A Cross-Sectional Study on Consumption of Iron and Folic Acid Supplements and its Determinants among Women During Pregnancy in Rural Punjab, India

BackgroundDuring pregnancy, nutritional requirements increase and if not met, pregnancy-related complications may manifest. To prevent these undesirable outcomes, the World Health Organization recommends daily oral iron and folic acid (IFA) supplementation as part of antenatal care. Despite this recommendation, the use of IFA supplements is still very low in several developing countries. Additionally, no prior information exists regarding the level of consumption of IFA in Eswatini. Thus, this study aimed to determine the prevalence of consumption of IFA supplements and to identify factors associated with the consumption of IFA supplements among pregnant women in Eswatini.MethodsA cross-sectional questionnaire survey was conducted among 330 pregnant women aged ≥ 18 years in their third trimester in Eswatini. Participants were recruited from eight purposively selected healthcare facilities from July 2019 to October 2019. Good consumption was defined as consuming all or almost all IFA supplements throughout pregnancy.ResultsDuring the first trimester, 10.3 % of the participants consumed all or almost all IFA supplements. In the second and third trimesters, those who consumed all or almost all supplements were 37 and 39.7 %, respectively, for iron and 37.6 and 40.9 %, respectively, for folic acid. Barriers, including side effects, forgetfulness, safe previous pregnancies without IFA, others’ advice against consumption, IFA stock-outs, inability to meet transport costs, and inadequate supply of IFA tablets, contribute to low consumption of IFA. Multivariate logistic regression models showed that the barriers were inversely associated with good consumption of IFA supplements. Better knowledge and attitude toward IFA and older maternal age were positively associated with good consumption of IFA supplements.ConclusionsLow consumption of IFA supplements in overall pregnancy is mainly owing to the late antenatal care attendance. Strategies such as establishing a preconception care unit and school-based provision of IFA may be helpful. It is evident that most women still lack knowledge, and some have negative attitudes about IFA supplements. Health education to raise awareness and emphasize the importance of starting antenatal care early as well as consuming supplements on time should be revisited and intensified. Multiple strategies such as including community health care workers for distributing IFA supplements, discussing with clients about the measures to reduce forgetfulness, advising ways to prevent and manage the side effects, providing subsidies to cover transport costs, and ensuring adequate supply of IFA supplements in facilities may need to be employed to reduce the identified barriers.

Iron and folic Acid (IFA) supplementation is an effective intervention for reducing the incidence of anaemia during pregnancy. The WHO recommends at least 6 months intake of IFA to pregnant women. However, in Ghana some women experience challenges with adhering to IFA supplementation. The main objective of the study was to assess the level of adherence to iron and folic acid supplementation and its associated factors among pregnant women in a peri-urban municipality in Northern Ghana. A cross-sectional study was conducted from March to December 2021 among 400 pregnant women who attended ANC in Sagnarigu municipality in Ghana and were selected through a 3-stage random sampling technique. A structured questionnaire was used to collect data. The data were analysed using descriptive statistics, univariate and binary logistic regression statistical tools. Self-reported level of adherence to iron and folic acid supplementation was 84.5%. Knowledge of iron and folic acid supplementation (AOR = 0.08: 021, 0.343) was associated with adherence. Three other factors: time of first antenatal visit (AOR = 0.32: 0.153, 0.649) having history of anaemia [AOR = 2.67: 1.373, 5.201] having side effects of IFA [AOR = 3.70, CI: (1.756, 7.793)], and having knowledge of management of side effects of iron and folic acid supplementation (AOR = 0.08: 021, 0.343) were found to be significantly associated with adherence. Adherence to iron and folic supplementation among the pregnant women was generally frequent. Strategies to increase iron and folic acid supplementation adherence among pregnant women could focus on encouraging pregnant women to have early ANC visits and educating them on how to manage side effects.

Objective:Antenatal multiple micronutrient supplements (MMS) are a cost-effective intervention to reduce adverse pregnancy and birth outcomes. However, the current WHO recommendation on the use of antenatal MMS is conditional, partly due to concerns about the effect on neonatal mortality in a subgroup of studies comparing MMS with iron and folic acid (IFA) supplements containing 60 mg of Fe. We aimed to assess the effect of MMS v. IFA on neonatal mortality stratified by Fe dose in each supplement.Methods:We updated the neonatal mortality analysis of the 2020 WHO guidelines using the generic inverse variance method and applied the random effects model to calculate the effect estimates of MMS v. IFA on neonatal mortality in subgroups of trials (n 13) providing the same or different amounts of Fe, that is, MMS with 60 mg of Fe v. IFA with 60 mg of Fe; MMS with 30 mg of Fe v. IFA with 30 mg of Fe; MMS with 30 mg of Fe v. IFA with 60 mg of Fe; and MMS with 20 mg of Fe v. IFA with 60 mg of Fe.Results:There were no statistically significant differences in neonatal mortality between MMS and IFA within any of the subgroups of trials. Analysis of MMS with 30 mg v. IFA with 60 mg of Fe (7 trials, 14 114 participants), yielded a non-significant risk ratio of 1·12 (95 % CI 0·83 to 1·50).Conclusion:Neonatal mortality did not differ between MMS and IFA regardless of Fe dose in either supplement.

Effective coverage of antenatal iron and folic acid (IFA) supplementation is important to prevent adverse maternal and newborn health outcomes. We interviewed 2572 women from two rural districts in Bangladesh who had a live birth in the preceding six months. We analysed the number of IFA tablets received and consumed during pregnancy and examined the factors influencing IFA consumption by multiple linear regression and user adherence-adjusted effective coverage of IFA (consuming ≥180 IFA tablets) by Poisson regression. Overall, about 80% of women consumed IFA supplements in any quantity. About 76% of women received antenatal care at least once, only 8% received ≥180 IFA tablets, and 6% had user adherence-adjusted coverage of antenatal IFA supplementation. Multivariable analysis showed a linear relationship between the number of antenatal care (ANC) visits and the number of IFA supplements consumed, which was modified by the timing of the first ANC visit. Women’s education, free IFA, and advice on IFA were also associated with higher IFA consumption. Interventions targeting at least eight ANC contacts, starting early in pregnancy, providing advice on the importance of IFA, and providing IFA supplements in higher quantity at ANC contacts are likely to increase effective coverage of antenatal IFA supplementation.

BackgroundThe World Health Organization recommends daily iron and folic acid (IFA) supplementation during pregnancy to prevent maternal anemia and adverse birth outcomes such as preterm birth. However, uptake of IFA has varied substantially in low- and middle-income countries due to issues regarding supply, knowledge, access to health services, and acceptability. In Botswana, nearly one-third of pregnant women do not receive IFA. Objectives: To assess knowledge of IFA supplementation, supplement availability, and barriers and facilitators to preconception and antenatal supplementation in Botswana.MethodsWe conducted qualitative interviews with 2 key stakeholder groups at 2 different levels: the individual level (pregnant women) and the service delivery level (healthcare providers). In this study, we present results from 16 interviews with healthcare providers at 2 representative antenatal clinic sites in Botswana in 2022—8 nurse/midwives, 4 pharmacists, 2 dieticians, and 2 Ministry of Health sexual and reproductive health officials.ResultsHealthcare providers were knowledgeable about the benefits of IFA supplementation and prescribed supplements when available. Several key barriers were identified: lack of availability of supplements due to frequent and long-lasting stockouts, late antenatal care registration, nonadherence and side effects, costs, and cultural and traditional beliefs. Healthcare providers indicated that foods rich in IFA were available and that fortification of staple foods with IFA would be feasible and acceptable.ConclusionsOur study identified an urgent need to increase the availability of IFA supplementation at antenatal clinics, with the ultimate goal of improving maternal and infant outcomes. In addition, addressing patient concerns around side effects and providing foods fortified with IFA to pregnant women could improve maternal and infant health.

Barriers to and Facilitators of Iron and Folic Acid Supplementation within a School-Based Integrated Nutrition and Health Promotion Program among Ghanaian Adolescent Girls.

Background:To prevent pre-eclampsia in populations with insufficient dietary calcium (Ca) intake, the World Health Organisation (WHO) recommends routine Ca supplementation during antenatal care (ANC). WHO guidelines suggest a complex dosing regimen, requiring as many as 5 pill-taking events per day when combined with iron and folic acid (IFA) supplements. Poor adherence may undermine public health effectiveness, so simpler regimens may be preferable. This trial will compare the effect of the WHO-recommended (higher-dose) regimen vs. a simpler, lower-dose regimen on supplement consumption and pill-taking behaviours in Kenyan ANC clients.Design and methods:This is a parallel, non-inferiority, cluster-randomized trial; we examined 16 primary care health facilities in Kenya, 1047 pregnant women between 16-30 weeks gestational age. Higher-dose regimen: 1.5 g elemental calcium in 3 separate doses (500 mg Ca/pill) and IFA (60 mg Fe + 400 µg folic acid) taken with evening dose. Lower-dose regimen: 1.0 g calcium in 2 separate doses (500 mg Ca/pill) with IFA taken as above. Measurements: Primary outcome is Ca pills consumed per day, measured by pill counts. Secondary outcomes include IFA pills consumed per day, client knowledge, motivation, social support, and satisfaction, measured at 4 to 10 weeks post-enrolment. Statistical analyses: Unit of randomization is the healthcare facility; unit of analysis is individual client. Intent-to-treat analysis will be implemented with multi-level models to account for clustering.Expected public health impact:If pregnant women prescribed lower doses of Ca ingest as many pills as women prescribed the WHO-recommended regimen, developing a lower-dose recommendation for antenatal Ca and IFA supplementation programs could save resources.Significance for public healthPre-eclampsia is a leading cause of maternal mortality. Based on clinical evidence of significant reduction in risk of pre-eclampsia, the WHO recommends including calcium (Ca) supplementation in antenatal care services in settings with inadequate dietary Ca intakes. A high daily amount of Ca administered in a complex dosing regimen is recommended to maximize efficacy and bioavailability. Factors such as client adherence, motivation, cost and logistical complexities may undermine effectiveness when implemented in public health programs. This cluster-randomized trial will compare Ca supplement consumption between higher and lower-dose regimens delivered through antenatal care in Kenya, integrated with iron-folic acid supplementation. If a lower-dose regimen improves adherence, women’s Ca supplement consumption may be comparable to that achieved under a complex, higher-dose regimen. Evidence gained from this trial will guide public health planning for antenatal calcium supplementation programs to maximize benefits through reducing logistical, cost and adherence barriers.

Introduction: Iron deficiency anemia (IDA) is a prevalent global health issue among pregnant women in developing countries. Increased iron demands during pregnancy, often coupled with low dietary intake, contribute to a high prevalence of IDA. This can lead to adverse maternal and fetal outcomes. The World Health Organization (WHO) recommends routine iron and folic acid (IFA) supplementation for pregnant women. In Nepal, the government has implemented the National Nutritional Program, which includes the free distribution of IFA tablets to pregnant and postpartum women through health institutions. Methods and Materials: This cross-sectional study assessed IFA compliance among postpartum women in Godawari Municipality, Lalitpur, Nepal. A semi-structured questionnaire was administered through face-to-face interviews with 250 postpartum women residing in Godawari Municipality within six months postpartum. Multistage sampling was used to select participants from five out of the 14 wards. Data were entered into EpiData software version 3.1 and analyzed using SPSS version 20. Results: The study found that 69% of the participants reported compliance with IFA supplementation. Anemia during pregnancy was reported by 47.4% of the participants. Factors associated with IFA compliance included age, ethnicity, marital status, education level of both the woman and her husband, and the husband’s occupation. Religion, family type, and the woman’s occupation were not significantly associated with IFA compliance. Side effects were the primary reason for non-compliance with IFA supplementation. Conclusion: The compliance rate of 69% with IFA supplementation among postpartum women in Godawari Municipality is encouraging. However, the high prevalence of anemia (47.4%) highlights the need for continued efforts to address IDA. Targeted interventions should focus on improving IFA compliance, particularly among younger women, those with lower education levels, and those whose husbands have lower education levels or occupations. Strengthening maternal health services and providing comprehensive counseling and support on IFA supplementation are crucial. Engaging families in promoting maternal health can also contribute to improved IFA compliance and reduced anemia.

Background: Anemia is a public health challenge in India among children, adolescents and reproductive age women. Still, 58% of under-five children in India and 43% in Puducherry are anaemic. To determine the proportion of mothers of one-to-nine-year children, aware about iron and folic acid (IFA) supplementation, the proportion of children adherent to the dosage of IFA and the barriers for the adherence to IFA. Methods: A community-based explanatory sequential mixed methods study consisting survey using a semi-structured questionnaire and followed by focus group discussions (FGD) using an interview guide. The data was collected using EpiCollect5 analysed using SPSS. The results were expressed as proportions with 95% confidence interval (CI) and the qualitative results were expressed as a conceptual framework. Results: Awareness about IFA supplementation given to children from the public health system was 57% (95% CI: 51.8-62.0) among mothers of one-to-nine-year children. Adherence to IFA supplementation was 34% (28.9.0-38.6). The main reason of the non-adherence reported by the mothers was non-availability of the supplements, nausea and vomiting among children and forgetfulness of the mother. In the FGD, supply side reasons were non-palatability and wrong dose administration, and demand side reasons were lack of awareness and coverage. Conclusions: Only one out of ten children among under five years were taking IFA syrup and only half of the children ages five-to-nine-years consumed IFA tablets given in their schools. Irregular distribution of IFA tablets, medication side-effects, and non-palatability of the medication were the main reasons quoted by the mother for non-adherence.

BackgroundAlive & Thrive supported the Government of Burkina Faso to strengthen the provision of iron and folic acid (IFA) supplementation and interpersonal counseling on maternal nutrition and breastfeeding through antenatal care (ANC) services and community-based contacts in 2 regions. ObjectivesWe assessed the impacts of intensified nutrition interventions during ANC compared with standard ANC services on intervention coverage and maternal nutrition practices. MethodsA cluster-randomized evaluation compared 40 health center catchment areas in intervention areas with 40 in control areas. Repeated cross-sectional surveys in 2019 and 2021 (960 pregnant women and 1920 women with children 0–5 mo of age per survey round) provided data on impact indicators, intervention exposure, and other factors. We derived difference-in-difference (DID) effect estimates, adjusted for geographic clustering, for maternal dietary diversity, IFA consumption, and early breastfeeding practices. ResultsMore women in intervention areas had 4+ ANC visits (DID: 8.3 percentage points [pps]) and started ANC during the first trimester (DID: 10.5 pp), compared with control areas. Improvements were achieved in exposure to nutrition counseling on dietary diversity (DID: 44.4 pp), food quantity (DID: 42.9 pp), adequate weight gain (DID: 35.1 pp), and breastfeeding (DID: 25.9 pp). Women in intervention areas consumed more IFA supplements during pregnancy (DID: 21 tablets). Early initiation of and exclusive breastfeeding also improved (DID: 17.0 and 8.3 pp, respectively). However, dietary diversity (4 out of 10 food groups) and mean probability of adequacy of micronutrient intake (14%) among pregnant women remained low in both areas. ConclusionsStrengthening maternal nutrition interventions delivered through government ANC services was feasible and effective in improving maternal nutrition practices. Continued efforts to strengthen the delivery and use of maternal nutrition services may be required for greater behavior changes, and to address family support, social norms, and other factors to improve women’s diets during pregnancy.

Prenatal iron and folic acid (IFA) supplements are offered free to all pregnant women in Malawi to reduce maternal anemia and improve birth outcomes. We investigated the association between self-reported compliance to IFA intake and risk of low birth weight (LBW). Pregnant women who attended Bwaila Maternity Wing of Lilongwe District Hospital for delivery were recruited (n = 220). We used a questionnaire to collect self-reported information on IFA use and maternal sociodemographic data. Before delivery, blood samples for maternal hemoglobin (Hb) and folate status, and upon delivery, birth weight, and other newborn anthropometrics were measured. We used multivariable logistic regression to determine risk of LBW by prenatal IFA intake. The self-reported number of IFA pills taken during pregnancy was positively associated with Hb, but not serum and RBC folate concentration: <45, 45–89 and ≥90 pills taken corresponded with mean (SD) Hb 10.7 (1.6), 11.3 (1.8), and 11.7 (1.6) g/dL, respectively (p = 0.006). The prevalence of LBW was 20.1%, 13.5% and 5.6% for those who reported taking IFA pills <45, 45–89, and ≥90 pills, respectively (p = 0.027). Taking >60 IFA pills reduced risk of LBW delivery (OR (95% CI) = 0.15 (0.03–0.70), p = 0.033) than taking ≤30 pills. Self-reported compliance to IFA use is valid for assessing prenatal supplement program in Malawi, especially Hb status, and can reduce the rate of LBW.

Prenatal iron and folic acid (IFA) supplements reduce low birth weight and maternal anemia, a risk factor for maternal mortality. However, many women who receive IFA through antenatal care (ANC) do not adhere to the recommended doses. We tested the hypotheses that depressive symptoms (DS), perceived social support (PSS) and perceived physical health (PPH) are associated with IFA adherence. Participants were 1760 pregnant women in rural Zimbabwe and enrolled in the SHINE trial. We assessed DS, PSS and PPH at enrolment (&lt;24 weeks gestation) and advised women to seek ANC. IFA adherence (&gt;5 pills/wk) was measured in the 3rd trimester by 7‐day recall. At this visit, 1693 (96.5%) women had attended ANC and 1461 (83%) received IFA. We used separate logistic regression models to explore associations between IFA adherence and each of the psychosocial factors, controlling for education, economic status, HIV status and parity. The causal steps approach was used to test possible mediation. On average, women took IFA 5.4 times/wk, and 67.3% took &gt;5 pills in the past week. Women with higher PSS were more likely to adhere (OR 1.31; 95% CI 1.04‐1.64) and those with higher levels of DS were less likely to adhere (OR 0.82; 95% CI 0.70‐0.96). DS mediated the link between PSS and IFA adherence, and similarly PSS mediated the link between DS and IFA adherence. PPH was not associated with adherence. Social support and mental health are modifiable correlates of IFA adherence in Zimbabwean women. Efforts to improve the psychosocial context of pregnant women could strengthen IFA interventions.

Background: In the context of the limited effectiveness of daily iron supplementation in national programs, intermittent iron supplementation is currently under debate as a possible alternative. Objective: To study the outcome of twice weekly iron supplementation compared to daily supplementation. Methods: A community-based interventional study was carried out in 283 women of the 15-49 years age group who were not pregnant and not lactating at the initiation of the study. For intervention purpose, women with mild and moderate anemia were taken. In two schedules, an interventional drug (100 mg elemental iron with 0.5 mg folic acid) was given for three months. In the daily schedule, one tablet every day; and in the weekly schedule, two tablets once a week on a fixed day were given. Result: Out of 283 anemic participants, 141 received daily while 142 received weekly iron and folic acid supplementation. Post intervention, the weekly iron supplementation group revealed that, proportion of anemia cases reduced to the tune of 32.4% and the mean increase in hemoglobin level was 1.42 gm/dl (SD ± 0.77). In contrast, in patients who had a daily supplementation regimen, the mean increase in hemoglobin level was 1.78 gm/dl (SD ± 0.83). Conclusion: Result of present study shows that, effect of daily Iron and Folic Acid (IFA) supplementation to raise hemoglobin level was higher as compared to weekly IFA supplementation. But weekly supplementation when considered separately also had significant effect to raise the hemoglobin level. It is observed that, there is no statistically significant difference in the rise of hemoglobin in both the groups, signifying weekly iron therapy as effective role as daily iron therapy in reducing anemia

The World Health Organization now recommends integrating calcium supplements into antenatal micronutrient supplementation programmes to prevent pre-eclampsia, a leading cause of maternal mortality. As countries consider integrating calcium supplementation into antenatal care (ANC), it is important to identify context-specific barriers and facilitators to delivery and adherence. Such insights can be gained from women's and health workers' experiences with iron and folic acid (IFA) supplements. We conducted in-depth interviews with 22 pregnant and post-partum women and 20 community-based and facility-based health workers in Kenya to inform a calcium and IFA supplementation programme. Interviews assessed awareness of anaemia, pre-eclampsia and eclampsia; ANC attendance; and barriers and facilitators to IFA supplement delivery and adherence. We analyzed interviews inductively using the constant comparative method. Women and health workers identified poor diet quality in pregnancy as a major health concern. Neither women nor health workers identified pre-eclampsia, eclampsia, anaemia or related symptoms as serious health threats. Women and community-based health workers were unfamiliar with pre-eclampsia and eclampsia and considered anaemia symptoms normal. Most women had not received IFA supplements, and those who had received insufficient amounts and little information about supplement benefits. We then developed a multi-level (health facility, community, household and individual) behaviour change strategy to promote antenatal calcium and IFA supplementation. Formative research is an essential first step in guiding implementation of antenatal calcium supplementation programmes to reduce pre-eclampsia. Because evidence on how to implement successful calcium supplementation programmes is limited, experiences with antenatal IFA supplementation can be used to guide programme development.

Anemia in pregnancy, which is a public health concern for most developing countries, is predominantly caused by iron deficiency. At least, 180 days of iron and folic acid (IFA) supplementation is recommended for pregnant women to mitigate anemia and its adverse effects. This study aimed to examine compliance with the recommendation of IFA supplementation and its underlying factors using the 2017 Philippine National Demographic and Health Survey data. The variables assessed included age, highest level of education, occupation, wealth index, ethnicity, religion, residence, number of pregnancies, time of first antenatal care (ANC) visit and number of ANC visits. Compliance with the recommendation of at least 180 days of IFA supplementation was the outcome variable. The study assessed 7983 women aged 15–49 years with a history of pregnancy. Of these participants, 25.8% complied with the IFA supplementation recommendation. Multiple logistic regression analysis showed that pregnant women of Islamic faith and non-Indigenous Muslim ethnicity were less likely to comply with the IFA supplementation recommendation. Being aged between 25 and 34 years, having better education and higher wealth status, rural residency, initiating ANC visits during the first trimester of pregnancy and having at least four ANC visits positively influenced compliance with IFA supplementation. The effect of residence on IFA adherence differed across the wealth classes. Strategies targeted at specific groups, such as religious minorities, poor urban residents, the less educated and young women, should be strengthened to encourage early and regular antenatal care visits for improving compliance.