Drivers of anemia reduction among women of reproductive age in Pakistan: a mixed-methods country case study

Background: In Pakistan, anemia prevalence among women of reproductive age (WRA) decreased from 50.5% in 2011 to 42.7% in 2018. The factors associated with this reduction are unclear. Objectives: We conducted a systematic, in-depth assessment of the quantitative and qualitative determinants of anemia among WRA in Pakistan between 2011 and 2018. Methods: Employing standard Exemplars mixed-methods methodology, we conducted quantitative analyses using Pakistan's National Nutrition Surveys. Qualitative analyses included a systematic literature review, program/policy analysis, key informant interviews, and focus group discussions with stakeholders to identify and understand country-level enablers and barriers to WRA anemia decline in Pakistan. A final Oaxaca-Blinder decomposition analysis (OBDA) evaluated the relative contribution of direct and indirect factors. Results: Among nonpregnant women, mean hemoglobin increased from 11.7 ± 1.8 g/dL in 2011 to 12.1 ± 1.6 g/dL in 2018 (P < 0.01), corresponding to an 11%-point decline in anemia prevalence during this time (51%–40%). However, inequities by geographical region, household wealth, and urban compared with rural residence persisted. From the policy and qualitative analyses, the Lady Healthcare Worker program was identified as being instrumental in improving women's health and nutrition, especially for antenatal care, including iron supplementation. However, at the community-level, government corruption was a perceived barrier to effective program implementation, especially the Benazir Income Support Program for women in poverty. OBDA explained 89% of the observed change in mean hemoglobin, with household enrollment in the Benazir Income Support Program (36%), household wealth (17%), and improvement in women's nutrition [body mass index (in kg/m²): 15%, serum retinol: 12%] emerging as the most critical drivers of anemia decline among nonpregnant women in Pakistan. Conclusions: To protect these gains and continue improvements, anemia prevention efforts should continue to focus on improving healthcare access, women's economic empowerment, and poverty alleviation.