Ebony Verbunt

Anaemia affects over one-third of pregnant women in Bangladesh, leading to serious consequences including maternal death and stillbirth. Yet, only about half of pregnant women are tested for anaemia, and few receive intravenous iron – an effective treatment option. It remains unclear whether health facilities have the resources, and whether health workers are willing and able, to deliver these services. Embedded within a demonstration project, our study aimed to evaluate the organisational readiness of Bangladesh’s primary health care system to provide point-of-care anaemia testing and intravenous iron treatment for pregnant women. We employed a multi-phase, mixed-methods, parallel convergent design. Formative research included a baseline health facility readiness assessment (n=20). In the parallel process evaluation, health workers completed the Organisational Readiness for Implementing Change questionnaire (n=35), and a sample participated in qualitative interviews (n=21). Quantitative data were analysed descriptively, while qualitative data were analysed using inductive thematic analysis and mapped to the Capability, Opportunity, and Motivation model of Behaviour Change. Findings were integrated across data sources for a comprehensive evaluation. We found high psychological readiness for implementing anaemia testing and intravenous iron treatment, with health workers demonstrating strong commitment and confidence in providing these services to pregnant women. However, structural readiness was incomplete, with sustaining both interventions beyond the demonstration project requiring addressing resource constraints, including shortages of equipment, guidelines, nurses, and doctors. Government support for implementation and resource provision will be essential to ensure the continued delivery of anaemia testing and intravenous iron treatment in Bangladesh’s primary health care system.

Background: Anaemia in pregnancy significantly increases the risk of maternal and neonatal complications. Oral iron supplementation, the standard treatment, is often poorly tolerated and associated with low adherence. Intravenous iron presents a rapid alternative, and we examined the factors influencing access to and utilisation of intravenous iron in treating anaemia in pregnancy within Malawi’s primary healthcare system. Methods: We conducted a qualitative study embedded with a clinical trial. We collected data through in-depth interviews (n=16) and focus group discussions (n=3) with pregnant women enrolled in the trial, those who withdrew and their husbands and caregivers. Interviews were audio-recorded, transcribed and analysed using a reflexive thematic approach in NVivo 12. Themes were mapped onto the supply and demand domains of the Patient-Centred Access to Healthcare framework. Results: Barriers to access and utilisation operated across both supply-side and demand-side domains. On the supply side, limited service awareness, logistical constraints and unclear provider communication reduced engagement with intravenous iron. On the demand side, pregnant women’s knowledge about anaemia, cultural norms, personal beliefs and social support shaped decision-making and ability to access care. Facilitators across both domains included patient-centred service delivery, clear and responsive provider communication and family or peer involvement in decision-making, which enhanced trust, understanding and uptake. Conclusion: In conclusion, our study demonstrates that patient-centred approaches are critical for improving health literacy, and strong health systems are essential for the effective delivery of intravenous iron intervention. Addressing supply and demand barriers is vital for optimising uptake of intravenous iron interventions, improving health system performance and ensuring equitable access to antenatal care interventions, ultimately improving the health outcomes for mother and child.

Anaemia during pregnancy is a serious public health problem, inequitably burdening women in low-and middle-income countries. Despite numerous strategies and programs, anaemia prevalence rates have stagnated. We aimed to explore women’s, health workers’, and other key stakeholders’ perceptions of anaemia in pregnant women, or their experiences with its prevention, testing, or treatment. We conducted a qualitative evidence synthesis. We searched MEDLINE (Ovid), Scopus, and CINAHL from inception to 12 November 2024, with no language or geographical restrictions. Data were analysed using thematic synthesis, and confidence in each review finding was assessed using the GRADE-CERQual approach. We included 61 papers from 23 countries. We grouped 25 review findings under four themes: (a) socio-cultural context of anaemia in pregnant women; (b) prevention and/or treatment of anaemia in pregnant women through diet, supplementation, or clinical intervention; (c) testing pregnant women for anaemia; and (d) factors affecting health workers’ engagement in the management of anaemia in pregnant women. Women’s management of anaemia in pregnancy was affected by the socio-cultural context, particularly their limited decision-making power and social position. Many women perceived a nutritious diet as integral to managing anaemia; however, high cost was often a barrier. Reasons women did not adhere to supplements included side-effects and difficulty remembering to take them, with family support improving adherence. Blood transfusion was perceived as treatment for severe anaemia, while intravenous iron was considered for women with iron-deficiency anaemia who were unable to take supplements, attended antenatal care late, or could not receive a transfusion. Health workers described difficulties testing pregnant women for anaemia and structural health-system deficiencies that affected their engagement. Findings may inform future WHO recommendations for managing anaemia in pregnant women. Future research could use review findings alongside implementation science frameworks to develop strategies for improving prevention, testing, and/or treatment of anaemia in pregnant women.

Introduction: Anaemia during pregnancy is a significant public health problem, disproportionately affecting women in low-and middle-income countries. In Bangladesh, anaemia affects 38.6% of pregnant women. Although much is known about the prevention of anaemia in pregnancy, it is unknown how women are tested and treated. This study therefore aimed to describe how pregnant women in Bangladesh are tested for anaemia, including variations by social and equity dimensions. We also aimed to explore how women are treated for anaemia and use of intravenous iron in pregnancy. Methods: An interviewer-administered cross-sectional survey was conducted in Narayanganj district, Bangladesh, with analysis limited to women who had previously been pregnant (n=1000). Outcomes of interest were anaemia testing, anaemia treatment, and intravenous iron use. We undertook descriptive analyses and derived estimates and 95% confidence intervals of the percentage of pregnant women tested for anaemia stratified by education, wealth, and person making decisions around women’s healthcare. Results: Approximately half of women were tested for anaemia in their previous pregnancy (505/963, 52.4%), with lower testing in women with no education (15.8%, 95% CI: 6.0 to 31.3), whose husband had no education (25.6%, 95% CI: 18.2 to 34.2), or in the poorest wealth quintile (34.0%, 95% CI: 27.4 to 41.2). Pregnant women were most commonly tested for anaemia at a private health facility (393/505, 77.8%), by a medical technologist (350/505, 69.3%), using venous full blood count (484/505, 95.8%). Most women diagnosed with anaemia in their previous pregnancy received treatment (135/142, 95.1%). In any prior pregnancies, a small number of women received intravenous iron (33/985, 3.4%). Conclusion: Our study reveals the need for substantial investments to ensure all women in Bangladesh are tested for anaemia in pregnancy. This could be achieved through increasing point-of-care testing in antenatal care. However, health facilities and health workers may need to be prepared for an increase in women diagnosed with anaemia.

Antenatal anaemia affects 48% of pregnant women in South Asia. In Bangladesh, the standard of care is oral iron and folic acid supplementation, but access and adherence are poor. Intravenous iron is an alternative treatment that deliver high dose of iron in a single short infusion and is commonly used in high-income countries. A demonstration project will be conducted to test the real-world feasibility and acceptability of implementing an intravenous iron intervention to treat pregnant women with moderate and severe anaemia in the primary healthcare setting of Bangladesh. This protocol paper outlines the development, implementation, and evaluation of an intravenous iron intervention. The demonstration project consists of three phases, supported by implementation science frameworks: (1) a formative phase involving a review, qualitative research, and readiness assessment; (2) the development and implementation of care pathways and strategies using a participatory research approach; and (3) a process evaluation of care pathways and strategies involving qualitative and quantitative assessment of the costs, processes and contextual factors affecting its implementation. Intravenous iron presents a novel opportunity to reduce antenatal anaemia in low-and-middle income countries. The demonstration project will ascertain whether an intravenous iron intervention can be effectively introduced into routine antenatal care and the extent to which it is considered an acceptable treatment by pregnant women, healthcare providers, and policymakers. If successful, insights into the care pathways and costs will provide guidance for integrating intravenous iron in the primary healthcare system of Bangladesh and other low-and-middle income countries.

Anaemia in pregnancy increases risks for both maternal and neonatal complications, including death, preterm birth, and low birth weight. Iron tablets are the recommended standard treatment but are often poorly tolerated and adhered to. Intravenous (IV) iron offers an effective and practical alternative with faster replenishment of iron stores and fewer side effects. A randomised controlled trial in Malawi evaluated the safety and efficacy of IV iron compared to standard oral iron supplementation for pregnant women with moderate to severe anaemia in the third trimester (REVAMP-TT). Our qualitative study, embedded within the trial, aimed to explore the factors affecting access to and utilisation of IV iron to treat anaemia in pregnancy within the primary healthcare system of Malawi. Methodology We conducted in-depth interviews (n=16) and focus group discussions (n=3) with pregnant women who participated in the REVAMP-TT trial, those who withdrew, and their husbands and caregivers. All interviews and discussions were audio-recorded, transcribed, and coded in NVivo 12. We iteratively used reflexive thematic analysis to develop the themes mapped across the supply and demand domains of the Patient-Centered Access to Healthcare framework. Results We identified five key themes under supply-side barriers, including i) lack of transparency in REVAMP-TT trial procedures and processes, ii) lack of continued community sensitisation about IV iron, iii) long distances from home to the health facilities, iv) long waiting times for procedures and IV iron administration, and v) pregnant women non-compliance with appointments. Four demand-side obstacles were highlighted, including i) myths and misconceptions about IV iron, ii) prevailing cultural norms like concealing pregnancy, iii) lack of social and financial support from husbands, and iv) physical discomfort when receiving IV iron. Five facilitators emerged from the supply side, including the i) availability of clear information about anaemia and antenatal care outreach services, ii) pregnant women were not pressured to participate in the REVAMP-TT trial, iii) flexible health facility opening hours and appointment mechanism, iv) perceived effectiveness and benefits of IV iron and v) healthcare providers’ interpersonal quality and skills. Four demand-side enablers included i) health literacy about anaemia, ii) social value and a sense of autonomy, iii) peer support, iv) available social and financial support from family or husband, and iv) caregiver support. Conclusion In conclusion, our study underscores the potential of IV iron therapy to address anaemia in pregnancy in LMICs like Malawi. Patient-centred approaches, improved health literacy, and strengthening health systems are vital for optimising intervention uptake and ensuring equitable access to antenatal care interventions, ultimately improving the health outcomes for mother and child. Contributions to literature Our study demonstrates the practical aspects and challenges of implementing an IV iron intervention in a low-resource setting, including how the Malawian healthcare system could be strengthened to effectively deliver IV iron in local healthcare facilities. It provides a blueprint for implementation in similar contexts to integrate this treatment into existing healthcare delivery structures. Our study offers insights into how cultural norms and beliefs shape health-seeking behaviour and practices, contributing to our understanding of how to tailor health interventions to cultural contexts. Additionally, it highlights facilitators, such as local health facilities, that can improve the uptake of IV iron therapy in rural and underserved areas, showcasing how these approaches can be scaled up to enhance maternal health.

Aim: To provide a systematic synthesis of primary care practice-based interventions and their effect on participation in population-based cancer screening programs.Background: Globally, population-based cancer screening programs (bowel, breast, and cervical) have sub-optimal participation rates. Primary healthcare workers (PHCWs) have an important role in facilitating a patient’s decision to screen; however, barriers exist to their engagement. It remains unclear how to best optimize the role of PHCWs to increase screening participation.Methods: A comprehensive search was conducted from January 2010 until November 2023 in the following databases: Medline (OVID), EMBASE, and CINAHL. Data extraction, quality assessment, and synthesis were conducted. Studies were separated by whether they assessed the effect of a single-component or multi-component intervention and study type.Findings: Forty-nine studies were identified, of which 36 originated from the USA. Fifteen studies were investigations of single-component interventions, and 34 studies were of multi-component interventions. Interventions with a positive effect on screening participation were predominantly multi-component, and most included combinations of audit and feedback, provider reminders, practice-facilitated assessment and improvement, and patient education across all screening programs. Regarding bowel screening, provision of screening kits at point-of-care was an effective strategy to increase participation. Taking a ‘whole-of-practice approach’ and identifying a ‘practice champion’ were found to be contextual factors of effective interventions.The findings suggest that complex interventions comprised of practitioner-focused and patient-focused components are required to increase cancer screening participation in primary care settings. This study provides novel understanding as to what components and contextual factors should be included in primary care practice-based interventions.

Introduction: Anaemia during pregnancy is a significant global health problem, disproportionately affecting women in low‐ and middle‐income countries (LMICs). Oral iron is the standard of care; however, challenges exist regarding adherence and coverage. Increasingly, evidence demonstrates the superiority of intravenous (IV) iron over oral iron. Although clinical experience on IV iron for antenatal anaemia is growing, there remains little understanding regarding implementation. Our mixed‐method systematic review aims to identify barriers and facilitators to implementing an IV iron intervention for pregnant women with anaemia and implementation strategies.Methods: Five bibliographic databases and grey literature were searched for studies. Barriers and facilitators were identified and mapped to the Consolidated Framework for Implementation Research (CFIR) and then matched to Expert Recommendations for Implementing Change (ERIC) strategies using the CFIR‐ERIC matching tool.Results: The search identified six studies. Most studies captured the perspective of healthcare providers, with some studies capturing the perspective of pregnant women. Barriers and facilitators were mapped to the following CFIR constructs: (1) intervention characteristics—cost, complexity, evidence strength and quality, and relative advantage; (2) outer setting—patient needs and resources; (3) inner setting—culture, available resources and access to knowledge and information; (4) characteristics of individuals—knowledge and beliefs about the intervention; (5) process—champions. Matching ERIC strategies included identifying and preparing champions, conducting educational meetings and assessing for readiness and identifying barriers and facilitators.Conclusion: Once tailored to each context, our findings can be used to improve the adoption, implementation, and sustainability of an IV iron programme for pregnant women with anaemia.

Background: Antenatal iron supplementation is critical to maternal and child health; however, access and adherence to oral iron are inconsistent in many low- and middle-income countries (LMICs). Modern intravenous (IV) iron products have become available in high-income clinical settings and provide an opportunity to deliver high doses of iron in a single-short infusion during pregnancy. However, there is limited knowledge of the drivers and barriers for such an intervention to be effectively delivered and upscaled in LMICs. In this study protocol, we describe the implementation research programme to support an IV iron intervention in Malawi for pregnant women with moderate and severe anaemia. Methods: The implementation research programme has three phases, each guided by implementation science conceptual frameworks. In Phase 1, we will conduct formative research (context assessment of the health system with key informant interviews) to determine how IV iron can be effectively introduced into routine antenatal care. We will use the findings to co-develop potential strategies with end-users and healthcare providers to improve intervention implementation. In Phase 2, we will disseminate the implementation strategies to support the uptake and delivery of the intervention in the study settings. In Phase 3, the intervention will be implemented, and we will conduct formative evaluation (interviews with end-users, healthcare providers, and analysis of health services data) to investigate the feasibility and acceptability of the intervention and strategies. We will also identify processes and contextual factors that facilitate or impede the delivery and uptake of IV iron. Discussion: In LMICs, modern IV iron products present a novel opportunity to rapidly cure moderate and severe anaemia in pregnancy, thereby improving maternal and child health outcomes. This implementation research programme will provide guidance and recommendations on how best an IV iron intervention for pregnant women with anaemia can be implemented in an LMIC setting like Malawi. We will develop locally relevant and culturally appropriate implementation strategies by engaging with key stakeholders (pregnant women, healthcare providers, and policymakers) and identifying factors likely to facilitate successful implementation. The findings of this research can guide the implementation of an IV iron intervention in Malawi and other LMICs.