Authored by: Francesco Branca, Zulfiqar A. Bhutta, Aatekah Owais
Five years ago, building on the Millennium Development Goals, the United Nations set the Sustainable Development Goals (SDGs), 17 global targets for the world to meet and in doing so, “achieve a better and more sustainable future” for all by 2030.
To spur action to address all forms of malnutrition, SDG 2 was created, highlighting child wasting and overweight – the double burden of malnutrition. And in 2020, a critical addition addressing the nutritional needs of women of reproductive age was made (SDG 2.2).
Maternal anemia – which affects 40 percent of all pregnant women globally, and disproportionately affects those in low-income countries – became an important part of SDG 2, with a key indicator being a 50 percent reduction in women of reproductive age (15-49) with anemia by the year 2030, as compared to the baseline level registered in 2012.
Anemia is a condition in which the absolute number of red blood cells or their hemoglobin content is reduced, affecting their oxygen carrying capacity. Whether it’s non-nutritional anemia (caused by postpartum hemorrhage, heavy menstrual bleeding, infections like malaria or hookworm, and others), anemia caused by genetic disorders (thalassemia, glucose-6-phosphate dehydrogenase deficiency, and others), or nutritional anemia (caused by deficiencies in iron, vitamins, folic acid, riboflavin, and others), the disorder poses increased risk for women during pregnancy.
Therein lies a particular challenge. A pregnant woman’s total blood volume can increase (usually around 50 percent) over the course of her gestation. This means women – who are already prone to anemia – are at increased risk of developing it when they are pregnant, in part because their iron supplies do not automatically increase with their rise in blood volume. With 40 percent of pregnant women – and one-third of women of reproductive age – being anemic worldwide, this increases their risk of having low birth weight babies, premature birth and maternal mortality. In addition, maternal anemia carries an increased risk of adverse newborn and childhood outcomes, with cascading effects into adulthood.
With less than ten years to achieve SDG 2.2, the stakes are high and the arduous path to achieving progress on maternal anemia will require facing several issues:
First, we still lack a comprehensive understanding of the epidemiology of maternal anemia. Not only because it is a disorder that can result from multiple causes and/or diseases, but because globally, the etiology of anemia differs substantially across regions of the world. Standards that account for what is an acceptable hemoglobin level differ across factors, such as pregnancy status, age and sex, or environmental factors, like altitude and smoking (these standards are currently under review by the WHO). Further compounding this are drivers like inflammation or genetic factors, which impact hemoglobin levels, but are often not measured or accounted for.
Second, tracking anemia, especially among vulnerable populations (like the poorest women of South Asia and Central and West Africa) only takes place via surveys that occur every four to five years, and may not paint the whole picture. The data on the correlation between anemia and nutrition program coverage or population compliance is lacking, making it hard to implement interventions that would help improve access to iron and nutrition programs.
Third, because anemia is multi-factorial and its exact drivers (ranging from malnutrition to economic inequity to water and sanitation to access to education) are hard to pinpoint within most given geographic regions, adequate solutions are not in place for most women.
Finally, nutrition supplementation guidelines for pre-pregnant and pregnant women have not changed substantially, and are mainly based on the distribution of iron folic acid (IFA) supplements, even though the use of multiple micronutrient supplement (MMS) is now recommended in the context of rigorous research.
When a challenge is so prevalent and its solution so complex, a unique kind of perfect storm tends to brew. We’re seeing that, in many ways, with COVID-19. But with disorders like anemia, that have long affected the poorest in the world – and especially the poorest women in the world – a renewed commitment must be made to tackle this problem.
The 2020 addition of maternal anemia to the SDGs was an important step to highlight both the magnitude of the problem and the focus that experts in the public health community know it demands.
And today, those experts can use this platform, Exemplars in Global Health, to learn what makes specific public health interventions successful.
In the case of anemia, EGH is working to highlight certain countries, policies, and programs that have been effective in reducing anemia prevalence among women of reproductive age, analyzing why they’ve worked, and exploring what difficulties they’ve faced. EGH researchers are also examining how programs have been implemented and where they have been successful by analyzing the results that have been delivered, so solutions can be replicated.
Meeting SDG 2.2 will involve the work of many and an unrelenting pursuit by governments, civil society and public health experts, but having a blueprint of proven success ameliorates the challenge, improving the chances that we will get closer to achieving progress in maternal anemia by 2030.
For us, this is good news. Extraordinary progress can be inspirational, and even aspirational. But it is perhaps most useful when it is informative. If we are to address the problem of maternal anemia, we can now do so using the lessons of those who have achieved great success and whose victories we can build upon.