by Neha Ramesh and Shambhavi Naik
Anemia incidence in India has escalated in 2020, necessitating mechanisms to control its
extraneous impact on not just children and adult health, but also to generational productivity.
Population-based studies on anemia in India are routinely conducted through the large-scale,
multi-round National Family Health Survey (NFHS). According to the recently published
State wise NFHS-5 Phase I (2019), anemia remains a pertinent problem that has seen a
drastic rise in particularly women of both rural and urban spheres. Between NFHS-4 (2016-
18) and NFHS-5 (2019-20), the number of anemic women in the 15-49 years age group in
India has increased to 58.8% from 54% with a corresponding figure of 16.2% in men.
Though there is a jump in anemia in men, it is important to note that anemia prevalence in
women is approximately double that of in men.
Chronic anemia in women is detrimental not only to the woman but also to fetal and child
development; it increases risk of prematurity, low birthweight, perinatal/ neonatal mortality.
Anemia in pregnant women physiologically manifests as stress, fatigue and reduction in some
cognitive abilities– these factors influence a mother’s ability to lactate, which in turn has a
lasting impact on the child’s nutritional intake and development. Iron deficiency anemia
contributes close to 6 lakh perinatal deaths and 1.2 lakh maternal deaths globally, creating a
clarion call for policy advancement or shift.
Primary reasons for disparity in anemia prevalence in men and women include childbirth and
menstruation. Menstrual losses are highly variable, ranging from 10 to 250 mL (4-100 mg of
iron) per period. Each healthy pregnancy is said to deplete the mother of approximately 500
mg of iron. NFHS-5 also raises another red flag by reporting the popular adoption of C-
Section style deliveries in government hospitals increasing from 23.6% in 2015-16 to 31.5%
in 2019-2020– the need for possible transfusion, high amount of blood loss in comparison to
a vaginal delivery and delayed postpartum recovery largely contributes to postpartum anemia
and potential development of early-onset anemia in the child. NFHS-5 also reports a fall in
mothers who consume folic acid tablets for 100 days or more (when pregnant) from 45.2% to
44.7%, with an even graver drop in mothers who consume IFA tablets for 180 days or more
(when pregnant) from 32.6% to 26.7%.
In the last two decades the prevalence of anemia among Indian women and children have
increased 20% more than world averages. India currently has a multitude of national and state
level schemes such as the integrated Child Development Services (ICDS), National
Nutritional Anaemia Prophylaxis Programme (NNAPP), Pradhan Mantri Surakshit Matritva
Abhiyan, Pradhan Mantri Matru Vandana Yojana and the Anaemia Mukt Bharat (AMB)
strategy, Muthapoorna, Ksheera Bhagya, SABLA to address nutritional requirement in
women and children. These schemes have had a significant impact on reducing cases of
anemia, however their progress has been impeded by low intervention during early
childhood, pregnancy, illiteracy, sanitation and socio-cultural misconceptions/ beliefs.
Anemia in India cannot be compared to Western nations, where there is access to affordable
fortified foods, such as breakfast cereals, supplemental iron and its targeted use for high-risk
groups, such as pregnant women, is better coordinated than in India. Furthermore, NFHS-5
has successfully been designed to identify various indicators in national, state and Union
Territory data; it still neglects a rural-urban breakdown that has the potential to shed light on
the efficacy of schemes on its target beneficiaries.
The increased incidence of anemia must be countered with a multipronged approach targeting
more than just its causal relationship with nutrition. While improvement in nutrition and
health interventions was the strongest driver of anemia reduction in children, improvements
in maternal schooling and socio-economic status (SES) were the key drivers of anemia
reduction in pregnant women. The clinical term “anaemia” in most states is seen to be
redefined by words colloquially used for general health ailments. An example of this, the
clinical term for “anemia” in Karnataka is ‘susthu, thalaisuthu, raktha heenathenot’
translating to ‘tiredness, dizziness and blood loss’. The lack of awareness is diluting the
severity and magnitude of generational implications of anemia. The existence of anemia is
directly linked to socio-cultural values and beliefs in various states. Furthermore, a large
proportion of women in India still follow patriarchal lifestyles such as eating last and eating
less and addressing traditional beliefs would be prudent to ameliorate health outcomes. The
potential negligence in acknowledging dietary preferences and traditional beliefs is a reason
that schemes haven’t reached full potential and its target beneficiaries. While positive
changes were observed in several states, others showed lack of improvement due to state
specific urban expansion, influx of migrant labor, increased vegetarianism and shifting
dietary landscape. The commencement of schemes need to be partially decentralised in order
to reckon with dietary preferences, geographical conditions and develop alternative foods.
Previous attempts to supply food supplements and diversify ration kits have proven to be
time-consuming, costly and cumbersome due to inefficient supply chains. The prudent
approach requires R&D investment into biofortification. Biofortification offers economically
remunerative options to cultivators and eliminates highly compound distributive chains.
Finally, a key determinant in the adoption of IFA supplements will be public engagement –
the government has to take a lead role in distributing IFA sources across all age groups of
women and encourage their consumption.
Addressing anemia in women is critical both for our current generation and for the health of
future generations. Breaking traditional beliefs, expanding nutritional delivery programmes
and extensive public engagement will be important to tackle this continued driver of poor
health in women.