Maternal Anemia

Maternal Anemia: Missing in Action Global Health Mini-University October 27, 2006 Philip Harvey MPH, PhD Bloomberg School of Public Health Johns Hopkins University Outline  Multiple causes, prevalence  Impacts on mortality  Efficacy & effectiveness of iron supplementation programs  Tailoring implementation  Conclusions Causes of Anemia Prevalence of Anemia in Women 15-49 Years of Age in 3 States of India in 1998-1999* and 2005-2006** by Residence and Education Residence Education 2006-2006 Gujarat Ever married 56 Urban Rural None 10 Years+ 48 1998-1999 51 60 58 46 Pregnant Maharashtra 61 59 62 72 38 47 Ever married Pregnant Orissa Ever married 49 58 47 60 51 56 51 61 44 48 49 53 63 56 64 70 49 63 Pregnant * NFHS II 68 46 71 79 53 61 ** NFHS III (Provisional data) Impacts on Mortality Observed Maternal Death Rates by Hemoglobin Level .6 Malaysia 65 Malaysia 58 Nigeria 62 Nigeria 75 Nigeria 85 Observed Proportion .4 India 80 India 95 Nigeria 67 Nigeria 76 .2 0 0 5 10 Mid - Point Hemoglobin (g/dL) 15 From Stoltzfus RJ, et al (2005) Observed Maternal Death Rates by Hemoglobin Level .08 Malaysia 65 Malaysia 58 Nigeria 75 Observed Proportion Nigeria 85 .06 India 80 India 95 Nigeria 76 .04 .02 0 4 6 8 10 Mid - Point Hemoglobin (g/dL) 12 From Stoltzfus RJ, et al (2005) Individual and Combined OR’s for Maternal Death India80 India95 Malaysia65 Nigeria75 Nigeria82 Nigeria85 Combined .15 .25 .5 Odds Ratio Estim ate .746 1 1.5 From Stoltzfus RJ, et al (2005) Adapted from Khan et al, Lancet April1 2006 Individual and Combined OR’s for Perinatal Death China96 India95 Kenya63 Malaysia65 Nepal98 Nigeria75 Nigeria82 Nigeria85 PNG99 UK86 Combined .3 .5 Odds Ratio Estim ate .75 1 1.1 From Stoltzfus RJ, et al (2005) Final estimates: OR Associated with a 1 g/dL Increase in Hb Outcome Maternal Mortality Estimate 0.80 95% CI 0.70-0.91 Perinatal Mortality, Africa Perinatal Mortality, Other From Stoltzfus RJ, et al (2005) 0.72 0.84 0.65-0.80 0.78-0.90 Efficacy and Effectiveness of Iron Supplementation Programs Prenatal Iron Supplementation Reduces Likelihood of Hb < 10 g/dL at Delivery Kulier et al. Int J Gyn Obs 1998 Programming Focus is on Effectiveness Supplement supply Compliance Supplements taken Delivery system Iron status improves Adapted from Ekstrom 2002 Iron-related health outcomes improve Intervention Packages IFA Supplement supply Motivation Delivery system Compliance Supplements taken Malaria Control: Bednets, IPTl Deworming Iron status improves Adapted from Ekstrom 2002 Anemia and other iron-related health outcomes improve Nicaragua: Prevalence of Anemia in Mothers/Caregivers 1993, 2000, & 2003 40 Percentage Hb<12 g/dL 35 30 25 20 33.6 23.7 16.1 15 10 5 0 1993 2000 2003 Source: SIVIN 2004 Nicaragua: Hb Distributions of Mothers/ Caregivers with Children 1-5 y, 1993, 2000 & 2003 40 35 30 25 20 15 10 5 0 <7 7 8 9 10 11 12 13 14 15 18+ Percentage Hemoglobin (g/dL) 1993 2000 2003 Source: SIVIN 2004 Characteristics of Effective Programs  Comprehensive approaches addressed major preventable causes (ID, malaria, parasitic worms)  Addressed known barriers  Commitment to action  Awareness of benefits by both clients & providers  Logistics (supply, tablets & packaging)  Access to quality ANC (motivation, training & supervision)  Communication materials & counseling (e.g. memory prompts, anticipate & cope with side-effects)  Tailored to country context Adolescents/Women of Reproductive Age  Improving iron status before pregnancy – fortification, weekly supplementation, deworming, diet diversification  Weekly IFA effective in improving iron status of WRA in three Asian countries (Cavalli-Sforza et al, Nutrition Reviews 2005)  Weekly IFA to adolescents improves Hb, but impact on improving iron status for subsequent pregnancy is uncertain  Umang data from India suggest behavioral advantages in targeting adolescents this option (Pers. Comm. Neelam Singh, Jan 2006)   Girls recognize benefit of IFA, more likely to use IFA when pregnant Programs provide “entry point” for other interventions (e.g. Family Life Education which may bring behavior change) Key Factors in Tailoring Interventions  Balance of benefits and risks  Balance of costs of interventions and resources available (Government, donors, NGOs, households)  Operational feasibility  Existing policies & programs being implemented  Capacity, commitment for action of Health systems (morale, quality, coverage) Communities (participation, empowerment)  Other issues potentially effecting the above  Targeting / screening  Private sector reach, infrastructure Conclusions  Greater commitment and enhanced capacity for program implementation required at countrylevel as a foundation  Universal IFA supplementation for pregnant women – one exception proving the rule that “one size does not fit all”?  Components for successful IFA intervention are well established and will enhance coverage & quality of antenatal care  Anemia interventions require tailoring to contexts of specific countries and target groups Thank you Phil Harvey pharvey@aed.org