C.M. Singh | Could Anaemia Be the Reason Behind Low Performance in India’s Schools?

Good nutrition underpins children’s growth and learning, yet the silent epidemic of anaemia continues to undermine both mothers’ health and their children’s futures. India has halved maternal deaths in the last decade. But though fewer mothers are at risk of dying during childbirth, more than half enter pregnancy anaemic -- and their children carry the consequences into classrooms and beyond.

Every parent in India wants their child to thrive in school; however, data released earlier this year state school performances are a cause for concern. According to the Annual Status of Education Report (ASER) 2024 report, barely 23.4 per cent of Class 3 students in government schools can read a Class 2-level text. Learning levels measured by the National Achievement Survey (NAS) declined between 2017 and 2021 across most grades and subjects, underscoring the need to tackle this challenge from multiple angles, including nutrition and health. Poor teaching and overcrowded classrooms may be part of the story. But as a clinician and public health expert, I know there is another factor we do not talk about nearly enough -- anaemia.

Anaemia is most often caused by iron deficiency and starves the body of oxygen, making women tired, dizzy and unable to function at their best. But its true impact is inter-generational.

These inter-generational effects are shaped during what global health experts call the first 1,000 days -- from conception to a child’s second birthday. This is the most critical window for brain development, immune strength and lifelong learning capacity. If anaemia in mothers is corrected during these 1,000 days, children are more likely to have better birth weights, healthier growth trajectories and stronger cognitive outcomes when they enter school. Conversely, missing this window often means irreversible losses in learning potential that no later intervention can fully restore.

When a mother is anaemic during pregnancy, her child is more likely to be born premature, underweight and with iron deficiency from day one. This deficiency directly impairs a child’s brain development, attention, memory, and learning.

In terms of school performance, anaemia translates into lower cognitive scores and poorer educational achievement. It is no surprise that children who start life anaemic struggle later in classrooms.

The statistics are sobering. NFHS-5 shows that 57 per cent of women of reproductive age in India are anaemic and so are 52 per cent of pregnant women. Among children under five, the figure is an alarming 67 per cent. These are not abstract percentages but millions of young children who may never reach their full physical and intellectual potential, because their mothers began pregnancy anaemic and the cycle was never broken.

Across states in India, maternal mortality rates are steadily declining. Bihar’s maternal mortality ratio has dropped to 100 per 100,000 live births, while Uttar Pradesh has halved its maternal deaths in the last decade. These are extraordinary achievements. But maternal anaemia numbers remain high in both states, at 63 per cent and 46 per cent respectively. It remains the single most stubborn barrier to healthier mothers and children.

Anaemia is not only a child development issue. It is a serious threat to women’s health. Women with severe anaemia are twice as likely to die in childbirth, largely due to complications such as postpartum haemorrhage. Even when they survive, they experience chronic weakness and fatigue that limits their ability to work, care for their families, or participate in their communities. Anaemia reduces productivity, drains household incomes, and weakens the economy.

The good news is that anaemia is both preventable and treatable. India has ambitious programmes like Anaemia Mukt Bharat and Poshan Abhiyaan, but we must sharpen how these reach families.

Three areas stand out.

Accurate and frequent testing is key, and reliable haemoglobin measurement must become routine. This ensures early diagnosis and treatment initiation. Digital screening tools are available within government programmes. Minimally invasive digital haemoglobinometers are simple to use and accurate, allowing frontline health workers to reach last-mile patients. Without reliable testing at the village level, anaemia will continue to go undiagnosed. However, for it to be truly effective, states must strengthen systems. Uttar Pradesh and Bihar need to standardise procurement, train ASHAs and ANMs in device use, and integrate results into digital dashboards that trigger follow-up and referral.

In terms of treatment, oral iron remains the default, but side-effects and poor adherence mean many women never recover. Intravenous iron, especially Ferric Carboxymaltose (FCM), has proven to be safe, fast and effective. Bihar is preparing to expand FCM access beyond medical colleges to community health centres. This must be done carefully, with training, infrastructure, and pharmacovigilance, but urgently. Bringing FCM closer to where women live will save lives and reduce complications.

Perhaps the most crucial element is ensuring communities -- women and their families -- trust and recognise the value of these solutions. Too many families dismiss fatigue, pallor or weakness as “normal” in pregnancy. Too many women quietly stop taking tablets. Normalising anaemia testing and treatment requires shifting community norms. Making haemoglobin checks at par with blood pressure or blood sugar, ensuring ASHA workers, equipped with simple counselling tools, draw men and mothers-in-law drawn into conversations about anaemia reduction, and women sharing recovery stories in self-help groups are all important ways to build trust. When communities demand services and support adherence, anaemia reduction accelerates.

None of this is beyond reach. The policies exist, the science is clear, and pilot initiatives are underway. At a recent national conclave on maternal anaemia convened by AIIMS Patna, experts, officials and development partners unanimously agreed that we cannot continue with business as usual. India already has robust platforms like Poshan Abhiyaan and Anaemia Mukt Bharat, with their ambitious 6x6x6 strategy. But success depends on institutions and the government collaborating closely to embed new innovations, close gaps in testing and treatment, and engage communities more directly.

Dr C.M. Singh is the director of the Ram Manohar Lohia Institute of Medical Sciences, Lucknow