Abstract
BackgroundTo reduce the prevalence of anemia, the Indian government recommends daily iron and folic acid supplements (iron supplements) for pregnant women and weekly iron supplements for adolescents and all women of reproductive age. The government has distributed free iron supplements to adolescents and pregnant women for over four decades. However, initial uptake and adherence remain inadequate and non-pregnant women of reproductive age are largely ignored. The aim of this study is to examine the multilevel barriers to iron supplement use and to subsequently identify promising areas to intervene.MethodsWe conducted a qualitative study in the state of Odisha, India. Data collection included key informant interviews, focus group discussions with women, husbands, and mothers-in-law, and direct observations in health centers, pharmacies and village health and nutrition days.ResultsWe found that at the individual level, participants knew that iron supplements prevent anemia but underestimated anemia prevalence and risk in their community. Participants also believed that taking too many iron supplements during pregnancy would “make your baby big” causing a painful birth and a costly cesarean section. At the interpersonal level, mothers-in-law were not supportive of their daughters-in-law taking regular iron supplements during pregnancy but husbands were more supportive. At the community level, participants reported that only pregnant women and adolescents are taking iron supplements, ignoring non-pregnant women altogether. Unequal gender norms are also an upstream barrier for non-pregnant women to prioritize their health to obtain iron supplements. At the policy level, frontline health workers distribute iron supplements to pregnant women only and do not follow up on adherence.ConclusionsInterventions should address multiple barriers to iron supplement use along the socio-ecological model. They should also be tailored to a woman’s reproductive life course stage: adolescents, pregnancy, and non-pregnant women of reproductive age because social norms and available services differ between the subpopulations.
Highlights
To reduce the prevalence of anemia, the Indian government recommends daily iron and folic acid supplements for pregnant women and weekly iron supplements for adolescents and all women of reproductive age
Later in 2013, the government adopted a life-cycle approach to address the problem of Anemia under the National Iron Plus Initiative (NIPI), which recommends weekly iron supplements for all women of reproductive age [24]
We designed a theoretical model to describe the spectrum of behaviors related to Iron and folic acid supplements (IFA) for all women of reproductive age, including seeking medical care, getting tested for anemia, obtaining IFA, taking IFA, and adhering to IFA throughout the reproductive health lifespan
Summary
To reduce the prevalence of anemia, the Indian government recommends daily iron and folic acid supplements (iron supplements) for pregnant women and weekly iron supplements for adolescents and all women of reproductive age. IFA are critical in India where anemia affects 53% of women between 15 and 49 years old [18] Given these high rates, in 2012, the World Health Assembly Resolution endorsed six Global Targets for 2025, with its second target aiming for a 50% reduction of anemia in women of reproductive age (WRA) [44]. Later in 2013, the government adopted a life-cycle approach to address the problem of Anemia under the National Iron Plus Initiative (NIPI), which recommends weekly iron supplements for all women of reproductive age [24]. In 2018, the government rolled out the Intensified National Iron Plus Initiative “Anemia Mukt Bharat” [17]
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