Published by: Epidemiology, Department of Public Health and Clinical Medicine, Umeå University, Sweden and Research and Evaluation Division, BRAC
Iron deficiency anaemia is a global public health problem that affects women in all stages of the reproductive cycle. Current iron supplementation strategies in public health settings have met with limited success. Alternatives with intermittent dose frequency have been suggested to reduce side effects, increase compliance and iron absorption and, thereby, improving effectiveness.
The objectives of this thesis were to assess the anaemia problem in rural Bangladeshi women, and to compare the impact of a daily and a weekly iron supplementation on haemoglobin (Hb) outcome in pregnancy and puerperium. In a survey of 179 rural non-pregnant women (15-45 years), anaemia (Hb <120 g/L) was highly prevalent in all social strata, however, severe anaemia (Hb <70 g/L) was uncommon. An iron supplementation trial was conducted in 50 antenatal care centres randomly assigned to provide women with either 60 mg iron daily or 2 x 60 mg once weekly from second trimester to 6 weeks post partum. Compliance was monitored over 11 weeks of supplementation during pregnancy by use of a pill-bottle equipped with an electronic counting device. Side effects were assessed by recall after 4 weeks. Hb was assessed at baseline, after 4, 8 and 12 weeks and at 6 weeks after delivery. Iron status was assessed at baseline and at 6 weeks post partum by serum ferritin (sFt) and serum transferrin receptors (sTfR). Half of the pregnant women (n = 214) at baseline had anaemia (Hb <110 g/L) while none had severe anaemia. Four out of five cases of moderate anaemia (Hb 70-99 g/L) and every second case of mild anaemia (Hb 100-109 g/L) had indications of iron deficiency (sFt <12 µg/L and/or sTfR >8.5 mg/L).
When evaluating the effect of iron supplementation on haemoglobin concentration no difference was found per iron tablet taken as daily or weekly dose schedule. The first 20 tablets consumed produced most of the effect, and the maximum response was achieved after about 40 tablets. Side effects were more common in the weekly group, but had limited influence on compliance. Compliance was higher among those taking tablets on a weekly basis. A significantly larger haemoglobin response was achieved by a 12-week daily regimen as compared to weekly. At 6 weeks post partum, there was a dose-dependent effect of iron supplementation that did not differ between the two regimens. Reduction of anaemia is dependent on the actual number of iron tablets consumed rather than on supplementation regimen. The current international recommendation of iron supplementation in pregnancy seems to be unnecessarily high. Since most of the improvement in haemoglobin concentration was found to occur early in treatment, the initial supplementation dose in pregnancy should be set as high as possible, which may then be followed by a lower (intermittent) dose. The study provides evidence that the impact of iron supplementation in pregnancy could be sustained after childbirth