Paving the way forward: Using implementation science to understand barriers and facilitators of uptake for Intravenous iron in the Management of Anaemia in Pregnancy for Resource-Limited Settings: IVON Nigeria Trial

Anaemia in pregnancy is defined by the World Health Organization (WHO) as a haemoglobin concentration of less than 11 g/dl at any stage of pregnancy.(*1) It is defined as <11g/dl in the first trimester and <10.5 g/dl in the second or third trimester per guidance from the United Kingdom and the United States Centre for Disease Control and Prevention.(*2,3) A survey by the WHO estimate the global prevalence of anaemia among pregnant women as 41.8% with the highest prevalence rate (57.1%) found among pregnant women in sub-Saharan Africa.(*4) It contributes to 20- 40% of maternal deaths.(*5) In particular, iron deficiency anaemia (IDA) accounts for 75% of all types of anaemia in pregnancy. If left untreated in pregnant women, it can lead to extreme fatigue, decreased work capacity, depression and ultimately, poor pregnancy outcomes such as intrauterine growth retardation, stillbirth, premature delivery and low infant birth weight.(*6,7) Studies have shown that anaemia increases the risk of postpartum haemorrhage (PPH) (*8) contributing to 40– 43% of maternal mortality in Africa and Asia.(*9) Due to the high prevalence of low iron status, iron deficiency and IDA in pregnancy, the WHO global recommendation for managing anaemia in pregnancy in low and middle income countries (LMICs) is the daily use of high-dose oral iron supplementation (60mg elemental iron taken twice daily).(*7) However, this is usually associated with poor tolerance and suboptimal adherence, due to significant gastrointestinal adverse effects.(*10,11) * References 1. WHO. Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity. Geneva: WHO; 2011. 2. National Collaborating Centre for Women's and Children's Health (UK). NICE Clinical Guidelines, no.62. Antenatal Care: Routine Care for the Healthy Pregnant Woman. London: RCOG Press; 2008. 3. CDC. Recommendations to prevent and control iron deficiency in the United States. MMWR Recomm Rep. 1998; 47: 1– 29. 4. World Health Organization (2000) Worldwide Prevalence of Anaemia 1993–2005: WHO. Global Database on Anaemia. Geneva: WHO 5. Daru J, Zamora J, Fernandez-Felix BM, Vogel J, Oladapo OT. Risk of maternal mortality in women with severe anaemia during pregnancy and post-partum: A multilevel analysis. Lancet 2018; 6: E548-54 6. Axemo P, Liljestrand J, Bergstrom S, Gebre-Medhin M. Aetiology of late fetal death in Maputo. Gynaecol Obstet Invest. 1995;39:103-9. 7. WHO. Treatments for iron-deficiency anaemia in pregnancy. 2007 [Available from: https://extranet.who.int/rhl/topics/pregnancy-and-childbirth/medical-problems-during-pregnancy/anaemiaduring-pregnancy/treatments-iron-deficiency-anaemia-pregnancy 8. Ramanathan G, Arulkumaran S. Postpartum hemorrhage. J Obstet Gynecol Can 2006;28(11):967–73. 9. Christian P. Nutrition and maternal survival in developing countries. In: Lammi-keefe CJ, Couch SC, Philipson EH. Handbook of nutrition and pregnancy (USA), 1st ed.; 2008. p. 319–36. 10. Balarajan Y, Ramakrishnan U, Özaltin E, Shankar AH, Subramanian SV. Anaemia in low-income and middle-income countries. The Lancet. 2011; 378(9809):2123-35.

Keywords:B680-public-health