Detection and treatment of anaemia in pregnancy in primary health care institutions - its impact on birth weight Data from NNMB, NFHS and DLHS surveys indicate that even now prevalence of anaemia in pregnancy is very high ranging between 50-90%. Research studies have shown that even after three decades after initiation of the National Anaemia Prophylaxis Programme, anaemia still remains the major factor responsible for maternal mortality and low birth weight. However NFHS has shown that in Delhi there has been some improvement in maternal nutritional status and access to antenatal care. There is no information whether these factors have mitigated the adverse consequences of anaemia on maternal health and birth weight. The present study will explore this aspect and the results will help in evolving appropriate strategy for control of this major public health problem. Objective To assess the prevalence of different grades of anaemia in women attending antenatal clinic and delivering in the urban primary health care institutions in Delhi. To assess the relationship between maternal haemoglobin levels and birth weight in women delivering in these institutions To operationalise screening for anaemia by cyanmeth haemoglobin method in all women attending antenatal clinic, detect anaemic women and provide them with appropriate therapy as envisaged in the Tenth Plan and assess its impact on haemoglobin status and birth weight. In India, the prevalence of anaemia is high because of low dietary intake, poor iron and folic acid intake; poor bioavailability of iron in phytate fibre-rich Indian diet; and infection such as Background information Effect of maternal haemoglobin level on birth weight and perinatal mortality Haemoglobin gm/deciliter (g/dl) <5 5-7.9 8-10.911.0 Mean birth weight (g) 2,400 2,530 2,660 2,710 Perinatal mortality rate /1000 500 174 76 55 Number of observations 312 362 1015 1456 Source: Prema et al, 1981 malaria, hook worm infestations. Studies conducted by the NFI, ICMR, NFHS, DLHS and NNMB show that the prevalence of anaemia is high among pregnant women (50-90 per cent) and children (50-70 per cent). Anaemia in pregnancy is associated with increased risk of low birth weight and also increased risk of maternal morbidity and mortality (Figure) India was the first developing country to take up a National Nutritional Anaemia Prophylaxis Programme to prevent anaemia among pregnant women and children. Screening for anaemia and iron-folate therapy in appropriate doses and route of administration for the prevention and management of anaemia in these
Kerala Himachal Pradesh Gujarat Tamil Nadu Punjab Orissa Andhra Pradesh Maharashtra Assam Karnataka West Bengal Haryana Madhya Pradesh Rajasthan Bihar Uttar Pradesh vulnerable groups have been incorporated as an essential component of antenatal care and paediatric practice. In spite of all these efforts anaemia continues to be a major problem affecting all segments of the population and there has not been any substantial decline in the adverse consequences of anaemia. District Level Household Survey showed that prevention, detection and management of anaemia in pregnant women has not been operationalised as a part of RCH programme. Majority of pregnant women are not screened for anaemia and their iron and folic acid tablet (IFA) intake is erratic (Figure). Poor 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Distribution of Districts as per 1 or 2 IFA Tablets regularly - Major States Bottom 20% 20-40% 40-60% 60-80% Top 20% Source: Rapid household survey 1998-99 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 low intake of IFA tablets. The recent efforts to improve packaging and availability of these IFA tablets has not yet had an impact on the regularity of intake. As a result very high rates of anaemia in pregnant women persist and the impact of severe anaemia on birth weight and maternal mortality remain unaltered. Studies carried out in the National Institute of Nutrition showed that pregnant women with Hb less than 8 g/dl show functional decompensation and constitute a high-risk group. A single Hb estimation done around the twentieth week of pregnancy is sufficient to detect the high-risk anaemic pregnant women. Unlike the situation elsewhere in the world, oral iron therapy is not effective in correction of moderate or severe anaemia in Indian pregnant women, within the short time available because of the poor bioavailability of iron in the Indian diet. Studies carried out in NIN have demonstrated the safety and efficacy of 2
intramuscular iron and oral folate therapy in management of moderate anaemia and improvement in birth weight of offspring. Tenth Plan envisages operationalisation of the multi-pronged strategy for the control of anaemia in pregnancy. The strategy consists of screening of all pregnant women for anaemia using a reliable method of haemoglobin estimation; oral iron folate prophylactic therapy for all non-anaemic pregnant women (with haemoglobin more than 11 g/dl); iron folate oral medication at the maximum tolerable dose throughout pregnancy for women with haemoglobin level between 8 and 11 g/dl; parenteral iron therapy for women with haemoglobin level between 5 and 8 g/dl if they do not have any obstetric or systemic complication; hospital admission and intensive personalised care for women with haemoglobin less than 5 g/dl; screening and effective management of obstetric and systemic problems in all anaemic pregnant women; and improvement in health care delivery systems and health education to the community to promote utilisation of available care. The strategy has so far not been fully operationalised in the critical primary health care institutions. The present study will attempt operationalisation of the strategy in selected Urban Primary healthcare institutions in Delhi. Study design Studies will be carried out in the urban maternal and child health centres developed by the NCT under the India Population Programme. All new cases will be enrolled for the cross sectional component of the study. Obstetric history, examination findings in the antenatal period and at delivery will be recorded in the proforma already developed and tested in the RCH programme. In all women accurate weight at the time of the visit will be taken and recorded. For haemoglobin estimation 20 microlitres of blood will be collected on the filter paper and dried at the centre. At NFI Hb will be estimated by using cyanmeth heaemoglobin method. Appropriate quality control procedure-s will be followed to ensure accuracy and consistency in Hb estimation. Based on the haemoglobin level all women will be given appropriate doses of oral iron and folic acid tablets or intramuscular iron therapy. Women receiving parenteral iron therapy will be followed up closely every week for the first four weeks. Haemoglobin estimation in this group will be repeated six weeks after initiation of therapy. In all women, Hb estimation will be carried out at 34-36 weeks and at delivery. All women will be advised to come at 20,28,32,36 and at term and to have 3
hospital deliveries. As and when women come for follow up to the hospitals findings will be recorded in the same form and data tabulated. If the women develop complications during pregnancy they will be treated appropriately either in the centre or referred to those centres where they could be treated appropriately. At delivery all women will be examined and the findings recorded. Details of the neonate will also be recorded. Attempts will be made to get the details of delivery and record birth weight even if women deliver at home provided they have not shifted out of the area. The second component will consist of all women who deliver in the hospital. Haemoglobin estimation will be carried out in all by cyanmeth haemoglobin method. They and their neonates will be examined and the findings recorded in the same proforma. Sample size From the available information the Defence colony centre gets about 50 pregnant women during the antenatal clinic days and has about 900-1000 deliveries every year. The enrolment will continue for two years. Attempt will be made to ensure that all pregnant women enrolled study will be followed up till delivery. Data analysis Both these data sets will be analysed. The data on women who had come to deliver will be analysed to ascertain the impact of maternal haemoglobin levels on birth weight. The data on birth weight in those treated for different grades of anaemia will also be analysed to assess the impact of treatment on maternal haemoglobin levels and birth weight of neonates. Thus, this study will help in assessing: feasibility of screening for anaemia in antenatal clinics the magnitude of anaemia in pregnancy and at delivery in primary health care institutions in Delhi, effect of anaemia on birthweight, providing appropriate management of anaemia in these centres and assess the impact of treatment on maternal haemoglobin levels and birth weight of the offspring Time Frame The study has two components. The situation analysis will begin at 6 months and will continue till 33 months. The intervention phase will begin at 25 th month and continue till 54 months. 2005 4
Feasibility of detection and treatment of anaemia in pregnancy in urban primary health care institutions - impact of intra-muscular (IM) therapy on birth weight Background information Data from Nutrition Foundation of India (NFI), Indian Council of Medical Research (ICMR), National Family Health Survey II (NFHS II), District Level Household Survey (DLHS) and National Nutrition Monitoring Bureau (NNMB) show that in India the prevalence of anaemia is quite high both among pregnant women (50-90 per cent) and children (50-70 per cent). This could be because of low dietary intake, poor iron and folic acid intake; poor bioavailability of iron in phytate fibre-rich Indian diet; and infection such as malaria, hook worm Effect of maternal Haemoglobin level on Birth weight & perinatal mortality Haemoglobin (g/dl) <5 5-7.9 8-10.911.0 Mean birth weight (g) 2,400 2,530 2,660 2,710 Perinatal mortality rate /1000 live births 500 174 76 55 Number of observations 312 362 1015 1456 Source: Prema et al, 1981 infestations. Anaemia in pregnancy is associated with increased risk of low birth weight and also increased risk of maternal morbidity and mortality (Table). India was the first developing country to take up a National Nutritional Anaemia Prophylaxis Programme to prevent anaemia among pregnant women and children. Research studies have shown that even three decades after the initiation of the National Anaemia Prophylaxis Programme (NAPP), anaemia still remains the major factor responsible for low birth weight and maternal mortality. 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 and paediatric practice. In spite of all these efforts anaemia continues to be a major problem affecting all segments of the population and there has not been any substantial decline in the adverse consequences of anaemia. Comparing the data from ICMR studies in Delhi with the NFHS has shown that in Delhi there has been some improvement in the maternal nutritional status and access to antenatal care. But there is no information whether these factors have mitigated the adverse consequences of anaemia on birth weight and maternal health. 5
Kerala Himachal Pradesh Gujarat Tamil Nadu Punjab Orissa Andhra Pradesh Maharashtra Assam Karnataka West Bengal Haryana Madhya Pradesh Rajasthan Bihar Uttar Pradesh The District Level Household Survey showed that prevention, detection and management of anaemia in pregnant women has not been operationalised as a part of RCH programme. Majority of pregnant women are not screened for anaemia and their iron and folic acid tablet (IFA) intake is erratic (Figure). Poor quality and inadequate supply of IFA tablets, erratic distribution due to poor worker motivation and erratic consumption by woman are some of the major 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Distribution of 1 or 2 IFA Tablets - district wise in major states Bottom 20% 20-40% 40-60% 60-80% Top 20% Source: Rapid household survey 1998-99 problems, which are responsible for low intake of IFA tablets. The recent efforts to improve packaging and availability of these IFA tablets have not yet had an impact on the regularity of intake. As a result very high rates of anaemia in pregnant women persist and the impact of severe anaemia on birth weight and maternal mortality remain unaltered. Studies carried out in the National Institute of Nutrition showed that pregnant women with Hb less than 8 g/dl show functional decompensation and constitute a high-risk group. A single Hb estimation done around the twentieth week of pregnancy is sufficient to detect the high-risk anaemic pregnant women. Unlike the situation elsewhere in the world, oral iron therapy is not effective in correction of moderate or severe anaemia in Indian pregnant women, within the short time available because of the poor absorption of iron due to high phytate / fibre content in the Indian diet. Studies carried out in NIN have demonstrated the safety and efficacy of intramuscular iron and oral folate therapy in management of moderate anaemia leading to improvement in birth weight of offspring. 6
The Tenth Plan envisages operationalisation of the multi-pronged strategy for the control of anaemia in pregnancy. The strategy consists of screening of all pregnant women for anaemia using a reliable method of haemoglobin estimation; oral iron folate prophylactic therapy for all non-anaemic pregnant women (with haemoglobin more than 11 g/dl); iron folate oral medication at the maximum tolerable dose throughout pregnancy for women with haemoglobin level between 8 and 11 g/dl; parenteral iron therapy for women with haemoglobin level between 5 and 8 g/dl, provided they do not have any obstetric or systemic complication; screening and effective management of obstetric and systemic problems in all anaemic pregnant women; hospital admission and intensive personalised care for women with haemoglobin less than 5 g/dl; and improvement in health care delivery systems and health education to the community to promote utilisation of available care. The strategy has so far not been fully operationalised in the critical primary health care institutions. The present study will attempt operationalisation of the strategy in selected Urban Primary healthcare institutions in Delhi. Objectives: Present study has been planned with the following objectives: To obtain data on demographic, health and nutritional status of women attending antenatal OPD or having delivery in Maternity centres; To assess the prevalence of different grades of anaemia in women attending antenatal clinic and delivering in the urban primary health care institutions in Delhi; To assess feasibility of screening for anaemia by cyanmethaemoglobin method in all women attending antenatal clinic, identify anaemic women and provide them with appropriate therapy as envisaged in the Tenth Plan (mentioned earlier); To find out the impact of IM therapy on haemoglobin status of the pregnant woman and the birth weight of the newborn; To assess dietary intakes and food consumption patterns (24 hour recall) in a sub sample of anaemic and non-anaemic individuals. Locale: The study will be carried out initially in the Defence Colony Maternity centre. 7
Methodology: The study consists of two components: Cross sectional component All women delivering in the hospital will be covered. Their haemoglobin will be determined using the Cyanmethaemoglobin method for estimating the prevalence of mild, moderate and severe anaemia. The birth weight of the infant will be taken within 24 hours of the delivery. This will help in assessing the association between anaemia on the birth weight of the baby. All women coming to the antenatal OPD will be covered for studying the feasibility of doing Hb estimation by Cyanmethaemoglobin method. Longitudinal component The longitudinal component will comprise of a sub sample group of crosssectional antenatal group of women. The women with Haemoglobin level between 5-7.9 g/dl will be given IM iron therapy. These women will be followed up for estimation of Hb one month after giving the IM therapy, just before delivery and at the time of delivery to assess its impact on maternal Hb and birth weight of the bay. All new cases in antenatal OPD (pregnant women) will be enrolled. Obstetric history, examination findings in the antenatal period and at delivery will be recorded in the proforma already developed and tested in the RCH programme. In all women height, weight, fundal height, abdominal girth at the time of the visit will be taken and recorded. Haemoglobin (Hb) estimation of the subjects will be done by the Cyanmethaemoglobin method. For this, an accurate volume (20ul) of blood is drawn from the pricked finger into the Hb pipette and immediately delivered into an accurately measured amount (5ml) of diluent (Drabkin's solution). The absorbance is read at 540 nm in a photoelectric colorimeter. The haemoglobin estimation will be done in the maternity centre itself so that by the time the subjects get their antenatal check up done; the results of the Hb estimation will be available. This will not only reduce the dropout rates but also help the NFI staff to segregate the women on the basis of their Hb level and to counsel the subject (and their attendant) about the importance of dietary diversity and management of anaemia. Appropriate quality control procedures will be followed to ensure accuracy and consistency in Hb estimation. Based on the haemoglobin level all women will be given appropriate iron folate medication therapy. The pregnant women with moderate anaemia (5-7.9g%) will be advised intra-muscular iron therapy. 1 gm of Jectofer will be given to the moderate anaemic subjects for 5 consecutive days (200mg/day). The maternity centre staff will give the Jectofer injections at times convenient to the women. All 8
these women will be counselled regarding minor side effects. They will be told that some of them may develop joint pains; they all will be given paracetemol tablets to be taken as and when they develop joint pains. All these women will be given 5 mg of folic acid tablets to be taken once a day for the next 30 days. They will be advised to get their Hb levels checked at the clinic after 1 month of the IM therapy and just before delivery. By the end of the study, efforts will be made to have atleast a 3-point antenatal record and the delivery record of as many women as possible who have been given the IM therapy. If any woman develops complications during pregnancy they will be treated appropriately either in the centre or referred to those centres where they could be treated appropriately. At delivery all women will be examined and the findings recorded. Details of the neonate will also be recorded. Attempts will be made to get the details of delivery and record birth weight even if women deliver at home provided they have not shifted out of the area. Dietary information: In India, the diets are predominantly cereal-based. As a result there is low bioavailability of iron from food. This is due to presence of iron absorption inhibitors like phytates, tannin and insoluble dietary fiber, coupled with the absence of iron absorption enhancers (ascorbic acid and animal protein). Large scale surveys have shown that the total dietary intake of the population, including the pregnant women, is also low which in turn leads to low intake of iron through diets. But still some of the pregnant women have normal haemoglobin level while others are anaemic. To find out the reasons for this difference, the dietary data will be collected using the 24-hour recall method in a subsample of non-anaemic (>11.0g/dl) and moderately anaemic (5.0-7.9g/dl) women. Using standardised utensils, the data will be collected throughout the year so as to avoid any seasonal discrepancy. Sample size The sample size required for the two components is as follows: a) Cross-sectional component: In this all women coming to the antenatal clinic and delivering in the hospital for one year will be enrolled. The Defence colony maternity home gets about 40 pregnant women during the antenatal clinic days. This makes about 80 women per week and more than 4000 women in one year. The number of deliveries per year is approximately 900. b) Longitudinal component: From the available information, 25% of the deliveries at the Defence Colony centre are LBW. The DLHS data shows the prevalence of moderate anaemia to be about 30%. Considering that Delhi is a metro with better antenatal facilities, expecting the prevalence of moderate anaemia to be 20% and with approximately 80% compliance rate, a total of atleast 300 women will have to be registered for the IM therapy. The Defence colony maternity home gets about 40 pregnant women during the antenatal 9
clinic days and has about 800-900 deliveries every year. The enrolment will continue till 300 subjects with moderate anaemia are registered for IM therapy (with their consent). Attempts will be made to ensure that all pregnant women enrolled for the study will be followed up till delivery. Data analysis Data will be analysed to assess : changes in nutritional status of the women during pregnancy; feasibility of screening for anaemia in antenatal clinics; the magnitude of anaemia in pregnancy in primary health care institutions in Delhi; effect of anaemia on birthweight (from the cross sectional postnatal component of the study) and the impact of IM therapy on maternal haemoglobin levels and birth weight of the offspring (comparing the birth weight in the IM iron group with those who had Hb between 5-.7.9 g/dl at delivery in the cross sectional un treated postnatal component); comparison of diets of anaemic and non-anaemic subjects with special reference to their energy, iron, vitamin C and free folic acid intake. Results Component I It has been possible to reorganize the out patient department so that the patients can now get the antental check up done without any further increase in their waiting period. The initial pattern of patient flow and the reorganization of the OPD is shown in Annexure I, II and III. The cost of heaemoglobin estimation by cyanmeth haemoglobin has been computed and it is not significantly higher than cost of Hb estimation by Sahli s method. Hb estimation is now being done using cyanmethhemoglobin method. Appropriate advice is being given to women based on their haemoglobin level. So far over sixty women have been enrolled for intramuscular iron therapy. Component II Women delivering in the maternity home are being enrolled to assess prevalence of anemia and its impact on birth weight in the absence of treatment for anemia 10
Annexure I OLD SYSTEM Not all screened for anaemia History taken but not segregated according to risk Haemoglobin estimation not done by appropriate technique No classification according to Hb level All women receive IFA irrespective of Hb level Regularity of intake not monitored No special attention to anemic women Continued neglect of anaemia 11
Annexure II Patient Flow in the Antenatal OPD (Old System): Old and new patients get registered at the OPD counter by the ANM. After taking obstetric history sent to the lab for tests Given the report of the tests and sent to the doctor Doctor examines the pregnant women Take medicines from the pharmacy as prescribed. 12
Patient Flow in the Antenatal OPD (New System) Annexure III New and old patients get registered at the counter by only giving their initial information i.e. name, LMP, address, age and family size. The women sent to the lab for Hb estimation. Time taken to get the report is twenty minutes. After Hb sent to the room across for BP, Height and Weight examination. Come back t the counter for giving their obstetric history while reading is being taken of Hb estimation. Collect the Hb report and go to the doctor for examination. Segregated as per their Hb level Normal Hb: 11.0g % Mild Hb: 8.0-10.9g % Moderate Hb: 5.0-7.9g % Severe Hb: <5.0g % Dietary Advice & IFA 1 Tablet Diet & 2 IFA Tab/or max. Tolerable dose Diet & IM iron therapy Hospitalization & Referral 13
2006 Detection and Management of anaemia in pregnancy in pregnancy in urban primary health care institutions Background Data from Nutrition Foundation of India (NFI), Indian Council of Medical Research (ICMR), National Family Health Survey II (NFHS II), District Level Household Survey (DLHS) and National Nutrition Monitoring Bureau (NNMB) show that in India the prevalence of anaemia is quite high both among pregnant women (50-90 per cent) and children (50-70 per cent). This could be because of low dietary intake, poor iron and folic acid intake; poor bioavailability of iron in phytate fibre-rich Indian diet; and infections such as malaria, hook worm Table 1 Effect of maternal Haemoglobin level on Birth weight & perinatal mortality Haemoglobin (g/dl) <5 5-7.9 8-10.911.0 Mean birth weight (g) 2,400 2,530 2,660 2,710 Perinatal mortality rate /1000 live births 500 174 76 55 Number of observations 312 362 1015 1456 Source: Prema et al, 1981 infestations. Anaemia in pregnancy is associated with increased risk of low birth weight and also increased risk of maternal morbidity and mortality (Table 1). India was the first developing country to take up a National Nutritional Anaemia Prophylaxis Programme (NNAPP) to prevent anaemia among pregnant women and children. Research studies have shown that even three decades after the initiation of the NNAPP, anaemia still remains the major factor responsible for low birth weight and maternal mortality. 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 and paediatric practice. In spite of all these efforts anaemia continues to be a major problem affecting all segments of the population and there has not been any substantial decline in the adverse consequences of anaemia. Comparing the data from ICMR studies in Delhi with the NFHS has shown that in Delhi there has been some improvement in the maternal nutritional status and access to antenatal care. But there is no information whether these factors have mitigated the adverse consequences of anaemia on birth weight and maternal health. 14
Kerala Himachal Pradesh Gujarat Tamil Nadu Punjab Orissa Andhra Pradesh Maharashtra Assam Karnataka West Bengal Haryana Madhya Pradesh Rajasthan Bihar Uttar Pradesh The DLHS showed that prevention, detection and management of anaemia in pregnant women has not been operationalised as a part of RCH programme. Majority of pregnant women are not screened for anaemia and their iron and folic acid tablet (IFA) intake is erratic (Figure 1). Poor quality and inadequate supply of IFA tablets, erratic distribution due to poor worker motivation and erratic consumption by woman are some of the major problems, which are responsible 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 1 Distribution of 1 or 2 IFA Tablets - district wise in major states Bottom 20% 20-40% 40-60% 60-80% Top 20% Source: Rapid household survey 1998-99 for low intake of IFA tablets. The recent efforts to improve packaging and availability of these IFA tablets have not yet had an impact on the regularity of intake. As a result very high rates of anaemia in pregnant women persist and the impact of severe anaemia on birth weight and maternal mortality remain unaltered. Studies carried out in the National Institute of Nutrition (NIN) showed that pregnant women with Hb less than 8 g/dl show functional decompensation and constitute a high-risk group. A single Hb estimation done around the twentieth week of pregnancy is sufficient to detect the high-risk anaemic pregnant women. Unlike the situation elsewhere in the world, oral iron therapy is not effective in correction of moderate or severe anaemia in Indian pregnant women, within the short time available because of the poor absorption of iron due to high phytate / fibre content in the Indian diet. Studies carried out at NIN have demonstrated the safety and efficacy of intramuscular iron (IM iron) and oral folate therapy in management of moderate anaemia leading to improvement in birth weight of offspring. 15
The Tenth Plan envisages operationalisation of the multi-pronged strategy for the control of anaemia in pregnancy. The strategy consists of screening of all pregnant women for anaemia using a reliable method of haemoglobin estimation; oral iron folate prophylactic therapy for all non-anaemic pregnant women (with haemoglobin more than 11 g/dl); iron folate oral medication at the maximum tolerable dose throughout pregnancy for women with haemoglobin level between 8 and 11 g/dl; parenteral iron therapy for women with haemoglobin level between 5 and 8 g/dl, provided they do not have any obstetric or systemic complication; screening and effective management of obstetric and systemic problems in all anaemic pregnant women; hospital admission and intensive personalised care for women with haemoglobin less than 5 g/dl; and improvement in health care delivery systems and health education to the community to promote utilisation of available care. The strategy has so far not been fully operationalised in the critical primary health care institutions. The present study will attempt operationalisation of the strategy in selected Urban Primary healthcare institutions in Delhi. Objectives: Present study has been planned with the following objectives: To assess feasibility of screening for anaemia by cyanmethaemoglobin method in all women attending antenatal clinic, identify anaemic women and provide them with appropriate therapy as envisaged in the Tenth Plan (mentioned earlier); To assess the prevalence of different grades of anaemia in women attending antenatal clinic and delivering in the urban primary health care institutions in Delhi; To Compare data on demographic, health and nutritional status of women anaemic and non anaemic women attending antenatal OPD or having delivery in Maternity centres; To find out the impact of IM therapy on haemoglobin status of the pregnant woman and the birth weight of the newborn; To assess dietary intakes and food consumption patterns (24 hour recall) in a sub sample of anaemic and non-anaemic individuals. Locale: The study is being carried out initially in the Defence Colony Maternity centre. 16
Methodology: The study consists of two components: Cross sectional component All women delivering in the hospital are covered. Their haemoglobin estimation is being done by Cyanmethaemoglobin method for assessing the prevalence of mild, moderate and severe anaemia. The birth weight of the infant is being taken soon after birth. This component is being taken up to assess the association between anaemia and the birth weight of the baby. All women coming to the antenatal OPD are being covered for studying the feasibility of doing Hb estimation by Cyanmethaemoglobin method. Longitudinal component The longitudinal component comprises of a sub sample group of cross-sectional antenatal group of women. The women with Haemoglobin level between 5-7.9 g/dl are being given IM iron therapy. These women are being followed up for estimation of Hb one month after giving the IM therapy, just before delivery and at the time of delivery to assess its impact on maternal Hb and birth weight of the baby. Results Operationalisation of screening for anaemia in antenatal OPD by cyanmethhaemoglobin method All new cases in antenatal OPD (pregnant women) are being enrolled. To begin with, a colorimeter has been installed by NFI in the laboratory attached to the antenatal clinic. Hb estimation by the Cyanmethaemoglobin method was standardized. Appropriate quality control procedures are being followed to ensure accuracy of Hb estimation. The patient flow routine in antenatal clinic in DCMC has been reorganized. All pregnant women who come to the OPD are first sent for Hb estimation, urine examination, height, weight, and blood pressure recording; then their obstetric history is obtained and entered in the antenatal care (ANC) card which has been already developed and tested in the RCH programme. By this time their urine and Hb results are available; these are entered in the ANC card. The doctor then examines the women and provides advice regarding future care. Based on their Hb level and period of gestation, all pregnant women and their attendants are given appropriate advice regarding the management of anaemia. This system has been in operation for the last 18 months and does not increase the time spent by the pregnant women in the antenatal OPD. The center has a lab technician and so this system is sustainable within the existing infrastructure and manpower. Profile of women attending the antenatal clinic Profile of women attending the antenatal clinic is given in Table 2. Majority of the women had their first or second delivery between 20-29 years of age. Abortion 17
Table 2: Profile of women attending Antenatal OPD at Defence Colony Maternity Centre No % 7. Type of family 1 Age Joint 1230 42.8 <20 205 6.8 Nuclear 1642 57.2 20-29 2560 85.1 Total 2872 100 30-39 242 8.0 8. Family Size >40 2 0.1 >= 3 1262 44.0 Total 3009 100 4-8 1400 48.8 2.Gravida >8 209 7.3 1 1318 43.8 Total 2871 100 2 902 30.0 9.Education of women >=3 789 26.2 Illiterate, read & write 335 20.9 Total 3009 100 Had schooling 1089 67.9 3. Parity College 179 11.2 0 1514 50.3 Total 1603 100 1 969 32.2 10.Education of husband 2 427 14.2 Illiterate, read & write 154 9.6 >=3 99 3.3 Had schooling 1122 70.0 Total 3009 100 College 327 19.7 4 Abortion Total 1603 100 0 2952 98.1 11.Work status of women 1 52 14.7 House wife 1348 84.1 >=2 5 3.0 Working 255 15.9 Total 3009 100 Total 1603 100 5 Still birth 12.Work status of husband 0 2952 98.1 Unskilled 442 27.6 1 52 1.7 Semi skilled 615 38.4 >=2 5 0.2 Skilled 546 34.0 Total 3009 100 Total 1603 100 6 IPI 13.Standard of living index < 12 m 189 11.6 Low 472 29.4 12-23 m 423 25.9 Middle 729 45.5 24-36 m 657 40.3 High 402 25.1 >36 m 362 22.2 Total 1603 100 Total 1631 100 18
and still birth rates among these women were quite low. This is perhaps because the population knew that centre is mainly providing care for women with normal pregnancies and those with complications will be referred to other centres. Interpregnancy interval (IPI) was short (<12months) in 11.6% of these women; over 60% of women conceived after 24 months after the last pregnancy. Analysis of the socio-economic data showed that majority of these women came from nuclear families with family size ranging between 4-8 members. It is surprising that nearly one-fourth of the women and one tenth of the husbands had no formal schooling. Over 80% of women were housewives. Majority of the husbands were semiskilled or skilled workers. Majority belonged to low middleincome group. Profile of women attending antenatal clinic Obstetric and nutrition profile of women attending the antenatal clinic is shown in Table 3. There were no significant differences in the obstetric profile of women Table 3 Obstetric and nutritional profile Parameters Haemoglobin (g/dl) I - <8.0 II 8.0-10.9 III - >11.0 Total Age (yrs) 23.5+3.40 (574) 23.8+3.60 (1999) 23.5+3.26 (407) 23.7+3.52 (2980) Gravida (no.) 2.0+1.04 (574) 1.9+1.05 (1999) 1.9+0.97 (407) 1.9+1.04 (2980) IPI (months) 30.4+19.75 (327) 29.8+20.58 (1081) 28.8+20.83 (208) 29.8+20.44 (1616) Height (cm) 150.8+4.86 (345) 151.2+5.05 (1171) 151.7+5.53 (240) 151.2+5.08 (1756) Weight (Kg) 49.2+7.37 (557) 49.8+8.43 (1940) 51.0+10.15 (401) 49.9+8.51 (2898) Haemoglobin (g/dl) 7.51+0.87 (574) 9.8+0.71 (1999) 11.6+0.41 (407) 9.6+1.38 (2980) The values are Mean+SD. Groups were compared on the basis of Hb levels. The number in parenthesis indicates the sample size. t-test for weight p value I vs III < 0.001; II vs III < 0.001; I vs II < 0.001 who were anaemic or not anaemic. The mean body weights of anaemic women were significantly lower as compared to non-anaemic women. The association between maternal undernutrition and anaemia reported in earlier studies from NIN and in the present study might be attributable to the fact that low dietary intake is one of the factors associated with both maternal under-nutrition and moderate or severe anaemia. 19
upto8w 9-12w 13-16 17-20 21-24 25-28 29-32 33-36 >36 Haemoglobin (g/dl) Detailed data on height, weight and Hb status in different categories for all women attending ANC clinic at their first visit is given in table 4. Less than 10% of the women were short (<145 cms). Nearly one fourth of these women weighed less than 45 kg at the time of their first visit to the antenatal OPD. Even though only 6% of the women had height over 159 cm; more than 12% of women had weight over 60kg. It is obvious that in Delhi both under-nutrition and over-nutrition are emerging as a public health problem among pregnant women from low middle-income group. Prevalence of anaemia in women attending the ANC clinic is over 80%. There were 8 women with Hb below 5 g/dl and they were referred to the tertiary care centers for management. Nineteen percent of the women had moderate anaemia (Hb level between 5.0 7.9g/dl). The mean Hb level in relation to period of gestation was computed and is Height (cm) Table 4 Nutritional Profile No % < 145 171 9.7 145-149 490 27.8 150-159 1006 57.1 >159 94 5.3 Total 1761 100 Weight (Kg) <40 215 7.4 40-44 549 18.8 45-49 776 26.6 50-54 613 21.6 55-59 390 13.4 >=60 356 12.2 Total 2917 100 Haemoglobin(g/dl) <5 8 0.3 5.0-7.9 566 19 8.0-10.9 1999 67.1 >11.0 407 13.7 Total 2980 100 11 10.8 10.6 10.4 10.2 10 9.8 9.6 9.4 9.2 9 Hb Figure 2 Mean Hb levels at different gestational period Gestational Age (wks) shown in Figure 2. The mean Hb declined from 10.3 g/dl to 9.8g /dl during 21-28 week gestation. Thereafter, the mean Hb increased to 10.0g/dl by 36 weeks. The mid-trimester fall in mean Hb was less than 0.5g/dl. Similar trends in Hb level in different periods of gestation have been reported in earlier studies. 20
Table 5 Profile of women who had IM iron therapy Parameter No % Height < 145 cm 23 8.9 145-149 69 26.6 150-159 153 59.1 >159 14 5.4 Total 249 100 Weight (Kg) <40 20 5.4 40-44 75 20.4 45-49 117 31.8 50-54 79 21.5 55-59 45 12.2 >=60 32 8.7 Total 368 100 associated with low birth weight. Similar data were reported two decades ago from NIN. The association between anaemia and low birth weight may partly be due to anaemia per se and partly due to maternal undernutrition and poor antenatal care. Operationalising detection and management of anaemia in pregnancy is one of the interventions for reducing the incidence of low birth weight. Parenteral iron therapy Detailed data on height and weight in different categories for women with moderate anaemia attending the antenatal care clinic at their first visit is given in table 5. Impact of Hb levels on birthweight Data on maternal parameters were collected and birth weight was recorded in all women who delivered in the DCMC between April 2005 and June 2006. There was a progressive reduction in mean birth-weight with decreasing Hb levels. The mean birth weight was lowest in women with Hb less than 8 g/dl (Table 3). Anaemia continues to be a major factor Table 3 Maternal Hb and birthweight Maternal Hb (g/dl) N Birth weight (g) I - < 8.0 44 2623.5+398.4 II - 8.0 11.0 499 2773.6+401.9 III - > 11.0 70 2940.7+431.9 Total 613 2781.9+410.3 Values are Mean+SD t-test p value I vs III < 0.001; II vs III < 0.001; I vs II NS All women who agreed to come to the hospital for IM iron therapy were given IM iron therapy injections daily (each ml of injection contained 150mg of iron, I.50mcg folic acid IP and 150 mcg of B12) for six consecutive days. 21
The maternity centre staff administered IM iron injections at times convenient to the women. Nearly eighty percent of women completed the course of six daily injections of IM iron therapy (Table 6). Side effects The most common side effect was metallic taste on the tongue; 110 women reported loss of appetite and nausea. They were counselled, reassured and given symptomatic treatment during the episode and given anti-emetic tablets for use in case they get nausea at home. Pain at the site of injection was reported by 150 women; they were given paracetamol tablets and injections were continued. One woman developed infection at the site of injection after completing the injections. She was treated with antibiotics and the infection was resolved. There are clear cut differences in the side effects associated with IM iron dextran and iron sorbitol citric acid complex. Fever, arthralgia and arthritis, which were reported in nearly a third of the women receiving IM iron dextran complex, were not seen in those receiving iron sorbitol citric acid complex. Follow up women who had IM iron folate therapy Effect of IM iron on Hb levels All women who received IM iron therapy were advised to get their Hb levels checked at the clinic after 1 month of the IM therapy and just before delivery. The data on Hb levels among women who had received IM iron therapy and came for follow up at various periods after completion of therapy is shown in Table 7. Table 7 Changes in haemoglobin (g/dl) after IM iron therapy Weeks after IM therapy Table 6 Number of injections taken by patients No of injections N (310) % 1 15 4.1 2 11 2.9 3 12 3.2 4 10 2.7 5 320 86.9 6 368 100 Initial Final p value (paired t test) N Mean Hb N Mean Hb (Initial vs Final) 1-2 41 7.2 +0.77 41 8.3 + 0.89 <0.001 3-4 143 7.4 +0.70 143 8.9 + 0.85 <0.001 5-6 155 7.3 +0.71 155 9.1 +0.94 <0.001 7-8 79 7.3 +0.72 79 9.3 +0.97 <0.001 > 9 298 7.3 +0.77 298 9.6 +1.04 <0.001 Values are Mean+SD Even at two weeks after IM therapy, there was significant improvement in Haemoglobin levels. By nine weeks the mean Hb in the treated group was 9.6 g/dl. The magnitude of improvement in mean haemglobin levels after eight weeks after 900mg of iron sorbital citric acid complex injection is found to be lower than the mean haemoglobin levels reported after IM injection of 1000 mg of 22
iron dextran complex. This is due to the fact that about a third of the iron dose injected is excreted in urine in women receiving iron sorbitol citric acid complex. Table 6 Maternal Hb in third trimester after IM iron therapy Haemoglobin (g/dl) <8.0 8.0-10.9 >11.0 %age (n) 18.1 (21) 74.1 (86) 7.8 (9) Follow up Hb examination in women who completed the IM iron therapy showed that in 21 subjects the Hb levels in the third trimester were less than 8g/dl (Table 6). This may be due to two factors: the dosage of iron sorbitol citric acid complex is inadequate to improve the Hb beyond 8 g/dl in women who are having initial Hb of 5-6 g/dl range ; even though iron and folate deficiencies are the most common factors responsible for anaemia in pregnancy, they are not the only factors responsible for anaemia in pregnancy. Further investigations may have to be done in cases who are not responding to IM iron therapy to ascertain the cause of anaemia and undertake appropriate interventions. All women who had Hb level between 5.0-7.9g/dl in the third trimester even after IM iron therapy were referred to the tertiary care hospitals for further investigations and management. Data from the present study suggest that the dose of IM iron sorbitol citric acid complex is insufficient to ensure improvement in the Hb levels beyond 11g/dl in majority of women and so they require about 1500 mg of iron to reach optimal Hb levels. As the women tolerate the injections well and there is no troublesome arthralgia, continuing the injection for ten days may not pose major problems. However, this would inevitably lead to higher cost of the therapy for the hospitals and also higher costs to the patients because they have to come to the hospital daily for ten days. Effect of parenteral iron therapy on birthweight Efforts were made to follow up women till delivery and obtain information on birthweight and Hb levels after delivery. Majority of women who received IM iron therapy did not deliver in DCMC but delivered in other hospitals (Table 7). Table 7 Place of delivery in those who received IM iron folate therapy (May 2005- June 2006) 2005 2006 Delivery May June July Aug Sep Oct Nov Dec Jan Feb Mar Apr May June Total Outside 1 8 7 18 12 21 11 11 6 7 10 7 10 3 132 Defence Colony 1 2 7 4 9 8 7 4 5 6 12 6 7 6 84 Total deliveries 2 10 14 22 21 29 18 15 11 13 22 13 17 9 216 23
However, it was possible to trace them and obtain information on birthweight and problems, if any, that they had during delivery. Information on maternal weight and maternal Hb after delivery and birth weight were available in women who delivered in DCMC (Tables 8 & 9). Inspite of the fact that these women continued to be undernourished, the mean birthweight was higher and the incidence of low birth weight was lower in women who received IM iron therapy. Women whose Hb was below 8 g/dl inspite of taking IM iron therapy had delivered infants with lower mean birth-weight. Table 8 Maternal weight after delivery in relation to B.wt. in IM iron therapy patients Category Mothers weight (Kg) No Mean B.wt (g) + SD Low birth weight (<2.5 Kg) No % I <40 7 2412.9+390.0 3 42.9 II 40-44 15 2857.3+360.3 2 13.3 III 45-49 22 2800.0+332.5 3 13.6 IV 50-54 12 2929.6+300.1 0 0 V 55-59 8 3048.1+503.7 0 0 VI > 60 3 3148.3+625.6 1 33.3 Total 67 2840.8+401.6 9 13.4 Table 9 Maternal post natalhb (g/dl) and birth weight in women with IM therapy Maternal Post natal Hb (g%) Birth weight (g) No Mean + SD No Mean + SD Total PNC 613 9.6+1.23 950 2773.6+398.97 IM iron therapy 71 9.4+1.03 216 2814.9+372.24 PNC Hb <8.0g% 44 7.1+1.07 44 2623.6+398.44 The mean birth weight of IM iron therapy group of women was compared with the mean birth weight in women who delivered in the DCMC (Table 10). Mean birth weight in the IM iron therapy group was higher than those with Hb <8.0g/dl, comparable to those with Hb between 8.0-10.9g/dl and lower than those with Hb>11.0g/dl. Comparison of birth-weight of infants born to women (in different Hb groups) who received IM iron therapy is given in Table 10. It is obvious that mean birth Table 10 Effect of maternal Hb on birthweight when compared with IM iron therapy group Hb (g/dl) N Birth wt (g) I - < 8.0 44 2623.5+398.4 II - 8.0 11.0 499 2773.6+401.9 III - > 11.0 70 2940.7+431.9 Total 613 2781.9+410.3 IV After IM iron therapy 248 2818.4+369.8 Values are Mean+SD t-test p value I vs III < 0.001; I vs IV <0.001; II vs III < 0.001; III vs IV < 0.02 I vs II NS, II vs IV NS weight was higher and low birth weight was lower among women with Hb >11.0g/dl (Table 11). 24
Table 11 Mother s haemoglobin after delivery (at DCMC) in relation to birth weight in IM therapy group Category Hemoglobin (g/dl) No Mean B wt (g) + SD Low birth weight (<2.5 Kg) Work plan for the next year Increase in the dose of IM iron It is obvious that the dosage of the IM iron is inadequate to ensure that majority of women become non-anaemic and mean Hb is above 11g/dl. This is because about a third of iron sorbital citric acid complex gets excreted in the urine. In the current year we have planned to increase the dose of IM iron therapy to 1500 g to be given in 10 injections. The compliance with the regimen, impact of the regimen on maternal Hb and birthweight will be assessed. It is expected that this will be done over the next 18 months. Dietary information In India, the diets are predominantly cereal-based. As a result there is low bioavailability of iron from food. This is due to presence of iron absorption inhibitors like phytates, tannin and insoluble dietary fibre, coupled with the absence of iron absorption enhancers (ascorbic acid and animal protein). Large scale surveys have shown that the total dietary intake of the population, including the pregnant women, is also low which in turn leads to low intake of iron through diets. But still some of the pregnant women have normal haemoglobin level while others are anaemic. To find out the reasons for this difference, a dietary survey is being done using the 24-hour recall method in a sub-sample of non-anaemic (>11.0g/dl) and moderately anaemic (5.0-7.9g/dl) women. Data will be collected throughout the year so as to take into account any seasonal variations in dietary intake. After obtaining adequate sample size data will be analysed. This part of the work will be carried out from with in the funds already being provided to the Advanced Centre. Additional fund requirement Normal birth weight (>2.5 kg) No % No % I <8 6 2823.3+412.4 2 33.3 4 66.7 II 8-11 60 2824.8+409.2 8 13.3 52 86.7 III >11 5 3102.0+230.3 0 0 5 100 Total 71 2844.2+401.8 10 14.1 61 85.9 Mean Birth weight T- test p value I Vs II NS, I Vs III < 0.01, II Vs III < 0.01 Currently all the drugs for the study and the reagents for Hb estimation are met from the ICMR grant. For the second year, in addition to the funding indicated by ICMR for the advanced centre NFI would require about Rs 5 lakhs/year to meet the increase in cost for the drug (due to increase in the amount of IM iron and other drug needed) and follow up. 25
Operationalising the Tenth Plan strategy for reduction in under-nutrition in preschool children (Study began in July 2006) There has been increasing concern that while mortality has come down by 50% and fertility by 40% reduction in under nutrition has been only 20% inspite of the fact that the Integrated Child Development Services (ICDS) has been in operation for nearly three decades. The Tenth Plan envisages a paradigm shift from untargeted food supplementation to screening of all the persons from vulnerable groups, identification of those with various grades of under-nutrition and appropriate management. This strategy indicated in the Tenth Plan is yet to be operationalised in most of the states. The present study is aimed at assessing the current modalities of implementation of the nutrition component of ICDS in selected AW centers in Delhi and assess the feasibility of implementing the strategy proposed and achieving the goals set in the Tenth Plan in these centers. Objectives To document the current modalities of implementation of ongoing Nutrition education, Growth monitoring, Supplementary feeding components of ICDS programme in the 6-72 month age group. coverage of all the children in the age group 0-6 years by weighment and identification of varying grades of under nutrition reasons for relatively low coverage under supplementary feeding and weighment dietary intake of the children those who attended anganwadi and those who did not - intrafamily distribution of food with special reference to adequacy in the critical 6-36 month age group extent to which undernourished children got the additional rations/priority in access to food supplements and health care impact of the supplements provided (both take home and on the spot feeding in the anganwadi) on increasing the dietary intake of the child the impact of these interventions on the nutritional status of the child To assess the feasibility of operationalising the strategy proposed in the Tenth Plan for intensive nutrition education to ensure appropriate infant and young child feeding, health education to improve access to health care, universal screening, identification of undernourished children, appropriate interventions and monitoring the impact of the interventions in terms of improvement in the infant and young child feeding practices, dietary intake of these children, 26