What Is Iron Deficiency Anemia And Why Is It Important To Treat It In Mothers?

Sangita*, a 28 year old mother of three children, was referred to our hospital from a rural primary health center 60 kilometers away. This was her first visit to our hospital. In the eighth month of her fourth pregnancy, in the hopes of bearing a male child this time, she was now carrying twins. 

For the past few weeks, Sangita had been experiencing immense fatigue and was reduced to lying in bed on most days. “Doctor, I feel extremely weak. Simple tasks, which I used to comfortably do previously, now make me breathless and give me palpitations,” Sangita told the examining physician.

She looked white as a sheet. The doctor ran a few tests to ascertain the cause of her symptoms and found her to have a hemoglobin of just 6 g/dl (normal for pregnant women- >11g/dl).  She soon gave birth to twins who were premature and weighed just 1 kg each, much lower than the expected normal of 2.5 kg. Despite being admitted to the neonatal intensive care unit for a month, only one of them survived. 

Anemia is a condition in which the body lacks enough healthy red blood cells to carry oxygen to the body tissues. Hemoglobin, a protein in the red blood cells, performs this vital function of delivering oxygen. Women need 11g/dl or more of hemoglobin to function well and a level less than this is seen in anemia. 

Anemia can be caused by blood loss as seen in hookworm infection or heavy menstrual bleeding in females. Decreased blood production due to nutritional deficiencies of iron, folic acid, and/or vitamin B12 among other micronutrients, and disorders of the red blood cells or hemoglobin can also lead to anemia. Multiple pregnancies and poor spacing between childbirths worsen the underlying nutritional deficiencies in women leading to anemia. 

This situation is of grave importance as most of these women fall in the childbearing age group. Globally, nearly one in every three pregnant women is anemic. In India, however, nearly one in every two women is anemic, with more of them in rural areas. These numbers are undeniably massive, considering that 70% of our population resides in rural India. 

As iron is the most important part of hemoglobin, iron deficiency is one of the leading causes of anemia among females around the world. Nearly 30-40% of all anemias are due to iron deficiency while the remaining are due to other reasons previously mentioned.

Why are pregnant mothers more prone to developing anemia?

Pregnant and lactating mothers have an increased iron demand, to support their growing child. Low iron levels lead to anemia in the mother which further leads to anemia in the unborn child. This has a profound effect on the child’s growth and development. The daily requirement of iron in pregnant women increases by 30 times, from 1.5 mg/day in non-pregnant women to 45 mg/day in pregnant and lactating women. 

As the diet does not contain enough iron to meet this requirement, supplementation in the form of iron pills or injections becomes necessary.  Most often women do not understand the cause of anemia and its impact on them and their children.  This lack of knowledge when coupled with the side effects related to oral iron therapy leads to poor adherence to the tablets.

How does anemia during pregnancy impact the mother and child?

Throughout pregnancy, anemia can adversely affect maternal and fetal well-being. Affected mothers may experience frequent breathing difficulties, dizziness, tiredness, palpitations, and sleep difficulties. There is also an increased risk of bleeding, spontaneous abortions, and high blood pressure which may even lead to convulsions. 

Mothers can also have behavioral problems after the birth of their children like depression and insomnia and may experience cognitive impairment including trouble in remembering or learning new things, concentrating, or making decisions. There is also a higher chance of birth by cesarean section than normal vaginal deliveries in anemic women. 

Anemia has adverse outcomes that hamper the growth of the child. Similar to what Sangita* underwent, it may lead to the premature birth of the child and low birth weight, all leading to an increased risk of death and disability of the baby. Children born to anemic mothers run a higher risk of being anemic too. 

Iron is also essential for the adequate functioning of the nervous system. Therefore, infants and young children with iron deficiency anemia are at risk of delayed neurological development - in mental, social, and emotional domains. This affects the child’s capacity to understand, experience, express, and manage emotions, participate in teamwork, and develop meaningful relationships. Studies have also found delays in both language and muscular development in anemic newborns.

In 2019, 4 out of every 10 children under the age of 5 years were anemic, which is equivalent to 62.3 million anemic children ( 6.23 crores) in India. As the deficiency worsens children become pale and weak, eat less, and tire easily. They gain weight poorly, have frequent infections, and may develop the habit of craving or chewing on substances that are not food- like clay, ice, or soil- which further affects their growth. The long-term impact of anemia on growth is evident from the decreasing average height of Indians over the years. Thus, it is imperative to treat anemia in women as the nation’s health depends on their health. 

How can iron deficiency anemia be prevented in pregnancy? 

Consuming iron tablets every alternate day has shown to have better compliance and absorption than consuming them every day as the former results in lesser side effects. Women should be educated regarding the right timing, i.e on empty stomach, and the method of consuming the tablet, i.e with water and not with milk or tea, to improve its absorption. Counseling women to anticipate the side effects of nausea, vomiting, and diarrhea related to the consumption of iron tablets can also help with ensuring compliance.

Consumption of locally available and affordable iron-rich food like soya beans, meat, fish, and peanuts, should also be encouraged. Besides spreading awareness regarding the causes and prevention of anemia, women should be encouraged to use contraception for delaying the next pregnancy by at least 3 years.

Even though the government has programs like Anemia Mukt Bharat in place to tackle anemia, we still have a long way to go.  Anemia is a public health emergency that requires urgent attention. However, the program focuses mainly on addressing iron deficiency anemia. As mentioned previously, iron deficiency is not the only reason for anemia. The percentage of anemic women has increased in India from 52.9% in 2015-16 to 53.4% in 2019-21. In our next article we critically examine the issue and offer explanations behind rising burden of anemia in India. 

Edited by Parth Sharma.