Community and International Nutrition

Preconception Hemoglobin and Ferritin Concentrations Are Associated with

Pregnancy Outcome in a Prospective Cohort of Chinese Women
1
Alayne G. Ronnenberg,
2
Richard J. Wood,* Xiaobin Wang,

Houxun Xing,**
Chanzhong Chen, Dafang Chen,**

Wenwei Guang,** Aiqun Huang,**

Lihua Wang,

and Xiping Xu
Department of Environmental Health, Harvard School of Public Health, Boston; *Mineral Bioavailability
Laboratory, Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging at Tufts
University, Boston, MA;

Department of Pediatrics, Boston University School of Medicine and Boston
Medical Center, Boston, MA; **Institute for Biomedicine, Anhui Medical University, Anhui, China;
and

Center for Ecogenetics and Reproductive Health, Beijing Medical University, Beijing, China
ABSTRACT Prenatal anemia and iron deciency are associated with adverse birth outcomes, but no previous
studies have examined the relation between preconception anemia, iron deciency, and pregnancy outcome in
healthy women. We measured hemoglobin (Hb), ferritin, transferrin receptor (TfR), and vitamins B-6, B-12, and
folate concentrations before pregnancy in 405 Chinese women (median time from sample collection to gestation
end 316 d). Both mild (95 Hb 120 g/L) and moderate (Hb 95 g/L) anemia were signicantly associated
with lower birthweight (139 and 192 g, respectively); iron-deciency anemia alone (Hb 120 g, ferritin 12 g/L,
no B-vitamin deciency) was associated with a 242-g decrease in birthweight. Both low (12 g/L) and high (60
g/L) ferritin were also signicantly associated with lower birthweight (106 and 123 g, respectively). The risks of low
birthweight (LBW) and fetal growth restriction (FGR) were signicantly greater among women with moderate
anemia compared with nonanemic controls [odds ratio (OR): 6.5; 95% CI: 1.6, 26.7; P 0.009 and OR: 4.6; 95%
CI: 1.5, 13.5; P 0.006, respectively]. TfR and low ferritin were not associated with adverse birth outcome, but
elevated ferritin, which could be a marker of inammation, was associated with increased risk of LBW (OR: 2.2;
95% CI: 0.9, 5.7; P 0.09) and FGR (OR: 2.7; 95% CI: 1.3, 5.6; P 0.008). Preconception anemia, particularly
iron-deciency anemia, was associated with reduced infant growth and increased risk of adverse pregnancy
outcome in Chinese women. J. Nutr. 134: 25862591, 2004.
KEY WORDS: anemia China ferritin pregnancy transferrin receptor
Anemia may occur in as many as half of pregnant women
worldwide (1). Although iron deciency is a common cause of
anemia, especially in women of reproductive age, anemia may
also result from other causes, including deciencies of folate,
vitamin B-12, and vitamin B-6. Numerous observational stud-
ies showed an association between anemia during pregnancy
and adverse birth outcomes (24). Despite these well-known
relations with anemia, less is known about the independent
contributions of iron deciency per se and anemia not associ-
ated with iron deciency on pregnancy outcome. With few
exceptions (58), studies in which supplemental iron was
provided to pregnant women generally showed little improve-
ment in birth outcomes, and routine iron supplementation
during pregnancy remains controversial (9,10). The frequent
failure of iron supplementation to improve pregnancy outcome
may be related to the observation that in some populations,
only a fraction of maternal anemia is related to iron deciency
alone (7,11). Unraveling the possible independent pregnancy
risks associated with anemia and iron deciency may improve
the effectiveness of nutrition interventions (9,10).
It was suggested that anemia and iron depletion that occur
very early in gestation could inuence birth outcomes differ-
ently than if they occurred later in pregnancy (10). One
advantage of assessing hematological indices before concep-
tion is that they are likely to reect status in the periconcep-
tional period. However, to our knowledge, no previous studies
examined the relation between preconception hemoglobin
(Hb),
3
ferritin, and B-vitamin status and pregnancy outcome
in apparently healthy women. Most studies that examined
these relations generally assessed biomarker concentrations at
various times throughout pregnancy. Interpretation of the
relation between these measures and birth outcome can be
challenging (7) because plasma volume expands during preg-
1
Supported in part by grants 1R01 HD32505 and 1R01 HD41702 from the
National Institute of Child Health and Human Development; and 1R01 ES08337
and P01 ES06198 from the National Institute of Environmental Health Science.
2
To whom correspondence should be addressed.
E-mail: ronnenberg@comcast.net.
3
Abbreviations used: Hb, hemoglobin; FGR, fetal growth restriction; LBW,
low birthweight; OR, odds ratio; RF ratio, ratio of transferrin receptor to ferritin;
TfR, transferrin receptor.
0022-3166/04 $8.00 2004 American Society for Nutritional Sciences.
Manuscript received 16 June 2004. Initial review completed 2 July 2004. Revision accepted 2 August 2004.
2586

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nancy, diluting Hb, ferritin, and vitamin concentrations even
in well-nourished, nutrient-replete women. In addition, the
use of low serum ferritin alone to assess iron deciency can
result in an underestimation of the true prevalence of depleted
iron stores because this protein is also an acute-phase reactant
that is elevated irrespective of body iron stores by infection or
inammation, which are common conditions in many popu-
lations. Better estimates of iron depletion under these condi-
tions may be made by measuring soluble plasma transferrin
receptor (TfR) concentration, which is unaffected by inam-
mation (12). Plasma TfR is elevated in iron deciency and was
shown to be an early and sensitive measure of tissue iron
deciency (13). Recently, the ratio of TfR (g/L) to ferritin
(g/L) was also used to identify more clearly persons with
functional iron deciency (14).
We previously reported a high prevalence of B-vitamin
deciencies, anemia, and depleted iron stores in a cohort of
young Chinese textile workers who were planning to become
pregnant (15). Of these women, 44% had some evidence of at
least 1 B-vitamin deciency, whereas only 17% of women with
anemia had evidence of depleted iron stores. We subsequently
reported that B-vitamin deciencies in this group were asso-
ciated with clinical spontaneous abortion (16) and other ad-
verse birth outcomes (17).
The purpose of the current prospective study was to exam-
ine the association between Hb, ferritin, and TfR concentra-
tions assessed one time before conception in young Chinese
women and infant growth and gestational age at birth in their
infants.
SUBJECTS AND METHODS
Subjects. The current study is part of a prospective study of the
effects of shift work on reproductive health among women textile
workers in Anhui, China. The study protocols were approved by the
Human Subject Committee of the Chinese Institutions involved in
the study and by the Institutional Review Board of the Harvard
School of Public Health. The eligibility criteria for enrollment were
as follows: 1) full-time, newly married female employees; 2) aged
2034 y; and 3) had obtained permission to have a child. Women
were excluded if they: 1) were already pregnant before enrollment; 2)
had tried unsuccessfully to become pregnant for at least 1 y at any
time in the past; or 3) planned to change jobs or move out of the city
over the 1-y course of follow-up. Of the 575 women originally
enrolled in the study, 405 women who gave birth to live infants and
for whom Hb data were available were included in the current
analysis. The 170 women who were excluded did not differ signi-
cantly from the study cohort in terms of sociodemographic charac-
teristics or available baseline biomarker concentrations (P 0.05).
A detailed description of data collection can be found elsewhere
(18). In brief, after obtaining informed consent, an interviewer ad-
ministered a baseline questionnaire that collected sociodemographic
information and health history. Women were followed-up during any
ensuing pregnancy or up to 1 y after beginning to attempt pregnancy,
and all pregnancy outcomes were recorded.
Measurements. At enrollment, single measurements of height
and weight in light clothing were made to the nearest 0.1 cm and 0.1
kg, respectively, by trained study personnel, and blood samples were
collected from nonfasting subjects via venipuncture into 10-mL
EDTA-treated tubes by a trained research phlebotomist. A small
aliquot of whole blood was used to obtain a single measurement of Hb
concentration using an automated colorimetric procedure. The re-
maining blood was centrifuged, and plasma was obtained and stored
at 20C in China until shipped on dry ice to the Harvard School of
Public Health, where it was stored at 70C before nutritional
analyses. Frozen samples were then transported to the Jean Mayer
USDA Human Nutrition Research Center on Aging, Tufts Univer-
sity, Boston, MA, where plasma concentrations of folate and vitamins
B-6 and B-12 were measured as previously described (15). Plasma
ferritin and TfR concentrations in a subset of 359 women for whom
adequate plasma samples were available were also measured at Tufts
University as previously described (15).
The ratio of TfR to ferritin (RF ratio) was calculated by dividing
TfR (in g/L) by ferritin (in g/L). Elevated plasma TfR was dened
as a concentration 8.3 mg/L (19). An elevated RF ratio was dened
as 500 (20). Vitamin deciencies [folate 6.8 nmol/L (3 g/L);
vitamin B-12 258 pmol/L (300 pg/mL); and vitamin B-6 30
nmol/L of pyridoxal-5-phosphate] were dened as in an earlier study
(17). Because ferritin and the RF ratio have skewed distributions,
these variable were converted to logarithms before means and SD
were determined.
Major outcomes. Infant birthweight (g) was measured immedi-
ately after delivery. Infant length (cm) was dened as crown-heel
length and was measured shortly after delivery. Birthweight ratio was
dened as an infants observed birthweight divided by the mean
birthweight of infants of the same gestational age within the cohort
(21,22). Birthweight ratio was multiplied by 100 for convenience.
Gestational age (d) was the number of days between d 1 of the last
menstrual period and the day of delivery. Preterm delivery was de-
ned as the spontaneous delivery of a live infant before 37 completed
wk (259 d) of gestation. Low birthweight (LBW) was dened as the
birth of a live infant weighing 2500 g. Fetal growth restriction
(FGR) was dened as a birthweight ratio 85% (21,22).
Statistical analysis
We created Hb and ferritin categories as follows: Hb 120 g/L
was considered normal based on WHO guidelines (23) and was used
as the referent; the middle category included those with Hb 120
g/L but 95 g/L, which we classied as mild anemia, and the lowest
Hb category (moderate anemia), which was also the 10th percentile,
was determined in part on the basis of the results of the LOESS
procedure (see below) and included women with Hb 95 g/L.
Plasma ferritin 12 g/L was considered indicative of depleted iron
stores (1), ferritin 12 g/L and 60 g/L was considered nor-
mal, and ferritin 60 g/L was considered elevated. This upper
cutoff value corresponded to the 80th percentile and was similar to
that used by Tamura et al. (24).
To determine the potential differential effects of iron deciency
anemia and anemia not related to iron deciency, we created 5
groups: group 1 included 131 anemic (Hb 120 g/L) women with
ferritin 12 g/L and no evidence of B-vitamin deciency; group 2
included 109 anemic women with at least 1 B-vitamin deciency but
ferritin 12 g/L; group 3 included 28 women with ferritin 12
g/L but no evidence of B-vitamin deciency; group 4 included 29
women with both ferritin 12 g/L and evidence of at least 1
B-vitamin deciency; and group 5, which served as the reference
group, included 62 women who were not anemic.
The equality of proportions across categories was assessed using
2
analyses. The determinants of Hb concentration (as binary variables)
were identied using multiple linear regression. Adjusted (least-
squares) means (and their 95% CI), calculated across various Hb,
ferritin, and anemia categories, were assessed using the general linear
models procedure (proc GLM) of SAS. Means were adjusted for the
following covariates: maternal age, height, height-squared, BMI, ed-
ucation, infant gender, gestational age (linear and quadratic terms),
and maternal exposure to dust, noise, passive smoking and work
stress.
We applied local regression to model Hb and ferritin concentra-
tion adjusted for birthweight, head circumference, and gestational age
using the SAS LOESS procedure and plotted the predicted values
from the LOESS model against observed maternal Hb. Results of the
LOESS procedure for Hb and birthweight were graphically depicted
using Sigma Plot graphical software (SPSS).
The risks of adverse pregnancy outcomes were assessed by TfR and
RF ratio status (as binary variables) and across maternal Hb and
ferritin categories using logistic regression and were expressed as odds
ratios (OR) with their 95% CI. Logistic regression models were
adjusted for the same covariates listed above. Statistical signicance
refers to P 0.05. Statistical analyses were performed using SAS for
Windows, release 8.2.
ANEMIA AND BIRTH OUTCOME IN CHINESE WOMEN 2587

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RESULTS
A total of 405 women were included in the study (Table 1).
Women tended to be young, lean, and anemic; mean Hb was
108.5 g/L, and nearly 80% had Hb 120 g/L. The geometric
mean ferritin concentration was 29.9 g/L; nearly 18% of
women had ferritin concentrations indicative of depleted iron
stores (12 g/L). Elevated TfR and an RF ratio 500 were
detected in 9.8 and 14.8% of women, respectively; 91% of
women with an elevated RF ratio also had depleted iron stores.
The median time from blood sampling to delivery was 316 d;
75% of women gave birth within 382 d of blood sampling.
Thus, given a typical 280-d gestational period, most blood
samples were obtained within 1 to 4 mo of conception. A total
of 33 infants (8.2%) were classied as LBW, 27 (6.7%) as
preterm, and 56 (13.8%) as FGR. Although many infants met
criteria for multiple birth outcomes, distinct categories were
still apparent, i.e., 31 infants were classied as both LBW and
FGR, but only 9 of those were also born preterm.
Both low ferritin and elevated TfR were signicantly asso-
ciated with Hb concentration (Table 2), although an RF ratio
500 was not. Deciencies of vitamins B-6 and B-12 were
also associated with Hb. Among the 40 women with Hb 95
g/L, 5 had depleted iron stores but no B-vitamin deciency, 17
had a B-vitamin deciency but ferritin 12 g/L, 9 had both
depleted iron stores and a vitamin deciency, and 9 had no
evidence of B-vitamin deciency or iron depletion. Of the 297
women who had some degree of anemia, 19% also had ferritin
12 g/L, and 16% had an elevated RF ratio. Among the 35
women with elevated TfR, 57% also had low ferritin, and all
but one was anemic.
The covariate-adjusted relations between Hb (as a contin-
uous variable) and birth outcomes were estimated using the
LOESS procedure; the relation between birthweight and Hb is
displayed graphically in Figure 1. This plot suggests at least 2
separate slopes, i.e., a relatively steep slope from the lowest Hb
value (78 g/L) up to a concentration of 95 g/L, and a
steady but much more gradual increase after this point. Similar
relations were evident for other birth outcomes (not shown).
Based in part on these diagrams, we divided Hb concentration
into 3 categories for subsequent analyses. We added broken
vertical lines to Figure 1 at 95 g/L and 120 g/L to illustrate the
3 categories. No linear relation was evident in the graphic
depiction of the relation between ferritin and the birth out-
comes as continuous variables (data not shown).
Both mild and moderate maternal anemia were associated
with reductions in all 3 measures of infant growth (Table 3).
The most profound association was noted for birthweight, with
mild anemia associated with a 139-g decrease and moderate
anemia associated with a 192-g decrease in birthweight. Both
low and high ferritin categories were also signicantly associ-
ated with lower birthweight (106 and 123 g, respectively)
compared with women with an intermediate ferritin concen-
tration. When we divided anemic women into groups based on
their ferritin and B-vitamin status, we found that all forms of
anemia were generally associated with some degree of growth
decit. The most pronounced decrements were observed for
iron-deciency anemia without concurrent B-vitamin de-
ciency; infants in this group were 242 g lighter on average than
those born to nonanemic women. Infants born to vitamin-
decient anemic women who had ferritin 12 g/L and those
born to anemic women with both low ferritin and a vitamin
deciency weighed 141 and 176 g less, respectively, than
infants born to nonanemic women. Elevated TfR was associ-
ated with a 0.9 cm lower birth length ( 0.89; SE 0.4;
P 0.03) but the RF ratio (as either a continuous or binary
variable) was not signicantly associated with any birth out-
come.
Logistic regression was used to assess the association be-
tween Hb and ferritin categories and adverse birth outcomes
(Table 4). Moderate anemia (Hb 95 g/L) was signicantly
associated with increased risk of LBW and FGR. In adjusted
models, the risk of LBW was 6.5 times greater and the risk of
FGR was nearly 5 times greater among women with moderate
anemia compared with those without anemia. Although mod-
erate anemia was associated with increased risk of preterm
birth in a logistic model adjusted for nonnutrient covariates
only (OR 3.9; 95% CI: 1.1, 14.1; P 0.04), this association
was weakened by inclusion of B-vitamin deciencies in the
model and was no longer signicant (OR 2.9; 95% CI: 0.8,
11.3; P 0.12). No signicant associations were observed
between mild anemia (95 Hb 120 g/L) and LBW, preterm
birth, or FGR.
No signicant associations were observed between depleted
iron stores (ferritin 12 g/L) and risk of preterm birth,
LBW, or FGR in either the crude or adjusted model. However,
the risk of FGR was nearly 3 times higher among infants born
to women with elevated ferritin compared with those in the
TABLE 1
Characteristics of the study population, Anqing, China
1
Variable n
Age, y 405 24.9 1.5
Height, m 405 1.58 0.05
Weight, kg 405 49.2 5.9
BMI, kg/m
2
405 19.8 2.1
Maternal Hb, g/L 405 108.5 13.0
Maternal ferritin, g/L 359 29.9 2.4
RF ratio 359 159.0 2.9
Infant birth weight, g 405 3116 480
Infant birth length, cm 370 50.0 2.4
Infant head circumference, cm 359 33.5 1.8
Infant gestational age, wk 405 39.6 1.7
%
Hb, g/L
95 g/L ( 10
th
percentile) 40 9.9
95 Hb 120 275 67.9
120 90 22.2
Ferritin, g/L
12 63 17.5
12 ferritin 60 221 61.6
60 ( 80
th
percentile) 75 20.9
High transferrin receptor, (TfR 8.3 mg/L) 35 9.8
High RF ratio, (TfR: ferritin 500) 53 14.8
Education completed
Middle school or less 295 72.1
High school 111 27.1
College or above 3 0.7
Rotating work shift 390 95.3
Exposure to
Passive smoking 271 66.3
Dust 397 97.1
Noise 382 93.4
Work stress 167 36.2
No use of vitamin/mineral supplements 399 97.8
LBW infants (2500 g) 33 8.1
Preterm infants (37 wk gestation completed) 27 6.7
FGR infants 56 13.8
1
Values are means SD or %. Ferritin and the ratio of transferrin
receptor (TfR) to ferritin (RF ratio) are presented as geometric means, n
359.
RONNENBERG ET AL. 2588

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reference group. Elevated ferritin was also signicantly associ-
ated with more than double the risk of LBW in an unadjusted
model, although the strength and signicance of the associa-
tion was attenuated somewhat after adjustment for covariates.
DISCUSSION
Numerous previous studies reported a relation between
prenatal maternal anemia, particularly iron-deciency anemia,
and shortened gestation (25,26) and lower birthweight (5,27).
Because of the unique design of the current study, in which the
subjects were women who were attempting to become preg-
nant, blood samples were obtained before pregnancy; thus,
they reect maternal Hb, ferritin, and B-vitamin status in the
periconceptional period. To our knowledge, ours is the rst
such prospective study to report an association between pre-
conception maternal anemia and ferritin status and adverse
pregnancy outcomes. Maternal anemia was signicantly asso-
ciated with infant growth, including birthweight and the risk
of LBW. The mean birthweights of infants born to women
with mild and moderate anemia were 144 and 199 g lower,
respectively, than those of infants born to women without
preconception anemia. In addition, women with moderate
anemia before conception were 6 times as likely to deliver a
LBW infant and 5 times more likely to have an infant with
FGR. Although anemia per se was an important predictor of
pregnancy outcome in our cohort, preconception iron-de-
ciency anemia had a particularly strong effect on birthweight,
i.e., infants born to women with preconception iron-deciency
anemia and adequate B-vitamin status weighed on average
241 g less than those born to women without anemia.
The deleterious effects of maternal anemia on pregnancy
outcomes that we observed are consistent with earlier studies
showing that maternal anemia during pregnancy triples the
risk of LBW (7). Our ndings raise the question whether
anemia in the periconceptional period may have an indepen-
dent effect on infant growth, perhaps by inuencing hormone
synthesis (28,29) or placental size or vascularization (30) re-
quired to sustain optimal fetal growth. Alternatively, women
who were classied as moderately anemic before pregnancy
may have developed more severe anemia during pregnancy,
(31,32) leading to the observed growth decits. Unfortunately,
we do not know whether prenatal micronutrient supplemen-
tation was implemented or whether nutritional status changed
substantially throughout the course of pregnancy; thus we
cannot speculate on which of these 2 pathways is more prob-
able, although the issue deserves further study.
We found that low ferritin (12 g/L), a marker of de-
pleted iron stores, was signicantly associated with reduced
birthweight. However, elevated ferritin (60 g/L) was also
associated with reduced birthweight and was a risk factor for
LBW and FGR. Our observation of an association between
pregnancy outcome and high ferritin levels before conception
is consistent with numerous reports indicating an increased
risk of adverse birth outcomes in women with elevated ferritin
during pregnancy (24,3336). Because ferritin is an acute-
phase protein, high ferritin concentration under these circum-
stances may not reect greater iron stores but rather may serve
as a biomarker of acute or chronic inammation (37,38). Our
ndings are particularly noteworthy because ferritin was mea-
sured in blood samples obtained before pregnancy; thus, the
association between elevated ferritin and pregnancy outcome
in our study was not due to pregnancy-related infections, such
as chorioamnionitis, or to inadequate plasma volume expan-
sion during pregnancy, both of which have been cited as
possible reasons for the association (34,39). Exposure to cotton
FIGURE 1 Independent relation between birthweight and mater-
nal prepregnancy Hb concentration (g/L) in Chinese women. Results
were derived from generalized additive models using SPLUS 2000. The
model was adjusted for maternal age, height, height-squared, BMI,
education, work stress, maternal exposure to dust, noise, and passive
smoking, infant gender, and gestational age. Dotted vertical lines at Hb
concentrations of 95 and 120 g/L indicate the cutoff points for Hb
categories in subsequent analyses.
TABLE 2
Associations among hemoglobin, ferritin, and B-vitamin status in Chinese women
Variables associated
with Hb concentration
Hb categories (g/L), n 359
Adjusted associations
1
Hb 95
n 40
95 Hb 120
n 257
Hb 120
n 62 SE P
% (n)
Ferritin 12 g/L 35.0 (14) 16.7 (43) 9.7 (6) 0.29 0.17 0.10
TfR 8.3 mg/L 22.5 (9) 9.7 (25) 1.6 (1) 0.59 0.22 0.01
Vitamin B-6 deciency 42.5 (17) 24.1 (62) 14.5 (9) 0.39 0.15 0.01
Vitamin B-12 deciency 22.5 (9) 16.7 (43) 11.3 (7) 0.37 0.17 0.03
Folate deciency 22.5 (9) 22.2 (57) 14.5 (9) 0.22 0.16 0.17
1
The linear regression model with Hb as a continuous outcome variable was adjusted for all of the nutrition-related covariates and exposure to
dust and work stress. The overall model was signicant, P 0.0001.
ANEMIA AND BIRTH OUTCOME IN CHINESE WOMEN 2589

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dust induces lung inammation in textile workers (40,41) and
is a possible cause of elevated ferritin in some of our textile
factory workers. We did not have an independent measure of
inammation, such as C-reactive protein, which would have
allowed us to study more directly the association between
inammation and adverse pregnancy outcomes, nor did we
have dietary data, which would have helped to determine the
role of micronutrient intake in nutritional status.
Several studies reported a high prevalence of anemia during
pregnancy in the absence of iron deciency (3,4244). We
found that preconception anemia that was not related to iron
deciency was common among women in this study. Only
20% of the women with anemia also had biochemical evi-
dence of depleted iron stores, whereas nearly half of these same
women were decient in at least 1 B vitamin, and 33% had
B-vitamin deciencies without evidence of depleted iron
stores. Because of the relatively small number of adverse preg-
nancy outcomes in this cohort, we did not have sufcient
statistical power to estimate the association between noniron-
deciency anemia and adverse pregnancy outcomes, such as
preterm birth or LBW, using logistic regression. However, we
were able to show that anemia related to B-vitamin deciency
without depleted iron stores was signicantly associated with a
decrease in birthweight of 141 g. In addition, we reported
previously that B-vitamin deciencies are important indepen-
dent determinants of adverse pregnancy outcomes in this
cohort (17). These observations support the suggestion (7,11)
that an important factor in the lack of improvement in birth
outcomes observed in many iron-only supplementation pro-
grams may be that, in some populations, only a fraction of
observed anemia is related to iron deciency alone. Given the
continuing high global prevalence of anemia in women of
reproductive age and the apparent importance of anemia as a
predictor of adverse pregnancy outcomes, greater public health
TABLE 3
Adjusted means for birth outcomes across categories of hemoglobin, ferritin, and anemia in Chinese women
1,2
Category n Birthweight Birth length Head circumference
g cm cm
Hemoglobin, g/L
95 40 3041 (2910, 3171)* 49.4 (48.7,50.1)** 33.0 (32.4, 33.5)*
95 Hb 120 275 3094 (3044, 3145)* 50.0 (49.7, 50.2)
#
33.4 (33.2,33.6)**
120
3
90 3233 (3128, 3338) 50.3 (49.7, 50.8) 33.9 (33.4, 34.3)
Ferritin, g/L
12 63 3051 (2947,3154)** 49.6 (49.0, 50.1)
#
33.3 (32.9, 33.8)
12 Ferritin 60
3
221 3157 (3101, 3212) 50.1 (49.8, 50.4) 33.4 (33.2, 33.7)
60 75 3034 (2938,3130)** 49.8 (49.2, 50.3) 33.4 (33.0, 33.8)
Anemia
No iron or B-vitamin deciency 131 3112 (3040, 3184)
#
50.0 (49.6, 50.4) 33.4 (33.1, 33.7)
#
B-vitamin deciency and no iron deciency 109 3091 (3011,3171)** 50.0 (48.9, 50.3) 33.3 (33.0,33.6)**
Iron deciency and no B-vitamin deciency 28 2990 (2836, 3145)* 49.2 (48.3,50.0)** 32.8 (32.2, 33.5)*
Both iron and B-vitamin deciencies 29 3056 (2902, 3209)
#
49.7 (48.9, 50.5) 33.6 (33.0, 34.3)
No anemia
3
62 3232 (3126, 3337) 50.3 (49.7, 50.8) 33.9 (33.4, 34.3)
1
Values are least-squares means (95% CI). Means are adjusted for maternal age, height and height-squared, BMI, education, exposure to dust,
noise, and passive smoking, work stress, infant gender, and gestational age (linear and quadratic terms).
2
Symbols indicate different from the reference group: * P 0.01; ** P 0.05;
#
P 0.1.
3
Reference group.
TABLE 4
Adjusted OR for preterm birth, LBW, and FGR by hemoglobin (Hb) and ferritin (Ft) categories in Chinese women
1
Category n
Preterm birth (n 27) LBW (n 33) FGR (n 56)
% OR 95% CI P % OR 95% CI P % OR 95% CI P
Hemoglobin, g/L
95 40 15.0 2.9 0.8, 11.3 0.12 17.5 6.5 1.6, 26.7 0.009 25.0 4.6 1.5, 13.5 0.006
95 Hb 120 275 5.1 0.7 0.3, 1.9 0.50 7.6 2.0 0.7, 5.9 0.22 13.1 1.4 0.7, 3.2 0.36
120
2
90 7.8 1.0 5.6 1.0 11.1 1.0
Ferritin, g/L
12
3
63 11.1 2.3 0.8, 6.5 0.12 6.4 0.7 0.2, 2.4 0.55 12.7 1.2 0.5, 2.8 0.75
12 Ferritin 60
2
221 5.0 1.0 6.8 1.0 11.3 1.0
60 75 9.3 1.9 0.7, 5.5 0.24 16.0 2.2 0.9, 5.7 0.09 22.7 2.7 1.3, 5.6 0.008
1
Logistic regression models were adjusted for maternal age, height and height-squared, BMI, education, exposure to dust, noise, and passive
smoking, work stress, infant gender, and gestational age (linear and quadratic terms), and deciency of folate, vitamin B-12, and vitamin B-6. Preterm
birth and FGR models were adjusted for all of the covariates above except for gestational age. Percentages are provided for convenience only.
P-values refer to the logistic regression models.
2
Reference group.
3
Because of unavailable ferritin data for some women, the number of cases was reduced slightly in this subset: n 31 cases for LBW, 25 cases
for preterm birth, and 50 cases for FGR.
RONNENBERG ET AL. 2590

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efforts to assess and combat the multiple causes of anemia in
women of reproductive age appear warranted.
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