Transcript
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 India Urban RuralChildren 5yrs 37 7 46 50 60Men 18 326 35 45Women 35 1147 50 60Pregnant 59 1451 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
Prevalence of anaemia is high in South Asia. Even among South Asian countries prevalence of anaemia in pregnancy is highest in India.
ANAEMIA IN PREGNANCY - ASIAN COUNTRIES
WHO 1992
BANGLADESH
CHINA
INDIA
INDONES IA
MALAYSIA
MYANMAR
NEPAL
PAKISTAN
PHILIPPINES
SPORE
SRILANKA
THAILAND
Trends in prevalence of anaemia in pregnant women in IndiaOver 70 % of pregnant women in India are anaemic. There has been no decline in anaemia in the last three decades
YEARAUTHORPLACEPREVALENCE %1975Sood et alDelhi801982Prema Hyderabad751987Agarwal et alBihar & UP871989Christian et alChandrapur, Panchmahal87,881988-92Agarwal et alRural Varanasi941989ICMR11 states871994Sheshadri Baroda742000NFHS 2All India52.0? 99- 2000ICMR11 states84.6 2002-04DLHS 2 All districts90.4 2006 NNMB8 states 70.32007 MFHS 3All India 57.9?
Anaemia begins in childhood, worsens during adolescence in girls and gets aggravated during pregnancy
Chart1
339.2507.8
2443285
33651.49.6
severe
moderate
mild
no anaemia
Group
Percentage
Prevalence of Anaemia (%){DLHS 2003}
Sheet1
prevalence of anaemia
severemoderatemildno anaemia
preschool children3.039.250.07.8
adolescent girls24.043.028.05.0
pregnant women3.036.051.49.6
Sheet1
0000
0000
0000
severe
moderate
mild
no anaemia
Group
Percentage
Prevalence of Anaemia (%)
Sheet2
Sheet3
Source: NNMB 2003Among 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 : DLHS2DLHS 2 showed that over 90% of pregnant women are anaemic both in urban and in rural areas
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 cycle of anaemia in all age groups
Chart8
25.724.745.64.1
15.111.860.113.1
3.850.742.53.1
30.847.120.61.5
9.932.150.97.1
2.221.948.727.2
33.123.741.12.1
3.749.2443.1
Normal
Mild
Moderate
Severe
Prevalence of anaemia in children, adolescent girls and pregnant women from 3 surveys
Sheet1
SevereModerate
Kerala05
Arunachal Pradesh34
Jammu & Kashmir09
Manipur09
Sikkim412
Goa018
Mizoram217
Tripura129
Tamil nadu228
Karnataka130
West Bengal433
Andhra Pradesh237
Meghalaya1228
Uttaranchal338
Jharkhand141
Bihar240
INDIA343
Rajasthan344
Himachal Pradesh444
Delhi147
Orissa445
Uttar Pradesh346
Maharashtra252
Gujarat549
Madhya Pradesh351
Haryana353
Punjab354
Chattisgarh556
Assam859
SevereModerate
Children (0-71 months)Rural345
Urban341
Adolescent girls (10-19 yrs)Rural2849
Urban2649
Pregnant women (15-44 yrs)Rural443
Urban240
SevereModerate
Jammu & Kashmir08
Kerala010
Manipur124
Goa025
Mizoram224
Arunachal Pradesh128
Nagaland231
West Bengal231
Tamil nadu431
Karnataka334
Uttaranchal337
Meghalaya635
Andhra Pradesh339
Rajasthan240
Jharkhand141
Sikkim539
Orissa341
Tripura143
India344
Bihar347
Assam743
Uttar Pradesh347
Himachal Pradesh348
Delhi448
Maharashtra350
Madhya Pradesh450
Punjab550
Gujarat552
Haryana554
Chattisgarh456
SevereModerate
Manipur06
Mizoram112
Jammu & Kashmir719
Kerala230
Sikkim2121
Meghalaya937
Goa1139
Tripura1937
Arunachal Pradesh1046
Karnataka1544
Nagaland2142
Uttaranchal2939
Tamil nadu1850
Andhra Pradesh2447
West Bengal1855
Uttar Pradesh2947
INDIA2749
Madhya Pradesh3345
Himachal Pradesh3147
Orissa2751
Rajasthan2257
Gujarat3941
Bihar2853
Jharkhand2456
Delhi2952
Assam4041
Maharashtra2953
Punjab3448
Haryana4046
Chattisgarh4840
EducationStandard of living index
Illiterate0-9 yrs> 10 yrsLowMediumHigh
Children (0-71 mnths)3.432.43.332.5
EducationStandard of living index
Illiterate0-9 yrs> 10 yrsLowMediumHigh
Adolescent girls32.626.424.129.325.725.1
Pregnant women3.83.11.64.22.31.8
Pregnant womenAdolescent girlsChildren
NNMBICMRDLHSNNMBICMRDLHSNNMBDLHS
Normal25.715.13.830.89.92.233.13.7
Mild24.711.850.747.132.121.923.749.2
Moderate45.660.142.520.650.948.741.144
Severe4.113.13.11.57.127.22.13.1
Sheet1
00
00
00
00
00
00
Source: DLHS-RCH, 2002-04
Severe
Moderate
Percentage of severe and moderate anaemia (rural & urban)
Sheet2
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
Source: DLHS-RCH, 2002-04
Severe
Moderate
Percentage of children (0-71 mnths) suffering from severe and moderate anaemia (state wise)
Sheet3
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
Source: DLHS-RCH, 2002-04
Severe
Moderate
Percentage of adolescent girls (10-19 yrs) suffering from moderate and severe anaemia (state wise)
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
Source: DLHS-RCH, 2002-04
Severe
Moderate
Percentage of pregnant women (15-44 yrs) suffering from moderate and severe anaemia
0
0
0
0
0
0
Source: DLHS-RCH, 2002-04
Children (0-71 mnths)
Percentage of severe anaemia in children by mothers education & standard of living index
00
00
00
00
00
00
Source: DLHS-RCH, 2002-04
Adolescent girls
Pregnant women
Percentage of severe anaemia by education and standard of living index
0000
0000
0000
0000
0000
0000
0000
0000
Source: NNMB-MND2003, ICMR 2001, DLHS-RCH 2002-04
Normal
Mild
Moderate
Severe
Prevalence of anaemia in children, adolescent girls and pregnant women from 3 surveys
Prevalence of anaemia is high even in high income groups and among well educated pregnant women
Chart2
32.648.5
26.449.2
24.147.1
29.349.5
25.748.1
25.148.1
3.847.8
3.140.6
1.633.4
4.245.7
2.341
1.836.8
Source: Ref 7.11.1.6
Severe
Moderate
Prevalence of anaemia in adolescent girls & pregnant women by education & standard of living index
Sheet1
SevereModerate
Children (0-71 months)Rural345
Urban341
Adolescent girls (10-19 yrs)Rural2849
Urban2649
Pregnant women (15-44 yrs)Rural443
Urban240
SevereModerate
EducationIlliterate3.447.8
0-9 yrs342.3
> 10 yrs2.436.5
Standard of living indexLow3.347.1
Medium342.4
High2.537.7
SevereModerate
Adolescent girlsEducationIlliterate32.648.5
0-9 yrs26.449.2
>10yrs24.147.1
Standard of living indexLow29.349.5
Medium25.748.1
High25.148.1
Pregnant womenEducationIlliterate3.847.8
0-9 yrs3.140.6
>10yrs1.633.4
Standard of living indexLow4.245.7
Medium2.341
High1.836.8
Pregnant womenAdolescent girlsChildren
NNMBICMRDLHSNNMBICMRDLHSNNMBDLHS
Normal25.715.13.830.89.92.233.13.7
Mild24.711.850.747.132.121.923.749.2
Moderate45.660.142.520.650.948.741.144
Severe4.113.13.11.57.127.22.13.1
MenWomen
Normal45.224.8
Mild45.841.9
Moderate8.430.5
Severe0.62.8
Any ANCWeight takenBP check upAbdominal check upIFA
Bihar30.99.514.626.317
UP46.79.211.727.727.7
Haryana70.430.131.85748.7
TN98.187.886.588.179.1
Sheet1
00
00
00
00
00
00
Source: DLHS-RCH, 2002-04
Severe
Moderate
Figure: Percentage of severe and moderate anaemia (rural & urban)
Sheet2
0000
0000
0000
0000
0000
0000
0000
0000
Source: NNMB-MND2003, ICMR 2001, DLHS-RCH 2002-04
Normal
Mild
Moderate
Severe
Prevalence of anaemia in children, adolescent girls and pregnant women from 3 surveys
Sheet3
0000
0000
Source: NNMB, 2006
Normal
Mild
Moderate
Severe
Figure 5: Prevalence of anaemia among adult men & women (NNMB, 2006)
00
00
00
00
00
00
Source: DLHS-2002-04
Severe
Moderate
Figure: Prevalence of anaemia in children by mothers education & standard of living index
00
00
00
00
00
00
00
00
00
00
00
00
Source: DLHS-RCH, 2002-04
Severe
Moderate
Figure: Prevalence of anaemia in adolescent girls & pregnant women by education & standard of living index
00000
00000
00000
00000
Source: Household survey, 1999-99
Any ANC
Weight taken
BP check up
Abdominal check up
IFA
Figure 7: Quality of antenatal survey (Household survey, 1998-99)
SevereModerate
KeralaPreg05
Children010
Adol230
J & KPreg09
Children08
Adol719
TNPreg228
Children431
Adol1850
KarnatakaPreg130
Children334
Adol1544
WBPreg433
Children231
Adol1855
AndhraPreg237
Children339
Adol2447
UttaranchalPreg338
Children337
Adol2939
JharkhandPreg141
Children141
Adol2456
BiharPreg240
Children347
Adol2853
INDIAPreg343
Children344
Adol2749
RajasthanPreg344
Children240
Adol2257
HPPreg444
Children348
Adol3147
DelhiPreg147
Children448
Adol2952
OrissaPreg445
Children341
Adol2751
UPPreg346
Children347
Adol2947
MaharashtraPreg252
Children350
Adol2953
GujaratPreg549
Children552
Adol3941
MPPreg351
Children450
Adol3345
HaryanaPreg353
Children554
Adol4046
PunjabPreg354
Children550
Adol3448
ChattisgrhPreg556
Children456
Adol4840
AssamPreg859
Children743
Adol4041
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00
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Severe
Moderate
Prevalence of severe and moderate by states
KeralaJammu and kashmirTamil naduKarnatakaWest BengalAndhraUttaranchalJharkhandBiharIndiaRajashanHPDelhiOrissaUttar PradeshMaharashtra
PregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdol
Severe002007241813154218
Moderate510309819283150303444333155
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)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 %
NutrientsNNMBRuralUrban1975-791988-901996-972000-012004-051975-791993-94Iron (mg)30.228.424.917.514.824.918.96Vit C37374051444042Folic acid**1536252.3**
Iron intake is low in all age groups and does not increase in pregnancy; there has been no increase in iron intake over 3 decades
Why is anaemia in pregnancy a cause of grave concern
INDIAIndias 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
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
Prevalence of Iron deficiency anemia in South Asia% CountryChildren< 5 yearsWomen15-49 yearsPregnant womenMaternal deaths from anemiaAfghanistan6561--Bangladesh5536742600Bhutan815568
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
Chart1
29.6
19
16.1
8.9
9.5
8.3
8.4
CAUSES OF MATERNAL MORTALITY
SRS-1998
Sheet1
Pie 2
Hemorrhage29.6
Anemia19
Sepsis16.1
Abortion8.9
Obst. Lab9.5
Toxemia8.3
Others8.4
Sheet1
0
0
0
0
0
0
0
Sheet2
Sheet3
- 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
- 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
Immune status of anaemic pregnant women
There is a fall in T and B cell count when maternal Hb is below < 11 g/dLThe fall in T and B cell counts are significant when Hb is
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 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 pregnancyObstetric text books in India provided country specific protocols for management of anaemia, based on studies carried out in the country Hb < 5 g/dLConstitute 5- 10 % of anaemic womenAdmission and intensive care preferably in secondary or tertiary care institutions to ensure maternal and fetal salvageHb 5 to 7.9g/dLConstitute 10 to 20% anaemic womenScreen for systemic/obstetric problems and infectionsIf she has no other systemic or obstetric problems give her parenteral iron (IV or IM)
Total Dose IV Iron (TDI) therapySafety and efficacy of Intravenous total dose iron therapy was proved by trials undertaken by Dr MenonSubsequently 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 and intramuscular iron therapy was preferred
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 : nausea, giddiness
Effect of IM iron dextran on Hb &birth weight (Prema 1982) GroupNo.No.Hb < 8g/dl untreated4432530 + 651IM iron from 20 weeks762890 + 428IM iron from 28 weeks1052734 + 416None of the women who received 1gm of IM iron dextran had Hb less than 11g/dl at delivery
Problems in implementation of anaemia prevention and control programmes
DLHS 1 (1998-99) showed that pregnant women were not being screened for anaemia and given appropriate therapyAll 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 the tablets that they got
Chart1
30.99.514.626.317
46.79.211.727.727.7
70.430.131.85748.7
98.187.886.588.179.1
Any ANC
Weight taken
BP check up
Abdominal check up
IFA
Content of antenatal care (Household survey, 1998-99)
Sheet1
SevereModerate
Children (0-71 months)Rural345
Urban341
Adolescent girls (10-19 yrs)Rural2849
Urban2649
Pregnant women (15-44 yrs)Rural443
Urban240
SevereModerate
EducationIlliterate3.447.8
0-9 yrs342.3
> 10 yrs2.436.5
Standard of living indexLow3.347.1
Medium342.4
High2.537.7
SevereModerate
Adolescent girlsEducationIlliterate32.648.5
0-9 yrs26.449.2
>10yrs24.147.1
Standard of living indexLow29.349.5
Medium25.748.1
High25.148.1
Pregnant womenEducationIlliterate3.847.8
0-9 yrs3.140.6
>10yrs1.633.4
Standard of living indexLow4.245.7
Medium2.341
High1.836.8
Pregnant womenAdolescent girlsChildren
NNMBICMRDLHSNNMBICMRDLHSNNMBDLHS
Normal25.715.13.830.89.92.233.13.7
Mild24.711.850.747.132.121.923.749.2
Moderate45.660.142.520.650.948.741.144
Severe4.113.13.11.57.127.22.13.1
MenWomen
Normal45.224.8
Mild45.841.9
Moderate8.430.5
Severe0.62.8
Any ANCWeight takenBP check upAbdominal check upIFA
Bihar30.99.514.626.317
UP46.79.211.727.727.7
Haryana70.430.131.85748.7
TN98.187.886.588.179.1
Sheet1
00
00
00
00
00
00
Source: DLHS-RCH, 2002-04
Severe
Moderate
Figure: Percentage of severe and moderate anaemia (rural & urban)
Sheet2
0000
0000
0000
0000
0000
0000
0000
0000
Source: NNMB-MND2003, ICMR 2001, DLHS-RCH 2002-04
Normal
Mild
Moderate
Severe
Prevalence of anaemia in children, adolescent girls and pregnant women from 3 surveys
Sheet3
0000
0000
Source: NNMB, 2006
Normal
Mild
Moderate
Severe
Figure 5: Prevalence of anaemia among adult men & women (NNMB, 2006)
00
00
00
00
00
00
Source: DLHS-2002-04
Severe
Moderate
Figure: Prevalence of anaemia in children by mothers education & standard of living index
00
00
00
00
00
00
00
00
00
00
00
00
Source: DLHS-RCH, 2002-04
Severe
Moderate
Figure: Prevalence of anaemia in adolescent girls & pregnant women by education & standard of living index
00000
00000
00000
00000
Source: Household survey, 1999-99
Any ANC
Weight taken
BP check up
Abdominal check up
IFA
Figure 7: Quality of antenatal survey (Household survey, 1998-99)
SevereModerate
KeralaPreg05
Children010
Adol230
J & KPreg09
Children08
Adol719
TNPreg228
Children431
Adol1850
KarnatakaPreg130
Children334
Adol1544
WBPreg433
Children231
Adol1855
AndhraPreg237
Children339
Adol2447
UttaranchalPreg338
Children337
Adol2939
JharkhandPreg141
Children141
Adol2456
BiharPreg240
Children347
Adol2853
INDIAPreg343
Children344
Adol2749
RajasthanPreg344
Children240
Adol2257
HPPreg444
Children348
Adol3147
DelhiPreg147
Children448
Adol2952
OrissaPreg445
Children341
Adol2751
UPPreg346
Children347
Adol2947
MaharashtraPreg252
Children350
Adol2953
GujaratPreg549
Children552
Adol3941
MPPreg351
Children450
Adol3345
HaryanaPreg353
Children554
Adol4046
PunjabPreg354
Children550
Adol3448
ChattisgrhPreg556
Children456
Adol4840
AssamPreg859
Children743
Adol4041
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Severe
Moderate
Prevalence of severe and moderate by states
KeralaJammu and kashmirTamil naduKarnatakaWest BengalAndhraUttaranchalJharkhandBiharIndiaRajashanHPDelhiOrissaUttar PradeshMaharashtra
PregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdol
Severe002007241813154218
Moderate510309819283150303444333155
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
Chart1
Kerala38.5
062.4
Karnataka68
048.5
077.3
054.2
Orissa72.9
%
% of pregnant women who received some IFA tablets (NNMB)
Sheet1
States
ParticularsKeralaTamilKarnatakaAndhraMahara-MadhyaOrissaWestPooled
NaduPradeshshtraPradeshBengal
N1432582843302992122691871982
Received38.562.46848.577.354.272.970.662.7
States
ParticularsKeralaTamilKarnatakaAndhraMahara-MadhyaOrissaWest
NaduPradeshshtraPradeshBengal
Received38.562.46848.577.354.272.9187
70.6
Sheet1
00
00
00
00
00
00
00
%
% who received some IFA tablets (NNMB)
Sheet2
Sheet3
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
Hb in Pregnant women taking Iron Supplementation(ICMR 2000)No of tablets ingestedNo. Hb (g/dL)MeanS.D1-153108.81.716-302519.21.531-601969.31.861-90999.21.6>90749.12.1Total who had IFA9309.12.2B.Not known169.12.6C.Not had IFA38299.13.8A+B+C47759.13.5
IM iron therapyIM 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 collegesSome 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 levelsOral 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 therapyHospitalisation and intensive care for those with severe anaemia
Components of antenatal care DLHS -2 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 IFA Per DayDuring Entire PregnancyDLHS 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 prevalence of anaemia in pregnancy
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 .
Impact of IM iron sorbital on Maternal Hb & birth-weight(NFI)Maternal Hb (g/dl)NBirth weight(g)I - < 8.0972577+378.3II - 8.0 11.06452796+394.7III - > 11.01032921+418.1Total8452786+4055 All women who had IM iron therapy 3402805+379.3
Side effects of IM iron sorbitol citric acid complex Metallic taste in the mouth 32.4%Nausea/vomiting 15.3%Pain at the site of injection 38.3%Infection at the injection site 0.3%None had muscle or joint pain which is commonly 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 anaemicThere 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 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 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 ANMIM 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 The country should take this opportunity to show case how it can cope with a major challenge effectively
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