Protocol · WHO antenatal care
Anaemia in pregnancy
Anaemia is common in pregnancy, makes women tired and breathless, and increases the risk of dying from bleeding at birth. Preventing it with daily iron and folic acid, finding it early and treating it properly are core antenatal tasks that nurses and midwives can do.
- Based on WHO antenatal care
- For midwives, nurses, clinical officers and doctors
- Reviewed October 2026
1Who / when
- All pregnant women: measure Hb at the first contact, and look for pallor at every contact.
- Also women up to 3 months after birth or after a miscarriage or abortion.
- Higher risk: malaria, hookworm or schistosomiasis areas, HIV, TB, sickle cell disease, and poor diet.
2Red flags: refer now
- Hb below 70 g/L.
- Severe pallor of the palms and inside the eyelids.
- Any pallor with breathing over 30 per minute, tiring easily, or breathless at rest.
- Anaemia with vaginal bleeding, or fever and too weak to get out of bed.
Severe anaemiaSevere anaemia: refer urgently. She must give birth in a facility that can give blood.
3Assess
- Ask: do you tire easily? Are you breathless during housework? Any bleeding, fever, dark urine?
- Look at the palms and conjunctiva: severe pallor, some pallor or none. Count breaths for one full minute.
- Measure Hb: full blood count if available; otherwise an on-site haemoglobinometer (WHO prefers this to the colour scale).
- Check: malaria test in endemic areas, deworming status, HIV status, diet, and how she takes her iron.
- Ask about sickle cell disease where it is common.
4Classify
| Trimester | No anaemia | Mild | Moderate | Severe |
|---|---|---|---|---|
| First | 110 or more | 100 to 109 | 70 to 99 | Below 70 |
| Second | 105 or more | 95 to 104 | 70 to 94 | Below 70 |
| Third | 110 or more | 100 to 109 | 70 to 99 | Below 70 |
| Signs (PCPNC) | Classify | Action |
|---|---|---|
| Hb below 70 g/L, and/or severe pallor, or any pallor with fast breathing, tiring easily or breathless at rest | Severe anaemia | Refer urgently; start double-dose iron; antimalarial if indicated; plan facility birth with blood available |
| Hb below the cut-off but 70 or more, or pallor | Anaemia | Double-dose iron for 3 months; antimalarial and deworming if indicated; reassess in 4 to 6 weeks |
| Hb at or above the cut-off, no pallor | No anaemia | Daily preventive iron and folic acid |
5Treat
| Elemental iron | Folic acid | How long | |
|---|---|---|---|
| Prevention (all) | 30 to 60 mg daily (60 mg where anaemia is very common) | 400 micrograms daily | Whole pregnancy, and 6 to 12 weeks (PCPNC: 3 months) after birth |
| Anaemia | 120 mg daily (for example two 60 mg tablets) | 400 micrograms daily | Until Hb is 110 g/L or more, then back to the preventive dose |
- Malaria areas: test and treat malaria; IPTp with SP from 13 weeks; sleep under a treated net. Keep folic acid at 0.4 mg, not 5 mg, with SP.
- Worms: deworming after the first trimester where your programme gives it (areas with over 20% infection).
- Treat other causes found (HIV, TB) per national guideline.
- Severe anaemia: transfusion and further tests are decided at the referral facility.
Weekly iron (120 mg with 2.8 mg folic acid) is only for prevention in women who cannot take daily iron, in places where under 20% of pregnant women are anaemic. It is not a treatment for anaemia.
6Follow-up
- Severe anaemia (after referral): review in 2 weeks for progress, test results and adherence.
- Anaemia: reassess Hb or pallor at the next contact in 4 to 6 weeks. Not better: check she is taking the tablets, then refer.
- Check her supply of tablets at every contact; give enough to last until the next one.
7Counsel
- Take iron every day. If side effects bother you, tell us rather than stopping: we can help you manage them.
- Store tablets in a dry place where children cannot reach them.
- Eat a varied diet: green and orange vegetables, beans, nuts, whole grains, fruit, and meat or fish where possible.
- Sleep under a bed net in malaria areas.
Your blood is weak. These tablets will build it up so you and the baby are stronger for the birth. Take two a day, every day, and come back if you feel very tired, short of breath or start to bleed.
8When to refer
- Urgently: severe anaemia, or any anaemia with breathlessness at rest or bleeding.
- Anaemia that does not improve after treatment taken correctly.
- Suspected sickle cell disease or other inherited anaemia.
- Any woman with severe anaemia should plan to give birth in a facility with blood transfusion.
9Sources
- World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 2016 (ISBN 9789241549912).
- World Health Organization. Guideline on haemoglobin cutoffs to define anaemia in individuals and populations. 2024 (ISBN 9789240088542).
- World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd edition. 2015. Used for the clinical classification, double-dose iron and follow-up intervals.
- World Health Organization. WHO recommendations on maternal and newborn care for a positive postnatal experience. 2022. Postpartum iron for 6 to 12 weeks.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.