The complex relationship between iron status and anemia in pregnant and postpartum women in India: Analysis of two Indian study cohorts of uncomplicated pregnancies

Abstract

Low hemoglobin is widely used as an indicator of iron deficiency anemia in India and other low‐and‐middle income counties, but anemia need not accurately reflect iron deficiency. We examined the relationship between hemoglobin and biomarkers of iron status in antenatal and postnatal period. Secondary analysis of uncomplicated singleton pregnancies in two Indian study cohorts: 1132 antenatal women in third trimester and 837 postnatal women 12–72 h after childbirth. Associations of hemoglobin with ferritin in both data sets, and with sTfR, TSAT, and hepcidin in the postnatal cohort were examined using multivariable linear regression. Multinomial logistic regression was used to examine the association between severity of anemia and iron status. Regression models were adjusted for potential confounders. Over 55% of the women were anemic; 34% of antenatal and 40% of postnatal women had low ferritin, but 4% antenatal and 6% postnatal women had high ferritin. No evidence of association between hemoglobin and ferritin was observed (antenatal: adjusted coefficient [aCoef] −0.0004, 95% confidence interval [CI] −0.001, 0.001; postnatal: aCoef −0.0001, 95% CI −0.001, 0.001). We found a significant linear association of hemoglobin with sTfR (aCoef −0.04, 95% CI −0.07, −0.01), TSAT (aCoef −0.005, 95% CI −0.008, −0.002), and hepcidin (aCoef 0.02, 95% CI 0.02, 0.03) in postnatal women. Likelihood of low ferritin was more common in anemic than non‐anemic women, but high ferritin was also more common in women with severe anemia in both cohorts. Causes of anemia in pregnant and postpartum women in India are multifactorial; low hemoglobin alone is not be a useful marker of iron deficiency.

Maternal and fetal factors associated with stillbirth in singleton pregnancies in 13 hospitals across six states in India: A prospective cohort study

“…The complex, multifactorial relationship between iron supplementation and anemia and risk of stillbirth supports MaatHRI's recent study findings, which emphasized the importance of using iron biomarkers and not relying solely on Hb measurement to facilitate tailored prevention, control, and treatment activities for managing anemia during pregnancy. 33 Additionally, further analysis should be conducted to explore early term birth (37 +0 to 38 +6 weeks) and birth weight below the 10th percentile for gestational age as risk factors for intrapartum stillbirth. While the association between preterm birth and stillbirth is relatively well established, 7,10,34,35 research on the relative risk of intrapartum stillbirth associated with early term birth is limited.…”

Treatment of Iron Deficiency Anaemmia in Pregnancy Study. The Clinical Impact of Treatment for Iron Deficiency Anaemia using an Optimized Care Pathway in accordance with national guidelines

“…However, this approach has problems too. While ferritin is a good marker of iron stores the cut-off point in pregnancy is disputed and it is not a measure of functional iron [26][27][28][29][30]. Therefore, we cannot exclude the possibility that some women diagnosed with IDA are in fact iron replete and have haemoglobin concentrations lower than the gestational threshold because of the haemodilution.…”

Anaemia in India and Its Prevalence and Multifactorial Aetiology: A Narrative Review

“…Sub-optimal iron status due to low dietary iron intake is usually regarded as the most common cause of anaemia, especially in low- and middle-income countries (LMICs) [ 3 ]. There are, however, increasing concerns that haemoglobin concentration may not be a satisfactory indicator of iron deficiency [ 8 ].…”