Impact of maternal anemia on neonatal outcomes

INTRODUCTION

Maternal anaemia is a worldwide health issue that can have detrimental effects on both the mother's and the baby's health.¹ The prevalence of anemia in women of reproductive age worldwide in 2019 was 29.9% which translates to more than half a billion women between the ages of 15 and 49.² Globally, anemia prevalence was 36.5% in pregnant women and 29.6% in non-pregnant women of reproductive age.² In India, the prevalence of anemia in pregnant women aged 15-49 in the National Family Health Survey-2005-06 (NFHS-3), NFHS-4 survey (2015-16), and NFHS-5 (2019-21) was 57.9%, 50.4%, and 52.2% respectively.³

Maternal anemia has been linked in the past to unfavorable pregnancy outcomes, including low birth weight (LBW), premature delivery, small for gestational age (SGA), postpartum hemorrhage, and eclampsia.^3,4 Various studies have reported that lower levels of hemoglobin (Hb) in mothers are linked to a higher chance of preterm birth, low birth weight babies, an APGAR score of less than five at one minute, and intrauterine death.^5,6

The most common cause of maternal anemia is iron deficiency, which can be attributed to either decreased iron supply or increased iron demand by a growing fetus.³ However, it can also be caused by dietary deficiencies such as vitamin B12, folate, riboflavin, and vitamin A, infections like malaria or helminthiasis, chronic illnesses such as tuberculosis or HIV, and genetic causes such as sickle cell anemia and thalassemia.^3,7

The hemoglobin level in umbilical cord blood is a crucial indicator of anemia in neonates at birth.³ Several studies have shown that newborns born to pregnant mothers with iron deficiency anemia have lower hemoglobin levels in their cord blood.³ There is a linear association between the mother's Hb and the neonates' cord blood Hb, according to recent studies.³ Delayed cord clamping for 30-60 seconds is associated with improved hematologic status and iron levels in term-born babies at 2-6 months.^8,9

This study evaluates the association of maternal anemia with demographics and the outcomes of newborns. i.e. birthweight, gestational age, APGAR score, and cord blood hemoglobin.

METHODS

Study design and setting

This cross-sectional study was done in the Department of Pediatrics and Department of Obstetrics and Gynaecology at Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh over 18 months after obtaining ethical approval from Institutes Ethical Committee and informed consent from mothers.

Inclusion criteria

We included pregnant women with a singleton pregnancy.

Exclusion criteria

Pregnant women with diabetes mellitus, hypertension, toxoplasmosis, rubella, cytomegalovirus, herpes infection, diagnosed renal or cardiac diseases, and newborns with congenital malformations, and Rh incompatibility were excluded.

Sampling

We used a convenient sampling method. Sample size (n) of 384 was calculated using OpenEpi online software for sample size calculation taking the prevalence of 52.2% of maternal anemia in India from National Family Health Survey (NFHS-5) data, with 95% confidence interval, and a margin of error of 5%.^3,10

Data collection procedure

For the data collection, a predesigned proforma was used which included the demographic and clinical parameters of mothers and neonates. Demographic and clinical parameters of mothers included age, livelihood, employment, mother’s education, type of diet, alcohol abuse, smoking/tobacco abuse, parity, and hemoglobin level. Clinical parameters of neonates included gestational age, birth weight, length, APGAR score, and cord blood hemoglobin levels.

Hematological estimation

The mother’s blood sample for pre-delivery hemoglobin estimation was collected within 24 hours before delivery. After the delivery of the baby, double clamping of the umbilical cord was done. Utilizing a sterile syringe, about 2 milliliters of blood were extracted from the umbilical vein of the discarded umbilical cord and poured into an ethylenediaminetetraacetic acid (EDTA) vial. The blood samples were analyzed in the pathology lab in a 5-part hematology analyzer (Mindray BC-5150) for hematological estimation.

Operational definitions

The World Health Organization (WHO) defines a hemoglobin level <11 gm/dl as maternal anemia during pregnancy.¹¹ Maternal anemia in pregnancy was classified as mild, moderate, and severe anemia with Hb levels being 10-10.9 gm/dl, 7-9.9 gm/dl, and <7 gm/dl respectively.¹¹

Neonatal outcomes

Gestational age

The New Ballard Score was used to calculate the newborn's postnatal gestational age.^12,13 The gestational age of neonates was divided into preterm <37 weeks of gestation, term between 37 completed weeks and 42 weeks of gestation, and post-term ≥42 weeks of gestational age.¹³

APGAR score

The APGAR score was noted 1 minute after birth which included five vital signs of neonate i.e., respiration, heart rate, muscle tone, reflexes, and colour.¹⁴

Birth weight

The newborn's birth weight (BW) was recorded in grams (gms) using a digital weighing scale. BW was divided into four groups i.e., ≥2500 gms, 1500-2499 gms, 1000-1499 gms, and <1000 gms. Low birth weight (LBW), very low birth weight (VLBW), and extremely low birth weight (ELBW) are defined as BW <2500 gm, <1500 gm, and <1000 gms respectively.¹³

Length

The newborn’s length was measured in centimeters (cm) using an infantometer. Length was divided into two groups i.e. <50 cm, and ≥50 cm.

All data were entered in the Microsoft excel sheet. Data analysis (descriptive statistics, Chi-square test, and Pearson’s correlation) was done using statistical package for the social sciences (SPSS) software version 20.0. A p value <0.05 was considered as the data statistically significant.

RESULTS

Out of 384 mothers under study, 298 (77.6%) were between the ages of 18 to <35 years. The mean age of mothers was 28.3 (5.99) years. The mean age of mothers in the 18 to <35 years and ≥35-49 years age groups was 25.92 (4.45) and 36.56 (1.98) years respectively. The mean body mass index (BMI) of mothers was 25.9 (3.47) kg/m². The mean hemoglobin of mothers was 10.061 (2.77) gm/dl. Table 1 summarizes maternal demographic and clinical parameters. The prevalence of maternal anemia was 53.4% among the study population, of which 11.2% were mildly anemic, 19.5% were moderately anemic, and 22.75 were severely anemic.

The mean cord blood hemoglobin was 16.56 (4.18) gm/dl. The mean birth weight was 2.254 (0.51) kg while the mean APGAR Score was 8.11 (1.52). The mean length was 49.06 (2.04) cm. The clinical parameters of neonates are summarized in Table 2.

The association of maternal anemia with demographic and clinical parameters of mothers is summarized in Table 3. Working mothers had lower chances of being anemic (p<0.0001) while mothers with vegetarian diets had higher chances of anemia (p<0.0001). A significant association was also found between educational status and anemia among mothers (p=0.003). Maternal anemia was significant in mothers who were smoking/tobacco abuse (p=0.021) and had alcohol intake (p=0.003).

The association of maternal anemia with clinical parameters of neonates is outlined in Table 4. Babies born to non-anemic mothers had higher birth weights than those born to anemic mothers (p<0.0001). Maternal anemia did not significantly impact the gestational age outcomes (p=0.404) or the APGAR score of the baby (p=0.616).

There was a significant association reported between maternal hemoglobin and cord blood hemoglobin levels (p<0.0001) (Table 5).

A weak positive correlation was observed between maternal and cord blood hemoglobin levels (Pearson R=0.230) (Figure 1).

DISCUSSION

This study addresses the effects of maternal anemia on neonatal outcomes providing critical insights to decrease the anemia prevalence during pregnancy in order to reduce neonatal morbidity and mortality.

In the present study, the mean age, mean BMI, and mean Hb of mothers were 28.3 (5.99) years, 25.9 (3.47) kg/m², and 10.061 (2.77) gm/dl respectively. The prevalence of maternal anemia was 53.4% among the study population, of which 11.2%, 19.5%, and 22.75% were mild, moderate, and severely anemic. This was comparable to the NFHS-5 survey prevalence of maternal anemia of 52.2% in India.³ Similarly, Bukhari et al study from Riyadh, reported the mean age of mothers as 30.59 (6) years and an overall maternal anemia prevalence of 39%, with 21% being moderately anemic and 18% being mild anemic.⁷ Similarly, Bernhardt et al reported a mean maternal Hb of 11.16 (2.51) gm/dl in their study.¹⁵

Maternal anemia among pregnant females was more prevalent in the 18 to <35 years age group as compared to ≥35-49 years age group in the present study but there was no significant association found between different age groups (p=0.823). This was similar to the findings of the Kefiyalew et al study.¹⁶ In comparison, Ahmad et al study reported a significantly higher prevalence of anemia in the early age group of mothers.¹⁷ A slightly higher prevalence of anemia was reported among the rural mothers but was not statistically significant in our study (p=0.881). In contrast, the Kefiyalew et al study reported significant anemia among rural mothers.¹⁶ Maternal anemia was significantly prevalent in unemployed mothers (p<0.0001) in the present study which was similar to the study by Mahashabde et al.¹⁸

This study revealed a significant association between a lower educational level and maternal anemia (p=0.003). Like our studies, the one conducted by Ahmed et al indicated a higher prevalence of anemia in poor and uneducated populations.¹⁹ An almost similar finding was observed by Lokare et al.²⁰ Maternal anemia was significantly associated with a vegetarian diet in this study. Different studies by Bansal et al and Bhaware et al reported similar findings.^21,22 Smoking/tobacco abuse (p=0.021) and alcohol abuse (p=0.003) in mothers were associated with anemia during pregnancy. Alike, Mistry et al study reported an association of tobacco abuse with anemia during pregnancy.²³ Similarly, Garcia et al study reported alcohol consumption was associated with anemia.²⁴ In our study, there was no significant association seen between maternal anemia and parity which was in contrast to a study by Khan et al that reported high parity to be associated with maternal anemia.²⁵

Among the clinical parameters of neonates, maternal anemia was significantly associated with lower birth weights (p<0.0001), while no significant association was found with the gestational age (p=0.404), APGAR score (p=0.616), and length (p=0.395). Lower gestational age (p=0.033), lower birth weight (p=0.04), and lower length of baby (p=0.003) were significantly associated with maternal anemia in Adhikari et al study.⁴ Similarly, Bakhtiar et al study revealed that maternal anemia in pregnancy is associated with lower gestational age delivery, lower birth weight babies, and low Apgar score at one minute.²⁶ The mean cord Hb likewise declined as the mean maternal Hb did, suggesting a linear relationship between the two variables in our research. Different studies by Timilsina et al, Najeeba et al, and Sareen et al reported similar findings.^27-29

Anaemia Mukt Bharat, the premier initiative of the Indian government, employs a multi-sectoral and multi-stakeholder strategy to eradicate anemia by employing preventive and curative measures.³⁰ The program enables India to achieve the sustainable development goals and is a part of the National Nutrition Mission (Poshan Abhiyaan).³¹ Given the current study's findings, these initiatives need to be strengthened. Additionally, women who have anemia should be screened in the community and directed to healthcare facilities so that the cause may be identified early and treated.

CONCLUSION

The present study concludes that maternal anemia was associated with unemployment, lower educational levels, vegetarian diet, alcohol, smoking/tobacco abuse in mothers, and lower birth weight and lower cord blood Hb levels in neonates. In developing countries like India, anemia interventional programs need to be intensified to prevent anemia, thereby potentially reducing the risk of complications for both mother and their neonates and increasing the overall survival rate of newborns.

ACKNOWLEDGEMENTS

The authors would like to thank all the mothers who participated in the study for their cooperation.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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