Skip to main content

Iron deficiency anemia status in Iranian pregnant women and children: an umbrella systematic review and meta-analysis



Iron deficiency anemia (IDA) is a global health challenge, especially affecting females and children. We aimed to conduct an umbrella systematic review of available evidence on IDA’s prevalence in Iranian pregnant women and children.


We searched the Web of Science, Science Direct, PubMed, Scopus, and Google Scholar databases for articles published by April 2023. Meta-analyses investigating the status of IDA in Iran were included. The findings of seven meta-analyses comprising 189,627 pregnant women with a mean age of 26 and 5,890 children under six years old were included in this study. The methodological quality of each study was evaluated with the Assessment of Multiple Systematic Reviews (AMSTAR2) instrument.


We estimated the prevalence of IDA at 15.71% in pregnant women and 19.91% in young children. According to our subgroup analysis of pregnant women, IDA’s prevalence in urban and rural regions was 16.32% and 12.75%; in the eastern, western, central, southern, and northern regions of Iran, it was estimated at 17.8%, 7.97%, 19.97%, 13.45%, and 17.82%, respectively.


IDA is common in young children and pregnant females and is a significant public health concern in Iran. The present umbrella review results estimated that Iran is in the mild level of IDA prevalence based on WHO classification. However, due to sanctions and high inflation in Iran, the prevalence of anemia is expected to increase in recent years. Multi-sectoral efforts are required to improve the iron status of these populations and reduce the burden of IDA in the country.

Peer Review reports


Anemia is a global health challenge that affects human health and socioeconomic development. While it can affect any individual, its prevalence is higher among pregnant and pediatric populations [1]. The World Health Organization (WHO) states that anemia affects roughly five hundred million reproductive-age women globally. Among women aged 15 to 49, over a third of those who were pregnant (32.4 million) and almost a third of those who were not pregnant (496 million) were anemic in 2011. The maximum rates of anemia have been recorded in South Asia and West and Central Africa [2]. In the developing world, roughly 33% of children aged below 4 and 50% of those aged 5 to 15 have anemia [3].

Iron is vital for growth and metabolism, affecting the electron transport chain, oxidation-reduction, DNA replication, hormone synthesis, and reactive oxygen species (ROS) defense [4,5,6]. The lack of erythrocytes and hemoglobin in anemia impairs the ability of the body to deliver oxygen to vital organs via the blood [7].

Iron deficiency anemia (IDA) has many dangerous maternal and neonatal complications [8, 9]. IDA in pregnant women augments the risk of premature delivery, mortality, pre-eclampsia, maternal sepsis, and low birth weight of the child; it can also affect the cognitive development of the child [8,9,10]. Several factors, such as nutrition, genetics, frequent labor, abortions, multiparity, and infectious diseases, are related to anemia, but iron deficiency (ID) accounts for 75% of cases [10,11,12]. One of the main causes of ID is a gap between the body’s increased demand (up to seven times) for iron during pregnancy and the inadequate intake and low bioavailability of iron [13, 14].

An IDA prevalence above 5% indicates a public health problem in any country. IDA accounts for roughly half of all cases of anemia and is the most common nutritional deficiency disorder worldwide, affecting the health of millions of people [15]. The most vulnerable groups are young children and pregnant females [16]. In the developing world, IDA is prevalent in between 40 and 88% of women [17].

Proper and good monitoring of anemia in developing countries will be effective in planning for better control of this disease. The public health importance of anemia in terms of serum hemoglobin levels in a population can be determined using WHO criteria (40% or higher = Severe, 20.0-39.9% = Moderate, 5.0-19.9% = Mild, and 4.9% or lower = Normal) [18]. According to the previous studies in Iran, the prevalence rate varied from 10 to 30% [19, 20]. However, a comprehensive analysis was yet to be conducted.

According to the WHO report, a remarkable decrease in anemia has been achieved in some settings. However, the expected progress has been insufficient overall. In order to reach the WHO target, which is a 50% diminution in anemia in reproductive-age women by 2025, more and better actions are needed [2]. To address these matters and ameliorate the knowledge base for superior decision-making and future research, a general assessment of the prevalence of IDA among Iranians is essential, as data on this topic is limited or outdated. Hence, we aimed to conduct an umbrella systematic review of the available evidence on IDA prevalence in young children and pregnant women in Iran.


Search strategy

We conducted our systematic review and umbrella meta-analysis study as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework [21] (Supplementary Table 1). This investigation was undertaken as a Ph.D. thesis titled “Policy analysis and development of upcoming policy options for the prevention of IDA in Iran,” approved by and registered with the Research Vice Chancellery of Tabriz University of Medical Sciences, Iran.

Table 1 PICOS criteria for inclusion of studies

Data sources and literature search

We searched PubMed, Google Scholar, Science Direct, Scopus, and Web of Science for all systematic reviews and meta-analyses on IDA in Iran published up until April 2023. We used the following search terms: iran OR Iran AND meta-analysis OR review, systematic OR systematic review AND anemia, iron deficiency OR hemoglobin OR iron OR “iron deficiency” OR iron deficiency anemia OR IDA OR ferritin OR iron-deficien* AND prevalence OR frequency OR percent OR mean OR estimation OR status.

Two authors conducted the literature search separately, with consensus being used to resolve disagreements. Furthermore, the “cited by,” “related articles,” and reference lists of the included studies were manually searched for further eligible studies. Supplementary Table 2 elucidates the search strategy.

Table 2 Characteristics of the included studies in Umbrella Systematic Review and Meta-Analysis of IDA prevalence in Iranian pregnant women and children

Study screening and selection

Definition of keywords and screening of articles obtained from databases will be done according to PICO criteria (Table 1). For the present study, which is the type of prevalence studies, it is defined as CoCoPop, which includes the studied complication or disease (Condition), context or studied area (Context), and studied population (population) [22]. The search was unrestricted by the publication period. All English and Farsi publications performed in Iran until 2023 were eligible to include. The purpose of not having a time limit was to gain insight into the country’s current IDA situation. The inclusion criteria encompassed all meta-analyses reporting IDA prevalence in children and pregnant women in Iran with effect sizes (ES) and 95% confidence intervals (95% CIs). Two authors (AD and RMG) independently screened all publications against the eligibility criteria. In the first screening stage, the titles and abstracts were examined; the remaining articles were subsequently assessed for eligibility according to their full text. Disagreements were resolved by reaching a consensus. The data from the included studies were extracted and entered into an Excel spreadsheet containing a standardized data extraction form. The following data were extracted: primary author, year published, population, sex, number of participants and studies in the meta-analysis, anemia criteria, study type, effect sizes, and 95% CIs.

Quality evaluation and evidence grading

We evaluated each included study using the Assessment of Multiple Systematic Reviews (AMSTAR2) instrument [23], a validated tool that examines the pooling method and study results through 16 questions. Each question is answered as yes, partial yes, no, or no meta-analysis. Then, each study is classified according to the final score as high, moderate, low, or very low quality. Based on Cochrane guidelines, we assessed the overall strength and quality of the studies using the GRADE tool. This tool assesses five risk factors of bias, consistency, directness, accuracy, and publication bias. Ultimately, the quality is graded in the same way as in the previous tool, declining if any of the mentioned factors are neglected [24].

Data synthesis

We evaluated the pooled ES and 95% CI using random effects models with the restricted maximum likelihood approach. We examined for significant heterogeneity between studies using the I2 statistic and Cochrane’s Q test, indicated by I2 values above 50% or Q test p-values below 0.1 [25]. To identify sources of heterogeneity, we performed subgroup analysis based on sample size, sex, resident area, and region. Using sensitivity analysis, we examined how the overall ES would be affected if we removed a particular study. We performed Egger’s and Begg’s formal tests and examined the funnel plots visually to assess the impact of studies with at least 10 studies or less than 10 studies, respectively [26,27,28]. Using the “trim-and-fill” method, we corrected asymmetries observed as a result of the small study effect. P-values below 0.05 indicated significance. All analyses were done using STATA v. 17.0 (Stata Corporation, College Station, TX, USA).


Literature search findings

Figure 1 demonstrates the study flow diagram. We retrieved 170 publications from Science Direct (n = 58), Scopus (n = 56), Web of Sciences (n = 13), PubMed (n = 17), and Google Scholar (n = 26). We removed duplicates, leaving 90 articles for the title/abstract screening stage. After initial screening, 12 articles entered the full-text screening phase. During this phase, five articles were deemed to lack the required information for inclusion [29,30,31,32,33]. Finally, seven studies were deemed eligible for inclusion in our umbrella meta-analysis [16, 34,35,36,37,38,39].

Fig. 1
figure 1

Flow chart of study selection for inclusion studies in the umbrella review

Study characteristics

The key characteristics of the reviewed articles are summarized in Table 2. All included studies were published by April 2023. A total of 189,627 pregnant women with a mean age of 26 years old and 5,890 children under 6 years (both genders) were included. The studies were conducted in different cities of Iran. In many studies, hemoglobin has been used to diagnose anemia, as well as ferritin as criteria for diagnosing IDA.

Methodological quality

The results of our evaluation of the method of each study with the AMSTAR2 tool are presented in Table 3 [40]. We found that most publications (n = 6) were of moderate quality, with only one having high quality. Hence, the overall quality was moderate. Similarly, with the help of the GRADE instrument, all qualitative effects achieved a moderate rating (Table 4).

Table 3 Results of assessment of the methodological quality of included meta-analysis
Table 4 Summary of results and quality of evidence assessment using the GRADE approach

Iron deficiency anemia prevalence in pregnant women

By combining the ES values of five meta-analyses of 105 studies comprising 189,627 pregnant women, we recorded an overall IDA prevalence of 15.71% (95% CI: 13.99, 17.44) (Fig. 2A). We also recorded low heterogeneity between the studies (I2 = 20.1%, p = 0.287).

Our subgroup analysis (Table 5) revealed that anemia was more prevalent in studies with sample size ≥ 2000 (ES = 16.12%, 95% CI: 13.766, 18.482) with a relatively high heterogenicity (I2 = 54.5%, p = 0.111) among the studies. The Begg’s tests indicated no small study effect (p = 0.327), with the funnel plot revealing no asymmetry (Fig. 2B). In addition, sub-group analysis based on area revealed that prevalence of anemia was 12.75% (95% CI: 4.89, 20.61) in rural regions, with low heterogeneity (I2 = 25.7%, p = 0.260) among the studies. Begg’s tests revealed no publication bias of significance (p = 0.117), and the funnel plot approved that too. In the urban areas, the prevalence of anemia was 16.32% (95% CI: 11.51, 21.14). Probably a high heterogeneity (I2 = 75.5%, p = 0.007) and no publication bias (p = 0.497) were observed. Also, in urban-rural and unknown areas the prevalence was (ES = 13.40%, 95% CI: 9.54, 17.27) and (ES = 15.27%, 95% CI: 12.29, 18.25), respectively. Heterogeneity was found to be low between the studies in both subgroups (I2 = 0.0%, p = 0.992). There was a significant publication bias (p = 0.042) in urban-rural and no significant publication bias in unknown areas (p = 0.602). However, after subgroup analysis based on location, we estimated the prevalence of anemia in the east (ES = 17.79%, 95% CI: 9.99, 25.58), west (ES = 7.97%, 95% CI: 5.04, 10.91), central (ES = 19.97%, 95% CI: 15.52, 24.43), south (ES = 13.45%, 95% CI: 8.76, 18.14) and north (ES = 17.82%, 95% CI: 15.43, 20.21). The studies were significantly heterogeneous in east (I2 = 83.4%, p = 0.002) and west (I2 = 67.0%, p = 0.048). We detected low heterogeneity in studies focused on the central (I2 = 0.0%, p = 0.687), south (I2 = 33.8%, p = 0.221), and north (I2 = 0.0%, p = 0.622) parts of Iran. No small study effect was noted in the east (p = 1.000), west (p = 0.602), center (p = 0.117), south (p = 0.221) and north (p = 0.602). Sensitivity analysis revealed no significant effect of excluding each particular study on the pooled ES among pregnant women (Supplementary Fig. 1).

Fig. 2
figure 2

(A) Forest plot detailing effect sizes and 95% confidence intervals (CIs) and (B) funnel plot for the prevalence of IDA in pregnant woman

Iron deficiency anemia prevalence in young children

By combining two meta-analyses of 18 studies comprising 5,890 young children, we found an IDA prevalence of 19.91% (95% CI: 14.057, 25.772) (Fig. 3). Heterogeneity between studies was low (I2 = 0.0%, p = 0.743). Our subgroup analysis revealed an IDA prevalence of 14.75% of boys (95% CI: 5.933, 23.577) and 13.24% of girls (95% CI: 5.055, 21.441), with relatively low heterogenicity (I2 = 0.0%, p = 0.450 and I2 = 0.0%, p = 0.676, respectively) (Table 5).

Fig. 3
figure 3

Forest plot detailing effect sizes and 95% confidence intervals (CIs) for the prevalence of IDA in all children under 6 years’ old

Table 5 Subgroup analyses for the prevalence of iron deficiency anemia among Iranian pregnant woman and under 6 years’ child


Our analysis indicates that IDA is prevalent in 15.71% of pregnant women and in 19.91% of children under 6 years old. Furthermore, the prevalence in pregnant women in urban areas is higher than in rural areas. This figure for the southern regions of Iran is lower than other geographical regions.

Our findings are consistent with studies conducted in Ethiopia (18%) [41], Pakistan (18.1%) [42] and Turkey (19.6%) [43], but the estimated rate in our country is lower than the results of studies recorded in Afghanistan (48.4%) [42], India (36.3%) [44], Côte d’Ivoire (20%) [45], Saudi Arabia (27%) [46] and Guatemala (30–60%) [47]. Also, in the United States, IDA is a concerning health challenge affecting 7% of females aged 12–49 years and up to 16% of pregnant women in this age range [48]. There are various programs to prevent iron deficiency anemia. But there are also obstacles about them, which can include the acceptance of these programs, insufficient priority, lack of awareness and training about its prevention and control; and the difficulty in meeting the needs of high-risk groups at certain times in their lives [11]. It seems that the prevalence of anemia is directly related to the socio-economic development of countries and the success of different countries in the prevention of anemia caused by iron deficiency. Global disparities and dissimilarity between countries and different exposure to multiple determinants of anemia indicate variation in the prevalence of anemia in them. Nationally representative demographic and health surveys in different low- and middle-income countries showed significant variation in the prevalence of anemia. At the national level, it has been shown that the prevalence of anemia has an inverse correlation with the economic development of countries [11]. Also, anemia is socially related to wealth, occupation (for example, agricultural workers), education and place of residence, which can justify the differences in various countries [49]. Moreover, malaria is one of the main causes of anemia in some countries that are malaria endemic areas, especially in Africa where there is a high prevalence of anemia. Therefore, malaria control can be one of the reasons for the difference in prevalence between countries [50].

IDA is a preventable widespread micronutrient deficiency [51], causing a significant health burden. Anemia, especially IDA, in pregnancy has been a neglected cause for a long time disability and is not considered as much as other diseases such as non-communicable diseases and cancer. However, it is time to look into it and understand that reducing IDA is just as impactful as other areas of focus [52]. Studies have shown that ID in women accounted for approximately 3% of global disability-adjusted life years (DALY) in 2010 [53]. Women’s health, especially reproductive health, indicates the nation’s health, which depends on various demographic and socio-economic factors [48]. It has been shown that that people aged 20 and 30 are more susceptible to anemia, encompassing many of the reproductive years [48]. Therefore, it is important for policymakers to determine the prevalence of anemia among women, especially in reproductive age.

Anemia caused by chronic ID leads to cognitive and behavioral disorders in infants and children, fatigue and reduced work ability in adolescents and adults, and perinatal mortality and premature births in pregnant females [54]. The results of statistics obtained from developing countries have shown that IDA is most prevalent in children younger than 5 years old. The most alarming range of its prevalence is 46.5% in Indonesia and between 33.7 and 50% in the African continent [38, 55, 56]. Anemia has been reported by different studies on Iranian teenagers and children at prevalence rates ranging from 9% to more than 40% [38, 57]. In the largest related study, the prevalence rate was 15% among Iranian children aged 2 to 12 [58]. Based on the WHO classification Iran was in the moderate range of IDA prevalence. However, according to our study, the prevalence of IDA is in the mild range [59]. WHO data is usually taken directly from the surveys conducted by the Ministry of Health and Medical Education of each country, which may not be part of the published documents and articles. While we used published meta-analysis studies in our umbrella meta-analysis. Due to the inflation and sanctions of recent years in Iran, the prevalence of anemia is expected to increase.

The National Integrated Micronutrient Survey I (NIMS-I) recently demonstrated that IDA is prevalent in all age/sex groups in Iran. These published results prompted a flour fortification program on the national scale, which aims to prevent deficiencies in iron and folic acid [60,61,62,63].

Iran is undergoing a nutritional transition and due to rapid socio-economic changes, lifestyle and food consumption have undergone changes. These changes in the consumption pattern in recent decades have greatly affected the micronutrient status of people [64]. In primary health care, prevention is the country’s priority instead of treatment. Despite the many programs and efforts of the government to eliminate malnutrition, the diet of the Iranian people in recent decades has been accompanied by less tendency towards healthy traditional diets and an increase in the tendency towards fast food options. Such an unhealthy diet can adversely impact the health of different social groups, especially children and women [65, 66].

Recent reports have shown that the amount of consumption of animal and vegetable products differs across urban and rural regions of Iran. For example, in Tehran city, the capital of Iran, a significant percentage of the energy intake is provided through the consumption of fatty foods and animal products. Animal products account for a minimum of 0.2% of energy intake in the southeast regions but exceed 11.0% in other provinces [66]. Sociocultural factors also influence food consumption in different regions [67].

The Iranian government is trying to adopt and implement appropriate programs in order to improve nutritional patterns as well as prevent obesity or underweight and cardiovascular diseases in metropolitan and rural regions and in all subgroups of populations [65, 66, 68]. Solutions like food fortification, supplementation, nutrition education and public health measures have been propounded as some crucial strategies to prevent and control micronutrient deficiency, including ID, by Iran’s Ministry of Health. In 1983, the government of Iran started the iron supplementation program. This program supplies free iron tablets to all women from the fifth month of pregnancy during regular visits to local health centers, continuing until three months postpartum [69]. Bread made from wheat flour undergoes iron and folic acid fortification and is subsidized by the government, particularly for large and low-income families. This option is low-cost and easily available in all regions [70].

Iron and folic acid supplements during pregnancy and after delivery diminish the risk of IDA and improve the consequences of childbirth [71,72,73,74]. Current WHO guidelines recommend that every pregnant woman in regions with a vast prevalence of anemia takes iron and folic acid supplements [75]. Many countries have implemented interventions to prevent anemia in young children and older girls since the 1970s [76, 77]. Interventions that are provided at the level of health centers do not operate on a large scale in most developing countries. This issue can be due to issues such as inappropriate provision of iron and folic acid supplements due to budget limitations, lack of demand from beneficiaries and health sectors, inefficient management of resources and stock outages [78,79,80,81]. The results of studies have shown that healthcare interventions and lifestyle modification in rural areas have had good results [16]. The observed difference in the prevalence of anemia in pregnant women between urban and rural regions is not statistically significant considering that their confidence intervals overlap with each other. This issue can be caused by the difference in the sample size, their lifestyle and diet, or the difference in the implementation of supplemental programs in the city and the village, as well as the difference in geographical areas [34, 36]. Poor nutritional behaviors and poor quality food products are potentially linked to anemia. In this regard, reducing the prevalence of anemia can be caused by more distribution of iron and folic acid supplements in rural health centers, as well as the program of flour fortification with iron and folic acid and consuming more bread in those areas [16, 82].

On the other hand, uncontrolled and unsupervised supplement consumption may be ineffective due to a lack of compliance or regularity [69]. Adherence to supplements is very different and influenced by demographic, social and health factors [83,84,85,86,87,88] and this reason can cause differences in different regions of Iran. According to reports, some of the key causes of anemia among Iranian children are factors related to nutrition and low iron intake [89].

Our findings align with Kadivar et al.’s study in Fars (southwest Iran) and Karimi et al.’s study in Yazd (central Iran). Similar to studies from different countries, we found no relationship between IDA and gender in young children [90,91,92,93]. It is also possible that these children have young mothers with frequent pregnancies, which cause depletion in iron stores, lower birth weight, IDA in the newborn and a higher probability of premature delivery [90]. However, because boys are born with less iron sources due to their higher weight at birth, and also because boys are exposed to more infections than girls, so male babies are at a greater risk of ID [94].

Strengths and limitations

We conducted the first umbrella meta-analysis to summarize the results of contemporary studies on the prevalence of IDA in young children and pregnant women in Iran. We conducted the umbrella systematic review and meta-analysis on IDA prevalence in young Iranian children and pregnant women. However, some limitations exist. All included studies had cross-sectional meta-analysis designs, limiting our review given the observational nature. This means that it is not possible to obtain the cause-and-effect relationship from the results. The small number of subjects entered was another limitation. Also, the number of studies on children under six years old was very small. In addition, no study was found in adolescents and young people of reproductive age and puberty. The overlap of studies among meta-analyses increased the weight of studies that were included multiple times in separate meta-analyses. This can be accounted as a major limitation of our umbrella meta-analysis, which is unavoidable and may affect the overall result and confound the findings. Given the above, any interpretation must take this limitation into account. Moreover, using sensitivity analysis, we examined how the overall ES would be affected if we removed a particular meta-analysis study. Sensitivity analysis revealed no significant effect of excluding each study on the pooled ES. As recommended in the Cochrane Handbook [95], when there is a significant overlap, samples from meta-analyses are preferably identified based on individual data when available. Since the number of our studies was small, we preferred to maximize the sample size.


The present umbrella review results estimated that Iran is in the mild level of IDA prevalence based on WHO classification. However, due to sanctions and high inflation in Iran, the prevalence of anemia is expected to increase in recent years. By understanding IDA’s prevalence in Iran, the authorities can improve strategies toward reaching the WHO target of a 50% diminution in anemia in reproductive-age women by 2025. Identifying local determinants and finding ways to improve the implementation of contextually appropriate strategies in IDA is very important to achieve global health goals. The causes of anemia are multifactorial, including infectious diseases, a complex interaction between nutrition, and other factors. This complexity leads to a challenge to effectively address the determining factors. Effective policy making and improving the implementation of appropriate strategies at the population level and reducing the knowledge gap in research will help reduce the burden of this disease in low-resource settings. Due to sanctions and high inflation in Iran, the prevalence of anemia is expected to increase in recent years. Our findings can improve evidence-informed decision-making, guide future research, and optimize programs aimed at preventing and controlling IDA in the most vulnerable population groups. Since systematic review and meta-analysis studies never replace national studies, it is recommended to design and implement a national study to estimate accurate statistics of the prevalence of anemia and its related factors in each geographical region of Iran.

Data availability

Data is provided within the manuscript or supplementary information files.


  1. Fatin A-S, et al. Prevalence of iron deficiency and iron deficiency anemia among females at university stage. J Med Lab Diagnosis. 2011;2(1):5–11.

    Google Scholar 

  2. WHO. Global nutrition targets 2025: anaemia policy brief. World Health Organization; 2014.

  3. Özdemir N. Iron deficiency anemia from diagnosis to treatment in children. Turkish Archives Pediatr, 2015. 50(1).

  4. Camaschella C. New insights into iron deficiency and iron deficiency anemia. Blood Rev. 2017;31(4):225–33.

    Article  CAS  PubMed  Google Scholar 

  5. Abbaspour N, Hurrell R, Kelishadi R. Review on iron and its importance for human health. J Res Med Sciences: Official J Isfahan Univ Med Sci. 2014;19(2):164.

    Google Scholar 

  6. Bathla S, Arora S. Prevalence and approaches to manage iron deficiency anemia (IDA). Crit Rev Food Sci Nutr. 2022;62(32):8815–28.

    Article  CAS  PubMed  Google Scholar 

  7. WHO. Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia 2008.

  8. Breymann C. Iron Deficiency Anemia in pregnancy. Semin Hematol. 2015;52(4):339–47.

    Article  PubMed  Google Scholar 

  9. Buzyan L. Mild anemia as a protective factor against pregnancy loss. Int J Risk Saf Med. 2015;27(s1):S7–8.

    Article  PubMed  Google Scholar 

  10. Sharma J. Nutritional anaemia during pregnancy in non-industrialized countries: progress in obstetrics and gynaecology. Spain: Churchill Livingstone; 2003.

    Google Scholar 

  11. Balarajan Y, et al. Anaemia in low-income and middle-income countries. Lancet. 2011;378(9809):2123–35.

    Article  PubMed  Google Scholar 

  12. Masukume G, et al. Risk factors and birth outcomes of anaemia in early pregnancy in a nulliparous cohort. PLoS ONE. 2015;10(4):e0122729.

    Article  PubMed  PubMed Central  Google Scholar 

  13. De Benoist B et al. Worldwide prevalence of anaemia 1993–2005; WHO Global Database of anaemia 2008.

  14. Christensen R, Ohls R. Anaemias unique to pregnancy and the perinatal period. Wintrobe’s Clin Hematol. 2004;2:1467–86.

    Google Scholar 

  15. Stevens GA, et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995–2011: a systematic analysis of population-representative data. Lancet Global Health. 2013;1(1):e16–25.

    Article  PubMed  Google Scholar 

  16. Barooti E, et al. Prevalence of iron deficiency anemia among Iranian pregnant women; a systematic review and meta-analysis. J Reprod Infertility. 2010;11(1):17.

    CAS  Google Scholar 

  17. Shams S, Ahmad Z, Wadood A. Prevalence of iron deficiency anemia in pregnant women of district Mardan Pakistan. J Preg Child Health. 2017;4(6):1–4.

    Google Scholar 

  18. WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. World Health Organization; 2011.

  19. WHO. The database on anaemia includes data by country on prevalence of anaemia and mean haemoglobin concentration. Vitamin and Mineral Nutrition Information System. Geneva. World Health Organization; 2007.

  20. Zamani M, et al. Prevalence and determinants of anemia among Iranian population aged ≥ 35 years: a PERSIAN cohort-based cross-sectional study. PLoS ONE. 2022;17(2):e0263795.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Liberati A, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151(4):pW–65.

    Article  Google Scholar 

  22. Munn Z, et al. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. JBI Evid Implement. 2015;13(3):147–53.

    Google Scholar 

  23. Shea BJ et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ, 2017. 358.

  24. Guyatt GH, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Higgins J et al. Cochrane handbook for systematic reviews of interventions: John Wiley & Sons Chichester, UK.[Google Scholar], 2019.

  26. Egger M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics, 1994: p. 1088–101.

  28. Doleman B, et al. Funnel plots may show asymmetry in the absence of publication bias with continuous outcomes dependent on baseline risk: presentation of a new publication bias test. Res Synthesis Methods. 2020;11(4):522–34.

    Article  Google Scholar 

  29. James SL, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the global burden of Disease Study 2017. Lancet. 2018;392(10159):1789–858.

    Article  Google Scholar 

  30. Karimi P et al. Association of Iron Deficiency Anemia and Febrile Seizure in Asia: a systematic review and Meta-analysis. Iran J Neonatology, 2018. 9(1).

  31. Mahadev S, et al. Prevalence of celiac disease in patients with iron deficiency anemia—a systematic review with meta-analysis. Gastroenterology. 2018;155(2):374–82. e1.

    Article  PubMed  Google Scholar 

  32. Shabani E et al. The relationship between the level of iron serum and the development of cardiovascular disease in Iran: A systematic review and meta-analysis Macro ergonomics: An approach to improve safety effi ciency and the quality of working life, 2017: p. 303.

  33. Rahmati S, et al. Maternal anemia and pregnancy outcomes: a systematic review and meta-analysis. Int J Pediatr. 2016;4(8):3323–42.

    CAS  Google Scholar 

  34. Sayehmiri K, et al. The prevalence of anemia in first, second and third trimester of pregnancy in Iran: a systematic review and meta-analysis. Iran J Obstet Gynecol Infertility. 2015;18(168):7–15.

    Google Scholar 

  35. Sayehmiri K, et al. The prevalence of iron deficiency anemia during pregnancy in Iran (1991–2015): a systematic review and meta-analysis. Epidemiol Health Syst J. 2015;2(4):221–32.

    Google Scholar 

  36. Azami M et al. The prevalence of anemia among pregnant women in Iran (2005–2016); a systematic review and meta-analysis study. J School Public Health Inst Public Health Res, 2016. 14(1).

  37. Azami M, Darvishi Z, Sayehmiri K. Systematic review and meta-analysis of the prevalence of anemia among pregnant Iranian women (2005–2015). 2016.

  38. Akbari M, et al. Estimation of iron deficiency anemia in Iranian children and adolescents: a systematic review and meta-analysis. Hematology. 2017;22(4):231–9.

    Article  CAS  PubMed  Google Scholar 

  39. Nazari M et al. Prevalence of iron deficiency anemia in Iranian children under 6 years of age: a systematic review and meta-analysis. J Blood Med, 2019: p. 111–7.

  40. Shea BJ, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7(1):1–7.

    Article  Google Scholar 

  41. Umeta M et al. Iron deficiency anaemia among women of reproductive age in nine administrative regions of Ethiopia. Ethiop J Health Dev, 2008. 22(3).

  42. Habib MA, et al. Prevalence and determinants of iron deficiency anemia among non-pregnant women of reproductive age in Pakistan. Asia Pac J Clin Nutr. 2018;27(1):195–203.

    PubMed  Google Scholar 

  43. Keskin Y, et al. Prevalence of iron deficiency among schoolchildren of different socio-economic status in urban Turkey. Eur J Clin Nutr. 2005;59(1):64–71.

    Article  CAS  PubMed  Google Scholar 

  44. Rajaratnam J, et al. Maternal anaemia: a persistent problem in rural Tamil Nadu. Natl Med J India. 2000;13(5):242–5.

    CAS  PubMed  Google Scholar 

  45. Asobayire FS, et al. Prevalence of iron deficiency with and without concurrent anemia in population groups with high prevalences of malaria and other infections: a study in Cote d’Ivoire. Am J Clin Nutr. 2001;74(6):776–82.

    Article  CAS  PubMed  Google Scholar 

  46. Taha A, et al. Iron deficiency anaemia in reproductive age women attending obstetrics and gynecology outpatient of university health centre in Al-Ahsa, Saudi Arabia. Afr J Tradit Complement Altern Med. 2014;11(2):339–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Lozoff B, et al. The effects of short-term oral iron therapy on developmental deficits in iron-deficient anemic infants. J Pediatr. 1982;100(3):351–7.

    Article  CAS  PubMed  Google Scholar 

  48. Tembhare A, et al. Socio-demographic determinants associated with iron deficiency anemia inpregnancy in rural population of central India. Int J Biomed Adv Res. 2015;6(12):6.

    Google Scholar 

  49. Shamah-Levy T, et al. Anemia in Mexican women: a public health problem. Salud Publica Mex. 2003;45(Suppl 4):S499–507.

    Article  PubMed  Google Scholar 

  50. Korenromp EL, et al. Impact of malaria control on childhood anaemia in Africa–a quantitative review. Tropical Med Int Health. 2004;9(10):1050–65.

    Article  Google Scholar 

  51. Holst M. Developmental and behavioral effects of iron deficiency anemia in infants. Nutrition today (USA); 1998.

  52. Abd Rahman R, et al. The prevalence and risk factors of Iron Deficiency Anemia among pregnant women in Malaysia: a systematic review. Front Nutr. 2022;9:847693.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Lim SS, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the global burden of Disease Study 2010. Lancet. 2012;380(9859):2224–60.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Anand T, et al. Issues in prevention of iron deficiency anemia in India. Nutrition. 2014;30(7–8):764–70.

    Article  PubMed  Google Scholar 

  55. Jeremiah ZA, Buseri FI, Uko EK. Iron deficiency anaemia and evaluation of the utility of iron deficiency indicators among healthy Nigerian children. Hematology. 2007;12(3):249–53.

    CAS  PubMed  Google Scholar 

  56. Gofin R, Palti H, Adler B. Time trends of haemologbin levels and anaemia prevalence in infancy in a total community. Public Health. 1992;106(1):11–8.

    Article  CAS  PubMed  Google Scholar 

  57. Safavi M, et al. Prevalence of iron deficiency anemia among Iranian pregnant women, Spring 2001. Iran J Epidemiol. 2006;2(3):1–10.

    Google Scholar 

  58. Sayyari A, Eslam RS, Abdollahi Z. Prevalence of anaemia in 2-12-year-old Iranian children EMHJ-Eastern Mediterranean Health Journal, 12 (6), 804–808, 2006, 2006.

  59. WHO. WHO. Nutrition Landscape Information System (NLiS) Country Profile: Iran (Islamic Republic of). World Health Organization, Department of Nutrition and Food Safety, Geneva, Switzerland 2024.

  60. Pouraram H, et al. Second national integrated micronutrient survey in Iran: study design and preliminary findings. Arch Iran Med. 2018;21(4):137–44.

    PubMed  Google Scholar 

  61. Pouraram H, et al. Long-term consequences of iron-fortified flour consumption in nonanemic men. Annals Nutr Metabolism. 2012;60(2):115–21.

    Article  CAS  Google Scholar 

  62. Sadighi J, et al. Flour fortification with iron: a mid-term evaluation. Public Health. 2008;122(3):313–21.

    Article  PubMed  Google Scholar 

  63. Abtahi M, et al. Iron-fortified flour: can it induce lipid peroxidation? Int J Food Sci Nutr. 2014;65(5):649–54.

    Article  CAS  PubMed  Google Scholar 

  64. Ghassemi H, Harrison G, Mohammad K. An accelerated nutrition transition in Iran. Public Health Nutr. 2002;5(1a):149–55.

    Article  PubMed  Google Scholar 

  65. Mirmiran P, et al. Nutritional knowledge, attitude and practice of tehranian adults and their relation to serum lipid and lipoproteins: Tehran lipid and glucose study. Annals Nutr Metabolism. 2010;56(3):233–40.

    Article  CAS  Google Scholar 

  66. Abdi F, et al. Review of nutritional status in Iranian population. Focus Sci. 2016;2(3):1–4.

    Article  Google Scholar 

  67. Jessri M, et al. Comparison of trends in dietary pattern in Iran, Middle Eastern and North African countries from 1961 to 2005. Pajoohandeh J. 2011;16(1):1–10.

    Google Scholar 

  68. Abdollahi M, et al. Shares of energy and nutrients intakes from subsidized food items in Iranian households in different socio-economic status. Iran J Nutr Sci Food Technol. 2011;6(1):43–56.

    Google Scholar 

  69. Bondarianzadeh D, et al. Low compliance with the iron supplementation program among pregnant women in the rural areas of Kerman District, IR Iran. Nutr Res. 1998;18(6):945–52.

    Article  CAS  Google Scholar 

  70. Abdollahi Z, et al. Efficacy of flour fortification with folic acid in women of childbearing age in Iran. Annals Nutr Metabolism. 2011;58(3):188–96.

    Article  CAS  Google Scholar 

  71. Preziosi P, et al. Effect of iron supplementation on the iron status of pregnant women: consequences for newborns. Am J Clin Nutr. 1997;66(5):1178–82.

    Article  CAS  PubMed  Google Scholar 

  72. Menendez C, et al. The effects of iron supplementation during pregnancy, given by traditional birth attendants, on the prevalence of anaemia and malaria. Trans R Soc Trop Med Hyg. 1994;88(5):590–3.

    Article  CAS  PubMed  Google Scholar 

  73. Peña-Rosas JP, Viteri FE. Effects and safety of preventive oral iron or iron + folic acid supplementation for women during pregnancy. Cochrane Database Syst Reviews, 2009(4).

  74. Dibley MJ, et al. Iron and folic acid supplements in pregnancy improve child survival in Indonesia. Am J Clin Nutr. 2012;95(1):220–30.

    Article  CAS  PubMed  Google Scholar 

  75. WHO. Standards for maternal and neonatal care 2007.

  76. Hirve S, et al. Delivering sprinkles plus through the Integrated Child Development Services (ICDS) to reduce anemia in pre-school children in India. Indian J Pediatr. 2013;80:990–5.

    Article  PubMed  Google Scholar 

  77. Charles DH, et al. Folic acid supplements in pregnancy and birth outcome: re-analysis of a large randomised controlled trial and update of Cochrane review. Paediatr Perinat Epidemiol. 2005;19(2):112–24.

    Article  PubMed  Google Scholar 

  78. Christian P, et al. Supplementation with micronutrients in addition to iron and folic acid does not further improve the hematologic status of pregnant women in rural Nepal. J Nutr. 2003;133(11):3492–8.

    Article  CAS  PubMed  Google Scholar 

  79. Team NA. Nepal nutrition assessment and gap analysis. 2009.

  80. Sharma JB, et al. A prospective, partially randomized study of pregnancy outcomes and hematologic responses to oral and intramuscular iron treatment in moderately anemic pregnant women. Am J Clin Nutr. 2004;79(1):116–22.

    Article  CAS  PubMed  Google Scholar 

  81. Kavle JA, Landry M. Community-based distribution of iron–folic acid supplementation in low-and middle-income countries: a review of evidence and programme implications. Public Health Nutr. 2018;21(2):346–54.

    Article  PubMed  Google Scholar 

  82. Torheim LE et al. Women in resource-poor settings are at risk of inadequate intakes of multiple micronutrients. J Nutr, 2010. 140(11): p. 2051S-2058S.

  83. Nilsen RM, et al. Patterns and predictors of folic acid supplement use among pregnant women: the Norwegian mother and child cohort study. Am J Clin Nutr. 2006;84(5):1134–41.

    Article  CAS  PubMed  Google Scholar 

  84. Timmermans S, et al. Determinants of folic acid use in early pregnancy in a multi-ethnic urban population in the Netherlands: the Generation R study. Prev Med. 2008;47(4):427–32.

    Article  CAS  PubMed  Google Scholar 

  85. Cogswell ME, Kettel-Khan L, Ramakrishnan U. Iron supplement use among women in the United States: science, policy and practice. J Nutr. 2003;133(6):S1974–7.

    Article  Google Scholar 

  86. Knudsen VK, et al. Iron supplement use among Danish pregnant women. Public Health Nutr. 2007;10(10):1104–10.

    Article  PubMed  Google Scholar 

  87. Lutsey PL, et al. Iron supplementation compliance among pregnant women in Bicol. Philippines Public Health Nutr. 2008;11(1):76–82.

    Article  PubMed  Google Scholar 

  88. Seck BC, Jackson RT. Determinants of compliance with iron supplementation among pregnant women in Senegal. Public Health Nutr. 2008;11(6):596–605.

    Article  PubMed  Google Scholar 

  89. Sh D, Derakhshan R. The prevalence of iron deficiency anemia in children 6 – 4 years old in Rafsanjan City in 2005. J Rafsanjan Univ Med Sci. 2007;6:109–14.

    Google Scholar 

  90. Keikhaei B, et al. Iron-deficiency anemia among children in southwest Iran. FoodNutr Bull. 2007;28(4):406–11.

    Google Scholar 

  91. Kadivar MR, et al. Prevalence of iron deficiency anemia in 6 months to 5 years old children in Fars, Southern Iran. Med Sci Monit. 2003;9(2):100–4.

    Google Scholar 

  92. Karimi M, Mirzaei M, Dehghani A. Prevalence of anaemia, iron deficiency and iron deficiency anaemia in a 6–60 months old population of Yazd rural area (2000–2001). Haema. 2003;6(4):503–18.

    Google Scholar 

  93. Gunnarsson BS, Thorsdottir I, Palsson G. Iron status in 2-year-old Icelandic children and associations with dietary intake and growth. Eur J Clin Nutr. 2004;58(6):901–6.

    Article  CAS  PubMed  Google Scholar 

  94. Domellöf M, et al. Sex differences in iron status during infancy. Pediatrics. 2002;110(3):545–52.

    Article  PubMed  Google Scholar 

  95. Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. The Cochrane Collaboration London, UK, 2011.

Download references


This investigation was undertaken as a Ph.D. thesis by the first author, approved by and registered with the Research Vice Chancellery of Tabriz University of Medical Sciences, Tabriz, Iran (Ethics Code: IR.TBZMED.REC.1401.032).


This study was funded by the Nutrition Research Center of Tabriz University of Medical Sciences, Tabriz, Iran (Grant No.: 69140).

Author information

Authors and Affiliations



A.D. and R.MG. conducted the search and data extraction and A.D. and R.KhZ. screened the studies. A.D. and F.MN. drafted the manuscript; M.R. and F.MN. commented on subsequent revisions. All authors read and approved the final content.

Corresponding author

Correspondence to Maryam Rafraf.

Ethics declarations

Ethics approval and consent to participate

This investigation was undertaken as a part of Ph.D. thesis titled “Policy analysis and development of upcoming policy options for the prevention of IDA in Iran,” approved by and registered with the Research Vice Chancellery of Tabriz University of Medical Sciences, Tabriz, Iran (Ethics Code: IR.TBZMED.REC.1401.032; Grant No.: 69140). As the present study is an umbrella systematic review and meta-analysis, the consent to participate is not applicable.

Consent for publication

Not applicable.

Conflict of interest

The authors declare no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary Material 2

Supplementary Material 3

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dehghani, A., Molani-Gol, R., Rafraf, M. et al. Iron deficiency anemia status in Iranian pregnant women and children: an umbrella systematic review and meta-analysis. BMC Pregnancy Childbirth 24, 381 (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: