1. Anemia in Pregnancy: Why such a big challenge? ( Uttar Pradesh: Rural Area: A Case Study of Intervention) Prakash V Kotecha, S. Muttoo, Anchita Patil, Rolf Klemm, Linda Tawfik, Zo Rambeloson A2Z, the USAID Micronutrient Project Contact: PVKOTECHA@YAHOO.CO.UK; PKOTECHA@AED.ORG PVKOTECHA@YAHOO.CO.UKPKOTECHA@AED.ORG Presentation at Second ESD Meeting at Bangkok 8 th March 2010

2. 2 Why Anemia and Why Uttar Pradesh, India? One in five maternal death is attributed to iron def anemia. In UP alone 28000 mothers die every year and that accounts for 75 maternal deaths every day 15 of them due to anemia… 30 times these figures are facing serious morbidities related to pregnancy Dr. Prakash V Kotecha Source: NFHS II 1998-99 NFHS III 2005-06 Anemia in Pregnancy: India & UP Population 190 million Districts73 Anemia in pregnancy Among highest SES group 52% 46% Three Antenatal checkups 36 % Anemia in children 6-3585% Mothers who consumed IFA for 90 days9% Electricity* Piped Drinking Water* supply 38 8 Source: NFHS III *DLHS III

3. 3 Technical Support in Three Districts of Uttar Pradesh: Anemia Control Package in Pregnancy Area covered 3 districts: 9 blocks: 1.Complete and early registration for ANC 2.Provide 100 IFA to ALL pregnant women with complete package of counseling (BCC as the focus) 3.Advice to provide and ensure the consumption of one extra meal 4.Deworming medicine after first trimester ALL pregnant mothers (ensure consumption) 5.Advice for Malaria control: IPT/Mosquito bednet/EDPT Dr. Prakash V Kotecha Policies & Guidelines: Systems Strengthening: Supplies and logistics, planning denominators, provider skills and tools, records, use of data. Capacity Building of front line and other workers, training, job aids etc through mentors BCC: Nutrition Health Days, home visits, community groups and leaders, local events. M&E: Baselines, routine data, LQAS, NFHS. Demand Creation: Print and Electronic Media and Folk Program

4. Progress and Lessons Learnt Anemia Prevalence and Severity declined and ANC coverage improved with focused intervention Improving Supply situation is the first key for success: both, procurement and logistics Compliance is the next issue that needed to be addressed, being able to provide effective counseling for BCC is crucial Dietary counseling important Dr. Prakash V Kotecha

5. What Worked Empowering Medical officers through (Self guide, a tools) Helping ANM to assist (Job Aid) for counseling, for complete registration, for stock for dietary advice Hand Holding aanganwadi workers of ICDS with the checklist for work that she is expected to do and provide check list Mentoring them to be able do these tasks by supportive supervision and provide help as required Demand Creation: Folk media, press and electronic media Institutional partners assistance including medical colleges & NGO Dr. Prakash V Kotecha

6. Critical Points Experienced Supply of Medicines: – Procurement (Country-State-District-Block-Beneficiary) – Adequacy – Timeliness – Logistic Compliance – Relative lack of importance for anemia as perception hardly exists..(provider and clients both) – Time availability by health workers for anemia (provider) – Priority for counseling vs other assignments (provider) – Capacity, conviction, understanding and desire to counsel Dr. Prakash V Kotecha

7. Anemia in Pregnancy & IFAS Basis of Management Iron deficiency is the main cause Adequate ANC (3 ANC) and sufficient IFA supplementation (90/100 IFA) will reduce/control anemia in pregnancy Dr. Prakash V Kotecha A2Z Countries: No data in 4 countries 100% 0.0% 7 Source: www.a2z.orgwww.a2z.org IFA Consumption Rate Anemia Prevalence

8. INDIA NFHS III: Anemia Vs IFAS Dr. Prakash V Kotecha 8 Source: NFHS III (2005-06)

9. Take Home Message 90/100 IFA tablets are recommended for PREVENTION of Anemia and is enough for additional requirement of iron for pregnancy for fetus, placenta and increased blood volume. With 100 IFA non anemic woman may remain non anemic during pregnancy. Anemic woman will NOT turn non anemic. We need to treat anemic women with higher dose than 100 IFA + Improved iron intake from diet + deworming where necessary. We will also have to address other causes of anemia Dr. Prakash V Kotecha 9