Review Article

IndianJMedRes130,November2009,pp627-633

Prevalence&consequencesofanaemiainpregnancy

K.Kalaivani

Department of Reproductive Biomedicine, National Institute of Health & Family Welfare, New Delhi, India

ReceivedApril24,2009

Prevalence of anaemia in India is among the highest in the world. Prevalence of anaemia is higher among pregnant women and preschool children. Even among higher income educated segments of population about 50 per cent of children, adolescent girls and pregnant women are anaemic. Inadequate dietary iron, folate intake due to low vegetable consumption, perhaps low B12 intake and poor bioavailability of dietary iron from the fibre, phytate rich Indian diets are the major factors responsible for high prevalence of anaemia. Increased requirement of iron during growth and pregnancy and chronic blood loss contribute to higher prevalence in specific groups. In India, anaemia is directly or indirectly responsible for 40 per cent of maternal deaths. There is 8 to 10-fold increase in MMR when the Hb falls below 5 g/dl. Early detection and effective management of anaemia in pregnancy can contribute substantially to reduction in maternal mortality. Maternal anaemia is associated with poor intrauterine growth and increased risk of preterm births and low birth weight rates. This in turn results in higher perinatal morbidity and mortality, and higher infant mortality rate. A doubling of low birth weight rate and 2 to 3 fold increase in the perinatal mortality rates is seen when the Hb is <8 g/dl. Intrauterine growth retardation and low birth weight inevitably lead to poor growth trajectory in infancy, childhood and adolescence and contribute to low adult height. Parental height and maternal weight are determinants of intrauterine growth and birth weight. Thus maternal anaemia contributes to intergenerational cycle of poor growth in the offspring. Early detection and effective management of anaemia in pregnancy can lead to substantial reduction in undernutrition in childhood, adolescence and improvement in adult height.

Key wordsAnaemiainpregnancy-immunedepression-inter-generationalimpact-lowbirthweight-morbidityofmaternalanaemia

Introduction

Anaemia is the most common nutritional deficiency disorder in the world. WHO has estimated that prevalence of anaemia in developed and developingcountriesinpregnantwomenis14percentindevelopedand51percentindevelopingcountriesand65-75percentinIndia1.Aboutonethirdoftheglobalpopulation(over2billion)areanaemic2.

Prevalenceofanaemiainall thegroupsishigherin India as compared to other developing countries1.

Prevalence of anaemia in South Asian countries isamong the highest in the world. WHO estimates that evenamong theSouthAsiancountries, Indiahas thehighest prevalence of anaemia. What is even more important is the fact that about half of the globalmaternaldeathsduetoanaemiaoccurinSouthAsiancountries;Indiacontributestoabout80percentofthematernal deaths due to anaemia in SouthAsia3. It isobviousthatIndia’scontributionbothtotheprevalenceof anaemia inpregnancy andmaternal deathsdue toanaemia is higher than warranted by the size of its

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Table. Prevalence of anaemia and its contribution to maternalmortality3

Country Prevalenceofanaemiainpreg-nantwomen%

Maternaldeathsfromanaemia

Afghanistan - -Bangladesh 74 2600Bhutan 68 <100India 87 22,000Nepal 63 760S.AsiaRegionTotal 25,560World Total 50,000

Fig. 1.Prevalenceofanaemiainpregnantwomen,adolescentgirlsandchildren(0-6yr)6-8.NationalNutritionMonitoringBureau(NNMB),IndianCouncilofMedicalResearch(ICMR)MicronutrientSurvey&DistrictLevelHouseholdSurvey(DLHS)2.

Fig. 2.Prevalenceofanaemiaindifferentsocioeconomicgroups6.

population (Table)3.Available estimates also suggestthat the magnitude of reduction in the prevalence ofanaemiaduringninetiesinIndiaislowerthanthatinneighbouringSouthEastAsiancountries.

Worried about the estimated high prevalence of anaemia in the country, five major surveys (National Family Health Survey (NFHS) 24 and 35,DistrictLevelHouseholdSurvey26 (DLHS), IndianCouncilofMedicalResearch(ICMR)MicronutrientSurvey7 and Micronutrient Survey conducted byNational Nutrition Monitoring Bureau8 (NNMB)were undertaken to estimate prevalence of anaemiain the country. All these showed that over 70 percent of preschool children were anaemic. NNMB,DLHS and ICMR surveys showed that over 70 percent of pregnant women and adolescent girls in thecountry were anaemic (Fig. 1). Anaemia begins inchildhood, worsens during adolescence in girls andgets aggravated during pregnancy. NFHS 2 and 3reportedlowerprevalenceofanaemiainwomenandpregnantwomenascomparedtoDLHS,NNMBandICMRMicronutrientsurveys.Thisappearstobedueto the use of Haemocue method for Hb estimation.Studies in India have shown that as compared toclassical cyanmethaemoglobin method, HaemocueoverestimatesHblevels9-13.DatafromDLHSshowedthat prevalence of moderate and severe anaemiawas high even among educated and higher incomegroups6(Fig.2).Prevalenceofanaemiaishighinallthe States, though there are considerable variationsbetweenStatesinprevalenceofmoderateandsevereanaemia6.

Factors responsible for high prevalence of anaemia

Studies carried out in India and elsewhere haveshown that iron deficiency is the major cause of anaemia followed by folate deficiency. In recent years, the contribution of B12 deficiency has been highlighted14.InIndia,theprevalenceofanaemiaishighbecauseof

(i)lowdietaryintake,pooriron(lessthan20mg/day)andfolicacidintake(lessthan70mg/day);(ii)poorbio-availability of iron (3-4% only) in phytate and fibre-rich Indiandiet;and(iii)chronicbloodlossduetoinfectionsuchasmalariaandhookworminfestations7,8.

DatafromNNMBsurveys15showedthatironandfolicacidintakeinthecountryinalltheagegroupswasverylow.Therehasnotbeenanyincreaseinironintakeoverthelastthreedecadesinanygroup.Theapparentreduction in iron intake in the NNMB surveys 2000-0115

and beyond was due to the finding that only 50 per centoftheironinIndiandietsisabsorbable.Poorironstores at birth16, low iron content of breast milk andlowdietaryironintakethroughinfancyandchildhoodresultsinhighprevalenceofanaemiainchildhood6,17.Anaemia gets aggravated by increased requirementsduringadolescenceandduringpregnancy6.Assumingthat the absorption of iron is 8 per cent in pregnantwomen,theiraveragedietaryintakewillmeetonly30-45per centof the requirement. Interstatedifferencesinironintakeareofsmallmagnitude.Thelowdietary

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intakeofiron,folicacidandfoodstuffsthatpromoteiron absorption, coupled with poor bioavailability ofiron are the major factor responsible for very highprevalenceofanaemiainthecountry18,19.

Anaemia and iron deficiency in the mother are not associated with significant degree of anaemia in the childrenduringneonatalperiod.However,ironstoresintheseneonatesarelow,ironcontentinbreastmilkinanaemicwomenislowandbecauseofthesefactorssubstantial proportion of infants become anaemicby six months16. Thus maternal iron deficiency and anaemiarendertheoffspringvulnerablefordevelopingiron deficiency and anaemia right from infancy. Poor ironcontentofcomplementary foodand family foodconsumedbytheyoungchildresultsinfurtherincreasein prevalence of anaemia in childhood17. With the onsetofmenstruationandassociatedbloodloss,thereisafurtherriseinprevalenceandseverityofanaemiain adolescent girls6. Early marriage and adolescentpregnancyaggravateanaemia6andresultinpoorironstores in the offspring. It is obvious that there is anintergenerational self perpetuating vicious cycle ofanaemiainIndianpopulation.

Immune status of anaemic pregnant women

In pregnancy, profound changes occur in severallaboratory parameters used for the assessment ofimmune status. Studies undertaken by the NationalInstitute of Nutrition, Hyderabad, showed thatthere was a fall in T and B cell count with fall inhaemoglobin levels below 11 g/dl.The fall inT andB cells was statistically significant in women with haemoglobinlevelsbelow8g/dl.ImmunoglobinlevelsshowedaprogressiverisewithdecreasingHblevels.Therewerenoalterationsinthephytohemagglutinin-induced lymphocyte transformation nor was thereany difference in the in vivo tests for cell mediatedimmunity20. Available data indicated that humoralimmunity as assessed by response to immunogensincluding tetanus toxoid remains unimpaired. Thechanges in T and B cells and immunoglobulin werereversedwithin6-12wkbyparenteralirontherapyandimprovement in haemoglobin levels, indicating thatthesealterationsareduetoanaemiaper seandnotduetoco-existentundernutrition18,19.

InvestigationscarriedoutinvillagesnearHyderabadindicated that the prevalence of morbidity due toinfections was doubled in women with haemoglobinlevelsbelow8.0g/dl18.Datafromboththedevelopedand the developing countries have documented the

association between asymptomatic bacteriuria andanaemia,oftenrefractorytotreatment,poorintrauterinegrowth,prematurityandlowbirthweight.Itispossiblethat immunodepression in anaemic women rendersthem more susceptible to infection, and increasedmorbidityduetoinfection,mightbeoneofthefactorsresponsible for the adverse effect of anaemia on thecourseandoutcomeofpregnancy18,19.

Maternal consequences of anaemia

Mild anaemia

Women with mild anaemia in pregnancy have decreased work capacity. They may be unable toearn their livelihood if the work involves manuallabour. Women with chronic mild anaemia may go through pregnancy and labour without any adverseconsequences,becausetheyarewellcompensated.

Moderate anaemia

Women with moderate anaemia have substantial reduction in work capacity and may find it difficult to copewithhouseholdchoresandchildcare.Availabledata from Indiaandelsewhere indicate thatmaternalmorbidity rates are higher in women with Hb below8gm/dl21.Theyaremoresusceptibletoinfectionsandrecoveryfrominfectionsmaybeprolonged.Prematurebirths are more common in women with moderateanaemia.Theydeliverinfantswithlowerbirthweightandperinatalmortalityishigherinthesebabies21.Theymaynotbeabletobearbloodlosspriortoorduringlabour and may succumb to infections more readily.Substantialproportionofmaternaldeathsduetoante-partum and post-partum haemorrhage, pregnancyinducedhypertensionandsepsisoccurinwomenwithmoderateanaemia.

Severe anaemia

Three distinct stages of severe anaemia havebeen recognized - compensated, decompensated,and that associated with circulatory failure. Cardiacdecompensation usually occurs when Hb falls below5.0g/dl.Thecardiacoutputisraisedevenatrest,thestrokevolumeislargerandtheheartrateisincreased.Palpitationandbreathlessnessevenatrestaresymptomsof these changes. These compensatory mechanismsareinadequatetodealwiththedecreaseinHblevels.oxygenlackresultsinanaerobicmetabolismandlacticacidaccumulationoccurs.Eventuallycirculatoryfailureoccurs further restricting work output. Untreated, itleads to pulmonary oedema and death. When Hb is <5 g/dl and packed cell volume (PCV) below 14,

KALAIVANI:PREVALENCE&CoNSEQUENCESoFANAEMIAINPREGNANCY 629

Fig. 3. Effectofmaternalhaemoglobinlevelonbirthweightandperinatalmortality198225.

cardiac failure is seen in a third of cases23.A bloodlossofeven200mlinthethirdstageproducesshockanddeathinthesewomen.Eventodaywomenintheremoteruralareas in India reach to thehospitalonlyat this latedecompensatedstage.AvailabledatafromIndiaindicatethatmaternalmorbidityratesarehigherinwomenwithHbbelow8.0g/dl.Maternalmortalityratesshowasteep increasewhenmaternalHb levelsfall below 5.0 g/dl. Anaemia directly causes 20 percentofmaternaldeathsinIndiaandindirectlyaccountsforanother20percentofmaternaldeaths24.

Foetal consequences of anaemia

Studies to define the effect of maternal anaemia on thefoetusindicatethatdifferenttypesofdecompensationoccur with varying degrees of anaemia. Most of thestudies suggest that a fall in maternal haemoglobinbelow 11.0 g/d1 is associated with a significant rise in perinatal mortality rate18,19,25. There is usually a 2to 3-fold increase in perinatal mortality rate whenmaternalhaemoglobin levels fallbelow8.0g/d1and8-10foldincreasewhenmaternalhaemoglobinlevelsfallbelow5.0g/dl21,26. A significant fall in birth weight due to increase in prematurity rate and intrauterinegrowth retardation has been reported when maternalhaemoglobinlevelswerebelow8.0g/d1(Fig.3)21,26.

Factors responsible for the adverse obstetric outcome

Investigationsundertakentodeterminethefactorsresponsible for the adverse maternal and perinataloutcome seen in association with anaemia indicatedthat anaemia per se might be responsible for someof the observed adverse effects18,19,21-24,26. However,prevalenceofseveralmaternal riskfactorswhichareassociatedwithlowbirthweight, increasedperinatal,maternalmorbidityandmortality,suchas twins,PIHandAPH are higher among anaemic women21. It is,therefore, possible that coexisting obstetric problemscontribute, at least in part, to the adverse obstetricoutcome reported among anaemic women. Anaemic

women should, therefore, be treated as a high riskobstetricgroup.

Immunedepressionduetoanaemiaandconsequentincreasedmorbidityduetoinfection,especiallyurinarytractinfection,mightbeoneofthefactorsresponsiblefor low birth weight babies in anaemic women.Screening for, and effectively treating infections inanaemic women might therefore result in improvedfoetalandmaternalprognosis19.

In the habitual cereal and pulse based dietsconsumedbyIndianwomen,thereisanalmostlinearcorrelationbetweencalorieandironintake18. Women with haemoglobin levels below 8.0 g/dl weigh lessthan their non-anaemic counterparts from similarincome groups19,21. These data suggest that anaemiamight be one manifestation of overall maternaldietary inadequacy and consequent undernutrition19.Itispossiblethatsupplementaryfeedingprogrammesaimedatimprovementofmaternaldietaryintakemightresultinsomeimprovementinmaternalhaemoglobinstatus.

Poverty,ignorance,nonavailabilityand/orfailuretoutilizeavailablemedicalfacilitieshavebeenshowntobeassociatedwithmaternalanaemiaontheonehandandmaternalandperinatalmorbidityandmortalityontheother,thoughtheassociationisnotcausal.Healtheducation to improve the utilization of availablefacilitiesandimprovementinthehealthcaredeliverysystem to cater to the needy, right at their doorstepsmightthusgoalongwayinreducingadverseobstetricoutcomeassociatedwithmaternalanaemia.

Prevention and management of anaemia in pregnancy

In view of the high prevalence of anaemia inpregnancy and serious adverse consequences inboth mother and baby, management of anaemia inpregnancy was accorded a very high priority bothin obstetric and public health practice. Mandatorymonthly screening for anaemia became the ‘routine’inallantenatalclinics.Skilledmanagementofseveregradesofanaemiadetectedlateinpregnancy,throughbloodtransfusionandparenteralirontherapybecamethe hallmark of good obstetric practice and resultedinmaternal andperinatal salvage rates inhospitals23.However,itbecameobviousthatunlesseffectivestepsweretakentoreducetheprevalenceofanaemia,furtherreductioninmorbidityandmortalityratescouldnotbeachieved.

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Fig. 4. IFAsupplementationinpregnancy27.

Programmes for prevention and management of anaemia

India was the first developing country to take up a National Programme to prevent anaemia amongpregnantwomenandchildren.TheNationalAnaemiaProphylaxis Programme of iron and folic aciddistribution to all pregnant women in India throughthe primary health care system was evolved andimplemented from1972, so that thevastmajorityofpregnant women who never seek health care, couldbenefit from this outreach programme. It was hoped thatthisprogrammewillbringaboutareductionbothintheprevalenceandseverityofanaemiainpregnancy.There were two major components of the anaemiaprophylaxis programme – pre-school children weretoreceive20mgelementalironand100mgfolicacidandpregnantwomentoreceive60mgelementalironand 500 μg of folic acid. Of the two components, the coverageunderthecomponentforchildrenhadalwaysbeenverypoor.

Comparatively the component for pregnantwomen has fared better. At that time antenatal carecoverageunderruralprimaryhealthserviceswasverylowandtherewasnoprovisionforscreeningpregnantwomen foranaemia.Thereforeanattemptwasmadeto identify all pregnant women and give them 100tablets containing 60 mg of iron and 500 μg of folic acid.Howeverallthenationalsurveys4-8indicatedthatcoverageunderalltheseprogrammeswasverylowandtherehasnotbeenanychangeeitherintheprevalenceof anaemia or the adverse consequences associatedwithanaemia.

Two decades after the initiation the NationalAnaemia Prophylaxis Programme, an ICMR studyconfirmed that most women received 90 tablets without Hb screening. Many did not take tabletsregularly.Evenamongsmallnumberofwomenwhotookover90tablets,riseinHbwaslowandmeanHblevelswerenomorethan9.1g/dl(Fig.4)27.Thestudyconductedin1989byICMR27indicatedthatcoverageunder the NationalAnaemia Pregnancy Programmewas low and that 60 mg of ferrous sulphate wasperhapsinadequatetotreatanaemia.TheProgrammewasrevisedandrenamedasNationalAnaemiaControlProgramme(NACP).TheProgrammeenvisagedthatall pregnant women will be screened for anaemia.Non anaemic women would get iron (100 mg) andfolate (500 µg) and those with anaemia should gettwotabletsdaily19.

Tenth Plan strategy for combating anaemia in pregnant women

The Tenth Five Year Plan28 suggested multi-pronged strategies for the control of anaemia inpregnancy.Theseinclude:(i) fortification of common food items like salt with iron to increase the dietaryintake of iron and improve the haemoglobin statusof the entire population, including girls and womenprior to pregnancy; nutrition education for dietarydiversification to improve the iron and folate intake; (ii)screeningofallpregnantwomenforanaemiausingareliablemethodofhaemoglobinestimation;(iii)oraliron folate prophylactic therapy for all non-anaemicpregnantwomen (withhaemoglobinmore than11g/dl); (iv) iron folate oral medication at the maximumtolerable dose throughout pregnancy for womenwith haemoglobin level between 8 and 11 g/dl; (v)parenteral iron therapyforwomenwithhaemoglobinlevel between 5 and 8 g/dl if they do not have anyobstetric or systemic complication; (vi) hospitaladmissionandintensivepersonalisedcareforwomenwith haemoglobin less than 5 g/dl; (vii) screeningand effective management of obstetric and systemicproblems in all anaemic pregnant women; and (viii)improvementinhealthcaredeliverysystemsandhealtheducationtothecommunitytopromoteutilizationofavailablecare.

Problems in implementation of anaemia prevention and control programmes

The DLHS29 (1998-99) showed that pregnantwomenwerenotbeingscreenedforanaemiaandgivenappropriatetherapy.MostwomeninpoorlyperformingStatesdidnotcomeforantenatalcheckup.Manyofthosewhocameforantenatalcheckup(ANC)didnotgetIFAthroughoutpregnancynordidtheyget100tablets(Fig.5)6,8,27,29.Majorityofthosewhogotthetabletsdidnotconsumeallthetablets6,29.NNMBsurveys8showed

KALAIVANI:PREVALENCE&CoNSEQUENCESoFANAEMIAINPREGNANCY 631

Fig. 5. IFAcoverage29.AntenatalCare(HousehouldSurveys1998-99).

that the proportion of pregnant women who receiveIFA tablets is not high even among well-performingStateslikeTamilNadu,KeralaandMaharashtra.

DLHS 2 (2006)6 showed that there was someimprovementinthecoverageandcontentofantenatalcare.About40percentwomenhadbloodexaminationdone which included Hb estimation. DLHS 2 alsoshowedthattherehasbeensomeimprovementin%ofpregnantwomenreceivingIFAtablets.Therehasbeena significant reduction in the percentage of women who receivedbutdidnot consume the tablets.Thesedatasuggest that if all pregnant women are screened foranaemiaandprovidedappropriatetherapyitmightbepossibletoachievesubstantialreductioninprevalenceofanaemiainpregnancy.

Parenteral therapy for moderate anaemia in pregnancy

AmpledataexistinIndiatoshowthatsupervisedoraladministrationofupto240mgironhasnotbeenable to raise theHb levelsabove11g/dl inpregnantwomen if their initial Hb levels was between 5.0and 7.9 g/dl30,31. Therefore, obstetricians have usedintramuscular (IM) iron therapy for correction ofanaemia22,25.Unlessthispracticeistakenupinalltheprimary care institutions, majority of women withmoderateanaemiawillnotbeabletoaccessIMtherapy.NIHFW32 and NFI33 undertook operational researchstudiesanddemonstratedthatinurbanprimaryhealthcare institutions it is possible to screen all pregnantwomenattendingtheantenataloPDforanaemiausingcyanmethaemoglobin method. Women in second trimesterofpregnancywhodidnothaveanysystemicandobstetricproblemswithHblevelsbetween5.0and7.9g/dlandwillingtocometoreceiveIMtherapyasoutpatients[sixinjectioneachcontainingironsorbitolcitric acid complex containing 150 mg of elementaliron, (NIHFW) and each containing iron sorbitol citric acid complex containing 150 mg of elemental iron,

folic acid 1500 mg and vitamin B12 150 mg (NFI)].BoththesestudiesdemonstratedthefeasibilityofIMiron sorbitol therapy to pregnant women in primarycare institutions. Both the studies showed that meanHb rose and there was significant improvement in birthweight32-34.Metallictasteonthetongue,nausea,vomiting and pain at the injection site were the sideeffects reportedwith IM therapy.Thesewere treatedsymptomatically. The subjects were followed upthrough pregnancy and till delivery. The mean Hblevel,even9wkaftercompletionofIMtherapywasonly 9.6 g/dl. But majority of women who received900mgofironsorbitolhadHblevelsaround10g/dlandbirthweightwaslowerthanthebirthweightinnonanaemicwomen33,34.Itwouldappearthat1500mgofironsorbitolcitricacidcomplexwouldberequiredforoptimalresults.

Summary and conclusions

Anaemiainpregnancyisassociatedwithadverseconsequences both for the mother and the foetus.Studieshaveshownthattheadverseconsequencesofmaternalanaemiamayaffectnotonlytheneonateandinfantbutalsoincreasetheriskofnoncommunicablediseaseswhenthechildgrowsintoanadultandtheriskoflowbirthweightinthenextgeneration.Technologyfordetectionofanaemiaanditseffectivetreatmentareavailableandaffordableanditispossibletoeffectivelyimplement theseeven inprimaryhealthcaresettingsand these are very cost effective interventions.Effectiveimplementationof theTenthPlanstrategiesforcombatinganaemiacangoalongwayinreducingthe short- and long- term adverse consequenees ofanaemia.

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Reprint requests: Dr K. Kalaivani, Professor, Department of Reproductive Biomedicine, National Institute of Health & Family Welfare NewDelhi110067,India

e-mail: kalaivanikrishnamurthy@gmail.com

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