The PANDA programme to investigate how to prevent anaemia in pregnancy has been running for a number of years. In this article, Professor David Churchill, obstetric lead for the programme, shares the progress of the trials and points to ongoing developments.
The PANDA Programme: (funded by NIHR 200869)
Iron deficiency anaemia (IDA) is a common problem during pregnancy, affecting about a third of pregnancies. Women who become anaemic may experience malaise, fatigue and “brain fog”. As well as making mothers feel unwell, anaemia is associated with several adverse outcomes affecting both the mother and her baby. These include prematurity, foetal growth restriction, postpartum haemorrhage, postnatal depression and, rarely, perinatal death.
The current approach in pregnancy is to treat anaemia with iron tablets once it is detected. Guidelines on treatment are produced by the British Society for Haematology. Unfortunately, treatment is imperfect and many women remain anaemic, leaving them at risk of poor outcomes. Therefore, a clinically effective way of preventing anaemia, that is both safe and cost effective would be of great benefit to pregnant women and their babies.
Work underway
The team involved in the Primary prevention of maternal ANaemia to avoid preterm Delivery and other Adverse outcomes (PANDA) programme has been investigating this problem for several years. Many groups have been involved in co-designing and delivering the programme, including academics, practising midwives, obstetricians, behavioural scientists and, most importantly, pregnant and recently pregnant women. The patient and public involvement (PPI) work was coordinated by Professor H. Spiby’s team at the University of Nottingham. We have now embarked on the definitive trial of prevention, which will provide evidence of effectiveness.
What we’ve learned so far
Our epidemiological investigations showed that the risk of stillbirth for women who had moderate to severe anaemia during pregnancy was between two and four times higher than the background risk, even when other factors were taken into account. An audit carried out in conjunction with NHS Blood and Transplant across 86 maternity units in the UK demonstrated inconsistencies in how guidance on the management of anaemia in pregnancy was applied. This was due to a lack of robust evidence and a high degree of uncertainty around best practice. We then carried out an investigation of treatment for anaemia, strictly applying the existing guidance. Even so, around 30-40% of women failed to respond to treatment, despite receiving the best possible care in a dedicated research clinic.
In the first two workstreams of the PANDA programme, a behavioural intervention was developed to help women adhere to taking the iron tablets. We know that some women suffer from troublesome side effects or simply forget to take medicines due to their busy schedules. A team of Behavioural Scientists from University College London worked with pregnant women and midwives to develop an ‘adherence intervention’, designed to support women to take iron correctly and consistently throughout pregnancy.
The second workstream was a pilot to the main trial, which aimed to select the best dose of oral iron to prevent anaemia and to refine the adherence intervention. Several important findings emerged. Many of the symptoms commonly attributed to iron tablets were already present before women began taking them. By supporting women with simple remedies, these symptoms were relieved, enabling them to continue taking iron. We also discovered that, due to the physiological changes that occur in pregnancy, the most appropriate dose of iron to prevent IDA was one tablet per day of ferrous sulphate. This decision was arrived at by a panel of independent international experts in the field.
What’s happening now
We have now embarked on the main PANDA Prevention trial to determine whether anaemia can be prevented and, crucially, whether this reduces the adverse outcomes such as preterm birth, foetal growth restriction and stillbirth. We are also assessing whether the intervention improves mothers’ quality of life and reduces the risk of postpartum haemorrhage and postnatal depression. The final component of the trial is to examine whether babies benefit from the supplements their mothers receive during pregnancy. We know that babies of mothers who develop anaemia during pregnancy are at greater risk of problems when growing up and can have some developmental delay. So, we will be following up the children to see the impact of the intervention on their health and development. This will be led by a team from Imperial College London.
The choice of outcomes was driven by pregnant women and what matters most to them. Therefore, to determine whether serious outcomes such as preterm birth, foetal growth restriction and stillbirth can be prevented, a large, randomised trial is required. The aim is to recruit 11,020 pregnant women, making PANDA one of the largest randomised trials ever undertaken in pregnancy. We have kept the trial procedures as simple as possible and over 90% of the required data is obtained from routinely collected sources. The care for participating women is not altered, and there are no additional blood tests or clinic visits. Participants are asked to complete questionnaires at baseline, 28 weeks of pregnancy and 6 weeks after the birth of the baby, which can be completed remotely.
What changes to practice might the study bring about in the future?
Finally, if we do manage to show a benefit, it is possible that the intervention could be recommended to all pregnant mothers in the future. However, before this can happen, it is essential to confirm that iron supplementation is as safe as currently believed and represents good value for money. This trial will answer both of those questions.
Currently we have over 50 maternity hospitals across England and Wales participating in the trial and thanks to the midwives, nurses and obstetricians in these units we have recruited more than 2,500 women. The real heroes, however, are the women themselves, and we thank them all for participating. But we still have a long way to go and need to push on towards our target of 11,020.
More information can be found from the PANDA website.
Useful references
1.Churchill, D., Ali, H., Moussa, M., Donohue, C., Pavord, S., Robinson, S. E., Cheshire, K., Wilson, P., Grant-Casey, J., & Stanworth, S. J. (2022). Maternal iron deficiency anaemia in pregnancy: Lessons from a national audit. British Journal of Haematology, 199(2), 277–284. https://doi.org/10.1111/bjh.18391
2.Churchill, D., Nair, M., Stanworth, S. J., & Knight, M. (2019). The change in haemoglobin concentration between the first and third trimesters of pregnancy: A population study. BMC Pregnancy and Childbirth, 19(1), 359. https://doi.org/10.1186/s12884-019-2495-0
3.Nair M, Churchill D, Robinson S, et al. Association between maternal haemoglobin and stillbirth: a cohort study among a multi-ethnic population in England. British Journal of Haematology 2017; doi: 10.1111/bjh.14961
4.Nair M, Knight M, Robinson S, Nelson-Piercy C, Stanworth S, Churchill D. Pathways of association between maternal haemoglobin and stillbirth: path-analysis of maternity data from two hospitals in England. BMJ Open 2018;8:e020149. doi:10.1136/ bmjopen-2017-020149
5.Nair M, Choudhury SS, Rani A, Solomi C, Kakoty S, Medhi R, Rao S, Mahanta P, Zahir F, Roy I, Chhabra S, Deka G, Mina B, Deka R, Opondo C, Churchill D, Lakhal-Littleton S & Nemeth E on behalf of the MaatHRI.The complex relationship between iron status and anemia in pregnant and postpartum women in India: Analysis of two Indian study cohort of uncomplicated pregnancies. American Journal of Haematology. 2023;98:1721-1731.
6.Tuck Seng Cheng, Farzana Zahir, Carolin Solomi, Ashok Verma, Sereesha Rao, Saswati Sanyal Choudhury, Gitanjali Deka, Pranabika Mahanta, Swapna Kakoty, Robin Medhi, Shakuntala Chhabra, Anjali Rani, Amrit Bora, Indrani Roy, Bina Minz, Omesh Kumar Bharti, Rupanjali Deka, Charles Opondo, David Churchill, Marian Knight, Jennifer J. Kurinczuk, Manisha Nair. Does induction or augmentation of labor increase the risk of postpartum hemorrhage in pregnant women with anemia? A multicenter prospective cohort study in India. International Journal of Gynecology & Obstetrics 2024 https://doi.org/10.1002/ijgo.16008
7.Churchill D, Hind Ali, Samaher Sweity, Dianne Bautista, Mahmoud Moussa, Laura Devison, Julie Icke and Simon J. Stanworth. The clinical impact of oral iron treatment for anaemia in pregnancy in accordance with current guidance: a prospective cohort study in a maternity unit in the Midlands of England. BMC Pregnancy and Childbirth 2025 25: 863 DOI 10.1186/s12884-025=07938-w
8.Stanworth, S. J., Churchill, D., Sweity, S., Holmes, T., Hudson, C., Brown, R., Lax, S. J., Murray, J., Spiby, H., Roy, N., Farmer, A., Gale, C., Crayton, E., Lorencatto, F., Griffiths, J., Mullings, J., Last, S., Knight, M., & On behalf of the PANDA Collaborator Group. (2024). The impact of different doses of oral iron supplementation during pregnancy: A pilot randomized trial. Blood Advances, 8(21), 5683–5694. https://doi.org/10.1182/bloodadvances.2024013408
9.Chibanda Y, Brookes M, Churchill D, Al-Hassi H. The ferritin, hepcidin and cytokines Link in the diagnoses of iron deficiency anaemia during pregnancy: A review. International Journal of Molecular Sciences 2023, 24, 13323. doi.org/10.3390/ijms241713323
10.Obianelli C, Afifi K, Stanworth S, Churchill D. Iron deficiency anaemia in pregnancy: a narrative review from a clinical perspective. Diagnostics 2024, 14,2306. doi.og/10.3390/diagnostics14202306
January 2026
Professor David Churchill, obstetric lead for the PANDA programme