In our <a href="https://nivarana.org/2022/12/13/anemia-in-women-and-children-a-public-health-emergency/">last article</a>, we discussed the why and how of prevention of iron deficiency anemia in women and children. We saw the consequences of anemia in women and how neglecting it can impact the physical as well as mental health of their child. A variety of efforts and guidelines have been made over the years to combat anemia efficiently and effectively. In this article, we discuss the role that the government has played in implementing these guidelines and the programs that were successful and those that weren&rsquo;t.&nbsp;

Currently, daily folic acid supplementation till the end of the first trimester and iron and folic acid supplementation thereafter is <a href="https://www.who.int/data/nutrition/nlis/info/antenatal-iron-supplementation">recommended</a> by WHO and the government of India as part of antenatal care. This helps in strengthening the existing iron and folic acid stores. This reduces the risk of low birth weight, anemia, and birth defects in the child.

The government has introduced several programs and schemes throughout the years to improve anemia in our country like the National Iron Plus Initiative, Integrated Child Development Services Scheme, and National Nutrition Mission. These programs, however, have <a href="https://academic.oup.com/heapol/article/37/5/597/6539775">not</a> been very successful in decreasing the prevalence of anemia in women and children.&nbsp; The coverage of iron and folic acid supplementation has been limited. According to the <a href="https://main.mohfw.gov.in/sites/default/files/NFHS-5_Phase-II_0.pdf">NFHS-5</a> report only around 54% and 40% of pregnant women in urban areas and rural areas, respectively, consumed iron-folic acid supplementation for 100 days during their pregnancy.

The <a href="https://anemiamuktbharat.info/home/interventions/">Anemia Mukt Bharat strategy</a>, started in 2018, under the POSHAN Abhiyaan, with its structured interventions has shown some promise in reducing anemia. It focuses on six key interventions.&nbsp;

<ul>
	<li>Giving IFA to children, adolescents, and women of reproductive age and pregnant women irrespective of anemia.&nbsp;</li>
	<li>Carrying out a bi-annual mass deworming for children in the age groups between 1-19 years.&nbsp;</li>
	<li>Conducting behavior change communication activities addressing key behaviors - improving compliance to iron folic supplements, deworming, appropriate infant and young child feeding with age-appropriate complementary foods, increased intake of iron-rich, protein-rich, and vitamin C-rich foods, and delayed cord clamping in health facility deliveries.&nbsp;</li>
	<li>Screening and testing of anemia in all age groups so that appropriate treatment may be initiated as per the hemoglobin level of the individual.&nbsp;</li>
	<li>Making the provision of iron and folic acid-fortified foods mandatory in government-funded health programmes.&nbsp;</li>
	<li>Improving awareness, screening, and treatment of non nutritional causes of anemia in endemic pockets, with a special focus on malaria, hemoglobin defects, and excessive fluorine intake.</li>
</ul>

There has been an increase in the number of beneficiaries across all groups including pregnant and lactating women and adolescent girls. However, the coverage for children between 6 months and 5 years is still <a href="https://academic.oup.com/heapol/article/37/5/597/6539775">lagging</a>. Despite the reported increase in coverage, according to the NFHS 5 report, in 2019-21 53.4% of women were anemic as opposed to 52.9% of women in 2015-16.

The shortfalls of the programs

A possible reason for the worsening status of anemia in the country could be a lack of <a href="https://academic.oup.com/heapol/article/37/5/597/6539775">compliance</a> with the supplements. Iron tablets are known to cause severe gastritis and diarrhea and thus have shown poor long-term compliance. Lack of awareness regarding the timing and method of consumption of the tablet could also be a barrier to its proper utilization.&nbsp;

Iron tablets should ideally be taken 1-2 hours before food on an empty stomach. Milk, eggs, tea, and calcium tablets (also prescribed in pregnancy) decrease iron absorption whereas Vitamin C-containing food items increase it. The impact of the stringent lockdown on the supply chain too would have affected the availability and access to these supplements, thus, explaining the worsening of anemia in the recent reports.&nbsp;

Anemia Mukt Bharat program mainly focuses on iron supplementation and deworming. Anemia occurs due to other causes apart from iron deficiency - deficiency of vitamin B12 and folic acid, impaired production, like in thalassemia, or excessive destruction of the red cells, like in sickle cell anemia, in our blood, or infections like malaria. Anemia also occurs because of chronic blood loss due to gynecological disturbances, conditions like piles, or due to intestinal worm infections. Hence sole supplementation of iron cannot be used to treat all anemias.&nbsp;

Nutritious food- the new unaffordable vaccine

A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367879/">vegetarian diet</a> is also linked with iron and vitamin B12 deficiency anemia. Even though a vegetarian diet contains as much dietary iron as a non-vegetarian diet, research has shown that animal-based iron is better absorbed (15-40%) than plant-based iron (1-15%). To make up for the low absorption, large quantities of green leafy vegetables, pulses, and nuts need to be consumed. But these are unaffordable for the majority.&nbsp;

In today&rsquo;s time, a non-vegetarian diet also doesn&#39;t assure adequate iron consumption as most people cannot afford to eat enough animal products either. The surge in prices of food has considerably shrunk the size of the Indian food basket. The declaration of the year 2023 as the Year of Millet by the United Nations, is a beneficial step in the direction of providing the average Indian adequate nutrition in a cost efficient manner.&nbsp;

The Way Forward

Improved testing and cause-specific treatment of anemic patients are essential instead of using the one-size-fits-all approach. Just focusing on distribution of iron tablets leads to unncessary iron supplementation in those who do not need it and also leaves people with other causes of anemia untreated. It is therefore essential to educate health providers at all the levels in the health system on the symptoms, causes and treatment of anemia.

Besides providing oral supplementations, the program should also focus on improving the nutritional content of mid-day meals in schools. Collaboration with other programs, like Swachh Bharat Mission, is also important as poor hygiene also plays a significant role in anemia.

The increased coverage across all beneficiary groups with the Anemia Mukt Bharat strategy is encouraging, but the pace of improvement has to be sustained to make a substantial impact on anemia in India. Decentralized decision-making is the need of the hour with region-specific interventions to tackle anemia. Finally, prioritizing women&rsquo;s health since birth and not just during the period of pregnancy could go a long way in substantially reducing the burden of anemia in our country.&nbsp;

Edited by Parth Sharma.

India has significantly invested in reducing the burden of anemia. Why is it still rising?

Why Is Anemia Not Reducing In India?

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.&nbsp;

For the past few weeks, Sangita had been experiencing immense fatigue and was reduced to lying in bed on most days.&nbsp;&ldquo;Doctor, I feel extremely weak. Simple tasks, which I used to comfortably do previously, now make me breathless and give me palpitations,&rdquo; 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- &gt;11g/dl).&nbsp; 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.&nbsp;

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.&nbsp;

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.&nbsp;

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 <a href="https://link.springer.com/article/10.1007/s10995-022-03450-1#:~:text=Discussion,among%20pregnancies%20globally%20is%2036.8%25.">anemic</a>. In India, however, nearly one in every two women is <a href="http://rchiips.org/nfhs/factsheet_NFHS-5.shtml">anemic</a>, with more of them in rural areas. These numbers are undeniably massive, considering that 70% of our population resides in rural India.&nbsp;

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 <a href="https://www.ncbi.nlm.nih.gov/books/NBK235228/?report=reader">iron demand</a>, 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 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375689/">effect</a> on the child&rsquo;s growth and development. The daily requirement of iron in pregnant women <a href="https://onlinelibrary.wiley.com/doi/abs/10.1016/j.jmwh.2007.07.003">increases</a> by 30 times, from 1.5 mg/day in non-pregnant women to 45 mg/day in pregnant and lactating women.&nbsp;

As the diet does not contain enough iron to meet this requirement, supplementation in the form of iron pills or injections becomes necessary.&nbsp; Most often women do not understand the cause of anemia and its impact on them and their children.&nbsp; 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 <a href="https://pubmed.ncbi.nlm.nih.gov/26739036/">affect</a> 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.&nbsp;

Mothers can also have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375689/#ref17">behavioral problems</a> 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 <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.12946">higher chance</a> of birth by cesarean section than normal vaginal deliveries in anemic women.&nbsp;

Anemia has <a href="https://www.who.int/data/gho/data/themes/topics/anaemia_in_women_and_children#:~:text=Among%20pregnant%20women%2C%20iron%20deficiency,may%20lead%20to%20impaired%20development.">adverse outcomes</a> 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 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375689/">death</a> and disability of the baby. Children born to anemic mothers run a higher risk of being anemic too.&nbsp;

Iron is also essential for the adequate <a href="https://www.frontiersin.org/articles/10.3389/fphys.2019.00463/full">functioning</a> 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&rsquo;s capacity to understand, experience, express, and manage emotions, participate in teamwork, and develop meaningful relationships. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1540447/">Studies</a> have also found delays in both language and muscular development in anemic newborns.

In 2019, <a href="https://www.who.int/data/gho/data/themes/topics/anaemia_in_women_and_children">4 out of every 10</a> 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 <a href="https://www.india.com/video-gallery/average-height-of-indian-adults-on-a-decline-alarming-claims-study-watch-video-to-find-out-why-4990951/">decreasing</a> average height of Indians over the years. Thus, it is imperative to treat anemia in women as the nation&rsquo;s health depends on their health.&nbsp;

How can iron deficiency anemia be prevented in pregnancy?&nbsp;

Consuming iron tablets every alternate day has shown to have <a href="https://www.jwatch.org/na45308/2017/10/26/daily-vs-alternate-day-oral-iron-therapy">better</a> 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 <a href="https://www.redcrossblood.org/donate-blood/blood-donation-process/before-during-after/iron-blood-donation/iron-rich-foods.html#:~:text=Heme%20iron%20is%20found%20in,than%20eating%20non%2Dheme%20iron.">iron-rich</a> 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.&nbsp; 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.&nbsp;

Edited by&nbsp;Parth Sharma.

Untreated anemia can have serious implications on pregnant mothers and their children.

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

Divya Shrinivas&nbsp;is a medical doctor and Managing Editor at Nivarana.

Divya Shrinivas is a medical doctor and Managing Editor at Nivarana.

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Divya Shrinivas

Divya Shrinivas

Why Is Anemia Not Reducing In India?

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

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