Anaemia in

Anaemia in pregnancychallenge or opportunity?

Prema Ramachandran

Director Nutrition Foundation of India and President , National Academy of Medical Sciences

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

Magnitude of the problem

Prevalence of anaemia Source: WHO

Global Developed Developing India Urban RuralChildren 5yrs 37 7 46 50 60Men 18 326 35 45Women 35 1147 50 60Pregnant 59 1451 65 75Women

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

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

ANAEMIA IN PREGNANCY - ASIAN COUNTRIES

WHO 1992

BANGLADESH

CHINA

INDIA

INDONES IA

MALAYSIA

MYANMAR

NEPAL

PAKISTAN

PHILIPPINES

SPORE

SRILANKA

THAILAND

Trends in prevalence of anaemia in pregnant women in IndiaOver 70 % of pregnant women in India are anaemic. There has been no decline in anaemia in the last three decades

YEARAUTHORPLACEPREVALENCE %1975Sood et alDelhi801982Prema Hyderabad751987Agarwal et alBihar & UP871989Christian et alChandrapur, Panchmahal87,881988-92Agarwal et alRural Varanasi941989ICMR11 states871994Sheshadri Baroda742000NFHS 2All India52.0? 99- 2000ICMR11 states84.6 2002-04DLHS 2 All districts90.4 2006 NNMB8 states 70.32007 MFHS 3All India 57.9?

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

Chart1

339.2507.8

2443285

33651.49.6

severe

moderate

mild

no anaemia

Group

Percentage

Prevalence of Anaemia (%){DLHS 2003}

Sheet1

prevalence of anaemia

severemoderatemildno anaemia

preschool children3.039.250.07.8

adolescent girls24.043.028.05.0

pregnant women3.036.051.49.6

Sheet1

0000

0000

0000

severe

moderate

mild

no anaemia

Group

Percentage

Prevalence of Anaemia (%)

Sheet2

Sheet3

Source: NNMB 2003Among the southern states, prevalence of anaemia in pregnancy is lower in Kerala and Tamil Nadu -?due to better access to health care

Anaemia pregnant women, India (Age between 15 - 44 years)Source : DLHS2DLHS 2 showed that over 90% of pregnant women are anaemic both in urban and in rural areas

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

Chart8

25.724.745.64.1

15.111.860.113.1

3.850.742.53.1

30.847.120.61.5

9.932.150.97.1

2.221.948.727.2

33.123.741.12.1

3.749.2443.1

Normal

Mild

Moderate

Severe

Prevalence of anaemia in children, adolescent girls and pregnant women from 3 surveys

Sheet1

SevereModerate

Kerala05

Arunachal Pradesh34

Jammu & Kashmir09

Manipur09

Sikkim412

Goa018

Mizoram217

Tripura129

Tamil nadu228

Karnataka130

West Bengal433

Andhra Pradesh237

Meghalaya1228

Uttaranchal338

Jharkhand141

Bihar240

INDIA343

Rajasthan344

Himachal Pradesh444

Delhi147

Orissa445

Uttar Pradesh346

Maharashtra252

Gujarat549

Madhya Pradesh351

Haryana353

Punjab354

Chattisgarh556

Assam859

SevereModerate

Children (0-71 months)Rural345

Urban341

Adolescent girls (10-19 yrs)Rural2849

Urban2649

Pregnant women (15-44 yrs)Rural443

Urban240

SevereModerate

Jammu & Kashmir08

Kerala010

Manipur124

Goa025

Mizoram224

Arunachal Pradesh128

Nagaland231

West Bengal231

Tamil nadu431

Karnataka334

Uttaranchal337

Meghalaya635

Andhra Pradesh339

Rajasthan240

Jharkhand141

Sikkim539

Orissa341

Tripura143

India344

Bihar347

Assam743

Uttar Pradesh347

Himachal Pradesh348

Delhi448

Maharashtra350

Madhya Pradesh450

Punjab550

Gujarat552

Haryana554

Chattisgarh456

SevereModerate

Manipur06

Mizoram112

Jammu & Kashmir719

Kerala230

Sikkim2121

Meghalaya937

Goa1139

Tripura1937

Arunachal Pradesh1046

Karnataka1544

Nagaland2142

Uttaranchal2939

Tamil nadu1850

Andhra Pradesh2447

West Bengal1855

Uttar Pradesh2947

INDIA2749

Madhya Pradesh3345

Himachal Pradesh3147

Orissa2751

Rajasthan2257

Gujarat3941

Bihar2853

Jharkhand2456

Delhi2952

Assam4041

Maharashtra2953

Punjab3448

Haryana4046

Chattisgarh4840

EducationStandard of living index

Illiterate0-9 yrs> 10 yrsLowMediumHigh

Children (0-71 mnths)3.432.43.332.5

EducationStandard of living index

Illiterate0-9 yrs> 10 yrsLowMediumHigh

Adolescent girls32.626.424.129.325.725.1

Pregnant women3.83.11.64.22.31.8

Pregnant womenAdolescent girlsChildren

NNMBICMRDLHSNNMBICMRDLHSNNMBDLHS

Normal25.715.13.830.89.92.233.13.7

Mild24.711.850.747.132.121.923.749.2

Moderate45.660.142.520.650.948.741.144

Severe4.113.13.11.57.127.22.13.1

Sheet1

00

00

00

00

00

00

Source: DLHS-RCH, 2002-04

Severe

Moderate

Percentage of severe and moderate anaemia (rural & urban)

Sheet2

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00


Severe

Moderate

Percentage of children (0-71 mnths) suffering from severe and moderate anaemia (state wise)

Sheet3

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00


Severe

Moderate

Percentage of adolescent girls (10-19 yrs) suffering from moderate and severe anaemia (state wise)

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00


Severe

Moderate

Percentage of pregnant women (15-44 yrs) suffering from moderate and severe anaemia

0

0

0

0

0

0


Children (0-71 mnths)

Percentage of severe anaemia in children by mothers education & standard of living index

00

00

00

00

00

00


Adolescent girls

Pregnant women

Percentage of severe anaemia by education and standard of living index

0000

0000

0000

0000

0000

0000

0000

0000

Source: NNMB-MND2003, ICMR 2001, DLHS-RCH 2002-04

Normal

Mild

Moderate

Severe


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

Chart2

32.648.5

26.449.2

24.147.1

29.349.5

25.748.1

25.148.1

3.847.8

3.140.6

1.633.4

4.245.7

2.341

1.836.8

Source: Ref 7.11.1.6

Severe

Moderate

Prevalence of anaemia in adolescent girls & pregnant women by education & standard of living index

Sheet1

SevereModerate


Urban341


Urban2649


Urban240

SevereModerate

EducationIlliterate3.447.8

0-9 yrs342.3

> 10 yrs2.436.5

Standard of living indexLow3.347.1

Medium342.4

High2.537.7

SevereModerate

Adolescent girlsEducationIlliterate32.648.5

0-9 yrs26.449.2

>10yrs24.147.1


Medium25.748.1

High25.148.1

Pregnant womenEducationIlliterate3.847.8

0-9 yrs3.140.6

>10yrs1.633.4


Medium2.341

High1.836.8



Normal25.715.13.830.89.92.233.13.7

Mild24.711.850.747.132.121.923.749.2

Moderate45.660.142.520.650.948.741.144

Severe4.113.13.11.57.127.22.13.1

MenWomen

Normal45.224.8

Mild45.841.9

Moderate8.430.5

Severe0.62.8

Any ANCWeight takenBP check upAbdominal check upIFA

Bihar30.99.514.626.317

UP46.79.211.727.727.7

Haryana70.430.131.85748.7

TN98.187.886.588.179.1

Sheet1

00

00

00

00

00

00


Severe

Moderate

Figure: Percentage of severe and moderate anaemia (rural & urban)

Sheet2

0000

0000

0000

0000

0000

0000

0000

0000


Normal

Mild

Moderate

Severe


Sheet3

0000

0000

Source: NNMB, 2006

Normal

Mild

Moderate

Severe

Figure 5: Prevalence of anaemia among adult men & women (NNMB, 2006)

00

00

00

00

00

00

Source: DLHS-2002-04

Severe

Moderate

Figure: Prevalence of anaemia in children by mothers education & standard of living index

00

00

00

00

00

00

00

00

00

00

00

00


Severe

Moderate

Figure: Prevalence of anaemia in adolescent girls & pregnant women by education & standard of living index

00000

00000

00000

00000

Source: Household survey, 1999-99

Any ANC

Weight taken

BP check up

Abdominal check up

IFA

Figure 7: Quality of antenatal survey (Household survey, 1998-99)

SevereModerate

KeralaPreg05

Children010

Adol230

J & KPreg09

Children08

Adol719

TNPreg228

Children431

Adol1850

KarnatakaPreg130

Children334

Adol1544

WBPreg433

Children231

Adol1855

AndhraPreg237

Children339

Adol2447

UttaranchalPreg338

Children337

Adol2939

JharkhandPreg141

Children141

Adol2456

BiharPreg240

Children347

Adol2853

INDIAPreg343

Children344

Adol2749

RajasthanPreg344

Children240

Adol2257

HPPreg444

Children348

Adol3147

DelhiPreg147

Children448

Adol2952

OrissaPreg445

Children341

Adol2751

UPPreg346

Children347

Adol2947

MaharashtraPreg252

Children350

Adol2953

GujaratPreg549

Children552

Adol3941

MPPreg351

Children450

Adol3345

HaryanaPreg353

Children554

Adol4046

PunjabPreg354

Children550

Adol3448

ChattisgrhPreg556

Children456

Adol4840

AssamPreg859

Children743

Adol4041

00

00

00

00

00

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Severe

Moderate

Prevalence of severe and moderate by states

KeralaJammu and kashmirTamil naduKarnatakaWest BengalAndhraUttaranchalJharkhandBiharIndiaRajashanHPDelhiOrissaUttar PradeshMaharashtra

PregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdol

Severe002007241813154218

Moderate510309819283150303444333155

Why is anemia so common

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

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 %

NutrientsNNMBRuralUrban1975-791988-901996-972000-012004-051975-791993-94Iron (mg)30.228.424.917.514.824.918.96Vit C37374051444042Folic acid**1536252.3**

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

Why is anaemia in pregnancy a cause of grave concern

INDIAIndias 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

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% CountryChildren< 5 yearsWomen15-49 yearsPregnant womenMaternal deaths from anemiaAfghanistan6561--Bangladesh5536742600Bhutan815568

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

Chart1

29.6

19

16.1

8.9

9.5

8.3

8.4

CAUSES OF MATERNAL MORTALITY

SRS-1998

Sheet1

Pie 2

Hemorrhage29.6

Anemia19

Sepsis16.1

Abortion8.9

Obst. Lab9.5

Toxemia8.3

Others8.4

Sheet1

0

0

0

0

0

0

0

Sheet2

Sheet3

Consequences of anaemia in pregnancy8-11 g/dL: easy fatigability, poor work capacity 5-7.9 g/dL: impaired immune function, increased morbidity due to infections

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

Immune status of anaemic pregnant women

There is a fall in T and B cell count when maternal Hb is below < 11 g/dLThe fall in T and B cell counts are significant when Hb is

Anaemia prophylaxis/control programme for pregnant women

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&500g 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 of antenatal care

Management of anaemia in pregnancyObstetric text books in India provided country specific protocols for management of anaemia, based on studies carried out in the country Hb < 5 g/dLConstitute 5- 10 % of anaemic womenAdmission and intensive care preferably in secondary or tertiary care institutions to ensure maternal and fetal salvageHb 5 to 7.9g/dLConstitute 10 to 20% anaemic womenScreen for systemic/obstetric problems and infectionsIf she has no other systemic or obstetric problems give her parenteral iron (IV or IM)

Total Dose IV Iron (TDI) therapySafety and efficacy of Intravenous total dose iron therapy was proved by trials undertaken by Dr MenonSubsequently 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

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 : nausea, giddiness

Effect of IM iron dextran on Hb &birth weight (Prema 1982) GroupNo.No.Hb < 8g/dl untreated4432530 + 651IM iron from 20 weeks762890 + 428IM iron from 28 weeks1052734 + 416None of the women who received 1gm of IM iron dextran had Hb less than 11g/dl at delivery

Problems in implementation of anaemia prevention and control programmes

DLHS 1 (1998-99) showed that pregnant women were not being screened for anaemia and given appropriate therapyAll pregnant women who were given antenatal check up were given tablets containing iron (100mg) and folic acid 500 g. 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

Chart1

30.99.514.626.317

46.79.211.727.727.7

70.430.131.85748.7

98.187.886.588.179.1

Any ANC

Weight taken

BP check up

Abdominal check up

IFA

Content of antenatal care (Household survey, 1998-99)

Sheet1

SevereModerate


Urban341


Urban2649


Urban240

SevereModerate

EducationIlliterate3.447.8

0-9 yrs342.3

> 10 yrs2.436.5


Medium342.4

High2.537.7

SevereModerate

Adolescent girlsEducationIlliterate32.648.5

0-9 yrs26.449.2

>10yrs24.147.1


Medium25.748.1

High25.148.1

Pregnant womenEducationIlliterate3.847.8

0-9 yrs3.140.6

>10yrs1.633.4


Medium2.341

High1.836.8



Normal25.715.13.830.89.92.233.13.7

Mild24.711.850.747.132.121.923.749.2

Moderate45.660.142.520.650.948.741.144

Severe4.113.13.11.57.127.22.13.1

MenWomen

Normal45.224.8

Mild45.841.9

Moderate8.430.5

Severe0.62.8

Any ANCWeight takenBP check upAbdominal check upIFA

Bihar30.99.514.626.317

UP46.79.211.727.727.7

Haryana70.430.131.85748.7

TN98.187.886.588.179.1

Sheet1

00

00

00

00

00

00


Severe

Moderate

Figure: Percentage of severe and moderate anaemia (rural & urban)

Sheet2

0000

0000

0000

0000

0000

0000

0000

0000


Normal

Mild

Moderate

Severe


Sheet3

0000

0000

Source: NNMB, 2006

Normal

Mild

Moderate

Severe

Figure 5: Prevalence of anaemia among adult men & women (NNMB, 2006)

00

00

00

00

00

00

Source: DLHS-2002-04

Severe

Moderate

Figure: Prevalence of anaemia in children by mothers education & standard of living index

00

00

00

00

00

00

00

00

00

00

00

00


Severe

Moderate

Figure: Prevalence of anaemia in adolescent girls & pregnant women by education & standard of living index

00000

00000

00000

00000

Source: Household survey, 1999-99

Any ANC

Weight taken

BP check up

Abdominal check up

IFA

Figure 7: Quality of antenatal survey (Household survey, 1998-99)

SevereModerate

KeralaPreg05

Children010

Adol230

J & KPreg09

Children08

Adol719

TNPreg228

Children431

Adol1850

KarnatakaPreg130

Children334

Adol1544

WBPreg433

Children231

Adol1855

AndhraPreg237

Children339

Adol2447

UttaranchalPreg338

Children337

Adol2939

JharkhandPreg141

Children141

Adol2456

BiharPreg240

Children347

Adol2853

INDIAPreg343

Children344

Adol2749

RajasthanPreg344

Children240

Adol2257

HPPreg444

Children348

Adol3147

DelhiPreg147

Children448

Adol2952

OrissaPreg445

Children341

Adol2751

UPPreg346

Children347

Adol2947

MaharashtraPreg252

Children350

Adol2953

GujaratPreg549

Children552

Adol3941

MPPreg351

Children450

Adol3345

HaryanaPreg353

Children554

Adol4046

PunjabPreg354

Children550

Adol3448

ChattisgrhPreg556

Children456

Adol4840

AssamPreg859

Children743

Adol4041

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Severe

Moderate

Prevalence of severe and moderate by states

KeralaJammu and kashmirTamil naduKarnatakaWest BengalAndhraUttaranchalJharkhandBiharIndiaRajashanHPDelhiOrissaUttar PradeshMaharashtra

PregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdolPregChildrenAdol

Severe002007241813154218

Moderate510309819283150303444333155

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

Chart1

Kerala38.5

062.4

Karnataka68

048.5

077.3

054.2

Orissa72.9

%

% of pregnant women who received some IFA tablets (NNMB)

Sheet1

States

ParticularsKeralaTamilKarnatakaAndhraMahara-MadhyaOrissaWestPooled

NaduPradeshshtraPradeshBengal

N1432582843302992122691871982

Received38.562.46848.577.354.272.970.662.7

States

ParticularsKeralaTamilKarnatakaAndhraMahara-MadhyaOrissaWest

NaduPradeshshtraPradeshBengal

Received38.562.46848.577.354.272.9187

70.6

Sheet1

00

00

00

00

00

00

00

%

% who received some IFA tablets (NNMB)

Sheet2

Sheet3

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 tablets rise in Hb was low and many continued to be anaemic

Hb in Pregnant women taking Iron Supplementation(ICMR 2000)No of tablets ingestedNo. Hb (g/dL)MeanS.D1-153108.81.716-302519.21.531-601969.31.861-90999.21.6>90749.12.1Total who had IFA9309.12.2B.Not known169.12.6C.Not had IFA38299.13.8A+B+C47759.13.5

IM iron therapyIM 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 collegesSome 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

New initiatives in the Tenth Plan NRHM

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 g folic acid once a day would be sufficient to prevent any deterioration in Hb levelsOral 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 g 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 therapyHospitalisation and intensive care for those with severe anaemia

Components of antenatal care DLHS -2 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 .

Iron & Folic Acid Supplementation in pregnancy DLHS 2 IFA Per DayDuring Entire PregnancyDLHS 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 prevalence of anaemia in pregnancy

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)NBirth weight(g)I - < 8.0972577+378.3II - 8.0 11.06452796+394.7III - > 11.01032921+418.1Total8452786+4055 All women who had IM iron therapy 3402805+379.3

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

Challenges in the Eleventh Plan period

Challenges in anaemia prevention and control programmes Majority of Indians are anaemic Over 3/4th of pregnant women are anaemicThere has not been any decline in the prevalence of anaemia or its adverse consequences on mother child dyad over the last six decades

Opportunities in the Eleventh Plan period

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

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

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 ANMIM 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.

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

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Anaemia in