Standards

for Maternal and

Iron and folate Neonatal Care
supplementation
INTEGRATED MANAGEMENT OF PREGNANCY AND CHILDBIRTH (IMPAC)

The standard
All pregnant women in areas of high prevalence of malnutrition should
routinely receive iron and folate supplements, together with appropriate
dietary advice, to prevent anaemia. Where the prevalence of anaemia in
pregnant women is high (40% or more), supplementation should continue
for three months in the postpartum period.

Aim
˜ȱ™›ŽŸŽ—ȱŠ—ȱ›ŽŠȱ’›˜—ȱŽęŒ’Ž—Œ¢ȱŠ—ŠŽ–’Šȱ’—ȱ ˜–Ž—ȱž›’—ȱ™›Ž—Š—Œ¢ȱŠ—ȱ
in the postpartum period in order to improve maternal and perinatal health.

Requirements
A national policy and locally adapted guidelines on iron and folate supplementation are
in place and are correctly implemented.
Health care providers of maternal and neonatal care are competent in: the importance of
iron supplementation during pregnancy and the postpartum period; the correct dosage
and duration of supplementation for the prevention and treatment of anaemia; anaemia
detection in pregnant women; and when to refer women for further diagnosis and
treatment.
Iron and folate supplements are available at all levels of care.
There is a functioning referral system that ensures timely referral of pregnant women
for monitoring and treatment, especially in the case of severe anaemia.
A mechanism is in place for recording cases and care of anaemia.
Health education activities are carried out to increase awareness among women and in
the community of the importance of iron and folate supplementation in pregnancy.

Applying the standard

World Health Organization

ŽŠ•‘ȱ™›˜Ÿ’Ž›œǰȱ’—ȱ™Š›’Œž•Š›ȱœ”’••ŽȱŠĴŽ—Š—œǰȱŠĴŽ—’—ȱ ˜–Ž—ȱž›’—ȱŠ—Ž—ŠŠ•ȱŠ—ȱ
postpartum visits must:

Give all pregnant women a standard dose of 60 mg iron + 400 μg folic acid daily for 6
months or, if 6 months of treatment cannot be achieved during the pregnancy, either
continue supplementation during the postpartum period or increase the dosage to 120
mg iron during pregnancy.
Where the prevalence of anaemia in pregnancy is over 40%, advise the woman to
continue the prophylaxis for three months in the postpartum period.
2006

Give iron supplementation even if folic acid is not available.

Examine or screen all women for anaemia during antenatal and postpartum visits.
Standards 1.8 Iron and folate supplementation 2

Treat anaemia with doses of 120 mg iron daily for three months.
Follow up in two weeks to check clinical progress, test results and compliance and again four
weeks later all women with severe anaemia that have been treated with iron and folate.
Refer women with severe anaemia to a higher level of care if they are in the last month of
pregnancy, have signs of respiratory distress or cardiac abnormalities such as oedema, or when
‘ŽȱŒ˜—’’˜—œȱ˜ȱ—˜ȱ’–™›˜ŸŽȱ˜›ȱ ˜›œŽ—ȱŠĞŽ›ȱ˜—Žȱ ŽŽ”ȱ˜ȱ’›˜—Ȧ˜•ŠŽȱ‘Ž›Š™¢ǯȱ
ȱ ›˜Ÿ’ŽȱŠŸ’ŒŽȱ˜—ȱ‘ŽȱŒ˜—œž–™’˜—ȱ˜ȱ’›˜—Ȭ›’Œ‘ȱ˜˜œȱŠ—ȱŸ’Š–’—ȱǯ
Record test results and the treatment provided in the woman’s card.

Audit
—™žȱ’—’ŒŠ˜›œ
ȱ Š’˜—Š•ȱœŠ—Š›œȱŠ—ȱ•˜ŒŠ••¢ȱŠŠ™Žȱž’Ž•’—Žœȱ˜›ȱ‘ŽȱŒ˜—›˜•ȱ˜ȱ’›˜—ȱŽęŒ’Ž—Œ¢ȱŠ—ŠŽ–’ŠȱŠ›Žȱ
available in health facilities.
Iron/folate supplements are available and are properly managed.
ȱ ŠěȱŠ›ŽȱŠŸŠ’•Š‹•Žȱ’—ȱŠ—Ž—ŠŠ•ȱŒŠ›ŽȱǻǼȱŠ—ȱ™˜œ™Š›ž–ȱŒŠ›ŽȱǻǼȱ˜ȱ™›ŽœŒ›’‹Žǰȱ™›˜Ÿ’ŽȱŠ—ȱ
administer iron/folate supplements.

›˜ŒŽœœȱŠ—ȱ˜ž™žȱ’—’ŒŠ˜›œ
ȱ ‘Žȱ™›˜™˜›’˜—ȱ˜ȱ ˜–Ž—ȱ›˜ž’—Ž•¢ȱ›ŽŒŽ’Ÿ’—ȱ’›˜—Ȧ˜•ŠŽȱœž™™•Ž–Ž—œȱž›’—ȱȱ˜›ȱǯ
ȱ ‘Žȱ™›˜™˜›’˜—ȱ˜ȱ ˜–Ž—ȱ›ŽŒŽ’Ÿ’—ȱ’ŽŠ›¢ȱŠŸ’ŒŽȱž›’—ȱȱŠ—ȱǯ
The proportion of women with severe anaemia referred.

žŒ˜–Žȱ’—’ŒŠ˜›œ
Maternal mortality associated with severe anaemia.
Maternal complications associated with severe anaemia.
Perinatal mortality associated with severe anaemia in pregnancy.
Incidence of low birth weight associated with anaemia in pregnancy.

Rationale
ž›Ž—ȱ˜ȱœžěŽ›’—
›˜—ȬŽęŒ’Ž—Œ¢ȱŠ—ŠŽ–’Šȱ’œȱ‘Žȱ–˜œȱŒ˜––˜—ȱ
–’Œ›˜—ž›’Ž—ȱŽęŒ’Ž—Œ¢ȱ’—ȱ‘Žȱ ˜›•ǰȱ
ŠěŽŒ’—ȱ–˜›Žȱ‘Š—ȱ ˜ȱ‹’••’˜—ȱ™Ž˜™•Žȱ
globally (1). It contributes to low birth weight,
lowered resistance to infection, poor cognitive
development and reduced work capacity (1).
Pregnant and postpartum women and children
aged 6–24 months are usually the most
ŠěŽŒŽȱ›˜ž™œȱ(1,2). It is highly prevalent in
less developed countries, where, in addition
to poor nutrition, parasitic and bacterial
infections can contribute to depletion of iron
reserves (1–4).
—ŠŽ–’Šȱ’—ȱ™›Ž—Š—Œ¢ȱ’œȱŽę—ŽȱŠœȱ
haemoglobin <11g/dl or haematocrit <33% (1).
ȱŠ›ŠŸŠŽœȱ‘ŽȱŽěŽŒœȱ˜ȱ–ŠŽ›—Š•ȱ‹•˜˜ȱ•˜œœȱ
and infections at childbirth, and is associated
with increased maternal and perinatal
mortality and morbidity (3,4). Where anaemia
’œȱ™›ŽŸŠ•Ž—ǰȱ’›˜—ȱŽęŒ’Ž—Œ¢ȱ’œȱžœžŠ••¢ȱ‘Žȱ
most common cause (1).
ȱœž‹œŠ—’Š•ȱ›ŽžŒ’˜—ȱ’—ȱ’›˜—ȱŽęŒ’Ž—Œ¢ȱ
anaemia by the year 2000 was among the
most important nutritional goals adopted by
‘Žȱꛜȱ˜›•ȱž––’ȱ˜›ȱ‘’•›Ž—ȱǻŗşşŖǼǰȱ
›Ž’Ž›ŠŽȱ‹¢ȱ‘Žȱ—Ž›—Š’˜—Š•ȱ˜—Ž›Ž—ŒŽȱ˜—ȱ
ž›’’˜—ȱǻŗşşŘǼȱ(1).
ĜŒŠŒ¢ȱŠ—ȱŽěŽŒ’ŸŽ—Žœœ
Anaemia prophylaxis
Where the prevalence of anaemia in pregnant
women is <40%, a dose of 60 mg iron and 400
μg folic acid daily for 6 months is considered
to meet the physiological requirements
for iron in pregnancy. If the duration of
supplementation is shorter, a higher dose
(120 mg) is recommended. However, the
majority of the systematic reviews on this
Standards 1.8 Iron and folate supplementation
topic refer to a dose of around 100 mg iron
and 350–500 μg folic acid daily for 16 weeks
or more during pregnancy (5–7). In areas
with a higher prevalence of anaemia, it is
recommended that supplementation continue
for three months postpartum.
Based on the possible association between
maternal anaemia and negative perinatal
outcome (8)ǰȱ’ȱ’œȱŠœœž–Žȱ‘ŠȱŽěŽŒ’ŸŽȱ’›˜—Ȭȱ
supplementing programmes where anaemia
is prevalent may reduce the incidence of
low birth weight and perinatal mortality, as
well as maternal mortality and obstetrical
complications associated to severe anaemia.
According to currently available reviews,
however, while there is clear evidence of a
™˜œ’’ŸŽȱŽěŽŒȱ˜ȱ›˜ž’—Žȱ’›˜—ȱœž™™•Ž–Ž—Š’˜—ȱ
during pregnancy in preventing low
haemoglobin at delivery or at six weeks
postpartum (5,6), there is no evidence of
Š—¢ȱŽěŽŒǰȱ‹Ž—ŽęŒ’Š•ȱ˜›ȱ‘Š›–ž•ǰȱ˜—ȱŒ•’—’ŒŠ•ȱ
outcomes for the mother and the baby (5,6).
‘Žȱ•ŠŒ”ȱ˜ȱŠȱ™˜œ’’ŸŽȱŽěŽŒȱ–’‘ȱ‹ŽȱžŽȱ˜ȱ
the small sample size in the studies that tried
to assess those clinical aspects. The results of
the largest trial included in one review suggest
that routine iron supplementation may reduce
the need for postpartum blood transfusions
(5). This result must be interpreted with
caution since, as noted by the authors of the
review, the trial was not blind in respect of
treatment allocation and therapeutic decisions
could thus have been biased. Nevertheless, if
Œ˜—ę›–Žǰȱ‘’œȱ›Žœž•ȱŒ˜ž•ȱ‘ŠŸŽȱ’–™•’ŒŠ’˜—œȱ
in HIV-prevalent areas.
Anaemia treatment
There is consensus on the need for higher
dosages in treating women with anaemia (9).
There is evidence that a combined treatment
with iron and vitamin A could have a greater
impact in anaemia treatment during the
second trimester of pregnancy (9)ǯȱŽŸŽ›Žȱ
anaemia is not frequent, but may cause a large
3
proportion of severe morbidity and mortality
›Ž•ŠŽȱ˜ȱ’›˜—ȱŽęŒ’Ž—Œ¢ǯȱ›˜–™ȱŽŽŒ’˜—ȱ
and timely treatment or referral of women
with severe anaemia are therefore important
at the primary care level. With proper training,
and using a multiple-site assessment (inferior
conjunctiva, palm and nail bed) (10), health
workers can assess extreme pallor or very
low haemoglobin levels with reasonable
œŽ—œ’’Ÿ’¢ȱŠ—ȱ‘’‘ȱœ™ŽŒ’ęŒ’¢ȱ(10–12). Further
’–™›˜ŸŽ–Ž—ȱ˜ȱ‘ŽȱœŽ—œ’’Ÿ’¢ȱŠ—ȱœ™ŽŒ’ęŒ’¢ȱ
of the clinical assessment could be achieved
by adding a few anamnestic symptoms to
the pallor assessment and using a simple
colorimetric scale (12).
’—ŒŽȱ‘ŽȱŽěŽŒ’ŸŽ—Žœœȱ˜ȱ˜›Š•ȱ’›˜—ȱ
supplementation is hindered by many
factors, including supply problems and poor
adherence to regimens owing to the frequency
˜ȱœ’ŽȬŽěŽŒœȱ(5,13,14), a variety of other
interventions have been proposed to prevent
Š—ȱŒ˜››ŽŒȱ’›˜—ȬŽęŒ’Ž—Œ¢ȱŠ—ŠŽ–’Šǰȱ’—Œ•ž’—ȱ
˜˜ȱ˜›’ęŒŠ’˜—ǰȱ‘ŽŠ•‘¢ȱ’ŽŠ›¢ȱŽžŒŠ’˜—ȱ
Š—ȱŠ—’™Š›Šœ’’Œȱ›ŽŠ–Ž—ǯȱ‘ŽȱŽěŽŒ’ŸŽ—Žœœȱ
of these interventions is still unclear. Dietary
improvements (15)ȱŠ—ȱ˜›’ęŒŠ’˜—ȱ˜ȱ ŠŽ›ȱ
(16) and foods (17) are not supported by
œ›˜—ȱŽŸ’Ž—ŒŽȱ˜ȱŽěŽŒ’ŸŽ—Žœœǰȱ ‘’•ŽȱŒ˜—›˜•ȱ
of parasitic (helminth and plasmodium)
infections seems to enhance iron prophylaxis
Š—ȱ‘ŽȱŽĜŒŠŒ¢ȱ˜ȱ‘Ž›Š™¢ȱ(14,18). More
research is needed in communities where iron-
ŽęŒ’Ž—Œ¢ȱŠ—ŠŽ–’Šȱ’œȱ™›ŽŸŠ•Ž—ȱ˜ȱŽœŠ‹•’œ‘ȱ‘Žȱ
most appropriate strategies.
There is promising evidence from studies
whereby iron cooking pots are introduced at
Œ˜––ž—’¢ȱ•ŽŸŽ•ǯȱ˜˜”’—ȱ’—ȱ’›˜—ȱ™˜œȱ‘Šœȱ
•Žȱ˜ȱŠȱœ’—’ęŒŠ—ȱ’—Œ›ŽŠœŽȱ’—ȱ‘ŠŽ–˜•˜‹’—ȱ
concentrations, especially among adults (19),
but there are problems of acceptability (pots
are heavy and when not properly dried will
become rusty) (20).
Standards 1.8 Iron and folate supplementation 4

The table below summarizes the evidence from the most relevant studies. The level of evidence is
™›ŽœŽ—Žȱžœ’—ȱ‘Žȱȱ–Ž‘˜˜•˜¢ȱ ‘’Œ‘ȱŠ™™•’ŽœȱŠȱŒ˜’—ȱ›˜–ȱŗȱǻ‘’‘ȱ•ŽŸŽ•Ǽȱ˜ȱŚȱǻ•˜ ȱ•ŽŸŽ•Ǽǯȱȱȱȱ
For details, see also the Introduction to the Standards for Maternal and Neonatal Care and the Process
to develop the Standards for Maternal and Neonatal Careȱ˜—ȱ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ–Š”’—ȏ™›Ž—Š—Œ¢ȏ
safer/publications/en. For an overview of a comprehensive list of evidence, please refer to the
reference section of the standard.

Study
Population & ‹“ŽŒ’ŸŽȱǭȱ žŒ˜–Žœȱ•’—”Žȱ
ǻ¢™ŽȱǭȱŽŸŽ•ȱ Results Comments
ŽĴ’— ’—Ž›ŸŽ—’˜— to the Standard
˜ȱŽŸ’Ž—ŒŽǼ
5. Mahomed 20 trials; pregnant To assess the Low pre-delivery Iron vs no iron
2004 women prior to 28 ŽěŽŒœȱ˜ȱ’›˜—ȱ haemoglobin (<10 min. NNT a 13 (12–14)
weeks’ gestation supplementation g/dl) max. NNT 2 (2–3)
Most recent and with normal on haematological 12 studies, 1802 women
substantive haemoglobin levels and biochemical
amendment, (>10 g/dl) (number parameters and on Low haemoglobin 6 –’—ǯȱȱŗśȱǻŗřȮŗşǼȱ
žžœȱŗşşŝ of enrolled women pregnancy outcomes weeks postpartum –Š¡ǯȱȱŝȱǻŜȮŗŖǼȱȱȱȱȱȱȱ
—˜ȱœ™ŽŒ’ꮍǼ 2 studies, 1482 women
Intervention: 100
Europe, North mg elemental iron Selective vs routine
¢œŽ–Š’Œȱ iron
›ŽŸ’Ž ȱ America, Australia, orally compared
Gambia, India, with placebo or no ŠŽœŠ›ŽŠ—ȱœŽŒ’˜— NNH bȱŚŘȱǻŘŖȮřŜşǼȱȱȱȱȱȱȱȱȱȱ ˜––Ž—ȱ›˜–ȱ‘Žȱ
1++ Myanmar, Niger treatment authors: increase in
Mother: blood 
ȱŝśȱǻřŗȮŗŖŗŗǼȱ
Baseline risk In one study: iron caesarean sections and
transfusion needed
Low pre-delivery given routinely blood transfusions
haemoglobin level vs iron given ’••‹’›‘Ȧ—Ž˜—ŠŠ•ȱ ȱŘŖŖȱǻŗśŖȮŗřȱŚśşǼȱ in the selective iron
Ȯȱ–’—’–ž–ȱşƖȱ selectively to death supplementation
– maximum 56% women with group possibly due to
’ŽȬŽěŽŒœȱ›˜–ȱ ȱŗŗȱǻşȮŗřǼȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ fear of midwife and
Low post-delivery haemoglobin <10 treatment avoided ŗȱœž¢ǰȱŘŜşŚȱ ˜–Ž—
haemoglobin level g/dl doctors (not blind to
Ȯȱ–’—’–ž–ȱşǯŝƖ treatment)

6. Mahomed 8 trials involving To assess the Iron & folic acid vs Results of relevant
2004 śŚŚşȱ™›Ž—Š—ȱ ŽěŽŒœȱ˜ȱ›˜ž’—Žȱ placebo clinical outcomes are
women prior to 28 iron and folate based on a very small
Most recent weeks’ gestation supplementation Low pre-delivery –’—ǯȱȱşȱǻşȮŗŖǼȱ single study (low
substantive and with normal on haematological haemoglobin (<10 max. NNT 3 (2–3) birth weight, stillbirth,
amendment, haemoglobin levels and biochemical g/dl) Ŝȱœž’ŽœǰȱŗŖşşȱ ˜–Ž— preterm delivery)
žžœȱŗşşŝ (>10g/dl) including parameters and on Low haemoglobin 6 min. NNT 11 (11–12)
adolescent women pregnancy outcomes weeks postpartum max. NNT 5 (5–6)
Myanmar, Nigeria, Intervention: 100 Řȱœž’ŽœǰȱŘŞşŜȱ ˜–Ž—
¢œŽ–Š’Œȱ
›ŽŸ’Ž  United Kingdom, mg elemental iron ŠŽœŠ›ŽŠ—ȱœŽŒ’˜— –’—ǯȱȱŗŚȱǻŗŘȮŜşǼȱ
plus 350 μg folic –Š¡ǯȱȱŗŗȱǻşȮśśǼȱȱȱȱȱ
1++ Baseline risk acid taken daily by 2 studies, 104 women
Low pre-delivery mouth compared
haemoglobin level with placebo or no Low birth weight ȱc
– minimum 14% treatment 1 study, 48 women
– maximum 56%  1 study, 48 women
’••‹’›‘Ȧ—Ž˜—ŠŠ•ȱ
Low post-delivery death
haemoglobin level
– minimum 10%
– maximum 20%
ŠŽœŠ›ŽŠ—ȱœŽŒ’˜—ȱ
Ȯȱ–’—’–ž–ȱşƖȱ
– maximum 11%

a
ȱȱž–‹Ž›ȱ—ŽŽŽȱ˜ȱ›ŽŠǯȱǻşśƖȱŒ˜—ꍮ—ŒŽȱ’—Ž›ŸŠ•Ǽ
b
ȱž–‹Ž›ȱ—ŽŽŽȱ˜ȱ‘Š›–ǯȱǻşśƖȱŒ˜—ꍮ—ŒŽȱ’—Ž›ŸŠ•Ǽ
c
ȱȱ˜—Ȭœ’—’ęŒŠ—

ŽŽ›Ž—ŒŽœ
ŗǯȱ ˜•£žœȱǰȱ›Ž¢žœœȱǯȱGuidelines for the use of iron supplements to prevent and treat iron
ŽęŒ’Ž—Œ¢ȱŠ—Ž–’ŠǯȱŠœ‘’—˜—ǰȱǰȱȱ›ŽœœǰȱŗşşŞȱǻ‘Ĵ™DZȦȦ’—ŠŒǯ’•œ’ǯ˜›ȦꕎȦ‹Řȏ
Ş ǯ
™ǰȱŠŒŒŽœœŽȱŝȱŠ—žŠ›¢ȱŘŖŖśǼǯ
2. ˜‘Ž›Ȯ‹Š‹¢ȱ™ŠŒ”ŠŽDZȱ’–™•Ž–Ž—’—ȱœŠŽȱ–˜‘Ž›‘˜˜ȱ’—ȱŒ˜ž—›’Žœǯ Geneva, World Health
›Š—’£Š’˜—ǰȱŗşşŜȱǻ˜Œž–Ž—ȱ
Ȧ
ȦȦȱşŚǯŗŗǼȱǻ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ›Ž™›˜žŒ’ŸŽȬ
‘ŽŠ•‘Ȧ™ž‹•’ŒŠ’˜—œȦȏşŚȏŗŗȦȏşŚȏŗŗȏŠ‹•Žȏ˜ȏŒ˜—Ž—œǯŽ—ǯ‘–•ǰȱŠŒŒŽœœŽȱŗřȱ
December 2004).
Standards 1.8 Iron and folate supplementation 5

Study
Population & ‹“ŽŒ’ŸŽȱǭȱ žŒ˜–Žœȱ•’—”Žȱ˜ȱ
ǻ¢™Žȱǭȱ•ŽŸŽ•ȱ Results Comments
œŽĴ’— ’—Ž›ŸŽ—’˜— the standard
˜ȱŽŸ’Ž—ŒŽǼ
ŗřǯȱ•˜Š—ǰȱ 23 randomized To review the Haemoglobin ŜŖȱ–DZȱƸȱŖǯŚŗȱǻƹŖǯŖŘŝǼȱȦ• The authors
˜›Š—ȱǭȱ controlled trials, ŽĜŒŠŒ¢ȱ˜ȱ’›˜—ȱ increase by daily question the
’—’”˜ěȱŘŖŖŘȱ 15 of which supplementation dose of iron ŜŗȮşŖȱ–DZȱƸȱŖǯŞŜȱǻƹŖǯŖŗŞǼȱȦ• opportunity of
conducted in on haemoglobin supplement şŗȮŗŘŖȱ–DZȱƸȱŗǯŞŝȱǻƹŖǯŖŘŝǼȱȦ• recommending
developing level in pregnant large-scale,
¢œŽ–Š’Œȱ countries; the women ǁŗŘŖȱ–DZȱƸȱŗǯŝŞȱǻƹŖǯŖŚŘǼȱȦ• public health
›ŽŸ’Ž  majority set in ˜ȱŠ’’˜—Š•ȱŽěŽŒȱ˜ȱ˜•ŠŽȱ oral iron
Here results refer Haemoglobin
antenatal clinics; compared to iron alone (6 supplementation
1++ only to developing increase by
only 2 set in rural studies) programmes
country studies Š’’˜—Š•ȱŽěŽŒȱ˜ȱ
areas; around 1000 as a means
folate
pregnant women ž™™•Ž–Ž—Š’˜—ȱ of reducing
dosages vary from Haemoglobin Only one small study: iron global maternal
<60 mg/day to increase by iron and + antimalarial is not more anaemia and
Average baseline >120 mg/day, the antimalarials ŽěŽŒ’ŸŽȱ‘Š—ȱŠ—’–Š•Š›’Š•ȱ call for further
haemoglobin level –Š“˜›’¢ȱ‹Ž’—ȱǁşŖȱ alone studies to
<11 g/dl mg/day determine the
Haemoglobin In one study there is additive ŽěŽŒ’ŸŽ—Žœœȱ˜ȱ
increase by iron and ŽěŽŒ other approaches
vitamin A (prevention
The majority of the studies
reported it as a problem of hookworm
infection, food
Adherence to Only two studies quantify ˜›’ęŒŠ’˜—ǰȱ
supplementation this aspect: 42% adherence prenatal
that increases (61%) with prophylactic
slow-release gastric delivery treatment of
system; low adherence is due falciparum
˜ȱœ’ŽȬŽěŽŒœȱŠ—ȱ‘ŽœŽȱŠ›Žȱ malaria)
dose-dependent
ŗŖǯȱ˜•£žœȱŽȱ şŚśȱ™›Ž—Š—ȱ To study the Pregnancy 3 months Multiple site
Š•ǯȱŗşşş women and association postpartum assessment
ŝŘŖȱ ˜–Ž—ȱ between clinical is highly
Validation at 3 months pallor as detected řśǯŝƖȱ recommended
study Haemoglobin 10 g/dl 18.2%
postpartum from by health workers – sensitivity şŚǯŗƖ şŚǯřƖ (increase in
rural area opportunely Ȯȱœ™ŽŒ’ęŒ’¢ sensitivity
trained and with just slight
Nepal haemoglobin decrease of
HaemoglobinȱşȱȦ•ȱȱȱȱȱȱȱ 28% 51.5%
concentration – sensitivity şřǯŚƖ şŘǯŘƖ œ™ŽŒ’ęŒ’¢Ǽ
(sensitivity and Ȯȱœ™ŽŒ’ęŒ’¢
œ™ŽŒ’ęŒ’¢Ǽ
Haemoglobin 8 g/dl 45.8% ŜŘǯŝƖȱȱȱȱȱȱ
•’—’ŒŠ•ȱ™Š••˜›ȱ – sensitivity ŞşǯŞƖ
şŘǯřƖ
assessed in three Ȯȱœ™ŽŒ’ęŒ’¢
sites: inferior
conjunctiva, palm
ŠŽ–˜•˜‹’—ȱŝȱȦ•ȱȱȱȱȱȱ ŜŝǯśƖȱȱȱȱȱ 81.0%
and nail bed – sensitivity şŗǯśƖ 88.1%
Ȯȱœ™ŽŒ’ęŒ’¢
Two days of
training

3. ˜œ™Š›ž–ȱŒŠ›Žȱ˜ȱ‘Žȱ–˜‘Ž›ȱŠ—ȱ—Ž ‹˜›—DZȱŠȱ™›ŠŒ’ŒŠ•ȱž’Žǯ Report of a technical working group.

Ž—ŽŸŠǰȱ˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŗşşŞȱǻ˜Œž–Ž—ȱ
Ȧ
ȦȦşŞǯřǼȱǻ‘Ĵ™DZȦȦ ‘š•’‹˜Œǯ
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ȏ
ȏȏşŞǯřǯ™ǰȱŠŒŒŽœœŽȱŝȱŽŒŽ–‹Ž›ȱŘŖŖŚǼǯ
4. ›Ž—Š—Œ¢ǰȱŒ‘’•‹’›‘ǰȱ™˜œ™Š›ž–ȱŠ—ȱ—Ž ‹˜›—ȱŒŠ›ŽDZȱŠȱž’Žȱ˜›ȱŽœœŽ—’Š•ȱ™›ŠŒ’ŒŽǯ Geneva, World

ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖřȱǻ‘Ĵ™DZȦȦ ‘š•’‹˜Œǯ ‘˜ǯ’—Ȧ™ž‹•’ŒŠ’˜—œȦŘŖŖřȦşŘŚŗśşŖŞŚǯ™ǰȱŠŒŒŽœœŽȱ
ŝȱŽŒŽ–‹Ž›ȱŘŖŖŚǼǯȱ
śǯȱ Š‘˜–Žȱ ǯȱ›˜—ȱœž™™•Ž–Ž—Š’˜—ȱ’—ȱ™›Ž—Š—Œ¢ȱǻ˜Œ‘›Š—ŽȱŽŸ’Ž Ǽǯȱ—DZȱThe Cochrane Library,
œœžŽȱŚǰȱŘŖŖŚǯȱ‘’Œ‘ŽœŽ›ǰȱ˜‘—ȱ’•Ž¢ȱǭȱ˜—œǰȱŘŖŖŚǯ
Ŝǯȱ Š‘˜–Žȱ ǯȱ›˜—ȱŠ—ȱ˜•ŠŽȱœž™™•Ž–Ž—Š’˜—ȱ’—ȱ™›Ž—Š—Œ¢ȱǻ˜Œ‘›Š—ŽȱŽŸ’Ž Ǽǯȱ—DZȱThe Cochrane
’‹›Š›¢ǰȱœœžŽȱŚǰȱŘŖŖŚǯȱ‘’Œ‘ŽœŽ›ǰȱ˜‘—ȱ’•Ž¢ȱǭȱ˜—œǰȱŘŖŖŚǯ
ŝǯȱ Š‘˜–Žȱ ǯȱ˜•ŠŽȱœž™™•Ž–Ž—Š’˜—ȱ’—ȱ™›Ž—Š—Œ¢ȱǻ˜Œ‘›Š—ŽȱŽŸ’Ž Ǽǯȱ—DZȱThe Cochrane Library,
œœžŽȱŚǰȱŘŖŖŚǯȱ‘’Œ‘ŽœŽ›ǰȱ˜‘—ȱ’•Ž¢ȱǭȱ˜—œǰȱŘŖŖŚǯ
Şǯȱ ’˜—ȱȱŽȱŠ•ǯȱ—Ž–’Šȱž›’—ȱ™›Ž—Š—Œ¢ȱŠ—ȱ‹’›‘ȱ˜žŒ˜–ŽDZȱŠȱ–ŽŠȬŠ—Š•¢œ’œǯȱAmerican Journal of
Perinatology,ȱŘŖŖŖǰȱŗŝDZŗřŝȮŗŚŜǯ
şǯȱ žŽ›Ÿ˜ȱ ǰȱŠ‘˜–Žȱ ǯȱ›ŽŠ–Ž—œȱ˜›ȱ’›˜—ȱŽęŒ’Ž—Œ¢ȱŠ—ŠŽ–’Šȱ’—ȱ™›Ž—Š—Œ¢ȱǻ˜Œ‘›Š—Žȱ
Review). In: ‘Žȱ˜Œ‘›Š—Žȱ’‹›Š›¢ǰȱœœžŽȱŚǰȱŘŖŖŚǯȱ‘’Œ‘ŽœŽ›ǰȱ˜‘—ȱ’•Ž¢ȱǭȱ˜—œǰȱŘŖŖŚǯ
 Standards 1.8 Iron and folate supplementation 6

ŗŖǯȱ ˜•£žœȱȱŽȱŠ•ǯȱ•’—’ŒŠ•ȱ™Š••˜›ȱ’œȱžœŽž•ȱ˜ȱŽŽŒȱœŽŸŽ›ŽȱŠ—Ž–’Šȱ’—ȱ™˜™ž•Š’˜—œȱ ‘Ž›ŽȱŠ—Ž–’Šȱ’œȱ

prevalent and severe. Journal of Nutrition,ȱŗşşşǰȱŗŘşDZŗŜŝśȮŗŜŞŗǯ
ŗŗǯȱ Ž ’œȱǰȱ˜Ĵȱ ǰȱ¢——ȱ ǯȱ—ȱ’—Ž¡™Ž—œ’ŸŽȱŠ—ȱ›Ž•’Š‹•Žȱ—Ž ȱ‘Ž–˜•˜‹’—ȱŒ˜•˜›ȱœŒŠ•Žȱ˜›ȱ
assessing anemia. Journal of Clinical Pathology,ȱŗşşŞǰȱśŗDZŘŗȮŘŚǯ
ŗŘǯȱ ‘˜ ‘ž›¢ȱȱŽȱŠ•ǯȱŠ”’—ȱŠȱ–Ž’ŒŠ•ȱ‘’œ˜›¢ȱŠ—ȱžœ’—ȱŠȱŒ˜•˜›ȱœŒŠ•Žȱž›’—ȱŒ•’—’ŒŠ•ȱ
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356:2101.
ŗśǯȱ ŸŠ—ȱŽħ•’—Ž—ȱȱŽȱŠ•ǯȱ쎌’ŸŽ—Žœœȱ˜ȱ’—Ž›ŸŽ—’˜—œȱ˜ȱ™›˜–˜Žȱ‘ŽŠ•‘¢ȱŽŠ’—ȱ’—ȱ™›Ž—Š—ȱ ˜–Ž—ȱŠ—ȱ
 ˜–Ž—ȱ˜ȱŒ‘’•‹ŽŠ›’—ȱŠŽDZȱŠȱ›ŽŸ’Ž ǯȱ˜—˜—ǰȱ
ŽŠ•‘ȱžŒŠ’˜—ȱž‘˜›’¢ǰȱŗşşŞDZŗȮŞşǯ
ŗŜǯȱ ž›ŠȬŽȬ•’ŸŽ’›ŠȱǰȱŽȱ•–Ž’Šȱǯȱ˜–Žœ’Œȱ›’—”’—ȱ ŠŽ›ȱȮȱŠ—ȱŽěŽŒ’ŸŽȱ Š¢ȱ˜ȱ™›ŽŸŽ—ȱ
anemia among low socioeconomic families in Brazil. Food and Nutrition Bulletin, 2002, 23:213–216.
ŗŝǯȱ Š••˜ȱȱŽȱŠ•ǯȱ˜›’ęŒŠ’˜—ȱ˜ȱŒž››¢ȱ™˜ Ž›ȱ ’‘ȱŠŽǻŗŗŗǼȱ’—ȱŠ—ȱ’›˜—ȬŽęŒ’Ž—ȱ
™˜™ž•Š’˜—DZȱ›Ž™˜›ȱ˜ȱŠȱŒ˜—›˜••Žȱ’›˜—Ȭ˜›’ęŒŠ’˜—ȱ›’Š•ǯȱAmerican Journal of Clinical Nutrition,
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’—”œȱŠ—ȱŠ’’˜—Š•ȱœ˜ž›ŒŽœ
I. ›˜—ȱŽęŒ’Ž—Œ¢ȱŠ—ŠŽ–’ŠȱŠœœŽœœ–Ž—ǰȱ™›ŽŸŽ—’˜—ȱŠ—ȱŒ˜—›˜•ǯȱȱž’Žȱ˜›ȱ™›˜›Š––Žȱ–Š—ŠŽ›œ. Geneva,
World Health Organization, 2001 ( document WHO/NHD/10.3).
ǯȱ Š—ŠŸȱȱŽȱŠ•ǯȱ˜œȱ˜ȱŸ’Š–’—ȱȱŠ—ȱ’›˜—ȱœž™™•Ž–Ž—Š’˜—ȱ˜ȱȃŠȱ›’œ”Ȅȱ™˜™ž•Š’˜—ǯȱIndian
Journal of PaediatricsǰȱŗşşŞǰȱŜśDZŞŚşȮŞśŜǯ
ǯȱ ’œ‘–Š—ȱǰȱ‘›’œ’Š—ȱǰȱŽœȱ ȱ›ǯȱ‘Žȱ›˜•Žȱ˜ȱŸ’Š–’—œȱ’—ȱ‘Žȱ™›ŽŸŽ—’˜—ȱŠ—ȱŒ˜—›˜•ȱ˜ȱŠ—ŠŽ-
mia. Public Health and Nutrition, 2000, 3:125–150.

Š—Š›œȱ˜›ȱŠŽ›—Š•ȱŠ—ȱŽ˜—ŠŠ•ȱŠ›ŽȱŽŽ›’—ȱ˜––’ĴŽŽȱȱ
This document ‘’œȱ˜Œž–Ž—ȱ’œȱ™Š›ȱ˜ȱ‘Žȱ ‘Š’›DZȱŠž•ȱŠ—ȱ˜˜”ǰȱ’›ŽŒ˜›ǰȱŽ™Š›–Ž—ȱ˜ȱŽ™›˜žŒ’ŸŽȱ
ŽŠ•‘ȱŠ—ȱŽœŽŠ›Œ‘Dzȱȱȱȱȱȱȱȱȱȱȱȱ
is not a formal Standards for Maternal and Neonatal ›—Ž••Šȱ’—ŒŽĴ˜ǰȱ
Ž•Šȱ˜œŠǰȱŽ••Šȱ‘Ž››ŠĴǰȱ——’Žȱ˜›Ž•Šǰȱ’Šȱ Š‹›ŠȱŠ—ȱžŒȱŽȱŽ›—’œȱ
publication of ǻŽ™Š›–Ž—ȱ˜ȱŠ”’—ȱ›Ž—Š—Œ¢ȱŠŽ›Ǽǯ
Š›ŽȱŽŸŽ•˜™Žȱ‹¢ȱ‘ŽȱŽ™Š›–Ž—ȱ
the World Health
˜ȱŠ”’—ȱ›Ž—Š—Œ¢ȱŠŽ›ǰȱ
Organization Œ”—˜ •Ž–Ž—œȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
World Health Organization.
(WHO), and ‘’œȱœŠ—Š›ȱ ŠœȱŽŸŽ•˜™Žȱ‹¢ȱ›—Ž••Šȱ’—ŒŽĴ˜ȱ ’‘ȱŸŠ•žŠ‹•Žȱ’—™žœȱ›˜–ȱ–Ž–‹Ž›œȱ˜ȱ‘ŽȱŠ‹˜ŸŽȱ
all rights are ŽŽ›’—ȱ˜––’ĴŽŽȱŠ—ȱ
ȱŽ’˜—Š•ȱĜŒŽœȱŠ—ȱ›ŽŸ’Ž ŽȱŠȱŠȱŽŒ‘—’ŒŠ•ȱ˜—œž•Š’˜—ȱ’—ȱ
For further information please Ž—ŽŸŠǰȱŗŚȬŗŜȱŒ˜‹Ž›ȱŘŖŖŘǯȱŽ–‹Ž›œȱ˜ȱ‘ŽȱŽ—Ž›ȱ˜›ȱŽŸŠ•žŠ’˜—ȱ˜ȱŽěŽŒ’ŸŽ—Žœœȱ˜ȱ‘ŽŠ•‘ȱŒŠ›ŽȬ
reserved by the
Œ˜—ŠŒ: Žȱǻ’–˜—Šȱ’ȱŠ›’˜ǰȱ’Ĵ˜›’˜ȱŠœŽŸ’ǰȱ ’Š—›Š—Œ˜ȱ ˜›’ǰȱŠ—’Ž•Šȱ™ŽĴ˜•’ǰȱŠ—ŽȱŠ›˜—Œ’Š—’ȱ
Organization.
Department of Making Pregnancy and Nicola Magrini) developed the table of evidence and provided additional insightful review of
The document
ŠŽ›ȱǻǼ ‘ŽȱŽŸ’Ž—ŒŽȱœŽŒ’˜—ǯȱŽȱ‘Š—”ȱ›ž—˜ȱŽ—˜’œȱŠ—ȱŠĴ‘Ž œȱŠ‘Š’ȱ˜›ȱ‘Ž•™ž•ȱŒ˜––Ž—œȱ˜—ȱ‘Žȱ
may, however, be ꗊ•ȱ›ŠĞǰȱ›Š—”ȱŽŒ”œ˜—ȱ˜›ȱ‘ŽȱŽ’’—ȱŠ—ȱž”Žȱ ¢Š–Ž›Š‘ȱ˜›ȱ‘Žȱ•Š¢˜žǯ
World Health Organization (WHO)
freely reviewed,
20 Avenue Appia
abstracted, WHO acknowledges the generous contribution of over 80 individuals and organizations in the
ŗŘŗŗȱ Ž—ŽŸŠȱŘŝ
reproduced and ꎕȱ˜ȱ–ŠŽ›—Š•ȱŠ—ȱ—Ž˜—ŠŠ•ȱ‘ŽŠ•‘ȱ ‘˜ȱ˜˜”ȱ’–Žȱ˜ȱ›ŽŸ’Ž ȱ‘’œȱ˜Œž–Ž—ȱŠȱ’쎛Ž—ȱœŠŽœȱ
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purposes. ™›Ž—Š—Œ¢ȏœŠŽ›Ȧ™ž‹•’ŒŠ’˜—œȦŽ—Ȧ
ȱȱ˜›ȱž—œ™ŽŒ’ꮍȱ™›˜›Š––Žȱœž™™˜›ǯȱ