Exploring the Link between Iron Deficiency Anemia & Severe Maternal Morbidity

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Dr. Nansi Boghossian deep dives into her research findings on the alarming connection between iron deficiency anemia and severe maternal morbidity risk among pregnant individuals. Her study, “Association between iron deficiency anemia and severe maternal morbidity: A retrospective cohort study,” can be found in the December 2024 (Vol. 100) issue of Annals of Epidemiology.

Read the full article here:

https://www.sciencedirect.com/science/article/abs/pii/S1047279724002485

Episode Credits:

• Executive Producer: Sabrina Debas
• Technical Producer: Paula Burrows
• Annals of Epidemiology is published by Elsevier.
  
  
  

Episode Transcript

Patrick Sullivan (00:12):
Hello, you're listening to EPITalk
Paper, a monthly podcast fromthe Annals of Epidemiology.
I'm Patrick Sullivan,Editor-in-Chief of the journal,
and in this series we take youbehind the scenes of some of the
latest epidemiologic researchfeatured in our journal.
Today we are here with Dr.

(00:35):
Nansi Boghossian to discuss herarticle "Association Between
Iron Deficiency, anemia andSevere Maternal orbidity: A
retrospective cohort study.
" You can read the full articleonline in the December 2024
issue of the journal atwwwannalsofepidemiologyorg.
Dr Nancy Boghossian is anassociate professor in the

(00:58):
Department of Epidemiology andBiostatistics at the University
of South Carolina.
Her research focuses oninvestigating factors
influencing maternal andneonatal health outcomes.
She's particularly interestedin healthcare access, quality
and state policies and how thesefactors result in racial and
ethnic disparities in maternaland newborn outcomes.

(01:20):
Dr Boghossian, thank you forjoining us today.

Nansi Boghossian (01:23):
Thank you for having me.
I'm looking forward to this.

Patrick Sullivan (01:26):
So I wonder if you could start just by briefly
describing the purpose of thestudy.
What was the research questionthat you were trying to answer?

Nansi Boghossian (01:34):
Yes, sure.
So we set out to examine theassociation between iron
deficiency anemia and severematernal morbidity during the
delivery, hospitalization and upto one year postpartum.

Patrick Sullivan (01:47):
Okay, and so you mentioned a couple of terms
there that everybody might notbe familiar with.
Can you just sort of explainwhat is iron deficiency anemia,
and how does it relate to severematernal morbidity?

Nansi Boghossian (01:59):
Sure.
So iron deficiency anemia isbasically a condition where the
body does not have enough ironin order to produce hemoglobin,
and that's the protein in redblood cells that carries oxygen,
and this usually leads tosymptoms like fatigue, weakness,
pale skin, shortness of breathand dizziness.

(02:20):
Severe maternal morbidity isthe unexpected outcomes of labor
and delivery that result inshort-term or long-term outcomes
for the mom, and these caninclude conditions such as
sepsis, acute renal failure oreclampsia, and iron deficiency
anemia has been linked toincreased risks of multiple

(02:41):
adverse maternal and fetaloutcomes, including placental
abruption, hemorrhage shock,intensive care unit admission
for the mom, low birth weightand preterm delivery for the
newborn.
But there has been no, or verylittle, examination of the
association between irondeficiency anemia and SMM or

(03:02):
severe maternal morbidity, andso we set out to examine this in
this current paper.

Patrick Sullivan (03:08):
Great.
So, given that question, canyou walk us through your study
design basically how youorganized the data and conceived
of the analysis, and say alittle bit about why you chose
that particular analytic method?

Nansi Boghossian (03:22):
Sure.
So this was again aretrospective, population-based
cohort study that used birth andfetal death certificates that
were linked to maternal andnewborn hospital discharge data,
and the states that wereincluded were Michigan, oregon
and South Carolina from 2008 to2020.

(03:43):
And these linkages of the birthand fetal death certificates are
done usually by state healthdepartments linkages to the
hospital discharge data withsome states routinely performing
this linkage and othersperforming it by request from
the investigators.
There are very well-establishedmethods in order to conduct

(04:03):
these linkages and the linkagerate is estimated between more
than 95%.
So the data were available forthe delivery, hospitalization
and up to one year postpartum.
Our primary outcomes looked atblood transfusion and
non-transfusion SMM, and forthat we used modified Poisson

(04:24):
regression models in order toexamine the adjusted relative
risks and 95% confidenceintervals.
We also estimated thepopulation attributable risk for
10,000 births and we adjustedfor a variety of factors,
including birth year, the stateof residence, insurance type,
education, race and ethnicity,the adequacy of prenatal care

(04:48):
utilization and the obstetriccomorbidity index, and that's an
index that includes 27 riskfactors for SMM that are each
scored and ranked by theirrelative significance.

Patrick Sullivan (05:03):
Great.
So, after you implemented thesemethods, what were the main
findings from your study andwhat do you think is important
from a public health point ofview to emphasize about your
findings?

Nansi Boghossian (05:15):
So we had almost two and a half million
individuals and the rate of irondeficiency anemia was around
10.3% and the rate increasedover time, particularly among
Black individuals.
And we found that individualswith iron deficiency anemia had
higher rates of bloodtransfusion and non-transfusion

(05:38):
SMM than those without irondeficiency anemia.
The risk of blood transfusionwas 8.2, and that's the adjusted
relative risk, and fornon-transfusion, the adjusted
relative risk was almost twofoldamong individuals with iron
deficiency anemia compared tothose without iron deficiency
anemia.
The relative risks were stillelevated at one year postpartum

(06:02):
and so for non-transfusion SMMthey were 30% higher among
individuals with iron deficiencyanemia.
And also we found differencesby race and ethnicity.
So iron deficiency anemia wasassociated with approximately
twofold increasing the risk ofSMM across all groups, but Black

(06:23):
individuals had the highestpopulation attributable risk for
both blood transfusion and SMM.
For SMM indicators, theindividuals with iron deficiency
anemia had more than twofoldincreased risk for sepsis, for
disseminated intravascularcoagulation, tracheostomy and
respiratory distress syndrome.

Patrick Sullivan (06:46):
So you mentioned some maternal outcomes
like disseminated intravascularcoagulation or DIC sepsis.
Are these sort of transient oreasy to treat things, or are
these pretty serious healthconcerns for the mother?

Nansi Boghossian (06:59):
These are serious health problems for the
mom and moms usually end upbeing hospitalized for them for
a couple days.
So again, these are seriousindicators that cause adverse
outcomes for the mother.

Patrick Sullivan (07:14):
Can you give us an idea of how your findings
compared with the previousliterature on this subject?
Is this a new findingconfirming a previous finding in
a new population?
How would you put this incontext of the existing
literature?

Nansi Boghossian (07:30):
Yes, so there's been a couple studies
that have examined generalanemia in relation to SMM
outcomes.
General anemia meaning lookingat all nutritional anemias,
sometimes excluding hereditaryanemias, but our paper focused
specifically on iron deficiencyanemia.
Our findings are in line withsome previous studies conducted

(07:54):
in California where the authorslooked at racial differences in
the SMM outcome and theyreported at least a
one-and-a-half-fold increasedadjusted relative risk of
non-transfusion SMM across allracial and ethnic groups.
So again, our study focusedmainly on iron deficiency anemia

(08:15):
, but they are in line withother studies, given that iron
deficiency anemia causes themajority of the nutritional
anemia.

Patrick Sullivan (08:25):
So, given that , what do you think the
implications are of yourfindings for iron deficiency
anemia?
Sort of practice or policy?

Nansi Boghossian (08:36):
So our findings highlight the need for
improved education andcounseling about the benefits of
iron supplementation and therisks of iron deficiency anemia.
This can lead to better patientunderstanding and adherence of
the importance of this.
For individuals who experiencesignificant side effects from
oral iron, such as constipationor vomiting, policies could

(09:00):
support the use of intravenousor IV iron as a potential viable
alternative.
This would ensure that allpatients have access to
effective treatment options.
Implementing policies thatwould mandate regular follow-ups
as well and monitoring of ironlevels can help identify
non-compliance early and addressit promptly.

(09:21):
In regard to advancing racialand ethnic equity, again there
should be an attempt to addressdisparities in access.
Basically, ensuring equitableaccess to iron supplementation
and alternatives such as IV ironcan reduce these disparities in
maternal health outcomes, andalso training healthcare

(09:44):
providers in culturallycompetent care can improve
communication and trust with thepatients from diverse
backgrounds, leading, hopefully,to better adherence to
supplementation guidelines.

Patrick Sullivan (09:57):
So you got at this a little bit in your answer
, which I appreciate, which isyou know, how do we deal with
the fact that there are medicalapproaches, you know, to
preventing this iron deficiencyanemia and the associated severe
maternal mortality, but thecompliance with them seems low
for those iron supplements.
So are there any specificrecommendations about how to

(10:20):
deal with just the lowcompliance with these
recommendations?

Nansi Boghossian (10:24):
So I would say the first step would be
education and counseling,providing comprehensive
education about the benefits ofiron supplementation and the
risk of iron deficiency anemia.
Not all care providers andpatients understand how iron
supports both the mom and thefetus, so more information and

(10:46):
more education on that isimportant.
But what's also important is totry to manage side effects.
So pills can result in symptomssuch as nausea and constipation
, and addressing these sideeffects can improve adherence.
This might involve recommendingtaking iron supplements with
food, or using a differentformulation or splitting the

(11:08):
dose.
Potentially, maybe implementingreminders in the healthcare
system once the patient goes tosee the care provider, or
sending text messages to the momcan help individuals remember
to take their supplements.
And then regular follow-ups,regular check-ins with the
healthcare providers in order tomonitor the iron levels and

(11:29):
discuss any potential issueswith supplementation.
That can also be a way in orderto improve adherence.

Patrick Sullivan (11:38):
Thank you.
So we're going to move now tosome questions that are less
about the clinical conditionsand more about what it's like to
be a researcher doing this kindof research and how the
research comes about.
We call this behind the paperand it's just a chance to talk a
little more about your process.
You know our listeners are acombination of epidemiologists
who might not work in your field.

(11:59):
We have earlier careercolleagues who might be in
graduate school or doctoralprograms or early career faculty
.
So just want to ask you a fewquestions about how you come up
with and execute this kind ofresearch.
So maybe if you could firstjust tell us how this particular
research question came up foryou, how did you land on this as

(12:19):
a good idea or an importantquestion to ask?

Nansi Boghossian (12:23):
Yes.
So I'm interested in sicklecell disease, and when we
started looking at that as anexposure in relation to severe
maternal morbidity and startedto code the ICD codes, we
realized that we have a veryhigh rate of iron deficiency
anemia.
And so that was a first looksort of at this important

(12:45):
question.
And then, looking back at theliterature, we realized there
aren't a whole lot of studieslooking at this important issue,
and so that was the reason whywe looked at that.
So it stemmed first frominterest in sickle cell disease
anemia in order to and thensubsequently looking at iron
deficiency anemia.

Patrick Sullivan (13:04):
Thank you.
What do you think is the mostchallenging and maybe also the
most rewarding part about beinga researcher working in this
particular area?

Nansi Boghossian (13:15):
I think there's more rewarding parts
compared to the challengingparts.
The main challenging part, Iwould say, is navigating the
unknown, especially when itcomes to applying for grant
funding.
I'm not sure the grant willmake it, so I would think that
this is the most challengingpiece.
The more rewarding parts are,just you know, the thrill of

(13:38):
discovering something new andcontributing to scientific
advancements and knowing that,hopefully, knowing that your
research would result in animpact in the society and in
people's lives, and that's veryhighly rewarding and in people's
lives and that's very highlyrewarding.

Patrick Sullivan (14:01):
Yeah, and I think some people, sometimes
people who don't do this kind ofwork, may not appreciate what
that life cycle is.
From like thinking about agrant, writing a grant, getting
the money, getting the data,doing the analysis.
It really can be quite a longtime frame.
Can you estimate how long thisproject ran from like the idea
to getting some support for it,to the getting the data, the
analysis and getting itpublished?

(14:21):
What's that lifecycle of aproject like for you?

Nansi Boghossian (14:25):
Yeah, so this is part of my R01.
And currently I'm in the fifthyear of the R01.
So it was one of the earlierprojects that we started and
it's a long process.
Long process in terms ofgetting the data, approaching
the states to get that data andgoing back and forth about the

(14:46):
data use agreements and then,after getting the data,
harmonizing the data between thestates.
Different states code thingsdifferently.
Things might be coded indifferent places in the birth
certificates and in the hospitaldischarge records, so deciding
on which source to use for thedata is also critical, given
that we know that birthcertificates under code a lot of

(15:09):
outcomes, especially related topregnancy complications.
And then doing the analysis,and so I agree it is a long
journey from the time you getthe grant until you execute the
analysis and publish the paper.

Patrick Sullivan (15:25):
Well, congratulations on the R01 grant
and thanks for sharing a littlebit of what has to happen, even
before you get to the beginningof your methods section,
probably in terms ofaccumulating those data, I'd
like to just end with one morequestion.
I know at Emory University whereI teach and I'm sure where you
do your work and teach thatthere's a lot of interest in

(15:45):
child and maternal health amongour students, child and maternal
health among our students.
So do you have any advice forpublic health students or other
students who are interested inchild and maternal health in
terms of pursuing a career inresearch in this field?

Nansi Boghossian (15:59):
Yes, I think it's really important to get
involved in research projectsearly on.
This helps in developing theseresearch skills, but it also
helps in networking andcollaborating and knowing how
teams function.
All of these are critical,important networks for also
-future- securing a postdoc, forexample, or securing your first

(16:23):
position after you finish yourpostdoc.
Keep yourself updated with thelatest literature and latest
research by reading journals.
But then the most importantthing I would say is to be
passionate about what you'redoing and be persistent.
I think to wake up and do whatwe're doing, you have to be

(16:44):
really passionate, and that'swhen a job doesn't feel like a
job anymore.
It feels like something youenjoy doing on a daily basis.
And so, being passionate aboutwhat you do and persistent, that
will result in importantoutcomes for your research and
future career trajectory.

Patrick Sullivan (17:04):
Well, that really feels like ending on a
high point and thank you forthat really positive reflection
about doing the work.
And our listeners can't seewe're on Zoom and can see each
other but just the visible joywhen you talk about doing this
work and it's clear from yourvoice and from how we are seeing
each other that this is an areaof passion for you.

(17:25):
So congratulations on findingthat meaningful thing and really
important thread of research.
So I want to just give you achance to share with us any last
thoughts you'd like to sharewith our listeners about your
research, about the process orabout actions that they could
take to improve public health inthis area.
Any last thoughts?

Nansi Boghossian (17:46):
Yeah, thank you again.
Thank you for all the questionsand I very much enjoyed this.
Last thoughts- I think there'sstill a lot to be done in this
area.
The research that we did didnot look at the severity of iron
deficiency anemia.
I know there's a couple ofstudies, couple of trials,
trying to look at how IV ironsupplementation can improve

(18:09):
maternal outcomes, but I believethis is an important topic for
future research and I'm lookingforward to seeing what can come
out of more research being donein this area and how that can
advance racial equity in termsof severe and adverse outcomes
to moms and babies.

Patrick Sullivan (18:30):
That brings us to the end of this episode.
Thank you so much again, Dr.
Boghossian, for joining ustoday.
It was such a pleasure to haveyou on the podcast.

Nansi Boghossian (18:39):
Thank you, thanks again for having me.

Patrick Sullivan (18:41):
I'm your host, Patrick Sullivan.
Thanks for tuning in to thisepisode and see you next time on
EPITalk, brought to you byAnnals of Epidemiology, the
official journal of the AmericanCollege of Epidemiology.
For a transcript of thispodcast, or to read the article
featured on this episode andmore from the journal, you can
visit us online at www.
annalsofepidemiology.
org.