1. Anaemia in pregnancychallenge or opportunity? Prema Ramachandran Director Nutrition Foundation of India and President , National Academy of Medical Sciences

2. 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 3. Magnitude of the problem 4. Prevalence of anaemia Source: WHO Global Developed Developing India Urban Rural Children 5yrs 37 7 46 50 60 Men 18 3 26 35 45 Women 35 11 47 50 60 Pregnant 59 14 51 65 75 Women 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 5. AN 0 10 20 30 40 50 60 70 80 90 Bangladesh China India Indonesia Malaysia Myanmar Nepal Pakistan Philippines Singapore Srilanka Thailand Prevalence of anaemia is high in South Asia. Even among South Asian countries prevalence of anaemia in pregnancy is highest in India. 6. YEAR AUTHOR PLACE PREVALENCE % 1975 Sood et al Delhi 80 1982 Prema Hyderabad 75 1987 Agarwal et al Bihar & UP 87 1989 Christian et al Chandrapur, Panchmahal 87,88 1988-92 Agarwal et al Rural Varanasi 94 1989 ICMR 11 states 87 1994 Sheshadri Baroda 74 2000 NFHS 2 All India 52.0? 99- 2000 ICMR 11 states 84.6 2002-04 DLHS 2 All districts 90.4 2006 NNMB 8 states 70.3 2007 MFHS 3 All India 57.9? Trends in prevalence of anaemia in pregnant women in India Over 70 % of pregnant women in India are anaemic. There has been no decline in anaemia in the last three decades 7. Prevalence of Anaemia (%){DLHS 2003} 0% 20% 40% 60% 80% 100% preschool children adolescentgirls pregnantw omen Group Percentage severe moderate mild noanaemia Anaemia begins in childhood, worsens during adolescence in girls and gets aggravated during pregnancy 8. Source:NNMB2003 Among the southern states, prevalence of anaemia in pregnancy is lower in Kerala and Tamil Nadu -?due to better access to health care 9. Anaemia pregnant women, India (Age between 15 - 44 years) 50.9 52.9 51.4 36 36 36 3 2 3 RURAL URBAN TOTAL Mild Moderate Severe Source : DLHS2 DLHS 2 showed that over 90% of pregnant women are anaemic both in urban and in rural areas 10. Prevalence of anaemia in children, adolescent girls and pregnant women from 3 surveys 0 20 40 60 80 100 NNMB ICMR DLHS NNMB ICMR DLHS NNMB DLHS Pregnantw omen Adolescentgirls Children Normal Mild Moderate Severe 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 11. Prevalence of anaemia in adolescent girls & pregnant women by education & standard of living index 0 20 40 60 80 Illiterate 0-9yrs >10yrs Low Medium High Illiterate 0-9yrs >10yrs Low Medium High Education Standardofliving index Education Standardofliving index Adolescentgirls Pregnantwomen Severe ModerateSource: Ref 7.11.1.6 Prevalence of anaemia is high even in high income groups and among well educated pregnant women 12. Why is anemia so common 13. 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 14. 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 * * 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 % 15. 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 Iron intake is low in all age groups and does not increase in pregnancy; there has been no increase in iron intake over 16. Why is anaemia in pregnancy a cause of grave concern 17. INDIA Indias 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 18. 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