Daily iron supplementation is safe for pregnant women in malaria-endemic regions

Daily iron supplementation is safe for pregnant women in malaria-endemic regions

A new study finds that daily iron supplements do not increase risk of malaria infection for pregnant women, as some public health experts fear

A recent study in JAMA has found that daily iron supplementation does not increase the risk of malaria for pregnant women in sub-Saharan Africa, buffering concerns from public health experts that it might. The authors further found that babies born to women who took iron supplements everyday were, on average, a third of a pound heavier than those born to women who took placebos (3202 g vs 3053 g, crude difference 150 g, 95%CI, 56 to 244; P = .002).

That’s a striking increase that’s never been shown before, according to Hans Verhoef, a researcher at Wageningen University in the Netherlands, and one of the study’s authors.

“It is among the largest effects ever measured for any nutritional intervention in these settings,” he said. “It is larger than the effect of malaria.” Furthermore, Verhoef noted, the effect was even greater for women who were iron-deficient at the beginning of the study — for those women, average birth weight increased by about half a pound.

Given their findings, Verhoef and his colleagues believe that clinics in malaria-endemic regions need to place greater priority on distributing iron supplements to pregnant women in conjunction with antimalarial drugs. “All countries have policies that pregnant women should receive daily iron supplementation,” he said. “But in practice, compliance is very low.”

Photo credit: Felicia Webb

Photo credit: Felicia Webb

In their study, the researchers, led by scientists from the Netherlands and Kenya, recruited 470 pregnant women from Kenyan villages, ranging from 15 to 45 years old and typically at the start of their second trimester. They sent all of the women to local health facilities to receive antimalarial drugs at the start of the study, then gave half of the women 5.7 milligrams of iron each day, and the other half a daily placebo. Screening blood samples collected from each woman after delivery, the researchers found no difference in rates of malaria infection between participants given iron supplements and those given a placebo (50.9%vs 52.1%, crude difference −1.2%, 95%CI, −11.8%to 9.5%; P = .83).

The study addresses concerns stemming from a 2006 landmark study that showed that giving iron to preschool-aged children could increase their risk of malaria infection — prompting public health experts to question whether pregnant women share the same risk.

“This study not only demonstrated the safety of giving iron,” said Parul Christian, a professor of global health and nutrition at Johns Hopkins University, who co-wrote an editorial accompanying Verhoef’s study, “but also that when you do that you actually achieve notable benefits.”

However, one concern that Christian had with the study was its relatively small size, which left the occurrence of hospitalizations and deaths among nine women who received iron and 12 women who received placebo unaddressed. “The study was unable to demonstrate that those adverse events were not higher in the iron group,” said Christian.

Nevertheless, Christian agrees that the new study strongly suggests that the antenatal care system in Africa needs reform. “It needs to be boosted in many countries,” she said.

At the start of their study, said Verhoef, there was no iron available at any nearby clinics. The problem, he believes, is that many health workers don’t perceive iron deficiency to be such a big problem.

“In the face of HIV, hemoglobin disorders and all that, I think health workers sometimes think, ‘oh, a little bit of anemia, who cares,’” said Verhoef. “Our hope is that coverage will increase with the results of our study — that countries, governments, and health workers will really make an effort to get iron to these women.”

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