Clinical audit on postpartum hemoglobin levels: A study on postpartum anemia

INTRODUCTION

Hemoglobin (Hb) in red blood cells (RBCs) acts as a carrier to transport oxygen from the lungs to tissues and organs through blood. It is a protein that contains iron and its deficiency could lead to insufficient oxygen supply in the body. During pregnancy, the mother requires more iron to meet the increase in blood volume and to enhance the oxygen transport to the baby. The normal Hb level in women is 12–16 g/dL and anemia arises if Hb content falls below the prescribed level.^[1] Postpartum anemia (PPA) is a low Hb concentration of <11 g/dL at 24–48 h after childbirth and ought to be considered severe at Hb level <8 g/dL. In general, delivery of placenta is followed by postpartum period which lasts up to 42 days and is considered as the crucial period of mother and infant’s health and survival.^[2] PPA is an escalating and severe form of maternal morbidity that affects up to 50–80% of women after child delivery. Worldwide, PPA remains a serious and enduring public health problem which could be preventable with awareness and implementation of adequate management strategies.^[3] The most common causes of PPA are iron deficiency before birth or severe bleeding during birth and serious health issue in women in the reproductive age. Women with PPA experience health-related quality of life including increased risk post-partum hemorrhage, emotional instability, palpitations, depression, insufficient milk syndrome, and reduced cognitive function.^[4-8] Preferred treatment choices for PPA patients are administration of intravenous (IV) iron, oral iron, and RBC transfusion (RBC-T). Without treatment, daily activities of PPA patients often met with difficulties after delivery. Therefore, when PPA is higher, it is highly advised to take up medical treatment and the most recommended options are IV-iron and RBC-T.^[4]

In India, the prevalence of PPA is estimated at 65%, highlighting the fact that it is a major public health problem. Since it is one of the silent factors contributing to maternal morbidity, it is important to assess Hb levels in women at a community level during postpartum period. We hypothesize that age of PPA patients and mode of delivery could be influential in determining the Hb levels in PPA patients. Hence, this study was proposed to evaluate the Hb levels in postpartum periods and investigate the association of age and mode of delivery of postpartum mothers on their Hb concentrations.

MATERIAL AND METHODS

Statistical analysis

Data obtained from MRD are represented as range, mean with standard deviation or percentage as appropriate. Valid and cumulative percentages were calculated for those undergone LSCS and NVD. The impact of age and mode of delivery as the risk factors on Hb level was evaluated through linear regression by Pearson correlation analysis using IBM Statistical Package for the Social Sciences Statistics version 24.0 (IBM Co., Armonk, NY, USA). A comprehensive flow chart of the study is depicted in Figure 1.

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Figure 1:

Flow chart of the retrospective study on PPA. PPA: Postpartum anemia, Hb: Hemoglobin, LSCS: Lower segment cesarean section, NVD: Normal vaginal delivery.

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RESULTS

Age distribution of postpartum mothers

Data from 70 women in the postpartum phase were considered for the study. Age of the mothers varied from 20 to 39 years with a mean value of 25 and was divided into two groups where 64.3% of them fall between 20 and 30 years and remaining 35.7% were within 30–40 years of age [Figure 2].

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Figure 2:

Distribution of age groups among postpartum mothers.

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PPA

Among all postpartum mothers, about 54% showed moderate anemia (8–10.9 g/dL), followed by 24% mild (11–11.9 g/dL) and 2% with severe anemic (<8 g/dL) condition. Twenty percent of mothers after delivery had normal Hb content indicating healthy status [Figure 3]. The prevalence of anemia in the study population is ~56% comprising a significant proportion of the postpartum mothers. The number of PPA patients was higher in LSCS with 48 compared to NVD having 8. However, considering the total number of patients undergone LSCS (No: 60) and NVD (No: 10), the percentage of PPA and healthy individuals remains the same in both modes of delivery with 80% and 20%, respectively [Figure 4].

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Figure 3:

Distribution of various stages of anemia among postpartum patients.

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Figure 4:

Postpartum anemic and healthy patients in LSCS and NVD. LSCS: Lower segment cesarean section, NVD: Normal vaginal delivery.

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DISCUSSION

The alteration in Hb values during the postpartum period in an optimal antenatal care would be of greater significance as it can provide baseline information to prevent a lot of morbid complications. This study highlights PPA as a persistent yet unacknowledged cause of women morbidity. About 56% of individuals included in the study were anemic having moderate-to-severe anemia although the latter was only 2% [Figure 3]. The value of Hb in severe anemia was 7.9 g/dL and in moderate anemia, Hb ranged from 8.2 to 10.9 g/dL. An earlier study stated that PPA with Hb level <11 g/dL can affect 50% of women after 24–48 h of delivery.^[9] A cross-sectional study on post-natal women from ethiopia reported 45% moderate anemia which is relatively less than the percentage obtained from our study (54%). However, these women had a high percentage (12%) of severe anemia as opposed to our findings.^[10]

A study conducted at the primary health-care center in Tanzania showed 34.2% prevalence rate of PPA although the authors admit that the Hb kit used in the study may not mirror the present scenario.^[2] Nevertheless, our study adds to the concern over high PPA in India as some previous studies also emphasized the prevalence of PPA of up to an alarming portion of 76.2% in the urban areas of Puducherry.^[11] Similar percentage range (76.5%) of anemic patients was also recorded in a tertiary care teaching hospital at Mumbai in 2008 where severe anemia accounted about 10.3%.^[12] Likewise, 70% anemia up to 6 weeks of postpartum period was reported among north Indian population.^[13] Other crucial factors that lead to high rate of PPA in India include low iron reserve before and during pregnancy, poor socioeconomic background, pregnancy at younger age, narrow interval between births, and higher parity.^[14] In contrast, studies from developed countries reported a general trend of lower prevalence of PPA. One of the states in Germany recorded an increase in PPA from 12.2 to 15.6% in the duration of 1998–2003. However, exceptionally, in the USA, anemia was diagnosed in 1 among every 5 cases of obstetric bleeding in the year 2003.^[9] Globally, data from the year 2019 show that 39% of pregnant women suffered from anemia, and 50–80% of women from countries of poor and middle economic status had PPA.^[15]

In our study, 85.7% underwent cesarean while 14.3% opted for vaginal delivery [Table 1]. This is contrary to the data from a hospital in Germany where 88% preferred vaginal delivery and 11.7% underwent cesarean.^[9] Our data indicate that percentage of anemic patients is the same in LSCS and NVD mode with 80% each [Figure 4] suggesting more volume of blood loss as a possible reason in both cases, although we lack the prenatal Hb level for comparison. A study by obstetric department in a hospital in Germany including 43000 women at post-partum phase concluded that blood loss during delivery was the most important reason for PPA and it was especially high in LSCS.^[9] As the rate of cesarean has increased significantly over the years, women undergoing LSCS are at a higher risk of PPA due to postpartum hemorrhage.^[16] Hence, high iron intake during pregnancy should be facilitated.

There was no significant finding on variation of PPA in relation to age or mode of labor in our study. A study in Karnataka has shown the prevalence of PPA in mothers <20 years, especially in the case of <2-year interpregnancy interval. However, a significant difference with respect to age was not reported either.^[17] Although there are a number of articles reporting the association of prenatal Hb level and mode of delivery, studies are scarce to support the relation between PPA and mode of delivery. Add to the existing data, our study showed an equal percentage of anemic patients in both modes of delivery.

CONCLUSION

The present study highlights the prevalence of PPA associated with both LSCS and NVD mode of delivery and emphasizes on the importance of adequate measures to improve nutrition and health of women during pregnancy and postpartum period. PPA is considered an underestimated health concern; however, routine Hb estimation, consumption of iron-rich foods and iron and folic acid supplementation along with proper management of antenatal anemia, and regular follow-ups will be helpful to prevent PPA.