This article is for someone who can understand medical language. Not recommended for a non-medical background.
We as a country have not been able to fight against anaemia. It’s a disease which is eating us from within. We are loosing far too many mothers to this white ghost.
Rising prevalence of anaemia in our country: Anemia is the most important indirect cause of maternal death and suffering in our country, each and every health care provider is aware of this fact. Then why are we taking so long to control it? Its been more than 50 years now since the efforts began. Our prevalence of anaemia is still around 60 %, some states even report close to 80% among pregnant and lactating women. (Iron deficiency is the most important cause)
The National Nutritional Anemia Control Program (NNACP) started way back in 1970, numerous other programs and strategies have been launched thereafter. But we still have almost the same prevalence of anaemia as earlier and we continue to lose our mothers to it. It’s high time we look closely and re-evaluate our strategy. Somewhere the plan is not working out. We have to look for better options.
Failure of the IFA programme: It has been found in one of the studies conducted by Parekh and Peggy et al in “Perceptions of anaemia and health-seeking behaviour among women in four Indian states Technical Working paper #9” That In North Haryana, although more than 90% of the pregnant women were receiving iron folate tablets at some point during pregnancy, only 10% of the women consumed the tablets regularly for the recommended duration of three months. (Similar findings were reported by Agarwal et al in Indian J Med Res2006:124:173-184 that Only 10% of women consume correctly) The reasons for low compliance in the working paper included: lack of knowledge of the importance of correcting anaemia, lack of understanding the purpose of iron-folate supplements, lack of time to obtain supplements, forgetfulness, unfamiliarity with the need to continue daily consumption for a minimum of 90-100 days, and side effect. Women do not seem to understand why it is important for them to consume the "red tablets" that are so widely promoted by their health providers and clinics. The low utilisation of antenatal services is another important factor in the high rates of anaemia among pregnant women in India. Majority of whom are registered in the late second or early third trimester of pregnancy.
Also in villages, women don't take a proper diet; they eat at last, whatever is leftover. Added to all this the illiteracy among our women is no less.
So till our women get educated and understand their body’s requirement for added nutrition and iron micronutrient supplementation. Till they start making independent decisions for themselves regarding their health, about taking early and adequate Antenatal care and care for the food they eat and medicines they should take. Until they get full control of their lives. We have to look for an alternative option to help them survive and live a better quality of life.
Fresh thinking at alternatives: Maybe its time now we look at options other than oral iron therapy. The new approach would be to catch them and treat them the moment we encounter them. Whatever be the gestational age if the haemoglobin % is less than 10 give them a push of iron sucrose 200mg iv in the same sitting. We don't know if she will turn up again before setting into labour. Iron sucrose is extremely beneficial even in the postpartum period! 200mg of elemental iron raises haemoglobin by 1gm %!
A recent meta-analysis by WHO 2004 shows that correcting anaemia of any severity reduces the risk of death: the risk of maternal mortality decreases by about 20% for each 1 gm% increase in Hb. This decreased risk is continuous over the full range of Hb between 5 and 12 but it is not linear- the decrease in risk is greater at the lower Hb concentrations.
So like two doses of TT if our women also get at least two shots of 200mg of iron sucrose direct intravenous push, we will make sure that we are improving her chances of survival even in the worst case scenarios.
There is ample evidence available now confirming the safety and efficacy of iron sucrose. It can be given in undiluted form direct intravenous route. Christian Breymann states that “With regard to the use of intravenous iron in obstetrics, there is increasing evidence that iron sucrose is safe for the mother and the fetus using the recommended dosages and therapy regimens. Whether it is reasonable to wait for a response to oral iron in moderate to severe anaemia is therefore questionable.” Divakar Manyonda et all also states that “The administration of iron sucrose by the bolus-push technique has similar efficacy to the conventional slow infusion technique.” Minor side effects like giddiness, itching and pain at injection site, are encountered but resolve rapidly.
The cost of this intervention is not very high, compared to blood transfusion and treatment of complications. Maybe down the line, our Government may even help us financially if it sees the tremendous difference that it can make to the health of our mothers.
Recommended schedule: After calculating the total iron requirement depending on present HB % and wt of the patient, multiple doses can be given till 11 gm % is achieved. (Calculation of total iron requirement = weight in kg x HB deficit x2.21 plus 500mg for depleted iron stores). Administer 200 mg slow injection (over 2-5 minutes) on 5 different occasions within a 14-day period. Total cumulative dose: 1000 mg in a 14-day period. The rate of administration should not exceed 20 mg per minute. A test dose is also not required and is at the physician’s discretion. Total dose infusion should not be given. Iron sucrose works very well in the treatment of postpartum anaemia. Repeated intermittent injections avoid the need for blood transfusion, and complications associated with it, in patients with severe to moderate anaemia.
Due to a number of social and economic constraints, our women may not be able to comply with the complete required care and treatment during pregnancy and puerperium. The IFA tablets have not worked for us. Our healthcare workers are experts in giving parenteral injections. Giving at least two doses of 200mg iron sucrose whenever possible, if not more, will surely make a difference in her ability to withstand the most amazing process of nature, labour. It may even give her and her baby a better chance of survival. There are many practitioners who have taken up the use of this intervention and have saved many lives already. So let us strike anaemia, where it strikes us the most, in the blood! .