Identifying opportunity gaps in the effective coverage cascade for prevention of anaemia among pregnant women in India

‘Effective Coverage’ cascades for prevention of anaemia among pregnant women in India have been developed using published results of National Family Health Survey – 5 (NFHS-5). Health Management Information System (HMIS) data from multiple states was also examined for the cascade. The measurement of ‘Effective coverage’ begins with required coverage; it takes into consideration health service contact coverage, crude coverage, quality adjusted coverage, user adjusted coverage and outcome adjusted coverage. The ‘effective coverage’ cascade is used to identify coverage gaps, quantify coverage at each step, determine where the largest gaps exist within the cascade and prioritize where actions are most urgent (Figure 1 and Table 1). Innovative and effective interventions can then be designed to specifically address the largest gaps. HMIS provides at least three of these indicators viz., estimates of pregnant women, numbers registered for antenatal care (ANC), and provided with 180 Iron and Folic Acid (IFA) tablets for the prevention of anaemia.

NFHS-5 data indicates that the ‘effective coverage’ of IFA supplementation among pregnant women is uniformly LOW across all states, with less than a third of all pregnant women effectively covered for the prevention of anaemia. States demonstrate variances in the cascade and in the levels of ‘effective coverage’ that range from less than 2% to about 32%.

The largest gap in the IFA cascade is in ‘user adjusted coverage’ denoting the proportion of pregnant women reporting having consumed IFA for 180 days. This drop is high in most states. In Jammu and Kashmir, despite high coverage (86.6%) of early registration in antenatal care, user adjusted coverage is less than 16%. The second largest and most consistent gap is between women who received any ANC versus those who received early ANC. Early ANC, or care during the first trimester, offers an opportunity to initiate IFA at the start of the second trimester, thus allowing compliance with guidelines to provide 180 days of IFA during pregnancy for anaemia prevention. We have used early ANC coverage as a proxy indicator for quality adjusted coverage, indicating the potential to receive IFA as per standards during ANC (i.e., for 180 days). This gap between any ANC and early ANC is also high ranging between 5-34% across states.

States may explore innovative methods to support user adherence to daily consumption of IFA for a period of not less than 180 days. Many states will also need to improve coverage rates for early (first trimester) registration of pregnant women. Finally, states could expand facility and community-based distribution systems to ensure uninterrupted availability of sufficient quantities of IFA during antenatal care sessions. NFHS surveys are conducted once in five years, whereas HMIS is available every year. HMIS can be used to track elements of the cascade annually, but the use of data is limited by its sub-optimal quality and restriction to public sector alone. HMIS quality can be improved by standardisation of indicator definitions and creation of mechanisms that amalgamate and validate data inputs, including private sector, to improve validity and timeliness.


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