Iron Deficiency Anemia: Developing and Implementing an Intervention to Treat this Preventable Cause of Maternal Morbidity

Paloma Toledo, MD, MPHPaloma Toledo, MD, MPH
Assistant Professor, Department of Anesthesiology, Northwestern University

Dr. Teledo’s project is entitled: “Iron Deficiency Anemia: Developing and Implementing an Intervention to Treat this Preventable Cause of Maternal Morbidity.

Background: Postpartum hemorrhage (PPH) complicates 4-6% of all deliveries in the US and is a leading cause of maternal morbidity and mortality worldwide.1 Hemorrhage-related morbidity includes blood transfusions, complications from blood transfusions, potential end-organ damage to the patient (e.g., renal injury), and loss of future fertility if a hysterectomy is performed. Poor outcomes from PPH are highly preventable and amenable to safety interventions.2 This prevention is possible through patient safety interventions such as clear guidelines, readiness, and effective emergency response. To date, many efforts have been focused on improving the in-hospital management of PPH, but fewer have focused on identifying and addressing modifiable risk factors prior to delivery. Iron deficiency anemia (IDA) complicates over >20% of all pregnancies, and is easily correctable.3 Early identification and treatment of anemia may prevent or mitigate adverse outcomes, such as depression, fatigue, or the need for transfusion should an anemic woman hemorrhage.3,4

Despite the frequency of iron deficiency anemia in the pregnant population, treatment protocols to guide peripartum anemia management are scarce. The American College of Obstetrician and Gynecologists recommends pregnant women be screened for IDA, but there is little guidance regarding the timing of this screening, and there is even less consensus of how to manage patients diagnosed with IDA (oral vs intravenous iron therapy).5 Oral iron therapy, while easy to administer and low-cost, is poorly tolerated due to side effects. Intravenous iron (IV) infusions are effective, and well tolerated, but have not been widely implemented in obstetric practice.

Aims: As anemic women are more likely to be harmed if they hemorrhage, it is important to identify barriers to treatment and create an anemia management algorithm. Using qualitative methodology, we will identify patient and provider awareness of the significance of maternal anemia, awareness of treatment options, and barriers to treatment. We will then convene a multidisciplinary expert panel to design a prenatal anemia management protocol and optimal workflows. We will then implement the anemia management protocol at our institution and evaluate the proportion of women who have received treatment for their anemia, as well as measure the impact on maternal outcomes.

Implications: While postpartum hemorrhage (PPH) is not preventable, poor outcomes, particularly maternal morbidity and mortality from hemorrhage are highly preventable. Anemia is easily recognized and treated, therefore, an ideal safety intervention to improve patient outcomes. This project will improve patient safety through systems-level improvements in patient outcomes and prevention of clinical deterioration in the event of a hemorrhage. We anticipate that this protocol will be most influential in resource-limited environments, where treatment options for postpartum hemorrhage are scant and the potential for maternal harm is great.


  1. Berg CJ, Callaghan WM, Syverson C, Henderson Z: Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116: 1302-9
  2. Berg CJ, Harper MA, Atkinson SM, Bell EA, Brown HL, Hage ML, Mitra AG, Moise KJ, Jr., Callaghan WM: Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol 2005; 106: 1228-34
  3. Drukker L, Hants Y, Farkash R, Ruchlemer R, Samueloff A, Grisaru-Granovsky S: Iron deficiency anemia at admission for labor and delivery is associated with an increased risk for Cesarean section and adverse maternal and neonatal outcomes. Transfusion 2015; 55: 2799-806
  4. VanderMeulen H, Strauss R, Lin Y, McLeod A, Barrett J, Sholzberg M, Callum J: The contribution of iron deficiency to the risk of peripartum transfusion: a retrospective case control study. BMC Pregnancy Childbirth 2020; 20: 196
  5. American College of Obstetricians and Gynecologists: ACOG Practice Bulletin No. 95: anemia in pregnancy. Obstet Gynecol 2008; 112: 201-7

Funding: $149,592 (January 1, 2022-December 31, 2023).