An analysis of anemia and pregnancy-related maternal mortality

The relationship of anemia as a risk factor for maternal mortality was analyzed by using cross-sectional, longitudinal and case-control studies because randomized trials were not available for analysis. The following six methods of estimation of mortality risk were adopted: 1) the correlation of maternal mortality rates with maternal anemia prevalence derived from national statistics; 2) the proportion of maternal deaths attributable to anemia; 3) the proportion of anemic women who die; 4) population-attributable risk of maternal mortality due to anemia; 5) adolescence as a risk factor for anemia-related mortality; and 6) causes of anemia associated with maternal mortality. The average estimates for all-cause anemia attributable mortality (both direct and indirect) were 6.37, 7.26 and 3.0% for Africa, Asia and Latin America, respectively. Case fatality rates, mainly for hospital studies, varied from <1% to >50%. The relative risk of mortality associated with moderate anemia (hemoglobin 40-80 g/L) was 1.35 [95% confidence interval (CI): 0.92-2.00] and for severe anemia (<47 g/L) was 3.51 (95% CI: 2.05-6.00). Population-attributable risk estimates can be defended on the basis of the strong association between severe anemia and maternal mortality but not for mild or moderate anemia. In holoendemic malarious areas with a 5% severe anemia prevalence (hemoglobin <70 g/L), it was estimated that in primigravidae, there would be 9 severe-malaria anemia-related deaths and 41 nonmalarial anemia-related deaths (mostly nutritional) per 100,000 live births. The iron deficiency component of these is unknown.