India, with a population of more than 1 billion people, has many challenges in improving the health and nutrition of its citizens. Steady declines have been noted in fertility, maternal, infant and child mortalities, and the prevalence of severe manifestations of nutritional deficiencies, but the pace has been slow and falls short of national and Millennium Development Goal targets. The likely explanations include social inequities, disparities in health systems between and within states, and consequences of urbanisation and demographic transition. In 2005, India embarked on the National Rural Health Mission, an extraordinary effort to strengthen the health systems. However, coverage of priority interventions remains insufficient, and the content and quality of existing interventions are suboptimum. Substantial unmet need for contraception remains, adolescent pregnancies are common, and access to safe abortion is inadequate. Increases in the numbers of deliveries in institutions have not been matched by improvements in the quality of intrapartum and neonatal care. Infants and young children do not get the health care they need; access to effective treatment for neonatal illness, diarrhoea, and pneumonia shows little improvement; and the coverage of nutrition programmes is inadequate. Absence of well functioning health systems is indicated by the inadequacies related to planning, financing, human resources, infrastructure, supply systems, governance, information, and monitoring. We provide a case for transformation of health systems through effective stewardship, decentralised planning in districts, a reasoned approach to financing that affects demand for health care, a campaign to Correspondence to: Prof Vinod Kumar Paul, Department of Paediatrics, All India Institute of Medical Sciences, New Delhi 110029, India vinodkpaul@hotmail.com. Contributors DG did the secondary analyses of the NFHS data. All other authors contributed to the conceptualisation, contents, and writing of the report.Conflicts of interest DO was originally a reviewer of this report and was requested to join as a co-author after the first draft; he has received payment for employment from the University College London Institute of Child Health, grants from a Wellcome Trust Fellowship, and payment for visiting lectures at the London School of Hygiene and Tropical Medicine.The other authors declare that they have no conflicts of interest. Europe PMC Funders Author ManuscriptsEurope PMC Funders Author Manuscripts create awareness and change health and nutrition behaviour, and revision of programmes for child nutrition on the basis of evidence. This agenda needs political commitment of the highest order and the development of a people's movement.

During the first half of the 20th century, chronic energy undernutrition due to low dietary intake, repeated infections, and rapid succession of pregnancy were the factors most responsible for maternal undernutrition and consequent adverse outcomes of pregnancy. Efforts to improve dietary intake, treatment of infections, and provision of contraceptive care were the major focuses of intervention from 1950 to 1990. These interventions resulted in reduction in severe grades of undernutrition. However, there was no reduction in mild and moderate degrees of undernutrition and anemia during pregnancy and there was no significant improvement in the course and outcome of pregnancy, or in birth weight. During the 1990s, among the middle- and upper-income groups, there has been a progressive rise in obesity and consequent adverse effects. The advent of HIV infection in India in the 1980s will inevitably lead to increases in severe undernutrition associated with HIV infection in pregnancy and an adverse impact of maternal HIV infection on the fetus. Practicing physicians and nutritionists in the new millennium will therefore have to assess each person individually and provide appropriate advice regarding diet, exercise, fertility, and infection prevention and control in order to achieve optimum health and nutrition status during pregnancy and to prevent adverse pregnancy outcomes.

Background & objectives:The prevalence of anaemia in pregnancy in India is among the highest in the world. In the last two decades, several national surveys have estimated haemoglobin levels in pregnant women. In this study, data from these surveys were analyzed to find out changes, if any, in prevalence of anaemia in pregnancy.Methods:National and State-level estimates on the prevalence of anaemia were tabulated from the reports of the National Family Health Survey (NFHS) 2, NFHS 3, Fact Sheets of NFHS 4 and District Level Household Survey (DLHS) 2. Unit level data from DLHS 4 and Annual Health Survey Clinical Anthropometric and Biochemical component (AHS CAB) were obtained and State level prevalence of different grades of anaemia was estimated. Time trends in the prevalence of anaemia and different grades of anaemia were assessed from these surveys.Results:NFHS 2, 3 and 4 reported relatively lower prevalence of anaemia as compared to DLHS and AHS CAB. There was not much change in the prevalence or severity of anaemia between NFHS 2, 3 and 4. There was substantial reduction in the prevalence and severity of anaemia in all States except Uttarakhand between DLHS 2 and 4 and DLHS 2 and AHS CAB.Interpretation & conclusions:There was a reduction in the prevalence and severity of anaemia in the last 15 years. The two-pronged strategy of increasing iron intake (dietary diversification and use of iron-fortified iodized salt) in all the population and testing, and detecting and treating pregnant women with anaemia will accelerate the pace of reduction in anaemia.

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