Diagnosing anaemia in pregnancy in rural clinics: assessing the potential of the Haemoglobin Colour Scale

Bull World Health Organ. 1999;77(1):15-21.


Anaemia in pregnancy is a common and severe problem in many developing countries. Because of lack of resources and staff motivation, screening for anaemia is often solely by clinical examination of the conjunctiva or is not carried out at all. A new colour scale for the estimation of haemoglobin concentration has been developed by WHO. The present study compares the results obtained using the new colour scale on 729 women visiting rural antenatal clinics in Malawi with those obtained by HemoCue haemoglobinometer and electronic Coulter Counter and with the assessment of anaemia by clinical examination of the conjunctiva. Sensitivity using the colour scale was consistently better than for conjunctival inspection alone and interobserver agreement and agreement with Coulter Counter measurements was good. The Haemoglobin Colour Scale is simple to use, well accepted, cheap and gives immediate results. It shows considerable potential for use in screening for anaemia in antenatal clinics in settings where resources are limited.

PIP: In developing country settings, screening of pregnant women for anemia may be limited to inspection of the conjunctiva for the presence of pallor. The potential for anemia diagnosis of a new color scale for the estimation of hemoglobin (Hb) was assessed in a study conducted at three rural hospitals and two health centers in southern Malawi. The Hemoglobin Color Scale, recently developed by the World Health Organization, is simple to use, inexpensive, and gives an immediate result. A total of 729 pregnant women underwent conjunctiva examination, HemoCue hemoglobinometer reading, electronic Coulter Counter analysis, and at least one Hemoglobin Color Scale reading (n = 1066 observations). Each of these tests was performed by a different trained nurse-midwife to reduce the potential for bias. According to the Coulter Counter measurements, 58.1% of participants had Hb levels of 11 g/dl or less, 32.0% were 10 g/dl or less, and 4.0% were 8 g/dl or less. Sensitivity was 80.0-96.6% for HemoCue, 33.2-62.1% for conjunctiva examination, and 50.0-81.6% for the Hemoglobin Color Scale. Positive predictive values were 46.8-68.1% for HemoCue, 1.2-75.0% for conjunctival examination, and 11.0-66.2% for the color scale. The highest sensitivity for the color scale was obtained at a cut-off point of 10 g/dl and the highest positive predictive value at 11 g/dl. Agreement of the Hemoglobin Color Scale readings to within +or- 1 g/dl of the Coulter Counter measurement was obtained in 40% of cases; agreement to within 2 g/dl occurred in 67% of cases. The positive predictive value of the Hemoglobin Color Scale increases with increases in the prevalence of severe anemia.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anemia / diagnosis*
  • Color
  • Evaluation Studies as Topic
  • Female
  • Hemoglobinometry / methods*
  • Humans
  • Likelihood Functions
  • Logistic Models
  • Pregnancy
  • Pregnancy Complications, Hematologic / diagnosis*
  • Rural Population
  • Sensitivity and Specificity
  • World Health Organization