This cohort analysis of the WOMAN-2 trial examined 14,444 women with moderate or severe anemia across Nigeria, Pakistan, Tanzania, and Zambia (Aug 2019–Sep 2023), investigating how maternal hemoglobin concentration at admission for vaginal birth relates to the risk of delivering a small vulnerable newborn (SVN: preterm, low birthweight, or small for gestational age).
39.5% (5,703/14,444) of newborns were SVNs. Compared to Hb 90–99 g/L, the adjusted odds of SVN roughly doubled at Hb 50–59 g/L (aOR 2.00, 95% CI 1.64–2.43) and more than doubled at Hb <50 g/L (aOR 2.51, 95% CI 1.85–3.41); the gradient was steep below 80 g/L.
- Study enrolled only women with moderate-to-severe anemia, so findings may not generalize to milder anemia or well-resourced settings. - Cohort analysis of a trial population may carry residual confounding despite multivariable adjustment. - Gestational age estimation in low-resource settings can be imprecise, affecting SGA and preterm classifications.
Pregnant women with hemoglobin below 70 g/L face markedly higher risk of delivering a small vulnerable newborn and should be prioritized for intensified monitoring and prompt treatment in high-burden settings. Screening and early correction of severe anemia could be a high-yield strategy to reduce adverse neonatal outcomes.
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