Daily oral iron supplementation during pregnancy
Editorial Group: Cochrane Pregnancy and Childbirth Group
Published Online: 12 DEC 2012
Assessed as up-to-date: 1 NOV 2012
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Peña-Rosas JP, De-Regil LM, Dowswell T, Viteri FE. Daily oral iron supplementation during pregnancy. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD004736. DOI: 10.1002/14651858.CD004736.pub4.
- Publication Status: New search for studies and content updated (conclusions changed)
- Published Online: 12 DEC 2012
Iron and folic acid supplementation has been the preferred intervention to improve iron stores and prevent anaemia among pregnant women, and it may also improve other maternal and birth outcomes.
To assess the effects of daily oral iron supplements for pregnant women, either alone or in conjunction with folic acid, or with other vitamins and minerals as a public health intervention.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 July 2012). We also searched the WHO International Clinical Trials Registry Platform (ICTRP) (2 July 2012) and contacted relevant organisations for the identification of ongoing and unpublished studies.
Randomised or quasi-randomised trials evaluating the effects of oral preventive supplementation with daily iron, iron + folic acid or iron + other vitamins and minerals during pregnancy.
Data collection and analysis
We assessed the methodological quality of trials using standard Cochrane criteria. Two review authors independently assessed trial eligibility, extracted data and conducted checks for accuracy.
We included 60 trials. Forty-three trials, involving more than 27,402 women, contributed data and compared the effects of daily oral supplements containing iron versus no iron or placebo.
Overall, women taking iron supplements were less likely to have low birthweight newborns (below 2500 g) compared with controls (8.4% versus 10.2%, average risk ratio (RR) 0.81; 95% confidence interval (CI) 0.68 to 0.97, 11 trials, 8480 women) and mean birthweight was 30.81 g greater for those infants whose mothers received iron during pregnancy (average mean difference (MD) 30.81; 95% CI 5.94 to 55.68, 14 trials, 9385 women). Preventive iron supplementation reduced the risk of maternal anaemia at term by 70% (RR 0.30; 95% CI 0.19 to 0.46, 14 trials, 2199 women) and iron deficiency at term by 57% (RR 0.43; 95% CI 0.27 to 0.66, seven trials, 1256 women). Although the difference between groups did not reach statistical significance, women who received iron supplements were more likely than controls to report side effects (25.3% versus 9.91%) (RR 2.36; 95% CI 0.96 to 5.82, 11 trials, 4418 women), particularly at doses 60 mg of elemental iron or higher. Women receiving iron were on average more likely to have higher haemoglobin (Hb) concentrations at term and in the postpartum period, but were at increased risk of Hb concentrations greater than 130g/L during pregnancy and at term. Twenty-three studies were conducted in countries that in 2011 had some malaria risk in parts of the country. In some of these countries/territories, malaria is present only in certain areas or up to a particular altitude. Only two of these reported malaria outcomes. There is no evidence that iron supplementation increases placental malaria. For some outcomes heterogeneity was higher than 50%.
Prenatal supplementation with daily iron are effective to reduce the risk of low birthweight, and to prevent maternal anaemia and iron deficiency in pregnancy. Associated maternal side effects and particularly high Hb concentrations during pregnancy at currently used doses suggest the need to update recommendations on doses and regimens for routine iron supplementation.
Plain language summary
Effects and safety of preventive oral iron or iron + folic acid supplementation for women during pregnancy
During pregnancy, women need iron and folate to meet both their own needs and those of the developing baby. The concern is that if pregnant women become deficient in these nutrients they are unable to supply them in sufficient quantities to their baby. Low folate before conceiving increases the risk of the baby having neural tube defects. Low iron and folate levels in women can cause anaemia, which can make women tired, faint, and at increased risk of infection.
We included 60 randomised trials in the review with 43 trials involving more than 27,402 pregnant women contributing to the analyses. The use of iron or iron and folic acid supplements was associated with a reduced risk of anaemia and iron deficiency during pregnancy and of giving birth to low birthweight babies. Daily iron supplementation was, however, associated with the women having side effects such as constipation and other gastrointestinal effects including nausea, vomiting and diarrhoea and an increased risk of high haemoglobin (Hb) concentrations at term. This may be harmful to mothers and babies and is associated with late pregnancy hypertension, pre-eclampsia and pregnancy complications. There is no evidence that iron supplementation increases placental malaria.