Implementation strategies and outcomes of intravenous iron use for treatment of anaemia during and after pregnancy in LMICs: a scoping review protocol
Creators: name: Ameh, Charles
name: Kumah, Elizabeth
name: Balogun, Mobolanle
name: Bosede Afolabi
name: Adaramoye, Victoria
Publisher: name: Open Science Framework
Year: 2023
Subjects: subject: Medicine and Health Sciences
subject: Social and Behavioral Sciences
subject: Pregnancy
subject: Implementation research
subject: Intravenous iron
subject: Postpartum
subject: Anaemia
subject: Scoping review

description: Anaemia is a global public health problem with a high burden among women of childbearing age in particular.1 Anaemia in pregnancy (AIP), defined as haemoglobin (Hb) concentration less than 11g/dL, affects two billion women globally, with a prevalence of 43% in low- and middle-income countries (LMICs).2 Iron deficiency anaemia (IDA) is the most common cause of anaemia and in pregnancy, it accounts for 40% of anaemia.3 Postpartum anaemia is caused mostly by untreated IDA in pregnancy and excessive blood loss during or after birth.4 The prevalence of AIP is estimated to be 56% while prevalence for postpartum anaemia ranges from 50 – 80% in LMICs.5,6 AIP has adverse consequences for mothers and neonates. It can result in extreme fatigue, reduced physical and mental function, depression and increased risk of postpartum haemorrhage for the mother.7-10 It also increases the risks for intrauterine growth retardation, premature delivery and low birth weight in the newborn.7,8 Postpartum anaemia increases the risk of infection, leads to poor wound healing, and causes fatigue and depression in the mother.11,12 It also adversely affects breastfeeding, due to insufficient milk production, and can reduce bonding between women and their newborn as a result of weakness and fatigue.11,13-15 Currently, oral iron is the standard treatment for obstetric anaemia. The World Health Organization recommends treatment with 120 mg of elemental iron daily until Hb rises to normal.16 However, the use of oral iron has been associated with gastrointestinal adverse events in up to 70% of patients, resulting in poor tolerance and compliance.17,18 It also takes several months of treatment for iron stores to be replenished. Intravenous (IV) iron is an alternative therapy for moderate to severe anaemia, in patients with intolerability or non-response to oral iron, or in situations where anaemia needs to be resolved quickly.19 It corrects anaemia faster and in fewer doses thus requiring fewer patient-provider interactions. This is advantageous in LMICs where postpartum care is limited20, and where financial, material, and human resource barriers hamper the implementation of maternal health interventions.21 Despite the advantages of IV iron, its use in treating obstetric anaemia in LMICs is limited, compared to high-income countries, where IV iron use have been included in treatment guidelines.22,23 Two systematic reviews and meta-analyses of randomized controlled trials, including several studies from LMICs, demonstrated the efficacy of IV over oral iron in treating AIP and in the postpartum.24,25 However, the different implementation strategies and the outcomes of this evidence-based intervention have not been widely studied in LMICs. A recent mixed-methods systematic review, which aimed to identify barriers and facilitators to implementing an IV iron intervention for pregnant women with anaemia and the implementation strategies used, identified six studies across high-income countries and LMICs.26 However, the authors did not study implementation outcomes or implementation among postpartum women. In addition, their search was restricted to five databases with a limited search of grey literature. As poor implementation of interventions can lead to little or no benefit, it is important to better understand the implementation strategies used and their outcomes in the administration of IV iron to pregnant and postpartum women in LMIC settings. Implementation strategies are methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice.27 Experts in implementation science compiled and validated 73 implementation strategies organized into nine categories in the Expert Recommendations for Implementing Change (ERIC) study.28,29 The nine categories include: a) engage consumers; b) use evaluative and iterative strategies; c) change infrastructure; d) adapt and tailor to context; e) develop stakeholder interrelationship; f) utilize financial strategies; g) support clinicians; h) provide interactive assistance; and i) train and educate stakeholders.29 Implementation outcomes are indicators of success that are the effects of deliberate and purposive actions to implement new treatments, practices, and services. According to Proctor’s conceptual framework, these outcomes include acceptability, adoption, appropriateness, feasibility, fidelity, implementation costs, penetration, and sustainability.30 Studying these strategies and outcomes would help to understand the process of translating evidence into practice. A scoping review is best suited for this topic as there is a dearth of published research in this area. Thus, it is important to map the available evidence and identify key factors related to the concept of our topic. This could in turn inform the objectives of future systematic reviews on the topic. We will identify knowledge gaps and the sources and types of evidence on implementation strategies and outcomes of the use of IV iron during and after pregnancy in LMICs. Findings from this scoping review will guide the design and implementation of IV iron treatment programs and interventions for pregnant and postpartum women. References 1. World Health Organization. Factsheet on Anaemia. 2023, May 1. Available at: https://www.who.int/news-room/fact-sheets/detail/anaemia (accessed: 01/06/23) 2. Karami M, Chaleshgar M, Salari N, Akbari H, Mohammadi M. Global Prevalence of Anemia in Pregnant Women: A Comprehensive Systematic Review and Meta-Analysis. Matern Child Health J. 2022 Jul 1;26(7):1473–87. 3. Pan American Health Organization (PAHO) news. WHO guidance helps detect iron deficiency and protect brain development. 2020, April 4. Available at: https://www.paho.org/en/news/4-4-2020-who-guidance-helps-detect-iron-deficiency-and-protect-brain-development (Accessed: June 8, 2023). 4. Moya E, Phiri N, Choko AT, Mwangi MN, Phiri KS. Effect of postpartum anaemia on maternal health-related quality of life: a systematic review and meta-analysis. BMC Public Health. 2022 Feb 21;22(1):364. doi: 10.1186/s12889-022-12710-2. 5. Stephen G, Mgongo M, Hussein Hashim T, Katanga J, Stray-Pedersen B, Msuya SE. Anaemia in Pregnancy: Prevalence, Risk Factors, and Adverse Perinatal Outcomes in Northern Tanzania. Anemia. 2018;2018:1846280. 6. Mremi A, Rwenyagila D, Mlay J. Prevalence of post-partum anemia and associated factors among women attending public primary health care facilities: An institutional based cross-sectional study. PLoS One. 2022 Feb 3;17(2):e0263501. doi: 10.1371/journal.pone.0263501. PMID: 35113955; PMCID: PMC8812965. 7. Oyelese AT, Ogbaro DD, Wakama TT, Adediran A, Gbadegesin A, Awodele IO, Ocheni S, Adetola A, Adenuga JO. Socio-economic determinants of prenatal anaemia in rural communities of South-West Nigeria: a preliminary report. Am J Blood Res. 2021 Aug 15;11(4):410-416. PMID: 34540350; PMCID: PMC8446826. 8. Sholeye OO, Animasahun VJ, Shorunmu TO. Anemia in pregnancy and its associated factors among primary care clients in Sagamu, Southwest, Nigeria: A facility-based study. J Family Med Prim Care. 2017 Apr-Jun;6(2):323-329. doi: 10.4103/jfmpc.jfmpc_74_16. 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