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Antenatal care and mothers’ education improved iron-folic acid adherence at Denbiya district health centers, Northwest Ethiopia: using pills count method

Archives of Public Health201977:30

https://doi.org/10.1186/s13690-019-0356-y

  • Received: 1 December 2018
  • Accepted: 21 May 2019
  • Published:
Open Peer Review reports

Abstract

Background

Anemia is the leading public health problem among pregnant women worldwide. Iron-Folic Acid (IFA) supplementation is the strategy to control pregnancy induced anemia, but its adherence status was not well studied.

Objective

The aim of this study was to assess the prevalence of IFA adherence and associated factors among pregnant women attending antenatal care at Denbiya district health centers.

Methods

Cross -sectional study design was conducted in Denbiya district health centers from April 2 to May 27, 2016. A total of 395 study participants were enrolled in the study. Systematic random sampling was used to select study participants. Data were collected using the interviewer-administered technique. Adherence to IFA supplementation was assessed by the pills count method. A logistic regression model was used.

Results

The study revealed that the prevalence of good adherence towards IFA supplementation among Antenatal care (ANC) service users’ at Denbiya district health centers were found to be 28.01% [95% CI, 24.01, 35.9]. Attending secondary school and above [Adjusted Odds Ratio (AOR) = 3.44, 95% CI: 1.09, 10.92], having two ANC visits [AOR = 2.53, 95% CI: 1.34, 4.76] and three and above ANC visits [AOR = 4.14, 95% CI: 2.14, 8.01] were significantly associated with good adherence of IFA supplementation. To the contrary, husband education status; secondary school and above reduced the odds of good adherence by 77% compared to illiterates to IFA supplementation [AOR = 0.23, 95% CI: 0.07, 0.72].

Conclusion

The prevalence of good adherence among pregnant women towards IFA supplementation was low. Mothers’ education and having two or more ANC visits were positively associated with good adherence towards IFA supplementation.

Keywords

  • Iron
  • Folic acid
  • Adherence
  • Compliance
  • Pregnant women
  • Antenatal care

Background

Anemia is the leading public health problem worldwide. Globally, the estimated prevalence of anemia was 24.8% in the general population; 47.4% in preschool-aged children, 41.8% in pregnant women, and 30.2% in non-pregnant women [1].

Pregnant women are at high risk of iron deficiency anemia due to increased nutrient requirements. As a result, 38.2% of pregnant women suffered from anemia worldwide [2]. Inadequate dietary intake, previous pregnancy, normal recurrent loss of iron from menstrual blood, morning sickness, and previous anemia history were the risk factors of anemia for pregnant women [3]. Prophylaxis IFA supplementation is an important option to prevent iron deficiency anemia in pregnant women [4]. IFA supplementation is part of Antenatal Care (ANC) to reduce the risk of low birth weight, maternal anemia, and iron deficiency [5]. In South India, the IFA adherence rate was 64.7%. The effectiveness of IFA supplementation depends on the adherence or compliance of pregnant women. In Muntinlupa, Philippine, the compliance rate of pregnant mothers to IFA is 54% [6]. In Brazil, the IFA adherence rate of pregnant women is 82%, but its adherence rate decreased as the frequency of doses increases [7]. Forget fullness, vomiting, nausea, heartburn, and diarrheas were the main reasons of drug interruption [810]. In Mozambique, the iron sulfate adherence was 79% for having two or more visits, 53% for those having adequate prenatal care, and 67% for those who complete their intake of IFA tablets [11]. In Tigray, Ethiopia the rate of adherence to IFA supplementation was 37.2% [12] and Addis Ababa 60% [13]. The presence of iron sulfate side effects such as constipation, darkened or green stools, diarrhea, loss of appetite, nausea, stomach cramp, and vomiting decrease the IFA adherence rate in pregnant women [7, 14]. Conducting research on IFA adherence for pregnant women provides a double benefit for the mother and the fetus [15]. Iron-folic acid supplementation is one of a strategy made to prevent anemia for pregnant women [4, 5], but there is no evidence on the adherence of IFA supplementation among pregnant women in the study area. Therefore, the present study determines the adherence to IFA supplementation among pregnant women.

Methods

Study setting and period

Cross-sectional study was conducted at Dembiya district health centers (Guramba, Kolladiba, Robit, and Chuahit) among pregnant women from April 2 to May 27, 2016. These health centers are found in the North Gondar zone of Amhara regional state of Ethiopia. Dembia district is situated around 772 Km away from Addis Ababa (the capital city of Ethiopia). These health centers serve for more than half a million of people in the town and rural areas. At the moment there were around 789 pregnant women in all of the health centers.

Sample size determination and sampling procedures

All pregnant women who had ANC follow up in the Denbiya district health centers were a source of population. Pregnant women who received IFA supplementation for at least one month prior to data collection were included in the study. The sample size was determined using a single population proportion formula through the EPi Info Stat Calc Program with the assumption of 95% level of confidence, 5% marginal error, and taking the prevalence of IFA adherence in Tigray, Ethiopia (37.2%) [12]. After computing the calculation, the sample size was 359. Finally, considering a10% non-response rates, the final sample size was 395. The sampling frame was developed according to the order of the pregnant women attending the ANC clinic. A systematic random sampling technique was used to select study participants by calculating a sampling interval as the total population to sample size. Then each participant was selected every two-person pattern.

Data collection tools and procedures

The structured interviewer-administered questionnaire which is composed of socio-demographic and obstetric history were used to collect the data [12, 13]. Besides, data on adherence of IFA was collected using pills count methods. Data were collected by three midwives (one supervisor and two data collectors). To maintain the quality of the data, the questionnaire was pretested and half day training was given to data collectors and supervisors. The questionnaire first developed in English and translated to Amharic local language to collect data then back to English for analysis to maintain its consistency.

Operational definitions

Antenatal care visit

Antenatal care provided by skilled health personnel (doctor, nurse or midwife) during pregnancy.

Trimester

The number of weeks during pregnancy (1st, 1-12 weeks, 2nd, 13–26 weeks, and 3rd, 27-40 weeks).

Gravidity

The number of pregnancy whatever the outcome.

Parity

The number of live births among pregnancy.

IFA adherence

Good Adherence was considered as a pregnant woman who took ≥65% of the total prescribed IFA supplementation per month; whereas the opposite is true for non-adherence [12].

Data processing and analysis

Data were entered into the EPi Info Version seven and exported to SPSS Version twenty for analysis. Descriptive statistics, such as means, medians, frequencies, and percentages were calculated. All variables having p-value ≤0.2 in bivariate analysis entered into the multivariate logistic regression model to identify the effect of the independent variable on the outcome variables. P-value < 0.05 was considered statistically significant and AOR with a 95% CI was calculated to see the presence of associations. Model fitness was checked by using Hosmer and Lemeshow goodness of fit test.

Result

Socio-demographic characteristics of pregnant women

A total of 395 pregnant women were enrolled in the study with a response rate of 96.7%. More than one-third (43.2%) of the pregnant women were found to be in the age range of 25-31 years. Majorities (96.6%) were married, and 84% were housewife. Nearly two-thirds (59.2%) of pregnant women were illiterate (Table 1).
Table 1

Socio demographic characteristics of pregnant women attending ANC service at Denbiya district health centers, Northwest Ethiopia, 2016 (n = 382)

Variables

Frequency (n)

Percent (%)

Age in years

 18–24

79

20.7

 25–31

165

43.2

 32–42

138

36.1

Marital status

 Married

369

96.6

 Unmarried

13

3.4

Religion

 Orthodox

357

93.5

 Muslim

23

6

 Protestant

2

0.5

Ethnicity

 Amhara

372

97.4

 Tigray

10

2.6

Mother’s education status

 Illiterate

226

59.2

 Primary school

83

21.7

 Secondary school and above

73

19.1

Husband education status

 Illiterate

209

54.7

 Primary school

97

25.4

 Secondary school and above

76

19.9

Occupation

 Housewife

321

84

 Government employee

23

6

 Private employee

11

2.9

 Merchant

27

7.1

Monthly household income in Ethiopia

 Birr (EB)

  < 1000

115

30.1

 1000–2000

114

29.8

 2001–3000

95

24.9

  > 3000

58

15.2

Obstetric and health-related characteristics of pregnant women

One hundred fifty-four (40.3%) of pregnant mothers had two ANC visits. Nearly two-thirds (62%) were multigravida, and (57.3%) were ≤ two trimesters (Table 2).
Table 2

Obstetric characteristics of pregnant women attending ANC service at Denbiya district health centers, Northwest Ethiopia, 2016 (n = 382)

Variables

Frequency (n)

Percent (%)

 

Number of ANC visit

 

 One times

119

31.2

 

 two times

154

40.3

 

 Three and above

109

28.5

 

Parity

 

 Nulliparous

58

15.2

 

 Primiparous

84

22

 

 Multiparous

240

62

 

Gravidity

 

 Primigravida

53

13.9

 

 Multigravida

329

86.1

 

Trimester

 

  ≤ two

219

57.3

 

 three

163

42.7

 

Acute illness

 

 Yes

66

17.3

 

 No

316

82.7

 

Prevalence of IFA adherence among pregnant women

The prevalence of good adherence among pregnant women towards IFA supplementation was found to be 28.01% [95% CI, 24.01, 35.9]. The mean (SD) IFA consumption among pregnant women was 1.08 ± 0.24 pills.

Gastrointestinal discomfort due to side effect 35%, forgetting 30.5%, and not giving attention 18.5% are the reasons of non-adherence to IFA supplementation (Fig. 1).
Fig. 1
Fig. 1

Reasons for IFA non-adherence among pregnant women attending ANC service at Denbiya district health centers, Northwest Ethiopia, 2016

Factors associated with IFA adherence among pregnant women

In both the bivariate and multivariable analysis; maternal education and numbers of ANC visits were significantly associated with good adherence to IFA supplementation. Education status; secondary school and above [AOR = 3.44, 95% CI: 1.09, 10.92], and antenatal care visits; two ANC visit [AOR = 2.53, 95% CI: 1.34, 4.76], and three and above ANC visit [AOR = 4.14, 95% CI: 2.14, 8.01] were significantly associated with good adherence to IFA supplementation. Whereas husband education status; secondary school and above reduced the odds of good adherence by 77% compared to illiterates to IFA supplementation [AOR = 0.23, 95% CI: 0.07, 0.72] (Table 3).
Table 3

Factors associated with IFA adherence among pregnant women attending ANC service at Denbiya district health centers, Northwest Ethiopia, 2016 (n = 382)

Variables

 

Crude OR

Adjusted OR

Adherence status

95% CI

95% CI

Good

Poor

  

Mother ‘s education status

 Illiterate

63

163

1

1

 Primary school

24

59

1.05 (0.603,1.836)

1.76 (0.88,3.50)

 Secondary school and

20

53

0.98 (0.54,1.76)

3.44 (1.09,10.92)*

 above

 

Husband education status

 Illiterate

63

146

1

1

 Primary school

26

71

0.85 (0.50,1.45)

0.60 (0.31,1.16)

 Secondary school and

18

58

0.72 (0.39,1.32)

0.23 (0.07,0.72)*

 above

 

Number of ANC visit

 One times

19

100

1

1

 two times

45

109

2.17 (1.19,3.96)

2.527 (1.341,4.761)*

 Three and above

43

66

3.43 (1.84,6.39)

4.14 (2.14,8.01)*

Trimester

  ≤ two

50

169

1

1

 three

57

106

1.82 (1.16,2.85)

1.16 (0.62,2.17)

*p-value < 0.05

Discussion

The prevalence of good adherence among pregnant women towards IFA supplementation was found to be 28.01% [95% CI, 24.01, 35.9]. The finding of the current study is higher than studies conducted in Afar, Ethiopia (22.9%) [12] and Mecha, Ethiopia (20.4%) [16]. To the contrary, the finding of this study is much lower than studies conducted from Addis Ababa, Ethiopia (60%) [13], Mizan Tepi, Ethiopia (70.6%) [17], Eritrea (64.7%) [18], Enugu, Southeastern Nigeria (64.5%) [19], Senegal (69%) [20], Kathmandu, Nepal (73.2%) [21], and Iraq (51.47%) [22]. The possible discrepancy might be due to variations in socio-demographic characteristics, data collection tools and the cut point of adherence status, and period of data collection.

The current study revealed that maternal education is an independent factor of good adherence to IFA supplementation. Pregnant mothers who had secondary education and above were 3.44 times more likely [AOR = 3.44, 95% CI; 1.09, 10.92] to have good adherence towards IFA supplementation compared to those had no secondary education and above. This finding is supported by studies from Addis Ababa, Ethiopia [13], Asela, Ethiopia [10], West Iran [23], and West Bengal, India [24]. This might be due to education is more likely to enhance pregnant women awareness on the outcome of IFD deficiency and ways to overcome these deficiencies from different sources including advice from health workers. This implies that educated women have a greater ability to stick to health care inputs such as IFA which offer better for fetal growth and development; and care for both the infant and the mother [25, 26].

Numbers of ANC visits are found to be the determinant factors of good adherence towards IFA supplementation. Pregnant mothers who had two ANC visits are 2.53 times more likely [AOR = 2.527, 95% CI; 1.341, 4.761] to have good adherence towards IFA supplementation compared to those who had one ANC visit. Similarly, Pregnant mothers who had three and above ANC visits are 4.14 times more likely [AOR = 4.14, 95% CI; 2.14, 8.01] to have good adherence towards IFA supplementation compared to those who had one ANC visit. This finding is supported by studies Eritrea [18], Kiambu, Kenya [27], and Northwest Ethiopia [28]. This is the fact that ANC is the vital route for the delivery of iron supplementation and reinforcement of adherence. This suggests increase ANC visits are a good opportunity to increase contact between pregnant women and health professionals. Thus, health professionals can disseminate key information/messages, especially the benefits of IFA supplementation.

Husband education status; secondary school and above reduced the odds of good adherence by 77% compared to illiterates [AOR = 0.23, 95% CI: 0.07, 0.72]. This might be due to the misunderstandings/misperception of educated husbands on side effects and may think IFA has a negative adverse effect on the fetus like the other unsafe drugs. This suggests that educated husbands may affect the autonomy of the mothers to take iron-folic acid supplementation. The relationship between IFA adherence and husbands’ education needs further investigation, triangulated with a quantitative and qualitative study.

Limitations

The study did not assess the level of adherence and some other factors like knowledge of anemia. Further studies are recommended with all the necessary variables with strong study designs triangulated with qualitative methods.

Conclusions

The prevalence of good adherence among pregnant women towards IFA supplementation is low. Mothers’ education and two or more ANC visits are positively associated with IFA adherence. The IFA side effect was the main reason for pregnant women not taking regularly. Hence, promoting the benefits of frequent ANC, provide information about the benefits of IFA, side effect, and the effect of micro-nutrient deficiency should be intensified. Health professionals at the health facility should sensitize pregnant women on the need to continuously take the supplements throughout pregnancy. Local health extension workers, husbands and generally community should also be strongly involved in the promotion of prenatal iron supplementation.

Abbreviations

ANC: 

Antenatal care

AOR: 

Adjusted odds ratio

CI: 

Confidence Interval

COR: 

Crude Odds Ratio

IFA: 

Iron-folic acid

Declarations

Acknowledgments

The authors would like to thank the study participant and data collectors for their collaboration during the data collection. We would also like to thank the University of Gondar for providing ethical clearance.

Funding

The authors received no specific funding for this work.

Authors’ contributions

MT carried out the IFA adherence study, participated in the sequence alignment and drafted the manuscript. MW carried out IFA adherence. AA participated in the sequence alignment. TD participated in the design of the study and performed the statistical analysis. AW conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The study was approved by the College of Medicine and Health Sciences Research and Ethical review committee of the University of Gondar. A formal letter indicating the ethical approval was obtained and submitted to Denbiya district woreda health offices and health centers coordinator. Consent was obtained from each study participant. Personal identifiers like name and phone number were not used.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Kolladiba Health center, Maternal and child health department, Gondar, Ethiopia
(2)
Paulos Medical College Addis Ababa University, Addis Ababa, Ethiopia
(3)
Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
(4)
Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

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Copyright

© The Author(s). 2019

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