Maternal hemoglobin concentrations across pregnancy and maternal and child health: a systematic review and meta-analysis

Understanding the Determinants of Anemia Reduction among Women of Reproductive Age: Exemplar Country Case-Studies' Methodology

BACKGROUND

Since 2000, only a few countries have substantially reduced the burden of anemia among women 15-49 years of age. The Exemplars in Anemia Reduction among Women of Reproductive Age (WRA) studied the determinants of success among these countries.

OBJECTIVE

To describe the methodology used to determine the factors associated with anemia reduction in high-performing countries, with the aim to guide policy and programmatic decisions in other countries with similar sociodemographic and health indices.

METHODS

This paper describes the process used to identify countries with exemplary reduction in WRA anemia burden, compared to their peers. We describe the Exemplars in Global Health methodology, the mixed-methods approach used to identify and quantify the macro- and micro-level characteristics associated with anemia burden decline among WRA. Quantitative analyses include descriptive and equity analyses, multivariate linear regression, and Oaxaca-Blinder decomposition analysis (OBDA). Qualitative analyses include in-depth interviews (IDIs) and focus group discussions (FGDs) with national, subnational, and community stakeholders, as well as review of programs and policies with the potential to impact women's health and/or nutrition, enacted in the countries over the last 20 years. A technical advisory group (TAG) oversaw all research activities.

RESULTS

We identified five countries, namely Mexico, Pakistan, Philippines, Uganda, and Senegal, as Anemia Exemplars, after considering the magnitude of anemia decline between 2000 and 2018, availability of at least two nationally representative anemia surveys, geographical diversity to account for the complex etiology of anemia, regional representation, and logistics of in-country work.

CONCLUSION

Exemplars in Anemia Reduction among WRA seeks to create awareness of how little anemia prevalence has changed globally and aims to inform and spur global efforts for improving women's health and nutrition.

Anemia Awareness Program in a Suburban Middle School: A Pilot Study Promoting Students as Public Health Advocates in Their Community

INTRODUCTION

Almost a quarter of the people on earth are anemic, and most of them reside in regions of sub-Saharan Africa and South Asia. Anemia in children is linked with impaired cognitive and motor development and affects the future earning capacity. The most common cause of anemia is iron deficiency. The Indian Government has initiated multiple programs for the eradication of anemia. The prevalence of anemia has not decreased despite the improvements in the country's economy. It increased from 58.7% in 2015-16 to 67.1% in 2019-21 in children and from 50.4% in 2015-16 to 52.2% in 2019-21 in pregnant women. Maternal education, socioeconomic status, and number of children in the family are some factors that influence the prevalence of anemia. As these factors cannot be improved in a short time, we aimed to increase awareness about this issue by targeting school students from rural/semi-urban backgrounds.

METHODS

This pilot study aimed at promoting school students as public health advocates in their community. Anemia Awareness Program was conducted in a local middle school in the suburban area, which was attended by 153 class eight students (72 female). Pre- and post-test questionnaires comprising 20 multiple-choice/true-false type questions were used. Pre- and post-test scores were obtained. The second part of the study was the identification of students with anemia. Blood hemoglobin levels of 127 students (58 female) were measured from venous blood samples. The students were also asked to inform their friends/relatives about anemia and to send people with symptoms of anemia to the free two-day Anemia Awareness Camp organized by the Medical College Hospital for check-ups.

RESULTS

The mean post-test score (15.68/20) was much higher than the pretest score (2.99/20). Thirty-eight (25 female) out of 127 students had mild/moderate microcytic hypochromic anemia, suggesting iron deficiency. Thirty-two persons visited the free health camp to receive information from the students, of whom four had normal hemoglobin levels.

CONCLUSION

This pilot study showed that physician-conducted anemia awareness programs are relatively low-cost methods to spread information among the general population in India.

Post-load glucose is a stronger predictor of adverse pregnancy outcomes than first-trimester HbA1c in women without gestational diabetes

AIMS/INTRODUCTION

A debate exists on the relation of adverse pregnancy outcomes with glycemic levels in early pregnancy. We aimed to investigate the association of maternal characteristics including post-load glucose and first-trimester HbA1c test results with adverse pregnancy outcomes in women without gestational diabetes mellitus.

MATERIALS AND METHODS

A dataset (January 2011 and September 2017) from a hospital prenatal clinic was explored to find the important predictors of adverse pregnancy outcomes using maternal characteristics and glucose assessments in mothers without gestational diabetes. We used two machine learning algorithms to capture nonlinearity in selecting important maternal characteristics and developed predictive models for each outcome. In total, 1,618 pregnant women were included in the analytic dataset with a mean (SD) age of 26.8 (3.5) years and gravida of 1.7 (0.9).

RESULTS

Important associations were detected between maternal features and primary cesarean section, fetal distress, premature rupture of membranes, macrosomia, small or large for gestational age, APGAR <7 at 1 or 5 min, hyperbilirubinemia, and poly- or oligo-hydramnios. Overall, the predictive models showed good performance and large areas under the curves (0.732, 0.765, 0.646, 0.651, 0.730, 0.646, 0.684, 0.716, and 0.678, respectively). Specifically, they had high positive likelihood ratios.

CONCLUSIONS

High glucose levels were associated with adverse pregnancy outcomes. Post-load glucose was the most reliable test for predicting the outcomes. Overall, fasting blood sugar was of more predictive value than HbA1c. Our study showed that further research should account for the nonlinearity and interactions inherent in the data.

Factors Associated with Anemia and Iron Deficiency during Pregnancy: A Prospective Observational Study in Japan

Gestational anemia (GA) is a global health concern with a remarkably high prevalence in Japan, which is associated with various maternal and neonatal outcomes. This study aimed to explore whether GA and non-anemic iron deficiency (NAID) during the third trimester is associated with maternal characteristics, nutrient intake, low birth weight (LBW), and preterm birth. Participants were categorized into GA, NAID, and normal groups, based on serum ferritin and hemoglobin levels. Nutrient intake was assessed using the Brief Diet History Questionnaire. Data from 317 pregnant women were analyzed, including 110 (34.7%), 151 (47.6%), and 56 (17.6%) women in the GA, NAID, and normal groups, respectively. Factors associated with GA included being multipara (p < 0.001) and not taking any type of iron supplements in the third trimester (p = 0.043). The normal group had a significantly higher proportion of preterm birth and LBW than the GA and NAID groups. The GA group had a significantly higher energy intake than the normal group (p = 0.044). Overall, energy and micronutrient intake were significantly below the estimated average requirement in the dietary reference intakes for Japanese. Health care professionals need to consider nutritional advice that can prevent GA by focusing on overall micronutrients, not just energy intake.

Maternal anaemia during early pregnancy and the risk of neonatal outcomes: a prospective cohort study in Central China

BACKGROUND

The purpose of this study was to explore the association between anaemia during early pregnancy and the risk of neonatal outcomes.

METHODS

We collected clinical data from pregnant women (≥18 years) who received their first antenatal care between 8 and 14 weeks of gestation in Hunan Provincial Maternal and Child Health Care Hospital. Multiple logistic regression models and restricted cubic spline regression models were used to analyse the association between anaemia during early pregnancy and the risk of neonatal outcomes. In addition, sensitivity analysis was further performed to assess the robustness of the results.

RESULTS

The prospective cohort study ultimately included 34 087 singleton pregnancies. In this study, the rate of anaemia during early pregnancy was 16.3%. Our data showed that there was a positive relationship between the rate of preterm birth, low birth weight as well as small for gestational age (SGA) and the severity of maternal anaemia (Ptrend<0.05). After adjustment, the association of early pregnancy anaemia and haemoglobin (Hb) levels with the risk of preterm birth (mild anaemia adjusted OR (aOR) 1.37 (95% CI 1.25 to 1.52), moderate anaemia aOR 1.54 (95% CI 1.35 to 1.76) and severe anaemia aOR 4.03 (95% CI 2.67 to 6.08), respectively), low birth weight (mild anaemia aOR 1.61 (95% CI 1.44 to 1.79), moderate anaemia aOR 2.01 (95% CI 1.75 to 2.30) and severe anaemia aOR 6.11 (95% CI 3.99 to 9.36), respectively) and SGA (mild anaemia aOR 1.37 (95% CI 1.25 to 1.52), moderate anaemia aOR 1.54 (95% CI 1.35 to 1.76) and severe anaemia aOR 2.61 (95% CI 1.74 to 4.50), respectively; Pnon-linear<0.05) was observed. However, no association was found between early pregnancy anaemia or Hb levels and the risk of congenital malformations. Sensitivity analysis verified the stability of the results.

CONCLUSIONS

Maternal anaemia during early pregnancy was associated with an increased risk of preterm birth, low birth weight and SGA and their rates may increase with the severity of maternal anaemia.

TRIAL REGISTRATION NUMBER

ChiCTR1800016635.

Gestational Weight Gain, Pregnancy Related Complications and the Short-Term Risks for the Offspring

BACKGROUND AND OBJECTIVES

Maternal obesity influences pregnancy course in several different manners, and imbalanced nutrition during pregnancy may lead to various adverse pregnancy outcomes. Additionally, nutritional status during pregnancy may have implications for the health of the offspring and may possibly influence early motor development in children. The aim of this study was to assess the impact of excessive gestational weight gain (EGWG) on pregnancy outcomes and infant's motor development within the first twelve months of life.

MATERIALS AND METHODS

The study included 200 participants divided in two groups based on their gestational weight gain. Maternal, perinatal, and neonatal factors were analyzed, and early motor development was assessed using the Alberta infant motor scale (AIMS).

RESULTS

EGWG was significantly associated with: pre-pregnancy BMI (p < 0.001), family history for cardiovascular diseases (p = 0.013) and diabetes mellitus (p = 0.045), hypertensive disorder of pregnancy (p = 0.003), gestational diabetes mellitus (p < 0.001), gestational anemia (p = 0.001), vitamin D deficiency (p = 0.001), metformin use (p = 0.045), pre-labor premature rupture of membranes (p = 0.031), amniotic fluid index (p = 0.047), and APGAR score in the first five min of life (p = 0.007). Scored by AIMS, EGWG was significantly associated with parameters of early motor development at the age of three AIMS total (p < 0.001), six AIMS total (p < 0.001), nine AIMS total (p < 0.001), and twelve AIMS total (p < 0.001) months of infant's life.

CONCLUSIONS

The link between EGWG and adverse neurodevelopmental outcomes in offspring is a complex and multifaceted issue. Our results imply significant alterations in early motor development in the group of infants born from mothers who gained weight excessively during pregnancy. Further studies are needed to unravel the intricacies of this relationship and inform strategies for preventive interventions and supportive care during pregnancy and infancy.

Dietary supplements, guideline alignment and biochemical nutrient status in pregnancy: Findings from the Queensland Family Cohort pilot study

In high-income nations, multiple micronutrient (MMN) supplementation during pregnancy is a common practice. We aimed to describe maternal characteristics associated with supplement use and daily dose of supplemental nutrients consumed in pregnancy, and whether guideline alignment and nutrient status are related to supplement use. The Queensland Family Cohort is a prospective, Australian observational longitudinal study. Maternal characteristics, nutrient intake from food and supplements, and biochemical nutrient status were assessed in the second trimester (n = 127). Supplement use was reported by 89% of participants, of whom 91% reported taking an MMN supplement. Participants who received private obstetric care, had private health insurance and had greater alignment to meat/vegetarian alternatives recommendations were more likely to report MMN supplement use. Private obstetric care and general practitioner shared care were associated with higher daily dose of supplemental nutrients consumed compared with midwifery group practice. There was high reliance on supplements to meet nutrient reference values for folate, iodine and iron, but only plasma folate concentrations were higher in MMN supplement versus nonsupplement users. Exceeding the upper level of intake for folic acid and iron was more likely among combined MMN and individual supplement/s users, and associated with higher plasma concentrations of the respective nutrients. Given the low alignment with food group recommendations and potential risks associated with high MMN supplement use, whole food diets should be emphasized. This study confirms the need to define effective strategies for optimizing nutrient intake in pregnancy, especially among those most vulnerable where MMN supplement use may be appropriate.

Risk factors for pre-eclampsia in clinical practice guidelines: Comparison with the evidence

OBJECTIVE

To compare pre-eclampsia risk factors identified by clinical practice guidelines (CPGs) with risk factors from hierarchical evidence review, to guide pre-eclampsia prevention.

DESIGN

Our search strategy provided hierarchical evidence of relationships between risk factors and pre-eclampsia using Medline (Ovid), searched from January 2010 to January 2021.

SETTING

Published studies and CPGs.

POPULATION

Pregnant women.

METHODS

We evaluated the strength of association and quality of evidence (GRADE). CPGs (n = 15) were taken from a previous systematic review.

MAIN OUTCOME MEASURE

Pre-eclampsia.

RESULTS

Of 78 pre-eclampsia risk factors, 13 (16.5%) arise only during pregnancy. Strength of association was usually 'probable' (n = 40, 51.3%) and the quality of evidence was low (n = 35, 44.9%). The 'major' and 'moderate' risk factors proposed by 8/15 CPGs were not well aligned with the evidence; of the ten 'major' risk factors (alone warranting aspirin prophylaxis), associations with pre-eclampsia were definite (n = 4), probable (n = 5) or possible (n = 1), based on moderate (n = 4), low (n = 5) or very low (n = 1) quality evidence. Obesity ('moderate' risk factor) was definitely associated with pre-eclampsia (high-quality evidence). The other ten 'moderate' risk factors had probable (n = 8), possible (n = 1) or no (n = 1) association with pre-eclampsia, based on evidence of moderate (n = 1), low (n = 5) or very low (n = 4) quality. Three risk factors not identified by the CPGs had probable associations (high quality): being overweight; 'prehypertension' at booking; and blood pressure of 130-139/80-89 mmHg in early pregnancy.

CONCLUSIONS

Pre-eclampsia risk factors in CPGs are poorly aligned with evidence, particularly for the strongest risk factor of obesity. There is a lack of distinction between risk factors identifiable in early pregnancy and those arising later. A refresh of the strategies advocated by CPGs is needed.

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.

Postpartum hemorrhage in Sub-Saharan Africa-a prospective study in metropolitan Mozambique

BACKGROUND

Estimates indicate approximately ≈500 to 1000 maternal deaths per 100,000 live births in Sub-Saharan Africa (SSA) (vs ≈5-20 in developed countries). Postpartum hemorrhage (PPH) seems a major contributor to maternal mortality (MM), but there are no comprehensive data for the region.

OBJECTIVES

Analyze MM, PPH, and associated risk factors.

METHODS

We collected prospective data on MM, PPH, and associated risk factors in metropolitan Mozambique. We recorded consecutive deliveries at the Maputo Central Hospital between February 2019 and January 2021. Data included age, HIV status, parity, delivery mode, notes, vital signs, laboratory values, and fetal parameters. PPH was determined by charted diagnosis, blood loss of >500 mL, transfusion, and/or notes indicating significant bleeding.

RESULTS

Of 8799 deliveries, ≈40% occurred in women residing outside Maputo City ("nonlocal"), with similar demographic characteristics between local and nonlocal women. However, compared with local women, nonlocal women had worse outcomes, including higher rates of MM (1.52% vs 0.78%; P =.0012) and PPH (16.51% vs 12.39%; P <.0001), whereby PPH was strongly associated with MM (adjusted odds ratio = 5.56; P <.0001). Almost all women with uterine atony (≈1%) experienced PPH. For women receiving laboratory tests on admission (drawn only if in distress; local, n = 561; nonlocal, n = 514), both cohorts revealed similar distributions of hemoglobin levels and platelet counts. Prepartum anemia (≈57%) and thrombocytopenia (≈21%) were prominent risk factors for PPH; risk increased with increasing severity and was additive in the presence of both.

CONCLUSIONS

PPH is a serious problem in Maputo province, a metropolitan area of SSA, portending high MM. Identification of correctable risk factors, including anemia, should catalyze the development of region-specific prevention protocols.

Biology of Anemia: A Public Health Perspective

Our goal is to present recent progress in understanding the biological mechanisms underlying anemia from a public health perspective. We describe important advances in understanding common causes of anemia and their interactions, including iron deficiency (ID), lack of other micronutrients, infection, inflammation, and genetic conditions. ID develops if the iron circulating in the blood cannot provide the amounts required for red blood cell production and tissue needs. ID anemia develops as iron-limited red blood cell production fails to maintain the hemoglobin concentration above the threshold used to define anemia. Globally, absolute ID (absent or reduced body iron stores that do not meet the need for iron of an individual but may respond to iron supplementation) contributes to only a limited proportion of anemia. Functional ID (adequate or increased iron stores that cannot meet the need for iron because of the effects of infection or inflammation and does not respond to iron supplementation) is frequently responsible for anemia in low- and middle-income countries. Absolute and functional ID may coexist. We highlight continued improvement in understanding the roles of infections and inflammation in causing a large proportion of anemia. Deficiencies of nutrients other than iron are less common but important in some settings. The importance of genetic conditions as causes of anemia depends upon the specific inherited red blood cell abnormalities and their prevalence in the settings examined. From a public health perspective, each setting has a distinctive composition of components underlying the common causes of anemia. We emphasize the coincidence between regions with a high prevalence of anemia attributed to ID (both absolute and functional), those with endemic infections, and those with widespread genetic conditions affecting red blood cells, especially in sub-Saharan Africa and regions in Asia and Oceania.

The Associations of Maternal Blood Hemoglobin and Serum Triglyceride Levels and the Risk of Preterm Delivery

The abnormal hemoglobin (HGB) and serum lipid concentrations during pregnancy will increase the risk of preterm delivery. Our study aimed to explore the correlation between prenatal HGB and serum lipid levels and preterm delivery. We enrolled 215 mother-infant pairs in a pilot cohort study. The logistic regression model and Restricted Cubic Spline model (RCS) were used to investigate the levels of prenatal blood HGB and serum lipid such as triglyceride (TG), total cholesterol, high-density lipoprotein, low density lipoprotein and preterm delivery. The results showed that moderate levels of prenatal blood HGB (OR=0.28; 95%CI: 0.10, 0.75, p-trend=0.018) and high level of serum TG (OR=0.29; 95%CI: 0.10, 0.84, p-trend=0.022) level were negatively associated with the risk of preterm delivery. The joint effect results showed that compared with lower level of prenatal blood HGB (≤123.13 g/l) and TG (≤3.7 mmol/l), we found that high levels prenatal blood HGB and serum TG (OR=0.32, 95%CI: 0.12, 0.89) had a negative association with the risk of preterm delivery. Moreover, prenatal blood HGB and serum TG levels had negative linear dose-effect relationships with the risk of preterm delivery in overall and girl group (p<0.05). Moderate levels of prenatal blood HGB and high level of serum TG were negatively associated with the risk of preterm delivery. The joint effect of high levels prenatal HGB and prenatal serum TG in the normal range were negatively correlated with preterm delivery. Moreover, the underlying mechanisms should be clarified in future studies.

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.

Exploring the perspective of young adults about anaemia prevention; the contributions of knowledge about at-risk groups and consequences of anaemia

BACKGROUND

Anaemia persistently remains a grave public health challenge in most sub-Saharan African countries. Understanding the perspectives of young adults concerning the multi-factorial nature of anaemia may be an important step towards meeting the 2025 global nutrition target of halving anaemia since these individuals might be in the process of reproductive decisions.

AIM

To explore the relationship between students' knowledge about individuals at risk of developing anaemia, and anaemia consequences, and anaemia prevention strategies in a tertiary student cohort.

METHODS

This sequential exploratory study adopted a mixed-methods approach to triangulate the data collection. A semi-structured questionnaire was used to gather baseline data regarding students' perspective on anaemia. Themes that emerged from the initial questionnaire data analyses guided a focus group discussion (FGD) to further explore students' perspectives on anaemia. FGD data was thematically analysed to unearth reasons behind questionnaire item selection. Structural equation modeling (SEM) was used to explore the relationship between constructs in the anaemia knowledge questionnaire.

RESULTS

Overall, 543 students participated in the initial questionnaire data acquisition compared to 16 in the FGD. Our latent variable structural model showed that knowing the causes of anaemia did not significantly (p > 0.05) associate with either knowledge about anaemia consequences (b = 0.113) or knowledge about anaemia prevention strategies (b = 0.042). However, knowledge about individuals at-risk of anaemia was significantly positively associated with both anaemia prevention strategies (b = 0.306, p < 0.05) and knowledge about consequences of anaemia (b = 0.543, 95%). Moreover, knowing the consequences of anaemia seemed to significantly positively mediate the association between knowledge about at-risk groups and preventive measures that could be adopted (b = 0.410, p < 0.05).

CONCLUSIONS

Systems thinking public health educational campaigns that highlight the consequences of anaemia and at-risk groups are more likely to inspire the adoption of preventive strategies among young adults.

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.

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.

An evidence review and nutritional conceptual framework for pre-eclampsia prevention

Pre-eclampsia is a serious complication of pregnancy, and maternal nutritional factors may play protective roles or exacerbate risk. The tendency to focus on single nutrients as a risk factor obscures the complexity of possible interactions, which may be important given the complex nature of pre-eclampsia. An evidence review was conducted to compile definite, probable, possible and indirect nutritional determinants of pre-eclampsia to map a nutritional conceptual framework for pre-eclampsia prevention. Determinants of pre-eclampsia were first compiled through an initial consultation with experts. Second, an expanded literature review was conducted to confirm associations, elicit additional indicators and evaluate evidence. The strength of association was evaluated as definite relative risk (RR) < 0·40 or ≥3·00, probable RR 0·40-0·69 or 1·50-2·99, possible RR 0·70-0·89 or 1·10-1·49 or not discernible RR 0·90-1·09. The quality of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluation. Twenty-five nutritional factors were reported in two umbrella reviews and twenty-two meta-analyses. Of these, fourteen were significantly associated with pre-eclampsia incidence. Higher serum Fe emerged as a definite nutritional risk factors for pre-eclampsia incidence across populations, while low serum Zn was a risk factor in Asia and Africa. Maternal vitamin D deficiency was a probable risk factor and Ca and/or vitamin D supplementation were probable protective nutritional factors. Healthy maternal dietary patterns were possibly associated with lower risk of developing pre-eclampsia. Potential indirect pathways of maternal nutritional factors and pre-eclampsia may exist through obesity, maternal anaemia and gestational diabetes mellitus. Research gaps remain on the influence of household capacities and socio-cultural, economic and political contexts, as well as interactions with medical conditions.

Association between maternal haemoglobin concentrations and maternal and neonatal outcomes: the prospective, observational, multinational, INTERBIO-21st fetal study

BACKGROUND

Anaemia in pregnancy is a global health problem with associated maternal and neonatal morbidity and mortality. We aimed to investigate the association between maternal haemoglobin concentrations during pregnancy and the risk of adverse maternal and neonatal outcomes.

METHODS

In this prospective, observational, multinational, INTERBIO-21st fetal study conducted at maternity units in Brazil, Kenya, Pakistan, South Africa, and the UK, we enrolled pregnant women (aged ≥18 years, BMI <35 kg/m2, natural conception, and singleton pregnancy) who initiated antenatal care before 14 weeks' gestation. At each 5±1 weekly visit until delivery, information was collected about the pregnancy, as well as the results of blood tests taken as part of routine antenatal care, including haemoglobin values. The outcome measures were maternal (gestational diabetes, pregnancy-induced hypertension, and preterm premature rupture of membranes) and neonatal outcomes (small for gestational age, preterm birth, and acute respiratory distress syndrome).

FINDINGS

Between Feb 8, 2012, and Nov 30, 2019, 2069 women (mean age 30·7 years [SD 5·0]) had at least one routinely haemoglobin concentration measured at 14-40 weeks' gestation, contributing 4690 haemoglobin measurements for the analysis. Compared with a haemoglobin cutoff of 110 g/L, the risk was increased more than two-fold for pregnancy-induced hypertension at haemoglobin concentrations of 170 g/L (risk ratio [RR] 2·29 [95% CI 1·19-4·39]) and higher, for preterm birth at haemoglobin concentrations of 70 g/L (RR 2·04 [95% CI 1·20-3·48]) and 165 g/L (RR 2·06 [95% CI 1·41-3·02]), and for acute respiratory distress syndrome at haemoglobin concentrations of 165 g/L (RR 2·84 [95% CI 1·51-5·35]). Trimester-specific results are also presented.

INTERPRETATION

Our data suggests that the current WHO haemoglobin cutoffs are associated with reduced risk of adverse maternal and neonatal outcomes. The current haemoglobin concentration cutoffs during pregnancy should not only consider thresholds for low haemoglobin concentrations that are associated with adverse outcomes but also define a threshold for high haemoglobin concentrations given the U-shaped relationship between haemoglobin concentration and adverse neonatal and maternal outcomes.

FUNDING

Bill & Melinda Gates Foundation.

Clinical characteristics and prognosis of pregnancy-related acute kidney injury: a case series study

OBJECTIVE

Acute kidney injury (AKI) seriously affects the health of both pregnant women and fetuses. This study aimed to investigate the clinical characteristics and prognosis of pregnancy-related AKI (PR-AKI).

METHODS

This case series study enrolled pregnant women with PR-AKI admitted to the surgical intensive care unit of Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine between January 2010 and December 2020.

RESULTS

Thirty-one PR-AKI patients were enrolled with a mean age of 29.16 ± 4.97 years. Seventeen pregnant women (54.84%) had complete recovery of renal function, 5 (16.13%) had partial recovery of renal function, 2 (6.45%) patients had no renal function improvement, and 7 (22.58%) died. Among the 31 patients with 35 fetuses, 25 (80.6%) pregnant women had poor fetal outcomes, including 5 cases of stillbirths, 5 neonatal asphyxia, 18 premature births, 10 low birth weight, and 8 deficient birth weight infants. Compared to cases with good fetal outcomes, cases with poor fetal outcomes had significantly shorter gestational weeks (39.26 ± 1.53 vs. 31.62 ± 5.50, P = 0.002), lower platelet count (217.13 ± 122.87 vs. 90.24 ± 84.88, P = 0.005), lower hemoglobin (94.19 ± 13.21 vs. 74.48 ± 20.78, P = 0.036), higher blood urea nitrogen (11.87 ± 4.28 vs. 19.47 ± 10.98, P = 0.013), and higher uric acid (262.41 ± 167.00 vs. 586.87 ± 144.52, P < 0.001).

CONCLUSIONS

The maternal renal function of women with PR-AKI might improve after treatment, but occurrence rates of adverse fetal outcomes were still high.

Prevalence, years lived with disability, and trends in anaemia burden by severity and cause, 1990-2021: findings from the Global Burden of Disease Study 2021

BACKGROUND

Anaemia is a major health problem worldwide. Global estimates of anaemia burden are crucial for developing appropriate interventions to meet current international targets for disease mitigation. We describe the prevalence, years lived with disability, and trends of anaemia and its underlying causes in 204 countries and territories.

METHODS

We estimated population-level distributions of haemoglobin concentration by age and sex for each location from 1990 to 2021. We then calculated anaemia burden by severity and associated years lived with disability (YLDs). With data on prevalence of the causes of anaemia and associated cause-specific shifts in haemoglobin concentrations, we modelled the proportion of anaemia attributed to 37 underlying causes for all locations, years, and demographics in the Global Burden of Disease Study 2021.

FINDINGS

In 2021, the global prevalence of anaemia across all ages was 24·3% (95% uncertainty interval [UI] 23·9-24·7), corresponding to 1·92 billion (1·89-1·95) prevalent cases, compared with a prevalence of 28·2% (27·8-28·5) and 1·50 billion (1·48-1·52) prevalent cases in 1990. Large variations were observed in anaemia burden by age, sex, and geography, with children younger than 5 years, women, and countries in sub-Saharan Africa and south Asia being particularly affected. Anaemia caused 52·0 million (35·1-75·1) YLDs in 2021, and the YLD rate due to anaemia declined with increasing Socio-demographic Index. The most common causes of anaemia YLDs in 2021 were dietary iron deficiency (cause-specific anaemia YLD rate per 100 000 population: 422·4 [95% UI 286·1-612·9]), haemoglobinopathies and haemolytic anaemias (89·0 [58·2-123·7]), and other neglected tropical diseases (36·3 [24·4-52·8]), collectively accounting for 84·7% (84·1-85·2) of anaemia YLDs.

INTERPRETATION

Anaemia remains a substantial global health challenge, with persistent disparities according to age, sex, and geography. Estimates of cause-specific anaemia burden can be used to design locally relevant health interventions aimed at improving anaemia management and prevention.

FUNDING

Bill & Melinda Gates Foundation.

Iron supplements in pregnant women with normal iron status: A systematic review and meta-analysis

INTRODUCTION

Effects of daily iron supplementation in iron replete pregnancy are unclear. This systematic review aimed to assess benefits and harms of oral iron supplements in pregnant women without anemia and iron deficiency.

MATERIAL AND METHODS

We predefined and registered a protocol in PROSPERO (CRD42020186210) and performed the review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. We searched for randomized clinical trials (RCTs) and observational studies comparing daily oral iron supplementation with no iron supplements in non-anemic iron replete pregnant women. Searches were conducted in MEDLINE (by PubMed), EMBASE (by OVID), Cochrane Library, and ClinicalTrials.gov from inception to September 2022 without language restrictions. Two authors independently screened records, extracted data, and assessed risk of bias using the revised Cochrane risk of bias tool (RoB2). One author read full-texts, assessed certainty of evidence by GRADE and conducted meta-analyses using a random-effects model. Primary outcomes included iron deficiency anemia, iron deficiency, hemoglobin >130 g/L, elevated iron status, small for gestational age newborns, low birthweight newborns, preterm birth, and congenital anomalies.

RESULTS

Eight RCTs (2822 women) but no observational studies were eligible for inclusion. Daily oral iron supplementation in pregnancy probably reduces iron deficiency anemia at term (risk ratio [RR]: 0.51, 95% confidence interval [CI]: 0.38-0.70; 4 RCTs, 1670 women; I2  = 13%; moderate-certainty evidence) and the incidence of low birthweight babies (RR: 0.30, 95% CI: 0.13-0.68; 2 RCTs, 361 infants; I2  = 0%; moderate-certainty evidence). In addition, it may reduce iron deficiency at term (RR: 0.74, 95% CI: 0.60-0.92; 4 RCTs, 1663 women; I2  = 58%; low-certainty evidence) and the incidence of small for gestational age babies (RR: 0.39, 95% CI: 0.17-0.86; 1 RCT, 213 infants; I2 not estimable; low-certainty evidence).

CONCLUSIONS

Daily iron supplementation in iron replete non-anemic pregnant women probably reduces the risk of maternal iron deficiency anemia at term and low birthweight.

Maternal and Neonatal Outcomes of Twin Pregnant Women With Anemia

The aim of this study was to investigate the prevalence of anemia in twin pregnancies and the influence of anemia on maternal and neonatal outcomes. This retrospective study included twin pregnant women who delivered in a tertiary hospital in China from January 2018 to December 2018. Patients were divided by WHO criteria (hemoglobin <11.0 g/dL): the anemic and nonanemic groups. Patients with anemia were further classified as recovered or unrecovered subgroup after oral iron therapy. Maternal and neonatal outcomes in women carrying twins were compared using Student's t test and the chi-squared test or the Fisher exact test. Univariable and multivariable logistic regression models were used to determine the association of maternal and neonatal characteristics with anemia. Linear regression analysis was used to estimate mean birth weight and gestational week. The prevalence of anemia was 42.6% (182/427) in twin pregnancies. The anemic group had higher rates of low 1-minute Apgar score (4.4% vs. 1.8%, p = .028), perinatal death (1.9% vs. 0.2%, p = .012) and neonatal intensive care unit (NICU) admission (27.2% vs. 20.2%, p = .017; adjusted OR, 1.478; 95% CI [1.07, 2.044]). The recovered subgroup had lower NICU admission rate (13.5% vs. 30.3%, p = .006; OR, 0.388; 95% CI [0.186, 0.809]), higher gestational week and birth weight (β, 0.954 week; 95% CI [0.114, 1.794] and β, 171.01 g; 95% CI [9.894, 332.126] respectively). The prevalence of anemia in twin gestation is high. Anemia is associated with adverse neonatal outcomes, and correction of anemia significantly improved the pregnancy outcomes.

The development of a prediction model for arrest of labour to be used at regular check-ups, during 36 or 37 gestational weeks, for primiparas: a retrospective cohort study

PURPOSE

An emergency caesarean section (CS) has more complications than a planned CS. The arrest of labour is a major indication for an emergency CS. This study aimed to develop a prediction model for the arrest of labour to be used in regular check-ups at 36 or 37 gestational weeks for primiparas.

METHODS

This was a retrospective cohort study conducted at a single institution in Japan using data from January 2007 to December 2013. Primiparas attending regular check-ups during 36 or 37 gestational weeks, with live single foetuses in a cephalic presentation were included. The outcome was the incidence of labour arrest. Candidate predictors included 25 maternal and foetal findings. We developed a prediction model using logistic regression analysis with stepwise selection. A score was assigned to each predictor of the final model based on their respective β coefficients.

RESULTS

A total of 739 women were included in the analysis. Arrest of labour was diagnosed in 47 women (6.4%), and all of them delivered by emergency CS. The predictors in the final model were a Bishop score ≤ 1, maternal height ≤ 154 cm, foetal biparietal diameter ≥ 91 mm, pre-pregnancy weight ≥ 54 kg, maternal haemoglobin concentration ≥ 11.0 g/dl, and amniotic fluid index ≥ 13. The area under the receiver operating characteristic curve was 0.783.

CONCLUSION

We have developed the first model to predict arrested labour before its onset. Although this model requires validation using external samples, it will help clinicians and pregnant women to control gestational conditions and make decisions regarding planned CS.

Opportunities and barriers for maternal nutrition behavior change: an in-depth qualitative analysis of pregnant women and their families in Uttar Pradesh, India

Background

Maternal undernutrition during pregnancy remains a critical public health issue in India. While evidence-based interventions exist, poor program implementation and limited uptake of behavior change interventions make addressing undernutrition complex. To address this challenge, Alive & Thrive implemented interventions to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in Uttar Pradesh, India.

Objective

This qualitative study aimed to: (1) examine pregnant women's experiences of key nutrition-related behaviors (ANC attendance, consuming a diverse diet, supplement intake, weight gain monitoring, and breastfeeding intentions); (2) examine the influence of family members on these behaviors; and (3) identify key facilitators and barriers that affect behavioral adoption.

Methods

We conducted a qualitative study with in-depth interviews with 24 pregnant women, 13 husbands, and 15 mothers-in-law (MIL). We analyzed data through a thematic approach using the Capability-Opportunity-Motivation-Behavior (COM-B) framework.

Results

For ANC checkups and maternal weight gain monitoring, key facilitators were frontline worker home visits, convenient transportation, and family support, while the primary barrier was low motivation and lack understanding of the importance of ANC checkups. For dietary diversity, there was high reported capability (knowledge related to the key behavior) and most family members were aware of key recommendations; however, structural opportunity barriers (financial strain, lack of food availability and accessibility) prevented behavioral change. Opportunity ranked high for iron and folic acid supplement (IFA) intake, but was not consistently consumed due to side effects. Conversely, lack of supply was the largest barrier for calcium supplement intake. For breastfeeding, there was low overall capability and several participants described receiving inaccurate counseling messages.

Conclusion

Key drivers of maternal nutrition behavior adoption were indicator specific and varied across the capability-opportunity-motivation behavior change spectrum. Findings from this study can help to strengthen future program effectiveness by identifying specific areas of program improvement.

Quantifying differences in iron deficiency-attributable anemia during pregnancy and postpartum

Pregnant women in resource-limited settings are highly susceptible to anemia and iron deficiency, but the etiology of postpartum anemia remains poorly defined. To inform the optimal timing for anemia interventions, changes in iron deficiency-attributable anemia through pregnancy and postpartum need to be understood. In 699 pregnant Papua New Guinean women attending their first antenatal care appointment and following up at birth and 6 and 12 months postpartum, we undertake logistic mixed-effects modeling to determine the effect of iron deficiency on anemia and population attributable fractions, calculated from odds ratios, to quantify the contribution of iron deficiency to anemia. Anemia is highly prevalent during pregnancy and 12 months postpartum, with iron deficiency increasing the odds of anemia during pregnancy and, to a lesser extent, postpartum. Iron deficiency accounts for ≥72% of anemia during pregnancy and 20%-37% postpartum. Early iron supplementation during and between pregnancies could break the cycle of chronic anemia in women of reproductive age.

Predicting nutritional status during pregnancy by women's empowerment in West Shewa Zone, Ethiopia

Background

Considerable proportions of pregnant women are affected by poor nutrition outcomes in Ethiopia. Women's empowerment, on the other hand, is highly recognized as a means to achieve better maternal nutrition outcomes. However, the role of pregnant women's empowerment in nutritional status during pregnancy has not been empirically examined in Ethiopia. This study aimed to address this gap.

Objective

To assess the association of individual and composite women's empowerment dimensions with pregnant women's nutrition outcomes in West Shewa Zone, Ethiopia.

Methods

A health facility-based cross-sectional study was performed on 1,453 pregnant women living in West Shewa Zone, Ethiopia, in 2021. Exploratory and confirmatory factor analyses were conducted on half of the samples to identify and validate dimensions of pregnant women's empowerment. The associations between pregnant women's empowerment dimensions and anemia status and mid upper arm circumference levels were examined by logistic regressions.

Results

Composite pregnant women's empowerment was positively associated with both anemia status and mid-upper-arm circumference level. The odds of not being anemic were higher among pregnant women empowered in economic [adjusted odds ratio (AOR) = 1.7, 95% confidence interval (CI): 1.26, 2.22] and assertiveness (AOR = 1.9, 95% CI: 1.46, 2.38) dimensions than those not empowered in these dimensions. Empowered pregnant women in household decision-making (AOR = 1.6, 95% CI: 1.19, 2.22) and psychological (AOR = 1.4, 95% CI: 1.04, 1.85) dimensions had higher odds of having normal mid-upper-arm circumference measures than those not empowered in the respective dimensions. Communication and time dimensions were not significantly associated with any of the nutrition outcomes.

Conclusions

This study suggests that empowered pregnant women are nutritionally better off than their less empowered counterparts. This is also important in child health outcomes. Policies and programs that aim to improve maternal and child health in the study area need to consider interventions that promote the decision-making power, economic, psychological, and assertiveness dimensions of pregnant women.

Maternal hemoglobin change from early pregnancy to second trimester is associated with risk of gestational diabetes mellitus: a retrospective cohort study

Introduction

The accrual of iron that is reflected in high maternal hemoglobin (Hb) status is increasingly recognized as a risk factor for gestational diabetes mellitus (GDM). Changes in maternal Hb level could also implicate glycemic status in pregnancy. This study aimed to determine the associations between maternal Hb levels and their changes with GDM.

Methods

In this retrospective cohort study, a total of 1,315 antenatal records of mothers with singleton pregnancies from eight health clinics of a district in the northern region of Peninsular Malaysia who delivered between 1st January 2016-31st December 2017 were analyzed. Data extracted from the records were socio-demographic, anthropometric, obstetrical, and clinical data. Hb levels were extracted at booking (<14 weeks) and second trimester (14-28 weeks). Change in Hb was determined by subtracting the Hb level in the second trimester from the booking Hb level and was categorized as decreased, unchanged, and increased Hb. The associations between maternal Hb levels and their changes with GDM risk were analyzed using multiple regression, adjusting for covariates in four different models. Model 1: maternal age and height. Model 2: covariates of Model 1 added with parity, history of GDM, and family history of diabetes. Model 3: covariates of Model 2 added with iron supplementation at booking. Model 4: covariates of Model 3 added with Hb level at booking.

Results and Discussions

Unchanged Hb level from booking to second trimester was significantly associated with GDM risk in Model 1 (AOR: 2.55; 95% CI: 1.20, 5.44; p < 0.05), Model 2 (AOR: 2.45, 95% CI: 1.13, 5.34; p < 0.05) Model 3 (AOR: 2.42; 95% CI: 1.11, 5.27; p < 0.05), and Model 4 (AOR: 2.51; 95% CI: 1.15, 5.49; p < 0.05). No significant associations were observed between maternal Hb levels and GDM in the study.

Conclusion

Unchanged Hb levels from the booking (<14 weeks of gestation) to the second trimester (14-28 weeks) increased GDM risk. Further investigation is warranted to evaluate the associations between changes in maternal Hb and GDM risk and to identify potential factors influencing this relationship.

Hemoglobin distributions and prevalence of anemia in a multiethnic United States pregnant population

BACKGROUND

Few normative longitudinal hemoglobin data are available to estimate the prevalence and risk factors for anemia among a multiethnic United States pregnant population.

OBJECTIVES

The aim of this study was to characterize hemoglobin distributions and prevalence of anemia in a pregnant population receiving care at a large urban medical center.

METHODS

A retrospective medical chart review was undertaken in 41,226 uncomplicated pregnancies of 30,603 pregnant individuals who received prenatal care between 2011 and 2020. Mean hemoglobin concentrations and anemia prevalence in each trimester and incidence of anemia during pregnancy in a subset of 4821 women with data in each trimester were evaluated in relation to self-reported race and ethnicity and other possible risk factors. Risk ratios (RRs) of anemia were determined using generalized linear mixed-effects models. Smoothed curves describing changes in hemoglobin across pregnancy were created using generalized additive models.

RESULTS

The overall prevalence of anemia was 26.7%. The observed fifth percentiles of the hemoglobin distributions were significantly lower than the United States CDC anemia cutoffs in the second and third trimesters (T3). The RR (95% CI) of anemia were 3.23 (3.03, 3.45), 6.18 (5.09, 7.52), and 2.59 (2.48, 2.70) times higher in Black women than that in White women in each trimester, respectively. Asian women recorded the lowest risk of anemia compared with other racial groups in T3 (compared with White womenRR: 0.84; 95% CI: 0.74, 0.96). Hispanic women presented a higher risk of anemia in T3 than non-Hispanic women (RR: 1.36; 95% CI: 1.28, 1.45). In addition, adolescents, individuals with higher parity, and those carrying multiple fetuses experienced a higher risk of developing anemia in late gestation.

CONCLUSIONS

Anemia was evident in more than one-quarter of a multiethnic United States pregnant population despite current universal prenatal iron supplementation recommendations. Prevalence of anemia was higher among Black women and lowest among Asian and White women.

Diagnosing anemia: Challenges selecting methods, addressing underlying causes, and implementing actions at the public health level

Accurate and affordable tools for diagnosing anemia and its main determinants are essential for understanding the magnitude and distribution of the problem and the appropriate interventions needed for its timely prevention and treatment. The objective of this review is to address methods, equipment, and sample-related and quality control aspects of hemoglobin measurement for anemia diagnosis. Also, other iron-, infectious-, and genetic-related causes of anemia are addressed in individuals and populations. The best practice for hemoglobin determination is the use of venous blood, analyzed on automated hematology analyzers, with high-quality control measures in place. The importance of a correct anemia diagnosis is highlighted by the cost of a misdiagnosis. A false-negative diagnosis may result in missing out and not treating anemia, its causes, and its adverse effects. On the other hand, a false-positive diagnosis may result in the provision of unneeded treatment or referral for expensive laboratory tests to determine a cause of anemia, wasting valuable resources and risking causing harm. At the individual level, clinicians must understand the causes of absolute and functional anemia to diagnose and treat anemia at the clinical level. Actions toward anemia diagnosis and control at public health levels require global, regional, and country actions that should cover general and context-specific characteristics.

Factors associated with anaemia in pregnancy: A retrospective cross-sectional study in the Bolgatanga Municipality, northern Ghana

BACKGROUND

Anaemia in pregnancy (AIP) remains a severe public health problem associated with adverse outcomes. This study assessed haemoglobin levels and the prevalence of anaemia during antenatal care (ANC) registration, at 28 weeks and 36 weeks of gestation as well as the factors associated with AIP at the different stages of pregnancy.

METHODS

A retrospective cross-sectional design was implemented. Using ANC registers as the sampling frame, 372 pregnant women, within 36 and 40 weeks of gestation were randomly sampled from 28 health facilities for the study. The participants were all receiving ANC in the Bolgatanga Municipality. Data were collected via clinical records review and a questionnaire-based survey between October and November, 2020. Using the Statistical Package for the Social Sciences (SPSS), descriptive analysis of haemoglobin levels and the prevalence of anaemia were performed. In addition, binary logistic regression was used to identify the factors associated with anaemia in pregnancy. AIP was determined using the national practice of 11.0g/dl haemoglobin cut-off point and the World Health Organisation's recommended adjustment for the 2nd trimester of pregnancy was made using the cut-off of 10.5g/dl to account for the effect of haemodilution.

RESULTS

At booking, AIP prevalence was 35.8% (95%CI:30.9, 40.9) using a cut-off of 11.0g/dl and 25.3% (95%CI:20.9, 30.0) using a cut-off of 10.5g/dl for those in the 2nd trimester. At 28 weeks, AIP prevalence was 53.1% (95%CI:45.8, 60.3) and 37.5 (95%CI:30.6, 44.8) using a cut-off of 11.0g/dl and 10.5g/dl for those in the 2nd trimester, respectively. At 36 weeks, AIP prevalence was 44.8% (95%CI:39.2, 50.4) using a cut-off of 11.0g/dl. At p<0.05, registering after the first trimester (AOR = 1.87, 95%CI: 1.17, 2.98, P = 0.009) and at a regional hospital (AOR = 2.25, 95%CI: 1.02, 4.98, P = 0.044) were associated with increased odds of AIP but registering at a private hospital (AOR = 0.32, 95%CI: 0.11, 0.92, P = 0.035) was associated with decreased odds of AIP at booking. At 28 weeks, age group 26-35 years (AOR = 0.46, 95%CI: 0.21, 0.98, P = 0.044), Christianity (AOR = 0.32, 95%CI: 0.31, 0.89, P = 0.028.), high wealth (AOR = 0.27, 95%CI: 0.09, 0.83, P = 0.022) and tertiary education (AOR = 0.09, 95%CI:0.02, 0.54, P = 0.009) were associated with decreased odds of AIP. At 36 weeks, booking after first trimester of pregnancy was associated with increased odds (AOR = 1.72, 95%CI: 1.05, 2.84, P = 0.033) whilst high wealth (AOR = 0.44, 95%CI: 0.20, 0.99, P = 0.049), higher age groups-26-35 (AOR = 0.38, 95%CI: 0.21, 0.68, P = 0.001) and 36-49 years (AOR = 0.35, 95%CI: 0.13, 0.90, P = 0.024) and secondary education of spouse were associated with reduced odds (AOR = 0.35, 95%CI: 0.14, 0.88, P = 0.026) of AIP.

CONCLUSION

AIP consistently increased from registration to 36 weeks of gestation. Given the observed correlates of AIP, we recommend that interventions geared towards early ANC registration, improved household wealth, and improved maternal education are required to reduce AIP.

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.

Prenatal Exposure to Air Pollution and Pre-Labor Rupture of Membranes in a Prospective Cohort Study: The Role of Maternal Hemoglobin and Iron Supplementation

BACKGROUND

Exposure to air pollution in prenatal period is associated with prelabor rupture of membranes (PROM). However, the sensitive exposure time windows and the possible biological mechanisms underlying this association remain unclear.

OBJECTIVE

We aimed to identify the sensitive time windows of exposure to air pollution for PROM risk. Further, we examined whether maternal hemoglobin levels mediate the association between exposure to air pollution and PROM, as well as investigated the potential effect of iron supplementation on this association.

METHOD

From 2015 to 2021, 6,824 mother-newborn pairs were enrolled in the study from three hospitals in Hefei, China. We obtained air pollutant data [particulate matter (PM) with aerodynamic diameter ≤2.5μm (PM2.5), PM with aerodynamic diameter ≤10μm (PM10), sulfur dioxide (SO2), and carbon monoxide (CO)] from the Hefei City Ecology and Environment Bureau. Information on maternal hemoglobin levels, gestational anemia, iron supplementation, and PROM was obtained from medical records. Logistic regression models with distributed lags were used to identify the sensitive time window for the effect of prenatal exposure to air pollutant on PROM. Mediation analysis estimated the mediated effect of maternal hemoglobin in the third trimester, linking prenatal air pollution with PROM. Stratified analysis was used to investigate the potential effect of iron supplementation on PROM risk.

RESULTS

We found significant association between prenatal exposure to air pollution and increased PROM risk after adjusting for confounders, and the critical exposure windows of PM2.5, PM10, SO2 and CO were the 21th to 24th weeks of pregnancy. Every 10-μg/m3 increase in PM2.5 and PM10, 5-μg/m3 increase in SO2, and 0.1-mg/m3 increase in CO was associated with low maternal hemoglobin levels [-0.94g/L (95% confidence interval (CI): -1.15, -0.73), -1.31g/L (95% CI: -1.55, -1.07), -2.96g/L (95% CI: -3.32, -2.61), and -1.11g/L (95% CI: -1.31, -0.92), respectively] in the third trimester. The proportion of the association between air pollution and PROM risk mediated by hemoglobin levels was 20.61% [average mediation effect (95% CI): 0.02 (0.01, 0.05); average direct effect (95%): 0.08 (0.02, 0.14)]. The PROM risk associated with exposure to low-medium air pollution could be attenuated by maternal iron supplementation in women with gestational anemia.

CONCLUSIONS

Prenatal exposure to air pollution, especially in the 21st to 24th weeks of pregnancy, is associated with PROM risk, which is partly mediated by maternal hemoglobin levels. Iron supplementation in anemia pregnancies may have protective effects against PROM risk associated with exposure to low-medium air pollution. https://doi.org/10.1289/EHP11134.

[Implementation of Patient Blood Management as Standard-of-Care]

Anaemia is among the most common co-morbidity in surgical patients. However, it often remains unrecognized and untreated, which results in an increased requirement for allogeneic blood products and complications. Patient Blood Management offers patient-centred and evidence-based therapies and preventive measures for anaemia. Patient Blood Management is composed of 3 main pillars: pre-operative anaemia management, blood loss reduction and the rational use of allogeneic blood products. The World Health Organization demands the implementation of Patient Blood Management measures since 2010. However, a comprehensive implementation of Patient Blood Management as a standard-of-care is still not achieved. Here, we describe the need for a comprehensive Patient Blood Management implementation and highlight several specific Patient Blood Management measures.

Long term association between of maternal preconception hemoglobin and anemia and child health and development in Vietnam

BACKGROUND

The long-term association between preconception maternal hemoglobin (Hb) concentrations and child health and development is unclear.

OBJECTIVE

We examined associations between maternal preconception Hb concentrations and anemia with: a) birth outcomes (weight, length, preterm, gestational age, small-for-gestational-age); b) child Hb at 3 mo, 6 mo, 12 mo, and 24 mo; c) motor and mental development at 12 mo and 24 mo (Bayley scales for infant development) and cognitive functioning at 6-7y (Wechsler Intelligence Scale for Children).

METHODS

We used data from a randomized controlled trial (PRECONCEPT) conducted in Vietnam. Over 5000 women who were intending to conceive were recruited and offspring were prospectively followed from birth (n=1599) through 6-7y (n=1318). Multivariable linear and logistic regressions were used to assess the association between preconception Hb or anemia (Hb < 11g/dL) on child health and development outcomes, adjusted by supplementation group (tested for interactions) and confounding at maternal, child and household levels.

RESULTS

At preconception enrollment, 20% of the women were anemic. Maternal preconception Hb was positively associated with child Hb at 3 mo (0.06; 95% CI: 0.01,0.12), 6 mo (0.08; 95% CI: 0.03,0.13), 12 mo (0.10; 95% CI: 0.04-0.15) and 24 mo (0.07; 95% CI: 0.02,0.12). Likewise, maternal preconception Hb was associated with reduced risk of child anemia at 6mo (0.89; 95% CI: 0.81-0.98), 12 mo (0.81; 95% CI: 0.74-0.89) and 24 mo (0.87; 95% CI: 0.79-0.95). Maternal preconception anemia was negatively associated with cognition (-1.64; 95% CI: -3.09, -0.19) and language development (-1.61; 95% CI: -3.20, -0.03) at 24mo. Preconception Hb was not associated with birth outcomes or cognitive outcomes at 6-7y.

CONCLUSION

Maternal preconception Hb was associated with child Hb across the first 1000 days of life. However, preconception Hb was not a significant predictor of birth outcomes or cognitive outcomes at 6-7y in this cohort from Vietnam.

Anemia in pregnancy and sleep of 6-month-old infants: A prospective cohort study

Objective

Anemia has been reported to adversely influence sleep in infants. However, the association between anemia in pregnancy and infant sleep remains unclear. We aimed to examine the association between maternal anemia in pregnancy and sleep parameters of 6-month-old infants.

Methods

We enrolled 2,410 mother-infant pairs between 2018 and 2021 in Hefei. Data on maternal hemoglobin concentration were collected at 24–28 gestational weeks from the electronic medical records of the hospitals. Nocturnal and daytime sleep duration, number of night awakenings, nocturnal wakefulness, and sleep latency of infants aged 6 months were measured using the Brief Infant Sleep Questionnaire with five items. A restricted cubic spline model was used to examine the relationship between maternal hemoglobin concentration and infant nocturnal sleep duration after adjusting for potential confounders.

Results

In our study, 807 (33.5%) mothers had anemia during pregnancy. Compared to infants born to mothers without anemia, infants born to mothers with anemia in pregnancy had shorter nocturnal sleep duration [mean (SD), 560.29 (79.57) mins vs. 574.27 (75.36) mins] at the age of 6 months. Subgroup analysis showed consistent significant differences in nocturnal sleep duration between infant born to anemic and non-anemic mothers, except in case of stratification by preterm birth [mean difference (mins), 2.03 (95% CI, −20.01, −24.07)] and pre-pregnancy obesity [mean difference (mins), −0.85 (95% CI, −16.86, −15.16)]. A J-shaped nonlinear correlation curve was observed between maternal hemoglobin concentration and infant nocturnal sleep duration. Compared with mothers without daily iron supplementation, mothers who had daily iron supplementation had higher hemoglobin concentrations [mean (SD), 112.39 (11.33) g/L vs. 110.66 (10.65) g/L] at delivery and their infants had longer nocturnal sleep duration [mean (SD), 565.99 (82.46) mins vs. 553.66 (76.03) mins].

Conclusion

Anemia in pregnancy may have an adverse influence on the sleep of 6-mon-old infants, and the relationship between maternal hemoglobin concentration and nocturnal sleep duration is nonlinear.

The interplay between maternal-infant anemia and iron deficiency

Iron deficiency anemia in pregnancy is a major public health problem known to cause maternal morbidity and adverse birth outcomes, and it may also have lasting consequences on infant development. However, the impact of the maternal hematological environment on fetal and infant hemoglobin and iron stores in the first year of life remains unclear. This review of the epidemiological evidence found that severe maternal iron deficiency anemia in pregnancy is associated with lower ferritin, and to a lesser degree hemoglobin levels, in infants at birth. Emerging data also suggests that severe anemia in pregnancy increases the risk of iron deficiency and anemia in infants 6-12 months of age, although longitudinal studies are limited. Effective anemia prevention in pregnancy, such as iron supplementation, could reduce the risk of infant anemia and iron deficiency during the first year of life; however, more evidence is needed to determine the functional impact of iron supplementation in pregnancy on infant hematological indices.

Maternal hemoglobin levels and adverse pregnancy outcomes: individual patient data analysis from 2 prospective UK pregnancy cohorts

BACKGROUND

Hemoglobin (Hb) is a modifiable risk factor for adverse pregnancy outcomes. Studies have reported conflicting associations between maternal Hb levels and adverse pregnancy outcomes, including preterm birth (PTB), low birth weight (LBW), and perinatal mortality.

OBJECTIVE

In this study, we aimed to estimate the shape and magnitude of associations between maternal Hb levels in early (7-12 wk gestation) and late pregnancy (27-32 wk gestation) and pregnancy outcomes in a high-income setting.

METHODS

We used data from 2 UK population-based pregnancy cohorts: the Avon Longitudinal Study of Parents and Children (ALSPAC) and Pregnancy Outcome Prediction Study (POPS). We used multivariable logistic regression models to examine the relationship between Hb and pregnancy outcomes, adjusting for maternal age, ethnicity, BMI, smoking status, and parity. Main outcome measures were PTB, LBW, small for gestational age (SGA), pre-eclampsia (PET), and gestational diabetes mellitus (GDM).

RESULTS

Mean Hb in ALSPAC were 12.5 g/dL (SD = 0.90) and 11.2 g/dL (SD = 0.92) in early and late pregnancy, respectively, and 12.7 g/dL (SD = 0.82) and 11.4 g/dL (SD = 0.82) in POPS. In the pooled analysis, there was no evidence of associations between a higher Hb in early pregnancy (7-12 wk gestation) and PTB (OR per 1 g/dL of Hb: 1.09; 95% CI: 0.97, 1.22), LBW (1.12: 0.99, 1.26), and SGA (1.06; 0.97, 1.15). Higher Hb in late pregnancy (27-32 wk gestation) was associated with PTB (1.45: 1.30, 1.62), LBW (1.77: 1.57, 2.01), and SGA (1.45: 1.33, 1.58). Higher Hb in early and late pregnancy was associated with PET in ALSPAC (1.36: 1.12, 1.64) and (1.53: 1.29, 1.82), respectively, but not in POPS (1.17:0.99, 1.37) and (1.03: 0.86, 1.23). There was an association with a higher Hb and GDM in ALSPAC in both early and late pregnancy [(1.51: 1.08, 2.11) and (1.35: 1.01, 1.79), respectively], but not in POPS [(0.98: 0.81, 1.19) and (0.83: 0.68, 1.02)].

CONCLUSIONS

Higher maternal Hb may identify the risk of adverse pregnancy outcomes. Further research is required to investigate if this association is causal and to identify the underlying mechanisms.

A New Artificial Intelligence Approach Using Extreme Learning Machine as the Potentially Effective Model to Predict and Analyze the Diagnosis of Anemia

The procedure to diagnose anemia is time-consuming and resource-intensive due to the existence of a multitude of symptoms that can be felt physically or seen visually. Anemia also has several forms, which can be distinguished based on several characteristics. It is possible to diagnose anemia through a quick, affordable, and easily accessible laboratory test known as the complete blood count (CBC), but the method cannot directly identify different kinds of anemia. Therefore, further tests are required to establish a gold standard for the type of anemia in a patient. These tests are uncommon in settings that offer healthcare on a smaller scale because they require expensive equipment. Moreover, it is also difficult to discern between beta thalassemia trait (BTT), iron deficiency anemia (IDA), hemoglobin E (HbE), and combination anemias despite the presence of multiple red blood cell (RBC) formulas and indices with differing optimal cutoff values. This is due to the existence of several varieties of anemia in individuals, making it difficult to distinguish between BTT, IDA, HbE, and combinations. Therefore, a more precise and automated prediction model is proposed to distinguish these four types to accelerate the identification process for doctors. Historical data were retrieved from the Laboratory of the Department of Clinical Pathology and Laboratory Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia for this purpose. Furthermore, the model was developed using the algorithm for the extreme learning machine (ELM). This was followed by the measurement of the performance using the confusion matrix and 190 data representing the four classes, and the results showed 99.21% accuracy, 98.44% sensitivity, 99.30% precision, and an F1 score of 98.84%.

Shooting shadows: India's struggle to reduce the burden of anaemia

Despite several efforts by the Government of India, the national burden of anaemia remains high and its growing prevalence (between 2015-2016 and 2019-2021) is concerning to India's public health system. This article reviews existing food-based and clinical strategies to mitigate the anaemia burden and why they are premature and insufficient. In a context where multiple anaemia control programmes are in play, this article proposes a threefold strategy for consideration. First, except the Comprehensive National Nutrition Survey, 2016-2018, which measured Hb concentration among children and adolescents aged 1-19 years using venous blood samples, all national surveys use capillary blood samples to determine Hb levels, which could be erroneous. The Indian government should prioritise conducting a nationwide survey for estimating the burden of anaemia and its clinical determinants for all age groups using venous blood samples. Second, without deciding the appropriate dose of Fe needed for an individual, food fortification programmes that are often compounded with layering of other micronutrients could be harmful and further research on this issue is needed. Same is true for the pharmacological intervention of Fe tablet or syrup supplementation programmes, which is given to individuals without assessing its need. In addition, there is a dire need for robust research to understand both the long-term benefit and side effects of Fe supplementation programmes. Third and final, the WHO is in process of reviewing the Hb threshold for defining anaemia, therefore the introduction of new anaemia control programmes should be restrained.

Establishing pregnancy-specific haematological reference intervals in Ghana; a three-center cross-sectional study

BACKGROUND

Abnormal intra-pregnancy haematological variables are associated with adverse feto-maternal outcomes. However, the reference intervals (RIs) employed in sub-Saharan Africa to inform clinical decisions are generally imported. Since RIs are influenced by age, geographical location, and race, we hypothesized that context specific RIs should be established in Ghana to contextualize intra-pregnancy decision making.

METHODS

This cross-sectional study retrospectively retrieved data of 333 pregnant women with no known clinically determined intra-pregnancy complications; 22 participants in their first trimester (T1; 1-13 weeks), 177 in their T2 (14-27 weeks), and 132 in T3 (28-41 weeks). RIs for haematological parameters were non-parametrically determined at 2.5th and 97.5th percentiles in accordance with CLSI guidance document EP28-A3c. Two-sample comparisons were undertaken using Wilcoxon rank-sum tests whereas more than two-sample comparisons were undertaken using Kruskal-Wallis test. Statistical significance was set at p <0.05 under the two-tailed assumptions.

RESULTS

In accordance with WHO trimester-specific haemoglobin cutoffs, anaemia prevalence was a moderate (T1: 36.4%; 8/22 & T2: 31.6%; 56/177) to severe (T3:68.0%; 90/132) public health problem. Additionally, 9.3% (31/333) individuals had high gestational haemoglobin levels (Hb >13.0 g/dL). Moreover, haemoglobin (T2: 8.6-14.3 vs T3: 7.5-13.6 g/dL), MCH (T2: 22.5-69.8 vs T3: 21.6-31.9 pg), MCHC (T2: 30.2-51.8 g/L vs T3: 30.5-37.9 g/L), TWBC (T2: 4.0-13.4 vs T3: 4.1-13.0 x 109/L) required trimester specific RIs, compared to RBC (2.8-5.1 x 1012/L), MCV (66.2-100.2 fL), and platelet counts (106.3-388.3 x 109/L) that each required combined reference intervals.

CONCLUSIONS

The intra-pregnancy haematological RIs determined have appreciable lower limits; there is the need to determine context-specific thresholds for haematological variables predictive of positive and/or adverse maternal and infant health outcomes.

Tranexamic acid for bleeding: Much more than a treatment for postpartum hemorrhage

The evidence that early tranexamic acid treatment reduces postpartum hemorrhage deaths has major implications for obstetrical care worldwide. Tranexamic acid may also have a role in the prevention of postpartum hemorrhage, but more evidence is needed on the balance of risks and benefits. Most deaths from postpartum hemorrhage are in low- and middle-income countries where tranexamic acid treatment is often unavailable. Several maternal health organizations including the Reproductive Health Supplies Coalition, Clinton Health Access Initiative, Concept Foundation, International Federation of Gynecology and Obstetrics, and Unitaid are working to increase access. However, a wider view of the evidence on tranexamic acid and bleeding shows that it can improve maternal health in many other ways. An appreciation of these other health benefits could facilitate efforts to increase access. By reducing heavy menstrual bleeding, tranexamic acid could reduce the prevalence of maternal anemia, a common and important risk factor for postpartum hemorrhage and other maternal and neonatal outcomes. Further clinical trials of tranexamic acid for the treatment of menstrual bleeding are needed. By reducing surgical bleeding and the need for blood transfusion, tranexamic acid would increase the availability of blood in countries where there is blood shortage so that more blood is available for use in life-threatening bleeding including postpartum hemorrhage. In countries where there is no blood shortage, tranexamic acid use would reduce healthcare costs and prevent transfusion-transmitted infections and reactions. Trauma affects women and men, and violence is a leading cause of death in pregnancy. Increased use of tranexamic acid in trauma would significantly reduce trauma deaths. Efforts to increase the availability and use of tranexamic acid for obstetrical hemorrhage should acknowledge its other health benefits and aim to increase its use across health services more generally.

Clinical risk factors of adverse outcomes among women with COVID-19 in the pregnancy and postpartum period: a sequential, prospective meta-analysis

OBJECTIVE

This sequential, prospective meta-analysis sought to identify risk factors among pregnant and postpartum women with COVID-19 for adverse outcomes related to disease severity, maternal morbidities, neonatal mortality and morbidity, and adverse birth outcomes.

DATA SOURCES

We prospectively invited study investigators to join the sequential, prospective meta-analysis via professional research networks beginning in March 2020.

STUDY ELIGIBILITY CRITERIA

Eligible studies included those recruiting at least 25 consecutive cases of COVID-19 in pregnancy within a defined catchment area.

METHODS

We included individual patient data from 21 participating studies. Data quality was assessed, and harmonized variables for risk factors and outcomes were constructed. Duplicate cases were removed. Pooled estimates for the absolute and relative risk of adverse outcomes comparing those with and without each risk factor were generated using a 2-stage meta-analysis.

RESULTS

We collected data from 33 countries and territories, including 21,977 cases of SARS-CoV-2 infection in pregnancy or postpartum. We found that women with comorbidities (preexisting diabetes mellitus, hypertension, cardiovascular disease) vs those without were at higher risk for COVID-19 severity and adverse pregnancy outcomes (fetal death, preterm birth, low birthweight). Participants with COVID-19 and HIV were 1.74 times (95% confidence interval, 1.12-2.71) more likely to be admitted to the intensive care unit. Pregnant women who were underweight before pregnancy were at higher risk of intensive care unit admission (relative risk, 5.53; 95% confidence interval, 2.27-13.44), ventilation (relative risk, 9.36; 95% confidence interval, 3.87-22.63), and pregnancy-related death (relative risk, 14.10; 95% confidence interval, 2.83-70.36). Prepregnancy obesity was also a risk factor for severe COVID-19 outcomes including intensive care unit admission (relative risk, 1.81; 95% confidence interval, 1.26-2.60), ventilation (relative risk, 2.05; 95% confidence interval, 1.20-3.51), any critical care (relative risk, 1.89; 95% confidence interval, 1.28-2.77), and pneumonia (relative risk, 1.66; 95% confidence interval, 1.18-2.33). Anemic pregnant women with COVID-19 also had increased risk of intensive care unit admission (relative risk, 1.63; 95% confidence interval, 1.25-2.11) and death (relative risk, 2.36; 95% confidence interval, 1.15-4.81).

CONCLUSION

We found that pregnant women with comorbidities including diabetes mellitus, hypertension, and cardiovascular disease were at increased risk for severe COVID-19-related outcomes, maternal morbidities, and adverse birth outcomes. We also identified several less commonly known risk factors, including HIV infection, prepregnancy underweight, and anemia. Although pregnant women are already considered a high-risk population, special priority for prevention and treatment should be given to pregnant women with these additional risk factors.

Association of Maternal Anemia and Cesarean Delivery: A Systematic Review and Meta-Analysis

Anaemia during pregnancy is associated with an increased incidence of caesarean delivery (CD). This study was conducted to explore the association between CD and maternal anaemia. The PubMed/MEDLINE, Cochrane, Google, Google Scholar and ScienceDirect databases were searched for relevant studies on this topic. The assessment and review were conducted with the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. The studies were assessed using the modified Newcastle−Ottawa quality assessment scale. Data were collected in an Excel sheet, and the ‘meta’ package of the R 4.0.3 software was used for statistical analysis. Fourteen studies that enrolled 336,128 pregnant women were included in the meta-analysis. Women with anaemia were found to be at a higher risk for CD (OR = 1.63, 95% CI = 1.23−2.17). As heterogeneity was detected in the studies, the random-effects model was used for the pooled meta-analysis (Q = 96.7, p < 0.001). In the subgroup analysis, anaemic women were found to be at higher risk for CD in studies from both low-middle-income (7) and high-income countries (7). In meta-regression analysis, none of the investigated covariates were associated with the pooled OR of CD. This evidence demonstrates with a moderate level of certainty that anaemic pregnant women are more likely to have CD than non-anaemic pregnant women.

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.

Prevalence of Low Birth Weight and its Association With Anemia in White Nile State, Sudan: A Cross-Sectional Study

Introduction

Low birth weight (LBW) remains a global health concern, especially in sub-Saharan African countries with fewer resources, such as Sudan. Despite ongoing preventive measures, LBW is still one of the main health problems and it is a leading risk factor for several adverse perinatal and neonatal outcomes.

Objective

To assess the prevalence of and factors associated (mainly maternal anemia) with LBW at Rabak Maternity Hospital, White Nile, Central Sudan.

Methods

A cross-sectional study was conducted involving live singleton newborns and their mothers who presented to Rabak Maternity Hospital from September to December 2021. Questionnaires were completed via face-to-face interviews to gather maternal information (maternal age, parity, history of miscarriage, educational status, and level of antenatal care [ANC]). Maternal hemoglobin levels were measured using an automated hematology analyzer. The neonate's birth weight and sex were recorded.

Results

Two hundred and fifty-three newborns were enrolled in this study, 40 (15.8%) of whom were LBW neonates. The median (interquartile range) maternal age and parity were 25 (21.0-30.0) years and 2 (1-4), respectively. While gestational age, maternal hemoglobin, and maternal anemia were associated with LBW, maternal age, parity, a history of miscarriage, education level, and level of ANC were not associated with LBW in the univariate analysis. Multivariate analysis showed that gestational age (adjusted odds ratio [AOR] = 0.80, 95% confidence interval [CI] = 0.66-0.96) and maternal hemoglobin (AOR = 0.76, 95% CI = 0.52-0.86) were inversely associated with LBW. Maternal anemia was associated with LBW (AOR = 4.70, 95% CI = 2.06-10.94).

Conclusion

LBW is a major health concern in White Nile, Sudan. Maternal age and maternal anemia are associated with LBW. Preventive measures for managing maternal anemia may help reduce the incidence of LBW.

Maternal hemoglobin concentrations across pregnancy and child health and development from birth through 6-7 years

Background

The role of changes in maternal hemoglobin (Hb) across pregnancy on child health and development (CHD) remains unclear.

Objective

We examined the association between maternal Hb trajectories and CHD outcomes: (a) birth outcomes (birth weight, length, gestational age, preterm, and small for gestational age); (b) child Hb at 3, 6, 12, and 24 months; and (c) motor and mental development at 12 and 24 months and cognitive functioning at age 6-7 years.

Methods

We used data from a randomized controlled trial (PRECONCEPT) conducted in Vietnam (N = 1,175 women enrolled during preconception with offspring follow-up through 6-7 years). Maternal Hb trajectories were developed using latent class analysis with Hb data at preconception, early (≤20 weeks), mid (21-29 weeks), and late (≥30 weeks) pregnancy. Multivariable linear and logistic regression models were used to assess the association between maternal Hb trajectories on CHD outcomes, adjusting for confounding variables at the maternal, child and household levels.

Results

Four distinct maternal Hb trajectories were identified. Track 1 (low initial Hb-decline) was associated with lower child Hb at 3 months (β [95% CI] -0.52 [-0.87, -0.16]), 6 months (-0.36 [-0.68, -0.05]), 12 months (-0.46 [-0.79, -0.13]), and 24 months (-0.44 [-0.72, -0.15]) and motor development at 12 months (-3.58 [-6.76, -0.40]) compared to track 4 (high initial Hb-decline). After adjustment for multiple testing, relationships remained robust with the exception of associations with child Hb at 6 months and motor development at 12 months. Track 2 (low initial Hb-improve) was the only Hb trajectory to increase across pregnancy; however, it was insufficiently powered. Track 3 (mid Hb-decline) was associated with lower child Hb at 12 months (-0.27 [-0.44, -0.10]) and 24 months (-0.20 [-0.34, -0.05]) compared to track 4 (high initial Hb-decline). Maternal Hb trajectories were not associated with birth outcomes or child development at 24 months or 6-7 years.

Conclusion

Maternal Hb trajectories during pregnancy are associated with child Hb concentrations across the first 1,000 days, but not with birth outcomes or later cognitive functioning. More work is needed to better understand and interpret changes in Hb levels during pregnancy especially in resource poor settings.

Non-linear connections between maternal hemoglobin during the third trimester of pregnancy and birth weight outcomes in full-term newborns: Estimating the breakpoints

Objective

Anemia is still an unfinished global health problem, and adverse birth weight outcomes have everlasting influences on the health of later life. However, the non-linear connections and breakpoints of maternal hemoglobin with birth weight outcomes are still needed to be further elucidated. We aimed to reveal the non-linear connections between maternal hemoglobin during the third trimester of pregnancy and birth weight, low birth weight (LBW), macrosomia, small for gestational age (SGA), and large for gestational age (LGA) in full-term newborns and elucidate the breakpoints of the connections.

Methods

A total of 11,411 singletons, full-term, and live newborns, whose mothers conducted the examination of hemoglobin concentration before delivery, were included in this study. A generalized additive model was used to identify and visualize the non-linear connections between maternal hemoglobin and birth weight outcomes. Piecewise linear regression model was adopted to estimate the breakpoints of the connections and report the non-linear connections in detail.

Results

There were inverted "U"-shaped exposure-response connections between maternal hemoglobin concentration and birth weight and the risk of macrosomia. There was an increasing trend of the risk of LBW and a decreased trend of LGA with the increase in maternal hemoglobin concentration. The breakpoints of maternal hemoglobin for birth weight were 100 and 138 g/L, and those for SGA were 97 and 138 g/L. The breakpoints of maternal hemoglobin were 119 g/L for LBW, 105 g/L for macrosomia, and 106 g/L for LGA. When maternal hemoglobin concentration ranged from 100 to 138 g/L, maternal hemoglobin concentration increased per 1 g/L, and birth weight significantly decreased by 2.58 g (95% CI: -3.33, -1.83). When maternal hemoglobin concentration ranged from 97 to 138 g/L, maternal hemoglobin concentration increased per 1 g/L, and the risk of SGA significantly increased by 2% (95% CI: 1%, 3%). When maternal hemoglobin concentration was equal to or lower than 119 g/L, maternal hemoglobin concentration increased per 1 g/L, and the risk of LBW significantly increased by 3% (95% CI: 0%, 5%). When maternal hemoglobin concentration was higher than the breakpoints, the risks of macrosomia (OR = 0.99, 95% CI: 0.98, 0.99) and LGA (OR = 0.99, 95% CI: 0.98, 1.00) declined as the increase of maternal hemoglobin concentration.

Conclusions

There were non-linear connections between maternal hemoglobin and birth weight outcomes, and there are breakpoints in the connections. Cost-effective interventions targeting pregnant women in the prevention of abnormal maternal hemoglobin concentration should be taken to reduce the incidence of adverse birth weight outcomes.