Postpartum anaemia in three New Zealand district health board regions: An observational study of incidence and management

Abstract

Background The incidence of postpartum anaemia (PPA) in New Zealand, and the extent of intravenous iron (IV‐iron) use in its treatment, are unknown. Aims To report the incidence of PPA in three district health board (DHB) regions and describe current management of moderate to severe PPA, including by ethnicity. Materials and Methods Retrospective observational study of PPA (haemoglobin (Hb) <100 g/L) in three DHBs from July–December 2019. Cases with moderate to severe PPA (Hb <90 g/L) were reviewed and management compared to local and national guidance. Logistic regression examined demographic associations of PPA. Results There were 8849 women who gave birth during the study period: 4076 (46%) had postpartum Hb testing and 1544 (38%) had PPA. Of those tested, and after adjusting for deprivation and region, European women had lower adjusted odds ratios compared to Māori for being identified as having PPA (0.46, 95% CI 0.37–0.57, P < 0.01). Of 681 women with Hb <90 g/L, 278 (41%) received IV‐iron only, 66 (10%) red blood cell transfusion (RBC‐T) only and 155 (23%) both. Of those receiving RBC‐T, 40/221 (18%) were actively bleeding. Māori (92/138, 67%) and Pacific (127/188, 68%) women with Hb <90 g/L had the highest incidence of IV‐iron use. No guidelines provided recommendations for haemodynamically stable women without active bleeding. Conclusion The incidence and management of PPA differs by ethnicity but fewer than half of the women had Hb testing, making precise determination of incidence impossible. The majority of women with Hb <90 g/L received IV‐iron, with or without RBC‐T.

The fatigue after infusion or transfusion pilot trial and feasibility study: A three‐armed randomized pilot trial of intravenous iron and blood transfusion for the treatment of postpartum anemia

“…5 We previously reported that of the 46% of women tested, 38% had PPA (Hb <100 g/L). 5 Pre-birth anemia and postpartum hemorrhage are the most significant contributors to PPA. [6][7][8][9][10][11] PPA is strongly associated with maternal mortality and severe morbidity, including admission to intensive care, particularly after major postpartum hemorrhage.…”

“…RBC-T is a limited resource and is associated with transfusion reactions including alloimmunization, with serious implications for subsequent pregnancies. 27 In the last decade, third-generation high-single-dose IV-iron formulations have been increasingly used 28,29 as an alternative to, or alongside, RBC-T for the treatment of more severe PPA, 5 and associated with escalating healthcare costs. 30 Despite the increasing popularity of IV-iron, and Patient Blood Management recommendations supporting its use as an alternative to RBC-T for hemodynamically stable women with PPA, 27,31,32 there is a lack of evidence on the comparative safety and effectiveness of IV-iron and/or RBC-T for both woman-centered and laboratorybased outcomes (Caljé et al 2023).…”

“…2,34 These social determinants of health are also likely to be drivers of differences for M aori (Indigenous people) and Pacific women in New Zealand, 35 who have a higher incidence of anemia before and after birth than women of other ethnicities. 5 PPA and fatigue are largely preventable, treatable physiological factors that require evidence-informed care. Gold-standard randomized clinical trial evidence directly comparing IV-iron, RBC-T, or a combination is urgently needed to guide practice, and should include populations most likely to benefit.…”

Māori women's reproductive health

“…Of those tested, and after adjusting for deprivation and region, European women had lower adjusted odds ratios compared to Māori for being identified as having postpartum anaemia in a three-region observational study by Calje et al 4 Cowan et al 5 evaluated the effect of the introduction of the Perinatal Institute's Growth Assessment Protocol (GAP) in the Counties Manukau Health region, South Auckland, New Zealand, on antenatal detection of small-for-gestational-age (SGA) infants and maternal and perinatal outcomes. They found GAP was associated with increased detection of SGA.…”

“…Of those tested, and after adjusting for deprivation and region, European women had lower adjusted odds ratios compared to Māori for being identified as having postpartum anaemia in a three‐region observational study by Calje et al 4 …”