Tackling Maternal Anaemia Saves Maternal and Infant Lives 34 TH SCIENTIF IC CONFERENCE OF NUTRITION SOCIETY OF MALAYSIA

Dr Faridah bt Abu Bakar

Public Health Physician & Director

Family Health Development Division

Outline • Current situation of anaemia and maternal anaemia

• Current indicators and target

• Impact of maternal anaemia

• Strategies to tackle maternal anaemia

• Challenges

• Way forward

WHAT IS Anaemia ?

Anaemia is a condition in which the number of red blood cells (and consequently their oxygen-carrying capacity) is insufficient to meet the body’s physiologic needs.

MATERNAL ANAEMIA

Anemia in pregnancy is defined as a hemoglobin concentration of less than 11 g/dL in venous blood.

The GLOBAL Burden of Anaemia

Anaemia is the world’s second leading cause of disability and thus one of the most serious global public health problems (WHO)

Global health problem that affects about 500 million women in 2011 ◦ 496 million non-pregnant women

◦ 32 million pregnant women Global, regional and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant women & non-

pregnant women for 1995-2011: a systematic analysis of population representative data, The Lancet 2013

The most recent estimates for 2016 indicate that anaemia affects 33% of women of reproductive age globally (about 613 million women between 15 and 49 years of age)

Why does ANAEMIA matter?

Impair physical capacity and

work performance

Reduce individual’s wellbeing

Fatigue and

lethargy

Impaired health and

quality of life

Impaired economic

productivity

Impaired development

and learning for children

Prevalence of Anaemia AMONG FEMALE in Malaysia

Women of reproductive age (15-49 years old)

(NHMS 2015)

Pregnant women – at any point during pregnancy

(NHMS 2016) 29% 34.7%

Milman N (2015) – Iron Deficiency And Anaemia In Pregnant Women in Malaysia – Still a Significant and Challenging Health Problem: J. Preg Child Health 2:

168. doi:10.4172/2376-127X.1000168

30.0%

Milman N (2015) – Iron Deficiency And Anaemia In Pregnant Women in Malaysia – Still a Significant and

Challenging Health Problem: J. Preg Child Health 2: 168. doi:10.4172/2376-127X.1000168

38%-42 %

Chethan et.al. 2017 - A Review On Anemia In Pregnancy Condition

Anaemic girls/women enters their reproductive age in an iron depleted state.

Why does ANAEMIA matter? – Girls and women at higher risk

Iron requirements in women throughout life-cycle

9 mg/ day 6 mg/ day 9 mg/ day 33 mg/ day *100 mg/day (non-anemic) 29 mg/day

11 mg/ day

11 mg/ day

Recommended Nutrients Intake For MALAYSIA, 2017 Note: Based On 10% Bioavailability

Nutritional iron deficiency anemia (IDA) is the

commonest cause of anaemia in pregnancy

WHAT CAUSES ANAEMIA IN PREGNANCY?

Nutritional deficiencies

Acute or chronic blood loss -GI bleeding

-heavy menses

Infections -Malaria

-HIV

Chronic diseases -renal failure

-neoplasia

Haemoglobinopathies -Sickle cell

-Thalassaemia

Parasites Physiological

adaptation

• An overall prevalence rate of anaemia in

pregnant mothers 57.4% - a study in Jerteh, Terengganu

• Poor compliance to haematinic intake by mothers was significantly associated with anaemia by the OR of 4.571

Nik Rosmawati et al, 2012 - The Rate and Risk Factors

for Anaemia among Pregnant Mothers in Jerteh Terengganu, Malaysia NH Nik Rosmawati1

Impact of Maternal Anaemia

Mother

Infant

• Increased risk of maternal death • Increased risk of PPH, decreased ability to

tolerate blood loss • Increased risk of sepsis • Heart failure during postpartum • decreased quality of life- increased fatigue,

breathlessness, palpitations and infections • greater stress and depression • less responsive, more controlling and more

“negative” towards their infants negative implications for infant development

• Increased perinatal morbidity and mortality

• SGA, LBW, Preterm birth • Increased risk of developing diabetes and cardiac

disease later in life • Lower iron status in infants • Impaired cognitive developments

Quality Assurance Indicator ◦ National Indicator Approach (NIA) – adopted as QAP in 2013 ◦ State/District Specific Approach ◦ Prevention and control programme for anaemia

◦ Percentage of anaemia among pregnant women at 36 weeks

Family planning programme ◦ for birth spacing using modern contraceptive, exclusive breastfeeding

Health Promotion to mothers/patient ◦ Healthy diet advice ◦ Cooking demonstration ◦ Self-hygiene

Strategies to tackle maternal anaemia

National Indicator Approach for Maternal Anemia

• Quality Assurance Programme - National Indicator Approach (NIA)

• Indicator : Percentage of anemic mothers (Hb<11gm%) at 36 weeks of gestation

NIA: Percentage of women with anaemia at 36 weeks gestation

32.6

28.9 26.7

24 21.5 20.8

16.2 14

11.8 9.1 8.2

7 6.4 6.4

0

5

10

15

20

25

30

35

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

%

Year Health Informatics Centre MOH 2005 - 2018

Percentage of women with anaemia

(Hb<11gm%) at 36 weeks of gestation : Malaysia

2017 & 2018

P'lis Kdah P.Pnang Perak KL P'jaya S'gor N9 Mlaka Jhor Phang Tganu Klntan Lbuan Sbah Srwk M'siaSem.Mal

aysiaMalaysia

Timur

2017 19.2 4.5 5.0 6.1 5.0 7.8 4.8 9.2 12.0 4.7 4.7 3.6 6.2 6.5 10.4 10.0 6.4 5.5 10.2

2018 16.4 4.4 4.5 9.2 3.8 6.8 5.3 12.3 13.8 3.7 4.2 3.2 5.3 9.3 10.9 6.9 6.4 5.8 9.3

19

.2

4.5

5.0

6.1

5.0

7.8

4.8

9.2

12

.0

4.7

4.7

3.6

6.2

6.5

10

.4

10

.0

6.4

5.5

10

.2

16

.4

4.4

4.5

9.2

3.8

6.8

5.3

12

.3 1

3.8

3.7

4.2

3.2

5.3

9.3

10

.9

6.9

6.4

5.8

9.3

0.0

5.0

10.0

15.0

20.0

25.0

2017 2018

Strategies to tackle maternal anaemia

Pre-pregnancy care ◦ Intervention of anaemia among women of reproductive age (adolescents and

menstruating women) before embarking on pregnancy

Supplementations for pregnant women and postpartum mothers ◦ Intermittent iron and folate supplementations among pregnant women even

with normal haemoglobin level

Comprehensive management of anemia in pregnancy and postpartum ◦ Multidisciplinary involvement ◦ Close monitoring of haemoglobin level throughout pregnancy and postnatal, and

among family planning users

National Control and Prevention Programme of Thalassemia ◦ To combat non-nutritional anaemia

Percentage of women with anaemia during 1st Antenatal Visit 2009-2015

22.1

29.3

65.1 66.9

31.1

16.6 14.6

0

10

20

30

40

50

60

70

80

2009 2010 2011 2012 2013 2014 2015

%

YEAR

National Obstetrics Registry (Malaysia) 2009 – 2015

Percentage of women with anaemia during admission for delivery 2009-2015

7.3 6.08

24.3 25.2

13

5.6 5.3

0

5

10

15

20

25

30

2009 2010 2011 2012 2013 2014 2015

%

Year

National Obstetrics Registry (Malaysia) 2009 – 2015

Percentage of Anaemia at Booking1, 36 Weeks2 POG & at Delivery1

22.1

29.3

65.1 66.9

31.1

16.6 14.6

21.5 20.8 16.2 14 11.8

9.1 8.2 7.3 6.08

24.3 25.2

13

5.6 5.3

0

10

20

30

40

50

60

70

80

2009 2010 2011 2012 2013 2014 2015

%

Booking

36 weeks

Delivery

1National Obstetrics Registry 2009 – 2015 2Health Informatics Centre MOH 2009-2015

Early Antenatal Booking (less than 12 weeks POG) 2011-2018

66.2

71.2

75.6

79.1 78.4

82.51 83.6

75.6

2011 2012 2013 2014 2015 2016 2017 2018p

Source of data : Health Informatics Centre, MOH

target >70% Early ANC (NHMS2016) 69.1% : 1st Trimester 28.5% : 2nd Trimester

Milman N (2015) – Iron Deficiency And Anaemia In Pregnant Women in Malaysia – review paper – concluded that …’efforts should focus on better implementation of early oral iron and vitamin prophylaxis, early diagnosis of anaemia and on increasing the low compliance women to the prophylaxis program”

No. of clinic equipped with: - Haematology analyser :

660 (61%) - Heamoglobin Analyser

(100%) Quality Assurance for Haematology Analyser: - Internal Quality Control

(IQC) - External Quality Assurance

(EQA)

2016 2017 2018

Male students 2.8 2.7 3.2

Female Students 15.8 17.8 19.3

2.8 2.7 3.2

15.8

17.8 19.3

0

5

10

15

20

25

Pe

rce

nta

ge o

f A

ne

mia

det

ect

ed

Percentage of Anaemia Detected among Form 4 (16yr old) Thalassaemia Screening 2016 - 2018

PerlisKeda

h

PulauPinan

gPerak

Selangor

WPKL

WPPutrajaya

NSembilan

Melaka

JohorPaha

ng

Terengga

nu

Kelantan

Sabah

Sarawak

WPLabu

an

Malaysia

Male Students 4.3 2.5 3.0 3.7 3.2 3.4 2.8 4.8 3.1 2.9 2.2 2.8 2.9 3.1 1.8 1.1 2.9

Female Students 23.5 18.7 19.1 18.6 20.2 17.5 19.8 22.8 19.2 19.4 17.2 14.5 16.0 22.2 13.1 26.0 18.6

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Pe

rce

nta

ge

Percentage Anaemia detected by Gender by State 2017

Prevalence of Anaemia AMONG FEMALE in Malaysia (various years and sources)

Pregnant women at 36

weeks in government

clinics (PIK 2015)

Women of reproductive

age (NHMS 2015)

Pregnant women

(NHMS 2016)

8.2%

29%

34.7%

Female Adolescent (16 year old school girls) (Thalassemia Screening

Program 2017)

17.8%

Anaemia at booking

(NOR) 2015

Anaemia at

delivery (NOR 2015)

14.6% 5.3%

Selected citations on impact of maternal anaemia

Linear association between maternal anaemia and death

◦ With each 1g/dL increase in maternal haemoglobin associated with a 29% reduction in maternal mortality.

Maternal and child undernutrition and overweight in low-income and middle-income countries, The Lancet 2013

Severe anaemia (Hb <7 g/dL) during pregnancy and postpartum doubled the risk of maternal death

Risk of maternal mortality in women with severe anaemia during pregnancy and postpartum : a multilevel analysis (WHO Multi-country

Survey), The Lancet 2018

Correlation of the prevalence of anemia in women and

maternal mortality ratios

THE JOURNAL OF NUTRITION, VOLUME 131, ISSUE 2, FEBRUARY 2001, PAGES 604S–615S, HTTPS://DOI.ORG/10.1093/JN/131.2.604S

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

Post PartumHeaemorrhage

HypertensiveDisorder inPregnancy

PulmonaryEmbolism

Amniotic FluidEmbolism

Ectopic pregnancy

Associated MedicalConditions

ROLLING 3-YEAR AVERAGE CAUSE SPECIFIC MMR Per 100,000 LB FOR COMMON CAUSES OF DEATH : MALAYSIA, 2000 – 2016

Source of data : BPKK

“The results showed that the relationship between anemia in the first trimester and SGA was significant .

However, the results showed that the overall relationship between anemia during pregnancy and SGA was not significant.”

Badfar et.al, 2019 - Maternal anemia during pregnancy and small for gestational age: a systematic review and meta-analysis

Selected citations on impact of maternal anaemia to newborn

Inadequate iron supply may have a negative impact on the growing fetal brain and permanently impair the psychomotor development of the newborn child

-GranthamMc-Gregor et al 2001 – A review of studies on the effect of iron deficiency on cognitive development in children

• No difference noted for hemoglobin level at booking in between cases and control group • Predictors of LBW infants: Younger maternal age, history of LBW infants, prematurity and hypertension

Long term effect on the baby

Global indicators

WHO GLOBAL NUTRITION TARGET

50% reduction in anaemia in women of reproductive age by 2025 from baseline of 2010

SDG TARGET 2.2 :

By 2030, to end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons.

Indicator : Percentage of women in reproductive age (15-49) with anaemia

WHO Recommended Actions - Global Targets 2025 – To improve maternal, infant and young child nutrition

Integrated Planning • Address nutritional and non-nutritional causes of anaemia • Include interventions with an effect on anaemia in national health,

education, agriculture and development plans

Multi-sectoral Approach • Use a multi-sectoral approach to anaemia prevention and control • Ensure that development policies and programmes beyond the

health sector

Strengthen Health Systems • Provide hospital and health facilities-based capacity for anaemia prevention and treatment

• Support antenatal iron and folic acid supplementaton as part of routine antenatal care

Community Support • Raise awareness of the value of iron supplementation in women of reproductive age

• Support community mobilisation and social marketing strategies

Challenges in tackling maternal anaemia..

• Require comprehensive & holistic interventions as anaemia is multifactorial • Early intervention & promotion of healthy eating before pregnant/ in homes/

schools/community

• Hard-to-reach individuals - The greatest burden of anaemia falls on the most "hard-to-reach" individuals, any programme that aims to reduce anaemia will need to be accessible by these groups

• Patient factors • Socioeconomic and contextual/ecological determinants factors, with many acting

simultaneously

• Compliance to iron supplementation is still the major issue

• Non-nutritional anaemia – a portion of anaemia cases will not be caused by iron

Way forward

• Intervention before conception – strengthen pre-pregnancy care services

• Life-course approach - break the intergenerational cycle of nutritional deficiency

• Holistic Interventions • Tackle social determinants • Inter-sectoral collaboration

Critical window of opportunity from conception to 2 years of age (the first 1000 days of life)

Before

1000

days

PPC

OPTIMISE

Thank you