CHAPTER ONE 1.0 INTRODUCTION

This chapter introduces the study by providing background information and statement of the problem. Thereafter, it further highlights the objectives of the study, research questions and the significance of the study. Folate is a type of B vitamin. It is also called folic acid. Daily oral iron and folic acid supplementation is recommended as part of the antenatal care to reduce the risk of low birth weight, maternal anaemia and iron deficiency. The overall quality of the evidence for iron supplementation versus no iron was moderate for low birth weight, preterm birth, and maternal anaemia at term and maternal iron deficiency at term. The evidence was of low quality for birth weight, neonatal death, congenital anomalies, maternal death, maternal severe anaemia, and infections during pregnancy; whereas it was of very low quality for side-effects. Daily folic acid supplementation is recommended as part of the antenatal care to reduce the risk of low birth weight, maternal anaemia and iron deficiency (WHO, 2012)

In Tanzania, 1999 data shows that only 44% of women were receiving iron supplements: In Eretria (1996-1997) only 29.5% were receiving iron tablets and in Yemen only 20.7% were receiving iron tablets. Coverage is higher in Ghana (1998), Indonesia (1997), and Philippines (1998) where three-quarters of women are receiving iron during pregnancy, (TDHS, 2004-05). The connection between folic supplement and anemia is that if the body has enough folic acid this mean that it is hard to get anemia during pregnancy.

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Anemia prevalence in pregnant women is one of the health problems confronting pregnant women. The prevalence of Anemia and severe anaemia in pregnant women were 60% and 3.8 % in pregnant women respectively. Pregnant women tend to become anemic because their blood is also used by the unborn child. The required blood of pregnant women is 11g/dl. However, during pregnant majority of the women are below 11g/dl thus during Ant natal (ANC) visit they are given folic acid supplement to help them increase the amount of blood which is real needed to their bodies and help them deliver safely (Massawe, 2002).

1.2 Background to the Research Problem

Anemia is a condition that occurs when the hemoglobin level in the blood is too low. Hemoglobin is a protein in red blood cells which carries oxygen from the lungs to different parts of the body. When blood does not have enough haemoglobin, the body will not get the oxygen it needs. Human body needs iron in order to generate haemoglobin thus low iron in blood cause the most common kind of anemia (iron- deficiency anemia). It is important that before conceiving, a woman should take folic acid for production of red blood cells, as well as nor epinephrine and serotonin (chemical components of the nervous system). Folic acid also helps to synthesize genetic material in every cell of the body and normalize brain function. Taking folic acid before conception reduces the risk of neural-tube defects such as spina bifida (Urassa, 2002).

Anemia in pregnancy is a serious public health problem worldwide. WHO (2001) estimates that, more than half of pregnant women in the World have a hemoglobin level indicative of anemia (< 11.0gldl), the prevalence may however be as high as

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56% or 61% in developing countries. Women often become anemic during pregnancy because the demand for iron and other vitamins is increased due to pregnancy. The inability to meet the required level for these substances either as a result of dietary deficiencies or infection gives rise to anemia. Anemia ranges from mild, moderate to severe and the rates of haemoglobin level for each of these types of anemia in pregnancy at 10.0 – 10.9g/d1 (mild anemia) 7 – 9.9g/dl (moderate anemia) and < 7g/dl (severe anemia) (WHO, 2001).

Foetuses are at risk of preterm deliveries, low birth weights, morbidity and perinatal mortality due to the impairment of oxygen delivery to placenta and fetus. It is suggested that, like vitamin A deficiency, at least 80% of pregnant women are taking the recommended number of iron tablets; there will be worldwide reduction in anemia. The Tanzania Demographic Health Survey (TDHS, 2004-05), report indicated that, only few countries are reaching this level coverage.

The analysis of anemia prevalence and iron pill taken proxies for income shows that anemia prevalence is high in the poor countries compared to rich countries. Therefore in order to reach women in generally and particularly the women who need iron the most, alternate deliver channels need to be found and may include places of work, private sector drug sellers and markets, and community networks (women’s groups and religious leaders) Thailand, for example improved coverage of ANC over the last 15 years and as a result has significantly reduced anemia prevalence over the same period. They used community volunteers to identify pregnant women early and encourage their frequent use of ANC, where women are provided with adequate supplies of iron tablets and effective messages to ensure that

4 they take iron tablets (TDHS, 2004).

WHO report estimated that 41% of women and 27% of children suffer from anemia due to iron deficiency. The consequences of iron deficiency anemia include suboptimal mental and motor development in young children, increased risk of maternal mortality, and decreased economic productivity of adults. Iron nutrition is not yet well integrated into the agendas for reducing morbidity and mortality of pregnant women and neonates. Iron supplementation in pregnancy has been advocated for decades as a means of controlling anemia, but this outcome has not been sufficient to motivate strong programs and policies (WHO, 2005).

1.3 Anemia in Pregnant Women

Anemia is regarded as a major risk factor for pregnant women. It has been associated with premature labor and low birth and some of these associations are not firmly established and severe anemia (Hb below 70 g/l) has consistently been associated with maternal mortality (Rush, 2000). Based on these associations and high prevalence of iron deficiency anemia, supplementation programs were expected to reduce poor outcome of pregnancy e.g. death of a child or miscarriage, but the results were often disappointing (Rush, 2000). This was often attributed to program implementation weaknesses, but more profound anemia, accounting for most of the anemia-related increased risk of maternal death, is likely to have complex and multiple causes (Beaton, 2000).

A study from Malawi showed that 60% of iron-deficient women had other deficiencies as well, and many had signs of inflammation (van den Broek & Letsky,

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2000). Similarly, a study from Tanzania identified iron deficiency, malaria, hookworms, and other infections as major causes of anemia (Massawe et al, 1999). Both of these studies used bone marrow aspiration as a gold standard for defining empty iron stores, and consequently using a control group of non-anemic women was not acceptable.

1.3.1 Tanzania Nutrition Policy and Strategies

The United Republic of Tanzania endorsed the commitment at the World Food Summit held at Rome Italy in 1996 and the World Summit for Children held at New York in 1990, that several forms of malnutrition including micronutrient deficiency should be eliminated. The commitment of the government for ensuring food quality and nutrient content of food is also implied in the National Health Policy of 2002, which specifically mentions salt iodization.

‘The Food & Nutrition Policy’, which was written in 2005 but still has not been, endorsed also explicitly mentions food fortification as a strategy to combat vitamin and mineral deficiencies. Similarly, Tanzania is signatory to resolution SA/HMC46/R10 that was adopted at the 46th conference of ECSA-HC Health Ministers in in February 2008 at Victoria, Mahe, Seychelles which among others, urges Member States to: adopt and support implementation of ECSA food enrichment guidelines by the end of 2009 and allocate and increase financial resources (in health budget /and basket funds) by at least 20% within the next two years, for nutrition with a focus on micronutrients interventions such as Vitamin A supplementation, iron and folic acid supplementation, fortification and other food‐based interventions. This will help to ensure sustainability and reduce donor

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dependence.

In addition, the National Nutrition Strategy for 2009‐2015, mentions food fortification as a potential strategy to reduce the prevalence of micronutrient

deficiencies in Tanzania. The strategy aims at ensuring that legislation, regulations, standards and guidelines are set in place for fortification of appropriate food vehicles; a quality assurance system is established at critical control points and the undertaking of social marketing of fortified foods among consumers.