Anemia during pregnancy is defined by the WHO as a hemoglobin level of less than 11 g/dl [1] . Anemia is a ubiquitous public health problem affecting both developed and developing countries with major human health consequences [2] .

According to the World Health Organization (WHO), 25% of the world’s population is affected by this condition [3] . This is a very common situation in developing countries where it affects between 30 and 80% of pregnant women [4] [5] ; In industrialized countries, only 10% of pregnant women are affected [3] [6] . Studies in Mali have shown that 30% to 65% of pregnant women are anaemic [7] [8] . In Mali, according to the national statistics of the demographic and health survey sixth edition, the prevalence of anemia is higher among pregnant women aged 15 - 49 (69%) than those who are breastfeeding (62%), severe anemia 4% and 52% in urban areas and 67% in rural areas.

The main cause of these anemias is martial deficiency [6] [9] , hence the WHO recommendation for iron supplementation during pregnancy [9] . There is low uptake of pregnant women in dietary supplementation programs offered during prenatal consultation (ANC) [10] . The reasons for poor compliance of pregnant women are varied, but one of them is the feeling expressed by them that a prolonged treatment with unpleasant side effects is useless, even though they do not feel sick at all [10] [11] . The role of malaria in anaemia during pregnancy in tropical Africa, 70 to 80% of pregnant women in malarial areas are anemic [12] .

Combination of anemia and pregnancy increases morbidity and maternal-fetal mortality [13] [14] .

We initiated this study to assess the status of the disease, and to improve management and prevention in the gynecology-obstetrics department of the Teaching Hospital (CHU) Gabriel Touré in Bamako, Mali.

Our study was carried out in the obstetric gynecology department of the Gabriel Touré Teaching Hospital of Bamako, Mali, which is a 3rd level structure of the health pyramid of the country receiving evacuations from the district but also those coming from the interior of the country.

All patients (pregnant and parturient with anemia) with anemia were included in our study regardless of the age of pregnancy, with a hemoglobin level of less than 11g/dL and patients received in the immediate postpartum for complication of anemia that was treated in the department.

We conducted a cross-sectional study of all admissions that can be direct or referred/evacuated in obstetrics for the period from January 1, 2006 to December 31, 2016. We included in our study all patients with a hemoglobin level of less than 11g/dl during the period of gravudo-puerperal care that was carried out in the department. Not all women who do not have anemia during pregnancy and women with no information on hemoglobin levels were included. We performed our work by analyzing a database of obstetric admissions which contains more than 700 variables. Including the parturient’s identity, sociodemographic profile, family history, medical-surgical, gynecologic, obstetric, the course of her pregnancy in the first trimester, the second trimester, the third trimester and its complications, the course of her delivery, its complications related to childbirth, her route of delivery, her deliveries and its complications, the parameters of the newborn and, in pediatric reference, the cause of death, the period of death of the newborn and the number of days of hospitalization. The data were collected through obstetric records, hospitalization records, mother-child health records, birth records, surgical reports and maternal death. Data was entered and analyzed on SPSS software. Frequencies were estimated using descriptive statistics. Statistical differences were evaluated by the Pearson khi-square test. Factors influencing maternal death as well as those influencing perinatal death were analyzed by logistic regression. This was a purely scientific work on the obstetric records constituting our database, and we took the necessary steps to anonymize all these records before data capture and analysis. Thus, in no case was it possible to identify a study participant. This database has been approved by the ethics committee of the Faculty of medecine and odonto-stomatology of Bamako Mali to make scientific publications.

For the operative definition we defined and classified anemia according to blood count data as follows:

(1) Anemia during pregnancy: is defined by the WHO as a hemoglobin level of less than 11 g/dL.

(2) Severe anemia: defined as a hemoglobin level of less than 7 g/dL.

(3) MGV: Mean globular volume. Its normal value is 75 - 95 fl.

(4) ACHC: Average corpuscular hemoglobin content. Its normal value is 27 - 32 pg/cell.

(5) CHMC: Average corpuscular hemoglobin concentration. Its normal value is 32 - 36 g/dl or %.

(6) Hypochromic microcytic anemia: Anemias in which MGV < 75fl and ACHC < 27 pg/cell.

(7) Hypochromic normocyte anemia: MGV between 75fl and 95fl and ACHC < 27 pg/ cell.

(8) Hypochromic Macrocytic Anemia: VGM 95fl and ACHC < 27 pg/cell.

(9) Normochromic microcytic anemia: Anemias in which VGM < 75fl and normal ACHC.

(10) Normochromic normocyte anemia: Are anemias characterized by VGM between 75fl and 95fl and normal ACHC.

(11) Normochromic Macrocytic Anemia: These are anemias characterized by a VGM 95fl and normal ACHC.

Our study found the following main findings: a prevalence of 14.7%, more than 60% of women did not have a prenatal consultation. Maternal comorbidities were the main factors influencing the risk of maternal death as well as perinatal death in women with anemia. Our prevalence is lower compared to that reported in the African literature which could be due to the difference of population studied [7] [15] - [21] . Only 40% of anemia women have completed, related to access to adequate care, socio-cultural barriers and religious beliefs and delays in the implementation of ANC, as medical culture remains very weak in our developing countries. What could be the cause of lack of iron supplementation? The low coverage is similar to that reported in the literature of developing countries and varies from country to country [22] .

The main cause of anemia was iron deficiency in the literature the main causes are malnutrition (iron, folic acid and vitamin deficiencies), infections such as malaria and hemoglobin abnormalities [14] [23] - [26] . The World Health Organization recommends prenatal supplementation of 30 mg to 60 mg of iron per day [9] [27] [28] . This supplementation could reduce the risk of anemia during pregnancy by 20% to 50% [14] [29] , 39% risk of mother transfusion and 96% risk of severe anemia after delivery [30] and increased chance of surviving maternal hemorrhage [31] . Iron supplementation during ANC increased birth weight by 31 g and decreased the risk of low birth weight by 19% [32] [33] .

We also observed that one in three women with anemia had an inter-reproductive interval of less than 12 months. Pregnancy increases iron needs [34] [35] . Pregnancy with a short birth interval could therefore lead to iron deficiency anemia [36] . The appropriate time after each pregnancy for recovery and replenishment of nutrient reserves is 2 to 5 years [37] - [39] .

Factors influencing the risk of maternal death were dominated by maternal comorbidities, hemorrhagic contexts requiring blood transfusion (abortion, abruptio placentae), eclampsia and high blood pressure. The relationship between low hemoglobin and maternal mortality is well established in the literature [40] , about 1 to 5% of maternal deaths are related to retro placental hematoma [41] [42] .

Like the mother, we observed a poor perinatal prognosis in case of maternal comorbidities and anemia. Indeed, severe pre-eclampsia, abruptio placentae and uterine rupture were strongly associated with a high risk of stillbirth [43] [44] .

Severe anemia during pregnancy was significantly associated with high maternal-fetal morbidity and mortality. Anemia was of the microcytic type secondary to iron deficiency. Regular obstetric follow-up combined with proper iron supplementation can significantly reduce the serious consequences of anemia in pregnancy.