Iron Status and Its Determinants in a Nationally Representative Sample of Pregnant Women

Published:January 24, 2013DOI:


      Iron-deficiency anemia is associated with adverse neonatal health outcomes. Iron status and its determinants were assessed in a representative sample of Belgian pregnant women. Blood samples were collected and a questionnaire was completed face-to-face. Hemoglobin (Hb) and mean cell volume were measured using a Beckman Coulter Hematology Analyzer and serum ferritin (SF) and transferrin receptor (sTfr) concentrations by immunoassay. In total, 55 obstetric clinics and 1,311 pregnant women were included. Approximately 40% of third-trimester and 6% of first-trimester women had SF levels less than 15 μg/L. Approximately 21% of third-trimester and 4% of first-trimester women had anemia (Hb <110 g/L). Of the third-trimester women, 23% were iron-deficient nonanemic (SF <15 μg/L and Hb ≥110 g/L), 16% had iron-deficiency anemia (SF <15 μg/L and Hb <110 g/L), and approximately 7% had tissue iron deficiency (sTfr >8.5 mg/L). The median body iron stores were 8.1 mg/kg among first-trimester women, but only 3.6 mg/kg among third-trimester women. SF levels were significantly positively associated with age and education level, and were higher among nulliparous women and lower among North-African women. sTfr concentrations were significantly negatively associated with age and were lower among smokers, nulliparous women, and women who planned their pregnancy. Despite the fact that two thirds of Belgian pregnant women took iron-containing supplements, iron deficiency and iron-deficiency anemia were frequent in third-trimester women. The World Health Organization regards this as a moderate public health problem. National iron supplementation guidelines are needed in Belgium to optimize iron status during pregnancy.


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        • McLean E.
        • Cogswell M.
        • Egli I.
        • et al.
        Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993-2005.
        Public Health Nutr. 2009; 12: 444-454
        • De Benoist B.
        • McLean E.
        • Egli I.
        • et al.
        WHO Global Database on Anaemia 1993-2005.
        World Health Organisation, Geneva, Switzerland2008
        • Milman N.
        Iron and pregnancy−a delicate balance.
        Ann Hematol. 2006; 85: 559-565
        • Milman N.
        Iron in pregnancy: How do we secure an appropriate iron status in the mother and child?.
        Ann Nutr Metab. 2011; 59: 50-54
        • Thomsen J.K.
        • Prien-Larsen J.C.
        • Devantier A.
        • et al.
        Low dose iron supplementation does not cover the need for iron during pregnancy.
        Acta Obstet Gynecol Scand. 1993; 72: 93-98
        • Hytten F.
        • Lind T.
        Volume and composition of the blood.
        in: Hytten F. Lind T. Diagnostic Indices in Pregnancy. Ciba-Geigy Ltd, Basel, Switzerland1973: 36-53
        • Scholl T.O.
        • Hediger M.L.
        • Fischer R.L.
        • et al.
        Anemia vs iron deficiency—Increased risk of preterm delivery in a prospective study.
        Am J Clin Nutr. 1992; 55: 985-988
        • Pasricha S.R.
        Should we screen for iron deficiency anaemia?.
        Pathology. 2012; 44: 139-147
        • Gibson R.S.
        Principles of nutritional assessment.
        Second ed. Oxford University Press, New York, NY2005
        • Cook J.D.
        • Lipschitz D.A.
        • Miles L.E.
        • et al.
        Serum ferritin as a measure of iron stores in normal subjects.
        Am J Clin Nutr. 1974; 27: 681-687
        • Asif N.
        • Hassan K.
        • Mahmud S.
        • et al.
        Comparison of serum ferritin levels in three trimesters of pregnancy and their correlation with increasing gravidity.
        Int J Pathology. 2007; 5: 26-30
        • Skikne B.S.
        • Flowers C.H.
        • Cook J.D.
        Serum transferrin receptor: A quantitative measure of tissue iron deficiency.
        Blood. 1990; 75: 1870-1876
        • Punnonen K.
        • Irjala K.
        • Rajamaki A.
        Serum transferrin receptor and its ratio to serum ferritin in the diagnosis of iron deficiency.
        Blood. 1997; 89: 1052-1057
        • Suominen P.
        • Punnonen K.
        • Rajamaki A.
        • et al.
        Serum transferrin receptor and transferrin receptor-ferritin index identify healthy subjects with subclinical iron deficits.
        Blood. 1998; 92: 2934-2939
        • Cook J.D.
        • Flowers C.H.
        • Skikne B.S.
        The quantitative assessment of body iron.
        Blood. 2003; 101: 3359-3364
        • Dowdle W.
        Centers for Disease Control: CDC Criteria for anemia in children and child-bearing-aged women.
        MMWR Morb Mortal Wkly Rep. 1989; 38: 400-404
        • World Health Organisation
        Iron deficiency anaemia assessment prevention and control: A guide for programme managers.WHO/NHD/01.3.
        World Health Organization, Geneva, Switzerland2001
        • Milman N.
        • Pedersen N.S.
        • Visfeldt J.
        Serum ferritin in healthy Danes: Relation to marrow haemosiderin iron stores.
        Dan Med Bull. 1983; 30: 115-120
        • McLaren C.E.
        • Barton J.C.
        • Adams P.C.
        • et al.
        Hemochromatosis and Iron Overload Screening (HEIRS) study design for an evaluation of 100,000 primary care-based adults.
        Am J Med Sci. 2003; 325: 53-62
        • Powell L.W.
        • George D.K.
        • McDonnell S.M.
        • et al.
        Diagnosis of hemochromatosis.
        Ann Intern Med. 1998; 129: 925-931
        • Hallberg L.
        • Bengtsson C.
        • Lapidus L.
        • et al.
        Screening for iron deficiency: An analysis based on bone-marrow examinations and serum ferritin determinations in a population sample of women.
        Br J Haematol. 1993; 85: 787-798
        • Akesson A.
        • Bjellerup P.
        • Berglund M.
        • et al.
        Serum transferrin receptor: A specific marker of iron deficiency in pregnancy.
        Am J Clin Nutr. 1998; 68: 1241-1246
        • De Benoist B.
        • McLean E.
        • Egli I.
        • et al.
        Worldwide prevalence of anaemia 1993-2005.
        World Health Organisation, Geneva, Switzerland2008
        • Massot C.
        • Vanderpas J.
        A survey of iron deficiency anaemia during pregnancy in Belgium: Analysis of routine hospital laboratory data in Mons.
        Acta Clin Belg. 2003; 58: 169-177
        • Baraka M.A.
        • Steurbaut S.
        • Laubach M.
        • et al.
        Iron status, iron supplementation and anemia in pregnancy: Ethnic differences.
        J Matern Fetal Neonatal Med. 2012; 25: 1305-1310
        • Pavord S.
        • Myers B.
        • Robinson S.
        • et al.
        UK guidelines on the management of iron deficiency in pregnancy.
        Br J Haematol. 2012; 156: 588-600
        • Pynaert I.
        • Matthys C.
        • Bellemans M.
        • et al.
        Iron intake and dietary sources of iron in Flemish adolescents.
        Eur J Clin Nutr. 2005; 59: 826-834
        • Huybrechts I.
        • Lin Y.
        • De K.W.
        • et al.
        Intake and dietary sources of haem and non-haem iron in Flemish preschoolers.
        Eur J Clin Nutr. 2012; 66: 806-812
        • Viteri F.E.
        • Berger J.
        Importance of pre-pregnancy and pregnancy iron status: Can long-term weekly preventive iron and folic acid supplementation achieve desirable and safe status?.
        Nutr Rev. 2005; 63: S65-S76
        • Pynaert I.
        • De B.D.
        • Matthys C.
        • Delanghe J.
        • et al.
        Determinants of ferritin and soluble transferrin receptors as iron status parameters in young adult women.
        Public Health Nutr. 2009; 12: 1775-1782


      S. Vandevijvere is a research scientist, Department of Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium.


      H. Van Oyen is an operational director, Department of Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium.


      S. Amsalkhir is a dietitian, Department of Nuclear Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.


      R. Moreno-Reyes is a medical doctor, Department of Nuclear Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.


      E. Ines is a research scientist, Human Nutrition Laboratory, Institute of Food, Nutrition and Health, Zurich, Switzerland.

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      • Erratum
        Journal of the Academy of Nutrition and DieteticsVol. 113Issue 9
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          In the article “Iron Status and Its Determinants in a Nationally Representative Sample of Pregnant Women” that appeared in the May 2013 issue of the Journal of the Academy of Nutrition and Dietetics, one of the authors was misidentified. Ines Egli, PhD, was incorrectly listed as “Egli Ines, PhD” in the article byline on page 659. She was also incorrectly identified as “E. Ines” instead of “I. Egli” in the Author Information section on page 666, and her institution, ETH Zurich, was mistakenly omitted from her affiliation information.
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