Determinants of compliance with iron supplementation: supplies, side effects, or psychology?

Factors Influencing the Use of Biomedical Health Care by Rural Bolivian Anemic Women: Structural Barriers, Reproductive Status, Gender Roles, and Concepts of Anemia

METHODS

Non-pregnant women from a rural town and its surrounding region were tested for anemia. During phase 1 (n = 181), anemic women received a written recommendation for low-cost purchase of iron pills at the nearest health center. They were subsequently interviewed on their actions and experiences.

RESULTS

Estimated anemia prevalence among these non-pregnant women was 50% higher than the national average. Despite holding conceptualizations of anemia generally aligned with biomedical concepts, only 40% of anemic women attempted to obtain iron supplements from the health center. Town residents were about twice as likely to attempt to purchase pills as outside-town residents. Town women who were concurrently breastfeeding and menstruating, considered anemia most serious for women, and considered family health the shared responsibility of spouses were most likely to decide to purchase iron pills. Age, education, or native language did not negatively influence this health care behavior.

CONCLUSIONS

Securing iron supplements involves individual trade-offs in the allocation of time, cost and effort. Nonetheless, suitably tailored programs can potentially harness local perceptions in the service of reducing anemia. Because of their comparatively high motivation to obtain iron supplements, targeting concurrently breastfeeding and menstruating women could have a positive cascade effect such that these women continue attending to their iron needs once they stop breastfeeding and if they become pregnant again. Because a sense of shared responsibility for family health appears to encourage women to attend to their own health, programs for women could involve their spouses. Complementing centralized availability, biomedical and traditional healers could distribute iron supplements on rotating visits to outlying areas and/or at highly attended weekly markets.

Effectiveness of Distribution of Multimicronutrient Supplements in Children and in Women and Adolescent Girls of Childbearing Age in Chiclayo, Peru

Background

There is a need to better understand the coverage of scaled-up multimicronutrient supplementation programs.

Objective

The coverage of the distribution of multimicronutrient supplements in 26 urban communities among women and adolescent girls 12 through 44 years of age and children under 5 years of age was evaluated for purposes of scaling-up.

Methods

Formative research and descriptive statistics were used to analyze the distribution of supplements.

Results

Despite a delayed memorandum of understanding with the health sector and delayed delivery by the producer of the supplement, a high coverage rate of supplement distribution to the children (88% on average during the 3 months of supplementation) was still achieved as a result of the strong commitment of the community and the Integrated Food Security Program. The lower coverage rate among women and adolescent girls (47% on average) was the result of too short a period of enrollment in the program. There was no decrease of coverage during the 3 months of supplementation in both groups.

Conclusions

Effective, sustainable, large-scale micronutrient supplementation programs require broad partnerships with commitments of governmental and nongovernmental organizations, communities, and the private sector. Availability of the supplements and communication materials must be secured well ahead of the supplementation campaign and distribution of the supplement.

The reproductive ecology of iron in women

Reproductive ecology focuses on the sensitivity of human reproduction to environmental variation. While reproductive ecology has historically focused on the relationship between energy status and reproductive outcomes, iron status is equally critical to women's reproductive health, given the wide-ranging detrimental effects of iron-deficiency anemia on maternal and infant well-being. This review interprets the vast literature on iron status and women's reproduction through an evolutionary framework. First, it will critique the evidence for iron deficiency caused by blood loss during menstruation, reinterpreting the available data as ecological variation in menses within and between populations of women. Second, it will highlight the scant but growing evidence that iron status is implicated in fertility, a relationship that has deep evolutionary roots. Third, this review proposes a new hypothesis for the transfer of iron from mother to infant via pregnancy and breastfeeding: reproductive iron withholding. In this hypothesis, mothers transfer iron to infants in a manner that helps infants avoid iron-mediated infection and oxidative stress, but trades off with potential risk of maternal and infant iron deficiency. Finally, this review explores two main factors that can modify the relationship between iron status and the gestation-lactation cycle: (1) the relationship between long-term reproductive effort (parity) and iron status and (2) supplementation schemes before and during pregnancy. The review concludes by suggesting continued research into iron homeostasis in women using evolutionary, ecological, and biocultural frameworks.

A mixed method study exploring adherence to and acceptability of small quantity lipid-based nutrient supplements (SQ-LNS) among pregnant and lactating women in Ghana and Malawi

BACKGROUND

Supplementing pregnant and lactating mothers with small quantity lipid-based nutrient supplements (SQ-LNS) has resulted in improvements in birth outcomes in some low-income settings. In order to be effective, SQ-LNS must be consumed regularly over sustained periods.

METHODS

The objective was to assess and compare acceptability of and adherence to SQ-LNS consumption among pregnant and lactating women in Ghana and Malawi throughout 12 months of supplementation. We enrolled women before 20 gestation weeks into randomized trials in Ghana (n = 1320) and Malawi (n = 869). In the SQ-LNS group participants received a 20 g sachet of supplement per day during pregnancy and the first 6 months of lactation. In the control groups participants received multiple micronutrients (MMN) during pregnancy and lactation or iron and folic acid (IFA) during pregnancy and calcium during lactation. We used questionnaires to collect data on self-reported adherence to daily use of supplements and conducted in-depth interviews with women in the SQ-LNS group to examine acceptability.

RESULTS

The mean self-reported adherence during the supplementation period was lower in Ghana (79.9 %) than in Malawi (91.7 %) for all supplements (difference 11.8 %, P < 0.001). Over time, adherence increased in Malawi but decreased in Ghana. In both countries, adherence in the SQ-LNS group was non-inferior to that in the control groups. Participants typically reported consuming SQ-LNS as instructed but when interviewers queried about experiences, most of the women described incidents of non-adherence. A usual reason for not consuming SQ-LNS was nausea and vomiting during pregnancy. Especially in Malawi, women reported sharing SQ-LNS with families and friends. Sustained use of SQ-LNS was attributed to expected health benefits and favorable sensory attributes. Often women compared their pregnancy to previous ones, and were of the view that SQ-LNS made a positive difference.

CONCLUSION

Self-reported sustained adherence to consume SQ-LNS daily was high in both sites but lower in Ghana than in Malawi. In Ghana, adherence decreased over time whereas in Malawi adherence increased. Acceptability and adherence appeared interlinked, complex and context-related. Sustained consumption of SQ-LNS may require tailoring interventions by context.

TRIAL REGISTRATION

The Ghana trial was registered at clinicaltrials.gov as NCT00970866 , and the Malawi trial as NCT01239693 .

A Qualitative Study of Factors Influencing Initiation and Adherence to Micronutrient Supplementation Among Women of Reproductive Age in Vietnam

Background and objectives:

Initiation and adherence are both critical challenges for micronutrient supplementation programs, especially during the preconceptional period. This study examines factors influencing initiation of supplement use and continued adherence among women participating in PRECONCEPT, a double-blind randomized controlled trial of preconception micronutrient supplementation.

Methods:

In-depth interviews were conducted with 39 participants during different periods (prepregnancy [n = 15], pregnancy [n = 8], postpartum [n = 8], and dropouts [n = 8]). We examined participants’ knowledge about nutritional needs and micronutrient deficiencies, individual experience with nutritional supplements, and perceived benefits and side effects of supplements. Four focus groups were conducted with 24 village health workers (VHWs) to collect information on VHWs’ perceptions of factors influencing participants’ adherence and logistics of supplement distribution. Influences on initiation and adherence were examined within the Health Belief Model framework.

Results:

Primary barriers to initiation of supplement use were low perceptions of severity of nutrient deficiencies and personal susceptibility. These are associated with low knowledge and awareness around deficiencies. Perceived seriousness and susceptibility varied by nutrient: high for iron during pregnancy but low for all other micronutrient deficiencies, including iron outside pregnancy. Continued maintained adherence to an initiated regimen was influenced by the woman’s perceptions of the health benefits of, and barriers to, regular supplement use.

Conclusion:

Initiation of supplement use was influenced by perceived susceptibility and severity of nutrient deficiencies, while maintained adherence to consistent use was influenced by perceived benefits and barriers. Recognizing the influences on each stage may help improve adherence and maximize positive effects of future interventions.

Effects of Therapeutic Touch on Blood Hemoglobin and Hematocrit Level

Background: Therapeutic Touch (TT) is a widely used complementary therapy. This study investigated the effects of TT on hemoglobin and hematocrit level in students who were basically healthy. Method: The volunteers with a hemoglobin level less than 12 grams per deciliter (g/dl) were randomly assigned to three groups of TT, mimic therapeutic touch (MT), and control. Blood samples were collected before the first treatment and again a week after the last one and measurements were taken. Results: TT increased the level of hemoglobin (.99 .13 g/dl) and hematocrit (2.82 .43%) significantly. MT also increased the level of hemoglobin (.55 .11 g/dl) and hematocrit (2.75 .44%) significantly. No significant changes were found in the control group. TT increased hemoglobin more effectively than MT ( p< .05). Conclusions: Significant changes of both variables in TT and MTgroups suggest that more careful precision might be needed while selecting individuals as sham therapists in further experiments.

Factors Influencing Anti-Malarial Prophylaxis and Iron Supplementation Non-Compliance among Pregnant Women in Simiyu Region, Tanzania

Malaria and iron-deficient anemia during pregnancy pose considerable risks for the mother and newborn. Intermittent Preventive Treatment during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) and iron supplement to prevent anemia to all pregnant women receiving antenatal care (ANC) services is highly recommended. However, their compliance remains low. This study aimed at identifying factors influencing non-compliance of medications among pregnant women. A descriptive cross-sectional study was conducted in Simiyu region in northwest Tanzania using a structured questionnaire to collect data from 430 women who were pregnant or gave birth 12 months prior to data collection. Data were analyzed using non-parametric statistical analysis with STATA 10. Overall, 284 (66%) and 195 (45%) of interviewed women received IPTp-SP and iron supplementation during their ANC visits, respectively. The majority (85%) of women whom received medications were aware if they had received IPTp-SP or iron supplementation. Of those received IPTp-SP, only 11% took all the three doses, while the remaining 89% took only two doses or one dose. For women who received iron supplementation, 29% reported that they did not take any dose at all. Reasons given for not complying with regiments included not liking the medications and disapproval from male partners. Our findings suggest that IPTp-SP and iron supplement compliance among pregnant women in Simiyu region is low. Intensification of community education, further qualitative research and administration of medication through directly-observed therapy (DOT) are recommended to address the problem.

Relationship between anemia and depressive mood in the last trimester of pregnancy

OBJECTIVE

To compare the relationship between the severity of anemia and depressive mood in the last trimester of pregnancy.

METHODS

A cross-sectional study, enrolled a total of 450 pregnant women who attended the antenatal clinics in their third trimester for their routine antenatal follow-up. Depressive symptoms were assessed by the Edinburgh Postnatal Depression Scale. The study group was divided into two groups according to presence of anemia; anemic group (Hb < 11 gr/L; n = 150) and non-anemic group (Hb ≥ 11 gr/L; n = 300) and depression scores were compared.

RESULTS

One hundred and fourteen (25.3%) women scored ≥13 points which were considered the cutoff value for depression on the EPDS. Anemia frequency was found as 33.3%. The total EPDS score was significantly higher in the anemic group (EPDS score 11 [min-max 0-29]) compared with the non-anemic group (EPDS score 7 [min-max 0-21]) (p = 0.000). Multiple regression analysis also revealed that serum Hb level was an independent factor for antenatal depressive mood.

CONCLUSIONS

As anemia is associated with higher depressive symptom levels, it should be carefully considered during pregnancy. Prospective studies are needed to confirm our results.

Factors associated with non-adherence to prescribed iron supplement use: a study with pregnant women in the city of Rio de Janeiro

Abstract Objectives: to identify factors associated with non-use of iron supplements (IS) by pregnant women attending National Health System (SUS) prenatal care in the Municipality of Rio de Janeiro. Methods: a cross-sectional study was conducted in 2007/2008 with a representative sample of pregnant women using SUS hospitals and basic care in the Municipality of Rio de Janeiro. The group that had gestational age of ≥ 20 weeks at the time of the interview and who had been prescribed IS (n=1407) was subjected to a Poisson multiple regression model to estimate the association between use and independent variables. Results: of the 1407 pregnant women, 65% reported use of IS. Younger age, black skin/race, larger number of births, not having received guidance on use of IS, not having tried to obtain IS at the SUS (with a stronger association between pregnant women with lower levels of education and lower household assets indicator - HAI) and not having been able to obtain them at the SUS (amongpregnant women with lower HAI) were significantly associated with non-use. Conclusions: the guidance of health professionals regarding use of IS and their regular availability may increase adherence to prescription among pregnant women and prevent iron deficiency anemia.

Role of family support and women's knowledge on pregnancy-related risks in adherence to maternal iron-folic acid supplementation in Indonesia

OBJECTIVE

To examine whether women's knowledge of pregnancy-related risks and family support received during pregnancy are associated with adherence to maternal iron-folic acid (IFA) supplementation.

DESIGN

Secondary data analysis of the 2002-03, 2007 and 2012 Indonesia Demographic and Health Survey. Analysis of the association between factors associated with adherence (consuming ≥90 IFA tablets), including the women's knowledge and family support, was performed using multivariate logistic regression.

SETTING

National household survey.

SUBJECTS

Women (n 19 133) who had given birth within 2 years prior to the interview date.

RESULTS

Knowledge of pregnancy-related risks was associated with increased adherence to IFA supplementation (adjusted OR=1·8; 95 % CI 1·6, 2·0), as was full family (particularly husband's) support (adjusted OR=1·9; 95 % CI 1·6, 2·3). Adequate antenatal care (ANC) visits (i.e. four or more) was associated with increased adherence (adjusted OR=2·2; 95 % CI 2·0, 2·4). However, ANC providers missed opportunities to distribute tablets and information, as among women with adequate ANC visits, 15 % reported never having received/bought any IFA tablets and 30 % had no knowledge of pregnancy-related risks. A significant interaction was observed between family support and the women's educational level in predicting adherence. Family support significantly increased the adherence among women with <9 years of education.

CONCLUSIONS

Improving women's knowledge of pregnancy-related risks and involving family members, particularly the husband and importantly for less-educated women, improved adherence to IFA supplementation. ANC visit opportunities must be optimized to provide women with sufficient numbers of IFA tablets along with health information (especially on pregnancy-related risks) and partner support counselling.

Impact of Text Message Reminders on Caregivers' Adherence to a Home Fortification Program Against Child Anemia in Rural Western China: A Cluster-Randomized Controlled Trial

OBJECTIVES

To test whether text message reminders sent to caregivers improve the effectiveness of a home micronutrient fortification program in western China.

METHODS

We carried out a cluster-randomized controlled trial in 351 villages (clusters) in Shaanxi Province in 2013 and 2014, enrolling children aged 6 to 12 months. We randomly assigned each village to 1 of 3 groups: free delivery group, text messaging group, or control group. We collected information on compliance with treatments and hemoglobin concentrations from all children at baseline and 6-month follow-up. We estimated the intent-to-treat effects on compliance and child anemia using a logistic regression model.

RESULTS

There were 1393 eligible children. We found that assignment to the text messaging group led to an increase in full compliance (marginal effect = 0.10; 95% confidence interval [CI] = 0.03, 0.16) compared with the free delivery group and decrease in the rate of anemia at end line relative to the control group (marginal effect = -0.07; 95% CI = -0.12, -0.01), but not relative to the free delivery group (marginal effect = -0.03; 95% CI = -0.09, 0.03).

CONCLUSIONS

Text messages improved compliance of caregivers to a home fortification program and children's nutrition.

Adherence to recommendations on lipid-based nutrient supplement and iron and folic acid tablet consumption among pregnant and lactating women participating in a community health programme in northwest Bangladesh

Limited knowledge exists on sustained adherence to small-quantity lipid-based nutrient supplements for pregnant and lactating women (LNS-PL) and how this compares with that of other prenatal supplements. To address these gaps, a random subsample of women (n = 360) during pregnancy, early (6- to 12-week post-partum) and late (12- to 24-week post-partum) lactation, from an ongoing effectiveness trial in Bangladesh, was selected for in-home interviews about LNS-PL or iron/folic acid (IFA) use and preferences. Prevalence of high adherence (≥70% of the recommendation) based on self-reported supplement consumption was 67%, 68% and 81% among LNS-PL recipients during pregnancy, early and late lactation, and was 87% and 71% among IFA recipients during pregnancy and early lactation, respectively (P = 0.044). Programmatic factors (e.g. distribution and visits by programme staff) were consistently statistically significantly associated with reported high adherence. Among LNS-PL recipients, high overall supplement acceptability score [odds ratio (OR): 8.62; 95% confidence interval (CI) 3.53, 20.83] and use of reminder techniques (OR: 4.41; 95%CI 1.65, 11.76) were positively associated, and reported vomiting at enrollment was negatively associated (OR: 0.34; 95%CI 0.14, 0.80), with reported high adherence. Selected women (n = 16) and key informants (n = 18) participated in in-depth interviews about perceptions and acceptability of LNS-PL. Women perceived benefits of taking LNS-PL, but some faced barriers to consumption including aversion to odour and taste during pregnancy, forgetfulness and disruptions in supply. To achieve high adherence, results from this study suggest that maternal supplementation programmes should focus on programmatic barriers and consider incorporating reminder techniques. Organoleptic acceptability of LNS-PL, particularly during pregnancy, may also need to be addressed.

Translating formative research findings into a behaviour change strategy to promote antenatal calcium and iron and folic acid supplementation in western Kenya

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.

The Karnataka Anemia Project 2--design and evaluation of a community-based parental intervention to improve childhood anemia cure rates: study protocol for a cluster randomized controlled trial

BACKGROUND

Childhood anemia is highly prevalent worldwide. Improving the hemoglobin level of preschool age children could yield substantial benefits in cognitive and psychosocial development and overall health. While evidence-based recommendations for reducing childhood anemia in high anemia prevalence countries are available, there is no experimental evidence of community centered education and counseling programs, as a route to improved acceptance of iron supplements, demonstrating beneficial effects on anemia outcomes. We report on the evaluation protocol of a complex educational intervention led by the community lay health worker (LHW) and delivered to mothers of 12-59-month-old anemic children living in and visiting village day care centers in a large district of southern India.

METHODS AND DESIGN

The study is designed as a cluster randomized controlled trial. The intervention is based on the social cognitive theory and aims to promote among mothers, anemia awareness, dietary modifications to increase iron intake in the child, and recognition of the need for enhanced adherence to supplemental iron in the anemic child. From 270 eligible villages in the study area, a sample of 60 villages will be randomized to intervention [n = 30] or to treatment as usual [n = 30] of the study. LHWs in the intervention arm will be trained to administer the following intervention components to mothers of anemic children: 1] monthly distribution of Iron and folic acid (IFA) supplements to mothers of anemic children, and 2] five monthly counseling sessions of mothers of anemic children covering: a] anemia awareness education b] IFA adherence counseling and assessment, c] dietary modification to improve iron intake, and d] hygiene and sanitation. LHWs in the control arm will distribute IFA to mothers of anemic children as in the intervention arm but will not provide monthly education and counseling support. The primary outcome is the difference between the two experimental groups in anemia cure rates of children found to be anemic at baseline. Secondary outcomes, assessed as differences between all participants in both experimental groups, are: change in mothers' knowledge regarding anemia; 24 hour dietary iron intake; net improvement in individual hemoglobin values; serum ferritin; and the difference in overall cluster level childhood anemia prevalence. All outcomes will be measured 6 months after the start of the intervention. Multilevel linear and logistic regression models will be used to analyze differences between intervention and control groups in outcome variables.

DISCUSSION

This trial is designed to evaluate the effectiveness of an intervention intended to improve anemia cure rates in anemic children living in villages of Chamarajnagar, Karnataka a large district in south India. The extensive study of secondary endpoints will be used to identify possible weak points in the compliance to intervention delivery and uptake. This evaluation is one of the few large randomized trials evaluating the impact of an education and counseling intervention to reduce childhood anemia prevalence.

TRIAL REGISTRATION

This trial was registered with ISRCTN.com (identifier: ISRCTN68413407) on 17 September 2013.

Compliance with Iron-Folate Supplement and Associated Factors among Antenatal Care Attendant Mothers in Misha District, South Ethiopia: Community Based Cross-Sectional Study

Background. In Ethiopia, higher proportions of pregnant women are anemic. Despite the efforts to reduce iron deficiency anemia during pregnancy, only few women took an iron supplement as recommended. Thus, this study aimed to assess compliance with iron-folate supplement and associated factors among antenatal care attendant mothers in Misha district, South Ethiopia. Method. Community based cross-sectional study supported with in-depth interview was conducted from March 1 to March 30, 2015. The sample size was determined using single population proportion to 303. Simple random sampling technique was used to select the study participants. Bivariate and multivariable logistic regression analyses were employed to identify factors associated with compliance to iron-folate supplement. Results. The compliance rate was found to be 39.2%. Mothers knowledge of anemia (AOR = 4.451, 95% CI = (2.027,9.777)), knowledge of iron-folate supplement (AOR = 3.509, 95% CI = (1.442,8.537)), and counseling on iron-folate supplement (AOR = 4.093, 95% CI = (2.002,8.368)) were significantly associated with compliance to iron-folate supplement. Conclusions. Compliance rate of iron-folate supplementation during pregnancy remains very low. This study showed that providing women with clear instructions about iron-folate tablet intake and educating them on the health benefits of the iron-folate tablets can increase compliance with iron-folate supplementation.

Intermittent oral iron supplementation during pregnancy

BACKGROUND

Anaemia is a frequent condition during pregnancy, particularly among women in low- and middle-income countries. Traditionally, gestational anaemia has been prevented with daily iron supplements throughout pregnancy, but adherence to this regimen due to side effects, interrupted supply of the supplements, and concerns about safety among women with an adequate iron intake, have limited the use of this intervention. Intermittent (i.e. two or three times a week on non-consecutive days) supplementation has been proposed as an alternative to daily supplementation.

OBJECTIVES

To assess the benefits and harms of intermittent supplementation with iron alone or in combination with folic acid or other vitamins and minerals to pregnant women on neonatal and pregnancy outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2015), the WHO International Clinical Trials Registry Platform (ICTRP) (31 July 2015) and contacted relevant organisations for the identification of ongoing and unpublished studies (31 July 2015).

SELECTION CRITERIA

Randomised or quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of trials using standard Cochrane criteria. Two review authors independently assessed trial eligibility, extracted data and conducted checks for accuracy.

MAIN RESULTS

This review includes 27 trials from 15 countries, but only 21 trials (with 5490 women) contributed data to the review. All studies compared daily versus intermittent iron supplementation. The methodological quality of included studies was mixed and most had high levels of attrition.The overall assessment of the quality of the evidence for primary infant outcomes was low and for maternal outcomes very low.Of the 21 trials contributing data, three studies provided intermittent iron alone, 14 intermittent iron + folic acid and four intermittent iron plus multiple vitamins and minerals in comparison with the same composition of supplements provided in a daily regimen.Overall, for women receiving any intermittent iron regimen (with or without other vitamins and minerals) compared with a daily regimen there was no clear evidence of differences between groups for any infant primary outcomes: low birthweight (average risk ratio (RR) 0.82; 95% confidence interval (CI) 0.55 to 1.22; participants = 1898; studies = eight; low quality evidence), infant birthweight (mean difference (MD) 5.13 g; 95% CI -29.46 to 39.72; participants = 1939; studies = nine; low quality evidence), premature birth (average RR 1.03; 95% CI 0.76 to 1.39; participants = 1177; studies = five; low quality evidence), or neonatal death (average RR 0.49; 95% CI 0.04 to 5.42; participants = 795; studies = one; very low quality). None of the studies reported congenital anomalies.For maternal outcomes, there was no clear evidence of differences between groups for anaemia at term (average RR 1.22; 95% CI 0.84 to 1.80; participants = 676; studies = four; I² = 10%; very low quality). Women receiving intermittent supplementation had fewer side effects (average RR 0.56; 95% CI 0.37 to 0.84; participants = 1777; studies = 11; I² = 87%; very low quality) and were at lower risk of having high haemoglobin (Hb) concentrations (greater than 130 g/L) during the second or third trimester of pregnancy (average RR 0.53; 95% CI 0.38 to 0.74; participants = 2616; studies = 15; I² = 52%; (this was not a primary outcome)) compared with women receiving daily supplements. There were no significant differences in iron-deficiency anaemia at term between women receiving intermittent or daily iron + folic acid supplementation (average RR 0.71; 95% CI 0.08 to 6.63; participants = 156; studies = one). There were no maternal deaths (six studies) or women with severe anaemia in pregnancy (six studies). None of the studies reported on iron deficiency at term or infections during pregnancy.Most of the studies included in the review (14/21 contributing data) compared intermittent oral iron + folic acid supplementation compared with daily oral iron + folic acid supplementation (4653 women) and findings for this comparison broadly reflect findings for the main comparison (any intermittent versus any daily regimen).Three studies with 464 women examined supplementation with intermittent oral iron alone compared with daily oral iron alone. There were no clear differences between groups for mean birthweight, preterm birth, maternal anaemia or maternal side effects. Other primary outcomes were not reported.Four studies with a combined sample size of 412 women compared intermittent oral iron + vitamins and minerals supplementation with daily oral iron + vitamins and minerals supplementation. Results were not reported for any of the review's infant primary outcomes. One study reported fewer maternal side effects in the intermittent iron group, and two studies that more women were anaemic at term compared with those receiving daily supplementation.Where sufficient data were available for primary outcomes, we set up subgroups to look for possible differences between studies in terms of earlier or later supplementation; women's anaemia status at the start of supplementation; higher and lower weekly doses of iron; and the malarial status of the region in which the trials were conducted. There was no clear effect of these variables on results.

AUTHORS' CONCLUSIONS

This review is the most comprehensive summary of the evidence assessing the benefits and harms of intermittent iron supplementation in pregnant women on haematological and pregnancy outcomes. Findings suggest that intermittent regimens produced similar maternal and infant outcomes as daily supplementation but were associated with fewer side effects and reduced the risk of high levels of Hb in mid and late pregnancy, although the risk of mild anaemia near term was increased. While the quality of the evidence was assessed as low or very low, intermittent may be a feasible alternative to daily iron supplementation among those pregnant women who are not anaemic and have adequate antenatal care.

An internal pilot study for a randomized trial aimed at evaluating the effectiveness of iron interventions in children with non-anemic iron deficiency: the OptEC trial

Background

The OptEC trial aims to evaluate the effectiveness of oral iron in young children with non-anemic iron deficiency (NAID). The initial sample size calculated for the OptEC trial ranged from 112–198 subjects. Given the uncertainty regarding the parameters used to calculate the sample, an internal pilot study was conducted. The objectives of this internal pilot study were to obtain reliable estimate of parameters (standard deviation and design factor) to recalculate the sample size and to assess the adherence rate and reasons for non-adherence in children enrolled in the pilot study.

Methods

The first 30 subjects enrolled into the OptEC trial constituted the internal pilot study. The primary outcome of the OptEC trial is the Early Learning Composite (ELC). For estimation of the SD of the ELC, descriptive statistics of the 4 month follow-up ELC scores were assessed within each intervention group. The observed SD within each group was then pooled to obtain an estimated SD (S₂) of the ELC. Correlation (ρ) between the ELC measured at baseline and follow-up was assessed. Recalculation of the sample size was performed using analysis of covariance (ANCOVA) method which uses the design factor (1- ρ²). Adherence rate was calculated using a parent reported rate of missed doses of the study intervention.

Conclusion

The new estimate of the SD of the ELC was found to be 17.40 (S₂). The design factor was (1- ρ2) = 0.21. Using a significance level of 5 %, power of 80 %, S_{2 =} 17.40 and effect estimate (Δ) ranging from 6–8 points, the new sample size based on ANCOVA method ranged from 32–56 subjects (16–28 per group). Adherence ranged between 14 % and 100 % with 44 % of the children having an adherence rate ≥86 %. Information generated from our internal pilot study was used to update the design of the full and definitive trial, including recalculation of sample size, determination of the adequacy of adherence, and application of strategies to improve adherence.

Trial registration

ClinicalTrials.gov Identifier: NCT01481766 (date of registration: November 22, 2011).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0829-4) contains supplementary material, which is available to authorized users.

Iron+folic acid distribution and consumption through antenatal care: identifying barriers across countries

OBJECTIVE

The prevalence of maternal anaemia remains unacceptably high in developing countries. At the same time, the percentage of women who consume one or more Fe+folic acid (IFA) tablets during pregnancy remains persistently low. The objective of the present study was to identify where, within antenatal care (ANC) programmes, pregnant women falter in obtaining and consuming an ideal minimum of 180 IFA tablets.

DESIGN

Data from Demographic and Health Surveys were used to develop a schematic which identifies four sequential 'falter points' to consuming 180 IFA tablets: ANC attendance, IFA receipt or purchase, IFA consumption and the number of tablets consumed.

SETTING

Twenty-two countries with high burdens of undernutrition.

SUBJECTS

A sample of 162 958 women, 15 to 49 years of age, with a live birth in the past 5 years.

RESULTS

Across all countries, 83 % of all pregnant women had at least one ANC visit, 81 % of whom received IFA tablets. Of those receiving IFA tablets, 95 % consumed at least one. Overall adherence to the ideal supplementation regimen, however, was extremely low: only 8 % consumed 180 or more IFA tablets. There were only two countries in which the percentage of pregnant women consuming 180 or more tablets exceeded 30 %.

CONCLUSIONS

While most women receive and take some IFA tablets, few receive or take enough. The analysis identifies where ANC-based distribution of IFA falters in each country. It enables policy makers to design and prioritize follow-up activities to more precisely identify barriers, an essential next step to improving IFA distribution through ANC.

Iron supplement use in pregnancy - Are the right women taking the right amount?

OBJECTIVES

To examine the prevalence and determinants of iron supplement use and the amount of iron consumed from iron-containing supplements.

METHODS

A cross-sectional survey was performed in antenatal clinics in two tertiary hospitals in Sydney, Australia between January and March 2014.

RESULTS

Of 612 (91% response rate) pregnant women, 589 with complete data were analysed. Overall iron-containing supplement use was 88.0%, of which 70.1% was multivitamin (MV) only, 7.2% was iron-only and 22.2% was both. Use of iron-containing supplements was associated with increased gestational age, a diagnosis of anaemia or iron deficiency (ID) in the current pregnancy and pre-pregnancy use of an iron-containing supplement. Several risk factors for ID or anaemia such as non-red meat eating and previous miscarriage were not associated with current iron supplement use. About 65% of women diagnosed with ID, and 62.3% of women diagnosed with anaemia were taking an iron-only supplement, with or without a MV. The proportion of women consuming low (<30), preventative (30-99) and treatment (≥100) mg/day doses were 36.8%, 45.4%, and 17.8%, respectively. Only 46.7% of women diagnosed with ID were taking ≥100 mg/day iron from supplements, while 23.3% were taking <30 mg/day.

CONCLUSION

Women are consuming varying doses of iron and some high-risk women are taking inadequate doses of iron to prevent or treat ID or iron deficiency anaemia. Healthcare professionals are best positioned to advise women on iron supplement use in pregnancy and should educate women individually about the type and dose of supplement best suited to their needs.

Adherence to multiple micronutrient powder among young children in rural Bangladesh: a cross-sectional study

BACKGROUND

Multiple micronutrient powder (MMNP) can be sprinkled onto any semisolid food and can be given to young children to address iron deficiency anemia. The female community health volunteers of BRAC (an NGO) known as Shasthya Shebikas (SS) sell MMNP sachets during their regular household visits. Currently there are no data on adherence or real uptake of MMNP by children. The objective of the study was to assess adherence to MMNP and associated factors among children aged 6-59 months in rural Bangladesh.

METHODS

A cross sectional study was conducted in Saturia Sub-district among 78 children aged 6-59 months who were fed MMNP supplied by BRAC SS in the past 60 days. A one stage cluster sampling technique was used to select mothers with eligible children. Semi-structured questionnaire was used for interviews. A logistic regression model was developed to obtain adjusted odds ratios (AOR) with 95% CI.

RESULTS

Sample mean adherence was calculated to be 70%. In multivariate analysis, age of mother in years (AOR = 0.74, 95% CI: 0.61-0.88), households belonging to poorer (AOR = 0.01, 95% CI: 0.00-0.68), middle (AOR = 0.04, 95% CI: 0.00-0.35) and richer (AOR = 0.11, 95% CI: 0.01-0.84) wealth quintiles and mothers who prefer to feed flexibly (AOR = 0.03, 95% CI: 0.00-0.26) were significantly associated with high adherence. Further, for every one unit increase in visit by BRAC SS in the past 60 days, the odds of having high adherence significantly increased by 55% (AOR = 1.55, 95% CI: 1.09-2.20).

CONCLUSIONS

SS are the key to improving adherence through regular visits to households of MMNP users. However, expanding coverage beyond the vicinity of the SS's household is a challenge. Perception of families whose children have low adherence should be studied.

How can formative research inform the design of an iron-folic acid supplementation intervention starting in first trimester of pregnancy in Bangladesh?

Background

The study objective was to understand community preparedness for iron and folic acid (IFA) supplementation early in pregnancy and to inform the design of a large-scale trial of early introduction of IFA supplementation in rural Bangladesh.

Methods

66 in-depth interviews (pregnant women, husbands, and older women in the household), 20 key-informant interviews, 3 focus-group discussions (community health workers and adolescent female students), and observation of two community-based clinics were conducted.

Results

Most of the women who used IFA tablets during pregnancy reported better health and physical strength after taking them. Women perceived that IFA increased blood volume, leading to foetal nourishment and compensated for blood loss during delivery. However, a culturally informed perceived barrier was the belief that IFA supplementation will increase foetus size, leading to birth complications, hospitalisation, caesarean section and financial burden for the family. Community health workers (CHWs) of BRAC (a non-government organisation) were the main sources of IFA information and supplements, although knowledge of IFA tablets among women’s social networks also helped to make it acceptable. Pregnant women felt that they could start taking IFA during the first trimester of pregnancy if advised by the CHWs. Programme managers and healthcare providers expressed concern about starting IFA supplementation early.

Conclusion

Our study suggests that introduction of IFA supplementation early in pregnancy is feasible with support from CHWs. Promotion of IFA could benefit from efforts to include culturally sensitive reasons for usage; improvement of the CHW training modules; targeted home visits and counselling; and outreach to standardize messages.

Individual and facility-level determinants of iron and folic acid receipt and adequate consumption among pregnant women in rural Bihar, India

Background

In Bihar, India, high maternal anemia prevalence and low iron and folic acid supplement (IFA) receipt and consumption have continued over time despite universal IFA distribution and counseling during pregnancy.

Purpose

To examine individual and facility-level determinants of IFA receipt and consumption among pregnant women in rural Bihar, India.

Methods

Using District Level Household Survey (2007–08) data, multilevel modeling was conducted to examine the determinants of two outcomes: IFA receipt (any IFA receipt vs. none) and IFA consumption (≥90 days vs. <90 days). Individual-level and facility-level factors were included. Factor analysis was utilized to construct antenatal care (ANC) quality and health sub-center (HSC) capacity variables.

Results

Overall, 37% of women received any IFA during their last pregnancy. Of those, 24% consumed IFA for 90 or more days. Women were more likely to receive any IFA when they received additional ANC services and counseling, and attended ANC earlier and more frequently. Significant interactions were found between ANC quality factors (odds ratio (OR): 0.37, 95% confidence interval (CI): 0.25, 0.56) and between ANC services and ANC timing and frequency (OR: 0.68, 95% CI: 0.56, 0.82). No HSC factors were significantly associated with IFA receipt. Women were more likely to consume IFA for ≥90 days if they attended at least 4 ANC check-ups and received more ANC services. IFA supply at the HSC (OR: 1.37, 95% CI: 1.04, 1.82) was also significantly associated with IFA consumption.

Conclusions

Our findings indicate that individual and ANC factors (timing, frequency, and quality) play a key role in facilitating IFA receipt and consumption. Although HSC capacity factors were not found to influence our outcomes, significant variation at the facility level indicates unmeasured factors that could be important to address in future interventions.

That's why I take my ONS. Means-end chain as a novel approach to elucidate the personally relevant factors driving ONS consumption in nutritionally frail elderly users

Oral nutritional supplements (ONS) are a recommended form of nutritional intervention for older malnourished persons when a 'food first' approach and/or food fortification prove ineffective. The efficacy of ONS will depend on, amongst other factors, whether persons do, or do not, consume their prescribed amount. Factors influencing ONS consumption can be product, context, or person related. Whereas product and context have received some attention, little is known about the person factors driving ONS consumption. In addition, the relative importance of the product, context, and person factors to ONS consumption is not known. Using the means-end chain (MEC) method, the current study elucidated personally relevant factors (product, context, and person factors) related to ONS consumption in two groups of older nutritionally frail ONS users: community-dwelling persons and care home residents with mainly somatic disorders. To our knowledge, the current work is the first to apply the MEC method to study older nutritionally frail ONS users. Forty ONS users (n = 20 per group) were recruited via healthcare professionals. The level of frailty was assessed using the FRAIL scale. Both groups were interviewed for 30 to 45 minutes using the soft laddering technique. The laddering data were analysed using LadderUX software™. The MEC method appeared to work well in both groups. The majority of the participants took ONS on their doctor's or dietician's prescription as they trusted their advice. The community-dwelling group took ONS to prolong their independence, whereas the care home group reported values that related more to small improvements in quality of life. In addition, care home residents perceived themselves as dependent on their caregiver for their ONS arrangements, whereas this dependence was not reported by community-dwelling persons. Key insights from this work will enable doctors and dieticians to customize their nutritional interventions to ONS users' personal needs and thus positively impact health outcomes.

Medication adherence in patients with Parkinson's disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder, after Alzheimer's disease, affecting the elderly worldwide. Current therapy for PD is largely based on prescription of drugs that act as either dopamine precursors, dopamine agonists or agents that inhibit key enzymes in the dopamine catabolic pathways. Most of these drugs are administered in tablet or capsule form and can involve multiple daily doses in complex dosing regimens, which contributes to sub-optimal compliance amongst patients. There is evidence to suggest that non-compliance with medications results in perceived poor response to therapy and may ultimately increase direct and indirect health care costs. Medication compliance in PD assumes a particularly important role, given that PD is a progressive, debilitating condition, and once medication is instituted for ameliorating the symptoms of PD, it is lifelong. We included nine research studies in our review of the medical literature, which report the prevalence of significant medication non-compliance in PD, using standard definitions, varies between 10 and 67%. This variation partly reflects differences in defining what clinically significant medication adherence is, the methods used to estimate the scale of the problem and the underlying population heterogeneity. Nevertheless, medication adherence is related to health costs and to the quality of life of patients affected by PD and, indirectly, their carers. Educating patients and their carers is one method of improving patient adherence to therapy. Simplifying drug regimens can also aid in this effort.

Survey of women's perceptions of information provided in the prevention or treatment of iron deficiency anaemia in an Australian tertiary obstetric hospital

BACKGROUND

There is limited literature to understand the perceptions of Australian women regarding the information provided by healthcare professionals relating to the prevention and treatment of iron deficiency anaemia in pregnancy.

AIM

To establish an insight into the key themes and trends within a tertiary obstetric hospital related to the provision of dietary advice and use of iron supplements in pregnancy.

METHODS

A prospective patient survey of pregnant women and women up to 4 weeks postnatal attending hospital.

FINDINGS

Of the 110 women who participated, 73.6% were provided with information on iron rich foods and 67% made dietary changes. Eighty percent of women were advised to take oral iron and 65.5% of women were taking it at the time of the survey. In women who had independently ceased oral iron, 41.7% failed to inform their healthcare professional. In the women who did inform their healthcare professional 89.5% received advice to help overcome the reason that led to cessation. The main causes included forgetfulness and side effects. Women were less likely to require intravenous iron if oral iron was commenced early.

CONCLUSIONS

Compliance with recommended oral iron is variable within a population of pregnant women. Women are provided with information on a range of issues relating to the prevention and treatment of iron deficiency anaemia; yet there is a disparity between the information provided and the resulting action. Further research should focus on targeted measures to improve understanding and compliance with treatment from the both women's and health professionals perspective.

Perceptions of antenatal iron-folic acid supplements in urban and rural Pakistan: a qualitative study

Background

In Pakistan, 51% of women are anaemic in pregnancy yet only 44% of women use antenatal iron-folic acid (IFA) supplements. Little information exits on the perception and barriers to the use of IFA supplements during pregnancy in Pakistan. The aim of the study was to understand women and healthcare providers’ perceptions, and to investigate the cultural and behavioural factors influencing the use of antenatal IFA supplements in rural and urban settings of Pakistan.

Methods

We conducted 10 focus group discussions with mothers, 10 in-depth interviews with currently pregnant women, 6 in-depth interviews with Lady Health Workers and 4 in-depth interviews with doctors providing antenatal care services. The study was conducted in two districts of Pakistan - district Swabi and Islamabad for rural and urban samples, respectively. Data was collected between August and November 2012.

Results

The majority of women were aware of the perceived benefits of antenatal IFA supplements. However, the rural women had more limited information about the benefits of IFA supplements than the urban women. The facilitating factors for the women’s use of supplements were: they had knowledge of benefits; they had trust in the healthcare providers; the supplements were available; they had the financial capacity to buy them; they felt better after taking these supplements; and they received support from family members. The barriers to the women’s use of supplements were: they forgot to take them; the non-availability of supplements; their limited financial capacity to buy them; the lack of antenatal care services; family members not allowing use of the supplements; not knowing about the benefits or no education; fear or experience of side effects; considering them as contraceptives; and felt better thus stopped.

Conclusion

The coverage of antenatal IFA supplementation can be improved by reducing the barriers related to the use of antenatal IFA supplementation in Pakistan. Interventions focused on providing adequate awareness, good quality counselling, reminder messages, availability of free supplements throughout pregnancy and reducing the side effects should be developed and implemented.

Factors associated with non-use of antenatal iron and folic acid supplements among Pakistani women: a cross sectional household survey

Background

World Health Organization recommends a standard daily oral dose of iron and folic acid (IFA) supplements throughout pregnancy to begin as early as possible. The aim of the present study was to determine the prevalence of use of antenatal IFA supplements, and the socio-demographic factors associated with the non-use of antenatal IFA supplements from 14 selected districts in Pakistan.

Methods

Data was derived from a cross sectional household survey conducted in 14 project districts across Pakistan. Trained female field workers conducted interviews with married women of reproductive age from December 2011 to March 2012. Women with the most recent live births in the preceding five years of the survey were selected for this study. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Multivariate logistic regression models were constructed to identify the independent factors associated with the non-use of antenatal IFA supplements.

Results

Of 6,266 women interviewed, 2,400 (38.3%, 95% CI, 36.6%, 40.1%) reported taking IFA supplements during their last pregnancy. Among IFA users, the most common source of supplements was doctors (49.4%) followed by community health workers (40.3%). The mean (±SE) number of supplements used was 76.9 (±51.6), and the mean (±SE) month of pregnancy at initiation of supplementation was 5.3 (±1.7) months. Socio-demographic factors significantly associated with the non-use of antenatal IFA supplements were living in Dera Ghazi Khan district (AdjOR: 1.72), maternal age 45 years and above (AdjOR: 1.97), no maternal education (AdjOR: 2.36), no paternal education (AdjOR: 1.58), belonging to the lowest household wealth index quartile (AdjOR: 1.47), and no use of antenatal care (ANC) services (AdjOR: 13.39).

Conclusions

The coverage of antenatal IFA supplements is very low in the surveyed districts of Pakistan, and the lack of parental education, older aged women, belonging to poorest households, residence in Dera Ghazi Khan district and no use of ANC services were all significantly associated with non-use of these supplements. These findings highlight the urgent need to develop interventions targeting all pregnant women by improving ANC coverage to increase the use of antenatal IFA supplements in Pakistan.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2393-14-305) contains supplementary material, which is available to authorized users.

Coverage, compliance and factors associated with utilization of iron supplementation during pregnancy in eight rural districts of Ethiopia: a cross-sectional study

Background

Despite the efforts to reduce iron deficiency during pregnancy, information on the coverage and factors associated with utilization of iron supplements is lacking. The study is intended to assess the coverage, compliance and factors associated with the use of prenatal iron supplements in eight rural districts of Ethiopia.

Methods

The study comprised two independent surveys conducted among pregnant women (n = 414) and women who gave birth in the preceding year of the survey (n = 1573). In both cases, respondents were selected using multistage sampling technique and data were collected via structured questionnaire. Predictors of iron supplement utilization (ranked categories of number of prenatal supplements taken) were identified using ordinal logistic regression. The outputs of the analysis are given using adjusted Odds Ratio (OR) with 95% Confidence Interval (CI).

Results

Among women who gave birth in the preceding year, 35.4% (95% CI: 31.3-39.5) were given/prescribed prenatal iron supplement during the index pregnancy and only 3.5% were supplemented for the recommended 91 or more days. Compared to women who had 4 or more ANC visits, those with 0, 1, 2 and 3 visits had 0.04, 0.33, 0.50 and 0.60 times less odds of iron supplement utilization, respectively. Women lacking comprehensive knowledge of anemia (OR = 0. 75 (95% CI: 0.57-0.97)) and those who weren’t informed about the importance of iron supplementation during the pregnancy (OR = 0. 05 (95% CI: 0.04-0.07)) had significantly lower utilization. On the other hand, in pregnant women the prevalence of anemia was 33.2%. Among pregnant women who were given/prescribed supplements, the average level of compliance was 74.9% and about 25.1% had less than 70% adherence. The leading reported reasons for non-adherence were side-effects (63.3%) and forgetfulness (16.7%).

Conclusion

Promoting early and frequent ANC, enhancing the quality of ANC counseling and promoting the knowledge of women on anemia are essential strategies for improving the utilization of iron supplements.

A rapid, simple questionnaire to assess gastrointestinal symptoms after oral ferrous sulphate supplementation

BACKGROUND

Oral iron supplementation is often associated with rapid onset of gastrointestinal side-effects. The aim of this study was to develop and trial a short, simple questionnaire to capture these early side-effects and to determine which symptoms are more discriminating.

METHODS

The study was a double-blind placebo-controlled randomized parallel trial with one week treatment followed by one week wash-out. Subjects were randomized into two treatment groups (n = 10/group) to receive either ferrous sulphate (200 mg capsules containing 65 mg of iron) or placebo, both to be taken at mealtimes twice daily during the treatment period. Subjects completed the questionnaires daily for 14 days. The questionnaire included gastrointestinal symptoms commonly reported to be associated with the oral intake of ferrous iron salts (i.e. nausea, vomiting, heartburn, abdominal pain, diarrhoea, and constipation).

RESULTS

Seventy five per cent of participants reporting the presence of one or more symptoms in the first week of the study were in the ferrous sulphate group. In the second week of the study (i.e. wash-out), 67% of the participants reporting one or more symptom(s) were in the ferrous sulphate group. In the first week of the study (treatment) the number of symptoms reported by participants in the ferrous sulphate group (mean ± SEM = 6.7 ± 1.7) was significantly higher than that for participants in the placebo group (1.2 ± 0.5) (p = 0.01). In the second week of the study (wash-out) the number of symptoms reported by participants in the ferrous sulphate group (4.6 ± 2.0) appeared higher than for participants in the placebo group (1.0 ± 0.7) although this did not reach significance (p = 0.12). Events for which the gastrointestinal symptom questionnaire was most discriminatory between ferrous sulphate and placebo groups were: heartburn, abdominal pain and the presence of black stools (all p ≤ 0.03).

CONCLUSIONS

A tool for the detection of commonly-occurring side effects should not require large study numbers to be effective. With just 10 subjects per group (iron or placebo), this simple questionnaire measures gastrointestinal side-effects associated with oral iron (ferrous sulphate) supplementation, and would be appropriate for use in intervention studies or clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02146053 (21/05/2014).

Comparison of two doses of elemental iron in the treatment of latent iron deficiency: efficacy, side effects and blinding capabilities

Adherence to iron supplementation can be compromised due to side effects, and these limit blinding in studies of iron deficiency. No studies have reported an efficacious iron dose that allows participants to remain blinded. This pilot study aimed to determine a ferrous sulfate dose that improves iron stores, while minimising side effects and enabling blinding. A double-blinded RCT was conducted in 32 women (18-35 years): 24 with latent iron deficiency (serum ferritin < 20 µg/L) and 8 iron sufficient controls. Participants with latent iron deficiency were randomised to 60 mg or 80 mg elemental iron or to placebo, for 16 weeks. The iron sufficient control group took placebo. Treatment groups (60 mg n = 7 and 80 mg n = 6) had significantly higher ferritin change scores than placebo groups (iron deficient n = 5 and iron sufficient n = 6), F(1, 23) = 8.46, p ≤ 0.01. Of the 24 who completed the trial, 10 participants (77%) on iron reported side effects, compared with 5 (45%) on placebo, but there were no differences in side effects (p = 0.29), or compliance (p = 0.60) between iron groups. Nine (69%) participants on iron, and 11 (56%) on placebo correctly guessed their treatment allocation. Both iron doses were equally effective in normalising ferritin levels. Although reported side-effects were similar for both groups, a majority of participants correctly guessed their treatment group.

Patterns of compliance with prenatal iron supplementation among Peruvian women

Prenatal iron supplementation is recommended to control anaemia during pregnancy. Low compliance and side effects have been claimed as the main obstacles for adequate impact of the supplementation. As part of a double-blind supplementation study carried out in a hospital located in a shantytown in Lima, Peru, we monitored compliance throughout pregnancy and evaluated factors associated with variation in compliance over time. Overall, 985 pregnant women were enrolled in a supplementation study that was administered through their prenatal care from 10 to 24 weeks of gestation until 4 weeks postpartum. They received 60 mg iron and 250 µg folate with or without 15 mg zinc. Women had monthly care visits and were also visited weekly to query regarding compliance, overall health status, and potential positive and negative effects of supplement consumption. Median compliance was 79% (inter-quartile range: 65-89%) over pregnancy, and the median number of tablets consumed was 106 (81-133). Primpara had lower average compliance; positive health reports were associated with greater compliance, and negative reports were associated with lower compliance. There was no difference by type of supplement. Women with low initial compliance did achieve high compliance by the end of pregnancy, and women who reported forgetting to take the supplements did have lower compliance. Compliance was positively associated with haemoglobin concentration at the end of pregnancy. In conclusion, women comply highly with prenatal supplementation within a prenatal care model in which supplies are maintained and reinforcing messages are provided.

Compliance with iron-folic acid (IFA) therapy among pregnant women in an urban area of south India

BACKGROUND

Anaemia is highly prevalent among pregnant women and iron deficiency is the most important cause. Like many other countries, India has policies to give pregnant women iron supplements. Non-compliance is one important challenging factor in combating anaemia.

OBJECTIVE

To estimate the compliance for IFA tablets among pregnant women and to study the social factors influencing it.

METHODOLOGY

This study included 190 pregnant women seeking ante-natal care in tertiary health Centres in the Mangalore city in South India. After Institutional Ethics Committee (IEC) approval, data was collected by personal interview. Missing ≥2 doses consecutively was considered non-compliance. The data was analyzed using SPSS (Statistical Package for Social Sciences) version 11.5.

RESULTS

The mean age of the study population was 25.8 years (SD: 4.1). Majority of the subjects consumed mixed diet and 72.1% belonged to lower socioeconomic status. Overall, compliance with IFA tablets was 64.7%. Compliance increased with the increase in age, birth order and single daily dose. Forgetfulness and both perceived as well as experienced side effects of IFA therapy were the important factors for non-compliance.

CONCLUSION

There was a moderate level of Compliance towards IFA tablets with key social and demographic factors playing important role.

A nano-disperse ferritin-core mimetic that efficiently corrects anemia without luminal iron redox activity

The 2-5 nm Fe(III) oxo-hydroxide core of ferritin is less ordered and readily bioavailable compared to its pure synthetic analogue, ferrihydrite. We report the facile synthesis of tartrate-modified, nano-disperse ferrihydrite of small primary particle size, but with enlarged or strained lattice structure (~ 2.7 Å for the main Bragg peak versus 2.6 Å for synthetic ferrihydrite). Analysis indicated that co-precipitation conditions can be achieved for tartrate inclusion into the developing ferrihydrite particles, retarding both growth and crystallization and favoring stabilization of the cross-linked polymeric structure. In murine models, gastrointestinal uptake was independent of luminal Fe(III) reduction to Fe(II) and, yet, absorption was equivalent to that of ferrous sulphate, efficiently correcting the induced anemia. This process may model dietary Fe(III) absorption and potentially provide a side effect-free form of cheap supplemental iron.

From the Clinical Editor

Small size tartrate-modified, nano-disperse ferrihydrite was used for efficient gastrointestinal delivery of soluble Fe(III) without the risk for free radical generation in murine models. This method may provide a potentially side effect-free form iron supplementation.

Improvements in iron status and cognitive function in young women consuming beef or non-beef lunches

Iron status is associated with cognitive performance and intervention trials show that iron supplementation improves mental function in iron-deficient adults. However, no studies have tested the efficacy of naturally iron-rich food in this context. This investigation measured the hematologic and cognitive responses to moderate beef consumption in young women. Participants (n=43; age 21.1±0.4 years) were randomly assigned to a beef or non-beef protein lunch group [3-oz (85 g), 3 times weekly] for 16 weeks. Blood was sampled at baseline, and weeks 8 and 16, and cognitive performance was measured at baseline and week 16. Body iron increased in both lunch groups (p<0.0001), with greater improvement demonstrated in women with lower baseline body iron (p<0.0001). Body iron had significant beneficial effects on spatial working memory and planning speed (p<0.05), and ferritin responders (n=17) vs. non-responders (n=26) showed significantly greater improvements in planning speed, spatial working memory strategy, and attention (p<0.05). Lunch group had neither significant interactions with iron status nor consistent main effects on test performance. These findings support a relationship between iron status and cognition, but do not show a particular benefit of beef over non-beef protein consumption on either measure in young women.

"How often? How much? Where from?" knowledge, attitudes, and practices of mothers and health workers to iron supplementation program for children under five in rural Tamil Nadu, south India

Iron deficiency anemia (IDA) affects 70% of under-5 children in India. The primary prevention strategy is regular iron supplementation. Little is known about what helps families adhere to daily iron supplementation. Our study explored the knowledge, attitudes, and practices of mothers and village health workers (VHWs) involved in a community health program in one hill district of Tamil Nadu. We conducted 30 semistructured interviews and 3 group discussions involving mothers, VHWs, and community stakeholders. Knowledge of IDA was widespread, yet no children were receiving the iron supplementation as recommended. The main determinants to adherence included the perception of its need, the ease of access, and the activity of VHWs. Preventive care requiring daily supplements is challenging. Our study suggests that increasing community awareness of mild anemia, simplifying dosage instructions, and further strengthening the supportive environment for VHWs would help in reducing the prevalence of IDA.

Unexplained chronic leukopenia treated with oral iron supplements

Case A 67-year-old woman known to have iron deficiency anemia and persistent unexplained chronic leukopenia was cared for by our medical center for about 16 years. During this period she was examined thoroughly and diagnosed to have chronic idiopathic neutropenia (also known as chronic benign neutropenia). Her iron deficiency was attributed to nutritional factors and she was non-compliant with her oral iron supplements. The patient fully received her iron supplement medication by nursing staff for two and a half months during an unexpected prolonged hospital stay after her suffering an acute ischemic cerebrovascular accident. An astonishing outcome was that in addition to having her iron deficiency anemia treated, her long-term unexplained neutropenia was also corrected. Conclusion Some patients diagnosed with chronic idiopathic neutropenia and clinically present as having unexplained chronic neutropenia might actually be suffering from a form of not yet described iron deficiency induced neutropenia.

Compliance with iron-folic acid (IFA) therapy among pregnant women in an urban area of south India

BACKGROUND

Anaemia is highly prevalent among pregnant women and iron deficiency is the most important cause. Like many other countries, India has policies to give pregnant women iron supplements. Non-compliance is one important challenging factor in combating anaemia.

OBJECTIVE

To estimate the compliance for IFA tablets among pregnant women and to study the social factors influencing it.

METHODOLOGY

This study included 190 pregnant women seeking ante-natal care in tertiary health centres in the Mangalore city in south India. After Institutional Ethics Committee (IEC) approval, data was collected by personal interview. Missing >2 doses consecutively was considered non-compliance. The data was analyzed using SPSS (Statistical Package for Social Sciences) version 11.5.

RESULTS

The mean age of the study population was 25.8 years (SD: 4.1). Most of the subjects consumed mixed diet and 72.1% belonged to lower socioeconomic status. Overall, compliance with IFA tablets was 64.7%. Compliance increased with the increase in age, birth order and single daily dose. Forgetfulness and both perceived as well as experienced side effects of IFA therapy were the important factors for non-compliance.

CONCLUSION

There was a moderate level of compliance towards IFA tablets with key social and demographic factors playing an important role.

Malabsorption anemia and iron supplement induced constipation in post-Roux-en-Y gastric bypass (RYGB) patients

PURPOSE

Over 250,000 bariatric surgical procedures for the management of morbid obesity are performed in the United States annually. The Roux-en-Y gastric bypass (RYGB) is an effective bariatric procedure because of its efficacy in achieving significant weight loss, low complication rates, and outcomes in reducing cardiovascular and all cause mortality. Because food bypasses the portion of the small intestine whereby micronutrients are normally absorbed, micronutrient deficiencies following surgery may lead to iron deficiency anemia. Iron deficiency anemia is estimated to occur in 6%-50% of post-RYGB patients. Consequently, the procedure requires lifelong behavioral change to ensure therapeutic iron supplementation.

DATA SOURCES

A nonsystematic literature search for clinical guidelines, review articles, and research was conducted.

CONCLUSIONS

Clinical recommendations include prophylactic iron supplementation with ferrous sulfate to prevent iron deficiency anemia. Ferrous sulfate is a well-established cause of constipation possibly resulting in low patient tolerability and subsequent low adherence rates.

CLINICAL IMPLICATIONS

Strategies for managing the side effects of iron supplementation including constipation may require a unique approach based on the anatomical and functional changes in the post-RYGB patient and the requirement for lifelong iron supplementation.

Compliance with pharmacotherapy and direct healthcare costs in patients with Parkinson's disease: a retrospective claims database analysis

BACKGROUND

Parkinson's disease (PD) is a progressive neurological disorder for which, at present, there is no cure. Current therapy is largely based on the use of dopamine agonists and dopamine replacement therapy, designed to control the signs and symptoms of the disease. The majority of current treatments are administered in tablet form and can involve multiple daily doses, which may contribute to sub-optimal compliance. Previous studies with small groups of patients suggest that non-compliance with treatment can result in poor response to therapy and may ultimately increase direct and indirect healthcare costs.

OBJECTIVE

To determine the extent of non-compliance within the general PD population in the USA as well as the patient characteristics and healthcare costs associated with compliance and non-compliance.

METHODS

A retrospective analysis from a managed care perspective was conducted using data from the USA PharMetrics patient-centric claims database. PharMetrics claims data were complete from 31 December 2005 to 31 December 2009. Patients were included if they had at least two diagnoses for PD between 31 December 2005 and 31 December 2008, were older than 18 years of age, were continuously enrolled for at least 12 months after the date of the most recent PD diagnosis, and had no missing or invalid data. The follow-up period was the most recent 12-month block of continuous enrollment that occurred between 2006 and 2009. Patients were required to have at least one PD-related prescription within the follow-up period. The medication possession ratio (MPR) was used to categorise patients as compliant or non-compliant. Direct all-cause annual healthcare costs for patients with PD were estimated for each patient, and regression analyses were conducted to determine predictors for non-compliance.

RESULTS

A total of 15,846 patients were included, of whom 46 % were considered to be non-compliant with their prescribed medication (MPR <0.8). Predictors of non-compliance included prescription of a medication administered in multiple daily doses (p < 0.0001), a period of <2 years since the initial PD diagnosis (p = 0.0002), a diagnosis of gastrointestinal disorder (p < 0.0001), and a diagnosis of depression (p < 0.0001). Non-compliance was also found to be related to age, with a lower odds of non-compliance in patients aged 41-80 years than in patients aged ≥81 years (p < 0.05). Although total drug mean costs were higher for compliant patients than non-compliant patients (driven mainly by the cost of PD-related medications), the mean costs associated with emergency room and inpatient visits were higher for patients non-compliant with their prescribed medication. Overall, the total all-cause annual healthcare mean cost was lower for compliant ($77,499) than for non-compliant patients ($84,949; p < 0.0001).

CONCLUSION

Non-compliance is prevalent within the general USA PD population and is associated with a recent PD diagnosis, certain comorbidities, and multiple daily treatment dosing. Non-compliance may increase the burden on the healthcare system because of greater resource usage compared with the compliant population. Treatments that require fewer daily doses may have the potential to improve compliance, which in turn could reduce the economic burden associated with PD.

A problemática da adesão na prevenção da anemia ferropriva e suplementação com sais de ferro no município de Viçosa (MG)

Foi analisada a apreensão das mães/responsáveis por lactentes suplementados com sulfato ferroso, sobre a anemia e suas consequências, por grau de adesão à suplementação. Pesquisa populacional, prospectiva e quanti-qualitativa. Selecionou-se crianças não anêmicas e que não estivessem recebendo suplementação. As mães/responsáveis foram orientadas a administrarem a suplementação profilática de ferro por seis meses e a adesão foi avaliada após o período. Dentre as 133 crianças elegíveis inicialmente para a pesquisa, foi possível reavaliar 90 pares crianças/responsáveis e realizaram-se entrevistas semiestruturadas com os responsáveis. Das crianças avaliadas, 56,7% apresentaram alta adesão e 43,3% baixa, sendo que 23,3% destas tinham interrompido a suplementação, sendo os motivos mais frequentes a ausência de orientação e apoio do serviço de saúde. Dentre as mães/responsáveis, um baixo percentual reconheceu o sulfato ferroso como forma de prevenção da anemia, e ambos os grupos demonstraram pouco conhecimento acerca da anemia, suas formas de prevenção e consequências à saúde da criança. Há necessidade de mais informação através de atividades de promoção e educação em saúde incluindo estratégias participativas, acompanhamento dos profissionais de saúde e avaliação da percepção dos indivíduos envolvidos na suplementação.

Relationship of maternal knowledge of anemia with maternal and child anemia and health-related behaviors targeted at anemia among families in Indonesia

Our specific aim was to characterize maternal knowledge of anemia and its relationship to maternal and child anemia and to behaviors related to anemia reduction. We examined the relationship between maternal knowledge of anemia and anemia in the mother and the youngest child, aged 6-59 months, in 7,913 families from urban slums and 37,874 families from rural areas of Indonesia. Knowledge of anemia was defined based upon the mother's ability to correctly name at least one symptom of anemia and at least one treatment or strategy for reducing anemia. Hemoglobin was measured in both the mother and the child. In urban and rural areas, respectively, 35.8 and 36.9% of mothers had knowledge of anemia, 28.7 and 25.1% of mothers were anemic (hemoglobin <12 g/dL), and 62.3 and 54.0% of children were anemic (hemoglobin <11 g/dL). Maternal knowledge of anemia was associated with child anemia in urban and rural areas, respectively (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.79, 1.02, P = 0.10; OR 0.93, 95% CI 0.87, 0.98, P = 0.01) in multivariate logistic regression models adjusting for potential confounders. There was no significant association between maternal knowledge of anemia and maternal anemia. Maternal knowledge of anemia was significantly associated with iron supplementation during pregnancy and child consumption of fortified milk. There was no association of maternal knowledge of anemia with child deworming. Maternal knowledge of anemia is associated with lower odds of anemia in children and with some health behaviors related to reducing anemia.

Antenatal iron/folic acid supplements, but not postnatal care, prevents neonatal deaths in Indonesia: analysis of Indonesia Demographic and Health Surveys 2002/2003-2007 (a retrospective cohort study)

OBJECTIVE

This study aimed to assess the contribution of postnatal services to the risk of neonatal mortality, and the relative contributions of antenatal iron/folic acid supplements and postnatal care in preventing neonatal mortality in Indonesia.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Data used in this study were the 2002-2007 Indonesia Demographic and Health Surveys, nationally representative surveys. The pooled data provided survival information of 26 591 most recent live-born infants within the 5-years prior to each interview.

PRIMARY OUTCOMES

Primary outcomes were early neonatal mortality, that is, deaths in the first week, and all neonatal mortality, that is, deaths in the first month of life. Exposures were antenatal iron/folic acid supplementation and postnatal care from days 1 to 7. Potential confounders were community, socio-economic status and birthing characteristics and perinatal healthcare. Cox regression was used to assess the association between study factors and neonatal mortality.

RESULTS

Postnatal care services were not associated with newborn survival. Postnatal care on days 1-7 after birth did not reduce neonatal death (HR=1.00, 95% CI 0.55 to 1.83, p=1.00) and early postnatal care on day 1 was associated with an increased risk of early neonatal death (HR=1.27, 95% CI 0.69 to 2.32, p=0.44) possibly reflecting referral of ill newborns. Early postnatal care on day 1 was not protective for neonatal deaths on days 2-7 whether provided by doctors (HR 3.61, 95% CI 1.54 to 8.45, p<0.01), or by midwives or nurses (HR 1.38, 95% CI 0.53 to 3.57, p=0.512). In mothers who took iron/folic acid supplements during pregnancy, the risk of early neonatal death was reduced by 51% (HR=0.49, 95% CI 0.30 to 0.79, p<0.01).

CONCLUSIONS

We found no protective effect of postnatal care against neonatal deaths in Indonesia. However, important reductions in the risk of neonatal death were found for women who reported use of antenatal iron/folic acid supplements during pregnancy.

Relative efficacy of micronutrient powders versus iron-folic acid tablets in controlling anemia in women in the second trimester of pregnancy

BACKGROUND

Iron deficiency is a major cause of anemia and the most prevalent nutrient deficiency among pregnant women in developing countries. The use of iron and folic acid supplements to treat and prevent iron-deficiency anemia has limited effectiveness, mainly due to poor adherence. Home fortification with a micronutrient powder for pregnant women may be an effective and acceptable alternative to traditional drug models.

OBJECTIVE

To determine whether home fortification with micronutrient powders is at least as efficacious as iron and folic acid tablets for improving hemoglobin concentration in pregnant women.

METHODS

A cluster-randomized noninferiority trial was conducted in the rural subdistrict of Kaliganj in central Bangladesh. Pregnant women (gestational age 14-22 weeks, n=478), were recruited from 42 community-based Antenatal Care Centres. Each centre was randomly allocated to receive either a micronutrient powder (containing iron,folic acid, vitamin C, and zinc) or iron and folic acid tablets. Changes in hemoglobin from baseline were compared across groups using a linear mixed-effects regression model.

RESULTS

At enrolment, the overall prevalence of anemia was 45% (n = 213/478). After the intervention period, the mean hemoglobin concentrations among women receiving the micronutrient powder were not inferior to those among women receiving tablets (109.5 ± 12.9 vs. 112.0 ± 11.2 g/L; 95% CI, -0.757 to 5.716). Adherence to the micronutrient powder was lower than adherence to tablets (57.5 ± 22.5% vs. 76.0 ± 13.7%; 95% CI, -22.39 to -12.94); however, in both groups, increased adherence was positively correlated with hemoglobin concentration.

CONCLUSIONS

The micronutrient powder was at least as efficacious as the iron and folic acid tablets in controlling moderate to severe anemia during pregnancy.

Efficacy of oral iron therapy in improving the developmental outcome of pre-school children with non-anaemic iron deficiency: a systematic review

OBJECTIVE

To systematically review the efficacy and safety of oral Fe therapy in pre-school children (1–5 years) with non-anaemic Fe deficiency, determined by children’s developmental and haematological status and the incidence of reported side-effects.

DESIGN

A random-effects model was used to show mean differences with 95% confidence intervals of developmental and haematological scores between Fe-treated and non-treated groups.

SETTING

MEDLINE, EMBASE, Cochrane library and bibliographies of identified articles were searched up to September 2011. Randomized and observational studies were assessed by two reviewers independently. Quality of the trials was assessed on the basis of concealment of allocation, method of randomization, masking of outcome assessment and completeness of follow-up.

SUBJECTS

From the titles of 743 articles, full text review was completed on forty-six and two randomized trials of acceptable quality met the inclusion criteria. The two trials included a total of sixty-nine children.

RESULTS

One study showed a statistically significant difference in the post-treatment Mental Developmental Index score among children who received oral Fe therapy v. no therapy (mean difference56?3, 95% CI 1?5, 11?0, P value not provided). Both studies showed significant improvement in serum ferritin level (mg/l: mean difference551? 1, 95% CI 33?6, 68?6, P,0?01 and mean difference517?1, 95% CI 7?5, 26?6, P value not provided, respectively) in children who received Fe therapy.

CONCLUSIONS

Evidence is insufficient to recommend oral Fe therapy to children with non-anaemic Fe deficiency. There is urgent need of conducting adequately powered, randomized trials examining the efficacy of oral Fe therapy in pre-school children with non-anaemic Fe deficiency.

Intermittent oral iron supplementation during pregnancy

BACKGROUND

Anaemia is a frequent condition during pregnancy, particularly among women from developing countries who have insufficient iron intake to meet increased iron needs of both the mother and the fetus.Traditionally, gestational anaemia has been prevented with the provision of daily iron supplements throughout pregnancy, but adherence to this regimen due to side effects, interrupted supply of the supplements, and concerns about safety among women with an adequate iron intake, have limited the use of this intervention. Intermittent (i.e. one, two or three times a week on non-consecutive days) supplementation with iron alone or in combination with folic acid or other vitamins and minerals has recently been proposed as an alternative to daily supplementation.

OBJECTIVES

To assess the benefits and harms of intermittent supplementation with iron alone or in combination with folic acid or other vitamins and minerals to pregnant women on neonatal and pregnancy outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 March 2012). We also searched the WHO International Clinical Trials Registry Platform (ICTRP) for ongoing studies and contacted relevant organisations for the identification of ongoing and unpublished studies (23 March 2012).

SELECTION CRITERIA

Randomised or quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of trials using standard Cochrane criteria. Two review authors independently assessed trial eligibility, extracted data and conducted checks for accuracy.

MAIN RESULTS

This review includes 21 trials from 13 different countries, but only 18 trials (with 4072 women) reported on our outcomes of interest and contributed data to the review. All of these studies compared daily versus intermittent iron supplementation.Three studies provided iron alone, 12 iron+folic acid and three more iron plus multiple vitamins and minerals. Their methodological quality was mixed and most had high levels of attrition. Overall, there was no clear evidence of differences between groups for infant primary outcomes: low birthweight (average risk ratio (RR) 0.96; 95% confidence interval (CI) 0.61 to 1.52, seven studies), infant birthweight (mean difference MD -8.62 g; 95% CI -52.76 g to 35.52 g, eight studies), premature birth (average RR 1.82; 95% CI 0.75 to 4.40, four studies). None of the studies reported neonatal deaths or congenital anomalies.For maternal outcomes, there was no clear evidence of differences between groups for anaemia at term (average RR 1.22; 95% CI 0.84 to 1.80, four studies) and women receiving intermittent supplementation had less side effects (average RR 0.56; 95% CI 0.37 to 0.84, 11 studies) than those receiving daily supplements. Women receiving intermittent supplements were also at lower risk of having high haemoglobin (Hb) concentrations (greater than 130 g/L) during the second or third trimester of pregnancy (average RR 0.48; 95% CI 0.35 to 0.67, 13 studies). There were no significant differences in iron-deficiency anaemia between women receiving intermittent or daily iron+folic acid supplementation (average RR 0.71; 95% CI 0.08 to 6.63, 1 study). There were no maternal deaths (six studies) or women with severe anaemia in pregnancy (six studies). None of the studies reported on iron deficiency at term or infections during pregnancy.Where sufficient data were available for primary outcomes, we set up subgroups to look for possible differences between studies in terms of earlier or later supplementation; women's anaemia status at the start of supplementation; higher and lower weekly doses of iron; and the malarial status of the region in which the trials were conducted. There was no clear effect of these variables on the results of the review.

AUTHORS' CONCLUSIONS

The present systematic review is the most comprehensive summary of the evidence assessing the benefits and harms of intermittent iron supplementation regimens in pregnant women on haematological and pregnancy outcomes. The findings suggest that intermittent iron+folic acid regimens produce similar maternal and infant outcomes at birth as daily supplementation but are associated with fewer side effects. Women receiving daily supplements had increased risk of developing high levels of Hb in mid and late pregnancy but were less likely to present mild anaemia near term. Although the evidence is limited and the quality of the trials was low or very low, intermittent may be a feasible alternative to daily iron supplementation among those pregnant women who are not anaemic and have adequate antenatal care.