Heliyon 9 (2023) e14197

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Heliyon
journal homepage: www.cell.com/heliyon

Research article

Prevalence and risk factors of anemia in first, second and third

trimesters of pregnancy in Iran: A systematic review and
meta-analysis
Monireh Faghir-Ganji a,b, Alireza Amanollahi c, Maryam Nikbina d,
Alireza Ansari-Moghaddam e, Narjes Abdolmohammadi f,*
a
Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
b
Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
c
Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
d
Department of Midwifery, Shoushtar Faculty of Medical Sciences, Shoushtar, Iran
e
Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
f
Department of Epidemiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

A R T I C L E I N F O
A B S T R A C T
Keywords:
Anemia is a common health problem during pregnancy worldwide that has many short-term
Pregnant women
Anemia
and long-term effects on women. This study examined the Prevalence and Risk factors of
Prevalence anemia in first, second and third trimesters of pregnancy in Iran between 2000 and 2021.
Pregnancy PubMed, Medline, Scopus, Google Scholar, and national databases of Magiran and SID were
Systematic review searched for articles, which were then subjected to PRISMA-compliant screening. A
systematic review and meta- analysis (using a random-effects model in STATA version 17)
were conducted on the 18 eligible cross-sectional studies (published between July 23, 2000 and
September 1, 2021) that revealed significant data on the prevalence of anemia in pregnant
women. This study included 18 reports with a total of 25,831 individuals in which 15% of
study subjects had anemia (95% CI:
12–19%). The pooled prevalence of anemia was 13% in people older than 26 years old (95% CI:
9–17%) compared to 22% in people younger than 26 years old (95% CI: 15–29). It was 18% (95%
CI: 11–27%) for pregnant women having their second child in comparison to 20% (95% CI: 11–
32%) for women who have had three or more children. Anemia was thought to affect 11% of
housewives (95% CI: 2–26%) and 10% of working women (95% CI: 6–16%). Anemia frequency
was 22%, 17% and 13% amongst first (22%), second (17%), and third (13%) trimesters,
respectively. Nevertheless, it happened much less often after the second trimester. Moreover, poor
education, a history of low birth weight in children, and a low socioeconomic level within women
were associated with the prevalence of anemia. The pooled prevalence of anemia in pregnant
women is marginally lower than in earlier report. However, it seems to be a health problem in
developing countries including Iran currently. Therefore, the study suggest that health system
should design comprehensive preventive and control measurements such as more effective
treatments to minimize anemia in vulnerable segments of society, particularly mothers, and
improve their health through increasing access to services for mothers.

* Corresponding author.
E-mail address: abdolmohammadi.n9096@gmail.com (N. Abdolmohammadi).

https://doi.org/10.1016/j.heliyon.2023.e14197
Received 8 August 2022; Received in revised form 21 February 2023; Accepted 23 February 2023
Available online 1 March 2023
2405-8440/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Faghir-Ganji et al. Heliyon 9 (2023) e14197

1. Introduction

Anemia is the most widespread nutritional deficiency among pregnant women in the world. According to recent reports from the
World Health Organization, in most countries, the prevalence of anemia in pregnant and non-pregnant women aged 15 –49 has
increased from 2012 to 2016 [1]. The 65th World Health Assembly announced a 50% reduction in the prevalence of anemia in
women
of childbearing age by 2025, but no significant progress has been made till yet [2]. In total, 40% of pregnant women worldwide had
anemia in 2016, with the highest prevalence in Southeast Asia. Due to the high prevalence of anemia, any adverse maternal and
fetal outcomes associated with anemia will have a significant impact on general health [3]. One of the primary and common causes
of anemia in pregnant women is IDA (iron deficiency anemia) [4]. Accordingly, IDA may affect maternal and fetal death, Physical
function, and child development which are in turn, indicators of community health [5]. Essential factors in distinguishing IDA from
other causes of anemia, epidemiologically, are parasitic diseases such as malaria, HIV, chronic inflammation, and protein-energy
malnutrition [6].
There is a big difference in the prevalence of IDA in developing countries compared to developed countries [7]. The prevalence
of IDA in pregnant women in Iran, including Zahedan, Bandar Abbas, and Tehran, has been reported to be between 8.6% and
21.5% [8]. Followed by a high prevalence of iron deficiency anemia and some complications, including low birth weight (LBW), preterm
delivery, and injuries. It is irreversible to the mental and physical abilities of the mother and fetus [ 9]. The prevalence of anemia
changes in Iranian pregnant women depends on several factors, including geographical area, lifestyle, diet, age, level of education
and number of deliveries, and socioeconomic status [8,9]. Although some studies have reported adverse maternal outcomes
associated with anemia during pregnancy, in Iran. In our knowledge, a comprehensive study on anemia has not been conducted in
this long period of time. Only several studies in shorter periods of time have reported the outcome of anemia or similar risks. In
addition, different studies have
reported different estimates of the prevalence of anemia in Iranian pregnant women (4.7–32.1) [10,11]. Then, the present study
aimed to investigate the Prevalence and Risk factors of anemia in first, second and third trimesters of pregnancy through pooling the
results
obtained from eligible cross-sectional studies on 26,084 pregnant women in Iran.

2. Methods

The systematic review has been registered on PROSPERO under ID number CRD42022383314.

2.1. Searching strategy

To conduct this study, accredited English and Farsi electronic resources related to anemia prevalence among pregnant women in
Iran were searched from English databases of Medline, PubMed, Scopus, Google scholar as well as Persian databanks including
Magiran, and SID till 2021. Only two of the six PICO components were tested to improve search sensitivity, and some databases
were not sensitive to search operators (NOT, OR, AND). Articles on the prevalence of anemia in Iranian pregnant women were
found using reliable databases such as PubMed, Scopus, Google Scholar, Magiran, and SID. In order to search in internal (Iranian)
databases, the following search strategy was used. (“anemia”) as well as (“pregnant women”). The OR operator is used to connect
synonyms in the
preceding example, and the AND operator is used to combine the OR operator’s results. Each database was searched using the same
database’s search strategy (Tables 1 and 2).
In addition, the reference lists of the relevant papers were scanned to ensure that no publications were overlooked. Endnote
software was used to screen all of the studies that were found. Following that, duplicate citations were removed. Unpublished
studies were not considered.

2.2. Inclusion/exclusion criteria

All the epidemiologic studies that met the following criteria were included: Cross-sectional studies on the prevalence of anemia
in Iranian adult pregnant women from 2000 to 2021. Other forms of observational research (including letters to the editor, review
ar- ticles, and case reports) were excluded, as well as books, editorials, conference abstracts, and notes. Those studies that did not
have separate data on the prevalence of anemia in pregnant women, as well as those that did not have full text access. Studies that
did not have a representative sample of pregnant women were eliminated. In addition, the following factors were evaluated for the
studies’

Table 1
Search keywords.
Keywords Search strategy

Anemia Anemia *[ Title/Abstract] OR“Anemia”[Title/Abstract] OR iron deficiency, Anemia[MeSH] OR “Iron-deficiency anemia” Title/Abstract] OR
iron deficiency*[Title/Abstract] OR Hemoglobin[MeSH] OR “Hemoglobin”[Title/Abstract] OR Hemoglobin*[Title/Abstract]
Pregnancy pregnant women[MeSH Terms] OR” pregnant women”[Title/Abstract] OR pregnant women* [Title/Abstract] OR pregnancy [MeSH Terms] OR

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M. Faghir-Ganji et al. Heliyon 9 (2023) e14197
“pregnancy” [Title/Abstract] OR pregnancy * [Title/Abstract]
Cross- Cross-Sectional[MeSH] OR Prevalence[MeSH] OR Epidemiology OR Survey[MeSH]
Sectional
Country Iran OR Iranian[Title/Abstract]
Search 1 AND 2 AND 3 AND 4

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inclusion/exclusion criteria: All research included in Persian and English; interventional studies or studies that evaluate individuals’
clinical conditions will be excluded. The study will exclude review studies and non-primary studies.

2.3. Data extraction

To avoid bias and make sure that the right articles about the frequency of anemia in pregnant Iranian women were chosen based
on the inclusion criteria, two reviewers (M.F.G. and N.A.) looked at the articles separately to see if they were eligible. There were
two different points of view. When there was a disagreement, it was settled by agreement or by talking to a third reviewer (A.A).
First, all articles about the number of pregnant women in Iran who have anemia gathered. At this point, all articles with keywords in
their titles or abstracts were added to the initial list, and articles that had nothing to do with the topic were taken off. In this study,
people were considered to have anemia if they had less than 11 dl/mgHB. In addition to anemia, the following information was
taken from the study: the first author’s name, the year it was published, the city, the age range or mean age and gender of the
participants, and the
number of people who took part.

2.4. Quality assessment

The Newcastle-Ottawa Scale (NOS), which was made for cross-sectional studies, was used to rate the quality of the studies in
this meta-analysis [12]. Based on this scale, each study could get a maximum of 9 points based on the following criteria: 4 points
for how the participants were chosen, 2 points for how comparable they were, and 3 points for how the results were measured. A
study with a score of 7–9 was considered as high quality, 4–6 as high risk, and 0–3 rated as very high risk of bias (Table 3).

2.5. Heterogeneity assessment and statistical analysis

Quantitative data from each study that reported the prevalence of anemia in pregnant women were used for meta-analysis.
Factors such as trimester (First, Second, and Third), parity, number of pregnancies, education level, having a history of abortion,
and mother’s age and occupation were also taken into account. Risk factors for the number of pregnant women with anemia were
also taken from the studies. Stata/SE 17 software was used for all statistical analyses. From the “metaprop” command, a Der-
Simonian and Laird random effects model with a 95% confidence interval (CI) was used to estimate the number of pregnant
women with anemia. Prevalence
percentage was calculated using the following formula: (number of pregnant mothers 𝚵 total number of sample) × 100.
The I2 statistic was used to explain heterogeneity, and a cutoff of 75% was kept to show that there was a lot of heterogeneity
[14]. Due to the amount of data that was available, subgroup analyses were done based on age, number of pregnancies, and
number of
months pregnant to check for heterogeneity. Metaregression analysis (the “metareg” command in STATA V.17.0) was used to confirm
any differences between subgroups. The authors tried to figure out what kind of sampling method was used in a study that didn’t
say for sure (like whether they used simple random sampling, multistage cluster sampling, etc.) but gave enough information about
the
sampling method and how data was collected. Was the sampling method used in the study one that was based on chance or not?
Publication bias is a problem with the article retrieval method when the results of a particularly relevant study are not published
because of the direction or strength of the study’s findings (if the results of a study are published, the chances of publication are
lower)
[15]. We used funnel plots and Egger’s linear regression test to figure out if there was publication bias in this meta-analysis. To test how
stable prevalence estimates were, sensitivity analysis was done by removing each record one by one.

Table 2
All keyboards and databases searched in the study.
Database type Search
engine Search strategy Number of
hits
International
PubMed Anemia *[ Title/Abstract] OR “Anemia”[Title/Abstract] Anemia [MeSH] OR “Iron-deficiency anemia” 233
databases
[MeSH] OR “Iron-deficiency anemia”[Title/Abstract] OR Iron-deficiency anemia*[Title/Abstract] OR
Hemoglobins [MeSH] OR Hemoglobin [Title/Abstract] OR Hemoglobin*[Title/Abstract] OR “Pregnant
women”[MeSH] OR “Pregnant women”[Title/Abstract] OR Pregnant women* [Title/Abstract] OR
Pregnancy [MeSH] OR Pregnancy[Title/Abstract] OR Pregnancy * [Title/Abstract] OR Prevalence
[MeSH] OR “Cross-Sectional Studies”[MeSH] OR Prevalence[Title/Abstract] OR Epidemiology[MeSH] OR
Frequency[Title/Abstract] AND Iran[MeSH] OR Iranian[Title/Abstract]
Scopus TITLE-ABS-KEY ((“Prevalence” OR “Incidence” OR “Epidemiology” OR “Frequency”) AND (“Iron 72
deficiency anemia” OR “Iron” OR “Anemia” OR “Anamia” OR “Anaemia” OR “HB” OR “Hemoglobin”)
AND “Pregnant women” OR “Pregnancy”) AND (“Iran” OR “Iranian”) AND (“Cross-sectional” OR
“Prevalence” OR “Epidemiology” OR” Frequency”))
Google Scoular Anemia OR

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M. Faghir-Ganji et al. Heliyon 9 (2023) e14197
Anamia OR Anaemia OR “Iron deficiency” OR Hemoglobin AND “Pregnant women” OR 17,600
Pregnancy AND Cross- sectional AND Iran
National databases SID Anemia OR Anamia OR Anaemia OR “Iron deficiency” OR Hemoglobin AND “Pregnant women” OR 10
Pregnancy AND Cross- sectional AND Iran
Magiran Anemia OR Anamia OR Anaemia OR “Iron deficiency” OR Hemoglobin AND “Pregnant women” OR 33
Pregnancy AND Cross- sectional AND Iran
TOTAL 17,948

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Table 3
Search keywords in all databases.

1
According to the Newcastle-Ottawa Scale (NOS) criteria [12,13].
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3. Results

3.1. Search and selection

The initial search of relevant databases produced a total of 17,948 articles. After excluding duplications and articles that did not
meet the inclusion criteria based on titles and abstracts, the full-text of 201 potentially relevant studies reviewed by authors. Of the
remaining reports, 54 articles were found to be useful for review. These articles were qualitatively evaluated and critically apprised
using the NOS checklist which 28 articles were selected based on this approach. Finally, we found 18 eligible articles with a total
population of 26,084 individuals to be appropriate for the current study. A flow diagram of the study selection is shown in Fig. 1.

3.2. Study characteristics

Table 4 ], [], [showed the baseline characteristics of the studies that were used. The number of included study subjects in these
studies ranged from 48 to 7233. Overall, the current systematic review carried out on a total of 26,084 people. The average age was
19.3 years at the youngest and 28.6 years at the oldest. The reported prevalence of anemia varied in different parts of the country
from 4.7%, in Kerman [10] to 32.1% in Semnan [11].

Fig. 1. PRISMA flow diagram of the included studies.

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Table 4
Characteristics of the included studies in Meta-analysis.
ID First Author Time Study Study Location Sampling Method Sample Size Mean Age SD Age Prevalence anemia (%)

1 Esmailymotkagh.M et al. [16] 2019 Tehran Multistage 2484 26.2 5.5 12.9
2 lashgardoost.Het al [17] 2019 SHirvan Systematic 400 29.2 5.3 10.3
3 Mardani.M et al. [18] 2017 KHoram abad Randomly 2821 26.7 5.5 16.8
4 Yaghoobi.H et al. [19] 2016 Bandar Lengeh Systematic 418 27.1 5.6 22.5
5 Vakili.M et al. [20] 2016 Yazd Randomly 550 28.3 6.3 7.2
6 Sanayifar.A et al. [21] 2015 Bojnord Multistage 515 26.2 5.5 29.3
7 Khademi.Zet al [22] 2014 Bandare abbas Count 401 19.8 5.5 17.5
8 Rajabzadeh.R et al. [23] 2013 Bojnord Multistage 221 25.2 5.1 18.2
9 Saghafi.N et al. [24] 2013 Mashhad Count 600 26.6 5.07 11.2
10 Rahbar.N et al. [11] 2013 Semnan conventional 546 25.6 5.3 32.1
11 Ranaei.A et al. [25] 2013 Sananadaj Randomly 1137 26.1 5.09 8
12 Mostajeran.M et al. [26] 2013 Esfehan Randomly 7233 28.6 6.2 9.4
13 Akbarzadeh.M et al. [27] 2011 Shiraz Count 89 25.7 5.6 29.2
14 Sofizadeh.N et al. [28] 2012 Sanandaj Randomly 1500 28.4 6.1 7.1
15 Mirzaie.F et al. [10] 2010 Kerman Multistage 2213 27.1 6.2 4.7
16 Veghari.M et al. [29] 2007 Gorgan Conut 48 24.2 4.6 25.8
17 Safavi.M. M et al. [30] 2006 11 seting Randomly 4368 26 4.8 21.5
18 Navidian.A et al. [31] 2006 Zahedan Randomly 287 19.3 4.6 12.9

3.3. Quality assessment and publication bias

The first and second authors used the Newcastle-Ottawa Scale (NOS) to evaluate the quality, and eligibility of 18 cross-sectional
studies. The 18 studies that were used in the analysis were checked for publication bias (if it existed) to get pooled estimates of
how common anemia is.
In all of the analyses, there wasn’t much difference between the studies, and Table 3, T2 values back up this claim. Also, the study
bias (Table 5, Figs. 2 and 3) shows the results of both the Begg and Egger tests, which were not seen in any of the analyses of publication
bias, and because the Egger test is so powerful, the number of studies in most of the analyses was less than 10. Most of Egger’s test
results were given in the article’s text.

3.4. Estimation of anemia prevalence by age groups

The prevalence of anemia was estimated to be 15% (95% CI, 12–19; T2 for heterogeneity = 0.04; egger’s publication bias P = 0.33)

Table 5
Summary of the analysis.
Variable Number of studies Pooled estimation (95% CI) Heterogeneity test Publication bias
2
I (%) 2 Egger’s Begg’s
Τ
Anemia 18 15 (12–19) 98.15 0.04 0.33 0.31
Age ≥ 26 12 13 (9— 17) 98.56
Age < 26 6 22 (15–29) 89.92
First trimester 11 22 (12–33) 98.85 0.18 0.25 0.31
Second trimester 4 17 (11–24) 89.61 0.03 0.73 0.17
Third trimester 10 13 (7— 21) 98.10 0.11 0.08 0.78
Multiparity 4 19 (5— 41) 98.75 0.23 0.62 0.99
Nulliparity 4 25 (5— 54) 99.26 0.37 0.27 0.17
1st pregnancy 6 26 (12–44) 98.17 0.22 0.43 0.19
2nd and 3rd pregnancy 7 18 (11–27) 93.96 0.07 0.33 0.29
More than third pregnancy 6 20 (11–32) 88.68 0.09 0.30 0.35
Low birth weight 4 28 (7— 55) 96.05 0.29 0.15 0.5
Lower than high school 5 18 (7— 33) 95.07 0.13 0.10 0.05
High school 5 9 (3— 18) 95.74 0.08 0.26 0.14
More than high school 5 8 (3— 16) 85.4 0.06 0.20 0.14
Lower than high school in third trimester 3 27 (6— 55) 96.92 0.25 0.47 0.6
High school in third trimester 3 36 (15–60) 98.02 0.18 0.78 0.6
More than high school in third trimester 3 25 (17–33) 66.51 0.02 0.63 0.6
Abortion 3 9 (4— 16) 63.85 0.02 0.85 0.6
Age < 20 3 13 (5— 23) 81.74 0.04 0.74 0.61
Age = 20-30 4 7 (3— 13) 94.32 0.03 0.73 0.99
Age > 30 4 10 (3— 19) 94.15 0.06 0.76 0.99
Housewife 4 11 (2— 26) 98.14 0.13 0.67 0.60
Housewife third trimester 3 29 (15–45) 98.21 0.09 0.84 0.61
Occupation 3 10 (6— 16) 0.0 0.0 0.31 0.6
Occupation in third trimester 3 29 (23–35) 0.0 0.0 0.18 0.12

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Fig. 2. Funnel plot for prevalence of anemia in pregnant women in Iran.

Fig. 3. Egger graph for prevalence of anemia in pregnant women in Iran.

(Fig. 4). In the age subgroups (Fig. 5), the estimated pooled prevalence was 13% (95% CI: 17-9) for those older than 26 years and
22% (95% CI: 15–29) for those younger than 26 years. Also, there was a big difference between subgroups, which shows that the
subgroup chosen based on age did a good job of separating the strata.

3.5. Estimation of anemia prevalence by trimesters

Pooled estimates of the prevalence of anemia in the first, second and third trimesters of pregnancy were shown in Fig. 6. For the first
quarter, this value was 22% (95% CI, 12–33; T2 for heterogeneity = 0.18; egger’s publication bias [P = 0.25]) (Fig. 6A). The prev-
alence of anemia in the second trimester of pregnancy was 17% (95% CI, 11–24; T2 = 0.03; egger’s [P = 0.73] (Fig. 6B) and for the
third trimester of pregnancy was 13% (95% CI, 7–21; T2 = 0.11; egger’s [P = 0.08]) (Fig. 6C).

3.6. Estimation of anemia prevalence by number of pregnancies

Fig. 7 depicts the pooled estimate of the prevalence of anemia in multiple pregnancies. The estimated estimate for pregnant
women who had their first pregnancy was 26% (95% CI, 12–44; T2 for heterogeneity between studies = 0.22; egger’s publication
bias [P = 0.43]) (Fig. 7A), 18% (95% CI, 11–27; T2 = 0.07; egger’s [P = 0.33]) (Fig. 7B), and 20% (95% CI, 11–32; T2 = 0.09;
egger’s [P =
0.29]) (Fig. 7C).

3.7. Other variables

The age group 20–30 years had the lowest pooled prevalence, which was calculated at 7% (95% CI, 3–13; T2 = 0.03; egger’s [P
= 0.99]). The prevalence of anemia in the third trimester of pregnancy among housewives and employed women differed from
the
pooled prevalence. Anemia was seen in 29% of housewives and 29% of working women during the third trimester of pregnancy.
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The pooled estimated prevalence of anemia for housewives was 11% (95% CI, 2–26) and 10% (95% CI, 6–16).

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Fig. 4. Forest plot showing the pooled prevalence of anemia in pregnant women in Iran.

3.8. Subgroup analysis

In the sensitivity analysis, excluding any single study had no effect on the pooled estimate for the effect of. Furthermore, no ev-
idence of substantial publication bias was found (P = 0.08) using the Begg’s test.

4. Discussion

According to WHO, the high incidence of anemia caused by iron deficiency in pregnant women in low socio-economic conditions is 25–
35% [1–3] in developing countries and 5–8% in developed countries [32]. Moreover, the prevalence of anemia in pregnant women
is estimated to be 80% in some developing countries compared to 5% in developed countries which demonstrated the fact that
anemia
is a global concern among Women in developing countries [33,34].
The prevalence of anemia in Iranian pregnant women in the present study was about 15%, which is less than the 2016 systematic
review study (17%) [35]. In several studies, the prevalence of anemia in different regions of Iran has been reported variously from
2.4 to 27.8% [8], which might be due to the socio-economic situation in different geographical areas of the country [36]. Numerous
other studies have also reported different prevalence of anemia, including 42.7% in North Africa [37], 40% in Bangladesh [38],
37% in India [39], 34.4% in Spain [40] and 21.6% in Mexico [41]. The lower prevalence of anemia in Iranian pregnant women may
be possibly due to the improvement in socioeconomic status and improved nutrition [8].
The prevalence of anemia was different in women of different ages. So that this difference in prevalence between the age groups
(less than 26 years old) was about 11% [39]. Other studies in Saudi Arabia, Isfahan, and Mashhad also confirmed a higher
prevalence of anemia in younger women [26,36]. In the United States and Canada race/ethnicity, age, transferrin saturation, and
serum ferritin were also assessed [42]. The proportion of women with anemia was higher in Hispanics and blacks than in whites and
Asians, and in women aged 25 to 54 of all races was significantly higher than in women over 55 of similar races [42]. Demographic
data, Household Hunger Scale (HHS), Living Poverty Index (LPI), FAO Women Diet Score (WDDS), and interventions in a 2021 prospective
cohort study among Ghanaian pregnant adolescents aged 13–19 years Intake during prenatal care (ANC), hemoglobin (Hb), serum levels
of ferritin,
pre albumin, vitamin A, total antioxidant capacity (TAC), and vitamin C were analyzed. The results showed that inadequate iron and
micronutrient intake was significant among participants, and participants who experienced hunger were almost three times more
likely to be deficient in iron stores than those who did not [43].
In different occupational groups, the difference in prevalence between employed and housewives was only one percent (more in
housewives), but in the third trimester of pregnancy, this rate increased significantly and almost tripled (29%). The prevalence of
anemia in multi-parity and nuli-parity women in this study was 19% and 25%, respectively, which decreased in women with more
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Fig. 5. Funnel plot for prevalence of anemia in pregnant women in Iran by age subgroup.

pregnancies so that those who experienced three or more pregnancies than those who had only one Pregnancy had a 6% reduction in
the prevalence of anemia.
Women with less education also suffered from a higher prevalence of anemia, which decreased significantly (about ten percent)
with increasing years of schooling and peaked in high school (36%).
The prevalence of anemia in the first, second and third trimesters of pregnancy decreased significantly from 22 to 13% from the first
to the third trimester. A study showed that in Yazdi pregnant women, anemia was not significantly associated with age, maternal
education, maternal occupation, sex of the infant, type of delivery, high-risk pregnancy, and infant weight at birth [20]. However, in
Bangladesh, maternal anemia was significantly related to age, education, income, area of residence, and need for education in
pregnant women and their family members [38]. More than half of housewives have anemia, but other studies have reported that
employment is one of the causes of anemia in pregnant women [17]. In line with of our findings, there was a relationship between
the higher prevalence of anemia in the third trimester of pregnancy and being employed [17].
The prevalence of anemia in pregnant women in the second, second and third trimesters decreased, respectively. Previous
studies in the world have shown a higher prevalence of anemia in the third trimester, too [17,19,26,40,44].
In Spain, the prevalence of iron deficiency (ID) and iron deficiency anemia (IDA) in late pregnancy was high in pregnant
women, especially in women with low initial iron stores or those who were not taking supplements. Those who had adequate iron
stores at the beginning of pregnancy or took iron supplements had a lower risk of iron deficiency during childbirth [40] iron status
in the first trimester had a significant effect on iron status in the second trimester [45]. Also in 2020, a total of 12,403 pregnant
women were enrolled in 24 hospitals in 16 provinces across China. About 20% of women were diagnosed with anemia and 14%
with iron deficiency anemia. The prevalence of anemia varied in different regions and increased with the increase of the month of
pregnancy and peaked in the eighth month of pregnancy. In addition, anemia was more common in women who were in the last
months of pregnancy or non-natives, multiple pregnancies, pre-pregnancy underweight, and those who had severe nausea or
vomiting during pregnancy [46]. Severe anemia also reported severe complications in the fetus due to anemia in the first trimester
compared to the second and third trimesters [47,48]. These problems can be due to poor nutrition of women and lack of
supplementation and inadequate care [17]. Studies have shown that low frequency of pregnancies and adequate care during
pregnancy can protect mothers from anemia in the third trimester [16].
The study’s strengths were that it included pooled data from 18 research published over a 20-year period. As a result, the huge
sample size provided enough power to discern the genuine influence of the independent variables. Second, throughout the analysis,

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Fig. 6. Pooled prevalence of anemia in the first (A), second (B) and third (C) trimesters of pregnancy in Iran.

sample weights were used to create credible estimates and standard errors.
As a limitation, because the study used cross-sectional data, it may have some weaknesses to establish a causal association
between anemia and the observed independent factors because of the nature of cross-sectional studies.
Furthermore, eating patterns, parasite infection (hookworm), prior hospitalization, and usage of nutritional supplements were
studied using secondary data (vitamin B12 and folic acid) One of the most significant constraints of our research was the inability to
examine certain databases owing to Sanctions and a lack of access to certain databases. The authors of the article suggest that future
prospective studies should be conducted in Iranian pregnant women to estimate the prevalence and relationship between its
relevance risk factors.

5. Conclusion

This study provided a reliable estimate of how often anemia happens among pregnant women in Iran. As the results show, the
number of pregnant women with anemia is slightly lower than in the previous studies. This is linked to a trend that is getting worse
during pregnancy. Also, anemia is more common in women with less education, a history of giving birth to babies with low birth
weights, and a lower socioeconomic status.
Considering the importance of anemia in pregnant women, vulnerable socioeconomic groups should be targeted for anemia
reduction. On the other hand, treating infectious disorders, particularly those caused by parasites, consuming a healthy diet,
receiving proper care and information throughout pregnancy, and taking supplements can aid in reducing anemia. Also, providing
pregnant women in various regions of Iran with improved access to services at comprehensive health facilities and health care
centers can aid in reducing the number of anemic women.

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M. Faghir-Ganji et al. Heliyon 9 (2023) e14197

Fig. 7. Pooled prevalence of anemia in the first (A), second (B), third and more (C) number of pregnancy in Iran.

Author contribution statement

Monireh Faghir-Ganji: Analyzed and interpreted the data; Materials, Analysis tools or data; Wrote the paper.
Alireza Amanollahi, Alireza Ansari-Moghaddam: materials, analysis tools or data; Wrote the paper.
Maryam Nikbina: Analyzed and interpreted the data; Materials, Analysis tools or data.
Narges Abdolmohamadi: Analyzed and interpreted the data; Wrote the paper.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

Data will be made available on request.

Declaration of interest’s statement

The authors declare no conflict of interest.

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