JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 18 Number 2 January 2010 59 Prevalence of Iron-Deficiency Anaemia in India: Results from a Large Nationwide Survey Ramesh Chellan Lopamudra Paul An Overview Worldwide, Iron-deficiency anaemia is a significant problem and especially indeveloping countries it is widespread yet the most neglected micronutrient deficiencydisorder among children, adolescence girls, and pregnant women. Iron-deficiencyanaemia suppresses human productivity. Although a moderate degree of anaemia maynot affect every day work, it has massive impact on those engaged in heavy physicalactivities. The consequences of anaemia among women include reduced energy andcapacity for work and poor pregnancy outcome that further enhances maternal mortality(Levin et al., 1993). It is estimated that almost twenty percent of maternal deaths aredirectly caused by anaemia and causes of another fifty percent of maternal deaths areassociated with anaemia in the world (Gillespie, Kevany and Mason, 1991). India is oneof the countries with the largest prevalence of anaemia. Weakness is assumed to be a normal condition during pregnancy and majorityof Indian women do not seek treatment for anaemia unless symptoms become severe.Anaemia is attributed to dietary inadequacy due to poor purchasing power, illiteracy,ignorance regarding nutritional value of available cheap food, cultural taboos,superstition, large families etc. (Rao, 1978). In a society where the status of women ispoor, women face both covert and overt discrimination within family. Women in Indiafollow the custom of ‘eating last’ or eating only the food left over after the meals ofmale members of the family. Nearly 50-80 percent of mothers suffer from anaemia dueto iron-deficiency in their diet. Puerperal morbidity is higher among women withhemoglobin (Hb) level below 6.5g/dl compared to women with normal Hb level (UnitedNations Children Fund-UNICEF-1984). Anaemia is not confined to pregnant womenalone but also has effect on other population in the society. For infants, it is caused dueto combination of limited iron stores at birth, timing of umbilical cord clamping, timing
60 JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010and type of complementary food intake and frequency of childhood illness. About 30-40 percent of newborn suffer from low birth weight due to maternal anaemia andmalnutrition (Park and Park, 1985). Low level of Hb among children enhancesmorbidity from various infections, especially children aged between 6-24 months(Stolzfus and Dreyfuss, 1998). Therefore, there is ‘Double Burden’ in the societycaused by anaemic mother and anaemic children. Moreover, girl children are moreprone to severe anaemia than their male counterpart, because with increasing age, theprevalence of anaemia declines among males (Swami, Thakur and Bhatia, 1998). TheHellen Kellar Institute for girls (1996) estimated that 83.9 percent girls of age between12 and18 years in rural India were found to be anaemic; the level is high among girlswith no schooling (92.7 percent). Adolescent girls require continuous replacement ofiron during menstruation (Brabin and Brabin, 1992). There is the ‘vicious cycle ofanaemia’ for women in India since girls are married and enter motherhood with pooriron status at very young ages. Anaemia present from the childhood throughadolescence aggravates during pregnancy causing maternal morbidity and prematurebirth of low birth weight baby (Figure 1). Figure1 Trends in Maternal Deaths in Rural India Due to Anaemia 30 PERCENTAGE OF MATERNAL DEATH DUE TO ANEAMIA IN RURAL INDIA 25 20 15 10 5 0 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 YEARSource: India, Registrar General. Several years.
JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 61 Other than clinical factors, there are many other factors attributed as the causesof anaemia in India. An analysis of the National Family Health Survey-2 data forGujarat showed that the prevalence rate is high among children with illiterate mother,low standard of living, working mother, belonging to Scheduled Caste (SC) and whosemothers are also anaemic (Krishna Mohan, 2003). It is well recognised that unregulatedfertility is associated with anaemia; moreover, health hazard increases sharply after thefourth pregnancy. Though anaemia is widely prevalent among women belonging tolower socio-economic strata of the society, it is not rare among the well-to-do classes ofthe society. The National Nutrional Anaemia Prophylaxis Programme (NNAPP) waslaunched in 1972 during the 4th five year plan in India with the aim to curb theprevalence of anaemia. One of the largest nutritional supplement programmes, theIntegrated Child Development Services (ICDS) scheme was initiated in 1975 in India toprovide nutritious food to pregnant women and children. Further, in 1991, theGovernment of India introduced policies to control nutritional anaemia throughpromotion of iron rich food (green leafy vegetables: mustard leaves, bengal gramleaves, clocasia leaves etc., shepu or sowa, cereals: wheats, ragi, jawar, bajara, pulses:sprouted pulses, and jaggery), provision of iron and folate supplements to high riskgroups (all pregnant and lactating women, Intra-Uterine Device (IUD) users, andchildren between 1-5 years), and identification and treatment to severely anaemicpeople. The recently launched National Rural Health Mission (NRHM), 2005,undertakes programme once in a month in villages to educate mothers on health andnutrition. In spite of the fact that the Health and Family Welfare Department in Indiahas policies to provide iron supplement to pregnant women to prevent maternal anemia,evaluation from large scale programmes shows that maternal anaemia has not declinedsignificantly. Some plausible reasons are the side effects of the iron pills and alsoimproper utilization of health service and personal beliefs (Fox, 1983; Galloway andMcguire, 1994).
62 JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 Objective of the Study The available evidence clearly shows that anaemia is very widely prevalent inIndia. However, the degree of severity varies across socio-economic classes. Therefore,this paper seeks to assess the influences of socio-economic and demographic factors ondegree of anaemia. This analysis focuses on children (age 0-71 months), adolescentgirls (age 10-19 years) and pregnant women. Data and Methods The data for the analysis are taken from the District Level Household Surveyunder the Reproductive and Child Health programme (DLHS-RCH), 2002-04,conducted by the International Institute for Population Sciences (IIPS), Mumbai inIndia. The survey covered 620,107 households in the country and contained informationon various aspects of reproductive and child health of the residents by interviewingwomen of reproductive age. Besides, blood samples from all children below six years ofage (0-71 months), adolescent girls (10-19 years of age: irrespective of marital statusand who were not pregnant at the time of survey), and pregnant women (15-44 years)from selected households were sought to be collected. Information on socio-economicbackground like place of residence, religion, caste, educational level of woman,household standard of living etc. of the households and respondents was also collected. A total of 430, 626 children, 311, 793 adolescents, and 41, 112 pregnantwomen were contacted for obtaining blood samples. The collection of blood sampleswas done only after an informed consent (from the person and in case of minors, fromparent or guardians) was obtained. As expected, there were some refusals and bloodsamples could be obtained for 56.1 percent children, 58.1 percent adolescent girls, and58.2 percent of pregnant women in the sample (Figure 2).
JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 63 Figure 2 Response Rate of Blood Examination for Anaemia in DLHS-RCH, 2002-04 Children (0-71 Months) Children (0-71 Months) Others 4% Not present 17% Refused by respondent 4% Blood sample taken 55% Parents refused 20% Adolescents Girls (10-19 Years) Adolescents Girls (10-19 Years) Missing 10% Others 3% Not present 20% Blood sampl e taken 52% Refused by respondent 7% Parents refused 8%
64 JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 Pregnant Women(15-44 Years) Years) Pregnant Women (15-44 Missi ng, 0.3 Others, 17.8 Not present, 9.2, 9% Blood sample taken, 58.1 Refused by respondent, 9.2 Parents refused, 5.5Source: Computed from DLHS-RCH, 2002-04 data files. In principle, non-response could bring in a bias in the results. This would beparticularly true if the non-response is selective. In order to see if this is the case,response rates are computed for various socio-economic and demographic groups.These show that in most cases, the response rate is in the range of 50 to 60 percent(Table 1). All socio-economic and demographic variables show only minor variations.Religion, other than Hindu has a lower response rate but the gap is only about 10 points.The only notable departure is seen for children whose mother was not interviewed.Thus, though there is considerable non response for blood samples, it does not appear tobe selective and hence, the data have been used for further analysis on anaemia exceptfor 22, 430 children whose mother was not interviewed.
JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 65Table 1: Percent of Response of Blood Sample Taken by Selected Background Characteristics in India Children Adolescent Girls Pregnant Women (0-71 Months) (10-19 Years) (15-44 Years) Background Response Number of Response Number of Response Number of Characteristics Rate Children Rate Adolescent Rate Pregnant Girls Women Residence Rural 57.5 308,974 58.5 208,467 58.8 29,904 Urban 52.6 121,652 57.2 103,326 56.7 11,208 Religion Hindu 58.5 336,002 60.2 238,712 60.1 32,462 Muslim 48.0 58,984 52.8 44,164 51.2 5,473 Others 47.6 35,593 49.1 28,898 51.3 3,176 Caste OBC 56.5 173,279 59.1 120,334 58.5 16,814 SC/ST 57.0 142,454 56.1 97,759 59.7 13,761 Others 54.4 114,845 58.9 93,681 55.8 10,536 Mother’s Education Non-literate 61.7 190,622 51.7 59,860 57.2 20,221 0-5 years of schooling † 62.2 43,420 59.0 93,951 60.7 5,067 6-10 years of schooling 60.3 90,767 60.3 134,004 60.1 11,358 11 + years of schooling 55.8 33,844 58.1 23,964 55.6 4,439 Mother not interviewed 32.5 71,770 na na na na Standard of Living Low 56.8 219,602 56.4 137,441 58.0 20,597 Medium 56.7 128,569 59.7 100,633 60.3 12,585 High 53.6 82,408 59.0 73,719 55.5 7,930 Sex of the Child Male 56.2 223,779 na na na na Female 56.2 205,747 na na na na Age of Child (Months) 0-11 45.4 72,231 na na na na 12-23 56.6 64,138 na na na na 24-47 58.9 140,567 na na na na 48-71 58.5 153,690 na na na na
66 JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010Table 1: (Continued) Children Adolescent Girls Pregnant Women (0-71 Months) (10-19 Years) (15-44 Years) Background Response Number of Response Number of Response Number of Characteristics Rate Children Rate Adolescent Rate Pregnant Girls Women Age of Mother/Girl/Woman (Years) 10-14 na na 59.4 169,838 na na 15-19 57.9 18,837 56.5 141,955 60.9 8,141 20-24 61.7 109,063 na na 59.8 17,045 25-29 61.4 123,895 na na 57.1 9,857 30-34 60.5 67,393 na na 53.7 4,033 35 + 58.7 39,668 na na 48.4 2,036 Mother not interviewed 32.5 71,770 na na na na Marital Status Not currently married na na 59.5 283,361 na na Currently married na na 43.5 28,387 na na Birth Order 1 58.8 108,359 na na na na 2 61.1 97,111 na na na na 3 61.8 64,258 na na na na 4+ 60.1 98,327 na na na na Mother not interviewed 31.7 62,571 na na na na Parity No child na na na na 58.8 13,101 1 na na na na 60.4 10,927 2-3 na na na na 58.1 11,046 4+ na na na na 53.4 6,038 Total 56.1 430,626 58.1 311,793 58.2 41,112Source: Computed from DLHS-RCH, 2002-04 data file. na: Not Applicable. †: Literate mothers or adolescent or woman with no schooling are also included.Note: 1. Total number may not add up to total sample size due to do not know and missing case. 2. Included only valid cases.
JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 67Data Quality The survey data examined the hemoglobin level among the study groups. Itshows that there were some data entry errors in the data files since some valuesappeared to be outside the range of the plausible levels (Table 2). It is well recognisedthat a person with Hb level of zero can not survive; similarly more than 20g/dl Hb levelin blood is considered as fatal (Winslow and Monge, 1987; Firkin et al., 1989).Therefore, the present paper considers only the hemoglobin level of the respondentmore than zero and less than 20.0 g/dl for the analyses. The survey used the cut-offlevels of hemoglobin for reckoning the degree of anaemia among the study populationaccording to the UNICEF recommendation (IIPS, 2006).Table 2: Hemoglobin Level among the Study Population Number of Population in Study Groups Hemoglobin Level Children Adolescent Women Pregnant Women (0-71 months) (10-19 years) (15-44 years) Zero g/dl 185 121 23 215800 164750 21233 More than zero-20.0 g/dl (89.3) (91.0) (88.7) More than 20.0 g/dl 24729 16103 2666 Missing cases 1011 138 15 Total 241725 181112 23937Source: Computed from DLHS-RCH, 2002-04 data files. According to the UNICEF classification, children are considered as mildlyanaemic if the Hb level in blood is between 8.0 and 10.99 g/dl. Similarly, with 10.0 to11.99 g/dl among adolescent girls and 8.0-10.99 g/dl Hb level among pregnant womenare considered as mildly anaemic. If the Hb level has dropped below 5.0 g/dl amongchildren, 8.0 g/dl among adolescent girls, and 5.0 among pregnant women, they areconsidered to be severely anaemic (for reference, see Table 3). The Hb level between
68 JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010mild and severe anaemia is denoted as moderate anaemia. The present study alsofollows the same system of classification to categorise the degree of anaemia in thestudy groups.Table 3: Level of Hemoglobin for Anaemia According UNICEF Hemoglobin Level Anaemia Level Children Adolescent Girls Pregnant Women Mild 8.0-10.99 g/dl 10.0-11.99 g/dl 8.0-10.99 g/dl Moderate 5.0-7.99 g/dl 8.0-9.99 g/dl 5.0-7.99 g/dl Severe Below 5.0 g/dl Below 8.0 g/dl Below 5.0 g/dlSource: IIPS, 2006. The prevalence of anaemia level has been calculated across different socio-economic classes for each study group on the basis of records with valid hemoglobinlevel. There are three levels of anaemia: mild, moderate, and severe, along with peoplewho are living with normal hemoglobin level. Normally for dichotomous dependentvariable, logistic regression model is used and in case of polytomy, multinomial logisticmodel is used. In this case, the categories for anaemia status are not merely ‘nominal’but ‘ordinal’, since they represent degree of anaemia: no anaemia, mild, moderate, andsevere anaemia. The factors under consideration could influence the degree and henceone should be able to see to what extent a particular factor raises or lowers the degree ofanaemia. In such a situation, the ordinal logistic regression model is more appropriatethan the multinomial logit and hence was applied to examine the net effect of socio-economic and demographic factors on degree of anaemia. The degrees are ordered as:no anaemia, mild anaemia, moderate anaemia, and severe anaemia. A positivecoefficient to an explanatory variable implies that a rise in it raises the degree ofanaemia.
JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 69Limitation of the Study The data did not provide any information on food intake of respondents at thetime of the survey, and therefore hemoglobin level of the population could not becorrelated directly with the dietary regime. The study was confined among the selectedgroups; Though it is recognised that menopausal women are also have high risk ofanaemia due to heavy bleeding which limits their social and physical activities (Daffary,1993), blood samples from this section of women were not collected during the survey,and hence this group could not be studied. Results and Discussion Prevalence of anemia is very high among all the study population in India. Theresults show that more than 95 percent of children, adolescent girls and pregnantwomen suffer from anaemia. The prevalence is the highest among the adolescents, 97.8percent. Nearly half of the children are mildly anaemic and 2.9 percent are severelyanaemic. More than half of the pregnant women in the country are mildly anaemic and42.6 percent are moderately anaemic. The situation is the worst for adolescent girls,27.1 percent of whom are severely anaemic. Place of residence and sex of the child shows marginal difference in differentdegrees of anaemia level among children in India (Table 4). The percentage of severelyanaemic children declines with increase in mother’s educational level, standard ofliving, age of the mother. Severe anaemia is found to be the highest among childrenaged between 12 and 23 months. Overall, nearly half of children in the country areeither moderately or severely anaemic. This rate is high among children with ScheduledCaste/ Scheduled Tribe (SC/ST) membership, with high birth order, adolescent mother,low standard of living, and among infants.
70 JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010Table 4: Prevalence of Iron-Deficiency Anaemia among Children (age 0-71 months) by Selected Background Characteristics, India Background Percentage of Children with Percentage of Number Characteristics Levels of Anaemia Children with of Severe Moderate or Severe any Anaemia Children Residence Rural 3.0 49.1 96.9 141,483 Urban 2.7 44.9 96.6 51,887 Religion Hindu 3.1 49.1 97.0 156,688 Muslim 2.5 44.4 96.4 22,943 Others 2.3 38.6 94.5 13,739 Caste OBC 3.0 48.0 96.6 78,975 SC/ST 3.5 53.5 97.8 64,129 Others 2.4 42.7 96.3 50,266 Mother’s Education Non-literate 3.3 52.2 97.4 103,662 0-5 years of schooling† 2.6 46.8 96.9 23,895 6-10 years of schooling 2.6 43.1 96.2 48,903 11 + years of schooling 2.2 37.7 95.1 16,910 Standard of Living Low 3.2 51.7 97.4 98,009 Medium 2.8 45.9 96.7 59,280 High 2.5 40.0 95.4 36,081 Age of Mother (Years) 15-19 3.9 57.8 98.4 9,532 20-24 3.0 50.0 97.2 59,426 25-29 2.8 46.2 96.7 67,694 30-34 2.8 45.4 96.3 36,142 35 + 2.9 46.0 96.0 20,576 Sex of the Child Male 3.0 47.3 96.7 100,958 Female 2.9 48.7 97.0 92,364 Age of Child (Months) 0-11 3.9 58.3 97.6 26,401 12-23 4.1 61.3 98.1 29,607 24-47 3.2 49.6 97.2 66,455 48-71 1.9 36.9 95.7 70,907 Birth Order 1 2.7 44.5 96.5 55,268 2 2.9 46.7 96.7 52,003 3 3.0 49.0 96.9 34,808 4+ 3.2 52.0 97.2 51,291 Total 2.9 47.9 96.8 193,370Source: Computed from DLHS-RCH, 2002-04 data files. †: Literate adolescent with no schooling are also included.Note: 1. Children with mothers not interviewed are not included in the analysis. 2. Total number may not add up to total sample size due to do not know and missing case. 3. The percentages are computed after applying survey sample weights and the numbers are given is unweighted.
JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 71 Table 5 shows that there are 97.8 percent adolescent girls are suffering fromanaemia in the country. Severe anaemia declines with increase in educational level from32.8 percent among illiterate to 22.6 percent among adolescent girls with 11 and aboveyears of schooling. Similarly, increase in household standard of living also showsgradual decline in anaemia level among adolescent girls in the country. More thanseventy percent of adolescent girls suffered either moderate or severe anaemia. Theprevalence of moderate or severe anaemia is high among girls with low standard ofliving, belong to Hindu religion; SC/ST membership and illiteracy.Table 5: Prevalence of Iron-Deficiency Anaemia among Adolescent Girls (age 10- 19 years) by Selected Background Characteristics, India Percentage of Adolescent Girls Percentage of Number of Background with Levels of Anaemia Adolescent Girls Adolescent Characteristics Severe Moderate or Severe with any Anaemia Girls Residence Rural 27.0 75.6 97.9 111,046 Urban 24.5 73.5 97.9 53,704 Religion Hindu 26.8 75.9 98.1 130,418 Muslim 24.0 71.9 97.5 21,599 Others 20.8 64.8 95.4 12,724 Caste OBC 25.7 73.6 97.6 64,702 SC/ST 30.0 78.6 98.3 49,396 Others 23.5 73.4 98.0 50,643 Women’s Education Non-literate 32.8 80.5 98.3 27,698 0-5 years of schooling† 26.0 76.8 98.3 50,459 6-10 years of schooling 24.3 72.5 97.7 73,769 11 + years of schooling 22.6 69.1 96.7 12,816 Standard of Living Low 28.6 78.4 98.3 69,928 Medium 24.4 72.5 97.6 55,000 High 23.9 71.5 97.5 39,822 Age of Girl (Years) 10-14 25.4 74.9 98.1 91,599 15-19 27.0 74.8 97.7 73,151
72 JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010Table 5: (Continued) Percentage of Adolescent Girls Percentage of Number of Background with Levels of Anaemia Adolescent Girls Adolescent Characteristics Severe Moderate or Severe with any Anaemia Girls Marital Status Not currently married 25.8 74.4 97.9 153,516 Currently married 30.1 80.1 98.2 11,207 Total 26.1 74.8 97.8 164,750Source: Computed from DLHS-RCH, 2002-04 data files. †: Literate adolescent with no schooling are also included.Note: 1. Total number may not add up to total sample size due to do not know and missing case. 2. The percentages are computed after applying survey sample weights and the numbers are given is unweighted. The prevalence rate of anaemia, irrespective to its severity, is 96.2 percentamong pregnant women in the country (Table 6). Overall, 2.8 percent of pregnantwomen are severely anaemic in India. The prevalence rate of severe anaemia fallssharply with rise in educational level and standard of living. Rural women are moreseverely anaemic than their urban counter part. The overall picture shows that morethan forty percent of pregnant women belonging to Hindu religion, SC/ST community,illiterate, and with low standard of living and high parity suffer from moderate or severeanaemia.Table 6: Prevalence of Iron-Deficiency Anaemia among Pregnant Women (age 15-44 years) by Selected Background Characteristics, India Percentage of Pregnant Percentage of Number of Women with Levels of Pregnant Women Pregnant Background Anaemia with any Anaemia Women Characteristics Severe Moderate or Severe Residence Rural 3.3 43.1 96.9 15,569 Urban 1.2 38.0 95.1 5,664
JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 73Table 6: (Continued) Percentage of Pregnant Percentage of Number of Women with Levels of Pregnant Women Pregnant Background Anaemia with any Anaemia Women Characteristics Severe Moderate or Severe Religion Hindu 3.1 43.4 96.6 17,251 Muslim 0.8 35.8 95.7 2,533 Others 1.6 31.8 95.4 1,449 Caste OBC 2.5 37.7 95.7 8,739 SC/ST 3.5 48.1 97.2 7,222 Others 1.9 39.1 96.3 5,272 Women’s Education Non-literate 4.1 50.7 97.7 10,104 0-5 years of schooling† 2.7 43.4 97.0 2,740 6-10 years of schooling 1.9 37.0 95.3 6,146 11 + years of schooling 1.1 30.2 95.7 2,238 Standard of Living Low 4.0 48.1 97.5 10,435 Medium 1.9 39.0 95.6 6,824 High 1.5 33.8 95.6 3,974 Age of Woman (Years) 15-19 2.8 42.7 96.5 4,391 20-24 2.5 40.3 96.2 9,063 25-29 2.4 41.1 96.3 4,966 30-34 3.1 44.0 96.6 1,923 35 + 3.9 47.3 96.7 890 Parity No child 2.0 35.0 95.7 6,899 1 2.6 41.4 96.2 5,827 2-3 3.8 49.7 97.2 5,633 4+ 2.4 55.0 99.0 2,874 Total 2.6 41.5 96.2 21,233Source: Computed from DLHS-RCH, 2002-04 data files. †: Literate adolescent with no schooling are also included.Note: 1. Total number may not add up to total sample size due to do not know and missing case. 2. The percentages are computed after applying survey sample weights and the numbers are given is unweighted.
74 JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 The preceding discussion was based primarily on differentials. Multivariateanalysis, using ordinal regression analysis allows us to assess net influences of variousfactors on the degree of anaemia after other factors are controlled. Results of ordinallogistic regression show that of number of socio-economic and demographic factorshave significant net influence on degree of anaemia in all the three population groups(Table 7). The severity of anaemia is significantly higher among urban children thanrural possibly due to difference in their food intake. That degree of anaemia is higheramong female children than male disclosed the existence of son preference and genderdiscrimination at food plate in that Indian society. Children with SC/ST membershiphave higher degree of anaemia than other children plausibly due to not being aware ofthe symptom of anaemia. Further, severity of anaemia rises with age among children inIndia. It shows that the supplement of nutritious food after six months of exclusivebreast feeding might not have been introduced to keep anaemia at bay. Appropriatesupplement of iron rich diet helps in growth of children and increases immunity.Children with higher birth order also show higher degree of anaemia perhaps due to lownutritional status of mother on account of frequent childbearing. On the other hand, forchildren belonging to religions other than Hindu, severity of anaemia is low. Propercare and availability of iron rich diet may have helped to keep the incidence of severeanaemia low at higher standard of living. The awareness of proper feeding practices forinfant and young children with adequate supplement of iron is plausibly higher amongeducated mother which translates into lower degree of anaemia for their children.Similarly, older mothers are more experienced with child’s nutrition and it may be thekey factor to keep the degree of anaemia low.
JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 75Table 7: Results of Ordinal Logistic Regression on Prevalence of Iron-Deficiency Anaemia among Children, Adolescent’s Girls and Pregnant Women in India Children Adolescent Girls Pregnant Women Background (0-71 Months) (10-19 Years) (15-44 Years) Characteristics Estimate Standard Estimate Standard Estimate Standard Error Error Error Residence Rural (RC) Urban 0.037** 0.011 0.037** 0.011 -0.013 0.034 Religion Hindu (RC) Muslim -0.180** 0.014 -0.218** 0.014 -0.247** 0.042 Others -0.082** 0.022 -0.169** 0.021 -0.079 0.063 Caste OBC (RC) SC/ST 0.133** 0.011 0.168** 0.012 0.190** 0.033 Others -0.056** 0.011 -0.030** 0.011 0.017 0.035 Mother’s Education Non-literate (RC) 0-5 years of schooling † -0.122** 0.015 -0.159** 0.015 -0.139** 0.043 6-10 years of schooling -0.252** 0.012 -0.294** 0.014 -0.315** 0.036 11 + years of schooling -0.402** 0.020 -0.431** 0.023 -0.419** 0.057 Standard of Living Low (RC) Medium -0.069** 0.011 -0.111** 0.012 -0.046 0.034 High -0.115** 0.016 -0.078** 0.015 -0.021 0.048 Sex of the Child Male (RC) na na na na Female 0.034** 0.009 na na na na Age of Child (Months) 24-47 (RC) na na na na 0-11 0.285** 0.015 na na na na 12-23 0.435** 0.014 na na na na 48-71 -0.475** 0.011 na na na na
76 JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010Table 7: (Continued) Children Adolescent Girls Pregnant Women Background (0-71 Months) (10-19 Years) (15-44 Years) Characteristics Estimate Standard Estimate Standard Estimate Standard Error Error Error Age of Mother/Girl/Woman (Years) 10-14 (RC) na na na na 15-19 0.218** 0.022 0.080** 0.011 0.098** 0.037 20-24 0.102** 0.012 na na -0.072 0.038 25-29 (RC) na na 30-34 -0.101** 0.014 na na -0.181** 0.057 35 + -0.168** 0.017 na na -0.214** 0.083 Marital Status Not currently married na na na na (RC) Currently married na na 0.108** 0.018 na na Birth Order 2 (RC) na na na na 1 -0.075** 0.012 na na na na 3 0.100** 0.014 na na na na 4+ 0.236** 0.015 na na na na Parity No child (RC) na na na na 1 na na na na 0.224** 0.036 2-3 na na na na 0.436** 0.042 4+ na na na na 0.590** 0.061 µ1 -3.491** 0.02 -4.027** 0.022 -3.218** 0.054 µ2 -0.019 0.016 -1.368** 0.015 0.260** 0.043 µ3 3.447** 0.02 0.789** 0.014 3.681** 0.058 Cases included in analysis 193873 164891 21326 -2 log likelihood 79892.17 10316.56 9487.51 Nagelkerke R2 0.057 0.014 0.032Source: Computed from DLHS-RCH, 2002-04. RC: Reference Category. †: Literate mothers or adolescent or woman with no schooling are also included. **: Significant level at 1 percent. *: Significant level at 5 percent. na: Not Applicable.Note: 1. Children with mothers not interviewed are not included in the analysis.
JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 77 The study also reveals that severity of anaemia is higher among adolescentgirls belonging to urban areas than rural areas. Further, degree of anaemia is higheramong currently married adolescent girls compared to those not currently marriedbecause these adolescent married women are physically immature to enter activereproductive life. Besides, they must make adjustments of living away from maternalhome and post marital household diet. The results show that older adolescents (15-19years) are more anaemic than younger adolescents (10-14 years) which could be due tohigher physical activity assigned to older adolescents. On the other hand, awarenessincreases with educational level and degree of anaemia decreases with increase in yearsof schooling as well as rise in standard of living due to availability of proper nutritiousfood among adolescent girls. Among pregnant women, the degree of anaemia rises with parity becauseconsecutive child birth leads to excessive blood loss and frequent pregnancy experiencewithout appropriate diet, the well recognised maternal depletion factor. But severity ofanaemia varies with age, with a ‘U’- shaped relationship. Results show that severity islow in prime child bearing ages because the physical condition is suitable for child birthwhereas complications related to pregnancy may rise with age and hence lower the Hblevel. Educational level plays an important role to curb the degree of anaemia amongpregnant women. Education increases the awareness regarding proper nutrition duringpregnancy (possibly including consumption of Iron and Folic Acid tablet) to keep Hb atnormal level. That the degree of anaemia is significantly lower among Muslim pregnantwomen compared to Hindus may be due to difference in food intake between these tworeligious communities. Degree of anaemia is higher among women who belong toscheduled castes, which poses the question on implementation of programmes forsocially deprived sections. Standard of living and place of residence do not show anysignificant effect on degree of anaemia among pregnant women in the country. Conclusions The study shows that the prevalence of any anaemia is very high in India;especially prevalence rate of severe anaemia is high among adolescent girls. Contrary tocommon perception, anaemia not only affects the lower strata as such, but has its markon well off sections of the society as well though at lower level. The degree of anaemia
78 JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010varies with education and standard of living, i.e., severe anaemia is low among highlyeducated and people with high standard of living. For pregnant women, frequentchildbirth increases the degree of anaemia. Moreover, early entry to sexual union andmotherhood also raises the severity of anaemia among women. The estimates from DLHS-RCH, 2002-04 data in the present study clearlyshow that the NNAPP in operation since 1972 in the country has unfortunately failed tofulfill its promise to achieve the desired results. The prevalence rate of anaemia isalarming for adolescent girls; in addition, almost thirty percent of them are severelyanaemic. For adolescent girls, implementation of policies may be difficult because theyare not easily identified and covered like pregnant women or children where continuousmonitoring is possible through several maternal and child health care programmes.Therefore, there should be a strategic shift in programmes to broaden the coverage ofpublic programmes to adolescent girls also to control anaemia. Besides, anaemia controlprogramme needs to be implemented more efficiently in poor performing states. Iron-deficiency anaemia lowers overall productivity but policy makers do not view thisseriously as an adverse effect on sustainable economic growth on the nation. Integratedstrategies are required with each intervention clearly related to particular groups at risk.However, economic constraints to dietary improvement are one of the primary barriersto a food based approach to alleviating anaemia in a developing country like India.Screening for anaemia, treatment of anaemic women and children and availability ofcheap and nutritious food, salt with iron fortification are the key to reduce anaemia. Ironfortified salt, supported by UNICEF, Food and Nutritional Board, and the Tamil Nadustate government, currently is consumed by all segments of the population in TamilNadu. Even food cooked in cast iron utensils improves iron content in diet. Anaemiabehaves as a silent killer to reduce the immune power of human body and enhances therisk of further infections. Anaemia is curable if diagnosed early, otherwise it may befatal. There are motivational problems among people because it is not a dramaticillness. Therefore, health workers should motivate the target population to introducemore iron rich food in the daily diet. Anaemic babies are retrospective marker of thenutritional status of women of the country. Improving mother’s health and reducingchild malnutrition are major challenges to human development in this millennium. Wellnourished and healthy children will be healthier in their adolescence and more
JOURNAL OF POPULATION AND SOCIAL STUDIES Volume 19 Number 1 July 2010 79productive ages and also will give birth to healthier babies tomorrow contributing tohuman development in the present and future generation. Acknowledgements We are cordially thankful to Dr. P. M. Kulkarni, Professor, Centre for theStudy of Regional Development, Jawaharlal Nehru University, New Delhi for his expertcomments and the help for this paper. We are also thankful to Mr. ParthaChattopadhyay, Chief Director, Department of Statistics, Ministry of Health and FamilyWelfare, New Delhi for making the nutrition data available to us for research purpose. ReferencesBrabin, L. and B. J. Brabin. 1992. The cost of successful adolescent growth and development in girls in relation to iron and vitamin A status. American Journal of Clinical Nutrition, 55: 955-958.Daffary, N. S. 1993. Endometrial ablation in clinical perspective. The Journal of Obstetric and Gynaeconogy of India, 43(2): 145-146.Firkin, F., C. Chesterman, D. Penington, and B. Rush. 1989. De Gruchey’s Clinical Haematology in Medical Practice. Delhi: Oxford University Press.Fox, W. 1983. Compliance of patients and physicians: experience and lessons from tuberculosis I and II. British Medical Journal, 287(33-35): 101-105.Galloway, R and J. Mcguire. 1994. Determinants of compliance with iron supplementation: supplies, side effects, or psychology? Social Science and Medicine, 39(3): 381-390.Gillespie. S., J. Kevany, and J. Mason. 1991. Controlling Iron Deficiency. UN administrative committee on coordination/ sub-committee on nutrition. State of the Art series. Nutrition policy discussion paper 9. Geneva: WHO.Hellen Kellar Institute for Girls. 1996. Annual Repots. Gizi: Intervensii Kepada Remaja Lokal di sckolah.
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