Global anaemia, pregnancy, and standardised haemoglobin cutoffs

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Anaemia in pregnancya renewed focus needed

S Allard
Barts Health NHS Trust, NHS Blood and Transplant, London, UK
Linked article: This is a mini commentary on S New et al., pp. 1669 in this issue. To view this article visit http://dx.doi.org/10.1111/
1471-0528.13225.

New & Wirth, in their paper in

BJOG 122:2 2014, have focused
attention on anaemia as a key global
maternal health issue. The authors
emphasise that despite being flagged
up as a common problem affecting
~30 million women worldwide, there
has been surprisingly little reduction
in the prevalence of maternal anaemia reported over the last three decades. The results of the WHO
Multicountry Survey on Maternal
and Newborn Health have highlighted anaemia as the most common indirect cause of adverse
maternal outcomes including maternal death (Lumbiganon P et al.
BJOG 2014;121 Suppl 1:329). Severe
anaemia in mothers also increases
the risk of perinatal mortality (Vogel
et al. BJOG 2014;121 Suppl 1:7688).
While the association between
anaemia and maternal morbidity
and mortality clearly merits more
detailed scrutiny, New & Wirth have
questioned the actual definitions for
anaemia in pregnancy and the recommendations for the haemoglobin
cut-offs used. Is there now a need
to look beyond the conventional
and well established contributory

factors,
such
as
physiological
changes in pregnancy related to gestational age, at more poorly understood variables that may also have
an impact? Although adolescents are
recognised to be at greater risk of
anaemia, the scope for considering
age-specific cut-offs for haemoglobin
in pregnancy certainly raises an
interesting question for further
study.
However, it is the lack of comparative data on ethnic differences on
haemoglobin in pregnancy in particular that has been flagged up by the
authors. Should we now move away
from attempts at simplified definitions of maternal anaemia and the
concept that one size fits all and
acknowledge that other factors may
contribute to differences? This will
require significant efforts to obtain a
better understanding of geographical
and ethnic variations in haemoglobin
levels in pregnancy, taking into
account other endemic diseases contributing to anaemia. Such initiatives
can potentially better inform and
underpin targeted attempts towards
more effective therapeutic interventions. However, the application of

2014 Royal College of Obstetricians and Gynaecologists

more complex algorithms for defining anaemia incorporating multiple

variables in day-to-day clinical
practice poses considerable challenges
that should not be underestimated.
There are already significant concerns
about
the
sub-optimal
management of maternal anaemia
even in high-resource countries (Parker et al. BMC Pregnancy Childbirth
2012;12:56), likely due in part to a
lack of consistent good quality
evidence.
There is now an urgent need for
us to respond collectively to this
timely call for action by the authors
of this paper as we focus on the Millennium Development Goals (MDG)
5A to reduce maternal mortality that
will not be addressed by 2015.
Research priorities should tackle the
current evidence gaps in the understanding and definition of anaemia
in pregnancy and also aim at the
development of more standardised
approaches to reporting outcomes of
maternal anemia together with the
impact of therapy.

Disclosure of interests
I have no conflicts of interest. &

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