Addressing Iron Deficiency Anemia in Pregnancy


Iron deficiency anemia (IDA) during pregnancy is a condition in which there are not enough healthy red blood cells to carry oxygen to the body’s tissues adequately. IDA may occur for many reasons. Internationally, food scarcity and a lack of access to micronutrients, such as iron, remains high in many countries. In the United States, rates of iron deficiency in pregnancy vary by region with a national average of around 14% of individuals with childbearing potential meeting diagnostic criteria. Despite the high prevalence, there are conflicting recommendations from organizations such as the American College of Obstetricians and Gynecologists (ACOG), the Center for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the Society for Maternal-Fetal Medicine (SMFM) on best practices for treatment and continued monitoring of IDA in pregnancy.

Untreated iron deficiency in pregnancy has been associated with maternal, fetal, and newborn complications. Maternal complications include increased fatigue, preeclampsia, blood loss with birth, risk for postpartum depression, decreased milk supply, and slower recovery in the postpartum period. General pregnancy complications include risk of miscarriage, preterm labor, fetal growth restriction, and intrauterine fetal demise. Research has investigated potential risks for fetal brain development in the context of maternal anemia, including risk for learning disorders, attention deficit disorders, and even correlation with autism spectrum disorder and schizophrenia. Practices such as delayed cord clamping and cord milking have been proven to reduce the risk of neonatal anemia and subsequent neurological consequences. The role of iron replacement treatments, oral supplementation, and intravenous infusion in preventing long-term neonatal and maternal morbidities warrants further investigation.

Oral supplementation has remained the standard treatment for IDA. One reason for this benchmark is affordability. Oral supplements are widely available in multiple formulations at most pharmacies without a prescription. With oral iron supplements, some patients find increase gastrointestinal side effects that may lead to poor tolerance. Often, a trial of alternative formulations may be beneficial in reducing these side effects. Stool softeners and the addition of dietary iron sources can also help reduce negative side effects and increase adherence. New research has guided clinicians on the appropriate administration of iron supplementation and a stepwise approach to treatment that investigates iron indexes at various points during pregnancy to optimize serum iron levels prior to birth.

Recent studies highlight the potential for intravenous iron infusion (IV iron) to expedite treatment and improve maternal, fetal, and neonatal outcomes. Older formulations of IV iron had a significant risk for anaphylaxis, making many providers wary of unnecessary use. Newer formulations have proven to be effective for the rapid treatment of iron deficiency anemia. While cost is still a consideration, the benefits of treatment appear to outweigh the costs in many cases of maternal anemia. Additional research is needed to further investigate the long-term cost-benefits of treating mild anemia or low ferritin without clinical anemia. 

Once the treatment method of choice has been identified, additional monitoring is needed to evaluate the effectiveness of treatment and continued plan of care. Depending on the trimester in which IDA is identified as well as the severity of the anemia, clinicians may be more inclined to recheck levels sooner rather than later. When iron indexes do not respond to initial treatments, a change in the treatment plan is indicated. Changing treatment may mean an alternative formulation of oral iron or initiation of an IV iron infusion. While research regarding monitoring low ferritin or TSAT without a clinical diagnosis of anemia is lacking, many clinicians believe it is beneficial to treat with hopes of preventing the development of anemia. The potential benefits must be weighed against the risk for excess iron to inhibit maternal absorption and transfer to the fetus. More research is needed in this area to better understand these benefits and risks. You can learn more about iron deficiency anemia treatment and monitoring at the upcoming ACNM 66th Annual Meeting, held virtually May 23 – 25, 2021.


Christina Elmore, MSN, CNM

Christina has been practicing clinically with Birth Care Health Care at the University of Utah since 2012. She is also an Assistant Professor at the University of Utah’s College of Nursing and teaches Intrapartum Normal and Intrapartum Complications to Doctoral Midwifery students. She has served as the Utah ACNM Affiliate President since 2017 and was the Vice President for two years before that position. She also serves on the ACNM Membership and Marketing Committee. She has been presenting on the topic of Persistent Occiput Posterior since 2017. She is passionate about International Midwifery and has worked with several organizations, including PRONTO International and Maya Midwifery International. Christina views her role as a midwife as having additional training and medical fluency to provide information, support, and advice to help women and families navigate their unique circumstances. She is passionate about the birth process, empowerment of women, and advancement of the profession of midwifery.

Jessica Ellis, PhD, CNM

Jessica is a Utah native who supports midwifery care for individuals and midwifery education. Jessica works with BirthCare HealthCare as a full scope clinical midwife, and she is an assistant professor at the University of Utah, where she teaches Advanced Pharmacology and Childbearing Complications. Jessica promotes the normal (physiologic) birth process through her clinical care and by engaging in research focused on birth processes and outcomes. She believes individuals are the healthiest when they listen to their bodies and engage in their own healthcare decisions through a shared decision-making model. In her free time, Jessica enjoys cooking, gardening, hiking, and skiing. She loves living in Utah and playing in the mountains.