European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 126–131

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Prevalence and risk factors for early postpartum anemia

Renate L. Bergmann *, Rolf Richter, Karl E. Bergmann, Joachim W. Dudenhausen
Department of Obstetrics, Charité University Medicine, Augustenburger Platz 1, 13353 Berlin, Germany

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To assess the prevalence and evaluate the most important risk factors for early postpartum
Received 8 June 2009 anemia.
Received in revised form 29 January 2010 Study design: The perinatal process data of 43 807 women delivering between 1993 and 2008 (90.1% of
Accepted 10 February 2010
all deliveries) in the largest university obstetric department in Germany were analyzed, and the
associations of Hb < 8 g/dl with maternal characteristics, pregnancy risks, delivery mode and estimated
Keywords: delivery blood loss were calculated. Multivariable logistic regression models were applied to compute
Early postpartum anemia
odds ratios. Additionally, the impact of these risk factors for delivery blood loss was estimated with
Obstetric blood loss
Iron deficiency
multivariable linear regression analysis.
Results: Twenty-two percent of mothers had Hb < 10 g/dl, and 3% had Hb < 8 g/dl. The adjusted odds
ratios (OR) for Hb < 8 g/dl were 4.8 (p = 0.001) for placenta previa, 2.9 (p < 0.001) for mothers of African
origin, 2.7 (p < 0.001) for diagnosed anemia in pregnancy, 2.2 (p < 0.001) for multiple pregnancy, and 2.1
(p = 0.021) for bleeding in late pregnancy. However, the delivery blood loss was the most important risk
factor for postpartum anemia. The adjusted OR for an estimated blood loss of 500–1000 ml was 15.3
(p < 0.001), and for a loss of >1000 ml was 74.7 (p < 0.001).
Conclusion: The estimated obstetric blood loss is the most important risk factor for severe postpartum
anemia, and the volume of blood lost is especially high in cesarean deliveries, which should be
considered when electing delivery procedures. Also, measures to boost iron stores in pregnancy should
be established.
ß 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Iron deficiency and anemia in pregnancy are prevalent even in
developed countries [1–3]. In contrast, the postpartum period is
considered to be characterized by physiologically low iron
requirements, particularly because the expanded red cell mass
contracts after delivery, and its iron can be utilized and stored [4].
But low iron stores during pregnancy may be carried over into the
postpartum period, and therefore iron supplements after delivery
enhance the postpartum recovery of hematological values [5–7].
However, these physiological regulations, the underlying nutri-
tional deficits and their control will be overridden by obstetric
hemorrhage, which is not a rare event even in developed countries,
and presents the major risk factor for maternal deaths in
developing countries [8–10]. In 2003, around 6% of pregnancy-
related hospital discharges in the USA had a diagnosis of obstetric
bleeding, and one in five of them an anemia diagnosis [10]. In
Australia the rate of obstetric hemorrhage was estimated to
amount to 13.1% of deliveries [11]. The prevalence of postpartum
anemia (Hb < 10 g/dl) on discharge in one of the German Federal
* Corresponding author. Tel.: +49 30 450 564 101; fax: +49 30 450 564 908.
E-mail address: renate.bergmann@charite.de (R.L. Bergmann).
States showed increasing rates from 12.2 to 15.6% during the years
1998 through 2003 [12].
Most mothers recover from postpartum anemia during the
weeks or sometimes months after delivery. But when recovery
takes a long time, e.g. with an unfavorable baseline Hb around
delivery, functional consequences of iron deficiency and anemia
may appear or worsen: depressive symptoms, deficits in cognitive
function, fatigue, lower work performance, impaired immune
function [13,14]. Also, poorer functioning of mother–child inter-
action and even delayed infant development were related to
maternal postpartum iron deficiency anemia [15,16].
In view of these consequences, it is important to monitor the
prevalence and time trends of postpartum anemia in any setting,
and to evaluate the most important risk factors for low hemoglobin
values after delivery.
2. Methods
The Virchow Hospital of the Charité University Medicine is
located in a low income district of Berlin with a high fluctuation
rate, which is the prevailing catchment area of our obstetric
department, the largest in Germany. The perinatal process data are
collected and electronically stored in the hospital documentation;
most of them are collected on a standard form for the purpose of

0301-2115/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2010.02.030
 R.L. Bergmann et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 126–131
Fig. 1. Distribution of hemoglobin concentrations the first day after delivery (n = 43 807 deliveries).
bench marking obstetric wards in Berlin regarding their clinical
performance. Medical history data were transferred from the
record of pregnancy care (filled in during antenatal care by
practicing gynecologists), and medical history, obtained at
admission, as well as delivery and birth characteristics were
electronically recorded by our obstetric team. The term ‘‘nullipar-
ity’’ in the records of pregnancy care was changed to ‘‘primiparity’’
in the electronic record after delivery, but we used the term
‘‘primiparity’’ throughout.
The data were checked twice before they were compiled and
stored. We received the data for the period 01 April 1993 through
31 March 2008 from our IT department on 48 623 deliveries of
40 263 women, containing basic characteristics of the mothers,
recorded pregnancy risks, and main characteristics of the delivery
and of the newborn. Some mothers had delivered repeatedly in our
hospital, and therefore were recorded several times, according to
the number of their deliveries. Our evaluation is based on
deliveries or births. Hb values were available on 43 807 mothers
after delivery (90.1% of deliveries), determined from venous blood
sampled on the morning of the second postpartum day, i.e.
between 24 and 48 h, with an automated analyzer (Cell Dyn 3500)
by our central clinical laboratory. Anemia was defined as an Hb
below 10.0 g/dl, and severe anemia as a value below 8.0 g/dl [17].
Blood loss at delivery was visually estimated and recorded by
the delivery team from the staining of sheets, pads, containers and
other materials used during delivery and in the delivery area, by
rules passed from one team to the other over the years.
Mothers were observed postpartum for about 2 h in the
delivery area, before they were transferred to the ward. Any
complication with larger blood loss postponed their transfer, and
the respective blood loss was added to the total loss.
2.1. Statistical methods
The associations of anemia or severe anemia with maternal
characteristics, pregnancy risks from the record of pregnancy care,
delivery mode and estimated delivery blood loss were univariably
assessed by chi2-test for nominal data and by Kendall’s tau b for
ordinal data, and by multivariable logistic regression analysis.
Odds ratios (OR) adjusted for all other influential variables were
calculated. The variables were entered into the equation in four
blocks: first maternal characteristics, second antenatal history,
pregnancy risks, and newborn characteristics, third mode of
delivery, and fourth estimated delivery blood loss. Less important
risk factors of the univariable analysis were excluded. Multi-
variable linear regression analysis was applied to estimate blood
127
volume lost as a continuous variable, according to pregnancy risk
factors and mode of delivery The data were analyzed with SPSS
14.0 (SPSS Inc., Chicago, IL), and p < 0.05 was considered
statistically significant.
3. Results
The distribution of postpartum Hb, and the percentile values
were skewed to the left with a mean of 11.0 g/dl and a median of
11.2 g/dl (Fig. 1). About one in five women was anemic (Hb < 10 g/
dl), and one in 30 was severely anemic (Hb < 8 g/dl) on the second
day after delivery. The prevalence of anemia increased slightly and
significantly over the observed time period, while there was no
significant change in severe anemia (Fig. 2).
3.1. Univariable analysis
Data over the observed 16 years were combined and associa-
tions calculated between low postpartum Hb values and different
factors of potential influence. There was no significant association
between low Hb values on one hand, and marital status, diabetes,
anticipated hemorrhage risk, history of recurrent abortions, short
birth spacing, fetal malpresentation, and nicotine or alcohol
dependency, on the other (data not shown). Other factors turned
out to be significantly associated at least with Hb values < 8 g/dl
(Table 1): young, short, non-German and primiparous mothers,
with an anemia diagnosis in pregnancy, bleeding after 28
pregnancy weeks, placenta previa, hypertension, multiple preg-
nancy, and those delivering prematurely or post-term, assisted or
Fig. 2. Secular trend in the prevalence of low values and anaemia immediately after
delivery. Hb < 10 g/dl: p < 0.001, Hb < 8 g/dl: n.s.
128 R.L. Bergmann et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 126–131

Table 1
Prevalence of low postpartum hemoglobin (Hb < 8 g/dl) according to parameter values. Odds ratios (OR) and their significance (p) for Hb < 8 g/dl by risk factors I n
multivariable logistic regression. Model 1 shows the results for maternal characteristics, pregnancy risks, birth outcomes, and delivery mode, and model 2 delivery blood loss
additionally to the other factors. p in first line applies to the difference of all parameter values, p in respective line to the difference against the reference group (Ref.) of each
parameter category. ns = non-significant. n = 43 807.

Hb < 8 g/dl Model 1 Model 2

% p OR p OR p

Age mother [years] ns 0.044 0.005

<18 (Ref.) 4.6 1 1
18–35 3.4 0.702 0.082 0.620 0.023
>35 3.1 0.601 0.020 0.503 0.003

Height mother [cm] <0.001 <0.001 <0.001

<160 (Ref.) 3.8 1 1
161–170 3.2 0.798 0.001 0.768 0.000
>170 2.8 0.680 0.000 0.616 0.000

Pregnancy weight gain [kg] <0.05 0.454 0.346

0 4.2 1.453 0.185 1.423 0.236
1–10 3.2 1.065 0.390 1.089 0.265
11–15 (Ref.) 3.1 1 1
16–20 3.3 0.979 0.784 0.939 0.437
>20 4.1 1.100 0.324 1.046 0.658

Nationality <0.001 <0.001 <0.001

German (Ref.) 3.1 1 1
Turkish/Near East 3.4 1.293 0.000 1.473 0.000
Africa 8.4 2.891 0.000 2.684 0.000
Other 3.6 1.149 0.093 1.180 0.054

Anemia in pregnancy 10.1 <0.001 2.675 <0.001 2.724 <0.001

Hemorhage/thrombosis risk 5.0 ns 1.749 0.013 1.519 0.079
Bleeding > 28 [weeks] 8.5 <0.01 2.097 0.021 1.896 1.896
Placenta previa 17.8 <0.001 4.835 <0.001 2.527 0.004
Hypertension 5.1 <0.05 1.204 0.419 1.013 0.957

Parity <0.001 0.001 0.001

1 4.0 1.234 1.236
1 (Ref.) 2.8 1 1

Multiple pregnancy 7.7 <0.001 2.247 <0.001 1.539 0.001

Pregnancy duration [weeks] <0.001 0.074 0.451

Term (37–41) 3.1 1 1
Premature (<37) 4.5 1.220 0.082 1.148 0.254
Post-term (>41) 4.5 1.211 0.121 1.080 0.555

Birth weight [g] <0.001 <0.001 0.024

<2500 (Ref.) 4.2 1 1
2500–4000 3.1 1.171 0.282 1.126 0.445
>4000 4.6 1.806 0.001 1.487 0.034

Newborn length [cm] <0.001 0.090 0.327

45 (Ref.) 4.3 1 1
46–54 3.2 0.920 0.609 0.811 0.222
55 4.5 1.158 0.033 1.102 0.388

Delivery mode <0.001 <0.001 <0.001

Vaginal (Ref.) 2.2 1 1
Manual support/extraction 1.9 1.048 0.927 0.787 0.650
Vacuum 7.9 3.627 0.000 2.361 0.000
Forceps 7.7 3.850 0.000 2.509 0.000
Elective cesarean 4.5 1.883 0.000 0.909 0.382
Emergency cesarean 5.1 2.055 0.000 0.936 0.462

Blood loss [ml] <0.001 <0.001

<250 (Ref.) 1.0 1
251–500 3.3 3.278 0.000
501–1000 13.0 15.263 0.000
>1000 43.6 74.670 0.000

by operation, and with a high estimated blood loss, were
significantly more often anemic. Pregnancy weight gain and
weight or length of the newborn showed a U-shaped association
with low Hb values.
Because many of the risk factors in the univariable analysis
were interrelated, we conducted a multivariable analysis to
simultaneously evaluate the importance of the risk factors for a
mother to have a postpartum Hb < 8 g/dl (Table 1). Some of the
maternal characteristics were related to severe anemia (model 1 in
Table 1): mothers of African origin had the highest risk of becoming
anemic after delivery. Of the pregnancy risk factors and birth
outcomes, placenta previa increased the postpartum anemia risk
about fivefold. A diagnosis of anemia in pregnancy increased it
nearly threefold; multiple pregnancy, bleeding after 28 weeks, and
a high birthweight nearly twofold. Compared to spontaneous
deliveries, cesarian deliveries increased the anemia risk twofold,
and vacuum or forceps deliveries nearly fourfold (model 1 in
Table 2).
 R.L. Bergmann et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 126–131 129

Fig. 3. Distribution of estimated delivery blood loss (n = 43 807 deliveries).

Model 2 in Table 1 introduces estimated delivery blood loss as after adjustment cesarean was no longer an independent factor for
an independent variable: after adjusting for the estimated delivery severe anemia in our data set (model 2 in Table 1).
blood loss, some of the other risks were displaced downward. But In view of the importance of the estimated delivery blood loss
forceps and vacuum extraction remained factors of high risk, while for the risk of immediate postpartum anemia, we explored the
estimated blood loss (Fig. 3). One percent of mothers lost more
Table 2
than 1000 ml. In a multivariable linear regression analysis we
Multivariable regression analysis for the change in delivery blood loss (in ml)
compared to the reference group (Ref.) of each parameter. B: regression coefficient
evaluated the additional volume (ml) of blood lost in the risk group
(blood loss change in ml); Beta: standardized regression coefficient; p: probability. compared to the respective reference group, simultaneously
n = 43 807. adjusting for the other factors (Table 2). Although multiple
Influential variable B [ml] Beta p
pregnancy remained an important risk factor, placenta previa
and operative deliveries were the most important factors for an
Age of mother [years], <18 (Ref.)
obstetric blood loss exceeding the blood loss under normal
18–35 0.05 0.000 0.989
>35 3.18 0.006 0.372 conditions. Especially high was the blood volume lost with
emergency and elective cesarean deliveries, which means more
Height of mother [cm], <160 (Ref.)
than 200 ml compared to uncomplicated deliveries.
161–170 5.68 0.015 0.012
>170 8.92 0.021 0.001 By adding the delivery mode to the other factors in the final
model, the explained proportion of the overall variance in obstetric
Pregnancy weight gain [kg], 11–15 (Ref.)
0 3.93 0.009 0.053
blood loss increased from 7.2 to 24.4%. The high beta value for
1–10 4.92 0.011 0.023 operative deliveries indicates that they are not only important but
16–20 6.63 0.010 0.026 also prevalent risk factors for the estimated delivery blood loss.
>20 11.46 0.026 <0.001 The rate of operative deliveries increased over the observed
Nationality, German (Ref.) time period, for cesarean deliveries from 18.5% in 1993 to 30.8% in
Turkish/Near East 23.56 0.016 <0.001 2008 (p < 0.001). The rate of vacuum deliveries remained constant
African 0.26 0.000 0.023 at around 9%, while the forceps delivery rate decreased signifi-
Other 6.08 0.003 0.026
cantly to 0.1% in 2008 (p < 0.001). On the other hand, we found no
Primiparity 5.23 0.002 <0.001 time trend for an estimated obstetric blood loss over 1000 ml, but a
Anemia in pregnancy 5.23 0.002 0.628 decreasing trend for an estimated blood loss between 501–
Heamorrhage/thrombosis risk 31.84 0.017 <0.001
1000 ml (p = 0.002), and for 251–500 ml (p < 0.001), while a low
History of 2 abortions 8.58 0.013 0.002
Bleeding < 28 weeks 29.63 0.017 <0.001 estimated blood loss of <250 ml occurred significantly more often
Bleeding > 28 weeks 16.90 0.005 0.208 from year to year (p < 0.001).
Placenta praevia 206.01 0.053 <0.001 To get an impression of the distribution of Hb values in low risk
Hypertension 19.59 0.011 0.011
mothers, we excluded mothers with an estimated blood loss over
Multiple pregnancy 78.87 0.074 <0.001
Premature (<37 weeks) 8.05 0.014 0.020
500 ml (90th percentile), and mothers with operative delivery,
Post-term (>42 weeks) 16.68 0.018 <0.001 with anemia in pregnancy and with placenta previa. The mean Hb
in these low risk mothers was only slightly higher than in the total
Birth weight [g], 2500–4000 (Ref.)
<2500 7.18 0.015 0.105 sample, i.e. 11.4 (1.4) g/dl vs.11.0 (1.5) g/dl. However, in the low
>4000 30.89 0.046 <0.001 risk mothers the prevalence of low values was markedly reduced:
Hb < 8 g/dl occurred in 1.3% instead of 3.4%, and Hb < 10 g/dl in
Birth length [cm], 46–54 (Ref.)
45 13.11 0.016 0.009 13.9% instead of 22.7%.
55 18.24 0.026 <0.001
4. Comment
Delivery mode, vaginal (Ref.)
Extraction/manual support 27.15 0.010 0.021
Vacuum 80.07 0.117 <0.001 The main strength of this study is the large sample size
Forceps 73.02 0.050 <0.001 originating from a single institution, which means that policies and
Elective cesarean 208.51 0.298 <0.001
procedures were likely to be more consistent than when they come
Emergency cesarean 217.07 0.373 <0.001
from multiple institutions. However, it cannot be expected that the
130 R.L. Bergmann et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 126–131
precision of process data, which in our case was collected for
clinical bench marking, can be as high as standards for prospective
studies. Especially the estimation of obstetric blood loss in a
clinical setting is imprecise, and underestimation up to 50% may
occur, although training can somewhat improve the precision [18–
21]. Additionally, our data file did not include all important
predictors for obstetric hemorrhage, like preeclampsia, duration of
labor, episiotomy, uterine atony, retained placenta or treatment
procedures like blood transfusions [9,22]. Nevertheless, it is
possible to get some insight into the prevalence of such a
significant clinical problem as post delivery anemia and to
recognize attributable risk factors.
Hb values below 10 g/dl during the second postpartum day
were found in 22% of mothers, i.e. about one in five mothers was
anemic according to this definition, with a slightly increasing trend
over the years. Severe anemia, which was defined as Hb < 8 g/dl,
was found in around 3% of the mothers, and the trend did not
change significantly. Since we did not receive Hb values in 10% of
mothers because they were discharged early after uncomplicated
deliveries, the anemia prevalence may be slightly overestimated.
There are marked changes in fluid dynamics after delivery, and
therefore for Hb determinations between 24 and 48 h after
delivery, a cut-off value of 8 g/dl is probably more predictive of
sustained anemia than the traditional postpartum anemia thresh-
old of 10.0 g/dl [23]. We used Hb < 8 g/dl for the multivariable
analysis. In Germany, the prevalence of cesarean deliveries
increased from 18% in 1995 to 28% in 2005 [24]. Although our
large obstetric department is part of a high risk perinatology
center, it has a relatively low cesarian rate, comparable to the
overall rate in Germany. Given the increase in cesarean deliveries,
the declining obstetric blood loss in our department may explain
why we found a nearly constant rate for severe anemia over the
years.
A blood loss over 500 ml was observed in 13.1% of all deliveries
in New South Wales, Australia, compared to 7.9% of the deliveries
in our institution, which could be due to underestimation in our
data [11]. On the other hand, among all mothers delivering in
Norway from 1999 to 2004, severe obstetric hemorrhage of
>1500 ml (delivery to 24 h postpartum) occurred in only 1.1%,
which is closer to our value, and similar risk factors as in our study
were observed [22]. In both studies cesarean deliveries had a
higher odds ratio for severe obstetric hemorrhage than forceps and
vaginal deliveries. But surprisingly, we found higher postpartum
anemia rates after forceps and vacuum deliveries than after
cesarean deliveries, possibly because excessive blood lost by
caesarean deliveries had been treated with blood transfusion.
Although our dataset does not contain the therapeutic use of blood
transfusion, our clinical experience is that we need less blood
transfusion from year to year due to improved operative
techniques, e.g. the Misgav–Ladach technique, which could explain
the decreasing rate of a blood loss over 250 ml, as well as over
500 ml, in our study.
Postpartum discharge anemia according to the Berlin perinatal
survey of the years 1993–1999 was most prevalent in primiparous
women of low social class, and of non-German background,
namely 18.5%, compared to 5.5% in multiparous German middle
class women [25]. In the USA, population representative data for
the years 1988–1994 found the highest prevalence of postpartum
anemia in low income women, i.e. 22% [26]. Black mothers had
twice the postpartum anemia rate compared to non-Hispanic
mothers [27,28]. Likewise, in our study, women of African
background had a threefold risk of postpartum anemia, which
might be due to nutritional iron deficiency, hemoglobinopathies,
behavioral factors, HIV or other infections.
Anemia during pregnancy was the strongest predictor for
postpartum anemia in an Iron Supplementation Study in North
Carolina [29]. The other risk factors in this prospective study were
similar to our findings. According to the present study, only 0.6% of
mothers came in with a diagnosis of ‘‘anemia during pregnancy’’, a
prevalence that probably is highly underestimated by our
practicing gynecologists. Our own findings showed that in 1999,
of around 400 mothers coming in for delivery 3.6% were anemic,
and 41% were iron deficient [3].
A diagnosis of anemia in women with obstetric bleeding was
associated with increased costs for hospitalization beside the
adverse impact on postpartum health status [10]. Treatment of
delivery blood loss is cost intensive, and prevention is usually less
expensive. As the volume of blood lost is closely related to labor
management, especially with cesarean deliveries, potential blood
loss should be included in the decisions on delivery procedures.
Also, measures to boost iron stores before and during pregnancy
should be implemented [2,4,5].
Conflicts of interest
No conflicts of interest.
Contributions
Prof. Dr. med. Renate L. Bergmann wrote the manuscript, all of
the authors participated in the interpretation of the data, in
repeated critical revisions of the manuscript, and in the final
approval. Dr. Rolf Richter performed the statistical analysis and
produced the figures.
Ethical approval
Not required for the analysis of anonymised process data.
Funding
Supported by a Grant to the Charité University Hospitals Berlin
by Vifor Pharma, Germany.
Acknowledgements
We thank the obstetric teams of our department for their
persistently devoted work!
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