Prevalence of Anemia Among Mothers and Children – Azerbaijan 2001

Medical News Today, UK
July 15 2004

Prevalence of Anemia Among Displaced and Nondisplaced Mothers and
Children — Azerbaijan, 2001

In the early 1990s, the war between Armenia and Azerbaijan over the
Azeri region of Nagorno-Karabakh resulted in approximately 600,000
internally displaced persons* and 200,000 refugees† in Azerbaijan
(1). After years of displacement and despite sustained humanitarian
assistance, these internally displaced persons and refugees (IDP/Rs)
are still coping with unfavorable living conditions and limited
employment opportunities (2). Results of a 1996 CDC survey in
Azerbaijan revealed high rates of malnutrition and anemia among both
the IDP/R and resident populations (3) and prompted further study of
the nutritional status of these populations. This report summarizes
results of a 2001 survey of IDP/R and non-IDP/R mothers and children
with anemia in Azerbaijan. Findings indicated that more than one
third of mothers and children were anemic, with no significant
difference in the overall prevalence between IDP/R and non-IDP/R
populations; however, among the IDP/R population, anemia was
associated with various socioeconomic factors such as education,
socioeconomic status (SES)§, and area of residence. Future studies
should focus on identifying causes for the high rates of anemia in
Azerbaijan and developing effective interventions such as iron
supplementation and behavior modification.

Data for this report are from the Azerbaijan Reproductive Health
Survey, 2001 (AZRHS01), the first nationally representative
reproductive health survey in Azerbaijan, which was conducted with
technical assistance from CDC at the invitation of the U.S. Agency
for International Development (USAID) (4). AZRHS01 was a face-to-face
household survey of a probability sample of 8,246 women aged 15–44
years; a total of 7,668 (93.0%) women responded. To examine
differences between IDP/R and non-IDP/R women and children, the
survey oversampled those regions heavily populated by IDP/Rs.

The survey also included a nutritional assessment module consisting
of anthropometric (i.e., height and weight) and hemoglobin (Hb)
measurements. This module was administered only to mothers with at
least one child aged 3–59 months and to those mothers’ children aged
12–59 months. A total of 2,206 mothers and 2,274 children were
eligible to participate in this anemia substudy. Before fingerstick
blood samples were taken, mothers were asked to provide written
consent for collection of blood from themselves and their children.
Trained personnel measured Hb levels on the HemoCue® (HemoCue, Inc.,
Lake Forest, California) hemoglobin test system. Mothers were
informed immediately of their results and those of their children.
Blood samples were collected from 1,913 (90.2%) mothers and 2,047
(89.7%) children. After respondents with missing Hb results or
outlying levels (i.e., <6 g/dL or >17 g/dL) were excluded, the final
sample consisted of 1,906 mothers (356 IDP/Rs and 1,550 non-IDP/Rs)
and 2,017 children (373 IDP/Rs and 1,644 non-IDP/Rs).

Anemia was defined according to the 1998 CDC criteria (5) as an Hb
level of <12.0 g/dL for nonpregnant mothers, adjusting for weeks of
gestation for pregnant mothers¶. Among children, levels for anemia
were age-specific (<11.0 g/dL for children aged 12–23 months and
<11.1 g/dL for children aged 24–59 months). Survey results were
weighted to adjust for the sampling design. Because <2% of the survey
participants were refugees, data for refugees and IDPs were combined
as one group (IDP/Rs). Data were analyzed by using SAS and SUDAAN.
Two-sided t-tests were used to determine the difference in anemia
prevalence between IDP/Rs and non-IDP/Rs and among subgroups within
those populations. Associations between sociodemographic variables
and anemia prevalence were determined by using chi-square tests,
which were calculated separately for the IDP/R and the non-IDP/R
groups. All differences are statistically significant (p<0.05) unless
otherwise noted.

The IDP/R and non-IDP/R mothers and children had similar
sociodemographic characteristics, with the exception of housing
arrangements (Table 1). At the time of the survey, approximately half
(48.5%) of the IDP/R mothers were living in temporary housing (e.g.,
public buildings, shelters, railroad wagons, and tents); 2% of
non-IDP/R mothers were living in temporary housing. Among the IDP/R
mothers, 44.2% had reported receiving humanitarian assistance (e.g.,
food supplies, household goods, clothing, and shelter) during the
previous year.

Both IDP/R and non-IDP/R mothers had a high prevalence of anemia
(39.0% and 40.1%, respectively) (Table 2). Anemia prevalence also was
high among children, in both the IDP/R and non-IDP/R groups (35.5%
and 33.2%, respectively). The prevalence of anemia did not differ
significantly by IDP/R status among mothers or among children.

Anemia prevalence was significantly higher among IDP/R mothers with
less than secondary education (64.2%), compared with non-IDP/R
mothers (37.5%) with a similar level of education. Among IDP/R
mothers, anemia decreased with higher education (64.2% for less than
secondary, 37.5% for completed secondary, and 27.3% for technicum**
or university education). Among IDP/R mothers, anemia prevalence also
was associated with other socioeconomic factors, including living in
rural versus urban areas (48.9% versus 31.9%); low versus medium-high
SES (48.3% versus 27.4%); and receiving humanitarian aid (48.2%
versus 31.2%).

For both IDP/R and non-IDP/R children, the prevalence of anemia
decreased with age and was significantly higher for those whose
mothers also were anemic (Table 2). Within the IDP/R group, children
living in households with low SES had higher levels of anemia than
those living in medium-high socioeconomic households (41.0% versus
27.6%). Children who were stunted†† were more likely to be anemic
than children who were not stunted (48.8% versus 32.8%).

Reported by: S Rahimova, PhD, Adventist Development and Relief
Agency, Azerbaijan. GS Perry, DrPH, Div of Nutrition and Physical
Activity; F Serbanescu, MD, PW Stupp, PhD, TM Durant, PhD, C Crouse,
MSc, Div of Reproductive Health, National Center for Chronic Disease
Prevention and Health Promotion; LI Bhatti, MBBS, EIS Officer, CDC.

Editorial Note:

The findings in this report indicate a high prevalence of anemia
among both mothers and children in Azerbaijan, with no overall
differences in prevalence between IDP/R and non-IDP/R populations.
Similar high levels of anemia have been reported among women in
neighboring central Asian countries (6).

Iron deficiency is the leading cause of anemia in most developing
countries and disproportionately affects groups with the highest iron
demands (7,8). The pattern of higher levels of anemia among younger
children and women of reproductive age in Azerbaijan, along with no
evidence of high prevalence of hookworms, malaria, or other
micronutrient deficiencies (e.g., vitamin A) suggests that iron
deficiency is the most probable cause. However, additional
assessments and research are necessary to determine the causes of the
high rates of anemia in Azerbaijan more conclusively.

At least two factors might have contributed to the similarity in
anemia prevalence between IDP/Rs and non-IDP/Rs. IDPs outnumbered
refugees by approximately 10 to 1; unlike refugees, IDPs are part of
the host population, sharing the same background characteristics,
food preferences, lifestyles, and risk factors for anemia as the
established population. In addition, nutritional deficiencies among
the IDP/R population at the beginning of displacement might have
attenuated because of the humanitarian aid provided for several years
by USAID and other international agencies.

Higher rates of anemia were found among IDP/R mothers receiving
humanitarian aid, likely because aid was provided to those groups who
were still not self-sufficient and at higher risk for anemia. The
higher prevalence of anemia among other subgroups of IDP/R women and
children (e.g., those in rural areas or with low SES) indicates the
existence of more vulnerable groups within the general population.
Special attention should be focused on improving the nutritional
status of these groups through targeted interventions such as iron
supplementation (7). In addition, iron fortification of staple foods
like flour is a key public health intervention strategy that would
benefit all mothers and children in Azerbaijan (7).

Comparing the data from the present study with the 1996 study, by
using the earlier 1989 CDC criteria for defining anemia (9),
indicates no significant change in overall anemia prevalence either
among children (43.5% in 1996 versus 35.6% in 2001) or nonpregnant
mothers (36.1% in 1996 versus 40.2% in 2001) (3,4). The lack of
improvement indicates a need to enhance health intervention programs
in Azerbaijan by including nutritional counseling, micronutrient
supplementation, and fortification of staple foods. Because anemia is
more prevalent in younger children, interventions are particularly
needed among children aged <24 months, including promotion of 1)
exclusive breastfeeding, 2) commercial or in-home fortification of
complementary foods, and 3) dietary practices that produce
improvement of iron bioavailability.

The findings in this study are subject to at least four limitations.
First, the CDC Hb levels used to define anemia are based on data from
the National Health and Nutrition Examination Survey of the U.S.
population. These levels are higher than World Health Organization
(WHO) cutoff levels, which are used primarily for developing
countries and might produce overestimates of anemia prevalence.
Second, higher inherent variability in capillary blood-sampling
techniques used for screening anemia might introduce errors in Hb
estimates. Third, enough information on food history and dietary risk
factors was not collected to assess whether iron deficiency was
caused by low iron intake or other factors. Finally, information on
other factors (e.g., inflammation or infection) that might affect Hb
levels was not available.

WHO considers anemia prevalence of >40% in a population as severe and
warranting immediate public health action (7); certain subgroups of
mothers and children in Azerbaijan had anemia prevalence of >40%.
With prevalence at these levels, WHO recommends the following daily
iron supplementation regimen: for children aged 6–23 months, 2 mg/kg
body weight per day; for children aged 24–59 months, 2 mg/kg body
weight up to 30 mg per day for 3 months; for nonpregnant women of
child-bearing age, 60 mg/day of iron and 400 µg of folic acid for 3
months; and for pregnant women, 60 mg/day of iron and 400 µg of folic
acid daily throughout pregnancy.

National efforts to prevent iron deficiency should involve community,
government, the private sector (e.g., food industry), and
nongovernmental organizations to develop long-term strategies that
incorporate behavior modification, food fortification, and
integration of iron deficiency–control into ongoing public health
programs. Surveillance systems should be implemented to monitor
development of these strategies and track the success of


This report is based on contributions from U.S. Agency for
International Development Azerbaijan; Adventist Development and
Relief Agency Azerbaijan; Azerbaijan Republic Ministry of Health.
United Nations Population Fund; United Nations High Commissioner for


United Nations High Commissioner for Refugees. The state of the
world’s refugees: fifty years of humanitarian action. New York, New
York: Oxford University Press, 2000.
Norwegian Refugee Council/Global IDP Project. Profile of internal
displacement, Azerbaijan: global IDP database, 2002. Available at

CDC. Health and nutrition survey of internally displaced and resident
population of Azerbaijan. Atlanta, Georgia: U.S. Department of Health
and Human Services, CDC, 1996.
CDC. Reproductive health survey Azerbaijan, 2001: final report.
Atlanta, Georgia: U.S. Department of Health and Human Services, CDC,
CDC. Recommendations to prevent and control iron deficiency in the
United States. MMWR 1998;47(No. RR-3).
U.S. Agency for International Development, CDC. Reproductive,
maternal and child health in eastern Europe and Eurasia: a
comparative report. Atlanta, Georgia: U.S. Agency for International
Development, U.S. Department of Health and Human Services, CDC, 2003.

United Nations Children’s Fund (UNICEF), United Nations University,
World Health Organization. Iron deficiency anaemia assessment,
prevention and control: a guide for programme managers. Geneva,
Switzerland: World Health Organization, 2001. Available at

Yip R. Iron deficiency: contemporary scientific issues and
international programmatic approaches. J Nutr 1994;124(suppl
CDC. CDC criteria for anemia in children and childbearing-aged women.
MMWR 1989;38:400–4.

* Persons who have fled their homes because of armed conflict or fear
of persecution for reasons of race, religion, nationality, social
group membership, or political opinion, and who have not crossed an
internationally recognized national border.

† Persons who have fled their countries because of armed conflict or
fear of persecution for reasons of race, religion, nationality,
social group membership, or political opinion.

§ Initially represented by a score based on household amenities and
goods (e.g., telephone, indoor toilet, central heat, television,
refrigerator, video recorder, automobile, cellular phone, uncrowded
living conditions, and recreational home/villa). Scores ranged from
zero (i.e., no amenities and goods) to 10 (i.e., all amenities and
goods). Respondents with scores of <3 were classified as having low
SES, and those with scores of >4 as having middle-high SES.

¶ For women 1–12 weeks pregnant, an Hb level of <11.0 g/dL was used.
For women 13–40 weeks pregnant, Hb levels were 10.6, 10.5, 10.5,
10.7, 11.0, 11.4, and 11.9 g/dL for 16, 20, 24, 28, 32, 36, and 40
weeks, respectively.

** Technical vocational school.

†† Children with height-for-age Z-scores <2 standard deviations below
the CDC/World Health Organization reference.