The document discusses anaemia in pregnancy in India. It notes that over 70% of pregnant women in India are anaemic, which has remained unchanged for decades. Maternal anaemia is a major cause of maternal mortality in India, accounting for around 20% of deaths. It also increases the risks of low birth weight, preterm birth, and infant and child mortality. National programmes to provide iron and folic acid supplements to pregnant women have had poor implementation and coverage. New initiatives under the National Rural Health Mission aim to screen all pregnant women for anaemia and provide appropriate oral or injectable iron therapy depending on their hemoglobin levels. However, challenges remain in ensuring regular intake of supplements and follow up treatment.

1. Anaemia in pregnancy–challenge or opportunity?
Prema Ramachandran
Director Nutrition Foundation of India and
President , National Academy of Medical Sciences

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

3. Magnitude of the problem

4. Prevalence of anaemia Source: WHO
Global Developed Developing India
Urban Rural
Children<5 yrs 43 12 51 60 70
Children > 5yrs 37 7 46 50 60
Men 18 3 26 35 45
Women 35 11 47 50
60
Pregnant 59 14 51 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

5. AN
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.

6. YEAR AUTHOR PLACE PREVALENCE %
1975 Sood et al Delhi 80
1982 Prema Hyderabad 75
1987 Agarwal et al Bihar & UP 87
1989 Christian et al Chandrapur, Panchmahal 87,88
1988-92 Agarwal et al Rural Varanasi 94
1989 ICMR 11 states 87
1994 Sheshadri Baroda 74
2000 NFHS 2 All India 52.0?
99- 2000 ICMR 11 states 84.6
2002-04 DLHS –2 All districts 90.4
2006 NNMB 8 states 70.3
2007 MFHS 3 All India 57.9?
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

7. Prevalence of Anaemia (%){DLHS 2003}
0%
20%
40%
60%
80%
100%
preschool
children
adolescent girls pregnant w omen
Group
Percentage
severe moderate mild no anaemia
Anaemia begins in childhood, worsens during
adolescence in girls and gets aggravated during
pregnancy

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

9. 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

10. 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
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

11. Prevalence of anaemia in adolescent girls & pregnant
women by education & standard of living index
0
20
40
60
80 Illiterate
0-9 yrs
>10yrs
Low
Medium
High
Illiterate
0-9 yrs
>10yrs
Low
Medium
High
Education Standard of living
index
Education Standard of living
index
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

12. Why is anemia so common

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

14. 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 %

15. 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 12
G 18 19 12.1 11.5
13-15
B 21 21 15.4 13.3
G 20 21 12.9 13
16-17
B 25 26 16.7 16.4
G 22 22 15.3 13.4
Adult males 26 27 17.5 19.6
Adult females(NPNL) 21 22 17.1 13.8
Pregnant women 20 23 14 14
Lactating women 23 23 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

16. Why is anaemia in pregnancy a cause of grave
concern

17. 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

18. 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 2600
Bhutan 81 55 68 <100
India 75 51 87 22000
Nepal 65 62 63 760
South Asia
Region Total
25,560
World Total 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

19. Hemorrhage
30%
Anemia
19%
Sepsis
16%
Abortion
9%
Obst. Lab
10%
Toxemia
8%
Others
8%
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

20. 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%

21. Effect of maternal hemoglobin level on birth weight and
perinatal mortality ( Prema 1982)
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%

22. 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

23. Anaemia prophylaxis/control programme for
pregnant women

24. 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&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

25. 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

26. 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 and
intramuscular iron therapy was preferred

27. Effect of IM iron dextran on Hb &birth weight (Prema 1982)
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
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 :

28. Problems in implementation of anaemia
prevention and control programmes

29. Content of antenatal care
(Household survey, 1998-99)
0
20
40
60
80
100
Bihar UP Haryana TN
Any ANC Weight taken
BP check up Abdominal check up
IFA
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
μg.
Most women in poorly performing states did not come for
antenatal check up. Many of those who came, did not get

30. %of pregnant women who received some IFA
tablets (NNMB)
0
20
40
60
80
100
Kerala Tamil Karnataka Andhra Mahara- Madhya Orissa
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

31. 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 most women received 90 tablets
without Hb screening. Many did not take tablets regularly.
Even among small number of women who took over 90

32. 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

33. New initiatives in the Tenth Plan – NRHM

34. 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 μg 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 μg
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

35. Components of antenatal care DLHS -2
16.4
20.4
27.6
42.2
41.4
43.8
42.1
49.8
17.4
Sonogram/Ultrasound
Height measured
Internal examination
Urine tests
Weight measured
Blood tests
Blood pressure checked
Abdominal examination
Breast examination
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 .

36. Iron & Folic Acid Supplementation
in pregnancy DLHS – 2
Iron & Folic Acid Supplementation
in pregnancy DLHS – 2
No IFA
38%
Received but
not consumed
5%
One IFA
39%
Two or More
18%
35.3
20
Less than 100
IFA
100+ IFA
IFA Per Day
During Entire Pregnancy
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

37. 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 .

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

39. Challenges in the Eleventh Plan period

40. 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

41. Opportunities in the Eleventh Plan period

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 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 technology
Opportunity: Affordable & sustainable interventions
to improve iron and folate intake of the entire
family and prevent anaemia are readily available .

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

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.

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; people’s
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