during childbirth but also concurrent morbidities brought on by the experience of pregnancy and childbirth.’ (World Bank, 2011, p. 128). The global estimate of maternal deaths is considered to be the ‘tip of the iceberg’ since an estimated 10 to 20 million women suffer pregnancy-related physical or mental disabilities every year (Filippi et al., 2006, p.2).<sup>9</sup> Maternal morbidities can have longlasting consequences –potentially affecting women’s survival– that can also lead to impoverishment, violence, stigmatization, and marital instability (Koblinsky et al., 2012). Also not encompassed in the standard definition, other causes of maternal deaths include injuries, accidents, suicide, murder, and domestic violence while women are pregnant (AbouZahr, 2003; Ronsmans and Graham, 2006).

Iron-deficiency anemia is the most common nutritional deficiency worldwide (Mukuria, Aboulafia, and Themme, 2005). It is pervasive in India where it affects 56 percent of ever-married women aged 15–49 (using NFHS-III data). It commonly results from a nutritional deficiency of iron, folate, or vitamin B12. It is more prevalent during adolescence, pregnancy and among breastfeeding mothers when nutritional requirements increase substantially (Sharman, 2000; Kalaivani, 2009).<sup>10</sup> In addition to indirectly causing maternal mortality, anemia is an important risk factor for other adverse health outcomes including impaired cognitive performance, higher incidence of infection, prenatal and perinatal infant loss, and reduced work capacity (World Bank, 1996; Sharman, 2000; Gragnolati et al., 2005; Ackerson, and Subramanian, 2008).

Progress has been made in improving maternal health in India (Bhat 2002a; 2002b).<sup>11</sup> The maternal mortality ratio declined from 570 in 1990 to 230 in 2008 (WHO, 2010).<sup>12</sup> World Bank (2011) states that ‘maternal mortality is fundamentally different from excess female mortality at other ages in that, to reduce it, societies must focus on an intrinsically female condition and specifically on improving the maternal health care system.’ (p. 128). Notwithstanding better health conditions in recent times, many women are still not receiving adequate maternal health care in India.<sup>13</sup> The decrease in maternal mortality has not been paralleled by improvements in anemia prevalence. Instead, the incidence of anemia among ever-married women has worsened over time: from 52 percent in 1998 to 56 percent in 2005. Given its magnitude, anemia is an extremely

> 9Permanent and chronic conditions include obstetric fistula, urinary or faecal incontinence, scarred uterus, pelvic inflammatory disease, palsy. Other main sequelae are severe anemia, eclampsia, and infertility. Psychological obstetric morbidity includes puerperal psychoses, post-partum depression, suicide, and strong fear of pregnancy and childbirth (AbouZahr, 2003).

> 10Iron needs increase during the second and especially the third trimester of pregnancy. During pregnancy, the required amount of iron is higher than what can be absorbed from the diet, therefore iron supplementation is necessary (Sharman, 2000).

> 11Safe motherhood is one of the objectives of the 1996 Reproductive and Child Health Programme and the National Population Policy adopted by the Government of India in 2000.

> 12The maternal mortality ratio is the number of maternal deaths during a given time period per 100,000 live births during the same time-period (WHO, 2010).

> 13For instance, NFHS-III data indicate that only 39 percent of births take place in health facilities and 58 percent of women did not receive any postnatal check-up after their most recent birth (IIPS and Macro International, 2007).

7