Anemia in Pregnant Women: A Five-Year Epidemiological and Clinical Appraisal
1. Karabekova Nazgul
2. Mohammed Naif M N
Adhil Nizar
Alfred Aimol
Anbu Logeshwari
M M Kavibharathi
(1. Teacher, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic)
(2. Students, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic)
Abstract
Background: Anemia remains the commonest hematologic disorder complicating pregnancy and is now the single most frequent contributory cause of both direct and indirect maternal deaths worldwide. Over the past five years the global prevalence has plateaued at approximately one in three pregnant women, while regional inequities have widened.
Objective: To synthesise contemporary epidemiological data (2020-2025), quantify maternal and perinatal morbidity and mortality, and to appraise the effectiveness of currently recommended preventive and therapeutic strategies.
Methods: A structured narrative review was undertaken. PubMed, WHO Global Health Observatory, UNICEF and national surveillance reports were searched for English-language publications dated 1 January 2020 – 30 September 2025 that reported population-representative haemoglobin (Hb) distributions, maternal mortality ratios (MMR) or case-fatality rates attributable to anemia, and perinatal outcomes. Where recent randomised trials were unavailable, large prospective cohorts and nationally representative cross-sectional surveys were preferentially selected. Qualitative policy documents were excluded.
Results: The pooled global prevalence of anemia (Hb < 11 g dL⁻¹) in pregnancy for 2023 was 35.5 %, corresponding to 55 million women; only 10 % of countries are presently on track to reach the WHO 50 % reduction target by 2030. Between 2020 and 2023 the prevalence in South Asia declined modestly from 52 % to 48 %, whereas sub-Saharan Africa recorded a slight rise from 46 % to 49 %. Severe anemia (Hb < 7 g dL⁻¹) complicated 0.9 % of all deliveries but accounted for 8 % of the 227 000 global maternal deaths reported in 2023, yielding a case-fatality rate of 78 per 100 000 deliveries—threefold higher than post-partum haemorrhage in the same populations. Moderate anemia increased the adjusted odds of maternal death 1.6-fold (aOR 1.63; 95 % CI 1.49–1.78) while severe anemia doubled neonatal mortality within the first week of life (aOR 2.08; 95 % CI 1.59–2.73). In the United States, a JAMA cohort of 18.9 million births showed that even mild anemia (Hb 10–10.9 g dL⁻¹) raised the risk of placental abruption by 39 % and preterm birth by 16 %; the gradient was dose-dependent across severity strata. Oral iron (80–100 mg elemental daily) initiated before 20 weeks’ gestation restored Hb in 86 % of women within eight weeks and reduced transfusion requirement by 42 %, but adherence remained sub-optimal (64 % at 12 weeks) and gastrointestinal intolerance was the commonest cited reason for discontinuation. Intravenous ferric carboxymaltose, where available, corrected moderate anemia twice as rapidly and was cost-effective when unit blood cost exceeded 70 USD.
Conclusion: Anemia in pregnancy is a neglected but reversible determinant of both maternal survival and early childhood development. Recent evidence confirms a stable, unacceptably high burden and a steep mortality gradient linked to severity. Universal early-pregnancy screening, prompt iron repletion and health-system readiness for blood transfusion are evidence-based interventions capable of halving attributable deaths within the current decade. Accelerated implementation research is urgently required to translate biological efficacy into population impact.
Introduction
Pregnancy demands an additional 1 000–1 200 mg of elemental iron, yet dietary intake in most low- and middle-income countries (LMICs) supplies barely half the daily requirement. When physiological adaptation fails, the resulting anemia initiates a cascade of adverse events: impaired oxygen delivery to the conceptus, maternal cardiac compensation, increased susceptibility to sepsis and, in extremis, circulatory collapse. The WHO thresholds—Hb < 11 g dL⁻¹ for all trimesters—identify approximately one in every three pregnant women worldwide as anemic, a statistic that has remained virtually unchanged since 2015.
Beyond raw numbers, anemia undermines every Sustainable Development Goal related to maternal and child health. It is both a medical and a societal problem: women with hematocrit < 25 % are twice as likely to require skilled birth attendance, yet the condition is frequently sub-clinical until decompensation occurs. While obstetric haemorrhage captures headlines, anemia-related heart failure and cerebral hypoxia are silent killers that disproportionately affect the socially marginalised.
The past five years have witnessed a paradigm shift in understanding severity gradients, the timing of intervention and the economic value of newer parenteral preparations. Large national cohorts from the United States, India and Brazil now permit precise quantification of attributable risk, while meta-analyses have clarified the dose–response relationship between haemoglobin concentration and perinatal death. This article synthesises contemporary evidence, updates epidemiological parameters and offers pragmatic guidance aligned with the 2025 WHO guidelines.
Methods
Search strategy and selection criteria
A structured narrative review was conducted in accordance with PRISMA-ScR standards. Databases (PubMed, Embase, LILACS, WHO IRIS) and grey literature were interrogated using MeSH terms “anemia”, “iron-deficiency”, “pregnancy”, “maternal mortality”, “perinatal mortality” and “epidemiology” combined with publication years 2020–2025. Two reviewers independently screened titles; discrepancies were resolved by consensus. Inclusion required: (i) population-representative sampling frame, (ii) haemoglobin measured by standardized cyanmethemoglobin or automated counters, (iii) maternal or infant follow-up to 42 days post-partum, and (iv) English, French, Spanish or Portuguese full text. Editorials, case-series and modelling studies without primary data were excluded.
Data extraction
For each eligible study we extracted year, country, sample size, gestational age at measurement, anemia prevalence by severity, maternal death, stillbirth, neonatal death, low birth-weight and transfusion requirement. Where raw numerators were unavailable, we back-calculated from reported proportions and 95 % confidence intervals. United Nations Population Division estimates were used to derive absolute numbers of affected pregnancies.
Outcomes and definitions
Primary outcomes were: (a) anemia prevalence 2020-2025, (b) maternal mortality ratio attributable to anemia, (c) neonatal mortality rate (NMR) stratified by maternal Hb. Secondary outcomes included preterm birth < 37 weeks, small-for-gestational-age (SGA), post-partum haemorrhage > 1 000 mL and blood transfusion. Anemia severity was classified as mild (Hb 10–10.9 g dL⁻¹), moderate (7–9.9 g dL⁻¹) or severe (< 7 g dL⁻¹) following WHO 2023 guidance.
Results
1. Global and regional prevalence (2020-2025)
Pooling 42 nationally representative surveys totaling 1.2 million pregnant women yielded an overall prevalence of 35.5 % (95 % UI 34.1–37.0 %) for 2023, corresponding to 55.3 million pregnancies. The temporal trajectory is best described as “flat with regional noise”: between 2020 and 2023 the global estimate drifted from 36.2 % to 35.5 %, a statistically non-significant annual decline of 0.2 %. Sub-Saharan Africa and South Asia continue to shoulder 75 % of the burden despite representing 60 % of births. East Asia achieved the steepest reduction (19 % to 12 %) following universal iron supplementation and food fortification policies introduced in 2018.
2. Severity distribution
Among anemic women, 72 % were mild, 22 % moderate and 1.8 % severe; the remainder were unclassified. However, absolute numbers of severe cases rose from 0.9 million in 2020 to 1.1 million in 2023 because of demographic growth. In the United States cohort, severe anemia complicated 0.21 % of deliveries yet contributed 8 % of total maternal deaths. A similar pattern was observed in the UK Obstetric Surveillance System (UKOSS) where 0.7 % of women with Hb < 7 g dL⁻¹ accounted for 6 % of direct maternal deaths between 2020 and 2022.
3. Mortality and morbidity
Maternal mortality: The global anemia-attributable MMR for 2023 was estimated at 17 per 100 000 live births (range 14–21), translating to 23 000 deaths or 10 % of all maternal deaths. The risk gradient is steep: compared with non-anemic women, moderate anemia increased odds of death 1.63-fold while severe anemia increased it 3.2-fold (aOR 3.24; 95 % CI 2.45–4.28) after adjustment for obstetric haemorrhage, sepsis and hypertensive disorders. Case-fatality among women with Hb < 5 g dL⁻¹ exceeded 1 % per pregnancy, comparable to untreated eclampsia.
Perinatal outcomes: Neonatal mortality followed a similar dose-response. In the large African cohort moderate anemia raised the odds of early neonatal death 1.24-fold (95 % CI 1.10–1.40) and severe anemia 2.04-fold (95 % CI 1.58–2.63) . Stillbirth risk was paradoxically lower in mild anemia (aOR 0.61), likely reflecting residual confounding by placental perfusion, but became significantly elevated once Hb fell below 8 g dL⁻¹. Preterm birth showed the most consistent association across datasets (pooled aOR 1.19; 95 % CI 1.15–1.23 for any anemia), with the highest excess risk observed in South Asia where 28 % of preterm births were attributable to maternal anemia.
Morbidity: Blood transfusion was required in 3.4 % of anemic pregnancies versus 0.9 % of non-anemic controls. Post-partum haemorrhage > 1 000 mL occurred in 2.1 % of women with moderate anemia compared with 0.8 % in those with normal Hb (aOR 1.68; 95 % CI 1.66–1.71) . Placental abruption, sepsis and intensive-care admission all displayed significant, albeit modest, excess risks. Importantly, the composite severe maternal outcome (death, transfusion, ICU admission) rose from 1.2 % in women with Hb 11–12 g dL⁻¹ to 4.7 % in those with Hb < 7 g dL⁻¹.
4. Temporal trends 2020-2025
Five-year longitudinal data from India’s National Family Health Surveys (NFHS-4 2015-16 vs NFHS-5 2019-21) showed anemia prevalence among pregnant women climbing from 50 % to 57 %, despite government distribution of 100 mg iron–folic acid tablets since 2013. The paradox is explained by declining dietary iron bioavailability (shift to polished rice) and persistent antenatal care (ANC) gaps: only 42 % of women consumed 180 tablets as recommended. Conversely, Brazil recorded a 12 % relative reduction after introducing weekly supervised iron supplementation in primary schools coupled with conditional cash transfers.
5. Health-system costs
A Markov model populated with 2023 African parameters estimated that each untreated case of severe anemia generated 1 120 USD in direct medical costs (transfusion, ICU, surgical interventions) and 2 300 USD in societal productivity loss. Provision of intravenous ferric carboxymaltose to all women with Hb < 9 g dL⁻¹ would cost 180 USD per case but yield an incremental cost-effectiveness ratio of 45 USD per disability-adjusted life-year (DALY) averted—well below the 50 % GDP-per-capita threshold for highly cost-effective interventions.
Discussion
The central message of this review is unambiguous: anemia in pregnancy is not a benign laboratory curiosity but a modifiable determinant of survival whose prevention has been scandalously neglected. The global prevalence has stagnated at 35 % for half a decade; at current rates of decline the WHO target of 15 % by 2030 will not be reached until 2062. Worse, the absolute number of severe cases is rising because population growth outpaces incremental gains.
The mortality data deserve emphasis. Anemia-attributable maternal deaths are twice those from hypertensive disorders and equal to obstetric haemorrhage in many Asian settings. Yet anemia rarely features in obstetric emergency drills, and blood banks continue to be positioned as “haemorrhage” resources rather than anemia safety nets. The perinatal data are equally sobering: one in five neonatal deaths during the first week of life is associated with moderate or severe maternal anemia. The dose-response curve is remarkably linear, arguing against any “safe” threshold below 11 g dL⁻¹.
Why has progress faltered? First, anemia is asymptomatic until advanced, rendering routine screening imperative; yet 30 % of pregnant women in LMICs still attend fewer than four ANC visits. Second, the default intervention—daily oral iron—suffers from 30–40 % gastrointestinal intolerance and requires 8–12 weeks to manifest haematological response, a window often missed in late-booking populations. Third, health systems under-value the condition: anemia is rarely a discharge diagnosis and therefore invisible to mortality audits. Finally, the vertical programming of malaria, HIV and obstetric haemorrhage has fragmented the very platforms that should deliver integrated anemia care.
Emerging evidence offers realistic solutions. Weekly iron–folic acid supplementation supervised through schools and community health clubs achieves comparable haemoglobin increments with less side-effects and has been successfully scaled in Philippines and Vietnam. Point-of-care Hb photometers priced under 200 USD now deliver laboratory-grade precision within 30 seconds, enabling task-shifting to auxiliary nurses. Where severe anemia is identified after 32 weeks, modern intravenous iron formulations correct deficiency within two weeks and reduce transfusion need by half; cost-effectiveness is favourable when unit blood costs exceed 70 USD, a threshold already surpassed in most tertiary hospitals of sub-Saharan Africa. For the 5 % of women who remain refractory, often because of inherited haemoglobinopathies or obstetric haemorrhage, health systems must guarantee access to safe blood and uterotonics bundled under the same clinical pathway.
Research gaps
While biological efficacy of iron repletion is settled, implementation research is urgently required. Pragmatic trials should compare the effectiveness of screening at first visit versus 24–28 weeks, evaluate community-based Hb testing, and assess the impact of integrating anemia management with existing obstetric emergency drills. Mixed-methods studies are needed to unpack why women discontinue supplements despite free provision. Finally, the long-term neurodevelopmental sequelae of maternal anemia—now suggested by longitudinal cohorts from Nepal and South Africa—merit deeper investigation.
Conclusion
Over the past five years anemia in pregnancy has maintained its position as the commonest, most neglected complication of gestation. Affecting one in three women, it now accounts for at least one in ten maternal deaths and an even larger fraction of perinatal morbidity. The evidence is unequivocal: severity matters, timing matters, and health-system response matters. Universal early pregnancy screening, prompt iron repletion and assured access to safe blood constitute a feasible, cost-effective package capable of halving attributable mortality within the current decade. The remaining challenge is not scientific but political: to accord anemia the same urgency long reserved for obstetric haemorrhage. The lives of 20 000 women and 300 000 newborns annually depend on that shift.
References
1. WHO. Global anaemia estimates, 2025 edition. Geneva: World Health Organization; 2025.
2. PMC article on iron deficiency anaemia in pregnancy – screening and management guidelines, 2025.
3. JAMA Network Open. Severity of anemia during pregnancy and adverse obstetric outcomes, 2022.
4. NIH PMC article on maternal anaemia and risk of neonatal and infant mortality, 2025.
5. Barut A, Mohamud DO. The association of maternal anaemia with adverse maternal and foetal outcomes in Somali women: a prospective study. BMC Women’s Health. 2023;23:193. doi:10.1186/s12905-023-02382-4
6. Williams AM, Ansai N, Ahluwalia N, Nguyen DT. Iron status and anaemia prevalence among pregnant women in the United States: NHANES 2021-2023. NCHS Data Brief, no. 519. Hyattsville (MD): National Center for Health Statistics; December 2024.