The burden of iron-deficiency anaemia among women in India: how have iron and folic acid interventions fared?

18 WHO South-East Asia Journal of Public Health | April 2018 | 7(1) Perspective The burden of iron-deficiency anaemia among women in India: how have iron and folic acid interventions fared? Rajesh Kumar Rai1, Wafaie W Fawzi2, Anamitra Barik3, Abhijit Chowdhury4 1Society for Health and Demographic Surveillance, Suri, West Bengal, India, 2Departments of Global Health and Population, Nutrition and Epidemiology, Harvard TH Chan School of Public Health, Boston, United States of America, 3Chest Clinic, Suri District Hospital, West Bengal State Department of Health and Family Welfare, Suri, West Bengal, India, 4Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India Correspondence to: Mr Rajesh Kumar Rai (rajesh.iips28@gmail.com) Abstract Iron-deficiency anaemia (IDA) among women in India is a problem of major public health significance. Using data from three waves of the National Family Health Survey, this article discusses the burden of and trend in IDA among women in India, and discusses the level of iron and folic acid (IFA) supplementation and its potential role in reducing the burden of IDA. Between 2005–2006 and 2015–2016, IDA in India decreased by only 3.5 percentage points (from 56.5% in 2005–2006 to 53.0% in 2015–2016) for women aged 15–49 years. However, during the same period, of 27 states compared, IDA increased in eight: Delhi, Haryana, Himachal Pradesh, Kerala, Meghalaya, Tamil Nadu, Punjab and Uttar Pradesh; furthermore, some of these (e.g. Kerala) are states that rank among the highest on the state Human Development Index but had failed to contain the burden of IDA. Although there is a standard guideline for IFA supplementation in place, the IFA intervention appears to be ineffective in reducing the burden of IDA in India (nationally only 30.3 % of mothers consumed IFA for 100 days or more when they were pregnant), probably due to irregular consumption of IFA where the provision of screening under the National Iron+ Initiative scheme appears to be unsuccessful. To strengthen the IFA intervention and its uptake, a concerted effort of community-level health workers (accredited social health activists, auxiliary nurse midwives and anganwadi workers) is urgently needed. In addition, food- based strategies (dietary diversification and food fortification), food supplementation and improvement of health services are required to reduce the burden of anaemia among women in India. Keywords: India, iron and folic acid, iron-deficiency anaemia, pregnancy Background Anaemia, defined as a reduction in haemoglobin concentration, red-cell count, or packed-cell volume below established cut- off levels, is a widely discussed public health challenge that India is facing.1 According to the World Health Organization (WHO), anaemia among women is defined as a haemoglobin concentration of <120 g/L for non-pregnant women aged 15 years and above, and a haemoglobin concentration of <110 g/L for pregnant women.2 In particular, a persistently high level of anaemia among women in India (53% of all women have anaemia as per the National Family Health Survey 2015–20163) is of great concern, and the 2017 National Health Policy tabled by the Ministry of Health and Family Welfare, Government of India, acknowledges this high burden.4 Iron- deficiency anaemia (IDA) is a common problem among women, primarily due to their recurrent menstrual loss. Demand for iron is higher among pregnant women, and women with anaemia in combination with early onset of childbearing, a high number of births, short intervals between births and poor access to antenatal care and supplementation are likely to experience poor pregnancy outcome.1 Prevention and management of IDA demands adequate iron intake and provision of bioavailable iron.5 The most recent estimates reflect an unacceptably low consumption of iron (median: 13.7 mg/day per person) among women in India aged ≥18 years and 51–83% of pregnant women in India are deprived of the recommended daily allowance of iron of 15–18 mg/day.6 Women in India largely derive iron from non-haem, inorganic sources, including grains, plants, cereals, lentils and vegetables; and, to a small extent, from iron supplements, such as iron or iron and folic acid (IFA) tablets for pregnant women, and iron-fortified foods, as compared to sources of haem iron such as meat and fish, which have a higher rate of absorption.7,8 Thus, it is not surprising that India has the highest number of women with anaemia globally, which increases the probability of maternal and child mortality and has significant economic implications 19WHO South-East Asia Journal of Public Health | April 2018 | 7(1) Rai et al.: Iron-deficiency anaemia among women in India for the nation’s development.9 A recently published study on the burden of disease in India concluded that the burden of IDA is 3.0 times higher than the average globally for other geographies at a similar level of development, and that women are disproportionately affected. The report also highlighted that between 1990 and 2016, the burden of IDA improved little and was the top cause of the years lived with disability (11% of all disability) in 2016.10,11 With this background, using three consecutive waves of published reports of the National Family Health Survey (NFHS, equivalent to a demographic and health survey) conducted during 1998–1999 (NFHS2),12 2005–2006 (NFHS3)13 and 2015–2016 (NFHS4),3 this article discusses the changes in the burden of anaemia and the extent to which the levels of IFA intervention may have contributed to addressing this challenge for women of reproductive age (15–49 years), especially pregnant women. Initiatives to control iron-deficiency anaemia in India To tackle IDA, India was the first country to launch a National Nutritional Anaemia Prophylaxis Programme in 1970.14,15 The National Nutrition Policy was launched in 199316 and this formed the basis for the National Plan of Action on Nutrition 1995,17 which laid out the sectoral Plan of Action to tackle anaemia.9 In light of the high burden of anaemia in India, one of the goals of the 12th Five Year Plan (2012– 2017) of the Government of India was to reduce anaemia in girls and women by 50% – that is to 28% by 2017.9,18 In 2013, the Ministry of Health and Family Welfare developed an intervention guideline – the National Iron+ Initiative – to mitigate the burden of IDA.9 On 1 December 2017, the Union Cabinet approved setting up of the National Nutrition Mission under the oversight of the Ministry of Women and Child Development. Among many targets, the National Nutrition Mission aims to reduce anaemia among young children, adolescent girls and women of reproductive age (15–49 years) by one third of NFHS4 levels by 2022.19 The aim of the National Iron+ Initiative was to target IDA across all life stages, thus expanding existing guidance for children, pregnant women and lactating mothers, to include adolescents (both boys and girls aged 10–19 years) and women of reproductive age (15–49 years).9 With respect to adolescents, the National Iron+ Initiative expanded on the 2012 Weekly Iron and Folic Acid Supplementation programmes for girls in and out of school,20 to include boys as well.9 Interventions with women of reproductive age are a recent endeavour under the National Iron+ initiative approved by the Ministry.9 According to the guideline, the primary intervention to tackle IDA is to administer IFA supplementation with elemental iron and folic acid, using a regimen that varies according to the intervention group (see Table 1).9 WHO has developed guidelines for daily iron supplementation for pregnant women and girls,21 infants and children22 and non-pregnant women and adolescent girls.23 However, in some cases, iron doses prescribed in the National Iron+ Initiative differ from the WHO recommendation. Trend in anaemia among women in India Data from the NFHS in India have been widely used to make national and state-level policy decisions.24 Estimates from the NFHS indicate that during the period 1998–2016, over 50% of women aged 15–49 years had IDA (see Table 2). Of all the states and union territories, data for 27 were available for comparison between 2005–2006 and 2015–2016. There was an average decrease of only 3.5 percentage points in IDA among all women in India, varying by states (see Fig. 1). In addition, NFHS4 (2015–2016) indicates that the National Iron+ Initiative did not yield the desired reduction in IDA nationally. This suboptimum reduction in IDA is highly concerning. However, during the same period, of the 27 states compared in Fig. 1, IDA in eight states increased: Delhi-National Capital Territory, Haryana, Himachal Pradesh, Kerala, Meghalaya, Table 1. National Iron+ Initiative IFA supplementation programme and service delivery Age group Intervention/dose Regime Service delivery 6–60 months 1 mL of IFA syrup containing 20 mg elemental iron and 100 µg folic acid Biweekly throughout the period 6–60 months of age and biannual deworming for children aged 12 months and above ● Through ASHA ● Inclusion in MCP card 5–10 years 45 mg elemental iron and 400 µg folic acid Weekly throughout the period 5–10 years of age and biannual deworming ● In school through teachers and for children who are out of school through anganwadi centre ● Mobilization by ASHA 10–19 years 100 mg elemental iron and 500 µg folic acid Weekly throughout the period 10–19 years of age and biannual deworming ● In school through teachers and for those out of school through anganwadi centre ● Mobilization by ASHA Pregnant and lactating women 100 mg elemental iron and 500 µg folic acid 1 tablet daily for 100 days, starting after the first trimester, at 14–16 weeks of gestation; repeated for 100 days postpartum ● ANC/ANM/ASHA ● Inclusion in MCP card Women of reproductive age (15–49 years) 100 mg elemental iron and 500 µg folic acid Weekly throughout the reproductive period ● Through ASHA during house visit for distribution of contraception ANC: antenatal care; ANM: auxiliary nurse midwife; ASHA: accredited social health activist; MCP: mother–child protection. Source: Guidelines for control of iron deficiency anaemia. National Iron+ Initiative. Towards infinite potential in an anaemia free India. New Delhi: Ministry of Health and Family Welfare, Government of India; 2013 (http://www.pbnrhm.org/docs/iron_plus_guidelines.pdf).9 20 WHO South-East Asia Journal of Public Health | April 2018 | 7(1) Rai et al.: Iron-deficiency anaemia among women in India Tamil Nadu, Punjab and Uttar Pradesh. This raises an alarming question – how did some states in India such as Delhi-National Capital Territory, Himachal Pradesh, Kerala and Punjab, which rank among the highest on the state Human Development Index (HDI), fail to contain IDA and instead join Uttar Pradesh, one of the lower-ranked HDI states? This question demands further investigation. Iron and folic acid intervention As the standard national guideline is in place, the next question is whether girls and women were receiving the recommended supplementation of IFA that is to be distributed through school teachers/anganwadi workers to adolescent girls; through auxiliary nurse midwives/accredited social health activists to pregnant and lactating mothers; and through accredited social health activists to women of reproductive age (15–49 years; see Table 1).9 Although no evaluation study has yet been conducted to measure the effect of IFA supplementation, some observational studies have indicated that IFA intervention has helped to improve haemoglobin levels in adolescent girls in India.25,26 However, poor uptake and adherence remains a challenge to India’s public health system.27 Nationally in the NFHS4 2015–2016 survey,3 over 50% of pregnant women were diagnosed with IDA and an average of only 30.3% of mothers consumed IFA for 100 days or more when they were pregnant in the 5 years preceding the survey; this ranged from the lowest in Nagaland (4.4%) to the highest in Lakshadweep (82.1%; see Table 2). The national policy of India dictates that pregnant and lactating mothers should be given 100 mg elemental iron and 500 µg folic acid daily, which is a much higher dose than that recommended by WHO (30–60 mg elemental iron).21 Irregular consumption of IFA during pregnancy may be due to its side-effects and its unacceptable metallic taste; there are significant gastrointestinal side-effects associated with the higher iron dose, which are likely to explain the poor adherence. Furthermore, stock-outs due to limited supply chains and suboptimum monitoring at the community level where poor socioeconomic conditions prevail are likely to compound the situation. A recent Cochrane systematic review concluded that pregnant women who intermittently receive iron supplementation are less likely to report side-effects (such as constipation and nausea), as compared to those who receive a daily regimen.28 Another systematic review suggests that compliance with IFA supplementation could be higher among those who have been counselled by health workers, especially when forgetfulness is the primary reason for low uptake of IFA in India.29 In 2013, the Ministry of Health and Family Welfare designed a guideline, the National Iron+ Initiative, that gave specific direction for screening and therapeutic management of anaemia among women of reproductive age (15–49 years).9 Although this initiative is in place, generalized practice of the guideline at facility and clinical level seems lacking. Non-pregnant women, especially in rural India, whose anaemia remains undiagnosed for various reasons, follow a different path of treatment from that recommended. The expectation is that if a woman is sick (owing to anaemia or any other reason) and she goes to a health facility, blood tests including a haemoglobin test are only recommended −25 −20 −30 −15 −10 −5 0 5 10 15 20 −25.1 −23.5 −16.1 −11.8 −10.6 −10.3 −10.0 −9.3 −7.1 −6.7 −6.7 −6.3 −4.3 −3.5 −3.5 −0.7 −0.4 −0.4 1.4 1.9 2.5 6.6 8.2 9.0 10.1 15.5 −10.5 −10.2 Pu nja b Him ac ha l P rad es h Me gh ala ya De lhi Ha rya na Utt ar Pra de sh Ta m il N ad u Ke ral a Ma ha ras htr a Gu jara t We st Be ng al Ma dh ya Pr ad es h IND IA Jh ark ha nd Ra jast hanGo a Ka rna tak a Bih ar Ma nip ur Utt ara kh an d Od ish a Aru na ch al Pra de sh Ch ha ttis ga rh Tri pu ra Ja mm u K as hm ir Mi zo ram As sa m Sik kim Pe rc en ta ge p oi nt c ha ng e Fig. 1. Percentage point change (from 2005–200613 to 2015–20163) in iron-deficiency anaemia for women aged 15–49 years by select states, National Family Health Survey 21WHO South-East Asia Journal of Public Health | April 2018 | 7(1) Rai et al.: Iron-deficiency anaemia among women in India Table 2. Iron-deficiency anaemia among ever-married/pregnant/all women aged 15–49 years and women who received iron and folic acid for 100 days or more, National Family Health Survey, 1998–2016 Anaemia among ever-married/all women, % NFHS4: 2015–20163 NFHS2: 1998–199912,a NFHS3: 2005–200613,b NFHS4: 2015–20163,b Anaemia among pregnant women, %c IFA consumption in pregnancy, %d India 51.8 56.5 53.0 50.3 30.3 State/union territory Andaman and Nicobar Islands na na 65.7 61.4 58.4 Andhra Pradesh 49.8 62.9 60.0 52.9 56.2 Arunachal Pradesh 62.5 50.6 40.3 33.8 8.3 Assam 69.7 69.5 46.0 44.8 32.0 Bihar 63.4 67.4 60.3 58.3 9.7 Chandigarh na na 75.9 na 44.9 Chhattisgarh na 57.5 47.0 41.5 30.3 Dadra and Nagar Haveli na na 79.5 67.9 43.9 Daman and Diu na na 58.9 na 38.3 Delhi 40.5 44.3 52.5 45.1 49.9 Goa 36.4 38.0 31.3 26.7 67.4 Gujarat 46.3 55.3 54.9 51.3 36.8 Haryana 47.0 56.1 62.7 55.0 32.5 Himachal Pradesh 40.5 43.3 53.4 50.2 49.4 Jammu and Kashmir 58.7 52.1 40.3 38.1 30.2 Jharkhand na 69.5 65.2 62.6 15.3 Karnataka 42.4 51.5 44.8 45.4 45.3 Kerala 22.7 32.8 34.2 22.6 67.1 Lakshadweep na na 45.7 36.5 82.1 Madhya Pradesh 54.3 56.0 52.5 54.6 23.6 Maharashtra 48.5 48.4 48.0 49.3 40.6 Manipur 28.9 35.7 26.4 26.0 39.2 Meghalaya 63.3 47.2 56.2 53.1 36.2 Mizoram 48.0 38.6 22.5 24.5 53.8 Nagaland 38.4 na 23.9 28.9 4.4 Odisha 63.0 61.2 51.0 47.6 36.5 Puducherry na na 52.4 26.0 66.3 Punjab 41.4 38.0 53.5 42.0 42.6 Rajasthan 48.5 53.1 46.8 46.6 17.3 Sikkim na 60.0 34.9 23.6 52.8 Tamil Nadu 56.5 53.2 55.1 44.4 64.0 Telangana na na 56.7 49.8 52.8 Tripura 61.1 65.1 54.5 54.4 13.4 Uttar Pradesh 48.7 49.9 52.4 51.0 12.9 Uttarakhand na 55.2 45.2 46.5 24.9 West Bengal 62.7 63.2 62.5 53.6 28.1 IFA: iron and folic acid supplements; na: data not available from the National Family Health Survey report; NFHS: National Family Health Survey. a Estimates are for ever-married women aged 15–49 years. b Estimates are for all women aged 15–49 years. c Pregnant women aged 15–49 years who have iron-deficiency anaemia. d Mothers who consumed IFA for 100 days or more while pregnant. Note: Caution in comparing some estimates is advised. For example, in 2005–2006 and 2015–2016, nearly 62.9% and 60.0% women, respectively, were diagnosed with anaemia in Andhra Pradesh, but these estimates are not comparable as they represent two different administrative boundaries. Telangana was a part of Andhra Pradesh in 2005–2006, but by 2015–2016, Telangana was separated from Andhra Pradesh. if the attending physician has enough time to examine the patient, and accordingly iron tablets may be prescribed. Alternatively, if anaemia is suspected through physical examination, the physician will recommend IFA supplementation as part of her daily regimen. This means that, in general in India, a woman must already be sick to be diagnosed with anaemia.14 In addition, the guidance is to distribute IFA tablets to all pregnant women, irrespective of their haemoglobin level.9 Prior to the National Iron+ Initiative, the guidance was that pregnant women should be given IFA in prophylactic doses, with a double dose if they had IDA.30 Also, irrespective of pregnancy status, for those with severe IDA there is a provision to administer blood transfusions if recommended by the physician.30 This implies that the treatment of IDA (by administering either a prophylactic dose or a higher dose in the case of severe anaemia) depends on the haemoglobin level of pregnant women.9 A common error 22 WHO South-East Asia Journal of Public Health | April 2018 | 7(1) Rai et al.: Iron-deficiency anaemia among women in India in this IFA distribution system is to put all women in the same bracket and administer the same dose. Women with anaemia therefore continue to be anaemic, thus increasing the burden to the nation. These dynamics of anaemia need to be understood before a “one size fits all” strategy is applied. The situation is even worse for individuals in underserved groups, including those who are poor or uneducated, or who belong to historically underprivileged social groups (women from scheduled castes and scheduled tribes), and those living in rural areas; these groups are all likely to experience reduced access to diagnosis.31 Data collection The accuracy of data on access to, and compliance with, IFA supplementation during pregnancy is problematic because of the way questions are asked and reported in the NFHS. In the women’s questionnaire for the survey, eligible women are asked about their intake of IFA during their last pregnancy (in NFHS4, 2015–2016, women were asked about their most recent pregnancy since January 2010).32 If a woman confirms any incidence of pregnancy, she is asked by the interviewer, “During this pregnancy, were you given or did you buy any iron and folic acid tablets or syrup?”. If the answer is affirmative, the follow-up question is, “During the whole pregnancy, for how many days did you take the tablets or syrup?”.32 If the response is not numeric, the respondent is probed for an approximate number of days, by asking how many months pregnant she was when she began taking the tablets and whether she took the tablets every day after that.33 It is difficult to assess the reliability of answers on all possible measures for a 5-year reference period. As data on the proportion of women who require probing are not available, it would not be appropriate to offer a figure on the extent of distortion in the reporting of IFA consumed. Secondly, even if a respondent comes up with a figure in response to the probe, there is no guarantee that the count of IFA is correct, as there may be recall errors and a propensity to inflated reporting, owing to social desirability bias. The protocol for data collection in the NFHS is not designed to capture this methodological gap. An alternative source of data is available if a woman’s pregnancy is registered with a subcentre (the lowest level of health-care facility in India). In these circumstances, the pregnant woman is provided with a mother–child protection card, where the number of IFA supplements delivered to her by the community health workers is recorded.9 However, owing to challenges to the performance of community health workers in pregnancy management and maternal care in different states, these data are also likely to be unreliable records of the actual number of IFA supplements either delivered or consumed.34 Therefore, while data on IFA consumed must be approached with caution, the failure of IFA interventions to date to address the challenge of IDA is apparent and requires greater scrutiny for future programming. Conclusion From the above discussion, a high burden of IDA is evident in India and the data on IFA supplements consumed are discouraging. Trends in anaemia since 1998–1999 give reason for scepticism about the future impact of an IFA intervention alone on IDA in India. WHO recommends that, to reduce the level of IDA, India should strengthen its strategy along three pillars – food-based strategies (dietary diversification and food fortification), food supplementation and improvement of health services.2 Among these three, food fortification together with dietary diversification is deemed a more sustainable alternative, but better implementation strategies are required to increase uptake.35 With the advent of The National Food Security Act, 2013,36 legal commitments have been made to supplement nutrition for adolescent girls and pregnant and lactating mothers. However, the latest round of NFHS data calls for a reality check and reflection on schemes and policies that have been developed to tackle IDA among women. The National Health Policy 2017 offers some hope,4 with a recommendation for community-based screening for IDA and its treatment. The present study calls for introduction of a nutrition-awareness intervention with intense monitoring of IFA distribution and uptake, especially among prospective mothers and pregnant women. Intensified action of community-level health workers (such as accredited social health activists and auxiliary nurse midwives) could help to target women with severe IDA, who need urgent attention, to reduce the rate of anaemia more quickly. Above all, strengthening the health system, and monitoring and evaluation of interventions for the prevention and treatment of anaemia are the most urgent needs, but are clearly not being done rigorously at present. Source of support: None. Conflict of interest: None declared. Authorship: RKR conceived and designed the study, performed the analysis and prepared the first draft. WWF, AB and AC reviewed the results and contributed to finalizing the report. All authors approved the study. How to cite this paper: Rai RK, Fawzi WW, Barik A, Chowdhury A. 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