SSR Institute of International Journal of Life Sciences

ISSN (O): 2581-8740 | ISSN (P): 2581-8732

Deo and Kumari, 2024
DOI: 10.21276/SSR-IIJLS.2024.10.1.14

Research Article

Study of Severity of Anemia during Pregnancy and Adverse

Maternal and Fetal Outcomes at Tertiary Care Centre
Sujata Deo1*, Pratibha Kumari2
1
Professor, Department of Obstetrics and Gynecology, King George’s Medical University, Lucknow, India
2
Research Scientist C, Department of Obstetrics and Gynecology, King George’s Medical University, Lucknow, India

*Address for Correspondence: Dr. Sujata Deo, Professor, Department of Obstetrics and Gynecology, King George’s
Medical University, Lucknow, India
E-mail: [email protected]

Received: 26 Aug 2023/ Revised: 23 Oct 2023/ Accepted: 03 Dec 2023

ABSTRACT
Background: Anemia is a recognized risk element for numerous adverse outcomes during pregnancy and childbirth. However,
limited comprehensive data is available regarding its influence on specific maternal health issues. Additionally, there is inadequate
research on the connections between anemia during pregnancy and the resulting impacts on both the mother and the fetus
outcome.
Methods: In this observational study, a total of 414 pregnant female participants were recruited according to their hemoglobin
levels (Hb). The subjects were divided into mild, moderate, and severe anemia according to their hemoglobin level,
Results: The study consisted of 414 women with varying degrees of anemia: mild (228,55.1%), moderate (128,30.9%), and severe
(58,14%). The morphological analysis indicated that the majority of cases exhibited normocytic normochromic anemia, as opposed
to microcytic hypochromic anemia, in both mild (60.5% vs 39.5%) and moderate anemic pregnant women (55.5% vs 44.5%).
However, this proportion was reversed in severe cases, with a prevalence of 84.5% for microcytic hypochromic anemia. The
results indicated that pregnant women with anemia were more likely to experience adverse outcomes, except for placental
complications (p-value=0.05), delivery method (p-value=0.02), and fatal consequences such as low birth weight and miscarriage
(p<0.05, respectively).
Conclusion: The prevalence of mild-moderate and severe anemia was found to be associated with maternal complications and
adverse outcomes such as low birth weight and miscarriage. Adopting a comprehensive approach to prevent anemia in women of
reproductive age is crucial to improving their hematological status and enhancing maternal and child health outcomes.

Key-words: Anemia, Hemoglobin, Preterm birth, IUD, Fetal growth restriction

INTRODUCTION
Anemia is the most commonly occurring nutritional it is an aim for a 50% decrease in the prevalence of
deficiency among pregnant women across the globe [1]. anemia among reproductive-aged women by 2025.
The World Health Organization's (WHO) latest data However, global progress falls short of meeting this
shows that between 2012 and 2016, most of anemic target [3]. In 2016, the worldwide prevalence of anemia in
women aged 15 to 49, whether pregnant or not, has pregnant women reached 40.05%. Southeast Asia
increased in most countries [2]. To combat this issue, the exhibited the highest rates, with 75% in general and a
65th World Health Assembly established a nutrition goal, staggering 88% prevalence in India [4]. Given the
alarmingly high prevalence of anemia, any detrimental
How to cite this article
impacts on the health of both the mother and the fetus
Deo S, Kumari P. Study of Severity of Anemia during Pregnancy and
Adverse Maternal and Fetal Outcomes at Tertiary Care Centre. SSR during pregnancy would significantly affect public health
Inst Int J Life Sci., 2024; 10(1): 3542-3549. [5]
.
Maternal mortality is influenced significantly by anemia,
Access this article online which is the primary cause in 20% of cases and an
http://iijls.com/ associated factor in another 20% [6]. The World Health
Organization (WHO) states that the prevalence of
anemia varies across different regions of India, ranging

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 SSR Institute of International Journal of Life Sciences
ISSN (O): 2581-8740 | ISSN (P): 2581-8732
Deo and Kumari, 2024
DOI: 10.21276/SSR-IIJLS.2024.10.1.14

from 33% to 89% [3]. In addition, anemia is responsible Data collection- The primary data were obtained from
for 19% of maternal fatalities in the country [6]. Previous the departmental antenatal records of patients. This data
studies have indicated that the occurrence of anemia included various socio-demographic characteristics such
during pregnancy varies among women with distinct as age, trimester, parity gravida, mode of delivery, and
socioeconomic backgrounds, lifestyles, and healthcare- other investigations conducted during routine antenatal
seeking behaviors, which differ across diverse cultures [6]. checkups, per the hospital's standard protocol. We
Maternal anemia not only increases the risk of low birth recorded maternal outcomes such as placental
weight, premature delivery, intrauterine growth complications, preterm birth, mode of delivery,
restriction, perinatal and neonatal mortality but also hypertension disorders, fetal growth restriction (FGR),
impairs iron storage for the baby. Consequently, it premature rupture of membranes (PROM), postdate
elevates the risk of maternal morbidity. The prevalence pregnancy, GDM (gestational diabetes mellitus),
of maternal anemia is rising, posing a significant threat cholestasis, heart disease, urinary diseases, antepartum
not only to the affected individual but also to their family hemorrhage, and abnormal placenta. Fetal outcomes
and the overall economic growth of the nation. WHO consisted of malformation (including deformations,
categorized anemia into three levels: mild anemia (10- congenital malformation, and chromosomal
10.9 gm/dl), moderate anemia (7-9.9 gm/dl), and severe abnormalities during hospitalization), growth restriction,
anemia (<7 gm/dl) [4]. Among the most common growth restriction, malformation (including congenital
problems that occur during pregnancy is anemia. This malformations, deformations, and chromosomal
condition is often considered a risk factor for an abnormalities diagnosed during hospitalization), baby
unfavorable pregnancy outcome, posing dangers to both weight, and IUD.
the mother and the fetus. It can lead to complications
such as preterm birth, low birth weight, fetal disability, Statistical Analysis- The data obtained from the research
and even maternal and fetal fatalities [7-9]. This research was analyzed using various statistical techniques. To
study aimed to examine the impact of anemia severity check the normality of continuous data, the Kolmogorov-
on the health of both the mother and the fetus Smirnov test was employed. On the other hand,
throughout pregnancy. categorical data was presented in terms of frequency
and percentage. The representation of continuous data
MATERIALS AND METHODS was done using the mean and standard deviation. SPSS-
Place of the study- The present observational record- 21 package software by IBM, located in Chicago, USA
based study was conducted at the Department of was used for the statistical data analysis. Additionally,
Obstetrics and Gynecology in King George's Medical the graphs illustrating the data were created using Prizm
University (KGMU), Lucknow, India, from 1st May to 31st software. A two-tailed p-value of less than 0.05 was
July 2022. considered significant to determine the significance of
the results.
Selection criteria of Subject- A total of 414 pregnant
women in the reproductive age group were included in Ethical Approval- Before starting the collection of data,
our research. Anemia, as defined by the WHO, was the authors obtained approval from the Ethical
categorized into three groups: mild anemia (Hb 10-10.9 Committee of KGMU, Lucknow, India.
g/dl), moderate anemia (Hb 7-9.9 g/dl), and severe
anemia (Hb<7 g/dl) [4]. RESULTS
The study included a total of 414 pregnant females. The
Inclusion Criteria- Anemic Pregnant women attending subjects were divided into categories based on their
the antenatal clinic who have less than 11 g/dl hemoglobin level: mild anemia, moderate anemia, and
Hemoglobin value. severe anemia. Our study revealed that the highest
prevalence of mild anemia was 55.1%, followed by 30.9%
Exclusion Criteria- Those pregnant women, who have
for moderate and 14% for severe anemia. Through this
not less than 11 g/dl Hemoglobin value excluded from
observational study, we have uncovered a heightened
the study.

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 SSR Institute of International Journal of Life Sciences
ISSN (O): 2581-8740 | ISSN (P): 2581-8732
Deo and Kumari, 2024
DOI: 10.21276/SSR-IIJLS.2024.10.1.14

vulnerability to anemia among pregnant women residing subjects in the three groups were otherwise similar and
in northern India, particularly among those aged can be considered comparable (Table 1). Furthermore, a
between 18 and 45 years. The application of binary correlation analysis was conducted to determine the
logistic regression analysis further demonstrates a level of similarity and linear relationship between the
correlation between the age of the mother and the risk blood parameters of the subjects. It was found that the
of anemia during pregnancy, indicating that those under values of Hct and MPV were positively correlated with
25 are more susceptible. By comparing these three each other (r2>0.33 and 0.25). This correlation is visually
groups’ blood parameters, an ANOVA test revealed represented as a heat plot in Fig. 1, providing a clear
significant variations in hemoglobin and MCH between overview of the relationship among the blood
them (p<0.05). This indicates notable differences in parameters.
these two parameters among the groups. However, the

Table 1: Baseline parameters of subjects

Variables Mild (n=228) Moderate (n=128) Severe (n=58) F/χ2 value p-value
N(%) N (%) N(%)
Age (years) 27.9±4.3 27.02±5.2 27.3±5.5 F= 1.48 0.23
mean±SD
18-25 79 (34.6) 63 (49.2) 30 (51.7)
25-30 84 (36.8) 37 (28.9) 13 (22.4) χ2=10.19 0.027*
≥30 65 (28.5) 28 (21.8) 15 (25.8)
Gravida (n, %)
1 80 (35.1) 42 (32.8) 10 (17.2)
2 73 (32) 43 (33.4) 21 (36.2) χ2=7.5 0.11
≥3 75 (35.9) 43 (33.6) 27 (46.5)
Trimester (n, %)
1st 15 (6.6) 3 (2.3) 3 (5.2)
2nd 13 (5.7) 6 (4.7) 5 (86)
3rd 194 (85.1) 115 (89.8) 49 (84.5) χ2=4.3 0.37

Post dated (>40 6 (2.6) 4 (3.1) 1 (1.7)

weeks)
Hematological parameters (mean±SD)
Hb 10.8±0.85 8.93±1.16 6.01±1.2 F=359.4 0.001*
MCH 30.89±9.34 27.95±4.81 26.79±6.25 F=7.15 0.009*
MCHC 34.57±4.37 34.4±4.86 34.08±3.48 F=0.24 0.78
MCV 79.71±15.24 77.42±15.68 73.90±17.44 F=2.66 0.07
Platelets 1.77±0.81 1.81±0.85 1.62±0.91 F=0.76 0.46
HCT 35.99±40.4 26.66±5.96 27.98±37.05 F=2.13 0.12
MPV 12.04±9.92 11.4±10.6 9.72±1.3 F=0.69 0.50

Hb: hemoglobin, MCH: mean corpuscular hemoglobin, MCHC: mean corpuscular hemoglobin concentration, MCV: Mean corpuscular volume,
Hct: Hematocrit, MPV: mean platelet volume

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 SSR Institute of International Journal of Life Sciences
ISSN (O): 2581-8740 | ISSN (P): 2581-8732
Deo and Kumari, 2024
DOI: 10.21276/SSR-IIJLS.2024.10.1.14

Fig. 1: Correlation matrix of baseline blood parameters

Table 2 illustrates unfavorable health consequences for fetal growth restriction, placental complications, delivery
both mothers and fetuses. In general, pregnant women method, and fatal consequences such as low birth weight
who experience anemia face a greater likelihood of and abortion, respectively (p<0.05).
encountering adverse outcomes, excluding instances of

Table 2: Maternal complication and fetal outcomes by severity of anemia during pregnancy

Parameters Mild (n=228), Moderate (n=128), Severe (n=58), N p-value

N (%) N (%) (%)
Maternal complications during pregnancy
Cholestasis 13 (5.7) 5 (3.9) 1 (1.7) NS
GDM 15 (6.5) 4 (3.1) 0 (0) NA
Heart diseases 1 (0.44) 1 (0.78) 0 (0) NA
Hypertension 23 (10.1) 9 (7.0) 4 (6.8) NS
Hypothyroidism 11 (4.8) 3 (2.3) 0 (0) NA
APH 5 (2.2) 8 (6.3) 4 (6.8) NS
Placental complications 45 (19.7) 35 (27.3) 19 (32.7) <0.05*
Post dated 5 (2.2) 4 (3.1) 1 (1.7) NA
PROM 20 (8.7) 10 (7.8) 3 (5.1) NA
Urinary complications 8 (3.5) 3 (2.3) 2 (3.4) NA
Other complications 67 (29.4) 35 (27.3) 9 (15.5) NS
Mode of delivery
Vaginal 87 (38.2) 39 (30.5) 12 (20.7) 0.029*
LSCS 141 (61.8) 89 (69.5) 46 (79.3)
Fetal outcomes
FGR 15 (6.5) 11 (8.6) 15 (25.8) <0.05*
Baby weight (Kg)

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 SSR Institute of International Journal of Life Sciences
ISSN (O): 2581-8740 | ISSN (P): 2581-8732
Deo and Kumari, 2024
DOI: 10.21276/SSR-IIJLS.2024.10.1.14

<2.5 93 (40.8) 65 (50.8) 19 (32.7) 0.001**

>2.5 118 (51.7) 59 (46.1) 11 (18.9)
IUD/abortion 17 (7.4) 4 (3.1) 28 (48.3)
NS: Not significant; NA: Not applicable; *: p<0.05; **p<0.01. GDM: Gestational Diabetes Mellitus, APH: Anti partum hemorrhage, PROM:
Premature rupture of membranes, FGR: Fetal growth restriction, IUD: Intrauterine death

Further, the morphological subtyping analysis indicated poses a significant risk of preterm delivery. A post hoc
that the majority of cases exhibited normocytic analysis uncovered a clear association between anemia
normochromic anemia, as opposed to microcytic severity and preterm delivery. It was observed that
hypochromic anemia, in both mild (60.5% vs 39.5%) and varying levels of hemoglobin have a positive impact on
moderate anemic pregnant women (55.5% vs 44.5%) preterm delivery. Women with severe levels of anemia
(Fig. 2). However, this proportion was reversed in severe are more likely to experience premature delivery
cases, with a prevalence of 84.5% for microcytic compared to those with mild or moderate levels
hypochromic anemia. Anemic women are more prone to (preterm delivery: mild-27%, moderate-27%, severe-
preterm delivery due to insufficient blood supply for 37%, p<0.01 for all comparisons) (Fig. 3) where
fetal intrauterine development. significance was different alphabets show significant
Maternal iron deficiency anemia in early pregnancy variation at p<0.05.

Fig. 2: Distribution of type of anemia in mild, moderate and severe

Fig. 3: Effect of Maternal anemia on fetal development concerning premature and full-term births

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 SSR Institute of International Journal of Life Sciences
ISSN (O): 2581-8740 | ISSN (P): 2581-8732
Deo and Kumari, 2024
DOI: 10.21276/SSR-IIJLS.2024.10.1.14

DISCUSSION prevalent reason behind microcytic anemia. The absence

During pregnancy, the epidemiological characteristics of of iron stores in the bone marrow stands as the most
anemia emphasize the necessity for a public health conclusive test to distinguish iron deficiency from other
intervention in India. To begin with, multiple sources of microcytic states, such as anemia of chronic disease,
data substantiate the escalating trend of anemia in thalassemia, and sideroblastic anemia. However, for
pregnant women in India [10,11]. The prevalence of other adverse outcomes such as preterm birth,
anemia, per the global estimates provided by the World intrauterine death (IUD), and FGR, we found increased
Health Organization, averages 56% worldwide, with risks among those with moderate or severe anemia
regional variations ranging from 35% to 75% [2]. In India compared to those with mild anemia or normal
specifically, the prevalence of anemia stands at more hemoglobin concentrations.
than 55% [12]. Our study revealed that the highest Anemia in young women necessitates particular
prevalence of mild anemia was 55.1%, followed by 30.9% attention, given that they are the demographic most
for moderate anemia and 14% for severe anemia. prone to becoming pregnant. The prevalence of anemia
Fortunately, we did not find many pregnant women in India has reportedly been rising, with several factors
suffering from severe anemia, which is a positive potentially contributing to this trend [16]. The
indication. However, the high occurrence of moderate advancement of prenatal care and increased focus on
and mild anemia in our study has raised concerns and maternal anemia have led to the identification and
calls for immediate action to reduce the overall burden clinical diagnosis of more pregnant women affected by
of anemia among pregnant women in this area. Parasitic anemia. Furthermore, dietary habits in India have
infections, such as malaria and intestinal worms, are undergone significant changes in recent decades,
primarily responsible for severe cases of anemia [13]. The characterized by a nutritional landscape that encourages
low incidence of severe anemia suggests that our the consumption of energy-dense but nutrient-deficient
strategies to control infectious diseases are effective in foods [16]. Interestingly, iron supplements are not
this region. regularly recommended to pregnant women in India. A
These findings align with a study by Mridul Malakar et al. study indicated that around 70% of anemia cases among
[14]
in the Lakhimpur district of Assam. They reported a pregnant women in India were linked to insufficient iron
prevalence of 61% for moderate anemia, followed by levels [17].
29.5% for mild anemia and 2.3% for severe anemia. In Additionally, there has been a growing trend among
this observational research, we have discovered an women to strive for a slender physique in recent years.
increased susceptibility to anemia in pregnant women Previous research has established that anemia can be
living in the northern regions of India. Specifically, we associated with placental or delivery-related conditions,
found that women between 18 and 45 are more prone such as placental abruption, which is also linked to
to this condition. Using binary logistic regression preterm birth [18]. Our study showed that pregnant
analysis, we have also demonstrated a relationship exists women with anemia, regardless of severity, were more
between the age of the mother and her risk anemia likely to experience unfavorable outcomes, such as these
during pregnancy, which varied depending on the diseases connected to the placenta. These results are in
severity of anemia. This analysis revealed that a great line with previous research [18-21]. On the other hand,
vulnerability in women under the age of 25. Regardless there was a correlation between mild anemia during
of the severity, we observed three adverse outcomes pregnancy and reduced risk of stillbirth and foetal
associated with anemia during pregnancy: microcytic growth restriction.
hypochromic condition, placental complications, and In terms of fetal outcomes, our study found that
mode of delivery. Microcytic hypochromic or Microcytic pregnant women who experience anemia face a greater
anemia refers to a condition with an abundance of small, likelihood of encountering adverse outcomes of fetal
frequently hypochromic red blood cells observed in a growth restriction, placental complications, preterm
peripheral blood smear. This type of anemia is typically delivery, and fatal consequences such as low birth
identified by a low MCV, usually below 83 microns cubed weight and abortion among pregnant women with
[15]
. Among the various causes, iron deficiency is the most anemia. It is worth noting that mild anemia during

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 SSR Institute of International Journal of Life Sciences
ISSN (O): 2581-8740 | ISSN (P): 2581-8732
Deo and Kumari, 2024
DOI: 10.21276/SSR-IIJLS.2024.10.1.14

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exhibited normocytic normochromic anemia, as opposed 12202, 2020.
to microcytic hypochromic anemia, in mild and moderate [3] World Health Organization. Global Nutrition
anemic pregnant women. In severe cases, this Monitoring Framework: operational guidance for
proportion was reversed, with a prevalence of 84.5% for tracking progress in meeting targets for 2025.
microcytic hypochromic anemia. Anemic women are Available at: https://www.who.int/data/nutrition/
more prone to preterm delivery due to insufficient blood nlis/gnmf, 2017.
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CONTRIBUTION OF AUTHORS
Research concept- Dr. Sujata Deo Maternal anemia during pregnancy is an
Research design- Dr. Sujata Deo independent risk factor for low birthweight and
Supervision- Dr. Sujata Deo preterm delivery. Europ J Obst Gynecol Repro
Materials- Dr. Sujata Deo & Dr. Pratibha Kumari Biol., 2005; 122(2): 182-86.
Data collection- Dr. Pratibha Kumari [8] Banhidy F, Acs N, Puho, E. H, Czeizel AE. Iron
Data analysis and Interpretation- Dr. Sujata Deo & Dr. deficiency anemia: pregnancy outcomes with or
without iron supplementation. Nutr., 2011; 27(1):
Pratibha Kumari
65-72.
Literature search- Dr. Pratibha Kumari
[9] Haas JD, Brownlie T. Iron deficiency and reduced
Writing article- Dr. Pratibha Kumari
Critical review- Dr. Sujata Deo work capacity: a critical review of the research to
determine a causal relationship. J Nutr.,
Article editing- Dr. Pratibha Kumari
Final approval- Dr. Sujata Deo 2001; 131(2): 676S-90S.
[10]Kulkarni PY, Bhawalkar, JS, Jadhav AA. Anemia
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