Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas.
Parkland Health, Dallas, Texas.
JAMA Netw Open. 2023 Sep 5;6(9):e2332100. doi: 10.1001/jamanetworkopen.2023.32100.
Postpartum transfusion is the most common indicator of severe maternal morbidity in the US. Higher rates of anemia are associated with a higher blood transfusion rate.
To determine if providing, rather than recommending, supplements with iron at prenatal visits in a medically underserved community is associated with improved hematologic indices and reduced blood transfusion.
DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study, patients who delivered between May 13 and December 13, 2020, and thus were provided a prenatal supplement with iron throughout pregnancy were compared with those who delivered between January 1 and August 1, 2019, before supplements were dispensed. The study was conducted at Parkland Health, a safety net hospital in Dallas, Texas, with a 95% Medicaid-funded or self-pay population and included all patients who delivered at our institution during the study period with available hematologic data.
In the earlier cohort, all patients were recommended to obtain and take iron supplements. In the later cohort, prenatal supplements with iron were dispensed via clinic pharmacy to all patients during prenatal visits.
Maternal hematocrit levels (28-32 weeks, delivery admission, and discharge), rates of anemia (hematocrit <30%), and postpartum transfusion for acute blood loss anemia were compared using χ2 and analysis of variance methods with P < .05 considered significant. The analysis took place in July of 2022.
Overall, 13 910 patients (98%) met inclusion criteria (mean age [SD], 27.9 [6.5] and 27.6 [6.5] years, mean [SD] body mass index at first visit, 29.2 [6.6] and 29.3 [6.6]). Mosty of the patients in both cohorts were of Hispanic ethnicity (76%). Providing iron-containing prenatal supplements was associated with higher average hematocrit levels at all time points including a mean difference of 1.27% (95% CI, 1.13%-1.42%) on admission for delivery, when compared with those who were not directly dispensed iron. Among patients prior to providing supplements, 18% had anemia on admission compared with 11% with iron-containing supplements dispensed (risk ratio [RR], 0.61; 95% CI, 0.56-0.66). Postpartum transfusion for acute blood loss anemia was reduced by one-third in patients after program implementation from 10 per 1000 to 6.6 per 1000 (RR, 0.62; 95% CI, 0.43-0.91).
In this quality improvement study, providing supplements with iron to patients at prenatal visits was associated with improved hematocrit levels, rates of anemia, and reduced transfusions unrelated to obstetric catastrophes among a predominantly Medicaid population.
产后输血是美国最常见的严重产妇发病率指标。较高的贫血率与较高的输血率有关。
确定在医疗服务不足的社区，在产前检查中提供而不是推荐补充铁剂是否与改善血液学指标和减少输血有关。
设计、地点和参与者：在这项质量改进研究中，2020 年 5 月 13 日至 12 月 13 日期间分娩的患者与 2019 年 1 月 1 日至 8 月 1 日期间分娩的患者进行了比较，在此期间，所有患者在整个孕期均接受了含铁的产前补充剂。研究在德克萨斯州达拉斯的 Parkland Health 进行，这是一家由医疗保险基金资助的 95%或自费的医疗机构，包括研究期间在我们机构分娩且有可用血液学数据的所有患者。
在较早的队列中，所有患者都被建议获得并服用铁补充剂。在后来的队列中，所有患者在产前检查期间通过诊所药房获得含铁的产前补充剂。
使用 χ2 和方差分析方法比较了产妇血细胞比容水平（28-32 周、分娩入院和出院）、贫血发生率（血细胞比容<30%）和因急性失血性贫血而产后输血的情况，以 P<0.05 为差异有统计学意义。分析于 2022 年 7 月进行。
总体而言，有 13910 名患者（98%）符合纳入标准（平均年龄[标准差]为 27.9[6.5]和 27.6[6.5]岁，首次就诊时的平均[标准差]体重指数为 29.2[6.6]和 29.3[6.6]）。两个队列中的大多数患者都有西班牙裔血统（76%）。与未直接给予铁的患者相比，给予含铁的产前补充剂与所有时间点的平均血细胞比容水平更高相关，包括分娩入院时的平均差异为 1.27%（95%CI，1.13%-1.42%）。在提供补充剂之前，入院时贫血的患者比例为 18%，而给予含铁补充剂的患者比例为 11%（风险比[RR]，0.61；95%CI，0.56-0.66）。该方案实施后，产后因急性失血性贫血而输血的患者减少了三分之一，从每 1000 例 10 例降至每 1000 例 6.6 例（RR，0.62；95%CI，0.43-0.91）。
在这项质量改进研究中，在产前检查中向患者提供铁补充剂与改善血液学指标、贫血发生率以及降低与产科灾难无关的输血有关，这在以医疗补助为主的人群中是有意义的。
