Anaemia and Caesarean Section in Caucasian race: Assessment of risk factors and management strategies

Background: Anaemia among pregnant women is a significant public health concern, particularly in developing countries, due to its adverse effects on both maternal and fetal health. This study addresses the gap in research regarding anaemia in pregnant women in northern Iran, specifically among those undergoing elective caesarean sections. The objective is to assess the prevalence of anaemia in this population.

Methods: This retrospective cross-sectional study included 719 pregnant women who were candidates for elective caesarean sections from September 2020 to March 2023. Data were collected from medical records, including haemoglobin levels, history of anaemia, previous pregnancy experiences, and demographic information. Data analysis was performed using SPSS version 20, with quantitative variables reported as means and standard deviations and qualitative variables presented as frequencies and percentages. The Chi-square test was employed to compare anaemia prevalence across different demographic groups, with a significance level set at p value < 0.05.

Results: Among the 719 participants, key demographic findings revealed that most had primary education (26.8%), while only 12.4% held university degrees. A majority (59.8%) resided in urban areas, with the largest age group being 31-36 years (30.5%). Most women (75.2%) reported no history of miscarriage, and 98.2% experienced no bleeding during pregnancy. The primary indication for caesarean section was a previous caesarean delivery (69.4%), with other reasons including fetal heart rate abnormalities, meconium presence, and various medical conditions. Notably, 57.7% of women reported no underlying health conditions; however, 9.2% had gestational diabetes, while others had blood disorders, neurological issues, or gastrointestinal problems.

Conclusion: The prevalence of anaemia among patients undergoing elective caesarean sections was found to be 10.85%. Anaemia was more prevalent in women aged 25-30 years, those with low educational attainment, urban residents, and mothers with a previous pregnancy history. The only underlying condition significantly associated with a higher prevalence of anaemia was diabetes or impaired blood sugar levels. Furthermore, a considerable proportion of patients reported irregular consumption or non-consumption of iron supplements and prescribed medications during pregnancy, highlighting the need for improved maternal care education programs. The most common indication for caesarean delivery was a history of previous caesarean sections.

The prevalence of anaemia worldwide is 24.8%, affecting 1.62 billion people [1]. The most affected groups are women and children in Africa and South-East Asia. The global prevalence of anaemia during pregnancy was estimated at 38% in 2011. Although this has decreased from 43% in 1995, it still constitutes a major public health problem in both low- and high-income countries. The prevalence of maternal anaemia in high-income countries was estimated at about 25% in 2011 [2]. According to UK guidelines on anaemia in pregnancy, anaemia in the first trimester is defined as haemoglobin less than 11 g/dL, in the second and third trimesters as haemoglobin less than 10.5 g/dL, and after delivery as haemoglobin less than 10 g/dL. Recent observational data from a multicentre study in the UK involving 2103 women estimated the prevalence of anaemia to be 24.4% [3, 4]. There is evidence that anaemia is a risk factor for maternal and neonatal clinical outcomes such as low birth weight [5]. A recent study on iron deficiency anaemia in Israel showed an increased risk of caesarean section, blood transfusion, and low Apgar score [ 6 and 9]. In a study conducted by Milad Azami and colleagues at Ilam University of Medical Sciences as a meta-analysis from 2005 to 2016, the prevalence of anaemia in Iranian pregnant women was reported to be 17%. The highest prevalence of anaemia in this study was related to the centre of the country (23%) and the lowest was related to the west of the country [12%]. In this study, the prevalence of anaemia in urban and rural pregnant women was calculated to be 21% and 8%, respectively. This study concluded that anaemia in Iranian pregnant women has increased in the last 11 years compared to the years before 2005. Therefore, appropriate intervention programs should be developed and implemented in prenatal clinics or before marriage [7 and 11]. During pregnancy, anaemia is a major cause of maternal morbidity and mortality in developing countries and has both maternal and fetal consequences [8 and 13]. It can also lead to preterm birth [14], low birth weight [15], fetal mental retardation, and stillbirth [16 and 17]. Iron deficiency anaemia is the most common form of malnutrition in the world and the most common type of anaemia [18]. Most anaemia during pregnancy are also due to iron deficiency [19]. The diagnosis of anaemia, especially iron deficiency anaemia, is simple and inexpensive [10]. More importantly, its treatment is also inexpensive and simple and can be treated after removing the underlying cause such as bleeding, parasitic factors [12], poor diet, gastrointestinal diseases, menstrual disorders, prescribing dietary supplements such as iron tablets, and in very severe cases, iron injections or blood transfusions. Given the importance of anaemia among pregnant women as one of the high-risk and sensitive population groups in the world and also our country, as well as the adverse effects of anaemia on the mother and foetus, timely diagnosis and treatment of this disease is important. Since a similar study has not been conducted in north of Iran and Caucasian race, a study was designed to investigate anaemia in pregnant women who are candidates for elective caesarean section. This study aims to investigate the prevalence of anaemia in this group of mothers, considering that bleeding in caesarean surgery is greater than in natural childbirth and also increases the likelihood of postpartum anaemia

719 pregnant woman who were candidates for elective Caesarean section from September 2020 to March 2023 enrolled in the study. data were extracted from the medical records archive. Then, using the laboratory archive, the patient’s haemoglobin values ​​at the time of term and before delivery were extracted. Also, other information included in the patient’s medical record, including history of anaemia, previous pregnancy history, history of abortion, history of bleeding during pregnancy, history of hereditary blood diseases, type of probable anaemia, dose and frequency of iron supplementation, current gestational age, place of residence (village or city), patient’s age, occupation, level of education, reason for caesarean section, were collected and recorded in the relevant checklists. In this study, according to UK guidelines, anaemia in the first trimester of pregnancy is defined as haemoglobin less than 11 g/dL, in the second and third trimesters as haemoglobin less than 10.5 g/dL, and after delivery as haemoglobin less than 10 g/dL. After data collection, data analysis was performed [27].

Type of study: a retrospective cross-sectional and descriptive study.

Study population: Pregnant women who candidates for elective caesarean section

Study sample: Pregnant women candidates for elective caesarean section referred to Motahari Educational and Treatment Centre in Urmia in North of Iran September from 2020 to March 2023.

Data collection tools: frome checklists and patients application records 

Data analysis method: Quantitative variables were reported as mean and standard deviation, and qualitative variables were reported as frequency (percentage) in the form of appropriate tables and charts. To compare the frequency of anaemia according to months of pregnancy, age groups, urban or rural residence, and educational level, the Chi-square test (Fisher’s exact test if necessary) was used. A significance level of less than 0.05 was considered. Data analysis was performed using SPSS20 software.

Ethical considerations

All patient information was kept confidential. The research project was implemented after approval by the Ethics Committee of Urmia University of Medical Sciences.

719 pregnant women who were candidates for elective Caesarean section from September 2020 to March 2023 enrolled in the study. The demographic characteristics of the qualitative variables are shown in Table (1). Most women had primary education (26.8%), and the lowest frequency was related to university education (12.4%). 59.8% of women were urban. 33.8% of them had one previous pregnancy and 15.2% were nulliparous. Most mothers were in the age group of 31-36 years (30.5%), and the age group above 36 years (20.6%) had the lowest frequency. 75.2% of mothers had no history of previous miscarriage. 98.2% had no history of bleeding during pregnancy. The indication for Caesarean section in 69.4% of women was having a previous Caesarean section. Other indications for Caesarean section included fetal heart rate drop (37 people with 5.1%), meconium (24 people with 3.3%), arrest of descent or dilatation (9 people with 1.3%), abnormal fetal presentation (60 people with 8.6%), anatomical problems (14 people with 1.9%), placental problems (12 people with 1.7%), heart problems (3 people with 0.4%), discopathy (5 people with 0.7%), valuable fetus (8 people with 1.1%), fetal distress (7 people with 1%), fetal macrosomia (2 people with 0.3%), severe preeclampsia (12 people with 1.7%), genital warts (2 people with 0.3%), trauma (10 people with 1.4%), positive OCT test (5 people with 0.7%), self-requested (1 person with 0.1%), and a combination of these (9 people with 1.3%). 

57.7% of women had no underlying disease, and 9.2% of them had gestational diabetes. Other underlying diseases included blood diseases (anaemia, thalassemia, thrombocytopenia) (2.4%), neurological diseases (epilepsy, migraine) (1.3%), infertility (1.9%), depression (0.4%), heart diseases (valvular), benign or malignant tumor (lipoma, meningioma, ovarian or breast cancer), liver problems (fatty liver, elevated liver enzymes), kidney and urinary tract problems (pyelonephritis, hydronephrosis, polycystic kidney, kidney stones, urinary tract infection), gastrointestinal problems (gastritis, dyspepsia), asthma (dyspnea), lupus, and a combination of these (11.4%).

Table 1: Frequency and Percentage of Qualitative and Quantitative Variables in Women Candidates for Elective Caesarean

Table 2: Mean and Standard Deviation of Quantitative Variables in Women Candidates for Elective Caesarean Section

Table 3: Frequency of Anaemia in the Third Trimester of Pregnancy Based on Studied Variables in Women Candidates for Elective Caesarean Section

Haemoglobin less than 10.5 was defined as anaemia in the third trimester of pregnancy. In general, 78 women (10.8%) had anaemia in the third trimester of pregnancy. The frequency of anaemia based on the studied variables, except underlying diseases, did not have a statistically significant difference. However, the highest frequency of anaemia was in the age group of 25-30 years (32.1%), in illiterate women (26.9%), urban women (69.2%), and women with one pregnancy (33.3%). The frequency of anaemia based on underlying disease was higher in women with diabetes or impaired blood sugar (19.2%) (P = 0.013). Table (3): Comparison of Anaemia Frequency in the Third Trimester of Pregnancy Based on Studied Variables in Women Candidates for Elective Caesarean Section

A and b: Based on Bonferroni correction test, the same letters in each column indicate no significant difference and different letters indicate a significant difference in the frequency of that grouping in each variable between the two groups (haemoglobin less than 10.5 and haemoglobin greater than or equal to 10.5. According to this, based on the underlying disease, the frequency between the two groups has a significant difference (the group of diabetes or impaired blood sugar). 

Table (4) shows the frequency of anaemia after delivery based on the studied variables in women candidates for elective caesarean section. Haemoglobin less than 10 was defined as anaemia after delivery. In general, 124 women (17.2%) had anaemia after delivery. The frequency of anaemia after delivery based on the studied variables, except based on the history of bleeding during pregnancy, did not have a statistically significant difference. However, the highest frequency of anaemia was in the age group of 25-30 years (26.6%), illiterate women (25%), and those with primary education (29.8%), women with 2 previous pregnancies (31.5%), women with 2 children (34.7%), gestational age more than 37 weeks (69.4%).

Table 4: Comparison of Anaemia Frequency After Delivery Based on Studied Variables in Women Candidates for Elective Caesarean Section

A: Based on Bonferroni correction test, the same letters in each column indicate no significant difference in the frequency of that grouping in each variable between the two groups (hemoglobin less than 10 and hemoglobin greater than or equal to 10. The mother’s weight and height were not studied, and the frequency of anemia in the first and second trimesters was not included in the study due to a lack of data in the patient’s hospital records

Anemia is one of the common medical problems worldwide, especially among women [1]. The physiological differences between women and men have increased the prevalence of this disease among women. Pregnancy in women increases the likelihood of anemia due to increased needs or exacerbates underlying anemia. The main population affected by anemia are African and Southeast Asian women and girls. The global prevalence of this disease, according to a 2011 review, is 38%, which is estimated to be 25% in high-income countries [2, 10]. A study by Milad Azami and colleagues between 2005 and 2016 estimated the prevalence of anemia in women's to be 17% [7]. In addition to maternal complications of anemia such as early fatigue, reduced tolerance to physical activity, lethargy, reduced mood, shortness of breath, there is evidence of the impact of this disorder on the infant, such as low birth weight [5]. Studies also cite pregnancy anemia as a risk factor for caesarean section, blood transfusion, and low infant Apgar scores [6]. This disease is more of a symptom than an independent disease, and medical, social, cultural, economic, and nutritional factors are involved in its development and progression. From this perspective, health and treatment systems around the world have prioritized this group of the population as a high-risk and high-priority population, and have developed and implemented extensive health and treatment programs for the diagnosis and treatment of anemia in pregnant mothers. In our country, with the expansion of health and treatment services for pregnant mothers, one of the goals of diagnosis, treatment, and more importantly, prevention of anemia, especially iron deficiency anemia, as the most common cause of anemia during pregnancy, has been prioritized. In the present study, anemia in the third trimester was defined as a hemoglobin concentration of less than 10.5 grams per decilitre, and based on this, this study was designed and implemented. According to the findings of this study, the prevalence of anemia in the studied patients was 10.85%. This finding is similar to the study conducted by Milad Azami and colleagues, which reported anemia in pregnant women in western Iran to be 12%. However, our study only determined the prevalence and was only conducted on patients undergoing elective caesarean section, not all pregnant patients (Table 1). This finding is noteworthy despite the fact that 41.4% of the studied patients did not use iron supplements or used them irregularly (Table 2). The prevalence of anemia in the study by Senadheera.D and colleagues, which included a study of 350 pregnant mothers in the first and second trimesters, was reported to be 16.6%. This study also examined the status of iron deficiency, which indicated iron deficiency in 36.6% of the studied mothers [20]. In our study, due to its retrospective nature and the lack of laboratory investigations in the patients' records, this investigation was not possible. The prevalence of iron supplement use in the study by Yesufu BM and colleagues was 31.8%, and the high rate of non-use or irregular use of these supplements among the patients in the present study necessitates more education and emphasis on the need for regular use. In examining the relationship between demographic factors and the prevalence of anemia, the interesting point was the higher prevalence of anemia at admission among urban patients compared to rural patients (69.2% vs. 30.8%, respectively, Table 3). This may be explained by the wider coverage of maternal care programs in rural areas compared to urban areas and the possibility of providing active services by service providers. Although this difference was not statistically significant (P = 0.072). This notable finding is consistent with the study by Milad Azami and colleagues, in which the prevalence of anemia was reported to be higher in the urban population than in the rural population [21% and 8%, respectively [7].

Our study showed that the prevalence of anemia was higher in the 25–30-year age group and illiterate women. This result is consistent with the results of the study by Amel.Ivan.E and other colleagues, although the statistical difference between the two groups was not significant. Also, in the present study, anemia was more common in women with one previous pregnancy than in nulliparous and multiparous mothers, while in the study by Amel.Ivan.E, it was more common in multiparous mothers (24). In the study by Adanikin AI and colleagues, the only demographic variable associated with high prevalence of anemia was the mothers’ occupation, with the disorder being more prevalent in unemployed or student patients (P = 0.007), which was explained by the relationship between patient income and anemia [21]. Senadheera D e al. In Sri Lanka had shown the prevalence of anemia during pregnancy is less than 20%. The aim of this study was to determine the prevalence of anemia, defined as hemoglobin concentration less than 11 g/dL, and iron deficiency using serum ferritin in women attending antenatal care. The prevalence of anemia was calculated to be 16.6%. The best cut-off level of serum ferritin for diagnosing anemia was less than 30 µg/L. 36.9% of pregnant women had iron deficiency. It was concluded that the prevalence of anemia (16.6%) and iron deficiency (36.9%) during pregnancy were of mild to moderate public health importance, respectively [20].

Late antenatal care uptake by women in low-income areas makes timely interventions in correcting anemia difficult. Identifying modifiable sociodemographic factors that predict anemia before antenatal care initiation and provide appropriate recommendation [21].

Ikeanyi EM et al. showed that the prevalence of anemia was 32.2% in this population at registration. At term or delivery, 736 of 1052 who met the study criteria improved from anemia (21.4%, odds ratio=3.2, P<0 OR=0.43,>0.05 in all) [22] another study showed that most respondents had a moderate level of knowledge and a positive attitude towards the use of contraceptive methods, but a high proportion of them did not agree with the daily intake of iron supplements. Therefore, it was recommended that health education for women and also close family members be strengthened to improve the agreement with the use of supplements [23].

Amel. Ivan. E et al showed in their study, there is a need for health education programs with emphasis on adherence to iron supplementation and adequate consumption of iron-rich diets during pregnancy to strengthen them and achieve safe maternal and fetal outcomes (24). Also. hemoglobinopathies should be screened in antenatal clinics to identify couples who need prenatal testing [25]. knowledge about the cause of anemia, signs and symptoms of anemia, and an appropriate diet to prevent anemia is poor, but women knowledge about the prevention and treatment of anemia is vital [26].

Finally, Iron supplementation during pregnancy is a very cheap, effective, and accessible method for preventing and treating iron deficiency anemia and preventing its direct and indirect complications. Given the lack of use or irregular use of these drugs, it is necessary to reflect this problem to the health sector and take necessary steps to change this behavior.

Pregnancy clinics are very important centers for the prevention, diagnosis, and if necessary, treatment of detected diseases. In addition to this, registering patient information for future follow-ups and extracting information for future studies is important. Unfortunately, the clinics in developing countries may can no be able to provide such a prevention care. On the other hand, it is necessary to provide the possibility of integrating clinical and laboratory information of pregnancy care with hospitalization information, especially in cases where examinations have been performed on an outpatient basis and in other private or public centers. The scattering of medical information, in addition to increasing unnecessary duplication in the diagnosis and treatment of patients, is a serious obstacle.

Funding

No funding or grant support was received. None of the authors have any financial interests related to the content of the manuscript.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. 

Declarations

Ethics approval and consent to participate This study was performed in accordance with Helsinki Declaration, and was approved by the Ethics Committee of Urmia University of Medical Sciences. No. IR.UMSU.REC.1397.125. The need for consent to participate was waived by the Ethics Committee of Urmia University of Medical Sciences.

Consent for publication

Not applicable. 

Competing interests

The authors declare no competing interests