IRON SUPPLEMENTATION DURING PREGNANCY
Iron Supplementation during Pregnancy
Iron deficiency anemia during pregnancy is a risk factor for adverse maternal and perinatal care. According to the World Health Organization, approximately 56 million pregnant women globally get affected with anemia, which is associated with iron deficiency. The large group of pregnant women affected with iron deficiency are mostly the poor and most vulnerable, especially those living in developing countries like South-east Asia. They have insufficient iron to meet the increased iron needs both for them and the foetus. According to Staff (2013), approximately 29% of the pregnant women experience iron depletion.
Iron is vital since it is needed to make haemoglobin, which helps the red blood cells to store and carry oxygen around the body. With less iron in the body, the tissues and body organs will not have enough oxygen supply, which will not be good for both the mother and the baby (Aranda et al., 2011). During pregnancy, there is increased blood causing a reduction in the haemoglobin concentration in the mother’s blood. Iron is a vital element required for the manufacture of haemoglobin. Increased iron intake means increased haemoglobin concentration.
According to Banhidy et al. (2011), iron deficiency anemia is associated with increased risk of mortality and at the same time reduced work capacity. It is also associated with babies complications. They conducted a study on pregnancy outcome on women who used iron supplements during their pregnancy term and those who did not use them. 90% of those who used it were active during there pregnancy period with only 4% giving birth to unhealthy babies. A larger percent of those who didn't use the iron supplements were quite inactive during there term. Iron deficiency was also found to increase the chances of perinatal complications, such as low birth weight, pre-eclampsia, infant prematurity and perinatal mortality. Expectant women with iron deficient anemia tend to have shorter pregnancies. Iron deficiency in most cases increases the chances of pre-term delivery. It is associated with a two times increase in the risk of preterm delivery when it is detected during the early stages of pregnancy (Banhidy et al. 2011).
When diagnosed during mid-pregnancy, maternal anemia is also associated with increased risk of preterm delivery. However, it is not associated with increased risk of adverse pregnancy outcomes when it is detected during the last semester of the pregnancy. It may just be an indication of an expansion of the maternal plasma volume. Aranda et al. (2011) carried out a study on the iron reserves in an expectant womam on the first days of pregnancy. On the women sampled 80% of them recorded iron depletion as the pregnancy progressed. 60% percent of them gave bith to underweight babies. Although other factors can also cause giving birth to underweight babies, deplition of irons could not be dismissed. The study further revealed that pre-term infants are likely to have perinatal complications, have low stores of iron and other minerals, and experience stunted growth. It is also associated with giving birth to underweight babies.
Iron deficiency is also associated with maternal mortality. According to Haider et al. (2013) study, women who take iron supplements during pregnancy have increased chances of having safe deliveries with health babies. Those that experienced iron depletion during pregnancy either had complications during pregnancy or gave birth to babies with complications while in some cases the baby died. They also associted iron deficiency anemia to increasing chances of maternal mortality. The weakness of their study is that there are no substantial studies to prove that iron deficiency increases the rate of maternal mortality per say. There is no adequate information on an established hemoglobin concentration below which the rate of maternal mortality will be increased (Banhidy et al. 2011). It is also hard to conduct trials to examine the efficacy of iron supplementation to reduce rates of maternal mortality. First of all, it is unethical to leave anemic women untreated. It would also require a large sample size. Maternal mortality among the Omani expectant women is usually associated with the kind of health care that the expectant woman has been receiving (Al-Riyami et al. 2011).
Maternal anemia is also associated with lower infant Apgar scores. An Apgar score is the very first test conducted to a newborn immediately after the child is born (Banhidy et al., 2011). The test is done one minute after birth and again five minutes later. There are five factors used to evaluate the condition of the baby and it is normally scored on a scale of 0-2, 2 being the best score. Haider et al. 2013 claim the factors are appearance, pulse (heart rate), grimace responses (reflexes), activity (muscle tone), and respiration (breathing rate and effort). A newly born baby whose mother was experiencing iron deficiency is likely to score low in the test. High maternal hemoglobin concentration is normally associated with higher Apgar scores (Haider et al. 2013). Although the placenta protects the foetus from the effects related to iron deficiency by up regulation of placental iron transport proteins, maternal iron deficiency affects the foetus within the first three months of life. It might impair the mental development of the foetus while affecting the social-emotional behaviors.
Aside from the birth complications, Iron deficiency has other physical effects on the mother to be. It causes increased fatigue on the expectant women. A woman may feel tired most of the time and lethargic (Haider et al. 2013). It reduces their productivity at work, and they might even find it hard to do even simple regular exercises. There are also chances that they may find it hard to stay awake. Iron deficiency also increases the risks to infections. Iron deficiency anemia can affect the body immune system of the mother (Banhidy et al., 2011). It means that the mother will remain vulnerable to many infections. It is not good for the mother or the developing fetus. Severe anemia may lead to complications that may affect the functioning of the heart and the lungs. The mother may experience abnormally increased heartbeat.
Management of Iron Deficiency during Pregnancy
Food is the best source of iron as it is with most vitamins and minerals. A pregnant woman ought to take in a lot of iron-rich food to help with the supply of iron. Some of the foods include beans, dark green leaves such as spinach, red meat, fish, poultry and many others. Increasing the amount of these foods in the diet will reduce the chances of a pregnant woman to get anemia later in pregnancy. Aranda et al. (2011) claim that vitamin C will also help the body to absorb non-haem iron in the food. Pregnant women should be cancelled on the importance of including iron rich foods to the diet. The intake proportions should also be communicated so that they don’t take excess or minimal iron foods. Excess intake of iron rich foods might have effects on some of the pregnant women
Iron supplementation is usually recommended during pregnancy to meet the increased iron needs of both the mother and the fetus. According to Al-Riyami et al. (2011), oral iron is a cheap and effective way of replacing iron, and it is highly used in Oman. Sometimes, expectant women are given iron by itself or sometimes combined with the folic acid in tablet form (IFA tablets). The requirements for the folic acids is increased due to the increased diving cells in the fetus and increased urinary losses (Pena-Rosas et al. (2012).
According to a study by Alfasoor et al (2011), the reported cases of spina difida had reduced due to the fortification of white flour with folic acid. In 1990, the Omani government introduced fortification of white f lour with 30 ppm iron as elemental (electrolytic) iron and 5 mg/kg folic acid. According to a study carried out between 1996-2010, the household coverage of fortified flour and products in Oman had gone up to 81%. During that period, the reported cases of spina difida had also gone down. When the program was initiated, there were was 3.06 cases of spina difida per 1000 births.
Oral iron is taken daily, and it is recommended that it should be taken on an empty stomach (Pena-Rosas et al.,2012). It is the most widely used public health measures. It is usually recommended that the expectant woman starts taking the iron supplements when they are at least 12 weeks pregnant. It is to reduce the possibility of the medications to harm the developing fetus. The supplements are normally taken daily until the child is born with some taken even after birth. The recommended iron for an iron deficiency case is 100-200mg daily (World Health Organization, 2014).
There should be restrictions of higher intakes since absorption will be saturated and the side effects will increase (Al-Riyami et al. 2011). Expectant women should be advised on how to take correctly the iron supplements. It should be taken daily, on an empty stomach usually one hour before a meal and it should be taken with a source of vitamin C, such as orange juice (Al-Riyami et al. 2011). Vitamin C maximizes the absorption. Supplementation of iron alone or with a combination of folic acid aids in the wellbeing of the foetus and the mother.
Blood screening should always be done on an antenatal visit to monitor the haemoglobin levels in the blood of the expectant woman (Cantor et al., 2015). Women with a Hb <100g/l during the first 12 weeks or 105g/l beyond the twelve weeks are anemic and should be offered a therapeutic iron replacement trial (World Health Organization, 2014*). Their treatment should start immediately, and if the case is considered or found to be severe, they should be referred to a higher or secondary care. Non-anemic women who are considered to be at a high risk of iron depletion should be checked regularly, and 65mg of iron be given to them which they should take daily (World Health Organization, 2014).
The blood tests and results should be rapidly reviewed always and a follow up be done with Hb testing being done every two weeks after the commencement of treatment for women found to be having anemia (Mei et al.,2015). It helps assess compliance, correct administration and how the patient is responding to the treatment. For women found to be non-anemic, Hb and serum ferritin is required eight weeks after commencement of treatment to examine how she is responding to the treatment (World Health Organization, 2014*). In cases where the condition seems to be worsening, and the anemia is becoming chronic, the patient should be referred to a secondary care (Al-Riyami et al. 2011).
The haemoglobin concentration should be able to raise over three to four weeks when taking the iron supplements (Mei et al.,2015). However, the rate of the increase may depend on the initial Hb and iron status, which is before the expectant woman started taking the iron supplements. It also depends on other macronutrients intake, infections or the renal impairment. The compliance of the women on taking the supplements affects efficacy. The intolerance of the oral irons preparation is also another thing that affects efficacy. Iron salts may have some side effects such as gastric irritation, epigastric comfort or even nausea. A third of the women taking the iron supplements are most likely to experience the effects. Preparations with low iron should be tried if the expectant woman has been experiencing gastric irritations (Cantor et al., 2015).
For women who are not responsive to oral iron, or are intolerant to oral iron, parenteral iron should be considered. Parenteral iron is associated with a faster increase in the Hb concentration and a better replenishment of iron stores. The dosage should be calculated based on the weight of the expectant mother.
Women Perception about Taking Supplementation during Pregnancy.
According to a World Health Organization report, cases of anemia in pregnant women have not decreased despite the increased awareness. Many health ministries in different regions provide the women with the supplements, but maternal anemia prevalence is still high (World Health Organization, 2014*). Different women have different views on anemia and on taking the iron supplements. Also, while many have the anemic symptoms, most Omani women don’t know the clinical term for the condition (Al-Yaqoobi et al. 2015). They majored their study on antenatal health services received by the omani women while analyzing their hemoglobin concentration in women who took the iron supplements. Women who receive prenatal health care are familiar with the iron supplements, though a percentage of them do not know why the supplements are prescribed.
Most women in Oman do not have much health education concerning iron supplement intakes (Alasfoor et al., 2010 ). Some women in the region are against consuming medication when they are pregnant. They believe that the medication might in some way harm their baby. Such women find it hard to take the iron supplements even when they are advised to or when the iron supplements are prescribed to them since they believe that it will have a negative effect on their unborn child. Some of the supplements have negative effects on the pregnant women (World Health Organization, 2014*). The effects are not adverse. Some of the effects may make the women discontinue their intake of the supplements.
According to a study by Alfasoor et al (2011), the reported cases of spina difida had reduced due to the fortification of white flour with folic acid. In 1990, the Omani government introduced fortification of white f lour with 30 ppm iron as elemental (electrolytic) iron and 5 mg/kg folic acid . According to a study carried out between 1996-2010, the household coverage of fortified flour and products in Oman had gone up to 81%. during that period, the reported cases of spina difida had also gone down. when the program was initiated, there were was 3.06 cases of spina difida per 1000 births.
In Oman, most women believe in using the traditional means of replacing irons in the body as compared to the iron supplements given at the health facilities (IM et al., 2011 ). Expectant women believe that much intake of the iron supplements might increase the blood levels or increase the weight of the unborn baby. A big baby with much weight is normally associated with a difficult delivery. The women thus cut down on their supplement intake or discontinue the intake on the fear of a bigger baby. The women also believe that the iron supplements might increase their weight. Such perceptions are normally associated with inadequate counselling or total lack of counselling. The woman is not educated on the benefits or the effects of the iron supplements on their health and the health of their babies (World Health Organization, 2014*).
Women who are having a baby for the first time are most likely not to put emphasize on the intake of the iron supplement. However, those that are having their second or more child will most likely take the iron supplements until they give birth (Alasfoor et al., 2010). They are more experienced and educated, and they understand the importance of taking the iron supplements. The new mothers tend to forget or even discontinue their intake of the iron supplements (Pena-Rosas et al., 2012). Older women have a positive perception towards taking the iron supplements.
The intake of the iron supplements also vary among women of different social and economic status. Most Omani women are not highly educated. Women who are educated will understand the importance and the benefits of the iron supplements. On the contrary, women that are less educated are less likely to comply with taking the iron supplements. Most of them may assume that the supplements may harm their babies or so. However, in some cases, they less educated might comply since they believe the word of the doctor concerning their health status and their well-being (Staff, 2013).
The perception of the expectant women largely depends on the counselling that they receive during their antenatal care visits ( Alasfoor et al. 2014). In areas where the healthcare institutions provide extensive counselling and health education concerning the effects of iron deficiency, and the benefits of the iron supplements, the women in that area will have a positive attitude towards the supplements. They will understand the harm that they may cause to their unborn babies and their health too. Access to the health services and the utilization of the health services is also another factor (World Health Organization, 2014*).
Conclusion
Iron supplementation in an expectant woman is associated with an improved biochemical status of the expectant mother regardless of her iron status before the commencement of the treatment. Most pregnant women experience iron deficiency. A greater percentage of them being in the developing countries. Most of them are not economically stable and have limited access to iron-rich foods or supplements. Some of them are not well informed on the benefits of iron supplements or the effects of iron deficiency to their health and the health of their unborn baby (World Health Organization, 2014).
Maternal anemia may have adverse effects such as premature birth, low birth weights or perinatal mortality. Pregnant women with anemia tend to have shorter pregnancies increasing the risks of pre-mature birth. Premature children may develop complications and also experience stunted growth. Women with iron depletion may also experience fatigue and increased the risk to infections since the immune system is undermined (Pena-Rosas et al., 2013). Infections might have adverse effects on the mother and especially on the developing foetus. Although iron depletion is associate with maternal mortality, there is enough information on an established haemoglobin level, below which the risk of maternal mortality is increased
The greatest remedy for iron deficiency conditions is eating foods that are rich in iron. The foods include green leaves such as spinach, poultry, fish and red meat. There are also iron supplements available. Oral iron is the most common simple and effective way of replacing irons. It is normally taken daily on an empty stomach usually one hour before a meal. It is usually recommended for women who are more than 12 weeks pregnant according to the ethical standards that medication might harm a developing foetus. Some women might not respond to the treatment while some might be intolerant. They are normally given parenteral iron to correct their condition (Haider et al., 2013).
Different women have different perception towards the oral supplements. Some believe that taking too much iron might increase the weight of the baby which might cause difficulties during delivery (Al-Yaqoobi, 2015). Some are against taking medication which they believe might harm the baby. The perceptions vary across regions which heavily depends on the educational levels and the information and health education that the women are given concerning the health of the mothers and their babies.
Reference List
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