DOI: 10.1111/1471-0528.

13225 Commentary
www.bjog.org

Anaemia, pregnancy, and maternal mortality: the

problem with globally standardised
haemoglobin cutoffs
S New, M Wirth
Maternova, Inc., Providence, RI, USA
Correspondence: S New, MPH, Maternova, Inc., 460 Harris Ave, Ste 201, Providence, RI 02909, USA. Email snew@ceip.us

Accepted 24 October 2014.

Please cite this paper as: New S, Wirth M. Anaemia, pregnancy, and maternal mortality: the problem with globally standardised haemoglobin cutoffs. BJOG
2015;122:166–169.

Linked article: This article is commented on by S Allard, p. 169 in this issue. To view this mini commentary visit http:// dx.doi.org/10.
1111/1471-0528.13226.

Maternal anaemia, mea sured as low haemoglobin (Hb) in
the blood during pregnancy, remains a serious global
health problem that has declined by 5% since 1995.1 An
estimated 38% of pregnant women are affected by anaemia
worldwide, translating into 32 million women globally.1
Severe maternal anaemia is strongly associated with mater-
nal mortality and is typically confounded by multiple
underlying conditions.2 Despite this known complexity,
iron deficiency is often misidentified as the single contribu-
tor to the onset of anaemia. Nutritional deficiencies of folic
acid and vitamin B12, etc., infectious diseases such as
human immunodeficiency virus (HIV), parasitic infections
such as hookworm and schistosomiasis and inherited
genetics are additional and often neglected causes of anae-
mia.3 As we approach 2015, many countries will fail to
meet Millennium Development Goals (MDGs) 5A, a target
to reduce maternal mortality by 75%. This shortfall may be
related to the under-appreciation of the multiple factors
that complicate maternal anaemia.
Current prevention efforts are concentrated on treating
iron deficiency with universal iron supplementation during
pregnancy. The World Health Organization (WHO) rec-
ommends a dosage of 60 mg iron and 400 lg folic acid
daily during the last 6 months of pregnancy.4 Nevertheless,
globally only 50% of anaemia in pregnant women is
responsive to iron.1 In developing countries where severe
anaemia is prevalent, a universal approach can neglect
other untreated diseases and may not be appropriate. Con-
versely, iron supplementation may be counterproductive in
non-anaemic pregnant women, for example, increasing the
risks of hypertension.5 Regardless of treatment, appropriate
indicators of iron status must be defined to evaluate the
effectiveness of universal strategies before targeted interven-
tions can occur.
Current screening guidelines for
anaemia
Haemoglobin concentration is used to determine the diag-
nosis and severity of anaemia in low resource settings, an
indicator that is routinely screened using WHO-defined
haemoglobin cutoffs. These thresholds are lower for preg-
nant women (females ≥ 15 years of age) than non-pregnant
women (11.0 g/dl versus 12.0 g/dl).3 Severity of anaemia is
determined using additional cutoffs, with severe anaemia
defined as a haemoglobin level of less than 7.0 g/dl.3 Due
to the complex factors underlying maternal anaemia, these
thresholds are perhaps oversimplified.
Neglected populations
Maternal anaemia is significantly more prevalent in adoles-
cent girls than in adult women throughout gestation, with
the largest differences exhibited during the third trimes-
ter.6,7 Existing haemoglobin cutoffs lack specific recom-
mendations for pregnant adolescent girls aged <15 years.
This population has a 40% increased risk of anaemia when
compared with 20–24-year-olds and are at additional risk
of postpartum hemorrhage.7 The role that anaemia plays in
postpartum haemorrhage requires considerable additional
research, as does determination of age-specific anaemia cut-
offs for pregnant women.

166 ª 2014 Royal College of Obstetricians and Gynaecologists

 Global anaemia, pregnancy, and standardised haemoglobin cutoffs

Lower haemoglobin levels are described in the literature
for specific populations, including African Americans
( 1.0 g/dl), 13–14-year-old Jamaican girls ( 1.1 g/dl),
people of Vietnamese descent ( 1.0 g/dl) and women in
Greenland ( 0.6 g/dl).8 Further research on pregnant pop-
ulations has been undertaken since these differences were
acknowledged by WHO. One of these studies found that
mean haemoglobin values were significantly lower in
non-Caucasian than Caucasian pregnant women from
27 weeks’ gestation and continuing through term.9 Other
studies have also identified varying thresholds during preg-
nancy in Chinese and Nigerian women.10,11 This could be
explained by different underlying genetics or pathologies
among ethnic groups. These variations highlight the need
to establish reference levels for local populations and for
more confirmatory research.
Pregnant women face natural fluctuations in haemoglo-
bin levels by trimester due to fetal and maternal physiologi-
cal demands. Generally, it is recognised that there is a
normal 1.0 g/dl decrease in haemoglobin that takes place
during the first and third trimester, with haemoglobin con-
centrations diminishing an additional 0.5 g/dl in the sec-
ond trimester of pregnancy.12 In many low resource
settings, pregnancy-adjusted haemoglobin levels are rarely
taken into account, let alone trimester-adjusted cutoffs.
More precise guidelines and training for maternal specific
screening should be considered essential in the effort to
monitor iron status better.
An algorithm for improvement
The simplest algorithm (Figure 1) to diagnose maternal
anaemia accurately integrates corrective adjustments to the
WHO recommended haemoglobin cutoffs for normal, non--
pregnant women.12 We can adjust first for features that
decrease haemoglobin levels, such as gestation and popula-

Normal haemoglobin threshold for women

> 15 Years of Age = l2.0 g/dl

Summation of variables that decrease haemoglobin (Hb) concentration:

12.0 g/dl - Trimester adjustment (g/dl) - Known population adjustment (g/dl) = New Hb threshold (g/dl)

Trimester adjustment options: Known population adjustment options:

Haemoglobin Haemoglobin
Trimester Population
(g/dl) (g/dl)
First -1.0 African American -1.0
Second -0.5 Jamaican girls (13-14 year olds) -1.1
Third -1.0 Vietnamese -1.0
Unknown dating -1.0 Greenland women -0.6

+
Summation of variables that increase Hb concentration:

+ Altitude Adjustment(g/dl) + Smoking adjustment (g/dl) = New Hb threshold (g/dl)

Altitude adjustment options: Smoking adjustment options:

Altitude Haemoglobin Haemoglobin

Smoking Status
(meters) (g/dl) (g/dl)
<1000 0 Non-smoker 0
1000 +0.2 Smoker (all) +0.3
1500 +0.5 1/2 –1 packet/day +0.3
2000 +0.8 1 –2 packets/day +0.5
2500 +1.3 >2 packets/day +0.7
3000 +1.9
3500 +2.7 Anaemia diagnosis:
4000 +3.5 New Hb threshold < Observed Hb = anaemic
4500 +4.5
New Hb threshold > Observed Hb = Not anaemic

Figure 1. Algorithm to better detect maternal anemia in low resource settings.

ª 2014 Royal College of Obstetricians and Gynaecologists 167

 New, Wirth
tion (if known), and then further adjust for well-known
factors that increase haemoglobin levels, such as altitude of
residence, specifically over 1000 m, and smoking behav-
iour.3,8,12 For example, the adjusted haemoglobin value in a
pregnant Vietnamese woman who is 22 weeks pregnant, over
the age of 15, living at 1000 m above sea level and a smoker
would be calculated as follows:
12.0 g/dl (non-pregnant) 1.5 g/dl (14–26 weeks)
1.0 g/dl (population) = 9.5 g/dl3,8,12
9.5 g/dl + 0.2 g/dl (altitude) + 0.3 (smoking) = 10.0
g/dl3,12
This calculated answer would then be compared with the
individual’s haemoglobin concentration. In this example,
the resulting value of 10.0 g/dl would be the individual’s
threshold for anaemia. In other words, if her haemoglobin
levels fell below 10.0 g/dl, the pregnant women would be
considered anaemic.
This algorithm can improve screening for anaemia. How-
ever, ignoring additional modifying factors (e.g. unknown
factors) may lead to inaccuracies. Another disadvantage of
this method is that the severity of anaemia cannot be deter-
mined. In any health setting, clinical examinations still
remain invaluable in diagnosing anaemia. Physical examina-
tions should always be performed prior to confirmatory
testing, especially checking for pallor in the conjunctiva of
the eye, pale fingernail cuticles and pale palms.4
A call to action
Because anaemia plays such a pernicious role in maternal
morbidity and mortality, careful attention must be paid to
variables affecting the aetiology of anaemia and the cutoffs
for diagnosis. The risks of ignoring these differences are
high. If large swathes of the population are over-diagnosed
with anaemia and subsequently treated, there is the risk
of overtreatment and unnecessary use of resources.
Conversely, if population groups are under-diagnosed
based on unadjusted thresholds, then the risk is that anae-
mia is left untreated. Under-diagnosis and under-treatment
leave women at increased risk for preventable causes of
death including postpartum haemorrhage and hypovo-
laemia.
Correct diagnosis of anaemia is only feasible when health
care providers adjust haemoglobin levels appropriately,
review other clinical symptoms and take into account mul-
tiple factors in their approach to care. In settings where
community health workers, for example, are providing the
majority of frontline care, modifying cutoffs adds a layer of
complexity that we recognise to be a challenge. Simple
visual charts and automated calculations could make diag-
nosis less cumbersome. With MDG 5A currently unattain-
able for many countries, a focus on the diagnosis of
168
anaemia should be considered an important part in reach-
ing maternal health targets beyond 2015.
Disclosure of interests
Not applicable.
Contribution to authorship
Sarah New was the main author who made substantial con-
tributions to conceptions and design of the paper, as well
as drafting the article. Meg Wirth conceived the paper and
assisted in drafting, editing, and revising the article. Both
authors gave final approval for publishing.
Details of ethics approval
Not applicable.
Funding
None.
Acknowledgements
We would like to thank Allyson Cote for her key insights
on anaemia and Dr Andre Shongo, Vicki Penwell, Robyn
Churchill, Eli Adashi and Isolde Maher for their valuable
contributions. &
References
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1995-2011: a systematic analysis of population- representative data.
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2 Brabin BJ, Hakimi M, Pelletier D. An analysis of anaemia and
pregnancy-related maternal mortality. J Nutr 2001;131:604S–15S.
3 World Health Organization (WHO). Haemoglobin Concentrations for
the Diagnosis of Anaemia and Assessment of Severity. Geneva:
WHO, 2011.
4 Stoltzfus RJ, Dreyfuss ML. Guidelines for the use of Iron
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Anaemia in pregnancy—a renewed focus needed

S Allard
Barts Health NHS Trust, NHS Blood and Transplant, London, UK
Linked article: This is a mini commentary on S New et al., pp. 166–9 in this issue. To view this article visit http://dx.doi.org/10.1111/
1471-0528.13225.

New & Wirth, in their paper in
BJOG 122:2 2014, have focused
attention on anaemia as a key global
maternal health issue. The authors
emphasise that despite being flagged
up as a common problem affecting
~30 million women worldwide, there
has been surprisingly little reduction
in the prevalence of maternal anae-
mia reported over the last three dec-
ades. The results of the WHO
Multicountry Survey on Maternal
and Newborn Health have high-
lighted anaemia as the most com-
mon indirect cause of adverse
maternal outcomes including mater-
nal death (Lumbiganon P et al.
BJOG 2014;121 Suppl 1:32–9). Severe
anaemia in mothers also increases
the risk of perinatal mortality (Vogel
et al. BJOG 2014;121 Suppl 1:76–88).
While the association between
anaemia and maternal morbidity
and mortality clearly merits more
detailed scrutiny, New & Wirth have
questioned the actual definitions for
anaemia in pregnancy and the rec-
ommendations for the haemoglobin
cut-offs used. Is there now a need
to look beyond the conventional
and well established contributory
factors, such as physiological
changes in pregnancy related to ges-
tational age, at more poorly under-
stood variables that may also have
an impact? Although adolescents are
recognised to be at greater risk of
anaemia, the scope for considering
age-specific cut-offs for haemoglobin
in pregnancy certainly raises an
interesting question for further
study.
However, it is the lack of compar-
ative data on ethnic differences on
haemoglobin in pregnancy in partic-
ular that has been flagged up by the
authors. Should we now move away
from attempts at simplified defini-
tions of maternal anaemia and the
concept that ‘one size fits all’ and
acknowledge that other factors may
contribute to differences? This will
require significant efforts to obtain a
better understanding of geographical
and ethnic variations in haemoglobin
levels in pregnancy, taking into
account other endemic diseases con-
tributing to anaemia. Such initiatives
can potentially better inform and
underpin targeted attempts towards
more effective therapeutic interven-
tions. However, the application of
more complex algorithms for defin-
ing anaemia incorporating multiple
variables in day-to-day clinical
practice poses considerable challenges
that should not be underestimated.
There are already significant con-
cerns about the sub-optimal
management of maternal anaemia
even in high-resource countries (Par-
ker et al. BMC Pregnancy Childbirth
2012;12:56), likely due in part to a
lack of consistent good quality
evidence.
There is now an urgent need for
us to respond collectively to this
timely ‘call for action’ by the authors
of this paper as we focus on the Mil-
lennium Development Goals (MDG)
5A to reduce maternal mortality that
will not be addressed by 2015.
Research priorities should tackle the
current evidence gaps in the under-
standing and definition of anaemia
in pregnancy and also aim at the
development of more standardised
approaches to reporting outcomes of
maternal anemia together with the
impact of therapy.
Disclosure of interests
I have no conflicts of interest. &

ª 2014 Royal College of Obstetricians and Gynaecologists 169