Effects of Ferric Carboxymaltose on Pica among Pregnant Women in Malawi: A Substudy to a Randomized Controlled Trial

Background

Pica is the craving and consumption of nonfood items, and includes the ingestion of earth, raw starch, and ice. Pica is common in sub-Saharan Africa, especially during pregnancy. Despite being ubiquitous, its etiology is not well understood.

Objectives

We leveraged the randomized trial of intravenous iron for anemia in Malawian pregnant women (REVAMP) to determine the effects of iron therapy, compared with standard-of-care oral iron, on pica among anemic pregnant women.

Methods

REVAMP was an open-label, individually randomized controlled trial, conducted in Malawi. A total of 862 pregnant anemic women in their second trimester were randomly assigned at baseline to receive either 1) a single dose of ferric carboxymaltose (FCM) or 2) standard-of-care oral iron. Pica was assessed at baseline and 4 wk postrandomization by asking participants whether they had craved and consumed earth (geophagy), unripe mango (amylophagy), raw rice (amylophagy), ice (pagophagy), ash, charcoal, or chalk in the past 2 wk. Venous blood was collected for hemoglobin and ferritin concentrations. A longitudinal Poisson model was used to examine the treatment effect of FCM on overall pica and types of pica.

Results

At baseline, the prevalence of any pica was 71.7%, and geophagy was 31.9%. Hemoglobin and ferritin concentrations improved following FCM compared with standard-of-care oral iron and were lower among participants with geophagy. From baseline to 4 wk post randomization, the prevalence of geophagy decreased more among women assigned to FCM compared with standard of care [FCM: 33.5%–12.9%, standard of care: 30.4%–22.3%, prevalence ratio (PR) = 0.53 (95% confidence interval: 0.39, 0.72), P < 0.0001]. There was no evidence of a treatment effect for overall pica [FCM: 70.7%–57.3%, standard of care: 72.6%–63.0%, PR = 0.93 (0.83, 1.06)], amylophagy, or pagophagy.

Conclusions

This study provides causal evidence that geophagy is reduced by improvements in iron status and anemia during pregnancy.

Trial registration number

This trial was registered at www.anzctr.org.au as ACTRN12618001268235.