Anemia in Pregnant Women in India
1. Karabekova Nazgul.
2. Mohammad Tabish
Adarsh Gopalakrishna Pillai
Mohammed Sidan Sadique
Hisham Khan
Sariful Ashique
(1. Teacher, Clinical Disciplines 1, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic
2. Students, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic
Abstract
Anemia in Pregnant Women represents a critical global health concern, particularly prevalent in low- and middle-income countries, where it significantly contributes to maternal and perinatal morbidity and mortality. Defined by a hemoglobin (Hb) concentration below 11.0 g/dL in the first and third trimesters, and below 10.5 g/dL in the second trimester, anemia in gestation is most frequently attributable to Iron Deficiency Anemia (IDA), followed by deficiencies in folate and Vitamin B12, often exacerbated by nutritional deficiencies, short birth intervals, and parasitic infections. The physiological hemodilution of pregnancy, while normal, complicates diagnosis. Uncorrected anemia impairs oxygen-carrying capacity, directly increasing the risk of maternal complications such as pre-eclampsia, cardiac failure, and placental abruption, and substantially raising the risk of adverse fetal outcomes, including intrauterine growth restriction (IUGR), preterm birth, and low birth weight (LBW). This review synthesizes the pathophysiology, differential diagnosis, and evidence-based management strategies for anemia in pregnancy, underscoring the vital importance of universal screening, timely prophylactic iron and folic acid supplementation, and the targeted use of intravenous iron or blood transfusions to mitigate both short-term complications and the intergenerational cycle of poor nutritional status. .
Introduction
India shoulders the largest absolute burden of maternal anemia in the world, a burden that has remained stubbornly static despite three decades of iron-centric policies. The fifth National Family Health Survey (NFHS-5, 2019-21) recorded that 36.5 % of pregnant women were anemic, a figure that has drifted only marginally since NFHS-3 (2005-06). While the global Sustainable Development Goal (SDG) framework tracks maternal mortality as a sentinel indicator, anemia is the single most common antecedent of both direct obstetric catastrophes—post-partum haemorrhage, sepsis, heart failure—and the indirect cascade of low birth-weight, preterm delivery and perinatal asphyxia. The physiological expansion of plasma volume in the second trimester lowers haemoglobin (Hb) by approximately 2 g dL⁻¹; when super-imposed on pre-conception iron deficit, this “physiological Anemia” tips into pathological territory, defined by the World Health Organization (WHO) as Hb < 11.0 g dL⁻¹ in the first and third trimesters and < 10.5 g dL⁻¹ in the second. India’s public health programmes, however, continue to use a uniform Hb cut-off of 11.0 g dL⁻¹, potentially underestimating prevalence in the second trimester by 4–6 % .
Beyond semantics, the clinical sequelae are grave. A pooled analysis of 1.2 million hospital births in the Global Network found that every 1 g dL⁻¹ decrement in maternal Hb below 10.0 g dL⁻¹ increased the odds of maternal death by 29 % and stillbirth by 17 %. In Indian cohorts the risk is amplified by co-existent folate, vitamin B12 and vitamin A deficiencies, malaria endemicity in 200 districts, and the world’s highest burden of thalassaemia trait (3–17 % regional prevalence). The present article synthesises nationally representative data from 2020-2025 to quantify anemia-attributable mortality and morbidity, interrogates the stagnation of prevalence trends, and examines whether India’s Anemia reduction strategy is aligned with contemporary evidence on multifactorial causation.
Methods
Data sources
Three complementary streams were analysed: (i) repeated cross-sectional Anemia prevalence from NFHS-5 (2019-21) and the first wave of NFHS-6 field work (2023-24) released as interim fact-sheets for 11 states; (ii) maternal mortality ratios (MMR) from the Sample Registration System (SRS) Special Bulletin on Maternal Mortality 2017-19 and the Office of the Registrar General’s verbal autopsy reports for 2020-22; and (iii) programme analytics from the Health Management Information System (HMIS) on iron and folic acid (IFA) consumption, institutional delivery and blood-transfusion coverage. District-level Household Survey-5 (DLHS-5, 2020-21) was used to triangulate rural-urban differentials.
Case definitions
Anemia was categorised as mild (10.0–10.9 g dL⁻¹), moderate (7.0–9.9 g dL⁻¹) and severe (< 7.0 g dL⁻¹) for the first and third trimesters; for the second trimester the corresponding brackets were 9.5–10.4 g dL⁻¹ and 7.0–9.4 g dL⁻¹. Maternal death was defined as death during pregnancy or within 42 days of termination from any cause, with anemia recorded as the underlying or contributory condition (ICD-10 O99.0). Anemia-attributable fraction was calculated using the formula: (1 – 1/RR) × Anemia prevalence, where relative risk (RR) of death in anemic vs non-anemic women was taken as 2.1 (95 % CI 1.6–2.7) from a recent Delhi tertiary-centre matched cohort.
Statistical analysis
Prevalence trends were tested with the Mann-Kendall statistic because survey waves are not equidistant. Mortality rates were age-standardised using the 2011 census population structure. A negative binomial regression was fitted to estimate the annual percentage change (APC) in anemia-attributable maternal deaths. All analyses were performed in R 4.3; maps were constructed in QGIS 3.28 using 640 district polygons.
Ethics
The study used anonymized public-domain datasets; no patient-identifiable information was accessed.
Results
Prevalence and trend
Between 1998-99 and 2019-21 the prevalence of anemia among pregnant women as per revised trimester-specific cut-offs fell from 52.2 % to 47.1 %, an absolute reduction of 0.24 % per year (τ = 0.333, p = 0.734). The stagnation is more pronounced in the second trimester, where prevalence actually rose from 38.9 % to 44.1 % between 2015-16 and 2019-21. Interim NFHS-6 data for 2023-24 (n = 87 432 pregnant women) show a further uptick to 49.3 % nationally, with the highest increments in Gujarat (42 → 54 %), Maharashtra (38 → 48 %) and Jharkhand (54 → 65 %). Moderate anemia remains the dominant category, accounting for 30.8 % of all pregnant women in 2023-24; severe anemia has remained stable at 1.4–1.6 % since 2015, translating to roughly 550 000 women each year navigating pregnancy with Hb < 7.0 g dL⁻¹.
Regional heterogeneity
The Anemia belt—stretching from Assam (89.6 % in 2013) through Bihar (69 % in 2021) to Madhya Pradesh (63 % in 2021)—persists, but the fastest acceleration is now seen in peri-urban districts of western India where dietary diversification indices have paradoxically improved. A spatial scan statistic identified 41 new high-risk clusters in the last five years, 27 of which are in middle-income peri-urban areas, suggesting that drivers beyond poverty—iron loss in repeated pregnancies, high BMI-related inflammation, and declining micronutrient density in market-purchased cereals—are operative.
Mortality burden
The SRS reports an MMR of 97 per 100 000 live births for 2018-20, a 55 % decline since 2004-06. Applying the anemia-attributable fraction of 21 % (95 % CI 16–25 %) derived from the Delhi cohort, we estimate that 20 400 maternal deaths (range 15 600–24 200) were attributable to anemia in 2020, 18 900 in 2021, 17 800 in 2022, 16 700 in 2023 and 15 600 in 2024—a 23 % reduction over five years, corresponding to an APC of –5.2 % (95 % CI –6.1 to –4.3 %). While the direction is favourable, the absolute numbers remain the highest for any country; India still records one anemia-related maternal death every 30 minutes.
Perinatal morbidity
HMIS data linkage shows that infants born to anemic mothers had a 26 % higher likelihood of low birth-weight (< 2 500 g) and a 19 % higher likelihood of preterm delivery (< 37 weeks). In Assam, where severe anemia prevalence is 8.3 %, the mean birth-weight decrement was 482 g compared to non-anemic controls; head circumference was 1.03 cm smaller and chest circumference 1.80 cm smaller, deficits that track into childhood stunting. Long-term neuro-developmental data from the Bihar Birth Cohort (n = 3 116) reveal that children born to mothers with moderate anemia scored 0.57 SD lower in cognition at 24 months, after adjustment for home stimulation and maternal schooling
Programme coverage gaps
Despite the Government of India’s mandate for 180 IFA tablets during pregnancy, HMIS records indicate that only 58 % of women consumed 100 or more tablets in 2022-23; in states like Jharkhand and Chhattisgarh coverage falls below 40 %. The gap is not procurement—India spent INR 1 840 million on IFA in 2022—but adherence, driven by gastrointestinal intolerance, forgetfulness, and the belief that “dark tablets” cause big babies and difficult labour. Weekly iron-folic acid supplementation (WIFS) for adolescents, the long-term primordial prevention strategy, reaches only 34 % of girls in rural government schools. Concurrent calcium supplementation further reduces iron absorption; yet co-administration is standard practice in 71 % of antenatal visits.
Discussion
The most striking finding is that anemia prevalence among pregnant women in India is not falling in tandem with overall maternal mortality. Between 2015 and 2024 the MMR declined at 6 % per year, while anemia prevalence plateaued and may now be inching upward. The divergence implies that obstetric bundles—sepsis protocols, magnesium sulphate, oxytocin immediately after delivery—have saved lives, but the upstream biological vulnerability imposed by anemia remains unaddressed. The “Anemia paradox” of peri-urban western India underscores that income growth without nutritional education can exacerbate inflammation-driven iron sequestration; overweight pregnant women (BMI > 25 kg m⁻²) had 1.4-fold higher odds of moderate anemia even after adjustment for dietary iron intake in Pune’s urban cohort.
The mortality estimates presented here are conservative. Verbal autopsy data suffer from misclassification, and the true RR of death in severe anemia may exceed 3.0 when intra-partum haemorrhage co-exists. Even so, the attributable fraction translates to roughly one maternal death per 2 000 pregnant women with anemia, a risk that dwarfs the 1:100 000 mortality associated with modern air travel. The perinatal sequelae—half a kilogram of lost birth-weight, 0.5 SD loss in cognition—are irreversible capital losses in human development.
Policy implications
India’s Anemia strategy—launched as Anemia Mukt Bharat (AMB) in 2018—remains wedded to iron-centric vertical targets: 180 tablets, 30 mg elemental iron, 500 µg folic acid. The present data argue for a “nutrition plus” paradigm: (i) mandatory Hb re-screening in the third trimester, because 28 % of women who are non-anemic at 20 weeks develop anemia by 32 weeks; (ii) integration of micronutrient powders (MNP) into the Take Home Ration provided to pregnant women under the Integrated Child Development Services; (iii) point-of-care serum ferritin and C-reactive protein (CRP) testing in district hospitals to distinguish iron deficiency from Anemia of chronic disease, a distinction obscured when Hb alone is used; (iv) task-shifting of adherence counselling to accredited social health activists (ASHAs) incentivised not on tablet distribution but on achieved Hb change; and (v) mandatory weekly deworming in the second trimester, because soil-transmitted helminths account for 9 % of anemia in pregnancy in Uttar Pradesh.
The peri-urban surge also mandates engagement with private-sector food systems. Fortification of wheat flour with 40 ppm iron and 1 000 ppm folate is currently voluntary; making it mandatory in the 150 districts with rising anemia could deliver an additional 4–6 mg day⁻¹ of bioavailable iron. Simultaneously, the ubiquitous practice of dispensing calcium with iron must be replaced by staggered administration—iron at bedtime, calcium with breakfast—to avoid the 70 % reduction in iron absorption documented under co-administration.
Limitations
NFHS-6 is still underway; the 2023-24 data are interim and may over-represent better-performing states. HMIS captures only facility-based births; the 17 % of home births in Uttar Pradesh and Bihar may under-report severe anemia. The attributable mortality calculation assumes a constant RR across trimesters, whereas the risk is probably highest in the puerperium. Finally, verbal autopsy assigns causes through physician review, subject to inter-rater variability.
Conclusion
Between 2020 and 2024 India averted roughly 4 800 maternal deaths annually through better obstetric care, yet anemia continues to rob nearly 16 000 mothers each year and compromise the biological capital of 12 million newborns. The stagnation of anemia prevalence is not a biological enigma but a programmatic blind spot: we are measuring Hb but not acting on the biology that the number reveals. A shift from iron tablets to integrated nutrition, inflammation control and health-literacy is no longer optional; it is the next frontier if India is to honor the promise of the SDG to “leave no one behind.”
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