Effect of Postpartum Anaemia on Maternal Health-Related Quality of Life: A Systematic Review

doi:10.21203/rs.3.rs-428388/v1

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Effect of Postpartum Anaemia on Maternal Health-Related Quality of Life: A Systematic Review

https://doi.org/10.21203/rs.3.rs-428388/v1

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Background: Postpartum anaemia remains a persistent and severe public health issue in many parts of the world. Studies have reported mixed findings on the effects of anaemia during the postpartum period on maternal health-related quality of life (HRQoL). We conducted this systematic review to summarise available evidence to inform public health practitioners on whether 1) anaemia negatively impact maternal health-related quality of life and 2) whether iron supplementation in anaemic women can improve maternal HRQoL during the postpartum period.

Methods: This review’s protocol was registered online with PROSPERO (CRD42020206618). We extensively searched Embase, PubMed, Cochrane and Scopus through the HINARI website to identify studies that reported either association or effect of postpartum anaemia on fatigue, depression and mother-child interaction. We restricted our search to studies of human females published in English from databases inception until August 2020. We followed a guideline for reporting systematic reviews without meta-analysis to synthesise data.

Results: Ten out of 15 studies where the direction of effect could be determined reported a significant association between lower Hb levels and physical fatigue symptoms. Fourteen out of 19 studies also reported a significant association between Hb levels and postpartum depression. There was evidence in six of the seven and seven of the eight randomised controlled trials that iron replenishment significantly decreased physical fatigue and postpartum depression respectively. Two of the four included studies showed that anaemic mothers were less responsive and had negative feelings towards their children than non-anaemic mother.

Conclusion: Evidence from this review suggests that postpartum anaemia negatively affects health related quality of life and that iron replenishment improved both symptoms of fatigue and depression. Nevertheless, it remains unclear whether postpartum anaemia affects mother-child interaction.

Health Economics & Outcomes Research

Maternal & Fetal Medicine

postpartum anaemia

fatigue

postpartum depression

mother-child interaction

iron deficiency anaemia

systematic review

Table 1: Study characteristics and association/effects of postpartum anaemia or iron deficiency on maternal physical health

Author & Year

Study Design and Setting

Risk of Bias

Sample Size

Assessment Tool

Direction

Significance

Tam et al. 2005¹⁸

RCT double blinded-placebo controlled; China

Low

N= 244 (Treatment; 61, placebo; 61 and control; 122)

General wellbeing Question

P< 0.05

Holm et al. 2017²⁰

RCT open-label; Denmark

Moderate

N=196 (97=IV and 99=Oral iron)

MFI

P=0.006

Holm et al. 2019²¹

RCT open-label; Denmark

Moderate

N=85 (Oral iron; 44, and Iron isomaltoside; 41)

MFI

p < .0001

Hamm et al. 2020²⁸

RCT open-label; USA

Moderate

N=66 (single RBCs: 33, multiple RBCs; 33)

MFI

p= 0.13

Westad et al. 2008²²

RCT open-label; Norway

Moderate

N=128 (IV + oral iron; 58, oral iron only; 70

MFI and SF-36

P=0.03

Prick et al. 2014²³

RCT open-label; Netherlands

Moderate

N= 521 (Non-intervention; 262, RBCs; 259)

MFI and SF-36

P = 0.01

Hatzis et al. 2003²⁴

Matched intervention trial; Greece

Moderate

N= 74 (EPO; 37 and oral iron; 37)

Physical assessment: clinical symptoms of fatigue

p=0.0012

Chandrasekaran et al. 2018⁹

Prospective Observational; Canada

Moderate

N=248

SF-36

OR -0.69; 95% CI -0.15-2.49

Güven et al. 2018²⁹

Prospective Observational; Denmark

Moderate

N=196

MFI

p=0.012

Holm et al. 2016¹⁹

RCT open-label; Denmark

High

N=13 (7=IV and 8=RBCs)

MFI

Van Der Woude et al. 2014⁸

Prospective Cohort; Netherlands

High

N=220 (Anaemic; 112, No anaemia; 108)

SF-36

P = 0.008*

Paterson et al. 1994²⁵

Prospective Observational; United Kingdom

High

N=1010

Physical assessment: feeling low energy

p= 0.05

Jansen et al. 2007²⁶

Prospective Cohort: Netherlands

High

N=141

MFI

p 0.002

Miller et al. 2016³⁰

Prospective Observational; USA

High

N= 63

SF-36 and MFI

P >0.05

Le et al. 1999²⁷

Prospective Observational; USA

High

N=30

Lee Fatigue Scale

r = -.27, p < .05**

r = -.44, p = .01***

Abbreviations: IV: intravenous; MFI: multi-fatigue dimension inventory; SF-36: Short Form-36; RCT: randomised controlled trial; RBCs: Red Blood Cells

Key: Improved -p; Reduced -q; Association -u; No difference -¢.

*Un-adjusted; **Low ferritin levels; *** Low haemoglobin levels

Table 2: Study characteristics and association/effects of postpartum anaemia or iron deficiency on maternal mental health (depression and anxiety)
Author & Year	Study Design and Setting	Risk of Bias	Sample Size	Assessment Tool	Direction	Significance
Perello et al. 2014³³	RCT double-blind; Spain	Low	N=72 anaemic (ferrous sucrose + oral iron; 36, placebo + oral iron; 36)	EPDS (cut off: ≥11)	¢	P >0.05
Sheikh et al. 2015³¹	RCT double-blind, placebo; Iran	Low	N=70 (iron supplementation; 35, placebo; 35)	EPDS (cut off: ≥11)	p	p = 0.03
Beard et al. 2005³⁴	RCT, double-blind; South Africa	Low	N=95 (30 in IDA-PL, 34 in IDA-Ferrous, & 31 in control)	EPDS (cut off: ≥10)	p	P <0.005
Meyer et al. 1995³²	RCT double-blind, placebo; Germany	Moderate	N=345 (non-anaemic; 274, anaemic: 71 [placebo; 36 and rhEPO; 35])	Physical assessment; signs of postpartum blues (distress)	u	P < 0.05
Holm et al. 2017²⁰	RCT open-label; Denmark	Moderate	N=196 (97=IV and 99=Oral iron)	EPDS (cut off: ≥10)	q	P <0.05
Holm et al. 2019²¹	RCT open-label; Denmark	Moderate	N=85 (Oral iron; 44, and Iron isomaltoside; 41)	EPDS (mean scores)	q	-2.39 (95% CI: -3.62; -1.16) (p =.0002)
Hamm et al 2020²⁸	RCT open label; USA	Moderate	N=66 (single RBCs; 33, multiple RBCs; 33)	EPDS (mean scores)	¢	[4 (1-11) vs 5.5 (2-8) p= .34]
Paoletti et al. 2013³⁵	RCT open-label; Italy	Moderate	N=852 (Group A: 424, Group B: 428)	EPDS (cut off: ≥12 )	u	P < 0.05
Chandrasekaran et al. 2018⁹	Prospective Observational; Canada	Moderate	N=145/248	EPDS ( cut off; ≥10)	u	OR-0.69; 95% CI-0.15-2.49
Maeda et al. 2019³⁶	Prospective cohort; Japan	Moderate	N=1128	EPDS ( cut off; ≥9)	u	AOR 1.63, 95% CI: 1.17–2.26
Eckerdal et al. 2016³⁷	Nested Cohort; Sweden	Moderate	N=446	EPDS (cut off; ≥12)	u	OR = 2.29, 95%CI = 1.15– 4.58
Alharbi et al. 2014³⁸	Case-Control; Saudi Arabia	Moderate	N=352 (Case: 117, Control: 235)	EPDS ( cut off; ≥10)	u	AOR 1.70, 95% CI 1.05–2.74; P=0.03
Armony-Sivan et al. 2012⁴²	Prospective Observational; China	Moderate	N=704 (pilot study; 137, confirmatory study: 567)	EPDS ( cut off; ≥10)	u	r = 0.07
Goshtasebi et al. 2013³⁹	Prospective Observational; Iran	Moderate	N=281	EPDS (cut off ≥13)	u	AOR 4.64; 95% CI 1.33-16.08
Albacar et al. 2010⁴⁰	Prospective Cohort; Spain	Moderate	N=729	EPDS ( cut off; ≥9)	u	OR 3.73, 95% CI: 1.84–7.56; P=0.0001
Güven et al. 2018²⁹	Prospective observational; Denmark	Moderate	N=196	EPDS (cut off; ≥10)	u	0.7 (95% CI 1.27-0.13), p=0.02
Paterson et al. 1994²⁵	Prospective observational; United Kingdom	High	N=1010	EPDS scores		P >0.05
Miller et al. 2016³⁰	Prospective Observational; USA	High	N= 63	EPDS (cut off; ≥10)	u	P >0.05
Corwin et al. 2003⁴¹	Prospective Observational; USA	High	N=37	CES-D	u	r =-0.381, P= 0.020
Abbreviations: CES-D: Epidemiological Studies-Depressive Symptomatology Scale; EPDS: Edinburg Postpartum Depression Scale; IDA-PL: Iron deficiency anaemia-placebo Key: Improved - p; Reduced - q; Association - u; No difference - ¢.

Table 3. Study characteristics and association/effects of postpartum anaemia or iron deficiency on mother-child interaction or bonding
Author & Year	Study Design and Setting	Risk of Bias	Sample Size	Assessment Tool	Direction	Significance
Murray-Kolb et al. 2009⁴³	RCT double-blind, placebo; South Africa	Low	N=95 (IDA-PL; 30, IDA-Fe; 34, and control; 31)	Video recorder	p	P= 0.007–0.032*
Perez et al. 2005⁴⁴	RCT double-blind; South Africa	Low	N=81 (IDA-PL; 21, IDA-Fe; 30 and Control; 30)	Parent/Caregiver Involvement Scale	p	P <0.05
Hamm et al. 2020²⁸	RCT open-label; USA	Moderate	N=66 (single RBCs; 33, multiple RBCs; 33)	Maternal Attachment Inventory	¢	104 (102-104) vs 104 (102-104) p= 0.55
Dearman et al. 2012⁴⁵	Case-Control; England	Moderate	N=115 (anaemic; 57, non-anaemic; 58)	Postpartum Bonding Questionnaire	u	P >0.05
Key: Improved - p; No difference - ¢; Association - u. *Ranges in subscale analysis; maternal sensitivity, structuring, and non-hostility

No competing interests reported.

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Editorial decision: Major revision
08 Aug, 2021
Reviews received at journal
28 Jul, 2021
Reviewers agreed at journal
08 Jul, 2021
Reviews received at journal
25 May, 2021
Reviewers agreed at journal
09 May, 2021
Reviewers invited by journal
25 Apr, 2021
Editor assigned by journal
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Editor invited by journal
21 Apr, 2021
Submission checks completed at journal
21 Apr, 2021
First submitted to journal
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