Iron Deficiency In Pregnant Women, Victoria University, Australia

HMG7130 Nutrition For Global Health

Title: Iron Deficiency In Pregnant Women In Low- And Middle-Income Countries.

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Introduction: Iron deficiency anaemia (IDA) is identified as a global nutritional epidemic characterized by depleted iron levels in the body. In the recent decade it has become alarmingly common in developing countries due to diverse factors. It is identified through the analysis of haemoglobin levels. Children under 10 years of age, pregnant women and elderly population are under high risk of Iron deficiency. World Health Organization described the gestational anaemia as less than 11g/dL and is one of significant causes of infant mortality rate and long-term deleterious effects in the children. Factors of iron deficiency are diverse including nutritional intake, haemolytic diseases, parasitic infections however, in this current essay only nutritional causes of iron deficiency are discussed. Low and middle-income countries (LMICs) reported highest number cases of anaemia in both general population and pregnant women and is now considered as a major public health problem and studies have shown the urgent need of preventative measures to mitigate the condition globally(Chowdhury et al., 2015)

Question 1. Outline the nutrition situation and identify the major nutrition issues in the population indicating which groups are most vulnerable and why.

Answer: World Health Organization (WHO), estimates a total of 1.5 billion people are affected by IDA with a 45% from South East Asian countries, 30% Africa, 7% in America, of which LMICs constitute around 97% of IDA cases (Pasricha et al., 2013). More than 50% of the cases reported are due to nutritional deficiency than due to other factors in pregnancy (Api et al., 2015). A cohort study conducted in the countries such as China, India, Zimbabwe reported at least 73% of women come under IDA category. Women were asymptomatic for most part of the chronic deficiency, the manifestation is only evident in advanced stages in the form of low weight gain, skin pallor and extreme fatigue with excessive water retention in the body. UNICEF reported 50,000 deaths due to IDA. IDA decreases the physical productivity attributed to the fatigue experienced by the individuals.

Diagnosis of IDA: Iron plays a crucial role in the transport of oxygen through haemoglobin. On an average an adult needs 15mg of iron per day. Laboratory testing of Haemoglobin has been the Gold standard to assess the degree of anaemia in the individuals. However, a relatively recent method of assessing serum ferritin levels is now considered as an adjunct diagnostic method for its reliability. Ferritin is a protein to which the iron binds and is available in the body. Haemoglobin (Hb) levels of 11g/dL during pregnancy indicate the existing anaemia. However, in some people the Hb values were found to be normal yet the symptoms of anaemia were observed. Upon further investigation the it has been shown that though Hb levels were adequate the storage reserves of iron are low. Hence, serum ferritin levels are equally significant in determining the presence of anaemic condition. Below 30 μg/L Serum ferritin levels represent anaemia (Api et al., 2015)

In a population cross-sectional surveys are ideal in determining the occurrence of a clinical condition. Samples from different sections of the society should be collected as a cluster-based sampling with at least 30 values from each cluster.

Question 2. What are the consequences of the nutrition problem. Consider health, social and economic consequences.

Answer: Health and socio-economic consequences: Iron is a crucial component in the metabolic processes. The wellbeing of the pregnant women and foetus is affected by IDA. Symptoms of IDA observed in Women include asphyxia, nausea, dizziness, blurred vision, increased heart rate to compensate the reduced oxygen supply to the foetus, dyspnoea. Reduced iron supply results in an increased risk towards perinatal infection. Psychological impact of these effects is undeniable (Pasricha et al., 2013). Health outcomes in the foetus include cognitive impairment, stunted growth, low birth weight, low immunity to infections, allergy. Studies have shown that the IDA in the initial months of pregnancy has drastic effects on the growth and cognitive development of the foetus than in the later stages.
Intrauterine IDA influences the iron levels in the new born as they are dependent on breastfeeding by mother. Long term consequences such as cognitive impairment in neural processes especially in myelination of neurons, stunted growth with improper height and weight gain, delayed progress in language skills and improper motor coordination. These difficulties in growth perpetuate into ill-social adaptability, stunted emotional maturity, low educational attainment and thereby negatively affecting economic productivity(Abu-Ouf and Jan, 2015).

In LMICs productivity is measured in the capacity of an individual to perform the daily tasks and earn income through manual labour. Socio-economic surveys revealed weakness, fatigue and cognitive impairment brought about by IDA interfere with the aerobic capacity of individuals, and energy efficiency thus reducing quality of work and an overall productivity by at least 50% causing economic losses both to the individuals as well as employer organizations(Moench-Pfanner et al., 2016)

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Question 3. Discuss and identify the causes of malnutrition (over or under) and state the level at which they act. Use the UNICEF Framework for Under-nutrition to map the cause of malnutrition.

Question 4. Consider how the various factors impacting on the nutrition situation are connected and how they are influenced by one another.

Question 5. Considering evidence-based interventions what are the priorities for action to address the identified nutrition problem?

Question 6. Identify and discuss a successful nutrition program in your population.

Question 7. Considering the UNICEF framework at what level does this program intervene?

Question 8. What are the key components that make this program successful and why?

Question 9. How does your program link with other programs in your population that aim to address the identified nutrition problem?

Question 10. What recommendations would you make to improve the program?

Answer: Factors of Iron deficiency: (UNICEF framework): 

Pregnancy is a period of extreme physiological stress on the body with the increased level of anabolic activities, hormonal changes, increased nutritional demands with a heavily altered body composition attributed to foetal development(Chowdhury et al., 2015). Major signs of IDA include low physical capacity, muscle cramps, intolerance towards colder temperature, vertigo (Api et al., 2015).

Diverse factors influence the abnormalities in iron levels in pregnant women. Post establishment of anaemia in an individual, the prevalence of other conditions should be considered such as, the initial concentration of iron in the body before pregnancy, any blood cell abnormalities such as thalassemia, and finally the inability to absorb iron during the digestion process (Osungbade and Oladunjoye, 2012, Chowdhury et al., 2015).

Women of reporductive age are prone to risk of anemia due to the regular menstrual bleeding. A preexisting low iron in the body are rapidly depleted due to the increased demands of expansion of foetus,

Level of educational attatinment is estimated to contribute to the care during the pregnancy, the higher the level of education the higher the levels of awareness that promoted adequate nutriion intake, practising proper hygiene, healthy behaviours towards self reducing the probability of anaemia cases. Socio-economic disparity in the LMICs is associated to reduced access to high quality nutrition, health care services to manage the symptoms. The geographical setting and the availability of vegetation resources contributed to the IDA (Van de Poel et al., 2007)

Role of social factors is undeniable as determining factors of overall health in a population. The mortality rate in emergency cases of childbirth is directly related to the availability of access to quality medical care equipment, antibiotics and intensive care units with skilled medical personnel. The increase in the life expectancy by 20th Century is attributed to the improved living conditions due to the technological advancements. However, medical care alone does not contribute to the health of the individuals instead improved sanitation, hygiene and awareness played a major role.Access to advanced medical care is reflects a higher social status of an individual. Racial discrimination within the same community results in the disparities in the access to the facilities and LMICs face the highest levels of disparity in distribution of Global resources.

Social rank or position, income, rank in the occupation influence the health outcome. Data showed that individuals belonging to a relatively higher position ranked better in health status due to their self-interest and society's cooperation.

Figure 1: UNICEF framework showing the causes of Iron deficiency anaemia at various levels.

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The relationship between the socio-economic factors and health outcomes is complex and often interconnected with many other factors such as psychosocial processes. Lack of proper housing leads to a general feeling of distress in the individuals and thus it also affects the pregnant women mentally promoting health risk behaviours such as smoking, substance use further affecting the development of the foetus. The allergens and pollution in such households expose the foetus to the harmful substances making it vulnerable to respiratory conditions such as asthma. Low income status of the mother can influence sleep patterns of mother also interfering with the foetal growth.
Availability of fresh food is scarce which decreases the bioavailability of micronutrients present in the food and diet alone is insufficient in providing the adequate iron. Presence of any existing familial conflict, emotional triggers, anxiety negatively influence the health status of pregnant mother which is also reported to interfere with the digestive process and absorption capacity of the nutrients.

Exposure to chronic stressors in the immediate physical environment affects the physiology of an individual in the form chronic inflammation, they are prone to cardiovascular disease (Braveman and Gottlieb, 2014)Influence of genetic factors and role of epigenetics is relatively recent development in analysing the effect of environment on the health. Cumulative disadvantage is observed in the cases of population in LMICs.

Treatment and preventative interventions: IDA treatment is specific to the severity of the condition in an individual. Oral iron therapy in the form of tablets is a common method in the mild cases of anaemia. With the oral therapy individuals often present complications in the form intolerance towards medications, non-adherence to the treatment regimen, insufficient results due to absorption issues. In the later stages of pregnancy IDA may require blood transfusion during childbirth as the Hb levels fall below 7g/dL. Severe cases require an effective modality of parenteral therapies such as Intravenous therapy (IV) and Intramuscular (IM). IValleviates the need for blood transfusion.

IM preparations iron sorbate and low-molecular weight iron dextran are available for therapy. However, there are many drawbacks associated with IM therapy as it places an individual at high risk for skin staining, abscess formation at the site of delivery and poor absorption rate.IV is a cost-effective alternative to oral and IM therapy with fewer side effects except for the extended hospital stay during the administration of the drugs.

Prevention strategies reduce the economic burden of IDA on LMICs with an increase health index. Major methods available for prevention of IDA include iron supplementation, fortification of foods, optimization of maternal intake, security of food quality,

Iron supplements: WHO recommends daily intake of iron and folic acid tablets as a measure in antenatal care to prevent low-weight births, maternal anaemia and ID. ID is usually considered as the last stage of iron deficiency anaemia i.e., the cellular deposits are estimated to be exhausted. Diet is an ideal source of iron. However, in LMICs poor nutritional intake is a common occurrence. The iron requirement during pregnancy rapidly increases in the first trimester slightly increasing towards second as a result of increased blood volume and again found to decrease in the third. The improper nutrition by pregnant women and low bio-availability in the foods cannot supply the required amounts of iron and hence they benefit from supplementation. The ideal dosage for non-anaemic women by International Nutritional Consultative Group is about 60mg per day for a period of six months.

Food fortification: Addition of iron to the staple foods is an ideal way of dealing with the non-compliance issues with oral supplements. Food fortification in wheat, rice, salt, sauces, have shown promising results in LMICs.

Anemia regulation programs: According the UNICEF framework the efficient strategies should be directed towards populations as a whole. A sustainable policy involving the local government and health agencies incorporating the mandatory consultations for pregnant women in the first few weeks of pregnancy, close monitoring and continuous evaluation of program outcome.Anaemia awareness programmes in the community and food choices to optimize the uptake of iron through diet, Local partnerships with the ration suppliers to distribute fortified foods.

WHO programmes included an iron and folic acid supplementation with an integration of antenatal and neonatal care that aims at improving the overall health of both mother and infant through regular visits to the local clinics. Communication regarding the benefits of a balanced diet, combinations of foods, iron supplements aiming at the change of attitude towards the health behaviours has shown to have positive outcomes in comparison to the mere distribution of medications.

Department of Nutrition for Health and Development collaborated with WHO to successfully implement the public health intervention in the case of micronutrient supplements. Policy makers, researchers and Civilians monitor the participation in this programme. Evaluation of the interventions is assured through the adaptation of standard guidelines,International Micronutrient Malnutrition Prevention and Control
(IMMPaCt) programme in collaboration with Centre for disease control CDC generated a generic micronutrient model that is highly adaptable according to the country and region to scale -up accordingly. Information regarding the implemented plan is shared on a global platform along with the recommendations to suggest the ideal strategy towards success(Guideline, 2012).

Effectiveness of the current modalities and Future recommendations: While many prophylactic measures are available a continuous assessment is needed to check the effectiveness of these programs.

Iron supplements were checked for their impact on the improvement in the Hb levels in the target population. Iron supplements may cause overdose due to excessive supplementation and gastrointestinal discomfort is due to rejection by the body(McMahon, 2010). WHO recommended dosages were based on the anaemic otherwise healthy population and does not consider the individuals with gastrointestinal disorders. The haematological status of the person is highly important while prescribing the daily intake of iron supplement to avoid the side effects. And a relatively less expensive and safer alternative is required to manage the cases of varying ethnicities, age, and health status

A study on Switzerland women displayed no difference in the effectiveness of oral therapy and IV in the maternal outcomes or infant health. An important observation made was on the general improvement in the health status of pregnant women was clinically insignificant and demanded a preventive measure to supply nutrients in the women of reproductive age at least six months before the conception. Although IV therapy promises a rapid correction of the existing anaemic condition it also presented complications and hence was recommended only to the population intolerant towards oral supplements.

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Food fortification showed a dramatic decrease in the number of anaemic cases reported in a study by Asibey-Berko et al. Fortification sugar and salt increased the iron stores in the body.

nfrastructure and managerial aspects at the end of distribution posed threat to the success of the World food programme (WFP). Funding required for the fortification processes and quality control were insufficient in attaining the target.

The success of any preventive programme is dependent upon the local staff. Lack of adequate skills in establishing a healthy relationship with the patients negatively affects the outcome. Some of these trainings involve the midwifery skills, CPR cardiopulmonary resuscitation of the mother and infant, blood specimen collection for the diagnosis, state of the art equipment for an accurate diagnosis of Hb levels, ferritin, Mean cell volume (MCV) and to further suggest a correct customised iron dosage. With a special emphasis on following the standard prenatal and antenatal guidelines.

Future recommendations of mass fortifications should aim at the general populations in prevention of anaemia (Osungbade and Oladunjoye, 2012).

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