Maternity iron, anaemia and blood management in South Australia: a practice-based evidence for clinical practice improvement.

Abstract

Anaemia at delivery is a strong modifiable risk factor for transfusion in women with a postpartum haemorrhage (PPH). A Maternity Patient Blood Management (PBM) Practice Based Evidence Clinical Practice Improvement (CPI) was conducted to optimize antenatal haemoglobin and iron stores prior to delivery. Australian maternity PBM CPI resources (featuring algorithms on diagnosing iron deficiency with both haemoglobin and ferritin screening, as well as information on oral iron therapy for maternity patients) were introduced at a major tertiary hospital from November 2016 to March 2017. To assess the effectiveness of these resources on haemoglobin and iron stores, an interrupted time series (ITS) analysis was conducted for 11,263 deliveries from January 2016 to June 2018. The evaluation timeframe was divided into baseline (pre-CPI), pilot (during CPI) and post-pilot (post-CPI). In 1550 patients with haemoglobin and ferritin in the first trimester, non-anaemic iron deficiency was detected in 416 women (26·8%) and iron deficiency anaemia (IDA) in 239 women (15·41%) throughout the whole study period. The number of women with IDA increases as pregnancy progresses but applying PBM CPI shows a reduction of IDA rate in all trimesters and reduction in anaemia at delivery in the post-pilot period from baseline. More anaemic episodes were observed in the postpartum period compared to the first trimester. ITS analysis for the whole study period showed a clinically significant increase in the monthly average predelivery haemoglobin of 0·9g/l (P=0·16). This corresponded with a reduction in the monthly rate of anaemic patients by 18% (P=0·12). There was a significant decrease in the rates of anaemia at delivery and decrease in red cell transfusion in anaemic women, even though the number of women with PPH was stable. The factors associated with red cell transfusion are anaemia at delivery (P<0·001) and the incidence of PPH (P<0·001). The maternity PBM CPI resources had a clinically relevant but not statistically significant effect in optimizing antenatal haemoglobin and decreasing the risk of predelivery anaemia. This study demonstrates how a CPI can modify one risk factor for blood loss, which is the anaemia at delivery, and subsequent transfusion in the perinatal period.