https://orcid.org/0000-0001-8811-8123
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ABSTRACT
Background: 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.
Responsible Editor Peter Byass, Umeå University, Sweden
Responsible Editor Peter Byass, Umeå University, Sweden
Acknowledgments
The authors would like to thank the patients and families who have attended SMRU’s ANC and delivery services, and the dedicated clinical staff whose work has improved the health of the patients. The IT team, lab scientists and technicians have been very supportive over the years this cohort was running. In addition, many students, volunteers and visitors at SMRU have contributed to the heavy work of cleaning the database. Though we cannot list them all here, their work is much appreciated.
Disclosure statement
No potential conflict of interest was reported by the authors.
Ethics and consent
Ethical approval was obtained from the Oxford Tropical Research Ethics Committee (OxTREC Reference 583-16) and from the Mahidol Faculty of Tropical Medicine Ethics Committee (TMEC 17-027). In addition, this study received approval from the Tak Community Advisory Board, a committee of local community representatives (T-CAB reference: TCAB-02/01/2016). This study was a retrospective review of anonymized clinical data so no informed consent was obtained from the participants.
Paper context
Anaemia in pregnancy is common with detrimental effects to both mother and fetus from iron deficiency. Protocol evaluation found high health worker compliance but the requirement of two consecutive low HCT measurements to diagnose anaemia led to missed opportunities for treatment. Four percent anaemic women missed treatment due to human error. These findings support the use of a simple protocol and have changed local practice to commence treatment at the first low HCT.
Supplementary Materials
Supplemental data for this article can be accessed here.
Additional information
Funding
Notes on contributors
Mary Ellen Gilder
MEG, JAS and RM conceptualized the study and wrote the original draft of the paper. MEG, RM, LM, NS, RvA, MKP, MP, JW, AMM, CT, MJR, MB, GH, GB, NWT, VIC and FN assisted with data acquisition and cleaning. RM and JAS performed the statistical analysis, and, with MEG, GB, PC and FN, contributed to interpretation of the data. All authors reviewed the manuscript for its intellectual content and agreed to publication.
