Shooting shadows: India's struggle to reduce the burden of anaemia.

Despite several efforts by the Government of India, the national burden of anaemia remains high and its growing prevalence (between 2015-2016 and 2019-2021) is concerning to India's public health system. This article reviews existing food-based and clinical strategies to mitigate the anaemia burden and why they are premature and insufficient. In a context where multiple anaemia control programmes are in play, this article proposes a threefold strategy for consideration. First, except the Comprehensive National Nutrition Survey, 2016-2018, which measured Hb concentration among children and adolescents aged 1-19 years using venous blood samples, all national surveys use capillary blood samples to determine Hb levels, which could be erroneous. The Indian government should prioritise conducting a nationwide survey for estimating the burden of anaemia and its clinical determinants for all age groups using venous blood samples. Second, without deciding the appropriate dose of Fe needed for an individual, food fortification programmes that are often compounded with layering of other micronutrients could be harmful and further research on this issue is needed. Same is true for the pharmacological intervention of Fe tablet or syrup supplementation programmes, which is given to individuals without assessing its need. In addition, there is a dire need for robust research to understand both the long-term benefit and side effects of Fe supplementation programmes. Third and final, the WHO is in process of reviewing the Hb threshold for defining anaemia, therefore the introduction of new anaemia control programmes should be restrained.

Population-level effective coverage of adolescent weekly iron and folic acid supplementation is low in rural West Bengal, India.

OBJECTIVE: To assess the coverage of the adolescent weekly iron and folic acid supplementation (WIFS) programme in rural West Bengal, India. DESIGN: We conducted a population-based cross-sectional survey of intended WIFS programme beneficiaries (in-school adolescent girls and boys and out-of-school adolescent girls). SETTING: Birbhum Health and Demographic Surveillance System. PARTICIPANTS: A total of 4448 adolescents 10-19 years of age participated in the study. RESULTS: The percentage of adolescents who reported taking four WIFS tablets during the last month as intended by the national programme was 9·4 % among in-school girls, 7·1 % for in-school boys and 2·3 % for out-of-school girls. The low effective coverage was due to the combination of large deficits in WIFS provision and poor adherence. A large proportion of adolescents reported they were not provided any WIFS tablets in the last month: 61·7 % of in-school girls, 73·3 % of in-school boys and 97·1 % of out-of-school girls. In terms of adherence, only 41·6 % of in-school girls, 38·1 % of in-school boys and 47·4 % of out-of-school girls reported that they consumed all WIFS tablets they received. Counselling from teachers, administrators and school staff was the primary reason adolescents reported taking WIFS tablets, whereas the major reasons for non-adherence were lack of perceived benefit, peer suggestion not to take WIFS and a reported history of side effects. CONCLUSIONS: The effective coverage of the WIFS programme for in-school adolescents and out-of-school adolescent girls is low in rural Birbhum. Integrated supply- and demand-side strategies appear to be necessary to increase the effective coverage and potential benefits of the WIFS programme.

The burden of iron-deficiency anaemia among women in India: how have iron and folic acid interventions fared?

Iron-deficiency anaemia (IDA) among women in India is a problem of major public health significance. Using data from three waves of the National Family Health Survey, this article discusses the burden of and trend in IDA among women in India, and discusses the level of iron and folic acid (IFA) supplementation and its potential role in reducing the burden of IDA. Between 2005-2006 and 2015-2016, IDA in India decreased by only 3.5 percentage points (from 56.5% in 2005-2006 to 53.0% in 2015-2016) for women aged 15-49 years. However, during the same period, of 27 states compared, IDA increased in eight: Delhi, Haryana, Himachal Pradesh, Kerala, Meghalaya, Tamil Nadu, Punjab and Uttar Pradesh; furthermore, some of these (e.g. Kerala) are states that rank among the highest on the state Human Development Index but had failed to contain the burden of IDA. Although there is a standard guideline for IFA supplementation in place, the IFA intervention appears to be ineffective in reducing the burden of IDA in India (nationally only 30.3 % of mothers consumed IFA for 100 days or more when they were pregnant), probably due to irregular consumption of IFA where the provision of screening under the National Iron+ Initiative scheme appears to be unsuccessful. To strengthen the IFA intervention and its uptake, a concerted effort of community-level health workers (accredited social health activists, auxiliary nurse midwives and anganwadi workers) is urgently needed. In addition, food-based strategies (dietary diversification and food fortification), food supplementation and improvement of health services are required to reduce the burden of anaemia among women in India.

Determinants of Skilled Delivery Assistance in a Rural Population: Findings from an HDSS Site of Rural West Bengal, India.

OBJECTIVE: This study examines the determinants of utilisation of skilled birth attendants (SBAs) amongst 2886 rural women in the state of West Bengal, India, using data from a survey of 2012-2013 conducted by the Birbhum Health and Demographic Surveillance System. METHOD: Multilevel logit regression models were estimated and qualitative investigations conducted to understand the determinants of utilisation of SBAs in rural West Bengal. RESULTS: Among women who delivered their last child during the 3 years preceding the survey, 69.1 % of deliveries were assisted by SBAs, while 30.9 % were home deliveries without any SBA assistance. Multivariate analysis revealed that apart from socio-demographic and economic factors (such as household affluence, women's education, birth order, uptake of comprehensive ANC check-ups, advice regarding danger signs of pregnancy and household's socio-religious affiliation), supply side factors, such as availability of skilled birth attendants in the village and all-weather roads, have significant effect on seeking skilled assistance. Our findings also show that unobserved factors at village level independently influence uptake of SBA-assisted delivery. CONCLUSIONS FOR PRACTICE: The present findings emphasise that both demand and supply side intervention strategies are essential prerequisites to enhance skilled birth attendance. Ample communication is observed at the individual level, but improving community level outreach and advocacy activities could generate further demand. SBAs can be better integrated by accommodating the socio-religious needs of local communities, such as providing female doctors and doctors with similar socio-religious backgrounds.