Journal of Mahatma Gandhi Institute of Medical Sciences

: 2020  |  Volume : 25  |  Issue : 1  |  Page : 6--10

Evidence-based intervention to prevent anemia among women of reproductive age group in developing countries

Mubashir Zafar 
 Department of Public Health, College of Public Health, Imam Abdul Rehman Bin Faisal University, Dammam, Kingdom of Saudi Arabia

Correspondence Address:
Dr. Mubashir Zafar
Department of Public Health, College of Public Health, Imam Abdul Rehman Bin Faisal University, Dammam
Kingdom of Saudi Arabia


Background and Objective: Anemia in developing countries is the biggest public health problem. Reproductive age group women have high prevalence. The objective of the present study is to determine the cost-effective intervention for the reduction of anemia among women of reproductive age group. Methodology: A review of the literature was done for identifying various preventive strategies regarding anemia and its implementation barriers in low- and middle-income countries. Google Scholar, PubMed, Web of Science, and Scopus were used as search engines.Results: The result of the review shows that the most cost-effective method for the prevention of anemia among women is iron fortification of food, iron supplementation, community-based health promotion of healthy nutrition. Women empowerment is the best tool for the implementation of all the above method for the prevention of anemia. Conclusion: Community-based intervention is the most effective method for reducing maternal anemia. It includes health promotion and women empowerment. There is a need to develop policies to improve the health promotion activities and involvement of women in society.

How to cite this article:
Zafar M. Evidence-based intervention to prevent anemia among women of reproductive age group in developing countries.J Mahatma Gandhi Inst Med Sci 2020;25:6-10

How to cite this URL:
Zafar M. Evidence-based intervention to prevent anemia among women of reproductive age group in developing countries. J Mahatma Gandhi Inst Med Sci [serial online] 2020 [cited 2020 Aug 13 ];25:6-10
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Full Text


In developing countries, anemia is an important public health problem. It is defined as low level of red-cell count in human blood.[1] Anemia affects the quarter of the global population.[2] The burden of anemia is estimated at 9% in high-income countries, and the burden is higher in developing countries, i.e., the prevalence is 43%.[2] Reproductive age group women and children were the most vulnerable population. The average prevalence of anemia in worldwide is an estimated 47% in children, 42% in pregnant women, and 30% in nonpregnant women aged 15–49 years.[2] In Africa and Asia, >85% of women had anemia. In developing countries, 3.1% of the disease burden due to iron deficiency anemia.[3] The pregnant woman is considered to be anemic if the hemoglobin level is <11 mg/dl.[4] Approximately 50% of the reproductive age group women were anemic in the Eastern Mediterranean and African regions.[3] In Pakistan, approximately 51% of pregnant women are anemic.[5]

Anemia has a wide range of complex determinants ranging from political, ecological, social, and biological factors [Figure 1].[6] Their interplay also makes it difficult to identify important factors because all the above-mentioned factors related to each other. The factors such as education, wealth status, empowerment, and employment also describe the probability of women to be having low hemoglobin levels.[7] Most of the time, anemia and low socioeconomic status are implicitly found together, with individuals having low education and being in the poorest quintile would be more prone to have anemia and its associated risk factors. [Figure 1] explains the broad determinants of anemia and the interplay of various levels of factors. These hierarchical determinants play an important role in the individual makeup of an individual; its vulnerability status which ultimately has an influence on the nutrition status. Literature has shown that low paternal schooling, cesarean births, and consumption of untreated water are important determinants of anemia.[8] Nationally representative surveys from India also highlighted that anemia is related to poverty, illiteracy, low cast, and tribes.[9] Some literature also suggested that sociocultural factors such as literacy, lower socioeconomic status, living in joint family and number of antenatal visits less than three are important predictors of anemia in pregnant women.[10] Dietary factors such as Khat Chewing and Pica (soil eating) are also found to be an important precursor of anemia in pregnant women. A study from the urban community from Hyderabad, Pakistan reported that consumption of clay during pregnancy, drinking three or more cups of tea per day during the pregnancy period, and egg and red meat consumption less in a week during pregnancy were associated with anemia.[11] Besides poor nutrition, frequent labor, multiparity, abortions, and parasitic infestations are strongly associated with anemia in the reproductive age group of women.[12]{Figure 1}

Pregnancies in the lower age group, i.e., age <20 years are common in developing countries. Its relationship with anemia has been an established fact. Developing countries have a higher proportion of frequent pregnancies as compared to developed countries. This poses additional nutritional demand on women of developing countries, which in turn affects their general well-being and lets them very little time to recover from consecutive pregnancies in short duration.[13]

Anemia has adverse medical and sociodemographic and financial effects in society. Slight to moderate anemia predispose the women of having severe anemia, in addition to also affects the general health, well-being, early fatigue, and decrease in ability to do routine work. Severe anemia that occurs in low- and middle-income is the main cause of maternal mortality rate.[14] Anemia caused the circulatory system of the human body which may cause myocardial infarct and death, whereas it also causes various infections and bleeding problems.[14] During pregnancy, it caused premature delivery, intrauterine growth retardation, low birthweight, and increase in perinatal mortality.[15] Baby born from anemic women are more likely chance of infant mortality due to reduced iron and hemoglobin.[15] Safe motherhood strategy developed by the World health organization, in which the major objective is to reduce the anemia during pregnancy.

Different interventions for the reduction of anemia such as enhancement of dietary intake, food fortification and food diversification, supplementation of micronutrient specifically iron, common disease control, and health education.[16] Recently, the United States for the International Development flagship program, i.e., maternal and child health integrated program (MCHIP) have started and major component is the integration of these evidence-based interventions for anemia prevention and control.[17] There were different studies results found that iron and folic acid supplementation in pregnancy improved the hemoglobin level in the body which reduced the prevalence of anemia. Integration of other interventions for reducing anemia in pregnancy such as antiworm and anti-malarial which can be effective to the reduction of anemia prevalence in women. The integrated interventions package that has been implemented in the field by MCHIP included supplementation of daily iron-folic acid, fortification of food with iron in primary health centers, health promotion like malaria prevention using insecticide-treated nets and combination therapy (Artemisinin).[17] Deworming and birth spacing of at least 2 years is also part of the package that has been implemented in the field.[17]


The main objective of this study is to identify evidence-based interventions in developing countries for reducing maternal anemia.


A narrative review of the literature was done for identifying various preventive strategies regarding anemia and its implementation barriers in developing countries. Google Scholar, PubMed, Scopus, and Web of Science were used as search engines. Search terms were used as “maternal, anemia, preventive, strategies, low- and middle-income, countries, high-income countries. A total of 200 articles retrieved from different databases, 150 articles from developing countries were extracted and 50 articles from developed countries were excluded. References of the relevant articles were also used for citations [Figure 2].{Figure 2}

 Results and Discussion

The important interventions for preventing maternal anemia based on an analysis of the available evidence.

Iron fortification of food in women reproductive age

First article included was a cost-effective analysis of iron supplementation and iron fortification interventions in four regions of the world (African sub-region [AfrD], the South American [AmrB], the European sub-region [EURA], and the Southeast Asian sub-region [SearD]).[18] This paper included articles following WHO guidelines for iron supplementation as daily 60 mg supplement iron given to pregnant women visiting antenatal clinic for 6 months during pregnancy, and for 3 months postpartum. While fortification of food with iron with folic acid, which leads to food vehicles that available in large community. In developing countries, cereal flour is stapled food. The study team collected primary data as well as a review of the literature was also done. It was concluded that on the majority of community (95%) used iron supplementation compare to iron fortification and its impact as improve the hemoglobin concentration of women in reproductive age groups. The result of iron supplementation found that approximately 12500 disability-adjusted life years (DALYS) has been reduced in the European community. In the African region, it is estimated that 2.5 million DALYS annually and increase maternal and child mortality. However, fortification of food is less cost compare to iron supplementation and most effective economically. However, it is awareness of health workers and community workers to promote the benefit of fortification of food with iron which saves the extra cost for this intervention.[18]

One of the studies reviewed the efficacy of iron-fortified flour to investigate the minimum daily amounts of iron consumed which improve the health status of women in the reproductive age group.[19] This study concluded that only a few countries such as Brazil, Arab countries, and central Asians were expected to increased the iron level among women of the reproductive age group.[19] Most of the countries were used substandard, low-bioavailability, hydrogen-reduced iron powders.[19] Another study in which meta-analysis of 60 trials found that 41% reduction risk of anemia among women of reproductive age group (relative risk [RR] 0·59, 95% confidence interval CI 0·48–0·71, P < 0·001) and a 52% reduction in maternal mortality (0·48, 0·38–0·62, P < 0·001).[20]

In countries, like Pakistan, mass fortification of food with iron and folic acid can be one of the important interventions to reduce the complications associated with maternal anemia. Micronutrient associated with anemia but if used with food, it is a safe and cost-effective strategy for the prevention of anemia. As an agricultural country, the people living in the rural population may have limited access to processed food that will result in limited utilization. However, it is recommended that apart from all these limitations, food should be fortified at the population level, and it will give the eventual benefit. The legislation is also required so that food can be fortified with adequate levels.

Iron and folic acid supplementation during reproductive age group women

Iron and folic acid supplementation have been important interventions for reducing the anemia among women of reproductive age and pregnant women. A several systematic reviews and randomized controlled trials and quasi-experimental studies found that giving iron supplementation during reproductive age group, significant reeducation of anemia (RR 0·73, 95% CI 0·56–0·95), hemoglobin in blood (MD 4·58 g/L, 95% CI 2·56–6·59), and ferritin concentration in blood (MD 8·32, 95% CI 4·97–11·66).[21] Few other reviews regarding the effectiveness of micro-nutrient interventions also confirmed that these interventions are cost-effective.[22],[23] On the other side, evidence from developing countries also found that iron supplementation on a large scale usually not effective.[24] Noncompliance of women is one of the important reasons for not having significant results.[24]

In Pakistan, decrease the accessibility of animal protein in faraway areas of countries and preference of good nutrition of food to boys and husband as major factors for anemia in women which leads to high mortality of women. Opposing to the belief that women stop taking iron tablets due to culture restraints, side effects and religious beliefs of infertility, but it a fact that only few women have side effects of iron supplementation. Hence, iron and folic acid supplementation and advocacy are recommended as a vital component of antenatal care to have a spillover effect on reducing complications and preventing maternal anemia. Training of health service providers should, therefore, emphasize knowledge and understanding of the importance of iron supplementation for the reduction of the prevalence of anemia among women of reproductive age group.

Health promotion for nutrition education in community involvement

Health promotion with community-involvement to reduce the prevalence of maternal anemia is important step to deliver key interventions. The 2008 Copenhagen Consensus has also prioritized community-based nutrition promotion as one of the key interventions among the top ten global issues.[25] Cost-benefit approach was adopted by the panel in the meeting to compare different topics after accounting for limitations of the method.[25]

Health promotion strategy is basic and practical among developing countries like Pakistan. Several studies suggest that 50% of complication has been reduced during pregnancy by health education and promotion of nutrition with community involvement and it improves the local health system.

Integrated anemia control strategy

Integrated anemia control strategy (IACS) can be used as an important strategy to combat anemia among women of reproductive age. In Nicaragua, the study shows that IACS has significantly improved the hemoglobin level in women and children.[26] This strategy developed by the Ministry of Health of Country and implemented 15 years back. They provide the iron and folic acid supplementation for pregnant women; fortification with iron of flour; anti-worm medication to children; Vitamin A supplementation; behavioral change communications; comprehensive training of health service personnel, community health volunteers (CHVs), and nongovernmental organizations; and a program monitoring and evaluation system.[26] A comprehensive plan was executed and from the baseline survey to follow-up at the end of the project, it was monitored and supervised by various stakeholders that were part of the project.[26]

Similarly, the iron intensification project in Nepal has also given promising results and has resulted in pregnant women giving iron supplementation for the reduction of the prevalence of anemia and improve antenatal care which effects to reduce the maternal mortality.[27] These interventions in the community were delivered by female FCHVs which were the major cornerstone of this project. The FCHVs delivered a package of services, not just iron and folic acid supplementation. The national prevalence of maternal anemia substantially decreased from 68% in 1998 to 36% in 2006 in women of reproductive age.[27]

In Pakistan, efforts can be done to integrate the prevention strategies done for anemia control. Collective efforts will give positive results, and female health workers’ coverage can be utilized for effective anemia control. There were efforts related to micronutrient initiative, but it was in bits and pieces. Other nongovernment organizations can also be taken on board for making effective strategies and implementation for anemia control.


Maternal anemia is still a widespread problem in low- and middle-income countries. There are different intervention to reduce maternal anemia and most important intervention is population level was fortification of food with iron and folic acid. Community-based intervention for health promotion of good nutrients was a good strategy in reducing the anemia among reproductive age group women. Along with this, iron supplementation, community-based interventions for nutrition education and promotion and IACS were also effective in reducing maternal anemia. Health system and health-care provider is the key stakeholder for reducing the anemia during pregnancy; it should be improved to prevent the complication associated with maternal anemia.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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