Abstract

Background: Anemia remains a critical global public health issue, significantly contributing to maternal morbidity and mortality, particularly in low-resource settings. Specific Background: In Iraq, the burden of anemia among pregnant women remains underexplored, with limited data on hematological profiles across trimesters. Knowledge Gap: Despite existing literature on anemia in pregnancy, there is a paucity of localized studies assessing its prevalence, severity, and potential causes beyond iron deficiency. Aim: This study aimed to determine the prevalence and severity of anemia among pregnant women attending Al-Alawiya Maternity Hospital in Baghdad, Iraq, and to evaluate associated hematological parameters. Results: A cross-sectional analysis of 110 pregnant and 50 non-pregnant women revealed a statistically significant decrease in hemoglobin and packed cell volume (PCV) among pregnant participants, particularly during the second and third trimesters and within the 26–40-year age group. Ferritin levels remained within normal limits across all groups. Novelty: The study highlights a modest prevalence of anemia not directly linked to iron deficiency, suggesting alternative etiologies such as micronutrient deficiencies or physiological changes during pregnancy. Implications: Routine monitoring of hematological parameters is essential, and further investigation is needed to identify non-iron-related causes of anemia in pregnancy to guide more effective interventions.

Highlights:

1. Hemoglobin drops in 2nd and 3rd pregnancy trimesters.

2. Anemia most common in women aged 26–40.

3. Ferritin normal—non-iron deficiency anemia suspected.

Keywords: Anemia, Pregnancy, Hemoglobin, Ferritin, Iraq

Introduction

Anemia is a condition in which the number of red blood cells or the hemoglobin concentration in them is lower than normal. It primarily affects women and children. Anaemia arises when the body does not have enough hemoglobin to transport oxygen to the organs and tissues [1]. In order to support and care for the developing fetus, the expectant mother experiences significant anatomical and physiological changes during pregnancy. These changes begin after conception and affect all organ system in the body [2].

Anemia in Pregnancy is commonly associated with many consequences as low birth weight, stillbirth [3], perinatal death, premature delivery in addition to increased risk of maternal mortality and morbidity [4]. Hemoglobin (Hb) is an oxygen-binding protein found in erythrocytes whose primary role is oxygen (O2) transportation from the lungs to tissues and Carbon Dioxide (CO2) and H transportation from the tissues to the lungs [4,40]. Hemoglobin increases the blood oxygen carrying capacity of plasma to about 70 times with little dissolved oxygen. (Hb) is a heme containing tetrameric globular protein, The reliability of packed cell volume (PCV) has received much less consideration than the reliability of hemoglobin and RBC count measurements [5].

If a ferritin test reveals a low blood ferritin level, it indicates that the body's iron stores are low [6].

Methods

Pregnant women who were randomly selected on October 15, 2024, and completed in March 2025 at Al-Alawiya Maternity Hospital in Baghdad, Iraq, participated in a cross-sectional study. Blood samples were collected to determine some hematological parameters among pregnant women in Iraq, including hemoglobin values, packed cell volume, and ferritin. One hundred ten pregnant women, 14 in the first trimester, 25 in the second trimester, and 21 in the third trimester, with ages ranging from 11 to 55 years, and other fifty non-pregnant women of similar ages were chosen as a healthy control group.

Sample collection

seven ml of blood samples were collected by vein puncture using disposable syringes preferred,3 ml for hematological analysis (Hb and PCV) and other 4 mal serum separated and freezing for serologlogical test, (ferritin level).

Methods

1- Hb and PCV values: Is automated analyzers carry out these processes quickly and accurately to provide information about (Hb and PCV).

2-Enzyme-Linked ImmunosorbentAssay (ELISA) Method for measurement ferritin level:

A solid-phase sandwich assay based on a streptavidin-biotin principle described by [7].

Hb and ferritin in this study is defined by using the WHO criteria of hemoglobin values of less than 11g/dL.13, Mild anaemia 9.0-10.9g/Dl, Moderate anemia 7.0-8.9g/ dL, severe anemia

Ferritin normal range <27.23 ng/mL

Statistical analysis; SPSS software version 23 was used to analyze the data. For every variable, the mean and standard deviations were determined at p-value = 0.08 and equal or less than 0.001 was considered statistically significant.

Result and Discussion

*; Highly-significant. At p value =0.001

Table 1 shows distribution of pregnant women according to age and trimester included in this study, highly significant differences between non pregnant women (36.58±4.21) and pregnant in the first (35.72 ±3.3), second (32.58 ± 3.69)), third trimester (31.96 ± 2.81) atp value =0.001

*; Non-significant.

Table 2 shows distribution of pregnant women according to age and trimester included in this study, non-significant differences between the age groups in the three trimesters at p-value =0. 08, the results agree with European Medicines Agency [8] who established that no significant differences between the age and trimesters.

* Highly-significant. At p value =0.001

Table (3) the mean and standard deviation of hemoglobin value (Hb) in pregnant women distributed according to trimester and non-pregnant, Highly-significant was found between pregnant women and non-pregnant (12 ±1.34) at p- value =0.001, the second trimester (25±10.35) followed by third trimester (21±10.93) showed low values of HB than first trimester. RBCs decreased linearly as pregnancy proceeded, according to most research, and the overall RBC count decreased considerably throughout pregnancy as compared to non-pregnant women [9] Purohit et al., 2015]. The hemoglobin content of pregnant women is lower than that of non-pregnant women, and it significantly drops from the first to the third trimester [10]. According to Verma et al. (2013) [11], Hb, RBCs, and PCV steadily decline from the end of the first trimester and return to normal within one to two months after giving birth. Omar and Elzahaf (2016). [12] observed that compared to other trimesters, the third trimester had a higher number of serious infection reports.

Table (4) The mean and standard deviation of hemoglobin values of (Hb) and pcv in pregnant women distributed according to age, highly-significant was found between age of pregnant women at p- value =0.001 the age between (26-40) showed low vales of Hb and pcv (10 ±1.14) Although Another study found that the percentage of iron deficiency increased with age, which could indicate that iron and/or vitamin deficiencies were mainly associated with nutritional anemia. With the rapid increase in the older population, the high prevalence of anemia appears to be a new issue among older people. (rows et al 2010) in other study by (Alaa et al 2020) who found that Packed cell volume (PCV%) values in the 2nd and trimesters highly decreased

* Highly-significant. a t p value =0.001

Table (5) showed the mean and standard deviation of hemoglobin values of ferritin in pregnant women distributed according to age, Highly-significant was found between age of pregnant women and the level of ferritin at p- value =0.001, all pregnant women showed normal values of ferritin compared with normal level range, this results was agree with [15] who found Increasing age and did not correlate directly with ferritin concentrations, and hemoglobin values while [16] discovered that maternal age significantly correlated with serum ferritin concentrations, as did maternal and pregnancy features. The preterm pathway may be triggered by clinical and subclinical vaginal infections, which are indicated by elevated ferritin concentrations[17, 18].One studies have demonstrated a link between vaginal infections and preterm delivery [19], and one randomized controlled trial found that treating asymptomatic vaginal infections and screening for them in the second trimester of pregnancy decreased the rate of preterm births by 50% [20].

Conclusion

In conclusion, this study demonstrates a statistically significant decline in hemoglobin and packed cell volume (PCV) levels among pregnant women in Iraq, particularly during the second and third trimesters, with women aged 26–40 years being the most affected. Despite the presence of anemia, ferritin levels remained within the normal range across all age groups, suggesting that anemia in this population may not be primarily due to iron deficiency but could involve other nutritional or physiological factors. These findings underscore the importance of routine hematological monitoring during pregnancy to mitigate risks associated with maternal morbidity and adverse perinatal outcomes. Further research is warranted to explore the underlying causes of non-iron deficiency anemia during pregnancy and to assess the potential role of subclinical infections and micronutrient deficiencies in contributing to maternal anemia.

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