IRON DEFICIENCY ANEMIA IN PREGNANT WOMEN (Screening)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 10/3/11

Evidence Statement

Clinical Preventive Service Recommendations

Special Note: This note is to inform employers of slight variations in the preventive service recommendations for iron deficiency anemia among pregnant women. The U.S. Preventive Services Task Force (USPSTF) recommends routine screening for iron deficiency anemia among pregnant women, but found insufficient evidence for routine supplementation. The Centers for Disease Control and Prevention (CDC) recommends both routine screening and iron supplementation for all pregnant women. To ensure transparency, this evidence statement provides all relevant recommended guidance.

Iron Deficiency Anemia (Screening)

U.S. Preventive Services Task Force Recommendation
The U.S. Preventive Services Task Force (USPSTF) recommends screening for iron deficiency anemia in asymptomatic pregnant women.1

Evidence Rating: B (Recommended/At Least Fair Evidence)
The USPSTF found no evidence addressing the harms of screening pregnant women for iron deficiency anemia and found fair evidence that treating asymptomatic pregnant women who have iron deficiency anemia results in moderate benefits in health outcomes. The USPSTF concludes that the benefits of routine screening for iron deficiency anemia in asymptomatic pregnant women outweigh the potential harms.1
CDC Recommendation
The Centers for Disease Control and Prevention (CDC) recommends pregnant women be screened for iron deficiency anemia at the first prenatal care visit.2

Evidence Rating: None specified

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Iron Deficiency Anemia (Preventive Medication)

Clinical Preventive Service Recommendations

The USPSTF concludes that evidence is insufficient to recommend for or against routine iron supplementation for non-anemic pregnant women.1

Evidence Rating: I (Insufficient Evidence)
The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing iron supplementation to pregnant women. Evidence is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.1
CDC Recommendation
The CDC also recommends universal supplementation to meet the iron requirements of pregnancy.2
Evidence Rating: None specified

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Condition / Disease Specific Information

Iron deficiency is a condition in which a lack of iron limits the body's ability to deliver and use oxygen for several vital functions.2,3 Iron deficiency exists along a continuum, with iron depletion as the least severe and iron deficiency anemia (IDA) being the most severe.2

During pregnancy, women need three to six times more iron to support fetal and placental growth.4,5 This increased iron demand often results in maternal IDA.

Maternal IDA is associated with adverse health outcomes, including low infant birth weight,6 inferior health of the newborn and maternal mortality.4,7 In one study, over 20% of maternal mortality was attributed to anemia.8 An analysis of several studies showed that there was a higher incidence of iron deficiency among infants born to mothers with IDA during pregnancy, as compared to infants born to mothers with adequate iron status.9 Iron deficiency at birth has also been associated with postpartum depression and developmental delays in children.10,11 Maternal depression has been shown to improve 25% with iron treatment.12

It is estimated that 4% of nonpregnant women aged 20-49 in the United States have IDA.2 Although the prevalence among pregnant women is unknown, it is expected to be greater, given the large iron requirements of pregnancy.4,5 The prevalence of iron deficiency anemia among pregnant women has been shown to be highly correlated with gestational age. Rates of IDA among low-income and minority women — a population at increased risk of IDA — were 1.8%, 8.2% and 27.4% in the first, second and third trimester, respectively.5
Condition / Disease Risk Factors
Risk factors for iron deficiency anemia among pregnant women include a diet lacking adequate iron consumption, obesity, and increased parity. Pregnant women of low socioeconomic status, low educational attainment, and ethnic minority are also at an increased risk for IDA.13

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The Value of Prevention

Economic Burden of Condition/Disease
The total societal economic burden of iron deficiency anemia among pregnant women is not available. However, iron deficiency is the most common nutritional disorder worldwide.13 The economic burden of IDA includes the costs associated with infants born at low birthweight, perinatal mortality and postpartum depression. According to the March of Dimes, children from birth to 15 years born at a low birthweight cost (health care, special education and child care) $5.5 - $6 billion more than they would have if born at a normal birthweight.14 A portion of these costs, as well as costs for postpartum depression and perinatal mortality comprise the total economic burden of IDA.
Workplace Burden of Condition/Disease
The workplace burden of iron deficiency anemia among pregnant women can be substantial. The largest cost is that associated with pregnancies resulting in a low birthweight delivery. A recent analysis of employer-paid health insurance data from 2004 to 2006 found that the net cost to employers of paying for the delivery of an infant born either low birthweight or preterm was approximately $46,000, compared with less than $4,000 for an uncomplicated delivery.15 Average costs of hospitalization rise exponentially with decreasing birthweight. For example, the median treatment cost of hospitalization for infants weighing under 1000 grams is $65,600, compared to $12,100 for infants weighing between 1000-24000 grams.16 Although there does not appear to be a short-term loss of employee productivity associated with a complicated delivery, the total workplace burden can include the direct and indirect costs associated with postpartum depression, maternal mortality and child developmental delays.
Economic Benefit of Preventive Intervention: Screening
The economic benefit of screening US pregnant women for iron deficiency is unknown, but employers may be able to track iron supplementation through medical claims.
Economic Benefit of Preventive Intervention: Preventive Medication
The economic benefit of iron supplementation is based upon the cost-savings that results from averted direct and indirect costs associated with the negative outcomes of IDA during pregnancy, including maternal mortality, postpartum depression, low birthweight infants, and diminished infant health. Two randomized controlled trials of iron supplements administered to low-income non-anemic pregnant women in the United States reported data on birth outcomes.17,18 Pooling the results from the two studies, 283 non-anemic women who received supplements containing iron had significantly fewer infants who were low birthweight (< 2500 g), 4.6% vs.12.1% (p < 0.01) than among 264 other women who were randomized to receive supplements not containing iron. The economic costs of very low birthweight (< 1500 g) are high, with initial hospital charges nearly $70,000 higher than those for a normal weight infant.19
Estimated Cost of Preventive Intervention: Screening
The cost of screening for iron deficiency anemia varies by location, provider and tests performed. In 2007, the average private-sector reimbursement for iron deficiency anemia screening among pregnant women using hemoglobin or hematocrit was $3.72 and $3.69, respectively.20
Estimated Cost of Preventive Intervention: Preventive Medication
Women can obtain iron-fortified prenatal vitamins by prescription or over-the-counter (OTC). The cost varies depending on the brand of supplement and duration of use. The mean average wholesale price (AWP) for a 30 day supply of prescription prenatal vitamins is $20.08; the median AWP for a 30-day supply is $16.59.21 The cost of over-the-counter prenatal vitamins varies widely and is an out-of-pocket expense for which flexible spending accounts (FSA) may be used.
Estimated Cost of Treatment
N/A
Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
A complete cost-effectiveness or cost-benefit analysis for iron deficiency anemia screening or iron supplementation has not been conducted.

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Preventive Intervention Information

Preventive Intervention: Purpose of Screening
The purpose of screening for and treating iron deficiency anemia in pregnancy is to identify those individuals who may benefit from additional iron supplementation in order to prevent poor maternal and infant outcomes of pregnancy. The CDC recommends all pregnant women consume 27 mg/day or iron.2 Screening identifies those women for whom the daily supplement is not sufficient and an increased dosage of 60-120 mg/day is recommended.
Preventive Intervention: Purpose of Preventive Medication
The purpose of routine supplementation is to help pregnant women maintain iron stores needed throughout pregnancy and prevent the onset of iron deficiency anemia.
Benefits and Risks of Intervention: Screening
Screening for iron deficiency anemia decreases the risk of negative pregnancy outcomes by identifying those women who are unable to maintain adequate iron levels through diet alone and would benefit from iron supplementation. Screening also decreases the risk of iron overload.

The potential risks of screening for iron deficiency anemia among pregnant women are similar to the risks of screening any demographic. They include the cost and time to complete screening tests, potential anxiety and false-positives. However, the USPSTF did not identify any information on these harms.13
Benefits and Risks of Intervention: Preventive Medication
Routine supplementation and/or treatment for iron deficiency anemia among pregnant women helps maintain or correct maternal iron levels. Adequate iron levels can decrease the risk of low birth weight infants18 and maternal mortality, as well as help improve postpartum depression and infant iron stores.22 Treatment of iron deficiency anemia may also improve symptoms of fatigue and decreased endurance experienced by pregnant women.23 The potential risks of iron supplementation among pregnant women are rare in developed countries. In some instances, genetic disorders such as hemochromatosis and thalassemia major can result in iron overload, however these disorders are rare in the US.24

Initiation, Cessation, and Interval of Screening
According to the CDC and the American College of Obstetricians and Gynecologists (ACOG), clinicians should screen pregnant women at the first prenatal visit. ACOG recommends rescreening all pregnant women for iron deficiency anemia early in the third trimester.2,13
Initiation, Cessation, and Interval of Preventive Medication
The CDC recommends pregnant women begin taking iron supplements at their first prenatal visit. Iron should be stopped at delivery unless other risk factors for iron deficiency are present.2
Intervention Process: Screening
The "gold standard" for diagnosing iron deficiency anemia is the absence of bone marrow iron. However, venous hemoglobin or hematocrit concentrations are more frequently assessed because the tests are easier and more cost-effective.1,2 A low hemoglobin or hematocrit value indicates only anemia. Iron deficiency is typically confirmed by assessing hemoglobin response to iron supplementation or by utilizing tests of iron status (e.g., serum ferritin and transferrin saturation).13 Among almost 60,000 privately insured pregnant US women who were screened for anemia, no laboratory tests for iron status were subsequently billed.19
Intervention Process: Preventive Medication
Pregnant women should be counseled on appropriate dietary needs during pregnancy. The recommended daily intake (RDI) for pregnant women of all ages is 27 mg of ferrous iron per day.25 Heme iron, found in meat, poultry and fish, is absorbed most efficiently by the body; non-heme iron, found in green-leafy vegetables, lentils and iron-fortified breads and cereals, is absorbed less efficiently.26,27 Vitamin C has been shown to increase the absorption of non-heme iron and may be recommended as part of an iron-rich diet.28

The CDC also recommends the universal supplementation of pregnant women with 27 mg/day.2 Due to contraindications of high hemoglobin levels on pregnancy outcomes, hemoglobin levels of those individuals using iron supplements should be monitored throughout pregnancy.29
Treatment Information
Pregnant women with diagnosed iron deficiency anemia should consume 60-120 milligrams (mg) of iron daily.2

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Strength of Evidence for the Clinical Preventive Service

The level of evidence supporting the recommendations contained in this chapter is described below.

Evidence-Based Research:
U.S. Preventive Services Task Force (USPSTF)
Strength of Evidence: B (Recommended/Fair Evidence)
  • The U.S. Preventive Services Task Force (USPSTF) found fair evidence that treating asymptomatic pregnant women who have iron deficiency anemia results in moderate benefits in health outcomes. The USPSTF found no evidence addressing the harm of screening pregnant women for iron deficiency anemia. The USPSTF concludes that the benefits of routine screening for iron deficiency anemia in asymptomatic pregnant women outweigh the potential harms.
U.S. Preventive Services Task Force (USPSTF)
Strength of Evidence: I (Insufficient Evidence)
  • The USPSTF concludes that evidence is insufficient to recommend for or against routine iron supplementation for non-anemic pregnant women.1
Recommended Guidance:
Centers for Disease Control and Prevention (CDC)
Strength of Evidence: Expert Opinion
  • The CDC recommends pregnant women be screened for iron deficiency anemia.2
  • The CDC recommends "universal iron supplementation to meet the iron requirements of pregnancy.

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Summary Plan Description

SPD Language

Covered Screening
All methods of screening for iron deficiency anemia are covered.
Initiation, Cessation and Interval
Screening for iron deficiency anemia is a covered benefit for pregnant women at their first prenatal care visit. Subsequent screenings are covered when medically indicated.
Covered Preventive Medications
  • Prenatal Vitamins with Iron
  • Prescription Strength Iron Supplements
Initiation, Cessation and Interval
Prescription strength iron supplementation is covered when used to prevent or treat iron deficiency anemia among pregnant women.

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CPT Codes

85013 Blood count; spun microhematocrit
85014 Blood count; hematocrit (Hct)
85018 Blood count; hemoglobin (Hgb)

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Other Information and Resources

Business Group Resource(s)

Centers for Disease Contol and Prevention

March of Dimes

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Author(s)

Sherrets D, Cusick S, Grosse S, Amendah D. Iron Deficiency Anemia among Pregnant Women: Screening and Preventive Medication. 2009. Updated 2011.

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References

  1. U.S. Preventive Services Task Force. Screening for Iron Deficiency Anemia -Including Iron Supplementation for Children and Pregnant Women. Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; May 2006. Available at: http://www.ahrq.gov/clinic/uspstf06/ironsc/ironscr.pdf. Accessed May 23, 2008.
  2. Centers for Disease Control and Prevention. Recommendations to prevent and control iron deficiency in the United States. MMWR.1998;47(RR-3):1-29.
  3. National Institutes of Health. MedlinePlus Medical Encyclopedia: Iron deficiency anemia. at: http://www.nlm.nih.gov/medlineplus/ency/article/000584.htm. Accessed May 23, 2008.
  4. Beard JL. Effectiveness and strategies of iron supplementation during pregnancy. Am J Clin Nutr. 2000;71(5):1288S-1294.
  5. Scholl TO. Iron status during pregnancy: setting the stage for mother and infant. Am J Clin Nutr. 2005;81(5):1218S-1222.
  6. Levy, A et al. Maternal anemia during pregnancy is an independent risk factor for low birthweight and preterm delivery. European Journal of Obstetrics & Gynecology and Reproductive Biology. October 1, 2005; 122(1): 182-186.
  7. Allen LH. Anemia and iron deficiency: effects on pregnancy outcome. Am J Clin Nutr. 2000;71(5):1280S-1284.
  8. Ross JS, Thomas EL. Iron deficiency anemia and maternal mortality. Washington, DC: Academy of Education Development; 1996.
  9. Chaparro, C. Setting the Stage for Child Health and Development: Prevention of Iron Deficiency in Early Infancy. The Journal of Nutrition. 2008; 138(12): 2529-2533.
  10. Corwin EJ, Murray-Kolb LE, Beard JL. Low Hemoglobin Level Is a Risk Factor for Postpartum Depression. J. Nutr. 2003;133(12):4139-4142.
  11. Perez EM, Hendricks MK, Beard JL, et al. Mother-infant interactions and infant development are altered by maternal iron deficiency anemia. Journal of Nutrition. 2005;135(4):850-855.
  12. Beard JL, Hendricks MK, Perez EM, et al. Maternal Iron Deficiency Anemia Affects Postpartum Emotions and Cognition. J. Nutr. February 1, 2005 2005;135(2):267-272.
  13. Helfand M, Freeman M, Nygren P, Walker M. Screening for iron deficiency anemia in childhood and pregnancy: Update of 1996 USPSTF Review. Evidence Synthesis No. 43. Rockville, MD: Agency for Healthcare Research and Quality; April 2006. Available at: http://www.ahrq.gov/clinic/uspstfix.htm.
  14. March of Dimes. National perinatal statistics. Available at: http://www.marchofdimes.com/aboutus/680_2203.asp. Accessed: January 5, 2009.
  15. The Cost of Prematurity to Employers. March of Dimes Foundation 2008.
  16. Russell, R et al. Cost of Hospitalization for Preterm and Low Birth Weight Infants in the United States. Pediatrics. 2007; 120(1): e1-e9.
  17. Siega-Riz AM, Hartzema AG, Turnbull C, Thorp J, McDonald T, Cogswell ME. The effects of prophylactic iron given in prenatal supplements on iron status and birth outcomes: a randomized controlled trial. Am J Obstet Gynecol. 2006;194(2):512-9.
  18. Cogswell ME, Parvanta I, Ickes L, Yip R, Brittenheim GM. Iron supplementation during pregnancy, anemia, and birth weight: a randomized controlled trial. Am J Clin Nutr. 2003;78:773-781.
  19. Cuevas KD, Silver DR, Brooten D, et al. The cost of prematurity: hospital charges at birth and frequency of rehospitalizations and acute care visits over the first year of life: a comparison by gestational age and birth weight. Am J Nurs. 2005;105(7):56-64.
  20. Thomson Reuters. 2007 MarketScan® Commercial Claims and Encounters Database. 2009.
  21. Physicians' Desk Reference, Micromedex, PDR. Red book 2009: pharmacy's fundamental reference. Montvale: Physicians' Desk Reference Inc; 2009.
  22. Raoa R, Georgieffab MK. Iron in fetal and neonatal nutrition. Semin Fetal Neonatal Med. 2007;12(1):54-63.
  23. Haas JD, Brownlie T. Iron Deficiency and Reduced Work Capacity: A Critical Review of the Research to Determine a Causal Relationship. Journal of Nutrition. 2001;131:676S-690S.
  24. Yip R. Significance of an abnormally low or high hemoglobin concentration during pregnancy: special consideration of iron nutrition. Am J Clinical Nutrition. 2000;72:272S-279S.
  25. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Anemia in Pregnancy. Number 95. July 2008.
  26. Hurrell RF. Preventing iron deficiency through food fortification. Nutr Rev. 1997;55:210-222.
  27. Miret S, Simpson RJ, McKie AT. Physiology and molecular biology of dietary iron absorption. Annual Review of Nutrition. 2003;23(1):283-301.
  28. Institute of Medicine. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington DC: National Academy Press; 2001.
  29. Beard, J. Iron (2008). Requirements and Adverse Outcomes. In Lammi-Keefe, C, Couch, S, and Philipson, E Handbook of Nutrition and Pregnancy (233-244). Humana Press.