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 Developed Developing Children<5 yrs 43 Children > 5yrs 37 Men 18 Women 35 Pregnant 59 Women 12 7 3 11 14 51 46 26 47 51 India Urban Rural 60 70 50 60 35 45 50 60 65 75

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 the population

ANAEMIA IN PREGNANCY ASIAN COUNTRIES

90 80

70

60

50

40

30

20

10

B A N G L A D E S H

I N D I A C H I N A

I N D O N E S I A

M A L A Y S I A

M Y A N M A R

N E P A L

P A K I S T A N

0
Ba ngla de sh China I ndia I ndone sia M a la y sia M y a nm a r N e pa l P a kista n

P H I L I P P I N E S
P hilippine s

S R I L A N K A
S P O R E
Singa por e Sr ila nka

T H A I L A N D

T ha ila nd

WHO 1992

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
1975 1982 1987

AUTHOR
Sood et al Prema Agarwal et al

PLACE
Delhi Hyderabad Bihar & UP

PREVALENCE %
80 75 87

1989
1988-92 1989 1994 2000

Christian et al
Agarwal et al ICMR Sheshadri NFHS 2

Chandrapur, Panchmahal
Rural Varanasi 11 states Baroda All India

87,88
94 87 74 52.0?

99- 2000
2002-04 2006 2007

ICMR
DLHS 2 NNMB MFHS 3

11 states
All districts 8 states All India

84.6
90.4 70.3 57.9?

Over 70 % of pregnant women in India are anaemic. There has been no decline in anaemia in the last three decades

Pre vale nce of Anae m ia (%){DLHS 2003}

100%

Percentage

80% 60% 40% 20% 0% preschool children adolescent girls Group pregnant w omen

severe

moderate

mild

no anaemia

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

Source: NNMB 2003

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)
3

Source : DLHS2
36 51.4

TOTAL

URBAN

36 52.9

RURAL

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 anaem ia in children, adolescent girls and pregnant w om en from 3 surveys 100 80 60 40 20 0 NNMB ICMR DLHS NNMB ICMR DLHS NNMB DLHS Children Severe

Pregnant w omen Normal Mild

Adolescent girls Moderate

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. There is thus an intergenerational self perpetuating vicious

Prevalence of anaemia in adolescent girls & pregnant women by education & standard of living index 80 60 40 20 0

Illiterate

Illiterate

High

Medium

Education

Standard of living index

Education

Standard of living index

Adolescent girls
Source: Ref 7.11.1.6

Pregnant women Severe Moderate

Prevalence of anaemia is high even in high income groups and among well educated pregnant women

Medium

>10yrs

>10yrs

0-9 yrs

0-9 yrs

High

Low

Low

Why is anemia so common

Major causes of anemia Inadequate iron, folate intake due to low vegetable consumption and perhaps low B12 intake Poor bioavailability of dietary iron from the fibre, phytate rich Indian diets Chronic blood loss Increased requirement of iron during pregnancy

Time trends in intake of iron, folic acid and vitamin C in rural and urban areas (c/day) (NNMB) Nutrients NNMB Rural
197579
Iron (mg) Vit C

Urban

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

30.2 37
*

28.4 37
*

24.9 40

17.5 51

14.8 44

24.9 40
*

18.96 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 B 10-12 G B 13-15 G B 16-17 Adult males
Adult females(NPNL)

1975-79 19 18 21 20 25 22 26 21 20 23

1996-97 20 19 21 21 26 22 27 22 23 23

2000-01 12.2 12.1 15.4 12.9 16.7 15.3 17.5 17.1 14 14.6

2004-05

12

11.5 13.3 13 16.4 13.4 19.6 13.8

Pregnant women Lactating women

14
14.7

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
Afghanistan Bangladesh

Children Women < 5 years 15-49 years

Pregnant women
-

Maternal deaths from anemia

-

Bhutan
India Nepal

65 55 81
75 65

61 36 55
51 62

74 68
87 63

2600 <100
22000 760

South Asia Region Total

World Total

25,560
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
Mean birth weigh(g)

5-7.9 2,530

8-10.9 2,660

11.0 2,710

2,400

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 give her parenteral iron (IV or IM)

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

IM iron from 20 weeks IM iron from 28 weeks

443
76 105

2530 + 651
2890 + 428 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

1 00 80 60 40 20 0

Conte nt of ante natal car e (Hous e hold s ur ve y, 1998-99)

B ihar

UP

Haryana

TN

Any ANC BP check up IFA

Weight taken Abdominal check up

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 IFA through out pregnancy. Majority did not consume even

Proportion of pregnant women who receive IFA tablets is not high even among well performing states like Tamil Nadu , Kerala and Maharashtra .

Many of those who received IFA did not receive 100 tablets
Many of those who received did not take the tablets regularly

Hb in Pregnant women taking Iron Supplementation(ICMR 2000)

No of tablets ingested No. Mean Hb (g/dL) S.D

1-15 16-30 31-60 61-90 >90 Total who had IFA

310 251 196 99 74 930

8.8 9.2 9.3 9.2 9.1 9.1

1.7 1.5 1.8 1.6 2.1 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 tablets rise in Hb was low and many continued to be anaemic

IM iron therapy

IM iron therapy mainly iron dextan was used mainly in some medical colleges and rarely at district hospitals. It never reached primary health care level There were problems in ensuring continuous supply of drugs even at medical colleges
Some women found it difficult to come to OPD daily for ten days for IM injections Though women who were counseled agreed to IM therapy, those who developed trouble some side effects like arthralgia wanted to discontinue; convincing them to continue was difficult

New initiatives in the Tenth Plan NRHM

New Initiatives in the Tenth Plan Emphasis on screening all pregnant women for anaemia and providing appropriate treatment depending upon Hb levels Anaemia prophylaxis For women who are not anaemic one tablet of iron 100mg and 500 g folic acid once a day would be sufficient to prevent any deterioration in Hb levels Oral iron therapy for mild anaemia Majority of anaemic women in pregnancy have mild anaemia . Oral iron folate therapy (one tablet of iron 100mg and 500 g twice a day) regularly should be able to improve their Hb IM iron therapy for moderate anaemia One fifth of pregnant women have moderate anaemia. They should get IM iron therapy

Components of antenatal care DLHS -2

Breast examination Abdominal examination Blood pressure checked Blood tests Weight measured Urine tests Internal examination Height measured Sonogram/Ultrasound

17.4 49.8 42.1 43.8 41.4 42.2 27.6 20.4 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 & Folic Acid Supplementation in pregnancy DLHS 2

Two or More 18%

IFA Per Day

No IFA 38%

During Entire Pregnancy

35.3

20

Received but not consumed 5% One IFA 39%

Less than 100 IFA 100+ IFA

DLHS 2 also showed that there has been some improvement in % of pregnant receiving IFA tablets.There has been a significant reduction in the % of women who received but did not consume the tablets. These data suggest that if all pregnant women are screened for anaemia and provided appropriate therapy it might be possible to achieve substantial reduction in

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

Maternal Hb (g/dl) I - < 8.0 II - 8.0 11.0 III - > 11.0 N 97 645 103 Birth weight(g) 2577+378.3 2796+394.7 2921+418.1

Total
All women who had IM iron therapy

845
340

2786+4055
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 Metallic taste in the mouth Nausea/vomiting 32.4% 15.3%

Pain at the site of injection

Infection at the injection site

38.3%
0.3% is commonly

None had muscle or joint pain which seen with iron dextran injections

Nausea and vomiting was treated with anti-emetics.

Patients with pain at injection site were given paracetamol and IM iron therapy continued; one patient who developed infection responded to antibiotics

Challenges in the Eleventh Plan period

Challenges in anaemia prevention and control programmes Majority of Indians are anaemic Over 3/4th of pregnant women are anaemic

There has not been any decline in the prevalence of anaemia or its adverse consequences on mother child dyad over the last six decades

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

iron folate oral medication at the maximum tolerable dose throughout pregnancy for women with Hb between 8 10.9g/dL possible through convergence between AWW and ANM
IM iron therapy for women with Hb between 5 and 7.9 g/dL if they do not have any obstetric or systemic complication- possible with urban & rural PHCs taking the major responsibility hospital admission and intensive personalised care for women with haemoglobin less than 5 g/dl- possible with referral to tertiary care centres using of emergency transport funds and ASHA screening and effective management of obstetric and systemic problems in anaemic pregnant women possible in hospitals improvement in health education to the community to promote utilisation of available care possible through AWW, ASHA, ANM and PRI 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