Association of the Iron Deficiency Anaemia on Maternal Mortality and Morbidity - Term Paper Example

Association of the Iron Deficiency Anaemia on Maternal Mortality and Morbidity In Developing Countries Iron deficiency, like most nutritional deficiencies of public health concern, is mainly a consequence of poverty (WHO 2001, p.47). i. Introduction to Nutrition in Developing Countries Children’s deaths in developing countries are commonly attributed to diarrhoeal and respiratory disease that are unlikely to happen in well-nourished children. It is therefore significant that these and other clinical nutritional disorders are usually triggered by incidents of infectious disease overlaid on an already inadequate diet brought about by extreme poverty. “Poverty takes many forms and is expressed in many ways” (Latham 1997, p.1). In the world today, every age group is vulnerable to iron deficiency anaemia and it remains as one of most critical and significant nutritional inadequacy that can deteriorate the cognitive development of children from formative years through to adolescence. Furthermore, it does not only impair cognitive functions but it is associated with increased morbidity rates and numerous adverse effects for both mother and infant during pregnancy. These include an increased risk of maternal and prenatal mortality, low birth weight, sepsis, and haemorrhage. The discussion on this paper will focus on the prevalence of this dreaded disease in developing countries, the nutritional status of women, infants, and children. It will also go through some issues of screening, diagnostic, treatment, and prevention, and finally conclude in the overall assessment of iron deficiency anaemia in developing countries. ii. Iron Deficiency According to WHO (2001, p.14), the majority of women to some extent are iron deficient and more than half of pregnant women in developing countries suffers from anaemia. In addition, iron deficiency is responsible to 30% of men and women’s physical work capacity and performance impairment, and for some reason it is not limited to the underprivileged areas alone as iron stores of most pregnant women in industrialized nations were deficient. Moreover, iron deficiency is a condition that is of “both age and gender specific” (Mathers and Tanuja 2002, p.5). It is estimated that around two billion people around the world are suffering from anaemia (USAID 2006, p.1) and one for every 5 persons in developing countries are “chronically undernourished” ( Latham 1997, p.1). Iron deficiency, based on the reported prevalence of iron deficiency anaemia in developing countries seems to emerge from infancy. In a test conducted in Costa Rica and Chile, the cognitive performance of children with moderate anaemia is significantly lower than those who were non-anaemic during infancy. An estimated 30 to 80% of pre-school children in developing countries are anaemic at 1 year of age compared to 10 to 20% in industrialized countries. These underprivileged children will have a 5 to 10 deficit in IQ since their delayed psychomotor development will negatively affect their performance when they reach school age. Consequently, morbidity from infectious disease increases as immunity deteriorates due to the adverse effect of iron deficiency. Work capacity of various workers in Columbia, Indonesia, and Sri Lanka has also been reported to be lower than with iron supplement. Moreover, anaemic female workers in China are 15% less efficient in their work compared to non-anaemic women. They had 4% lower maximal work capacity and 12% lower overall productivity compared to levels achieved after iron deficiency treatment. In pregnancy, 40% of all maternal prenatal deaths are caused by anaemia and favourable pregnancy outcomes for anaemic mothers are 30 to 45% less likely to occur. In addition, their infants will often have less than ½ iron reserves than normal, which as a result require more iron supplement from breast milk than infants with normal birth weight do. Lastly, women and infants will suffer all the detriments of iron deficiency effects discussed earlier if no medication is undertaken to rectify this pregnancy-generated inadequacy (WHO 2001, p.9). iii. Prevalence Iron Deficiency Anaemia in Developing Countries Iron deficiency anaemia is ubiquitous in poor countries as this impairs individual health and self-gratification hence it also spoils national socioeconomic development. Apparently, a society with lower income generating capacity or “financial difficulties” (Berg-Warman and Brodsky 2004, p.2) caused by iron deficiency impairment, more often leads to malnutrition that would later transform to higher rates of such disease. This vicious cycle is harming every individual in the community as well as the overall socioeconomic development of a country. This is the reason why anaemia is predominantly widespread in most part of south Asia. In India, for instance, 88% of pregnant and 74% of non-pregnant women are affected. In Africa, 50% of pregnant women are anaemic and in the Caribbean, prevalence of anaemia is as high as 60% in most pregnant women in some islands (WHO 2002, p.17). In Cambodia, anaemia prevalence among pregnant women is 57% and 50% of anaemia is caused by iron deficiency (NMCHC, 2007, p.1). Although data of anaemia pervasiveness for various age groups are not accessible, prevalence rate involving preschool children is in general analogous at 75% (Zlotkin et. al. 2004, p.1015) and (Mathers and Tanuja 2002, p.7) or greater than the rate among pregnant women. In addition, epidemiological mapping confirms the prevalence of anaemia among pregnant women in industrialized countries to only around 20% thus indicating higher anaemia prevalence in poorer countries (WHO 2002, p.17). iv. Iron Deficiency in Pregnant Women, Infants Mortality/Morbidity, and Children Iron deficient women even those that are non-anaemic, suffer increased risk of associated complications during pregnancy. These include urinary tract infections, pyelonephritis, pre-emclampsia, and iron deficiency anaemia. Anaemia, which is determined by low haemoglobin concentration or hematocrit prevalent among women, contributes to maternal and poor pregnancy outcomes such as foetal abnormality and death (Sholl and Hediger 1994, p.4). Maternal mortality and morbidity are the most adverse of effects of anaemia. In a report, maternal mortality in developing countries such as India and Pakistan is in the range of 27 to 194 deaths per 100,000 births. In Indonesia, maternal mortality rate for women is 70 out 10,000 deliveries which is much higher than 19 for every 10,000 deliveries for non-anaemic mothers (Allen 2000, p.2). Severe anaemia makes women less resistant to infections that often cause morbidity and increases the risk of women to pass away to during childbirth. UNICEF estimated women’s death to around 50,000 a year during childbirth (Bendich 2005, 905). In addition, it can also greatly affect infants to premature morbidity risks (Reed et. al. 2000, p.15). The detriment of anaemia in pregnancy is severe, dropping a woman’s capability to endure bleeding during and after delivery (postpartum haemorrhage). Anaemia not only may result in premature or lower birth weight babies but also contributes the higher risk of death and cause weakness, fatigue and reduced physical ability to work (NMCHC 2007, p.6). Zlotkin et. al. (2004, p.1016), reported lost of productivity at work due to childhood anaemia to the country’s GDP is 4.5%. v. Health Issues in Iron Deficiency Anaemia a. Diagnostic and Early Detection of Iron Deficiency Anaemia Punctual recognition of anaemia at the earliest stage is critical to avoid further complications that may lead to high-output heart failure. The severity of anaemia is a major risk factor associated with greatly increased morbidity and mortality for young children and pregnant women thus early detection and treatment are necessary. In the absence of laboratory haemoglobin test particularly in resource-poor setting, clinical assessment may be done by detecting significant signs (clinical indicators) of pallor or paleness in the eyelids, palms, nail beds, and tongue of subjects. The primary objective of screening is to recognize a high-risk subject sooner before life-threatening complications begins (WHO 2001, p.34). On the other hand, the haemoglobinometry for population-based determination of anaemia prevalence is comparatively simple and economical than biochemical iodine and Vitamin A deficiency assessment. Cyanmethemoglobin method and Hemocue system are generally recommended for this type of anaemia prevalence surveys. In pregnancy however, Ferritin is considered the norm for diagnosis since low haemoglobin and haematocrit together with a low serum ferritin concentration indicate iron deficiency anaemia, which is considered the most serious phase of iron depletion. Low serum ferritin seems limited to pregnant women as other anaemia cases are not characterized by low ferritin concentrations (Fischer et. al. 1992, p.987). For better comprehension, Fischer et. al. (1992) explains that iron deficiency anaemia is measured by the occurrence of microcytic red cells discernible as an MCV (Mean Corpuscular Volume). The MCV of red blood cells normally decreased when anaemia is caused by iron depletion. However, although MCV alone cannot stand as a decisive factor for iron deficiency anaemia in pregnancy, test results reveal most anaemic women do have lower MCV than non-anaemic women. For instance, the average MCV of anaemic women with low serum ferritin concentration is 81.5 fL., which is significantly lower than non-anaemic women and anaemic women with high concentrations of serum ferritin or other causes of anaemia (Fischer et. al. 1992, p.986). Iron deficiency anaemia in pregnancy is considered the result of inadequate iron-containing food intake since the bulk of anaemia cases during pregnancy are not from other causes such as infection, chronic disease, and an effect of hemodilution (an increased in the quantity of plasma resulting in lower concentration of red blood cells in blood). b. Screening and Treatment Treatment of iron deficiency varies depending on the levels of haemoglobin or haematocrit after oral iron supplementation. As a general indicator, an increase of at least 10 g/l in haemoglobin or 0.03 l/l in haemotocrit after 1 or 2 months of iron supplementation is a sign of iron deficiency. According to Miere (2003) report, iron supplementation reduced the incidence of iron deficiency anaemia and augment iron status during pregnancy (32). However, in areas where numerous causes of anaemia exist, combining iron and vitamin A as supplements for pregnant women can greatly reduce anaemia. This conclusion originates from the result of a survey conducted in Indonesia where 97% of pregnant women responded favourably and became non-anaemic from to the combine iron and vitamin A supplementation (WHO 2002, p.42) and (Reed 2003, p.16). Treatments involving iron supplement requires careful assessment as preventing anaemia and correcting already established iron deficiency anaemia calls for dissimilar approach. For instance, supplementation to prevent iron deficiency without anaemia needs novel approaches in order to provide appropriate preventive supplements to groups at risk. These approaches can be community-based initiatives and programmes pointing towards delivery of supplements in a regular basis. Alternatively, Therapeutic supplementation, ferrous sulphate 30mg 3 times a day (Meier 2003, p.31), for correcting active iron deficiency anaemia remains part of the health care delivery system that can carry out intensive diagnostic and treatment (WHO 2001, p.57). According to Reynolds and Wright (2004, p.3), health care particularly maternal related care are influenced by various factors. For instance, delays in detection of complication, hesitation to seek care, and sufficient health facilities are recognized as primary obstacles for pregnant women’s care. In developing countries similar Bangladesh and Nigeria, pregnant women are reluctant to make decisions to use medical care as they often favour traditional birth attendants. In Cambodia, a report positively recorded an increase in the number of women accessing pre-natal care along with a considerable increase in distribution of iron folate. In addition, an estimated 63% of pregnant women are receiving iron tablets during pregnancy. This figure is higher by 43% compared to the 2000 report (NMCHC, 2007, p.1). This report is supported by another study confirming the provision of iron supplements as a key strategy for reaching target populations at high risk of iron deficiency. Normally, iron supplements are being administered to women during pregnancy to prevent maternal anaemia and to provide adequate iron to meet the needs of the foetus. On the other hand, little attention has been given to the requirements of other vulnerable groups, such as infants, young children, adolescents and the elderly. In poor countries, these groups are also at increased risk of iron deficiency and strategies necessary to serve them efficiently (Yip 2002, p. 856S). Treatment of anaemia caused by iron deficiency is most of the time life threatening and normally it cannot be cured by mere dietary intake. For effective treatment, improved diets and eating habits, proper hygiene, and sanitation practices, parasite removal and other body cleansing should accompany iron supplements, which must be in the form of ferrous sulphate. A good technique in oral iron supplement intake is to them with an empty stomach to maximize iron absorption. On the other hand, not all people can stand this approach and may prepare to take iron supplement with their daily meal. The problem with taking iron supplement and food at the same time is the fact that milk and antacids interferes with the body’s absorption of iron. It is much better to take Vitamin C supplements or Vitamin C rich food with iron supplement, as it will boost iron absorption and at the same time help in the production of haemoglobin. More importantly, iron supplement during pregnancy and lactation is necessary, as normal dietary intake of iron-rich food is enough to cover the amount of iron required for the mother and the developing foetus (UNICEF 2002, p.5). For 2 months after delivery, iron supplementation should continue to let haematocrit return to its normal level. However, to bring back the body’s required iron stores, predominantly in the bone marrow, iron tablets intake should continue for at least six months. In a different situation, patients should be given intravenous iron when oral supplementation is not tolerated. Some may require blood transfusion if the anaemia is so severe but this will increase the risk of shock or death as patients with long-term iron deficiency will be upset by the abrupt increase of iron in the blood. In addition, unlike mild anaemia, repetition of nutritional anaemia is possible and anaemic persons are usually susceptible to infections and therefore require consistent observations (UNICEF 2002, p.5). Although iron supplements are important to prevent or cure iron deficiency, care in iron supplementation should be regulated to avoid severe implications. In ICMR (2000, p.2) study in the implication of iron supplements suggests that iron absorption is a highly regulated process as the small intestine retains a large fraction of unabsorbed supplemented dose. In addition, clinical studies suggest that irregular intake of iron supplements is comparably beneficial to daily supplementation. The reason is whenever the intestine is continually exposed to high doses of iron absorption is reduced considerably. Therefore, iron should be supplemented in a regulated phase so as not to upset the intestines absorptive cells. In another situation, while the relationship between haemoglobin levels and pregnancy outcome is evident, exposing the intestine to large amount of iron supplements can generate free radical via the Fenton reaction leading to peroxidative damage of the tissue. Free radicals alter the structure and function of the absorptive microvill and therefore to reduce the effect oxidative human stress, it is suggested that iron supplementation should be accompanied with antioxidants like Vitamin C and E. c. Prevention of Iron Deficiency Anaemia UNICEF describes Nutritional Anaemia as a “condition in which the haemoglobin or red blood cell content of the blood is lower than normal because of too little iron and is the most common anaemia in South Asia”. Considerable small amount of iron in the diet combined with inefficient body absorption of iron, lost of blood in serious menstrual bleeding, and lead poisoning in children is the common source of iron deficiency. Anaemia coming from the lack of nourishment in the body develops gradually after the normal iron content of the body and the bone marrow run down. The reason why most women suffer iron deficiency anaemia is the reality that women biologically stores less quantities of iron than men. Therefore, a considerable loss of blood through heavy menstruation, long-term aspirin used, colon and uterine cancer, bleeding ulcers, parasite infections, and repeated blood donations put them at higher risk of nutritional anaemia. The most vulnerable group are pregnant women, infants, children, adolescents, and people with insufficient dietary iron intake through diets with no meat or eggs for a number of years. Malnutrition is a cycle and thus its effects spread through generations. Once the mother is nutritionally deficient, the children or even her grandchildren are likely suffer the same scarcity To break the cycle of malnutrition and to enhance nutrition, people particularly women and girls (child-bearing and reproduction) must be able to have better access to healthy foods and health care in all stages of the cycle. Women should be in good health and with high nutritional status since there are the primary caregivers of the whole family. Therefore, a new baby’s good start in life depends on how well is the health and nutrition of his/here mother when she was a girl and her maternal years. An effective for programme to prevent malnutrition must focus on the nutritional status of the infant, the adolescent, the mother, and the grandmother (UNICEF 2002, p.4). In addition, children with two years of age are at higher risk for iron deficiency and iron deficiency anaemia as their “growth spurts” (NAAC 2005, p.1) makes their iron requirements similar to an adult. Therefore, they should have substantial food intake to sustain their iron requirements. Unfortunately, most infants and young children in developing countries, foods like cereal are low in iron content and bioavailability. Moreover, even if their food intakes are administered with meats and vegetables, they seldom met their iron requirements due to high-cost of such iron-rich food and irregular feeding due to poverty. In industrialized countries, the strategy of fortifying foods for infants and young children is used widely and effective in reducing the risk of iron-deficiency. However, in poor countries where such foods are apparently not available or affordable, routine supplementation with iron, and preferably multi-micronutrients, must be recognized, organized and promoted as a key aspect of young children’s nutrition (Yip 2002, p. 856S).. Prevention is always better than cure. Iron deficiency even in industrialized countries influence a considerable percentage of people predominantly in groups intensely susceptible. A sustainable preventive strategy involves participation of a broad range of sectors and organizations willing to devote time and resources. Excellent examples of these sectors are those closely linked to the underprivileged communities such as agriculture, commerce, education, communication, and health, which undoubtedly will work in collaboration with population and local organizations. To enhance the overall nutritional well-being of the community, the endeavour must fundamentally focus on reducing poverty, easy access to diversified diets, hygiene and heath services enhancement, and encourage better care and feeding habit. Dietary improvement or food based approaches is the highly recommended method to prevent malnutrition as it has the potential to deliver numerous nutritional benefits. In particular, work should concentrate in promoting and ensuring the availability and accessibility of iron-rich foods such as cattle meat, fish, poultry, and green leafy vegetables (WHO 2001, p.48). The iron-rich diet should also include good sources of vitamin A, C, and folic acid (Bendich 2005, p.14) such as fruits, vegetables, and root crops. Most importantly, proper and persistent nutrition education and information drive to increase the demand and consumption of such foods. Interventions to avert and correct iron deficiency anaemia incorporate dietary improvement, iron supplementation, enrichment of foods with iron, and other public health procedures such as helminth control. All of these methods improve iron status in some contexts. Iron supplementation is at all times indispensable for pregnant women as the physiological iron necessities during pregnancy are high that cannot be supported by ordinary diet alone (NMCHC 2007, p.1). A more detailed dietary prevention of iron deficiency anaemia according to UNICEF (2002, p.3), red meat, fish, liver, and egg yolks are iron sources under the non-vegetarian category. Breast milk, beans and lentils, whole grains and products made from these foods are also good sources of iron as budding grains and beans augment the bioavailability of their iron content. It has the effect similar to iron-rich foods with absorption boosting elements like Vitamin C contents. In contrast, tannin, caffeine, and other similar minerals are considered iron inhibitors, and should be taken separately from other iron sources, as they impede the rapid absorption of iron. Bread, flour, and other cereals in some parts of South Asia are iron fortified. However, iron supplements should be taken orally if these diets are not sufficient to maintain normal iron stores in the body. Iron supplements for pregnant women are extremely necessary as its requirements during pregnancy and lactation increases, which dietary intake alone cannot provide. Folate and iron are known to cause anaemia thus iron supplements are better taken with Folate or folic acid. Another problem that must be address is iron lost through parasite infection thus hygiene is very important. To avoid such infection people must wash their hands regularly using soap and clean water principally after using the toilet and before eating any food. Washing vegetables and fruits thoroughly and disinfecting kitchen utensils may help prevent parasites from spreading. In general, the best way to prevent infectious parasite is to observe hygienic practices and keep the environment always clean and free from human and animal droppings. Always wash and clean the family’s living area and toilets used by the members of the family. More importantly, especially in developing countries, do not let animals roam around and keep them in fenced areas where they cannot contaminate children. If there is prevalence of malarial mosquitoes, the use of bed nets are highly recommended as malaria increases the risk of anaemia. De-worming and other parasite control should be carried out frequently as possible particularly in areas with high rates of parasitic infestation (UNICEF 2002, p.3). Methods in the prevention of iron deficiency anaemia in infants have to start first with early detection efforts to identify and subsequently get on a course of iron therapy. Another method is to conduct primary prevention in a population where infants will be provided with iron fortified formula or cereal. In the standpoint of early detection, a number of tests are available and as we mentioned earlier, laboratory test for haemoglobin level and haematocrit and serum ferritin is the most reliable. Although early detection is important, primary prevention seems to be more beneficial to the whole population and preventing the spread of iron deficiency anaemia. The difference is early detection seems to focus only on subjects already infected with iron deficiency anaemia and does not promote prevention at all. Assuming that all necessary iron supplement is available in the community, primary prevention is potentially more effective as infants will be healthier and will not suffer low iron stores (Feightner 1997, p.247). Iron fortification is a proven approach in large population of low-income families. Study of fortified formula and cereals intake indicates a significant decrease in anaemic infants. For infants taking nourishment other than suckling, anaemia rates for 8 months old were 6% for iron-fortified cereal, 4.5% for fortified formula, and 20% for those infants who are not taking iron-fortified foods. In infants with the same age at the breast-fed groups, the rate of anaemia is 3.5%. Moreover, in a further study of infants age 6 to 12 months of age and infants fed with iron fortified cereal, 22% of these infants have ferritin values Read More