An Unassuming Pill and the Fight for Maternal Health

The U.S. has the largest rate of maternal deaths of any high-income nation—more than double, sometimes triple, that of peer countries. An American woman today is 50 percent more likely to die in childbirth than her mother was a generation ago. The outlook is even worse for women of color. The U.S. is also in the midst of a maternal morbidity crisis, an increase in severe obstetric complications resulting in adverse short- or long-term consequences to a woman’s health.

These trends have persisted for years. So what would solving the crisis actually look like? It begins by spending pennies a day on each patient. 

A new strategy led by the Burnett School of Medicine at TCU and UT Southwestern Medical Center focuses on the often-overlooked issue of anemia, a condition that becomes critical during labor and delivery, which always involves some amount of blood loss. 

For about seven cents a day per patient, this North Texas initiative aims to put free iron supplements straight into the hands of every pregnant woman in Dallas and Tarrant counties as part of its effort to significantly reduce severe obstetric complications. 

Hospitals in Dallas and Tarrant counties deliver about 65,000 babies annually, more than the number born in each of 30 other states. The initiative to provide iron to every mother regardless of her ability to pay launched in January; already 56 clinics in and around Dallas, Fort Worth, and Arlington are dispensing the tablets. With new locations added regularly, the goal is to provide iron access at every site that offers pre-natal care.

Research shows direct distribution—as opposed to a doctor merely suggesting that patients take iron—can cut anemia-related postpartum transfusions by a third. That’s important because blood loss and the resulting need for transfusions account for 70 percent of severe obstetric complications, also known as severe maternal morbidities. 

“Imagine reducing that burden of transfusion by simply being able to provide iron,” says Dr. David Nelson, division chief of maternal-fetal medicine at UT Southwestern and Parkland Health. Nelson says handing the iron to a patient is key because it eliminates barriers such as affordability and the need for transportation—even the time to get to the store to purchase the over-the-counter supplement.

“Anything that requires one more step, like a stop at a store to pick up the iron, means that we're going to lose some people,” says Dr. LaTasha Jarrett, the chief medical officer at HHM Health. 

Every day, Jarrett and her OB-GYN colleagues see the direct-distribution benefits play out in real time among their patients. HHM Health was among the first clinics to sign up for the free iron program. “This is brilliant, right?” Jarrett says during a quick break between the heavy load of morning and afternoon appointments. “We now are constantly giving out iron and, when I see the young ladies back, I check and make sure they're taking it.”

The HHM clinics provide care to women from all walks of life, including those who are uninsured or on Medicaid and other health plans. About 700 mothers-to-be received services last year at HHM's Vickery Health Center before delivering their babies at nearby Texas Health Presbyterian Hospital Dallas.

Just after noon on a late July day, pregnant women—some with young kids in tow, others with a partner or parent—began lining up outside the clinic’s second-floor waiting room for afternoon appointments. These patients’ knowledge of nutrition and other lifestyle choices varies widely. “The equalizer is that we emphasize the importance of taking your iron,” Jarrett says.

The simple concept requires significant education. Clinicians must help the women understand why the iron tablets matter. They help patients navigate gastrointestinal issues the supplement might cause. And they lay out what the health problems can be for mother and baby if a woman becomes anemic in the third trimester or just after delivery.

“Having a baby can be very, very unpredictable, even in the best circumstances,” Jarrett says. “Many of those situations that required transfusions were ones we may have been able to avoid if they had gotten their blood count up.”

HHM caregivers say patients’ response to the direct distribution of iron is, “wow, this is something I really should be doing.” “It takes on a greater sense of importance when your doctor hands it to you,” Jarrett says.

Dr. Elaine Duryea, the chief of obstetrics at Parkland Memorial Hospital, offers a similar story, this one personal. Pregnant with her first child, she admits she only took an iron supplement a couple of times. “If it had been emphasized and handed to me at the doctor’s office, I may have been more compliant with it,” she says. “That goes for anyone in the community.”

Iron deficiency anemia is a major risk factor for adverse maternal and neonatal outcomes, and its prevalence increases as the pregnancy progresses. Recent research uncovered rates of iron deficiency as high as 80 percent in the third trimester. The condition is disproportionately higher among pregnant Hispanic and Black women, contributing to elevated severe obstetric complications in these populations. 

A woman’s blood volume nearly doubles during pregnancy, which means she will require extra iron to produce sufficient hemoglobin, a protein in red blood cells that transports oxygen. Anemia occurs when there are insufficient healthy red blood cells. The condition is linked to adverse health outcomes for mothers and babies, including blood transfusion, postpartum anemia and depression, premature birth, low birth weight, and perinatal mortality.

Catastrophic blood loss and the ensuing need for transfusion due to a hemorrhage event such as uterine atony can occur in a woman regardless of whether she’s anemic. But many transfusions are required simply because the mother came into the hospital anemic. “This is the woman who, on postpartum day one, you check her blood count, and she's so low you know she needs blood before she can leave the hospital,” Duryea says.

Efforts to focus more attention on the importance of iron have run up against the U.S. Preventive Services Task Force, a panel of experts that argues there is not enough evidence to assess the effectiveness of iron supplements during pregnancy. Undeterred, TCU’s Burnett School of Medicine and UT Southwestern have committed to the direct distribution of iron as part of a blueprint to reduce severe obstetric complications and upgrade the national discussion around maternal health. 

“The effort will lead to a national mandate,” says Dr. Stuart Flynn, the founding dean of TCU’s Burnett School of Medicine. “It's going to have a ripple throughout the U.S.”

Four percent of women in Texas suffer severe obstetric complications annually, significantly higher than the 2.5 to 3 percent national rate, according to U.S. Department of Health and Human Services research. Texas mothers of color and those who are uninsured or on Medicaid suffer complications at an even higher rate. 

“Most important, our prime objective is to improve the healthcare outcomes for our community,” says Nelson, of UT Southwestern. “And because we will track our findings, this very simple intervention will have the potential to change practice.”

The distribution is one of four initiatives crafted by the North Texas Maternal Health Accelerator, a coalition of nonprofits and caregivers brought together under the leadership of the two medical schools. TCU’s Burnett School of Medicine is the administrative lead for the iron effort and UT Southwestern is the clinical lead.

In December, the group applied for federal funding for its four-pronged proposal. Along with the iron distribution plan are strategies aimed at reducing hypertension, improving reaction times when postpartum hemorrhages occur, and helping hospitals to coordinate with community groups that support mothers.

The Advanced Research Projects Agency for Health, or ARPA-H, is a federal funding agency that seeks to accelerate breakthroughs with ambitious, high-impact research. The North Texas accelerator aims to reduce the rate of severe obstetric complications 20 percent in a population of 5 million patients over three years. 

While ARPA-H’s decision on the grant hasn’t been announced, the North Texas Maternal Health Accelerator already has received enough funding from other sources to ensure the iron program continues. Among the group’s members is the Dallas Federal Funding Accelerator, an initiative of the Child Poverty Action Lab that is designed to help government and organizations bring dollars and opportunities to North Texas. (The Lab Report is a local journalism project published by the Child Poverty Action Lab. Our newsroom operates with editorial independence.)

UT Southwestern and Parkland are international leaders in obstetrics knowledge. UTSW trains more OB-GYNs than any other medical program in the country and Parkland, Dallas County’s safety-net hospital, is among the nation’s largest birthing centers. UT Southwestern also oversees Williams Obstetrics, the seminal textbook in maternal health care that will soon release its 27th edition. 

The iron distribution plan grew out of a 2023 Parkland-UT Southwestern study that found providing the supplement at no cost to medically underserved pregnant patients—as opposed to simply recommending the tablets—significantly reduced anemia and postpartum blood transfusions. 

Parkland doctors have long encouraged their patients to take iron, but in 2015, the tablets were reclassified as a nutritional supplement and no longer stocked in hospital pharmacies. The result was that many patients quit using them and doctors began seeing the need for more postpartum transfusions. In response, the hospital began providing free supplements at prenatal visits to all its clinics. Researchers then studied the results.

Their findings revealed patients who received iron supplements had consistently higher red blood cell levels at each assessment period compared with patients who received only a recommendation to take them. Maternal anemia at admission was 7 percent lower among patients who were provided iron. The rate of postpartum transfusion for acute blood loss anemia—those not related to obstetric catastrophes—was reduced by a third.

Dr. Catherine Spong, who co-led the iron study and is chair of the Department of Obstetrics and Gynecology at UT Southwestern, considers direct distribution to be a practical intervention with a big payoff. “This can really affect the health of the entire community,” she says.

Getting this seemingly simple initiative rolling involved months of complicated behind-the-scenes work—product selection, supply chain management, delivery methods, to name a few—led by the Burnett School of Medicine at TCU.

The school’s clinical pharmacologists oversaw the research to determine which over-the-counter iron supplement would be best for the distribution. That work included finding an iron composition that is effective against anemia but also gentle on the gastrointestinal tract. “We know that even if we give it to moms for free,” Flynn says, “if they immediately become constipated, they're just going to quit taking it.”

The team settled on Nutricost, at a price of $12.25 a bottle for a 180-day supply, or a little less than 7 cents per tablet. The Burnett School of Medicine also created and implemented the rollout to participating clinics. “The goal is each of our clinical entities always has iron on board and never runs out,” Flynn says.  

As do the other Dallas and Tarrant County partners in this initiative, Flynn tips his cap to Fort Worth Mayor Mattie Parker for pushing the maternal health agenda. Intent on improving outcomes for mothers and babies, in 2022 she created the Tarrant County Maternal & Infant Health Coalition. Members of that group have subsequently helped implement the iron effort. For instance, Catholic Charities operations in both Fort Worth and Dallas have lent their expertise in food distribution to perfect the iron deliveries in the two counties.

Flynn said the initiative wouldn’t be possible without the clinical expertise of Burnett’s medical school partner in Dallas County. “We have the national exemplar for OB care with Parkland, and that’s huge for both Dallas and Tarrant counties,” he says. “This partnership is just a beautiful thing.”

Nelson describes the teamwork as many ensembles blending together for a richer sound. “This is an orchestra of North Texas,” he says. “We want to harmonize all of the great work across all of the different health systems—all of the partners—for the healthiest outcomes.”

Sharon Grigsby is the co-founder and senior writer of The Lab Report. [email protected].

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The Lab Report Dallas is a local journalism project published by the Child Poverty Action Lab (CPAL). Its newsroom operates with editorial independence.

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