Abstract
ABSTRACTBackground: Anaemia in pregnancy is typically due to iron deficiency (IDA) but remains a complex and pervasive problem, particularly in low resource settings. At clinics on the Myanmar–Thailand border, a protocol was developed to guide treatment by health workers in antenatal care (ANC).Objective: To evaluate the clinical use of a protocol to treat anaemia in pregnancy.Methods: The design was a descriptive retrospective analysis of antenatal data obtained during the use of a standard anaemia treatment protocol. Two consecutive haematocrits (HCT) <30% prompted a change from routine prophylaxis to treatment doses of haematinics. Endpoints were anaemia at delivery (most recent HCT before delivery <30%) and timeliness of treatment initiation. Women whose HCT failed to respond to the treatment were investigated.Results: From August 2007 to July 2012, a median [IQR] of five [4–11] HCT measurements per woman resulted in the treatment of anaemia in 20.7% (2,246/10,886) of pregnancies. Anaemia at delivery was present in 22.8% (511/2,246) of treated women and 1.4% (123/8,640) who remained on prophylaxis. Human error resulted in a failure to start treatment in 97 anaemic women (4.1%, denominator 2,343 (2,246 + 97)). Fluctuation of HCT around the cut-point of 30% was the major problem with the protocol accounting for half of the cases where treatment was delayed greater than 4 weeks. Delay in treatment was associated with a 1.5 fold higher odds of anaemia at delivery (95% CI 1.18, 1.97).Conclusion: There was high compliance to the protocol by the health workers. An important outcome of this evaluation was that the clinical definition of anaemia was changed to diminish missed opportunities for initiating treatment. Reduction of anaemia in pregnancy requires early ANC attendance, prompt treatment at the first HCT <30%, and support for health workers.
Highlights
Anaemia in pregnancy is typically due to iron deficiency (IDA) but remains a complex and pervasive problem, in low resource settings
Additional exclusions were: women with less than 2 HCT values during antenatal care (ANC) follow-up as this was the minimum number needed to meet the definition of anaemia; first ANC visit less than 4 weeks before delivery as there was no time to monitor the response; and severe acute anaemia or nonstandard oral treatment because response to treatment would be atypical compared to the norm, e.g. known haemoglobinopathy from involvement in studies at Shoklo Malaria Research Unit (SMRU) [15,16]
ANC attendance was high with a median [inter-quartile range (IQR)] of 12 [8,9,10,11,12,13,14,15,16,17] visits per woman; just over half (51.2%) presented in the first trimester; and less than 10% of women presented for the first consultation in the third trimester
Summary
Anaemia in pregnancy is typically due to iron deficiency (IDA) but remains a complex and pervasive problem, in low resource settings. The global burden of maternal morbidity and mortality attributable to anaemia remains high in lowresource settings. Anaemia is the second highest cause of maternal mortality in Asia [2,3]. A fundamental goal of all targeted antenatal care (ANC) programs is to detect and correct iron deficiency anaemia (IDA) to reduce serious complications [4], and provide prophylactic iron supplementation [5]. The published literature suggests that most women with anaemia living in rural, limitedresource settings where screening for IDA is cost prohibitive (and complicated by infections such as malaria) have a component of IDA and will respond to haematinics [7].
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