e-Library of Evidence for Nutrition Actions (eLENA)

Daily iron and folic acid supplementation during pregnancy

Guidance summary*

WHO recommendations

Daily oral iron and folic acid supplementation with 30 mg to 60 mg of elemental irona and 400 µg (0.4 mg) folic acidb is recommended for pregnant women to prevent maternal anaemia, puerperal sepsis, low birth weight, and preterm birth.

a The equivalent of 60 mg of elemental iron is 300 mg ferrous sulfate heptahydrate, 180 mg ferrous fumarate or 500 mg of ferrous gluconate.
b Folic acid should be commenced as early as possible (ideally before conception) to prevent neural tube defects.

Remarks

  • This recommendation supersedes the 2012 WHO Guideline: daily iron and folic acid supplementation in pregnant women (1) and should be considered alongside Recommendation A.2.2 on intermittent iron found in the guideline, WHO recommendations on antenatal care for a positive pregnancy experience.

  • In settings where anaemia in pregnant women is a severe public health problem (i.e. where at least 40% of pregnant women have a blood haemoglobin [Hb] concentration < 110 g/L), a daily dose of 60 mg of elemental iron is preferred over a lower dose.

  • In the first and third trimesters, the Hb threshold for diagnosing anaemia is 110 g/L; in the second trimester, the threshold is 105 g/L (2).

  • If a woman is diagnosed with anaemia during pregnancy, her daily elemental iron should be increased to 120 mg until her Hb concentration rises to normal (Hb 110 g/L or higher) (3, 4). Thereafter, she can resume the standard daily antenatal iron dose to prevent recurrence of anaemia.

  • Effective communication with pregnant women about diet and healthy eating – including providing information about food sources of vitamins and minerals, and dietary diversity – is an integral part of preventing anaemia and providing quality antenatal care.

  • Effective communication strategies are vital for improving the acceptability of, and adherence to, supplementation schemes.

  • Stakeholders may need to consider ways of reminding pregnant women to take their supplements and of assisting them to manage associated side-effects.

  • In areas with endemic infections that may cause anaemia through blood loss, increased red cell destruction or decreased red cell production, such as malaria and hookworm, measures to prevent, diagnose and treat these infections should be implemented.

  • Oral supplements are available as capsules or tablets (including soluble tablets, and dissolvable and modified-release tablets) (5). Establishment of a quality assurance process is important to guarantee that supplements are manufactured, packaged and stored in a controlled and uncontaminated environment (6).

  • A better understanding of the etiology of anaemia (e.g. malaria endemnicity, haemoglobinopathies) and the prevalence of risk factors is needed at the country level, to inform context-specific adaptations of this recommendation.

  • Standardized definitions of side-effects are needed to facilitate monitoring and evaluation.

  • Development and improvement of integrated surveillance systems are needed to link the assessment of anaemia and iron status at the country level to national and global surveillance systems.

  • To reach the most vulnerable populations and ensure a timely and continuous supply of supplements, stakeholders may wish to consider task shifting the provision of iron supplementation in community settings with poor access to health-care professionals (see Recommendation E.6.1, in section E: Health systems interventions to improve the utilization and quality of antenatal care, found in the guideline, WHO recommendations on antenatal care for a positive pregnancy experience).

* This is an extract from the relevant guideline (7). Additional guidance information can be found in this document.


References

1. Guideline: Daily iron and folic acid supplementation in pregnant women. Geneva: World Health Organization; 2012 [archived](http://www.who.int/nutrition/publications/micronutrients/guidelines/daily_ifa_
supp_pregnant_women/en/)

2. The clinical use of blood in general medicine, obstetrics, paediatrics, surgery & anaesthesia, trauma & burns. Geneva, World Health Organization; 1998 (http://www.who.int/bloodsafety/clinical_use/en/Manual_EN.pdf).

3. WHO; de Benoist B, McLean E, Egli I, Cogswell M, editors. Worldwide prevalence of anaemia 1993–2005. WHO global database on anaemia. Geneva: World Health Organization (WHO); 2008 (http://apps.who.int/iris/ bitstream/10665/43894/1/9789241596657_eng.pdf).

4. Iron and folate supplementation: integrated management of pregnancy and childbirth (IMPAC). Standards for maternal and neonatal Geneva: Department of Making Pregnancy Safer, World Health Organization; 2006 (http://www.who.int/reproductivehealth/publications/maternal_perinatal_
health/iron_folate_supplementation.pdf).

5. The international pharmacopoeia, 5th edition, volumes 1 and 2. Geneva: World Health Organization; 2015 (http://apps.who.int/phint/en/p/about).

6. The WHO Expert Committee on Specifications for Pharmaceutical Preparations. Quality assurance of pharmaceuticals: meeting a major public health challenge. Geneva: World Health Organization; 2007 (WHO/PSM/QSM/2007.5; http://www.who.int/medicines/publications/brochure_pharma.pdf).

7. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization; 2016 (http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/).