anaemia
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Anaemia National Challenge: Midwives Perspective
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
Magnitude of the problem
Prevalence of anaemia Source: WHO
Global Developed Developing India Urban Rural
Children<5 yrs 43 12 51 60 70Children > 5yrs 37 7 46 50 60Men 18 3 26 35 45Women 35 11 47 50
60Pregnant 59 14 51 65 75Women
•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
A N A EM IA IN PR EG N A N C Y -A SIA N C O U N T R IES
W H O 1992
0
10
20
30
40
50
60
70
80
90
Bangladesh China India Indonesia Malaysia Myanmar 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.
Prevalence of Anaemia (%){DLHS 2003}
0%
20%
40%
60%
80%
100%
preschoolchildren
adolescent girls pregnant w omen
Group
Perc
enta
ge
severe moderate mild no anaemia
Anaemia begins in childhood, worsens during adolescence in girls and gets aggravated during pregnancy
Anaemia pregnant women, India (Age between 15 - 44 years)
50.9
52.9
51.4
36
36
36
3
2
3
RURAL
URBAN
TOTAL
Mild Moderate Severe
Source : DLHS2
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 women from 3 surveys
0
20
40
60
80
100
NNMB ICMR DLHS NNMB ICMR DLHS NNMB DLHS
Pregnant w omen Adolescent girls Children
Normal Mild Moderate Severe
Source NNBM
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 cycle of anaemia in all age groups
Prevalence of anaemia in adolescent girls & pregnant women by education & standard of living index
0
20
40
60
80Ill
itera
te
0-9
yrs
>10yr
s
Low
Mediu
m
Hig
h
Illite
rate
0-9
yrs
>10yr
s
Low
Mediu
m
Hig
h
Education Standard of livingindex
Education Standard of livingindex
Adolescent girls Pregnant women Severe ModerateSource: Ref 7.11.1.6
Prevalence of anaemia is high even in high income groups and among well educated pregnant women
Why is anemia so common in pregnancy
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
Nutrients NNMB
Rural Urban
1975-79
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 * *
Time trends in intake of iron, folic acid and vitamin C in rural and urban areas (c/day) – (NNMB)
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
10-12
B 19 20 12.2 12G 18 19 12.1 11.5
13-15
B 21 21 15.4 13.3G 20 21 12.9 13
16-17
B 25 26 16.7 16.4G 22 22 15.3 13.4
Adult males 26 27 17.5 19.6Adult females(NPNL) 21 22 17.1 13.8
Pregnant women 20 23 14 14Lactating women 23 23 14.6 14.7
Iron intake is low in all age groups; no increase in iron intake during pregnancy; there has been no increase in iron intake over three decades
Why is anaemia in pregnancy a cause of grave concern ?
INDIA
India’s share in global maternal deaths
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
< 5 years
Women
15-49 years
Pregnant women
Maternal deaths from anemia
Afghanistan 65 61 - -
Bangladesh 55 36 74 2600Bhutan 81 55 68 <100India 75 51 87 22000Nepal 65 62 63 760South Asia Region Total
25,560
World Total 50,000About 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
Hemorrhage30%
Anemia19%
Sepsis16%
Abortion9%
Obst. Lab10%
Toxemia8%
Others8%
CAUSES OF MATERNAL MORTALITY SRS-1998
Anaemia directly causes 20% of maternal deaths and indirectly accounts for another 20% of maternal deaths. These figures have remained unchanged in the last five decades .
Consequences of anaemia in pregnancy8-11 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
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 further reduction in Hb levels 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 them 100 tablets containing 60mg of iron & 500μg of folic acid
In hospital settings, screening for anaemia and iron-folate therapy in appropriate doses and route of administration for the prevention and management of anaemia have been incorporated as an essential component of antenatal care
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 IM iron therapy
Effect of IM iron dextran on Hb & birth weight
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
Following initial successful trials by Dr Menon, Dr Bhatt and others, IM iron dextran injections were widely used in medical college hospital settings on out patient basis ; between 10-30 % report side effects fever, arthralgia or myalgia .
However IM iron dextran injections never reached primary health care settings
IM IRON SORBITOL COMPLEX
Initial trials by Dr Menon showed promising results but it was not widely used because
1/3rd of the drug gets excreted in urine and higher dose of is required
It was more expensive
Advantages
Side effects are mild: nausea, metallic taste in the tongue and giddiness; all these respond readily to symptomatic treatment
Impact of IM iron sorbital on Maternal Hb & birth-weight(NFI)
Maternal Hb (g/dl) N Birth weight(g)
I - < 8.0 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
Metallic taste in the mouth 32.4%
Nausea/vomiting 15.3%
None had muscle or joint pain which is commonly seen with iron dextran injections
Nausea and vomiting was treated with anti-emetics.
It maybe worth while to initiate its use in medical colleges and later at smaller hospitals
Problems in implementation of anaemia prevention and control programmes
Content of antenatal care (Household survey, 1998-99)
0
20
40
60
80
100
Bihar UP Haryana TN
Any ANC Weight takenBP check up Abdominal check upIFA
DLHS showed that pregnant women were not being screened for anaemia and given appropriate therapy
All pregnant women who came for antenatal check up were given tablets containing iron (100mg) and folic acid 500 μg.
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 the tablets that they got .
Hb in Pregnant women taking Iron Supplementation(ICMR 2000)
No of tablets ingested
No.
Hb (g/dL)
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 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 not significant
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
With iron dextran women who developed trouble some side effects like arthralgia wanted to discontinue;
Iron sorbital citric acid complex was associated with fewer and milder side effects but this drug has not been widely used
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 NRHM’s 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 technologyOpportunity: 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 pregnancy- can 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 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 management of anemia in pregnant women
India currently has the necessary infrastructure , manpower, technology for this task
Indians are rational and responsive; people’s institutions are in place for 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
The country should take this opportunity to show case how it can cope with a major challenge to maternal and child health effectively within a short time
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