Maternal and Child Anemia-Why, what works, what needs more

work?

Rolf Klemm Johns Hopkins School of Public Health and A2Z

Micronutrient and Child Blindness Project

Pre-Session: Maternal & Child AnemiaCore Group Spring Meeting-April 26, 2010

Anemia Control Interventions– Weakest Links in the Chain of Maternal Nutrition and Health?

Overview

• Anemia “101”

• Public Health Rationale—Old and New Findings

• Interventions: What works? Effective? Safe?

• Interventions: What needs more work?

• Opportunities for Integration

Anemia “101”

The Basics

–Defined as… Hemoglobin (Hb) concentration <2 standard deviations of the age- and sex specific normal reference–Hb binds to oxygen and carries it to tissues–Red blood cells (RBCs) consist mostly of Hb.–Commonly used indicator to screen for iron deficiency in population-based surveys but not specific for iron deficiency

Anemia

Normal RBCs Anemic RBCs

Not all anemia is caused by iron deficiency. But iron deficiency is a major cause of anemia in many developing countries.

Ane

mia Iron deficiency

Iron Deficiency

Anemia

Other vitamin deficiencies

Hookworm

Malaria

HIV/AIDS

Anemia of Inflammatory Conditions

Hemoglobin-opathies

Overlapping causes of Anemia

Malaria Anemia Hookworm

Severe: ≥40%

Moderate: 20-39%

Causes of Anemia – Relative Importance by Region

Iron Deficiency

Malaria Hookworm High Fertility HIV/AIDS

Sub-Saharan Africa

South and South East Asia

North Africa

Americas

Central Asia/Caucasus

Western Pacific (includes China)

Adapted from: Galloway, R. Anemia Prevention and Control: What Works. Washington, DC: USAID, June 2003.

Relative Importance by Region High Medium Low

• Physiologic needs not met by iron absorption in diet• Low dietary bioavailability from monotonous plant-

based diets with little meat

Anemia is NOT all caused by iron deficiency. BUT ~50% of anemia in developing countries is due to iron deficiency

Institute of Medicine, 2001

Increased growth needs exhaust stores accumulated during gestation

Menstrual losses superimposed with needs for rapid growth

Iron requirement increases 3 x’s due to expansion of maternal red-cell mass & growth of fetal-placental unit.Net iron requirement is 1 g (~4 units of blood)

Iron requirement at different life stages

Public Health Rationale for

Controlling Iron Deficiency Anemia?

Old and New Findings

WHO, World Health Report, 2002

Iron Deficiency ranks 9th on the list of risk factors for global disease burden

McLean et al. Public Health Nutr, 2008, 12: 444-454

Anemia is one the most widespread disorders in the world!

~50% pre-school children~42% pregnant~30% non-pregnant

~50% haveIDA

New analysis suggests a continuous risk relationship between Hb and maternal mortality

• Low Hb level is associated with an increased risk of maternal and perinatal mortality 0

500100015002000

2500300035004000

5 7 9 11

Hemoglobin (g/ dL)

mort

ality

Stoltzfus, et al, Comparative Quantification of health risks: Global and regional burden of disease attributable to selected major risk factors:, WHO, 2004

Zeng L, BMJ 2008;337:a2001doi:10.1136/bmj.a2001

Maternal IFAS associated with 0.23 wks longer gestation & 54% ↓ early neonatal mortality

Folic Acid + Iron

Control

Maternal Iron+folic acid ↓ mortality among Nepalese children by 31% between birth & 7 years

Christian et al Am J Epidemiol, 2009, 170: 1127-1136

0 1 y 2 y 3 y 4 y 5 y 6 y 7y 8 y

Developmental risk factors with sufficient evidence to recommend intervention

Walker et al. Lancet 2007; 369: 145-57

Economic Loss Associated Iron Deficiency

Estimated Loss

Physical productivity loss $2.32/per capita

Loss in GDP 0.6%

Dollar value of losses $4.2 billion

Including cognitive losses $16.78/per capita

Loss in GDP 4.0%

Horton S The Economics of Iron Deficiency, Food Policy, 2003, 51-75

Women play critical role in agricultural production, esp. in subsistence agriculture

The World Bank, Gender in Agriculture Sourcebook, 2009

Increases or little change in Anemia Prevalence

0 10 20 30 40 50 60 70 80Anemia Prevalence

LAC

S/SE Asia

N Africa/Middle East

West Africa

East Africa

Haiti 2005-06Haiti 2000

India 2005/2006India 1998-99

Cambodia 2005Cambodia 2000

Jordan 2007Jordan 2002

Egypt 2005Egypt 2000

Senegal 2008-09Senegal 2005

Mali 2006Mali 2001

Ghana 2008Ghana 2003

Uganda 2006Uganda 2000-01

Source: Demographic and Health Survey Compiler Data 2004-2008

Anemia Prevalence among Pregnant Women Over Time By Country

Severe Moderate

Mild

Klemm R, et al. Unpublished

↑ Maternal Mortality

↑Perinatal Mortality

↑ Low birth weight

↑ Neonatal mortality

↑ Post-neonatal, child mortality

↑Negative effects on child cognition and behavior

↓Productivity and economic gains

Summary of Health Risks of Iron Deficiency Anemia

Pregnancy

Childhood

Adults

Interventions to reduce iron

deficiency anemia-What works?

Effectiveness and Safety?

Home fortification?

Central fortification?

Delayed cord clamping?

Dietary modification?

Screen?

Iron Supplements?

Intervention strategies-Iron Deficiency

Intervention strategies-Malaria & Hookworm

Use of insecticide treated nets (ITN)

Intermittent Preventive Treatment (IPT)

Quality Focused Antenatal Care (FANC)

De-worming for hookworm

Increased consumption of iron rich foodsUse of iron cooking pots

Increased iron bioavailability of traditional foods– Germination (50-64% ↓ phytate)– Microbial fermentation (up to 90% ↓ phytate)– Soaking (47-98%↓ phytate)– Adding ascorbic acid containing foods– Use of iron cooking pots

Dietary Modification

Dietary modification--Effective and safe?

• Traditional food processing may increase Fe bioavailability but does not sufficiently increase Fe intake of young children• Dietary diversification, while important for overall dietary quality, is generally unsuccessful at closing the Fe gap for young children• Fe-rich animal source foods are expense and often unavailable• Use of Fe pots has had limited success. Excess Fe content (e.g. fermented beverages) may be a risk.

Summary: It is unlikely that dietary modification strategies alone will be sufficient in most low-income populations

Food Fortification

Addition of Fe to commonly consumed foods, beverages, condiments– Centrally fortified: Fe added at time of processing– Home or “point-of-use”: Fe added to meals just before consumption

Centrally-processed iron-fortified foods

Effective and safe?

• With careful choice of the Fe compound and amount added, fortification can improve Fe status of all at-risk groups

• However, products have not been developed for pregnant women and the higher Fe level needed may cause sensory changes

• It is difficult to meet Fe needs for all children in the target range with a single formulation

• There is no evidence that these foods are not safe, but no studies have focused on safety in malarial areas

• There are few examples of widespread application of the approach in developing countries.

Home fortification:Effective and safe?

Home fortification mixtures with appropriate amounts of absorbable Fe compounds can be formulated to improve or maintain the Fe status of infants, children, pregnant and non-pregnant women

In children, highly effective at reduction Fe deficiency (RR 0.44 [0.22, 0.86]) and anemia (RR 0.54 [0.46, 0.64]) There is no evidence that home fortification is not safe, but no studies have focused on safety in malaria

endemic areas

Innovative Approaches to Iron and micronutrient “supplementation”

CrushableTablet

“Foodlet”

Fat-based ProductsPowders

Iron supplementation

• Delivery of medicinal Fe orally in the form of pills or liquids, usually consumed in the absence of food.

Routine iron supplementation in pregnancy prevents anemia at delivery

Kulier et al, Int J Gyn & Obst 1998, 63: 231-246

Reduces Risk

IncreasesRisk

Consistent results showing reduction of anemia risk

Iron SupplementationSafe and effective?

• Fe supplementation prevents and ameliorates nutritional Fe-deficiency in children and pregnant women• However, providing Fe supplements in liquid or table form may increase the incidence, and possibly the severity, of malaria (and other infections)

among Fe-replete children• In pregnant women, increased placental malaria has been demonstrated with intravenous infusions and is suspected with Fe supplements but has

not been demonstrated with the few studies available.

Delayed chord clamping

• Delay clamping of umbilical cord by 2-3 minutes• Results in greater transfusion of placental blood to the infant• Increases the total body Fe content of the infant at birth (+~75 mg Fe) which helps to

prevent Fe deficiency during the first years of life

Delayed cord clamping—Effective and safe?

• Reduces the risk of anemia (RR=0.53 [0.40, 0.70]) at 2-6 months of age• Increases indices of Fe status (Ferritin concentration and stored Fe)• Guidelines have been developed for implementation and uptake of this strategy in low-resource settings• There are no data on safety in the context of malarial endemic areas

Conclusions:NIH Technical Working Group

• When there is comprehensive surveillance and prompt malaria diagnosis and treatment there is no increased risk

• When health care is insufficient there is an increased risk of malaria with Fe supplementation

Conclusions:NIH Technical Working Group

• At this time, the provision of Fe via tablets of liquids requires caution and may be the least desirable approach in malaria endemic areas• Fortified foods may be the most viable alternative intervention. This includes Fe fortification (central or home) of complementary foods for infants and

young children and of staple foods or condiments of women and older children• Assuming that the Fe from these foods is absorbed more slowly than Fe from supplements, and that this leads to little or no excess NTBI formation or

associated harmful effects, Fe-fortified foods are expected to be safe in such areas.

What needs more work?

Barriers to Effective Implementation-

2008 Innocenti Process

• Inadequate political support• Low priority for IFA within maternal health programs• Inadequate supplies, low utilization, and weak demand• Community-based delivery platforms to complement the ANC platform are missing• Insufficient bundling of interventions to address the multiple causes of anemia

Klemm R et al Micronutrient Programs: What Works and What Needs More Work? A Report of the 2008 Innocenti Process. July 2009, Micronutrient Forum, Washington, DC.

First Visit Re-visit

Current Practice

(minutes)

Desiredbased on

FANC(minutes)

Current Practice

(minutes)

Desiredbased on

FANC(minutes)

Registration 2:10 5:00 1:30 0:00History taking 4:20 10:00 1:20 5:00Examination 3:30 8:00 3:00 8:00Drug Administration 1:00 3:00 1:40 3:00Immunization 1:40 1:00 1:00 1:00Health education & counseling 1:30 15:00 0:00 15:00Total time direct activities 12:20 42:00 6:30 32:00Welcoming the client 1:00 1:00 1:00 1:00Documentation of findings 2:00 3:00 1:30 3:00Total contact time 15:20 46:00 9:00 36:00

Comparison of current performance and anticipated standard of focused ANC model,

Tanzania

Von Both, BMC Pregnancy and Childbirth, 2006, 6:22

Reasons given by women based on exit interviews

1. Obtain an ANC card.

2. When mother is sick/suspects a pregnancy complication

3. When mother is close to delivery time

4. When mother wants to know if her baby is well

5. If referred by TBAs or lower health unit

6. When mother is unsure of pregnancy and wants confirmation

MOST, Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda, 2002

Reasons given for using ANC services, Uganda

Reasons given by women based on exit interviews

1. Long waiting hours

2. Fear of being asked to pay a fee for services

3. Perception that they would not be given drugs/medicines or services

4. Have no wish to deliver in a health unit

5. Fear of being referred to other health centers away from home with no transport or assistance

6. Health workers are rude (“They shout at us especially when we are tired”)

Modified from MOST, Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda, 2002

Reasons given for NOT using ANC services, Uganda

Use of iron and folic acid tablets by ANC attendees, Uganda, n=612

High proportion of women have at least 1 ANC visit

A2Z Survey (2009) of ANC platforms, unpublished data

~40% who had an ANC visit did NOT receive ANY

IFA tablets

AND….<10% consumed ≥30 tablets

Opportunities for Integration

Delivery & Newborn Care

BreastFeeding

ComplementaryFeeding

Delayed CordClamping

↑ iron intakeITN

•Anemia•↑ maternal mortality•↑ LBW•↑ neonatal and child mortality

•Anemia•Altered development and behavior

Birth &Colostrum

Infant and Young ChildFeeding (IYCF)

Pre-conception

↑ iron intakeTreat hookwormIPT, ITN for malaria

•High risk of iron deficiency

Fortification

Pregnancy

↑ iron intakeTreat hookwormIPT, ITN for malaria

•Anemia•Constrained productivity•Less well baby

Focused Antenatal Care (FANC)

Woman-Mother-Newborn-Young ChildContinuum of Care

• Making Pregnancy Safe (MPS)– Focused Antenatal Care (FANC)

• Saving Newborn Lives (SNL)• Infant and young child feeding (IYCF)• Fortification• Presidential Malaria Initiative (PMI)• Neglected Tropical Disease (NTD)• Global Health Initiative (GHI)• Feed the Future

Major global health initiatives relevant to iron and anemia

Maternal Anemia “Brief” for Policy Makers

Additional Resources with Weblinks

Thank You