Maternal and Child Health
Food and Nutrition Security
Solution Exchange for the Maternal and Child Health
Solution Exchange for the Food and Nutrition Security
Query: Anemia Control in Pregnancy for NRHM - Experiences
Compiled by Meghendra Banerjee and Gopi N. Ghosh, Resource Persons and Deeksha
Sharma and T. N. Anuradha, Research Associates
Issue Date: 14 July 2008
From Prakash Kotecha, Academy for Education Development, New Delhi
Posted 17 June 2008
I am following up with interest maternal health discussion going in this community. Continuing the
discussion, I would like to mention that safe motherhood interventions in NRHM include anemia control
(http://www.solutionexchange-un.net.in/health/cr/res21050801.doc (Size: 66 KB).
Considering that anemia is responsible for 20% of maternal deaths, which could be prevented with
appropriate intervention, it becomes a critical issue. Despite program in place, anemia prevalence does
not change or in fact has increased over time. Interventions are known but often they do not work, either
because of the way of implementation or the way supply is neglected. NRHM provided decentralization
for Iron Folic Acid (IFA) procurement that did not work with most of the states making non availability for
IFA a long process of three years in most of the states.
Maternal anemia is so common and acknowledged so long but needs multiple pathways and not only IFA
supply. Besides ensuring adequate nutrition to mother during pregnancy, the strategy that would work
includes 1) effective behavior change communication; 2) ensuring availability and accessibility of IFA with
counseling for its importance (this will counter side effects to be tolerated, when mothers know its
benefits to her and her child); 3) checking for side effects; 4) providing deworming where worm load is
high; 5) and protection from malaria. For performing all these services front line workers need support
To effectively control this scourge in future we need a comprehensive package based on existing
experiences and lessons learnt. I request members to share their efforts to address anemia in pregnancy,
irrespective of whether these efforts made measurable success or not.
Your efforts will help us make a strong case with the Government for including interventions that work to
control anemia, a priority in the national programmes.
Responses were received, with thanks, from
1. H. V. Wadgave, HALO Medical Foundation, Sure Start Project, Solapur
2. Kartik Kalyanram, Rishi Valley Eduction Centre (KFI), Madanapalle
3. K. V. Peter, World Noni Research Foundations, Chennai
4. Richa Som, Japan International Cooperation Agency (JICA)- Reproductive Health Project
5. Indira Chakravarty, All India Institute of Hygiene and Public Health, Kolkata
6. Atanu Ghosh, CINI ASHA, Kolkata
7. Prakash Nayak, Tata-Dhan Academy, Madurai
8. Daksha Pandit, Lokmanya Tilak Municipal Medical College (LTMMC), Mumbai
9. Prasen Raptan, JANAKALYAN, Raichur
10. Pravin H. Khobragade, United Nations Children's Fund (UNICEF), Raipur
11. Smita Bajpai, CHETNA, Ahemdabad
12. Parul Kotdawala, Kesar Sal Medical College, Ahmedabad
13. Vanisha Nambiar, The M. S. University of Baroda, Vadodara
14. Madhu Suri, Department of Education, New Delhi
15. Yuman Hussain, Azad India Foundation, Kishanganj
16. B. L. Kaul, Society for Popularization of Science and Progressive Educational Society,
17. Shubhada Kanani, The M S University of Baroda, Vaddodara
18. Aboli Gore, Japan International Cooperation Agency (JICA), Bhopal*
19. Aditya Agnihotri, Anchal Charitable Trust, New Delhi*
20. Rakhee Yadav, The Micronutrient Initiative, Bhopal*
21. Anita Malhotra, Lakshmibai College, New Delhi*
22. Prema Ramachandran, Nutrition Foundation of India, New Delhi*
Further contributions are welcome!
Summary of Responses
Responses in Full
Summary of Responses
Members appreciated efforts to develop a strategy for anemia control among pregnant mothers to help
achieve the National Rural Health Mission (NRHM) programme goal of reducing the Maternal Mortality
Ratio. Noting anemia is preventable, discussants shared experiences, reviewed field level challenges and
suggested measures for developing a comprehensive intervention package to control anemia.
The high prevalence of iron deficiency in India, respondents explained is due to poor iron and folic acid
intake, and the poor bioavailability of iron in phytate fibre-rich Indian diet. Other causes include
nutritional deficiencies (i.e. Vitamin A and B-12, and Folate), infection (i.e. malaria) and hookworm
infestation. Anemia is a micronutrient deficiency leading to emaciation, loss of appetite and a weak body
frame. Reduced iron consumption along with low levels of Vitamin A in non–pregnant girls may also
increase risk of menorrhagia (regular abnormally heavy and prolonged menstruation), which contributes
As anemia in pregnancy is nearly universal and a cause of 20% maternal deaths, discussants highlighted
that screening for anemia and iron-folate therapy for prevention and management of anemia is essential,
and noted that the government has recognized this fact and since the 1960s have incorporated anemia
screening and iron-folate therapy into antenatal care (ANC) programs. Additionally, under the National
Nutritional Anemia Prophylaxis Programme, an attempt was made to improve intake of iron and prevent
deterioration of haemoglobin (Hb) levels during pregnancy by providing 60 mg of elemental iron and 500
micro gram of folic acid at least for 100 days during pregnancy with ANC checkups. Members also
highlighted the multi-pronged strategy for controlling anemia laid out in the Tenth Five-Year Plan:
Fortify common food items with iron to increase dietary intake of iron and improve the haemoglobin
status of entire population, including girls and women prior to pregnancy
Screen all pregnant women for anemia using a reliable method of haemoglobin estimation
Provide oral iron folate prophylactic therapy for all non-anemic pregnant women
Give iron folate oral medication at the maximum tolerable dose throughout pregnancy for women
with haemoglobin levels between 8 and 11 g/dl
Give parenteral iron therapy to women with Hb from 5-8 g/dl, if no obstetric or systemic complication
Hospitalize and provide intensive, personalised care for women with a Hb less than 5 g/dl
Screen and effectively manage obstetric and related problems among pregnant anemic women
Improve community level health delivery systems and education to promote use of existing care
However, members pointed out, that limited outreach of primary healthcare services has made anemia
detection and appropriate correction difficult to operationalise beyond medical college hospitals. Further,
they noted that even with increased ANC registration, consumption of IFA tablets remains poor, for
various reasons, including poor quality and inadequate supply of IFA tablets, erratic distribution due to
low worker motivation, lack of faith in IFA tablets and awareness on adverse effect of anemia on
maternal and newborn outcomes.
Given the current situation, members outlined a number of suggestions for controlling anemia. They
advised using a food-based approach, which focuses on the quantity as well as nutritional value of
food intake by women, like Green Leafy Vegetables (GLVs) that are rich in iron and Vitamin A. GLV can
also be served to children during their mid-day meals and during community meals for Below Poverty
Line women. For example, in Karnataka an NGO is working with Dais to encourage use of locally
available food items and in Thailand village health volunteers identified and encouraged pregnant
women to attend ANC services, where universal iron supplementation was an integral component of ANC.
Another suggestion was to promote healthy dietary habits, like taking “enhancers of iron absorption” (i.e.
guava, lime, amla, orange juice, tomato) with meals and avoiding tea or coffee just before or after food.
Additionally, they suggested encouraging fortification of staple foods.
Respondents advised focusing on adolescent nutrition by empowering adolescent girls to serve as
educators in secondary schools, through awareness programs under “Sarva Shikhsha Abhiyan.” They also
suggested learning from the work done in Chhattisgarh with this approach and using teen clubs
through “Kishori Shakti Yojana” like in Maharashtra.
Third recommendation was to emphasize sanitation and hygiene. Programmes need to stress the
importance of personal, home and environmental cleanliness, engaging in regular water quality
monitoring and looking into overall food and water safety to reduce incidences of chronic gastro-intestinal
infestation/infection, leading to poor absorption. For example, an NGO in Bihar is supplying de-worming
tablets and promoting hygiene and sanitation along with advocating indigenous methods (i.e. iron
utensils and local vegetables) to improve nutrition among its target group.
Another suggestion was to engage in intensive IEC activities, such as counseling, which helps in
improving compliance. At the same time, members noted there are other factors i.e. gender equations
and socio-economic background, influence haemoglobin level and therefore there is a need for dedicated
and district specific communication strategies to engage stakeholders in controlling anemia. For example
in Gujarat, an organization used a multi-pronged awareness programme to address anemia.
Finally, discussants shared several innovative ideas of controlling anemia, including
Try Direct Observed Anemia Control Therapy under NRHM via home visits or for hospitalized patients
Utilize social marketing models, the NRHM officials learn from these experiences and appreciate the
work (e.g. HLFPPT successfully sold IFA tablets to adolescent girls and pregnant mothers in rural
areas through its Community Based Social Marketing of health care products )
Use iron cook wares (allowing for iron assimilation while cooking and preserving food)
Include good quality IFA tablets for 3 months with other health educational material and where to
seek help in “Pregnancy Kit” given to newly-weds under NRHM
Work with more nutrition experts in government programs to identify and promote natural remedies
Give weekly iron for anemic women with mild anemia (i.e. two-third of total anemic women), to
address poor compliance with IFA
Members felt that consumption of IFA tables is the fastest way to make Hb rise during pregnancy,
considering the short span. Thus, they advised improving the implementation of IFA supplementation
programs through better management of supplies and distribution, and making counseling efforts more
effective by emphasizing the benefits and providing information on how to manage side effects.
Another recommendation was to provide a comprehensive package of services for combating the
problem, through greater coordination between ICDS and the Health and Family Welfare Programme
(HFWP). Better coordination between the ICDS workers (Anganwadi workers and helpers) and HFWP
workers (ANMs and ASHA), would give pregnant women access to IFA supplementation, behavior change
communication (BCC) and counseling along with a Take Home Ration provided under ICDS. In
Chhattisgarh, under NRHM an initiative is trying this approach through 'Sishu Samrakshak Maah'-
offering Vitamin A supplementation, immunization, deworming and IFA tablets to pregnant women.
Moreover, discussants advised monitoring of such activities through Panchayati Raj Institutions (PRI) and
developing simple and feasible mechanisms for the capacity building of frontline health workers. They
cited an experience from Madhya Pradesh, where trainings of frontline health workers enabled them to
identify high-risk Hb ranges so they could make timely referrals, which helped control anemia rates.
In conclusion, members recommended universal screening during pregnancy and management of anemia
through IFA supplementation in all primary, secondary and tertiary healthcare institutions along with
nutrition-health education/communication to improve intake of Vitamin A and C, and iron, offering
deworming and malaria prevention to combat the massive problem of anemia among pregnant women
and its adverse consequences.
Multiple Approches to Improve Haemoglobin Levels, Madanapalle (from Kartik Kalyanram, Rishi
Valley Eduction Centre (KFI), Madanapalle)
The Rural Health Centre of Rishi Valley Education Centre (KFI), works with Dai's to counsel pregnant
women and their husbands and in-laws. Along with encouraging consumption of IFA tables, it also
promte eating homegrown green leafy vegetables, jaggery made in iron pots, groundnuts and gooseberry
to improve iron absorption. These multiple approaches have worked successfully to improve haemoglobin
levels even in women with haemoglobin levels as low as 5 gm%. Read more
Capacity Building of Frontline Workers, Bhopal (from Richa Som, Japan International Cooperation
Agency (JICA)- Reproductive Health Project (RHP), Bhopal)
The JICA/MP Reproductive Health Project in its repeated field level intervention provided intensive
trainings to front line health workers, specifically ANMs on doing ANC check ups. During training they also
provided WHO Hb colour strips and skill imparting need to be given together. They were specifically
taught high risk ranges and when exactly to refer. As a result, the identification and resultant referrals
increased. Read more
Targeting Adolescent Girls, Dharavi Slum, Mumbai (from Prakash Nayak, Tata-Dhan Academy,
LTMMC & LTMGH, Sion Mumbai observed compliance among pregnant women with antenatal visits and
drugs was not satisfactory, and thus they launched the "Kishori Project". The project used a girl-to-girl
approach to empower adolescents with knowledge on reproductive health and life skills. The girls were
given a prophylactic/therapeutic IFA dose based on their Hb along with nutrition education. Additionally,
good quality drugs improved compliance, resulting in a remarkable improvement in their Hb status.
State Level Initiaves under NRHM and Sarva Shiksha Abhiyan (from Pravin H. Khobragade,
United Nations Children's Fund (UNICEF), Raipur)
With UNICEF's technical and financial assistance under 'Sarva Shiksha Abhiyan,' approximately 150,000
girls receive weekly IFA supplementation and bi-annual deworming, which improved Hb levels. In another
government initiative, under NRHM called 'Sishu Samrakshak Maah' (SSM) Vitamin A supplementation,
immunization, deworming, and IFA tablets were given to pregnant women and along mosquito nets in
districts with high rates of malaria. Data indicates now more pregnant women are receiving IFA tablets.
Multiple Choices with Women, Ahemdabad (from Smita Bajpai, CHETNA, Ahemdabad)
In 2004-05, CHETNA with support from the Department of AYUSH implemented an awareness
programme on anemia. It involved building community awareness, implementation of strategies to
promote locally available foods and making sure vaidyas were available for providing ayurvedic
treatment. A cohort of 30 women was followed for three months with a pre and post Hb test. After three
months the women showed an improvement in Hb levels by 1.5-2 gm%. Read more
Indigenous Methods for Anemia Control, Kishanganj (from Yuman Hussain, Azad India
Azad India Foundation works to improve maternal and child health, one of its main objectives along these
lines is preventing anemia among pregnant women and adolescent girls. Iron tablets are not easily
available and women report intolerance to iron tablets, so community health workers promote the use of
iron utensils and local vegetables to increase iron intake. Provision of de-worming tablets and efforts to
promote hygiene and sanitation has resulted in improved nutrition among the target group. Read more
Community Based Social Marketing (from Prakash Nayak, Tata-Dhan Academy, Madurai)
HLFPPT uses conventional and non-conventional channels for Community Based Social Marketing of its
health care products in rural areas. From August 2001 onwards, HLFPPT started promoting IFA tablets
(Ferro Plus) among adolescent girls and pregnant mothers through three programme interventions-
coordinated rural distribution, communication strategies and capacity building. These efforts helped
increase the number of IFA tablets sold, even in places where government supplied free IFA tablets.
Volunteers Play Key Role in Improving Iron Supplementation of Pregnant Women (from T.N.
Anuradha, Research Associate)
Village Health Volunteers (VHV) have played a pivotal role in identifying and encouraging pregnant
women to recieve ANC services. Universal iron supplementation is implemented as an integral component
of the ANC, with iron tablets (60 mg dose) provided along with multi-vitamin mineral tablets. Available
data indicate that now anemia rates have declined among pregnant women and preschool children. Read
Safe Motherhood Interventions in the National Rural Health Mission (from Prakash Kotecha,
Academy for Education Development, New Delhi)
Available at http://www.solutionexchange-un.net.in/health/cr/res21050801.doc (Document Size: 60 KB)
Indicates that to improve the quality of Antenatal Care involves ensuring ingestion of 100 tablets
of Iron Folic Acid by pregnant women to combat anemia
From H. V. Wadgave, HALO Medical Foundation, Sure Start Project, Solapur
Evaluation of National Nutritional Anaemia Control Programme (NNACP) in Dharwad
Study; by Usha Malagi, Madhavi Reddy and Rama K. Naik; Department of Food Science and Nutrition,
University of Agricultural Sciences; Dharwad; 2006
Available at http://www.krepublishers.com/02-Journals/JHE/JHE-20-0-000-000-2006-Web/JHE-20-4-000-
Usha-Text.pdf (PDF Size: 16 KB)
Evaluation of the NNACP revealed about 11% of women within reproductive age did not receive
IFA tablets and were not registered by any health functionaries
Feasibility of "Directly Observed Home-Based Twice-Daily Iron Therapy" (DOHBIT) for
Management of Anemia in Rural Patients: A Pilot Study
Article; by Bharti Sahul; Bharti Healthy India Movement (BHIM); Indian Journal of Medical Sciences;
Mohali (SAS Nagar), Punjab; 2004
Available at http://www.indianjmedsci.org/article.asp?issn=0019-
Concludes that providing iron supplementation through home-based therapy successfully
decreases anemia in resource-poor settings, especially among pregnant women
Prevalence of Micronutrient Deficiency Based on Results Obtained from the National Pilot
Program of Micronutrient Malnutrition Results on Control (from Indira Chakravarty, All India
Institute of Hygiene and Public Health, Kolkata)
Article; by Chakravarty I. and Sinha R. K.; Nutrition Reviews, Vol. 60, Supplement 1; International Life
Sciences Institute; May 1, 2002; Permission Requires: Yes, Paid Publication
Argues that iron, Vitamin A and iodine deficiency major public health concerns, because they lead
to anaemia in various age groups and night blindness in young children and pregnant women
Integrated Child Development Services (ICDS) Scheme (from Atanu Ghosh, CINI ASHA, Kolkata)
Report Chapter; Ministry of Women and Child Development
Available at http://wcd.nic.in/chap8.htm
Mentions that tablets of iron and folic acid are administrated to expectant mothers for
prophylaxis and treatment and to children with anemia
Kishori Shakti Yojana (from Daksha Pandit, Lokmanya Tilak Municipal Medical College (LTMMC),
Report Chapter; Ministry of Women and Child Development
Available at http://wcd.nic.in/KSY/ksyintro.htm
Explains that the scheme aims to improves nutritional, health and development status of
adolescent girls by educating adolescents, and suggested as a way to control maternal anemia
Trend of IFA Coverage on Pregnant Women in Chattisgarh (from Pravin H. Khobragade, United
Nations Children's Fund (UNICEF), Raipur)
Available at http://www.solutionexchange-un.net.in/health/cr/res17060802.jpg (JPEG Size: 48 KB)
Graph presents date shows the relationship between adequate IFA tablet availability and
consumption among pregnant women clearly indicates there are problems with availability of IFA
From T. N. Anuradha, Research Associate
Indiamix - Development of a Low Cost Blended Food
Project Details; World Food Programme
Available at http://www.wfp.org.in/..%5Cpublications%5Cindiamix.htm
Note explaining that Indiamix is a nutritious food supplement which provides almost one-third of
the daily nutritional requirements of folic acid, calcium and iron supplements to pregnant women
Prevention and Control of Anemia: Thailand Experiences
Article; by Pattanee Winichagoon; Institute of Nutrition, Mahidol University; The Journal of Nutrition;
Pathom, Thailand; 2002
Available at http://jn.nutrition.org/cgi/content/full/132/4/862S
Explains an initiative in Thailand where universal iron supplementation was the major strategy
targeted towards preventing anaemia among pregnant women using village health volunteers
Recommended Organizations and Programmes
Hindustan Latex Family Planning Promotion Trust, Noida (from Prakash Nayak, Tata-Dhan
B-11, Sector-59, Noida, Uttar Pradesh 201301; Tel: 91-120-4231060/61/62; Fax: 91-120-4231065;
email@example.com; http://www.hlfppt.org/index.html; Contact Manoj; CEO
Have been successful in selling Ferro Plus (Iron Folic Acid Tablets) among adolescent girls and
pregnant mothers in rural areas
Centre for Health Education Training and Nutrition Awareness (CHETNA), Ahmedabad (from
B-Block 3rd Floor SUPATH-II, Opposite Vadaj Bus Terminus Ashram Road, Vadaj, Gujarat 380013; Tel:
91-79-27559976/77; Fax: 91-79-27559978; firstname.lastname@example.org;
Developed a community based model to enhance maternal health care, which managed to
achieve a rate of more than 50% of pregnant women receiving IFA tablets
Azad India Foundation, Kishanganj (from Yuman Hussain)
Line Mohalla, Kishanganj 855107 Bihar; Tel: 06456-222483; email@example.com;
To control anemia, encourages the use of indigenous methods, like using iron utensils and local
vegetables, supplies de-worming tablets and promotes hygiene and sanitation
Rishi Valley Education Centre, Chittoor (from Kartik Kalyanram)
Chittoor District, Andhra Pradesh 517352; Tel: 08571-280622/280582/280044/280086; Fax: 08571-
280261; firstname.lastname@example.org; http://www.rishivalley.org/rural_health/maternal_health.htm
Its Rural Health Centre supplies IFA, works with Dai's to counsel pregnant women and their
family on using home grown green leafy vegetables (GLVs) and other foods to control anaemia
Recommended Portals and Information Bases
JICA/MP-Reproductive Health Project, Japan International Cooperation Agency (JICA),
Bhopal (from Richa Som)
Provided intensive trainings to front line health workers to identify high risk ranges and timely
referral to control anaemia during pregnancy and prevent resulting consequences
Related Consolidated Replies
Controlling Undernutrition and Anemia in Pregnancy, from Shubhada Kanani, M. S.
University of Baroda, Vadodara (Experiences). Maternal and Child Health Community. Issued 29
Available at http://www.solutionexchange-un.net.in/health/cr-public/cr-se-mch-food-05050701-public.pdf
(PDF,Size: 180 KB)
Experiences of projects that have supplemented government’s iron-folate supplementation program
to control iron deficiency anemia in adolescent and pregnant women
Overcoming Short Supply of Vitamin A and IFA Tablets, from Ranjan Das, Lady Hardinge
Medical College (LHMC), New Delhi (Experiences). Maternal and Child Health Community and Food
and Nutrition Security Community. Issued 13 November 2007
Available at http://www.solutionexchange-un.net.in/health/cr-public/cr-se-mch-17100701-public.pdf
(PDF, Size: 104 KB)
Documents experiences on overcoming the short supply of vitamin A and IFA Tablet, specifically
with respect to the geographical area and level of care
Double Fortified Salt for Combating Anaemia, from Rita Patnaik, NFI, New Delhi
(Experiences). Food and Nutrition Security Community and Maternal and Child Health Community.
Issued 6 October 2006
Available at http://www.solutionexchange-un.net.in/food/cr-public/cr-se-food-mch-26090601-public.pdf
(PDF,Size: 144 KB)
Members share their experiences with Double Fortified Salt (DFS) as a way to reduce anemia,
explores utility of DFS and appropriateness of employing it in national programs
Reaching Out of School Adolescents for Anemia Control, from Prakash Kotecha, Medical
College Vadodara, Gujarat (Experiences). Maternal and Child Health Community and Food and
Nutrition Security Community. Issued 8 December 2005
Available at http://www.solutionexchange-un.net.in/health/cr-public/cr-se-mch-food-08120501-public.pdf
(PDF,Size: 144 KB)
Recommends ways and means of reaching out of school adolescent girls to improve their
nutritional status and control anemia effectively.
Responses in Full
H. V. Wadgave, HALO Medical Foundation, Sure Start Project, Solapur
Anemia is major cause of maternal mortality in India and contributes directly or indirectly up to 20-30%
of all maternal deaths. There are so many efforts going on to tackle the issue of anemia through various
programs like National anemia control program, ICDS program, Special nutritional program but no
Even though now days the percentage of ANC registration is increased but the consumption of IFA tab is
not to the point due to various reasons e.g. lack of faith on IFA tab, lack of awareness on adverse effect
of anemia on maternal and newborn outcome etc and so the dream of control of anemia is still distant
My suggestions are:
1. Intensive IEC activity through community programs.
2. Monitoring of ICDS nutritional supplementation activity.
3. Trial of Direct Observed Anemia Control Therapy is a one of the innovative idea of anemia
management as it is possible under NRHM by ASHA through home visits or at least in admitted
4. Focus on adolescent nutrition will be vital.
Kartik Kalyanram, Rishi Valley Eduction Centre (KFI), Madanapalle
At the Rural Health Centre, we try and work with the Dai's, giving them an incentive to accompany
pregnant women to the Health Centre. Counselling of pregnant women and more importantly their
husbands and in-laws helps a great deal. Apart from IFA, we also encourage use of homegrown methi
leaves, drumstick leaves, jaggery made in iron pots, groundnuts and gooseberry (Amla) to improve iron
absorption. Since water is an issue here we tell them to use kitchen and bath water (grey water) for the
plants, which seem to thrive on this grey water. These multiple approaches seem to have worked. We
have had successes with women having Hbs as low as 5 gm%. This is a small scale effort, scalability may
be an issue.
K. V. Peter, World Noni Research Foundations, Chennai
Anemia is the single micronutrient deficiency leading to emaciated body, loss in appetite and above all
very weak body frame. In pregnant women, it leads to irreversible weight loss in infant. Many parasites
are also reported to blood loss, which further complicates an anemic patient. As a student of Vegetable
Crops, I am told about leaf vegetables, male flowers of pumpkins, ash gourd, cowpea leaf, colocasia leaf,
alocasia leaf etc. rich in iron and Vitamin A to be ideal to deal with anemia. Food supplement in the form
of leaf vegetables in midday meals to children and community meals to the unfortunate BPL women
would go a long way in ameliorating anemia.
Richa Som, Japan International Cooperation Agency (JICA)- Reproductive Health Project
Your concerns about anaemia control in pregnancy are well placed and all the challenges being faced in
field have been mentioned. I am working with JICA/MP Reproductive Health Project in Bundelkhand
Region (Sagar division) of M.P. Our team through its repeated field level intervention has been able to
make some dent towards this issue. Though, I am afraid that we have not been able to track/collect the
evidence base for the difference made.
To start with, the front line health workers, specifically the ANMs were given intensive trainings on ANC
check ups. The need for this was felt primarily because of two reasons:
1. Although SBA training guidelines mention core competency as an essential prerequisite there is no
practical method to address this
2. ANMs at field level, given the fact that not many SHCs are undertaking deliveries (at least in M.P),
are more responsible for proper ANC check ups.
During the training, they were also provided with the WHO Hb colour strips, the assumption being that
the equipment and skill imparting should be given together. They were specifically taught the high risk
ranges and when exactly to refer. As a result of this, the identification and resultant referrals have
increased. We are in the process to track the increase in referrals but given the behavioural attributes of
the ANMs, it is taking time to build their accurate data recording skills.
As regards counseling, although it is required, but there are many other factors involved which include
gender equations, socio-economic background etc. We are trying to come up with some other methods
also. The field trail is awaited.
The point I would like to reiterate is that simple and feasible mechanisms need to be developed for the
frontline health workers. Capacity building might take time but it is worth the efforts and there are high
chances that we will be able to address the issues, which have been pending for long.
Indira Chakravarty, All India Institute of Hygiene and Public Health, Kolkata
I am so glad that you have initiated discussion on this most critical problem in public health. I agree to all
the five interventions you have suggested to be included as a package. But additionally Sanitation and
Hygiene - personal, home and environment; Water quality monitoring; as well as issues related to overall
food and water safety may be added.
We have just completed a long study in 7 states of India- The National Pilot Programme on Control of
Micronutrient Malnutrition- supported by the MOHFW, GOI, which covers most of these issues. The final
report will be published shortly.
Atanu Ghosh, CINI ASHA, Kolkata
This is high time to discuss about this issue. As we, all know that the NRHM programme seeks to reduce
Maternal Mortality Ratio (MMR) to 100 per 100000 live births by 2012 so, reduction of iron deficiency
anemia among the pregnant mother could be good strategy to achieve the milestone of reducing MMR.
Some NGOs have tried to promote locally available food for preventing maternal anemia through IEC and
Behaviour Change Communication (BCC) activities, and came out with good result. But it is known to all
that IFA supplementation is the easiest way to deal with this problem. You have rightly pointed out that
apart from supplying IFA focus should be given on adequate nutrition, BCC and counseling. It could work
better if convergence of ICDS and Health and Family Welfare Programme could be strengthened. Under
ICDS system pregnant women are given Take Home Ration (THR) for improving the nutritional status of
women during their pregnancy. If supplementation of IFA, BCC and Counseling could be merged with the
THR day of ICDS then it could be comprehensive package of services for combating the problem of
maternal anemia. Coordination between the front line workers of ICDS i.e. AWW, AWH and Health i.e.
ANM, ASHA is need of the hour for bringing about such a convergence.
Monitoring of such activities through Panchayati Raj Institutions (PRI) could bring value addition into the
system, as discussed in NRHM. Such initiative has been taken in some of Indian states.
Prakash Nayak, Tata-Dhan Academy, Madurai
I take this opportunity to thank Mr. Kartik for sharing his experience in Rishi Valley Education Centre.
Promotion of traditional supplementary food by Dai (Traditional Birth Attendants (TBA) is one of the most
efficient and cost effective methods to counter anemia during pregnancy. That has been our practice
since time immemorial in rural areas. You will agree with me, the support system that was instrumental
in keeping live the TBA are eroding very fast. Over the years, even in rural area, we see lot of changes in
lifestyle and way of life. With the exposure to different media, the health seeking behavior has started
changing. As a result of which, we are de-linking ourselves from the age old practices of TBA and their
valued services and getting more urban oriented.
Off late, social marketing of health care products and services took a front seat in last few decades.
Social Marketing Agencies (SMOs) have not only created a new user base, they have contributed
significantly in reducing Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) by making
available different products and services. Their services have been duly recognized at the national level.
Some states give due emphasis on the later more products were introduced and continue with the
Hindustan Latex family Planning Promotion Trust (HLFPPT) is operating in all these states intermittently
under the Community Based Social Marketing (CBSM) of condoms and contraceptives in Madhya Pradesh,
Bihar, Jharkhand and Orissa through conventional and non-conventional channels in the rural and remote
August 2001 onwards, HLFPPT is promoting Ferro Plus (Iron Folic Acid Tablets) among adolescent girls
and pregnant mothers in many states by using three important programme interventions. Among other
products and services, IFA tablets are successfully sold in rural areas where government supplied, free
IFA tablets are also available. In otherwords, Ferro Plus has created a niche market among the
adolescent and pregnant mothers.
1. Coordinated Rural Distribution: Distribution of condoms and OCPs has been one of the key
strengths of HLFPPT in all its social marketing programmes. For reaching its products at the rural
outlets, HLFPPT has developed its own system of distribution and redistribution, which comprises of
Stockists and Redistribution stockists, Traveling Rural Salesman (TRSM), Rural Based Distributor
(RBD), Rural Sales Representatives (RSR) Block Field Workers (BFW) etc.
With the help of such a network, contraceptive products are made available through different type of
outlets, such as:
Conventional Chemist outlets
Non-chemist trade outlets, which would include outlets like grocery shops, kirana stores, paan
shops, ladies corners, beauty parlours etc.
Provider channels like RMPs and PMPs in the towns and Larger Villages.
Other Non-Traditional outlets like Anganwadi workers, MPHWs etc.
2. Communication: To increase demand and create brand awareness, the social marketing projects
have an extensive promotional strategy that includes various strategies for generic promotion, brand
promotion and consumer promotions. A mix of media like stalls in melas (fairs) and haats (weekly
markets), video vans, radio, press, wall and shop paintings and hoardings have been extensively
used for creating a direct impact among the audience. Use of local folk media with possible Inter-
personal communication has been the USP of HLFPPT.
To facilitate ease in purchase as well as to boost top of the mind recall, product messages are
prominently displayed at retail outlets through posters, danglers, stickers etc. Innovative means like
printing promotional messages for oral pills on bindi packets ensure recall amongst rural women.
3. Capacity Building: A trained and dedicated service provider is very much crucial for strengthening
a supply chain. Regular training and exposure are planned and executed from grass-root workers to
district and state-level managers.
To take maximum benefits from the social marketing models, the NRHM officials should duly experience
and appreciate the work elsewhere and create a space for them. It needs state and district-level
advocacy among all the players and so that all would be working towards a shared responsibility. A
dedicated and district specific communication strategy is needed to bring together all players for the
For more details, kindly contact Mr. G. Manoj, CEO, HLFPPT, New Delhi at www.hlfppt.org/. For impact
assessment and more reports on evaluation, kindly contact Prof. S. K. Singh, International Institute of
Population Sciences (IIPS), Mumbai.
Hope this would contribute positively to control anemia on a priority basis.
Daksha Pandit, Lokmanya Tilak Municipal Medical College (LTMMC), Mumbai
It is very well known that we were not able to address the problem of maternal anaemia since ages
inspite of launching of health programs like ANAEMIA CONTROL CSSM, RCH & NRHM though anaemia
control & prevention was the most important intervention.
We at LTMMC & LTMGH, Sion Mumbai have made some attempts to address this issue. Our pregnant
women start a pregnancy with a disadvantage of anaemia. It was observed that compliance with
reference to visits as well as drugs is not satisfactory. Sometimes late registration is there. Thus anaemia
remains uncorrected. We address this problem in adolescents. Kishori project is launched in Dharavi slum
since 6 years ago. The aim is to empower adolescents with knowledge on health, reproductive health
&life skills. It is a girl to girl program through peer educators. Girls are given prophylactic/therapeutic
dose based on their Hb along with nutrition education. Good quality drugs purchased in bulk with good
appearance improve compliance. There was a remarkable improvement in their Hb status. This will
definitely decrease women with anaemia in pregnancy. We have initiated 'Well Woman Clinic" where
again she is taken care off.
Under NRHM, there is a move to give “PREGNANCY KIT” to newly-weds as a gift. My suggestion is to give
newly-weds a box containing pregnancy kit, emergency contraceptives, good quality IFA tablets for 3
months, condoms for 1 month and health educational material on limiting family size and where to seek
GOI has already rolled out “Kishori shakti yojana”, let us empower adolescents to reach out to others to
prevent anaemia through kishori shakti or teen clubs. This will go long way in controlling maternal
anaemia by targeting adolescents.
Prasen Raptan, JANAKALYAN, Raichur
While all your 5 points are valid for controlling maternal anemia but another very important point could
also be added to the list, learnt from JANAKALYAN's experience of working with rural Indians.
In rural India having poor sanitation facilities, the pregnant women are reported to eat less as it may
cause them to go for open defecation (since they don't have a toilet); and they have difficulties in going
for open defecation during the day time, especially in the plain areas and paddy belt. The women have to
wait till dark for defecation and thus consumes very little food (forget nutritive food) causing anemia in
most of the cases. The consequences are known.
Therefore, not only these 5 factors but "sanitation" shall also be given its due priority in order to control
MMR as well as IMR.
Pravin H. Khobragade, United Nations Children's Fund (UNICEF), Raipur
The discussion on anemia control in pregnancy was the need of the hour. As experiences under NRHM
from States has been asked, let me brief you on the situation in Chhattisgarh and what has been done till
now under the NRHM (and other flagships) apart from the National Anemia Control Programme.
a) As per NFHS III, 58 percent of ever married women in 15 to 49 years age are anemic. It is most
likely that they were anemic even before marriage.
b) 63 percent of pregnant women are anemic in the State as per NFHS III
c) The trend of adequate IFA availability and consumption is presented in the graph below
http://www.solutionexchange-un.net.in/health/cr/res17060802.jpg (46 KB). The graph clearly shows
that there is a problem in receipt of adequate quantities of IFA.
What has been done:
1. UNDER NRHM: 'Sishu Samrakshak Maah' (SSM), an intensive bi-annual drive is held on every April
and October in the state. The drive is statewide and involves Vitamin A supplementation of eligible
children, immunization to due beneficiaries, deworming of children, Provision of atleast 30 IFA tablet to
all the pregnant women (one months supply) and impregnation of bed-nets in select high malaria
incidence districts. The reported data indicate that twice the number of pregnant women receive Tab IFA
during SSMs (at least 30 tablets) in comparison to non – SSM months (which could be less than 30
2. UNDER SARVA SHIKSHA ABHIYAN (with technical and financial support from UNICEF):
There are National Programmes for Girls Elementary Learning (NPEGEL) and Kastruba Gandhi Balika
Vidhyalayas (KGBV) schools totaling to 1,500 schools across the State. These are ashram schools having
adolescent girls from SC and ST communities; KGBV schools have drop out girls who are under the bridge
programme. Since last year approximately 150,000 girls have received weekly supplementation of IFA on
Tuesdays. These girls are also dewormed bi-annually.
Smita Bajpai, CHETNA, Ahemdabad
The issue of anemia is critical both from bio medical as well as nutrition point of view. Anemia has been
identified as an indirect cause of Maternal Mortality. However, the prevalence and severity of anemia
makes it almost a direct and leading cause of maternal mortality and morbidity. However, the focus of
maternal mortality reduction strategies continues to be skilled attendance, institutional deliveries and
comprehensive emergency obstetric care. Measures to address Anemia largely focus on iron tablets and
In 2004-05, CHETNA with support for Department of AYUSH implemented an awareness programme on
nutrition deficiency anemia. While Community awareness and locally available food based strategies were
implemented, the vaidyas provided Ayurvedic treatment.
A cohort of 30 women was followed up for three months with a pre and post Hb test and the
improvement in Hb levels was by 1.5-2 gm%. Interviews with women indicated that increased intake of
food and milk was regarded as the contributing factor by women.
To sum up- we need to focus on quantity as well as nutritional value of food intake by women. Some
women will need iron tablets or blood transfusion but women must have multiple choices with them.
Parul Kotdawala, Kesar Sal Medical College, Ahmedabad
I am a Gynecologist & also a faculty in medical college. I have been treating anemia in pregnancy since a
long time. Observing patient responses & behavior, I have made some observations, which I wish to
share. These may be personal opinions, but there are some strong supporting evidences upon which they
are based. I would like to know your opinions too.
1. We have been giving (literally pushing) iron tablets to the mass of women since decades, and have
failed to make any significant impact.
2. The ICMR also accepted this fact after a long trial, admitting that the anemia prevalence in their
study population & the control population remained the same!
3. If we want to make any tangible impact, we need to think out of box & develop some innovative
4. We also accept that in fact anemia prevalence has increased over time!
5. The reason for this perhaps is that stainless steel, aluminum & other metals replaced the traditional
cast iron utensils as cook wares. Adequate iron used to be assimilated from the cookware in to the
food while cooking & preservation. In fact some authorities in USA have also now recommended the
use of cast iron utensils especially for vegans & vegetarians. I had great difficulty in procuring CI
utensils & in fact got them only from the metal market in Mumbai! In Ahmedabad these are just not
available! Mild steel is not such a good option as this reacts with additives like lemon, or other
condiments added to the dal or sabji. Can we revive use of these implements of cooking? A free
supply of them may work wonders, and at a far lower cost then iron therapy, which works only while
it is on! Shall we in the MCH community take a pilot project on this?
6. We need to bring about changes in our food habits. We do think of worms & malaria, which are very
visible causes of blood loss. But another cause that interferes in absorption is often missed out. We,
Indians eat a lot of food which may not be clean, water in public meetings - marriage gathering,
parties in restaurants, community gathering where food & water used is so unclean. Panipuries,
chatwallas, hawkers selling cooked eatables - all these bring about a chronic gastro-intestinal
infestation/infection leading to upsets & poor absorption. Most of the drinking water in villages -
ponds & wells - has amoeba, & among villagers amebic & giardia infestation is massive. So many
people merrily take a course of metrogyl whenever they eat from the hawkers at pilgrimage places!
So an awareness on this aspect & providing clean drinking water becomes a vital issue! I firmly
believe that the clue in anemia control lies in health & sanitation! We focus too much on therapy &
do very little on this issue!
7. Oral tablets are not tolerated well by many women & at best they stop taking them after a couple of
weeks. If they continue, they may develop GI upsets, & their overall nutrition gets affected! We have
studies that even gynecologist residents/doctor patients do not continue iron therapy beyond a short
period, when they are fully aware of the consequences of anemia! We have to innovate here too! For
mild anemia, giving a weekly iron works equally well. Almost 2/3 of anemic women have mild
anemia, & once a week tablet is accepted well & compliance is superb. For those having severe
forms, some newer injections which do not have major side effects can help. Some simplifications in
blood-banking rules are also in order, as the current rules have reduced blood availability in rural
areas very drastically.
We need to innovate & I look forward to some fresh thinking!
Vanisha Nambiar, The M. S. University of Baroda, Vadodara
As a nutritionist my view to increase or maintain the Hb levels for safe motherhood under NRHM is via
diet i.e. using a Food Based Approach.
It is a well documented fact that women and adolescent girls are especially at high risk of malnutrition,
due to various reasons relating to social, cultural & economic factors. Iron Deficiency Anemia is prevalent
in more than 50% of all reproductive age women. During the past several decades’ considerable
attention has been focused on Iron Deficiency Anemia due to its wide prevalence & potential threat to
individual health. Despite increased global efforts the prevalence of this nutritional disorder has virtually
remained unchanged over the years.
Since long-term iron supplementation is an impractical solution, providing fortified staple foods as well as
working to increase the bioavailability of iron in various foods, are steps toward decreasing the
prevalence of iron deficiency world wide.
Other prevalent causes of anemia include malaria, chronic infection & nutritional deficiencies of Vitamin
A, folate & Vitamin B-12. Vitamin A and Beta carotene may form a complex with Iron, keeping it soluble
in the intestinal lumen and preventing the inhibitory effect of phytate and polyphenol on the absorption.
One consequence of reduced iron along with low levels of vitamin A stores in non–pregnant young girls
may be increased risk of menorrhagia, which contributes further to the problem of anemia in poorly
nourished girls in their pre – reproductive years and beyond.
Dietary iron is classified into two distinct categories: Heme iron, which is readily absorbed and non-heme
iron, which has a poor bioavailability. Heme iron is present in animal foods (meat, fish and poultry), while
non-heme iron is present in both animal and vegetarian foods (particularly cereals and legumes). The
high prevalence of iron deficiency in most developing countries, including India, where the staple diet
consists of cereals and legumes, is thought to be due to the lack of adequate heme iron in the diet.
Because heme iron is generally better absorbed (15-35%) than non-heme iron (2-20%), it has been
suggested that vegetarians may be at a greater risk of iron deficiency. Non-heme iron absorption is
strongly influenced by many inhibitory and enhancing factors in the diet whereas, heme iron absorption is
very little affected by dietary components. Enhancers of iron include vitamin C, which is easily available
throughout the country in guava, lime, amla, orange juice, tomato products, or other good sources of
Hope the Government will include more of Nutrition experts, as much of the resources to maintain good
health has spent on pharmaceutical products rather than natural products, which can be identified and
promoted using the right guidance of these experts.
Madhu Suri, Department of Education, New Delhi
I have come across a number of Girls in their teens, who are undernourished. There may be Multiple
Factors due to which this condition becomes obvious. These girls can be targeted through a program at
the secondary school level through Sarva Shikhsha Abhiyan. If these young girls are taken care of early in
life, may be they can change their eating habits over the years ahead in their lives. This can be done
through awareness programme, which can go along with the supplementation of Iron programme. This
can help them grow into healthy young women.
Yuman Hussain, Azad India Foundation, Kishanganj
I completely agree with the views put forward by Dr Parul. What he has written is being experienced by
us in our intervention area.
Our organization Azad India Foundation is working on improving maternal and child health in Pothia block
(Kishanganj) under Project NIRMAN (http://azadindia.org/Project_NIRMAN/index.html) and Project
DISHA. One of our main objectives is prevention of anemia among pregnant women and adolescent girls.
During the course of our intervention, we have seen that mostly all women especially pregnant women
suffer from different levels of anemia. Most of them are also underweight with 5-6 children.
Iron tablets are not easily available locally besides many women have also reported intolerance to iron
tablets. They reported symptoms such as headache, dizziness etc on taking iron tablets.
Therefore as a strategy our community health workers promote use of iron utensils and local vegetables
grown within the community. Most women also reported irregular bowels, stomach upsets and general
weakness in the health camps organized at regular intervals. The main causes are worms and dirty
drinking water. We are also giving de-worming tablets besides promoting hygiene and sanitation.
We believe that it is equally important to promote indigenous methods of anaemia control besides
procuring iron tablets from the government sources for the severe cases of anemia.
B. L. Kaul, Society for Popularization of Science and Progressive Educational Society, Jammu
I fully agree with suggestions made by Dr. Parul Kotdawala. From experience I know that G.I Tract
infections inflicted by community meals, hawker served chats and meals, free meals served at pilgrimage
centres combined with impure and unclean water that majority of us use everyday are responsible for
prevalence of anaemia in children, women and even some men. Pure clean water, good sanitation and
improvement of personal hygiene can help us in living better and healthy lives. To improve iron intake
going back to cast iron utensils may be a little difficult now since we are used to stainless steel and
aluminum utensils, I think it is essential to eat lots of green leafy vegetables and fruits.
Shubhada Kanani, The M S University of Baroda, Vaddodara
Many interesting views have been put forward regarding anemia control. In my view:
1. While there are many problems with the IFA tablet supplementation program and it has not shown
the desired impact; let us remember that it is because the Anemia control program has not been
implemented properly and not because the IFA supplements strategy has inherent weaknesses. Let
us not throw the baby with the bathwater! Let us try to seriously improve implementation of the IFA
supplementation program and advocate for better management in terms of supplies, distribution to
those who are eligible (and not anyone who asks for the tablets or who is conveniently available);
some effective counseling to stress on its benefits and managing side effects and so on. Research in
our department since 1990s and other studies have clearly shown that if iron supplementation if
implemented well with good counseling; Hb levels rise significantly in the pregnant women. Besides,
for the short period available in pregnancy, it is vital to have the tablets reach the women and ensure
that they are consumed with meals because IFA is the fastest way to make HB rise so as to have a
2. This is not to undermine the importance of food based strategy and other health measures. In fact
comprehensive anemia control measures integrating IFA, Nutrition-health education and
communication to improve dietary intake of vitamin A, C and iron - and deworming; malaria control -
will not only improve hemoglobin but lead to many other benefits.
Again, the bottom-line is do well what you do!
Aboli Gore, Japan International Cooperation Agency (JICA), Bhopal*
Iron deficiency anaemia is rampant in almost all parts of the country. There have been intense efforts
from the service delivery side as well. However, the scene does not seem to be changing much. On the
contrary, change in dietary practices and deteriorating sanitation has put the population more at the risk.
Compliance of IFA depends upon the communication skills of the provider. We are somehow giving less
emphasis on the dietary practices in the household. Minor changes in daily intake are able to take care of
the mild and moderate anaemia with or without IFA consumption.
Reverting back to the usage of iron utensils is a very good option. Intake of gud and chana, nimbu and
avoiding tea (or coffee) just before or after the food is very useful. I am not advocating much GLV as in
our project area, which is draught, affected, people hardly get vegetables.
Aditya Agnihotri, Anchal Charitable Trust, Delhi*
I have an idea for anemia control:
1. Anemia control programme should be for girls students of every school.
2. Girl students will come with new non-going girls from village or community.
3. If we will control the anemia in school, we will achieve the target and reach the better position.
Rakhee Yadav, The Micronutrient Initiative, Bhopal*
It is indeed heartening to see the concern shared by all of you for a subject that is close to my heart.
Anaemia in general is an alarming issue more so when this is coupled with pregnancy.
Thinking out of the box is really the need of the hour. At the same time I would also like to flag the issue
that compliance levels are low only with the government provided IFA tablets? This may be my personal
opinion but if I may share experiences during my responsibility as a Lady Medical Officer at CHC Anni,
Dist Kullu Himachal State Medical Services. Almost all educated primis coming for ANCs were concerned
about delivering healthy babies and were aware that some medicines are provided in the CHC towards
this effect, but when they were given the routine IFA government supply they would revert back saying if
a better medicine could be prescribed which they would buy from an outside pharmacist.
6 years down the line and now I am working on micronutrient supplementation issues with the state
government of MP yet I am faced with the same dilemma. In my understanding supply and logistics is
not a problem. There are supplies at the Anganwadi center, at the schools under school health
programme but various times on field visits IFA tabs were found after expiry dates also, but no
responsible person had disposed of them because no one shares the concern. Awareness that routine IFA
supplementation can combat anaemia is a major hurdle. The general impression is that government
supplies do not work as well as medicines bought from private pharmacists. Maybe the government too
can think of attractive packaging of IFA to ensure that these supplies are equally good and at no cost.
Anita Malhotra, Lakshmibai College, New Delhi*
Since the strategy of providing iron and folic acid tablets to women after they conceive and very often
when they reach the third trimester of pregnancy has not been found much effective, iron
supplementation for girls may be started from the adolescent period itself. The rationale for considering
adolescent girls as a vulnerable group for iron supplementation is based on three considerations -
Many girls/women are often already anaemic when they conceive;
Pregnancy is too short a period to reduce persisting anaemia particularly when women do not seek
antenatal care until second or third trimester.
Thirdly, intervention channels already exist through which adolescent girls may be targeted for iron
Iron supplementation during adolescence would have greater impact on reproductive health and
pregnancy success than interventions during pregnancy alone.
Prema Ramachandran, Nutrition Foundation of India, New Delhi*
In India, the prevalence of anaemia is high because of
low dietary intake, poor iron and folic acid intake;
poor bio-availability of iron in phytate fiber-rich Indian diet; and
infection such as malaria, hook worm infestations.
Anemia is seen from infancy and childhood and adolescence; it gets aggravated during pregnancy and is
perpetuated due to repeated pregnancies.
Obstetricians and nutritionists in India recognized that anaemia in pregnancy was nearly universal in
lower income groups and was common even in the high-income group. Right from sixties, screening for
anaemia and iron-folate therapy in appropriate doses and route of administration for the prevention and
management of anaemia in these vulnerable groups have been incorporated as an essential component
of antenatal care. However the out reach of the primary health care services in the country was very low
and hence anaemia detection and appropriate correction did not get operationalised beyond medical
An attempt was made to improve intake of iron and prevent deterioration of Hb levels during pregnancy
by providing 60 mg of elemental iron and 500 micro gram of folic acid atleast for 100 days during
pregnancy under the National Nutritional Anaemia Prophylaxis Programme. However, ample data exist to
show that though this dosage will prevent further deterioration in Hb status, it will not result in
substantial improvement in Hb levels especially in those with moderate and severe anaemia.
By nineties the primary health care infrastructure especially in rural areas was well established. In view of
the fact that there has been no reduction in prevalence of anaemia in pregnancy or its adverse effects
(increased maternal morbidity, maternal mortality and low birth weight), the Ministry of Health and
Family Welfare modified the programme and renamed it as anaemia control programme. The programme
envisaged that all pregnant women will be screened for anaemia and treated for anaemia depending
upon the severity.
The multi-pronged strategy for the control of anaemia in pregnancy, in the Tenth Five Year Plan includes:
1. fortification of common food items with iron to increase the dietary intake of iron and improve the
haemoglobin status of the entire population, including girls and women prior to pregnancy;
2. screening of all pregnant women for anaemia using a reliable method of haemoglobin estimation;
3. oral iron folate prophylactic therapy for all non-anaemic pregnant women (with haemoglobin more
than 11 g/dl);
4. iron folate oral medication at the maximum tolerable dose throughout pregnancy for women with
haemoglobin level between 8 and 11 g/dl;
5. parenteral iron therapy for women with haemoglobin level between 5 and 8 g/dl if they do not have
any obstetric or systemic complication;
6. hospital admission and intensive personalised care for women with haemoglobin less than 5 g/dl;
7. screening and effective management of obstetric and systemic problems in all anaemic pregnant
8. improvement in health care delivery systems and health education to the community to promote
utilization of available care.
However, the progress in implementation has been tardy. Evaluation of the ongoing RCH programme by
the District level Household survey showed that a majority of pregnant women are not screened for
anaemia and their iron and folic acid tablet (IFA) intake is erratic. Poor quality and inadequate supply of
IFA tablets, erratic distribution due to poor worker motivation and erratic intake by woman are some of
the major problems, which are responsible for poor IFA intake. DLHS showed that in states like Kerala
where majority of women sought antenatal care, received and took IFA tablets, the prevalence of
moderate and severe anaemia was low. However in majority of the states there were no efforts to
universalize antenatal care, screen for anaemia or ensure appropriate management of anaemia in
It is imperative that universal screening during pregnancy for detection of varying grades of anemia and
its appropriate management envisaged in the RCH programmes is operationalized in all primary,
secondary and tertiary health care institutions. Merely providing 100 tablets of IFA to pregnant women
who come for antenatal check up will not be able to combat the massive problem of anemia in pregnancy
and its adverse consequences.
Many thanks to all who contributed to this query!
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