospective cohort of 352 pregnant women at a tertiary academic Ugandan hospital. One hundred and seventy-six (50%) of women were living with HIV. Hemoglobin was measured in labor, and placentas were collected postpartum. Maternal outcomes included mode of delivery, hemorrhage, blood transfusion, intensive care unit admission, and maternal mortality. Neonatal outcomes included gestational age at delivery, birthweight, stillbirth, and neonatal mortality. Placental descriptors included weight and thickness. Categorical variables were analyzed using Chi-squared and Fisher's exact tests.

RESULTS

Hemoglobin < 10 g/dl, was present in 17/352 (5%) of women. Significantly more women with moderate or severe anemia were HIV-infected: 14/17 (82%) versus 162/335 (48%) (p = .006). Blood transfusions (2/17, 12% versus 5/335, 2%, p = .04) and neonatal deaths (2/17, 12% versus 9/335, 3%, p = .01) were more common in the anemia group. Placental thickness was lower in the anemia group (1.4 cm versus 1.7 cm, p = .04).

CONCLUSIONS

Moderate and severe anemia was associated with maternal HIV infection, maternal blood transfusion, neonatal death, and decreased placental thickness. The overall rate of moderate and severe anemia among this cohort was lower than previously reported.

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis

BACKGROUND

Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries.

OBJECTIVES

Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings.

SEARCH METHODS

We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers.

DATA COLLECTION AND ANALYSIS

We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice.

MAIN RESULTS

We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence).

AUTHORS' CONCLUSIONS

Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.

Burden of malaria during pregnancy in perennial transmission settings of two densely forested and remote blocks (Baihar and Birsa) of district Balaghat, Madhya Pradesh, central India

Background Malaria in pregnancy (MIP) is a major public health problem due to the vulnerability of pregnant women to infections, resulting in adverse maternal/foetal outcomes in endemic areas. Methods We did a field-based study to assess the burden of MIP (prevalence at the time of enrolment and follow-up) and to identify risk factors for MIP in the Birsa and Baihar blocks of district Balaghat in Madhya Pradesh, which have perennial malaria transmission. Malaria screening (during 2015-2017) was done by microscopy and bivalent rapid diagnostic test (SD Bioline RDT, malaria antigen Plasmodium falciparum/Plasmodium vivax Pf/Pv). Dried blood spots were used for haemoglobin estimation. Sociodemographic details with past and present pregnancy status were obtained. A subset of pregnant women were followed up for malaria during pregnancy. Women were also screened for malaria post delivery. Malaria treatment was given as per the National Guidelines of 2013. Multivariate analysis was done to assess independent risk factors for malaria. Results A total of 1728 pregnant women were screened, of which 1651 were included in the final analysis. Malaria prevalence at first screening was 23.4% (Pf 88%). Prevalence and Pf parasitaemia both were significantly higher among primigravid (G1) compared to multigravid (G>2; p value 0.012 and 0.019, respectively). Pregnant women of the Baiga ethnic group were more likely to have malaria compared to those belonging to the Gond group (OR [95% CI]; 2.4 [1.7-3.4]; p<0.00001) and non-indigenous group (OR [95% CI]; 8.3 [3.9-19.7]; p<0.00001). Primigravid status of women, first and second trimester of pregnancy, women belonging to indigenous ethnic tribal group and cash crop insufficiency for whole year (a socioeconomic indicator) in the family were the independent risk factors for malaria. Conclusion MIP is a major public health problem in forested tribal settlements of Birsa and Baihar blocks of Balaghat district in Madhya Pradesh and requires immediate intervention.

Prevalence and factors associated with anaemia among pregnant women attending antenatal care in a district hospital and its feeder community healthcare centre of the Limpopo Province, South Africa

Background

Pregnancy anaemia is a significant public health concern in South Africa (SA), particularly in rural areas, but little is known about its prevalence and risk factors in rural areas. The objective of the study was to determine the prevalence and identify risk factors of pregnancy anaemia in the public health facilities of Limpopo Province (LP), SA.

Methods

A cross-sectional study was conducted among a consecutive sample of 211 pregnant women attending antenatal care at Seshego Hospital and its feeder health centre (May to June 2019). Anaemia was defined as haemoglobin (Hb) <11 g/dL and classified as mild (10-10.9 g/dL), moderate (7-9.9 g/dL) and severe anaemia (<7 g/dL). A multiple logistic regression analysis was used to identify predictors of anaemia.

Results

The mean age of the women was 28.4 ± 5.7 years (range from 18 to 41 years). Over half (52%) had secondary education, 65% were unmarried, 72% were unemployed, 34% were nulliparous, 15% were human immunodeficiency virus (HIV) infected and 67% were in the third trimester. The anaemia prevalence was 18.0% and was significantly associated with parity, HIV status and body mass index (BMI) in a multivariate logistic regression analysis.

Conclusion

This study found that less than one-third of pregnant women were affected by anaemia, associated with parity, HIV infected and BMI. It is essential to promote routine screening for anaemia, health education and prompt treatment of infections to reduce this burden. In addition, further studies on risk factors for anaemia during pregnancy in both urban and rural communities should be conducted to strengthen these findings.

The physiological basis with uterine myometrium contractions from electro-mechanical/hormonal myofibril function to the term and preterm labor

Background

Most labor-related problems can be attributed to the uterine myometrium muscle, as this irritable tissue must suppress its irritability potential during pregnancy. Unfortunately, fewer studies have investigated the causes of this lack of suppression in preterm labor.

Methods

We conducted a scoping narrative review using three online databases (PubMed, Scopus, and Science Direct).

Results

The review focused on ion channel functions in the myometrium, including sodium channels [Na K-ATPase, Na-activated K channels (Slo2), voltage-gated (SCN) Na+, Na+ leaky channels, nonselective (NALCN) channels], potassium channels [KATP (Kir6) channels, voltage-dependent K channels (Kv4, Kv7, and Kv11), twin-pore domain K channels (TASK, TREK), inward rectifier Kir7.1, Ca2+-activated K+ channels with large (KCNMA1, Slo1), small (KCNN1-3), intermediate (KCNN4) conductance], and calcium channels [L-Type and T-type Ca2+ channels, calcium-activated chloride channels (CaCC)], as well as hyperpolarization-activated cation channels. These channels' functions are associated with hormonal effects such as oxytocin, estrogen/progesterone, and local prostaglandins.

Conclusion

Electromechanical/hormonal activity and environmental autocrine factors can serve as the primary practical basis for premature uterine contractions in term/preterm labor. Our findings highlight the significance of.1.the amplitude rate of hyperpolarization and the frequency of contractions,2.changes in the estrogen/progesterone ratio,3.Prostaglandins E/F involvement in initiating potential spikes and the increase of intracytoplasmic Ca2+.This narrative study highlights the range of hyperpolarization and the frequency of myometrium contractions as crucial factors. The synchronized complex progress of estrogen to progesterone ratio and prostaglandins plays a significant role in initiating potential spikes and increasing intracytoplasmic Ca2+, which further influences the contraction process during labor. Insights into myometrium physiology gained from this study may pave the way for much-needed new treatments to reduce problems associated with normal and preterm labor.

Hemostatic biomarkers associated with postpartum hemorrhage: a systematic review and meta-analysis

Postpartum hemorrhage (PPH) is a leading cause of maternal morbi-mortality. Although obstetric risk factors are well described, the impact of predelivery hematologic and hemostatic biomarkers remains incompletely understood. In this systematic review, we aimed to summarize the available literature on the association between predelivery hemostatic biomarkers and PPH/severe PPH. Searching MEDLINE, EMBASE, and CENTRAL databases from inception to October 2022, we included observational studies on unselected pregnant women without bleeding disorder reporting on PPH and on predelivery hemostatic biomarkers. Two review authors independently performed title, abstract and full-text screening, upon which quantitative syntheses of studies reporting on the same hemostatic biomarker were conducted, calculating the mean difference (MD) between women with PPH/severe PPH and controls. A search on 18 October 2022 yielded 81 articles fitting our inclusion criteria. The heterogeneity between studies was considerable. With regard to PPH, the estimated average MD in the investigated biomarkers (platelets, fibrinogen, hemoglobin, Ddimer, activated partial thromboplastin time, and prothrombin time) were not statistically significant. Women who developed severe PPH had lower predelivery platelets than controls (MD = -26.0 109/L; 95% confidence interval, -35.8 to -16.1), whereas differences in predelivery fibrinogen concentration (MD = -0.31 g/L; 95% confidence interval, -0.75 to 0.13) and levels of factor XIII or hemoglobin were not statistically significant in women with and without severe PPH. Predelivery platelet counts were, on average, lower in women with severe PPH compared with controls, suggesting the potential usefulness of this biomarker for predicting severe PPH. This trial was registered at the International Prospective Register of Systematic Reviews as CRD42022368075.

Maternal anemia and long-term respiratory morbidity of the offspring-Results of a population-based cohort

PURPOSE

To evaluate the association between prenatal maternal anemia (hemoglobin, Hb < 11 g/dl) and long-term respiratory morbidity of the offspring.

METHODS

A retrospective population-based cohort analysis was performed at a single tertiary medical center. We include all singletons born between 1991-2014 and discharged alive. Offspring with congenital malformations were excluded. The 3 study groups were defined on maternal Hb levels on discharge: severe anemia (< 7.0 g/dl), mild to moderate anemia (7.0-11.0 g/dl) and unexposed (≥ 11.0 g/dl). Offspring respiratory morbidity was predefined on ICD-9 codes and recruited from the hospitalized medical records. A Kaplan-Meier survival curve was formed to compare the cumulative hospitalization and a multivariable Cox survival analysis was used to control for cofounders (gestational age, maternal age, diabetes, hypertensive disorders, post-partum hemorrhage and transfusion of blood products).

RESULTS

214,305 deliveries met the inclusion criteria: 807 (0.3%) mothers had severe anemia, 105,196 (49.1%) mothers had mild-moderate anemia, and the remaining were not anemic (108,302, 50.5%). Respiratory hospitalization was significantly higher among the offspring born to anemic mothers (6.2%; 5.3% and 5.1%; p = 0.020, in the study groups). However, association between maternal anemia and respiratory-related hospitalization remained significant only among the mild-moderate anemic group (adjusted Cox hazard ratio = 1.1; 95% CI 1.05-1.14; p < 0.01). The Kaplan-Meier survival analysis showed significant higher total respiratory hospitalizations in offspring according to maternal anemia status (Log Rank p-value =  < .001).

CONCLUSION

Maternal anemia was associated with long-term respiratory morbidity of the offspring.

The Interplay of Hypertension and Anemia on Pregnancy Outcomes

Background Anemia and pregnancy-induced hypertension (PIH) are two significant high-risk conditions that can have a profound impact on maternal health during pregnancy. The scarcity of studies investigating the potential links and interactions between these two conditions adds to the gap in our understanding of their combined impact on pregnant women. This study aimed to assess the impact of PIH in conjunction with anemia and without anemia on pregnancy outcomes. Methods A prospective study was conducted among 150 primi pregnant women (third trimester of pregnancy) from a secondary-care hospital (Government General Headquarters Hospital, Cuddalore) in Tamil Nadu, India. The study population was selected using a purposive sampling technique. Data were collected using a structured questionnaire to assess sociodemographic characteristics, dietary patterns, and outcomes of pregnancy. Clinical parameters such as blood pressure were measured using a sphygmomanometer, and hemoglobin and urine tests for protein were obtained from the patient's medical records. Results The result showed that out of 150 primi pregnant women, 73 (49%) had PIH and 77 (51%) experienced both PIH and anemia. On comparing the outcomes, pregnant women with PIH accompanied by anemia exhibited developing preeclampsia (p<0.001), encountered maternal complications (p=0.034), delivered preterm babies (p=0.03), and gave birth to low-birth-weight babies (p<0.001), and their newborns admitted to the NICU (p=0.02). Additionally, pregnant women with both PIH and anemia demonstrated significantly higher levels of systolic blood pressure after delivery (p=0.009). Conclusion  The study calls for the immediate attention of healthcare providers for vigilant monitoring and addressing anemia in conjunction with PIH to improve maternal and neonatal outcomes.

Interventions in Maternal Anaemia to Reduce Maternal Mortality Rate Across India

Anaemia is one of the most prevalent issues encountered throughout pregnancy, with Iron deficiency anaemia and megaloblastic anaemia being the most common causes in India. It is critical to address anaemia in pregnancy since it has been linked to adverse pregnancy outcomes like preterm delivery, low-birth-weight newborns, fetal mortality, and, in certain circumstances, maternal death. The maternal mortality rate (MMR) is one of the significant health challenges, particularly in developing countries. It has substantially impacted the population's social situation and requires quick management. In this review article, we discuss recent developments and advancements in treating maternal anaemia with the aid of some government health programs, which can help with lowering the risk of maternal mortality. The primary goal of this manuscript is to raise awareness about anaemia in pregnancy. We examined the literature on anaemia during pregnancy, with a view to offering current and unambiguous guidance for preventing and managing this illness, which, if not appropriately managed, can result in severe maternal and neonatal problems.

Impact of Maternal Preoperative Hemoglobin Levels on Intraoperative Hemorrhage Risk in Placenta Accrete Spectrum Disorders: A Retrospective Cross-Sectional Study

BACKGROUND Placenta accreta spectrum (PAS) disorders involve abnormal adhesion or invasion of chorionic villi through the myometrium and uterine serosa. Maternal anemia during pregnancy is common and may contribute to complications during delivery, particularly with abnormal placentation. This study examines the association between preoperative maternal hemoglobin levels and the risk of intraoperative massive hemorrhage in pregnant women with PAS disorders. MATERIAL AND METHODS A retrospective study included 538 consecutive participants (mean age=31.12±4.68 years) who underwent cesarean sections and met the diagnostic criteria for PAS disorders. Logistic regression analysis was performed to investigate the relationship between maternal preoperative hemoglobin levels and the risk of massive intraoperative hemorrhage (blood loss ≥1500 mL). RESULTS The incidence of intraoperative massive hemorrhage among patients with PAS disorders was 38.66%. The mean preoperative maternal hemoglobin level was 10.99±1.39 g/dL, and overall anemia incidence (<11 g/dL) was 48.88% in our study. After adjusting for potential confounders, a non-linear relationship was observed between preoperative maternal hemoglobin levels and the risk of intraoperative massive hemorrhage. When the preoperative hemoglobin level of pregnant women was below 11.5 g/dL (OR=0.52, 95% CI 0.39-0.70), the lower hemoglobin level significantly increased the risk of intraoperative hemorrhage. CONCLUSIONS Maternal preoperative hemoglobin levels were inversely associated with the risk of massive intraoperative hemorrhage in PAS disorders. A non-linear relationship was identified, with a turning point at 11.5 g/dL. These findings emphasize the importance of monitoring and managing maternal hemoglobin levels to mitigate the risk of intraoperative hemorrhage in pregnant women with PAS disorders.

Nutritional and health status of Afghan refugee women living in Punjab: A cross-sectional study

Afghan refugees are the world's densely populated community, with 2.6 million registered Afghan refugees living globally, of whom about 2.2 million are in Iran and Pakistan. Pakistan is a densely populated country, and due to its low socioeconomic status, food insecurity, unhygienic conditions, and inadequate access to health care, the Afghan refugees have high chances of being malnourished; the chances of death for these Afghans are 25 times more every year from undernourishment and poverty than those from violence. This study aimed to assess anthropometric and biochemical analyses, their health complications, and the socioeconomic status of Afghan refugee women living in Islamabad Punjab as women are the most vulnerable and highly malnourished group in any community. This cross-sectional study involved 150 Afghan women aged 15-30 years; they were assessed for their nutritional status using Anthropometric, Biochemical, Clinical and Diet (ABCD). The results indicate the prevalence of underweight, normal weight, and overweight at 74.7%, 16.7%, and 8.7%, respectively. Majority of the women have extremely low hemoglobin (Hb) level, which indicates iron deficiency as well as low body mass index for their age. As the results indicate that there are high chances of severe malnutrition among this most vulnerable segment of the population, this situation must be addressed immediately; the main aim of this study is to highlight the current situation of these Afghan refugees in Pakistan. More research is needed to determine how normal body weight women with low hemoglobin levels are compared to women with ideal body mass index ratios.

The association of maternal anaemia with adverse maternal and foetal outcomes in Somali women: a prospective study

BACKGROUND

Anaemia in pregnant women is one of the most common public health problems, especially in low- and middle-income countries, such as Somalia. This study aimed to examine the association between the severity of anaemia during pregnancy and the risk of adverse maternal and foetal outcomes in Somali women.

METHODS

We prospectively enrolled pregnant women who had deliveries from May 1 to December 1, 2022, at Mogadishu Somali Turkey Recep Tayyip Erdoğan Training and Research Hospital. Blood haemoglobin levels were measured for each participant at admission for delivery. Anaemia was defined as a haemoglobin level of less than 11 g/dL, with mild (10 to 10.9 g/dL), moderate (7 to 9.9 g/dL), and severe (< 7 g/dL) forms. The associations between maternal anaemia and maternal-foetal outcomes were investigated.

RESULTS

The study included 1186 consecutive pregnant women (mean age 26.9 years, range 16-47). The incidence of maternal anaemia at delivery was 64.8%, with 33.8%, 59.8%, and 6.4% of women having mild, moderate and severe forms, respectively. Anaemia at delivery was associated with increased oxytocin administration to prompt labour (OR, 2.25, 95% CI, 1.34-3.78). Both moderate and severe anaemia were associated with increased risks for postpartum haemorrhage (moderate, OR, 4.93; severe, OR, 41.30) and the need for maternal blood transfusions (moderate, OR, 9.66; severe, OR, 301.50). In addition, severe anaemia was associated with increased risks for preterm delivery (OR, 2.50, 95% CI, 1.35-4.63), low birth weight (OR, 3.45, 95% CI, 1.87-6.35), stillbirths (OR, 4.02, 95% CI, 1.79-8.98), placental abruption (OR, 58.04,95% CI, 6.83-493.27) and maternal ICU admission (OR, 8.33, 95% CI, 3.53-19.63).

CONCLUSION

Our findings suggest that anaemia in pregnancy is associated with adverse maternal and foetal outcomes, with moderate or severe anaemia leading to increased risks for peri-, intra- and postpartum complications and that treatment of severe anaemia in pregnant women should be given particular consideration in our efforts to prevent preterm births, LBW and stillbirths.

Maternal low and high hemoglobin concentrations and associations with adverse maternal and infant health outcomes: an updated global systematic review and meta-analysis

BACKGROUND

Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment.

METHODS

We conducted an updated systematic review (using PubMed and Cochrane Review) on low (< 110 g/L) and high (≥ 130 g/L) maternal Hb concentrations and associations with a range of maternal and infant health outcomes. We examined associations by timing of Hb assessment (preconception; first, second, and third trimesters, as well as at any time point in pregnancy), varying cutoffs used for defining low and high hemoglobin concentrations and performed stratified analyses by iron-deficiency anemia. We conducted meta-analyses to obtain odds ratios (OR) and 95% confidence intervals.

RESULTS

The updated systematic review included 148 studies. Low maternal Hb at any time point in pregnancy was associated with: low birthweight, LBW (OR (95% CI) 1.28 (1.22-1.35)), very low birthweight, VLBW (2.15 (1.47-3.13)), preterm birth, PTB (1.35 (1.29-1.42)), small-for-gestational age, SGA (1.11 (1.02-1.19)), stillbirth 1.43 (1.24-1.65)), perinatal mortality (1.75 (1.28-2.39)), neonatal mortality (1.25 (1.16-1.34), postpartum hemorrhage (1.69 (1.45-1.97)), transfusion (3.68 (2.58-5.26)), pre-eclampsia (1.57 (1.23-2.01)), and prenatal depression (1.44 (1.24-1.68)). For maternal mortality, the OR was higher for Hb < 90 (4.83 (2.17-10.74)) than for Hb < 100 (2.87 (1.08-7.67)). High maternal Hb was associated with: VLBW (1.35 (1.16-1.57)), PTB (1.12 (1.00-1.25)), SGA (1.17 (1.09-1.25)), stillbirth (1.32 (1.09-1.60)), maternal mortality (2.01 (1.12-3.61)), gestational diabetes (1.71 (1.19-2.46)), and pre-eclampsia (1.34 (1.16-1.56)). Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent. Lower Hb cutoffs were associated with greater odds of poor outcomes; for high Hb, data were too limited to identify patterns. Information on anemia etiology was limited; relationships did not vary by iron-deficiency anemia.

CONCLUSION

Both low and high maternal Hb concentrations during pregnancy are strong predictors of adverse maternal and infant health outcomes. Additional research is needed to establish healthy reference ranges and design effective interventions to optimize maternal Hb during pregnancy.

Variation Patterns of Hemoglobin Levels by Gestational Age during Pregnancy: A Cross-Sectional Analysis of a Multi-Center Retrospective Cohort Study in China

Background: Pregnancy anemia is a global health concern. However, to our knowledge, there still has little consensus on the reference value of hemoglobin levels. Particularly, little evidence from China was accessible in most existing guidelines. Objective: To evaluate hemoglobin levels and anemia prevalence of pregnant women in China and offer evidence for anemia and its reference values in China. Methods: A multi-center retrospective cohort study was conducted among 143,307 singleton pregnant women aged 15–49 at 139 hospitals in China, with hemoglobin concentrations routinely tested at each prenatal visit. Subsequently, a restricted cubic spline was performed to reveal a non-linear variation of hemoglobin concentrations during the gestational week. The Loess model was used to describe the changes in the prevalence of different degrees of anemia with gestational age. Multivariate linear regression model and Logistic regression model were applied to explore influencing factors of gestational changes in hemoglobin level and anemia prevalence, respectively. Results: Hemoglobin varied nonlinearly with gestational age, and the mean hemoglobin levels decreased from 125.75 g/L in the first trimester to 118.71 g/L in the third trimester. By analyzing hemoglobin levels with gestational age and pregnancy period, we proposed new criteria according to 5th percentile hemoglobin concentration in each trimester as a reference for anemia, with 108 g/L, 103 g/L, and 99 g/L, respectively. According to WHO’s criteria, the prevalence of anemia sustainably increased with gestational age, with 6.2% (4083/65,691) in the first trimester, 11.5% (7974/69,184) in the second trimester and 21.9% (12,295/56,042) in the third trimester, respectively. In subsequent analysis, pregnant women in non-urban residents, multiparity, and pre-pregnancy underweight tended to have lower hemoglobin levels. Conclusions: This research, the first large-sample study to present a set of gestational age-specific reference centiles for hemoglobin levels in China, could be used to obtain a better understanding of the overall levels of hemoglobin in Chinese healthy pregnant women and ultimately offer clues for a more precise hemoglobin reference value of anemia in China.

A continuous quality improvement strategy to strengthen screening practices and facilitate the routine use of intravenous iron for treating anaemia in pregnant and postpartum women in Nigeria: a study protocol

BACKGROUND

Pregnancy-related anaemia is a public health challenge across Africa. Over 50% of pregnant women in Africa get diagnosed with this condition, and up to 75% of these are caused by iron deficiency. The condition is a significant contributor to the high maternal deaths across the continent and, in particular, Nigeria, which accounts for about 34% of global maternal deaths. Whereas oral iron is the mainstay treatment for pregnancy-related anaemia in Nigeria, this treatment is not very effective given the slow absorption of the medication, and its gastrointestinal adverse effects which lead to poor compliance by women. Intravenous iron is an alternative therapy which can rapidly replenish iron stores, but fears of anaphylactic reactions, as well as several misconceptions, have inhibited its routine use. Newer and safer intravenous iron formulations, such as ferric carboxymaltose, present an opportunity to overcome some concerns relating to adherence. Routine use of this formulation will, however, require addressing misconceptions and systemic barriers to adoption in the continuum of care of obstetric women from screening to treatment. This study aims to test the options to strengthen routine screening for anaemia during and immediately after pregnancy, as well as evaluate and improve conditions necessary to deliver ferric carboxymaltose to pregnant and postpartum women with moderate to severe anaemia.

METHODS

This study will be conducted in a cluster of six health facilities in Lagos State, Nigeria. The study will employ continuous quality improvement through the Diagnose-Intervene-Verify-Adjust framework and Tanahashi's model for health system evaluation to identify and improve systemic bottlenecks to the adoption and implementation of the intervention. Participatory Action Research will be employed to engage health system actors, health services users, and other stakeholders to facilitate change. Evaluation will be guided by the consolidated framework for implementation research and the normalisation process theory.

DISCUSSION

We expect the study to evolve transferable knowledge on barriers and facilitators to the routine use of intravenous iron that will inform scale-up across Nigeria, as well as the adoption of the intervention and strategies in other countries across Africa.

Sociodemographic patterns of preterm birth and low birth weight among pregnant women in rural Mysore district, India: A latent class analysis

Few studies have utilized person-centered approaches to examine co-occurrence of risk factors among pregnant women in low-and middle-income settings. The objective of this study was to utilize latent class analysis (LCA) to identify sociodemographic patterns and assess the association of these patterns on preterm birth (PTB) and/or low birth weight (LBW) in rural Mysore District, India. Secondary data analysis of a prospective cohort study among 1540 pregnant women was conducted. Latent class analysis was performed to identify distinct group memberships based on a chosen set of sociodemographic factors. Binary logistic regression was conducted to estimate the association between latent classes and preterm birth and low birth weight. LCA yielded four latent classes. Women belonging to Class 1 "low socioeconomic status (SES)/early marriage/multigravida/1 child or more", had higher odds of preterm birth (adjusted Odds Ratio (aOR): 95% Confidence Intervals (CI): 1.77, 95% CI: 1.05-2.97) compared to women in Class 4 "high SES/later marriage/primigravida/no children". Women in Class 2 "low SES/later marriage/primigravida/no children" had higher odds of low birth weight (aOR: 2.52, 95% CI: 1.51-4.22) compared to women in Class 4. Women less than 20 years old were twice as likely to have PTB compared to women aged 25 years and older (aOR: 2.00, 95% CI: 1.08-3.71). Hypertension (>140/>90 mm/Hg) was a significant determinant of PTB (aOR: 2.28, 95% CI: 1.02-5.07). Furthermore, women with a previous LBW infant had higher odds of delivering a subsequent LBW infant (aOR: 2.15, 95% CI: 1.40-3.29). Overall study findings highlighted that woman belonging to low socioeconomic status, and multigravida women had increased odds of preterm birth and low birth weight infants. Targeted government programs are crucial in reducing inequalities in preterm births and low birth weight infants in rural Mysore, India.

What is already done by different societies in reduction of maternal mortality? Are they successful at all?

Maternal mortality represents a major issue for every health system, especially in developed countries that aim on creating protocols to retain a declining pattern. With the appropriate medical supplies and training, some of these countries have made a remarkable progress in preventing maternal morbidity and mortality. On the contrary, developing countries have still made little or even no progress. Identifying determinants and designing strategies is of great importance in order to overcome such difficulties. The aim of this study is to identify the main causes of maternal mortality in the different societies.

Prepartum Anemia and Risk of Postpartum Hemorrhage: A Meta-Analysis and Brief Review

Postpartum hemorrhage (PPH) is responsible for 30% to 50% of maternal deaths. There is conflicting evidence if prepartum anemia facilitates PPH. A comprehensive analysis of studies describing their relation is missing. An extensive database search was conducted applying the terms "anemia" OR "hemoglobin" AND "postpartum hemorrhage." We used a random-effects meta-analysis model to estimate an overall odds ratio (OR) for PPH and prepartum anemia, separating studies that were conformant and non-conformant with the World Health Organization (WHO) definitions for anemia. The search yielded 2519 studies, and 46 were appropriate for analysis. The meta-analyses of WHO-conformant (n = 22) and non-conformant (n = 24) studies showed that the risk of PPH was increased when anemia was present. The ORs were 1.45 (CL: 1.23-1.71) for WHO-conformant studies, 2.88 (CL: 1.38-6.02) for studies applying lower thresholds for anemia, and 3.28 (CL: 2.08-5.19) for undefined anemia thresholds. PPH risk appeared to increase with lower anemia thresholds. Prepartum anemia is associated with an increased risk of PPH, an observation that is important regarding improved anemia correction strategies such as iron supplementation.

Maternal anemia and risk of adverse maternal health and birth outcomes in Bangladesh: A nationwide population-based survey

BACKGROUND

Maternal anemia is an ongoing public health challenge in low- and middle- income countries, including Bangladesh. The aim of this study was to explore the association of maternal anemia with a range of adverse maternal health and birth outcomes in Bangladesh.

METHODS

A total of 2,259 maternal women data was analyzed, extracted from the 2011 Bangladesh Demographic and Health Survey. Outcome variables considered were a range of maternal health and birth outcomes. Adverse maternal health outcomes were pregnancy complications, pregnancy termination, menstrual irregularities, cesarean delivery, diabetes, and hypertension. Adverse birth outcomes considered were low birth weight, stillbirths, early neonatal deaths, perinatal deaths, preterm birth, and prolonged labor. The main exposure variable was maternal anemia status. Mixed effect multilevel logistic/poisson regression model was used to determine the association between exposure and outcome variable adjusted for individual-, household-, and community-level factors.

RESULTS

The reported prevalence of anemia was 44%. A higher likelihoods pregnancy complication (AOR, 1.39, 95% CI, 1.09-2.41, p<0.05) and lower likelihoods of menstrual irregularities (AOR, 0.79, 95% CI, 0.58-0.94, p<0.05), diabetes (AOR, 0.78, 95% CI, 0.49-0.98, p<0.05) and hypertensive (AOR, 0.79, 95% CI, 0.60-0.96, p<0.05) were found among anemic maternal women as compared to the non-anemic maternal women. Adverse birth outcomes, including preterm birth (AOR, 2.03, 95% CI, 1.01-4.25, p<0.05), early neonatal mortality (AOR, 1.87, 95% CI, 1.06-5.10), and perinatal mortality (AOR, 1.54, 95% CI, 1.09-3.52, p<0.05), were also found higher among newborn of anemic maternal women as compared to the newborn of non-anemic maternal women.

CONCLUSION

Anemia during pregnancy increases the occurrence of adverse maternal health and birth outcomes. Strategies to reduce anemia, such as iron supplementation, during pregnancy and among reproductive-aged women need to be prioritized in the policies and programs.

Mode of Delivery and Neonatal Outcome in Adolescent Pregnancy (13-16 Years Old) Associated with Anemia

Background: Adolescent pregnancy represents an important public-health problem due to its maternal and fetal outcomes. Adolescent patients are predisposed to multiple obstetrical complications, including anemia and preterm birth which has a higher incidence among this population; withal, in the specialty literature, anemia is considered to be a risk factor for preterm delivery; furthermore, multiple studies have demonstrated that a very young age is an independent risk factor for preterm birth. Objectives: The study aims to reveal if anemia during adolescent pregnancy has a negative impact on the time and mode of delivery and newborns’ outcomes. Patients and methods: We performed a retrospective multicentric study on adolescent pregnancy. We analyzed 172 patients aged between 13 and 16 years who delivered in two large tertiary hospitals between 1 October 2018 and 15 April 2022. We divided the patients into two groups—a study group (n = 64) with anemia and a control group (n = 108) without anemia. We evaluated the modes of delivery, the times of birth, and the neonatal outcomes by 1-min newborn’s Apgar score, neonatal intensive-care unit (NICU) admission, and the newborns’ weights. Results: The rate of cesarean section was higher in patients with anemia than in the control group (45.31% vs. 38.88%, p < 0.001). We found that patients between 13 and 16 years diagnosed with anemia have a higher risk of preterm birth than those without anemia (35.93% vs. 21.29%, p < 0.001); however, an increased rate of LBW neonates was observed in the anemic adolescent group ≤14 years (p < 0.001). Regarding the newborns’ 1-min Apgar score, NICU admission, no statistically significant differences were recorded between the two groups according to the severity of anemia. In the anemic patients’ group, prenatal screening was identified in 9.37% of cases, while in the control group, in 16.67% (p = 0.034), which represents negative predictive factors, along with a low socio-economic status for the presence of anemia in young adolescent patients. Conclusions: Anemia is a risk factor for preterm birth, LBW, and cesarean section in young adolescent pregnancy. The association of lack of prenatal care and low socio-economic status worsens maternal and neonatal outcomes.

Maternal hemoglobin levels and neonatal outcomes: the Japan Environment and Children's Study

BACKGROUND

Low birth weight (LBW), small for gestational age (SGA), and preterm birth (PTB) are important neonatal outcomes that may affect infant morbidity and mortality. The aim of this study is to investigate associations between maternal hemoglobin (Hb) concentrations and pregnancy outcomes of LBW, SGA, and PTB.

METHODS

This was a prospective birth cohort study using data of the Japan Environment and Children's Study. Participants were divided into five groups according to maternal Hb (g/dL) in the first and second trimesters: group 1, Hb < 9; group 2, 9 ≤ Hb < 11.0; group 3, 11.0 ≤ Hb < 13.0; group 4, 13.0 < Hb < 14.0; and group 5, 14.0 ≤ Hb. We examined the relationships between LBW, PTB, SGA, and maternal Hb in the first and second trimesters.

RESULTS

Excluding 29,673, a total of 74,392 newborns (first trimester: n = 39,084, second trimester: n = 35,308) were included. We obtained adjusted odds ratios (aORs) (95% confidence intervals (CIs)) using multivariate analysis; compared with group 3 in the first trimesters, women in group 1 were at increased risk of PTB (aOR, 3.20; 95% CI, 1.69-6.09), LBW (aOR, 2.21; 95% CI, 1.19-4.09). In the second trimester, multivariate analysis revealed that, compared with group 3 in the second trimester, women in group 1 were at increased risk of PTB (aOR, 2.30; 95% CI, 1.19-4.42) and women in group 5 were at increased risk of LBW (aOR, 1.87; 95% CI, 1.24-2.81) and PTB (aOR, 1.73; 95% CI, 1.06-2.83).

CONCLUSIONS

Elevated maternal Hb in the second trimester was associated with risks of PTB and LBW.

The effect of maternal anaemia on low birth weight among newborns in Northwest Ethiopia

Low birth weight is an indicator of maternal-related multifactorial problems such as malnutrition, illness, and work overload. As a result, low birth weight is associated with maternal anaemia, and both of them were significant public health issues in developing nations. Low birth weight and anaemia are caused by insufficient nutrient intake, which is especially severe during pregnancy. So, this study aimed to assess the effect of maternal anaemia during the late trimester on low birth weight among newborns in Northwest Ethiopia. A systematic random sampling technique was used to select 211 participants for the primary data collection. Face-to-face interviews were used to collect data, while blood samples were collected using standard operating procedures. For further analysis, the data file was imported into Stata version 16 (MP) software. The binary logistic regression model was used to investigate significant factors related to low birth weight. Finally, the statistical significance of the variables was determined using a p value of ≤ 0.05. The prevalence of anaemia among pregnant women in the late trimester and newborns was 34 (16.11%, 95% CI: 11.42, 21.78) and 64 (30.33%, 95% CI: 24.20, 37.01), respectively. The mean ± standard deviation of the newborn babies' weight was 3.19 ± 0.49 kg. The proportion of low birth weight among newborns was 26 (12.32%, 95% CI: 8.20, 17.53%). The independent effect of anaemia on low birth weight was 4.19 times while all other factors were constant (COR = 4.19, 95% CI: 1.70, 10.30). Maternal educational status [unable to read and write (AOR = 10.94, 95% CI: 1.74, 68.58) and attained secondary education (AOR = 8.06, 95% CI: 1.53, 42.36)], and maternal anaemia (AOR = 3.51, 95% CI: 1.29, 9.55) were associated with low birth weight after adjusting with all other variables. In this study, the proportion of low birth weight was high. Here, maternal anaemia alone had a significant independent role in the development of low birth weight. Maternal education status and anaemic conditions were associated with low birth weight among newborns. Early detection and treatment of maternal anaemia during pregnancy is crucial with the usual nutritional-related care.

Intravenous versus oral iron for iron deficiency anaemia in pregnant Nigerian women (IVON): study protocol for a randomised hybrid effectiveness-implementation trial

Background

Anaemia in pregnancy is highly prevalent in African countries. High-dose oral iron is the current recommended treatment for pregnancy-related iron deficiency anaemia (IDA) in Nigeria and other African countries. This oral regimen is often poorly tolerated and has several side effects. Parenteral iron preparations are now available for the treatment of IDA in pregnancy but not widely used in Africa.

The IVON trial is investigating the comparative effectiveness and safety of intravenous ferric carboxymaltose versus oral ferrous sulphate standard-of-care for pregnancy-related IDA in Nigeria. We will also measure the implementation outcomes of acceptability, feasibility, fidelity, and cost-effectiveness for intravenous ferric carboxymaltose.

Methods

This is an open-label randomised controlled trial with a hybrid type 1 effectiveness-implementation design, conducted at 10 health facilities in Kano (Northern) and Lagos (Southern) states in Nigeria. A total of 1056 pregnant women at 20–32 weeks’ gestational age with moderate or severe anaemia (Hb < 10g/dl) will be randomised 1:1 into two groups. The interventional treatment is one 1000-mg dose of intravenous ferric carboxymaltose at enrolment; the control treatment is thrice daily oral ferrous sulphate (195 mg elemental iron daily), from enrolment till 6 weeks postpartum.

Primary outcome measures are (1) the prevalence of maternal anaemia at 36 weeks and (2) infant preterm birth (<37 weeks’ gestation) and will be analysed by intention-to-treat. Maternal full blood count and iron panel will be assayed at 4 weeks post-enrolment, 36 weeks’ gestation, delivery, and 6 weeks postpartum. Implementation outcomes of acceptability, feasibility, fidelity, and cost will be assessed with structured questionnaires, key informant interviews, and focus group discussions.

Discussion

The IVON trial could provide both effectiveness and implementation evidence to guide policy for integration and uptake of intravenous iron for treating anaemia in pregnancy in Nigeria and similar resource-limited, high-burden settings. If found effective, further studies exploring different intravenous iron doses are planned.

Trial registration

ISRCTN registry ISRCTN63484804. Registered on 10 December 2020

Clinicaltrials.govNCT04976179. Registered on 26 July 2021

The current protocol version is version 2.1 (080/080/2021).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06690-2.

Maternal Anemia during the First Trimester and Its Association with Psychological Health

Anemia during pregnancy is known to be associated with an increased risk of antenatal and/or postnatal depression, as well as adverse pregnancy outcomes. However, there are few studies evaluating psychological health throughout the antepartum and postpartum periods in women with anemia in early pregnancy. This study analyzed data collected by the Korean Pregnancy Outcome Study, a multicenter prospective cohort study conducted in South Korea, to determine the impact of anemia during the first trimester on birth outcomes and maternal mental health during pregnancy and postpartum. Hemoglobin levels were measured during the first trimester, and psychological health was evaluated at 12, 24, and 36 gestational weeks and 4−6 weeks postpartum. Anxiety and depression were defined using the Hospital Anxiety and Depression Scale and the Edinburgh Postnatal Depression Scale, respectively. Among 4067 Korean participants, 119 (2.9%) were diagnosed with anemia during the first trimester. Incidences of anxiety and depression did not differ over the pregnancy period between those with and without anemia during the first trimester. However, postpartum anxiety and depression were significantly more common in participants with anemia than in those without (p < 0.05, both). Hence, obstetricians should pay attention to postpartum mental health in women with anemia during the first trimester.

The Global Network Socioeconomic Status Index as a predictor of stillbirths, perinatal mortality, and neonatal mortality in rural communities in low and lower middle income country sites of the Global Network for Women's and Children's Health Research

BACKGROUND

Globally, socioeconomic status (SES) is an important health determinant across a range of health conditions and diseases. However, measuring SES within low- and middle-income countries (LMICs) can be particularly challenging given the variation and diversity of LMIC populations.

OBJECTIVE

The current study investigates whether maternal SES as assessed by the newly developed Global Network-SES Index is associated with pregnancy outcomes (stillbirths, perinatal mortality, and neonatal mortality) in six LMICs: Democratic Republic of the Congo, Guatemala, India, Kenya, Pakistan, and Zambia.

METHODS

The analysis included data from 87,923 women enrolled in the Maternal and Newborn Health Registry of the NICHD-funded Global Network for Women's and Children's Health Research. Generalized estimating equations models were computed for each outcome by SES level (high, moderate, or low) and controlling for site, maternal age, parity, years of schooling, body mass index, and facility birth, including sampling cluster as a random effect.

RESULTS

Women with low SES had significantly higher risks for stillbirth (p < 0.001), perinatal mortality (p = 0.001), and neonatal mortality (p = 0.005) than women with high SES. In addition, those with moderate SES had significantly higher risks of stillbirth (p = 0.003) and perinatal mortality (p = 0.008) in comparison to those with high SES.

CONCLUSION

The SES categories were associated with pregnancy outcomes, supporting the validity of the index as a non-income-based measure of SES for use in studies of pregnancy outcomes in LMICs.

Anemia in Pregnancy: Effects on Maternal and Neonatal Outcomes at a University Hospital in Riyadh

Background: Anemia in pregnancy has a number of adverse effects. This study aims to estimate anemia prevalence in pregnant women and examine the associations between maternal anemia with maternal characteristics, maternal outcomes during pregnancy and delivery, and neonatal outcomes at a university hospital in Riyadh.

Materials and methods: A cross-sectional study was undertaken among 400 women who delivered at the hospital. Data were collected through a data extraction sheet. Multivariate analysis was adopted according to the results of univariate analysis.

Results: Overall anemia prevalence was 39% (including 21% moderate anemia and 18% mild anemia); the rest, 61%, were normal. Non-intake of intravenous iron was more common among mothers with mild anemia (65.3%) compared to normal and moderately anemic (p=0.001). Significant differences between groups were found in relation to maternal outcomes such as pregnancy-induced hypertension (p=0.019), antepartum hemorrhage (p=0.001), postpartum hemorrhage (p=0.002), and non-intake of blood transfusion during pregnancy (p=0.012) and emergency cesarean section (p=0.017). Neonatal outcomes, including congenital malformations (p=0.003) and admission to the neonatal intensive care unit (NICU) (p<0.001), were higher in mildly anemic mothers. Statistically significant relationships were found between anemia in pregnancy and postpartum hemorrhage (odds ratio [OR] = 3.61; confidence interval [CI] 1.52-8.58; p=0.004), congenital malformations (OR = 5.09; CI 1.81-14.29; p=0.002), NICU admissions (OR=8.32; CI 2.77-24.96; p=0.001), and low birth weight (LBW; OR=1.833; CI 1.021-3.294; p=0.042).

Conclusions: The study highlights the association of maternal anemia with adverse events in mothers, such as postpartum hemorrhage. Among neonates, congenital malformations, low birth weight, and higher admissions to the NICU have been reported.

Association of Single Nucleotide Polymorphisms from Angiogenesis-Related Genes, ANGPT2, TLR2 and TLR9, with Spontaneous Preterm Labor

In this study, we hypothesized that the changes localized at angiopoietin-2 (ANGPT2), granulocyte-macrophage colony-stimulating factor (CSF2), fms-related tyrosine kinase 1 (FLT1) and toll-like receptor (TLR) 2, TLR6 and TLR9 genes were associated with spontaneous preterm labor (PTL), as well as with possible genetic alterations on PTL-related coagulation. This case-control genetic association study aimed to identify single nucleotide polymorphisms (SNPs) for the aforementioned genes, which are correlated with genetic risk or protection against PTL in Polish women. The study was conducted in 320 patients treated between 2016 and 2020, including 160 women with PTL and 160 term controls in labor. We found that ANGPT2 rs3020221 AA homozygotes were significantly less common in PTL cases than in controls, especially after adjusting for activated partial thromboplastin time (APTT) and platelet (PLT) parameters. TC heterozygotes for TLR2 rs3804099 were associated with PTL after correcting for anemia, vaginal bleeding, and history of threatened miscarriage or PTL. TC and CC genotypes in TLR9 rs187084 were significantly less common in women with PTL, compared to the controls, after adjusting for bleeding and gestational diabetes. For the first time, it was shown that three polymorphisms-ANGPT2 rs3020221, TLR2 rs3804099 and TLR9 rs187084 -were significantly associated with PTL, adjusted by pregnancy development influencing factors.

High hemoglobin level is a risk factor for maternal and fetal outcomes of pregnancy in Chinese women: A retrospective cohort study

BACKGROUND

To examine the association of hemoglobin (Hb) levels during gestation with the risk of selected adverse pregnancy outcomes such as preterm birth (PTB), low-birth-weight infants (LBW) and small-for-gestational-age infants (SGA) in Chinese women.

METHODS

This retrospective cohort study was conducted in the Department of Gynecology and Obstetrics at the Union Shenzhen Hospital of the Huazhong University of Science and Technology, using routinely collected maternity and hospital data on pregnancies (2015-2018). Hb levels were measured during the second (16-18th weeks) and third (28-30th weeks) trimesters of pregnancy, and pregnancy outcomes were recorded in the hospital information system. Hb levels were categorized into four groups as follows: < 110 g/L, 110-119 g/L, 120-130 g/L, and > 130 g/L. The second group (Hb 110-119 g/L) was defined as the reference group. Statistical analysis was performed using multivariate logistic regression.

RESULTS

A total of 1911 singleton mothers were included. After multivariable adjustment, Hb levels > 130 g/L in the second trimester increased the risk of LBW (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.12-5.76). In the third trimester of gestation, compared with women whose Hb levels between 110 and 119 g/L, women with Hb levels > 130 g/L had an increased risk of LBW (OR, 2.20; 95% CI, 1.07-4.51) and SGA (OR, 2.00; 95% CI, 1.05-3.80). When we compared the highest and lowest quartiles of changes in the Hb across the second and third trimesters, the adjusted ORs were 0.35 (95% CI: 0.18-0.68) for PTB and 0.47 (95% CI: 0.23-0.98) for LBW.

CONCLUSION

Maternal Hb > 130 g/L was associated with increased risk of adverse pregnancy outcomes. Reduction of the risks of PTB and SGA were observed with the appropriate increase of Hb level during the third trimester.

Postpartum haemorrhage in anaemic women: assessing outcome measures for clinical trials

Background

Postpartum haemorrhage (PPH) is a leading cause of maternal mortality worldwide. Maternal anaemia greatly increases the risk of PPH, and over a third of all pregnant women are anaemic. Because anaemia reduces the oxygen-carrying capacity of the blood, anaemic women cannot tolerate the same volume of blood loss as healthy women. Yet the same blood loss threshold is used to define PPH in all women. The lack of an established PPH definition in anaemic women means the most appropriate outcome measures for use in clinical trials are open to question. We used data from the WOMAN-2 trial to examine different definitions of PPH in anaemic women and consider their appropriateness as clinical trial outcome measures.

Main body

The WOMAN-2 trial is assessing tranexamic acid (TXA) for PPH prevention in women with moderate or severe anaemia at baseline. To obtain an accurate, precise estimate of the treatment effect, outcome measures should be highly specific and reasonably sensitive. Some outcome misclassification is inevitable. Low sensitivity reduces precision, but low specificity biases the effect estimate towards the null. Outcomes should also be related to how patients feel, function, or survive. The primary outcome in the WOMAN-2 trial, a ‘clinical diagnosis of PPH’, is defined as estimated blood loss > 500 ml or any blood loss within 24 h sufficient to compromise haemodynamic stability. To explore the utility of several PPH outcome measures, we analysed blinded data from 4521 participants. For each outcome, we assessed its: (1) frequency, (2) specificity for significant bleeding defined as shock index ≥1.0 and (3) association with fatigue (modified fatigue symptom inventory [MFSI]), physical endurance (six-minute walk test) and breathlessness. A clinical diagnosis of PPH was sufficiently frequent (7%), highly specific for clinical signs of early shock (95% specificity for shock index ≥1) and associated with worse maternal functioning after childbirth.

Conclusion

Outcome measures in clinical trials of interventions for PPH prevention should facilitate valid and precise estimation of the treatment effect and be important to women. A clinical diagnosis of PPH appears to meet these criteria, making it an appropriate primary outcome for the WOMAN-2 trial.

Trial registration

ClinicalTrials.gov NCT03475342, registered on 23 March 2018; ISRCTN62396133, registered on 7 December 2017; Pan African Clinical Trial Registry PACTR201909735842379, registered on 18 September 2019.

Synergistic Effects of Acacia Prunings-Derived Biochar and Nitrogen Application on the Mineral Profile of Maize (Zea mays L.) Grains

Despite the proven impact of biochar (BC) on crop yield, little is known about its effect on cereal grain quality. We explored the effect of acacia pruning-derived biochar and nitrogen (N) applications on the mineral profile of maize grains in a field study. Biochar was applied at the rates of 5, 10, 15, and 20 t ha−1 and N at 100, 150, and 200 kg ha−1 along with the control (BC or N not applied) in a split-plot arrangement using a randomized complete block design. At crop maturity, the grains were analyzed for K, P, Ca, Mg, Zn, Fe, and Cu content. The results showed that BC application at the rate of 10 t ha−1 along with N at 200 kg ha−1 resulted in the highest concentrations of K, P, Ca, and Mg in grains. The Fe content was the maximum at the N application rate of 200 kg ha−1 while Zn and Cu had the highest concentration at 150 kg N ha−1 with no BC. It was concluded that the integrated use of BC and N could be a valuable strategy to improve the nutritional quality of maize grains. The enrichment of BC with micronutrients is recommended to achieve the desired concentration of micronutrients in maize grains to help cure malnutrition. However, further investigation is warranted to validate the impact of BC made of different feedstocks on soils of contrasting mineralogy as organo-mineral interactions might mask the true potential of BC.

U-Shaped Association between Maternal Hemoglobin and Low Birth Weight in Rural Bangladesh

Low birth weight (LBW) is associated with a higher risk of neonatal mortality and the development of adult-onset chronic disease. Understanding the ongoing contribution of maternal hemoglobin (Hgb) levels to the incidence of LBW in South Asia is crucial to achieve the World Health Assembly global nutrition target of a 30% reduction in LBW by 2025. We enrolled pregnant women from the rural Tangail District of Bangladesh in a Maternal Newborn Health Registry established under The Global Network for Women's and Children's Health Research. We measured the Hgb of pregnant women at enrollment and birth weights of all infants born after 20 weeks gestation. Using logistic regression to adjust for multiple potential confounders, we estimated the association between maternal Hgb and the risk of LBW. We obtained Hgb measurements and birth weights from 1,665 mother-child dyads between July 2019 and April 2020. Using trimester-specific cutoffs for anemia, 48.3% of the women were anemic and the mean (±SD) Hgb level was 10.6 (±1.24) g/dL. We identified a U-shaped relationship where the highest risk of LBW was seen at very low (< 7.0 g/dL, OR = 2.00, 95% CI = 0.43-7.01, P = 0.31) and high (> 13.0 g/dL, OR = 2.17, 95% CI = 1.01-4.38, P = 0.036) Hgb levels. The mechanisms underlying this U-shaped association may include decreased plasma expansion during pregnancy and/or iron dysregulation resulting in placental disease. Further research is needed to explain the observed U-shaped relationship, to guide iron supplementation in pregnancy and to minimize the risk of LBW outcomes.

RAPIDIRON: Reducing Anaemia in Pregnancy in India-a 3-arm, randomized-controlled trial comparing the effectiveness of oral iron with single-dose intravenous iron in the treatment of iron deficiency anaemia in pregnant women and reducing low birth weight deliveries

Background

Anaemia is a worldwide problem and iron deficiency is the most common cause. In pregnancy, anaemia increases the risk of adverse maternal, foetal and neonatal outcomes.

India’s anaemia rate is among the highest in the world with India’s National Family Health Survey indicating over 50% of pregnant women were affected by anaemia.

India’s Anaemia Mukt Bharat-Intensified National Iron Plus Initiative aims to reduce the prevalence of anaemia among reproductive-age women, adolescents and children by 3% per year and facilitate the achievement of a Global World Health Assembly 2025 objective to achieve a 50% reduction of anaemia among women of reproductive age.

However, preliminary results of the NFHS-5 survey completed in 2020 indicate that anaemia rates are increasing in some states and these targets are unlikely to be achieved. With oral iron being the first-line treatment for iron deficiency anaemia (IDA) in pregnancy, these results are likely to be impacted by the side effects, poor adherence to tablet ingestion and low therapeutic impact of oral iron. These reports suggest a new approach to treating IDA, specifically the importance of single-dose intravenous iron infusions, may be the key to India effectively reaching its targets for anaemia reduction.

Methods

This 3-arm, randomized controlled trial is powered to report two primary outcomes. The first is to assess whether a single dose of two different intravenous formulations administered early in the second trimester of pregnancy to women with moderate IDA will result in a higher percentage of participants achieving a normal for pregnancy Hb concentration at 30–34 weeks’ gestation or just prior to delivery when compared to participants taking standard doses of oral iron. The second is a clinical outcome of low birth weight (LBW) (< 2500 g), with a hypothesis that the risk of LBW delivery will be lower in the intravenous iron arms when compared to the oral iron arm.

Discussion

The RAPIDIRON trial will provide evidence to determine if a single-dose intravenous iron infusion is more effective and economically feasible in reducing IDA in pregnancy than the current standard of care.

Trial registration

Clinical Trials Registry – India CTRI/2020/09/027730. Registered on 10 September 2020, http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=46801&EncHid=&userName=anemia%20in%20pregnancy

Maternal anemia and severe maternal morbidity in a US cohort

BACKGROUND

Maternal anemia is a common pregnancy complication and often leads to a requirement for additional treatments and interventions. Identifying the frequency at which women with antenatally diagnosed anemia experience severe morbidity at the time of admission to the labor and delivery unit will guide future recommendations regarding screening and interventions for anemia during pregnancy.

OBJECTIVE

The objective of this study was to evaluate the association between antenatally diagnosed anemia and severe maternal morbidity as defined by the Centers for Disease Control and Prevention in a large, contemporary, US cohort. Neonatal outcomes were also examined.

STUDY DESIGN

This was a secondary analysis of the Consortium on Safe Labor database from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, which collected data on 228,438 deliveries in 19 United States hospitals from 2002 to 2008. This analysis included women with viable, singleton gestations and excluded stillbirths and gestations with severe congenital anomalies. Women with a diagnosis of antenatal anemia were compared with those without. Identification of diagnoses of antenatal anemia was obtained via electronic medical record abstraction and International Classification of Diseases coding according to each hospital protocol within the Consortium on Safe Labor. The primary maternal outcome consisted of a composite of severe maternal morbidity as defined by the Centers for Disease Control and Prevention and included maternal death, eclampsia, thrombosis, transfusion, hysterectomy, and maternal intensive care unit admission. The primary neonatal outcome was a composite that included a 5-minute Apgar score of <7, hypoxic ischemic encephalopathy, respiratory distress syndrome, necrotizing enterocolitis, seizures, intracranial hemorrhage, periventricular or intraventricular hemorrhage, neonatal sepsis, neonatal intensive care unit admission, and neonatal death. Each outcome within the composites was assessed individually along with other additional secondary outcomes, including a composite of severe maternal morbidity not including transfusion morbidity. All statistical analyses were performed with Stata version 14.2 (StataCorp LLC, College Station, TX) using Student's t test, chi-square test, Fisher's exact test, and Wilcoxon rank-sum (Mann-Whitney U) test, as appropriate. A multivariable logistic regression was performed with potential confounding variables entered into the regression equation if they differed between groups at a significance level of P<.05.

RESULTS

A total of 166,566 women met the inclusion criteria. From the original cohort, 56,734 women could not be included because of an unknown diagnosis of anemia. Of those included, 10,217 (6.1%) were diagnosed with anemia during the pregnancy. Women with anemia were more likely to be younger, non-Hispanic Black, single, multiparous, and have a higher prepregnancy body mass index than those without anemia. The frequency of the primary maternal composite outcome, the neonatal composite outcome, and other secondary outcomes including the severe maternal morbidity composite not including transfusion, maternal death, transfusion during labor and the postpartum period, hysterectomy, postpartum hemorrhage, infectious morbidity, cesarean delivery, and preterm delivery were more common in women with anemia (P<.05). After multivariable logistic regression analysis adjusting for confounders, higher rates of severe maternal morbidity remained persistently associated with anemia (adjusted odds ratio, 2.04; 95% confidence interval, 1.86-2.23) in addition to the association of anemia with the severe maternal morbidity composite not including transfusion, maternal death, thrombosis, transfusion, hysterectomy, intensive care unit admission, postpartum hemorrhage, hypertensive disorders of pregnancy, cesarean delivery, and infectious morbidity. The composite neonatal outcome also remained associated with anemia after adjusting for confounders (adjusted odds ratio, 1.14; 95% confidence interval, 1.06-1.23).

CONCLUSION

Women with antepartum anemia experienced increased rates of severe maternal morbidity and other serious adverse outcomes. Diagnosis and treatment of anemia during the antepartum period may lead to the identification and treatment of women at higher risk for maternal morbidity and mortality.