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Maternal Anemia

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					    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   Urban Rural   None   10       1998-1999
                                                       Years+
Gujarat
 Ever married              56      51     60     58       48       46
      Pregnant             61      59     62     72       38       47

Maharashtra
 Ever married              49      47     51     51       44       49
      Pregnant             58      60     56     61       48       53


Orissa
 Ever married              63      56     64     70       49       63
      Pregnant             68      46     71     79       53       61
* NFHS II
** NFHS III (Provisional data)
Impacts on Mortality
                           Observed Maternal Death Rates by
                        .6        Hemoglobin Level                                    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             15
                                                      Mid - Point Hemoglobin (g/dL)
                      From Stoltzfus RJ, et al (2005)
    Observed Maternal Death Rates by Hemoglobin Level

                                                                     Malaysia 65
                      .08
                                                                     Malaysia 58
                                                                     Nigeria 75
                                                                     Nigeria 85
Observed Proportion




                      .06                                            India 80
                                                                     India 95
                                                                     Nigeria 76


                      .04




                      .02




                        0
                            4   6               8               10         12
                                     Mid - Point Hemoglobin (g/dL)
   From Stoltzfus RJ, et al (2005)
     Individual and Combined OR’s for
              Maternal Death




From Stoltzfus RJ, et al (2005)
Adapted from Khan et al, Lancet April1 2006
Individual and Combined OR’s for Perinatal Death




  From Stoltzfus RJ, et al (2005)
    Final estimates: OR Associated
      with a 1 g/dL Increase in Hb
Outcome                            Estimate    95% CI

Maternal Mortality                   0.80     0.70-0.91

Perinatal Mortality,                 0.72     0.65-0.80
Africa
Perinatal Mortality,                 0.84     0.78-0.90
Other

 From Stoltzfus RJ, et al (2005)
  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                 Delivery
                 supply                   system


                       Compliance

                         Supplements
                            taken


                            Iron status
                             improves


                          Iron-related
                        health outcomes
Adapted from                improve
Ekstrom 2002
                   Intervention Packages
               IFA Supplement                      Delivery
                    supply          Motivation     system


                                Compliance

                                 Supplements       Malaria
                    Deworming       taken          Control:
                                                 Bednets, IPTl



                                  Iron status
                                   improves


                       Anemia and other iron-related
                            health outcomes
Adapted from                    improve
Ekstrom 2002
                         Nicaragua: Prevalence of Anemia in
                        Mothers/Caregivers 1993, 2000, & 2003
Percentage Hb<12 g/dL




                                                       Source: SIVIN 2004
 Nicaragua: Hb Distributions of Mothers/
Caregivers with Children 1-5 y, 1993, 2000 &
                   2003
  Percentage




                                   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 country-
  level 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

				
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