The use of intravenous iron in pregnancy: for whom and when? A survey of Australian and New Zealand obstetricians

The fatigue after infusion or transfusion pilot trial and feasibility study: A three-armed randomized pilot trial of intravenous iron and blood transfusion for the treatment of postpartum anemia

BACKGROUND

Evidence for the management of moderate-to-severe postpartum anemia is limited. A randomized trial is needed; recruitment may be challenging.

STUDY DESIGN AND METHODS

Randomized pilot trial with feasibility surveys.

INCLUSION

hemoglobin 65-79 g/L, ≤7 days of birth, hemodynamically stable.

EXCLUSION

ongoing heavy bleeding; already received, or contraindication to intravenous (IV)-iron or red blood cell transfusion (RBC-T). Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T.

PRIMARY OUTCOME

number of recruits; proportion of those approached; proportion considered potentially eligible.

SECONDARY OUTCOMES

fatigue, depression, baby-feeding, and hemoglobin at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. Surveys explored attitudes to trial participation.

RESULTS

Over 16 weeks and three sites, 26/34 (76%) women approached consented to trial participation, including eight (31%) Māori women. Of those potentially eligible, 26/167 (15.6%) consented to participate. Key participation enablers were altruism and study relevance. For clinicians and stakeholders the availability of research assistance was the key barrier/enabler. Between-group rates of fatigue and depression were similar. Although underpowered to address secondary outcomes, IV-iron and RBC-T compared with RBC-T were associated with higher hemoglobin concentrations at 6 (mean difference [MD] 11.7 g/L, 95% confidence interval [CI] 2.7-20.7) and 12 (MD 12.8 g/L, 95% CI 1.5-24.2) weeks, and higher ferritin concentrations at 6 weeks (MD 136.8 mcg/L, 95% CI 76.6-196.9).

DISCUSSION

Willingness to participate supports feasibility for a future trial assessing the effectiveness of IV-iron and RBC-T for postpartum anemia. Dedicated research assistance will be critical to the success of an appropriately powered trial including women-centered outcomes.

An implementation research programme to support an intravenous iron intervention for pregnant women with moderate and severe anaemia in Malawi: study protocol

Background

Antenatal iron supplementation is critical to maternal and child health; however, access and adherence to oral iron are inconsistent in many low- and middle-income countries (LMICs). Modern intravenous (IV) iron products have become available in high-income clinical settings and provide an opportunity to deliver high doses of iron in a single-short infusion during pregnancy. However, there is limited knowledge of the drivers and barriers for such an intervention to be effectively delivered and upscaled in LMICs. In this study protocol, we describe the implementation research programme to support an IV iron intervention in Malawi for pregnant women with moderate and severe anaemia.

Methods

The implementation research programme has three phases, each guided by implementation science conceptual frameworks. In Phase 1, we will conduct formative research (context assessment of the health system with key informant interviews) to determine how IV iron can be effectively introduced into routine antenatal care. We will use the findings to co-develop potential strategies with end-users and healthcare providers to improve intervention implementation. In Phase 2, we will disseminate the implementation strategies to support the uptake and delivery of the intervention in the study settings. In Phase 3, the intervention will be implemented, and we will conduct formative evaluation (interviews with end-users, healthcare providers, and analysis of health services data) to investigate the feasibility and acceptability of the intervention and strategies. We will also identify processes and contextual factors that facilitate or impede the delivery and uptake of IV iron.

Discussion

In LMICs, modern IV iron products present a novel opportunity to rapidly cure moderate and severe anaemia in pregnancy, thereby improving maternal and child health outcomes. This implementation research programme will provide guidance and recommendations on how best an IV iron intervention for pregnant women with anaemia can be implemented in an LMIC setting like Malawi. We will develop locally relevant and culturally appropriate implementation strategies by engaging with key stakeholders (pregnant women, healthcare providers, and policymakers) and identifying factors likely to facilitate successful implementation. The findings of this research can guide the implementation of an IV iron intervention in Malawi and other LMICs.

Survey of iron prescribing practices for post-partum anaemia

OBJECTIVE

Treatment for postpartum anaemia frequently entails iron supplementation, but questions remain regarding its optimal dosing, frequency, and efficacy. Our objective was to learn about the current prescribing practices of obstetrical providers at multiple hospitals, including indications and regimens used; further, we sought to understand how these practices are learned.

METHODS

A 10-question web-based survey was developed via expert consensus. The survey was distributed via email to obstetrical providers (including trainees) practising at seven hospitals affiliated with the University of Toronto, including from Obstetrics & Gynaecology (OBGYN), Family Practice (FP-OB) and midwifery.

RESULTS

The survey was directly sent to 469 participants and 140 responses were collected from the direct email recruitment pool (response rate 30%). Half of respondents were OBGYN physicians. The most common indication was a post-partum haemoglobin threshold of 90 g/L. Both intravenous and oral formulations were used; the most common oral formulation was ferrous fumarate (77%). Prescribing practices were most commonly shaped using passed-down knowledge.

CONCLUSION

Through this survey, we have learned about the most common post-partum iron supplementation indications, formulations and regimens used in both academic and community hospitals in the greater Toronto area. This insight will help inform future studies investigating the efficacy of oral iron supplementation in the treatment of post-partum anaemia.

Inter-hospital and inter-disciplinary variation in planned birth practices and readiness for change: a survey study

BACKGROUND

How the application of evidence to planned birth practices, induction of labour (IOL) and prelabour caesarean (CS), differs between Australian maternity units remains poorly understood. Perceptions of readiness for practice change and resources to implement change in individual units are also unclear.

AIM

To identify inter-hospital and inter-professional variations in relation to current planned birth practices and readiness for change, reported by clinicians in 7 maternity units.

METHOD

Custom-created survey of maternity staff at 7 Sydney hospitals, with questions about women's engagement with decision making, indications for planned birth, timing of birth and readiness for change. Responses from midwives and medical staff, and from each hospital, were compared.

FINDINGS

Of 245 completed surveys (27% response rate), 78% were midwives and 22% medical staff. Substantial inter-hospital variation was noted for stated planned birth indication, timing, women's involvement in decision-making practices, as well as in staff perceptions of their unit's readiness for change. Overall, 48% (range 31-64%) and 64% (range 39-89%) agreed on a need to change their unit's caesarean and induction practices respectively. The three units where greatest need for change was perceived also had least readiness for change in terms of leadership, culture, and resources. Regarding inter-disciplinary variation, medical staff were more likely than midwifery staff to believe women were appropriately informed and less likely to believe unit practice change was required.

CONCLUSION

Planned birth practices and change readiness varied between participating hospitals and professional groups. Hospitals with greatest perceived need for change perceived least resources to implement such change.