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Anaemia in pregnancychallenge or opportunity? Prema Ramachandran Director Nutrition Foundation of India and President, National Academy of Medical Sciences Slide 2 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 Slide 3 Magnitude of the problem Slide 4 Prevalence of anaemia Source: WHO Global Developed Developing India Urban Rural Children 5yrs 37 7 46 50 60 Men 18 326 35 45 Women 35 1147 50 60 Pregnant 59 1451 65 75 Women 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 Slide 5 Prevalence of anaemia is high in South Asia. Even among South Asian countries prevalence of anaemia in pregnancy is highest in India. Slide 6 YEARAUTHORPLACEPREVALENCE % 1975Sood et alDelhi80 1982PremaHyderabad75 1987Agarwal et alBihar & UP87 1989Christian et alChandrapur, Panchmahal87,88 1988-92Agarwal et alRural Varanasi94 1989ICMR11 states87 1994SheshadriBaroda74 2000NFHS 2All India52.0? 99- 2000ICMR11 states84.6 2002-04DLHS 2All districts90.4 2006NNMB8 states70.3 2007MFHS 3All India57.9? Trends in prevalence of anaemia in pregnant women in India Over 70 % of pregnant women in India are anaemic. There has been no decline in anaemia in the last three decades Slide 7 Anaemia begins in childhood, worsens during adolescence in girls and gets aggravated during pregnancy Slide 8 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 Slide 9 Anaemia pregnant women, India (Age between 15 - 44 years) Source : DLHS2 DLHS 2 showed that over 90% of pregnant women are anaemic both in urban and in rural areas Slide 10 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 Slide 11 Prevalence of anaemia is high even in high income groups and among well educated pregnant women Slide 12 Why is anemia so common Slide 13 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 Slide 14 Nutrients NNMB Rural Urban 1975- 79 1988-901996-972000-012004-051975-791993-94 Iron (mg) 30.228.424.917.514.824.918.96 Vit C 37 4051444042 Folic acid ** 1536252.3 ** 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 % Slide 15 Time trends in intake of iron (mg / day) in different groups Age group1975-791996-972000-012004-05 10-12 B192012.2 12 G181912.1 11.5 13-15 B21 15.4 13.3 G202112.9 13 16-17 B252616.7 16.4 G22 15.3 13.4 Adult males262717.5 19.6 Adult females(NPNL) 212217.1 13.8 Pregnant women202314 Lactating women23 14.6 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 3 decades Slide 16 Why is anaemia in pregnancy a cause of grave concern Slide 17 INDIA Indias 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 Slide 18 Prevalence of Iron deficiency anemia in South Asia% CountryChildren < 5 years Women 15-49 years Pregnant women Maternal deaths from anemia Afghanistan 6561 -- Bangladesh 5536742600 Bhutan 815568 Impact of IM iron sorbital on Maternal Hb & birth- weight(NFI) Maternal Hb (g/dl)NBirth weight(g) I - < 8.0972577+378.3 II - 8.0 11.06452796+394.7 III - > 11.01032921+418.1 Total8452786+4055 All women who had IM iron therapy 3402805+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. Slide 38 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 Slide 39 Challenges in the Eleventh Plan period Slide 40 Challenges in anaemia prevention and control programmes Majority of Indians are anaemic Over 3/4 th 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 Slide 41 Opportunities in the Eleventh Plan period Slide 42 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. Slide 43 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 Slide 44 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. Slide 45 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 Slide 46