2018 Audit of the Management of Maternal Anaemia and Iron Deficiency in United Kingdom and Republic of Ireland

Key objectives

To determine the prevalence of Iron Deficiency Anaemia (IDA) during pregnancy and the pueperium in a sample of women
To provide national comparative data on the screening, recognition and treatment of anaemia in pregnancy
To present information on adherence to best practice as recommended in the BSH and NICE guidelines
To examine the steps in the management pathway for IDA in pregnancy from screening through to treatment and follow-up of women during and immediately after pregnancy
To compare the pregnancy outcomes of the women who developed iron deficiency anaemia in pregnancy, with those from the cohort who did not develop anaemia

What did we audit?

All hospitals with a maternity unit were invited to enrol in the audit, and to audit a sample of 10 consecutive live births per maternity unit
There was an agreed 72 hour time frame in which these births occurred, and if sites have 10 births in first 24 hours, they could stop collecting data. Otherwise, they would continue until the target of 10 births was reached
Data collection stopped after 72 hours from the start of the audit period, regardless of how many births had been audited
Data was submitted either using an online data collection tool, or sites could return completed audit proformas when data was entered by Comparative Audit staff
Data was cleaned and analysed by the Project Group and an interim report was issued in August 2019
STATA v15.1 was used to perform the analyses. Chi² was used for significant testing of categorial data

Who took part?

86 maternity units participated
860 births were included in the data collection
Conducted between November 2018 and March 2019

What did we find?

Main findings and recommendations

97-98% of pregnant women were screened for anaemia at first presentation of pregnancy, ideally in the first trimester, and again at 28 weeks gestation
30.4% overall prevalence of anaemia in all women screened (262/845), in accordance with BSH Hb levels, regardless of diagnosis
A total of 55 women were started on oral iron during their pregnancy
2.6% of women were found to be anaemic in the first trimester (20/765), rising to 4.14% (35/845) when including those whose "booking in" was after their first trimester:

- only half commenced oral iron therapy
- 16.3% (133/815) women screened received a new diagnosis of anaemia at 28 weeks
- only 30% of these women were started on oral iron treatment
41.3% of women tested up to 6 weeks post-partum were found to be anaemic:

- of which 74% were started on oral iron and discharged home on treatment 74%
- of those diagnosed with anaemia a higher prevalence was observed in black, asian and minority women. They were also found to be more at risk of blood loss post delivery

Recommendations

Hospitals should review local guidelines for the detection and management of anaemia in pregnancy to ensure they align local guidance with the latest BSH and NICE guidelines
Act on all gestationally adjusted abnormal Hb results within 2 weeks by starting affected women on treatment
Treat with oral iron in the first instance. Document type, frequency and dose of iron in the care record
Provide written information on how to take oral iron to maximise absorption
Provide written dietary information to maximise the availability of iron through diet
Review anaemic women within 2 to 4 weeks of starting treatment depending upon the gestation
Document the response to treatment and any side effects experienced by the woman
If the response is sub-optimal (<10-20g/L) check the woman’s level of B12 and folate, and treat accordingly
Provide clear documentation and a plan for primary care detailing the on-going management required in the postnatal period
Audit local screening uptake at the first trimester/presentation and at 28 weeks ensuring that it exceeds 95%
Audit the testing and treatment in the pueperium to ensure that all at-risk women are tested