Anaemia in pregnancy (1)
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Anaemia in pregnancy (1) Presentation Transcript

  • 1. Anaemia in pregnancy–challenge or opportunity?Prema RamachandranDirector Nutrition Foundation of India andPresident , National Academy of Medical Sciences
  • 2. Magnitude of the problemWhy is anemia so common?Why anaemia in pregnancy is a cause of graveconcern?National anaemia prophylaxis/control programmesProblems in implementationNew initiatives in the Tenth Plan – NRHMChallenges and opportunities in Eleventh Plan
  • 3. Magnitude of the problem
  • 4. Prevalence of anaemia Source: WHO             Global Developed Developing IndiaUrban RuralChildren<5 yrs 43 12 51 60 70Children > 5yrs 37 7 46 50 60Men 18 3 26 35 45Women 35 11 47 5060Pregnant 59 14 51 6575WomenAbout one third of the global population ( over 2 billionpersons ) are anaemic .Anaemia is the most common nutritional deficiencydisorder in the worldPrevalence of anaemia is higher in developing countries
  • 5. AN0102030405060708090Bangladesh China India Indonesia Malaysia Myanmar Nepal Pakistan Philippines Singapore Srilanka ThailandPrevalence of anaemia is high in South Asia. Evenamong South Asian countries prevalence ofanaemia in pregnancy is highest in India.
  • 6. YEAR AUTHOR PLACE PREVALENCE %1975 Sood et al Delhi 801982 Prema Hyderabad 751987 Agarwal et al Bihar & UP 871989 Christian et al Chandrapur, Panchmahal 87,881988-92 Agarwal et al Rural Varanasi 941989 ICMR 11 states 871994 Sheshadri Baroda 742000 NFHS 2 All India 52.0?99- 2000 ICMR 11 states 84.62002-04 DLHS –2 All districts 90.42006 NNMB 8 states 70.32007 MFHS 3 All India 57.9?Trends in prevalence of anaemia in pregnant women in IndiaOver 70 % of pregnant women in India are anaemic. Therehas been no decline in anaemia in the last three decades
  • 7. Prevalence of Anaemia (%){DLHS 2003}0%20%40%60%80%100%preschoolchildrenadolescent girls pregnant w omenGroupPercentage severe moderate mild no anaemiaAnaemia begins in childhood, worsens duringadolescence in girls and gets aggravated duringpregnancy
  • 8. Source: NNMB 2003Among the southern states, prevalence of anaemia inpregnancy is lower in Kerala and Tamil Nadu -?due tobetter access to health care
  • 9. Anaemia pregnant women, India(Age between 15 - 44 years)50.952.951.4363636323RURALURBANTOTALMild Moderate SevereSource : DLHS2DLHS –2 showed that over 90% of pregnant women areanaemic both in urban and in rural areas
  • 10. Prevalence of anaemia in children, adolescentgirls and pregnant women from 3 surveys020406080100NNMB  ICMR DLHS NNMB ICMR DLHS NNMB DLHSPregnant w omen Adolescent girls Children Normal Mild Moderate SevereSource NNBMMajority of children, adolescents, adult men& women areanaemic.Anaemia antedates pregnancy& gets aggravated duringpregnancy. Maternal anaemia results in poor iron stores infoetusPrevalence anaemia in children is high because of pooriron stores, low iron content of breast milk andcomplementary foods.There is thus an intergenerational self perpetuating vicious
  • 11. Prevalence of anaemia in adolescent girls & pregnantwomen by education & standard of living index020406080 Illiterate0-9 yrs>10yrsLowMediumHighIlliterate0-9 yrs>10yrsLowMediumHighEducation Standard of livingindexEducation Standard of livingindexAdolescent girls  Pregnant women Severe ModerateSource: Ref of anaemia is high even in high incomegroups and among well educated pregnant women
  • 12. Why is anemia so common
  • 13. Major causes of anemiaInadequate iron, folate intake due to low vegetableconsumption and perhaps low B12 intakePoor bioavailability of dietary iron from the fibre,phytate rich Indian dietsChronic blood lossIncreased requirement of iron during pregnancy
  • 14. Nutrients NNMBRural Urban1975-791988-90 1996-97 2000-01 2004-05 1975-79 1993-94Iron (mg) 30.2 28.4 24.9 17.5 14.8 24.9 18.96Vit C 37 37 40 51 44 40 42Folicacid* * 153 62 52.3 * *Time trends in intake of iron, folic acid and vitamin C in ruraland urban areas (c/day) – (NNMB)Dietary intake of iron and folate are less than 50% of the RDABioavailability of iron from phytate and fibre rich Indian diets isonly 3 %
  • 15. Time trends in intake of iron (mg / day) in different groupsAge group 1975-79 1996-97 2000-01 2004-0510-12B 19 20 12.2 12G 18 19 12.1 11.513-15B 21 21 15.4 13.3G 20 21 12.9 1316-17B 25 26 16.7 16.4G 22 22 15.3 13.4Adult males 26 27 17.5 19.6Adult females(NPNL) 21 22 17.1 13.8Pregnant women 20 23 14 14Lactating women 23 23 14.6 14.7Iron intake is low in all age groups and does not increasein pregnancy; there has been no increase in iron intake over
  • 16. Why is anaemia in pregnancy a cause of graveconcern
  • 17. INDIAIndia’s share in global maternal deathsIt is estimated that globally there are over 5 lakh maternaldeaths every year.There are about 1 to 1.2 lakh maternal deaths in India everyyearIndia 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 yearsWomen15-49 yearsPregnantwomenMaternal deathsfrom anemiaAfghanistan 65 61 - -Bangladesh 55 36 74 2600Bhutan 81 55 68 <100India 75 51 87 22000Nepal 65 62 63 760South AsiaRegion Total25,560World Total 50,000About half the deaths from anaemia in the worldoccur in South Asian countries. India accounts forover 80% of deaths due to anaemia in South Asia
  • 19. Hemorrhage30%Anemia19%Sepsis16%Abortion9%Obst. Lab10%Toxemia8%Others8%CAUSES OF MATERNAL MORTALITYSRS-1998Anaemia directly causes 20% of maternal deaths andindirectly accounts for another 20% of maternaldeaths.These figures have remained unchanged in the last
  • 20. Consequences of anaemia in pregnancy8-11 g/dL: easy fatigability, poor work capacity5-7.9 g/dL: impaired immune function, increasedmorbidity due to infections<5 g/dL: compensated stage: increasedmorbidity and maternal mortality due toinability to withstand even small amount ofbleeding during pregnancy /delivery andincreased risk of infections<5 g/dL: decompensated stage about 1/3rddevelop severe congestive cardiac failure andmany with congestive failure succumb eitherduring pregnancy or during labourThere is 8 to 10 fold increase in ↑ MMR whenthe Hb is <5 g%
  • 21. Effect of maternal hemoglobin level on birth weight andperinatal mortality ( Prema 1982)Effects on Hemoglobin (g/dL)<5 5-7.9 8-10.9 11.0Mean birth weigh(g) 2,400 2,530 2,660 2,710Perinatal mortality(rate/1000 live births)500 174 76 55Maternal anaemia is associated with poor intrauterinegrowth and increased risk of preterm births resulting inincrease low birth weight rates.This in turn results in higher perinatal morbidity andmortality, higher IMR and poor growth trajectory in infancy,childhood and adolescence. A doubling of low birthweightrate and 2 to 3 fold increase in the perinatal mortality ratesis 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 maternalHb is below < 11 g/dL•The fall in T and B cell counts are significantwhen Hb is <8g/dL•There is no alterations in lymphocytetransformation or in cell mediated immunity• Prevalence of morbidity due to infectionsincluding asymptomatic bacteriuria is higher inanaemic pregnant women•Higher morbidity rates might contribute to thehigher low birth-weight rates in anaemic pregnantwomen
  • 23. Anaemia prophylaxis/control programme forpregnant women
  • 24. Programmes for prevention and management ofanaemia in pregnancyIndia was the first developing country to take up aNational Nutritional Anaemia Prophylaxis Programme toprevent anaemia among pregnant women and children in1973At that time AN care coverage under rural primary healthcare was very low and there was no provision forscreening pregnant women for anaemia. Therefore anattempt was made to identify all pregnant women and givethem100 tablets containing 60mg of iron&500μg of folicacidIn hospital settings, screening for anaemia and iron-folate therapy in appropriate doses and route ofadministration for the prevention and management ofanaemia have been incorporated as an essential component
  • 25. Management of anaemia in pregnancyObstetric text books in India provided countryspecific protocols for management of anaemia,based on studies carried out in the countryHb < 5 g/dLConstitute 5- 10 % of anaemic womenAdmission and intensive care preferably insecondary or tertiary care institutions to ensurematernal and fetal salvageHb 5 to 7.9g/dLConstitute 10 to 20% anaemic womenScreen for systemic/obstetric problems andinfectionsIf she has no other systemic or obstetric problems
  • 26. Total Dose IV Iron (TDI) therapySafety and efficacy of Intravenous total doseiron therapy was proved by trials undertaken byDr MenonSubsequently IV total dose iron therapy was usedin several hospitals in Chennai and and elsewhereAdvantage : Only two day hospital admissionDisadvantage: On rare occasions anaphylacticreaction occurred; even in the tertiary carehospitals it was not possible to save all womenwho had anaphylactic reactionIn view of this TDI was given up andintramuscular 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 + 651IM iron from 20 weeks 76 2890 + 428IM iron from 28 weeks 105 2734 + 416None of the women who received 1gm of IM iron dextranhad Hb less than 11g/dl at deliveryIM iron therapyIRON DEXTRAN- Following initial successful trials by DrMenon, Dr Bhatt and others, IM iron dextran injections werewidely used in hospital settings often on out patient basis ;about 1/3rddevelop fever arthralgia or myalgiaIRON SORBITOL COMPLEX : Initial trials by Dr Menonshowed promising results but it was not so widely usedbecause 1/3rdof the drug gets excreted in urine and higherdose of elemental iron is required .Side effects are mild :
  • 28. Problems in implementation of anaemiaprevention and control programmes
  • 29. Content of antenatal care(Household survey, 1998-99)020406080100Bihar UP Haryana TNAny ANC Weight takenBP check up Abdominal check upIFADLHS 1 (1998-99) showed that pregnant women were notbeing screened for anaemia and given appropriate therapyAll pregnant women who were given antenatal check upwere given tablets containing iron (100mg) and folic acid 500μg.Most women in poorly performing states did not come forantenatal check up. Many of those who came, did not get
  • 30. %of pregnant women who received some IFAtablets (NNMB)020406080100Kerala Tamil Karnataka Andhra Mahara- Madhya OrissaProportion of pregnant women who receive IFA tablets is nothigh even among well performing states like Tamil Nadu , Keralaand Maharashtra .Many of those who received IFA did not receive 100 tabletsMany of those who received did not take the tablets regularly
  • 31. Hb in Pregnant women taking Iron Supplementation(ICMR 2000)No of tablets ingestedNo.Hb (g/dL)Mean S.D1-15 310 8.8 1.716-30 251 9.2 1.531-60 196 9.3 1.861-90 99 9.2 1.6>90 74 9.1 2.1Total who had IFA 930 9.1 2.2B.Not known 16 9.1 2.6C.Not had IFA 3829 9.1 3.8A+B+C 4775 9.1 3.5ICMR study confirmed that most women received 90 tabletswithout Hb screening. Many did not take tablets regularly.Even among small number of women who took over 90
  • 32. IM iron therapyIM iron therapy mainly iron dextan was used mainlyin some medical colleges and rarely at districthospitals. It never reached primary health care levelThere were problems in ensuring continuous supplyof drugs even at medical collegesSome women found it difficult to come to OPD dailyfor ten days for IM injectionsThough women who were counseled agreed to IMtherapy, those who developed trouble some sideeffects 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 PlanEmphasis on screening all pregnant women foranaemia and providing appropriate treatment dependingupon Hb levelsAnaemia prophylaxis For women who are not anaemicone tablet of iron 100mg and 500 μg folic acid once aday would be sufficient to prevent any deterioration inHb levelsOral iron therapy for mild anaemia Majority of anaemicwomen in pregnancy have mild anaemia . Oral ironfolate therapy (one tablet of iron 100mg and 500 μgtwice a day) regularly should be able to improve theirHbIM iron therapy for moderate anaemia One fifth ofpregnant women have moderate anaemia. They shouldget IM iron therapy
  • 35. Components of antenatal care DLHS -216.420.427.642.241.443.842.149.817.4Sonogram/UltrasoundHeight measuredInternal examinationUrine testsWeight measuredBlood testsBlood pressure checkedAbdominal examinationBreast examinationDLHS 2 (2006) showed that there was someimprovement in coverage and content of antenatalcare. About 40% women had blood examination –which might include Hb estimation .
  • 36. Iron & Folic Acid Supplementationin pregnancy DLHS – 2Iron & Folic Acid Supplementationin pregnancy DLHS – 2No IFA38%Received butnot consumed5%One IFA39%Two or More18%35.320Less than 100IFA100+ IFAIFA Per DayDuring Entire PregnancyDLHS 2 also showed that there has been some improvementin % of pregnant receiving IFA tablets.There has been asignificant reduction in the % of women who received but didnot consume the tablets. These data suggest that if all pregnantwomen are screened for anaemia and provided appropriatetherapy 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+378.3II - 8.0 – 11.0 645 2796+394.7III - > 11.0 103 2921+418.1Total 845 2786+4055All women who had IM irontherapy340 2805+379.3NFI study showed that IM iron sorbital therapy is feasible inprimary care institutions. Mean Hb rose and there wassignificant improvement in birth weight. BUT majority ofwomen who received 900 mg of iron sorbital had Hb levelsaround 10 g/dl and birth weight was lower than the birthweight in non-anaemic women.It would appear that 1500mg of iron sorbital citric acidcomplex would be required for optimal results .
  • 38. Side effects of IM iron sorbitol citric acid complexMetallic 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 commonlyseen with iron dextran injectionsNausea and vomiting was treated with anti-emetics.Patients with pain at injection site were givenparacetamol and IM iron therapy continued; one patientwho developed infection responded to antibiotics
  • 39. Challenges in the Eleventh Plan period
  • 40. Challenges in anaemia prevention and controlprogrammesMajority of Indians are anaemicOver 3/4thof pregnant women are anaemicThere has not been any decline in the prevalence ofanaemia or its adverse consequences on motherchild dyad over the last six decades
  • 41. Opportunities in the Eleventh Plan period
  • 42. Strategy for prevention of anaemia in pregnancyhealth and nutrition education to improve over alldietary intakes and promote consumption of ironand folate-rich foodstuffs- possible through NRHM’shealth and nutrition daysdietary diversification inclusion of iron folate richfoods as well as food items that promote ironabsorption- possible with proper linkages withNational Horticultural Missionintroduction of iron and iodine-fortified saltuniversally to improve iron intake- possible withNIN technologyOpportunity: Affordable & sustainable interventionsto improve iron and folate intake of the entirefamily and prevent anaemia are readily available .
  • 43. Strategy for prevention of anaemia in pregnancyfocus on Hb estimation for detection and treatment ofanemia in adolescent school girls as a part of school healthcheck – 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 usingfilter paper techniqueproviding one tablet of IFA to prevent any fall in Hb levelsin non anaemic pregnant women- possible through NRHMOpportunity:All these interventions are feasible& affordablefor the individual and health system. With universal coverageand monitored supplementation it is possible to ensure thatnon anaemic women do not become anaemic
  • 44. Strategy for detection&management of anaemia in pregnancyiron folate oral medication at the maximum tolerable dosethroughout 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 ifthey do not have any obstetric or systemic complication- possiblewith urban & rural PHCs taking the major responsibilityhospital admission and intensive personalised care for womenwith haemoglobin less than 5 g/dl- possible with referral to tertiarycare centres using of emergency transport funds and ASHAscreening and effective management of obstetric and systemicproblems in anaemic pregnant women possible in hospitalsimprovement in health education to the community to promoteutilisation of available care possible through AWW, ASHA, ANMand PRIOpportunity:All these interventions are feasible& affordablefor the individual and health system.
  • 45. Opportunities for prevention, detection andappropriate management of anemia in pregnantwomenIndia currently has the necessary infrastrucutre ,manpower, technology for this taskIndians are rational and responsive; people’sinstitutions are in place providing the necessarycommunity supportPrevention, detection and appropriate managementof anemia in pregnant women and preventing theadverse consequences of anaemia on the motherchild dyad is feasible under NRHM and its urbancounterpart