1. Anaemia National Challenge: Midwives Perspective

3. Magnitude of the problem

5. Prevalence of anaemia is high in South Asia. Even among South Asian countries prevalence of anaemia in pregnancy is highest in India.

6. Anaemia begins in childhood, worsens during adolescence in girls and gets aggravated during pregnancy

7. 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

9. Prevalence of anaemia is high even in high income groups and among well educated pregnant women

10. Why is anemia so common in pregnancy

12. 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 % 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 * *

13. Iron intake is low in all age groups; no increase in iron intake during pregnancy; there has been no increase in iron intake over three decades 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

14. Why is anaemia in pregnancy a cause of grave concern ?

15. 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

16. 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% 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

17. 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 .

21. Anaemia prophylaxis/control programme for pregnant women

24. Following initial successful trials by Dr Menon, Dr Bhatt and others, IM iron dextran injections were widely used in medical college hospital settings on out patient basis ; between 10-30 % report side effects fever, arthralgia or myalgia . However IM iron dextran injections never reached primary health care settings Effect of IM iron dextran on Hb & birth weight 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

26. 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) 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

27. Side effects of IM iron sorbitol citric acid complex Metallic taste in the mouth 32.4% Nausea/vomiting 15.3% None had muscle or joint pain which is commonly seen with iron dextran injections Nausea and vomiting was treated with anti-emetics. It maybe worth while to initiate its use in medical colleges and later at smaller hospitals

28. Problems in implementation of anaemia prevention and control programmes

29. DLHS showed that pregnant women were not being screened for anaemia and given appropriate therapy All pregnant women who came for 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 IFA through out pregnancy. Majority did not consume even the tablets that they got .

30. ICMR study confirmed that 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 not significant 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

32. Challenges in the Eleventh Plan period

34. Opportunities in the Eleventh Plan period

38. Opportunities for prevention, detection and management of anemia in pregnant women India currently has the necessary infrastructure , manpower, technology for this task Indians are rational and responsive; people’s institutions are in place for 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 to maternal and child health effectively within a short time

39. THANK YOU