|Year : 2020 | Volume
| Issue : 2 | Page : 145-153
Adherence to iron/folic acid supplementation and associated factors among pregnant women attending governmental health center in Yeka Sub City, Addis Ababa, Ethiopia
Birhanu Tadesse Urgessa1, Ziyad Ahmed Abdo2
1 Department of Food and Drug Administration, Yeka Sub City Administration, Addis Ababa, Ethiopia
2 Department of Public Relation and Communication, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
|Date of Submission||22-May-2020|
|Date of Decision||27-Jul-2020|
|Date of Acceptance||25-Aug-2020|
|Date of Web Publication||18-Dec-2020|
Mr. Birhanu Tadesse Urgessa
Department of Food and Drug Administration, Yeka Sub City Administration, Addis Ababa
Source of Support: None, Conflict of Interest: None
CONTEXT: Iron-folic acid deficiency is the leading nutritional deficiency globally, affecting the lives of >2 billion people, accounting over 30% of the world's population. Provision of iron-folic acid supplement to all pregnant women, is among the very critical interventions to reduce the burden of anemia. Even though the service is free in Ethiopia, the prevalence of anemia is slowly increased in the country.
AIM: The aim is to assess adherence to iron-folic acid supplementation and associated factors among pregnant women attending governmental health center in Yeka sub city, Addis Ababa, Ethiopia, from November 1 to 30, 2019.
METHODOLOGY: An institutional-based quantitative cross-sectional study was used to conduct the study. Systematic sampling system was used to select 408 study populations. Data were collected through interview using structured questionnaire. Bivariate and multivariable logistic regressions were employed to identify the predictor variables. Statistical significance was considered at P < 0.05 with adjusted odds ratio (AOR) calculated at 95% confidence interval (CI).
RESULTS: A total of 408 pregnant women attending anti-natal care (ANC) were participated in this study, with response rate of 100%. The overall adherence rate was found to be 71.3%. Women whose family income >1500 Ethiopian Birr (ETB) (AOR [95% of CI]) = 3.77 (0.58–24.38)], having secondary or higher educational level (AOR [95% of CI]) = 1.48 (0.90–2.43), having history abortion (AOR [95% of CI] = 6.99 (1.11–44.19), starting ANC visit in first trimester (AOR [95% of CI] = 3.0 (0.24–37.18) were significantly associated with iron-folic acid supplementation.
CONCLUSION: According to this study, adherence to iron-folic acid supplementation was relatively high. Empowering women in economy and education are very important. Proper counseling and health promotion about iron-folic acid supplementation, promoting the benefits of early and frequent ANC visit are very important to increase adhere to iron-folic acid supplementation.
Keywords: Adherence, antenatal care, Ethiopia, folic acid supplementation, iron deficiency, pregnant women
|How to cite this article:|
Urgessa BT, Abdo ZA. Adherence to iron/folic acid supplementation and associated factors among pregnant women attending governmental health center in Yeka Sub City, Addis Ababa, Ethiopia. BLDE Univ J Health Sci 2020;5:145-53
|How to cite this URL:|
Urgessa BT, Abdo ZA. Adherence to iron/folic acid supplementation and associated factors among pregnant women attending governmental health center in Yeka Sub City, Addis Ababa, Ethiopia. BLDE Univ J Health Sci [serial online] 2020 [cited 2021 Apr 14];5:145-53. Available from: https://www.bldeujournalhs.in/text.asp?2020/5/2/145/303969
Iron and folic acid deficiency is the most common nutritional deficiency globally., It is the leading single nutrient deficiency causing anemia both in developing and developed countries, affecting the lives of >2 billion people globally. Children and women of reproductive age are at a particular risk of iron deficiency., It is estimated that more than half of the pregnant women in the world suffer from anemia, and it is a major cause of maternal morbidity and mortality. Unless managed well, it can lead to several adverse outcomes including preeclampsia, malformations, low birth weight, preterm delivery, fetal growth restriction, stillbirth, and maternal and neonatal mortality.,,
The provision of iron-folic acid supplement to all pregnant women is among the very critical interventions to reduce the burden of anemia. The World Health Organization (WHO) and Ethiopian Government recommended initiating the daily iron and folic acid (IFA) supplementation during pregnancy as early as possible as a part of antenatal care (ANC) programs for positive pregnancy outcome.,, Accordingly, all pregnant women should receive and consume a standard dose of 30–60 mg iron +400 μg folic acid, one supplement daily and taken throughout pregnancy.,
The WHO estimates that iron deficiency is responsible for approximately 50% of all anemia cases. It is estimated that 38% of pregnant women worldwide are anemic with highest in Africa followed by South East Asia which accounts for 62.3% and 53.8%, respectively.,,, In Ethiopia, one in every, three women had folic acid deficiency and anemia.
Reducing anemia is an important component of achieving women and children's health. The second global nutrition targeted a 50% reduction of anemia in women of reproductive age in 2025. Similarly, the Ethiopia, National Nutrition Program (NNP II) also set a key target to increase the number of women receiving iron-folic acid supplement for more than 90 days during pregnancy to 40% by 2020.
A meta-analysis done in Ethiopia show that the pooled estimated prevalence of adherence to iron-folic acid supplementation among pregnant women in Ethiopia was 41.38%. Another systematic review done in Ethiopia show that, the lowest adherence rate to IFA supplement was 17.1% and the highest was 74.5% with the pooled national level of adherence of IFA supplementation among pregnant women was 46.15% based on the random effect analysis. Similarly, different studies conducted in Ethiopia show that, the prevalence of anemia among pregnant women were between 21% and 54%.,,,,,
Different studies show many factors are associated with adherence to IFA supplementation. Educational status of the women, early registration ANC follow-up, having a complication of anemia during the current pregnancy, having a good knowledge of IFAS, having four times or more than ANC follow-up, getting health education or counseling about the advantage of IFAS, parity, residence area (urban vs. rural), house hold wealth index, and having a good knowledge about anemia were factors associated with adherence to IFAS. [19,26-30]
Even though every government health institution provides IFA supplementation and the service is free of charge to supplement the mother, the prevalence of anemia is slowly increased in Ethiopia. In addition, to the investigators best knowledge no information is available in the study area. Due to these facts, this study aimed to assess adherence to iron and folic acid supplementation and associated factors among pregnant women attending governmental health center in Yeka sub city, Addis Ababa, Ethiopia, from October 1 to 30, 2019.
| Methodology|| |
Institutional-based cross-sectional study design was used to assess adherence to iron-folic acid supplementation and associated factors among pregnant women attending governmental health center in Yeka sub city, Addis Ababa, Ethiopia, from October 1-30, 2019.
Source and study population
The source populations were, all pregnant women who were previously supplemented with IFA tablets and attending ANC follow-up in governmental health centers in Yeka sub city. Study population were sampled pregnant women who previously supplemented with IFA tablets and attending ANC in health center and who come to antenatal clinics for the second or more visit during the time of data collection.
Inclusion and exclusion criteria
Pregnant women who had at least two ANC follow-up visit in governmental health center and supplemented with IFA tablets for at least 1 month before the date of interviews were included in the study. Pregnant women who had not followed ANC visit at least two times and those who did not supplemented with IFA tables for at least 1 month during data collection were excluded from the study.
Sample size determination and sampling procedure
By using single proportion formula sample size was calculated.
Assuming 95% confidence level of , d = margin of error of 0.05.
Proportion (p) was taken from similar study done in government health center in Akakai Kality sub city with adherence to IFA 60%. Based on this information, the sample size calculated was 368. Finally, including 10% nonresponse rate the total sample size of the study was 408.
In Yeka sub city, there were 13 health centers (W) and all of them were included in the study in order to make the data more representative. There were a total of 992 pregnant women who fulfilled eligibility criteria (all pregnant mothers who were taking IFAS during their 2nd, 3rd and 4th ANC follow-up) were included. Systematic random sampling system was used to select study population (408) out of source population (992) which fulfills all criteria. An interval of k = N/n = 992/408 = 2 is used to select the study participants from each health facility. Overall schematic presentation of the sampling procedure is shown in [Figure 1].
- Independent variable: Adherence to iron-folic acid supplementation
- Dependent variable: Socio-economic and demographic factors (mothers' age, marital status, educational status, husband's educational status, mother's occupational, family size, and family monthly income), knowledge related to IFA and anemia, obstetric and medical factors (history of abortion, ANC start time, having history of anemia, supplement side effect), and health service-related factors (shortage of supplement with in the facility, distance from health facility, health education, nutrition counseling during pregnancy, collected tablet per visit, accessibility to ANC service).
It refers to degree to which a patient correctly follows a medical advice.
Knowledge to benefits of iron-folic acid
It refers to those who score mean value and above of questions asked about benefits of iron-folic acid are considered as having good knowledge of benefits of iron-folic acid.
Knowledge to anemia
It refers to those who score mean value and above of questions asked about cause, consequence, risk group, and method of prevention of anemia are considered as having good knowledge of anemia
It refers to routine health control of presumed healthy pregnant women without symptoms (screening), in order to diagnose diseases or complicating obstetric conditions without symptoms, and to provide information about lifestyle, pregnancy, and delivery.
It refers to a visit a pregnant woman optimally begins within 16 weeks of gestation and has four consecutive follow-up at least each visit 1 month apart throughout the antepartum period.
Iron-folic acid supplement
It refers to additional combined nutrient to be taken by pregnant women to make up for iron-folic acid deficiency.
Data collection instrument and procedure
Data were collected with structured pretested questionnaire which was adapted from different literatures. The questionnaire was prepared in English and translated in to Amharic then back to English by different translator to check correctness and consistency of translation. Data were collected and supervised by health-care professionals. For data quality control purpose, the data collectors were trained before the data collection and supervised during the data collection period. The questionnaire was pretested in 5% of the calculated sample size in public health institutions which was not included in the study before the actual data collection. Principal investigator and supervisors made spot-checking and reviewing the completed questionnaires to ensure completeness and consistency of the information collected. Those incomplete questionnaires were omitted from the analysis.
Data management and analysis
The data were entered into Epi info version 3.5.1., which is epidemiological software packages for editing, cleaning, coding, and check completeness and consistency. Then, the data were exported to SPSS version 23 for data management and analysis. Descriptive statistics, percentages, and mean were carried out. Hence, bivariate logistic regression was performed to identify variable that associate with dependent variables. Variables with P < 0.2 during bivariate analysis were include in multiple logistic regression to determine factors associated with adherence to iron-folic acid supplementation by controlling potential confounding variables. Statistical significance was considered at P < 0.05 was used to see the determinant factors for adherence to iron-folic acid supplementation with adjusted odds ratio calculated at 95% confidence interval.
Ethical clearance was obtained from Bahir DarUniversity, Institutions of Technology's Research and Ethics Committee. Letter of support was taken from Addis Ababa health bureau and Yeka sub city health office. A formal letter obtained from Addis Ababa health bureau and Yeka sub city was submitted to all health center included in the study. The purpose of study was well explained to the study participants and informed consent was obtained. The participant's involvement in the study was on voluntary bases and they informed that, they can withdraw any time if they want. All the information given by the respondents is used for research purposes only. Confidentiality and privacy were maintained by omitting the name of the respondents during data collection procedure.
| Results|| |
Sociodemographic characteristics of respondents
A total of 408 mothers attending ANC follow-up were participated in the study, with a response rate of 100%. The mean age of the respondents was 26.3 with standard deviation of (5.1) years. Majority of the respondents 375 (92.2%) were married. Round 95 (23.3%) of respondents were illiterate. However, most of husbands of the respondents had higher educated level 150 (36.9%). Almost half of the study participants 186 (45.6%) were homemaker, whereas 51 (12.5%) were daily laborer. Around 394 (95%) of the study participants had family size of less than five. About 244 (59.8%) of the participants had monthly income of 900–1800 birr. More detail statistics is depicted in [Table 1].
|Table 1: Sociodemographic characteristics of respondents in public health center in Yeka sub city, Addis Ababa, Ethiopia (n=408)|
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Knowledge related to iron and folic acid and anemia of respondents
Concerning to respondents knowledge related to IFA and anemia, majority of respondents 231 (78.6%) and 107 (62.0%) were knowledgeable about IFA supplementation and anemia respectively.
Obstetric and health service-related characteristics
Regarding ANC started time, around 196 (48%) of the respondents were started their ANC follow-up in their first trimester, while 164 (40.24%) and 48 (11.76%) are in second and third trimester, respectively. About 46 (11.3%) of respondents had a story of abortion. Two and twenty (53.3%) of the respondents visited the ANC for <4 time while 188 (46.8%) of respondents visits for four time or more. More detail on obstetrics and health service-related characteristics depicted in [Table 2].
|Table 2: Obstetric and health service related characteristics of respondents in public health center in Yeka sub city, Addis Ababa, Ethiopia (n=408)|
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Self-reported rate of adherence to iron and folic acid supplementation
Regarding adherence, around 291 (71.3%) of respondents were adhered to IFAS (took ≥4 tablets per week in the previous 1 month preceding the survey) and 117 (28.7%) were not adhered to IFAS (took <4 tablets per week in the previous 1 month preceding the survey). Self-reported rate of adherence to IFAS is shown in [Figure 2]. Similarly, reason for adherence and not adherence to IFAS is depicted in [Figure 3] and [Figure 4].
|Figure 2: Self-reported rate of adherence to IFAS in Yeka sub city health centers, Addis Ababa, Ethiopia|
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|Figure 3: Reason given for adherence to iron/folic acid supplement, in Yeka sub city health centers, Addis Ababa, Ethiopia|
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|Figure 4: Reason given for not adhere to iron/folic acid supplement, in Yeka sub city health centers, Addis Ababa, Ethiopia|
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Factors associated with adherence to iron and folic acid supplementation
Bivariate analysis was conducted to see the association of one independent variable with the dependent variable. Based on this, variables with P < 0.2 during the bivariate analysis were included in the multivariate logistic regression analysis to see the association of variables with adherence to IFA supplementation by controlling confounding variables. After computing multivariate analysis educational status of respondents, ANC started time, history of abortion, and income of respondents were significantly associated with Adherence to IFA supplementation. More detail about associated factors is depicted in [Table 3].
|Table 3: Factors associated with adherence to iron and folic acid supplementation at in public health center in Yeka sub city, Addis Ababa, Ethiopia|
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| Discussion|| |
Pregnant women are among the most vulnerable groups of iron deficiency anemia. Iron and folic acid supplementation has been a major strategy to reduce iron-folic acid deficiency anemia. The WHO recommends giving all pregnant women a standard dose of 60 mg iron and 400 μg folic acid daily for 6 months' duration., The aim of this study was to determine the adherence status and identify factors associated with iron and folic acid supplementation among pregnant women attending ANC in governmental health centers.
Self-reported rate of adherence to iron and folic acid supplementation
Iron-folic acid deficiency during pregnancy is risk factors for anemia, preterm delivery, low birth weight, and this contributes to the poor neonatal health and increased maternal mortality. To prevent this problems, the WHO and Ethiopian Government recommended all pregnant women should receive and consume a standard dose throughout the pregnancy., Finding of this study shows that 71.3% of pregnant women were adhered to IFA supplementation. This finding support the Ethiopia NNP target to increase the number of women receiving iron-folic acid supplement for >90 days during pregnancy to 40% by 2020. This study is slightly lower than study done in eight rural district of Ethiopia. However, it is higher than study done in health center in Akaki Kality Sub City, Misha District, South Ethiopia, North Western Zone of Tigray, Ethiopia, and also higher than studies done in Assaita districts, Afar, Ethiopia, and similarly higher than study done in south India. The possible reason for high adherence may be due to increased knowledge of pregnant women about anemia and IFA, all of the respondents being urban residents related to accessibility of information and accessibility of health center which support them to adhere more.
Sociodemographic characteristics of respondents
Many studies identified different sociodemographic variables as determinant factors for adherence to IFA supplementations.,, Out of these factors, age of respondents, educational level of respondents and their husbands, occupation of respondents, marital status of respondents, family size, and family income of respondents were analyzed in this study. From this, educational level of mothers and family income were found as determinant factors for adherence to IFA supplementation.
The results of this study indicated that women who had higher education had higher odds of consuming IFA supplements during their pregnancy. This study is consistent with studies done in different place: Enugu, Southeastern Nigeria, urban area of south India and study in Pakistan. The possible reason behind is, the educated women have greater access to information about health, which increases their concern about their health and the health of their future newborns and utility of ANC services than illiterate women.
Family income is one of the determinant factors for adherence to many health services utilization.,, The current study has shown that mothers from higher family income are more likely adhere to IFA supplementation compared to those with lower family income. This is consistent with studies done in Akaki Kality Sub City, Governmental health centers and study done in the Mangalore city in south India. However, this result is not similar with the study done in Pakistani.
Obstetric and health service-related characteristics
There are many obstetric and health service-related determinant factors for adherence to IFA supplementations. This study shows that, abortion history and number of ANC visit were found to be significantly related to adherence to IFA supplementation.
Abortion continues to be a major public health issue that evokes social, political, legal, cultural, and religious sentiments and debates in all societies. Studies shows that mother with history of abortion adhere more to heath service follow-up., According to this study, Women who had a history of abortion were more likely adhere to IFA supplementation than those who had not. This result is similar with studies done in Ethiopia. This may be due to at health institution mothers who have history of abortion are more supplemented with IFA, this may improve adherence, the other reason might be clients need to be free from the illness, and fear of anemia complications both on them and their infant.
Maternal health services have a potentially critical role in the improvement of reproductive health. One of these services is ANC follow-up. The primary target of ANC is to detect problem, treat on time and prevention of complications by health care provision. The number of ANC visits has a significant effect on adherence with IFA supplementation and also is a crucial channel for supplementing iron and folic acid during pregnancy. This study supports this reality. As such, those mothers who started ANC in first trimester were three times more likely to adhere to IFA supplementation than those mothers started ANC in third trimester. The result of this study is supported by other studies done in Misha District, South Ethiopia and Indonesia. This result and other realities show that adherence to ANC is very important for mother health.
Limitation of the study
Adherence to IFA supplementation was determined by self-reporting, which may affect actual compliance due to the potential for over-reporting or under-reporting of tablets consumed. Since the study was based on the consumption of iron and folic acid tablets from the previous month, they might be subject to potential recall bias. In addition, the hemoglobin level in the blood of pregnant women was not measured to confirm a diagnosis of anemia. Therefore, further studies are recommended with all necessary variations with robust study designs supported by qualitative methods.
| Conclusion|| |
According to this study, adherence to iron-folic acid supplementation was relatively high. The study found that family income, educational level, history of abortion, and ANC started time was found significantly associated with adherence. Empowering women in economy, promoting and strengthening strategy for female education is very important measure for increasing maternal health service utilization. Proper counseling and health promotion about IFA supplementation, promoting the benefits of early and frequent ANC visit is very important to increase adhere to IFA supplementation and prevention of anemia. Hence, all concerned body should work together to combat the problem.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]