From Essential obstetric and newborn care › Chapter 4: Pathologies during pregnancy and pregnancy-related disorders · Médecins Sans Frontières, Current online edition, 2026
MSF guidance on diagnosis and treatment of anaemia in pregnant women.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition, 2026
- Audience
- Midwives, obstetricians, general practitioners providing antenatal care
- Evidence
- Expert consensus with reference to WHO 2012 guideline
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF clinical guideline defines anaemia in pregnancy as haemoglobin below 11 g/dl in the first and third trimesters and below 10.5 g/dl in the second trimester. Anaemia increases the risk of intrauterine growth restriction, preterm birth, and vulnerability to haemorrhage, particularly postpartum.
Treatment centres on ferrous sulfate 200 mg (65 mg elemental iron) with folic acid 400 micrograms, 2 to 3 times daily until haemoglobin normalises. In endemic areas, anthelmintic treatment (for hookworm) and antimalarial treatment should be added. Severe anaemia requires transfusion at specific thresholds: haemoglobin ≤5 g/dl before 36 weeks or ≤6 g/dl at 36 weeks or later, with lower thresholds when signs of decompensation or co-morbidities are present.
Women with haemoglobin below 7 g/dl in the third trimester should deliver in a comprehensive emergency obstetric and newborn care (CEmONC) facility with transfusion readiness, given the risk of rapid decompensation during delivery.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Anaemia defined as Hb <11 g/dl in first and third trimesters, <10.5 g/dl in second trimester
- Treatment: ferrous sulfate 200 mg (65 mg elemental iron) + folic acid 400 micrograms PO, 1 tablet 2–3 times daily until Hb normalises
- Ascorbic acid 500 mg once daily improves iron absorption
- Transfusion indicated if Hb ≤5 g/dl before 36 weeks LMP (or ≤6 g/dl at ≥36 weeks), even without decompensation
- Transfusion also indicated for Hb >5 to <7 g/dl (<36 weeks) or >6 to <8 g/dl (≥36 weeks) with decompensation, sickle cell disease, severe malaria, serious infection, or heart disease
- In hookworm-endemic areas, add anthelmintic treatment from second trimester onwards
- In malaria-endemic areas, add intermittent preventive or curative antimalarial treatment based on test results
- Women with Hb <7 g/dl in third trimester should deliver in CEmONC facility with transfusion preparedness
Transfusion indications in severe anaemia during pregnancy
Table extracted from the guideline
| Gestational age | Haemoglobin threshold | Additional conditions |
|---|---|---|
| <36 weeks LMP | ≤5 g/dl | Even without decompensation |
| <36 weeks LMP | >5 and <7 g/dl | With decompensation, sickle cell disease, severe malaria, serious bacterial infection, or pre-existing heart disease |
| ≥36 weeks LMP | ≤6 g/dl | Even without decompensation |
| ≥36 weeks LMP | >6 and <8 g/dl | With decompensation, sickle cell disease, severe malaria, serious bacterial infection, or pre-existing heart disease |
Source: Médecins Sans Frontières, Iron deficiency anaemia — MSF Essential obstetric and newborn care. Reproduced in summary form.
From the guideline
Verbatim
“Given the risk of haemorrhage and rapid decompensation during delivery, be prepared for transfusion for any woman whose Hb is < 7 g/dl, even if anaemia is relatively well-tolerated.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute, I recognise that anaemia in pregnancy remains underdiagnosed in Georgia, particularly in rural Samegrelo, Racha and Kakheti regions where antenatal care access is limited. The MSF thresholds for transfusion—haemoglobin ≤5 g/dl before 36 weeks or ≤6 g/dl thereafter—provide clear, actionable criteria that Georgian obstetricians should adopt in national protocols, alongside the recommendation to deliver all women with haemoglobin below 7 g/dl in CEmONC facilities. The practical caveat for Georgia is that HemoCue devices and reliable blood transfusion services are not uniformly available in district maternity hospitals, requiring investment in point-of-care diagnostics and strengthening referral pathways from rural health posts to regional perinatal centres. Our national maternal mortality reduction strategy, supported by the Universal Health Care programme since 2013, must prioritise iron-folic acid supplementation coverage and ensure that severe anaemia cases are identified early and managed in appropriately equipped facilities.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
Iron deficiency anaemia in pregnancy remains a significant public health concern in Georgia and the South Caucasus, particularly in rural areas with dietary insufficiency and inadequate antenatal care coverage. National antenatal programmes should ensure availability of co-formulated iron-folic acid tablets and HemoCue testing at primary care level. In mountainous regions of Georgia, Armenia and Azerbaijan, hookworm prevalence may be lower than in tropical MSF settings, but malaria risk persists in some lowland areas. Georgian maternity facilities should review their transfusion protocols and CEmONC capacity to manage severe anaemia, ensuring rural women with haemoglobin below 7 g/dl can access comprehensive facilities for delivery.
Questions this guideline answers
Quick answers
Can ferrous fumarate be used instead of ferrous sulfate?
Yes, 185 mg ferrous fumarate (60 mg elemental iron) + 400 micrograms folic acid may replace the standard 200 mg ferrous sulfate (65 mg elemental iron) + 400 micrograms folic acid formulation.
When should anthelmintic treatment be added?
In areas where hookworm is endemic, add anthelmintic treatment from the second trimester onwards to address parasitic causes of anaemia.
What are the signs of serious anaemia requiring urgent attention?
Intense pallor, impaired consciousness, dyspnoea, and haemoglobin level below 7 g/dl indicate serious illness requiring urgent assessment and possible transfusion.
How long should iron-folic acid treatment continue?
Give 2–3 tablets daily until haemoglobin level rises to normal, then change to preventive treatment (one tablet daily as per standard antenatal supplementation).
Related on GMJ
Interconnected resources
Dictionary of Public Health
Conditions A–Z
GMJ News coverage
- Micronutrients Are the Hidden Engine of Cellular Energy: What You Need to KnowOct 2026
- Second pregnancy rewires the brain differently than the first, study revealsOct 2026
- World-First Prenatal Surgery Saves Identical Twins from Life-Threatening Pregnancy ConditionOct 2026
- Why Women Choose Freebirth: What Research Reveals About Unattended ChildbirthJul 2026
Quality & accreditation
Same guideline
- Diagnosis of bleeding during the second half of pregnancy (summary) — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
- Uterine rupture — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
- Abruptio placentae — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
- Placenta praevia — Essential obstetric and newborn care — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
- Molar pregnancy (hydatidiform mole) — MSF Essential obstetric and newborn careChapter 2: Bleeding during the first half of pregnancy
- Ectopic pregnancy — MSF Essential obstetric and newborn careChapter 2: Bleeding during the first half of pregnancy
Other guidelines on this topic
- Diagnosis of bleeding during the second half of pregnancy (summary) — MSF Essential obstetric and newborn care
- Uterine rupture — MSF Essential obstetric and newborn care
- Abruptio placentae — MSF Essential obstetric and newborn care
- Placenta praevia — Essential obstetric and newborn care — MSF Essential obstetric and newborn care
- Treatment of rifampicin-susceptible and isoniazid-resistant tuberculosis — Introduction — MSF Tuberculosis
- Issuer
- Médecins Sans Frontières
- Guideline
- Essential obstetric and newborn care
- Chapter
- Chapter 4: Pathologies during pregnancy and pregnancy-related disorders
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition, 2026
- Status
- Current
- Published
- 2026-10-14
- Scope
- Diagnosis and treatment of iron deficiency anaemia in pregnant women
- Audience
- Midwives, obstetricians, general practitioners providing antenatal care
- Evidence
- Expert consensus with reference to WHO 2012 guideline
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Iron deficiency anaemia. In: Essential obstetric and newborn care. MSF; 2026. Section 4.1.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
Was this article helpful?
