Anaemia in pregnancy


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Anaemia in pregnancy

  1. 1. Anaemia in pregnancy–challenge or opportunity? Prema Ramachandran Director Nutrition Foundation of India and President , National Academy of Medical Sciences
  2. 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. 3. Magnitude of the problem
  4. 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. 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. 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. 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. 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. 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. 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. 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 Prevalence of anaemia is high even in high income groups and among well educated pregnant women
  12. 12. Why is anemia so common
  13. 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. 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. 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. 16. Why is anaemia in pregnancy a cause of grave concern
  17. 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. 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. 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. 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. 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. 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. 23. Anaemia prophylaxis/control programme for pregnant women
  24. 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. 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. 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. 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. 28. Problems in implementation of anaemia prevention and control programmes
  29. 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. 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. 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. 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. 33. New initiatives in the Tenth Plan – NRHM
  34. 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. 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. 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. 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. 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. 39. Challenges in the Eleventh Plan period
  40. 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. 41. Opportunities in the Eleventh Plan period
  42. 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. 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. 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. 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