Causes of Anemia among pregnant women In

Jammu and Kashmir

(A case study of District Kupwara)

Submitted to
Ministry of Health and Family welfare
Government of India
New Delhi -10008

Jaweed Ahmad

Population Research Centre

Department of Economics
University of Kashmir Srinagar-190006
March -2019

0
CONENTS Page
Contents 1

Preface 3

1. Background 4
2. World Scenario 4

2.1 Anemia in India 5

2.2 Prevalence of Anemia in Jammu and Kashmir 5
3. Demographic and socio-economic features of Jammu and Kashmir 7
4. Objectives 8
5. Methodology 8
6. Sample Size 8
7. Survey Tools 9
8. Survey duration and discussion with District Health. Functionaries 9
9. Data entry 9

9.1 Study population 9

9.2 Eligibility criteria 9
9.3 Data collection tools and technique 9
10. Data processing and analysis 9
11. Background and details of Pregnant Women 10

11.1 Antenatal Care Registration of Pregnant women 13

11.2 Antenatal Care visits by health functionaries ANM/ASHA 14
12 Knowledge of ANC care & Advices given by ANM/ASHA 15
12.1 Get two doses of Tetanus Taxied 16
12.2 Consumption of IFA tablets 16
12.3 Blood Pressure 16
12.4 Abdominal Examination 17
12.5 Get 3 ANC check-ups by trained personnel 17
13. Advice Received by the Pregnant Women to take Extra nutrition 17

14. Knowledge about causes of Anemia 20

14. 1 Un balanced Diet 21

14.2 Hook Worms 21
14.3 Excessive Menstrual loss 21
14.4 Ulcers and TB 21
14.5 Lack of iron in Food 21
1
14. 6 Inability to absorb iron from food 15.
15. Consumption of Iron Folic Acid by the pregnant women 23
16. Problems by IFA Consumption 25
17. Knowledge about Symptoms of Iron Deficiency Anemia 26

18. Level of anemia among pregnant women 27

18.1 Mild Anemia 27

18.2 Moderate anemia 28
18.3 Severe Anemia 28
19. Discussion 30
20. Conclusion 31
31. Recommendations 32

2
 PREFACE

Nutritional deficiency anemia during pregnancy continues to be a major health problem in

India. To eradicate it certain steps have been taken at individual and community level like
education of the women as regards anemia, its causes and health implication. Imparting
nutritional education, with special emphasis on strategies based on locally available food
stuffs to improve the dietary intake of proteins and iron, administration of appropriate iron
supplements and ensuring maximum compliance and universal antenatal care to pregnant
women will help in combating this serious problem. Long term policies by government, non-
government agencies and the community can be directed to formulate effective plans like
eradicating anemia in children and adolescent girls. Since Independence various nationally
designed Health and Family Welfare Programmes have been implemented in J&K to improve
the health care delivery system. National Health Mission is the latest in the series which was
initiated during 2005-2006. It has proved to be very useful intervention to support the State in
improving health care by addressing the key issues of accessibility, availability, financial
viability and accessibility of services. The Annual work Plan of Jammu and Kashmir, 2018-19
has been approved and PRC is completing the given tasks and targets. While approving the
AWP, Ministry has also decided to know the implementation of various components of State
by Population Research Centre, Srinagar. This Study Causes of Anemia among pregnant
women In Jammu and Kashmir a case study of Kupwara District is one of the AWP
studies which was conducted in Kupwara district.

The study was successfully completed due to the efforts, involvement, cooperation, support
and guidance of a number of officials and individuals at different levels. We wish to express
our thanks to the Ministry of Health and Family Welfare, Government of India for giving us an
opportunity to be part of this exercise of National importance. Our special thanks go to
Director Health Services Kashmir and Deputy Director Health Services (Schemes) Kashmir
for his cooperation and support extended to us from time to time. We are highly thankful to
Chief Medical Officer Kupwara and all BMOs of visited blocks for extending their full
cooperation and sharing with us their experiences for the successful completion of this
exercise. We also appreciate the cooperation rendered to us by the officials of the District
Programme Management Unit of Kupwara District.
We thank Mr. Bashir Ahmad Bhat, Associate Professor of the PRC for his
immense support and guidance during the completion of this study.
We also thank to all our respondents who spent their valuable time and responded with
tremendous patience to our questions. It is hoped that the findings of this study will be helpful
to both the Union Ministry of Health and Family Welfare and the State Government in taking
necessary changes.
3
Jaweed Ahmad Mir
(Research Assistant)

1. Background:
Anemia is considered as a condition in which the number and size of red blood cells, or the
hemoglobin concentration, falls below an established cut-off value, as a result lead to impairment
of the capacity of the blood to transport oxygen around the body .Anemia is observed as an
indicator of both poor nutrition and poor health. It impairs health and well-being in women and
increases the risk of maternal and neonatal adverse outcomes. During pregnancy anemia is
responsible for a lot of complications in women. Even if anemia is a worldwide public health
problem affecting numerous people in all age groups, particularly the burden of the problem is
higher among pregnant women. According to the World Health Organization (WHO), anemia
among women is defined as a hemoglobin concentration of <120 g/L for non-pregnant women
aged 15 years and above, and a hemoglobin concentration of <110 g/L for pregnant women.
Maternal mortality is the prime health indicator in any society. Therefore, this study aimed at
determining prevalence of anemia and assessing associated factors among pregnant women
which might help for intervention and further study. Anemia is a condition characterized by a
reduction in the red blood cell count or in the concentrations of hemoglobin. Anemia is not a
disease; it is a manifestation of various diseases and pathologic conditions. Blood consists of
cellular elements and plasma. The cellular elements include erythrocytes, or red blood cells;
leucocytes, or white blood cells; and platelets. Red blood cells are the most numerous cells in the
blood; approximately 20 billion of them circulate in the blood of an adult. They are required to
trans-port oxygen to the tissues and organs of the body. Red blood cells contain hemoglobin, an
iron-containing protein that acts in the transportation of oxygen to the tissues and carbon dioxide
from the tissues. When the concentrations of hemoglobin or red blood cells in the blood are
reduced to below normal, anemia is developed. WHO defines anemia as a condition in which the
Hemoglobin (Hb) content of blood is lower than normal (11.0 g/dl) as a result of deficiency of
one or more essential nutrients, regardless of the cause of such deficiencies. The anemia levels
for ever-married women age 15–49. Three levels of severity of anemia are distinguished: mild
anemia (10.0–10.9 grams/deciliter for pregnant women and 10.0–11.9 g/dl for non pregnant
women), moderate anemia (7.0–9.9 g/dl), and severe anemia (less than 7.0 g/dl).

2. World Scenario: Anemia affects 1.62 billion people, which corresponds to 24.8% of the
population. The highest prevalence is in preschool-age children (47.4%), and the lowest
prevalence is in men (12.7%). However, the population group with the greatest number of
individuals affected is pregnant women (41.8%). Nine out of ten anemia sufferers live in
developing countries, about 2 billion people suffer from anemia and an even larger number of
people present iron deficiency. Anemia is estimated to contribute to more than 115,000 maternal
deaths and 591,000 prenatal deaths globally per year. South Asia (52% among pregnant and
4
47% among non-pregnant) region had the second highest anemia prevalence in the world only
after Central and West Africa (56% among pregnant and 48% among non-pregnant) region
during 2011. An alarming 600 million people in South-East Asia are suffering from iron
deficiency anemia, predominantly affecting adolescent girls, women of reproductive age and
young children. Moreover, the study show that the anemia prevalence decreased from 33% to
29% among non-pregnant women, and 43% to 33% among pregnant women during 1995-2011.
Though, the decrease in the prevalence of anemia is observed both in pregnant and non-pregnant
women, but the gap between both pregnant and non-pregnant, which is around 10% point during
1995 as well as 2011, is stagnant.

2.1 Anemia in India: Anemia, defined as a reduction in hemoglobin concentration, red-cell

count, or packed-cell volume below established cut- off levels, is a widely discussed public
health challenge that India is facing. In particular, a persistently high level of anemia among
women in India (53% of all women have anemia as per the National Family Health Survey
2015–2016) is of great concern, and the 2017 National Health Policy tabled by the Ministry of
Health and Family Welfare, Government of India, acknowledges this high burden. Iron-
deficiency anemia (IDA) is a common problem among women, primarily due to their recurrent
menstrual loss. Demand for iron is higher among pregnant women, and women with anemia in
combination with early onset of childbearing, a high number of births, short intervals between
births and poor access to antenatal care and supplementation are likely to experience poor
pregnancy outcome. In India, under the Government’s Reproductive and Child Health
Programme, iron and folic acid tablets are provided to pregnant women in order to prevent
anemia during pregnancy. Because anemia is such a serious health problem in India,

Data from the NFHS in India have been widely used to make national and state-level policy
decisions. Estimates from the NFHS indicate that during the period 1998–2016, over 50% of
women aged 15–49 years had IDA. Of all the states and union territories, data for 27 were
available for comparison between 2005–2006 and 2015–2016. There was an average20decrease of
only 3.5 percentage points in IDA among all women in India, varying by states. In addition, 15.5
15
NFHS4 (2015–2016) indicates that the National Iron+ Initiative did not yield the desired
reduction in IDA nationally. This suboptimum reduction in IDA is highly concerning.10However, 10.1
9.0
8.2
during the same period, of the 27 states compared in Fig. 1, IDA in eight states increased: Delhi- 6.6

National Capital Territory, Haryana, Himachal Pradesh, Kerala, Meghalaya Tamil Nadu, Punjab
5
2.5
1.9
1.4
and Uttar Pradesh. This raises an alarming question – how did some states in India such0
as Delhi-
National Capital Territory, Himachal Pradesh, Kerala and Punjab, which rank among the highest 0.7 0.4
 0.4


4.3 3.5
 3.5

on the state Human Development Index (HDI), fail to contain IDA and instead join Uttar5
7.1 6.7
 6.7
 6.3

Pradesh, one of the lower-ranked HDI states? This question demands further investigation.
10 10.3 10.2
 9.3
10.0
 
 0.6 10.5
1 
11.8

2.2 PREVALENCE OF ANEMIA IN JAMMU AND KASHMIR: 15

16.1
Anemia is a major health problem in Jammu & Kashmir, especially among women and children.
20
Forty percent of women in Jammu & Kashmir have anemia, including 29 percent with mild
anemia, 11 percent with moderate anemia, and 1 percent with severe anemia. Anemia25 exceeds
23.5
25.1
35

5 30
percent for every group of women. Anemia among women has declined by 11 percentage points
since NFHS-3. The highest overall rates of anemia are reported in Kupwara with 74.6 followed
by Udhampur 54.5 and district Baramulla has 41.7 percent anemic pregnant women between 15-
49 years age group. In district Leh the lowest pregnant women between 15-49 years age group
have lowest percentage of 16.4 followed by Poonch with 20.9 percent and Doda though hilly
district having difficult topography has a percentage of 23.7 has anemic pregnant women
between 15-49 years age group.
Table 1: Percentage Anemia in Jammu and Kashmir , 2002-2016
District All women Age 15-49 Non Pregnant women Age 15-49 Pregnant women Age 15-49
Kupwara 59.0 57.8 74.6
Udhampur 50.3 50.0 54.5
Srinagar 48.8 49.4 33.9
Shopian 38.8 38.8 38.7
Samba 37.1 37.1 37.9
Reasi 39.6 40.6 26.3
Ramban 33.9 34.3 29.5
Rajouri 33.4 33.0 41.1
Pulwama 48.8 49.1 39.4
Poonch 28.2 28.5 20.9
Leh 33.6 34.3 16.4
Kulgam 42.2 42.6 29.3
Kishtwar 29.3 44.5 40.9
Kathua 38.1 38.1 38.1
Kargil 29.7 29.6 32.2
Jammu 35.6 35.5 37.2
Ganderbal 42.4 42.7 38.2
Doda 20.7 20.5 23.7
Baramula 44.9 45.0 41.7
Bandipora 43.3 43.5 37.2
Badgam 53.6 54.2 38.8
Anantnag 26.8 26.8 27.7
J&K 40.3 40.4 38.1

The highest overall rates of anemia are reported in Kupwara with 74.6 followed by Udhampur
54.5 and district Baramulla has 41.7 percent anemic pregnant women between 15-49 years age
group. In district Leh the lowest pregnant women between 15-49 years age group have lowest
percentage of 16.4 followed by Poonch with 20.9 percent and Doda though hilly district having
difficult topography has a percentage of 23.7 has anemic pregnant women between 15-49 years
age group.

6
3. Demographic and socio-economic features of Jammu and Kashmir
The total population of the country is 1210 million in which Jammu and Kashmir comprises 12
million accounting roughly one percent of the total population of the country. The decadal
growth rate of population is 31 percent substantially higher than the national decadal growth rate
of 21 percent. It is evident that the population grew by 70 percent during 1991-2011, with much
higher rate than in 1981-91. The crude birth rate and crude death rate of the State is lower than
the national average (Table 1). Infant and child mortality rates are good indicators of socio-
economic development and the status of health and population programmes. The infant mortality
rate has come down from 50 in 2001 to 26 in 2017 which is lower than the national average of
34. The total fertility rate of the State is 1.9 which is lower than the national average of 2.4. The
sex ratio, which has alarmingly come down from 933 in census 2001 to 883 in census 2011 is
lower than the national sex ratio (940 females per thousand males). The scheduled caste
population of the State is only 8 percent as against 16 percent in the country. However the
schedule tribes of the State are higher (11 percent) than the national average (8.6 percent). The
literacy rate in the State has improved by more than 14 percent points from 54 percent in 2001 to
68.7 percent in 2011. The literacy rate for the population of seven years and above is 78 percent
for males and 58 percent for females and 69 percent for the total population, although it is lower
than the national average. The detailed figures of major health and demographic indicators are
mentioned in above Table 2

Table 2: Demographic Characteristics of Jammu and Kashmir and India

Indicator J&K India

Total Population (Crores) 12.54 1210.19

Decadal Growth (percent) 31.42 21.54

Crude Birth Rate (SRS 2017) 15.7 20.4

Crude Death Rate (SRS 2017) 5.2 6.9

Natural Growth Rate (SRS 2017) 10.8 14.0

Infant Mortality Rate (SRS 2017) 24 34

Maternal mortality Rate (SRS 2011) NA 254

Total Fertility Rate (SRS 2014) 1.9 2.4

Sex Ratio (Census 2011) 883 940

Child Sex Ratio (Census 2011) 859 914

Schedule Caste Population (percent) (Census 2011) 8.0 16.6

Schedule Tribe Population (percent) (Census 2011) 11.0 8.6

7
 Total Literacy rate (percent) (Census 2011) 68.74 74.04

Male Literacy Rate (percent) (Census 2011) 78.26 82.14

Female Literacy Rate (percent) (Census 2011) 58.01 65.46

4. Objectives:
1. To assess the availability and utilization of IFA services by beneficiaries and its
determinants in the various health facilities.
2. To assess the level of nutritional education and counselling provided by health functionaries
(ASHA, ANM, AWWs) to the pregnant women during ANC visits.
3. To assess the availability and consumption of IFA among pregnant women

5. Methodology
After analyzing the NFHS-4 data of Jammu And Kashmir State the area selected for the study is
Kupwara district because it is the highest district with highest prevalence of anemia among
pregnant women. It was a hospital based cross-sectional observational study conducted in six
Medical blocks in each block one CHC and a PHC was selected in block Kupwara CHC
Kupwara and PHC Drugmulla, in block Zachaldara CHC Zachaldara PHC Bahminpura , in
block Kalaroos CHC Kalaroos and PHC Machil, in block Sogam CHC Sogam and PHC Maidan
Pora in block Langate CHC Langate and PHC Chiitarkot in block Kralpora CHC Kralpora and
PHC Trehgam of Kupwara district were visited from October 2018 to November 2018. A total
of 240 cases were screened and studied. Informed consent was taken from all the pregnant
women who were included in the study. No ethical issues were involved in the study. Thorough
clinical history was taken from all the cases who attended the antenatal outpatient clinic
including gravida, parity, number of abortions, number of live and still births, occupation,
personal history, dietary history, socio-economic status and type of family whether joint or
nuclear type. General examination was done with special emphasis on signs of anemia. The tests
were done on antenatal visit of the patient irrespective of the trimester. Venous blood samples
collected from all 240 cases were sent for routine investigations that included Hemoglobin
estimation.

6. Sample Size
Institutional based cross-sectional study was conducted among pregnant women attending
antenatal ANC this study aimed at understanding the prevalence of anemia among pregnant
women and to some extent the impact of IFA distribution and awareness provided by the health
officials at various levels. The tests were done on antenatal visit of the patient irrespective of the
trimester. Venous blood samples collected from all 240 cases were sent for routine investigations
that included Hemoglobin estimation. Despite the nature of study, we used statistical methods for
determining sample size and sample selection.

8
7. Survey Tools
Structured schedules of inquiry were used for pregnant women. A schedule inquired about the
background of the household, delivery place, birth details, knowledge of women about anemia,
practices about IFA taken and its distribution, knowledge provided by health functionaries at
various levels. The Schedule is designed to seek information regarding their background, which
include details of advices received, their knowledge about anemia and details of home visits by
ASHAs and questions related support for reducing the anemia in the area. Study sought
responses from 240 currently pregnant women and from medical officers present at the day of
our visit.

8. Survey duration and discussion with District Health. Functionaries:

The survey at the selected institutions was conducted during the month of from October 2018 to
November 2018.. The survey team comprised one official for the study from the Centre.

9. Data entry
Data entry of the questionnaires was carried out on SPSS based custom made data entry
applications developed in the Centre. Then the tables were generated and discussed in detail.

9.1 Study population: All pregnant women attending antenatal care (ANC) service at selected
health facilities that fulfill the inclusion criteria during the data collection period was considered
as study participants.
9.2 Eligibility criteria: All pregnant women who came for antenatal care services during the
study period were included in the study. Seriously ill patient due to other medical condition,
unable to respond, mentally ill pregnant women and pregnant women with repeated visits were
excluded during study time.
9.3 Data collection tools and technique
The data was collected using questionnaire, physical examination and laboratory investigation.
The interview and physical examination was conducted at antenatal care (ANC) visiting the
selected facilities. The hemoglobin level was determined using hemoglobin meter. All laboratory
investigations were done by laboratory technician as part of their routine activity.
.
10. Data processing and analysis
Data was entered, cleaned and checked using Epi Info version 3.5.3 and analyzed using SPSS
version 20 statistical software. Categorical variables were summarized as numbers and
percentages, whereas normally distributed continuous was presented as means and standard
deviations by descriptive statistics. To identify factors associated with the outcome variable
(anemia), a bi variate logistic regression analysis was performed for each independent variable
and crude odds ratio (COR) with 95% confidence intervals was obtained. The strength of
statistical association was measured by adjusted odds ratios (AOR) and 95% confidence

9
intervals. Value <0.05 was considered statistically significant. Finally, the result was presented
using tables.

11. Background and details of Pregnant Women:

Background of Pregnant Women Interviewed:
A total of 240 pregnant women attending antenatal care were included in this study. Fortunately,
due to the availability of all respondents during data collection time the response rate was 100%.
Majority, 100(41.7%), of the study participants were found in the age group of up to 25 years.
and above 25-29 years were more than 35 years old. Only 22 percent of the pregnant women
interviewed were 30 years and above old (Table2).

Table-3 Percent Distribution of Sample Respondents by background characteriscts in

Kupwara District of Jammu and Kashmir
Number Percentage
Age of Woman <25 100 41.7%
25-29 85 35.4%
30 and above 55 22.9%
Education No Schooling 72 30.0%
<5 18 7.5%
5-9 35 14.6%
10-12 75 31.3%
13 and above 40 16.7%
Caste of Pregnant woman ST 7 2.9%
OBC 139 57.9%
General 94 39.2%
Monthly Income < 5000 40 16.7%
5000-1000 118 49.2%
10000-20000 65 27.1%
>20000 17 7.1%
Occupation Business 34 14.2%
Agriculture 92 38.3%
Labour/skilled worker 81 33.8%
Salaried 33 13.8%
Age at Marriage <18 16 6.7%
18-21 128 53.3%
22-25 74 30.8%
>25 22 9.2%
Total Family size 1-5 92 38.3%
6-10 118 49.2%
>10 30 12.5%
Total Living Children 0 90 37.5%
1 62 25.8%
2 46 19.2%
3 or more 42 17.5%
10
Looking at educational status of interviewed pregnant women it is notable that 37 percent of
these women were illiterate or had less than 5 years of schooling. Fourteen percent had
completed Middle level of schooling and another 31 percent had completed high school or higher
secondary school level while only 16 percent were having education above graduation or more.
Among the 240 interviewed pregnant women 7(2.9%) were from ST social group followed by
139 (58.0%) from other backward classes and 94 (39.2%) from ‘General’.

Mean monthly reported income of households of pregnant women was Rs 4037 with range of
less than Rs 5000 to Rs 30000Average. It was reported by 16 percent of women that their
monthly house hold income is less than 5000. The monthly income of another 49 percent ranged
between Rs. 5000-10000 and the monthly income of 27percent was more than 10000 to 20000
and only 7 percent women were having above 20000 monthly house hold income.

Large majority of the women had agriculture as a main source of income 14 percent were having
business 33 labour or skilled labour while only lesser number (33)13 percent of women were
having source of income from salaries.
The percentage of pregnant women having age less than 18 years at marriage was on 6 percent
while majority of the women were having age between 18-21 about 53 percent while women in
the age group of 22-25 were 30 percent and above 25 years age at marriage only 9 percent of the
interviewed pregnant women.
The family size also effects to the health of a pregnant women the pregnant women interviewed
were having family size 1-5 were 38 percent ,6-10 were majority about fifty percent and those
whose family size was more than 10 members were only 12 percent.

The majority of the interviewed pregnant women were having first pregnancy of 37 percent those
having one living child were 25 percent while 19 percent were having two children and only 17
percent were having 3 0r more living children.

Table-4 % Distribution of Women by Week of Pregnancy in Kupwara District

Total Duration of Pregnancy

1 2 12 weeks 12-24 weeks 25-36 weeks
Count % Count % Count % Count %
Age of Woman <25 100 100 22 22.0% 31 31.0% 47 47.0%
25-29 85 100 27 31.8% 20 23.5% 38 44.7%
30 and 55 4 7.3% 20 36.4% 31 56.4%
above 100
Education No 72 8 11.1% 24 33.3% 40 55.6%
Schooling 100
<5 18 100 5 27.8% 5 27.8% 8 44.4%
5-9 35 100 10 28.6% 15 42.9% 10 28.6%
10-12 75 100 21 28.0% 16 21.3% 38 50.7%
13 and 40 9 22.5% 11 27.5% 20 50.0%
above 100

11
The pregnancy of the women age less than 25 who came for ANC checkups during the visit were
near about fifty percent who were having pregnancy of 25-36 weeks 31 percent were having 12-
24 weeks and 22percent were having up to 12 weeks pregnancy .
More than 44 of pregnant women 25-29 years age were 44 percent 25-36 weeks while 12-24
weeks pregnancy were having 23 percent and 31 percent were having up to 12 weeks pregnancy.
Looking at educational status of interviewed pregnant women it is notable that 72 of these
women were illiterate those who had less than 5 years of schooling were 18. Thirty five had
completed Middle level of schooling and another 75 had completed high school or higher
secondary school level while only 40 women were having education equalant to graduation or
above.

Table-5 . Distribution of Women by place, Timining of registration and person provided ANC in Kupwara District
Total Registration ANC Month of Person Checked up
Registration
1 2 SC PHC CHC First Second Doctor ANM/
Trimest Trimes Nurse
er ter
Percentage

Percentage

Percentage

Percentage

Percentage

Percentage

Percentage
Percentage
Count

Age of <25 100 100 69.0% 25.0% 6.0% 95.0% 5.0% 54.0% 46.0%
Woman
25-29 85 100 69.4% 18.8% 11.8% 95.3% 4.7% 61.2% 38.8%
30 and 55 100 63.6% 21.8% 14.5% 90.9% 9.1% 61.8% 38.2%
above
Education No 72 100 69.4% 22.2% 8.3% 91.7% 8.3% 63.9% 36.1%
Schooling
<5 18 100 61.1% 27.8% 11.1% 88.9% 11.1% 50.0% 50.0%
9-May 35 100 68.6% 28.6% 2.9% 94.3% 5.7% 34.3% 65.7%
12-Oct 75 100 68.0% 18.7% 13.3% 96.0% 4.0% 64.0% 36.0%
13 and 40 100 67.5% 20.0% 12.5% 97.5% 2.5% 62.5% 37.5%
above
‘Caste of ST 7 100 14.3% 71.4% 14.3% 71.4% 28.6% 28.6% 71.4%
Pregnant
woman’
OBC 139 100 75.5% 18.0% 6.5% 95.0% 5.0% 70.5% 29.5%
General 94 100 60.6% 24.5% 14.9% 94.7% 5.3% 42.6% 57.4%
Monthly < 5000 40 100 60.0% 35.0% 5.0% 90.0% 10.0% 50.0% 50.0%
Income
5000-1000 118 100 75.4% 15.3% 9.3% 94.1% 5.9% 63.6% 36.4%

10000- 65 100 66.2% 24.6% 9.2% 95.4% 4.6% 52.3% 47.7%

20000
>20000 17 100 41.2% 29.4% 29.4% 100.0% 64.7% 35.3%
Occupatio Business 34 100 76.5% 20.6% 2.9% 100.0% 55.9% 44.1%
n

12
 Agricultur 92 100 71.7% 18.5% 9.8% 93.5% 6.5% 68.5% 31.5%
e
Labour/ski 81 100 64.2% 24.7% 11.1% 91.4% 8.6% 53.1% 46.9%
lled
worker
Salaried 33 100 57.6% 27.3% 15.2% 97.0% 3.0% 45.5% 54.5%
Age at <18 16 100 50.0% 43.8% 6.3% 93.8% 6.3% 37.5% 62.5%
Marriage
18-21 128 100 69.5% 21.9% 8.6% 93.8% 6.3% 57.0% 43.0%
22-25 74 100 68.9% 23.0% 8.1% 97.3% 2.7% 62.2% 37.8%
>25 22 100 68.2% 4.5% 27.3% 86.4% 13.6% 68.2% 31.8%
Total 5-Jan 92 100 66.3% 21.7% 12.0% 94.6% 5.4% 55.4% 44.6%
Family
size
10-Jun 118 100 66.1% 25.4% 8.5% 92.4% 7.6% 58.5% 41.5%
>10 30 100 80.0% 10.0% 10.0% 100.0% 66.7% 33.3%
Total 0 90 100 71.1% 21.1% 7.8% 96.7% 3.3% 57.8% 42.2%
Living
Children
1 62 100 69.4% 22.6% 8.1% 96.8% 3.2% 56.5% 43.5%
2 46 100 63.0% 23.9% 13.0% 91.3% 8.7% 58.7% 41.3%
3 or more 42 100 64.3% 21.4% 14.3% 88.1% 11.9% 61.9% 38.1%
Total 240 100 67.9% 22.1% 10.0% 94.2% 5.8% 58.3. 41.7%

11.1Antenatal Care Registration of Pregnant women:

It was inquired from pregnant women about the ANC registration majority 94 percent of the
(226) pregnant women were registered in first trimester only 6 percent (14) were registered in
second or third trimester. Of these (168) pregnant women 67 percent have been registered at sub
center while at PHC 22 percent and at CHC institutions only 10 percent have been registered for
ANC. All women were given MCP cards while analyzing the first ANC checkups it was revealed
by the interviewed pregnant women more than 58 percent were examined by the doctor at
various health facilities while 42 percent were examined at first visit by the ANM/ Nurse at sub
center level of at PHCs were the doctor are not available.

Table-6 % Distribution of Women by place, Timing of registration and ANC Service

Provider in Kupwara District
13
 Visit by Health
Total No. of ANC Visits worker’ Visit by ASHA
1 2 1-3 4-10 11+ Yes Never 1-5

Percentage

Percentage

Percentage

Percentage

Percentage

Percentage

Percentage
<25 Count
100 100 37.0% 58.0% 5.0% 74.0% 37.0% 63.0%

25-29 85 100 43.5% 50.6% 5.9% 60.0% 45.9% 54.1%

30 and above 55 100 38.2% 56.4% 5.5% 70.9% 36.4% 63.6%

No Schooling 72 100 33.3% 61.1% 5.6% 61.1% 47.2% 52.8%

<5 18 100 38.9% 55.6% 5.6% 66.7% 38.9% 61.1%

5-9 35 100 45.7% 54.3% 77.1% 31.4% 68.6%

10-12 75 100 44.0% 49.3% 6.7% 73.3% 37.3% 62.7%

13 and above 40 100 37.5% 55.0% 7.5% 65.0% 40.0% 60.0%

11.2 Antenatal Care visits by health functionaries ANM/ASHA.

It was inquired from pregnant women about the ANC visits performed by the women at various
health facilities majority 40 percent of the (95) pregnant women have visited (1-3) times only
55 percent (132) were have visited four to ten times during their pregnancy. Of these only(13)
pregnant women 5 percent have visited more than eleven times out of 240 pregnant women 164
women were visited by health worker while as only 144 have been visited by the concern
ASHAs between (1-5) times during their pregnancy .those who are having education graduation
or above have been visited by ASHAs up to 60 percent this means that the women who are
highly educated are more visited than illiterate though the number of illiterate pregnant women is
nearly double (74) and have been visited ( 52 %) by ASHAs.

12. Knowledge of ANC care & Advices given by ANM/ASHA:

Doctors ANM/ ASHAs are supposed to provide some counseling and advice to pregnant women
during postnatal period. All the seven items were dichotomized by recoding correct responses to
unity and remaining to zero. These seven were summated to generate the services provided to
pregnant women. Distribution of pregnant women as per scores is presented in table: 7

Table-7 % Distribution of Women by information provided about various ANC components in Kupwara District
Total Get 2 Consume Blood Abdominal Get 3 ANC Any
doses of 100 IFA Pressure Examinati check-ups Other
TT tablets on by trained
injections personnel
14
 1 2 Yes Yes Yes Yes Yes Yes

Number

Percentage

Percentage

Percentage
Percentage

Percentage

Percentage

Percentage
Age of <25 100 100.0% 86.00% 75.00% 4.00% 100.0% 24.00% 1.00%
Woman
25-29 85 100.0% 83.50% 71.80% 4.70% 100.0% 14.10% 1.20%

30 and above 55 100.0% 83.60% 70.90% 1.80% 100.0% 20.00%

Education No Schooling 72 100.0% 84.70% 66.70% 5.60% 100.0% 8.30%

<5 18 100.0% 88.90% 77.80% 16.70% 100.0% 27.80%

9-May 35 100.0% 91.40% 82.90% 100.0% 28.60%

12-Oct 75 100.0% 85.30% 76.00% 2.70% 100.0% 21.30% 1.30%

13 and above 40 100.0% 75.00% 67.50% 100.0% 25.00% 2.50%

‘Caste of ST 7 100.0% 85.70% 71.40% 100.0% 28.60%

Pregnant
woman’ OBC 139 100.0% 82.70% 68.30% 2.20% 100.0% 15.10%

General 94 100.0% 87.20% 79.80% 6.40% 100.0% 25.50% 2.10%

Monthly < 5000 40 100.0% 92.50% 82.50% 10.00% 100.0% 32.50%

Income
5000-1000 118 100.0% 83.10% 72.00% 1.70% 100.0% 15.30% 0.80%

10000-20000 65 100.0% 84.60% 72.30% 4.60% 100.0% 15.40%

>20000 17 100.0% 76.50% 58.80% 100.0% 35.30% 5.90%

Occupatio Business 34 100.0% 85.30% 79.40% 5.90% 100.0% 14.70%

n
Agriculture 92 100.0% 81.50% 65.20% 3.30% 100.0% 14.10%

Labour/skilled 81 100.0% 88.90% 81.50% 3.70% 100.0% 24.70% 1.20%

worker
Salaried 33 100.0% 81.80% 66.70% 3.00% 100.0% 27.30% 3.00%

Age at <18 16 100.0% 100.00% 93.80% 6.30% 100.0% 43.80%

Marriage
18-21 128 100.0% 83.60% 68.00% 3.90% 100.0% 17.20% 1.60%

22-25 74 100.0% 87.80% 81.10% 2.70% 100.0% 14.90%

>25 22 100.0% 68.20% 59.10% 4.50% 100.0% 31.80%

Total 1-5 92 100.0% 88.00% 78.30% 6.50% 100.0% 22.80%

Family
size 6-10 118 100.0% 82.20% 71.20% 1.70% 100.0% 21.20% 1.70%

>10 30 100.0% 83.30% 63.30% 3.30% 100.0% 3.30%

Total 0 90 100.0% 84.40% 75.60% 4.40% 100.0% 24.40%

Living
Children 1 62 100.0% 85.50% 72.60% 3.20% 100.0% 22.60% 1.60%

15
 2 46 100.0% 84.80% 80.40% 2.20% 100.0% 19.60%

3 or more 42 100.0% 83.30% 59.50% 4.80% 100.0% 4.80% 2.40%

Total 240 100.0% 84.60% 72.90% 3.80% 100.0% 19.60% 0.80%

12.1 Get two doses of tetanus toxide: In district Kupwara 86 percent pregnant women were
advised to two doses of Tetnus toxide in the age group of less than 25 years. While in the age
group of (25-29) 83 percent were have been given advise to take two doses of TT injection and
in the age group 30 years and above same percentage was a wear of taking the TT injection
during the pregnancy.

12.2 Consumption of IFA tablets: when asked about the knowledge received about the IFA
consumption near about 75 percent pregnant women were advised to take IFA tablets in the age
group of less than 25 years. While in the age group of (25-29) 71 percent were have been given
advice to take IFA tablets and in the age group 30 years and above 70 percentage was aware of
taking the IFA tablets during the pregnancy. It is note worthy that the illiterate pregnant women
have been give more knowledge than the pregnant women who are graduate or above in the
education less than 9 percent.

12.3 Blood Pressure: In district Kupwara the blood pressure indicator is a neglected indicator
because only 9 percent pregnant women in all age groups were advised or have received
knowledge about blood pressure. The numbers of pregnant women who have received advice or
have knowledge are more from illiterate group than who have higher education.non from this
group have received or have any knowledge of blood pressure during pregnancy.

12.4 Abdominal Examination: All pregnant women who have visited for ANC checkups have
been advised to go for abdominal examination so all women in all age groups have received this
advice.

12.5 Get 3 ANC check-ups by trained personnel: as it is mandatory that any pregnant women
should get at least 3 ANC checkups but no attention has been given to this indicator so that the
pregnant mwomen can get at least 3 ANC checkups. The respondents in the age group0f less than
25 years near about 24 percent pregnant women were advised to go at least for 3ANC checkups
in the age group of less than 25 years. While in the age group of (25-29) only 14.1 percent were
have been given advice to go for 3ANC checkups and in the age group 30 years and above 20
percentage were aware of to go at least for 3ANC checkups during 9 months of pregnancy.

13. Advice Received by the Pregnant Women to take Extra nutrition: The consumption of a
wide variety of nutritious foods is important for women’s health. Adequate amounts of protein,
fat, carbohydrates, vitamins, and minerals are required for a well-balanced diet. Meat, fish, eggs,
and milk, as well as pulses and nuts, are rich in protein. Green, leafy vegetables are a rich source
16
of iron, folic acid, vitamin C, carotene, riboflavin, and calcium. Many fruits are also good
sources of vitamin C. Bananas are rich in carbohydrates. Papayas, mangoes, and other yellow
fruits contain carotene, which is converted to vitamin A. Vitamin A is also present in milk and
milk products, as well as egg yolks. NFHS-4 asked ever-married women how often they
consume various types of food (daily, weekly, occasionally, or never). Women consume
vegetables (other than green, leafy vegetables) most often .Almost two-thirds of women consume
these vegetables every day and 93 percent of women eat these vegetables at least once a week.
Pulses and beans, as well as green, leafy vegetables, are also an important part of the diet

It was asked to the respondents that during ANC visits have they received any advice regarding
taking extra calories most of them recalled that they were asked about to take the complete meals
in a day. A large proportion (50%) of women in the age group of less than 25years age(41%) in
the age group of 25-30 years while (47 %) were advised whos age was more than 30 years.
While we analyse the data according to the education level of the respondents only 40 percent
those who were illiterate were advised to take extra calories to reduce the anemia while 74
p2rcent were in the education level of 5-9 classes. Rest all groups were between 40 to 50 percent
as per the education level.

The respondents received these advices from various health officials in which 62 percent
received advice from doctor in the age group of less than 25 while 60 percent in the age group of
25-29 years and above 30 years this group were asked to take extra calories. Nearly 24 percent in
all age groups received advice from ANM while ASHA has advised to a total of 12 of the women
during their interaction with them. but a large majority has been educated by the relatives about
to take the extra calories about 46 percent of the total pregnant women . While 6 percent have
received advice from other sources. About 98 percent of interviewed pregnant women were have
heard about anemia a very low percentage was not aware as the topography of the district is hilly
and the staff at all facilities is not available. But this percentage is of educated women who have
passed secondary school education or higher secondary school education. And those who have
large family size as 1 to have shown the ignorance about the knowledge of anemia by (3.3 %)
And those who have more than three children are about (7.1%) who were not aware about te
anemia. But this raises the question that those who have delivered more children have not been
told enough about the anemia.(Table 8 , 9 and 10.)

Table-8 % Distribution of Women told to take supplementary food during pregnancy in Kupwara District

Total ‘Received advice to take extra collieries’

1 2 Yes No

Count % Count % Count %

Age of Woman <25 100 100.0% 50 50.0% 50 50.0%
25-29 85 100.0% 35 41.2% 50 58.8%
30 and above 55 100.0% 26 47.3% 29 52.7%
Education No Schooling 72 100.0% 29 40.3% 43 59.7%

17
 <5 18 100.0% 9 50.0% 9 50.0%
5-9 35 100.0% 26 74.3% 9 25.7%
10-12 75 100.0% 31 41.3% 44 58.7%
13 and above 40 100.0% 16 40.0% 24 60.0%
‘Caste of Pregnant ST 7 100.0% 5 71.4% 2 28.6%
woman’ OBC 139 100.0% 42 30.2% 97 69.8%
General 94 100.0% 64 68.1% 30 31.9%
Monthly Income < 5000 40 100.0% 29 72.5% 11 27.5%
5000-1000 118 100.0% 47 39.8% 71 60.2%
10000-20000 65 100.0% 28 43.1% 37 56.9%
>20000 17 100.0% 7 41.2% 10 58.8%
Occupation Business 34 100.0% 12 35.3% 22 64.7%
Agriculture 92 100.0% 35 38.0% 57 62.0%
Labour/skilled 81 100.0% 47 58.0% 34 42.0%
worker
Salaried 33 100.0% 17 51.5% 16 48.5%
Age at Marriage <18 16 100.0% 14 87.5% 2 12.5%
18-21 128 100.0% 55 43.0% 73 57.0%
22-25 74 100.0% 34 45.9% 40 54.1%
>25 22 100.0% 8 36.4% 14 63.6%
Total Family size 1-5 92 100.0% 45 48.9% 47 51.1%
6-10 118 100.0% 56 47.5% 62 52.5%
>10 30 100.0% 10 33.3% 20 66.7%
Total Living 0 90 100.0% 45 50.0% 45 50.0%
Children 1 62 100.0% 32 51.6% 30 48.4%
2 46 100.0% 16 34.8% 30 65.2%
3 or more 42 100.0% 18 42.9% 24 57.1%
Total 240 100.0% 111 46.3% 129 53.8%

Table-9 % Distribution of Women by person who advised them to take supplementary nutrition during pregnancy in
Kupwara District
‘Other
Total Doctor ANM ASHA
specify’
1 2 Yes Yes Yes Yes
Count % % % % %
Age of Woman <25 50 100.0% 62.0% 56.0% 16.0% 6.0%
25-29 35 100.0% 60.0% 51.4% 28.6% 20.0%
30 and above 26 100.0% 53.8% 46.2% 38.5% 23.1%
Education No Schooling 29 100.0% 75.9% 34.5% 20.7% 6.9%
<5 9 100.0% 44.4% 55.6% 33.3% 11.1%
5-9 26 100.0% 46.2% 80.8% 19.2% 19.2%
10-12 31 100.0% 58.1% 35.5% 25.8% 16.1%
13 and above 16 100.0% 62.5% 68.8% 37.5% 18.8%
‘Caste of Pregnant ST 5 100.0% 40.0% 100.0%
woman’ OBC 42 100.0% 81.0% 11.9% 16.7% 4.8%
General 64 100.0% 46.9% 75.0% 32.8% 21.9%
Monthly Income < 5000 29 100.0% 48.3% 62.1% 31.0% 13.8%
5-10 Th 47 100.0% 76.6% 38.3% 12.8% 8.5%
18
 10-20 TH 28 100.0% 46.4% 67.9% 35.7% 21.4%
>20000 7 100.0% 42.9% 42.9% 42.9% 28.6%
Occupation Business 12 100.0% 33.3% 66.7% 50.0% 41.7%
Agriculture 35 100.0% 80.0% 34.3% 17.1% 2.9%
Labour/ Skilled labour 47 100.0% 57.4% 59.6% 19.1% 12.8%
Salaried 17 100.0% 41.2% 58.8% 41.2% 23.5%
Age at Marriage <18 14 100.0% 71.4% 57.1% 14.3% 7.1%
18-21 55 100.0% 58.2% 47.3% 20.0% 10.9%
22-25 34 100.0% 50.0% 58.8% 35.3% 23.5%
>25 8 100.0% 87.5% 50.0% 37.5% 12.5%
Total Family size 1-5 45 100.0% 62.2% 44.4% 31.1% 20.0%
6-10 56 100.0% 58.9% 60.7% 21.4% 12.5%
>10 10 100.0% 50.0% 40.0% 20.0%
Total Living 0 45 100.0% 62.2% 51.1% 17.8% 8.9%
Children 1 32 100.0% 56.3% 62.5% 31.3% 25.0%
2 16 100.0% 50.0% 43.8% 62.5% 18.8%
3 or more 18 100.0% 66.7% 44.4% 5.6%
Total 111 100.0% 59.5% 52.3% 25.2% 14.4%

Table-10 % Distribution of Women who have heard about anemia in Kupwara District

Total ‘Heard about Anemia’

1 2 Yes No
Count % Count % Count %
Age of <25 100 100 99 99.0% 1 1.0%
Woman 25-29 85 83 97.6% 2 2.4%
100
30 and above 55 100 54 98.2% 1 1.8%
Education No Schooling 72 100 70 97.2% 2 2.8%
<5 18 100 17 94.4% 1 5.6%
5-9 35 100 35 100.0%
10-12 75 100 74 98.7% 1 1.3%
13 and above 40 100 40 100.0%
‘Caste of ST 7 100 7 100.0%
Pregnant OBC 139 136 97.8% 3 2.2%
100
woman’ General 94 93 98.9% 1 1.1%
100
Monthly < 5000 40 100 39 97.5% 1 2.5%
Income 5000-1000 118 116 98.3% 2 1.7%
100
10000-20000 65 100 64 98.5% 1 1.5%
>20000 17 100 17 100.0%
Occupation Business 34 100 33 97.1% 1 2.9%
Agriculture 92 100 90 97.8% 2 2.2%
Labour/skilled worker 81 100 80 98.8% 1 1.2%
Salaried 33 100 33 100.0%
Age at <18 16 100 16 100.0%
Marriage 18-21 128 125 97.7% 3 2.3%
100
22-25 74 100 73 98.6% 1 1.4%
>25 22 100 22 100.0%
Total 1-5 92 100 89 96.7% 3 3.3%

19
 Family size 6-10 118 100 117 99.2% 1 .8%
>10 30 100 30 100.0%
Total Living 0 90 100 89 98.9% 1 1.1%
Children 1 62 62 100.0%
100
2 46 100 46 100.0%
3 or more 42 100 39 92.9% 3 7.1%
31 Total 240 100 236 98.3% 4 1.7%

14. Knowledge about causes of Anemia:

Commonly, anemia is the final outcome of nutritional deficiency of iron, folate, vitamin B 12, and some
other nutrients (Lee and Herbert, 1999). Many other causes of anemia have also been identified. They
include malaria, hemorrhage, infection, parasite infestation (hookworm), chronic disease, and others. A
vegetarian diet is also linked with iron-deficiency anemia. Even though a vegetarian diet contains as
much dietary iron as a non-vegetarian diet, research has shown that animal-based iron is better
absorbed (15-40%) than plant-based iron (1-15%). To make up for the low absorption, large
quantities of green leafy vegetables, pulses and nuts need to be consumed. But these are unaffordable
for the poor.

14.1 Un balanced Diet: NFHS-4 asked ever-married women how often they consume various
types of food (daily, weekly, occasionally, or never). Women consume vegetables (other than
green, leafy vegetables) most often. Fruits are eaten daily by a lesser percent of women and only
one-third of women eat fruits at least once a week.

It was asked to the respondents what are the causes of anemia most of them replied that the un
balanced diet is responsible for the cause of anemia. A large proportion (98%) of women in the
age group of less than 25years age(97.6%) in the age group of 25-30 years while (92.7 %) were
saying that un balanced diet is responsible for anemia whose age was more than 30 years. While
we analyze the data according to the education level of the respondents only 69 percent those
who were illiterate were considering unbalanced diet as main cause of the anemia about we have
heard while 98 percent were in all education level were of the same opinion.

14.2 Hook Worms: In many areas of Kashmir however, a number of other factors besides iron
deficiency contribute to the burden of anemia. Of particular importance in many areas are
intestinal parasites, especially hookworm infestation. The level of contribution of these factors to
the overall prevalence of anemia depends on the magnitude of malaria epidemics, the existence
of iron supplementation and fortification programs, and other conditions in each particular area.
Only 21 respondents were aware that hook worms also add to the cause of the anemia in
pregnancy.

14.3 Excessive Menstrual loss: Anemia may be caused by excessive bleeding. Bleeding may be
sudden, as may occur as a result of an injury or during surgery. Often, bleeding is gradual and
repetitive (chronic bleeding), typically due to abnormalities in the digestive or urinary tract
or heavy menstrual periods. Chronic bleeding typically leads to low levels of iron, which leads to

20
worsening anemia. With the onset of menstruation and associated blood loss, there is a further
rise in prevalence and severity of anemia in pregnant women .A large number of (86 %)
respondents were have heard that excessive menstrual loss is a one of the measure cause
responsible for anemia in pregnancy.

14.4 Ulcers and TB: Only about one percent pregnant women have heard that ulcer and TB as
cause of anemia in pregnancy.

14.5 Lack of iron in Food: In light of the minimum daily requirement, it is not surprising that a
deficiency will occur within months if dietary intake or intestinal absorption is curtailed. There
are certain critical periods when iron requirements are significantly increased and the iron
balance can be easily disturbed. Such situations include pregnancy. Only 10 percent of the
respondents have heard about the lack of iron in food as a cause of anemia in all age groups
while in salaried class 24 percent have heard this as cause of anemia.

14.6 Inability to absorb iron from food: The amount of Iron absorbed by the body depends not
only on the amount consumed through the diet, but also how much of that can be absorbed and
assimilated within the body. Iron present in plant-based foods (non-haem iron) has lower
absorbability than that present in animal foods such as red and organ meats (haem iron). Patients
with folic acid deficiency are often malnourished and are likely to appear wasted. Diarrhea is
often present, as well as visible defects of the tongue and mucosal surfaces of the mouth. A very
little percentage only 2 percent have heard that poor absorption is also a cause of the anemia in
pregnancy (Table 11).

Table-11 % Distribution of Women who have heard about causes of anaemia in Kupwara District

Un Excessive Lack Inability to

balanced Hook menstural Ulcers of iron absorb iron
Total die worms loss TB in food from food
1 2 Yes Yes Yes Yes Yes Yes

Count % % % % % % %
Age of <25 100 100 98.0% 15.0% 85.0% 1.0% 10.0%
Woman 25-29 85 100 97.6% 5.9% 90.6% 14.1% 1.2%
30 and above 55 92.7% 1.8% 81.8% 12.7% 5.5%
100
Education No Schooling 72 95.8% 9.7% 87.5% 6.9% 2.8%
100
<5 18 100 100.0% 16.7% 88.9% 33.3%
5-9 35 100 100.0% 14.3% 80.0% 2.9% 20.0%
10-12 75 100 96.0% 5.3% 85.3% 8.0% 2.7%
13 and above 40 95.0% 5.0% 90.0% 12.5%
100
‘Caste of ST 7 100 100.0% 42.9% 71.4% 42.9%
Pregnant OBC 139 100 95.7% 2.2% 84.9% 5.0% 2.9%
woman’ General 94 97.9% 16.0% 89.4% 1.1% 20.2%
100
Monthly < 5000 40 100 100.0% 22.5% 90.0% 12.5% 2.5%

21
 Income 5000-1000 118 96.6% 5.9% 84.7% .8% 9.3% 1.7%
100
10000-20000 65 93.8% 7.7% 86.2% 15.4% 1.5%
100
>20000 17 100 100.0% 88.2% 17.6%
Occupation Business 34 100 91.2% 91.2% 11.8%
Agriculture 92 97.8% 8.7% 82.6% 5.4% 3.3%
100
Labour/skilled 81 96.3% 13.6% 90.1% 1.2% 14.8% 1.2%
worker
100
Salaried 33 100 100.0% 6.1% 81.8% 24.2%
Age at <18 16 100 93.8% 12.5% 87.5% 6.3% 12.5%
Marriage 18-21 128 100 97.7% 7.0% 84.4% 15.6% 1.6%
22-25 74 100 97.3% 10.8% 89.2% 8.1% 1.4%
>25 22 100 90.9% 9.1% 86.4% 4.5% 4.5%
Total 1-5 92 100 95.7% 5.4% 87.0% 1.1% 16.3% 1.1%
Family size 6-10 118 100 98.3% 11.9% 86.4% 8.5% 2.5%
>10 30 100 93.3% 6.7% 83.3% 13.3%
Total Living 0 90 100 96.7% 11.1% 85.6% 3.3% 1.1%
Children 1 62 100 98.4% 14.5% 88.7% 1.6% 16.1%
2 46 100 97.8% 89.1% 23.9%
3 or more 42 100 92.9% 4.8% 81.0% 11.9% 7.1%
Total 240 100 96.7% 8.8% 86.3% .4% 12.1% 1.7%

15. Consumption of Iron Folic Acid by the pregnant women:

India was the first developing country to take up a National Programme to prevent anemia among
pregnant women and children. The National Anemia 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 anemia in pregnancy. There were two major components of the anemia
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 anemia. 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 surveys 4-8 indicated that coverage under all these
programmes was very low and there has not been any change either in the prevalence of anemia or the
adverse consequences associated with anemia. Two decades after the initiation the National Anemia
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
22
tablets, rise in Hb was low and mean Hb levels were no more than 9.1 g/dl . The study conducted in 1989
by ICMR27 indicated that coverage under the National Anemia Pregnancy Programme was low and that 60
mg of ferrous sulphate was perhaps inadequate to treat anemia. The Programme was revised and renamed
as National Anemia Control Programme (NACP). The Programme envisaged that all pregnant women
will be screened for anemia. Non anemic women would get iron (100 mg) and floated (500 μg) and those
with anemia should get two tablets daily. The IFA received by the pregnant women in district
Kupwara has been discussed (Table 12).

Table-12 % Distribution of Women by No. of IFA Tablets Received and Consumed by

Pregnant women in Kupwara District

Total IFA Tablets received Consumption

1 2 None >30 30-60 60+ None >30 30-60 60+

Cou Coun
nt % t % % % % % % % %
Age of <25 100 100.0% 43 43.0% 28.0% 13.0% 16.0% 1.8% 64.9% 17.5% 15.8%
Woma 25-29 85 100.0% 53 62.4% 16.5% 15.3% 5.9% 65.6% 28.1% 6.3%
n 30 and 55 100.0% 26 47.3% 20.0% 25.5% 7.3% 55.2% 34.5% 10.3%
above
Educat No 72 100.0% 41 56.9% 25.0% 6.9% 11.1% 74.2% 9.7% 16.1%
ion Schooling
<5 18 100.0% 7 38.9% 27.8% 27.8% 5.6% 72.7% 18.2% 9.1%
5-9 35 100.0% 16 45.7% 28.6% 11.4% 14.3 5.3% 52.6% 15.8% 26.3%
%
10-12 75 100.0% 39 52.0% 20.0% 18.7% 9.3% 63.9% 33.3% 2.8%
13 and 40 100.0% 19 47.5% 12.5% 30.0% 10.0 47.6% 42.9% 9.5%
above %
‘Caste ST 7 100.0% 3 42.9% 28.6% 28.6 50.0% 50.0%
of %
Pregna OBC 139 100.0% 75 54.0% 21.6% 15.1% 9.4% 70.3% 21.9% 7.8%
nt General 94 100.0% 44 46.8% 22.3% 20.2% 10.6 2.0% 54.0% 30.0% 14.0%
woma %
n’
Month < 5000 40 100.0% 15 37.5% 27.5% 17.5% 17.5 4.0% 56.0% 16.0% 24.0%
ly %
Incom 5000-1000 118 100.0% 61 51.7% 26.3% 12.7% 9.3% 68.4% 21.1% 10.5%
e
10000- 65 100.0% 36 55.4% 16.9% 20.0% 7.7% 65.5% 27.6% 6.9%
20000
>20000 17 100.0% 10 58.8% 29.4% 11.8 28.6% 71.4%
%
Occup Business 34 100.0% 20 58.8% 14.7% 20.6% 5.9% 57.1% 42.9%
ation Agriculture 92 100.0% 45 48.9% 28.3% 15.2% 7.6% 2.1% 66.0% 23.4% 8.5%

Labour/skil 81 100.0% 41 50.6% 19.8% 12.3% 17.3 67.5% 10.0% 22.5%

led worker %

Salaried 33 100.0% 16 48.5% 18.2% 27.3% 6.1% 47.1% 47.1% 5.9%

23
 Age at <18 16 100.0% 4 25.0% 31.3% 12.5% 31.3 58.3% 16.7% 25.0%
Marria %
ge 18-21 128 100.0% 71 55.5% 20.3% 14.8% 9.4% 1.8% 61.4% 26.3% 10.5%

22-25 74 100.0% 35 47.3% 25.7% 18.9% 8.1% 66.7% 23.1% 10.3%

>25 22 100.0% 12 54.5% 13.6% 22.7% 9.1% 60.0% 30.0% 10.0%
Total 1-5 92 100.0% 47 51.1% 13.0% 25.0% 10.9 55.6% 35.6% 8.9%
Family %
size 6-10 118 100.0% 58 49.2% 28.8% 10.2% 11.9 1.7% 70.0% 13.3% 15.0%
%
>10 30 100.0% 17 56.7% 23.3% 16.7% 3.3% 53.8% 38.5% 7.7%
Total 0 90 100.0% 33 36.7% 27.8% 20.0% 15.6 1.8% 61.4% 24.6% 12.3%
Living %
Childr
1 62 100.0% 35 56.5% 19.4% 16.1% 8.1% 66.7% 22.2% 11.1%
en
2 46 100.0% 31 67.4% 17.4% 15.2% 73.3% 26.7%
3 or more 42 100.0% 23 54.8% 19.0% 11.9% 14.3 52.6% 26.3% 21.1%
%
Curren Severe 11 4.6% 7 2.9% .4% .8% .4% .8% 1.7% .8%
t anemia
Moderate 222 92.5% 111 46.3% 21.3% 15.4% 9.6% 61.9% 22.0% 10.2%
Mild 7 2.9% 4 1.7% .4% .4% .4% .8% .8% .8%
Total 240 100.0% 122 50.8% 22.1% 16.7% 10.4 .8% 62.7% 24.6% 11.9%
%

while analyzing the consumption of the pregnant women in the age group of less than 25 years
(28%) have received up to 30 tablets of IFA while (13 %) have received 30 to 60 tablets and only
16 percent have received more than 60 tablets of IFA. In the age group of 25-30 years (14%) have
received upto 30 tablets while 15% have received 30 to 60 tablets and more than sixty tablets
have been received by only (5 %) in this age group .in the elderly age group only (11%) have
received up to 30 tablets and same percentage have received also more than 60 tablets while
only(14%) have received 30 to 60 tablets in the district. The consumption percentage in the three
groups of age is (37%) who have received 30 tablets 17.5% who have received 30 to 60 tablets
and only 15.8% have consumed IFA who have received more than 60 tablets.
The total number of respondents (PW) who have not received the IFA at all in age group of up to
25 years were (43 %) between 25 to 30 years were (62%) and more than 30 years age group
(26%) have not received any IFA tablet. Which means that (51%) in all age groups have not
received IFA.

16. Problems by IFA Consumption:

India has been running the National Nutritional Anemia Prophylaxis Programme (NNAPP) since
1970 to battle anemia. Three years ago, it also launched a weekly iron and foliate programme
which administers iron and folic acid tablets to adolescent girls, screens them for moderate-to-
severe anemia and ensures biannual de-worming and counseling.

However, public health experts have pointed out that NNAP’s strategy of simply handing out iron
tablets to pregnant women has not worked as a solution. Only 23.6% of pregnant women
consumed more than 100 iron and folic acid blets out of the 31.2% who received them during

24
pregnancy, according to the Rapid Survey on Children 2014. The problems faced by the pregnant
who consumed the IFA in the district are as in Table 13. Iron tablets have many side-effects–
diarrheas and vomiting, for instance–which, during pregnancy, add to a woman’s discomfort .It is
also important to build a woman’s iron reserves Mostly about (55 %) have not faced any problem
while consuming IFA tablets. 30 pregnant women have experienced pain in stomach while 15
have constipation followed by 11 belly pain and 9 have experienced diarrhea out of a total 118
pregnant women who have received IFA for consumption.

Table-13 % Distribution of Women by Problems experienced with IFAby Pregnant women in Kupwara
District
Upset Conspitatio Belly
Diarrhea
Total Any Problem Stomach n Pain
1 2 Yes Yes Yes Yes Yes

Count % Count % % % % %
Age of <25 100 100.0% 24 24.0% 12.0% 5.0% 4.0% 5.0%
Woman 25-29 85 100.0% 17 20.0% 11.8% 5.9% 4.7% 3.5%
30 +above 55 100.0% 12 21.8% 14.5% 9.1% 5.5% 1.8%
Education illitrate 72 100.0% 15 20.8% 11.1% 5.6% 4.2% 4.2%
<5 18 100.0% 4 22.2% 16.7% 5.6%
5-9 35 100.0% 7 20.0% 8.6% 5.7% 2.9% 2.9%
10-12 75 100.0% 15 20.0% 13.3% 4.0% 4.0% 5.3%
13+ above 40 100.0% 12 30.0% 15.0% 15.0% 7.5% 2.5%
‘Caste of ST 7 100.0% 1 14.3% 14.3%
Pregnant OBC 139 100.0% 26 18.7% 12.2% 6.5% 4.3% 2.9%
woman’ General 94 100.0% 26 27.7% 13.8% 6.4% 4.3% 5.3%
Monthly < 5000 40 100.0% 11 27.5% 17.5% 2.5% 5.0% 7.5%
Income 5-10 Th 118 100.0% 26 22.0% 11.0% 8.5% 4.2% 3.4%
10-20TH 65 100.0% 12 18.5% 13.8% 3.1% 3.1% 3.1%
>20000 17 100.0% 4 23.5% 5.9% 11.8% 11.8%
Occupati Business 34 100.0% 5 14.7% 11.8% 5.9% 5.9% 2.9%
on Agriculture 92 100.0% 21 22.8% 14.1% 6.5% 4.3% 3.3%
labour 81 100.0% 20 24.7% 13.6% 6.2% 3.7% 4.9%
Salaried 33 100.0% 7 21.2% 6.1% 6.1% 6.1% 3.0%
Age at <18 16 100.0% 3 18.8% 18.8% 6.3%
Marriage 18-21 128 100.0% 22 17.2% 7.8% 7.8% 3.1% 2.3%
22-25 74 100.0% 22 29.7% 17.6% 5.4% 6.8% 6.8%
>25 22 100.0% 6 27.3% 18.2% 4.5% 4.5% 4.5%
Total 1-5 92 100.0% 22 23.9% 14.1% 6.5% 3.3% 2.2%
Family 6-10 118 100.0% 26 22.0% 11.9% 6.8% 5.1% 3.4%
size >10 30 100.0% 5 16.7% 10.0% 3.3% 6.7% 10.0%
Total 0 90 100.0% 26 28.9% 14.4% 4.4% 6.7% 7.8%
Living 1 62 100.0% 10 16.1% 11.3% 3.2% 1.6%
Children 2 46 100.0% 8 17.4% 10.9% 6.5% 6.5% 2.2%
3 or more 42 100.0% 9 21.4% 11.9% 14.3% 2.4% 2.4%
Current Severe 11 4.6% 2 .8% .4% .4% .4% .4%
Moderate 222 92.5% 49 20.4% 11.7% 5.8% 3.8% 3.3%
Mild 7 2.9% 2 .8% .4% .4%
Total 240 100.0% 53 22.1% 12.5% 6.3% 4.6% 3.8%
17. Knowledge about Symptoms of Iron Deficiency Anemia:
25
Initially, iron deficiency anemia can be so mild that it goes unnoticed. But as the body becomes
more deficient in iron and anemia worsens, the signs and symptoms intensify.Iron deficiency
anemia signs and symptoms may include Fatigue, weakness, paleness, giddiness,pica or some
more. The knowledge of the symptoms of iron deficiency anemia was responded as by the
respondents. The respondents were aware of the symptoms of the iron deficiency anemia about 90
percent of the women under the age of 25 years are aware of fatigue symptom in the age group of
25-30 years are 70 percent while 30 years age group 44 are aware of this symptom.

The symptom of weakness was responded in affirmation by 76 women in the age group below 25
years and 51 women are aware in the age group of 25-30 years while 42 women are aware in the
age group of above 30 years . The Paleness was not responded well only a few only 8 women
were aware of paleness as symptom.

Giddiness as a symptom was responded by 65 pregnant ladies in all age groups. While pica was
responded as a symptom by only 29 pregnant women as a anemia symptom. Table 14

Table-14 Distribution of Women by Symptoms of iron deficiency anemia with by Pregnant women in Kupwara District

Fatigue Weakness Paleness Giddiness Pica

Total Yes No Yes No Yes No Yes No Yes No
Age of Woman <25 100 90 10 76 24 3 97 34 66 6 94
25-29 85 70 15 51 34 85 20 65 14 71
30 and above 55 44 11 42 13 2 53 11 44 9 46
Education No Schooling 72 65 7 50 22 3 69 11 61 5 67
<5 18 16 2 15 3 1 17 5 13 18
5-9 35 33 2 28 7 35 20 15 5 30
10-12 75 60 15 49 26 75 16 59 6 69
13 and above 40 30 10 27 13 1 39 13 27 13 27
‘Caste of Pregnant ST 7 7 6 1 7 4 3 7
woman’ OBC 139 117 22 90 49 1 138 17 122 16 123
General 94 80 14 73 21 4 90 44 50 13 81
Monthly Income < 5000 40 34 6 34 6 2 38 22 18 8 32
5000-1000 118 104 14 82 36 3 115 23 95 8 110
10000-20000 65 52 13 41 24 65 15 50 10 55
>20000 17 14 3 12 5 17 5 12 3 14
Occupation Business 34 27 7 22 12 1 33 11 23 5 29
Agriculture 92 81 11 64 28 3 89 18 74 6 86
Labour/skilled 81 70 11 61 20 1 80 24 57 11 70
worker
Salaried 33 26 7 22 11 33 12 21 7 26

18. Maternal consequences (Level) of anemia among pregnant women:

18.1Mild Anemia
Women with mild anemia in pregnancy have decreased work capacity. They may be unable to

26
earn their livelihood if the work involves manual labour. Women with chronic mild anemia may
go through pregnancy and labour without any adverse consequences, because they are well
compensated.

18.2 Moderate Anemia

Women with moderate anemia 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 aternal morbidity rates are higher in women with Hb below 8gm/dl21.

18.3 Severe Anemia

Three distinct stages of severe anemia have been recognized - compensated, ecompensated, 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 edema and death.
When Hb is <5 g/dl and packed cell volume (PCV) below 14, cardiac failure is seen in a third of
cases23. 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. Anemia directly causes 20 per cent of maternal deaths in India and indirectly
accounts for another 20 per cent of maternal deaths.

The number of a total severe anemic pregnant women was (4.6%) 11 of which 7 (2.9%) have not
received IFA while in moderate anemic group of pregnant women 222 (92.5%) only 111(46.3%)
have not received IFA and while out of 7 mild anemic group 4 (1.75) have not received any IFA
tablets this reveals that the sever anemic group have suffered more than other two groups of
anemia. And out of 4 severe anemic pregnant women only(8%) lone have consumed less than 30
tablets while two have consumed 30 to 60 and one have (8%) consumed more than 60 tablets of
IFA.

27
Table-14 % Distribution of Women by Level of Anemia among Pregnant women in Kupwara District
Total Registration Current
Severe Severe
1 2 anemia Moderate Mild Normal anemia Moderate Mild
Coun
t % % % % % % % %
Age of <25 100 100.0% 3.0% 90.0% 4.0% 3.0% 1.0% 95.0% 4.0%
Woman 25-29 85 100.0% 1.2% 92.9% 5.9% 8.2% 89.4% 2.4%
30 and above 55 100.0% 1.8% 94.5% 1.8% 1.8% 5.5% 92.7% 1.8%

Education No Schooling 72 100.0% 2.8% 93.1% 4.2% 6.9% 93.1%

<5 18 100.0% 100.0% 100.0%

5-9 35 100.0% 91.4% 2.9% 5.7% 2.9% 85.7% 11.4
%
10-12 75 100.0% 2.7% 89.3% 8.0% 4.0% 93.3% 2.7%
13 and above 40 100.0% 2.5% 92.5% 5.0% 5.0% 92.5% 2.5%
‘Caste of ST 7 100.0% 100.0% 100.0%
Pregnant OBC 139 100.0% 3.6% 89.2% 5.8% 1.4% 2.9% 95.0% 2.2%
woman’ General 94 100.0% 95.7% 2.1% 2.1% 7.4% 88.3% 4.3%
Monthly < 5000 40 100.0% 2.5% 90.0% 5.0% 2.5% 7.5% 87.5% 5.0%
Income 5000-1000 118 100.0% 2.5% 92.4% 3.4% 1.7% 3.4% 94.1% 2.5%

10000-20000 65 100.0% 1.5% 90.8% 6.2% 1.5% 4.6% 92.3% 3.1%

>20000 17 100.0% 100.0% 5.9% 94.1%

Occupation Business 34 100.0% 94.1% 2.9% 2.9% 5.9% 85.3% 8.8%
Agriculture 92 100.0% 1.1% 93.5% 3.3% 2.2% 4.3% 93.5% 2.2%

Labour/skilled 81 100.0% 3.7% 88.9% 7.4% 4.9% 93.8% 1.2%

worker
Salaried 33 100.0% 3.0% 93.9% 3.0% 3.0% 93.9% 3.0%
Age at <18 16 100.0% 6.3% 93.8% 100.0%
Marriage 18-21 128 100.0% 2.3% 93.0% 3.9% .8% 6.3% 91.4% 2.3%
22-25 74 100.0% 1.4% 90.5% 5.4% 2.7% 2.7% 91.9% 5.4%
>25 22 100.0% 90.9% 4.5% 4.5% 4.5% 95.5%
Total 1-5 92 100.0% 3.3% 90.2% 5.4% 1.1% 5.4% 92.4% 2.2%
Family size 6-10 118 100.0% 1.7% 91.5% 4.2% 2.5% 3.4% 92.4% 4.2%
>10 30 100.0% 100.0% 6.7% 93.3%
Total Living 0 90 100.0% 4.4% 86.7% 5.6% 3.3% 3.3% 91.1% 5.6%
Children 1 62 100.0% 98.4% 1.6% 96.8% 3.2%
2 46 100.0% 2.2% 89.1% 6.5% 2.2% 13.0% 87.0%
3 or more 42 100.0% 97.6% 2.4% 4.8% 95.2%
Current Severe anemia 11 4.6% .4% 4.2% 4.6%

Moderate 222 92.5% 1.7% 86.3% 4.2% .4% 92.5%

Mild 7 2.9% 1.7% 1.3% 2.9%
Total 240 100.0% 2.1% 92.1% 4.2% 1.7% 4.6% 92.5% 2.9%

28
After consuming the IFA we found the interesting results that severe anemic were at the time of
registration 5 which increased to 7 pregnant women while moderate were 221 which were now
222 and mild anemic were 10 at the time of registration only 7 have been found after consuming
the IFA tablets.

19. Discussion:
Despite the fact that India was the first developing country to implement a national program to
prevent anemia with notable attention to control anemia during pregnancy and lactation, the
severity of the problem remains. Anemia is still a major public health issue of greater magnitude
for the country. The recently published fact sheets based on NFHS-4 Information from IIPS and
MoHFW (2017) suggest that, despite the rigorous efforts of government to reduce the prevalence
of anemia in terms of free distribution of Iron Folic Acid (IFA) tablets and free advice on the
nutritional requirements during pregnancy and lactation, the prevalence of anemia (50.3%) in
India remains one of the highest in the world. The prevalence of anemia among NP-NL women
(15- 49 year) had increased from 52% in NFHS-1 (1992-93) to 53% in NFHS-4 (2015-16).
This study was conducted with intention of assessing magnitude of anemia and identifying its
determinants. According to finding from this study the prevalence of anemia among studied
pregnant women in district Kupwara attending Anti natal care (ANC) was 3% (7 pregnant
women) with mild anemia 92% (222 pregnant women) with moderate anemia and 5% (11
pregnant women) with severe anemia .the number of severe anemic is higher in the age group of
25 to 30 years which is a matter of concern. However the presence of anemia was found higher
than found in 74.6% NFHS-4 which was the base of this study while Jammu and Kashmir has
38.1% pregnant women anemic in the state. As per NFHS-4 data of Jammu and Kashmir only
32.4 % pregnant women consumed IFA tablets, clearly shows that the flaw could be due to non
compliance to treatment and current programme has not achieved a reduction in the prevalence
of anemia in our state. The results are in agreement with other studies in india and indicate that
the iron supplementation programme for pregnant women should also be monitored better. This
study showed a high percentage of moderate anemic pregnant women about 92%. As per the
survey of NFHS-2 (1998-99) the prevalence of anemia in Jammu and Kashmir was 58.7% which
decreased to 52.1 % in NFHS-3 (2005-2006) and in NFHS-4(2015–2016) to 40.3 % . Even after
the consumption 30.2% (90 tablets) of IFA anemia among the pregnant women was 38.1 % in
NFHS-4 in the state though the state has improved by 10.6% points and ranks at forth position in
the country but still a lot has to be done to reduce the anemia.

In addition to identifying the demand-side factors, this study also attempted to identify the
supply-side factors which determine the prevalence of anemia among pregnant, lactate ing and
NP-NL women, although association is weak and statistically not significant. Anemia is found to
be more with others. It may be because nutrition advice and supplementary nutrition provided by
frontline health workers under Integrated Child Development Scheme (ICDS) is targeted toward
disadvantaged women who are already suffering from anemia. Women from better-off
households seek nutrition advice and supplementary nutrition from private health care.
29
Nevertheless, these findings give a strong message that the program interventions are ineffective
to bring them out of vicious cycle of anemia. To conclude, food fortification, behavior to
decrease this level of anemia communication, patient compliance to treatment information and
communication remain the key to decrease this level of anemia burden in our population.

20. Conclusion:
Nutritional deficiency anemia during pregnancy continues to be a major health problem in India.
To eradicate it certain steps can be taken at individual and community level like education of the
women as regards anemia, its causes and health implication. Imparting nutritional education,
with special emphasis on strategies based on locally available food stuffs to improve the dietary
intake of proteins and iron, administration of appropriate iron supplements and ensuring
maximum compliance, deworming, treatment of chronic disease like malaria and universal
antenatal care to pregnant women will help in combating this serious problem. Long term
policies by government, non-government agencies and the community can be directed to
formulate effective plans like eradicating anemia in children and adolescent girls. Very high
prevalence of anemia (92 %) early in pregnancy, an indicator of the maternal anemia, continues
to be a major health problem not only in this part of the country but also in many other states of
country and worldwide that needs attention. So further study need to be taken to find the various
other factors responsible for this high level of anemia in pregnant women and monitoring of the
interventions being taken at this point of time so that the burden is decreased or brought to
control. The supplementary food scheme in the country should be enhanced and coordination
should be linked between ICDS and Health department to combat the anemia in the women folk
in our population .The compliance, patient preferences, behaviors need to be addressed.

Interestingly, the prevalence of anemia is higher in lower age group compared with higher age
group among pregnant women. Further, Women reside in rural areas, belonged to OBC/ST, poor
households, who are not literate, do not have any exposure to mass media, currently working,
and whose partner was illiterate are suffering more from anemia. Moreover, women with higher
parity/gravida suffer more from anemia compared to lower parity/gravid. Similarly, anemia
prevalence by duration of pregnancy shows that as pregnancy gestation advances the proportion
of pregnant women suffering from anemia increases. Hence, the above population sub-groups
must be considered for the effective intervention to reduce the burden of anemia in India.

Based on these factors, deciding the exact target population sub-groups and addressing specific
needs including health and nutrition care among pregnant, lactating and NP-NL women through
effective care providing systems will help in reducing the anemia. Further, in addition to early
pregnancy registration, the frontline workers need to concentrate on promoting knowledge on
adopting healthy reproductive life, i.e. avoiding early childbirth and higher parity/gravid, etc.;
and importance of balanced nutrition, nutrition rich food, dietary diversity and provision of
supplementary nutrition which can prevent anemia among pregnant and lactating mothers.

30
31. Recommendations
The IFA distribution programme is not well placed and to the ground reality as this is directly
related to maternal and infant mortality so needs to be accorded high priority. A quality vigil on
this programme is recommended by engaging ASHA coordinators and ANMs. Also continuous
monitoring and supportive supervision to ASHAs may provide impetus to well planted
programme to shape in a good public programme. Training on IFA providing and consumption is
to be provided to all ASHAs as contents deal with more specifically on the severe anemia. The
themes to be covered under anemia prevention guidelines require constant practice and
continuous learning so refreshers’ training assumes very high place. Message retention on crucial
IFA and anemia practices is quite low, suggesting the improved inputs to ASHAs new recruited
ANMs through training, encouraging them to adhere to the guidelines on follow up of severe
anemia, strictly following the protocols on using paper formats and ensuring constant scrutiny
and support by ANMs. The IFA tablets should be made available well in time at all health
facilities in the state. Any slowness in releasing the funds under JSSK for IAF tablets purchasing
need to be taken care . Nutritional food items should be made available for ICDS so that the
pregnant women from weak socio economic back ground can be benefited.

31