Feature Articles

Women & Anemia: Childbirth and Postpartum Anemia

October 9, 2008
This three part series on Women & Anemia discusses a few common causes of anemia unique to women, including heavy menstrual bleeding, pregnancy and child delivery. Part 3 focuses on postpartum anemia following childbirth. Part 1 | Part 2
Dr. Indu Lew's Story

A working mother and wife, a pharmacist, and a well respected anemia expert herself, Indu learned first-hand what many of her patients had already experienced: what it was like to suffer from anemia. Indu was a woman with seemingly boundless energy, but following the birth of her second child via caesarian section she experienced unexpected heavy bleeding. Blood tests revealed she was severely anemic. She chose not to receive a blood transfusion and was discharged from the hospital with her newborn son and instructions to take her iron pills three times a day.

Importance of Taking Medication

Indu’s experience as a pharmacist taught her the importance of taking her medication as directed, but she was unable to take her iron pills three times a day as directed. “I often told my patients that they needed to take their medication, but I was unable to take my iron pills regularly. They gave me stomach cramps and constipation that I could not tolerate. I did the best I could, but I am sure that my non-compliance caused my anemia to go on longer than necessary.”

Dealing with Fatigue

It took Indu eight long months to recover from her anemia. She would wake up in the morning with overwhelming feelings of exhaustion and would often need to lie down for a rest. She frequently felt cold, lightheaded, and her heart would race whenever she exerted herself in any way. Even simple things like showering, dressing, or eating a meal were difficult for Indu. She was not able to breastfeed her newborn son as long as she had wanted to because of the fatigue. Luckily, Indu’s supportive husband and mother were able to step in and help. After 6 months, Indu was able to go back to work. It was a struggle, but eventually her energy returned and she began to feel like herself again.

Indu’s recovery from anemia took longer than average since she chose not to receive a transfusion and at the time she gave birth, doctors were not yet using erythropoietin and intravenous iron as options for postpartum anemia. Therefore, her very severe anemia was treated only with sporadic oral iron therapy and an iron-rich diet. She had to rely on her body’s natural production of red blood cells to correct her anemia.

Understanding the Difficulties of Anemia

Indu can attest to the difficulties anemia poses after childbirth, describing her battle with postpartum anemia as, “A life changing experience – I could truly understand how my patients felt and all they were dealing with. I’ve been there.”

Luckily today there are more options for women. Indu and other health professionals are ready to help patients successfully treat their anemia.

The postpartum period can be a wonderful yet challenging time for new moms experiencing profound physical and emotional changes after giving birth. Recovering from the birth, taking care of a new baby as well as herself requires a lot of energy. Frequent tiredness is expected during the six or so weeks after childbirth, however, new moms should be concerned when their fatigue is disabling, lasts more than six weeks after delivery, stops them from performing normal activities, and worries family members. If these symptoms are present, the new mother may have what’s called postpartum anemia. It is most likely caused by iron deficiency.

Be concerned about fatigue if:
  • It remains disabling
  • Lasts more than six weeks after delivery
  • Stops you from performing normal activities
  • Worries family members

New mothers are at a greater risk for postpartum anemia if they were anemic during the third trimester of pregnancy, lost a large amount of blood during childbirth, or had twins or other multiple births.1 Depending on the amount of blood lost, these women may experience dizziness, fatigue, infections, problems with breast feeding and a need for a longer hospital stay.2

Dr. Indu Lew, PharmD, anemia expert, and Director of Education and Research at St. Barnabas Health Care System in New Jersey, stated, “Anemia is a serious health issue, yet it often goes undiagnosed and untreated. Many women come to believe that it’s normal to feel tired, weak, or irritable—just the price they pay for leading a busy life. But iron deficiency anemia is not normal, and, if treatment isn’t started, the new mom and baby could suffer long term consequences.”

Studies show that moms with postpartum anemia have more overall symptoms, more symptoms of “maternity blues”,3 have a reduced sense of well-being,4 and are at increased risk for postpartum depression5 compared to non-anemic mothers. The adverse effects of the mother’s altered mood and behavior are especially worrisome because disturbed maternal-infant interactions during this period may have lasting negative effects on early childhood development.6 Lew quoteMothers who still suffer from iron deficiency ten weeks after childbirth are less responsive to and more controlling of their infants, leading to developmental delays, which may be irreversible.7 Fortunately, postpartum anemia is treatable and can be prevented.

Prevention and Treatment of Anemia

The first line of defense against postpartum iron deficiency anemia is prevention. Pregnant women should be taking in extra iron to build up their stored iron and provide enough for the growing baby. For more information about iron, see our feature articles about an Increased Need for Iron During Pregnancy and The Important Role of Iron in nutrition.

Your doctor will evaluate your blood following the birth of your baby. If your iron or hemoglobin levels are low, your doctor can offer several options for increasing it. Some possible options include a blood transfusion, intravenous iron treatment, or injections of a drug (erythropoietin) which helps your body create more red blood cells. Your doctor may also recommend for you to continue taking prenatal vitamins, supplemental iron pills, and to eat a diet high in iron rich foods. It’s important to discuss these options thoroughly with your doctor in order to make the best decision for your particular circumstances.

Mom and babyThe time period for recovery from anemia is variable and depends on the severity of the anemia, the treatment chosen, and the patient. If you receive a transfusion, your recovery is very rapid, since you are receiving the mature red blood cells you need. If you choose intravenous iron and/or the erythropoietin, your recovery depends on your iron levels and how fast your body produces the red blood cells you need. It takes about 7 to 10 days to make a new red blood cell.8 The erythropoietin will increase the amount of cells your body makes at one time, and you should start feeling better in 1-2 weeks. If you choose oral iron or dietary treatment this may take a little bit longer before you start to feel better. With appropriate iron supplementation, your blood levels should be back to normal within 3 months.9

Helpful Tips

If you are having difficulty taking your iron supplements due to nausea, vomiting, constipation or diarrhea, there are strategies to help. Rather than stopping and risking a longer recovery, start with half the recommended dose and gradually increase to the full dose to help minimize these side effects. Taking the supplement in divided doses and with food also may help limit these symptoms. Iron from enteric coated or delayed-release preparations may have fewer side effects, but is not as well absorbed.10

Having Trouble Taking Iron?
  • Take a half-dose, then gradually increase to the full dose prescribed
  • Divide each dose of iron into smaller doses taken more frequently
  • Take the full supplement doses with food

If you are suffering from the extreme fatigue that sometimes accompanies anemia, help is available. Often times, your family, church, school, and neighborhood friends can spare some time to help out so you can get some rest. Hiring a teenager or mother’s helper to help with daily chores is another option. Consider having groceries delivered if that service is available where you live. Consult with your doctor or nurse practitioner for advice on breastfeeding and other available resources.

Becoming a mother can be very rewarding, but fatigue due to postpartum anemia is a serious health issue. Be sure to discuss with your doctor your blood tests, iron levels and any fatigue you may be having while pregnant or after childbirth. Diagnosing and treating anemia in a timely manner will help speed up your recovery following childbirth and allow you to focus on the important matters of caring for and raising your child.

For more information about iron, see our feature articles about an Increased Need for Iron During Pregnancy and the Important Role of Iron in nutrition. The National Institutes of Health’s Office of Dietary Supplements also offers an online iron fact sheet.


  1. Centers for Disease Control and Prevention. Recommendations to Prevent and Control Iron Deficiency in the United States. MWR 1998; 47(No. RR-3):25.
  2. Breymann C, Zimmermann R, Huch R, Huch A. Use of recombinant human erythropoietin in combination with parenteral iron in the treatment of postpartum anaemia. European Journal of Clinical Investigation 1996; 26: 123-13.
  3. Meyer J, Eichorn Karl-Heinz, Vetter K, Christen S, Schleusner E, Klos A, Huch R. Journal Perinat Med 1995; 23:99-109.
  4. Mamelle N. Gerin P, Measson A, Munoz F, Collet P. Assessment of psychological modifications during pregnancy: contribution of Derogatis Symptom check-list (SCL 90-R). Journal of Psychosomatic Obstetrics and Gynaecology 1987;7:39-50.
  5. Corwin EJ, Murray-Kolb LE, Beard JL. Low hemoglobin level is a risk factor for postpartum depression. J Nutr. 2003 Dec;133(12):4139-42.
  6. Bodnar LM, Cogswell ME, Scanlon KS. Low income postpartum women are at risk of iron deficiency. J Nutr. 2002 Aug;132(8):2298-302.
  7. Perez EM, Hendricks MK, Beard JL, Murray-Kolb LE, Berg A, Tomlinson M, Irlam J, Isaacs W, Njengele T, Sive A, Vernon-Feagans L. Mother-infant interactions and infant development are altered by maternal iron deficiency anemia. J Nutr. 2005 Apr;135(4):850-5.
  8. MacKinney A. Hematology for Students. New York, NY: Martin Dunitz; 2001:p17. Link.
  9. Atkinson L, Baxlet E. Postpartum fatigue. American Family Physician July 1994. Link.
  10. National Institute of Health. Office of Dietary Supplements. Dietary Supplement Fact Sheet : Iron. Link.