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Anaemia in mothers and infants living in disadvantaged communities.

Over 90% of anaemia is due to iron deficiency anaemia (IDA) in pregnant women and infants globally [1, 2]. Other causes include thalassemia, sickle cell anaemia, malaria and chronic infection. IDA is preventable. Women and infants with a nutritious diet are at low risk of IDA [1, 2]. IDA is highly prevalent in pregnant women and infants globally, especially those living in disadvantaged communities [3, 4]. Major differentials between highand low-income countries persist. Anaemia prevalence is highest in South Asia and West Africa [4] (see Table 1 below). Data from Indigenous and minority groups within high-income countries are sparse [5]. Risk of IDA has been reported to be 3–10-fold higher in indigenous compared to non-indigenous mothers and infants in Australia, Canada and Brazil [6]. There has been substantial investment in programs to prevent, diagnose and treat IDA in highand lowincome countries. In 2012, the 65th World Health Assembly approved an action plan and global targets for maternal, infant and child nutrition, with a commitment to halve anaemia prevalence in women of reproductive age by 2025, from 2011 levels. Attention to nutritional interventions, such as the Scaling Up Nutrition initiative, The UN SecretaryGeneral’s Every Woman Every Child initiative and the Global Strategy for Women’s and Children’s Health has also increased. Many observational studies report strong associations between IDA and neurodevelopmental problems in poor and marginalized communities worldwide [7]. These studies indicate that complications from IDA take place along a continuum of low concentrations, with each decrement associated with worse outcomes [3]. Other experts consider that these data are confounded by deprivation and socioeconomic status and that poor neurodevelopmental outcomes could be attributable to poverty and deprivation rather than IDA [7, 8]. In addition, systematic reviews and meta-analyses of iron treatment trials in children above 6 months have shown no effect on shortor long-term neurodevelopmental outcomes [9]. One hypothesis is that the neurodevelopmental damage from poor maternal nutrition and iron deficiency occurs early in life and must be prevented in utero and before infants reach 6 months of age [7, 8]. The antenatal period is a critical period where women are able to focus on their own health care, and behaviour change is more sustainable than during other periods [10]. Antenatal care programs are holistic, they provide multiple pathways to improving maternal and infant health, include preventative and curative care and have more substantial effects than single-level interventions. Controlled trials from the 1990s demonstrated that comprehensive antenatal care programs could substantially improve maternal anaemia and morbidities such as pre-eclampsia [11, 12]. However, few trials of maternal health interventions have assessed impact on infant health and neurodevelopment beyond the neonatal period. Information on the effectiveness of these programmes in low-income countries and disadvantaged populations with high levels of substance abuse, domestic violence and malnutrition is also lacking [13, 14]. Cluster randomization and stepped wedge study designs provide robust data for the evaluation of health service interventions [15, 16]. However, they are time-consuming to implement and require substantial investment. Exciting new models based on causal inference modelling, instrumental variable methodology and epigenetics can implemented