Objective: Strict compliance to iron and folic acid supplementation is vital for prevention of anemia in pregnancy. However, data are scarce in Ethiopia. So, we conducted this study to assess the level of compliance to iron and folic acid supplementation during pregnancy and its associated factors. Results: Of 418 women, over half, 231 (55.3%), adhered to the recommended iron and folic acid supplementation. Women who started antenatal care (ANC) follow up early [AOR; 95% CI 2.43 (1.12–5.26)], had more frequent number of ANC visit [AOR; 95% CI 2.73 (1.32–5.61)], took small number of tablets per visit [AOR; 95% CI 3.0 (1.21–7.43)], had his- tory of anemia [AOR; 95% CI 1.9 (1.17–3.12)], and were from urban areas [AOR; 95% CI 2.2 (1.29–3.77)], were more likely to conform to recommended iron and folic acid supplementation. Therefore, there need to be prescription of the lowest possible number of tablets per visit. Furthermore, education targeting on increasing maternal health service utilization need to be in place. There need to also be further research aimed at determining the number of tablets to be prescribed per visit specific to individuals’ background characteristics. Keywords: Compliance/adherence, Iron and folic acid supplementation, Antenatal care, Ethiopia Maternal anemia is associated with mortality and mor- Introduction bidity of the mother and the baby, including risk of mis- Anemia, a low blood hemoglobin concentration, is an carriages, stillbirths, prematurity and low birth weight. It important public health problem affecting all countries impairs children’s development and learning too, further with varied impact across population segments. Pregnant impacting economic productivity and development . women are usually among the most affected groups glob - A number of causes are reported to influence the ally [1, 2]. According to WHO (World Health Organiza- occurrence of anemia during pregnancy. Nevertheless, tion) report, 38.2% of global and 46.3% of African region iron deficiency is the leading cause, constituting 41.8% pregnant women are affected by anemia [ 3]. In Ethiopia, of the global burden . Consequently, WHO recom- the prevalence is 23% , which seems lower than the mended 60 mg iron plus 400 µg folic acid supplementa- aforementioned global and regional prevalences. How- tion during pregnancy in areas of iron deficiency anemia ever, reports show Ethiopia is among countries in the (IDA), prevalence of above 40% . However, literature world where the highest maternal and child mortalities indicate that the proportion of women taking iron and are documented, which may likely be due to poor mater- folic acid (IFA) supplementation is much lower, specially, nal services utilization like micronutrient supplementa- in low and middle income countries, continuing to hin- tion . der the prevention of anemia. There are several factors believed to be responsible for not conforming to the rec- ommended iron and folic acid supplementation during *Correspondence: firstname.lastname@example.org Department of Epidemiology and Biostatistics, Institute of Public Health, pregnancy which would be broadly grouped as: socio- College of Medicine and Health Sciences, University of Gondar, Gondar, economic, ANC utilization and previous illness etc. Ethiopia [8–12]. In Ethiopia the compliance to iron and folic acid Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/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://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Birhanu et al. BMC Res Notes (2018) 11:345 Page 2 of 5 Table 1 Socio demographic characteristics ANC attendants Table 2 Compliance to IFA of ANC attendants at the Uni- at the University of Gondar hospital, 2017 versity of Gondar hospital, 2017 Variables Frequency Percent Variables Frequency Percent Age (years) Compliance to supplement < 28 204 48.8 Yes 231 55.3 ≥ 28 214 51.2 No 187 44.7 Marital status Reason for compliance Married 398 95.2 Advice of health worker 142 61.5 Single 20 4.8 Knowing it prevents anemia 36 15.5 Residence Getting the supplement for free 29 12.6 Urban 308 73.7 Use of reminder 24 10.4 Rural 110 26.3 Reason for non-compliance Religion Fear of side effects 109 58.3 Orthodox Christian 302 72.3 Forget fullness 39 20.9 Muslim 87 20.8 Too many pills 22 11.8 Protestant 29 6.9 Unpleasant tests 17 9.0 Occupation Tablets collected Housewife 192 45.9 30 162 38.8 Government employee 112 26.8 60 121 28.9 Merchant 64 15.3 90 106 25.4 Daily laborer 28 6.7 > 90 29 6.9 Student 22 5.3 ANC starting time Education status First trimester 157 37.6 Can’t read and write 97 23.2 Second trimester 219 52.4 Primary and high school 211 50.5 Third trimester 42 10.0 College and university 110 26.3 Current anemia status Family size Yes 143 34.2 < 4 191 45.7 No 275 65.8 ≥ 4 227 54.3 Monthly income < $148 245 58.6 It serves more than 6 million people. The hospital has dif - ≥ $148 173 41.4 ferent specialty units which, included internal medicine, pediatrics, gynecology/obstetrics, surgery, dentistry, psy- chiatry, ophthalmology, hospital pharmacy and derma- tology. The study was conducted from March 8 to April supplementation is between 20.4 and 60% [8–10], which 10, 2017. is lower than what it should normally be. Nonetheless, the factors contributing for this low level of compliance Sample size and sampling procedure have not been well studied in the country. Even no study We determined the sample size using single population has been conducted in our study setting so far. Therefore, proportion formula. We took 60% level of compliance we conducted this study to find out the level of compli - from a previous study . We also considered a 5% level ance to iron and folic acid supplementation during preg- of significance (α) and 5% margin of error. The sample nancy and its associated factors in Northwest Ethiopia. size calculated was, therefore, 384. After adding a non- response rate of 10%, the final sample size obtained was Main text 418 study participants. Methods The sample women were selected by systematic random Study design and setting sampling from the population attending ANC during We conducted an institution based cross-sectional study the study period. The total number of ANC attendants among women attending ANC, and currently taking the (sampling frame) for the current study was assumed supplementation at the University of Gondar Hospital, to be similar to the total number of ANC attendants Ethiopia. The University of Gondar Hospital is one of of the 2 months preceding this study period and it was oldest and largest federally established teaching hospitals. 2500 attendants. So, we divided 418 (sample) by 2500 Birhanu et al. BMC Res Notes (2018) 11:345 Page 3 of 5 (sampling frame) so that a sampling fraction of 1/6 was statistically significant. SPSS version 20 was used to per - obtained. To determine the order of the first respondent, form the analysis. we employed simple random sampling technique among the first six participants, and it was found to be the 5th Ethical consideration participant. Thus, every 6th participant starting from the Letter of ethical clearance was obtained from Institution first respondent was then included and interviewed until Ethics Review Board of the University of Gondar. Letter we get the required sample size. of permission was secured from the University of Gondar referral hospital and informed oral consent was obtained Data collection and analysis from the study participant after providing them with the The data were collected by interview on variables like, information concerning the purpose of the study, benefits number of iron and folic acid tablets taken per week, and harms of participating in the study. The study partici - reasons for missing tablets, history of anemia status, pants were also told that participation in the study was information provision regarding iron and folic acid sup- completely voluntary and the information will be kept plementation, pregnancy and delivery related charac- strictly confidential. teristics using structured and pretested questionnaire. Compliance to iron and folic acid supplementation was Results defined as taking iron and folic acid tablets for at least Socio‑demographic characteristics 4 days in the most recent week, which otherwise was The mean age of the study participants was 28 ± 5 years. considered as non-compliance . Data were checked for The majority of the respondents were married, 398 consistency and completeness, and then descriptive and (95.2%), and urban residents, 308 (73.7%). Three-fourth analytic computations were carried out. Multivariable of the study participants, 302 (72.2%), were Orthodox binary logistic regression model was fitted to the data to Christians. More than half, 227 (54.3%), had four or more identify predictor variables associated with the depend- household family member. Below half, 192 (45.9%), of the ent variable. Variables with p < 0.05 were considered women were house wives and half, 211 (50.5%), of them Table 3 Predictors of compliance to IFA among ANC attendants at the University of Gondar hospital, 2017 Variables Compliance COR, (95% CI) AOR, (95% CI) Yes, no (%) No, no (%) Residence Urban 185 (80.1) 123 (65.8) 2.1 (1.35–3.26) 2.2 (1.29–3.77)* Rural 46 (19.9) 64 (34.2) 1 1 Marital status Married 228 (98.7) 170 (90.9) 7.6 (2.19–26.35) 6.3 (1.66–23.89)* Single 3 (1.3) 17 (9.1) 1 1 Family size ≥ 4 140 (60.6) 87 (46.5) 1.8 (1.20–2.61) 2.0 (1.16–3.57)* ≤ 3 91 (39.4) 100 (53.5) 1 1 First ANC visit First trimester 104 (45) 53 (28.3) 2.4 (1.19–4.74) 2.4 (1.12–5.26)* Second trimester 108 (46.8) 111 (59.4) 1.2 (0.61–2.29) 1.3 (0.63–2.83) Third trimester 19 (8.2) 23 (12.3) 1 1 Current anemia status Yes 93 (40.3) 50 (26.7) 1.9 (1.22–2.80) 1.9 (1.17–3.12)* No 138 (59.7) 137 (73.3) 1 Tablet collected 30 109 (47.2) 53 (28.3) 2.9 (1.3–6.54) 3.0 (1.21–7.43)* 60 59 (25.5) 62 (33.2) 1.2 (0.59–3.06) 1.3 (0.50–3.14) 90 51 (22.1) 55 (29.4) 1.3 (0.57–3.02) 1.0 (0.48–2.64) > 90 12 (5.2) 17 (9.1) 1 1 “*” Significant at 5% level of significance Birhanu et al. BMC Res Notes (2018) 11:345 Page 4 of 5 attended primary or high school education. The average from results of studies conducted in India (80.5%)  monthly income of study participants was $170 ± 97$ and Bicol Philippines (85%) . This difference may be (Table 1). due to variations in socio-cultural and political environ- ment between the countries [18, 19]. Compliance to iron and folic acid supplementation Concerning the factors associated with compliance to The level of compliance to iron and folic acid supple - iron and folic acid supplementation, the variables which mentation was 55.3%. Around two-third, 142 (61.5%), of included, marital status, residence, family number, ANC the respondents, mentioned advice of the health service starting time, facing anemia in the current pregnancy, providers as a reason for their compliance to the supple- and number of tablets collected per visit were statisti- ment followed by the knowledge they had that iron and cally significantly associated. Consequently, women who folic acid supplementation prevents anemia, 36 (15.5%). were urban dwellers were more likely to adhere to their The main reason for not taking the supplement as per the supplements than rural dwellers. This is consistent with recommended, on the other hand, was fear of side effects, a finding of study conducted in Tigray, Ethiopia . 116 (62.0%). Two-fifth, 162 (38.8%), of the respondents This association seems obvious that being urban resident collected 30 tablets per ANC visit, and 157 (37.6%) ini- privileges to different enabling factors as compared to tiated the ANC visit during their first trimester. One- rural residents. For instance, urban residents have better third, 143 (34.2%), had anemia in the current pregnancy access to health facilities [4, 9]. Study participants who (Table 2). had husbands were, similarly, more likely to comply with their supplements compared to their single counter parts. Factors associated with adherence to iron and folic acid This could be due to the fact that married women gets supplementation support from their husband in many ways, like a help in A total of eleven independent variables were examined remembering to take the supplement. In addition, higher for the presence of association with the dependent vari- family number was also associated with better adher- able, of which six variables which included, marital sta- ence . Women who initiated ANC follow up early was tus, residence, family number, ANC starting time, facing also more likely to adhere to the medicines as compared anemia in the current pregnancy, and number of tablets to those who initiated lately. This result is supported by collected per visit were statistically significantly associ - study done in Bicol Philippines . In the current study, ated with compliance to iron and folic acid supplemen- women who had anemia during their recent pregnancy tation in the final multivariable logistic regression model were more adherent than those who did not have ane- (Table 3). mia. This result is in line with a study from Mecha dis - trict, Ethiopia . This may be associated with a better Discussion emphasis that might have been payed to those who were This study estimated a 55.3% [95% CI:(50.74%, 60.26%)] sick by health care professionals while providing health level of compliance to iron and folic acid supplementa- education and counseling. It might also be due to a fear tion in ANC attendant women already taking the sup- in women’s of further complication. In addition, par- plements, and the factors statistically significantly ticipants who collected few numbers of tablets per visit influencing the compliance were marital status, resi - had higher adherence level. This result is supported by dence, family size, ANC starting time, facing anemia in studies from Ethiopia and Egypt [9, 21]. This is because the current pregnancy, and the number of tablets col- higher number of pills had negative psychological impact lected per ANC visit. on adherence. Studies concluded that as number of tab- The level of compliance identified by this study is con - lets decreases adherence to medication increases due to sistent with the result in Addis Ababa, Ethiopia (60%) , decreasing pill burden . but higher than the findings from other areas of Ethiopia; Overall, more than half of the ANC attendant women Mecha (20%) , Mishan (39%) , and Tigray (33%) took the iron and folic acid supplementation as per WHO . The inconsistency could be due to differences in recommendation. This is an average level of compliance training level of health care professionals and standard of as compared to compliances reported from different lit - the health care institution in the different level of health erature. Antenatal care visit starting time, number of care facilities as this study was conducted on one of the tablets collected per visit and current anemia status were few referral hospitals in the country. This explanation is statistically significantly associated with compliance to supported by a study stating high adherence is expected the iron and folic acid supplementation in ANC attend- in well-organized setups as adequate counseling and sus- ants. Therefore, there need to be prescription of the low - tainable product availability are better in such facilities est possible number of tablets per visit. Furthermore, [14–17]. However, our finding is significantly lower than education targeting on increasing maternal health service Birhanu et al. BMC Res Notes (2018) 11:345 Page 5 of 5 References utilization need to be in place. There need also be further 1. Stoltzfus RJ, Dreyfuss ML. Guidelines for the use of iron supplements to research aimed at determining the number of tablets to prevent and treat iron deficiency anemia, vol. 2. Washington DC: Ilsi Press; be prescribed per visit specific to individuals’ background 2. World Health Organization. Mother-baby package: implementing safe characteristics. motherhood in countries: practical guide. Geneva: World Health Organi- zation; 1996. Limitations 3. World Health Organization. The global prevalence of anaemia in 2011. Geneva: World Health Organization; 2015. The results of our study might have still be affected by 4. Central Statistical Agency. Ethiopia demographic and health survey 2016. reporting bias since compliance was assessed using self- Addis Ababa: CSA and ICF; 2017. reported pills intake though the interview required a 5. World Health Organization. World health statistics 2016: monitoring health for the SDGs sustainable development goals. Geneva: World week-long memory. Health Organization; 2016. 6. World Health Organization. Global nutrition targets 2025: anaemia policy brief. Geneva: World Health Organization; 2014. Abbreviations 7. World Health Organization. Guideline: daily iron and folic acid sup- ANC: antenatal care; EDHS: Ethiopian Demographic and Health Survey; IDA: plementation in pregnant women. Geneva: World Health Organization; iron deficiency anemia; WHO: World Health Organization. 8. Taye B, Abeje G, Mekonen A. Factors associated with compliance of Authors’ contributions prenatal iron folate supplementation among women in Mecha district, TMB, MKB, and FAM have substantial contributions to the conception, design Western Amhara: a cross-sectional study. Pan Afr Med J. 2015;20(1):43. and execution of this work and agreed to be accountable for all aspects of 9. Gebreamlak B, Dadi AF, Atnafu A. High adherence to iron/folic acid sup- the work that questions related to the integrity of any part of the work were plementation during pregnancy time among antenatal and postnatal appropriately investigated and resolved. All authors read and approved the care attendant mothers in Governmental Health Centers in Akaki Kality final manuscript. Sub City, Addis Ababa, Ethiopia: Hierarchical Negative Binomial Poisson Regression. PLoS ONE. 2017;12(1):e0169415. Author details 10. Arega SA, Gebretsadik LA, Hussen MA. Compliance with iron folate sup- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine plement and associated factors among antenatal care attendant mothers and Health Sciences, University of Gondar, Gondar, Ethiopia. Department in Misha district, south Ethiopia: community based cross-sectional study. of Epidemiology and Biostatistics, Institute of Public Health, College of Medi- J Environ Public Health. 2015;2015:7. cine and Health Sciences, University of Gondar, Gondar, Ethiopia. 11. Godara S, Hooda R, Nanda S, Mann S. To study compliance of antenatal women in relation to iron supplementation in routine ante-natal clinic at Acknowledgements a tertiary health care centre. J Drug Deliv Ther. 2013;3(3):71–5. Authors would like to thank the study participants and data collectors. 12. Lutsey PL, Dawe D, Villate E, Valencia S, et al. Iron supplementation com- pliance among pregnant women in Bicol, Philippines. Public health Nutr. Competing interests 2008;11(1):76–82. The authors declare that they have no competing interests. 13. Gebre A, Afework M, Belachew E. Assessment of factors associated with adherence to iron-folic acid supplementation among urban and rural Availability of data and materials pregnant women in North Western Zone of Tigray, Ethiopia: comparative The data which the authors used to produce this manuscript are available and Study. Int J Nutr Food Sci. 2015;4(2):161–8. the authors are prepared to share the raw data on request recognizing the 14. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, et al. WHO analysis of causes benefits of such transparency. of maternal death: a systematic review. Lancet. 2006;367(9516):1066–74. 15. Kiguli J, Ekirapa KE, Okui O, Mutebi A, et al. Increasing access to quality Consent for publication health care for the poor: community perceptions on quality care in Not applicable. Uganda. Patient Preference Adherence. 2009;3:77. 16. Nezenega ZS, Tafere TE. Patient satisfaction on tuberculosis treatment Ethics approval and consent to participate service and adherence to treatment in public health facilities of Sidama Ethical clearance was obtained from Institutional Review Board (IRB) of the zone, South Ethiopia. BMC Health Serv Res. 2013;13(1):110. University of Gondar and letter of permission was obtained from the Univer- 17. Hegazy NN. Quality of care and medication adherence among sity of Gondar Hospital. Informed verbal consent was obtained from each patients with type (2) diabetes mellitus. Egyptian Family Med J (EFMJ ). study participant after explaining the benefits and risks of participating in the 2017;1(2):5–16. study. Participation in the study was completely voluntary. 18. Arcury TA, Gesler WM, Preisser JS, Sherman J, Spencer J, et al. The effects of geography and spatial behavior on health care utilization among the Funding residents of a rural region. Health Serv Res. 2005;40(1):135–56. The funding body had no any role in the design of the study, collection, analy- 19. Jacobs B, Bigdeli M, Annear PL, Wim VD. Addressing access barriers sis, and interpretation of the data, and in the writing of the manuscript. to health services: an analytical framework for selecting appropri- ate interventions in low-income Asian countries. Health Policy Plan. 2011;27(4):288–300. Publisher’s Note 20. Farrell B, Merkley VF, Ingar N. Reducing pill burden and helping with Springer Nature remains neutral with regard to jurisdictional claims in pub- medication awareness to improve adherence. Can Pharm J Revue des lished maps and institutional affiliations. Pharmaciens du Can. 2013;146(5):262–9. 21. Neupane N, Sharma S, Kaphle HP. Factors affecting compliance of iron Received: 21 March 2018 Accepted: 11 May 2018 and folic acid among pregnant women attaining Western Regional Hospital, Pokhara, Nepal. Int J Res Curr Dev. 2015;1(1):43–7.
BMC Research Notes – Springer Journals
Published: May 30, 2018
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