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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 36  |  Issue : 2  |  Page : 43-47

Prevalence of nonadherence to iron and folic acid supplementation among pregnant women in Bishnupur district of Manipur


Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission01-Jul-2021
Date of Decision09-Sep-2021
Date of Acceptance10-Sep-2021
Date of Web Publication16-Nov-2022

Correspondence Address:
Dr. Soubam Christina
Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_82_21

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  Abstract 


Context: Iron and folic acid (IFA) supplementation is an important strategy to reduce the prevalence of iron-deficiency anemia (IDA) during pregnancy. Consequently, it reduces risk of maternal mortality, neonatal mortality, and poor birth outcomes. Nonadherence to IFA supplementation is a challenging factor in combating IDA.
Aims: The aim of this study was to determine the prevalence of nonadherence to IFA supplementation among pregnant women and identify the factors associated with it.
Subjects and Methods: A cross-sectional study was conducted among pregnant women attending public health facilities of Bishnupur district, Manipur. Pregnant women with ≥20 weeks of period of gestation were recruited consecutively from the antenatal care clinics of the selected public health facilities. Face-to-face interviews were conducted using a pretested semi-structured interview schedule. Association between nonadherence to IFA supplementation and background characteristics and antenatal profile was analyzed using Chi-square test.
Results: The mean age of the participants was 28 ± 5.7 years, and 69% were multigravida. Among 396 women who were currently consuming IFA tablets, 25% were nonadherent. Bad taste, side effects, and inadequate supply were cited as the main reasons for irregular intake. The presence of comorbidities (P < 0.001), government supply as source of IFA tablets (P = 0.001), and adequate knowledge about IFA tablets (P = 0.04) were found to be significantly associated with nonadherence. Other associated factors were religion, education, socioeconomic status, and period of gestation.
Conclusions: The prevalence of nonadherence was high among pregnant women in Bishnupur district. The importance of IFA supplementation and its adherence should be emphasized to pregnant women.

Keywords: Iron and folic acid supplementation, nonadherence, pregnant women


How to cite this article:
Debbarma B, Konjengbam S, Elangbam V, Christina S, Akoijam BS. Prevalence of nonadherence to iron and folic acid supplementation among pregnant women in Bishnupur district of Manipur. J Med Soc 2022;36:43-7

How to cite this URL:
Debbarma B, Konjengbam S, Elangbam V, Christina S, Akoijam BS. Prevalence of nonadherence to iron and folic acid supplementation among pregnant women in Bishnupur district of Manipur. J Med Soc [serial online] 2022 [cited 2022 Dec 1];36:43-7. Available from: https://www.jmedsoc.org/text.asp?2022/36/2/43/361286




  Introduction Top


Iron deficiency is one of the most common forms of micronutrient malnutrition across the globe. Iron-deficiency anemia (IDA) results from inadequate amount of red blood cells caused by lack of iron.[1],[2] Approximately 50% of anemia is attributed to iron deficiency.[3] Iron deficiency could be from increased demand or requirement in the body, decreased intake of iron-rich food, decreased absorption and utilization, and increased loss due to presence of comorbidities such as malaria, hookworm infestation, menorrhagia, blood-related diseases, and gastric ulcer. Iron supplementation is one of the major preventive and control measures along with deworming, food fortification, improved dietary practices, and promotion of infant and young child feeding practices.[2] Iron supplementation alone or in combination with folic acid is an important strategy to reduce the prevalence of IDA during pregnancy. Iron and folic acid (IFA) supplementation has been shown to reduce maternal anemia and consequently reduce risk of maternal mortality, neonatal mortality, and poor birth outcomes such as low birth weight, preterm birth, and neural tube defects.[1],[2],[3] To tackle IDA, the Government of India introduced the National Nutritional Anaemia Prophylaxis Programme in 1970. In 2013, the Ministry of Health and Family Welfare, the Government of India, developed an intervention guideline – National Iron Plus Initiative[4] to mitigate the burden of IDA among all age groups: children aged 6–59 months, 5–10 years, adolescents aged 10–19 years, pregnant and lactating women, and women in reproductive age group. In March 2018, the Ministry of Health and Family Welfare, Government of India, and UNICEF under POSHAN Abhiyaan launched Anemia Mukt Bharat (AMB) to bring down anemia prevalence from 50% to 32% by 2022 among pregnant women.[4],[5],[6] Under the Reproductive and Child Health-II and AMB program, pregnant women are advised to take IFA tablets, one tablet daily starting from the second trimester, and continue throughout pregnancy (180 days). Each IFA tablet contains 60-mg elemental iron and 500-mcg folic acid.[4],[5],[6]

Effectiveness and success of such a program depends on the “adherence” of the pregnant women to IFA supplementation. According to the National Family Health Survey (NFHS)-4,[7] the prevalence of “adherence” to IFA supplementation was 69.7% in India. In Manipur and Bishnupur districts, the prevalence of nonadherence to IFA supplementation was 39.2% and 43.6%, respectively, among pregnant women.[7],[8] A pregnant woman is said to be adherent to IFA supplementation when she has consumed 30, 60, and 90 tablets of IFA at 20, 24, and 28 completed weeks of period of gestation, respectively.[4]

Thus, nonadherence is an important challenging factor in combating IDA in Manipur where the prevalence of adherence to IFA supplementation is lower than the national average. Many studies have been conducted across the globe to determine the prevalence of nonadherence to IFA supplementation and its associated factors.[9],[10],[11],[12],[13] Such studies that look into these associated factors have not yet been conducted in Bishnupur district of Manipur and hence this study aimed to determine the prevalence of nonadherence to IFA supplementation among pregnant women in the district and the factors associated with it.


  Subjects and Methods Top


A cross-sectional study was conducted among pregnant women attending public health facilities of Bishnupur district, Manipur, one of the northeastern states in India, between July 2018 and June 2020. As per census 2011, Bishnupur district has a population of 2,40,363. The district has three subdivisions, namely Nambol, Moirang, and Bishnupur. According to the District Health Management Information System data of 2017–2018, a total of 3812 pregnancies were registered in all the different health centers of the district. Pregnant women with ≥20 weeks of period of gestation attending the public health facilities of Bishnupur district were included. Those who were attending antenatal care (ANC) for the first time, taking two tablets of IFA per day, or on alternative therapy of iron supplementation/anemia were excluded. A sample of 434 was calculated taking the prevalence of nonadherence to IFA supplementation in Bishnupur district as 43.6% with 5% absolute precision, 5% significance, and 10% nonresponse rate.[8] There are seven primary health centers (PHCs), two community health centers (CHCs), and one district hospital (DH) in the district. For this study, Bishnupur DH, Nambol and Moirang CHCs, and three PHCs (Kumbi, Oinam, and Ningthoukhong) were included in the study. The PHCs were selected conveniently, one each from the three subdivisions. The number of participants to be recruited from each facility was allocated proportionately to the number of ANC registrations in these facilities in the previous year (total of 3072 registrations): DH – 113, Nambol CHC – 81, Moirang CHC – 103, Kumbi PHC – 67, Oinam PHC – 41, and Ningthoukhong PHC – 30. Eligible participants were recruited consecutively during ANC clinic hours.

A pretested semi-structured interview schedule was used to collect the data. It consisted of background characteristics (8 questions), pregnancy-related characteristics (6 questions), and questions related to IFA supplementation (11 questions). Knowledge on IFA supplementation was assessed by six questions. A score of 1 was assigned for correct response and 0 for incorrect response. A participant was considered to have adequate knowledge if a score >3 was obtained. Socioeconomic status was classified based on per capita income per month for Prasad's scale (January 2019).

A pregnant woman was said to be nonadherent to IFA supplementation if she had not taken at least 30, 60, and 90 tablets by the end of 20, 24, and 28 weeks of gestation, respectively. Prior to the interview, participants were explained about the purpose of the study and written informed consent was obtained. A face-to-face interview was taken in a separate room. Data were entered and analyzed using IBM SPSS Statistics for Windows, version 21.0 (IBM Inc. Armonk, NY, USA: IBM Corp.). Descriptive statistics such as frequencies, percentages, mean, and standard deviation were used to summarize the data. Association between nonadherence to IFA supplementation and background characteristics, antenatal profile, and knowledge on IFA supplementation was analyzed using Chi-square (χ2) test. P < 0.05 was considered statistically significant. Ethical approval was taken from the Research Ethics Board, Regional Institute of Medical Sciences, Imphal, Manipur.


  Results Top


A total of 440 pregnant women were approached for the interview. Of this, 425 women participated giving a response rate of 96.6%. The mean age of the study participants was 28 ± 5.7 years with minimum and maximum age of 18 years and 38 years, respectively. The mean age at marriage was 20 ± 3.3 years. Maximum age at marriage was 30 years and minimum age was 17 years. Currently, 396 participants (93.1%) were consuming IFA tablets [Table 1]. A total of 358 participants (84.2%) had adequate knowledge on IFA tablet consumption. More than 80% of the participants answered correctly to five of the knowledge questions [Table 2]. [Figure 1] shows that 99 participants (25%) were nonadherent to IFA supplementation. The common reasons for irregular intake of IFA tablets are listed in [Table 3], the most common being bad taste as reported by 90 participants (40.8%). The study findings showed that factors such as Muslim community (P < 0.001), higher education (P < 0.001), lower social class (P = 0.02), longer period of gestation (P < 0.001), presence of comorbidities (P < 0.001), government supply as source of IFA tablets (P = 0.001), and adequate knowledge about IFA tablets (P = 0.04) were found to be significantly associated with nonadherence to IFA tablet consumption among pregnant women [Table 4].
Table 1: Pregnancy profile of the participants and iron and folic acid tablet consumption (n=425)

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Table 2: Participants knowledge on iron and folic acid tablet consumption (n=425)

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Table 3: Reasons for irregular intake of iron and folic acid tablets (n=225)

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Table 4: Association between nonadherence to iron and folic acid supplementation and background characteristics of the participants (n=396)

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Figure 1: Distribution of the participants by nonadherence to Iron and folic acid tablet supplementation (n = 396)

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  Discussion Top


In this study, it was observed that the prevalence of nonadherence to IFA supplementation was 25%. This finding is contradictory to the NFHS-4 report[7] where nonadherence rate in Bishnupur district, Manipur, to IFA supplementation among pregnant was much higher (43.6%). The reason for this reduction in nonadherence rate could be because of continuous enforcement of anemia control program by initiatives such as AMB and improved access to health-care services compared to earlier years. A similar finding was reported by other studies conducted in India by Selvaraj et al.[14] and Sing et al.[15]

Further, the present study showed that the reasons for nonadherence were bad taste, perceived side effects (nausea, vomiting, and acidity), inadequate supply, and forgetfulness. A few respondents also cited difficulty in swallowing (4.2%) and peer pressure (2.8%) for not taking IFA tablets. Studies conducted by Sentil et al.,[9] Mir et al.,[11] Mithra et al.,[13] Selvaraj et al.,[14] and Sing et al.[15] also observed that side effects and taste were the prime reasons for being nonadherent. As per NFHS-4 report,[7] forgetfulness was the most common reason for nonadherence; other factors such as inadequate supply, perceived side effects, and fear of big baby were the reasons for nonadherence. In the present study, nonadherence was more among Muslim community (P < 0.001). Lower level of education of the participants also has been shown to have an effect on nonadherence by many other studies.[7],[10],[12],[14] However, in the present study, higher educational status was significantly associated with nonadherence (P < 0.001). Nonadherence to IFA supplementation was also seen more in those having adequate knowledge about IFA supplementation. A probable explanation is that participants with higher educational status or better knowledge may also be more concerned with the side effects. Lower socioeconomic status was also one of the factors (P = 0.02) for nonadherence which is similar to the study conducted by Selvaraj et al.[14] According to the study by Mithra et al.,[13] upper-class families were more nonadherent which is contradictory. Proper health education may improve the adherence rate among women irrespective of education level and socioeconomic status. Mithra et al.[13] found that lower age group women were more nonadherent (P = 0.031), whereas in this study, age ≥30 years was more nonadherent, but the finding was statistically not significant. This finding is similar to the study conducted by Siabani et al.[10] and Selvaraj et al.[14] The present study showed that nonadherence rate is higher among those with longer period of gestation (P < 0.001); hence, number of tablets and duration of prophylaxis or therapy could be the determining factors of nonadherence. The study also revealed that pregnancies with comorbidities such as diabetes, gestational hypertension, or any other conditions which require continuous medication were more nonadherent (P < 0.001) which is in line with previous studies.[10],[15] It was found that those who were taking IFA tablet from government health centers free of cost were more nonadherent (29.9%) compared to those who purchased (13.9%) and it was found to be statistically significant (P = 0.001). This finding may be due to the perception that government-supplied medicines are of low quality.[16] However, another study conducted by Mithra et al.[13] had shown that those who purchased medicine were more nonadherent (P = 0.02) due to cost matter as pregnancy progresses. This study demonstrated that nonadherence was not influenced by age of pregnant mother, gravida, and their occupation. Invariably, many factors have been identified which are reasons for nonadherence such as perceived side effects and inadequate supply. Factors which are significantly associated with nonadherence are higher education, lower socioeconomic status, longer period of gestation, pregnancies with comorbidities, adequate knowledge of IFA supplementation, Muslim community, and government-supplied medicine. This is probably the first study conducted in a rural setting of Manipur to determine the associated factors for nonadherence to IFA supplementation among pregnant women. The study findings can be utilized for addressing the barriers in an anemia control program.

Limitation

All the measures were self-reported. Ascertainment of number of tablets consumed could have been affected by limitation in recall.

Generalizability

The findings can be generalized to similar settings in Manipur.


  Conclusions Top


The prevalence of nonadherence is high among pregnant women attending the public health facilities in Bishnupur district, Manipur, with one out of every four pregnant women being nonadherent to IFA supplementation. Factors associated with nonadherence are higher education, lower socioeconomic status, gestational age, pregnancies with comorbidities, knowledge regarding IFA supplementation, religion, and government-supplied medicine. The common reasons for skipping the doses of IFA tablets were bad taste, perceived side effects, inadequate supply, and forgetfulness. It is recommended that during antenatal visits, the importance of IFA tablets should be emphasized keeping in mind the problem of nonadherence and its associated factors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kassebaum NJ, Jasrasaria R, Naghavi M, Wulf SK, Johns N, Lozano R, et al. A systematic analysis of global anemia burden from 1990 to 2010. Blood 2014;123:615-24.  Back to cited text no. 1
    
2.
Lokeshwar MR, Mehta M, Mehta N, Shelke P, Babar N. Prevention of iron deficiency anemia (IDA): How far have we reached? Indian J Pediatr 2011;78:593-602.  Back to cited text no. 2
    
3.
World Health Organization. Anaemia Policy Brief 2014, Global Nutrition Targets 2025. Available from: http/www/WHO/nmh/nhd/14thousand/days.org.pdf/573.88Kb. [Last accessed on 2018 Jul 20].  Back to cited text no. 3
    
4.
Ministry of Health and Family Welfare. Guidelines for Control of Iron Deficiency Anaemia. National Iron Plus Initiative; 2013. Available from: https://www.nhm.gov.in/images/pdf/programmes/child-health/guidelines/Control-of-Iron-Deficiency-Anaemia.pdf. [Last accessed on 2018 Jul 20].  Back to cited text no. 4
    
5.
Ministry of Health and Family Welfare. Reproductive & Child Health, Govt. of India. Available from: https://rch.nhm.gov.in/RCH/. [Last accessed on 2018 Jun 30].  Back to cited text no. 5
    
6.
Ministry of Health and Family Welfare. Anemia Mukt Bharat: Intensified National Iron Plus Initiative; 2018. Available from: https://anemiamuktbharat.info/. [Last accessed on 2018 Jul 06].  Back to cited text no. 6
    
7.
Indian Institute for Population Sciences and MoHFW. National Family Health Survey – 4; 2017. Available from: http://www.rchiips.org/nfhs-4. [Last accessed on 2018 Jul 20].  Back to cited text no. 7
    
8.
International Institute for Population Sciences and Macro International. National Family Health Survey (NFHS-3) 2005-06 Mumbai, India: 2007. Available from: http://rchiips.org/nfhs/NFHS-3%20Data/VOL1/India_volume/I_corrected_17octpdf. [Last accessed on 2018 Jul 20].  Back to cited text no. 8
    
9.
Sentil KP, Yuva PB. Compliance to Iron Folic Acid supplementation among antenatal mothers attending a primary health centre: A community based cross-sectional study. Indian J Adv Res 2018;3:223-32.  Back to cited text no. 9
    
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Siabani S, Arya MM, Babakhani M, Rezaei F. Determinants of adherence to Iron and folate supplementation among pregnant women in West Iran: A population based cross-sectional study. Qual Prim Care 2017;25:157-63.  Back to cited text no. 10
    
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Mir MR, Jan R, Munshi IH. Socio-demographic factors influencing utilization of antenatal health care services under JSSK in a rural area of J&K: A cross-sectional study. J Evol Med Dent Sci 2016;5:3299-302.  Back to cited text no. 11
    
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Chadalawada UR, Rani SM. Study on knowledge regarding iron deficiency anemia & iron folic acid compliance in pregnant women of rural areas of Andhra Pradesh. SMJ 2016;3:1-7.  Back to cited text no. 12
    
13.
Mithra P, Unnikrishnan B, Rekha T, Nithin K, Mohan K, Kulkarni V, et al. Compliance with iron-folic acid (IFA) therapy among pregnant women in an urban area of south India. Afr Health Sci 2013;13:880-5.  Back to cited text no. 13
    
14.
Selvaraj K, Arumugasamy P, Sarkar S. Compliance and patterns of iron-folic acid intake among adolescent girls and antenatal women in rural Tamil Nadu. CHRISMED J Health Res 2017;4:87-93.  Back to cited text no. 14
  [Full text]  
15.
Sing SR, Ratanasiri T, Thapa P, Koju R, Ratanasiri A, Arkaravichien T, et al. Effect of knowledge and perception on adherence to iron and folate supplementation during pregnancy in Kathmandu, Nepal. J Med Assoc Thai 2014;97 Suppl 10:S67-74.  Back to cited text no. 15
    
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Javali R, Wantamutte A, Mallapur MD. Socio-demographic factors influencing utilization of antenatal health care services in a rural area – A cross-sectional study. Int J Med Sci Public Health 2014;3:308-12.  Back to cited text no. 16
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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