WHO/NMH/NHD/14.

Global Nutrition Targets 2025

Anaemia Policy Brief

TARGET:
50% reduction of
anaemia in women of
reproductive age

WHO/Pallava Bagla

WHAT’S AT STAKE
In 2012, the World Health Assembly Resolution 65.6 endorsed a Comprehensive implementation plan on maternal, infant
and young child nutrition (1), which specified six global nutrition targets for 2025 (2). This policy brief covers the second
target: a 50% reduction of anaemia in women of reproductive age. The purpose of this policy brief is to increase
attention to, investment in, and action for a set of cost-effective interventions and policies that can help Member States
and their partners in reducing the rates of anaemia among women of reproductive age.

A
naemia (see Boxes 1 and 2) impairs health and well- and west Africa (3). While the causes of anaemia are variable,
being in women and increases the risk of maternal it is estimated that half of cases are due to iron deficiency. In
and neonatal adverse outcomes. Anaemia affects half some settings, considerable reductions in the prevalence of
a billion women of reproductive age worldwide. In 2011, 29% anaemia have been achieved; however, overall, progress has
(496 million) of non-pregnant women and 38% (32.4 million) been insufficient. Further actions are required to reach the
of pregnant women aged 15–49 years were anaemic (3). The World Health Assembly target of a 50% reduction of anaemia
prevalence of anaemia was highest in south Asia and central in women of reproductive age by 2025 (4, 5).

BOX 1: WHAT IS ANAEMIA?

Anaemia is a condition in which the number and size of red blood cells, or the haemoglobin concentration, falls
below an established cut-off value, consequently impairing the capacity of the blood to transport oxygen around
the body. Anaemia is an indicator of both poor nutrition and poor health.

Anaemia and iron deficiency reduce individuals’ well- women to impaired health and quality of life, generations
being, cause fatigue and lethargy, and impair physical of children to impaired development and learning,
capacity and work performance. Median losses in physical and communities and nations to impaired economic
productivity due to iron deficiency are important (6). productivity and development. Maternal anaemia is
Failure to reduce anaemia worldwide consigns millions of associated with mortality and morbidity in the mother and
baby, including risk of miscarriages, stillbirths, prematurity in anaemia now, as a means to promote human capital
and low birth weight. development and their nations’ economic growth and
long-term health, wealth and well-being. Policy-makers
Globally, the prevalence of anaemia fell by 12% should consider prioritizing the following actions, in order
between 1995 and 2011 – from 33% to 29% in non- to reach the global nutrition target of a 50% reduction of
pregnant women and from 43% to 38% in pregnant anaemia in women of reproductive age:
women, indicating that progress is possible but presently
insufficient to meet these goals. It is therefore urgent • improve the identification, measurement and
that countries review national policies, infrastructure understanding of anaemia among women of
and resources and act to implement strategies for the reproductive age and scale up coverage of
prevention and control of anaemia. The World Health prevention, control and treatment activities;
Organization (WHO) has published revised guidelines that
support policies for the prevention and control of anaemia
(7). Once implemented, these interventions work to restore • create partnerships between state and non-
appropriate haemoglobin concentrations in individuals state actors for financial commitment, and a
and reduce the prevalence of anaemia in a population. supportive environment for the implementation
Successful reduction in the prevalence of anaemia in of comprehensive policies for nutrition and
women of reproductive age will improve children’s school nutrition-sensitive actions that facilitate
performance and women’s work productivity, and improve prevention and control of anaemia in women of
pregnancy outcomes for mothers and infants, resulting in reproductive age;
intergenerational benefits for individual health, well-being
and economic potential and community development.
• ensure that development policies and programmes
Anaemia is interlinked with the five other global beyond the health sector include nutrition as well
nutrition targets (stunting, low birth weight, childhood as other major causes of anaemia relevant to the
overweight, exclusive breastfeeding and wasting). country context, specifically the agriculture and
In particular, the control of anaemia in women of education sectors;
childbearing age is essential to prevent low birth
weight and perinatal and maternal mortality, as well as
the prevalence of disease later in life. It is therefore in • monitor and evaluate the implementation of
policy-makers’ interests to make necessary investments anaemia control programmes.

BOX 2: WHAT CAUSES ANAEMIA?

• The most common cause of anaemia worldwide is iron deficiency, resulting from prolonged negative iron
balance, caused by inadequate dietary iron intake or absorption, increased needs for iron during pregnancy
or growth periods, and increased iron losses as a result of menstruation and helminth (intestinal worms)
infestation. An estimated 50% of anaemia in women worldwide is due to iron deficiency (3).

• Other important causes of anaemia worldwide include infections, other nutritional deficiencies (especially
folate and vitamins B12, A and C) and genetic conditions (including sickle cell disease, thalassaemia – an
inherited blood disorder – and chronic inflammation).

• Anaemia is common in severe malaria and may be associated with secondary bacterial infection.

• Anaemia is a particularly important complication of malaria in pregnant women. In moderate- and high-
transmission settings, pregnant women, especially women who are pregnant for the first time, are susceptible
to severe anaemia.

• Pregnant adolescents are particularly vulnerable to anaemia because they have dual iron requirements, for
their own growth and the growth of the fetus, and are less likely to access antenatal care.

2
FRAMEWORK FOR ACTION
Public health strategies to prevent and control anaemia These guidelines are based on objective,
include improvements in dietary diversity; food fortification comprehensive systematic reviews of the literature, and
with iron, folic acid and other micronutrients; distribution were developed using WHO methodology for evidence-
of iron-containing supplements; and control of infections informed guideline development (7). Guidelines are
and malaria. Achieving a 50% reduction in the prevalence available on a central electronic platform: the WHO
of anaemia among women of reproductive age by 2025 will e-Library of Evidence for Nutrition Actions (10). Box 3
require a relative reduction in the prevalence of anaemia in summarizes current WHO recommendations targeting
this group of 6.1% per year. Recognizing the complexity of anaemia in women. Appropriate implementation of these
anaemia can lead to the establishment of effective strategies. recommendations can produce a marked reduction in the
An integrated, multifactorial and multisectoral approach is prevalence of anaemia in target populations.
required to achieve this global target (9).
The beneficiaries include the infant and the mother
WHO has developed guidelines for the prevention, (i.e. longer amenorrhoea, increased birth spacing), as well
control and treatment of anaemia in women of as the neonate (breast milk is an important source of iron,
reproductive age. which is very well absorbed).

BOX 3: SUMMARY OF CURRENT WHO RECOMMENDATIONS FOR THE PREVENTION,

CONTROL AND TREATMENT OF ANAEMIA IN WOMEN
• Intermittent iron and folic acid supplementation is advised in menstruating women living in settings where the
prevalence of anaemia is 20% or higher.
• Daily oral iron and folic acid supplementation is recommended as part of antenatal care, to reduce the risk of
low birth weight, maternal anaemia and iron deficiency. In addition to iron and folic acid, supplements may
be formulated to include other vitamins and minerals, according to the United Nations Multiple Micronutrient
Preparation (UNIMAP), to overcome other possible maternal micronutrient deficiencies.
• In areas where the prevalence of anaemia among pregnant women is lower than 20%, intermittent iron and
folic acid supplementation in non-anaemic, pregnant women is advised, to prevent anaemia and to improve
pregnancy outcomes.
• In the postpartum period, iron supplementation, either alone or in combination with folic acid, for at least 3
months, may reduce the risk of anaemia by improving the iron status of the mother.
• Fortification of wheat and maize flours and rice with iron, folic acid and other micronutrients is advised in
settings where these foods are major staples.
• In malaria-endemic areas, the provision of iron and folic acid supplements should be made in conjunction with
public health measures to prevent, diagnose and treat malaria.
• In emergencies, pregnant and lactating women should be given the United Nations Children’s Fund (UNICEF)/
WHO micronutrient supplement providing one RNI (recommended nutrient intake) of micronutrients daily
(including 27 mg iron), whether or not they receive fortified rations. Iron and folic acid supplements, when
already provided, should be continued.
• All pregnant women with active tuberculosis should receive multiple micronutrient supplements that contain
iron and folic acid and other vitamins and minerals, according to the UNIMAP, to complement their maternal
micronutrient needs.
• Exclusive breastfeeding of infants up to 6 months of age should be protected, promoted and supported. The
beneficiaries include the infant and the mother (i.e. longer amenorrhoea, increased birth spacing), as well as
the neonate (breast milk is an important source of iron, which is very well absorbed).
• A diet containing adequate amounts of bioavailable iron should underpin all efforts for prevention and
control of anaemia.

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INTERVENTIONS FOR PREVENTION AND
CONTROL OF ANAEMIA

• A diet containing adequate amounts of bioavailable • Delayed cord clamping (not earlier than 1 min after
iron should underpin all efforts for prevention and birth) is recommended for improved maternal and
control of anaemia. infant health and nutrition outcomes, including
increased iron stores in term infants, reducing the
need for blood transfusions for low blood pressure
• Malaria control: chemoprophylaxis/intermittent or anaemia in preterm neonates.
preventative treatment, insecticide-treated nets
and vector elimination.
• Early interventions targeting adolescent girls for
prevention of iron deficiency anaemia are critical,
• Deworming: periodic treatment with especially in areas with high adolescent birth rates
anthelminthic (deworming) medicines, without and early marriages.
previous individual diagnosis, for all women
of childbearing age (including pregnant
women in the second and third trimesters and • Basic hygiene reduces the risk of infection; therefore,
breastfeeding women) living in endemic areas. water and sanitation interventions can be integrated,
For non-pregnant women, treatment should in order to reduce nutritional losses incurred by
be given once a year when the prevalence of infection, and also reducing inflammation.
soil-transmitted helminth infections in the
community is over 20%, and twice a year when
• Education must encompass the component of
the prevalence of soil-transmitted helminth
reproductive health and family planning services
infections in the community exceeds 50%.
for women and adolescent girls, to encourage
dialogue and promote adequate birth spacing.
Education will help promote gender equality and
female empowerment.

WHO/TDR /Andy Crump

4
SUCCESS IS POSSIBLE
Improvements in the prevalence of anaemia among women of reproductive age have been seen in countries around
the world: for example, Burundi (64.4% to 28% in 20 years); China (50.0% to 19.9% in 19 years); Nepal (65% to 34% in
8 years); Nicaragua (36.3% to 16.0% in 10 years); Sri Lanka (59.8% to 31.9% in 13 years); and Viet Nam (40.0% to 24.3%
in 14 years). Boxes 4–6 illustrate examples from three countries that have successfully implemented strategies for
prevention and control of anaemia.

BOX 4: PREVENTION OF ANAEMIA IN VIET NAM

In 2006, a pilot project distributing weekly iron-folic acid, together with de-worming for all women of reproductive
age, was implemented in two districts of Yen Bai province, covering approximately 50 000 women aged 15 to
45 years. Following an evaluation survey after 12 months, the programme was expanded to target all women of
reproductive age in the province (250 000 women), with management of the programme led by provincial health
authorities. The prevalence of anaemia fell from 38% at baseline to 19% after 12 months and 18% after 54 months
of intervention; the prevalence of iron deficiency anaemia fell from 18% at baseline to 3% at 12 months and
remained at 4% at 54 months, confirming that this condition had essentially been eliminated in this population (8).

BOX 5: PREVENTION OF ANAEMIA IN VENEZUELA

In 1992, Venezuelan health authorities began a programme to fortify precooked maize and wheat flours with iron
and other vitamins. The authorities achieved success by selecting an effective and well-absorbed iron compound,
choosing food vehicles that are consumed daily, and maintaining quality control over the process. Precooked
maize was fortified to 50 mg/kg and white wheat to 20 mg/kg. The prevalence of anaemia in children aged 7, 11
and 15 years fell by 50% within 12 months of introduction of this programme, and average ferritin concentrations
had almost doubled in the first 6 years since implementation (11).

BOX 6: PREVENTION OF ANAEMIA IN INDIA

A programme of weekly iron–folic acid supplementation for adolescent girls was piloted in 52 districts in 13
states. The programme reached both school-attending and non-attending girls aged 10–19 years. Evaluation of
the pilot programmes indicated a 24% reduction in the prevalence of anaemia after 1 year of implementation.
For example, in Gujarat, implementation of intermittent (weekly) iron–folic acid supplementation to over
1.2 million adolescent girls led to a reduction in the prevalence of anaemia, from 74.2% to 53.5% within 1 year,
with estimated compliance of over 90%. The cost of the programme was estimated at US$ 0.58 per adolescent
per year. The project was expanded to cover 11 entire states by the end of 2011. In 2013, the Government
of India introduced national implementation of weekly iron–folic acid supplementation to approximately
120 million adolescent girls (12).

5
Interventions for the prevention and control of anaemia The following actions should facilitate the adoption
can be implemented by leveraging existing health, and implementation of these guidelines and create an
education and food-production systems as a delivery environment in which the target can be achieved.
platform in the ways listed next.

1. Improve the identification, measurement

• Intermittent iron supplementation for non-pregnant and understanding of anaemia among women
women can be delivered via a range of community of reproductive age and scale up coverage of
and health systems, including schools (to adolescent prevention and treatment activities.
girls using weekly “iron days”), local health workers
(via the primary health system), and community-
based social marketing (via the local health system • Include required interventions with an effect on
and/or local vendors). anaemia in national health, education, agriculture
and development plans as appropriate, addressing
nutritional and non-nutritional causes of anaemia
• Antenatal iron and folic acid supplementation and their determinants, as well as nutrition strategies.
(daily or intermittent) can be delivered via medical
facilities, social marketing or community health
workers, as part of routine antenatal care. 2. Create partnerships between state and non-state
actors for financial commitment, and a supportive
environment for the implementation of
• Food fortification can be delivered through mass comprehensive food policies for nutrition and
fortification, with the addition of iron to staple foods nutrition-sensitive actions that facilitate prevention
commonly consumed by the general public, such and control of anaemia in women of reproductive age.
as wheat flour, maize flour and corn meals, rice and
condiments such as soy sauce or fish sauce, or targeted 3. Ensure development policies and programmes
fortification adding iron to foods consumed by beyond the health sector include nutrition as well
populations at particular risk of anaemia (e.g. fortified as other major causes of anaemia relevant to the
biscuits for schoolchildren, adolescents and women). country context, specifically the agriculture and
education sectors.

ACTIONS TO DRIVE PROGRESS IN REDUCING • Community mobilization and social marketing

ANAEMIA can be used to raise awareness of the value of iron
Appropriate and context-sensitive implementation of supplementation in women of reproductive age
evidence-informed recommended interventions, such as and other actors involved in the supply chain. For
the WHO-recommended interventions described above, example, local women’s groups and health networks
will effectively reduce the prevalence of anaemia among can improve the uptake by encouraging women to
women of reproductive age. purchase and use the intervention.

Poverty and exclusion are the driving forces of health

4. Monitor and evaluate the implementation of
inequities in the general population and among women 1
anaemia control programmes.
of reproductive age. The extent of health inequities is
typically proportionate to the level of disadvantage, with
populations experiencing poverty and social exclusion
having fewer opportunities for health than those in more
privileged positions.

Primary outcome indicators include: prevalence of anaemia (haemoglobin lower than 120 g/L, adjusted for altitude and smoking) among non-pregnant women
1

aged 15–49 years; and prevalence of anaemia among pregnant women (haemoglobin lower than 110 g/L, adjusted for altitude and smoking). Intermediate
outcome indicators include: proportion of adolescent girls with haemoglobin lower than 120 g/L; and proportion of children aged under 5 years with haemoglobin
lower than 110 g/L. Process indicators include: proportion of pregnant women receiving supplements containing iron and folic acid; percentage of households
consuming iron-fortified staple foods or condiments; and proportion of children aged under 5 years receiving iron supplements.

6
 WORLD HEALTH ORGANIZATION NUTRITION TRACKING TOOL
To assist countries in setting national targets to achieve the global goals – and tracking their progress toward
them – WHO’s Department of Nutrition for Health and Development and partners have developed a web-based
tracking tool that allows users to explore different scenarios to achieve the rates of progress required to meet the
2025 targets. The tool can be accessed at www.who.int/nutrition/trackingtool (13).

WHO Essential nutrition actions – improving maternal, newborn, infant and young child health and nutrition
(http://www.who.int/nutrition/publications/infantfeeding/essential_nutrition_actions/en/, accessed 7
October 2014)
This document summarizes the rationale and the evidence for nutrition interventions targeting the first
1000 days of life and describes the actions required to implement them. It uses a life-course approach, from
preconception throughout the first 2 years of life, and includes guidance for anaemia control in pregnant and
non-pregnant women of reproductive age.

SOURCES OF DATA
Key national health and nutrition surveys frequently include measurement of haemoglobin in women of reproductive
age and children aged under 5 years (e.g. demographic and health surveys, national micronutrient surveys). Data on
distribution of iron supplements may also be included. Specific surveys to measure these indicators may be required.

ACKNOWLEDGMENTS
This work was coordinated by Dr Juan Pablo Peña-Rosas and Dr Maria Nieves García-Casal, Evidence and
Programme Guidance Unit, Department of Nutrition for Health and Development, WHO. WHO would like to
acknowledge contributions of the following individuals (in alphabetical order): Mr Oscar Arcos, Dr Francesco
Branca, Ms Nita Dalmiya, Dr Luz Maria De-Regil, Ms Kaia Engesveen, Ms Patrizia Fracassi, Dr Roelf Klemm, Dr Roland
Kupka, Ms Lina Mahy, Mr Jason Montez, Dr Chizuru Nishida, Dr Sorrell Namaste, Dr Sant-Rayn Pasricha, Dr Gretchen
Stevens and Mr Gerardo Zamora. WHO would also like to thank 1,000 Days for their technical support, especially
Rebecca Olson.

FINANCIAL SUPPORT
WHO would like to thank the International Micronutrient Malnutrition Prevention and Control (IMMPaCt)programme,
Centers for Disease Control and Prevention (CDC) and the Bill & Melinda Gates Foundation for providing financial
support for this work.

SUGGESTED CITATION
WHO. Global nutrition targets 2025: anaemia policy brief (WHO/NMH/NHD/14.4). Geneva: World Health
Organization; 2014.

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 © WHO/2014
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For more information, please contact:

Department of Nutrition for Health and Development

World Health Organization
Avenue Appia 20, CH-1211 Geneva 27, Switzerland
Fax: +41 22 791 4156
Email: nutrition@who.int
www.who.int/nutrition