Anaemia in Pregnancy in India

The prevalence of anaemia in pregnancy in India is the highest in the world. Anaemia in pregnancy is a major public health problem leading to high maternal morbidity and mortality, low birth weight, and high infant mortality.

Earlier, iron folic acid supplements were centrally procured and provided to all the states. In the last two decades, state governments had been procuring and supplying iron and folic acid tablets to antenatal clinics. The Delhi Government had been procuring and supplying 60 mg of iron and 5 mg of folic acid (IFA) tablets for the ongoing IFA supplementation programme in antenatal clinics. Obstetricians in many hospitals had been advising anaemic pregnant women to take two tablets each containing 60 mg of iron with breakfast and dinner and one tablet of folic acid 5 mg with lunch. There are no published studies assessing the impact of this treatment on haemoglobin (Hb) levels. Research studies published in the last two decades had reported a decline in folate deficiency and an increase in vit B12 deficiency. Taking this into account, some obstetricians had been giving pregnant women vit B complex tablets containing 15 µg of vit B12 in addition to iron tablets. The impact of the addition of vit B12 to IFA supplements on Hb and vit B12 levels has not been investigated.

Study by Sharma et al.

A hospital-based open randomised study by Sharma et al. was taken up to assess the impact of supplementation with 240 mg of iron and 5 mg of folic acid as compared to supplementation with iron 240 mg, folic acid 1.5 mg, and vit B12 15 µg. The impact of supplementation for eight weeks on Hb, ferritin, folic acid, and vit B12 levels was assessed. Data from the study will help to decide the dosage of iron and folic acid required for the treatment of anaemia and the impact, if any, of the addition of vit B12 on Hb and B12 levels.

In the present study, screening of anaemic pregnant women attending antenatal clinics in urban primary health care institutions was operationalised, and at the initial screening, anaemic women with Hb between 8.0 and 10.9 g/dL were identified. The Delhi government had been procuring and providing 60 mg iron tablets and 5 mg folic acid tablets to antenatal clinics in government hospitals. Obstetricians in these antenatal clinics requested anaemic women to take two tablets of iron each after breakfast and dinner and one tablet of folic acid after lunch. In the present study, women in Group 1 followed this practice; women in Group 2 took two tablets of iron each after breakfast and dinner and one tablet of vitamin B complex after lunch.

Study Results

Anaemic pregnant women willing to participate in the study were randomised into Group 1 (240 mg iron and 5 mg folic acid) or Group 2 (240 mg iron, 1.5 mg of folic acid, and 15 µg vitamin B12); the impact of supplementation on Hb, ferritin, folic acid, and vitamin B12 was assessed.

In both groups, mean Hb improved by 1 g/dL at 8 weeks and by 1.5 g/dL by 38 weeks of pregnancy; at 38 weeks, only 30% were anaemic. Mean ferritin and folic acid levels improved in both groups. There was a fall in the mean vitamin B12 levels in the group which received 5 mg of folic acid.

Prevalence of side-effects and compliance with the supplementation regimen over 60 days of supplementation were computed in women who had continued taking the tablets for eight weeks and provided the second blood sample. Nearly 60% of women taking 240 mg of elemental iron/day reported abdominal discomfort, fullness, colic, and/or constipation.

All research studies and surveys indicate that even in pregnant women, the continued intake of IFA supplementation was relatively low. There had been suggestions that women forgetting to take the tablets could be a factor responsible for the poor compliance with IFA supplementation. In the present study, the importance of continued intake of the supplements was emphasized, and compliance with iron, folic acid, and vitamin B complex was checked separately at each visit.

Key Findings

Data from the present study showed that under research conditions:

• Compliance and tablet intake were highest with folic acid tablets, which was not associated with any side effects;
• Compliance and tablet intake were lower with vit B complex tablets; there were no side-effects reported with vit B complex, but some of the women did not like the smell of the tablets;
• Compliance and tablet intake were lowest with iron tablets.

Compliance computed for the 60 days showed that women took the iron tablets only for about 40 days because over half of the women had side effects with iron supplementation.

These data suggest that side effects were the major reason for lower compliance with iron supplementation. Pregnant women do remember to take tablets after meals and try to comply with supplementation because they want their child to be born healthy. With intensive nutrition education and supportive supervision, it was possible to improve compliance with supplementation during pregnancy to about 65%.

With assured supply and supportive supervision, it was possible to achieve good compliance with supplementation and substantial reduction in anaemia in both groups receiving 240 mg of elemental iron, despite troublesome minor gastrointestinal disturbances experienced by two-thirds of women. Data from earlier studies showed that a lower dose of iron was associated with a lower prevalence of side effects and that similar improvement in Hb can be achieved with a lower dose of iron. Supplementation with folic acid 5 mg should not be done because it causes a fall in vitamin B12 levels. The reason why the addition of vitamin B12 to iron folic acid supplementation did not result in improvement in mean Hb, or vitamin B12 levels has to be investigated.

Source: Sharma et al. / Indian Journal of Obstetrics and Gynecology Research 2024;11(3):364–373; https://doi.org/10.18231/j.ijogr.2024.067