Anaemia in pregnancychallenge or opportunity?

Prema Ramachandran

Director Nutrition Foundation of India and

President , National Academy of Medical Sciences

Magnitude of the problem

Why is anemia so common?
Why anaemia in pregnancy is a cause of grave
concern?
National anaemia prophylaxis/control programmes
Problems in implementation
New initiatives in the Tenth Plan NRHM
Challenges and opportunities in Eleventh Plan

Magnitude of the problem

Prevalence of anaemia Source: WHO

Global

Children<5 yrs
Children > 5yrs
Men
Women
Pregnant
75
Women

43
37
18
35
59

Developed Developing
12
7
3
11
14

51
46
26
47

India
Urban Rural
60
70
50
60
35
45
50
60
51
65

About one third of the global population ( over 2 billion

persons ) are anaemic .
Anaemia is the most common nutritional deficiency
disorder in the world
Prevalence of anaemia is higher in developing countries
Prevalence of anaemia in India is very high in all groups of

AN

90

80

70

60

50

40

30

20

10

0
Bangladesh

China

India

Indonesia

Malay sia

My anm ar

Nepal

Pakistan

Philippines

Singapore

Srilanka

Thailand

Prevalence of anaemia is high in South Asia. Even

among
South
Asian countries prevalence of
anaemia in pregnancy is highest in India.

Trends in prevalence of anaemia in pregnant women in India

YEAR

AUTHOR

PLACE

PREVALENCE %

1975

Sood et al

Delhi

80

1982

Prema

Hyderabad

75

1987

Agarwal et al

Bihar & UP

87

1989

Christian et al

Chandrapur, Panchmahal

87,88

1988-92

Agarwal et al

Rural Varanasi

94

1989

ICMR

11 states

87

1994

Sheshadri

Baroda

74

2000

NFHS 2

All India

52.0?

99- 2000

ICMR

11 states

84.6

2002-04

DLHS 2

All districts

90.4

2006

NNMB

8 states

70.3

2007

MFHS 3

All India

57.9?

Over 70 % of pregnant women in India are anaemic. There

has been no decline in anaemia in the last three decades

Prevalence of Anae m ia (%){DLHS 2003}

Pe r c e n ta g e

100%
80%
60%
40%
20%
0%
preschool
children

adolescentgirls

pregnantw omen

Group

severe

moderate

mild

noanaemia

Anaemia begins in
childhood, worsens
during adolescence in girls and gets
aggravated during pregnancy

Source:NNMB2003

Among the southern states, prevalence of anaemia in

pregnancy is lower in Kerala and Tamil Nadu -?due to
better access to health care

Anaemia pregnant women, India

(Age between 15 - 44 years)
Source : DLHS2

TOTAL

36
51.4
2

URBAN

36
52.9

RURAL

3
36
50.9

Mild

Moderate

Severe

DLHS 2 showed that over 90% of pregnant women are

anaemic both in urban and in rural areas

Prevalence of anaemia in children, adolescent

girls and pregnant w om en from 3 surveys
100
80
60
40
20
0
NNMB ICMR

DLHS NNMB ICMR

Pregnantw omen
Normal

DLHS NNMB DLHS

Adolescentgirls
Mild

Moderate

Children
Severe

Source NNBM

Majority of children, adolescents, adult men& women are

anaemic.
Anaemia antedates pregnancy& gets aggravated during
pregnancy. Maternal anaemia results in poor iron stores in
foetus
Prevalence anaemia in children is high because of poor
iron stores,
low iron content of breast milk and
complementary foods.

Prevalence of anaemia in adolescent girls & pregnant

women by education & standard of living index
80
60
40

Education

Standardofliving
index

Adolescentgirls

Source: Ref 7.11.1.6

Education

High

Medium

Low

>10yrs

0-9yrs

Illiterate

High

Medium

Low

>10yrs

0-9yrs

Illiterate

20

Standardofliving
index

Pregnantwomen
Severe Moderate

Prevalence of anaemia is high even in high income

groups and among well educated pregnant women

Why is anemia so common

Major causes of anemia

Inadequateiron,folateintakeduetolowvegetable
consumptionandperhapslowB12intake
Poorbioavailabilityofdietaryironfromthefibre,
phytaterichIndiandiets
Chronicbloodloss
Increasedrequirementofironduringpregnancy

Time trends in intake of iron, folic acid and vitamin C in rural

and urban areas (c/day) (NNMB)
Nutrients
NNMB
Rural

Urban

197579

1988-90 1996-97 2000-01 2004-05 1975-79 1993-94

Iron (mg)

30.2

28.4

24.9

17.5

14.8

24.9

18.96

Vit C

37

37

40

51

44

40

42

Folic
acid

153

62

52.3

Dietary intake of iron and folate are less than 50% of the RDA
Bioavailability of iron from phytate and fibre rich Indian diets is
only 3 %

Time trends in intake of iron (mg / day) in different groups

Age group

1975-79

1996-97

2000-01

2004-05

19

20

12.2

12

18

19

12.1

11.5

21

21

15.4

13.3

20

21

12.9

13

25

26

16.7

16.4

22

22

15.3

13.4

Adult males

26

27

17.5

19.6

Adult females(NPNL)

21

22

17.1

13.8

Pregnant women

20

23

14

14

Lactating women

23

23

14.6

14.7

10-12

13-15

16-17

Iron intake is low in all age groups and does not increase
in pregnancy; there has been no increase in iron intake over

Why is anaemia in pregnancy a cause of grave

concern

Indias share in global maternal deaths

INDIA

It is estimated that globally there are over 5 lakh maternal

deaths every year.
There are about 1 to 1.2 lakh maternal deaths in India every
year
India with 16% global population accounts for 20-25 % %
of all maternal deaths in the world

Prevalence of Iron deficiency anemia in South Asia%

Country

Children Women
< 5 years 15-49 years

Pregnant
women

Maternal deaths
from anemia

Afghanistan

61
36
55

Bhutan

65
55
81

74
68

2600
<100

India

75

51

87

22000

Nepal

65

62

63

760

Bangladesh

South Asia
Region Total

25,560

World Total

50,000

About half the deaths from anaemia in the world

occur in South Asian countries. India accounts for
over 80% of deaths due to anaemia in South Asia

CAUSES OF MATERNAL MORTALITY

SRS-1998
Toxemia
8%

Others
8%

Hemorrhage
30%

Obst. Lab
10%
Abortion
9%

Sepsis
16%

Anemia
19%

Anaemia directly causes 20% of maternal deaths and

indirectly accounts for another 20% of maternal
deaths.These figures have remained unchanged in the last

Consequences of anaemia in pregnancy

8-11 g/dL: easy fatigability, poor work capacity
5-7.9 g/dL: impaired immune function, increased
morbidity due to infections
<5 g/dL: compensated
stage: increased
morbidity and maternal mortality due to
inability to withstand even small amount of
bleeding during pregnancy /delivery and
increased risk of infections
<5 g/dL: decompensated stage about 1/3rd
develop severe congestive cardiac failure and
many with congestive failure succumb either
during pregnancy or during labour
There is 8 to 10 fold increase in MMR when
the Hb is <5 g%

Effect of maternal hemoglobin level on birth weight and

perinatal mortality ( Prema 1982)
Effects on

Hemoglobin (g/dL)

<5

5-7.9

8-10.9

11.0

Mean birth weigh(g)

2,400

2,530

2,660

2,710

Perinatal mortality
(rate/1000 live births)

500

174

76

55

Maternal anaemia is associated with poor intrauterine

growth and increased risk of preterm births resulting in
increase low birth weight rates.
This in turn results in higher perinatal morbidity and
mortality, higher IMR and poor growth trajectory in infancy,
childhood and adolescence. A doubling of low birthweight
rate and 2 to 3 fold increase in the perinatal mortality rates
is seen when the Hb falls<8 g%

Immune status of anaemic pregnant women

There is a fall in T and B cell count when maternal
Hb is below < 11 g/dL
The fall in T and B cell counts are significant
when Hb is <8g/dL
There is
no alterations in lymphocyte
transformation or in cell mediated immunity

Prevalence of morbidity due to infections

including asymptomatic bacteriuria is higher in
anaemic pregnant women
Higher morbidity rates might contribute to the
higher low birth-weight rates in anaemic pregnant
women

Anaemia prophylaxis/control programme for

pregnant women

Programmes for prevention and management of

anaemia in pregnancy
India was the first developing country to take up a
National Nutritional Anaemia Prophylaxis Programme to
prevent anaemia among pregnant women and children in
1973
At that time AN care coverage under rural primary health
care was very low and there was no provision for
screening pregnant women for anaemia. Therefore an
attempt was made to identify all pregnant women and give
them100 tablets containing 60mg of iron&500g of folic
acid
In hospital settings, screening for anaemia and ironfolate therapy in appropriate doses and route of
administration for the prevention and management of
anaemia have been incorporated as an essential component

Management of anaemia in pregnancy

Obstetric text books in India provided country
specific protocols for management of anaemia,
based on studies carried out in the country
Hb < 5 g/dL
Constitute 5- 10 % of anaemic women
Admission and intensive care preferably in
secondary or tertiary care institutions to ensure
maternal and fetal salvage
Hb 5 to 7.9g/dL
Constitute 10 to 20% anaemic women
Screen for systemic/obstetric problems and
infections
If she has no other systemic or obstetric problems

Total Dose IV Iron (TDI) therapy

Safety and efficacy of
Intravenous total dose
iron therapy was proved by trials undertaken by
Dr Menon
Subsequently IV total dose iron therapy was used
in several hospitals in Chennai and and elsewhere
Advantage : Only two day hospital admission
Disadvantage: On rare occasions anaphylactic
reaction
occurred; even in the tertiary care
hospitals it was not possible to save all women
who had anaphylactic reaction
In view of this TDI was given up
intramuscular iron therapy was preferred

and

Effect of IM iron dextran on Hb &birth weight (Prema 1982)

Group

No.

No.

Hb < 8g/dl untreated

443

2530 + 651

IM iron from 20 weeks

76

2890 + 428

IM iron from 28 weeks

105

2734 + 416

None of the women who received 1gm of IM iron dextran

had Hb less than 11g/dl at delivery
IM iron therapy
IRON DEXTRAN- Following initial successful trials by Dr
Menon, Dr Bhatt and others, IM iron dextran injections were
widely used in hospital settings often on out patient basis ;
about 1/3rd develop fever arthralgia or myalgia
IRON SORBITOL COMPLEX : Initial trials by Dr Menon
showed promising results but it was not so widely used
because 1/3rd of the drug gets excreted in urine and higher
dose of elemental iron is required .Side effects are mild :

Problems in implementation of anaemia

prevention and control programmes

100

Conte nt of ante natal car e

(Hous e hold s ur ve y, 1998-99)

80
60
40
20
0
B ihar

AnyANC
BPcheckup
IFA

UP

Haryana

TN

Weighttaken
A bdominalcheckup

DLHS 1 (1998-99) showed that pregnant women were not

being screened for anaemia and given appropriate therapy
All pregnant women who were given antenatal check up
were given tablets containing iron (100mg) and folic acid 500
g.
Most women in poorly performing states did not come for
antenatal
check up. Many of those who came, did not get

% of pregnant women who received some IFA

tablets (NNMB)
100
80
60
40
20
0
Kerala

Tamil

Karnataka

Andhra

Mahara-

Madhya

Orissa

ProportionofpregnantwomenwhoreceiveIFAtabletsisnot
highevenamongwellperformingstateslikeTamilNadu,Kerala
andMaharashtra.
ManyofthosewhoreceivedIFAdidnotreceive100tablets
Manyofthosewhoreceiveddidnottakethetabletsregularly

Hb in Pregnant women taking Iron Supplementation(ICMR 2000)

No of tablets ingested

Hb (g/dL)
No.

Mean

S.D

1-15

310

8.8

1.7

16-30

251

9.2

1.5

31-60

196

9.3

1.8

61-90

99

9.2

1.6

>90

74

9.1

2.1

Total who had IFA

930

9.1

2.2

B.Not known

16

9.1

2.6

C.Not had IFA

3829

9.1

3.8

A+B+C

4775

9.1

3.5

ICMR study confirmed that most women received 90 tablets

without Hb screening. Many did not take tablets regularly.
Even among small number of women who took over 90

IM iron therapy
IMirontherapymainlyirondextanwasusedmainly
insomemedicalcollegesandrarelyatdistrict
hospitals.Itneverreachedprimaryhealthcarelevel
Therewereproblemsinensuringcontinuoussupply
ofdrugsevenatmedicalcolleges
SomewomenfounditdifficulttocometoOPDdaily
fortendaysforIMinjections
ThoughwomenwhowerecounseledagreedtoIM
therapy,thosewhodevelopedtroublesomeside
effectslikearthralgiawantedtodiscontinue;
convincingthemtocontinuewasdifficult

New initiatives in the Tenth Plan NRHM

New Initiatives in the Tenth Plan

Emphasis on screening all pregnant women for
anaemiaandprovidingappropriatetreatmentdepending
uponHblevels
AnaemiaprophylaxisForwomenwhoarenotanaemic
onetabletofiron100mgand500gfolicacidoncea
daywouldbesufficienttopreventanydeteriorationin
Hblevels
OralirontherapyformildanaemiaMajorityofanaemic
women in pregnancy have mild anaemia . Oral iron
folate therapy (one tablet of iron 100mg and 500 g
twiceaday)regularlyshouldbeabletoimprovetheir
Hb
IM iron therapy for moderate anaemia One fifth of
pregnantwomenhavemoderateanaemia.Theyshould
getIMirontherapy

Components of antenatal care DLHS -2

Breast examination

17.4
49.8

Abdominal examination

42.1

Blood pressure checked

43.8

Blood tests

41.4

Weight measured
Urine tests

42.2

Internal examination

27.6
20.4

Height measured
Sonogram/Ultrasound

16.4

DLHS 2 (2006) showed that there was some

improvement in coverage and content of antenatal
care. About 40% women had blood examination
which might include Hb estimation .

Iron
Iron &
& Folic
Folic Acid
Acid Supplementation
Supplementation
in
DLHS
in pregnancy
pregnancy
DLHS22
During Entire Pregnancy
IFA Per Day

Two or More
18%

35.3
No IFA
38%

20

Received but
not consumed
5%
One IFA
39%

Less than 100

IFA

100+ IFA

DLHS2alsoshowedthattherehasbeensomeimprovement
in%ofpregnantreceivingIFAtablets.Therehasbeena
significantreductioninthe%ofwomenwhoreceivedbutdid
notconsumethetablets.Thesedatasuggestthatifallpregnant
womenarescreenedforanaemiaandprovidedappropriate
therapyitmightbepossibletoachievesubstantialreductionin

Impact of IM iron sorbital on Maternal Hb & birthweight(NFI)

Maternal Hb (g/dl)
I - < 8.0

Birth weight(g)
97

2577+378.3

II - 8.0 11.0

645

2796+394.7

III - > 11.0

103

2921+418.1

Total

845

2786+4055

All women who had IM iron

therapy

340

2805+379.3

NFI study showed that IM iron sorbital therapy is feasible in

primary care institutions. Mean Hb rose and there was
significant improvement in birth weight. BUT majority of
women who received 900 mg of iron sorbital had Hb levels
around 10 g/dl and birth weight was lower than the birth
weight in non-anaemic women.
It would appear that 1500mg of iron sorbital citric acid
complex would be required for optimal results .

Side effects of IM iron sorbitol citric acid complex

Metallictasteinthemouth

32.4%

Nausea/vomiting 15.3%
Painatthesiteofinjection

38.3%

Infectionattheinjectionsite0.3%
None had muscle or joint pain which is commonly
seenwithirondextraninjections
Nauseaandvomitingwastreatedwithanti-emetics.
Patients with pain at injection site were given
paracetamolandIMirontherapycontinued;onepatient
whodevelopedinfectionrespondedtoantibiotics

Challenges in the Eleventh Plan period

Challenges in anaemia prevention and control

programmes
MajorityofIndiansareanaemic
Over3/4thofpregnantwomenareanaemic
Therehasnotbeenanydeclineintheprevalenceof
anaemia or its adverse consequences on mother
childdyadoverthelastsixdecades

Opportunities in the Eleventh Plan period

Strategy for prevention of anaemia in pregnancy

health and nutrition education to improve over all
dietary intakes and promote consumption of iron
and folate-rich foodstuffs- possible through NRHMs
health and nutrition days
dietary diversification inclusion of iron folate rich
foods as well as food items that promote iron
absorption- possible with proper linkages with
National Horticultural Mission
introduction of iron and iodine-fortified salt
universally to improve iron intake- possible with
NIN technology
Opportunity: Affordable & sustainable interventions
to improve iron and folate intake of the entire
family and prevent anaemia are readily available .

Strategy for prevention of anaemia in pregnancy

focus on Hb estimation for detection and treatment of
anemia in adolescent school girls as a part of school health
check possible through school health system
focus on Hb estimation in girls / women who are married,
for detection and treatment of anemia prior to pregnancycan be attempted through coordination with AWW
screening all pregnant women for anemia-Possible using
filter paper technique
providing one tablet of IFA to prevent any fall in Hb levels
in non anaemic pregnant women- possible through NRHM
Opportunity:All these interventions are feasible& affordable
for the individual and health system. With universal coverage
and monitored supplementation it is possible to ensure that
non anaemic women do not become anaemic

Strategy for detection&management of anaemia in pregnancy

ironfolateoralmedicationatthemaximumtolerabledose
throughoutpregnancyforwomenwithHbbetween810.9g/dL
possiblethroughconvergencebetweenAWWandANM
IMirontherapyforwomenwithHbbetween5and7.9g/dLif
theydonothaveanyobstetricorsystemiccomplication-possible
withurban&ruralPHCstakingthemajorresponsibility
hospitaladmissionandintensivepersonalisedcareforwomen
withhaemoglobinlessthan5g/dl-possiblewithreferraltotertiary
carecentresusingofemergencytransportfundsandASHA
screeningandeffectivemanagementofobstetricandsystemic
problemsinanaemicpregnantwomenpossibleinhospitals
improvementinhealtheducationtothecommunitytopromote
utilisationofavailablecarepossiblethroughAWW,ASHA,ANM
andPRI
Opportunity:All these interventions are feasible& affordable
for the individual and health system.

Opportunities for prevention, detection and

appropriate management of anemia in pregnant
women
India currently has the necessary infrastrucutre ,
manpower, technology for this task
Indians are rational and responsive; peoples
institutions are in place providing the necessary
community support
Prevention, detection and appropriate management
of anemia in pregnant women and preventing the
adverse consequences of anaemia on the mother
child dyad is feasible under NRHM and its urban
counterpart