Women and Birth 28 (2015) 166–172

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Women and Birth

journal homepage: www.elsevier.com/locate/wombi

Original Research – Quantitative

Survey of women’s perceptions of information provided

in the prevention or treatment of iron deficiency anaemia
in an Australian tertiary obstetric hospital
Emma Vosnacos a, Deborah J. Pinchon b,*
a
Infusion Unit, King Edward Memorial Hospital, Perth, WA, Australia
b
Obstetric and Gynaecology Clinical Care Unit, King Edward Memorial Hospital, Perth, WA, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Background: There is limited literature to understand the perceptions of Australian women regarding the
Received 15 May 2014 information provided by healthcare professionals relating to the prevention and treatment of iron
Received in revised form 6 November 2014 deficiency anaemia in pregnancy.
Accepted 7 November 2014
Aim: To establish an insight into the key themes and trends within a tertiary obstetric hospital related to
the provision of dietary advice and use of iron supplements in pregnancy.
Keywords: Methods: A prospective patient survey of pregnant women and women up to 4 weeks postnatal
Pregnancy
attending hospital.
Anaemia
Iron deficiency
Findings: Of the 110 women who participated, 73.6% were provided with information on iron rich foods
Perception and 67% made dietary changes. Eighty percent of women were advised to take oral iron and 65.5% of
Midwives women were taking it at the time of the survey. In women who had independently ceased oral iron, 41.7%
failed to inform their healthcare professional. In the women who did inform their healthcare professional
89.5% received advice to help overcome the reason that led to cessation. The main causes included
forgetfulness and side effects. Women were less likely to require intravenous iron if oral iron was
commenced early.
Conclusions: Compliance with recommended oral iron is variable within a population of pregnant
women. Women are provided with information on a range of issues relating to the prevention and
treatment of iron deficiency anaemia; yet there is a disparity between the information provided and the
resulting action. Further research should focus on targeted measures to improve understanding and
compliance with treatment from the both women’s and health professionals perspective.
Crown Copyright ß 2014 Published by Elsevier Australia (a division of Reed International Books Australia
Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.

1. Introduction malabsorption, socio-economic status and ethnic grouping.3 Addi-

Iron deficiency anaemia in pregnancy continues to present a
significant health problem throughout the world.1 The presence of
iron deficiency anaemia is not exclusive to low health resourced
countries, where it is linked to socio-economic grouping, dietary
intake/food shortage, worm infestation, spacing of pregnancy,
parity, education, knowledge, compliance and access to iron
supplementation.2,3 Whereas in greater health resourced countries,
iron deficiency anaemia in pregnancy, is linked to dietary intake,
* Corresponding author at: Department of Haematology, King Edward Memorial
Hospital, Subiaco, Perth, WA 6148, Australia. Tel.: +61 08 9340 2733.
E-mail address: deborah.pinchon@health.wa.gov.au (D.J. Pinchon).
tionally iron deficiency anaemia is associated with haemoglobino-
pathy, malaria and other parasitic infections.1 Within Australia, iron
deficiency is seen as a problem within subgroups of the population
including indigenous remote communities, particularly so with
women and children4; and teenage mothers.5 Within this sub-group
poor dietary intake and worm infestation are contributory factors.4,6
Despite current national and international guidelines, bench-
marking standards to prevent or treat identified iron deficiency
anaemia in pregnancy,7–11 it continues to challenge healthcare
professionals, in part due to the lack of robust evidence from well-
designed clinical trials reporting on important clinical out-
comes.12–15 Primary prevention of iron deficiency anaemia is
focussed upon improving dietary intake of iron through the
consumption of a well-balanced diet which includes both animal

http://dx.doi.org/10.1016/j.wombi.2014.11.004
1871-5192/Crown Copyright ß 2014 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All
rights reserved.

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 E. Vosnacos, D.J. Pinchon / Women and Birth 28 (2015) 166–172
sources of iron (haem iron) and vegetable and cereal sources of
iron (non-haem iron). In addition dietary absorption is enhanced
with the action of Vitamin C and inhibited with the concurrent
consumption of tannins (tea and coffee), phytates (legumes and
cereals) and calcium.9–11,16 Second line therapy includes the use of
oral iron supplements. There is a lack of consensus in relation to
optimal dosing of oral iron supplementation, universal versus
targeted treatment or indeed daily versus intermittent versus no
routine oral iron supplementation.10–18 The Royal Australian and
New Zealand College of Obstetricians and Gynaecologists do not
recommend the routine use of iron supplements in pregnancy.11
The current Australian and New Zealand dietary guidelines
recommend an intake of elemental iron per day in pregnancy of
27 mg.16 Expert recommendations for Asia-Pacific region suggest
80–100 mg elemental iron supplements daily if the haemoglobin
(Hb) < 105 g/L and serum ferritin < 20 mg/L.8 National guidelines
from the United Kingdom do not recommend routine iron
supplementation for all women, the guidelines suggest the use
of 100–200 mg elemental iron daily in the treatment of established
iron deficiency anaemia.10 Cochrane reviews acknowledge the
paucity of good trial evidence and conclude: daily oral iron
treatment improves haematological indices.12 More specifically
Cochrane concludes that daily iron supplements reduce the risk of
low birth weight and can prevent maternal anaemia and iron
deficiency in pregnancy,14 intermittent iron and folic acid
supplements produce similar results as daily supplements and
are associated with fewer side effects.15 Notwithstanding the lack
of consensus regarding optimal dosing, researchers, clinicians and
authors concur regarding reduced compliance to iron supplemen-
tation.3,9,10,12,14–16 Gastro-intestinal side effects are frequently
cited as a causative factor in reduced compliance to oral iron
supplementation in pregnancy.17,19–24 However studies suggest
that education, communication, social and cultural determinants
also play a role in lack of motivation to comply with treat-
ment.7,17,19,25 This is compounded by a lack of recognition of the
importance of preventing and treating iron deficiency anaemia,
congruence of the symptoms of anaemia with advancing
pregnancy and the use of natural or traditional remedies.17
The aim of this study is to establish an insight into the key
themes and trends within a tertiary obstetric hospital that includes
a population of high, medium and low risk pregnancies. Themes
related to the provision of dietary advice and use of oral iron
supplements in pregnancy including; barriers to compliance, types
of supplements used, and the timing of commencement and
cessation of oral iron supplements were explored.
2. Subjects and method
2.1. Sample
This prospective patient survey was conducted with pregnant
and postnatal women who attended a tertiary obstetric hospital
within Western Australia for antenatal care and/or delivery using
convenience sampling. In keeping with guidelines for sampling
size in quality improvement activities a sample size of 150 would be
required to demonstrate a 95% confidence interval.26 The population
demographics of the hospital are diverse including; indigenous
groups, migrant groups, and refugees from a widespread geographi-
cal area. As the sole tertiary obstetric referral centre for Western
Australia its specialised services include co-existing maternal
disease, elevated body mass index, teenage pregnancy, drug and
alcohol addiction, foetal abnormality/disease, mental health dis-
orders and maternal diabetes. The average annual delivery rate is
6000 women and in keeping with its tertiary referral role and
geographic catchment, cares for a range of women with ‘low’
through to the ‘high’ risk pregnancies. In addition the hospital
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167
operates a day treatment Infusion Unit, where intravenous iron is
used to treat established iron deficiency anaemia that fails to
respond to oral iron (unless birth is imminent which precludes a trial
of oral iron).
Women were invited to participate in the survey if they were
pregnant, aged over 16 and were deemed to have a sound
comprehension of the English language to provide verbal consent
to participate and to read, understand and complete the survey.
Women included were in their 2nd and 3rd trimester of pregnancy
or less than one month postnatal, they were sourced as in-patients,
out-patients and day treatment patients. Exclusion criteria includ-
ed: women who were not pregnant, or whose newborn infants
were greater than 1 month old, age < 16 years, inability to complete
the survey due to language barriers and if they expressed a
preference not to complete the survey. In addition hospital in-
patients whom the Ward Co-ordinators felt it was inappropriate to
disturb regarding the survey at the time were also excluded. This
group included women who had an exacerbation of a mental illness,
had just given birth and were sleep deprived or had had a traumatic
adverse event.
2.2. Methods
The Midwife conducting the survey asked the women whether
they would like to participate in the study. It was explained that we
were trying to establish some of the patterns associated with the
prevention of anaemia in pregnancy. Additional permission to
approach women admitted as in-patients was obtained from the
Ward Co-ordinators. The women, who provided verbal consent,
completed the survey anonymously and were provided with a pre-
paid envelope for the reply. On completion the survey was
returned in the sealed envelope directly to the midwife conducting
the survey, by internal/external mail or by placement in a survey
results box. The survey or envelope contained no identifying
patient information. If more than 50% of the survey data fields were
incomplete, then the survey would be excluded from the analysis.
The sample size was not calculated on a primary endpoint as it was
designed to provide an insight into a range of women’s perceptions
of current practice. The results were analysed prospectively using
basic descriptive statistics with Microsoft Excel.
The hospital encourages all women to eat a well-balanced diet
in pregnancy with particular attention to improving dietary iron
content, whilst limiting dietary practices associated with im-
paired iron absorption. Assessment of the full blood picture is
undertaken routinely at the 20 week booking visit, and repeated at
28 and 34–36 weeks gestation. In addition serum ferritin levels
are assessed in women deemed at high risk of iron deficiency
anaemia, with known or suspected haemoglobinopathy disease or
in the presence of other maternal co-morbidities such as chronic
disease, bleeding disorders, major abnormal placental presenta-
tions, etc. Further testing is undertaken as directed by clinical
guidelines if anaemia is suspected or in the monitoring of
treatment efficacy. If iron deficiency is identified without anaemia
(serum ferritin < 30 mg/L), women are recommended to com-
mence 65 mg oral elemental iron daily. If women present with
iron deficiency anaemia Hb < 110 g/L in the first and third
trimester, or Hb < 105 g/L in the second trimester and serum
ferritin < 30 mg/L, they are advised to commence 100 mg
elemental iron daily. Third line treatment is the use of intravenous
iron in confirmed iron deficiency anaemia which has failed to
respond to a trial of oral iron supplementation (unless birth is
imminent which precludes a trial of oral iron).
The hospital Institutional Ethics Committee provided permis-
sion to conduct the survey and publish the results via the
Governance, Evidence and Knowledge Outcomes database (GEKO).
This process includes a formal review of the aims of the activity, a
168 E. Vosnacos, D.J. Pinchon / Women and Birth 28 (2015) 166–172
review of the survey tool, the final report that includes an
assessment of governance procedures including data protection
and patient confidentiality.
2.3. Survey tool
A unique survey tool was developed, informed by key themes in
the literature regarding predictors of iron deficiency anaemia to
establish what we theorised would provide some insight into the
information provided to women regarding the prevention and
treatment of iron deficiency anaemia in pregnancy. We wanted the
women to be open with their dialogue, so chose not to request
information that could be perceived as identifiable. Thus we were
unable to provide objective measures to validate any information
provided including: actual changes in dietary practice; resulting
improvements with Hb values and serum ferritin levels. Nor were
we able to provide any baseline demographics or the presence of
any co-morbidities/risk factors of the population sampled. We felt
that including this information could introduce confounding
variables and detract us from the primary objective of women’s
insights regarding anaemia prevention. Likewise assessing indi-
vidual’s motivation to comply with iron supplementation was
outside the scope of this study.
Compliance with oral iron supplementation is defined as the
woman taking the supplementation as advised by the healthcare
professional.19 As the survey was not designed to validate the
responses provided by the woman in relation to the volume of iron
consumed versus the healthcare information provided. We were
unable to exclude over estimating the volume of oral iron
supplementation compliance due to either recall failure or fear
of being judged.27
3. Results
In total 116 women participated in the survey. Prospective
analysis of the findings identified data saturation occurred towards
the end of a 2 month period which included over 100 women and
thus the survey was discontinued with 116 participants. Ten
women expressed a preference not to participate and 6 surveys
were excluded as less than 50% of the survey was completed. The
most frequent reason cited for non-participation was tiredness. A
total of 110 (94.8%) surveys were included in the final analysis.
3.1. Understanding the need for additional iron in pregnancy
The need for additional iron in pregnancy was understood by
many of the women who participated in the survey. This included a
high number of women who recalled receiving information on iron
rich food, the majority of those women indicated they went on to
make dietary changes as a result of the information (see Table 1).
One woman stated that the need to make changes to her diet did
Table 1
Women’s understanding of the need for iron and use of supplements in pregnancy.
Yes No Don’t
know/remember
1. Women understood the need for iron during this pregnancy
n = 110 74 (67.3%) 15 (13.6%) 21 (19.1%)
2. Women who were provided with information on iron rich foods
n = 110 81 (73.6%) 25 (22.7%) 4 (3.6%)
3. Women who made changes to their diet based on information on iron rich foods
n = 109 73 (67%) 28 (25.7%) 8 (7.3%)
4. Women who were advised to take oral iron supplements
n = 110 88 (80%) 19 (17.3%) 3 (2.7%)
5. Women who were taking iron supplements at time of survey
n = 110 72 (65.5%) 38 (34.5%)
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not apply to her. Women indicated receiving information from
multiple sources including midwives, hospital doctors, general
practitioners, obstetricians, naturopaths, friends and family at the
time of the survey. No women identified a dietician within our
survey. Whilst dieticians are a valuable member of the multidisci-
plinary team, they do not see women routinely on the first booking
visit except in women with an elevated body mass index, diabetes
or a known dietary deficiency. We identified a disparity between
the numbers of women who were specifically advised to take oral
iron supplements (80%) from their health care professional, in
comparison to the women who identified they were taking some
form of oral iron supplementation (65.5%). Standard clinical
practice ensures that iron supplements are only recommended to
treat confirmed iron deficiency or iron deficiency anaemia. Further
analysis of the type and dose of iron supplementation taken by the
women identified that sub-optimal dosing was a common feature
in the survey group. Sub-optimal dosing had two main compo-
nents: the type of formulation used and lack of compliance with
recommended regime (as stated by the woman following the
healthcare professional advice).
3.2. Types of oral iron supplementation used in pregnancy
We asked the women to indicate the type of iron supplement
they were taking and they identified 15 different formulations in
use. This included one woman who listed her folic acid by brand
name as an iron supplement. Fifty-eight and half percent of
women’s iron formulations provided a daily dose of more than
100 mg elemental iron, 20% provided a daily dose of 60–99 mg
elemental iron and 21.5% provided a daily dose of less than 60 mg
elemental iron. The survey was not designed to assess women’s
knowledge of the adequacy of the formulation they were taking.
However anecdotally, when questioned a number of women stated
they were unaware of how to assess the adequacy, i.e. establishing
the elemental iron content of their formulation.
3.3. Compliance with oral iron supplementation
A number of women failed to fully answer the questions designed
to assess oral iron supplement compliance at a fundamental level.
Seventy-two women identified they were taking oral supplements
at the time of completing the survey, only 64 women completed the
information required to assess a broad overview of their compliance
to oral iron supplementation. Frequently women cited they could
not remember the specific information requested, which included
the formulation type, the gestation they started supplementation
and when/if they discontinued the supplementation. Despite poor
responses to these questions (see Tables 2 and 3), whether taking an
adequate formulation or not, compliance with recommended
dosages was low, particularly amongst women who required an
iron infusion to augment haemoglobin values in the treatment of
confirmed iron deficiency anaemia following failure to respond to
oral iron. We observed that improved compliance to oral iron
supplementation aimed to improve haemoglobin values was
associated with lower dosing regimens.
Table 2
Women who were taking oral iron supplements as recommended on formulation.
Taking oral iron as recommended on formulation
Sub-group Takes oral as Takes oral less than No answer
recommended recommended
Oral iron only, n = 64 26 (40.6%) 26 (40.6%) 12 (18.8%)
Iron infusion and 8 (28.6%) 10 (35.7%) 10 (35.7%)
oral iron, n = 28
 E. Vosnacos, D.J. Pinchon / Women and Birth 28 (2015) 166–172
Table 3
Women who were taking oral iron supplements to improve haemoglobin.
Taking iron as recommended to improve haemoglobin
Sub-group Dose > 700 mg/ Dose < 700 mg/ No answer
week week
Oral iron only, n = 64 11 (17.2%) 40 (62.5%) 13 (20.3%)
Iron infusion 8 (28.6%) 19 (67.9%) 1 (3.6%)
and oral iron, n = 28
Women were asked to identify the reasons for not taking the
iron. Twenty-three women cited forgetfulness, and 16 women
stated the side effects. ‘Other’ reasons were reported by 12 women
and included: ‘‘consuming iron rich diet,’’ ‘‘taking multivitamins,’’
‘‘Crohn’s disease,’’ ‘‘advised not to,’’ ‘‘too lazy,’’ ‘‘severe Hyperem-
esis Gravidarum’’ and one woman was felt it unnecessary to take
oral iron as she could receive it intravenously. Cost emerged as a
small problem with 4 women indicating it as a factor. Eight women
indicated they ‘ran out’ and the reason they never replaced their
supply was not provided.
3.4. Commencement and cessation of oral iron
We identified the women who consumed oral iron without the
need for an additional iron infusion, on average started taking oral
iron supplements 9 weeks earlier in their pregnancy than women
who required an iron infusion. None of the 10 women who started
oral iron preconception required an iron infusion (see Table 4). Our
hospital has a robust screening process in place relating to the use
of intravenous iron in line with evidence based guidelines. It is only
administered when a trial of oral iron therapy has failed or birth is
imminent in the presence of confirmed iron deficiency anaemia on
assessment of red cell indices and serum ferritin levels. Women
who stated they commenced oral iron ‘preconception’ were
documented as starting at week 0. Women who stated they
ceased oral iron at birth were documented as ceasing at 40 weeks,
unless they stated otherwise.
We found a large proportion of women (41.7%) who had
discontinued oral iron independently failed to inform their
healthcare professional they had done so. A further group of women
could not remember if they had informed their health professional
of cessation (18.7%). In the small number of women who did
inform their healthcare professional of self-cessation, 89.5% received
additional advice to overcome the problems that caused the
discontinuance.
4. Discussion
The aim of this study was to establish an insight into the key
themes and trends within a tertiary obstetric hospital, that
includes a population of high, medium and low risk pregnancies,
related to the provision of dietary advice and use of oral iron
supplements in pregnancy including; barriers to compliance, types
of supplements used, and the timing of commencement and
cessation of oral iron supplements.
The study was not designed with a statistical calculation based on
a primary outcome and thus the results may not be considered
generalisable, despite this our findings are consistent with the
Table 4
Gestation in weeks when oral iron supplements commenced.
Group (no. in group) Mean Standard deviation
Consumed oral iron only, n = 64 13.5 11.5
Iron infusion and oral iron, n = 24 22.5 9.5
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169
literature and suggests there are other factors aside from side effects
which impact upon compliance rates to oral iron supplementation in
pregnancy in health resourced countries.19,20,24,25
There is key information that pregnant women clearly
comprehend, our results indicate that many pregnant women
appear to make changes to their diet based on the information
provided to them; however the survey was not designed to qualify
the specific changes they made to their diet in response to this. It is
highly likely that this message is reinforced through peer support
and family social patterns.28 Furthermore pregnant women are
highly motivated to make changes to their diet in pregnancy.29 In
addition it is acknowledged that nausea in early pregnancy
influences dietary changes.30 Women are clearly being counselled
regarding the need for additional oral iron supplementation in
pregnancy, but there is a dichotomy between information
provided/understood and resultant action. Some authors indicate
the quality of the information/counselling is a significant factor in
continued compliance.19,25 However it should be remembered that
clinical trials and research studies designed to assess or improve
compliance to oral iron supplementation may indeed provide this
focus and consistency with robust consent processes, patient
information, frequent visits and trial protocols. Other barriers to
compliance include prescribing complicated regimens, failing to
take account of the patient’s lifestyle and failure to explain the
full benefits and side effects.31 Our results indicate sub-optimal
dosing and discontinuation of oral iron supplements seems
commonplace. Many women tended to cease oral iron mid to
late third trimester (see Table 5) this coincides with the period in
pregnancy of highest absorption of iron and the period in
pregnancy of increased adverse side effects generally.3 As women
are faced with a plethora of oral iron supplements, this is perhaps
not unsurprising. Indeed one study suggests that women are
largely naive to the dissimilarity between the wide varieties of oral
iron supplements.23 Previous studies have suggested improving
compliance rates would be better achieved with a focus upon the
appropriate dosing regimens21 and motivating the women to take
supplements.21,25 Interestingly Melamed et al.,23 demonstrated
that women did frequently comply with the supplementation
suggested by the their physician; which highlights the decisive
responsibility for all healthcare professionals in delivering a
consistent message regarding the use of iron supplementation in
women whom have an identified need. Strategies which may
enhance compliance include straightforward dosing, i.e. one tablet
once daily, positive re-enforcement, good communication and the
provision of educational information.31
Despite the widespread circulation and use of evidence based
shared care guidelines and monitoring for the prevention and
treatment of iron deficiency anaemia locally,32 our survey has
identified that there appears to some dissection in the information
provided by healthcare professionals and ultimate understanding
and action from the woman’s perspective in our sample group. This
is distinctly evident in the number of women using inadequate low
dose brands of iron and at self-cessation of oral iron supplemen-
tation, as women frequently failed to inform healthcare profes-
sionals of cessation, raising the question as to whether we, as
health professionals make assumptions that women are reliably
taking previously identified iron supplements. It is imperative
that the information regarding iron supplementation is provided
Table 5
Gestation at cessation of oral iron supplements.
Group (no. in group) Mean Standard deviation
Consumed oral iron only, n = 21 29.7 11.8
Iron infusion and oral iron, n = 12 30.41 10.6
170 E. Vosnacos, D.J. Pinchon / Women and Birth 28 (2015) 166–172
consistently,25 with an emphasis upon the maternal health
benefits for maintained compliance.19 We suggest that this goes
one step further and is reiterated at every antenatal visit from
confirmation of pregnancy through to delivery, by all healthcare
professionals involved in maternity care. This includes primary,
secondary and tertiary care. Effective oral iron consumption in the
presence of iron deficiency anaemia appears to reduce the need for
intravenous iron therapy and its attendant risks as the pregnancy
advances.
In the last 18 months we have successfully raised the profile of
the prevention of iron deficiency anaemia in pregnancy locally
with a multidisciplinary education programme to translate
knowledge into practice, simplified guidelines, developed deci-
sion support tools, raised awareness of the findings of this survey,
improved staff and patient resources within primary and
secondary care all of which combine to deliver a consistent
message to women and health care professionals.31 In collabora-
tion with our women and the Consumer Advisory Committee
we have developed patient information leaflets to advise specific
behaviours which fit into a modern lifestyle. Our multifaceted
approach is essential as we are crossing the boundaries of
influencing both patient and healthcare professional’s behaviour.
Guiding behavioural change is a complex process and has a greater
role within modern healthcare due to the greater incidence of
behavioural induced disease and lifestyle choices.33,34 Whilst it is
outside the scope of this paper to evaluate the theories of
behavioural change, our evolving practice acknowledges the
importance of influencing behavioural change at a fundamental
level in modern healthcare.
There is some debate over the impact of pregnancy impairing
cognition and memory either transiently or longer term,35,36 yet
forgetfulness appeared to be the main factor in lack of compliance
with oral iron supplementation. It is suggested that compliance
and forgetfulness can be improved by the provision of clear
instructions and the use of education regarding the health benefits
of iron supplementation.37,38 Tackling forgetfulness in a developed
health system requires a two pronged approach. Health care
professionals need to be mindful that women are unlikely to retain
all the information provided to them earlier in the pregnancy and
thus should not make assumptions that women remember and/or
understand every detail. Reinforcing the message at every ante-natal
visit is essential: this could be enhanced by the use of decision
support tools which prompt staff to assess and document the impact
of oral iron supplementation at regular and directed intervals.
Health care professionals are in a unique position to provide
guidance on strategies and tools to aid remembering, emphasising
the importance of prevention of iron deficiency anaemia and
highlighting the risks of uncorrected iron deficiency. Our approach
has been to suggest strategies to aid memory such as mobile phone
alarms, smart phone medication reminder applications and for those
without electronic devices a reminder note on the fridge to improve
compliance. All of these help provide the impetus and motivation to
remember. New and emerging technologies will continue to have a
valuable role in influencing patient behaviour, in particular relating
to compliance with medication in the future.33,34,39
The presence of side effects appear to impact upon the
compliance with oral iron supplementation or as suggested by
Melamed et al.,23 the woman’s perceptions that the symptoms are
related to the iron supplementation. It is accepted that oral iron
supplements do cause gastrointestinal side effects,1,16,21,22,37,38
many women appear to react to these perceived unacceptable side
effects by ceasing their iron altogether without informing their
healthcare professional. This reinforces the need for healthcare
professionals to assess compliance to oral iron supplementation
at every antenatal visit, as many side effects could be reduced to
acceptable levels or resolved with changes to timing, dosage,
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brand or other measures including simple modifications to diet to
counter side effects such as constipation. As discussed earlier,
modifying the medication, explaining the potential side effects,
emphasising the benefits, empathy to the perceived side effects
and positive affirmation are a number of mechanisms which may
result in behavioural change and improved compliance.31,33,39
Cost did not appear a major factor in compliance rates to oral
iron supplementation. Whilst the provision of free oral iron
supplements is viewed as an incentive to improve compliance
in poorly resourced countries,25 it is suggested that placing a
nominal cost to the patient provides a monetary value upon
the medication and may improve compliance.19 We now provide
women with a clear take home guide that includes: the impor
tance of iron, daily dosage recommendations and management of
side effects. Similar information has been provided to staff which
in addition includes the costs of common oral iron supplements,
including government subsidised formulations and the elemental
iron content of each. This supports the woman to make informed
active decisions as to which formulation is best for her.
The results of this survey provide an additional perspective for
healthcare professionals involved in the care of women from
remote and rural communities: in that we now have strong
evidence that anaemia is associated with low birth weight.40
Remote areas are associated with poorer maternity outcomes in
comparison to less remote populations, particularly with indige-
nous mothers.41–43 Transfer to a tertiary centre because of iron
deficiency has significant financial, cultural and emotional impact
on the pregnant woman.41 This transient relocation results in
detrimental separation from the family group and support
network at a time of the greatest need.44–46 Whilst the presence
of anaemia is one element of a multifactorial problem com-
pounded by remoteness, it is preventable and treatable and
represents an area of risk which could be reduced.
We suggest it is the provision of detailed and high quality
information, fostering continued motivation, positive affirmation
and delivering a consistent message from healthcare profes-
sionals which is the most significant factor influencing compli-
ance within a health resourced and developed nation.27,31,33,34,39
Only a small number of studies have been designed to assess the
determinants of compliance to oral iron supplementation in
pregnancy. Whilst these have been undertaken in lower health
resourced countries, they deliver a pragmatic message regarding
consistent information, continued motivation, relationship be-
tween the woman and the caregiver, aside the issues of supply and
cost.19,25 In order for health care professionals to deliver this
message they need to utilise the latest evidence based guidance
supported by up to date resources for women. The next step would
be to formally assess the impact of targeted patient information
and directed health care professional assessments; raised
awareness and motivation of women through clinical audit/
action based research.
5. Limitations
Our findings were obtained with a small sample of women
attending a single tertiary obstetric unit, and as such the results
may not be generalisable to pregnant women without additional
risk factors for developing iron deficiency anaemia. We did not
validate the responses from the women against the documented
advice recorded within the medical records, nor establish
the haematological response to iron supplementation. Nor did
we assess the impact of any co-morbidity which may influence the
course of iron deficiency anaemia in pregnancy. Conversely all
healthcare professionals have something to take away from the
results of the survey.
 E. Vosnacos, D.J. Pinchon / Women and Birth 28 (2015) 166–172
6. Conclusion
Whilst the primary prevention strategy of iron deficiency
anaemia in pregnancy remains a well-balanced diet, high in iron
rich food; once identified then generally a trial of treatment with
oral iron supplements is commenced. Key to attaining compliance
with recommended oral iron supplementation in pregnancy is
establishing a good relationship, empathy and understanding
with good communication between healthcare professional and
the woman from the beginning of pregnancy.19,25,31,33,34,39 The
trust engendered will encourage behavioural change, continued
motivation and compliance with recommended treat-
ment.19,21,25,33,39 Early intervention and supervision, supported
by additional take home resources and the use of modern
technologies relating to maximising dietary intake, enhancing
oral iron absorption and consumption, the management of side
effects and positive affirmation may greatly improve compliance
and optimal dosing.31
It is important to remember our unique role as the only
obstetric tertiary referral centre within a vast geographical area:
iron deficiency anaemia has implications for our women that goes
beyond their physical health. For some women severe anaemia
prior to birth necessitates a transfer thousands of kilometres from
their intended place of birth. This has many concomitant issues for
these women including: cost, childcare, transport, accommoda-
tion and isolation.42–46 It is critically important to prevent this
dislocation. We firmly believe adopting proactive targeted
strategies to improve the prevention, detection and management
of iron deficiency anaemia can begin to address some of our
unique problems as a tertiary referral centre responding to a
preventable volume of antenatal anaemia.
Conflict of interest
The authors have no conflicts of interests to declare.
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