Compliance to Iron-Folic Acid Supplementation and Its Association with the Number of ANC Visits in Ethiopia: Systematic Review and Meta-Analysis

Individual and contextual-level factors associated with iron-folic acid supplement intake during pregnancy in Ethiopia: a multi-level analysis

BACKGROUND

Anemia is still one of the major public health problems in many developing countries including Ethiopia. Thus, this study aimed to assess individual and contextual-level factors associated with iron-folic acid supplement intake during pregnancy in Ethiopia.

METHODS

A secondary analysis was done on the 2019 mini-Ethiopian Demographic and Health Survey (EDHS) dataset. A total of 3,927 pregnant women who gave birth five years before the survey were included in the analysis. Multi-level mixed-effect logistic regression analysis was done by STATA/SE version 14.0 to identify individual and contextual-level factors. Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was used to show the strength and direction of the association. The level of statistical significance was declared at a P value less than 0.05.

RESULTS

Those primary educated [AOR = 1.83, 95% CI: (1.24, 2.74)], secondary educated [AOR = 2.75, 95% CI: (1.57, 4.824)], women who had greater than 5 living children [AOR = 2.02, 95% CI: (1.25, 3.27)], women who had ANC visit [AOR = 21.26, 95% CI: (13.56, 33.32)] and women who lived in a cluster with high proportion of women had ANC visit [AOR = 1.72, 95% CI: (1.17, 2.54)] and women who lived in Somali [AOR = 0.44 0.73, 95% CI: (0.22, 0.87)] were significantly associated with iron-folic acid intake during pregnancy.

CONCLUSIONS

Both individual and contextual-level factors were significantly associated with iron-folic acid intake during pregnancy. From individual-level factors: education status of women, the total numbers of living children, and ANC follow-up are significant and from contextual-level factors: region and living in a high proportion of women who had ANC follow-up were found to have a statistically significant association. Promoting women's education and maternal health services like ANC and intervention targeting the Somali region would be the recalled area of the government.

Poor adherence to iron-folic acid supplementation and associated factors among pregnant women who had at least four antenatal care in Ethiopia. A community-based cross-sectional study

Background

In developing countries, including Ethiopia, maternal mortality is a major public health concern. The Ethiopian Demographic Health Survey (EDHS) reported that the maternal mortality ratio (MMR) was 420 per 100,000 live births in 2016. Iron-folic acid supplementation (IFAS) is a key intervention to reduce these deaths. Therefore, this study aimed to assess the magnitude of poor adherence to IFAS and associated factors among pregnant women who had at least four antenatal care in Ethiopia.

Methods

Secondary data analysis was used using 2016 Ethiopian Demographic and Health Survey (EDHS). We analyzed the data using Stata version 14. To identify factors associated with poor adherence to IFAS, a multilevel mixed-effect logistic regression model was fitted. Variables with a p < 0.05 in the multilevel mixed-effect logistic regression model were declared as significant factors associated with poor adherence to IFAS.

Result

The magnitude of poor adherence to IFAS was 82.87% (95% CI: 80.96-84.65). Women education; primary [adjusted odds ratio (AOR) = 0.48; 95% CI: 0.31-0.75] and secondary (AOR = 0.52; 95% CI: 0.29-0.96), husband education; primary (AOR = 0.56; 95% CI: 0.36-0.86) and secondary (AOR = 0.51; 95% CI: 0.29-0.95), and community media exposure (AOR = 0.47; 95% CI: 0.27-0.79) were significantly associated with poor adherence to IFAS.

Conclusion

In the current study, more than eight out of ten pregnant women who had at least four antenatal care had poor adherence to IFAS. Thus, promoting maternal and husband education and establishing community media with a priority on iron-folic acid supplementation and health-related programs are essential strategies to reduce poor adherence to IFAS.

Utilization and compliance with iron supplementation and predictors among pregnant women in Southeast Ethiopia

Anemia is predicted to affect 38% (32 million) of pregnant women worldwide. However, evidence for utilization and compliance with iron supplementation and predictors during pregnancy in low-income countries, including Ethiopia, is sparse and inconclusive. Therefore, we aimed to assess utilization and compliance with iron supplementation and predictors among pregnant women in Robe Town, Southeast Ethiopia. A community-based cross-sectional study was employed among randomly selected 445 pregnant women attending antenatal care at health facilities from May to July 2015. A systematic random sampling was used to select respondents. Data were collected using a pre-tested, interviewer-administered, structured questionnaire. Bivariable and multivariable logistic regression analyses were conducted to identify predictors of compliance with iron supplementation. An odds ratio, along with a 95% confidence interval (CI), was used to estimate the strength of the association. In this study, 54% [95% CI (49.4, 58.4%)], 45.2% [95% CI (40.9, 49.4%)], 4.3% [95% CI (2.5, 6.3%)], and 2.2% [95% CI (1.1, 3.6%)] of women received iron supplements during their first, second, third, and fourth antenatal care visits, respectively. The level of compliance with iron supplementation was 92.4% [95% CI (89.9, 94.6%)]. Having a formal education (AOR = 4.45, 95% CI 1.41, 13.99), being in the high wealth quintile (AOR = 0.18, 95% CI 0.05, 0.68), medium wealth quintile [(AOR = 0.33, 95% CI (0.11, 0.98)], receiving iron supplements for free (AOR = 3.77, 95% CI 1.33, 10.69), not experiencing discomfort related to iron supplements intake (AOR = 2.94, 95% CI 1.17, 7.39), having comprehensive knowledge about anemia (AOR = 2.62, 95% CI 1.02, 6.70), being knowledgeable about iron supplements (AOR = 3.30, 95% CI 1.12, 9.76), having information about importance of iron supplementation during pregnancy (AOR = 2.86; 95% CI 1.04, 7.87), and ever being visited by urban health extension workers (AOR = 0.31; 95% CI 0.12, 0.83) was significantly associated with compliance with iron supplementation during pregnancy. The utilization of iron supplementation during pregnancy was low, with relatively high compliance with the supplements. Thus, comprehensive nutrition education and free provision of iron supplementation are crucial tools to increase utilization and compliance with iron supplementation during pregnancy. Further research with a strong study design using golden standard methods is warranted.

Effectiveness of Health Information Package Program on Knowledge and Compliance among Pregnant Women with Anemia: A Randomized Controlled Trial

Despite the availability of iron supplements during pregnancy for all pregnant women receiving antenatal care in Saudi Arabia, anemia remains to be a global public health concern leading to adverse maternal, fetal, and neonatal effects. We aimed to evaluate the effectiveness of the Health Information Package Program on the knowledge anemic pregnant women had about anemia, their compliance with iron and folic acid supplementation, and their hemoglobin levels. A single-blind randomized controlled trial was carried out in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines between January and May 2021. Pregnant women (n = 196) aged 18–45 years old and diagnosed with anemia during the first trimester of their pregnancy were randomly assigned into two groups: the intervention group (Health Information Package Program plus routine care, n = 98) and the control group (routine care only, n = 98). Knowledge, the ability to select appropriate food, and hemoglobin levels were assessed at baseline and after three months, while compliance with iron and folic acid supplementation was also measured at the end of three months. This study indicated that the post-education mean knowledge score, food selection ability score, compliance rate, and hemoglobin level were significantly higher for the intervention group than for the control group. The Health Information Package Program with regular follow-ups using the WhatsApp platform was an effective educational intervention for anemic pregnant women.

Factors Associated With Uptake of Iron Supplement During Pregnancy Among Women of Reproductive Age in Tanzania: an Analysis of Data From the 2015 to 2016 Tanzania Demographic and Health Survey and Malaria Indicators Survey

Background: Pregnant women are vulnerable to iron deficiency due to the fact that more iron is needed primarily to supply the growing fetus and placenta and to increase the maternal red cell mass. Little is known on the factors associated with uptake of iron supplement during pregnancy.

Methods: The study used data from the 2015 to 2016 Tanzania Demographic and Health Survey and Malaria Indicators Survey. A total of 6,924 women of active reproductive age from 15 to 49 were included in the analysis. Both univariate and multiple regression analyses were used to determine factors associated with uptake of iron supplement during pregnancy.

Results: Majority of the interviewed women 5,648 (81.6%) always took iron supplement during pregnancy, while a total of 1,276 (18.4%) women never took iron supplement during pregnancy. After controlling for confounders, the predictors for uptake of iron supplement during pregnancy were early antenatal booking (adjusted odds ratio, AOR = 1.603 at 95% CI = 1.362–1.887, p < 0.001); rural residence (AOR = 0.711 at 95% CI = 0.159–0.526, p = 0.007); wealth index [rich (AOR = 1.188 at 95% CI = 0.986–1.432, p = 0.07)]—poor was the reference population; level of education [primary education (AOR = 1.187 at 95% CI = 1.013–1.391, p = 0.034)]—no formal education was the reference population; parity [para 2 to 4 (AOR = 0.807 at 95% CI = 0.668–0.974, p = 0.026), para 5 and above (AOR = 0.75 at 95% CI = 0.592–0.95, p = 0.017)], para 1 was the reference population; zones [mainland rural (AOR = 0.593 at 95% CI = 0.389–0.905, p = 0.015) and Unguja Island AOR = 0.63 at 95% CI = 0.431–0.92, p = 0.017]—mainland urban was the reference population; and current working status [working (AOR = 0.807 at 95% CI = 0.687–0.949, p = 0.009)].

Conclusion: The study revealed that, despite free access to iron supplement during pregnancy, there are women who fail to access the supplement at least once throughout the pregnancy. The likelihood to fail to access iron supplement during pregnancy was common among pregnant women who initiated antenatal visits late, were from poor families, had no formal education, reside in rural settings, had high parity, were from mainland rural, and were in working status. Interventional studies are recommended in order to come up with effective strategies to increase the uptake of iron supplement during pregnancy.

Interventions to increase adherence to micronutrient supplementation during pregnancy: a systematic review

Prenatal micronutrient supplements are cost‐effective in reducing nutritional deficiencies and adverse pregnancy and birth outcomes. However, poor adherence remains a potential barrier to the successful implementation of these supplementation programs. This systematic review assessed the effectiveness of interventions designed to increase adherence to prenatal micronutrient supplementation. Following the Cochrane Collaboration Methodology, literature searches were conducted in six electronic databases and gray literature (on July 24, 2020), and abstract screening, data extraction, and risk of bias assessment were conducted independently by two reviewers. We included 22 studies. Interventions that resulted in increased adherence were most of the education‐based strategies, consumption monitoring by volunteer health workers or family members, SMS reminders, free provision of supplements, a multicomponent intervention with community mobilization, and a participatory action research intervention. In several studies, increased adherence was accompanied by beneficial effects on pregnancy and birth outcomes. Given the heterogeneity of study designs and methods used to define and measure adherence, a meta‐analysis was not appropriate. We identified several potentially effective strategies to improve supplementation adherence, which may need to be adapted to specific contexts when considered for program implementation. However, additional high‐quality studies are critically needed to effectively guide policies and programs.