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Postpartum Iron Deficiency & Postpartum Anemia: Rethinking Low Iron Requirements

Sometimes I feel like I live on another planet from the people that set the nutrition guidelines for pregnancy and postpartum.

The recommendations can be so far off from what seem logical, not only from understanding basic physiology, but also accounting for the dietary practices of traditional cultures (that date back hundreds and thousands of years).

One such recommendation is the target levels for iron in breastfeeding women, which—in the United States—are set at one-third the level of pregnancy (and half the level of non-pregnant women).

Not pregnant: 18 mg/day
Pregnant: 27 mg/day
Breastfeeding: 9 mg/day

From all that I can gather, the sole rationale behind these low iron targets is that it’s assumed breastfeeding women will not be menstruating (lactational amenorrhea), thus avoiding the typical iron losses from a monthly cycle. Even though iron is transferred in small amounts in breast milk, overall losses of iron in breast milk are about half of what is typically lost during menstruation.

However, what these postpartum iron recommendations don’t consider is that:

  • Most women go into pregnancy with low iron stores (some research shows only 20% of childbearing aged women have adequate iron stores)
  • Iron stores are further depleted during pregnancy
  • Many have significant blood losses at delivery (keep reading for some shocking statistics!)
  • After birth, you continue to lose blood—and thus, iron—via lochia (the normal postpartum bleeding that most experience for about a month after delivery)

There are several other factors to consider, but these are some of the most relevant.

It’s also worth noting that not all countries agree with the low iron requirements set by the United States.

Germany, Austria, Switzerland, The Netherlands, and many Nordic countries recommend significantly higher iron levels for breastfeeding women than the United States. In fact, The Netherlands set their iron requirements for postpartum at more than TWICE the levels of the U.S.

Postpartum Iron Deficiency & Postpartum Anemia: Rethinking Low Iron Requirements

One of the most striking statistics I came across in my extensive literature review in preparation for my Postpartum Recovery & Nutrient Repletion webinar was how significantly blood losses at delivery can affect the risk of anemia.

When blood losses are more than 500 ml, the risk of postpartum anemia is 15.3x higher.

When the losses are greater than 1,000 ml, that risk is a whopping 74.7x higher.

What’s worrisome is that under and over-estimates of blood losses at delivery are very common, which makes it difficult for mothers and providers alike to identify who’s at risk UNLESS they implement routine screening with a full iron panel for new mothers. This is something that has yet to become standard of practice (or when they DO test, they often aren’t checking the most reliable markers of iron status—sigh… if you rely ONLY on hemoglobin/hematocrit, you don’t get a comprehensive look at iron status).

Postpartum iron deficiency and anemia are extremely common and can have downstream effects on things like thyroid function and risk for postpartum depression.

In other words, iron deficiency affects a new mother’s quality of life.

Common Symptoms of Postpartum Anemia

  • Fatigue
  • Unusually rapid heart beat, particularly with exercise
  • Shortness of breath, headache, dizziness
  • Difficulty concentrating
  • Pale skin
  • Leg cramps
  • Insomnia
  • Cold hands & feet
  • Depression (2.5x more likely if iron deficient)
  • Thyroid dysfunction (iron is one of many nutrients vital to thyroid function)

Maybe instead of taking a myopic view of “iron needs are decreased due to lactational amenorrhea,” our guidelines could view this time as an opportunity to rebuild what had been depleted from pregnancy at a time when your body can finally “catch a break.”

Insight from Traditional Cultures on Postpartum Iron Repletion

Maybe we could take a hint from traditional cultures that specifically emphasized iron-rich foods for new mothers—foods like organ meats (like liver and heart), seafood (especially clams and oysters), and hearty soups/stews made with red meat & bones (remember, the marrow is rich in highly-absorbable heme iron!).

If you look at the concentration of iron in organ meats compared to muscle meats, it’s 2-6x higher for the same serving size. Not to mention, these foods are also rich in vitamin B12, preformed vitamin A (retinol), and folate—all of which work synergistically to support red blood cell production. In other words, these traditionally prized foods are the ideal choices to help combat anemia.

Maybe, just maybe, if we weren’t so dismissive of the wisdom of generations before us (outlined in detail in Ch 12 of Real Food for Pregnancy), we wouldn’t be in a predicament where upwards of 30% of new mothers face postpartum anemia and go through early motherhood completely exhausted and depleted.

One can hope that we’ll someday correct this gross oversight.

Until then, it’s up to moms to advocate for themselves and for fellow healthcare professionals to demand better.

If you want to learn more about preparing and supporting new moms for a smoother postpartum recovery and provide the best guidance on rebuilding maternal nutrient stores, I invite you to check out my webinar on Postpartum Recovery & Nutrient Repletion.

We recorded the live event (including the excellent Q&A at the end, too!) and it’s now available on-demand on the Women’s Health Nutrition Academy website. Check it out here.

There are countless nutritional pearls in this webinar (and 75 scientific references to support my recommendations), so it’s well worth your time.

Dietitians earn 1.5 continuing education credits for attending.

And before you ask, yes, you can re-watch the webinar however many times you’d like.

Do you have personal (or professional) experience with postpartum iron deficiency & postpartum anemia?

Tell me about it in the comments below.

Until next week,
Lily

P.S. – If you know a friend or colleague who might appreciate this insight about postpartum iron needs, please feel free to share this post with them. Spread the word and you may help a new mom avoid the extreme fatigue of anemia, help her reduce her chances of postpartum thyroid dysfunction, or even lessen the risk of postpartum depression. That’s big.

References

Medina Garrido, Carola, Jaime León, and Adriana Romaní Vidal. “Maternal anaemia after delivery: prevalence and risk factors.” Journal of Obstetrics and Gynaecology 38.1 (2018): 55-59.

Bodnar, Lisa M., Mary E. Cogswell, and Thad McDonald. “Have we forgotten the significance of postpartum iron deficiency?.” American journal of obstetrics and gynecology 193.1 (2005): 36-44.

Dama, Manish, et al. “Iron deficiency and risk of maternal depression in pregnancy: an observational study.” Journal of Obstetrics and Gynaecology Canada 40.6 (2018): 698-703.

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Lily Nichols is a Registered Dietitian/Nutritionist, Certified Diabetes Educator, researcher, and author with a passion for evidence-based prenatal nutrition and exercise. Her work is known for being research-focused, thorough, and unapologetically critical of outdated dietary guidelines. She is the author of two bestselling books, Real Food for Pregnancy and Real Food for Gestational Diabetes.

7 Comments

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  1. Thanks for this important post! My comment is that I was told I had great iron levels by my midwife 7 years ago (I don’t remember the numbers but I didn’t have any of the above symptoms) yet I was a pescatarian. I ate at least 2 servings of fish per week (low mercury) and lots of leafy greens and other veggies as well as legumes. Thoughts on iron sources for those who don’t eat red meat? There are many, correct?

    • Shellfish, especially oysters and clams, are extremely high in iron and it comes in a highly absorbable form with complementary nutrients.

  2. As a student midwife and a mother who has suffered from post-partum anemia with thyroid dysfunction, I so appreciate this blog post! Do you believe in consuming the placenta as a way to replenish iron and mineral depletions? Would also love to know of some options for vegan mamas to consume sufficient amounts of iron to make up for whats is lost after birth! Thanks!

    • I cover the controversial topic of placenta consumption in Ch 12 of Real Food for Pregnancy. It can supply *some* iron, but would not meet postpartum needs alone. I also address more recent research on the topic, potential benefits/risks based on the limited research thus far in this webinar on postpartum recovery.

      I’d recommend reading this post on vegetarian/vegan diets and following up with the lengthy section on this topic in Ch 3 of Real Food for Pregnancy. Non-heme iron (the kind in plants) is very poorly absorbed for a variety or reasons, though some of the tips in that section of the book can be used to boost absorption. Vitally important for plant based mamas to have a full iron panel during and after pregnancy; a supplement is likely necessary.

  3. I think this is what’s happening to me! So you have a favorite iron supplement?

    • See Ch 6 of Real Food for Pregnancy for info on iron supplementation & best forms to look for (I don’t partner with specific brands of supplements as a matter of professional ethics). I prefer getting as much from food as possible as this has no negative side effects and is absorbed far more efficiently than supplements.

  4. Wow, 9 mg! I didn’t realize that was the recommendation. I’ll definitely be upping that when I give birth (23 weeks now!)

    What is confusing to me is that since heme iron sources are supposed to be better-absorbed, does the recommended 27 mg/day for pregnant women still make sense if a good portion of that is coming from heme sources? How much of heme iron is sufficient in a given day, given higher rates of absorption?

    I find it difficult to get to 27 mg/day even when I’m eating liver and meat (tracking on Cronometer, a calorie/nutrient app). So (again) I’m wondering if since heme sources are absorbed more efficiently there should be some more guidance as to how many mg we should be getting from heme and non-heme sources.

    Any direction you could give me would be amazing!

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