Reducing Anaemia in Pregnancy in a Block with Poor IFA Compliance
A block health team in Villupuram district screens 300 pregnant women attending antenatal clinics. Overall, 58% have haemoglobin below 11 g/dL and 7% below 7 g/dL. Only 38% report having received the full course of 180 iron-folic acid tablets, 45% stopped because of nausea and black stools, and many take their tablet with tea. Only 52% registered for antenatal care in the first trimester. Take-home ration from the anganwadi is distributed, but field workers report that it is often shared with the whole family or sold. The district wants to reduce anaemia prevalence by one-third within a year using existing staff and the Anemia Mukt Bharat framework. The block medical officer asks you to prioritise what should be done, how severe anaemia should be handled, and which indicators the team should track every month to know whether the plan is working.
1. Prioritise five interventions for the next 12 months and explain why simply increasing IFA tablet supply will not reduce anaemia prevalence by one-third.
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Five priorities
- Supervised IFA with compliance support. 60 mg elemental iron with 500 µg folic acid daily for 180 days, plus 180 days postpartum, given at the antenatal visit and followed up by the ASHA. Address side effects directly: take at bedtime or with food, start with one tablet, explain that black stools are harmless, and manage constipation with water and fibre.
- Deworming after the first trimester and testing and treatment for malaria where endemic, because these are non-nutritional causes of anaemia.
- Dietary counselling on enhancers and inhibitors. Iron-rich foods (green leafy vegetables, legumes, jaggery, liver, eggs) with vitamin C (amla, guava, lemon); tea and coffee at least one hour away from the tablet and meals; calcium supplements separated from iron by two hours.
- Food-based approaches and fortification: double-fortified salt, fortified rice where supplied, dietary diversity counselling, and ensuring the take-home ration is actually consumed by the pregnant woman, with counselling of the family against sharing or selling it.
- Early registration and haemoglobin testing at first visit and again in the second and third trimesters, so that treatment follows a test rather than assumption.
Why supply alone fails The tablets are already reaching only 38% as a full course; the binding constraints are side effects, timing with tea, late registration and poor follow-up. Anaemia is also multifactorial - iron deficiency, folate deficiency, worm infestation, malaria, haemoglobinopathies and repeated pregnancies all contribute. Without testing, counselling and adherence support, more stock simply means more unused tablets.
2. How should the 7% of women with haemoglobin below 7 g/dL be managed, and why is oral iron alone inadequate for them?
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Management
- Refer to the primary health centre or medical college without delay. Haemoglobin below 7 g/dL in pregnancy is severe anaemia and carries a high risk of maternal mortality, preterm birth and low birth weight.
- The physician decides on parenteral iron (intravenous iron sucrose or ferric carboxymaltose) or blood transfusion, according to gestational age, symptoms, cardiac status and availability. Transfusion is generally reserved for very severe anaemia near term or when there is breathlessness or cardiac decompensation.
- Investigate the cause: iron and folate status, stool for ova and cysts, malaria in endemic areas, and screening for haemoglobinopathies such as thalassaemia, which will not respond to iron and may cause iron overload if treated blindly.
- Treat infection and inflammation, since they block iron absorption and utilisation.
- Admit for rest, oxygen if needed, and monitoring during labour; plan delivery in a facility with blood available.
Why oral iron is not enough Oral iron raises haemoglobin slowly, roughly 1 g/dL in two to three weeks at best, which is too slow when the woman is symptomatic or near term. Absorption is also limited by the same inhibitors at play here - tea, calcium, and inflammation - and many women cannot tolerate the tablets. In severe anaemia there is simply not enough time or absorptive capacity, so parenteral iron or transfusion is needed, followed by oral iron to replenish stores.
3. Design a monthly monitoring plan for the block. Which process, output and outcome indicators would you track, and from which records?
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Process indicators (are we doing the work?)
- Proportion of pregnant women registered in the first trimester.
- Proportion receiving at least one haemoglobin test, and the proportion tested in each trimester.
- Proportion of ASHA-supervised IFA distribution rounds completed.
- Proportion of eligible women who received deworming after the first trimester.
- Stock availability of IFA, and number of stock-outs at sub-centres.
Output indicators (are women receiving the intervention?)
- Proportion of registered women who received 180 IFA tablets, and self-reported adherence in the last 30 days.
- Proportion counselled on diet, tea/coffee timing and side effects, verified from the MCP card.
- Proportion of take-home ration packets actually consumed by the pregnant woman.
Outcome indicators (is anaemia falling?)
- Prevalence of haemoglobin below 11 g/dL at third trimester, and below 7 g/dL.
- Proportion of severe anaemia cases referred and the proportion that completed treatment.
- Low birth weight proportion and postpartum haemorrhage rates.
Sources and review Use the MCP card, the RCH portal, the anganwadi take-home ration register, the IFA stock register and labour room records. Hold a monthly review with the medical officer, ASHA and anganwadi worker: compare each sub-centre with its own previous month, discuss defaulters by name, and reallocate effort to the lowest-performing areas. A single prevalence survey after 12 months is not monitoring; monthly process data tell you where the plan is failing while there is still time to correct it.