Dr. Ashutosh Mishra, clinical epidemiologist and senior Regional technical director, Southeast Asia, Vitamin Angels. Dr. Hema Divakar, senior consultant obstetrician and gynaecologist and is the chairman and CEO of ARTIST for Her, a premier institute based in Bangalore to create a lasting social impact for the advancement of women’s health care in India.
Anemia in pregnant women aged 15-49 years reduced from 57.9% in 2005-06 (National Family Health Survery-3) to 50.4% in 2015-16 (NFHS-4), giving us a hope that we are on the right trajectory to addressing maternal anemia. However, the recently released NFHS-5 data is concerning and points towards a trend reversal-anemia prevalence has shot up to 52.2% in 2019-21. With the current state of anemia prevalence, India could miss the World Health Assembly’s Global Nutrition Target for 2025 of reducing anemia in women of reproductive age by 50%.
A common misconception is that anemia is only due to low iron levels in the body. While 50% of anemia in the South Asian population is due to low dietary intake of iron, other 50% is caused by malaria, micronutrient deficiencies (especially, folate and vitamins B12, A, and C), genetic conditions (such as sickle cell disease, thalassemia – an inherited blood disorder), and chronic inflammation. Micronutrient deficiencies particularly are prevalent in the population in varying magnitude and severity but are often left undetected until symptoms become severe.
Micronutrients are vitamins and minerals required by our bodies in very small quantities. Although required in minimal quantities, their deficiencies during pregnancy can lead to poor pregnancy (women with severe anemia are twice as likely to die during pregnancy) and birth outcomes (children born to malnourished mothers are more likely to be born too small, too soon, or stillborn). Further, children born to malnourished women who survive infancy are more likely to experience physical and cognitive setbacks affecting their full potential later in life. Secondary data analysis of nutrition data for India shows that 32.35% of pregnant women are vitamin D deficient, 41.6% are folic acid deficient, 16.4% are vitamin A deficient, and 41% are zinc deficient. However, there is a dearth of primary data on micronutrient deficiency beyond anemia and a few other micronutrients among pregnant women and women of reproductive age group-without this evidence, targeted interventions for micronutrient deficiencies take a back seat. These deficiencies become prominent in women who are unable to access or afford nutritious foods, especially, when they are pregnant due to the elevated nutrient requirements of their bodies and their developing babies.
Several interventions like dietary diversification, food fortification, and supplementation are underway to address maternal micronutrient deficiencies. While achieving dietary diversification has a financial cost to it, consuming fortified foods can address only a few micronutrient deficiencies–namely, iron, iodine, Vitamin A and D. Although supplementation is being currently deployed through the existing antenatal care platform to address iron and folic acid deficiency, these interventions alone are generally insufficient to address the various micronutrient gaps that may exist in pregnancy. A formulation that combines key micronutrients can replenish their dietary requirement and lead to a positive pregnancy experience. One such formulation, backed by global evidence, is United Nations International Multiple Micronutrient Antenatal Preparation’s (UNIMMAP’s) multiple micronutrient supplementation (MMS)-a once-daily supplement that provides the Recommended Daily Allowance of 15 vitamins and minerals (iron and folic acid, vitamin A, vitamin D, vitamin E, thiamine, riboflavin, niacin, vitamin B12, vitamin B6, vitamin C, zinc, iodine, copper, and selenium) to address a broad spectrum of micronutrient deficiencies and has equivalent benefits as iron folic acid supplementation, the current standard of antenatal care, in preventing maternal anemia.
Multiple micronutrient supplements aren’t something new. In fact, they have been prescribed to pregnant women in the private sector for more than a decade. Even the World Health Organization has recognized the role of MMS in improving pregnancy and birth outcomes and included MMS in its Essential Medicines List in October 2021. MMS has also been shown to be highly cost-effective compared to iron and folic acid supplementation. In fact, the cost-benefit tool developed by Nutrition International models that over a period of ten years and with 30% coverage MMS is ‘very cost effective’ and can avert around 100,000 child deaths in India. However, this is yet to be introduced as part of a comprehensive nutrition policy in India.
The ongoing Covid-19 pandemic has disrupted the food and health systems, affected the availability of micronutrient rich food, and limited the access to antenatal care. This has adversely affected the diets of pregnant women who are unable to meet the micronutrient levels required for their health and well-being. Intensifying advocacy towards communicating the proven benefits of MMS in pregnant mothers to key stakeholders-both policy makers and programme implementers along with instilling a sense of collective responsibility among a range of key players from academia, civil societies, non-governmental organisations, and the public and private sectors needs to be prioritized. With established efficacy and safety data on MMS from high-quality randomized controlled trials of MMS spanning two decades in more than a dozen countries, the government should start exploring the benefits of MMS and integrating it with the country’s functional antenatal care platform. We do not want to miss the global nutrition targets this time but emerge as a nation that is progressive in its approach and leverages the global best practices and evidence-based nutrition interventions to address the hidden hunger.
(Dr. Ashutosh Mishra, clinical epidemiologist and senior Regional technical director, Southeast Asia, Vitamin Angels. Dr. Hema Divakar, senior consultant obstetrician and gynaecologist and is the chairman and CEO of ARTIST for Her, a premier institute based in Bangalore to create a lasting social impact for the advancement of women’s health care in India.)
By Hindustan Times