Iron supplementation is the fastest method of addressing clinical iron deficiency anaemia, but this strategy faces barriers, including low compliance due to gastric side effects a risk of toxicity and exacerbation of concomitant infection (Sazawal et al., 2006 World Health Organization, 2007) and supply side issues stemming from poorly functioning health systems (Kosec et al., 2015 Maity, 2016). ![]() ![]() Among populations in developing countries with predominantly plant-based diets such as India, poor iron status is typically due to low intake of bioavailable iron combined with chronic infection hindering iron absorption. The aetiology of anaemia is complex and context specific, though iron deficiency is a causal factor in about one quarter to one half of all cases, with other causes including haemoglobin disorders, other micronutrient deficiencies such as vitamin B12 and folate, blood loss through heavy menstruation or trauma, and disease states (Bahizire et al., 2017 Kassebaum et al., 2014 Petry et al., 2016 Wieringa et al., 2016). Half of pregnant Indian women are anaemic (Hb < 110 g/L) according to a recent national survey (Government of India, 2017), which is troubling, given that anaemia during pregnancy is associated with higher risk of low birth weight, preterm birth, and perinatal mortality (Rahman et al., 2016), as well as a higher risk of maternal mortality (Daru et al., 2018). Within South Asia, the most cases of anaemia occur in India. Worldwide, 29% of nonpregnant women and 38% of pregnant women were affected in 2011 (World Health Organization, 2011b) and regionally, anaemia prevalence is highest in Southeast Asia (Stevens et al., 2013). This severe public health issue is especially problematic in women of childbearing age, and the second World Health Assembly global nutrition target is to halve anaemia in this group by 2025 (World Health Organization, 2015). National Sample Survey of Consumer ExpenditureĪpproximately one third of the global population is estimated to be anaemic (Lopez, Cacoub, Macdougall, & Peyrin-Biroulet, 2016).As policymakers expand fortification programs, it is critical to ensure that the fortified food is universally available and distributed widely through well-functioning and popular outlets. India's wheat fortification programmes were largely ineffective in terms of reducing anaemia among pregnant women. In southern India, where intervention coverage was high, we found no impact on Hb (β = −0.001, P = 0.998) but did see an impact on anaemia reduction (β = −0.08, P = 0.042), which was unexpected given low consumption of wheat in this predominantly rice-eating region. ![]() ![]() In northern India, we found no impact on Hb (β = −0.184, P = 0.793) or anaemia reduction (β = −0.01, P = 0.859), as expected, given that the intervention targeted only nonpoor households and demand for fortified wheat was low. The difference-in-differences method was used to estimate the impact on haemoglobin (Hb) and anaemia in pregnant women living in northern India (Punjab) and southern India (Tamil Nadu), with pregnant women in neighbouring states without wheat fortification programmes serving as controls. We assessed programme impact on anaemia among pregnant women ( n = 10,186) using data from the 2002–20–2013 Indian District Level Health Surveys. In India, the government implemented a 4-year food-based safety net programme from 2008 to 2012 involving the provision of fortified wheat flour through its public distribution system. India accounts for the most cases of anaemia in the world, and half of all pregnant Indian women are anaemic. The World Health Assembly called for a 50% global anaemia reduction in women of reproductive age (15–49 years of age) from 2012 to 2025.
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