Iron deficiency anemia (IDA) remains a significant global nutritional challenge, affecting populations worldwide, with a particularly high prevalence among pregnant women in developing countries.[1,2] Recent data reveal that anemia affects 41.8% of pregnant women globally, with the highest rates observed in Africa.[3] In developing nations, the prevalence of anemia during pregnancy ranges from 50% to 90%, primarily due to inadequate dietary intake and the low bioavailability of iron.[4,5] Maternal anemia is associated with a range of adverse outcomes for both the mother and neonate, including fetal anemia, low birth weight (LBW), preterm birth, low APGAR scores, intrauterine growth restriction, and increased perinatal mortality.[6,7] These complications underscore the urgent need for effective screening, prevention, and management strategies to improve maternal health and reduce the risks associated with anemia during pregnancy.

Maternal hemoglobin levels are critical in determining pregnancy outcomes and are significantly influenced by physiological changes during gestation, such as blood volume expansion. This expansion can result in a nearly 20

dl decrease in hemoglobin during the first two trimesters,

even with adequate iron supplementation.[8,9] Studies show that maternal hemoglobin levels typically decrease further in the third trimester, often accompanied by reduced serum iron and ferritin levels.[10] The prevalence of anemia among women in public health nutrition programs increases as pregnancy progresses: approximately 8% in the first trimester, 12% in the second, and 29% in the third.[11] Maintaining adequate hemoglobin levels throughout pregnancy is crucial for minimizing the risk of complications, such as low birth weight and preterm birth, emphasizing the importance of consistent maternal iron intake and supplementation to support healthy pregnancy outcomes.

Despite extensive research on the prevalence and consequences of maternal anemia during pregnancy, significant gaps remain in understanding the specific factors that influence maternal hemoglobin levels and their direct impact on neonatal health outcomes. While studies consistently link low hemoglobin levels to adverse pregnancy outcomes, variations in results across different populations highlight the need for targeted research. Additionally, although iron supplementation is widely recommended, the optimal strategies for preventing and managing maternal anemia are still debated. Given the high prevalence of anemia, especially in developing countries, further exploration is needed on how maternal hemoglobin concentrations can be effectively monitored and maintained throughout pregnancy. This study aims to evaluate the relationship between maternal hemoglobin levels during pregnancy and their impact on neonatal health outcomes, with the goal of contributing to more effective maternal care practices and improving neonatal health, particularly in resource-limited settings.

OBJECTIVE

The aim of the study was to evaluate the relationship between maternal hemoglobin levels during pregnancy and their impact on neonatal health outcomes.

This cross-sectional study was conducted at the Department of Obstetrics and Gynecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, between January 2008 and December 2009. A total of 150 pregnant women were included in the study, selected based on specific inclusion and exclusion criteria to evaluate maternal hemoglobin status and its association with neonatal health outcomes.

Inclusion Criteria:

• Pregnant women aged 17–40 years
• Singleton pregnancy
• Willingness to provide informed consent

Exclusion Criteria:

• Multiple pregnancies
• Known chronic medical conditions (e.g., diabetes, hypertension, or renal disease)
• Severe obstetric complications (e.g., preeclampsia or eclampsia)

Written informed consent was obtained from all participants before enrollment. Data were collected through structured interviews, medical records, and laboratory investigations. Sociodemographic characteristics, including maternal age and residence (urban/rural), as well as clinical characteristics such as gestational age at enrollment and trimester of pregnancy, were recorded. Maternal hemoglobin levels were measured using standard laboratory methods and categorized as anemic (Hb < 11.0 g/dL) or non-anemic (Hb ≥ 11.0 g/dL). Neonatal outcomes, including low birth weight (<2.5 kg), preterm birth (<37 weeks), neonatal anemia (Hb <13.5 g/dL), APGAR score at 1 minute, and NICU admission, were also recorded. Data were analyzed using statistical software version 22, with descriptive statistics used to summarize sociodemographic and clinical characteristics. Frequencies and percentages were calculated for categorical variables, while means and standard deviations (SD) were used for continuous variables. The association between maternal hemoglobin levels and neonatal outcomes was assessed using chi-square tests, as appropriate. A p-value <0.05 was considered statistically significant.

Table 1: Sociodemographic and Clinical Characteristics of the Study Population (N = 150)

This table presents the demographic and clinical characteristics of the 150 pregnant women included in the study. The mean maternal age was 24.5 ± 4.0 years, with the majority (60.0%) aged 21-29 years, while 16.7% were ≤20 years and 23.3% were ≥30 years. The mean gestational age at enrollment was 26.5 ± 4.5 weeks, with most participants (66.7%) enrolling in the third trimester. A higher proportion of mothers (66.7%) resided in urban areas compared to 33.3% in rural settings. Regarding maternal hemoglobin status, 28.7% of women were anemic (Hb < 11 g/dL), while 71.3% were non-anemic (Hb ≥ 11 g/dL), highlighting the prevalence of maternal anemia in the study population.

Table 2: Neonatal Health Outcomes among Study Participants (N = 150)

Table 2 summarizes the neonatal health outcomes observed in the study. Among the 150 neonates, 36.7% had low birth weight (<2.5 kg), and 23.3% were born preterm (<37 weeks). Neonatal anemia (hemoglobin <13.5 g/dL) was present in 47.4% of cases. Additionally, 18.7% of neonates had an APGAR score <7 at 1 minute, indicating potential distress at birth, and 14.7% required admission to the Neonatal Intensive Care Unit (NICU).

Table 3: Distribution of Maternal Hemoglobin Levels Among Study Participants (N = 150)

Table 3 presents the distribution of maternal hemoglobin levels among the 150 pregnant women included in the study. Overall, 28.7% of women were anemic (hemoglobin <11.0 g/dL), while 56.7% had hemoglobin levels within the optimal range (11.0–12.9 g/dL). A smaller proportion (14.6%) had hemoglobin levels ≥13.0 g/dL.

Table 4: Association between Maternal Hemoglobin Levels and Neonatal Outcomes (N = 150)

Table 4 examines the association between maternal hemoglobin levels and neonatal outcomes. Neonates born to mothers with hemoglobin levels <11.0 g/dL (anemic) had significantly higher rates of low birth weight (58.1%, p = 0.0004), preterm birth (41.9%, p = 0.002), neonatal anemia (81.4%, p < 0.001), low APGAR scores (34.9%, p = 0.005), and NICU admission (27.9%, p = 0.015) compared to those born to mothers with hemoglobin levels in the optimal range (11.0–12.9 g/dL). Mothers with hemoglobin levels ≥13.0 g/dL also showed increased risks for some adverse outcomes, such as low birth weight (45.5%) and preterm birth (22.7%). 

This study examines the association between maternal hemoglobin levels during pregnancy and neonatal health outcomes among a cohort of pregnant women in Bangladesh. Maternal anemia, a common nutritional concern in many developing countries, is associated with a range of adverse pregnancy and neonatal outcomes, including low birth weight, preterm birth, and neonatal

anemia. The findings emphasize the importance of maintaining optimal hemoglobin levels during pregnancy, as both anemia and excessively high hemoglobin levels were found to significantly affect neonatal health. The results underline the need for improved screening and intervention strategies to address maternal anemia and optimize pregnancy outcomes, particularly in resource-limited settings.

The mean maternal age in our study was 24.5 ± 4.0 years, which is comparable to Shobeiri et al.[12], who reported a mean age of 24.0 ± 4.2 years, indicating a similar maternal age distribution across different populations. In our study, 28.7% of mothers were anemic (Hb < 11 g/dL), closely aligning with Dairo et al.[13], who reported an anemia prevalence of 32.8%. This highlights the persistent burden of maternal anemia, which has been widely associated with adverse neonatal outcomes such as low birth weight, preterm delivery, and neonatal anemia. Furthermore, the majority of mothers in our study (66.7%) were enrolled in the third trimester, consistent with Dairo et al.'s[13] findings that most women booked antenatal visits late (after 25 weeks of gestation). Late antenatal booking often limits early interventions for anemia, increasing the risk of neonatal complications. Additionally, our study found that 66.7% of mothers were from urban areas, similar to Dairo et al.’s[13] findings, reflecting potential disparities in healthcare access and anemia prevalence between urban and rural populations. Given the established link between maternal hemoglobin levels and neonatal health, our findings emphasize the importance of early screening and intervention for maternal anemia to improve neonatal outcomes.

The neonatal outcomes observed in our study align with findings from previous research on the effects of maternal hemoglobin status. Scanlon et al.[14] demonstrated that maternal anemia is associated with adverse neonatal outcomes, including low birth weight (LBW) and preterm birth, which is consistent with our findings of 36.7% LBW and 23.3% preterm birth rates. They also highlighted mechanisms such as chronic hypoxia and placental insufficiency, which may explain the observed association between maternal hemoglobin status and adverse neonatal outcomes, including low APGAR scores (18.7% in our study). Furthermore, Kilbride et al.[15] and Kumar et al.[16] emphasized the intergenerational impact of maternal anemia, noting that infants of anemic mothers are at a higher risk of developing neonatal anemia. This is reflected in our study, where 47.4% of neonates had anemia (Hb <13.5 g/dL). Additionally, the increased risk

of NICU admission (14.7% in our study) may be linked to the long-term sequelae of maternal anemia, as discussed by Kilbride et al.[15], who reported that preterm and LBW infants are prone to complications requiring intensive care. These findings collectively underscore the importance of addressing maternal hemoglobin status to improve neonatal health outcomes, which is the central focus of our study.

In our study, 28.7% of pregnant women were anemic (hemoglobin <11.0 g/dL), while 56.7% had hemoglobin levels within the optimal range (11.0–12.9 g/dL). These findings are consistent with Gonzales et al.[17], who reported that hemoglobin levels below 11 g/dL were associated with increased risks of adverse neonatal outcomes, such as preterm birth and low birth weight. However, the prevalence of anemia in our study (28.7%) was higher than the 11.5% reported by Gonzales et al.[17], which may reflect differences in population characteristics or regional nutritional status. Additionally, 14.6% of women in our study had hemoglobin levels ≥13.0 g/dL, which aligns with their observation that high hemoglobin levels (>14.5 g/dL) may also pose risks for adverse neonatal outcomes. These findings highlight the importance of maintaining optimal hemoglobin levels during pregnancy to minimize risks to neonatal health.

In our study, we found a significant association between maternal anemia and adverse neonatal outcomes, including low birth weight (LBW), preterm birth, neonatal anemia, and NICU admission. Specifically, 58.1% of neonates born to anemic mothers (Hb <11.0 g/dL) were classified as LBW, which aligns with previous studies showing that anemia during pregnancy increases the risk of LBW, with odds ranging from 1.9 to 5.1.[18,19,20] Our findings also demonstrated a high prevalence of neonatal anemia, with 81.4% of neonates born to anemic mothers having anemia, supporting the results of Desalegn et al.[21] and Meda et al.[22], who found a similar association between maternal anemia and neonatal anemia. Additionally, preterm births were significantly more common in anemic mothers, with 41.9% of neonates born preterm, which corroborates findings from previous research that identified anemia as a risk factor for preterm birth.[18] Moreover, our study found a higher incidence of NICU admissions among neonates born to anemic mothers, a result consistent with previous studies that highlighted the increased need for intensive care among neonates affected by maternal anemia. These findings underscore the critical importance of addressing maternal anemia, as its prevalence is linked to several negative neonatal outcomes. This reinforces recommendations from studies like Adam et al.[19], which emphasize the need for preventive measures to reduce maternal anemia and its associated risks to neonatal health.

Limitations of the study

This study had some limitations:

• The study was conducted in a selected tertiary-level hospital.
• The sample was not randomly selected.
• The study's limited geographic scope may introduce sample bias, potentially affecting the broader applicability of the findings.

In conclusion, this study highlights a significant relationship between maternal hemoglobin levels during pregnancy and neonatal health outcomes. Anemia in pregnant women (hemoglobin <11 g/dL) was associated with higher rates of adverse neonatal outcomes, including low birth weight, preterm birth, neonatal anemia, low APGAR scores, and NICU admissions. In contrast, while maternal hemoglobin levels in the optimal range (11.0–12.9 g/dL) were associated with better outcomes, even higher hemoglobin levels (≥13.0 g/dL) were linked to some increased risks for low birth weight and preterm birth. These findings emphasize the importance of monitoring and managing maternal hemoglobin levels to improve neonatal health outcomes.

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