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Saturday, 14 November 2015

Why You Never Need A Tetanus Vaccine

Why You Never Need A Tetanus Vaccine, Regardless of Your Age or Location

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By Dave Mihalovic
As with most vaccines, we have been led to believe that a tetanus shot is a necessity to protect us from a supposedly virulent germ that can lead us to our death. When we carefully consider some of the facts on tetanus reported in the medical literature, we find many contradictions, inconsistencies and even falsities in relation to actual facts on the bacteria that produces the neurotoxin. If spores of the bacteria have been found in vast numbers of wounds without producing any tetanus, then why is it considered such a threat at all?
Tetanus is unique among the so-called vaccine-preventable diseases as it is not communicable and therefore the ‘herd immunity’ argument is not applicable. Tetanus as a clinical entity is linked to the bacterium Clostridium tetani, however this bacterium is recovered from a wound in only 30% of cases, and is often isolated from patients who have not developed tetanus.
The tetanus bacterium is ubiquitous. It is not here today gone tomorrow. It is found on the surface of the body, in the mouth, in the gastro-intestinal tract, in house dust and clothing. It occurs extensively in cultivated soils. The organism lives as a harmless commensal in the gut of many animals, in addition to humans (rural residents tend to have higher rates of intestinal carriage than city dwellers). In spite of the ubiquity of the so-called cause, the incidence of tetanus is significantly low.
It is not the bacterium itself that causes the development of tetanus but the toxins it produces under anaerobic conditions. “Under normal conditions, no disease will occur if spores are introduced into a wound.”(J. Ark Med Soc Vol 80, No 3 p134) and “It is the compromised host, or traumatised patient, either by surgery or accident, who is most apt to develop tetanus.” (J Foot Surgery Vol 23, No 3 p235).
The clostridium tetani is relatively innocuous but it elaborates a certain toxin, tetanospasmin, the effects of which are hard to determine. Drs. Cecil and Loeb, in their Textbook of Medicine, say “Tetanus toxin fails to produce any recognisable pathological lesions in the tissues it affects, nor do any specific changes occur at the site of infection by the clostridium tetani.”
Let us consider some of the facts reported in the medical literature in 1920, Sir Leonard Hill said in a report to the Medical Research Committee, “Tetanus and gas gangrene bacilli washed clean and injected are innocuous.” In ‘A System of Bacteriology’ Vol III, page 307, Drs Bosanquet and Eyre say “The bacilli are in pure culture incapable of vegetating in viro,” ie of multiplying in the body. Furthermore, in the Official History of the War, Pathology 1923, it is stated “Tetanus bacilli have been found in 20% of war wounds although no symptoms of tetanus were present, ” and “in 50% of undoubted tetanus cases the bacilli have been undiscoverable.” In the same volume also appears clostridium tetani has been “cultivated from the wound of a man showing no evidence of tetanus, 882 days after it had been inflicted,” and “it has been realised during the war that the tetanus bacillus or its spores may be present in vast numbers of wounds without producing tetanus.”
We may deduce from the above facts that we have, as the cause of tetanus, a bacterium which is (a) harmless in pure culture (b) incapable of multiplying in the body (c) absent in 50% of cases of undoubted tetanus (d) present in 20% of cases where no tetanus symptoms appeared and often remaining in the body for months or years without producing symptoms. This is certainly a peculiar cause.
It is thought that whilst the bacteria themselves are somewhat feeble, their spores may remain dormant in the tissues for lengthy periods. If this is so, what are the factors which enable the spores to develop into bacteria and elaborate their toxins? What causes them to become active? Why do they remain dormant for long periods? As yet the answers to these questions are not forthcoming. They could supply the answer to the cause of the disease, in fact, all disease, for these questions obviously concern the host rather than the bacteria, and it is to the host that we must look for causes. Here we will find the cause of tetanus, not in some microscopic piece of protoplasm which we endow with almost omnipotent properties. Bacterial diseases, so-called, have a biochemical basis. The tetanus bacteria may be a factor in tetanus. The toxin may be involved in some way but that these are fundamental causes is nonsense, otherwise the disease would be more common, in view of the fact that the bacteria is so frequently found on and in our bodies.
The geographical distribution of tetanus across the globe generally follows the areas of moist, warm climate and fertile soil — the highest rates occur in the developing world, particularly in countries near the equator.
Most people associate tetanus with the wound from a rusty nail or deep puncture wound where it is difficult for oxygen to reach. These kind of wounds account for just over half of the cases in the developed countries, as other causes have been observed, i.e. middle-ear infection, tonsillitis, appendicitis, dental infection, abortions and in some cases there is neither a history of injury, nor a detectable wound! Also laboratory investigations frequently produce negative results.
What is the real cause of tetanus? How may it be prevented, and how may a patient recover once tetanus has developed? The real cause of tetanus is not a germ, but dirt and filth. The bacteria are harmless when placed into a surgically clean wound. Tetanus develops when drainage of a wound is checked and dirt is retained in the tissues. The bacilli do not circulate in the blood. They remain at the point of entry and produce toxins. One of these poisons, tetanospasmin, is one of the most dangerous poisons known to man which occasions vigorous activity in the nervous tissues. The other toxin, tetano-lycin, occasions a breakdown of the blood cells. If good drainage is facilitated from the beginning, tetanus will not result from a wound. If tetanus has developed, an incision should be made to afford drainage, removing the foreign matter, and once the wound is drained and cleaned, the bacteria will not be able to elaborate the powerful toxins which are poison in the body. Once the poisoning ceases, the patient will start to recover. The ability to combat, destroy and eliminate the toxins will depend on the health and vigour of the patient. The patient suffering from tetanus should be put to bed, permitted to rest, kept warm and fasting should be immediately instituted. They should receive all the salubrious hygienic influences and the fasting should be continued until all symptoms have disappeared. Wounds should never be permitted to become pent-up. Drainage must be afforded, and if this is done, there is no danger.
Types of Tetanus
A 1940 text still provides some of the most valuable information on Tetanus that there is. It was written before antibiotics, and at a time when people had a very thorough knowledge of tetanus.

There are five kinds of tetanus.
All can be preceded by nonspecific premonitory symptoms such as restlessness, irritability and headache.
1) Subacute tetanus which is characterised by some degree of neck stiffness involving the muscles at the back of the neck; spasticity, as well as increased muscle stretch reflexes, especially in the lower limbs. Patients usually have brief nocturnal generalised spasms.
2) Local tetanus (rare) where the contractions of the muscles are only in the area of the injury. These contractions can persist for weeks when treated by the traditional hospital method.
3) Cephalic tetanus (very rare) which can often occur after otitis media with a burst ear drum, or removal of teeth or dental work, with inappropriate wound management. (But again, host conditions determine the outcome). Clostridium tetani can be found from swabs taken from the middle ear, but sometimes the entry point can be from the cone put in the ear by the doctor to have a look, or from fingers transferring tetanus spores into the ear. The main symptoms for this form of tetanus are in the head and face area.
4) Generalised tetanus (most common sort about 80%) The symptoms start at the head and work down. Reflex spasms normally occur within 24 – 72 hours, known as the “onset time”. First the person will find it hard to open their mouth; will have a stiff neck and have difficulty swallowing.
5) Neonatal tetanus was eliminated from developed countries BEFORE either a vaccine or antibiotics were invented primarily because of basic cleanliness.
Tetanus spores are everywhere in the environment. On your bookcase, in your back yard, in clothing and house dust and in your mouth and feces. Tetanus has been known to follow surgery and innocuous procedures such as skin testing or intramuscular injections of medications and vaccinations themselves.
Clostridium bacteria are especially common in the intestines and feces of rats, guinea pigs, chickens, cats, dogs, sheep, cattle and horses. Approximately 5% of humans have clostridium tetani multiplying in their guts yet don’t even know it, although the 1940 text puts that figure at 25%.
Vaccines Do Not Prevent Tetanus
A tetanus vaccine does NOT protect you from getting tetanus. While the medical profession likes to take the credit for ALL the decline of tetanus courtesy of a vaccine, this is simply NOT true.
The proof of that lies with neonatal tetanus in the developed world, which DISAPPEARED well before the existence of either anti-toxin or a vaccine.
If we look at the documented Tetanus Mortality England & Wales from 1901 to 1999, we find that the administration of tetanus vaccine is likely to be pointless and puts children especially at risk of adverse reactions to the vaccines.
Deaths related to Tetanus and tetanus incidents overall, sharply decreased long before the vaccine was introduced widely during World War II.
Debate as to whether humans can develop circulating antitoxin against tetanus in the absence of vaccination is futile since evidence of natural immunity has been observed globally.
Although there have been conflicting results, some studies in Brazil, China, Ethiopia, India, Italy, Israel, Spain and the USSR have shown substantial proportions of unimmunised populations with detectable levels of antitoxin. Specifically, up to 80% of persons in India and up to 95% of persons in a group of Ethiopian refugees had levels of antitoxin suggestive of protection. It is admitted by medical experts that this phenomenon has not been adequately studied, and yet it is apparent that when unexpected or undesirable findings emerge, rather than acknowledging the results, it is presented as an ongoing debate!
The development of tetanus by a deep puncture injury is known not to induce any subsequent immunity, which then raises the serious question — how is a vaccine able to produce any long-term immunity? Proper and natural immunity is achieved by the ingestion of tetanus spores through natural entry, stimulating the immune system at all levels in an appropriate way. Critics of vaccination often highlight the fact that injecting foreign antigen into the body by-passes a branch of the immune system leading to a compromised host. Dr Viera Scheibner, a researcher on the ineffectiveness and dangers of vaccination, points out that any injection is a deep-puncture wound, so that is why contracting tetanus through a wound does not produce any long-term proper immunity because of the similar action to a vaccination, i.e. the by-passing of our multi-levelled immune system due to unnatural entry.
With an obvious lack of understanding on this aspect, from the world health ‘experts’ of the day, it is surprising that their general conclusion is that ‘even if natural immunity occurs in some populations, it can not be relied on to control tetanus.’ In 1973, of the estimated one million tetanus deaths throughout the world, 60 to 90% were due to neonatals (in otherwords most tetanus cases). Clearly the most simple and effective way to reduce this problem would be improved hygiene in childbirth practices, along side obvious health improvements for the population at large.
The following is taken from the Medical Press, Nov 3, 1948. “The not infrequent failure of tetanus anti-toxin prophylactically is indicated by the fact that deaths from tetanus occur in 7% of civilian cases and 50% of military cases, in spite of its use.” From the Medical History of the Second World War, Medicine and Pathology, we note, “It is disappointing to find that the case mortality is the same as in 1914-18. There is still no convincing evidence that anti-tetanic serum possesses curative value.” Many more such statements from strictly “orthodox” sources could be quoted to consolidate our claim that the serum is incapable of affording any protection against tetanus. However, we must now turn to another important aspect concerning the employment of the serum.
Is there any danger associated with the injection of the vaccine, and if there is, does any test exist which can show the probability of the development of “allergic reactions” in a particular patient. There can be serious effects following the introduction of tetanus anti-toxin into the body and there is no valid method of revealing the possibility of these side effects beforehand. Most textbooks on bacteriology point out the ‘fallibility of the intradermal sensitivity test.” The so-called allergic manifestations may appear immediately following the injection or they may be delayed for 1-14 days. Early “reactions” to toxoid include anaphylactic shock, unconsciousness and death. The later reactions may be chills, fever, urticaria, angioneurotic oedema, swollen lymph glands, pains in the muscles and joints. The anti-toxin may prove fatal but there is also another hazard associated with the dangerous yet dramatic practice of transfusing blood. Dr Meyer in his book “Side Effects of Drugs,” has this to say: “Six cases of transfusion reactions occurred in 8 recipients with blood of O donors previously vaccinated with anti-toxins (diphtheria and tetanus anti-toxins).”
They refuse to blame the drugs, vaccine and sera for the “reactions” which follow their administration, but assert that the patient was “sensitive”. All this means is that the drug was not to blame. The blame was the patient’s. He or she was “sensitive”. To a greater or lesser degree, we are all sensitive to poisons, that is, when poisons are taken into the body through any channel, an attempt is made to resist these poisons, to expel them or to neutralise them, to get rid of them, to destroy them. In the process of neutralising, expelling and resisting the poisons acute symptoms are the actions of the body, not the drug or serum, actions of the body defending itself against the poison.
Tetanus Vaccine Ingredients
There are 15 different tetanus-containing vaccines manufactured by various drug companies, which are licensed in the U.S. The tetanus containing vaccines are licensed for adults only; four are licensed for use as booster shots; one of the vaccines contains tetanus only and is licensed for use by persons age 7 years and older; and the rest are combination vaccines that may contain one or more of the following vaccines: pertussis, diphtheria, hepatitis B, Hib, polio, and/or meningococcal.
As of August 2012, there had been 22,143 adverse events in children and adults reported to the Vaccine Adverse Events Reporting System (VAERS) following tetanus or tetanus containing vaccines combined with diphtheria vaccine (TT, TD, DT) and 67 deaths.
Severe reported tetanus vaccine adverse events include shock; neuropathy; convulsions; encephalopathy; paralysis; Guillain-Barre Syndrome (GBS); and death;

The vaccine is made from the tetanus toxoid inactivated withformaldehyde. To produce the toxoid the bacterium is cultured in liquid medium in large-capacity fermenters. The medium consists of digestive enzymes of milk protein, allegedly free of contaminants, which is harvested by filtration, purified and detoxified. The vaccine also contains aluminium hydroxide or phosphate, which acts as an adjuvant (any substance used in conjunction with another to enhance its activity), and thimerorsal, a mercury-containing compound, is found in the ingredients of some of the DTaP formulations which is claimed to prevent bacterial contaminant overgrowth.
The Risks of Tetanus Vaccines Outweigh Any Benefit
According to medical literature, tetanus toxoid is one of the most potent vaccinations used routinely in children with protective levels being obtained with schedules that start in the newborn period. Apparently in contrast to the diphtheria toxoid, which is clearly impeded in the presence of passively transferred maternal anti-toxin, the tetanus toxoid has been considered to be minimally inhibited by maternal antitoxin. However, interestingly enough, studies in US have shown that infants have high levels of circulating tetanus antitoxin, well above the protective level, at 2 months of age before beginning vaccination schedules. (Barkin RM et al. DTP reactions and serologic response with a reduced dose schedule, J Pediatr 105: 189-94, 1984. — Barkin RM et al Pediatric diphtheria and tetanus toxoids vaccine. J Pediatr 106: 779-81, 1985).
In one study 11 healthy subjects receiving the tetanus booster vaccine produced a lowering of the t-lymphocyte helpers/suppressor ratio such as might be seen in patients with AIDS. (NEJM,1984, 310:198-9. Eibi MM et al Abnormal T-lymphocyte subpopulations in healthy subjects after tetanus booster.)
In an article on tetanus by Dr Kris Gaublomme, a medically qualified homeopath and vaccine researcher, he concludes with:
’The overwhelming amount of literature on tetanus toxoid vaccine adverse side-effects and the severity of those complications make it absolutely impossible to ridicule them as rare and benign. Doing so could only demonstrate a profound lack of knowledge of the literature concerned. Some medical professionals insist on having adrenalin readily available when tetanus toxoid is administered, thus admitting that the vaccination is in fact a life-threatening medical intervention, even in apparently healthy individuals. This speaks for itself. Risking one’s life by an intervention which is probably ineffective, to avoid a disease which will probably never occur, is not sound medical practice. All it takes, on a world scale, to avoid the majority of tetanus cases is clean scissors to cut the newborn’s cord. Information, soap and peroxide might do a far better job than tetanus vaccine.’
Drugs, vaccines and anti-toxins are a hazard to health. The sick cannot be poisoned into good health.
Other worthy scientific publications linking tetanus vaccines with disease:
Griffin MR, et al, “Risk of seizures and encephalopathy after immunization with the diphtheria-tetanus-pertussis vaccine,” JAMA 1990 Mar 23 30;263(12):1641-1645.
Blumberg DA, “Severe reactions associated with diphtheria-tetanus-pertussis vaccine: detailed study of children with seizures, hypotonic-hypo-responsive episodes, high fevers, and persistent crying.”Pediatrics 1993 Jun; 91(6):1158-1165. Vaccinations and Convulsions Citations.
Baraff LJ, “Infants and children with convulsions and hypotonic-hypo-responsive episodes following diphtheria-tetanus-pertussis immunization: follow-up evaluation,” Pediatrics 1988 Jun; 81(6):789-794.
Gross TP, Milstien JB, Kuritsky JN, “Bulging fontanelle after immunization with diphtheria-tetanus-pertussis vaccine and diphtheria-tetanus vaccine.” J Pediatr 1989 Mar;114(3):423-425.
Jacob J, Mannino F, “Increased intracranial pressure after diphtheria, tetanus, and pertussis immunization.” Am J Dis Child 1979 Feb;133(2):217-218.
Paradiso, G et al, “Multifocal Demyelinating Neuropathy after Tetanus Vaccine”, Medicina (B Aires), 1990, 50(1):52-54.
Walker AM, “Neurologic events following diphtheria-tetanus-pertussis immunization,” Pediatrics 1988 Mar;81(3):345-349.
Greco D, et al, “Case-control study on encephalopathy associated with diphtheria-tetanus immunization in Campania, Italy,” Bull World Health Organ 1985;63(5):919-925.
Baraff, LJ, et al, “Possible Temporal Association Between Diphtheria-tetanus toxoid-Pertussis Vaccination and Sudden Infant Death Syndrome”, Pediatr Infect Disorder, Jan-Feb 1983, 2(1): 5-6.
Flahault A, “Sudden infant death syndrome and diphtheria/tetanus toxoid/pertussis/poliomyelitis immunisation.”, Lancet 1988 Mar 12;1(8585):582-583.
Burmistrova AL, “[Change in the non-specific resistance of the body to influenza and acute respiratory diseases following immunization diphtheria-tetanus vaccine],” Zh Mikrobiol Epidemiol Immunobiol 1976; (3):89-91.
Pantazopoulos, PE, “Perceptive Deafness Following Prophylactic use of Tetanus antitoxin”, Laryngoscope, Dec 1965, 75:1832-1836.
Article originally posted at PreventDisease
Dave Mihalovic is a Naturopathic Doctor who specializes in vaccine research, cancer prevention and a natural approach to treatment.

source: http://www.naturalblaze.com/2013/05/why-you-never-need-tetanus-vaccine.html

CIRCUMCISION VS. INTACT - WHY CIRCUMCISING YOUR BABY IS WRONG.

CIRCUMCISION VS. INTACT - WHY CIRCUMCISING YOUR BABY IS WRONG.




The final cut: What parents should know about circumcision and why it’s wrong 

 



Stop Infant Circumcision


Infant Circumcision, Sexual Torture, Medical Rape, and the Marks of a Satanic-Infested Industry

Homebirth and Low Haemoglobin (iron-deficiency, anaemia, anemia, hemoglobin)

source: Home Birth Reference Site by Angela Horn http://www.homebirth.org.uk/

 

You are anaemic or have low iron levels... what are your birth options?

This page is aimed at women in the UK who are considering a home birth, but will also be relevant to anyone investgating anemia in pregnancy. It discusses when a woman is at higher-risk, and when supplements may be useful.
This page in a nutshell:
  • The standard blood screening test for anaemia, the haemoglobin count (Hb level) gives a high rate of false positives - you can have a low Hb count as a normal variation of pregnancy, or it can mean that you are iron-deficient or have some other form of anaemia which can adversely affect your health.
  • Haemoglobin levels alone are not enough to diagnose iron-deficiency anaemia. Nowadays there are more specific tests which should be used in conjunction with Hb counts.
  • If you are genuinely iron-deficient, you need accurate blood tests to confirm this, so you can start taking iron supplements and find the best one for you.
  • If your low Hb is not due to iron-deficiency, then taking iron supplements is unlikely to benefit you, and may have side-effects.
  • If you have slightly lower than average Hb but no deficiencies or other anaemias, then I cannot find any evidence that you are higher-risk.
  • Even if you are genuinely anaemic, you can still choose a homebirth - but make it an informed choice.
  • Severe haemorrhage is less likely at a homebirth, because of the reduced need for surgical delivery (caesarean and forceps/ventouse).

What's the worry about anaemia?

One of the routine blood tests in pregnancy is for iron-deficiency anaemia. This is because pregnant women need more iron than non-pregnant women - the baby needs iron, and if you don't have enough iron for both of you, your red blood cells may not be able to carry enough oxygen around your body. This can make you feel tired and sometimes breathless, as well as increasing the risk of a low birthweight baby.
The main concern for labour is that, if you are genuinely iron-deficient, your blood will not be able to carry as much oxygen as it should. You are no more likely to haemorrhage, but IF you were to suffer a severe haemorrhage, you might be in more danger than a woman whose blood was able to carry more oxygen.
It is partly for this reason that most hospitals recommend a hospital birth if you have iron-deficiency anaemia - so that you can have quick access to emergency support if you have a severe haemorrhage.
Women who are iron-deficient are thought to be at higher risk of premature labour, although some sources dispute this [Lao, 2000]. However, this seems less relevant to the home birth issue, since most women would change their plans and choose hospital birth when faced with premature labour. Another concern is the possibility of a low birthweight baby, but this is something which can be screened for separately. If you are concerned about your baby's growth, please see 'Homebirth with a suspected small baby'. Both prem labour and low birthweight babies are issues which you can consider if they start to affect your pregnancy. Therefore it seems that the main concern for women with anaemia who are considering a homebirth, is what would happen if she had a severe haemorrhage - see the discussion of PPH risks below.
Note that these are some of the risks of genuine iron-deficiency anaemia. However, many women who have a low Hb level, which is the inital screening test for anaemia, will not actually be iron-deficient; a low haemoglobin level frequently just means that your blood has become well diluted in pregnancy, which is a good sign. This is called ' normal haemodilution of pregnancy'.

What is 'normal haemodilution'?

Haemodilution literally means dilution of the blood. In pregnancy, your overall blood volume increases by up to 50%, but because your red blood cells don't increase in total volume by as much as the plasma, the red blood cells are spread more thinly. In some women, this 'dilution' is stronger than others - you can see from the extract below that estimates of the different increases vary according to which study you look at. In this situation, your haemoglobin levels might well be lower than average, but you would not see signs of iron deficiency such as a low MCV or Serum Ferritin, which are explained below.
Here's an explanation aimed at family doctors, from the UK's GP Notebook:
During pregnancy:
  • there is an increase in the total blood volume, the plasma volume and the red cell volume during pregnancy. The total blood volume increases by about 30-40% by about 34 weeks of pregnancy
  • there is a relative increase in plasma with respect to red cells - 45% increase in plasma versus 18% increase in red cells respectively. This imbalance causes a haemodilution
Normal haemodilution is a good sign, and is not something that iron supplementation can 'cure'.
Writing in the Journal of Family Practice, Alper and colleagues found that:
Standard obstetrical practice has included screening for anemia and the provision of iron supplements to anemic patients. This approach has been based on assumptions about anemia and iron deficiency that are not supported by the literature.
"In our population of prenatal patients with anemia, only 54% had an iron deficiency. Diagnostic and therapeutic approaches to screening for anemia in pregnancy should be reconsidered and further evaluated to avoid unnecessary iron therapy."

Blood Tests for Anaemia

The first 'screening' test for anaemia is the haemoglobin count, or Hb level. Until recently this was often the only test for anaemia which would routinely be given, which is perhaps why there is a 'hangover' effect and not all midwives are up to speed with the other tests.
The following tests help us to tell the difference between normal haemodilution and iron-deficiency anaemia.

Haemoglobin levels

Here is more on haemoglobin from patient.co.uk:
"Red blood cells are made in the bone marrow, and millions are released into the bloodstream each day. A constant new supply of red blood cells is needed to replace old cells that break down. Red blood cells contain a chemical called haemoglobin. Haemoglobin binds to oxygen and takes oxygen from the lungs to all parts of the body.
To constantly make red blood cells and haemoglobin you need a healthy bone marrow and nutrients such as iron and certain vitamins which we get from food."
The Hb result states how much of your blood, by weight, is haemoglobin. The result is normally given as grams per decilitre (100ml), or g/dLL, but it may also be given as grams per litre.
What should your Hb level be?
Mayes' Midwifery textbook says:
"The World Health Organization (1979) considers anaemia to be present in the pregnant woman when haemoglobin is 11g/dl or less. More arbitrary levels may be decided locally and usually range between 10 and 10.5g/dl"
In the UK, the most common definition of mild anaemia is an Hb level of 10 g/dl (100g per litre of blood) or less. Severe anaemia is usually defined internationally as 7g/dl (70g/L) or less, but to complicate matters, some studies define this as 'moderate' anaemia, and 'severe' as 4.7g/dll or less.
In the UK, the NICE Guidelines on Intrapartum Care state that a haemoglobin level of less than 8.5g/dLL at the start of labour suggests a woman is at increased risk and should be advised to give birth in an obstetric unit rather than at home or a low-risk centre, and women with Hb of 8.5 - 10.5g/dl should have 'individualised assessment' to help them plan their place of birth (p11).

MCV: Mean Cell Volume or Mean Corpuscular Volume

MCV is a measure of how 'fat' or 'skinny' your red blood cells are, ie whether they really are deprived of iron or not.
From Lab Tests Online UK:
"Mean corpuscular volume (MCV) is a measurement of the average size of your red blood cells (RBCs). The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anaemia caused by vitamin_b12 deficiency. When the MCV is decreased, your RBCs are smaller than normal (microcytic), such as is seen in iron deficiency anaemia or thalassaemias. "
Here's an extract from the NHS patient information database on Anaemia in Pregnancy:
Investigations Hb < 11.0g/dl 3
MCV (mean cell volume): if < 76fl then probable cause is iron deficiency ...
Normal MCV (76-96fl) with low Hb is typical of pregnancy.
MCV doesn't tell the whole story, because it is affected by other things. For example, vitamin B12 deficiency can make your MCV higher than average, so it is possible that this could mask an iron deficiency. MCV is part of the Full Blood Count, which gives a good overall picture of your blood's health.

Serum Ferritin

The serum ferritin, or 'ferritin', test measures your body's iron stores. A healthy person has reserves of iron in the body so that you do not become anaemic if you have a short period where your diet does not provide enough iron. If you have genuine iron-deficiency anaemia then you would expect your body to have very little stored iron. On the other hand, if iron stores are high and diet adequate, then taking iron supplements is unlikely to be effective.
Alper and colleagues published a very detailed article on using ferritin levels to determine iron-deficiency anaemia in pregnancy, in the Journal of Family Practice (2000). It says:
"Ferritin levels are considered the gold standard for the diagnosis of iron-deficiency anemia in pregnancy"
Lab Tests Online UK says:
If a blood count indicates that your haemoglobin and haematocrit are low, especially if your red blood cells are smaller and paler than normal ('microcytic' and 'hypochromic'), this indicates that you have anaemia due to iron deficiency. Ferritin and other iron tests can be used to confirm the diagnosis.
What does the test result mean?
Ferritin levels are low in long-term iron deficiency, or if your body's protein levels are very low, as in some cases of malnutrition.
If serum ferritin is the 'gold standard', why don't we just test for that and forget Hb and MCV? Because ferritin levels can fluctuate for other reasons. In particular, they can rise in women with pregnancy-induced hypertension or pre-eclampsia, both of which are relatively common in the third trimester [Lao, 2000]. So serum ferritin can't be taken in isolation, but together with Hb and MCV levels, it can give you a good picture.

Other causes of anaemia

There are other reasons for anaemia besides iron deficiency, eg inherited conditions like sickle-cell disease or thalassemia - your midwife would probably already have considered these possibilities. Nonetheless it's worth checking - if you find out your Hb level and MCV, and your MCV is normal, then you could ask your midwife why she thinks you are iron-deficient, or indeed higher-risk in any way.

Anaemia Worldwide

Severe anaemia is a major problem in the developing world and it increases the risk that a baby will be born prematurely, or have a low birthweight. The risks are highest when the mother is anaemic in the first trimester of pregnancy as this suggests that her nutritional status before pregnancy was poor - her low Hb levels cannot be caused by her blood volume expanding ('haemodilution of pregnancy') because blood volume will not have expanded greatly at this stage. If a woman is anaemic in the first trimester because of poor nutrition, it may also suggest that she will not have a good diet or healthcare during her pregnancy. Many women in the developing world who suffer from anaemia may not simply be deficient in iron, but may also have malaria, sickle-cell anaemia or other blood diseases ('haemoglobinopathies') and some of the research into anaemia in pregnancy looks at different categories individually. However, you will occasionally see attention-grabbing quotes saying that women with anaemia have significantly higher rates of stillbirth. Where references are given, it often turns out that the source is a study looking at severely anaemic women in the developing world - not necessarily relevant to a woman in the UK with only mild anaemia.

Is low Hb dangerous if there's no sign of iron deficiency?

There seems to be no good evidence that a woman in the developed world with an Hb level of 9 or 10, and no other complicating factors, is at any increased risk of complications in labour, nor her baby at increased risk after birth. For instance, in a study of Swedish women, Stephansson (2000)found that anaemia was not significantly associated with risk of stillbirth in multivariate analyses, although high haemoglobin (146 g/l or more) was associated with an increased risk of stillbirth. Several studies have now found that the best outcome for the baby, in terms of avoiding low birthweight and prematurity, arises when the mother is actually mildly anaemic by standard definitions. For instance, Malhotra et al (2002) compared outcomes for women with 'normal' blood (Hb above 11g/dll) with those for women with mild anaemia (9 - 10.9 g/dll), moderate and severe anaemia (severe being Hb lower than 7g/dll). They found that:
"Women in Group II (mild anaemia) had lowest number of low birth weight and IUGR babies, no stillbirths and neonatal deaths, lowest induction and operative delivery rates. ... Mild anemia fared best in maternal and perinatal outcome. Severe anemia was associated with increased low birth weight babies, induction rates, operative deliveries and prolonged labor."

The Expert View

"A Guide to Effective Care in Pregnancy & Childbirth (2nd Edition) " by Enkin, Keirse, Renfrew and Neilson, is the UK's 'gold-standard' textbook on evidence-based maternity care and is generally respected by all midwives and obstetricians. Here's what it says on this subject:
The normal haematological adaptations to pregnancy are frequently misinterpreted as evidence of iron deficiency that needs correcting. Iron supplements have been given with two objectives in view: to try to return the haematological values towards the normal non-pregnant state, a strange objective when millions of years of evolution have determined otherwise, and to improve the clinical outcome of the pregnancy and the future health of the mother. The first objective can certainly be accomplished; the key question is whether or not achieving the "normalized" blood picture benefits the woman and her baby. Routine iron supplementation raises and maintains serum ferritin above 10 microgram/litre and results in a substantially lower proportion of women with a haemoglobin level below 10 or 10.5 grams per cent (below 6-6.5 mmol/litre) in late pregnancy. Routine folate supplementation as a haematinic after the first few weeks of pregnancy substantially reduces the prevalence of low serum and red cell folate levels, and of megaloblastic haematopoiesis.
As yet, neither iron nor folate supplementation after the first trimester have shown any detected effect on the following substantive measures of maternal or fetal outcome: proteinuric hypertension, antepartum haemorrhage, postpartum haemorrhage, maternal infection, preterm birth, low birthweight, stillbirth, or neonatal morbidity. Women do not feel any subjective benefit from having their haemoglobin concentration raised.
A possible advantage claimed for a high level of haemoglobin in pregnancy is that the woman would be in a stronger position to withstand haemorrhage. There is no evidence to support this claim. Indeed, as a low haemoglobin in healthy pregnant women generally implies a large circulating blood volume, it is at least possible that women with a low haemoglobin might better withstand a loss of blood....
Whether routine iron supplementation causes any harm in well-nourished communities is still unclear, but it is clearly wasteful. The evidence suggests that, except for genuine anaemia, the best reproductive performance is associated with levels of haemoglobin that are traditionally regarded as pathologically low. There is cause for concern in the findings of two well-conducted trials that iron supplementation resulted in an increase in the prevalence of preterm birth and low birthweight. Perhaps there is an adverse effect on fetal growth due to the increased viscosity of maternal blood that follows the iron-induced marcrocytosis and increased haemoglobin concentration, which may impede uteroplacental blood flow.
An individual's haemoglobin concentration depends much more on the complex relation between red-cell mass and plasma volume than on deficiencies of iron or folates. The advent of electronic blood counters has given an opportunity for more appropriate criteria to be applied to the diagnosis of anaemia. Mean cell volume may be the most useful; it is not closely related to haemoglobin concentration and declines quite rapidly in the presence of iron deficiency. A low haemoglobin without other evidence of iron deficiency requires no treatment.

What's wrong with taking iron supplements even if you don't need them?

There are questions over whether unnecessary iron supplementation may be harmful in pregnancy. Around 40% of women who are prescribed iron supplements are unable to tolerate them because of the severity of side-effects. It is possible that unnecessary supplementation may be harmful for the baby. [Lao, Tam and Chan, 2000, and see also Alper, 2000 for further refs]. Recently there has also been high-quality research which found that pregnant women who were not iron-deficient had a significantly higher risk of developing high blood pressure if they were given iron supplements (as ferrous sulphate). There was also a higher risk of having a low-birthweight baby [Ziaei et al, 2007 and RCOG press release]. Dietary experiments with pregnant rats have also shown harmful effects for both mother and offspring [Ward et al, 2003]. It is important to note that these studies only looked at mothers who had a 'normal' haemoglobin level and thus their results may not be applicable to women with lower Hb. We do not know in what circumstances the benefits of iron supplementation outweigh the risks, because the risks appear not to have been well studied. It is likely that it was considered unethical or impractical to include women with lower Hb in the study group because standard management is to supplement with iron where low Hb is found. However, now that it is relatively cheap and easy to obtain more specific blood tests, it is to be hoped that researchers may start to consider women who have lower Hb but who are not iron-deficient. The Cochrane Review of evidence on treatment for iron-deficiency anaemia in pregnancy found that:
..it is unclear if women and babies are healthier when women are given iron for anaemia during pregnancy. It also remains unclear what the effects of treatments given by different routes and in different populations are; therefore, it is not possible to draw a well-informed balance of benefits and harms for the differing levels of severity of anaemia.
Michel Odent, obstetrician and natural birth supporter, writes in an article on the value of antenatal tests:
The regrettable consequence of routine evaluation of hemoglobin concentration is that, all over the world, millions of pregnant women are wrongly told that they are anemic and are given iron supplements. There is a tendency both to overlook the side effects of iron (constipation, diarrhea, heartburn, etc.) and to forget that iron inhibits the absorption of such an important growth factor as zinc (18). Furthermore iron is an oxidative substance that can exacerbate lipid peroxidation (free radicals) and might even increase the risk of pre-eclampsia (19).

How can I raise my iron levels?

Lots of women have a diet which is plentiful in iron, but still for some reason do not absorb enough of it. If you are convinced that your iron level is genuinely low then it is worth taking action to increase it. Before you do this, however, please read 'Is the problem really iron deficiency?'. If you are not deficient in iron then the best-case scenario is that taking iron supplements will give you expensive bowel movements; however, if you take prescribed iron supplements then you may end up with unpleasant side-effects including nausea, constipation, etc..
The iron supplement usually prescribed on the NHS is ferrous sulphate, because it's a very cheap way of getting a high dose of iron. You can also get ferrous gluconate and ferrous fumarate on prescription, which may cause fewer side-effects.
The British Society of Gastroenterology guideline on iron deficiency anaemia explains:
“Iron therapy Treatment of an underlying cause should prevent further iron loss but all patients should have iron supplementation both to correct anaemia and replenish body stores (B). This is achieved most simply and cheaply with ferrous sulphate 200 mg twice daily. Lower doses may be as effective and better tolerated and could be considered in patients not tolerating traditional doses. Other iron compounds (e.g. ferrous fumarate, ferrous gluconate) or formulations (iron suspensions) may also be tolerated better then ferrous sulphate. Ascorbic acid (250–500 mg twice daily with the iron preparation) may enhance iron absorption. We recommend that oral iron is continued until three months after the iron deficiency has been corrected so that stores are replenished.” [1]
Two iron supplements which are popular with pregnant woman are Floradix and Spatone. Both can be bought from health food stores like Holland and Barrett, and often from Boots, as well as from plenty of online retailers. Midwives and mothers on the Homebirth UK egroup have reported very rapid results from Spatone raising Hb levels.
Spatone has a section on its website for health professionals which cites some impressive research showing that it is absorbed incredibly quickly into the bloodstream and is extremely effective at raising blood Hb levels. It's actually only a form of naturally iron-rich water - even tastes like rusty water.
The real bonus of this, and other forms of 'natural' iron like Floradix, is that they don't usually cause any gastric symptoms; the NHS iron supplements are cheap and nasty, and while they give you a massive whack of iron, it's in a form which is hard for your body to absorb. The unused portion can cause diahorrhea, constipation, nausea, you name it - which is why there is such a market for less offensive alternatives.
There are four studies on Medline of the effectiveness of Spatone and they all seem to confirm the manufacturer's claims, which you can find on the 'health professionals' section of its website (www.spatone.co.uk).
Some GPs have prescribed Spatone for pregnant women on the NHS, if they suffer adverse symptoms from the other iron supplements.
All iron supplements are allegedly most effective when taken with vitamin C as it helps absorption of iron (eg take in/with a glass of orange juice), and avoid tea as tannins hinder absorption.

Does a low Hb level mean you're more likely to haemorrhage?

I've trawled through Medline, the international database of medical research, and found nothing on correlations between low Hb antenatally and risk of haemorrhage. Not surprisingly, there are papers showing that a low postpartum Hb level is associated with having had a PPH. This is like saying that cars with dents are likely to have been involved in accidents than cars without dents. However, that does not mean that your car is more likely to be involved in a crash in future, just because it has a dent already!
Another view, less commonly heard, is that a woman can be said to have had a PPH if her Hb levels fall below a certain level after the birth. Thus she might lose only 100ml of blood, but still be said to have haemorrhaged because her postpartum Hb level was, say, 8 - even though it was, say, 8.5 before the birth. This is not the way most women think of postpartum haemorrhage, and if we are trying to screen out emergency transfers to hospital, it is probably not most relevant.
The extract from 'A Guide to Effective Care in Pregnancy and Childbirth', above, explains that Hb levels in pregnant women are generally lower than in non-pregnant women, but that this does not mean that low Hb levels are a problem. Iron supplements can normally raise Hb levels in pregnant women to the 'normal' level for non-pregnant women, but there is no evidence that raising the Hb levels in this way benefits mother or baby at all.
The UK's NICE Intrapartum Care Guidelines include women with Hb of 8.5g/dl in their list of women at higher risk of PPH (p254), but the supporting text (p250) states that only one study was included on this topic and it found no difference in rates. I assume that NICE included women with low Hb in this category because of the possible increased dangers to them of severe blood loss, as mentioned above:
Anaemia
"A cohort study was conducted in New Zealand in 1996 comparing haemoglobin levels at 4 weeks prior to birth on PPH (blood loss 600 ml or greater within 24 hours of birth).578 [EL = 2-] Although the study reported no difference, the analysis did not control confounding factors and hence was inconclusive."
Some years ago, I asked doctors and medical students on sci.med.obgyn newsgroup if there was any evidence that low Hb levels might increase the chances of post-partum haemorrhage. These were the responses:
I am studying obstetrics at the moment... I know of no evidence to this effect. The mechanisms of PPH are uterine atony, lacerations, and retained products. None of these should be affected by anaemia, though I guess a general aplasia of marrow could lead to thrombocytopenia as well as anaemia.
The reason why haemoglobin levels are low is because the plasma volume increases, while erythrocyte production doesn't increase so much. Hb levels are measured as a concentration, not as an absolute amount. Thus there is a normal 'anaemia' associated with pregnancy, which causes no problems. Of course one can also get folate/iron deficiency or malnutrition which causes a genuine anaemia.
Richard Cavell
This myth has been around a while...I've never seen any evidence...
It also depends on definition...if your definition of PPH is need for transfusion, then maybe it's true since if you start with a lower Hgb, you can suffer less blood loss before you need a transfusion. If your definition is strictly how much you bleed, then starting Hgb is irrelevant...
Adam Newman, MD
(Postpartum haemorrhage is defined in most countries as blood loss over 500mls, but some midwives and obstetricians prefer to look at the condition of the individual woman, and consider her blood loss to have been excessive if she is showing syptoms suggesting that, regardless of how much her measured blood loss is. While this is good for individualised care, it's not helpful if you want to collect data, make comparisons, and so on!)
It seems that it is probably irrelevant to 'risk out' a woman from home birth because of her Hb level. Such advice is probably due to an incorrect understanding of the implications of low Hb levels.
Some people suggest that, while the actual risk of haemorrhage doesn't increase when Hb levels are low, if a mother with low Hb does haemorrhage, she might find it harder to recover. This reflects the point made above by Dr Newman. However, there appears to be little evidence to support even this. For example, in the section from 'A Guide to Effective Care in Pregnancy & Childbirth' by Enkin, Keirse, Renfrew and Neilson copied below,
"A possible advantage claimed for a high level of haemoglobin in pregnancy is that the woman would be in a stronger position to withstand haemorrhage. There is no evidence to support this claim. Indeed, as a low haemoglobin in healthy pregnant women generally implies a large circulating blood volume, it is at least possible that women with a low haemoglobin might better withstand a loss of blood. "
Of course, any mother suffering a serious haemorrhage would be transported to hospital immediately, where she could receive a blood transfusion. Transfer times to hospital should be taken into account when making any decision about home birth, but when transfusions are given, it is often a day or more after the birth, rather than as an emergency measure.
An important consideration for women who are worried about blood loss is that there is less risk of severe blood loss with a homebirth. This is largely because starting off at home reduces your risk of ending up with an operative delivery, either cesarean or forceps or ventouse - all of which are associated with significantly increased blood loss. Therefore, if you are genuinely iron-deficient and are struggling to get your levels up before the birth, homebirth could be said to have a protective effect, and is a positive step to reduce your risk of haemorrhage.
This website has more information on Postpartum Haemorrhage and Homebirth - how likely it is, and what happens if you have a PPH at home. You can find references for homebirths and PPH risks there.

Arranging a homebirth when you have low Hb

If your midwife or doctor maintains that a low Hb level makes you an unsuitable candidate for home birth, please consider asking them for evidence and citations to support their claims. I would be very interested to hear of any research which backs it up. I've been looking for ten years now and nothing convincing has been forthcoming!
If you make an informed choice to continue with homebirth plans 'against advice' then it can be helpful to write a letter to the Head of Maternity or the Community Midwifery Manager at your hospital, copied to your community midwives. Here is a sample letter:
Dear Community Midwifery Manager,
I am booked for a home birth under the care of Team X, and my estimated due date is (date).
Midwife Z has informed me that your guideline is to recommend hospital birth whenever a woman's haemoglobin count is below 10 g/dLL, and my count at the last test was (result).
I am writing to inform you that I have looked into the matter and have decided to continue with my homebirth plans. I believe that the risks of hospital birth in my situation outweigh the benefits at the moment. If my circumstances change then I will of course consider the situation again. I appreciate the advice of my midwives, but I am prepared to take responsibility for my own decisions. I am informing you of my decision now so that you have plenty of time to make the necessary arrangements, to ensure that staff are available to attend my birth at home.
[If you want to, and fully understand the subject, you could add a paragraph here giving more details of your individual circumstances. You do not need to justify your decision to give birth at home, or to explain it, or to 'persuade' anyone to 'allow' you a homebirth. However, you may choose to discuss it further, both to make sure that you are fully informed, and perhaps to help your midwives be more open-minded with other women! If you show that you understand the subject it may reassure your midwives - they may be concerned that you might blame them if you went ahead with a homebirth, and, unlikely though it is, had a heavy bleed, and then needed to transfer to hospital afterwards. I believe it is important, if you want to get involved in a technical discussion, that you understand all the terms involved and feel confident using and discussing them. If you don't feel confident, it may be better to avoid using them!] So - the sort of thing you might add here could be:
I have been given the results of my full blood count and my Mean Cell Volume is 88. This is well within normal limits of 80-100 and therefore there is no reason to suppose that I am iron-deficient. There have been no abnormal results suggesting ill health of any kind. I believe that my Hb level of 9.5 g/dLL is accounted for by normal haemodilution of pregnancy and, following the guidelines in A Guide to Effective Care in Pregnancy and Childbirth, that I am not at any increased risk, nor in need of any treatment, as a result.
Yours faithfully,
Ms Stroppy

The Third Stage of Labour, and Your Baby

Finally, if you are genuinely iron-deficient, you may wish to think about your options for the third stage of labour - the delivery of the placenta.
You may find that you are encouraged to have a managed third stage, where you are given an injection to assist the delivery of the placenta and hopefully to reduce the averge blood loss. See The Third Stage for your options. Side-effects of this can include sudden nausea, headache and blood pressure fluctuations, so many women who are aware of this risk, prefer to wait and see how the third stage progresses and to have the injection only if their blood loss is worrying.
If you do decide to have a managed third stage, please give serious consideration to the issue of when the baby's cord will be clamped. In many places it is still routine to give the injection as the shoulders are being born, and to clamp the cord immediately after birth. This results in up to a third of the baby's blood volume being trapped inside the placenta and cord, and it is lost with the placenta; neither baby nor mother can use it.
An alternative is to wait around three minutes for the cord to finish pulsating, before clamping and giving the injection. This means that the full complement of blood has been transfused to the baby. This is particularly relevant if the mother is iron-deficient, because if her iron stores are low, then the baby's will be too. The baby who is born with low iron stores is at risk of anaemia in its first year, and can ill-afford to have up to a third of its blood volume thrown away with the placenta.
If the cord is allowed to finish pulsating, the baby gets its full share of placental blood. Any excess red blood cells are broken down and the iron appears to be scavenged for the baby's iron stores. Iron-deficiency anaemia is much more common in babies whose cords were clamped early, throughout the first year. You can read more about this, and find references, on The Third Stage page.

Links

For more discussion of these issues, and suggestions of ways to raise your Hb levels through diet and supplements, see the Association of Radical Midwives archive on the Third Stage of Labour.
Merck medical manual - chapter on Anemia in Pregnancy
http://www.merck.com/mmpe/sec18/ch261/ch261b.html
Anaemia in Pregnancy - patient.co.uk information sheet
www.patient.co.uk/showdoc/40000289/
Iron-Deficiency Anaemia - patient.co.uk information sheet.
www.patient.co.uk/showdoc/23068889/
Lab Test Online UK - "A clinical resource on clinical lab testing, from the professionals who do the testing" - explains how and when different tests are used, and what the results mean.
www.labtestsonline.org.uk
Anemia: When Is it Not Iron Deficiency?: Differential Diagnosis of Anemia by RBC Indices and Biochemical Markers
Very technical, but well-referenced, Medscape article.
British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. 2005.
http://www.bsg.org.uk/pdf_word_docs/iron_def.pdf
NHS Clinical Knowledge Summary (formerly Prodigy) on iron-deficiency anaemia
http://www.cks.library.nhs.uk/anaemia_iron_deficiency
Royal College of Obstetricians and Gynaecologists press release on risks of iron supplementation in non-anaemic pregnant women.
www.rcog.org.uk/news/care-over-taking-iron-supplements-non-anaemic-pregnant-women
(backup copy on this site)
The Rise of Preconceptual Counseling Vs The Decline of Medicalized Care in Pregnancy - Michel Odent MD
http://www.wombecology.com/maternalemotional.html
And see also links in the References, below.

References

Stephansson et al (2000): JAMA. 2000 Nov 22-29;284(20):2611-7.
Maternal hemoglobin concentration during pregnancy and risk of stillbirth.
Stephansson O, Dickman PW, Johansson A, Cnattingius S.
PMID: 11086368 [PubMed - indexed for MEDLINE]
Malhotra et al (2002):
Int J Gynaecol Obstet. 2002 Nov;79(2):93-100.
Maternal and perinatal outcome in varying degrees of anemia.
Malhotra M, Sharma JB, Batra S, Sharma S, Murthy NS, Arora R.
PMID: 12427391 [PubMed - indexed for MEDLINE]
Using Ferritin Levels To Determine Iron-Deficiency Anemia in Pregnancy
Journal of Family Practice , Sept, 2000
Brian S. Alper, Roger Kimber, Anuradha Kudumala Reddy
Lao, Tam and Chan [2000]
Human Reproduction, Vol. 15, No. 8, 1843-1848, August 2000
© 2000 European Society of Human Reproduction and Embryology
Third trimester iron status and pregnancy outcome in non-anaemic women; pregnancy unfavourably affected by maternal iron excess T.T. Lao1,3, K.-F. Tam2 and L.Y. Chan1,2
Ziaei et al, 2007:
BJOG. 2007 Jun;114(6):684-8
A randomised placebo-controlled trial to determine the effect of iron supplementation on pregnancy outcome in pregnant women with haemoglobin > or = 13.2 g/dl.
Ziaei S, Norrozi M, Faghihzadeh S, Jafarbegloo E.
Royal College of Obstetricians and Gynaecologists press release on risks of iron supplementation in non-anaemic pregnant women.
www.rcog.org.uk/news/care-over-taking-iron-supplements-non-anaemic-pregnant-women
Ward et al, 2003
Iron Supplementation During Pregnancy- A Necessary or Toxic Supplement?
Roberta J. Ward, Stephanie Wilmet, Rachida Legssyer, and Robert R. Crichton
Bioinorg Chem Appl. 2003; 1(2): 169–176.
Cochrane Review of evidence on treatment for iron-deficiency anaemia in pregnancy
www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003094/frame.html
A note on spellings: 'Anaemia' is the UK spelling for what, in US English, is 'anemia'; likewise here we use 'Haemoglobin' rather than 'Hemoglobin' . Search engines may be slightly confused by this, so I have varied spellings through the text. The occasional Americanism is not a typo - it's so that Google can still rank the page effectively.