What are the recommended doses of iron and folic acid for pregnant women in India?

Recommended Doses of Iron and Folic Acid for Pregnant Women in India

In the Indian setting, pregnant women should receive 120 mg elemental iron combined with 0.5 mg (500 μg) folic acid daily for at least 100 days during pregnancy, starting as early as possible in the second trimester. 1

Iron Supplementation Dosing

Standard Prophylactic Dose

• 120 mg elemental iron daily is the optimal dose for Indian pregnant women, as it consistently increases both hemoglobin and ferritin levels while maintaining an acceptable side effect profile 1
• The currently used 60 mg dose in India's National Nutritional Anemia Prophylaxis Programme shows inconsistent results in maintaining adequate iron stores, though it does prevent severe anemia 2, 1
• A landmark Indian study demonstrated that 120 mg elemental iron significantly improved iron stores (serum ferritin) compared to 60 mg, with no additional benefit from increasing to 240 mg 1

Timing and Duration

• Supplementation should be given daily for at least 100 days during pregnancy 3
• Starting supplementation by 16-19 weeks of gestation reduces low birth weight incidence to 12.1%, compared to 20.4% when started later and 37.9% without supplementation 3
• International guidelines support 45-60 mg elemental iron daily throughout pregnancy, though this may be insufficient for populations with high baseline anemia prevalence like India 4

Side Effects Consideration

• Side effects increase with dose: 32.4% at 60 mg, 40.3% at 120 mg, and 72% at 240 mg 1
• Despite higher side effects at 120 mg compared to 60 mg, the improved efficacy in replenishing iron stores justifies this dose in the Indian context where anemia prevalence exceeds 50% 1

Folic Acid Supplementation Dosing

Standard Prophylactic Dose

• 0.4-0.5 mg (400-500 μg) folic acid daily is the standard dose for pregnant women without risk factors 5, 1
• The American College of Medical Genetics and USPSTF recommend 400-800 μg (0.4-0.8 mg) daily throughout pregnancy 5
• Indian studies have successfully used 500 μg (0.5 mg) folic acid combined with iron supplementation 3, 1

High-Risk Populations Requiring Higher Doses

• 4-5 mg folic acid daily is recommended for women with: 5, 6
  • Previous pregnancy affected by neural tube defects
  • Personal or family history of neural tube defects
  • Type 1 diabetes mellitus
  • BMI >30 kg/m²
  • Epilepsy on anticonvulsant medications
• This higher dose should be started at least 1 month before conception and continued through the first 12 weeks of gestation, then reduced to 0.4 mg for the remainder of pregnancy 5

Safety Ceiling

• Total daily folic acid intake should not exceed 1 mg (1000 μg) unless specifically prescribed for high-risk conditions, to avoid masking vitamin B12 deficiency which could lead to irreversible neurologic damage 7, 5

Practical Implementation in Indian Context

Supply Chain Challenges

• A critical barrier in India is inconsistent supply: 14 of 52 villages surveyed had no access to IFA tablets, with 16 villages requiring travel >5 km to obtain supplements 8
• Ensuring constant supply at the village or sub-center level is essential for improving uptake and reducing anemia 8

Demand-Side Factors

• Consistent IFA consumption is strongly protective against anemia (OR: 0.26,95% CI: 0.12-0.55) 8
• Common barriers include: not registering for antenatal care, not receiving tablets from health workers, and perceived lack of need 8
• Despite anemia prevalence declining from 57.9% to 50.3% between NFHS-3 and NFHS-4, uptake of IFA for 100 days improved by only 15% 8

Monitoring Requirements

Laboratory Surveillance

• Check at least once per trimester: 4
  • Full blood count
  • Serum ferritin and iron studies (including transferrin saturation)
  • Serum folate or red blood cell folate
  • Serum vitamin B12

Clinical Follow-up

• Women should be kept under close supervision with adjustment of maintenance levels if relapse appears imminent 9
• In the presence of alcoholism, hemolytic anemia, anticonvulsant therapy, or chronic infection, maintenance levels may need to be increased 9

Critical Pitfalls to Avoid

• Do not use only 60 mg iron in populations with high anemia prevalence: While this dose prevents severe anemia, it inadequately replenishes iron stores in Indian women 1
• Do not delay supplementation: Starting by 16-19 weeks gestation significantly improves birth outcomes compared to later initiation 3
• Do not exceed 1 mg folic acid daily without specific high-risk indications, as this may mask B12 deficiency 7, 5
• Do not assume dietary intake is adequate: Food folates are only half as bioavailable as synthetic folic acid, and careful food selection alone is insufficient in most cases 7
• Calcium should not be taken simultaneously with iron as it inhibits iron absorption; these supplements should be separated by several hours 4