Components of the Integrated Package
Because there are multiple causes of anemia in most developing countries, a single intervention such as iron supplementation will be ineffective in reducing anemia. Deliverying an integrated package of interventions to address the main causes of anemia will be most effective. The components of the package can be delivered through both public and private sectors.
Knowing the causes of anemia is important in designing an integrated package to reduce anemia. This package will be specific to the geographic setting because some of the causes vary by region and country. Click here for the major causes of anemia by region.
Knowing who is most vulnerable to anemia will help in targeting the integrated package. Based on the prevalence and consequences of anemia, pregnant women and children younger than two years of age are the most vulnerable individuals worldwide. Click here for information on the prevalence of anemia. Anemia does exist in other groups, including reproductive-age women, adolescents, school-age children, and men, particularly those affected by helminths and malaria and doing heavy physical labor. These other groups also should be targeted with interventions, when resources are available.
However, two interventions need to be part of the integrated package due to their cost-effectiveness in reducing anemia and other morbities in entire populations or large groups of individuals, including fortification and family planning. When a centrally-processed staple food is available, this food should be fortified with iron because it will benefit most of the population. Family planning services need to be offered to all couples because family planning, including birth spacing of at least two years, will reduce anemia. These interventions will not be enough to satisfy the iron needs of women during pregnancy or their vulnerability to malaria, particularly those in their first and second pregnancies, so targeted interventions during pregnancy will continue to be needed.
Components of the integrated package include:
- Birth spacing of less than 24 months is associated with poor maternal, newborn, and child health outcomes. Stunting and underweight in children increase as birth intervals decrease (Rutstein, 2005 and 2008). Optimal birth spacing allows for the mother’s body to fully recover from birth and build stores of nutrients lost during delivery including iron. In many countries, women stop breastfeeding when they become pregnant. Ensuring the mother does not become pregnant before her current child reaches his/her second birthday will ensure that the child is adequately cared for during this vulnerable period and continues to receive breast milk. Breast milk continues to be an important source of nutrition until two years of age and decreases the risk of diarrhea and other infections which increase iron requirements and loss. Continued breastfeeding delays subsequent pregnancy , when the three criteria of the Lactational Amenorrhea Method (LAM) are met. Click here to go to the K4Health Toolkit on Maternal Infant Young Child Nutritoin and Family Planning Integration Toolkit.
- Delayed cord clamping allows blood flow to continue between the mother and newborn for 1-3 minutes after birth or until the cord stops pulsing. This practice can be done while initiating simultaneous essential newborn care. This delay in clamping can build iron stores in the infant to last up to six months after birth, which is particularly relevant for infants living in low-resource settings whose mothers have less access to iron-rich foods. Delayed cord clamping particularly increases iron stores in low birth weight infants and infants of anemic mothers. Click here for more information on delayed cord clamping.
- Food-based approaches to reduce anemia include increasing the availability and access to iron-rich foods and other nutrients that play a role in preventing anemia. Increasing agriculture production of crops with higher iron content, raising animals to consume, or fortifying foods with iron are all effective food-based approaches. Food-based approaches also include food processing to increase the absorption of iron and changing dietary habits by avoiding the intake of iron inhibitors and ensuring that vulnerable groups are consuming iron-rich foods when they are available. Click here for more information on food based approaches.
- Helminth prevention and control should be part of the integrated anemia prevention and control package where helminths are prevalent. Hookworm and schistosome are the two most common types of helminth infections that can cause excessive red blood cell loss and result in iron-deficiency anemia. Endemic hookworm infection is a significant cause of anemia in children. Click here for more information on helminth prevention and control.
- Iron -Folic Acid Supplementation during pregnancy is a policy in most developing countries and in most countries some pregnant women receive iron-folic acid supplements but coverage is still limited. Harmonizing the dose of folic acid with malaria control and treatment programs using sulphadoxine-pyrimethamine (SP) is imperative to ensure the effective treatment of malaria. The World Health Organization recommends giving a dose of folic acid less than 5 mg. A combined iron-folic acid supplement contains much less folic acid---only 400 mcg of folic acid. Giving iron routinely to children is less common, although giving iron as drops or syrup is a policy in some countries. Giving iron with other micronutrients in the form of micronutrient powders, which can be incorporated into the child’s porridge, is being tested as an alternative to iron drops. Click here for more information on iron-folic acid supplementation.
- Malaria prevention and control is another important intervention to help address anemia. Pregnant women living in stable and unstable malaria transmission areas, who get malaria are at higher risk of severe anemia, and are at the greatest risk in their first and second pregnancies. Malaria infection - usually accompanied by iron deficiency - causes life-threatening, severe anemia in children younger than two years of age. Click here for more information on malaria prevention and control.
In thinking about an integrated anemia prevention and control package, one should think of the contact point at which each component is delivered. This contact point may be health contacts or may be the contacts women have with other sectors or channels. A useful document titled Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health has been adapted for the anemia integrated package that can be delivered to women and children younger than five years at different contact points and channels. However, other interventions can be delivered by different sectors such as education and agriculture and by the private sector. In the section below, we have described and provided resources for some of these health and other sector interventions. This section has focused on providing in-depth information in SUB-TABS on addressing iron deficiency and helminth and malaria infections. There also are resources below on birth spacing and delayed cord clamping, a neglected but important action to build iron stores in newborns.