Reducing Maternal and Neonatal Anemia to Enhance Health

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Reducing Maternal and Neonatal Anemia to Enhance
Health

• ACCESS Program Seminar on Nutrition
• September 12, 2006
• Philip Harvey MPH, PhD
• Bloomberg School of Public Health
• Johns Hopkins University

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Outline

• Multiple causes, prevalence
• Impacts on mortality
• Efficacy effectiveness of iron supplementation
  programs
• Pregnancy
• Newborns
• Adolescents/WRA
• Tailoring implementation
• Conclusions

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• Impacts on Mortality

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From Stoltzfus RJ, et al (2005)
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From Stoltzfus RJ, et al (2005)
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Individual and combined ORs for maternal death
From Stoltzfus RJ, et al (2005)
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Adapted from Khan et al, Lancet April1 2006
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Individual and combined ORs for perinatal death
From Stoltzfus RJ, et al (2005)
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Final estimates OR associated with a 1 g/dL
increase in Hb
From Stoltzfus RJ, et al (2005)
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• Efficacy and Effectiveness of
• Iron Supplementation Programs

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Prenatal iron supplementation reduces likelihood
of Hb lt 10 g/dL at delivery
Kulier et al. Int J Gyn Obs 1998
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Programming Focus is on Effectiveness
Supplement supply
Delivery system
Compliance
Effectiveness
Supplements taken
Efficacy
Iron status improves
Iron-related health outcomes improve
Adapted from Ekstrom 2002
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Nicaragua Prevalence of anemia in
mothers/caregivers 1993, 2000 2003.
Percentage Hblt12 g/dL
Source SIVIN 2004
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Nicaragua Hb distributions of mothers/care-giver
s with children 1-5 y, 1993, 2000 2003.
Percentage
Source SIVIN 2004
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Characteristics of Effective Programs

• Comprehensive approaches addressed major
  preventable causes (ID, malaria, parasitic worms)
• Addressed known barriers
• Commitment to action
• Awareness of benefits by both clients providers
• Logistics (supply, tablets packaging)
• Access to quality ANC (motivation, training
  supervision)
• Communication materials counseling (e.g. memory
  prompts, anticipate cope with side-effects)
• Tailored to country context

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Improving Iron Status of Newborns

• Improve maternal iron status
• Prevent LBW
• Screen for LBW for supplmt at 2 mo.
• Improve IYCF
• Delay cord clamping, recent results from Mexico
  contribute to debate (Chaparro et al, Lancet June
  17, 2006)

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Adolescents/Women of Reproductive Age

• Improving iron status before pregnancy
  fortification, weekly supplementation, deworming,
  diet diversification
• Weekly IFA to adolescents improves Hb (UNICEF,
  Umang in India), but impact on improving iron
  status for subsequent pregnancy is uncertain
• Umang data suggest behavioral advantages in this
  option (Pers. Comm. Neelam Singh, Jan 2006)
• Girls recognize benefit of IFA, more likely to
  use IFA when pregnant
• Programs provide entry point for other
  interventions (e.g. Family Life Education which
  may bring behavior change)
• Weekly IFA effective in improving iron status of
  WRA in three Asian countries (Cavalli-Sforza et
  al, Nutrition Reviews 2005)

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Pers. Comm. Neelam Singh, Jan 2006
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Key Factors in Tailoring Interventions

• Balance of benefits and risks
• Balance of costs of interventions and resources
  available (Government, donors, NGOs, households)
• Operational feasibility
• Existing policies programs being implemented
• Capacity, commitment for action of
• Health systems (morale, quality, coverage)
• Communities (participation, empowerment)
• Other issues potentially effecting the above
• Targeting / screening
• Private sector reach, infrastructure

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Conclusions

• Greater commitment and enhanced capacity for
  program implementation required at country-level
  as a foundation
• Universal IFA supplementation for pregnant women
  one exception proving the rule that one size
  does not fit all?
• Components for successful IFA intervention are
  well established and will enhance coverage
  quality of antenatal care
• Anemia interventions require tailoring to
  contexts of specific countries and target groups

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Thank you

• Phil Harvey
• pharvey_at_aed.org