Toward Comprehensive Interventions to Improve the Health of Women of Reproductive Age

In lesser-developed countries (LDCs), the causes of anaemia during pregnancy are multi-factorial, yet much of the aetiological fraction of disease is attributable to a few entities. Iron deficiency is the most common cause of anaemia among pregnant women, resulting from both dietary insufficiency of iron as well as losses through the gastrointestinal tract. These losses are largely due to hookworm infection, but schistosomiasis at higher intensities of infection may also lead to blood loss [1]. The argument for hookworm treatment during pregnancy as proposed by Brooker et al. [2] and the WHO [3] is based largely on expected consequences of hookworm-related iron deficiency anaemia for both mother and newborn. It is beyond the scope of this commentary to address the complex relationship between hemoglobin levels assessed at different stages of pregnancy and peri-natal morbidity [4]. However, the relationship between iron status early in pregnancy and birth outcomes is clearer and more relevant here. It is fairly well established that iron deficiency anaemia present during the first trimester of pregnancy is associated with a 2-fold risk of low birth weight [5]. This risk is much lower among women with non–iron deficiency anaemia during the first trimester, arguing for an important mechanistic role for iron per se, discussed in greater detail in recent reviews [6]. In addition to its effects on birth weight, transfer of iron to the developing fetus is compromised among women with depleted iron stores [7]. Maternal iron deficiency is related to decreased newborn and infant iron stores, as well as increased risk of anaemia during infancy [4]. Given the established relationship between hookworm and iron deficiency, hookworm treatment is likely to positively affect maternal and infant health, though the timing of treatment as well as provision of micro-nutrient supplementation are key factors discussed further below.