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(OR10-03-26) Beyond Iron Deficiency: Quantifying the Contribution of Anemia Risk Factors Among a Cohort of Pregnant Women in Africa and South Asia

Sunday, July 26, 2026
10:54 AM - 11:06 AM ET
Location: Maryland Ballroom C
Disclosure(s):
Jaime Marquis, MSPH: Hyperfine: Stock Shareholder (excluding mutual funds) (Ongoing)
Veronica Agyemang, PhD Candidate: No relevant financial relationship(s) with ineligible companies to disclose.
Objectives: We estimated the contribution of nutritional, infection, hemoglobinopathies, and other risk factors to anemia burden among pregnant women in the Redefining Anemia in Pregnancy and Postpartum (ReMAPP) study conducted in Ghana, Kenya, Zambia, Pakistan, and India.

Methods: We enrolled 12,214 pregnant women between 2022 and 2025. Pregnant women < 20 weeks gestation by ultrasound and aged < 45 years were eligible. Hemoglobin was measured at < 20, 20, 28, and 36 weeks gestation, and biomarkers were assessed at < 20 weeks. A cross-sectional sample of 100 participants per trimester per site provided additional etiologic data. Relative risks were calculated using generalized linear mixed log-binomial models, adjusted for site and distal factors. Partial population attributable risks (PAR) were calculated using model estimates and risk factor prevalence.

Results: More than one in three women had moderate or severe anemia at some point in pregnancy. Though iron deficiency (ID) had a prevalence of 68% and accounted for the largest share of anemia burden, the PAR was 13% in Africa (95% CI: 9.4, 15.5) and 36% in South Asia (95% CI: 32.3, 40.0). Zinc deficiency emerged as an important contributor in African sites (PAR: 18%, 95% CI: 8.8,27.2%). Within African sites, use of polluted cooking fuel (66% prevalence) contributed to 9% of cases (95% CI: 3.6,15.1) and HIV infections (10% prevalence) accounted for ~7% of moderate or severe anemia cases (95% CI: 5.6,8.4). Within Asian sites, folate deficiency (26% prevalence) was the second leading contributor (PAR: 15%, 95% CI: 11.3,19.0). Across all sites, vitamin A deficiency, malaria, smoking, chewing tobacco, thalassemia trait, and sickle cell disease yielded marginal, yet statistically significant contributions (PARs < 3%).

Conclusions: Iron deficiency was the leading factor for moderate to severe anemia during pregnancy, however, its contribution fell short of the 50% contribution often cited. Interventions should move toward context-specific, etiology-informed approaches to reduce the burden of anemia in pregnancy.

Funding Sources: Gates Foundation