Method
Methodists review’s protocol was registered online with PROSPERO (CRD42020206618). We extensively searched Em base, PubMed, Cochrane and Scopus through the HENRI website to identify studies that reported either association or effect of postpartum anemia on fatigue, depression and mother–child interaction. We restricted our search to studies of human females published in English language from the database's inception until August 2020. We followed a Cochrane guideline for reporting systematic reviews and meta-analysis to synthesize data.
Results
Twenty-seven studies were included in this systematic review, with some reporting all three domains (fatigue, depression and mother–child interaction) of HRQoL. Seven observational studies with pooled dichotomous outcomes showed that iron deficient or anemic women were 1.66 times more likely to experience symptoms of depression than non-academic or iron-replete women [RR = 1.66 (95% CI: 1.28; 2.16), I2 = 67.0%, P < 0.01]. In three randomized controlled trials (Rats), pooled continuous data showed statistically significant reduction in fatigue scores in women who received iron supplementation than the control group [MD: -1.85 (95% CI: -3.04; -0.67), I2 = 65.0%, p < 0.06]. Two of the four included studies showed that anemic mothers were less responsive and had negative feelings towards their children than non-academic mothers.
Conclusion
Evidence from this review suggests that postpartum anemia negatively affects health-related quality of life, and that iron replenishment improves both symptoms of fatigue and depression. Nevertheless, it remains unclear whether postpartum anemia affects mother–child interaction.
Background
Postpartum anemia remains a persistent and severe public health issue in many parts of the world [1]. The World Health Organization defines postpartum anemia as a hemoglobin concentration of < 11 g/DL at one week post-delivery and < 12 g/DL in the first postpartum year [2]. Although maternal iron stores are expected to replenish after delivery, the prevalence of anemia in women after childbirth remains unacceptably high in both developed (22–50%) and developing (50–80%) countries [3]. Postpartum anemia is mainly caused by untreated antenatal iron deficiency or anaemia and excessive blood loss during or after childbirth [3]. Postpartum anemia is classified as anemia due to iron deficiency in many women [1, 4]. Iron deficiency anemia (IDA) is the state in which there is insufficient body iron to maintain the tissue’s normal physiological function, i.e. blood, brain and muscles [5]. A reduction of serum ferritin below 30 mg/l in settings where inflammatory conditions are uncommon is suggestive of iron deficiency (ID) [5].
Untreated postpartum anemia affects the wellbeing of both the mother and child. Maternal ID or anemia related complications may impair physical capacity and performance and negatively impact health-related quality of life [6]. Health-Related Quality of Life (HRQoL) is the patient’s self-report on how her wellbeing and functioning level are affected by individual health or medical treatment received [7]. There is now consensus that HRQoL is a multidimensional construct. At a minimum, it consists of the physical, mental and social domains. Symptoms such as fatigue, psychological distress (anxiety and depression) and altered mother–child relationship, among others, are common indicators of poor HRQoL.
Since health care is becoming more patient-centered, patient-reported outcomes such as quality of life are increasingly important [8]. Worldwide, studies have reported mixed results on the association between postpartum anemia and maternal HRQoL. For example, Chandrasekaran et al. (2018) [9] reported no association between postpartum anemia and HRQoL. Conversely, Khalafallah et al. (2012) [10] found a strong association between maternal iron stores and improved HRQoL. Due to controversies surrounding the role of iron deficiency or anaemia on maternal HRQoL and the fact that improved maternal HRQoL after childbirth is linked to the improved wellbeing of the child and “family and society”[11]; reaching a consensus can be influential in deciding whether postpartum iron supplementation improves maternal wellbeing. Therefore, we conducted a systematic review to determine the effect of postpartum anaemia on maternal HRQoL in the first postpartum year. In assessing the effect of iron deficiency or anemia on HRQoL, we used the Wilson and Clearly model [12], which links the biological and physiological variables (iron and hemoglobin levels) to measures of HRQoL such as symptom status (fatigue, depression) and functional status (mother–child interaction).
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