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Replacing Iron and Preventing anemia in Pregnant patients of Limited Economic means (RIPPLE): Assessing the Impact of Funding Iron Supplementation in Pregnancy.

Suman Memon,Jeannie L Callum,C. Armali,E. Herer,Amie Malkin,Anne McLeod,H. Meirovich,M. Sholzberg,Yulia Lin,Heather VanderMeulen

Published 2025 in Journal of Obstetrics and Gynaecology Canada

ABSTRACT

OBJECTIVES Can funding iron supplementation for low-income pregnant patients reduce socioeconomic disparities in anemia rates at delivery? METHODS This single-center cohort study reviewed hematologic parameters and iron supplementation patterns in three groups: patients from low-income neighbourhoods, non-low-income neighbourhoods, and low-income patients enrolled in the RIPPLE program. RIPPLE provided access to intravenous iron to patients with an annual household income ≤$50 000 CAD and moderate-to-severe iron deficiency anemia, symptomatic iron deficiency with intolerance/inadequate response to oral iron, or iron deficiency anemia with less than 4 weeks to delivery. Patients were referred by their obstetrical provider, hematologist or pharmacist. The primary outcome was anemia (hemoglobin <110 g/L) at delivery. RESULTS Among 1206 patients (577 low-income, 603 non-low-income, 26 RIPPLE), anemia at delivery was more frequent in RIPPLE (54%) versus low-income (10%) and non-low-income (7%) groups (P < 0.0001). RIPPLE participants exhibited lower nadir hemoglobin (98.8 ± 9.9 g/L) and ferritin (9.6 ± 6.4 μg/L) compared to low-income (hemoglobin 114.2 ± 10.1 g/L; P < 0.0001; ferritin 30.0 ± 24.0 μg/L; P < 0.0001) and non-low-income groups (hemoglobin 115.9 ± 8.1 g/L, P < 0.0001; ferritin 40.9 ± 44.1 μg/L; P < 0.0001), and received infusions later in pregnancy (≤3 weeks pre-delivery: 42% vs. 27% vs. 9%). The RIPPLE cohort included more racial and ethnic minoritized individuals (73% vs. 58% vs. 33%). CONCLUSION While funding for iron supplementation addressed cost barriers, disparities in care persisted. Our findings underscore the need for universal access to early screening and timely escalation of oral to intravenous iron to reduce social, racial and ethnic disparities in care.

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