What works for anemia reduction among women of reproductive age? Synthesized findings from the exemplars in anemia project

Background: Few countries have succeeded to decrease the prevalence of anemia in women of reproductive age (WRA), and where improvements have been observed, contributing factors are not well understood. Objectives: To synthesize cross-cutting findings from specific exemplar studies in Uganda, Senegal, the Philippines, and Pakistan by reviewing anemia trends, policies, and programs, comparing drivers of change, and proposing strategies to achieve further reductions in WRA anemia. Methods: A mixed-methods approach was used for exemplar case studies: 1) descriptive analyses of Demographic and Health Surveys and national survey data; 2) review of relevant policies/programs; 3) stakeholder in-depth interviews and focus group discussions with WRA and community members; and 4) Oaxaca–Blinder decomposition to identify determinants of hemoglobin change over time. This cross-country analysis performs triangulation of qualitative and quantitative analyses. Results: Compound annual change rates for anemia from the ∼2005–2018 period were –0.7% in Senegal, –2.4% in Uganda, –3.4% in Pakistan, and –6.2% in the Philippines. Despite these reductions, WRA anemia burden in Senegal and Pakistan continues to be a severe public health problem. Direct and indirect health sector strategies, such as iron–folic acid supplementation in pregnancy, vitamin A supplementation during lactation, malaria control (Uganda and Senegal), investments in family planning, and better access to health services through community-based approaches, contributed to a median of 36.5% (range: 30%–66%) change in hemoglobin. Nonhealth sector strategies, including social protection and poverty alleviation schemes, empowering of girls and women, and improving household conditions, contributed to a 21% (18%–58%) change in hemoglobin. Large-scale food fortification (for example, wheat flour with iron) could have also contributed to improved micronutrient intakes and reduction in iron deficiency anemia. Conclusions: A context-specific, multisectoral approach is needed to decrease WRA anemia, incorporating direct nutritional interventions and indirect strategies within the health and nonhealth sectors. Lessons from the successes and challenges from exemplar countries could help accelerate global anemia reduction.