Gujarat has reported high prevalence of anaemic women, especially in the rural parts, going by the National Family Health Survey – 5 that was released last December and yet what appears to have been left unaddressed by existing policies is the prevalence of non-iron deficiency anaemia, which affects a significant proportion of anaemic women. For example, a study conducted across 258 pregnant and lactating women in Devbhoomi Dwarka saw two out of every five women were anaemic but with sufficient iron levels. Of the total sample 170 were found to be anaemic of which 105 were not iron-deficient.
The study led by Somen Saha, associate professor with the Indian Institute of Public Health (IIPH) Gandhinagar along with others from the institute was conducted in the “peak of Covid-19” when schools and anganwadis were closed, thus limiting the sample size to pregnant and antenatal women, leaving out adolescents. However further expansion of the study is planned that will also account for adolescent girls. The AYUSH department of the state too has taken an interest in the study, with a meeting held on Wednesday.
Current policies towards tackling maternal anaemia involves screening and management by haemoglobin estimation only, and treatment of iron folic acid tablets is given irrespective of the status of iron as well as other micronutrient storage. The national-level Anaemia Mukt Bharat 2018 document finds no mention of non-iron deficiency anaemia despite the Comprehensive National Nutrition Survey (CNNS) conducted between 2016 and 2018 found a greater percentage prevalence of children aged between five and 19 years anaemic but not iron deficient, compared to those who are anaemic with iron deficiency. The CNNS was the first ever nationally representative nutrition survey of children and adolescents in India by the Ministry of Health and Family Welfare.
Saha too confirmed that the Anaemia Mukt Bharat program guideline “entirely focuses on iron deficiency anaemia,” and no national-level change in the guideline was seen despite CNNS findings that reflected a similar pattern of significant prevalence of non-iron deficiency anaemia.
“We suggest that this one size fits all needs to be relooked at, because (under the programme) we are only detecting anaemia and not the causes behind the anaemia…and not all anaemia is due to iron deficiency,” says Saha.
Without a policy-level change, districts are left at the mercy of individual district health officers and the interventions they initiate at an individual-level.
“When we were conducting the study we consulted experts including a haematologist and we were told that estimating iron level from serum ferritin has got some flaws. The flaw is essentially that if the body had any kind of inflammation owing to infections, the serum ferritin level will be elevated and results may not be accurate. As a result, it is recommended to conduct a battery of tests to conclusively deduce that anaemia is due to non -iron deficiency. We suggest that from the public health perspective, we do not need a diagnostic tool but rather a screening tool and for that a health history of say, the past seven days will suffice,” added Saha.
In the study conducted in Devbhoomi Dwarka, currently published as a preprint, a total of 258 pregnant or antenatal and postnatal, that is lactating women were drawn from 27 primary health centres as samples. Anaemia was assessed based on haemoglobin concentration in blood and serum ferritin was assessed using an immunoassay to check iron status. Any women with signs or symptoms of acute inflammation in the last 7 days were excluded from the study.
The study found that of the 258 women, 170 were found to be anaemic. Of the 170, 105 were anaemic but owing to reasons of non-iron deficiency. “For them, iron folic acid tablets will be of no use,” said Saha.
“What we do not know from our study is the reason for non-iron deficiency anaemia. There could be multiple reasons – there can be red blood cell disorders, there can be B12 deficiency which is quite prevalent in Devbhoomi Dwarka … We plan to essentially scale up and do more such assessments in Dwarka among adolescent, pregnant and lactating women and then have some interventions to address the issue,” added Saha.
The AYUSH department on Wednesday had a meeting with regard to scaling up of similar assessment with grant from the department but at the moment the discussion has remained on paper and awaits a nod from the department, confirmed deputy director of research and training at AYUSH department Falgun Patel.
At present, Saha said, the health department’s nutrition cell has taken note and has shown interest to explore the study in greater detail.
Before translating the findings to effective policy-level change, Saha says a point-of-care device is required to be made available that can detect the serum ferritin levels on the field. “What we did for our study was take the samples and send it to a laboratory. You need laboratory access. We are now trying a point-of-care device that can be used during routine programmes on the field. This is a conceptual stage at present,” he adds.