HUN 3800

Literature Review
Can proper Fe supplementation help reduce preterm labor in anemic pregnant women?
Paola Arturo
N00934136
November 18, 2014

Background on Iron deficiency

One of the health risks that get overlooked easily for women is iron deficiency. It is the most
common cause of anemia, and according to the World Health Organization it is the most widely
spread nutritional disorders in both developed and underdeveloped coutnries.1Womens iron
stores are exhausted and replete on and off after they reach puberty and they start
menstruation.1Once a woman becomes reproductively active, her risk of developing irondeficiency anemia is greatly increased. Menstruation, pregnancy, and delivery are three events
that greatly deplete a womans iron stores.2 The increased risk of anemia is not only a danger to
women, but also a danger to the fetus they may be carrying if they are pregnant while suffering
from iron deficiency. Low iron stores in the mother, can have an impact in how well the
pregnancy goes.
During pregnancy the mother is not only responsible for taking care of her health but also of the
fetus by having a proper diet. Proper maternal nutrition can determine the health of the fetus,
unless there is chromosomal issues in which case the mothers diet and lifestyle cannot undo it. 2
One of the complications that come with pregnancy is preterm labor, which is defined as birth
occurring between 20 to 37 weeks of pregnancy. It is thought that the reason why iron deficiency
can lead to preterm labor is because it can lead to hypoxia, since not enough oxygen is getting
around the body due to the low iron in the blood.4 The hypoxia is thought to lead to an increase
in norepinephrine concentration which then stimulates the hormone that regulates the process of
delivery.4 When this happens the baby is at a higher risk for serious health concerns such as
intellectual disabilities, cerebral palsy, respiratory problems, visual problems, hearing loss, and
feeding and digestive issues because the baby may not be fully developed when it is delivered.4, 5
Some of the lifestyle factors that are known to be associated with preterm labor are low weight

gain during the pregnancy, smoking or substance abuse during the pregnancy.4 Those are the
factors that have shown a direct correlation with preterm labor, but scientist are always looking
further and deeper to see what other links they can find. If a direct link between iron deficiency
in the mother and preterm labor can be found, then many preterm deliveries and the risks
associated with them could be prevented or at least the risk of them happening could be reduce.
Increased Needs of Iron During Pregnancy
As the fetus grows and develops it takes nutrients form the mothers diet to sustain itself, this
requires the woman to consume a higher intake of many vitamins and minerals in order to keep
up with the increased demand for them. One of the minerals that the woman needs in greater
amount is iron. During pregnancy iron needs are almost double the amount of that of a nonpregnant woman. The body uses the iron to help carry oxygen throughout the body; during
pregnancy the body has a higher requirement for iron because it also needs to carry oxygen to the
fetus. As the pregnancy progresses and the baby increases in size, it also increases how much it is
taking form the mother, by the third trimester the iron demand on the mother is much higher than
at the start of the pregnancy.2, 5 If a woman with low iron stores becomes pregnant she will most
likely suffer from iron deficiency anemia at some point in her pregnancy unless she begins to
supplement her iron needs with prenatal vitamins or a more iron rich diet. Current research
shows that iron deficiency in the mother may be a factor contributing to preterm labor and low
birth weight.6 Women who have iron deficiency anemia during the pregnancy have shown to
have inadequate weight gain needed to lead a healthy pregnancy.8 As stated earlier one of the
factors that has been linked to preterm labor is not enough weight gain during the pregnancy. If
iron deficiency anemia is connected to inadequate weight gain in the mother, it can be presumed
that if there is a way to cure the anemia or keep it from happening all together, then the risk of

preterm delivery is being minimized because the risk of low maternal weight gain is being
reduced.
Even when a woman seems to be perfectly healthy and is not iron deficient at the start of the
pregnancy, as the fetus grows and begins to demand more of the mother, the iron needs increase.
In a study done to see if a normal diet without supplementation sufficed to meet the iron needs
during pregnancy, it was discovered that in the early stages of the pregnancy a woman with good
iron stores does not need supplementation because diet alone can meet the majority of her needs,
but by the end of the pregnancy those women were only getting about 41% of the iron they
needed through diet alone.8 This study goes to show that iron intervention is an important part of
prenatal care that sometimes can be overlooked because it is not something that always has
visible signs, but internally the body is trying to do the best it can with a lack of resources.
Different views on proper Iron supplementation
Different studies show varying results for what is considered the optimal amount of iron
supplementation. So far there is not one set of recommended guidelines of iron needs for
pregnant women; this could be attributed to the fact that studies have found that the optimal dose
of iron supplementation varies depending on if the woman is iron deficient, and if she is how
close to iron deficiency anemia she is.3 If the woman has perfectly good iron stores before the
pregnancy she does not need as much iron supplementation as a woman who starts the pregnancy
with iron deficiency.3 One study done on Danish women to see which dose of iron would be the
most appropriate for pregnant women to reduce the instance of iron deficiency and iron
deficiency anemia in women postpartum showed that supplementation of 40 mg/daily of ferrous
iron was the dose that showed the most benefits for the mother.9 This study did not test the
effects of the iron supplementation on the infants gestational age, and birth weight outcome.

Another randomized controlled trial study done in the United States, tested the effects of iron
supplementation versus no supplementation (placebo) on non-anemic pregnant women to see
how it would effect the birth outcome.6 The results of this study showed that the women who
started taking 30 mg of iron before 20 weeks gestation delivered babies with a higher birth
weight, and had lower incidence of preterm delivery.6 Unlike with the Danish study, this one took
into account the health of the baby, not just that of the mother, but just like in the Danish trial the
women who were supplemented with iron during their pregnancies had a decreased risk of iron
deficiency and iron deficiency anemia postpartum.6
While those were single studies results, a meta-analysis done on 48 randomized trials and 44
cohort studies of prenatal iron use gave a different answer. According to this analysis,
supplementing with iron increased the mothers overall iron stores, decreased her iron deficiency,
and her iron deficiency anemia, and improved the babys chances of not being born at a low birth
weight, but it did not have a significant impact on preterm birth.10
While the meta-analysis gives an overall view of the results of several studies, when we take a
look at another individual study that tested the effects of different doses of iron supplementation
we see similar results to the second study discussed. A study done in 2012, tested four different
doses of iron on pregnant women on the verge of being iron deficient, to see if there was a
difference in the health of the mother and infant depending on how much iron they were
supplemented with. In the study, the scientist wanted to see the effect of no supplementation, low
supplementation <60 mg/day, moderate supplementation (between 60-100 mg/day) and high iron
supplementation (>100 mg/day). The results showed again like in the first study discussed, that
those who had higher does of iron supplement had a lower percentage of preterm delivery
compared to those with no supplementation. The study found that the optimal level of

supplementation for that group of women was the moderate level (between 60-100 mg/day). The
groups that had a lower dose had higher instances of preterm deliveries, low birth weights and
the mothers had a higher risk of having iron deficiency, or iron deficiency anemia post partum.
The group that got the highest does had less preterm deliveries, but they also had an increased
risk of hemoconcentration at delivery which is associated with preeclampsia, oxidative stress,
and low birth weight infant.3 As it is apparent form the varying results between studies, further
testing and research has to be done on what is considered a safe dose of supplementation for both
mom and baby.
Conclusion
Thousands of women die every year during childbirth, and sometimes a little more attention to
prenatal care would have saved them.8 Iron supplementation is part of that prenatal care. Not
only is the need for iron increased during pregnancy to help the fetus continue to grow, but also it
is also important to keep in mind that the mother needs it to be able to have her body function at
its best during and post delivery. Understanding the nutritional needs of a woman as she goes
through a pregnancy is key to helping her have as healthy a pregnancy as possible, both for her
safety and that of the baby she is carrying.
As of right now there is not one answer regarding iron supplementation and preterm delivery.
Some studies show promising results while other, show that there is no correlation. When
looking at individual studies some show that iron supplementation does help reduce preterm
labor, but when looking at meta-analyses of several studies the answers become more uncertain.
Both meta-analyses reviewed had similar conclusions, that there was no significant difference
between the instance of preterm labor of the supplemented and non-supplemented groups. On the
other hand, both did show that there was a significant correlation between iron supplementation

and a reduced risk of low birth weight infant, reduced risk of postpartum iron deficiency and iron
deficiency anemia for the women.
Further research still needs to be done looking at other factors that are affected by iron, and other
factors that affect preterm delivery. Something that could be looked into is how the diets differ
between women who do not have iron deficiency before the pregnancy and those who do, and
whether or not supplementation is beneficial to both. Another improvement that could be made
to future studies is to educate the women on the interaction between vitamin C and iron. If the
women who were being supplemented with iron took the supplement with a source of vitamin C,
would that help them meet their iron needs better than strictly iron supplementation alone. Would
the presence of vitamin C help their bodies and the fetus absorb the iron better? Interactions
between iron and other nutrients should be further explored to see if a combination of two or
more nutrients would have an improved effect versus iron by itself.

References
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2. Elizabeth M. Miller, Iron Status and Reproduction in US Women: National Health

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