daily oral iron supplementation during pregnancy: what's the evidence?
TRANSCRIPT
Welcome! Daily oral iron supplementation during pregnancy: What's the
evidence?
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What’s the evidence? Peña-Rosas J.P., De-Regil L.M., Garcia-Casal M.N., & Dowswell T. (2015). Daily oral iron supplementation during pregnancy. Cochrane Database of Systematic Reviews, 2015(7), CD004736. http://www.healthevidence.org/view-article.aspx?a=20405
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Poll Question #4
Dr. Luz Maria De-RegilDirector of Research and Evaluation at the Micronutrient Initiative
Daily oral iron supplementation improves health outcomes for pregnant womenA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree
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Poll Question #5
ReviewPeña-Rosas J.P., De-Regil L.M., Garcia-Casal M.N., & Dowswell T. (2015). Daily oral iron supplementation during pregnancy. Cochrane Database of Systematic Reviews, 2015(7), CD004736.
Review focus:P Pregnant women of any gestational age and
parity
I Daily oral use of iron supplements, either alone or in conjunction with folic acid or with other vitamins and minerals
C Same supplement without iron/ no treatment/ placebo
O - Maternal: Maternal anaemia, iron deficiency and iron deficiency anaemia at term - Infant: Low birth weight, premature birth, Hb concentrations in first 6 months
Iron deficiency anaemia• Iron deficiency is the most common nutrient
deficiency among women• 38.2% of pregnant women suffer anaemia• Main causes:
– Poor diet in absorbable iron– Uncover increased iron requirement – Iron loss due to parasitic infections (e.g. hookworms)– Other blood losses
Global landscape of anaemia
Source: WHO. Global prevalence of anaemia in 2011. Geneva: World Health Organizaiton, 2015
Iron supplementation• Iron supplementation for pregnant women has
been used extensively in most low- and middle- income countries
• Inclusion of folic acid is also recommended because of increase requirements in pregnancy due to rapidly dividing cells in the fetus in increased urinary losses
• Iron supplementation has been used in variety of doses and frequencies
Recommendations for iron supplementation• Daily dose of 30-60 mg of elemental iron and 0.4
mg of folic acid and to start as soon as possible (WHO)
• Anaemia in populations >40%: Daily dose of 60 mg of elemental iron is preferred over a lower dose (INACG )
• Women with anaemia in clinical settings: Daily dose of 120 mg of elemental iron and 0.4 mg supplementation until her Hb recovers (WHO)
Why is this review important?• Impact of iron supplementation under field
conditions is limited• Effectiveness of iron supplementation have been
evaluated mostly in terms of improvement of haemoglobin (Hb), rather than improvements of maternal and infant health
• Limited results in malaria settings• These are the results of an update of the
systematic review done in 2012
ObjectiveTo assess the effects of daily oral iron
supplementations by pregnant women, either alone or in conjunction with folic acid or with other
vitamins and minerals as a public health intervention in antenatal care.
PICO QUESTION
MethodologyIncluded studiesRandomized, cluster-randomized and quasi-randomized trials
Types of participantsPregnant women of any gestational age and parity
ComparisonsAny supplements containing iron vs Same supplement without iron/no
treatment/ placeboAny supplements containing IFA vs Same supplement without IFA
Supplementation with iron alone vs No treatment/placebo
Supplementation with IFA vs No treatment/placebo
Supplementation with IFA vs FA alone
Supplementation with iron and other vitamins
vs Same other vitamins without iron
Supplementation with IFA acid+ other vitamins and minerals
vs Same FA and other vitamins without iron
Supplementation with IFA +other vitamins
vs Same other vitamins and minerales withou IFA
OutcomesPrimary outcomes
Infant MaternalLow birth weight Maternal anaemia at term
Birthweight Maternal iron deficiency at termPreterm birth Maternal iron deficiency anaemia (IDA) at term
Neonatal death Maternal deathCongenital anomalies Side effects
Severe anaemia at any time during second or third trimester
Clinical malariaInfection during pregnancy
Secondary outcomesInfant Maternal
Very low birthweight Maternal anaemia at or near termVery premature birth Maternal iron deficiency at or near term
Hb concentration within the first 6 months Maternal IDA at or near term
Ferritin concentration with the first 6 months Maternal Hb concentration at or neat termDevelopment and monitor skills Maternal Hb concentration within one month postpartum
Electronic searches• Cochrane Central Register of Controlled Trials
(CENTRAL)• MEDLINE• EMBASE• CINAHL• Hand search of 30 journals and proceedings of
major conference proceedings
Study flow diagram
The review included studies across the globe:
•24 trials from Europe•11 in the Americas•4 in Africa•18 in Asia•3 in Australia
Characteristics assessing risk of bias• Random sequence generation (selection bias)• Allocation concealment (selection bias)• Blinding of participants and personal
(performance bias)• Blinding of outcome assessment (detection bias)• Incomplete outcome data (attrition bias)• Other bias
Example
Butler 1967
Summary of risk of bias for all included studies
Summary risk of bias for individual studies
GRADE – grading the quality of evidence• Assess the quality of the evidence quality so one
can be confident that an estimate of effect or association is close to the quantity of specific interest.
Level of quality depending of study design, limitations,
indirectness, inconsistency of
results, imprecision of results or
publication bias
ResultsMaternal outcomes
•Reduced maternal anaemia at term by 70% (RR 0.30; (0.19-0.46), 14 trials, 2199 women, low quality evidence)
•Reduced Iron-deficiency anaemia at term by 67% (RR 0.33; (0.16 -0.69), six trials, 1088 women
•Reduced Iron deficiency at term by 57% (RR 0.43; (0.27 -0.66), seven trials, 1256 women, low quality evidence)
No clear differences between groups:
•For severe anaemia in the second trimester: RR 0.22 (0.01 -3.20), nine trials, 2125 women, very low quality evidence
•For severe anaemia in the third trimester: RR 1.21(0.33 to 4.46), one trial, 727 women, low quality evidence
•For maternal mortality: (RR 0.33; 95% CI 0.01 to 8.19, two trials, 12,560 women, very low quality evidence)
•Side effects: (RR 1.29( 0.83 -2.02), 11 trials, 2423 women, very low quality evidence)
•Women receiving iron were on average more likely to have higher Hb concentrations at term and in the postpartum period, but were at increased risk of Hb concentrations greater than 130 g/L during pregnancy, and at term.
Infant outcomesComparing with controls:•Low birthweight newborns (8.4% versus 10.3%, average RR 0.84(0.69 -1.03), 11 trials, 17,613 women, low quality evidence)•Preterm babies (RR 0.93 (0.84 -1.03), 13 trials, 19,286 women, moderate quality evidence). •They appeared to also deliver slightly heavier babies (MD 23.75 (-3.02 to 50.51, 15 trials, 18,590 women, moderate quality evidence).
None of these results were statistically significant.
Infant outcomesNo clear differences between groups:•For neonatal death (RR 0.91(0.71 -1.18), four trials, 16,603 infants, low quality evidence)• Congenital anomalies (RR 0.88, 95% CI 0.58 to 1.33, four trials, 14,636 infants, low quality evidence)
Malaria settings• Twenty-three studies malaria risk in 2011• Only two of these studies reported malaria
outcomes• No evidence was found that iron supplementation
increases placental malaria
Conclusions: Daily oral iron supplementation
Women consuming daily oral iron supplementation have:•Lower risk of anaemia at term•Higher haemoglobin (Hb) concentrations at term and six weeks postpartum•Higher risk of high Hb concentrations during the second and third trimesters of pregnancy
Infants from mothers consuming daily oral supplementation have: •Borderline lower risk of delivering low birthweight babies•Borderline lower risk of giving birth to infants less than 37 weeks’ gestation•Lower risk of giving birth to infants less than 34 weeks’ gestation
OVERALL SUMMARY • Supplementation reduces the risk of maternal anaemia and
iron deficiency in pregnancy.• The positive effect on other maternal and infant outcomes
is less clear. • Implementation of iron supplementation recommendations
may produce heterogeneous results depending on the populations' background risk for low birthweight and anaemia, as well as the level of adherence to the intervention.
Daily oral iron supplementation improves health outcomes for pregnant womenA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree
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Poll Question #6
Poll Question #7Do you agree with the findings of this review?A.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree
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A Model for Evidence-Informed Decision
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