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Maternal Anemia : A Preventable Killer

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Iron deficiency is one of the most prevalent nutritional deficiencies in the world and is reported by the World Health Organization (WHO) to affect four to five billion people. WHO estimates that two billion people suffer from anemia. Approximately 50% of all anemia is estimated to be due to iron deficiency, a condition of deteriorating iron reserves in the body caused by low dietary intake of iron, poor absorption of dietary iron, or blood loss (for example, from hookworm, repeated childbirth or heavy menstruation) which leads to loss of iron. Iron deficiency anemia (IDA) is the most severe form of iron deficiency, and results when the body’s iron supply cannot support production of hemoglobin in adequate amounts to maintain normal functioning of the body. Anemia from other causes (and therefore, not iron deficiency anemia), results from malaria or from genetic disorders, among other causes. Other micronutrient deficiencies (e.g., vitamins A, B6 and B12, riboflavin, and folic acid) are also known to cause anemia.
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Maternal Anemia: A Preventable Killer
Iron deficiency is one of the most
prevalent nutritional deficiencies in
Figure 1: Iron deficiency, iron deficiency anemia (IDA) and anemia
the world and is reported by the
World Health Organization (WHO) to
CAUSES
CONSEQUENCES
affect four to five billion people. WHO
• Low dietary
• Increased
estimates that two billion people
intake of iron
maternal and
suffer from anemia. Approximately
• Poor absorption
perinatal
50% of all anemia is estimated to be
of iron
mortality
due to iron deficiency, a condition
Iron Deficiency
• Malaria
• Increased
of deteriorating iron reserves in the
numbers of pre-
body caused by low dietary intake
• Hookworm
term birth and/or
of iron, poor absorption of dietary
• High fertility
Iron Deficiency
low birthweight
iron, or blood loss (for example, from
Anemia
• Other
• Impaired
hookworm, repeated childbirth or
micronutrient
cognitive
heavy menstruation) which leads to
deficiencies
Anemia
development
loss of iron. Iron deficiency anemia
• Diarrhea, HIV/
• Reduced work
(IDA) is the most severe form of iron
AIDS and other
productivity
deficiency, and results when the body’s
infectious diseases
iron supply cannot support production
of hemoglobin in adequate amounts
to maintain normal functioning of the
body. Anemia from other causes numbers of maternal and perinatal chidren under five years of age are
(and therefore, not iron deficiency deaths associated with iron deficiency anemic in developing regions.1 The
anemia), results from malaria or from anemia underscore the urgent need consequences of anemia include:
genetic disorders, among other causes. to refocus resources and public health • Increased maternal and perinatal
Other micronutrient deficiencies (e.g., priorities to more effectively tackle the
mortality
vitamins A, B6 and B12, riboflavin, and problem.
• Increased numbers of preterm
folic acid) are also known to cause
birth and/or low birthweight
anemia (Figure 1).
1. Anemia and iron deficiency • Impaired cognitive development in
Anemia and iron deficiency remain are highly prevalent conditions
children
at epidemic levels among women and with major consequences for • Reduced adult work productivity
children in many nations. Given the health, survival, and economic
development
Hence, anemia prevention programs
availability of proven interventions to
can contribute significantly to achieving
prevent and treat anemia caused by a Anemia prevalence is highest among many of the Millennium Development
variety of determinants, the persistent pregnant women, infants, and young Goals (MDGs) including MDGs 1
high prevalence represent a lack of children due to the high iron demands (Poverty and hunger); 2 (Universal
political will and failure of the public of growth and pregnancy. On average, education); 4 (Child mortality
health sector. New estimates of the 45% of pregnant women and 49% of reduction); and 5 (Improved maternal
health).
Iron is critical to oxygen transport in the body
2. Iron deficiency is high on
In the human body, iron is present in all cells and has several vital functions—
the list of risk factors for
as a carrier of oxygen to the tissues from the lungs in the form of hemoglobin
global maternal and perinatal
(Hb); as a facilitator of oxygen use and storage in the muscles as myoglobin
mortality
and as an integral part of enzymes. Anemia is defined as a low level of Hb in
blood.
WHO’s 2002 Global Burden of Disease
Report
identified iron deficiency as
the 12th most important risk factor
for all mortality globally, and the 9th
1 Mason, Rivers and Helwig. “Recent trends in malnutrition in developing regions: Vitamin A deficiencies,
anemia, iodine deficiency, and child underweight,” Food and Nutrition Bulletin 26: 57-162, 2005.
most important risk factor for the

2
global burden of disease. Recent Figure 2. Causes of Maternal Death2 and Contribution of Iron
WHO analysis of causes of maternal Deficiency Anemia (IDA)3
death showed that hemorrhage is the
major contributor to maternal deaths
Unclassified

Anemia
Deaths
in developing countries.
6%
2
Other Direct
8%
Causes 5%
Associated
In a separate analysis, iron deficiency
with IDA
anemia (IDA) was an underlying risk
HIV 3%
22%
factor for maternal and perinatal
mortality and morbidity, and was
estimated to be associated with
Indirect
115,000 of the 510,000 maternal
Causes
deaths (22%) and 591,000 of the
14%
2,464,000 perinatal deaths (24%)
Hemorrhage
occurring annually around the world
31%
(Figure 2). 3, 4
The consequences of anemia are
Obstructed
serious:
Labor 7%
• Anemia in pregnant women
reduces a woman’s ability to
survive bleeding during and
after childbirth (i.e., post partum
Sepsis 11%
hemorrhage (PPH)) and may
Hypertensive
result in premature and/or lower
Unsafe Abortion
Disorder 10%
birthweight babies with a higher
5%
risk of death
• Iron
deficiency
with
or
without anemia limits cognitive
development in children. It reduces 3. New analyses show that mild More women are affected by
their achievement in school and and moderate – not just severe – increased mortality risk. Previous
ultimately undercuts the benefits anemia has serious consequences estimates of the number of women at
of investing in education.
for women and children
increased risk of death associated with
• Anemia and iron deficiency cause A recent meta-analysis3 shows that anemia only considered those women
weakness, fatigue, and reduced correcting anemia of any severity with severe anemia. In light of the
physical ability to work. Economic reduces the risk of death: the risk meta-analysis results, more pregnant
analysis show that for every $1 of maternal mortality decreases women are estimated to be at risk,
spent on iron supplementation by about 20% for each 1 g/dL since the majority of anemic women
programs for pregnant women, increase in Hb. This decreased risk have
hemoglobin
concentrations
there is a return of US $24 in is continuous over the full range of Hb between 7 and 12 g/dL (mild and
decreased disability and increased between 5 and 12 but it is not linear moderate anemia) compared to the
wages over a woman’s lifetime.4
— the decrease in risk is greater at relative few with severe (Hb < 7 g/dL)
the lower Hb concentrations. This is or very severe anemia (Hb < 5 g/dL).
a new finding and different from the Hence programs should focus on mild
Anemia/low hemoglobin
earlier view that only severe anemia and moderate anemia, in addition to
creates cardiovascular
is associated with increased mortality. severe anemia, for public health
problems
It has important policy and program impact.
Underpinning the relationship
implications:
between hemoglobin
concentration and mortality
risk is the fact that death
from cardiovascular causes is
2 Calculated from “ WHO Analysis of Causes of Maternal Deaths: A Systematic Review,” The Lancet 367:
a function of blood volume,
1066-1074, 2006.
3 Stoltzfus, Mullany and Black. Iron Deficiency Anemia, “Comparative quantification of health risks: Global and
blood loss, cardiac fitness, and
regional burden of disease attributable to selected major risk factors,” WHO 2004.
hemoglobin concentration.
4 Based on the quantitative relationship, one can estimate the percent of maternal mortality attributable to
iron deficiency anemia (IDA) in a given country when maternal mortality ratio, prevalence of anemia, and
number of births per year are known (PROFILES, IDA Calculator at www.fantaproject.org).

3
4. Knowing the various causes of 5. Proven interventions are 6. Maternal anemia programs
anemia in a target population is available to address the major are most effective when they
the first step in designing tailored causes of anemia in women
address the multiple causes
intervention strategies
of anemia through integrated
There is consensus on a number of interventions12
The main causes of anemia include:
evidence-based interventions to reduce
• inadequate intake and poor anemia prevalence among pregnant Programs need to address the primary
absorption of iron
women/women of reproductive age preventable causes of anemia in a
• malaria, particularly in young when they are applied effectively to coordinated way. The global Roll
children and pregnant women
a population with known causes of Back Malaria initiative has worked in
• hookworms
anemia.
tandem with maternal health and safe
• diarrhea, HIV/AIDS and other • Universal supplementation of motherhood programs since 1998 to
infections
pregnant women with daily iron prevent and control anemia caused by
• genetic disorders (e.g., sickle cell
folic acid tablets;6
malaria in pregnant women through
and thalassemia)
• Fortification
of
commonly integrated program interventions.
• blood loss during labor and
consumed food products with Efforts to address maternal anemia
delivery; heavy menstrual blood
micronutrients;7
should be tailored to the local context
flow; closely spaced pregnancies
• Control of malaria by intermittent and situation and take advantage
of partnerships with agencies and
Table 1 below highlights the relative
preventive treatment (IPT), long-
programs that are implementing
importance of these causes by region.
lasting insecticide treated bed nets relevant interventions. Presently,
The relative importance of various
(ITN), indoor residual spraying there are several global initiatives that
causes differs by age and sex of the
(IRS), and Artemisinin-Containing focus on prevention of anemia:
population and setting. The greatest
Antimalarial Combination Therapy • The Global Alliance for Improved
burden of death and disease due to
(ACT);8
Nutrition (GAIN – a fortification
anemia is in Africa and Asia and is • Control of hookworms by
initiative at www.gainhealth.org)
associated with the consequences of
deworming medication such as • The Presidential Malaria Initiatives
anemia among pregnant women and
albendazole and mebendazole
(PMI, www.fightmalaria.gov)
young children.
as a routine part of ANC where
hookworm prevalence >20%;9
• Partners for Parasite Control
• Optimal birth spacing;10 and
(www.who.wormcontrol/en/)
• Programs that improve the iron • Global Fund for AIDS, Tuberculosis
stores of adolescents with weekly
and Malaria (www.globalfund.org)
iron/folic acid supplements.11
• President’s Emergency Plan for
AIDS Relief (www.state.gov/s/gac)
Table 1: Causes of Anemia - Relative Importance by Region
Relative
Iron Deficiency
Malaria
Hookworm
High Fertility
HIV/AIDS
Importance
by Region

Sub-Saharan Africa
l
l
v
l
v
Key:
South and SouthEast Asia
l
v
t
v
t
l high
North Africa
l
t
t
v
t
v medium
Americas
l
t
t
t
t
t low
Central Asia/Caucasus
l
v
t
v
t
Western Pacific (includes China)
l
t
v
t
t
Adapted from: Galloway, R. Anemia Prevention and Control: What Works. Washington, DC: USAID, June 2003.
6 Yip. “Iron supplementation during pregnancy: Is it effective?” American Journal of Clinical Nutrition 63: 835-855, 1996.
7 Mannar and Gallego. “Iron fortification: Country level experiences and lessons learned,” Journal of Nutrition 132:856S-858S, 2002.
8 Strategic framework for malaria control during pregnancy in the WHO Africa region. WHO 2003.
9 “Report of the WHO Informal Consultation on Hookworm Infection and Anemia in Girls and Women,” WHO, 1996.
10 Conde-Agudelo and Belizan. “Maternal morbidity and mortality associated with interpregnancy interval: Cross sectional study,” British Medical Journal 321: 1255-1259,
2000.
11 Soekarjo, de Pee, Kusin and Bloem. “School-based supplementation: Lessons learned in Indonesia,” Standing Committee on Nutrition News 31, 2005.
12 Abel, Rajaratnam, Kalaimani and Kirubakaran. “Can iron status be improved in each of the three trimesters? A community-based study.” European Journal of Clinical
Nutrition
54: 490-493, 2002.

4
USAID health and nutrition programs
(DHS) has been collecting data on
that address maternal anemia include:
FIGURE 3. Nicaragua: Prevalence
anemia prevalence and coverage of
of anemia in mothers/caregivers
• A2Z Micronutrient and Child
iron supplementation during pregnancy
1993, 2000 & 2003
Blindness Project,
since the mid-1990s. DHS also collects
• Access to Clinical and Community
data on malaria programs, such as ITN
??
Maternal, Neonatal, and Women’s
use, use of IPT by pregnant women and
33.6
??
Health
Services
(ACCESS)
starting in 2006, DHS will also obtain
Program, and
??
information on the use of drugs for
• Food and Nutrition Technical
23.7
intestinal worms. Combined data on
??
Assistance (FANTA) Project.
these indicators will assist countries to
??
assess and improve anemia prevention
16.1
7. Success with national level
??
and control programs.
centage Hb < 12 g/dL
anemia prevention programs has
P
er ??
Information on the following key
been documented
?
indicators is available for selected
In Nicaragua the prevalence of anemia
countries from DHS:
?
in reproductive-age women steadily
????
????
????
• Anemia prevalence among children
decreased from 1993 to 2003, going
Source: SIVIN 2004
and women of reproductive age
from 34% to 16% (Figure 3). Hallmarks
• Iron
supplementation
during
of the Nicaragua anemia prevention year of program implementation,
pregnancy
program included the following
anemia prevalence decreased in all • Use of ITN by children and
• Iron was distributed through states, varying from reductions of 5
pregnant women
antenatal care (ANC) clinics and percentage points in Jharkhand to 50 • Use of IPT by pregnant women
community volunteers did follow- percentage points in Uttar Pradesh. • Use of deworming drugs among
up and counseling work to support In Andra Pradesh, anemia prevalence
children and pregnant women
women.
decreased 43 percentage points at one
• Supplies
of
iron/folic
acid year and 70 percentage points after two
Moving forward with a package of
supplements (IFA) were adequate years of the program implementation.
proven interventions to prevent
and a strong behavior change The components of the anemia
and control maternal anemia
communication (BCC) program programs included:
It is clear from experiences that
was implemented.
countries implementing a package
• 87% of women reported taking • Weekly IFA
of proven interventions are much
IFA in their last pregnancy, and of • Abendazole to treat worm
more likely to succeed in improving
those who took IFA, 53% took it
infestation
maternal anemia than countries
for longer than 6 months.
• Behavior change communication
implementing any one of the single
• Side-effects were not reported
that covered the importance of
interventions. Hence countries are
as a major issue. Women were
nutrition including the intake of
encouraged to plan for an integrated
counseled to expect side-effects
iron/folic acid tablets
package of interventions that may
and reported knowing how to
include iron supplementation of
cope with them.
8. Progress of anemia programs
pregnant women and adolescent girls,
• Universal wheat flour fortification is being monitored
fortification of food with iron, malaria
was introduced in 1997; the To monitor the progress of anemia
and hookworm control and optimal
introduction of vitamin A sugar
birth spacing as appropriate.
fortification
may
have
also programs at the national level, the
contributed to anemia reduction.
Demographic and Health Survey
August 2006
India recently intensified its anemia
control programs for adolescent girls,
This report is the product of a collaboration among USAID’s A2Z Micronutrient and Child Blindness
Project, ACCESS Program, and Food and Nutrition Technical Assistance (FANTA) Project. This report

ages 10 to 19 years, in seven states.
is made possible by the generous support of the American people through the Office of Health,
Diets with low bioavailable iron
Infectious Disease, and Nutrition, Bureau for Global Health, United States Agency for International
combined with helminth infections
Development (USAID). The A2Z and FANTA Projects are implemented by the Academy for
are the main causes of anemia among
Educational Development (AED). The ACCESS Program is implemented by JHPIEGO. The contents do
girls and women in India.13 After one
not necessarily reflect the views of USAID or the United States Government.
FOOD AND
13 Dwidedi and Schultink. “Reducing anemia
NUTRITION
TECHNICAL
among Indian adolescent girls through once-weekly
ASSISTANCE
supplementation with iron and folic acid,” SCN News
31:19-23, 2006.

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