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