Iron deficiency anaemia is defined as anaemia accompanied by depleted iron stores and signs of a compromised supply of iron to the tissues [
There are two known factors which contribute to development of iron deficiency anaemia (IDA) in pregnancy; the first is the woman’s iron stores at the time of conception and the second is the amount of iron absorbed during gestation. The fact that anaemia frequently does occur in pregnancy among women in developing countries is an indication that preexisting iron stores are often inadequate and physiological adaptations to pregnancy are insufficient to meet the increased requirements [
We conducted a review of literature on evidence-based preventive treatments of iron deficiency anaemia in pregnancy with particular reference to developing countries. The following search terms were used: prevalence, burden, iron deficiency, anaemia in pregnancy, preventive treatments, and developing countries. Cross-sectional, observational, and randomized control trials’ literature on the subject published between 2000 and 2011 served as the main sources of information. These works of literature were obtained from the commonly used medical databases such as PubMed (Medline), AJOL, and Google Scholar; in addition, Cochrane Library was used as source for systematic reviews on the subject matter.
The search generated 27 related articles in the following categories: prevalence—2, treatments—8, reviews—6, interventions/trials—6, dosage—1, and technical reports—4. This paper was limited to the six randomised and quasi-randomised trials (listed in Table
A list of randomised and quasi-randomised trials used for review.
Study | Study site | Subject number | Study question | Study methods | Study outcome | |
---|---|---|---|---|---|---|
(1) | Zamani et al., 2008 [ |
Iran | 152 pregnant women | Twice weekly iron supplementation versus daily regimen | Randomised control trial | Haemoglobin concentration |
(2) | Bencaiova et al., 2009 [ |
Switzerland | 260 pregnant women | intravenous iron sucrose versusdaily oral ferrous sulphate | Randomised control trial | Haemoglobin concentration; iron stores |
(3) | Asibey-Berko et al., 2007 [ |
Ghana | 184 women | Double-fortified salt versus weekly oral iron supplement versus weekly placebo | Double-blind randomisedcontrolled trial | Haemoglobin concentration |
(4) | Hoa et al., 2005 [ |
Vietnam | 168 women | Milk fortified with iron versus milk nonfortified with iron versus iron supplementation versus placebo | Quasirandomised trial | Haemoglobin concentration |
(5) | Young et al., 2000 [ |
Malawi | 413 pregnant women | Daily regimen versus weekly iron supplementation | Randomised controlled trial | Haemoglobin concentration |
(6) | Latham et al., 2003 [ |
Tanzania | Pregnant women | Micronutrient dietary supplementversus placebo | Randomised controlled trial | Iron stores |
Worldwide, anemia affects over two billion people and the World Health Organization (WHO) has estimated that half of these are due to iron deficiency [
Iron deficiency is the most common cause of anaemia in pregnancy [
Among pregnant women, IDA has been associated with increased risks of low birth weight, prematurity, and maternal morbidity [
The high physiological requirement for iron in pregnancy is difficult to meet with most diets; this is so especially in developing countries where food requirement is a problem. During pregnancy, iron requirements are not uniform [
Overall, a woman requires about 2–2.8 mg of iron per day during pregnancy [
Iron deficiency in nonpregnant populations can be measured quite precisely using laboratory tests such as serum ferritin, serum iron, transferrin, transferrin saturation, and transferrin receptors [
There are different forms of preventive treatment of iron deficiency anaemia in pregnancy. Iron supplements can be given by mouth and parenteral route as intramuscular and intravenous injections; in addition, it can be administered as blood transfusion and recombinant erythropoietin with iron. The first choice in the prophylaxis of iron deficiency anaemia for almost all women is oral iron replacement because of its effectiveness, safety, and low cost [
The International Nutritional Anaemia Consultative Group had recommended a daily dose of 60 mg of iron for pregnant nonanaemic women, if supplementation for more than six months is possible before delivery [
Iron fortification involves the addition of iron, usually with folic acid, to an appropriate food vehicle that is made available to the population at large. Food fortification with iron has thus become a promising approach for preventing iron deficiency anaemia in pregnancy in developing countries. Iron fortification of foods might be particularly useful and cost effective in settings where the logistics of oral iron supplementation among pregnant women are highly challenging. In addition, it is found very useful in developing countries where the rate of compliance with preventive treatment of iron is poor [
To this end, a variety of food items such as cereal flour (maize or wheat), salt, beverage, milk, sugar, noodles, rice, and fish sauce had been fortified with iron and used successfully as dietary supplements to boost iron stores, and hence improve haemoglobin levels in the population [
The overall impact of interventions on iron supplementation under field conditions has been limited and its effectiveness questioned [
A Cochrane review of a randomized control trial conducted in Pakistan reported that daily iron treatment is better than intermittent iron supplementation in increasing haemoglobin level at delivery among pregnant women in developing countries [
Some researchers, on the other hand, believe that both daily and weekly iron supplementation are relatively unsuccessful in the reduction of prevalence of anemia in pregnancy. They opined that sufficient attention should be paid to adolescent girls and women of reproductive age long before pregnancy and suggested intermittent low-dose iron supplements and in some cases, combined with necessary micronutrients [
Experiences on parenteral iron use are predominantly, but not exclusively, from the developed world as reports of its prophylactic use in pregnancy are scant; this may be related to concerns about adverse reactions associated with its use in parenteral form. However, intravenous iron sucrose in particular has been used in several recent studies and might be highly beneficial in refractory patients or those intolerant of oral iron formulations [
The WHO technical working group on the prevention and the treatment of severe anaemia has documented that parenteral iron therapy produces a rapid and complete correction of iron deficiency, including replacement of iron stores; thereby producing a more rapid erythropoietic response than oral iron replacement [
Food fortification with iron has also been shown to be an equally effective strategy of boosting haemoglobin level in the population, including pregnant women. Asibey-Berko et al. in 2007 recorded 19.5% significant increase in the prevalence of anaemia among rural Ghanaian women, who were not exposed to iron-fortified salt [
Gastrointestinal distress is commonly observed in women consuming high levels of supplemental iron on an empty stomach [
Intramuscular or intravenous iron is thought to be associated with allergic reactions and anaphylactic shock; furthermore, parenteral iron is thought to predispose to venous thrombosis and occasionally cardiac arrest and death [
Other disadvantages of intravenous iron supplementation include cost and invasiveness of the procedure. However, it is argued that cost benefit of intravenous iron prophylaxis may be large taking into consideration the opportunity costs of erythropoiesis-stimulating agents, blood transfusions, and hospitalization [
It is well established that antenatal care provides pregnant women with opportunities to receive cost-effective interventions which are beneficial to mother and child; these interventions include preventive treatments of iron deficiency anemia. However, the potentials of antenatal service have not been maximally utilized in developing countries. This is because these settings are characterized by poor maternal health service indicators such as nonutilization of service or delayed antenatal visit.
For example, researchers have reported a common occurrence of unbooked pregnancies [
The success of routine iron and folate supplementation, especially in areas with a high prevalence of anemia, recommended as a component of antenatal care package for all pregnant women by the World Health Organization is threatened by the practice of partial implementation of preventive treatments of health workers. Researchers have persistently reported noncompliance with this recommendation at a given antenatal visit. Van Eijk et al. in 2006 reported that 53% and 44% of pregnant women received iron and folate supplementation, respectively, during last pregnancy [
The efforts of World Food Programme (WFP) in overcoming micronutrient deficiencies in nutritionally-vulnerable groups and low-income food-deficit countries continue to be thwarted by challenges such as technical and managerial capacity constraints, the need for systematic compliance with procurement specifications and quality control, clearer policies on micronutrient content labeling, and the need for cash resources to support many aspects associated with local processing and fortification activities [
The World Health Organization has recommended that weekly iron and folic acid supplementation should be considered as a strategy for prevention of iron deficiency in population groups. This is particularly so where the prevalence of anemia is above 20% among women of reproductive age [
Alternatively, an equally effective, safe, and affordable iron compound with little or no side effect can be developed for use especially in public health antenatal supplementation programmes. To this end, we recommend a cue to be taken from new approaches to iron fortification technology development whereby iron-mediated undesirable taste and appearance are prevented while its stability and bioavailability are preserved [
Thus, clinical skills of local health staff could be improved through targeted trainings such as the WHO training on Life Saving Skills [
Mass fortification programme of common local staple foods with iron and folic acid is a long-term goal, which national governments in developing countries should consider as a strategy aimed at reducing the prevalence of iron deficiency anaemia in the general population. Since iron deficiency anaemia in pregnancy is determined by preexisting body iron stores, among other factors, we recommend that the mass fortification programme should be located and implemented within the context of reproductive health services.
Iron deficiency remains the most important cause of anaemia in pregnancy in developing countries. Hence, its contribution to increased risks of low birth weight, prematurity, and maternal morbidity cannot be underscored. Prophylaxis iron supplement and food fortification with iron have the prospects of improving maternal and child health, except for the identified constraints. Sustained advocacy in tackling micronutrient deficiencies at national and international policy levels is also a prerequisite to the attainment of Millennium Development Goals 4 and 5.