































 

 Epidemiology and Society Health Review| ESHR 
Vol. 7, No. 1, 2025, pp. 12-24 ISSN 2656-6052 (online) | 2656-1107 (print) 
      http://journal2.uad.ac.id/index.php/eshr/index                                                   eshr@ikm.uad.ac.id 

 

 

      10.26555/eshr.v7i1.11332  

 
 

12 

 
 

  

 
Research Article  
 
Anaemia and Caesarean Section in Caucasian Race: 
assessment of Risk Factors and Management Strategies 
 
Yaser Khakpour1*, Mahshid Moradi Heidarlou1**, Shahram Shukohi2, Mahla 
Akbari1 
1 Departement of Obstetrics and Gynecology, Gynecology Research Center, Shahid 

Motahari Hospital, School of Medicine, Urmia University of Medical Sciences, West 
Azerbaijan, Iran 

2 Departement of Anaesthesiology, Research Center, Shahid Motahari Hospital, School of 
Medicine, West Azerbaijan, Iran 

 
* Correspondence: y.khm888@gmail.com* and mahshid76@gmail.com**  
 
Received 9 August 2024; Accepted 29 January 2025; Published 31 January 2025 

ABSTRACT 

Background: Anaemia among pregnant women is a significant public health concern, particularly 
in developing countries, due to its adverse effects on both maternal and fetal health. This study 
addresses the gap in research regarding anaemia in pregnant women in northern Iran, specifically 
among those undergoing elective caesarean sections. The objective is to assess the prevalence of 
anaemia in this population. 
Method: This retrospective cross-sectional study included 719 Caucasian pregnant women who 
were candidates for elective caesarean sections from September 2020 to March 2023. Patient data 
was collected from hospital electronic records. Anaemia was defined as haemoglobin <10.5 g/L in 
the three months before delivery and under 10 g/L after delivery. The Chi-square test was 
employed to compare anaemia prevalence across different demographic groups, with a 
significance level set at p-value < 0.05. 
Results: Among the 719 participants, key demographic findings revealed that most had primary 
education (26.8%), while only 12.4% held university degrees. Most (59.8%) resided in urban areas, 
with the largest age group being 31-36 (30.5%). Most women (75.2%) reported no history of 
miscarriage, and 98.2% experienced no bleeding during pregnancy. Notably, 57.7% of women 
reported no underlying health conditions; however, 9.2% had gestational diabetes, while others had 
blood disorders, neurological issues, or gastrointestinal problems. The prevalence of anaemia 
among patients undergoing elective caesarean sections was found to be 10.85%. Anaemia was 
more prevalent in women aged 25-30 years. 
Conclusion: integrating nutritional counselling into routine prenatal care can help address dietary 
deficiencies before they contribute to anaemia. Moreover, collaboration between healthcare 
providers and community leaders may foster greater acceptance of health interventions. By 
tailoring educational programs to local contexts and addressing specific cultural beliefs about 
nutrition and health, policymakers can create more effective strategies to combat anaemia in 
pregnant women.  

Keywords: Anaemia; Caesarean Section; Foetus; Pregnancy 

http://journal2.uad.ac.id/index.php/eshr/index
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https://doi.org/10.26555/eshr.v3i1.3629
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mailto:y.khm888@gmail.com*
mailto:mahshid76@gmail.com


 
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INTRODUCTION 

The prevalence of anaemia worldwide is 24.8%, affecting 1.62 billion people.1 The most 
affected groups in Africa and Southeast Asia are women and children. The global 
prevalence of anaemia during pregnancy was 38% in 2011. Although this decreased from 
43% in 1995, it still constitutes a significant public health problem in low- and high-income 
countries. The prevalence of maternal anaemia in high-income countries was estimated at 
25% in 2011.2 According to UK guidelines on anaemia in pregnancy, anaemia in the first 
trimester is defined as haemoglobin less than 11 g/dL, in the second and third trimesters as 
haemoglobin less than 10.5 g/dL, and after delivery as haemoglobin less than 10 g/dL. 
Recent observational data from a multicentre study in the UK involving 2103 women 
estimated the prevalence of anaemia to be 24.4%.3,4 There is evidence that anaemia is a 
risk factor for maternal and neonatal clinical outcomes such as low birth weight.5 A recent 
study on iron deficiency anaemia in Israel 2015 showed an increased risk of caesarean 
section, blood transfusion, and low Apgar score.6, 7 

In a study conducted by Milad Azami and colleagues at Ilam University of Medical Sciences 
as a meta-analysis from 2005 to 2016, the prevalence of anaemia in Iranian pregnant 
women was reported to be 17%. The highest prevalence of anaemia in this study was 
related to the centre of the country (23%), and the lowest was related to the west (12%). In 
this study, the prevalence of anaemia in urban and rural pregnant women was calculated to 
be 21% and 8%, respectively. This study concluded that anaemia in Iranian pregnant women 
has increased in the last 11 years compared to the years before 2005. Therefore, 
appropriate intervention programs should be developed and implemented in prenatal clinics 
or before marriage.7,8 Furthermore, in some countries, folate deficiency and human 
immunodeficiency virus infection were not strongly associated with anaemia; 
parasitaemia was associated with a decrease in mean haemoglobin level in 
pregnancy.9 The diagnosis of anaemia, especially iron deficiency anaemia, is simple and 
inexpensive.10 More importantly, its treatment is also inexpensive and simple and can be 
treated after removing the underlying cause such as bleeding, parasitic factors,11 poor diet, 
gastrointestinal diseases, menstrual disorders, prescribing dietary supplements such as iron 
tablets, and in very severe cases, iron injections or blood transfusions. During pregnancy, 
anaemia is a significant cause of maternal morbidity and mortality in developing countries 
and has both maternal and fetal consequences.12,13 It can also lead to preterm birth,14 low 
birth weight,15 fetal mental retardations, and stillbirth.16,17 

Iron deficiency anaemia is the most common form of malnutrition in the world and the most 
common type of anaemia.18 Most anaemia during pregnancy is also due to iron deficiency.19 
There is a correlation between anaemia and caesarean delivery, with anaemia potentially 
increasing the risk of needing a C-section and complicating the outcomes of such surgeries. 
Pregnant women with anaemia who undergo caesarean sections face increased risks 
related to blood loss, recovery challenges, and infection. Healthcare providers must monitor 
haemoglobin levels and manage anaemia effectively throughout pregnancy to minimize 
these risks and ensure better outcomes for both the mother and baby. 

Managing pregnant women with anaemia who are undergoing a caesarean section (C-
section) requires careful planning and consideration. Here are key strategies for effective 

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management: 1. preoperative assessment, such as assessing the severity of anaemia and 
determining the underlying cause; 2. preoperative optimization, such as iron 
supplementation and nutritional support; 3. Intraoperative management includes using 
techniques to minimize blood loss during surgery and preparing for potential blood 
transfusions if significant blood loss is anticipated. Given the importance of anaemia among 
pregnant women as one of the high-risk and sensitive population groups in the world and in 
our country, Iran, as well as the adverse effects of anaemia on the mother and foetus, timely 
diagnosis and treatment of this disease is essential. The primary indication for caesarean 
section was a previous caesarean delivery (69.4%), with other reasons including fetal heart 
rate abnormalities, meconium presence, and various medical conditions. Since a similar 
study has not been conducted in north Iran and Caucasian race-based, a study was 
designed to investigate anaemia in pregnant women who are candidates for elective 
caesarean section. The study assessed only elective, rather than emergency, caesarean 
section patients to focus on those most likely to benefit from targeted preoperative iron 
therapy. This study aims to investigate the prevalence of anaemia in this group of mothers, 
considering that bleeding in caesarean surgery is more significant than in natural childbirth 
and also increases the likelihood of postpartum anaemia. 

METHOD 

This was a retrospective cross-sectional and descriptive study including Caucasian Pregnant 
women candidates for elective caesarean section referred to Motahari Educational and 
Treatment Centre in Urmia in North Iran from September 2020 to March 2023 as the sample. 

A total of 719 pregnant women who were candidates for an elective caesarean section 
between September 2020 and March 2023 were enrolled in the study. This study period was 
chosen to provide a sufficiently large sample size for analysis and recent data relevant to our 
current and evolving practice. The laboratory archive extracted the patient's haemoglobin 
values during term and before delivery. Also, other demographic, laboratory and outcomes 
data were collated from the hospital electronic data warehouse, including history of anaemia, 
previous pregnancy history, history of abortion, history of bleeding during pregnancy, history 
of hereditary blood diseases, type of probable anaemia, dose and frequency of iron 
supplementation, current gestational age, place of residence (village or city), patient’s age, 
occupation, level of education, reason for caesarean section, were collected and recorded in 
the relevant checklists. In this study, anaemia was defined as haemoglobin <10.5 g/L.19 

Patient data was collected from hospital electronic records. Anaemia was defined as 
haemoglobin <10.5 g/L in the three months before delivery and under 10 g/L after delivery. 
The primary aim was to establish the incidence of anaemia at the time of delivery and any 
associated predictors. Secondary outcomes included any association between the primary 
outcome and complications defined by the hospital discharge complication coding system 
and an evaluation of the number of blood tests carried out antenatal per trimester. 

Quantitative variables were reported as mean, standard deviation and qualitative variables 
as frequency (percentage) in appropriate tables. The Chi-square test was used to compare 
the frequency of anaemia according to months of pregnancy, age groups, urban or rural 
residence, and educational level. A significance level of less than 0.05 was considered. Data 
analysis was performed using a computer program. 

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All patient information was kept confidential. The research project was implemented after 
approval by the Ethics Committee of Urmia University of Medical Sciences and obtaining an 
ethical code (IR.UMSU.REC.1397.125) 

RESULTS 

A total of 719 pregnant women who were candidates for an elective caesarean section 
between September 2020 and March 2023 were enrolled in the study. The demographic 
characteristics of different variables are shown in Table 1. According to Table 1, Most 
women had primary education (26.8%), and the lowest frequency was related to university 
education (12.4%). Almost half of women (about 59.8%) were urban. Two hundred forty-
three women (33.8%) had one previous pregnancy, and 15.2% were nulliparous. Most 
mothers were in the age group of 31-36 years (30.5%), and the age group above 36 years 
(20.6%) had the lowest frequency. Five hundred forty-one mothers (75.2%) had no history of 
previous miscarriage. Almost all (98.2%) had no history of bleeding during pregnancy. The 
indication for Caesarean section in 69.4% of women was having a previous Caesarean 
section. Other indications for Caesarean section included fetal heart rate drop (37 people 
with 5.1%), meconium (24 people with 3.3%), arrest of descent or dilatation (9 people with 
1.3%), abnormal fetal presentation (60 people with 8.6%), anatomical problems (14 people 
with 1.9%), placental problems (12 people with 1.7%), heart problems (3 people with 0.4%), 
discopathy (5 people with 0.7%), valuable fetus (8 people with 1.1%), fetal distress (7 people 
with 1%), fetal macrosomia (2 people with 0.3%), severe preeclampsia (12 people with 
1.7%), genital warts (2 people with 0.3%), trauma (10 people with 1.4%), positive OCT test 
(5 people with 0.7%), self-requested (1 person with 0.1%), and a combination of these (9 
people with 1.3%).  

Almost half of women (57.7%) had no underlying disease, and 9.2% of them had gestational 
diabetes. Other underlying diseases included blood diseases (anaemia, thalassemia, 
thrombocytopenia) (2.4%), neurological diseases (epilepsy, migraine) (1.3%), infertility 
1.9%), depression (0.4%), heart diseases (valvular), benign or malignant tumour (lipoma, 
meningioma, ovarian or breast cancer), liver problems (fatty liver, elevated liver enzymes), 
kidney and urinary tract problems (pyelonephritis, hydronephrosis, polycystic kidney, kidney 
stones, urinary tract infection), gastrointestinal problems (gastritis, dyspepsia), asthma 
(dyspnea), lupus, and a combination of these (11.4%). 

Table 1. Frequency and Percentage of Qualitative and Quantitative Variables in Women 
Candidates for Elective Caesarean 

Variables 
 

Frequencies Percentage 

Mothers’ education  
Illiterate 

157 21.8% 

Primary school 193 26.8% 
Middle School 114 15.9% 
High School 71 9.9% 
Diploma 95 13.2% 
University degrees 89 12.4% 

Place of Residence   
Village 289 40.2% 
City 
 
 

430 59.8% 

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Variables Frequencies Percentage 
Number of Previous Pregnancies   

0 109 15.2% 
1 243 33.8% 
2 185 25.7% 
> 2 182 25.3% 

Mother's age per year   
< 25 150 20.9% 
25-30 202 28.1% 
31-36 219 30.5% 
< 36 148 20.6% 

Number of Children   
0 145 20.2% 
1 304 42.3% 
2 195 27.1% 
> 2 75 10.4% 

Number of Previous Miscarriages   
0 541 75.2% 
1 133 18.5% 
2 25 3.5% 
3 15 2.1% 
4 5 0.7% 

History of Bleeding During Pregnancy   
- 706 98.2% 
+ 13 1.8% 

Supplement use   
No or Unorganized 298 41.4% 
Yes 421 58.6% 

Caesarean Section Indication   
Previous Caesarean Section 499 69.4% 
Other Indications 220 30.6% 
Underlying disease   

No disease 415 57.7% 
Diabetes 66 9.2% 
Hypertension 34 4.7% 
Thyroid disease 53 7.4% 
Other 151 21% 

Gestational age   
< 37 weeks 238 33.1% 
≥ 37 weeks 481 66.9% 

Third Trimester Haemoglobin   
< 10.5 78 10.8% 
≥ 10.5 641 89.2% 

Haemoglobin After Delivery   
< 10 124 17.2% 
≥ 10 595 82.8% 

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Table 2. Mean and Standard Deviation of Quantitative Variables in Women Candidates 
for Elective Caesarean Section 

 

 

 

 
 

Table 3. Frequency of Anemia in the Third Trimester of Pregnancy Based on Studied 
Variables in Women Candidates for Elective Caesarean Section 

a and b: Based on the Bonferroni correction test, the same letters in each column indicate no significant difference, 
and different letters indicate a significant difference in the frequency of that grouping in each variable between the two 
groups (haemoglobin less than 10.5 and haemoglobin greater than or equal to 10.5). According to this, based on the 
underlying disease, the frequency between the two groups is significantly different (the group of diabetes or impaired 
blood sugar).  

Variables 
 

Mean SD Max Min 

Mother’s Age 
 

30.77 6.2 46 16 

Gestational Age 
 

37.35 2.3 42 25 

Haemoglobin in the 
third  

trimester 

11.85 1.08 15.5 8.4 

Haemoglobin After 
Delivery 

11.28 1.29 17.7 5.9 
 

 
 

p-value     

Haemoglobin 
≤ 10.5 

 

Haemoglobin > 
10.5 

 Variables 

n(%) n(%) 
0.623 132(20.6)a 18(23.1)a < 25 Mother’s Age 

(Years)  177(28.6)a 25(32.1)a 25-30 
 200(31.2)a 19(24.4)a 31-36 
  132(20.6)a 16(20.5)a > 36 

0.291 136(21.2)a 21(26.9a Illiterate Mother’s 
Education  173(27)a 20(25.6)a Primary school 

 197(15.1)a 17(21)a Middle school 
 65(10.1)a 6(7.7)a High school 
 86(13.4)a 9(11.5)a Diploma 
 84(13.1)a 5(6.4)a High degree 

0.072 265(41.3)a 24(30.8)a Rural  Place of 
Residence  367(58.7)a 54(69.2)a Urbane 

0.942 97(15.1)a 12(15.4)a 0 Number of 
Previous 
Pregnancies 

 217(33.9)a 26(13.3)a 1 
 163(24.5)a 22(28.2)a 2 
 164 (25.6)a 18 (23.1)a > 2 

0.591 132 (20.6)a 13 (16.7)a 0 Number of 
children's  273 (42.6)a 31 (39.7)a 1 

 169 (26.4)a 36 (33.3)a 2 
 67 (10.5)a 8 (10.3)a > 2 

0.712 629 (98.1)a 77 (98.7)a Negative History of 
Bleeding during 
Pregnancy 

 12 (1.9)a 1 (1.3)a Positive 

0.013 375 (58.5)a 40 (51.3)a Negative Underlying 
disease  51 (8)b 15(19.2)a Diabetes 

 33 (5.1)a 1 (3/1)a Hypertension 
 48 (7.5)a 5 (6.4)a Thyroid disease 
 134 (20.9)a 17 (21.8)a Other disease 

        0.515        263 (41)a 35 (44.9)a Negative Supplement use 
 378 (59)a 43 (55.1)a Positive 

 0.931 482 (75.2)a 59 (75.6)a Negative Miscarriage 
 159 (24.8)a 19 (24.4)a Positive 

0.314 441 (68.8)a 58 (74.4)a Positive Caesarian 
history   200(31.2)a 20 (25.6)a Other indications   

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Table 2 shows different variables in women candidates for elective caesarean section. 
Haemoglobin less than 10.5 was defined as anaemia in the third trimester of pregnancy. In 
general, 78 women (10.8%) had anaemia in the third trimester of pregnancy. The frequency 
of anaemia based on the studied variables, except underlying diseases, did not have a 
statistically significant difference. However, the highest frequency of anaemia was in the age 
group of 25-30 years (32.1%), in illiterate women (26.9%), urban women (69.2%), and 
women with one pregnancy (33.3%). The frequency of anaemia based on the underlying 
disease was higher in women with diabetes or impaired blood sugar (19.2%) (p=0.013), as 
shown in Table 3. 

Table 4. Comparison of Anemia Frequency After Delivery Based on Studied Variables in 
Women Candidates for Elective Caesarean Section 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a : Based on the Bonferroni correction test, the same letters in each column indicate no significant difference in the frequency 

of that grouping in each variable between the two groups. 

 

 
 

p-value     

Haemoglobin 
≤ 10.5 

 

Haemoglobin > 
10.5 

 Variables 

n(%) n(%) 
0.535 125 (21) a 25 (20.2) a < 25 Mother’s Age 

(Years)  167 (28.1) a 35 (28.2) a 25-30 
 186 (31.3) a 33 (26.6) a 31-36 
 117 (19.7) a 31 (25) a > 36 

0.491 126 (21.2) a 31 (25) a Illiterate Mother’s 
Education  156 (26.2) a 37 (29.8) a Primary school 

 95 (16) a 19 (15.3) a Middle school 
 58 (9.7) a 13 (10.5) a High school 
 85 (14.3) a 10 (8.1) a Diploma 
 75 (12.6) a 14 (11.3) a High degree 

0.067 86 (14.5) a 23 (18.5) a 0 Number of 
Previous 
Pregnancies 

 213 (35.8) a 30 (24.2) a 1 
 146 (24.5) a 39 (31.5) a 2 
 150 (25.2) a 32 (25.8) a > 2 

0.095 118 (19.8) a 27 (21.8) a 0 Number of 
children's  263 (44.2) a 41 (33.1) a 1 

 152 (25.5) a 43 (34.7) a 2 
 62 (10.4) a 13 (10.5) a > 2 

0.599 450 (75.6) a 91 (73.4) a No Abortion 
 145 (24.4) a 33 (26.6) a Yes  

0.041 587 (98.7) a 119 (96) a No History of 
Bleeding during 
Pregnancy 

 8 (1.3) a 5 (4) a Yes 

0.621 345 (58) a 70 (56.5) a Negative Underlying 
disease  52 (8.7) a 14(11.3) a Diabetes 

 29 (4.9) a 5 (4) a Hypertension 
 47 (7.9) a 6 (4.8) a Thyroid disease 
 122 (20.5) a 29 (23.4) a Other disease 

                   
  0.748        

245 (41.2) a 53 (42.7) a Negative Supplement use 

 350 (58.8) a 71 (57.3) a Positive 
 0.523 200 (33.6) a 38 (30.6) a Less than 37 

weeks 
Gestational age 

 395 (66.4) a 86 (69.4) a Greater than or 
equal to 37 weeks 

0.131 420 (70.6) a 79 (63.7) a Positive Caesarian history  
 175 (29.4) a 45 (36.3) a Other indications   

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Table 4 shows the frequency of anaemia after delivery based on the studied variables in 
women candidates for elective caesarean section. Haemoglobin less than 10 was defined as 
anaemia after delivery. In general, 124 women (17.2%) had anaemia after delivery. The 
frequency of anaemia after delivery based on the studied variables, except based on the 
history of bleeding during pregnancy, did not have a statistically significant difference. 
However, the highest frequency of anaemia was in the age group of 25-30 years (26.6%), 
illiterate women (25%), those with primary education (29.8%), women with two previous 
pregnancies (31.5%), women with two children (34.7%), gestational age more than 37 
weeks (69.4%). 

DISCUSSION  

Anaemia is one of the most common medical problems worldwide, especially among 
women.1 The physiological differences between women and men have increased the 
prevalence of this disease among women. Pregnancy in women increases the likelihood of 
anaemia due to increased needs or exacerbates underlying anaemia. The main population 
affected by anaemia are African and Southeast Asian women and girls. The global 
prevalence of this disease, according to a 2011 review, is 38%, estimated to be 25% in high-
income countries.2,10 In addition to maternal complications of anaemia, such as early fatigue, 
reduced tolerance to physical activity, lethargy, reduced mood, and shortness of breath, 
there is evidence of the impact of this disorder on the infant, such as low birth weight.5 
Studies also cite pregnancy anaemia as a risk factor for caesarean section, blood 
transfusion, and low infant Apgar scores.6 This disease is more of a symptom than an 
independent disease, and medical, social, cultural, economic, and nutritional factors are 
involved in its development and progression. 

From this perspective, health and treatment systems around the world have prioritized this 
group of the population as a high-risk and high-priority population and have developed and 
implemented extensive health and treatment programs for the diagnosis and treatment of 
anaemia in pregnant mothers. For managing low haemoglobin levels in pregnant mothers, 
healthcare providers start with an emergency assessment to rule out urgent issues like 
internal bleeding. In cases of severe anaemia (haemoglobin <7 g/dL), consultation with a 
haematologist and blood transfusion is needed. For moderate anaemia (7-10 g/dL), 
prescribing nine elemental iron tablets daily for one month is recommended, and performing 
a reticulocyte index test after one week is also recommended, along with dietary iron advice. 
In mild anaemia (10-11 g/dL), prescribing two elemental iron tablets daily for one month is 
advised; also request a reticulocyte index test and dietary recommendations. Additionally, 
checking ferritin levels in suspected beta thalassemia minor cases before starting iron 
therapy is essential to prevent side effects.29,30 In Iran, with the expansion of health and 
treatment services for pregnant mothers, one of the goals of diagnosis, treatment, and, more 
importantly, prevention of anaemia, especially iron deficiency anaemia, as the most common 
cause of anaemia during pregnancy, has been prioritized. In the present study, anaemia in 
the third trimester was defined as a haemoglobin concentration of less than 10.5 grams per 
decilitre, and based on this, this study was designed and implemented. According to the 
findings of this study, the prevalence of anaemia in the studied patients was 10.85%. This 
finding is similar to the study conducted by Milad Azami and colleagues, which reported 

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anaemia in pregnant women in western Iran to be 12%. However, our study only determined 
the prevalence and was only conducted on patients undergoing elective caesarean section, 
not all pregnant patients (Table 1). This finding is noteworthy even though 41.4% of the 
studied patients did not use iron supplements or used them irregularly (Table 2). The 
prevalence of anaemia in the study by Senadheera.D and colleagues, which included a 
study of 350 pregnant mothers in the first and second trimesters, was reported to be 16.6%. 
This study also examined iron deficiency status, which indicated iron deficiency in 36.6% of 
the studied mothers.20 In our study, this investigation was impossible due to its retrospective 
nature and the lack of laboratory investigations in the patient's records. 

The prevalence of iron supplement use in the study by Yesufu BM and colleagues was 
31.8%. The high rate of non-use or irregular use of these supplements among the patients in 
the present research necessitates more education and emphasis on the need for regular 
use. In examining the relationship between demographic factors and the prevalence of 
anaemia, the interesting point was the higher prevalence of anaemia at admission among 
urban patients compared to rural patients (69.2% vs. 30.8%, respectively, Table 3). This may 
be explained by the broader coverage of maternal care programs in rural areas compared to 
urban areas and the possibility of service providers providing active services. However, this 
difference was not statistically significant (p = 0.072). This notable finding is consistent with 
the study by Milad Azami and colleagues, in which the prevalence of anaemia was reported 
to be higher in the urban population than in the rural population [21% and 8%, respectively].7  

Senadheera D et al. In Sri Lanka, the prevalence of anaemia during pregnancy is less than 
20%. This study aimed to determine the prevalence of anaemia, defined as haemoglobin 
concentration less than 11 g/dL, and iron deficiency using serum ferritin in women attending 
antenatal care. The prevalence of anaemia was calculated to be 16.6%. The best cut-off 
level of serum ferritin for diagnosing anaemia was less than 30 µg/L. 36.9% of pregnant 
women had iron deficiency. It was concluded that the prevalence of anaemia (16.6%) and 
iron deficiency (36.9%) during pregnancy were of mild to moderate public health importance, 
respectively.20 In the study by Adanikin AI and colleagues, the only demographic variable 
associated with high prevalence of anaemia was the mother's occupation, with the disorder 
being more prevalent in unemployed or student patients (P = 0.007), which was explained by 
the relationship between patient income and anaemia.21  

Late antenatal care uptake by women in low-income areas makes timely interventions in 
correcting anaemia difficult. Identify modifiable sociodemographic factors that predict 
anaemia before antenatal care initiation and provide appropriate recommendations.21 Ikeanyi 
EM et al. showed that anaemia was 32.2% in this population at registration. At term or 
delivery, 736 of 1052 who met the study criteria improved from anaemia (21.4%, odds 
ratio=3.2, p<0.0001), which was a 69.9% prevention, and 316 remained anaemic despite 
antenatal services (9.2%, OR=0.43, p<0.00001). These individuals were similar in most 
confounding factors, such as social class, median age, body mass index, and gestational 
age at delivery (p>0.05).22 

Another study showed that most respondents had a moderate level of knowledge and a 
positive attitude towards contraceptive methods. Still, a high proportion of them did not agree 
with the daily intake of iron supplements. Therefore, it was recommended that health 

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education for women and close family members be strengthened to improve the agreement 
with using supplements.23 

In their study, Sinha M et al. showed that health education programs are needed to 
emphasize adherence to iron supplementation and adequate consumption of iron-rich diets 
during pregnancy to strengthen them and achieve safe maternal and fetal outcomes.24 Poor 
knowledge about the cause of anaemia, signs and symptoms, and an appropriate diet to 
prevent anaemia. Still, women's knowledge about the prevention and treatment of anaemia 
is vital.25 Hemoglobinopathies should be screened in antenatal clinics to identify couples 
needing prenatal testing.26  

Management strategy: For managing low haemoglobin levels in pregnant mothers, 
healthcare providers start with an emergency assessment to rule out urgent issues like 
internal bleeding. In cases of severe anaemia (haemoglobin <7 g/dL), consultation with a 
haematologist and blood transfusion is needed. For moderate anaemia (7-10 g/dL), 
prescribing 9 elemental iron tablets daily for one month is recommended, and performing a 
reticulocyte index test after one week is also recommended, along with dietary iron advice. 
In mild anaemia (10-11 g/dL), prescribing two elemental iron tablets daily for one month is 
advised; also request a reticulocyte index test and dietary recommendations. Additionally, 
checking ferritin levels in suspected beta thalassemia minor cases before starting iron 
therapy is essential to prevent side effects.28,29 In Iran, with the expansion of health and 
treatment services for pregnant mothers, one of the goals of diagnosis, treatment, and, more 
importantly, prevention of anaemia, especially iron deficiency anaemia, as the most common 
cause of anaemia during pregnancy, has been prioritized. Consistent patient blood 
management (PBM) guidelines in obstetrics are still lacking, and recommendations 
regarding the timing of anaemia screening and the treatment recommendations for iron 
deficiency and IDA during pregnancy are still controversial27.  

The findings from our study underscore the critical need for enhanced health education and 
policy implementation to improve iron supplementation adherence among pregnant women. 
In Iran, while there are established health programs targeting maternal health, including 
anaemia screening and treatment protocols, the irregular use of iron supplements indicates 
potential barriers to effective implementation. Culturally, there may be misconceptions 
regarding the necessity of iron supplements or dietary iron sources. In some communities, 
traditional nutritional practices may not prioritize iron-rich foods, leading to inadequate 
intake.28 Furthermore, socioeconomic factors play a significant role; women from lower-
income backgrounds may face challenges in accessing quality prenatal care or affordable 
nutritional supplements. Government policies to improve maternal health must consider 
these cultural and socioeconomic dimensions. Enhanced community outreach programs that 
educate women about the importance of iron during pregnancy and provide accessible 
supplementation could improve adherence rates. 

Additionally, integrating nutritional counselling into routine prenatal care can help address 
dietary deficiencies before they contribute to anaemia. Moreover, collaboration between 
healthcare providers and community leaders may foster greater acceptance of health 
interventions. By tailoring educational programs to local contexts and addressing specific 
cultural beliefs about nutrition and health, policymakers can create more effective strategies 
to combat anaemia in pregnant women. 

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This study has several limitations. The mother’s weight and height were not studied, and the 
frequency of anaemia in the first and second trimesters was not included in the study due to 
a lack of data in the patient's hospital records. As this is a retrospective series, its duration is 
also a limitation. By studying for three years, we obtained a reasonable sample size and a 
meaningful estimate of the prevalence of anaemia among patients undergoing elective 
caesarean sections. Increasing the study period in further research could improve the 
precision of these estimates. The mother's weight and height were not studied, and the 
frequency of anaemia in the first and second trimesters was not included in the study due to 
a lack of data in the patient’s hospital records. 

CONCLUSION 

Iron supplementation during pregnancy is a very cheap, effective, and accessible method for 
preventing and treating iron deficiency anaemia and preventing its direct and indirect 
complications. Given the lack of use or irregular use of these drugs, it is vital to reflect this 
problem to the health sector and take necessary steps to change this behaviour. While our 
study contributes valuable insights into the prevalence of anaemia among pregnant women 
in Iran, it also highlights the need for continued research and targeted interventions that 
consider cultural practices and socioeconomic barriers. Addressing these factors is crucial 
for improving maternal health outcomes and reducing the incidence of anaemia during 
pregnancy. 

Pregnancy clinics are significant centres for the prevention, diagnosis, and, if necessary, 
treatment of detected diseases. In addition to this, registering patient information for future 
follow-ups and extracting information for future studies is essential. Unfortunately, the clinics 
in developing countries may be unable to provide such prevention care. On the other hand, it 
is necessary to consider integrating clinical and laboratory information on pregnancy care 
with hospitalization information, especially in cases where examinations have been 
performed on an outpatient basis and in other private or public centres. The scattering of 
medical details and increasing unnecessary duplication in the diagnosis and treatment of 
patients is a serious obstacle. 

Acknowledgement 

Ethics approval and consent to participate This study was performed according to the 
Helsinki Declaration and was approved by the Ethics Committee of Urmia University of 
Medical Sciences. No. IR.UMSU.REC.1397.125. The Ethics Committee of Urmia University 
of Medical Sciences waived the need for consent to participate.  

Declarations 

Authors' contribution 

YK contributed to the investigation, review, and data analysis and wrote an article. MMH did 
the investigation and data collection. SS did supervision and formal analysis. MA conducted 
revision, reanalysis, and writing. 

 

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Funding statement 

No funding or grant support was received. None of the authors have any financial interests 
related to the manuscript's content. 

Conflict of interest 

There is no conflict of interest in this research.  

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