Anaemia in Pregnancy: Signs, Iron Deficiency and Diet

You sleep eight hours and wake up exhausted. Climbing one flight of stairs leaves you out of breath, and the people around you say you look pale. Everyone puts it down to pregnancy, and they are often right. But this tiredness can also be a sign of anaemia in pregnancy, which is almost always linked to a lack of iron.

It is one of the most common problems picked up during antenatal care. The World Health Organization estimates that 37% of pregnant women worldwide are anaemic. The good news is that it can be detected with a simple blood test, and it is easy to prevent and treat.

Why do you run short of iron during pregnancy?

Because your needs shoot up. Iron is used to make haemoglobin, the protein in red blood cells that carries oxygen. During pregnancy your blood volume increases, the placenta and the baby grow, and the baby builds up stores for its first months. Quebec's INSPQ sums it up: your iron needs have never been so high.

If your diet does not keep up, or if your stores were already low before pregnancy (heavy periods, pregnancies close together, a diet low in meat), anaemia sets in. The WHO also lists other causes: a lack of folate or vitamin B12, infections, and inherited red blood cell disorders such as thalassaemia.

The risk rises as the months go by. In a study carried out at the Mohammed V Military Hospital in Rabat and published in 2023, the proportion of anaemic women rose from 10% in the first trimester to 24% in the second, then 42% in the third. The study covered only 66 women, but it illustrates the trend well.

What are the signs of anaemia when you're pregnant?

They are subtle and look like the minor discomforts of pregnancy, which is why the blood test matters. The NHS and the WHO list:

• unusual tiredness that does not go away with rest;
• breathlessness at the slightest effort;
• palpitations, a racing heart;
• pale skin, lips or nails;
• headaches, dizziness when you stand up;
• cold hands and feet.

More surprisingly, the NHS mentions irresistible cravings for things that are not food. This is called pica. It is not a whim: mention it to your doctor.

How is anaemia in pregnancy detected?

With a blood test called a full blood count (FBC), which measures, among other things, your haemoglobin level. It is one of the tests prescribed during antenatal care, and your doctor may repeat it depending on your results and how far along you are. If iron deficiency is suspected, they may add a ferritin test, which reflects your stores.

The thresholds change with the trimester, because the blood naturally becomes more diluted during pregnancy. The Rabat study, which follows the criteria of the WHO and the US CDC, defines anaemia as below 11 g/dl in the first and third trimesters, and below 10.5 g/dl in the second. Only your doctor can interpret your results.

Which iron-rich foods should you eat when pregnant?

Iron comes in two forms. Iron from animal foods is better absorbed than iron from plants, the INSPQ points out.

In Morocco, wheat flour has been fortified with iron since 2005 as part of a national programme, according to a study published by the WHO regional office. So bread also contributes to your intake.

What about liver? Kebda (liver) is very rich in iron, but the INSPQ advises against it during pregnancy because of its excess vitamin A. Save it for later.

For a fuller picture of your nutritional needs in pregnancy, see our guide to what to eat when you're expecting.

Mint tea: keep it away from meals

This is the most useful tip for a Moroccan mum. Tea, coffee and, in large amounts, milk and dairy products reduce iron absorption, according to the NHS. The INSPQ advises avoiding tea and coffee with meals and in the hour before or after.

In practice, atay (Moroccan mint tea) served straight after the tagine or with msemen at breakfast reduces the benefit of the meal. There is no need to give it up: have it an hour later, make it lighter, or replace it at mealtimes with water or freshly squeezed orange juice.

Should you take iron during pregnancy?

Countries do not agree, and that is worth knowing. In Quebec, the INSPQ recommends a prenatal multivitamin containing iron and folic acid for all pregnant women. In France, the National Authority for Health (HAS) states that the guidelines do not justify routine iron supplements: they are offered to women at risk, for example after previous anaemia, recent bleeding, multiple or closely spaced pregnancies, in teenagers or when the diet is lacking.

In Morocco, the national programme to fight micronutrient deficiencies provides iron supplements for pregnant women, according to a Moroccan scientific paper from 2002: ask at your health centre or your doctor.

What everyone agrees on: if anaemia is confirmed, iron treatment is prescribed. The product, the dose and the length of treatment are decided by your doctor or midwife. Do not take any on your own initiative, and do not stack supplements.

A few practical tips:

• Side effects are common: black stools, constipation, nausea, heartburn. The NHS suggests taking the tablet with or just after a meal. If constipation sets in, our article on the common discomforts of pregnancy offers some ideas.
• Antacids reduce iron absorption: the NHS advises not taking them within 2 hours of your iron. If you need them, read our tips for heartburn during pregnancy.
• Children's safety: the NHS warns that an iron overdose can be fatal for a young child. Store tablets up high and out of sight, especially if there is an older child at home.

After the birth, iron is still important for you, and it soon becomes important for your baby too: our article on anaemia and iron deficiency in children takes over from here. And if you are expecting twins, your needs are even higher: see our feature on twin pregnancy.