Natural history of postpartum hematocrit recovery in an urban, safety-net population

Ragsdale, Alexandra S.; Thiele, Lisa R.; Byrne, John J.; Zofkie, Amanda C.; McIntire, Donald D.; Spong, Catherine Y.

doi:10.1016/j.ajogmf.2021.100541

Cited by 2 publications

(2 citation statements)

References 11 publications

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Section: Discussionmentioning

confidence: 99%

“…The study is potentially limited in its generalizability to other populations; however, previous studies completed at our institution did not demonstrate a change in hematologic indices at delivery when comparing 2 demographically unique populations. 13 This study is also limited by the availability of indirect adherence data in both cohorts. Our clinics dispensed a total of 20 383 ninety-capsule bottles of the iron-containing prenatal supplement during the study period, which suggests that patients were requesting an average of 2 refills of the supplements at prenatal visits.…”

Section: Strengths and Limitationsmentioning

confidence: 98%

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Direct Dispensation of Prenatal Supplements With Iron and Anemia Among Pregnant People

Thiele,

Duryea,

Ragsdale

et al. 2023

JAMA Netw Open

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ImportancePostpartum transfusion is the most common indicator of severe maternal morbidity in the US. Higher rates of anemia are associated with a higher blood transfusion rate.ObjectiveTo determine if providing, rather than recommending, supplements with iron at prenatal visits in a medically underserved community is associated with improved hematologic indices and reduced blood transfusion.Design, Setting, and ParticipantsIn this quality improvement study, patients who delivered between May 13 and December 13, 2020, and thus were provided a prenatal supplement with iron throughout pregnancy were compared with those who delivered between January 1 and August 1, 2019, before supplements were dispensed. The study was conducted at Parkland Health, a safety net hospital in Dallas, Texas, with a 95% Medicaid-funded or self-pay population and included all patients who delivered at our institution during the study period with available hematologic data.ExposuresIn the earlier cohort, all patients were recommended to obtain and take iron supplements. In the later cohort, prenatal supplements with iron were dispensed via clinic pharmacy to all patients during prenatal visits.Main Outcomes and MeasuresMaternal hematocrit levels (28-32 weeks, delivery admission, and discharge), rates of anemia (hematocrit &lt;30%), and postpartum transfusion for acute blood loss anemia were compared using χ2 and analysis of variance methods with P &lt; .05 considered significant. The analysis took place in July of 2022.ResultsOverall, 13 910 patients (98%) met inclusion criteria (mean age [SD], 27.9 [6.5] and 27.6 [6.5] years, mean [SD] body mass index at first visit, 29.2 [6.6] and 29.3 [6.6]). Mosty of the patients in both cohorts were of Hispanic ethnicity (76%). Providing iron-containing prenatal supplements was associated with higher average hematocrit levels at all time points including a mean difference of 1.27% (95% CI, 1.13%-1.42%) on admission for delivery, when compared with those who were not directly dispensed iron. Among patients prior to providing supplements, 18% had anemia on admission compared with 11% with iron-containing supplements dispensed (risk ratio [RR], 0.61; 95% CI, 0.56-0.66). Postpartum transfusion for acute blood loss anemia was reduced by one-third in patients after program implementation from 10 per 1000 to 6.6 per 1000 (RR, 0.62; 95% CI, 0.43-0.91).Conclusions and RelevanceIn this quality improvement study, providing supplements with iron to patients at prenatal visits was associated with improved hematocrit levels, rates of anemia, and reduced transfusions unrelated to obstetric catastrophes among a predominantly Medicaid population.

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Section: Discussionmentioning

confidence: 99%

Section: Strengths and Limitationsmentioning

confidence: 98%

Direct Dispensation of Prenatal Supplements With Iron and Anemia Among Pregnant People

Thiele,

Duryea,

Ragsdale

et al. 2023

JAMA Netw Open

Self Cite

View full text Add to dashboard Cite

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Anemic Data for Preventive Screening and Supplementation to Address Iron Deficiency Anemia in Pregnancy

Duryea,

Spong

2024

JAMA

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The US Preventive Services Task Force (USPSTF) recently released a Recommendation Statement examining the data to support screening for iron deficiency anemia in pregnancy and finding them lacking. 1 It also found insufficient evidence to make a clear recommendation for or against preventive iron supplementation in pregnancy, 2,3 which has been a routine practice for decades, with up to 77% to 89% of patients reporting supplement use. 4 As highlighted previously by the USPSTF and others, there is an urgent need for studies and clinical trials to support evidence-based medicine in the obstetric population, and this can only be accomplished by ceasing paternalistic approaches that have led to the exclusion of pregnant patients in research. [5][6][7][8][9][10][11] All of this remains true, and there is still so very far to go.In the updated USPSTF review, an additional 5 randomized clinical trials (RCTs) were included with the 12 RCTs carried forward from the 2015 review. The USPSTF determined that the availability of good-and fair-quality RCTs was sufficient; observational studies were included only for the association questions. However, it is important to acknowledge that while RCTs provide rigor and purity for evaluating medical interventions, they may not always be the best study design for all clinical questions. Indeed, the many traditional RCT designs and implementation approaches limit real-world applicability, discourage involvement and thus applicability to marginalized and underserved populations, and decrease the likelihood that the effect on rare outcomes such as severe maternal morbidity will be detected. Large, populationbased studies provide additional useful evidence when examining uncommon outcomes with a high impact such as severe maternal morbidity and mortality, transfusion, and death. An RCT examining such rare outcomes may be costprohibitive and thus an ineffective method to approach several aspects of the question at hand.Importantly, it is vital to ensure that the outcomes assessed in studies are physiologically plausible. Some of the outcomes reviewed by the USPSTF, such as gestational diabetes, hypertensive disorders, and cesarean delivery, have been associated with iron deficiency anemia in observational studies but not in RCTs. It is more likely that the association in observational studies was due to confounders such as nutritional status, body mass index, healthy lifestyle choices, socioeconomic status, and systemic racism rather than iron defi-

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Natural history of postpartum hematocrit recovery in an urban, safety-net population

Cited by 2 publications

References 11 publications

Direct Dispensation of Prenatal Supplements With Iron and Anemia Among Pregnant People

Direct Dispensation of Prenatal Supplements With Iron and Anemia Among Pregnant People

Anemic Data for Preventive Screening and Supplementation to Address Iron Deficiency Anemia in Pregnancy

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