Effects of implementing a standardized protocol for identifying and treating iron-deficiency anemia in pregnancy

Iron-deficiency anemia is a common finding in pregnancy; however, current obstetric practice lacks standardized recommendations for its diagnosis and treatment during pregnancy, and data are limited regarding the effectiveness of diagnosis and treatment strategies toward improving pregnancy outcomes.

We conducted a retrospective study to examine the impact of a standardized protocol for the diagnosis and management of iron-deficiency anemia in pregnancy implemented in June 2018 across all 61 prenatal care facilities in an integrated healthcare delivery system. Our primary aim was to compare the prevalence of anemia at the time of delivery among pregnant patients who received prenatal care before protocol implementation with those who received care after protocol implementation. Secondary outcomes included receipt of iron infusions and peripartum red blood cell transfusions. Relative risks for each outcome were adjusted (aRR) for potential confounders.

During the specified pre-protocol study period, there were 16,151 eligible pregnancies with iron-deficiency anemia (prevalence 19.5%); during the post-protocol period, 8604 pregnancies were identified with iron-deficiency anemia (prevalence 23.3%). Patients with iron-deficiency anemia receiving prenatal care post-protocol had 21% lower risk of anemia at the time of delivery compared with those receiving care pre-protocol (aRR 0.79, 95% confidence interval, CI 0.76-0.83). In stratified analyses, post-protocol (vs. pre-protocol) prenatal care was also associated with lower risk of anemia at delivery in each racial and ethnic subgroup. Parenteral iron therapy utilization was more than twofold higher in the post-protocol cohort (aRR 2.25, 95% CI 2.09-2.42). While not statistically significant, a modest reduction in risk of peripartum blood transfusion was also observed in the post-protocol cohort (aRR 0.89, 95% CI 0.78-1.02).

Implementation of a standardized protocol for the diagnosis and management of iron-deficiency anemia during pregnancy was associated with uniformly lower risk of anemia at delivery. Maternal care in the post-protocol time frame was associated with greater utilization of iron infusions for management of iron-deficiency anemia and reduced peripartum red blood cell transfusion.