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CORRESPONDENCE
Year : 2018  |  Volume : 148  |  Issue : 3  |  Page : 345-346

Reduction in prevalence of anaemia in pregnant women


1 Department of Food and Nutrition, Lady Irwin College, New Delhi, Delhi 110 001, India
2 Department of Pathology, Jawaharlal Nehru Medical College, Belagavi 590 010, Karnataka, India
3 Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi 110 029, India

Date of Submission13-Jul-2018
Date of Web Publication13-Nov-2018

Correspondence Address:
Umesh Kapil
Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_1429_18

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How to cite this article:
Gupta A, Kapil R, Kapil U. Reduction in prevalence of anaemia in pregnant women. Indian J Med Res 2018;148:345-6

How to cite this URL:
Gupta A, Kapil R, Kapil U. Reduction in prevalence of anaemia in pregnant women. Indian J Med Res [serial online] 2018 [cited 2018 Dec 14];148:345-6. Available from: http://www.ijmr.org.in/text.asp?2018/148/3/345/245284

Sir,

We read the article by Kalaivani and Ramachandran[1] with great interest. The study analyzed the datasets of National Family Health Survey (NFHS)-II, III, IV, District Level Household Survey (DLHS) II, IV and Annual Health Survey (AHS)-Clinical and Anthropometric and Biochemical (AHS CAB). Authors reported that there has been a reduction in the prevalence of anaemia among pregnant women in the past 15 years.

We would like to discuss a few concerns about the interpretation of the predicted trend of reduction in the prevalence of anaemia using the National Survey data:

  1. The sampling procedure and inclusion criteria of Pregnant women differed greatly in NFHS II (1998-1999)[2], NFHS-III (2005-2006)[3] and NFHS-IV (2015-2016)[4] as compared to DLHS-II (2002-2004)[5], DLHS-IV (2012-2013)[6] and AHS CAB surveys (2014)[7] presented in the study[1].
  2. NFHS II and III were designed to provide State-level estimates of anaemia. However, DLHS II, IV, AHS and AHS CAB and NFHS IV were designed to provide district level estimates of anaemia. There were large variations in the total number of pregnant mothers included for estimation of prevalence of anaemia in NFHS-II (n=2796), III (n=3788) and IV (n=30,320), DLHS II (n=38,710), IV (n=12,306) and AHS CAB (n=20,832).
  3. The methods used for haemoglobin estimation were different in NFHS-II, NFHS-III and NFHS-IV as compared to DLHS-II, IV and AHS surveys. The NFHS used HemoCue analyzer for estimation of haemoglobin while DLHS-II, IV utilized cyanmethaemoglobin method. In addition, different models of HemoCue analyzers were used during NFHS-II, III and IV as consistent results of Hb estimations were not produced by the earlier models of the machine[8].
  4. The classification for grading of anaemia used in NFHS-II, NFHS-III and NFHS-IV as compared to DLHS-II, IV and AHS surveys also differed across the surveys. The NHFS II, III and IV graded anaemia according to the WHO grading of anaemia[9]; pregnant women with Hb levels ≥11 g/dl were graded as non-anaemic; those with Hb levels between 10.0 and 10.9 g/dl as mildly anaemic, those with Hb levels between 7.0 and 9.9 g/dl as moderately anaemic and those with Hb levels below 7.0 g/dl as severely anaemic. Whereas, DLHS 2 used the grading of anaemia as per the earlier published Indian data based on functional decompensation[10],[11],[12] which has been associated with a fall in Hb levels. Pregnant women with Hb ≥11 g/dl were graded as not anaemic; while those with Hb levels between 8.0 and 10.9 g/dl as mildly anaemic, those with Hb levels between 5.0 and 7.9 g/dl as moderately anaemic and those with Hb levels below 5.0 g/dl as severely anaemic.
  5. All the NFHS surveys (II, III and IV)[2],[3],[4] have documented lower prevalence of anaemia in pregnant women as compared to non-pregnant women. This is in contradiction to the existing knowledge according to which the prevalence of anaemia among pregnant women is higher due to haemo dilution during pregnancy[9]. The WHO also has recommended lower “cut-off” for Hb by 0.5 g/dl for defining anaemia among pregnant mothers[9].
  6. High reduction in the prevalence of anaemia was recorded between NFHS-III and IV in Chhattisgarh (63-41%), Assam (72-44%), Haryana (71-51%), Odisha (68-47%) and Kerala (62-45%). However, the coverage of iron folic acid (IFA) supplementation (major intervention to reduce anaemia) among pregnant women was only 30.3 per cent in Chhattisgarh, 32.0 per cent in Assam, 32.5 per cent in Haryana, 36.5 per cent in Odisha and 67.1 per cent in Kerala in NFHS-IV[4]. The distribution of IFA tablets and monitoring of their consumption were poorly undertaken due to various logistic reasons. Furthermore, anaemic pregnant women, possibly received only prophylactic dose of iron (instead of therapeutic dose) while the majority of them were suffering from anaemia[2],[3],[4]. It has been suggested that only up to 50 per cent of women with anaemia in countries of South East Asia region are amenable to iron supplementation[13].
  7. The drastic reduction in the prevalence of anaemia mentioned in this study[1] between DLHS II to AHS conducted in Odisha (97-62%), Chhattisgarh (96-63%), Jharkhand (97-80%) and Madhya Pradesh (97-71%) could possibly be due to limitations in the process of estimation of haemoglobin rather than health interventions for reduction in anaemia.


In view of the above, combining the haemoglobin data of NFHS, DLHS and AHS surveys and concluding reduction in the prevalence of anaemia possibly does not provide true scenario. True trends in the prevalence of anaemia could be provided by utilizing data from similar sampling framework surveys with the same method for haemoglobin estimation.

Conflicts of Interest: None.



 
   References Top

1.
Kalaivani K, Ramachandran P. Time trends in prevalence of anaemia in pregnancy. Indian J Med Res 2018; 147 : 268-77.  Back to cited text no. 1
    
2.
International Institute of Population Sciences. National Family Health Survey (NFHS) 2. International Institute of Population Sciences; 2009. Available from: http://www.rchiips.org/nfhs/nfhs2.shtml, accessed on June 2, 2018.  Back to cited text no. 2
    
3.
International Institute of Population Sciences. National Family Health Survey (NFHS) 3. Available from: http://www.rchiips.org/nfhs/nfhs3.shtml, accessed on June 2, 2018.  Back to cited text no. 3
    
4.
International Institute of Population Sciences. National Family Health Survey (NFHS) 4 Fact Sheets. Available from: http://www.rchiips.org/nfhs/factsheet_NFHS-4.shtml, accessed on June 2, 2018.  Back to cited text no. 4
    
5.
International Institute of Population Sciences. DLHS-2 - District Level Household and Facility Survey. Available from: http://www.rchiips.org/PRCH-2.html, accessed on June 2, 2018.  Back to cited text no. 5
    
6.
International Institute of Population Sciences. DLHS-4 - District level household and facility survey. Available from: http://www.rchiips.org/DLHS-4.html, accessed on June 2, 2018.  Back to cited text no. 6
    
7.
Registrar General of India. Annual Health Survey 2014: CAB Component. Available from: http://www.censusindia.gov.in/2011census/hh-series/cab.html, accessed on June 2, 2018.  Back to cited text no. 7
    
8.
Sari M, de Pee S, Martini E, Herman S, Sugiatmi, Bloem MW, et al. Estimating the prevalence of anaemia: A comparison of three methods. Bull World Health Organ 2001; 79 : 506-11.  Back to cited text no. 8
    
9.
World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity of anaemia. Geneva: WHO; 2011. Available from: http://www.who.int/vmnis/indicators/haemoglobin/en/, accessed on June 2, 2018.  Back to cited text no. 9
    
10.
Prema K, Neela Kumari S, Ramalakshmi BA. Anaemia and adverse obstetric out come. Nutr Rep Int 1981; 23 : 637-43.  Back to cited text no. 10
    
11.
Prema K, Ramalakshmi BA, Madhavapeddi R, Babu S. Immune status of anaemic pregnant women. Br J Obstet Gynaecol 1982; 89 : 222-5.  Back to cited text no. 11
    
12.
Prema K. Anaemia in pregnancy. In: Ratnam SS, Rao KB, Arulkumaran S, editors. Obstetrics and gynaecology, Vol. 1. Madras: Orient Longman; 1992. p. 42-53.  Back to cited text no. 12
    
13.
World Health Organization. The global prevalence of anaemia in 2011. WHO Report. Geneva: World Health Organization; 2015.  Back to cited text no. 13
    




 

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