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Maternal and pediatric nutrition

Anaemia and iron deficiency in pregnancy and adverse perinatal outcomes in Southern India

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We examined the prevalence of anaemia, iron deficiency, and inflammation during pregnancy and their associations with adverse pregnancy and infant outcomes in India.


Three hundred and sixty-six women participating in a randomised trial of vitamin B12 supplementation were monitored to assess haemoglobin (Hb), serum ferritin (SF), hepcidin, C-reactive protein (CRP), and alpha-1-acid glycoprotein (AGP) during pregnancy. Women received vitamin B12 supplementation (50 µg per day) or placebo daily; all women received daily prenatal iron–folic acid supplementation. Binomial and linear regression models were used to examine the associations of maternal iron biomarkers with pregnancy and infant outcomes.


Thirty percent of women were anaemic (Hb < 11.0 g/dl), 48% were iron deficient (SF < 15.0 µg/l), and 23% had iron deficiency anaemia at their first prenatal visit. The prevalence of inflammation (CRP > 5.0 mg/l: 17%; AGP > 1.0 g/l: 11%) and anaemia of inflammation (Hb < 11.0 g/dl, SF > 15.0 µg/l, plus CRP > 5.0 mg/l or AGP > 1.0 g/l: 2%) were low. Infants born to anaemic women had a twofold higher risk of low birth weight (<2500 g; risk ratio [RR]: 2.15, 95%CI: 1.20–3.84, p = 0.01), preterm delivery (RR: 2.67 (1.43–5.00); p = 0.002), underweight (WAZ < −2; RR: 2.20, 95%CI: 1.16–4.15, p = 0.02), and lower MUAC (β(SE): −0.94 (0.45)cm, p = 0.03). Similarly, maternal Hb concentrations predicted higher infant birth weight (p = 0.02) and greater gestational age at delivery (β(SE): 0.28 (0.08) weeks, p = 0.001), lower risk of preterm delivery (<37 weeks; RR: 0.76, 95%CI: 0.66–86, p < 0.0001); and higher infant MUAC (β(SE): 0.36 (0.13) cm, p = 0.006). Maternal SF concentrations were associated with greater birth length (β(SE): 0.44 (0.20) cm, p < 0.03). Findings were similar after adjusting SF concentrations for inflammation. IDA was associated with higher risk of low birth weight (RR: 1.99 (1.08–3.68); p = 0.03) and preterm birth (RR: 3.46 (1.81–6.61); p = 0.0002); and lower birth weight (p = 0.02), gestational age at birth (p = 0.0002), and infant WAZ scores (p = 0.02).


The prevalence of anaemia and iron deficiency was high early in pregnancy and associated with increased risk of adverse pregnancy and infant outcomes. A comprehensive approach to prevent anaemia is needed in women of reproductive age, to enhance haematological status and improve maternal and child health outcomes.

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We thank the mothers and children, and field teams, including physicians, nurses, midwives, research and laboratory, and administrative staff, who made this study possible; Tinu Samuel, Ramya Rajendran, Sumithra Muthayya, Ammu Lukose, Wafaie Fawzi, and Ron Bosch for their contributions to the parent randomised trial of vitamin B12 supplementation; and St. John’s Medical College, Bangalore, India, for its institutional support.

Author contributions

CD, JLF, KS, and AVK designed the research; all authors conducted the research; JLF conducted the data analysis and wrote the initial draft of the manuscript; BB conducted the laboratory analyses; JLF and CD had primary responsibility for final content. All authors contributed to the interpretation of data and in the development of this manuscript, read and approved the final version.



National Institutes of Health (NICHD R03HD054123 and K24DK104676); Indian Council of Medical Research (ICMR: 5/7/192/06-RHN); Rose Fellowship in Chronic Disease Epidemiology and Biostatistics; Harvard Institute for Global Health; Uwe Brinkmann Memorial Fellowship; Michael von Clemm Fellowship; South Asia Initiative Graduate Grant; Division of Nutritional Sciences, Cornell University

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Correspondence to Julia L. Finkelstein or Christopher Duggan.

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The research protocols and study procedures were approved by the Institutional Ethical Board of St. John’s Medical College and the Harvard T.H. Chan School of Public Health Human Subjects Committee, and written informed consent was obtained from all participants. A Data Safety and Monitoring Board met twice annually during the course of the trial.

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Finkelstein, J.L., Kurpad, A.V., Bose, B. et al. Anaemia and iron deficiency in pregnancy and adverse perinatal outcomes in Southern India. Eur J Clin Nutr 74, 112–125 (2020).

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