Review Article

Indian J Med Res 130, November 2009, pp 627-633

Prevalence & consequences of anaemia in pregnancy

K. Kalaivani

Department of Reproductive Biomedicine, National Institute of Health & Family Welfare, New Delhi, India

Received April 24, 2009

Prevalence of anaemia in India is among the highest in the world. Prevalence of anaemia is higher among
pregnant women and preschool children. Even among higher income educated segments of population
about 50 per cent of children, adolescent girls and pregnant women are anaemic. Inadequate dietary iron,
folate intake due to low vegetable consumption, perhaps low B12 intake and poor bioavailability of dietary
iron from the fibre, phytate rich Indian diets are the major factors responsible for high prevalence of
anaemia. Increased requirement of iron during growth and pregnancy and chronic blood loss contribute
to higher prevalence in specific groups. In India, anaemia is directly or indirectly responsible for 40 per
cent of maternal deaths. There is 8 to 10-fold increase in MMR when the Hb falls below 5 g/dl. Early
detection and effective management of anaemia in pregnancy can contribute substantially to reduction
in maternal mortality. Maternal anaemia is associated with poor intrauterine growth and increased
risk of preterm births and low birth weight rates. This in turn results in higher perinatal morbidity and
mortality, and higher infant mortality rate. A doubling of low birth weight rate and 2 to 3 fold increase in
the perinatal mortality rates is seen when the Hb is <8 g/dl. Intrauterine growth retardation and low birth
weight inevitably lead to poor growth trajectory in infancy, childhood and adolescence and contribute to
low adult height. Parental height and maternal weight are determinants of intrauterine growth and birth
weight. Thus maternal anaemia contributes to intergenerational cycle of poor growth in the offspring.
Early detection and effective management of anaemia in pregnancy can lead to substantial reduction in
undernutrition in childhood, adolescence and improvement in adult height.

Key words Anaemia in pregnancy - immune depression - inter-generational impact - low birth weight - morbidity of maternal anaemia

Introduction Prevalence of anaemia in South Asian countries is

among the highest in the world. WHO estimates that
Anaemia is the most common nutritional deficiency
even among the South Asian countries, India has the
disorder in the world. WHO has estimated that
highest prevalence of anaemia. What is even more
prevalence of anaemia in developed and developing
important is the fact that about half of the global
countries in pregnant women is 14 per cent in developed
maternal deaths due to anaemia occur in South Asian
and 51 per cent in developing countries and 65-75 per
countries; India contributes to about 80 per cent of the
cent in India1. About one third of the global population
maternal deaths due to anaemia in South Asia3. It is
(over 2 billion) are anaemic2.
obvious that India’s contribution both to the prevalence
Prevalence of anaemia in all the groups is higher of anaemia in pregnancy and maternal deaths due to
in India as compared to other developing countries1. anaemia is higher than warranted by the size of its
627
628 INDIAN J MED RES, november 2009

Table. Prevalence of anaemia and its contribution to maternal

mortality3
Country Prevalence of Maternal deaths
anaemia in preg- from anaemia
nant women %
Afghanistan - -
Bangladesh 74 2600
Bhutan 68 <100
India 87 22,000
Nepal 63 760
S. Asia Region Total 25,560
World Total 50,000

population (Table)3. Available estimates also suggest

that the magnitude of reduction in the prevalence of
anaemia during nineties in India is lower than that in
neighbouring South East Asian countries.
Worried about the estimated high prevalence
of anaemia in the country, five major surveys
(National Family Health Survey (NFHS) 24 and 35,
District Level Household Survey 26 (DLHS), Indian
Council of Medical Research (ICMR) Micronutrient
Survey7 and Micronutrient Survey conducted by
National Nutrition Monitoring Bureau8 (NNMB)
were undertaken to estimate prevalence of anaemia
in the country. All these showed that over 70 per
cent of preschool children were anaemic. NNMB,
DLHS and ICMR surveys showed that over 70 per
cent of pregnant women and adolescent girls in the
country were anaemic (Fig. 1). Anaemia begins in
childhood, worsens during adolescence in girls and
gets aggravated during pregnancy. NFHS 2 and 3
reported lower prevalence of anaemia in women and
pregnant women as compared to DLHS, NNMB and
ICMR Micronutrient surveys. This appears to be due
to the use of Haemocue method for Hb estimation.
Studies in India have shown that as compared to
classical cyanmethaemoglobin method, Haemocue
overestimates Hb levels9-13. Data from DLHS showed
that prevalence of moderate and severe anaemia
was high even among educated and higher income
groups6 (Fig. 2). Prevalence of anaemia is high in all
the States, though there are considerable variations
between States in prevalence of moderate and severe
anaemia6.
Factors responsible for high prevalence of anaemia
Studies carried out in India and elsewhere have
shown that iron deficiency is the major cause of anaemia
followed by folate deficiency. In recent years, the
contribution of B12 deficiency has been highlighted14.
In India, the prevalence of anaemia is high because of
Fig. 1. Prevalence of anaemia in pregnant women, adolescent girls and
children (0-6 yr)6-8. National Nutrition Monitoring Bureau (NNMB),
Indian Council of Medical Research (ICMR) Micronutrient survey
& District Level Household Survey (DLHS) 2.
Fig. 2. Prevalence of anaemia in different socioeconomic groups6 .
(i) low dietary intake, poor iron (less than 20 mg /day)
and folic acid intake (less than 70 mg/day); (ii) poor bio-
availability of iron (3-4% only) in phytate and fibre-rich
Indian diet; and (iii) chronic blood loss due to infection
such as malaria and hookworm infestations7,8.
Data from NNMB surveys15 showed that iron and
folic acid intake in the country in all the age groups was
very low. There has not been any increase in iron intake
over the last three decades in any group. The apparent
reduction in iron intake in the NNMB surveys 2000-0115
and beyond was due to the finding that only 50 per
cent of the iron in Indian diets is absorbable. Poor iron
stores at birth16, low iron content of breast milk and
low dietary iron intake through infancy and childhood
results in high prevalence of anaemia in childhood6,17.
Anaemia gets aggravated by increased requirements
during adolescence and during pregnancy6. Assuming
that the absorption of iron is 8 per cent in pregnant
women, their average dietary intake will meet only 30-
45 per cent of the requirement. Interstate differences
in iron intake are of small magnitude. The low dietary
 Kalaivani: Prevalence & consequences of anaemia in pregnancy 629
intake of iron, folic acid and food stuffs that promote
iron absorption, coupled with poor bioavailability of
iron are the major factor responsible for very high
prevalence of anaemia in the country18,19.
Anaemia and iron deficiency in the mother are not
associated with significant degree of anaemia in the
children during neonatal period. However, iron stores
in these neonates are low, iron content in breast milk
in anaemic women is low and because of these factors
substantial proportion of infants become anaemic
by six months16. Thus maternal iron deficiency and
anaemia render the offspring vulnerable for developing
iron deficiency and anaemia right from infancy. Poor
iron content of complementary food and family food
consumed by the young child results in further increase
in prevalence of anaemia in childhood17. With the
onset of menstruation and associated blood loss, there
is a further rise in prevalence and severity of anaemia
in adolescent girls6. Early marriage and adolescent
pregnancy aggravate anaemia6 and result in poor iron
stores in the offspring. It is obvious that there is an
intergenerational self perpetuating vicious cycle of
anaemia in Indian population.
Immune status of anaemic pregnant women
In pregnancy, profound changes occur in several
laboratory parameters used for the assessment of
immune status. Studies undertaken by the National
Institute of Nutrition, Hyderabad, showed that
there was a fall in T and B cell count with fall in
haemoglobin levels below 11 g/dl. The fall in T and
B cells was statistically significant in women with
haemoglobin levels below 8 g/dl. Immunoglobin levels
showed a progressive rise with decreasing Hb levels.
There were no alterations in the phytohemagglutinin-
induced lymphocyte transformation nor was there
any difference in the in vivo tests for cell mediated
immunity20. Available data indicated that humoral
immunity as assessed by response to immunogens
including tetanus toxoid remains unimpaired. The
changes in T and B cells and immunoglobulin were
reversed within 6-12 wk by parenteral iron therapy and
improvement in haemoglobin levels, indicating that
these alterations are due to anaemia per se and not due
to co-existent undernutrition18,19.
Investigations carried out in villages near Hyderabad
indicated that the prevalence of morbidity due to
infections was doubled in women with haemoglobin
levels below 8.0 g/dl18. Data from both the developed
and the developing countries have documented the
association between asymptomatic bacteriuria and
anaemia, often refractory to treatment, poor intrauterine
growth, prematurity and low birth weight. It is possible
that immunodepression in anaemic women renders
them more susceptible to infection, and increased
morbidity due to infection, might be one of the factors
responsible for the adverse effect of anaemia on the
course and outcome of pregnancy18,19.
Maternal consequences of anaemia
Mild anaemia
Women with mild anaemia in pregnancy have
decreased work capacity. They may be unable to
earn their livelihood if the work involves manual
labour. Women with chronic mild anaemia may go
through pregnancy and labour without any adverse
consequences, because they are well compensated.
Moderate anaemia
Women with moderate anaemia have substantial
reduction in work capacity and may find it difficult to
cope with household chores and child care. Available
data from India and elsewhere indicate that maternal
morbidity rates are higher in women with Hb below
8gm/dl21. They are more susceptible to infections and
recovery from infections may be prolonged. Premature
births are more common in women with moderate
anaemia. They deliver infants with lower birth weight
and perinatal mortality is higher in these babies21. They
may not be able to bear blood loss prior to or during
labour and may succumb to infections more readily.
Substantial proportion of maternal deaths due to ante-
partum and post-partum haemorrhage, pregnancy
induced hypertension and sepsis occur in women with
moderate anaemia.
Severe anaemia
Three distinct stages of severe anaemia have
been recognized - compensated, decompensated,
and that associated with circulatory failure. Cardiac
decompensation usually occurs when Hb falls below
5.0 g/dl. The cardiac output is raised even at rest, the
stroke volume is larger and the heart rate is increased.
Palpitation and breathlessness even at rest are symptoms
of these changes. These compensatory mechanisms
are inadequate to deal with the decrease in Hb levels.
Oxygen lack results in anaerobic metabolism and lactic
acid accumulation occurs. Eventually circulatory failure
occurs further restricting work output. Untreated, it
leads to pulmonary oedema and death. When Hb
is <5 g/dl and packed cell volume (PCV) below 14,
630 INDIAN J MED RES, november 2009
cardiac failure is seen in a third of cases23. A blood
loss of even 200 ml in the third stage produces shock
and death in these women. Even today women in the
remote rural areas in India reach to the hospital only
at this late decompensated stage. Available data from
India indicate that maternal morbidity rates are higher
in women with Hb below 8.0 g/dl. Maternal mortality
rates show a steep increase when maternal Hb levels
fall below 5.0 g/dl. Anaemia directly causes 20 per
cent of maternal deaths in India and indirectly accounts
for another 20 per cent of maternal deaths24.
Foetal consequences of anaemia
Studies to define the effect of maternal anaemia on
the foetus indicate that different types of decompensation
occur with varying degrees of anaemia. Most of the
studies suggest that a fall in maternal haemoglobin
below 11.0 g/d1 is associated with a significant rise
in perinatal mortality rate18,19,25. There is usually a 2
to 3-fold increase in perinatal mortality rate when
maternal haemoglobin levels fall below 8.0 g/d1 and
8-10 fold increase when maternal haemoglobin levels
fall below 5.0 g/dl21,26. A significant fall in birth weight
due to increase in prematurity rate and intrauterine
growth retardation has been reported when maternal
haemoglobin levels were below 8.0 g/d1 (Fig. 3)21,26.
Factors responsible for the adverse obstetric outcome
Investigations undertaken to determine the factors
responsible for the adverse maternal and perinatal
outcome seen in association with anaemia indicated
that anaemia per se might be responsible for some
of the observed adverse effects18,19,21-24,26. However,
prevalence of several maternal risk factors which are
associated with low birth weight, increased perinatal,
maternal morbidity and mortality, such as twins, PIH
and APH are higher among anaemic women21. It is,
therefore, possible that coexisting obstetric problems
contribute, at least in part, to the adverse obstetric
outcome reported among anaemic women. Anaemic
Fig. 3. Effect of maternal haemoglobin level on birth weight and
perinatal mortality 198225.
women should, therefore, be treated as a high risk
obstetric group.
Immune depression due to anaemia and consequent
increased morbidity due to infection, especially urinary
tract infection, might be one of the factors responsible
for low birth weight babies in anaemic women.
Screening for, and effectively treating infections in
anaemic women might therefore result in improved
foetal and maternal prognosis19.
In the habitual cereal and pulse based diets
consumed by Indian women, there is an almost linear
correlation between calorie and iron intake18. Women
with haemoglobin levels below 8.0 g/dl weigh less
than their non-anaemic counterparts from similar
income groups19,21. These data suggest that anaemia
might be one manifestation of overall maternal
dietary inadequacy and consequent undernutrition19.
It is possible that supplementary feeding programmes
aimed at improvement of maternal dietary intake might
result in some improvement in maternal haemoglobin
status.
Poverty, ignorance, non availability and/or failure
to utilize available medical facilities have been shown
to be associated with maternal anaemia on the one hand
and maternal and perinatal morbidity and mortality on
the other, though the association is not causal. Health
education to improve the utilization of available
facilities and improvement in the health care delivery
system to cater to the needy, right at their doorsteps
might thus go a long way in reducing adverse obstetric
outcome associated with maternal anaemia.
Prevention and management of anaemia in pregnancy
In view of the high prevalence of anaemia in
pregnancy and serious adverse consequences in
both mother and baby, management of anaemia in
pregnancy was accorded a very high priority both
in obstetric and public health practice. Mandatory
monthly screening for anaemia became the ‘routine’
in all antenatal clinics. Skilled management of severe
grades of anaemia detected late in pregnancy, through
blood transfusion and parenteral iron therapy became
the hallmark of good obstetric practice and resulted
in maternal and perinatal salvage rates in hospitals23.
However, it became obvious that unless effective steps
were taken to reduce the prevalence of anaemia, further
reduction in morbidity and mortality rates could not be
achieved.
 Kalaivani: Prevalence & consequences of anaemia in pregnancy 631
Programmes for prevention and management of
anaemia
India was the first developing country to take up
a National Programme to prevent anaemia among
pregnant women and children. The National Anaemia
Prophylaxis Programme of iron and folic acid
distribution to all pregnant women in India through
the primary health care system was evolved and
implemented from 1972, so that the vast majority of
pregnant women who never seek health care, could
benefit from this outreach programme. It was hoped
that this programme will bring about a reduction both
in the prevalence and severity of anaemia in pregnancy.
There were two major components of the anaemia
prophylaxis programme – pre-school children were
to receive 20 mg elemental iron and 100 mg folic acid
and pregnant women to receive 60 mg elemental iron
and 500 μg of folic acid. Of the two components, the
coverage under the component for children had always
been very poor.
Comparatively the component for pregnant
women has fared better. At that time antenatal care
coverage under rural primary health services was very
low and there was no provision for screening pregnant
women for anaemia. Therefore an attempt was made
to identify all pregnant women and give them 100
tablets containing 60 mg of iron and 500 μg of folic
acid. However all the national surveys4-8 indicated that
coverage under all these programmes was very low and
there has not been any change either in the prevalence
of anaemia or the adverse consequences associated
with anaemia.
Two decades after the initiation the National
Anaemia Prophylaxis Programme, an ICMR study
confirmed that most women received 90 tablets
without Hb screening. Many did not take tablets
regularly. Even among small number of women who
took over 90 tablets, rise in Hb was low and mean Hb
levels were no more than 9.1 g/dl (Fig. 4)27. The study
conducted in 1989 by ICMR27 indicated that coverage
under the National Anaemia Pregnancy Programme
was low and that 60 mg of ferrous sulphate was
perhaps inadequate to treat anaemia. The Programme
was revised and renamed as National Anaemia Control
Programme (NACP). The Programme envisaged that
all pregnant women will be screened for anaemia.
Non anaemic women would get iron (100 mg) and
folate (500 µg) and those with anaemia should get
two tablets daily19.
Tenth Plan strategy for combating anaemia in
pregnant women
The Tenth Five Year Plan28 suggested multi-
pronged strategies for the control of anaemia in
pregnancy. These include: (i) fortification of common
food items like salt 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; nutrition education for dietary
diversification to improve the iron and folate intake;
(ii) screening of all pregnant women for anaemia using
a reliable method of haemoglobin estimation; (iii) oral
iron folate prophylactic therapy for all non-anaemic
pregnant women (with haemoglobin more than 11 g/
dl); (iv) iron folate oral medication at the maximum
tolerable dose throughout pregnancy for women
with haemoglobin level between 8 and 11 g/dl; (v)
parenteral iron therapy for women with haemoglobin
level between 5 and 8 g/dl if they do not have any
obstetric or systemic complication; (vi) hospital
admission and intensive personalised care for women
with haemoglobin less than 5 g/dl; (vii) screening
and effective management of obstetric and systemic
problems in all anaemic pregnant women; and (viii)
improvement in health care delivery systems and health
education to the community to promote utilization of
available care.
Problems in implementation of anaemia prevention
and control programmes
The DLHS29 (1998-99) showed that pregnant
women were not being screened for anaemia and given
appropriate therapy. Most women in poorly performing
States did not come for antenatal check up. Many of
those who came for antenatal check up (ANC) did not get
IFA throughout pregnancy nor did they get 100 tablets
(Fig. 5)6,8,27,29. Majority of those who got the tablets did
not consume all the tablets6,29. NNMB surveys8 showed
Fig. 4. IFA supplementation in pregnancy27.
632 INDIAN J MED RES, november 2009
Fig. 5. IFA coverage29. Antenatal care (Househould surveys 1998-99).
that the proportion of pregnant women who receive
IFA tablets is not high even among well-performing
States like Tamil Nadu, Kerala and Maharashtra.
DLHS 2 (2006)6 showed that there was some
improvement in the coverage and content of antenatal
care. About 40 per cent women had blood examination
done which included Hb estimation. DLHS 2 also
showed that there has been some improvement in % of
pregnant women receiving IFA tablets. There has been
a significant reduction in the percentage of women who
received but did not consume the tablets. These data
suggest that if all pregnant women are screened for
anaemia and provided appropriate therapy it might be
possible to achieve substantial reduction in prevalence
of anaemia in pregnancy.
Parenteral therapy for moderate anaemia in
pregnancy
Ample data exist in India to show that supervised
oral administration of up to 240 mg iron has not been
able to raise the Hb levels above 11 g/dl in pregnant
women if their initial Hb levels was between 5.0
and 7.9 g/dl30,31. Therefore, obstetricians have used
intramuscular (IM) iron therapy for correction of
anaemia22,25. Unless this practice is taken up in all the
primary care institutions, majority of women with
moderate anaemia will not be able to access IM therapy.
NIHFW32 and NFI33 undertook operational research
studies and demonstrated that in urban primary health
care institutions it is possible to screen all pregnant
women attending the antenatal OPD for anaemia using
cyanmethaemoglobin method. Women in second
trimester of pregnancy who did not have any systemic
and obstetric problems with Hb levels between 5.0 and
7.9 g/dl and willing to come to receive IM therapy as
outpatients [six injection each containing iron sorbitol
citric acid complex containing 150 mg of elemental
iron, (NIHFW) and each containing iron sorbitol citric
acid complex containing 150 mg of elemental iron,
folic acid 1500 mg and vitamin B12 150 mg (NFI)].
Both these studies demonstrated the feasibility of IM
iron sorbitol therapy to pregnant women in primary
care institutions. Both the studies showed that mean
Hb rose and there was significant improvement in
birth weight32-34. Metallic taste on the tongue, nausea,
vomiting and pain at the injection site were the side
effects reported with IM therapy. These were treated
symptomatically. The subjects were followed up
through pregnancy and till delivery. The mean Hb
level, even 9 wk after completion of IM therapy was
only 9.6 g/dl. But majority of women who received
900 mg of iron sorbitol had Hb levels around 10 g/dl
and birth weight was lower than the birth weight in non
anaemic women33,34. It would appear that 1500 mg of
iron sorbitol citric acid complex would be required for
optimal results.
Summary and conclusions
Anaemia in pregnancy is associated with adverse
consequences both for the mother and the foetus.
Studies have shown that the adverse consequences of
maternal anaemia may affect not only the neonate and
infant but also increase the risk of non communicable
diseases when the child grows into an adult and the risk
of low birth weight in the next generation. Technology
for detection of anaemia and its effective treatment are
available and affordable and it is possible to effectively
implement these even in primary health care settings
and these are very cost effective interventions.
Effective implementation of the Tenth Plan strategies
for combating anaemia can go a long way in reducing
the short- and long- term adverse consequenees of
anaemia.
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