Determinants of compliance with iron supplementation: supplies, side effects, or psychology?

Multiple micronutrient supplementation during pregnancy does not lead to greater infant birth size than does iron-only supplementation: a randomized controlled trial in a semirural community in Mexico

BACKGROUND

Little is known about the benefits of prenatal multivitamin and mineral supplements in reducing low birth weight.

OBJECTIVE

We conducted a randomized, double-blind clinical trial in semirural Mexico to compare the effects of multiple micronutrient (MM) supplements with those of iron supplements during pregnancy on birth size.

DESIGN

Pregnant women (n = 873) were recruited before 13 wk of gestation and received supplements 6 d/wk at home, as well as routine antenatal care, until delivery. Both supplements contained 60 mg Fe, but the MM group also received 1-1.5 times the recommended dietary allowances of several micronutrients.

RESULTS

At recruitment, the women in the 2 groups were not significantly different in age, parity, economic status, height, or hemoglobin concentration but differed significantly in marital status (4.6% and 2.0% of women in the MM and iron-only groups, respectively, were single mothers) and mean (+/- SD) body mass index (in kg/m(2); 24.6 +/- 4.3 and 23.8 +/- 3.9 in the iron-only and MM groups, respectively). Losses to follow-up (25%) and compliance (95%) did not differ significantly between the groups. In intent-to-treat analyses (MM group: n = 323; iron-only group: n = 322), mean (+/- SD) birth weight (2.981 +/- 0.391 and 2.977 +/- 0.393 kg in the MM and iron-only groups, respectively) and birth length (48.61 +/- 1.82 and 48.66 +/- 1.83 cm in the MM and iron-only groups, respectively) did not differ significantly between the groups.

CONCLUSION

These findings suggest that MM supplementation during pregnancy does not lead to greater infant birth size than does iron-only supplementation.

The burden of anemia among women in India

OBJECTIVE

This research investigates the prevalence and determinants of anemia among women in Andhra Pradesh. We examined differences in anemia related to social class, urban/rural location and nutrition status body mass index (BMI). We hypothesized that rural women would have higher prevalence of anemia compared to urban women, particularly among the lower income groups, and that women with low body mass index (BMI; <18.5 kg/m(2)) would have a higher risk compared to normal or overweight women.

DESIGN

The National Family Health Survey 1998/99 (NFHS-2) provides nationally representative cross-sectional survey data on women's hemoglobin status, body weight, diet, social, demographic and other household and individual level factors. Ordered logit regression analyses were applied to identify socio-economic, regional and demographic determinants of anemia.

SETTING

Andhra Pradesh, a southern Indian state.

SUBJECTS

A total of 4032 ever-married women aged 15-49 from 3872 households.

RESULTS

Prevalence of anemia was high among all women. In all 32.4% of women had mild (100-109.99 g/l for pregnant women, 100-119.99 for non-pregnant women), 14.19% had moderate (70-99.99 g/l), and 2.2% had severe anemia (<70 g/l). Protective factors include Muslim religion, reported consumption of alcohol or pulses, and high socioeconomic status, particularly in urban areas. Poor urban women had the highest rates and odds of being anemic. Fifty-two percent of thin, 50% of normal BMI, and 41% of overweight women were anemic.

CONCLUSIONS

New program strategies are needed, particularly those that improve the overall nutrition status of women of reproductive ages. This will require tailored programs across socio-economic groups and within both rural and urban areas, but particularly among the urban and rural poor.

Concepts of iron deficiency anemia and public health measures in rural Costa Rica

In rural Costa Rica, lay people conceptualize iron deficiency anemia differently from health care providers, and these differences impede public health initiatives. This research is based on 70 ethnographic interviews with mothers of young children 24-48 months of age and interviews with health care personnel in eight rural neighborhoods. Lay explanations of anemia draw on biomedical concepts, such as the amount of iron in the blood or in food, but one common explanation is elaborated to involve a biomedical life-threatening disease, leukemia, in cases where the anemia is not treated. Furthermore, mothers often view the liquid iron given free at the clinic as treatment for anemia as too strong, causing negative dental effects; many refuse to administer the iron drops to their children and give other treatments. Formal public health measures result in effects local people consider unacceptable and not congruent with being a good parent; with few exceptions, the medical community dismisses those preoccupations as inappropriate signs of ignorance on the part of caretakers. The existence of several systems of healing allows for parental rejection of public health measures and easy access to alternative remedies.

Acceptability of the use of iron cooking pots to reduce anaemia in developing countries

OBJECTIVE

To evaluate acceptability, compliance and attitude towards the use of iron pots compared with aluminium pots, for cooking in a community that traditionally did not use iron pots.

DESIGN

Randomised trial.

SETTING

Two rural Malawian villages.

SUBJECTS

Fifty-two households received iron pots and 61 aluminium pots.

RESULTS

Pot characteristics were assessed by a questionnaire after 3, 6, 11 and 20 weeks of use. Within households using iron pots there was a significant decrease in acceptability score with usage, from an initial value of 13.7 to 11.4 (range 1-20) Answers to questions concerning cooking characteristics showed that after 3 weeks' use the aluminium pot scored better, whereas after 20 weeks fewer answers differed between the iron and aluminium pot groups. Almost a third of the households planned to continue using iron pots daily after 20 weeks, although they had ready access to their former aluminium pot. The presence of a group of consistent pot users suggests that if households were convinced about daily use, then they were likely to maintain consistent use. Some householders considered that iron pots required less firewood for cooking than aluminium pots. The main problems related to lower acceptability were rusting and pot weight. About 25% of problems with iron pots were unrelated to their cast iron characteristics. Overall 23.4% of the households indicated they would buy an iron pot.

CONCLUSIONS

The low acceptability of iron pots for cooking could limit their value as an intervention to control iron-deficiency anaemia. Design modifications and better instructions on pot use should improve acceptability. The study highlights the need to assess the acceptability of interventions in order to facilitate their adoption in traditional communities.

Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries

The World Health Organization estimates that 58% of pregnant women in developing countries are anemic. In spite of the fact that most ministries of health in developing countries have policies to provide pregnant women with iron in a supplement form, maternal anemia prevalence has not declined significantly where large-scale programs have been evaluated. During the period 1991-98, the MotherCare Project and its partners conducted qualitative research to determine the major barriers and facilitators of iron supplementation programs for pregnant women in eight developing countries. Research results were used to develop pilot program strategies and interventions to reduce maternal anemia. Across-region results were examined and some differences were found but the similarity in the way women view anemia and react to taking iron tablets was more striking than differences encountered by region, country or ethnic group. While women frequently recognize symptoms of anemia, they do not know the clinical term for anemia. Half of women in all countries consider these symptoms to be a priority health concern that requires action and half do not. Those women who visit prenatal health services are often familiar with iron supplements, but commonly do not know why they are prescribed. Contrary to the belief that women stop taking iron tablets mainly due to negative side effects, only about one-third of women reported that they experienced negative side effects in these studies. During iron supplementation trials in five of the countries, only about one-tenth of the women stopped taking the tablets due to side effects. The major barrier to effective supplementation programs is inadequate supply. Additional barriers include inadequate counseling and distribution of iron tablets, difficult access and poor utilization of prenatal health care services, beliefs against consuming medications during pregnancy, and in most countries, fears that taking too much iron may cause too much blood or a big baby, making delivery more difficult. Facilitators include women's recognition of improved physical well being with the alleviation of symptoms of anemia, particularly fatigue, a better appetite, increased appreciation of benefits for the fetus, and subsequent increased demand for prevention and treatment of iron deficiency and anemia.

Low compliance of iron supplementation in infancy and relation to socioeconomic status in Israel

OBJECTIVE

To evaluate the compliance of parents in purchasing iron-containing drugs for their infants. In addition, we looked for possible socioeconomic characteristics of the parents who prevent their infants from accessing these medications.

DESIGN

All infants (4-12 months) whose parents bought (from January to August 1999 and from January to August 2000) the iron-containing drugs as recommended by the Israeli Ministry of Health were retrieved from a database. The socioeconomic status of the citizens was determined according to the "mean real income" (INCMV) and "relative income" (INCMS). The percentage of parents who purchased the medication from each district was compared with the socioeconomic status of this population.

RESULTS

Forty-four pediatricians' offices in the Tel Aviv metropolitan area were included. The data of 4929 infants was summarized. Only 27% of the parents bought the drugs. Only 11.5% to 20% of parents from the 5 highest socioeconomic classes purchased the medication compared with 43.6% to 57.1% of the parents from the 5 lowest socioeconomic classes.

CONCLUSION

There was low compliance by parents in obtaining iron-containing medications for their infants, mainly among parents from high socioeconomic classes.

Can supplements help meet the micronutrient needs of the developing world?

Supplementation has many potential advantages over fortification and dietary approaches for improving micronutrient intake. Pregnant and lactating women and infants are most likely to benefit from supplementation. Recent experience with vitamin A supplementation in young children has proved to be remarkably successful. Demonstrated efficacy of vitamin A supplements for improved child survival in many settings and a technical consensus on how to implement interventions were major factors in achieving this success. Bilateral and UN agencies worked together so that in 1999 80 % of children under 5 years of age in the least-developed countries received a vitamin A capsule in the last 6 months. At least one million child lives saved were associated with the increase in coverage in the last 2 years of the 1990s. Experience with Fe-folate supplements has not been as successful. Whilst a technical consensus has been reached on how to implement programmes to control Fe deficiency, the lack of convincing evidence of efficacy of Fe-folate supplements in terms of maternal and child survival outcomes has undoubtedly contributed to the limited pursuit of effective action. A new multiple micronutrient supplement for use amongst women of reproductive age in developing countries has been formulated. UNICEF is employing the supplement in programmes aimed at helping to prevent low birth weight. The new supplement is likely to be more efficacious than Fe-folate supplements for both maternal and child survival and development outcomes. Successful completion of rigorous efficacy trials will be critical for creating the political support needed to achieve universal coverage.

Iron supplements: scientific issues concerning efficacy and implications for research and programs

Iron supplementation remains an important strategy for the prevention and treatment of iron deficiency anemia and can produce substantial improvements in the functional performance of iron deficient individuals and populations. Many potential benefits of iron supplementation require further exploration, including its effect on vitamin A and iodine metabolism. There is strong evidence that vitamin A and riboflavin deficiencies affect iron utilization from supplements and are important on a global scale, but little evidence that folate and vitamin B-12 deficiencies play a major causal role in the global burden of anemia. The efficacy of multiple micronutrient supplements for the prevention and treatment of anemia must be further evaluated. Because weekly supplementation with iron is effective at improving iron status, this option should be thoroughly explored and evaluated in the context of programs for the prevention and the treatment of iron deficiency and anemia. More conformation is warranted concerning the number of tablets that must be consumed in different situations, and the efficacy of supplying other micronutrients weekly with iron. Weekly supplementation programs may improve the logistical and economic constraints that currently limit the provision of supplements to the many target population groups for whom they are recommended, but usually fail to reach. Further work is required to clarify the purpose, delivery and outcomes of iron supplementation programs.

Toward better compliance with iron-folic acid supplements: understanding the behavior of poor urban pregnant women through ethnographic decision models in Vadodara, India

This study made an attempt to develop ethnographic decision models to understand and improve iron-folic acid supplement procurement and compliance-related behaviors of poor urban pregnant women in Vadodara, India, based on data obtained through the use of qualitative research tools. Open-ended, in-depth interviews were conducted with 36 pregnant women (17-32 weeks of gestation) purposively selected from four urban slums. Fortnightly home visits were made to the houses of 20 pregnant women-family member pairs to elicit behaviors related to iron-folic acid supplement procurement and compliance at the household level, from which the ethnographic decision models were developed. The hemoglobin levels of these women were also assessed. Regular counseling until delivery, based on the ethnographic data, helped to improve compliance, which resulted in 95% of the women consuming over 90% of the required dose. The mean hemoglobin level also improved from 9.6 to 11.08 g/dl until the end of the last trimester. This study highlighted the need for qualitative ethnographic data to develop such models that would help in the understanding of specific behaviors that influence program acceptance. Such data would have policy-level implications, for example, developing appropriate information-education-communication material and counseling strategies.

Effects of iron supplementation on maternal hematologic status in pregnancy

OBJECTIVES

Prenatal iron supplementation has been the standard recommendation for reducing maternal anemia in developing countries for the past 30 years. This article reviews the efficacy of iron supplementation on hemoglobin levels in pregnant women in developing countries.

METHODS

Data from randomized controlled trials published between 1966 and 1998 were pooled. Meta-analyses of the relative change in maternal hemoglobin associated with iron supplementation were stratified by initial hemoglobin levels, duration of supplementation, and daily gestational supplement dose and supplementation with other nutrients.

RESULTS

Iron supplementation raises hemoglobin levels. Its effects are dose dependent and are related to initial hematologic status. The extent to which iron supplementation can reduce maternal anemia is unclear.

CONCLUSIONS

The extent to which maternal hemoglobin levels can be increased by recommended prenatal supplementation is limited and has uncertain physiological benefits. Other approaches, including food fortification and prevention and treatment of other causes of anemia, require methodologically rigorous evaluation to find effective answers to this global problem.

Treatment of anemia with microencapsulated ferrous fumarate plus ascorbic acid supplied as sprinkles to complementary (weaning) foods

BACKGROUND

Standard therapy for anemia in infants is ferrous sulfate drops administered 3 times/d. Adherence to treatment, however, is often poor. One likely reason for poor adherence is the unpleasant side effects associated with drops.

OBJECTIVE

The objective was to evaluate the use of a new form of iron and a delivery system to treat anemia in infants that is likely to produce better adherence to treatment.

DESIGN

Using a prospective, randomized, controlled design, we studied 557 anemic children aged 6-18 mo (hemoglobin: 70-99 g/L) in rural Ghana. One group received a daily sachet of microencapsulated ferrous fumarate (80 mg elemental Fe) in powder form plus ascorbic acid to be sprinkled onto any complementary food eaten (sprinkles group); a control group received ferrous sulfate drops 3 times/d for 2 mo (total dose: 40 mg elemental Fe). Hemoglobin and serum ferritin concentrations were measured at baseline and at the end of treatment.

RESULTS

Successful treatment of anemia (hemoglobin > 100 g/L) occurred in 58% of the sprinkles group and in 56% of the drops group, with minimal side effects in both groups. Geometric mean ferritin concentrations increased significantly in each group from baseline to the end of treatment (P < 0.001).

CONCLUSION

Use of ferrous sulfate drops or a single daily dose of microencapsulated ferrous fumarate sprinkles plus ascorbic acid resulted in a similar rate of successful treatment of anemia without side effects. To our knowledge, this is the first demonstration of the use of microencapsulated iron sprinkles to treat anemia. Improved ease of use may favor the use of sprinkles to deliver iron.

Dietary treatment of iron deficiency in women of childbearing age

BACKGROUND

The Australian Iron Status Advisory Panel advocates dietary intervention as the first treatment option for mild iron deficiency [serum ferritin (SF) = 10-15 microg/L]. However, there appear to be no studies on the efficacy of dietary treatment for iron deficiency.

OBJECTIVE

We compared the effects of iron supplementation and of a high-iron diet on serum ferritin (SF) and hemoglobin in iron-deficient women of childbearing age.

DESIGN

Forty-four iron-deficient women (SF <15 microg/L or SF = 15-20 microg/L plus serum iron <10 micromol/L and total-iron-binding capacity >68 micromol/L) and 22 iron-replete women (hemoglobin > or =120 g/L and SF >20 microg/L) matched for age and parity categories were enrolled and completed 7-d weighed food records at baseline. The iron-deficient women were randomly allocated to receive iron supplementation (105 mg/d; supplement group) or a high-iron diet (recommended intake of absorbable iron: 2.25 mg/d; diet group) for 12 wk. Hematologic and dietary assessments were repeated at the end of the intervention and again after a 6-mo follow-up.

RESULTS

Mean SF in the supplement group increased from 9.0 +/- 3.9 microg/L at baseline to 24.8 +/- 10.0 microg/L after the intervention and remained stable during follow-up (24.2 +/- 9.8 microg/L), whereas the diet group had smaller increases during the intervention (8.9 +/- 3.1 to 11.0 +/- 5.9 microg/L) but continued to improve during follow-up (to 15.2 +/- 9.5 microg/L). Mean hemoglobin tended to improve in both intervention groups, but the change was only significant in the supplement group.

CONCLUSIONS

In iron-deficient women of childbearing age, a high-iron diet produced smaller increases in SF than did iron supplementation but resulted in continued improvements in iron status during a 6-mo. follow-up.

Randomized, controlled trial of single versus 3-times-daily ferrous sulfate drops for treatment of anemia

OBJECTIVE

Adherence to treatment of iron-deficiency anemia often is poor in both developed and developing countries. The current standard therapy is ferrous sulfate drops (or syrup) administered 3 times daily. It is possible that adherence would improve with a single-dose daily treatment regimen. We compared the use of single versus 3-times-daily ferrous sulfate drops, at the same total iron dose, on treatment of anemia in infants.

METHODS

To obtain a large enough cohort of anemic subjects, we performed the study in rural Ghana. Using a prospective, randomized, controlled design, we studied 557 anemic children (age range: 6-24 months; hemoglobin values: 70-99 g/L). One group (n = 280) received ferrous sulfate drops once daily (40 mg elemental iron), and the control group (n = 277) received ferrous sulfate drops 3 times per day (total dose, 40 mg elemental iron). Treatment lasted for 2 months. Hemoglobin and serum ferritin values were measured at baseline and at the end of the study.

RESULTS

Successful treatment of anemia (hemoglobin >100 g/L) occurred in 61% of the single-dose and in 56% of the 3-times-daily group. Geometric mean ferritin levels increased significantly in each group from baseline to the final visit. Side effects were minimal and similar between the 2 groups.

CONCLUSION

A single versus a 3-times-daily dose of ferrous sulfate drops over 2 months resulted in a similar rate of successful treatment of anemia, without side effects. To our knowledge, this is the first demonstration of the use of a single-dose daily regimen to treat anemia. Although not examined in the current study, use of a single-dose daily regimen may improve adherence to treatment of anemia in infants.

Albendazole therapy and reduced decline in haemoglobin concentration during pregnancy (Sierra Leone)

WHO recommends that anthelmintic treatment be included in strategies to improve maternal nutrition in areas where hookworms are endemic and anaemia is prevalent. At present, few countries have adopted this recommendation, partly owing to the lack of data to support the adverse effects of hookworms on maternal health. A longitudinal study was conducted on 125 women in Sierra Leone (in 1995/96) to measure the impact of single-dose albendazole (400 mg) and daily iron-folate supplements (36 mg iron and 5 mg folate) on haemoglobin and serum ferritin concentration during pregnancy. Women who received both albendazole and iron-folate supplements experienced no significant change (P > 0.05) in the prevalence of anaemia and iron-deficiency anaemia between the first and third trimesters. These prevalence levels significantly increased (P < 0.05) in women who received either albendazole or iron-folate supplements or neither. After controlling for baseline haemoglobin concentration and season, the mean decline in haemoglobin concentration between the first and third trimester in women who received albendazole was 6.6 g/L less than in women who received the control (P = 0.0034). The corresponding value for iron-folate supplements was 13.7 g/L haemoglobin (P < 0.001). The effects of albendazole and iron-folate supplements were additive. These findings lend support to WHO's recommendation for anthelmintic treatment during pregnancy.

Daily iron supplementation is more effective than twice weekly iron supplementation in pregnant women in Pakistan in a randomized double-blind clinical trial

In the context of limited effectiveness of iron supplementation programs, intermittent iron supplementation is currently under debate as a possible alternative strategy that may enhance the effectiveness of operational programs. This field-based trial assessed the outcome of twice weekly iron supplementation compared to daily in Pakistan. A double-blind, randomized, clinical trial was conducted in Northern Pakistan. Anemic pregnant women (n = 191) were assigned to receive daily (200 mg ferrous sulfate) or twice weekly (2 x 200 mg ferrous sulfate) iron supplementation. Hemoglobin was measured at baseline and at 4-wk intervals for up to 12 wk. Serum ferritin was measured at baseline and 8 or 12 wk. Analysis was by intention to treat. The two groups did not differ in age, parity, sociodemographic characteristics, hemoglobin or serum ferritin concentrations at baseline. Women who received iron daily had a greater rise in hemoglobin compared with women who received iron twice weekly (17.8 +/- 1.8 vs. 3.8 +/- 1.2 g/L, P < 0.001). The serum ferritin concentrations increased by 17.7 +/- 3.9 microgram/L (P < 0.001) in the daily supplemented group and did not change in the twice weekly group. Daily iron supplementation remained superior to twice weekly supplementation after controlling initial hemoglobin Z-scores and duration of treatment. The body mass index (BMI) modified the effect of daily versus twice weekly iron supplementation. For every unit increase in BMI, the difference between the two treatment groups was reduced by 0.0014 (final hemoglobin Z-score; P = 0.027). We recommend continuation of daily iron supplementation as opposed to intermittent iron supplementation in pregnant women in developing countries.

Improving prenatal nutrition in developing countries: strategies, prospects, and challenges

In developing countries, the health and nutrition of females throughout their entire life is affected by complex and highly interrelated biological, social, cultural, and health service-related factors. Rather than focusing exclusively on the prenatal period, we describe a life cycle approach to improving maternal nutrition, which goes beyond the traditional provision of nutrition services during pregnancy, by addressing risk factors that are present well before pregnancy, even before childbearing age. This approach involves specific policy initiatives and a "minimum package" program that is targeted at females. Policy actions and the components for effective implementation of the program are described. The prospects and challenges to be overcome-which include translating scientific knowledge into action, removing conceptual and implementational constraints, identifying biologically meaningful indicators for problem identification, and improving understanding of physiologic and social adaptation mechanisms-are discussed, as are persistent problems with health care delivery systems.

Effectiveness and strategies of iron supplementation during pregnancy

Iron deficiency continues to be one of the most prevalent single-nutrient deficiencies in the world. Interventions are often designed to prevent the decrease in hemoglobin concentration and the decline in iron stores associated with pregnancy. Although this is believed to be desirable for both the health of the mother and the well-being of the growing fetus, some scientists disagree. Enrichment and fortification of food items, and dietary changes resulting from education interventions, have met with some success in developed countries, but not often in the developing world. A therapeutic approach to iron supplementation, rather than a public health-based approach, is used throughout much of the world but suffers from real, or perceived, problems of compliance. Large doses of iron are most often prescribed and are associated with side effects and with increased oxidative damage. Alternatively, delayed-release preparations and intermittent oral iron supplementation lead to better overall compliance and alleviate side effects. Daily iron intervention provides more protection against a decline in the storage iron pool in pregnant women than does an intermittent schedule, but the latter is generally associated with fewer side effects, better compliance, and possibly a reduction in risk of oxidative damage. An improved cost-benefit ratio associated with a lower-dose oral iron supplement may prove to be quite positive in the future. Currently, no single approach may be universally acceptable, although a moderate iron dosage protocol will likely provide the most benefit to those who require supplemental iron.

[Evaluating the impact of a hematinic iron-rich nutritional supplement]

A quasi-experimental epidemiological study was performed to evaluate the effect of a nutritional supplement made from bovine blood on human blood parameters. Healthy women who were neither pregnant nor breast-feeding were allocated to two groups: study (n=32) and control (n=17). Women in the study group received 0.5 mg of iron per day, while controls received placebo. Food intake frequency and side effects related to ferrous sulfate were recorded. A 24-hour dietary recall was performed every two weeks, and blood samples were collected to determine biochemical parameters. Compared to controls, the study group showed higher serum iron and iron retention capacity, lower calorie, protein, and vitamin C intake, and lower consumption of dairy products and fruit. Adjusted mean blood parameters were calculated using ANOVA. The output showed increased serum iron (p=0.009) and decreased iron retention capacity (p=0.031) at the end of the study. The results favor use of the product to treat iron deficiency anemia.

Effects of chronic parasitosis on women's health

Parasitic diseases are closely related to the lack of sanitation (unavailability of potable water, inadequate disposal of human waste, lack of latrines) or the absence of personal hygiene. They are also closely linked to warm and humid climates, and are therefore considered tropical diseases. This chapter addresses chronic hookworm parasitosis and malaria, and their effect on women's health. Of all Helminthes, hookworms cause the most severe anemia because of iron deficiency due to chronic blood loss. Worldwide, an estimated 51% of pregnant women suffer from anemia-almost twice as many as non-pregnant women. In severe cases (Hb < 70 g/l) the risk of perinatal maternal and child death increases up to 500-fold. Anemia due to maternal deficiency affects the fetus, causes retarded intrauterine growth, and reduces fetal ability to absorb iron provided by the mother. Hookworms are nematodes that infect roughly 1 billion people. Their preferred habitat is the jejunum, where they attach to the mucous tissue to feed, and secrete an anticoagulant causing bleeding. Hookworm infections often begin in childhood. The worm enters the body through the skin and reaches the highest number at the end of adolescence and young adulthood. Little attention has been given to the treatment of pregnant women because of unavailability of safe antiparasitic drugs and fear of teratogenesis. However, there are new treatments, and the anthelminthic drugs may be administered in schools and organized women's groups in communities. During pregnancy anthelminthic treatment can improve maternal, fetal and infant health. Treatment given every 4 months has been shown to interrupt the transmission cycle of the parasite and help to improve the iron status of all women. Therapeutic strategies should be linked to other measures, such as promoting the use of shoes, introduction of potable water, education and treatment of the population at large, especially the school-age population. An estimated 267 million people are annually infected by malaria, a parasitic disease caused by Protozoa of the genus Plasmodium. Malaria is transmitted by the Anopheles mosquito and is highly prevalent in tropical and subtropical regions located between 40 degrees latitude North and 30 degrees latitude South. It causes acute attacks that leave the human body in such a poor state that health problems resulting from these attacks become chronic. Due to the high mortality and morbidity associated with it, malaria is considered the most serious of tropical diseases and a major public-health dilemma. Pregnant women are at high risk of becoming infected, as well as children in their first years of life. In pregnant women, malaria can cause anemia which can be the major cause of maternal mortality, especially during the first pregnancy. Malaria can also cause fetal anemia which frequently results in retarded intrauterine growth and low birth weight. Prophylactic treatment with antimalarial drugs during pregnancy is recommended in areas where the disease is endemic. The prophylactic treatment should focus primarily on primiparous women who are most susceptible. Chloroquine is safe and effective for antimalarial prophylaxis, and is not teratogenic. Proguanil is also safe for prophylactic use during pregnancy, particularly in areas where P. falciparum is resistant to chloroquine. Mefloquine may be used during the third trimester of pregnancy, only if other antimalarial drugs are unavailable or ineffective.

Pregnancy and iron deficiency: unresolved issues

Iron deficiency and iron deficiency anemia are prevalent among pregnant women. The extent to which iron deficiency affects maternal and neonatal health is uncertain. Existing data suggest that maternal iron deficiency anemia may be associated with adverse outcomes, including preterm delivery and higher maternal mortality. Further research is needed on the maternal and neonatal benefits of iron supplementation during pregnancy.